If you’re living with Long COVID and struggling to recover, you’ve probably heard mixed advice about exercise. Some people say it’s the key to getting better. Others warn it can make you worse.
The truth? It depends on your body, your symptoms, and whether you experience post-exertional malaise (PEM).
For some people, the right kind of movement can help rebuild strength, improve mood, and support recovery. For others especially those with moderate to severe PEM the wrong type or amount of exercise can trigger debilitating crashes lasting days or weeks.
What is PEM and Why Does It Matter?
Post-exertional malaise (PEM), is a hallmark symptom of ME/CFS and is now widely recognised in a large cohort of people with Long COVID.
PEM occurs when physical, cognitive or emotional effort triggers a delayed worsening of symptoms, often 12–48 hours later. These “crashes” can bring severe fatigue, brain fog, pain, dizziness and flu-like symptoms and more. Research suggests over half and in some studies up to 75% of people with Long COVID experience PEM.
If brushing your teeth or showering leaves you wiped out, it’s not the time to start “training.” You need a different approach.
Why “Pushing Through” Can Backfire
Older rehab models like graded exercise therapy (GET) used fixed, step-by-step activity increases. For those with PEM, it carries risk.
The UK NICE guidelines for ME/CFS (2021) removed GET for people with PEM. Long COVID specialists are applying the same principle: activity should be symptom titrated adjusting daily based on your body’s response.
A New Approach: Movement Based on PEM Severity
A 2024 international systematic review of 46 trials and expert consensus recommended a PEM-based framework:
- No PEM: Conventional, individualised programmes with strength, endurance and breathing exercises, progressed cautiously.
- Mild/Moderate PEM: Symptom titrated movement low load, short bouts, long rests, recumbent if needed, no fixed weekly increases.
- Severe PEM: Prioritise pacing and energy-envelope management. Only add tiny, gentle movements if that don’t trigger crashes.
Movement That Doesn’t Make You Crash
Even with PEM, not all movement is harmful. Your body still benefits from gentle activity for circulation, joint mobility and mental well-being if kept within your energy envelope.
For severe PEM if doesn’t trigger crashes:
- Gentle range-of-motion stretches while lying down
- Diaphragmatic breathing
- Light isometric holds (no big muscle strain)
- Hand and foot movements to support circulation
For mild/moderate PEM if doesn’t trigger:
- Very short, low-intensity sessions with long recovery periods
- Heart-rate and symptom tracking to avoid exceeding your crash threshold
- Recumbent yoga stretches or gentle recumbent cycling
- Advance only when stable for at least 2-4 weeks
- As above
Pacing: Your First Line of Defence
Pacing means balancing activity and rest to stay within your daily energy limit, avoiding the “push-crash” cycle. Strategies include:
- Breaking tasks into smaller chunks
- Resting before you feel exhausted
- Using tools like shower stools, electric toothbrushes, pre-prepared meals
- Keeping a symptom and activity diary to identify triggers
Studies show structured pacing can reduce the frequency and severity of PEM episodes in Long COVID.
For Clinicians: Screening Is Essential
Physiotherapists, occupational therapists and doctors should screen for PEM and related conditions (e.g. orthostatic intolerance) before prescribing exercise. This includes:
- Using tools like the DSQ-PEM questionnaire
- Ruling out cardiac, respiratory and autonomic red flags
- Recognising that for some patients, traditional “exercise” is not yet appropriate
- Most important listening your patients
The Takeaway
There’s no point starting an exercise plan if you can’t manage basic daily tasks without crashing. First stabilise your baseline and protect your energy. Then if and when your body allows add safe, symptom-aware movement.
For some people with Long COVID, some traditional exercise helps. For others, it causes setbacks and can be dangerous. The safest way forward is individualised, compassionate care that respects PEM and works with your body, not against it.
Your recovery isn’t a race. It’s a negotiation between your body and your goals and the key is staying in control of the pace.
Disclaimer: This article is for general informational and educational purposes only. It is not medical advice and should not replace consultation with a qualified healthcare professional. Always discuss any new activity or treatment plan with your doctor or specialist, particularly if you have Long COVID or PEM.
Long Covid Journey 