If you are living with Long COVID and trying to recover, you have likely been given mixed advice about movement and exercise. Some people are told that exercise is essential for recovery. Others are warned that it can make symptoms significantly worse.
The reality is that there is no single answer. Whether movement is helpful or harmful depends on your individual symptom profile and, most importantly, on whether you experience post exertional malaise, commonly referred to as PEM.
For some people with Long COVID, carefully chosen movement may support circulation, joint comfort, or mental wellbeing. For others, particularly those with PEM, the wrong type or amount of activity can trigger severe symptom worsening that lasts days or weeks.
Understanding PEM is essential before making any decisions about movement or rehabilitation.
What Is Post Exertional Malaise and Why It Matters
Post exertional malaise is a core feature of ME CFS and is now recognised in a large proportion of people with Long COVID.
PEM occurs when physical, cognitive, or emotional effort leads to a delayed worsening of symptoms. This deterioration typically appears 12 to 48 hours after the activity, although for some people it may take longer. During a crash, symptoms can include overwhelming fatigue, brain fog, pain, dizziness, flu like sensations, autonomic symptoms, and a significant reduction in functional ability.
Research suggests that more than half of people with Long COVID experience PEM, with some studies reporting rates as high as seventy percent or more.
If routine activities such as showering, preparing food, or basic self care consistently leave you worse the following day, traditional exercise based approaches are unlikely to be safe.
Why Pushing Through Symptoms Can Cause Harm
Older rehabilitation models often assumed that gradually increasing activity would rebuild strength and endurance. One example is graded exercise therapy, which involved fixed increases in activity regardless of day to day symptom variation.
For people with PEM, this approach has been shown to carry a real risk of harm.
The 2021 NICE guideline for ME CFS explicitly removed graded exercise therapy for people with PEM. The guidance makes clear that activity programmes based on fixed or planned increases are not appropriate when post exertional symptom worsening is present.
Many Long COVID specialists now apply the same principle. Activity should be entirely symptom led, flexible, and responsive to the body’s signals. Ignoring early warning signs or pushing through fatigue can deepen crashes, reduce baseline function, and prolong illness.
A PEM Informed Approach to Movement
Movement in Long COVID must be considered differently depending on whether PEM is present. The goal is never conditioning or fitness, but safety, stability, and harm prevention.
When PEM Is Not Present
Some people with Long COVID do not experience post exertional malaise. In these cases, movement may be considered as part of recovery, provided it remains individualised, flexible, and continuously reviewed.
Any activity should stay within current tolerance and should never follow a fixed schedule or set targets. There should be no expectation of improvement over time. If delayed symptom worsening appears, the approach should be paused and reassessed.
When PEM Is Present
For people who experience PEM, traditional exercise based rehabilitation is not appropriate.
The primary goal is stability. Activity must remain within the person’s energy limits and be guided entirely by symptom response.
This means:
No fixed routines
No targets
No planned increases
No expectation of progression
Any movement should be optional, minimal, and immediately reversible if symptoms worsen.
When PEM Is Severe
In severe PEM, protecting energy and avoiding deterioration are the priorities. Even very small increases in activity can trigger significant crashes.
At this stage, movement is not a therapeutic goal. Gentle movements may be considered only if they do not cause symptom worsening and only to support comfort or circulation. For some people, even this may not yet be safe.
Movement That May Be Better Tolerated by Some People
When PEM is present, the aim of movement is not rehabilitation but comfort and maintenance, and only if symptoms allow.
For Severe PEM, If Tolerated
Gentle range of motion movements performed lying down
Diaphragmatic breathing
Very light isometric holds without strain
Small hand and foot movements to support circulation
For Mild to Moderate PEM, If Stable
Very short, low intensity movements with generous rest
Seated or recumbent stretches
Use of heart rate or symptom awareness to avoid exceeding limits
Stopping immediately if symptoms worsen during or after activity
Any change should be immediately reversible and abandoned if it leads to delayed symptom worsening.
Pacing as the Foundation of Safety
Pacing is the practice of balancing activity and rest to stay within available energy and avoid the push crash cycle. It is a protective strategy, not a training method.
Effective pacing may involve breaking tasks into smaller steps, resting before exhaustion sets in, using adaptive tools such as shower stools or mobility aids, and simplifying daily routines where possible.
Many people find it helpful to keep a simple activity and symptom record to identify triggers. Evidence suggests that structured pacing can reduce the frequency and severity of post exertional symptom worsening in Long COVID.
Important Considerations for Clinicians
Before recommending movement or rehabilitation, clinicians should actively screen for post exertional malaise and related conditions such as orthostatic intolerance or autonomic dysfunction.
This includes the use of validated tools where appropriate, exclusion of cardiac or respiratory red flags, and recognition that for some patients, exercise is not safe at this stage of illness.
Above all, clinicians should listen carefully to patient reports. A person’s lived response to activity is often the most reliable guide to what is safe.
The Key Takeaway
There is little benefit in starting any form of exercise if basic daily activities already trigger crashes. The first goal in Long COVID recovery is stabilising function and protecting energy.
For some people, gentle movement may be possible. For others, it can cause serious setbacks. The safest approach is individualised, compassionate care that respects post exertional malaise and works with the body rather than against it.
Recovery is not a race. It is an ongoing negotiation between your health and your goals, and progress is often measured in stability rather than activity.
Disclaimer
This article is for general informational and educational purposes only. It does not constitute medical advice and should not replace consultation with a qualified healthcare professional. Always discuss changes in activity or rehabilitation with your doctor or specialist, particularly if you have Long COVID or post exertional malaise.
Long Covid Journey 