Long COVID Physiotherapy: Safe Activity

A better first question than “Which exercise should I do?”

Long COVID can affect breathing, energy, thinking, pain, sleep and everyday function in different combinations. The WHO definition describes symptoms that usually begin within three months of the infection, last at least two months, affect daily life, and are not better explained by another diagnosis. Its global estimate—about 6 in 100 people after COVID-19—comes largely from early-pandemic data, and WHO emphasizes substantial variation and uncertainty. It is not a prediction for any one person or a current India-specific rate. [1]

My central point is simple: with long COVID, a physiotherapy conversation should not begin by assuming that more activity is always better. First ask what happens during and after activity. Post-exertional symptom exacerbation (PESE, also called post-exertional malaise or PEM) can mean a delayed worsening after physical, cognitive or emotional effort. A person may feel able during a session and feel much worse later. A video visit cannot rule this out or “clear” someone for exercise.

What the evidence does—and does not—show

A 2026 European Respiratory Society guideline suggests personalized rehabilitation for adults with long COVID, with appropriate professional oversight and screening for PEM first. When PEM is present, the guideline emphasizes activity management rather than simply adding exertion. That is a meaningful safeguard, not a universal exercise prescription. [2]

The PHOSP-R trial randomized 181 adults who had been hospitalized with COVID-19 to face-to-face rehabilitation, remote rehabilitation, or usual care. Both rehabilitation arms improved walking-test distance versus usual care, but this does not show the remote and face-to-face programs were equivalent to each other. The trial excluded people whose severe PEM/PESE left them bedbound, as well as people with other reasons exercise was unsafe. Its results therefore cannot be extended to people excluded from the study. [3]

A separate randomized tele-rehabilitation study enrolled 132 people, most of whom had not previously been hospitalized. It found no significant between-group difference on its primary mobility outcome, although some secondary outcomes improved. Its findings are promising but specific to that program and selected sample; they do not establish that online physiotherapy works for everyone. [4]

What an online appointment can usefully do

A teleconsultation can map symptoms against daily activity, discuss delayed responses and recovery time, review current medical advice, identify goals, and decide whether remote follow-up is reasonable. The therapist may observe breathing, movement, transfers or a task in the person’s home when safe and relevant. These observations are limited by camera angle, connection, lighting, space and the lack of hands-on examination. Telehealth guidance supports individualized shared decisions—not automatic remote suitability. [5]

If activity is followed by a delayed flare, say so plainly and describe the timing, duration and effect on daily life. Do not increase exercise solely because it felt manageable in the moment. Ask the treating clinician how to manage activity and whether another medical assessment is needed. For severe or rapidly worsening symptoms, seek appropriate local medical care rather than waiting for a physiotherapy video visit.

Home physiotherapy in India

A home visit may let a physiotherapist see the actual environment and daily tasks, but it is not a substitute for medical assessment or a promise that exercise is appropriate. Goswami Rehab’s in-person home physiotherapy is India-only; online discussion is a separate, suitability-reviewed option. Availability and clinical fit must be confirmed. Neither format should be presented as a cure or as proof that symptoms are harmless.

Questions worth taking to the clinician

**Public video reference:** WHO, “Episode #47 — Post COVID-19 condition” (2021). It is an introductory explainer, not current treatment guidance: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/media-resources/science-in-5/episode-47---post-covid-19-condition

• Do symptoms worsen hours or a day after physical, mental or emotional effort?
• What should I track about activity, symptoms and recovery before changing a plan?
• Which parts of assessment can be done by video, and what would require in-person or medical review?
• If we try remote support, what changes mean we should pause and contact a clinician?