Key Points

• Some aspects of long COVID are a great match for the benefits massage therapy can provide, so it behooves bodywork practitioners to learn what they can about it, so they can work safely in this context.

• Risks of massage therapy include: overwhelming a compromised system; coagulopathy and organ damage; and interaction with medications, especially anticoagulants and anti-inflammatories.

• Benefits of massage therapy include support during a difficult time; reflection of improvement over time; and reduction of fatigue, shortness of breath, pain, sleeplessness, headaches, and other symptoms (depending on the client’s goals).

Author’s note: People in the massage therapy community may be familiar with Michele Renee, DC, MAc. She was the president of the Alliance for Massage Therapy Education, the director of integrative care at Northwestern Health Sciences University, and a tireless advocate for the profession of massage therapy education.

In September 2020, Michele developed all the symptoms of COVID-19. Because of restrictions in testing at the time, she never got a positive test, but her symptoms were typical of the disease. Then, in December, she began to experience a whole new range of challenges that have never resolved. She had to take an extended leave of absence from her work, and a year later she is still only back to 20 hours a week.

Michele generously allowed me to interview her about her experiences with long COVID, and the quotations that appear in this article come from our conversation.

Not long after the initial onset of the COVID-19 pandemic, strange things began to happen to some people during their COVID-19 recovery. A lot of them lost their sense of taste or smell as part of their acute infection, but those senses didn’t always return—at least not within several months. A lot of patients didn’t get their energy back, and many developed entirely new symptoms—some involving the extremities, like numbness and tingling in the feet, and some involving internal organs, like scarring in the lungs, heart damage, and newly failing kidneys. Some people experienced abnormal blood clotting while they struggled with severe, acute infection, but sometimes that clotting abnormality followed them home from the hospital. And a lot of people experienced fatigue, weakness, brain fog, depression, anxiety, and other symptoms that were severe enough to be debilitating. And these problems are outlasting their initial infections by weeks, by months . . . and maybe longer.

This phenomenon, which we now call long COVID or post-acute sequelae of COVID (PASC—we will use the terms interchangeably here), affects an unknown portion of the population for an unknown amount of time, but it is common enough and serious enough to draw the attention of many experts who specialize in chronic conditions. The self-identified label for these patients is “long haulers.”

The parameters of long COVID are still hazy. We can’t determine how common it is until we agree on what it is. We can’t determine a medical treatment protocol that is likely to be successful until we know how it comes about. But some aspects of long COVID are a great match for the benefits massage therapy can provide, so it behooves practitioners to learn what they can about this situation, in order to work safely in this context.

In this article, we will address a very brief history of COVID-19, and then we will look at the phenomenon of PASC, given the limited information currently available. We will conclude with some suggestions about massage therapy as a safe and effective intervention.

We all know that long COVID is a moving target. Ideas and theories about pathophysiology or conventional treatment strategies that are given here may well prove to be incorrect as we learn more. If that happens in a way that could impact clinical decisions for massage therapy, we promise to publish updates as quickly as possible. But much of the information about living with PASC has been consistent and predictable, and the potential for massage therapy to be helpful for this challenge is rich.

COVID-19 Snapshot

It seems like ancient history, but really it was just two years ago when we began hearing about a new type of respiratory infection that had been identified in China and was making its way around the world. In January 2020, we called it 2019-nCoV: “n” for novel or not seen before, and “CoV” for coronavirus.

As it happened, I taught a class on infectious diseases early that February, and the information I could find as of January 30, 2020, is that at that time there were 13,000 suspected cases of this infection, with 170 deaths—worldwide. It was mostly confined to China, but 82 cases had been confirmed in 18 other countries, and it had already demanded international attention.

The causative agent was identified very early in the process. It was a member of the coronavirus family and was similar to the viruses responsible for two previous widespread outbreaks of respiratory diseases: Middle East respiratory syndrome, or MERS, and severe acute respiratory syndrome, or SARS—which is why the virus is called SARS-CoV-2. The US was not strongly affected by either SARS (contained in 2003) or MERS (contained in 2012), but this new form of coronavirus infections presented a different story.

In those early days of the pandemic, anyone who was paying attention learned a lot about epidemiology and statistics. We learned about transmissibility and R0 numbers, testing of various types, positivity rates, and projections for economic impacts.

We learned about using appropriate personal protective equipment (PPE), air filtration systems, and the joy of having hand sanitizer stations in massage session rooms.

Thankfully, we also learned about mRNA vaccines and viral vector vaccines, and what it means to be vaccinated.

Then, just when it looked like there was light at the end of the tunnel (in the US at least), we learned some hard lessons in humility as the Delta variant, combined with low vaccination rates, taught us about the power of mutations.

In all the early sorting out of panicky information about COVID-19, we had a lot of questions. What is the real transmissibility rate? Is it really worse than the flu? Will blowing a hairdryer up my nose kill the virus? Should I take hydroxychloroquine/ivermectin/betadine/hydrogen peroxide internally to prevent or treat it? And most of all: Most people survive, so why should I be worried about it?

In all that questioning, some people missed the fact that mortality is not the only cost of this epidemic. Millions of survivors have been left with lingering symptoms. Some are mild and go away. Some are long-lasting and debilitating. And our options for treating these long-term complications are limited. The aftermath of COVID-19 is proving to be a poorly understood, widespread, and expensive (in terms of both dollars and time lost) health problem.

Acute COVID: What’s Going On?

In order to get a handle on long COVID, it is useful to have a brief reminder of what the acute infection entails. The pathophysiology of COVID-19 involves a viral attack, usually by way of the respiratory system. The virus, SARS-CoV-2, is capable of invading any cell with a membrane marker called an ACE-2 receptor. This is bad news, because many cells have this marker. ACE-2 receptors are found in mucosa, in alveoli, in myocardium, hepatocytes, the gastrointestinal tract, the liver, the pancreas, the kidneys, and, perhaps most alarmingly, in the endothelial lining of the blood vessels and in neurons and glial cells of the central nervous system. This means any of these tissues are vulnerable to being invaded by the virus, which may then lead to serious repercussions.

The damage done by a SARS-CoV-2 infection begins much in the same way as damage related to any viral infection like common colds or flu: The viruses invade their target cells, and they retool the cellular machinery to turn that host cell into a virus factory. The cell ruptures, releasing virions (extracellular copies of the virus) to invade nearby cells and spread the infection further. Fortunately, early in that process, the immune system is alerted to the infected cells and kills them—and all their neighbors, just in case. And that works out well, because it prevents further viral replication, and those dead cells are easily replaced. For most viral infections, that is the typical story of invasion, immune system response, symptoms, and recovery. And for many people with COVID-19, although their symptoms may be severe, this is as far as it goes. Their symptoms subside, they regain their pre-infection levels of vitality, and so far, they have no long-term repercussions.

But some patients go beyond the damage related to viral invasion and immune system response. They develop a third component: an exaggerated, excessive, dangerous inflammatory reaction to the infection. This is the reaction that causes acute respiratory distress syndrome and respiratory failure. It leads to massive blood clotting in the small and large vessels throughout the body. It causes septic shock: a system-wide drop in blood pressure with inflammation that can lead to damage in the extremities that may require amputation, or to multiple organ failure, and ultimately to death.

The precipitating factors for this outsized inflammatory reaction are the subject of ongoing study. If we can identify what causes some people to have such extreme reactions while others have milder infections, we may be able to prevent this life-threatening consequence of COVID-19.

PASC: A Post-Viral Syndrome

As we’ve said, long COVID or PASC is a condition some patients develop in the weeks and months after their initial infection—it is a post-viral syndrome. The phenomenon of developing long-term problems after an infection is not unique to SARS-CoV-2; other infections also sometimes show lingering post-infectious consequences. Flu viruses sometimes do this, and it has been well documented among Ebola survivors. In the November/December 2021 issue of Massage & Bodywork (“Sepsis: The Hidden Crisis,” page 38), I discussed post-sepsis syndrome, which, although it usually involves bacterial rather than viral infection, has a lot in common with what COVID long haulers describe. And another condition appears to be a post-viral issue, at least some of the time, and it has a lot of overlap with symptoms of long COVID: chronic fatigue syndrome (CFS). We will address connections between long COVID and CFS shortly.

Long COVID affects a lot of people, but at this point, the condition itself is difficult to define. There are no agreed-upon diagnostic criteria to help identify who has long COVID versus any other health issues, and the pathophysiology of this condition is still a mystery. This means we can’t count how many people have it—we can only guess at who is most at risk, and our ability to treat it is limited to the management of symptoms.

Who Gets Long COVID?

One of the many frustrating things about trying to understand this condition is the wide variety of ways researchers have begun to gather data—especially regarding timing. Long COVID has been documented in elders, middle-aged people, young adults, and children. Men are more likely to have very severe COVID-19 infections, but women are up to four times more likely to report having long COVID symptoms. Some studies survey patients at six weeks post-diagnosis; others look at six months or more. Consequently, estimates of what percentage of patients develop this condition range from 5 to 80 percent. That said, several studies have landed on estimates in the neighborhood of 30–40 percent as the proportion of patients who have symptoms at six months or more after their diagnosis.

Long COVID seems to be most common in people who had severe infections that required hospitalization, but one study reported that about one-third of the people with long COVID nine months after their infection had no symptoms at the time of their diagnosis. This suggests that people with mild or even asymptomatic infections can develop long COVID.

Long COVID Pathophysiology

What causes long COVID? What functional changes produce these signs and symptoms that last for weeks, or months, or longer? This question is under active investigation, but so far, we have seen many theories and not much confirmation. As with most complicated health issues, long COVID is almost certainly multifactorial. And because it looks so different in one person from another—and in one person from day to day—we will probably eventually find several contributing factors join to create the whole syndrome.

Some of the theories about the pathophysiology of PASC getting the most attention include these:

Maybe the virus was never fully cleared. Some specialists propose that small colonies of SARS-CoV-2 may find ways to hide in the body, causing continuing symptoms and immune system activity. Other viruses have this capacity: the Herpesviridae that cause cold sores, chickenpox, and shingles can hide from immune system activity, and human immunodeficiency virus (HIV) is notorious for this behavior. Alternatively, it is possible that while intact viruses have been eradicated, viral particles and debris may linger and continue to elicit an immune system response, with accompanying symptoms.

Maybe latent pathogens wake up. When our immune system is stretched thin or overwhelmed, latent infectious agents can sometimes reactivate. We see this with shingles (a resurgence of herpes zoster) and some other pathogens. Some experts suggest that long COVID is the result of this process as well, and Epstein-Barr virus, the causative agent for mononucleosis, is a potential culprit. 

Maybe the immune system doesn’t know when to turn off. It is possible that even after the virus is vanquished, the immune system keeps fighting, which causes cellular damage and symptoms. This has been seen with some other viruses, especially those that cause highly inflammatory conditions. At one time, it was also a leading theory behind CFS, which was thought to be a complication of Epstein-Barr virus. 

Maybe COVID stimulates autoimmune reactions. Some long haulers test positive for autoantibodies, suggesting that PASC is an autoimmune disease, or at least has elements of autoimmune diseases. 

Other theories. Other theories and contributors to the symptoms of long COVID cover a wide variety of possibilities, including the consequences of organ damage, inflammation in the central nervous system that causes dysautonomia, and disruptions of the microbiome and virome in the lungs and in the gastrointestinal tract.

“The majority of my symptoms have been related to dysautonomia, which leads me to think my primary problem is that my brain is inflamed.”

Why Does it Matter to Massage Therapists?

Figuring out the causes of long COVID is vitally important for the people who have it, and the people who care for them. This is the only way we can reliably reduce the burden of illness and help those who are affected to regain their health and vitality. But does it matter to massage therapists whether long COVID is an autoimmune condition as opposed to the result of an upset in the client’s microbiome? It does, at least a bit, because to be sure our work is safe, we want to know as much as we can about how a condition changes function, and what the client does to manage it.

Signs and Symptoms of Long COVID

Name a symptom, any symptom, that might arise when an organ or tissue loses function. Chances are good that someone with long COVID has had it. Arrhythmia? Check. Hair loss? Check. Odd rashes, muscle wasting, new-onset diabetes? Check, check, check.

The signs and symptoms of long COVID are so many, and so varied, that it can be hard to distinguish what is due to the infection and what just came up regardless of COVID. And of course, that makes it difficult to establish a diagnostic criterion for this condition, because we can’t rule anything out.

“This disease is like having a hat with a hundred different symptoms in it, and every day you reach in and pull out a handful of them. And it could be any of them that day: maybe it’s dizziness, maybe it’s nausea, maybe it’s this horrific headache, or insomnia. Maybe it’s that I just can’t get up. It’s just this ridiculous list that makes you feel crazy.”

Experts discuss signs, symptoms, and complications of PASC in a variety of ways. For the sake of this discussion, I am going to make a loose category of issues related to specific organ and blood vessel damage, and another category of whole-body problems that may be equally debilitating, but are not related to any single organ dysfunction. These categories have some overlap, and they may change as we learn more, so this is just a starting place. 

Signs and Symptoms Due to Organ and Blood Vessel Damage

Because ACE-2 receptors are found in cells throughout the body, localized infections can attack many organs.

The Lungs. The lungs are often the most severely affected organs during and following COVID-19. Damage that persists for six months or more may arise from scar tissue and residual inflammation. Scarring in the lungs can become self-perpetuating, leading to pulmonary fibrosis.

Consequences of lung damage include vulnerability to secondary infection, chronic shortness of breath and low oxygen saturation, and a risk of injury to the alveoli and capillaries that supply them. Unlike some other long COVID features, the severity of lung problems usually seems to be tied to the severity of the acute infection.

Coagulopathy. Issues with micro- and macrovascular thrombosis got a lot of attention in the early days of COVID, and with good reason: People who would not otherwise be at risk were dying from heart attacks, strokes, and pulmonary emboli. Surgeons reported seeing the blood form clots mid-procedure. While severe infections with other pathogens can also cause excessive clotting, it seemed to be especially dramatic with COVID-19.

The coagulopathy associated with the infection is probably related to the severity of the inflammatory state, but the duration of this risk is still unknown. Many patients are discharged with long-term prescriptions for anticoagulant medications, but best practices for preventing venous thromboembolism in long haulers haven’t been established.

Signs and symptoms of long-lasting macrovascular coagulopathy are the same as we would expect for deep vein thrombosis or other blood clot related issues like stroke, pulmonary embolism, or heart attack. But microvascular thromboses, especially combined with immune system reactivity, can interfere with organ function and cause damage to the skin, possibly leading to blisters, rashes, and other COVID-related skin signs.

The Heart. COVID-19 may affect the heart through direct infection and destruction of cells, through generalized inflammation, or through myocardial infarction related to coagulopathy or poor oxygen supply. In addition, signs of myocarditis and pericarditis have been found among survivors with no specific heart symptoms.

Young people who survive COVID may develop a condition called multisystem inflammatory syndrome in children (MIS-C). MIS-C is often a short-term problem with a good prognosis, but permanent heart damage is one possible consequence.

COVID-related heart damage can lead to weakness, fatigue, and poor stamina; palpitations and irregular heartbeat; and chest pain.

The Kidneys. The kidneys seem to be especially vulnerable to damage, as the virus can attack various parts of the nephron, leading to inflammation, scarring, and permanent loss of function. Microthrombi from coagulopathy may also contribute to renal injury.

Long haulers with COVID-related kidney damage require ongoing renal support in the form of dialysis and other care.

The Central Nervous System. COVID-19 can affect the central nervous system (CNS) by way of direct viral infection, severe inflammation, microvascular thrombosis, and degeneration of nerves. It’s not clear exactly how the virus changes CNS function, but theories include invasion of extracellular spaces, problems with lymphatic drainage in the CNS, and blood-brain barrier breakdown.

Among the nervous system signs and symptoms that people with PASC report are migraines and other new-onset headaches, cognitive impairment, memory loss, and many others. The nervous system is also vulnerable to the complications of stroke, anoxic damage due to microthrombi and poor perfusion, and pain and paresthesia in the extremities.

“Some days I feel like my brain is on fire. The headaches got so bad I was afraid I would have a stroke. I’ve had migraines all my life, but nothing like this.”

Other Organs. COVID can affect pancreas function, leading to new-onset diabetes that does not resolve with the acute infection. It may also affect thyroid function, leading to both Hashimoto’s disease (a type of hypothyroidism) and Grave’s disease (a type of hyperthyroidism). Some experts are concerned that changes in metabolism, hormone secretion, and digestive function may make long haulers more susceptible to osteopenia and osteoporosis. And changes in blood flow to bones may increase the risk for avascular necrosis.

Generalized Signs and Symptoms

The list of generalized long COVID symptoms is long and depressing. The most commonly reported complaints involve debilitating tiredness and fatigue, shortness of breath, and brain fog, which may go along with measurable loss of cognitive power.

Other generalized symptoms include:

Anxiety

Chronic cough

Depression

Diarrhea

Dizziness on standing

Dysautonomia

Erectile dysfunction

Fever

Hair loss

Joint and muscle pain

Loss of smell and taste

Mast cell activation syndrome

Memory loss

Menstrual cycle changes

Mood changes

Numbness, paresthesia in the extremities

Post-exertional malaise

Post-intensive care syndrome

Posttraumatic stress disorder

Postural orthopedic tachycardia syndrome

Rashes and petechiae

Sleeping problems

Stomach pain

Swollen lymph nodes

Tinnitus

These issues turn up in the published literature, but dozens more are reported by long haulers on every social media platform. These can include hearing loss, shingles, autoimmune disease flares, panic attacks, and many more. 

The dysautonomia that occurs with long COVID may create a whole panoply of these symptoms. Dysautonomia is a complex situation that is discussed in detail in this issue’s Pathology Perspectives column (page 76).

How is Long COVID Treated?

At this point, there is no widely agreed-upon treatment protocol for long COVID. Long haulers are typically referred to specialists with expertise for their specific kind of organ damage. Beyond that, it’s mainly a matter of finding coping mechanisms that will help improve function and quality of life.

“People have this feeling of being failed by the medical system, or being disbelieved or ignored. And I think massage therapists can really fill that gap by just being good listeners—just having the therapeutic presence to say, ‘I hear you, and I’m really sorry this is happening for you.’ ”

Some evidence suggests that about one-third of patients with long COVID find their symptoms improve after they get a COVID vaccination.

Pacing—setting goals for activity and gradually increasing them—is recommended by some experts to improve stamina and strength. However, others point out that muscle wasting, cardiomyopathy, and poor tissue perfusion may make this approach both ineffective and extremely unpleasant for the patient.

Some long haulers have aspects of new-onset autoimmune disease, so this may point to a treatment strategy to suppress immune system hyperactivity. Others find that they are alarmingly vulnerable to other new infections however, so this is not a universally acceptable option.

Ultimately, it looks like most long haulers will have to learn to live with long-term problems that may or may not eventually resolve. They are not alone. The similarities between long COVID and CFS, fibromyalgia, post-sepsis syndrome, chronic Lyme disease, and other long-term challenges are striking. We don’t understand these conditions well, but with the advent of several million new patients just from these past two years, we may see a shift in scientific and medical interest that will benefit long haulers and those with other chronic conditions as well.

“To be frank, I feel stupid. I feel like my IQ has decreased. I feel like I’m not my creative, innovative self anymore, and I don’t know if that person will ever come back.”

How Long COVID Compares to Other Chronic Conditions

If you have clients who live with long-term, lingering, persistent problems like CFS, fibromyalgia, or chronic Lyme disease, then the descriptions of what it’s like to live with long COVID may ring a bell. The symptomatic profiles are strikingly similar, including unrelenting fatigue that is unrelieved by rest, brain fog that ranges from mildly annoying to completely debilitating, and post-exertional malaise: prolonged pain and fatigue after any kind of exertion—physical or mental. The one clear difference at this point is that people with long COVID often have shortness of breath immediately following physical activity, and this isn’t a typical sign of other chronic conditions.

CFS is sometimes discussed as a post-viral syndrome. At one time, it was thought to be a consequence of an Epstein-Barr virus infection: Essentially a person contracts mononucleosis and, although the infection is conquered, the body continues to behave as though it’s under attack. Since then, we have concluded that this post-viral consequence may be a trigger for some people with CFS, but others have different precipitating events—and the vast majority of people who contract Epstein-Barr virus do not develop CFS.

In the US, CFS has traditionally been discussed as an immune system dysfunction. However, in Europe and the UK, the label for CFS is myalgic encephalomyelitis or ME, which describes muscle pain with inflammation of the brain and spinal cord. This means ME could be classified as a nervous system disorder, instead of (or in addition to) an immune system problem. And to make things even more confusing, CFS/ME has several features in common with some other poorly understood chronic pain conditions, including fibromyalgia and irritable bowel syndrome—both of which have features involving central nervous system dysfunction.

One predictable feature in CFS/ME is a problem with HPA axis function. The HPA axis is the link between the hypothalamus, pituitary gland, and adrenal glands that helps determine our stress response system. People with CFS/ME and fibromyalgia (and depression, anxiety, and a number of other chronic conditions) often have a stress response system that is over-reactive and persistent. Stress responses are out of proportion to the triggers, and the stress-related chemicals, especially cortisol, tend to linger in circulation for longer than we see in people with a healthy HPA axis.

It turns out that HPA axis irregularities may also be a consequence of COVID-19 infection and of COVID-19 treatment, which involves glucocorticoids for their anti-inflammatory effects.

This is relevant for massage therapists because our work has an impact on perceived stress levels. The research on whether massage therapy improves HPA axis function over the long term is not deep or consistent, but in the short run at least, we can help clients break through the vicious circles from stress to anxiety to stress that living with a chronic, painful, scary condition can cause.

Massage Therapy for Clients with Long COVID?

When we distill all the variables in long COVID down to evaluating the risks, benefits, and appropriate accommodations in massage therapy, it might look like this:

Risks

• Overwhelming a compromised system

• Coagulopathy and organ damage

• Interaction with medications, especially anticoagulants and anti-inflammatories

Benefits

• Support during a difficult time

• Reflection of improvement over time

• Reduction of fatigue, shortness of breath, pain, sleeplessness, headaches, other symptoms (depending on the client’s goals)

“A very generous massage therapist gave me two long sessions of full-body relaxation massage. That was the best my body has felt since I got sick.”

Accommodations

• Identify situations that limit the safety of massage therapy first (see “Long COVID Screening Questions” on page 45 for suggested screening questions)

• Carefully control the room and equipment for overstimulation regarding light, sound, odors, and skin sensitivity

• Emphasize functional goals (“What would you like to be able to do that I can help you with?”)

• Consult with the health-care team to be sure your goals are in alignment with theirs (see video in the digital edition or by scanning the QR code below for more on this communication)

• Work conservatively for incremental change

Where Does All This Leave Us?

The American Academy of Physical Medicine and Rehabilitation¹ recommends these treatment options to address fatigue in people affected by PASC (emphasis mine):

• Begin an individualized, structured, titrated return to activity program

• Discuss energy conservation strategies

• Encourage a healthy dietary program and hydration

• Treat, in collaboration with appropriate specialists, underlying medical conditions such as pain, insomnia/sleep disorders, and mood issues that may be contributing to fatigue

We have a strong depth of evidence that supports the use of massage therapy for pain, sleep, mood disorders (especially depression, anxiety, and PTSD), and fatigue.

Will massage therapy solve the problem of PASC? Probably not—our work is unlikely to dissolve scar tissue in the lungs or restore damaged cells in the central nervous system. Might massage therapy help certain aspects of PASC, especially those centered on fatigue and quality of life? That seems like a safer prediction.

Conservative estimates suggest that 5 percent of people who had COVID-19 will develop long-term symptoms or complications. With that lowest of all approximations, we are still looking at a population of over 2 million people in the US with long COVID who could benefit from our skills. More realistically, that number is probably closer to 10 million people who, as long haulers, will struggle with debilitating fatigue, poor sleep, pain, problems breathing, brain fog, depression, anxiety, and a myriad of other symptoms—in addition to their risks of substantial organ damage.

The role of massage therapy for people with long COVID is promising but unstudied. The work we can do for mood, fatigue, ease of breathing, and a general sense of self-efficacy and resilience are exciting options to pursue. I encourage massage therapists who work with clients living with long COVID to carefully record their experiences so we can gather data in the form of case reports that form the basis for future research.

“This illness doesn’t have a timeline. When you go through cancer treatment, you know you have a certain number of treatments, and then you can see what’s happened. But we don’t know anything about this, and that creates a sense of helplessness and hopelessness.”

COVID is a scourge, a tragedy, a disaster unlike anything in this generation. We have the capacity to make it less so for the people who live with long-term consequences of this disease. I am eager to see massage therapists step up to this challenge.

Long COVID Screening Questions for Massage Therapy

Have you been diagnosed with specific organ damage since your infection? If yes, what is your situation, and how are you treating it?

Rationale: We need to know what organs have been affected to predict safety for massage therapy, and we need to know what medications or other interventions the client uses to manage this problem.

What are your other long COVID symptoms? Which are most bothersome to you?

Rationale: This will give us a sense of the client’s major complaints and ideas about their priorities for treatment. This is where we may learn about skin signs, mood issues, neuropathy, and any number of other possibilities.

Are you under a doctor’s care? If yes, what are your goals for that care?

Rationale: This will help us understand medical priorities, so we can support them with our work as well.

Are you taking any medication related to your COVID infection?

Rationale: This should have been answered within the first two questions, but it never hurts to ask it one more time.

What would you like to accomplish with massage therapy today?

Rationale: This helps us establish the client’s priorities, which are typically functional goals (“I want to sleep better,” “I want to breathe more easily,” “I want to feel more energetic”) as opposed to medical goals, like oxygen saturation, blood pressure readings, or white blood cell counts.

Please describe your activities of daily living, especially your physical challenges.

Rationale: This vital question helps us understand more about our client’s allostatic capacity: their ability to maintain homeostasis. It is important to have as clear an idea as possible what their well-tolerated physical activities include—do they climb stairs? How many times a day? Do they walk for exercise? How long? How fast? How often? 

Do you notice any pain following physical activity? If yes, where, and how long does it last?

Rationale: Muscular pain may accompany exercise after deconditioning, but any chest pain or shortness of breath suggests cardiopulmonary problems that the client should discuss with their doctor.

May I have your permission to talk with your medical team?

Rationale: People with long COVID may be medically complex and receive care from a variety of specialists. If our work might influence their progress, it is useful and ethical to communicate with their team to make sure we’re all working toward the same goals.

May I contact you tomorrow to see how you are after your massage?

Rationale: This will alert us to any unexpected changes related to our work. With a low-but-not-zero chance that massage may create an adverse reaction, we can advise our client to seek medical help sooner rather than later.

Resources

Agarwala, S. R., M. Vijayvargiya, and P. Pandey. “Avascular Necrosis as a Part of ‘Long COVID-19.’” BMJ Case Reports 14, no. 7 (July 2021): e242101. https://doi.org/10.1136/bcr-2021-242101.

Al-Aly, Z. “Op-Ed: Don’t Drop the Ball on Long COVID.” MedPage Today, June 3, 2021. www.medpagetoday.com/infectiousdisease/covid19/92908.

Al Refaei, A. “The Case for Therapeutic Massage as an Adjuvant in Hospitalized COVID-19 Patients.” International Journal of Therapeutic Massage & Bodywork 14, no. 1 (March 2021): 49–50.

Aschman, T., J. Schneider, and S. Gruel. “Association Between SARS-CoV-2 Infection and Immune-Mediated Myopathy in Patients Who Have Died.” JAMA Neurology 78, no. 8 (July 2021): 948–60. https://doi.org/10.1001/jamaneurol.2021.2004.

Brooks, M. “COVID-19–Related Myopathy a Postinfectious Phenomenon?” Medscape, June 28, 2021. www.medscape.com/viewarticle/953833.

Brown, D. A., and K. K. O’Brien. “Conceptualising Long COVID as an Episodic Health Condition.” BMJ Global Health 6, no. 9 (September 2021): e007004. https://doi.org/10.1136/bmjgh-2021-007004.

Centers for Disease Control and Prevention. “COVID-19 Science Update.” Updated July 16, 2021. www.cdc.gov/library/covid19/07162021_covidupdate.html.

Citroner, G. “Fauci Warns about ‘Post-Viral’ Syndrome after COVID-19.” Healthline, July 16, 2020. www.healthline.com/health-news/fauci-warns-about-post-viral-syndrome-after-covid-19.

Cleveland Clinic. “Treatment of Post-Acute Sequelae of COVID-19 Requires a Multidisciplinary Approach.” Consult QD, April 9, 2021. https://consultqd.clevelandclinic.org/experts-are-hopeful-that-multidisciplinary-approach-will-help-patients-with-long-covid.

Cox, D. “Why are Women More Prone to Long Covid?.” The Observer, June 13, 2021. www.theguardian.com/society/2021/jun/13/why-are-women-more-prone-to-long-covid.

Crook, H. et al. “Long Covid—Mechanisms, Risk Factors, and Management.” BMJ 374, no. 1648 (July 2021). https://doi.org/10.1136/bmj.n1648.

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Note

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at ruthwerner.com or wernerworkshops@ruthwerner.com.