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Most people with COVID-19 recover within 2–6 weeks. For some, a full recovery will take up to 12 weeks. A smaller group of people report a diverse range of symptoms for weeks or months after the expected recovery period, a condition termed ‘long COVID’.
The presence of lingering symptoms may have a significant impact on the daily lives of those who are affected, and their family and whānau.
The term ‘long COVID’ is commonly used to describe signs and symptoms that continue or develop for weeks or months after acute COVID-19 and cannot be explained by an alternative diagnosis.
Long COVID usually presents with clusters of symptoms, often overlapping, which can fluctuate, relapse and change over time and can affect any system in the body (as described by NICE – the UK National Institute for Health and Care Excellence, 2022).
Progression of the disorder
- Acute COVID-19 – Signs and symptoms of COVID‑19 for up to 4 weeks
- Ongoing symptomatic COVID-19 - Signs and symptoms of COVID‑19 post the acute period of the illness from 4 weeks up to 12 weeks
- Post-COVID-19 syndrome - Signs and symptoms that develop during or after an infection, consistent with COVID-19, continue for more than 12 weeks, and are not explained by an alternative diagnosis.
For recording purposes in New Zealand, long COVID is divided into either ongoing symptomatic COVID-19 or Post-COVID-19 syndrome as defined above.
Who is more likely to develop long COVID?
Anyone can develop long COVID, but it appears to be more commonly experienced by those who had severe symptoms when they first got COVID-19. Long COVID may be triggered by COVID-19 reinfection.
Some people may be at greater risk of long COVID, including those who:
- are older (50 years and over)
- have more than one underlying chronic medical condition
- are obese
- are female
- had multiple symptoms in their initial infection
- were admitted to hospital with acute COVID-19.
Long COVID is less common in children and young adults.
Symptoms and signs
There are a wide range of symptoms for acute COVID-19 and for long COVID, but these symptoms are also common in many other conditions. Ongoing symptoms can vary widely and affect people differently. Some of the more commonly reported symptoms of long COVID are listed below.
General symptoms include:
- abdominal pain
- joint pain
- muscle pain
- nausea and vomiting
- weight loss
- reduced appetite
- sleep issues.
Cardiovascular symptoms include:
- chest tightness
- chest pain
- skipped, extra or irregular heartbeats (palpitations).
Neurological symptoms include:
- loss of concentration or memory issues (cognitive impairment, 'brain fog')
- sleep disturbance
- pins and needles and numbness
- delirium (in older people)
- lack of strength in arms or legs (mobility impairment)
- visual disturbance.
Ear, nose and throat symptoms include:
- sore throat
- loss of taste or smell
- blocked nose (nasal congestion).
There are often very few signs of long COVID, and there is no specific test for long COVID. Therefore, the diagnosis is made based on persistent symptoms occurring after a person has had COVID-19 after careful exclusion of other diagnoses.
Information for primary care
Long COVID – an update for primary care was published by the British Medical Journal on 22 September 2022.
The update covers symptoms and case definition, and answers to common patient questions, such as ‘what is the cause of long COVID’.
Also included is this infographic – long COVID: a guide for primary care
Treatment, management and support options
Recovery from viral infections often requires rehabilitation for extended periods of time. Managing and recovering from long COVID will be different for each person. The severity of symptoms can vary from mild to debilitating and fluctuate over time. In some cases, people begin to feel better before experiencing a return of symptoms such as fatigue.
Treatment options will need to take a holistic approach, as each person will present with a range of symptoms. Allied health professionals including occupational therapists, physiotherapists, speech and language therapists, dieticians, social workers, psychologists and exercise physiologists will be able to offer supports to individuals based on their unique circumstances.
Supports could include energy conservation and fatigue management, confidence building, muscle strengthening, anxiety management, nutritional advice, speech and swallowing advice, breathing re-education, assessment for aids and adaptations and activities to support individuals to regain function. Other multidisciplinary team members will also be involved including relevant medical specialties.
Some people find it useful to keep track of their symptoms. Keeping a log of symptoms can help identify which symptoms are of most concern and to identify patterns and changes in symptoms. This information is also useful to take to appointments with healthcare professionals. There are several apps that can be downloaded for this purpose. An example of a paper version for tracking symptoms is available from the National Institute for Health Innovation.
Managing post-exertional symptoms exacerbation or malaise
Post-exertional malaise (PEM) or post-exertional symptom exacerbation (PESE) is when symptoms are made worse from physical or mental activities. Onset can occur immediately or up to 72 hours from the exertion and affects people differently. Recovery from this can take from days to weeks or months.
Management of PESE/PEM can include breathing retraining, pacing and establishing a symptom-free baseline. Physiotherapists can assess individuals to provide an individualised/personalised management plan.
It is essential to understand that long COVID is not a linear presentation. Graded exercise therapy (GET) is not recommended for these individuals because it can exacerbate symptoms (GET is planned, regular exercise, with incremental increases in frequency and/or intensity and/or duration and /or type with a goal to increase fitness).
For advice on how to assist people with PEM/PESE, see the Clinical Rehabilitation Guideline for People with Long COVID, including the summary of resources below.
Individuals with long COVID will be presenting across the specialties, and we must work collaboratively with allied health colleagues to ensure best practice.
Clinical guidelines for rehabilitation
There are two guidelines developed by the Ministry of Health on rehabilitation of people recovering from COVID in Aotearoa – New Zealand, one for the acute phase of rehabilitation, and the other is clinical rehabilitation guideline for people with long COVID.
The clinical rehabilitation guideline is an evidence-based summary that covers the definition and diagnosis of long COVID. It seeks to provide the best evidence currently available to assist informed decision-making to improve the health, vocational and social outcomes for both adults and children with long COVID.
There are also two summary fact sheets available – for clinicians, and for individuals and whanau.
Summary of symptoms and management resources for clinicians
A summary of common symptoms and resources for clinicians supporting individuals with long COVID, whānau and carers is found below.
A website for health professionals to make enquiries about specific cases to support complex clinical reasoning: The Immunisation Advisory Centre
- The use of specific outcomes measures should align with the recommendations from PC-COS Study on the Long COVID core outcome set – PC-COS
- Consider the paediatric specific core outcome set for long COVID in children – The Lancet
Breathing Pattern Disorder
- Leicester cough questionaire – CenterforCough
- Long COVID: Cough- NHSinform - Information for individuals and whānau
- Still coughing after COVID? Here’s why it happens and what to do about it – The Conversation - Information for individuals and whānau
Thought processing, memory and ‘brain fog’
- Post-COVID Syndrome (Long Covid) – Royal College of Occupational Therapists - a range of resources for occupational therapy practitioners supporting people to manage Post-COVID syndrome, and those who are experiencing Long Covid themselves.
Post Exertional Malaise / Post Exertional Symptom Exacerbation
- Lessons from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome for Long COVID: Postexertional Symptom Exacerbation is an Abnormal Response to Exercise/Activity – Journal of Orthopaedic & Sports Physical Therapy
- ME/CFS Activity Management with a Heart Rate Monitor – WorkwellFoundation poster
- Pacing penguins – Long Covid Kids for children
- Cautious tortoise – Long Covid Kids for children
- Long Covid Kids: Back to School - Tips for Teachers – longcovidkids.org
Dysautonomia Orthostatic intolerance and PoTS
Communication or swallowing issues
Care plans and action plans
Children and young people
Long COVID programme
The Ministry of Health has established a long COVID programme with the goal of disseminating emerging models of care, clinical practice, patient self-management and digital enablement to support patients with long COVID in the New Zealand context.
The Ministry has established the Long COVID Expert Advisory Group to assess the evidence on long COVID and apply it to the Aotearoa New Zealand context, to help inform recommendations for clinical practice and guidelines.
Teams within the Ministry of Health also produce a long COVID evidence brief which is updated over time. This document is accessible on the COVID-19: Science News page.
Sector updates about the Long COVID programme:
- Sector update on long COVID July 2022 (PDF, 152 KB)
- Sector update on long COVID July 2022 (Word, 202 KB) 1 July 2022
- Sector update on long COVID April 2022 (PDF, 217 KB)
- Sector update on long COVID April 2022 (Word, 179 KB) 28 April 2022
- Presentation on the Ministry of Health’s approach to long COVID - 7 April 2022 (PDF, 261 KB)
- Presentation on the Ministry of Health’s approach to long COVID - 7 April 2022 (Powerpoint, 747 KB) 27 April 2022
Impact of vaccination on long COVID
The best way to prevent long COVID is to prevent infection with COVID-19. Vaccines reduce the risk of long COVID by lowering the chances of getting COVID-19 in the first place.
There is also evidence that vaccination reduces the risk of people who do get COVID-19 going on to develop long COVID.
UKHSA review shows vaccinated less likely to have long COVID than unvaccinated
Find out the latest on the vaccine programme: