Long Covid: Fatigue- helpful information and how Physio can help

The Therapies for Long COVID (TLC) Study Group (the University of Birmingham), recently summarised the current research on the symptoms, complications, and treatment of long COVID.

The ten most common symptoms of Long COVID were highlighted as fatigue, shortness of breath, muscle pain, cough, headache, joint pain, chest pain, altered smell, diarrhoea, and altered taste.
The two main symptom clusters for people experiencing Long COVID were:

  1.  fatigue, headache, and upper respiratory complaints.
  2.  ongoing fever and gastroenterological symptoms.


What is fatigue?

Fatigue is a feeling of constant tiredness or weakness, that does not improve with rest. Despite the fact that fatigue is sometimes referred to as tiredness, fatigue is not the same as being tired or sleepy.

A person often will feel fatigued for a number of reasons, whether it is physical, mental, or a combination of both. People of all ages will experience fatigue at some point in their lives.

In the case of viral infections such as COVID-19, fatigue is a normal part of the body’s response. After an infection is cleared, fatigue sometimes persists for some time. Fatigue can make you sleep more, feel unsteady on your feet, it can make exercise very difficult and affect your ability to concentrate and remember.


What causes post-viral or Long covid fatigue?

We now think that (based on post-mortem SARS research), the virus crosses the blood brain barrier.

Proposed Mechanism of how Long Covid causes fatigue by Vitality Physiotherapy


The blood-brain barrier is a specialised boundary between the blood supplying the brain and the spaces between the cells of the brain (the extracellular matrix). This incredibly specialised feature of the brain is very sensitive and selective. It allows very few substances to move from the blood into the brain, stopping toxins and harmful substances from entering the brain. It allows useful substances such as water, glucose, and oxygen to enter the brain. For more detailed information on this important mechanism, watch this:



The current idea about how the virus probably enters the brain is that when the virus enters your nose, it travels through the olfactory (nasal pathway). Then, it travels through the soft tissue in the nose via the drainage mechanism of the brain (lymphatic system). It may also possibly explain why anosmia (lack of ability to smell) is observed in patients with COVID-19.

Pro-inflammatory substances, such as cytokines (interferon gamma, and interleukin 7) start to increase in the brain area. This seems to affect the glymphatic system (macroscopic waste clearance system that use tunnels around blood vessels, formed by astroglial cells (star-shaped nerve cells), to help rid the brain of soluble proteins, waste, and metabolites from the central nervous system. The glymphatic system (largely active whilst we sleep) also helps deliver glucose, lipids (fats), proteins, growth factors, and neuromodulators to the brain. This is one of the reasons why we as humans need quality sleep because many of the toxins in our brains are eliminated when we do so.

The cytokines likely pass through the blood-brain barrier in organs such as the hypothalamus, leading in the longer term to interruption of the sleep/wake cycle, cognitive dysfunction and profound fatigue (post-exertional malaise), all characteristic of Chronic Fatigue Syndrome Myalgic Encephalomyelitis (CFS/ME).

We think that as it was the case with the SARS outbreak, some patients who contracted the COVID-19 virus may go on to develop a severe post-viral syndrome we term ‘Post COVID-19 Syndrome’ or Long COVID


What can I do to help myself?

There are many interventions and self-management strategies to help with ongoing fatigue after recovering from your initial infection.


Eat regular healthy nutrient-rich foods including fresh vegetables, fruit, carbohydrates, and healthy fats. Vitamin D has been shown to decrease viral load and boost your immune system, so get some sun too! Remember that your body is comprised of between 50 and 65% water and it is crucial to your recovery to keep topped up.


A short break every few hours is so beneficial to enhance your wellbeing and productivity. A mini-break does not need to be complicated. It can simply be a few minutes away from your work; this may be chatting with someone who is in the room with you or getting a drink, looking at a piece of art, listening to music, doodling, or drawing.


Sleep is critical to your recovery because when you sleep your immune system works more efficiently. Our sleep hygiene top tips are to ensure you train your body to get to sleep every night at the same time, keep your room as dark as possible, avoid caffeine after 2 pm and stop using screens at least an hour before bed.


Get active, initially, it might just be a gentle 5 min stroll or a few simple arm exercises, but you can slowly build up your activity levels. A little exercise often, allowing periods of rest in between activities is a great way to start. If you’re back at work, try standing up from your desk, if you’re office-based, every hour and march on the spot. Try going for a walk every day, starting with 5 min or so, and gradually increasing your walk time

If however, you find that simple exercises like climbing up a single flight of stairs, leaves you breathless, speak to your GP. If you feel like after exercise, you experience exceptional fatigue and malaise, speak to one of our Physios, about a more structured exercise plan, that may involve goal setting, exercise tolerance prescription, and pacing.

Wind down, allow time

The severity of the virus is not directly proportional to the level of fatigue you may be experiencing. We are all ‘wired’ differently, and our experience of illness is not the same. There is no carbon copy reference, so don’t rush with your rehab. Some patients experience levels of anxiety, fear, or even sadness.  Decompress your thoughts by engaging in calming activities such as meditation, prayer, relaxing with a pet, or listening to music. Activating your creative brain too, or by being “inflow” has been shown to help many people with their levels of happiness. Drawing, writing, and other repetitive creative activities activate “flow” and produce dopamine, which is a feel-good chemical that energises and motivates you.

Breathing exercises

Many of us over breathe, taking more oxygen than we require and in turn, can experience chronic fatigue. Mouth breathing is one of the biggest culprits that cause us to over breathe. Nasal breathing, on the other hand, is a more effective, more efficient method of breathing. Its benefits are vast in number and include improved lung volumes, reduced exposure to foreign substances, improve the function of your diaphragm, improve athletic performance, sleep better, and have better-smelling breath!

Check out this video about nasal breathing by our in-house respiratory Physiotherapist, Janine Enoch:




If you are experiencing fatigue with exercise, diminished tolerance for exercise, or simply confused about where to start, speak to one of our Physiotherapists for a free 15 min chat, which we can do over the phone or in person. Help is at hand, live well with Vitality Physiotherapy.

Long Covid: Breathing pattern disorder


Without it, life cannot be sustained, it is as simple as that. Breathe in, breathe out, our simple but most important automatic reflex-controlled function. Most of the time, our brain and reflexes do all the work for us. Have you ever observed a sleeping baby, breathing gently as their chest rises and falls, effortless and without any conscious process involved?

When the demand arises, we can consciously decrease or increase our rate of breathing. Do you remember the days of “hide and seek” when the suspicious seeker was dangerously so close you’d dare not breathe, or the exhilaration associated with the rapid preparatory breathes I take before that first jump off the highboard at the local swimming pool?

What is a normal breathing pattern?

  • Gentle breathing through the nose
  • Breathing in for 1-1.5 sec
  • Breathing out for 1.5-2 sec
  • Pause between in and out breath
  • Take 10-14 breaths per minute in adults
  • Breathe about 500ml of air per breath
  • Breathing is quiet


The normal breath cycle

Sometimes it goes wrong and our breathing becomes dysfunctional. What is dysfunctional breathing (DB)?

This can occur with heavy exercise, strong smells, cold weather, stress or other triggers. People would breathe rapidly through the mouth, breathe using the upper chest. The accessory neck muscles work hard and you will effectively hyperventilate.

The primary symptom is often breathlessness but is usually clarified as a feeling or need for more air or “air hunger”. Additionally, DB may cause non-respiratory symptoms such as dizziness and palpitations. It has been identified across all ages. In the United Kingdom, its prevalence is approximately 9.5% among adults.

What happens when we breathe?

We breathe in air containing a mixture of oxygen (O2) and carbon dioxide (CO2) and other gases. Our bodies process and use some of the inhaled oxygen to make energy, and creates carbon dioxide as a result. When you breathe out the air contains less oxygen and more carbon dioxide. However, carbon dioxide is not just a waste product of our body’s processes, it also has a vital role in regulating the pH of the blood. During stressful situations, a higher level of CO2 in your blood, helps your body to produce adrenaline which will help you flee from danger.

How does hyperventilation affect our bodies?

Some of the most common symptoms of hyperventilation

When we hyperventiltate, and there is less CO2 and more O2 in the blood, this causes respiratory alkalosis, or decreased acidity of the blood. This causes our blood vessels to constrict and causes reduced blood supply to the brain, among other things. This causes a feeling of light-headedness and pins and needles in the fingers, muscle cramps and exhaustion.

When overbreathing becomes regular and more permanent, the brain recognizes this lower level of carbon dioxide and accepts it as being normal. Consequently, the body is constantly on alert. This cycle of hyperventilation causes a self-perpetuating cycle, that fuels back into the system making you feel more anxious, more breathless and more hungry for air.

We also alter our posture significantly when we over breathe, adopting hunched-up shoulders as a result of rapid breathing. This causes us to use our neck accessory muscles to help draw air into our lungs. Prolonged and ongoing use of these neck muscles can cause an aching neck and stiff shoulders. Typically we can overuse sternocleidomastoid and scalene muscles which are at the front of our necks to do so. Check out this helpful video to hear more about breathing pattern disorder.

What is COVID-19 and why can it make you so sick? 

What is COVID-19 and why can it make you so sick blog article


Most of us know someone in our social circles who has had COVID-19, with or without becoming sick from it. 

Within the last 20 months, more than 203M cases of coronavirus infections were reported worldwide. Some people recovered from SARS-CoV-2 COVID having only a sniffle or a cough. Others got COVID and became sick with unremitting fever for days or even weeks. Sadly for 4.3 million people, this terrible disease was fatal. 

It begs the question – why do some people get so sick from COVID, whilst others suffer just mild symptoms? Is it a case of genetics, age, sex, or previous co-morbidities?

This article aims to answer this question. 

The journal Science Immunology published a study in March 2021 found that severe COVID-19 is accompanied by elevated levels of multiple inflammatory blood markers. It became apparent that a persons immune response to SARS-CoV-2 determines who is at the greatest risk rather than the virus itself. 


In COVID-19, coronavirus particles spread across the respiratory tract and infect surrounding uninfected cells. This triggers a series of immune responses. It results in some changes in immune cells, particularly lymphocytes, which then leads to immune system dysfunction. 

Cells of the immune system communicate with each other through a process known as signaling. Cells respond to viruses by secreting proteins called cytokines. However, in the presence of excessive inflammation, sometimes there is an uncontrolled release of cytokines. This triggers a ‘cytokine storm.’ The cytokines released by the SARS-COV2 infection lower white blood cells (such as lymphocytes) and suppress the immune response. 

Some cytokines cause lung cells to die. As those lung cells break down and die, the alveoli (air sacs in your lungs) fill with fluid. This causes pneumonia and prevents the exchange of air in the lungs. The body becomes deprived of oxygen (hypoxia) and respiratory distress occurs.

Are you starting to understand why COVID makes some people so sick? 



A recent study published in The Lancet Diabetes and Endocrinology analyzed COVID-19 severity in 6.9 million people in England. It demonstrated that a BMI over 23 kg/m2 was associated with an increased risk of severe COVID-19. 

It has been suggested that obesity is associated with an inflammatory state. WE see a surplus of macronutrients in obesity fat tissues. The macronutrients cause increased production of inflammatory mediators (tumor necrosis factor* and interleukin-6) and reduce adiponectin. Adiponectin is a hormone that plays a crucial role in protecting against insulin resistance/diabetes. The result is oxidative stress and pro-inflammatory reaction. During oxidative stress, the body is overloaded with free radicals and not enough antioxidants 

During normal metabolic processes, the body’s cells produce free radicals. The cells also produce antioxidants that neutralize these free radicals. In general, the body can maintain a balance between antioxidants and free radicals. An imbalance favoring free radicals causes oxidative stress. 



Clinical manifestations and mechanisms for COVID-19 risk in individuals with obesity 

Individuals with obesity and COVID-19: A global perspective on the epidemiology and biological relationships. Obesity Reviews November 2020 e13128 


Individuals with obesity are more likely to develop diabetes type 2. Hyperglycemia (excessive blood sugar), and uncontrolled blood glucose, have been shown to significantly impair immune cell function and was associated with a higher mortality rate.  

A high-fat diet also triggers an inflammatory response in the body. The fatty acid, Cholesterol is an essential ingredient in the spread of SARS COV-2. This virus enters the cell in the presence of cholesterol in the form of lipid rafts, The virus attaches and enters the cell by being engulfed by the cell (endocytosis). An exciting discovery was recently discovered by the University of Birmingham, Keele University, and the San Raffaele Scientific Institute in Italy, where fenofibrate, a blood cholesterol-lowering drug, decreased sARS-COV-2 significantly in laboratory testing. 



Over 65-year-olds represent 80% of hospitalizations and have a 23-fold greater risk of death. Cardiovascular disease, diabetes, and obesity increase the risk of fatal disease, but they do not explain why age is an independent risk factor.
By 29 May, the Office for National Statistics reported that more than 46,000 people had died from Coronavirus in England and Wales, and that more than 4 in 5 of those people were over the age of 70. When we examine the number of deaths caused by Coronavirus per thousand people, the correlation is even starker. 

In age groups up to and including 60-69, fewer than 1 in 1,000 people have died from coronavirus. 

Age 70-79, is 2 in every 1,000 people. 

Age 80-89, is 7 in every 1,000 people. 

Age 90 and over, is 18 people in every 1,000 people. 


By Colin D. Funk, Craig Laferrière, and Ali Ardakani – Funk CD, Laferrière C y Ardakani A (2020)  A (2020) A Snapshot of the Global Race for Vaccines Targeting SARS-CoV-2 and the COVID-19 Pandemic.


The virus typically enters an individual’s airways and enters a cell by attaching its spike protein to the ACE-receptors found on the surface of many organs in the body. The virus becomes engulfed by the the cell (endocytosis), and then begins to replicate, taking over and replicating itself using the body’s own protein making mechanism.  

 Two major changes occur in the immune system as we age. There is a gradual decline in immune function known as immunosenescence, which hampers pathogen recognition, alert signaling, and clearance of pathogens. Other classic immune system changes during aging are chronic inflammation and inflamaging, which result from an overactive, but ineffective alert system. 

The virus continues replicating and spreading in the body, causing chaos and damage as it does.


The aging immune system 

A patient’s ability to control viral load is one of the best predictors of whether they will become mildly or severely sick from COVID-19. The immune system requires four main functions: (1) recognise, (2) alert, (3) destroy, and (4) clear to destroy any virus. In older adults, each of these mechanisms is dysfunctional and increasingly variable.  The immune system’s response is usually two-fold. Our first reaction relates to the innate immune response which is characterised by the cytokine and interleukin response, which serves to slow down the replication of the virus, and to allow the body to launch it is personal bespoke acquired immune response which seeks to destroy the virus. However, in older people where the immune workings are less than optimal and variable, the virus is by default is more opportunistic. 

image showing the immune response such as in covid-19

Image: The mechanism of the human immune response   Source Cell Signaling Technology



Several health conditions, such as diabetes, can increase the risk of becoming severely sick from COVID-19 by suppressing the immune system; whilst COPD, increases the risk due to the weakened state of the lungs. This is largely due to poor underlying lung reserve (The amount of extra air inhaled — above normal shallow breathing when taking a forceful breath) as well and increased expression of angiotensin-converting enzyme 2 (ACE-2) receptor in the small airways 

Increased risk has also been seen in people with high blood pressure (hypertension) and coronary artery disease. Fever and infection cause the heart rate to speed up, increasing the work of the heart in COVID-19 patients who develop pneumonia. Blood pressure may drop or spike, causing further stress on the heart, and the resulting increase in oxygen demand can lead to heart damage. This is especially so, if the heart arteries or muscle were unhealthy, to begin with. Heart damage is most often caused by heart attacks, which result from the formation of a blood clot in a vulnerable heart artery, blocking the delivery of oxygen to the heart muscle. COVID-19-related inflammation raises the risk of this type of heart attack by activating the body’s clotting system and disrupting the blood vessel lining. This lining loses its ability to resist clot formation when inflamed. Clots in the large and small arteries of the heart cut off the heart’s oxygen supply. The increased clotting tendency can also cause blood clots in the lungs, which can cause the oxygen level in the blood to drop. A severe case of pneumonia further reduces blood oxygen levels. 

As previously described when the ‘spike’ molecule on the surface of the virus particle binds to ACE2 on the surface of a cell. This causes the virus particle to be taken into the cell. It replicates its genetic material to form new virus particles. Normally, cells in the airways, lungs, and heart, as well as those in the circulatory system, contain ACE2.  

However, patients with heart failure or respiratory conditions like COPD have an increase in ACE2. A higher level of ACE2 means that there are more entry points for the virus and therefore increase the risk of severe illness. Please note that if you have been prescribed ACE inhibitors, you should continue taking them. ACE inhibitors and ARBs are safe to use. 

The researchers at Kings College London found that there was no link between the use of angiotensin-converting enzyme (ACE) inhibitors, used to treat blood pressure or diabetes, and how sick you get from Covid-19. 


“This study has addressed a very important clinical question since a large proportion of the UK population takes these cardiovascular drugs. Our study indicates that it is perfectly safe to continue taking these agents and that people’s concerns about them can be alleviated”

– Professor Ajay Shah, BHF Chair of Cardiology & James Black Professor of Medicine Director,

King’s BHF Centre of Excellence, King’s College London and King’s College Hospital


So, the older you are, the more health issues and underlying conditions that you may have, the more severe the risk of severe infection. However, taking the necessary steps to protect yourself and others from becoming sick with COVID-19, is possible.  

Vaccination, social distancing, wearing a face covering, and practicing hand hygiene remain crucial to help reduce the spread of COVID-19.    

If you would like to learn more about how physiotherapy can help you recover from Long-COVID, this article will answer all your questions!

If you are currently experiencing symptoms associated with COVID-19 or Long-COVID and would like to speak to an expert, get in touch:  info@vitality-physio.co.uk 


COVID-19 Rehab: Your Questions Answered (And How Physio Can Help)

COVID-19 Rehabilitation and Long-COVID Recovery

It is staggering to think that these words never existed two years ago. Now, entire market sectors are dedicated to them. In January 2020, the World Health Organisation (WHO) called the new Coronavirus outbreak a “Public Health Emergency of International Concern”.

Three months later, a global pandemic was declared, and life as we knew it changed. Early on, the WHO did not expect a vaccine in less than 18 months. Then, against all odds, the world’s institutions combined their forces and produced a vaccine within 11 months.

Hope was renewed, and a way forward pathed.

With more than half of the UK population now vaccinated, it’s tempting to assume the COVID nightmare is almost over. But, this may be short-sighted. Although we’ve made progress, there’s still much more to learn about this disease before we can move on from this pandemic.

The reality is the world is healing, and many people have a long journey ahead of them.

These are the most common questions we get from patients and carers, and we hope by the end of this article you will have found the answers you’re looking for.



Coronaviruses (CoV) are a large family of viruses that cause illnesses ranging from mild common colds to more severe conditions like SARS and MERS. The Coronavirus at the centre of the pandemic is a new strain called SARS-CoV-2. The virus spreads through direct contact or respiratory droplets that contact the nose, mouth, or eyes. 

Data shows Black and Asian ethnic minority populations have poorer outcomes but, ongoing symptoms occur across all population groups. The WHO reports, ‘anyone can get sick with COVID-19 and become seriously ill’. Those found to be at most significant risk of severe COVID-19 illness are:

  • Men
  • People over 60
  • Those with an underlying health condition.


COVID-19 can show up as a mild or severe disease. In some cases, it can progress quickly, so knowing the symptoms and understanding the difference between mild and severe cases helps save lives. These are the most common symptoms:


Covid-19 rehabilitation, covid-19 symptoms

COVID-19 Coronavirus Symptoms (Source: WHO)


As with any new outbreak, little is known about the condition until more studies are conducted. Time brings more information, improved knowledge, and ultimately, better management of the disease or condition.

Since COVID-19 is a new condition, the list of symptoms may change in the future. Therefore, it’s best to keep up to date with current evidence.



COVID-19 recovery is different for everyone. The WHO reports most people (about 80%) will recover without needing hospital treatment. Around 15% will require oxygen treatment, and 5% will need intensive care due to critical illness.

Many people get back to their normal activities within a few weeks, but most recover within 12 weeks. Unfortunately for some, symptoms can last longer than 12 weeks. New initiatives provide guidance and support for those dealing with COVID-19, either directly or indirectly.

The NHS has done a terrific job with its website, www.yourcovidrecovery.nhs.uk. It’s an incredible resource for anyone needing support through their or a loved one’s COVID-19 recovery.



Long-COVID is the extended period of illness after initial COVID-19 infection.

The National Institute for Health and Care Excellence (NICE) develops COVID-19 care guidance based on these definitions and timelines:

  • Acute COVID-19: Signs and symptoms up to 4 weeks
  • Ongoing symptomatic COVID-19: Signs and symptoms from 4 -12 weeks
  • Post-COVID-19 syndrome: Signs and symptoms presenting as clusters during or after COVID-19 infection, with no alternative diagnosis and lasting longer than 12 weeks
  • Long-COVID includes both the ongoing symptomatic COVID-19 and post-COVID-19 syndrome stages


Covid-19 rehabilitation, Covid-19 symptoms

Image: Vitality Physiotherapy. Source: NICE


In a joint UCL 2021 study, researchers found patients hospitalised with COVID-19 still had symptoms more than seven weeks after hospital discharge.

These included:

  • Persistent breathlessness (53%)
  • Cough (34%)
  • Fatigue (69%)
  • Depression (14.6%)

They also found that 38% of Chest X-Rays remained abnormal and 9% showed worsening.

As much as we want this pandemic over, some symptoms are an ongoing reality in many people’s lives.

Long-COVID symptoms are wide-ranging and fluctuating, and these can change in nature over time.


Covid-19 rehabilitation, symptoms, Long covid

Image: Vitality Physiotherapy, Source: NHS



The research is scarce about the causes of Long-COVID. However, a theory about viral persistence has emerged. Certain body parts (brain, testes, eyes, spinal cord) are considered ‘safe havens’ or immune-privileged organs to our immune cells. These are ‘no-go areas’ for immune attacks.

When viruses hide out in these body sites and come out later, causing relapses, it’s called viral persistence. In these organs, damage from an immune attack is riskier than allowing an invader (a virus, for example) to infect the cells.

In June 2020, a National Geographic article called ‘How long does Coronavirus last inside the body?’ explored viral persistence and explained how it impacts your recovery. 



The short answer? Anyone who gets COVID-19 can get Long-COVID. Many people believe they will not experience severe symptoms if they are not at risk.

The chances of having long term symptoms does not seem to be linked to how ill you are when you first get COVID-19.



The NHS clarifies an important aspect here – your initial and post-COVID symptoms may not be related. But why can’t we predict how unwell we’ll get with COVID-19 or tell whether we will develop long-term symptoms?


In a review into the global health strategies surrounding COVID-19, a researcher explained it like this:

‘What follows after the acute phase of SARS-CoV-2 infection depends on the extension and severity of viral attacks in different cell types and organs.’

Aging clinical and experimental research 


In other words, how sick you become after acute infection depends on how severely the virus attacked during the acute phase.

Viruses also affect our immune systems differently. Unfortunately, we cannot predict which patients will have a worse outcome from the limited clinical evidence and research data.

This NHS video discusses how post-COVID symptoms affect healthy young people. For example, a 26-year-old former marathon runner describes how ten weeks after her initial infection, she still couldn’t walk for more than 15 minutes at a time in this BBC article.

These stories, along with countless others, demonstrate that no one is safe from Long-COVID.



Your appointment will include a thorough assessment and a concise treatment plan.

Assessment includes:

  • screen for serious illness
  • discussion about your case history to find out about your current and previous functional abilities and challenges
  • respiratory examination 
  • musculoskeletal examination

Treatment includes:

  • A uniquely designed custom treatment plan according to your specific goals and functional requirements determined in your assessment.



COVID-19 Rehabilitation tools, techniques and exercises help:

  • Reduce breathlessness
  • Increase your lung capacity
  • Pace your activities
  • Manage fatigue
  • Improve your exercise tolerance
  • Rehabilitate muscle and joint dysfunction

We show you a way forward and help you manage your symptoms better so you can live your life.

In any holistic Physiotherapy Rehabilitation programme, an onward referral network is essential. We work with experts to help you recover fully. 

If we suspect you need further investigation, we will refer you to our trusted colleagues for extra help:

  • Specialist Medical Physicians
  • Respiratory consultants
  • GP’s
  • Psychiatrists
  • Sports and Exercise Medicine Consultants
  • Speech and Language Therapists
  • Occupational Therapists
  • Psychotherapists


There is more to COVID-19 than just a virus. You can feel the impact on every aspect of your life – physically, mentally, socially and financially.


Have you waited long enough for things to improve on their own? You are not alone on this journey – we’re on your team!

COVID-19 is a complex puzzle, and we are here to help you solve it! Don’t wait any longer to restore your quality of life and start doing the things you love again! 

Get in touch with our specialist team now!