Treatment Approach for COVID-19 Long Haulers
All COVID-19 long haulers should be screened for rehabilitation needs in terms of physical, cognitive, and mental disorders to facilitate timely management and appropriate referrals. 1
Definition and Prevalence
Long COVID (or post-COVID syndrome) refers to persistent symptoms or development of new symptoms lasting more than 28 days after initial COVID-19 diagnosis 2. Studies indicate that approximately 80% of patients infected with SARS-CoV-2 develop one or more long-term symptoms 3, with the most common being:
- Fatigue (58%)
- Headache (44%)
- Attention disorder (27%)
- Hair loss (25%)
- Dyspnea (24%)
Comprehensive Assessment and Management Algorithm
Step 1: Initial Screening and Assessment
- Screen for physical, cognitive, and mental health symptoms
- Assess impact on activities of daily living
- Evaluate respiratory function, particularly in those who had severe COVID-19
- Note: Most patients may have normal laboratory and imaging results despite debilitating symptoms 4
Step 2: Symptom-Based Management
For Respiratory Symptoms:
- Breathing control techniques: high side lying, forward lean sitting, pursed lip breathing, square box breathing 1
- Appropriate walking pace regulation to prevent oxygen desaturation 1
- Pulmonary rehabilitation training for those with impaired function 1
For Fatigue and Physical Deconditioning:
- Gradual resumption of activities at a safe and manageable pace 1
- Structured physical therapy with incremental increases based on symptoms 4
- Traditional Chinese exercises such as Baduanjin and Tai-chi 1
For Mental Health Issues:
- Psychological counseling and mental health education 1
- Non-drug treatments: breathing relaxation training, mindfulness training, cognitive behavioral therapy 1
- For severe anxiety: consider short-acting medications with low drug-drug interaction risk 1
For Cognitive Symptoms:
- Brain rehabilitation therapy 4
- Cognitive exercises and memory training
- Occupational therapy for functional adaptation 4
Step 3: Integrative Approaches
For patients open to complementary approaches, Traditional Chinese Medicine (TCM) offers additional options:
- TCM decoctions based on syndrome differentiation 1
- Non-oral TCM therapies: acupuncture, moxibustion, manipulation, auricular points therapy 1
- Diet therapy and emotional therapy 1
Special Considerations
Gastrointestinal Symptoms
- For abdominal fullness, anorexia, nausea, and diarrhea: Consider TCM herbs with "regulating stomach and dissipating dampness" or "tonifying spleen and appetizing" effects 1
- For constipation and abdominal distension: Consider Chengqi decoction series 1
Pulmonary Fibrosis
- Early intervention is crucial to reduce severity 1
- Consider TCM herbs with "dispelling wind, dredging collaterals, and resolving hard lumps" effects 1
- For those without high fever: Guizhi Fuling decoction/pill may be considered 1
Return to Work Considerations
- Only about one-third of patients return to unrestricted work duty in early follow-up 4
- Staged return to work may be necessary
- Occupational therapy to address workplace adaptations
Pitfalls and Caveats
Diagnostic Challenges: Laboratory and imaging tests often show no abnormalities despite debilitating symptoms 4. Don't dismiss symptoms due to normal test results.
Multisystem Involvement: Symptoms can fluctuate and affect multiple organ systems, requiring holistic management 2.
Underestimation of Impact: Many long haulers were not hospitalized during acute infection (75%) but still develop significant disability 4.
Mental Health Stigma: Avoid attributing physical symptoms solely to anxiety or depression, as these may be part of the post-COVID syndrome itself.
Pacing Challenges: Patients must be cautioned against overexertion which can worsen symptoms. Activity increase should be gradual and based on symptoms 1.
Recent advances in clinical phenotyping and biomarker identification may soon lead to more mechanism-informed and personally tailored approaches to clinical care 5, but current management remains largely symptomatic and supportive.