What is the primary approach to managing long covid syndrome?

Management of Long COVID Syndrome

The primary approach to managing long COVID syndrome is a multidisciplinary rehabilitation program that addresses physical, psychological, and psychiatric symptoms, with self-management strategies and symptom-specific supportive care as the foundation of treatment. 1

Initial Assessment and Validation

Listen to patients with empathy and validate their experience, as many patients report feeling dismissed by healthcare professionals when reporting long-term symptoms. 1 This validation is critical because long COVID often presents as an "invisible disability" that may not be readily acknowledged. 2

Core Management Strategy: Multidisciplinary Rehabilitation

Initiate integrated multidisciplinary rehabilitation services as the primary treatment approach, ideally starting from initial assessment and continuing throughout recovery. 1 This should include:

• Physical rehabilitation specialists with expertise in treating fatigue and respiratory symptoms (breathlessness are among the most commonly reported symptoms). 1
• Psychological and psychiatric support to address mental health components. 1
• Fatigue management as a key component of the rehabilitation plan, given that fatigue is one of the most prevalent symptoms. 1

Evidence from a study of 30 consecutive LCS patients demonstrated that multidisciplinary rehabilitation programs are effective, safe, and feasible, with significant improvements in muscular strength, cardiopulmonary parameters, quality of life, depression, and anxiety, with no adverse effects or dropouts. 3

Self-Management and Supported Self-Management

Provide advice and information on self-management starting from initial assessment, including: 1

• Setting realistic goals for symptom management
• Energy conservation strategies to prevent postexertional malaise/symptom exacerbation. 2
• Contact information for when patients need support or are worried about symptoms
• Access to support groups, online forums, and apps for peer support
• Information about financial support, housing, employment, and social care services
• Materials that patients can share with family, carers, and friends to help them understand the condition

Consider symptom diaries and tracking apps for self-monitoring, though no specific product can be recommended based on current evidence. 1

Critical Physical Activity Considerations

Exercise recommendations must be carefully tailored to the patient's current activity tolerance because overly intense activity can trigger postexertional malaise/symptom exacerbation and worsen muscle damage. 2 This is a common pitfall—standard exercise prescriptions can harm rather than help these patients.

Perform functional assessments including the 1-minute sit-to-stand test, recording breathlessness, heart rate, and oxygen saturation during the test. 1

Pulmonary Rehabilitation

Offer pulmonary rehabilitation for patients with respiratory symptoms, as meta-analysis demonstrates improved walking distance (effect size: 44.55), quality of life (effect size: 0.52), dyspnea (effect size: 0.39), and lung function. 1

Initiate rehabilitation within the first 30 days post-acute phase when possible, though explicit timing should be guided by symptom stability. 1

Essential Investigations

Perform baseline blood tests including: 1

• Full blood count
• Kidney and liver function
• C-reactive protein
• Ferritin
• B-type natriuretic peptide
• Thyroid function

Obtain chest radiography for patients with continuing respiratory symptoms who have not had one already, though be aware that plain chest radiographs may not be sufficient to rule out lung disease. 1

For patients with postural symptoms (palpitations, dizziness on standing), perform lying and standing blood pressure and heart rate recordings using a 3-minute active stand test, or 10 minutes if postural tachycardia syndrome or other autonomic dysfunction is suspected. 1

Urgent Referral Criteria

Refer urgently to acute services if patients have: 1

• Severe hypoxemia or oxygen desaturation on exercise
• Signs of severe lung disease
• Cardiac chest pain
• Multisystem inflammatory syndrome (in children)

Service Organization and Continuity

Deploy multidisciplinary clinics (possibly using the "one-stop" clinic model) to assess physical and mental health symptoms and conduct appropriate investigations. 1

Provide a care coordinator or single point of contact to ensure continuity of care across multiple specialists. 1

Integrate referral pathways between primary and community care, multidisciplinary rehabilitation services, specialist services, and specialist mental health services. 1

Return to Work/Education

Discuss phased return to work or education with employers or educational institutions, as the return-to-work process can be challenging due to fluctuating symptoms and "invisible disability" status. 1, 2

Identify suitable workplace accommodations and provide necessary documentation when needed. 2

Medication Management

There is insufficient evidence to recommend specific medications for long COVID, so medication use generally follows standard practice for symptom-specific indications with careful attention to: 2

• Shared decision-making prioritizing patient preference
• Cautious use of medications that may improve some symptoms (e.g., cognitive impairment) but worsen others (e.g., postexertional malaise)

Avoid overmedication with unproven supplements, as they may interact with other medications and lack evidence for efficacy in long COVID. 4

Follow-Up and Monitoring

Agree with the patient on frequency of follow-up and which healthcare professionals should be involved. 1

Tailor monitoring to the patient's symptoms, discussing any changes including new or worsening symptoms and their effects on the person's life and wellbeing. 1

Monitoring can be conducted in person or remotely depending on availability, patient preference, and clinical suitability. 1

Common Pitfalls to Avoid

• Dismissing or minimizing patient symptoms—validation is therapeutic and essential. 1, 2
• Prescribing standard exercise programs—this can worsen postexertional malaise. 2
• Relying on chest radiography alone—it may not be sufficient to rule out lung disease. 1
• Recommending unproven supplements—there is no evidence for their efficacy in long COVID. 4
• Fragmented care—ensure integrated working and information sharing between services. 1