Long COVID does not always worsen over time, but certain factors—including repeated post-exertional malaise (PEM), reinfection, pushing beyond your energy limits and returning to intense exercise too soon—may increase the risk of prolonged symptoms. While there is no guaranteed way to prevent worsening, research suggests that pacing, avoiding repeated crashes, reducing reinfection risk and managing underlying conditions may help protect recovery.
Tuesday you made dinner, had a conversation, maybe even went for a short walk. Wednesday you cannot get out of bed. You lie there running through everything you did, looking for the variable you got wrong, and sometimes there is no answer. Sometimes Tuesday was just Tuesday and Wednesday is just Wednesday and the only thing that changed is that your body decided.
If you know this feeling, you already understand something that is almost impossible to explain to people who have not lived it. The inconsistency is not laziness or catastrophising or having a bad attitude. It is the defining feature of this illness, and it is also the thing that makes it so exhausting to navigate. Not just because your body is unpredictable. But because everyone around you saw Tuesday and is now quietly waiting for Tuesday again.
This article is not another explanation of what Long COVID is. It is about what you can actually do to protect yourself from things getting worse. What the research supports. Where the genuine dilemmas are. And the questions people ask when nobody is watching, at 2am, when they are trying to work out how to live inside a body that no longer follows the rules they were given.
Can Long COVID Actually Get Worse?
Long COVID does not affect everyone in the same way. Some people improve steadily, others fluctuate for months, and some experience periods where symptoms become significantly worse. Worsening may occur after reinfection, repeated episodes of post-exertional malaise, major physical or emotional stress, surgery, pregnancy or another illness. Although not everyone experiences permanent deterioration, protecting your current level of function is one of the main reasons pacing is recommended.
What Can Make Long COVID Worse?
| Factor | Evidence | Can you reduce the risk? |
|---|---|---|
| Reinfection | Strong | ✔ |
| PEM | Strong | ✔ |
| Poor pacing | Moderate | ✔ |
| High-intensity exercise | Moderate | ✔ |
| Sleep deprivation | Emerging | ✔ |
| Severe stress | Emerging | ✔ |
A quick word on PEM — because you need to know what you are protecting yourself from
Post exertional malaise, or PEM, is when your body responds to effort by making everything worse. Not normal tiredness after a long day. Not the satisfying ache of a workout. A systemic crash that can include a wave of exhaustion, brain fog, pain, and a full flare of all your other symptoms. And it often does not arrive during the activity. It arrives 12 to 72 hours later, which is why it is so easy to miss the connection — and why so many people spend months thinking they keep catching something or eating the wrong thing before they find the words for what is actually happening.
The trade is different for everyone, and this is part of what makes it so hard to explain. For some people the trigger is a shower. For others it is a loud room, a ten minute conversation, being in bright light, or concentrating on a screen. Some people can walk for five minutes but talking for ten floors them. Some can cook a meal but cannot process the noise of other people in the same room afterwards. The logic does not map onto the world’s idea of what being ill looks like. You do not get to choose which things cost you. Your body has made its own decisions and your job is to work out what they are.
PEM is not universal in Long COVID. Some people have it clearly and severely. Some have a moderate version that is easy to confuse with just being a tired adult. Some have immediate symptoms during activity — breathlessness, racing heart, dizziness — driven more by autonomic dysfunction than by the classic delayed crash. Some have both. Understanding your own pattern matters because the approach is different.
What we know is that PEM, when it becomes established, significantly limits life. So the most useful question is: can you do anything to stop it developing or deepening? The answer, based on the evidence, is yes. Not completely, not with certainty, but meaningfully.
The acute phase: what you do in the first weeks matters more than most people realise
Here is the thing nobody told you when you first tested positive: the decisions you make in the first two to four weeks of a COVID infection may influence what happens over the following months and years.
The research signals are consistent. Early antiviral treatment where it is available and clinically appropriate appears to reduce the risk of developing Long COVID. A large analysis found antiviral treatment was associated with around 27 percent lower odds of Long COVID on average. Metformin, a widely used diabetes drug, showed more than 40 percent reduction in Long COVID risk in a randomised trial when given within the first week of symptoms. The working theory is that higher viral replication in the first days drives more immune and cellular disruption downstream. Which means anything that reduces early viral load may be doing some protective work.
What does this mean practically? If you are in a higher risk group — prior autoimmune disease, previous Long COVID, or a sense that something is going wrong — ask your doctor early whether antivirals are appropriate. The window is typically five days from symptom onset. Do not wait and see for two weeks.
And beyond medication: rest. Genuinely. Not the rest you do while also answering emails. The boring, frustrating rest that makes you feel like you are losing time. You probably cannot take two weeks off. Most people cannot. There are jobs, children, responsibilities, people depending on you. You are the only one who knows your situation. But if there is any way to protect those first weeks, it is worth fighting for even if it means having the uncomfortable conversation with your employer or asking for help you would rather not need.
Reinfection is not just another cold
If you already have Long COVID, or you recovered and are not fully certain you are clear of it, this section matters in a way that might feel uncomfortable to read.
Reinfection with COVID does not start the clock again from zero. Research involving millions of patients found that each reinfection raises the cumulative risk of Long COVID. A 2025 study found roughly a 35 percent increase in Long COVID risk with reinfection. Survey data from the Patient Led Research Collaborative found that people with two COVID infections were more than twice as likely to report Long COVID, and those with three or more were nearly four times as likely. The odds of PEM and severe fatigue specifically increased with each reinfection.
This is not a reason to never leave your house. That is not a life, and it is not what we are suggesting. But if you have spent eight months of symptoms and finally reached two almost normal weeks, and your children come home with runny noses and you feel that specific cold dread that fear is not irrational. It is based in real biology. And it deserves a real answer, not dismissal.
Masking in crowded indoor spaces, particularly in winter or during known waves, is one of the more effective things you can do. The cultural moment has moved on. Masking feels unusual now, sometimes pointed, sometimes exhausting to explain. You are allowed to feel all of that and still do it anyway. A well fitted FFP2 or N95 in a high risk setting is meaningful harm reduction. Ventilation matters too. Vaccination remains the most accessible structural protection, reducing Long COVID risk by around 40 percent on average across studies.
Pacing before the crash: the window most people miss
Most pacing advice is written for people who already have established PEM. But there is a window before that when you have Long COVID symptoms, maybe some post exertional worsening, but not yet a clear crash pattern where what you do may shape what comes next.
A landmark 2024 Nature Communications study took muscle biopsies from Long COVID patients before and after exercise designed to induce PEM. The researchers found mitochondrial collapse, immune cell infiltration, and abnormal protein deposits in muscle tissue. These changes were not subtle. If repeated push and crash cycles accumulate this kind of damage, catching the pattern early may prevent it from becoming more entrenched.
Heart rate monitoring can help. Research published in 2025 found that wearable heart rate variability data can help approximate individual PEM thresholds. A practical starting point is resting heart rate plus 15 beats per minute, adjusting based on your own response. Many people in this community use a heart rate monitor as their canary in the mine.
What pacing actually looks like in everyday life
This is the section most people need and almost nobody writes honestly. Not the theory of pacing. The real, daily, unglamorous practice of it. And the genuine dilemma at the heart of it: am I pacing so carefully that I am missing my life, or not carefully enough and paying for it? There is no perfect answer. There is only your answer, for your body, on this particular day.
Pacing is not the dark room with earmuffs. That is the most severe end of a spectrum, and most people do not need to live there. It is also not pushing through and hoping. It is finding the level of activity your body can sustain without triggering significant worsening, and staying within it consistently especially on the days when you feel better and your brain tells you to make the most of it.
The good days are the most dangerous days. This sounds absurd. It is also true. The good day is usually your body having banked enough recovery to feel temporarily better, not evidence that the underlying problem has resolved. What feels like permission is not permission. Doing significantly more on a good day reliably produces a worse week, and you end up further back than if you had stayed steady. This goes against every instinct. It takes practice. And nobody expects you to get it right every time.
Sleep
More sleep is not automatically better. Many people find their sleep is unrefreshing regardless of duration — waking exhausted after eight or nine hours is a recognised symptom of Long COVID, not a sign you need more sleep. What tends to help is consistency rather than quantity. A regular sleep and wake schedule, even when the sleep quality is poor, helps anchor an autonomic nervous system that is already dysregulated. Daytime horizontal rest, distinct from sleep, also supports recovery. This is not optional comfort. It is physiology.
Screens and cognitive exertion
Cognitive exertion counts. This surprises people until they think about it and then it suddenly explains a lot. Watching television, scrolling, reading, having a conversation, making decisions, being in an emotionally demanding situation these all draw on the same energy systems as physical activity. The crash after a screen heavy afternoon is the same mechanism as the crash after a walk. Passive, undemanding watching tends to cost less than active scrolling, social media, or anything requiring emotional processing. Low stimulus rest — lying quietly without screens costs least and is genuinely underrated.
Going out
Going out is never just the activity itself. It is getting ready, travelling, being upright, processing stimulation, managing noise and light, and usually performing some version of being well enough for other people who have not seen you on the bad days. The total cost is frequently much higher than the planning stage suggests. This does not mean you cannot go. It means the day after is a rest day by design, not a surprise. It means giving yourself permission to leave early. It means arriving already knowing the exit strategy and that using it is not failure.
Sport and exercise
If sport was part of your identity before, this is one of the most painful adjustments and also one of the most important to get right. High intensity exercise is genuinely contraindicated while PEM is present or at risk of developing. The 2024 muscle biopsy research showed measurable cellular damage above the individual threshold. The standard wisdom that exercise helps most conditions does not apply here in the same way. This is not a conservative opinion. It is what the biology currently shows.
Gentle movement within your threshold slow walking, very gentle stretching, restorative yoga may be possible and beneficial for some people. The test is whether it causes increased symptoms 12 to 48 hours later. If it does, it is above your current threshold regardless of how gentle it seems. The goal right now is not fitness. The goal is not causing more damage while your body tries to recover.
The things nobody wants to say out loud
There is a kind of fear that lives underneath the symptom management and the appointment preparation and the careful tracking. The fear that does not get named in clinical consultations because it feels too big, or too personal, or because you are already fighting hard enough to be taken seriously and you cannot afford to also sound frightened.
The fear of who takes care of you. Not in the abstract, not someday, but concretely: if you get significantly worse, who does it? Your partner is already stretched. Your mother is 80 and you do not want her showering you even if she would. Your friends are kind but they have their own lives and this is not a short term crisis. The healthcare system has no pathway for someone who is too ill for normal life and not ill enough to qualify for formal care. You sit in the gap and you know you sit in the gap and nobody in any appointment has ever acknowledged that gap exists.
Should you be planning? What does planning even look like? These are reasonable questions and they deserve more than the silence they usually receive. If you are worried about this, it is worth having a frank conversation with whoever is closest to you about what the realistic scenarios look like and what support might be needed. Not catastrophising. Just naming it. The things we name are easier to make contingency plans for than the things we keep not saying.
And then there is the noise. The magical cures, the supplement protocols, the clinic in another country charging thousands for a treatment with no peer reviewed evidence, the person in the Facebook group who was cured by cold showers, the breathwork that someone’s cousin swears by. When you are frightened and the NHS has nothing to offer you and you are lying awake at 3am, that noise is everywhere. It is exhausting to filter and it is designed to reach you at your most vulnerable. Being sceptical does not mean being closed minded. It means asking for evidence, checking who is making money from what they are telling you, and being appropriately cautious about anything that promises more than the current science can honestly deliver.
You deserve honesty more than you deserve hope dressed up as certainty.
The Five Things Most Likely to Worsen Long Covid
- Repeated push-crash cycles
- Reinfection
- Ignoring post-exertional symptoms
- High intensity exercise while PEM is active
- Lack of recovery after illness or crashes
When Worsening Symptoms Need Urgent Medical Attention
Although Long COVID symptoms often fluctuate, not every worsening should automatically be attributed to the condition.
Seek urgent medical attention if you experience:
- new or severe chest pain
- sudden weakness or numbness affecting one side of the body
- difficulty speaking or confusion that is new or rapidly worsening
- severe shortness of breath at rest
- fainting with injury or prolonged loss of consciousness
- symptoms of a blood clot, such as sudden leg swelling or severe chest pain
- a high fever or signs of a serious infection
People living with Long COVID can still develop unrelated medical conditions.
It is important not to assume that every new symptom is simply “part of Long COVID.” If something feels significantly different from your usual pattern, seek medical advice promptly.
What Can Improve Long COVID Recovery?
There is currently no single treatment that cures Long COVID, but several strategies have consistently been associated with better symptom management and, for many people, gradual improvement over time.
Current evidence and clinical experience suggest that recovery is more likely to be supported by:
- recognising and avoiding repeated post-exertional malaise (PEM)
- pacing physical, cognitive and emotional activity
- treating associated conditions such as POTS, dysautonomia or sleep disorders when present
- correcting vitamin or mineral deficiencies where appropriate
- eating a balanced diet that supports overall health
- staying well hydrated, particularly for people with autonomic dysfunction
- maintaining regular sleep routines
- protecting yourself from COVID reinfection where practical
- seeking medical advice when new or changing symptoms develop
Recovery rarely follows a straight line. Many people experience periods of improvement followed by temporary setbacks before gradually moving forwards again.
Although this can feel discouraging, fluctuations do not necessarily mean that recovery has stopped.
What Can Improve Long COVID Recovery?
There is currently no single treatment that cures Long COVID, but several strategies have consistently been associated with better symptom management and, for many people, gradual improvement over time.
Current evidence and clinical experience suggest that recovery is more likely to be supported by:
- recognising and avoiding repeated post-exertional malaise (PEM)
- pacing physical, cognitive and emotional activity
- treating associated conditions such as POTS, dysautonomia or sleep disorders when present
- correcting vitamin or mineral deficiencies where appropriate
- eating a balanced diet that supports overall health
- staying well hydrated, particularly for people with autonomic dysfunction
- maintaining regular sleep routines
- protecting yourself from COVID reinfection where practical
- seeking medical advice when new or changing symptoms develop
Recovery rarely follows a straight line. Many people experience periods of improvement followed by temporary setbacks before gradually moving forwards again.
Although this can feel discouraging, fluctuations do not necessarily mean that recovery has stopped.
Frequently asked questions
I do not know if I actually have PEM or if I am just tired. How do I tell the difference?
This is more common than you might think, and it matters because ordinary tiredness and PEM are managed differently. The key distinguishing features of PEM are the delay feeling significantly worse 12 to 72 hours after activity rather than during it and the disproportionality, meaning the level of worsening does not match what you actually did. If you have a long hard day at work and feel tired that evening, that is probably ordinary fatigue. If you have a fairly ordinary Tuesday and wake up on Thursday unable to function, and this pattern repeats with no obvious other cause, that is more consistent with PEM. Moderate PEM can be subtle and easy to dismiss or attribute to something else a weird sleep, something you ate, a coming cold. Keeping even brief notes of activity and how you feel 24 to 48 hours later for two to three weeks tends to reveal the pattern clearly if it is there.
I pushed through last week and I am crashed now. Have I done permanent damage?
One crash, or even several, is unlikely to have caused permanent damage. What the research shows is that repeated cycles of push and crash over time are associated with worsening function. A single episode is a signal, not a sentence. Rest as completely as you can until you return to your baseline. Do not try to test whether you are better by attempting something normal too soon. The period immediately after a crash is when your threshold is lowest and another crash is easiest to trigger. Treat recovery from the crash as its own phase. And treat this as information about where your threshold is, not as evidence of failure.
My doctor told me to try gentle exercise. What do I do with that advice?
This is one of the most common and most frustrating situations. The advice to try gentle exercise is based on evidence from conditions where deconditioning is the main driver. In Long COVID with PEM, the mechanism is different, and graded exercise in the traditional sense is not supported as a safe approach. The respectful way to handle this is to ask whether your doctor is aware of the PEM research, explain your own pattern of post exertional worsening, and request that any movement approach be paced below your threshold with careful monitoring of symptoms 24 to 48 hours later. If gentle movement consistently makes you worse the day after, it is above your current threshold. That is a clinical fact, not a failure of attitude or effort.
Am I pacing too much and missing my life, or not pacing enough?
This is the question nobody warns you about and it does not have a clean answer. The dark room with earmuffs all day is the extreme end of a spectrum. So is pretending nothing has changed and paying for it repeatedly. Most people need to find something in between that preserves some quality of life while not triggering worsening. The honest answer is that you will get this wrong sometimes in both directions. There will be weeks you protected yourself too much and felt like you were disappearing. There will be weeks you pushed too far and crashed. The goal is not perfection. The goal is understanding your own pattern well enough to make informed choices rather than being ambushed by your body. And the goal is also a life worth living inside whatever constraints exist, because that matters too.
My kids keep getting ill. I am terrified of being reinfected and losing the ground I have gained. What do I do?
That fear is completely rational and the research backs it up. Reinfection genuinely does increase Long COVID risk and can worsen existing symptoms. Eight months of symptoms followed by two almost normal weeks is hard won ground and worth protecting. Practical steps: mask in enclosed spaces when community transmission is high, improve ventilation in your home where possible, keep your vaccinations current, and if you do catch COVID again, contact your doctor early about whether antivirals are appropriate rather than waiting to see how it goes. You cannot live in a bubble and you should not have to. But you can reduce the risk meaningfully with measures that are less socially costly than full isolation.
Do I need to stay in bed all day?
No, and for most people complete inactivity is neither necessary nor helpful. The goal is finding your sustainable activity level, which varies enormously between people. Some people can work part time, cook, go for short walks, and manage a social life within a carefully managed envelope. Others are more severely affected and need much more rest. Neither is wrong. The question is not how much you can push but what level of activity you can sustain without worsening over time.
I feel fine today. Can I do more than usual?
The good day is the most dangerous day. It feels like permission. It is not. What feels like you are back to normal is usually your body having recovered enough to feel temporarily better, not the underlying problem resolving. Doing significantly more on a good day reliably produces a worse week. The most protective approach is staying at roughly your usual sustainable level even when you feel better, rather than catching up on everything you could not do the rest of the week. This goes against every instinct. It takes practice. And it is one of the most consistent findings in how people with PEM manage more successfully over time.
Can I watch television or use my phone?
Yes, with awareness. Cognitive exertion counts. Passive undemanding watching tends to cost less than scrolling, social media, or anything emotionally demanding or requiring decisions. If a screen heavy afternoon reliably precedes a worse day, reducing the cognitive load is worth trying. Low stimulus rest with no screen at all is genuinely restorative for many people and worth building into your day deliberately, not as deprivation but as a tool.
Should I sleep more?
More sleep is not automatically better. Unrefreshing sleep regardless of duration is a recognised Long COVID symptom. Consistency tends to help more than quantity — a regular sleep and wake schedule anchors the autonomic nervous system. Daytime horizontal rest distinct from sleep also supports recovery. If you are sleeping very long hours and still waking exhausted, raise this with your doctor specifically as unrefreshing sleep rather than just fatigue, because it may point to something addressable.
Why does everyone in my household seem exhausted and forgetful too?
You are not imagining it, and you are not alone in noticing it. COVID’s effects on cognition, energy, and mood are not limited to people with formal Long COVID diagnoses. Milder and unrecognised COVID sequelae appear to be common in the general population brain fog that gets attributed to stress, fatigue that gets attributed to busy lives, mood changes and sleep disruption that seem to have no obvious cause. If multiple people in your household are consistently exhausted, forgetful, or not quite themselves since COVID, that pattern is worth naming and worth mentioning to a GP. The recognition of COVID’s broader cognitive and systemic effects is growing in the research literature even if it is not yet fully reflected in clinical practice.
My family does not know how to support me. What do I tell them?
This is one of the hardest parts of the illness and one of the least discussed in clinical settings. The invisibility of Long COVID looking fine on a good day, crashed the next is deeply confusing for people who love you, partly because it is also confusing for you. A few things tend to help. Explaining the delay specifically: that what you do today can cause consequences two days from now is counterintuitive and often the single biggest source of confusion for families. Being concrete about what help looks like rather than asking them to figure it out. Sharing credible information sources. And accepting that some people will not fully understand, not because they do not care but because the illness does not fit any framework they have. Online Long COVID communities can help offset the isolation of not being understood at home.
My doctor does not take this seriously. I am too ill for normal life but not ill enough for the system to catch me. What do I do?
This is a real and structural problem that many people with Long COVID face and it deserves to be named as such rather than treated as a personal failure to navigate the system correctly. The gap between too ill for normal life and ill enough for formal care is where a huge number of people are sitting. Practically, documenting your symptoms in writing before appointments rather than trying to communicate them verbally helps. Framing symptoms in clinical language where possible, mentioning specific named conditions like autonomic dysfunction or post exertional malaise, and requesting that concerns be recorded in your notes even when no action is taken all create a paper trail that matters over time. Patient advocacy organisations and Long COVID clinics where they exist can provide additional support. You should not have to fight this hard. The fact that you do is a failure of the system, not of you.
There are so many cures and protocols online. How do I know what to believe?
There is a lot of noise and it is designed to reach you when you are most frightened and most desperate. The questions worth asking about any treatment or protocol: has it been tested in a proper clinical trial, is there peer reviewed published evidence, who is making money from it, and what is the risk if it does not work or causes harm. There are currently no approved treatments specifically for Long COVID or PEM. Some things have emerging evidence low dose naltrexone, certain autonomic treatments, antihistamines for suspected MCAS. Others are speculation dressed as certainty. Being sceptical is not the same as being closed minded. It is protecting yourself from spending money, time, and hope on things that may not help and may occasionally harm. You deserve honesty more than hope dressed up as certainty.
Do I need to plan for getting worse? Who will take care of me?
This is the fear that rarely gets named in appointments and it deserves a direct answer rather than reassurance that avoids the question. If you are worried about this, it is worth having a frank conversation with whoever is closest to you about realistic scenarios and what support might be needed. Not catastrophising, just naming it. It is also worth understanding what formal support you may be entitled to — in the UK this includes PIP for disability, carer assessments if you have a family member supporting you, and social care assessments if your needs are significant enough. These are not easy to access but they exist. Knowing they exist is different from needing them, but knowing gives you options. The things we name are easier to plan around than the things we keep not saying.
Will I always be like this?
Nobody can answer this with certainty and anyone who tells you they can is not being straight with you. What the data shows is that trajectories vary enormously. A significant proportion of people with Long COVID do see improvement over time, particularly in the first one to two years. Some reach a stable plateau. A smaller group have persistent severe symptoms. The factors associated with better outcomes include avoiding repeated exertion above threshold, avoiding reinfection, and addressing treatable components like autonomic dysfunction. None of this is a guarantee. The uncertainty itself is genuinely hard to live with. What you can do is protect what you have while the research continues to develop. That is not giving up. That is the most rational response to the current state of knowledge.
Can emotional stress make Long COVID worse?
Yes, for many people emotional stress can worsen Long COVID symptoms. Stress activates the body’s hormonal and autonomic systems, increasing the overall physiological load. While stress does not cause Long COVID, significant emotional stress may contribute to fatigue, brain fog, sleep disturbance and post-exertional malaise (PEM) in people whose nervous system is already dysregulated.
Can poor sleep make Long COVID worse?
Poor sleep is one of the most common triggers for worsening Long COVID symptoms. Sleep disruption can reduce the body’s ability to recover from physical and cognitive activity, increase pain sensitivity and worsen autonomic dysfunction. Improving sleep quality may not cure Long COVID, but it can help reduce symptom severity for some people.
Can another viral infection make Long COVID worse?
Yes. Influenza, norovirus, glandular fever and other viral infections may temporarily worsen Long COVID symptoms because they place additional demands on the immune system. Many people report setbacks after common infections, although recovery often occurs gradually over time.
Can surgery or anaesthesia make Long COVID worse?
Some people report a temporary worsening of symptoms after surgery or general anaesthesia. Surgery places significant stress on the body through inflammation, altered sleep, reduced mobility and the healing process. If you have Long COVID, discuss your condition with your surgical team before any planned procedure so appropriate support can be arranged.
Can hot weather make Long COVID worse?
Yes. Many people with Long COVID, particularly those with dysautonomia or POTS, find that hot weather significantly worsens symptoms. Heat causes blood vessels to widen, making it more difficult to maintain blood pressure and adequate blood flow to the brain. This can increase dizziness, fatigue, palpitations and brain fog.
Can alcohol make Long COVID symptoms worse?
Many people notice that alcohol temporarily worsens fatigue, brain fog, sleep quality and autonomic symptoms. Alcohol can also contribute to dehydration, which may further aggravate symptoms in people with POTS or dysautonomia. Sensitivity varies considerably between individuals.
Does every Long COVID crash cause permanent damage?
Current research does not show that every episode of post-exertional malaise causes permanent damage. Many people recover from crashes and gradually return to their previous baseline. However, repeated severe crashes may delay recovery in some individuals, which is one reason pacing is widely recommended.
How do I know if my Long COVID is getting worse or if I’m just having a setback?
Temporary setbacks are common in Long COVID and may occur after overexertion, illness, stress or poor sleep. If symptoms remain significantly worse for weeks, continue to decline without improvement or are accompanied by new symptoms, it is important to seek medical advice to rule out other causes.
Should I stop all exercise if my Long COVID gets worse?
Not necessarily. The most appropriate approach depends on your symptoms and whether you experience post-exertional malaise. High-intensity exercise may worsen symptoms in people with PEM, while carefully paced movement within individual limits may be appropriate for others. Management should always be individualised.
Is it possible to recover after Long COVID has become worse?
Yes. Many people experience periods where symptoms worsen before gradually improving again. Recovery from Long COVID is often non-linear, with setbacks forming part of the journey rather than necessarily indicating permanent deterioration.
References
Bramante CT et al. Metformin reduces risk of Long COVID. New England Journal of Medicine, 2023.
Choi et al. Meta analysis of antiviral treatments and Long COVID: 27.5 percent average reduction. 2023.
Appelman B et al. Muscle abnormalities worsen after post exertional malaise in long COVID. Nature Communications, 2024. https://doi.org/10.1038/s41467-023-44432-3
Jamieson et al. Mechanisms underlying exercise intolerance in long COVID: an accumulation of multisystem dysfunction. Physiological Reports, 2024.
Patient Led Research Collaborative. Reinfection and Long COVID odds. Research Square preprint, 2023.
Wearable heart rate variability monitoring identifies autonomic dysfunction and thresholds for post exertional malaise in Long COVID. medRxiv, 2025.
Science.org. Solving the puzzle of Long COVID: vaccines reduce risk by average 40 percent. 2024.
Reinfection with COVID 19 increases Long COVID risk by approximately 35 percent. medRxiv preprint, 2025.
Workwell Foundation. Pacing with a heart rate monitor for ME/CFS and Long COVID. 2025.
Patient Led Research Collaborative. Clinician pacing and management guide for ME/CFS and Long COVID.
About Long Covid Journey
Long Covid Journey is an independent educational resource dedicated to explaining Long COVID through evidence-informed articles, peer-reviewed research and lived experience.
This article focuses on one of the most common concerns among people living with Long COVID: whether symptoms can worsen over time and what practical steps may help reduce the risk of setbacks.
It has been developed using published research on post-exertional malaise (PEM), pacing, autonomic dysfunction, Long COVID recovery, rehabilitation and patient-led research. Where scientific evidence is limited or still evolving, we distinguish clearly between established findings, emerging evidence and clinical observations.
Our goal is to explain complex medical topics in clear, balanced language without overstating what is currently known. Every article is reviewed periodically as new research becomes available, reflecting the rapidly evolving understanding of Long COVID.
Long Covid Journey does not replace personalised medical advice. Instead, it aims to help patients, carers and healthcare professionals better understand the biology of Long COVID so they can make more informed decisions together.