Post-COVID treatment

Regular follow-up is recommended for individuals suffering from post-COVID fatigue. You should keep an energy diary to track how your symptoms evolve when following the four Ps: plan, pace, prioritize and position. You should also adjust their routine to focus on everyday activities and avoid exhausting your daily energy reserves. If physical therapy is put in place,  the exercises and your daily activities must not cause you to exceed your energy limits so as to avoid post-exertional malaise, which would require a prolonged subsequent recovery period. It is therefore a question of “pacing yourself” or returning to activities in a measured way by finding a balance between active and rest periods.

Complementary therapies such as hypnosis, meditation, vagal nerve stimulation, acupuncture and vitamins are recommended for certain symptoms (for example, vitamin B2 for headaches). More information about specific treatments is available on the specific pages for each symptom.
Psychotherapy and psychological and psychiatric support are important for symptoms such as anxiety, post-traumatic stress and depression.
If treatment is ineffective or you need interdisciplinary follow-up, visit the next page for more information about the post-COVID clinic at the Geneva University Hospitals (HUG).
 

The vagus nerve is a major axis of the parasympathetic nervous system and plays an important role in the functioning of many organs (digestive, sexual, bladder, heart, etc.). In the case of a dysautonomic disorder, certain individuals show an over-stimulation of the sympathetic system. Activation of the parasympathetic system through stimulation of the vagus nerve could potentially correct this and help in the management of dysautonomia. There are several ways to stimulate the vagus nerve, some examples are: cardiac coherence (abdominal breathing exercise), mindfulness meditation, cold showers, dynamic stretching exercise, etc. (see Dysautonomia disorders).

Rehabilitation has an important part to play in care for patients with post-COVID symptoms, especially given the lack of pharmaceutical treatment to date.

Primary care physicians and ergotherapists can advise on how to manage daily life activities and how to respect the person’s daily energy reserve. An energy diary, identifying activities that require a lot of effort, and respecting the 4P's: Plan, Take Time, Prioritise, are essential in the management of post-COVID symptoms.

If physical activity is recommended, it is necessary to assess the person before starting physical therapy treatment. This assessment should be done by a health professional. In the case of post-COVID fatigue, an assessment of potential post-exertional malaise should be made prior to starting the rehabilitation program. This assessment can be made using the DePaul questionnaire validated in people with encephalomyelitis/chronic fatigue syndrome.

Post-COVID patients undergoing outpatient or hospital treatment can benefit from rehabilitation programmes tailored according to the primary condition and severity of infection. This page is focused on rehabilitation for people treated as outpatients who suffer from post-COVID symptoms such as fatigue, shortness of breath or difficulty concentrating.
 

Physical physiotherapy treatment consists of rehabilitation for orthostatic issues (symptoms on standing up) or heart palpitations after exertion. In such cases, exercises may begin in the horizontal position to avoid dysautonomia (malfunction of the autonomic nervous system) and extra effort when standing up. The treatment also involves working on muscle strengthening, doing isometric exercises and restoring joint range of motion. The main aim is to enable you to carry out your day-to-day activities while not exceeding your energy limits and by avoiding post-exertional malaise. Physiotherapy should help you understand the right balance between activity and rest. Patients should never be pushed beyond their capabilities, which could lead to a longer recovery time. The aim should always be to keep your heart rate below 60 per cent of the maximum. To calculate this: (220 – your age) x 0.6 = 60 per cent of maximum heart rate. Therapeutic patient education (learning how to understand your illness, safety precautions, etc.) or group therapy can be helpful, providing comprehensive patient care.

In case of:

• Discomfort
• Low oxygen saturation < 90% 
• Elevated respiratory rate > 22 breaths per minute
• High heart rate > 175 beats per minute
• Low blood pressure < 85/84 mmHg
• Accompanying symptoms, including chest pain, blurred vision, headache, feelings of dizziness or loss of balance, shortness of breath or tinnitus, you should stop the exercise immediately and will need to recover. 

Monitoring heart rate and its variations is a tool to help identify activities that are energy intensive. Under beta blockers, there is less variation in heart rate. It would therefore be necessary to determine a resting heart rate based on a heart rate obtained during activities that are well tolerated (e.g. 10min walk). This will be the threshold for which any activities that result in an increase in heart rate above this value will be costly activities. It is important to note that symptoms remain the primary criterion in pacing, not heart rate. It is therefore important to assess the change in symptoms (worsening or not) following exercise or activity within 24-48 hours. This will help to identify energy-intensive activities and will assist in the application of pacing for rehabilitation.

Respiratory rehabilitation using physiotherapy is a treatment for post-COVID shortness of breath. Respiratory physiotherapy is recommended in cases of post-COVID pulmonary sequelae (following a moderate-to-severe acute phase of the infection with or without hospitalization) and in cases of hyperventilation syndrome. A pulmonologist will diagnose hyperventilation syndrome once structural lung damage has been ruled out, using specific tools including the Nijmegen questionnaire and a hyperventilation test. In these cases, the aim is to work on breathing control and improve ventilation under the supervision of specially trained respiratory therapists.

Cognitive rehabilitation can help people who have difficulty concentrating, with tips and tricks for organization, monotasking, etc. Resources are not always available or reimbursed for cognitive rehabilitation, but you can do it as part of your everyday life by focusing on some cognitive tasks without exhausting your daily energy reserves. This may include paying bills, reading two or three pages of a book, holding conversations for increasingly long periods of time or playing games (crossword puzzles, sudoku, board games) that require coordination or concentration. There is no need to start something new; rather, focus on activities you already are familiar with.

Speech therapy is indicated for a chronic cough or as a complement in case of shortness of breath that does not improve with respiratory physiotherapy. Speech therapy can also help with managing time and effort when speaking, in order to adjust the energy level in speech activities for example.

Are you being followed at the Geneva University Hospitals (HUG) for post-COVID symptoms (often called long COVID) and would you like to share your experience (experiences, difficulties, resources) with other people in a similar situation?  
We offer monthly discussion groups at the consultative psychiatry and crisis intervention (SPLIC) at 51 Boulevard de la Cluse. The meetings last 1 hour and 15 minutes and generally bring together 4 to 15 people on various themes (COVID and me, others and my COVID, thinking about the future, etc.). These discussion groups are led by a psychiatrist accompanied by a mental health nurse. They are covered by your basic insurance (LAMal).  
To register and/or receive more information, talk to your doctor at the HUG. 
If you are not being treated at the HUG, there are other discussion groups in Switzerland and in other countries. You will find all the information on the associations page.