Fatigue and postexertional malaise associated with long COVID should be treated with titrated structured activity and energy conservation strategies1

To avoid precipitating postexertional malaise, patients should be advised to begin a structured and symptom-guided return to activity program, tailored to their severity of fatigue. The 4 Ps (pacing; prioritizing which activities need to get done on specific days and which activities can be postponed; positioning to modify activities to make them easier to perform [e.g., while sitting]; and planning) is a helpful framework to educate people about how to apply physical, emotional and cognitive energy conservation strategies.1

Guideline-directed use of psychosocial interventions and medications can be used to treat mental health complications of long COVID

Anxiety, depression and posttraumatic stress disorder are among the most common mental health manifestations of long COVID and may be treated according to relevant guidelines in people with these conditions, which are similar to recommendations among people with myalgic encephalitis (ME).2 The use of cognitive behavioural therapy for the treatment of fatigue is controversial and not currently endorsed by the ME Association.2

Breathing exercises, body positioning and pulmonary rehabilitation may improve dyspnea2

In people with mild dyspnea, pursed lip or deep breathing exercises may improve symptoms. Persistent hypoxemia is not a common manifestation of long COVID and may be caused by severe lung disease or organizing pneumonia. Its presence should prompt referral to a respirologist and consideration of pulmonary rehabilitation.2,3

People with sleep disturbances should receive counselling on sleep hygiene, relaxation techniques and stimulus control2

Sleep disturbances may be a result of their SARS-CoV-2 infection or the negative effects of the pandemic.2 They can be managed using cognitive behavioural therapy or 1 of the following medications currently available in Canada: eszopiclone, zolpidem or doxepin.4

Specific guidelines exist for the treatment of palpitations and tachycardia with particular causes

Current recommendations for the treatment of inappropriate sinus tachycardia and postural orthostatic tachycardia syndrome include behavioural modifications, oral fluids, salt, compression stockings, β-blockers, ivabradine and midodrine.5


  • Competing interests: Kieran Quinn is a former assistant scientific director of the Ontario COVID-19 Science Advisory Table from Aug. 8, 2022, to Sept. 30, 2022. He is the current assistant scientific director of the Ontario Public Health Emergencies Science Advisory Committee and has received Canadian Institutes of Health Research (CIHR) grants (awarded to his institution) to study the long-term effects of COVID-19. He has served as an advisor for the chief science advisor of the Canada Task Force on Post-COVID-19 Condition. Fahad Razak holds a salary award as the Graham Farquharson knowledge translation fellow from the PSI Foundation and is an employee of Ontario Health. He was also an employee of Public Health Ontario during the writing of this manuscript. Fahad Razak has received grants (outside the current article) to study COVID-19 from the CIHR, Canadian Frailty Network, University of Toronto (including the Department of Medicine, St. Michael’s Hospital and the Sunnybrook Health Sciences Centre), Digital Research Alliance of Canada (Data Champions Pilot Project) and Royal College of Physicians and Surgeons of Canada. Angela Cheung has received CIHR grants (awarded to her institution) for CANCOV (platform observational study of COVID-19 in Canada) and RECLAIM (adaptive platform randomized controlled trials for long COVID interventions). MediciNova is providing a study drug and placebo for the RECLAIM trial, a multicentre study across Canada. Angela Cheung has served as an advisor for the Ontario COVID-19 Science Advisory Table, Public Health Agency of Canada, Canadian Agency for Drugs and Technologies in Health, COVID-19 Immunity Task Force and chief science advisor of the Canada Task Force on Post-COVID-19 Condition. No other competing interests were declared.

  • This article has been peer reviewed.

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