Long COVID

What is Long COVID?

Long COVID, also called post-COVID-19 condition, is a condition in which symptoms continue or appear after COVID-19 and cannot be explained by another diagnosis. A WHO-led consensus definition says it usually shows up about 3 months after the start of infection and lasts at least 2 months.^[1]

Researchers estimate that at least 10% of infections lead to long COVID, and more than 200 symptoms have been described.^[2]

Common symptoms

The most common symptoms are fatigue, shortness of breath and problems with thinking, memory and concentration, and these usually affect everyday life.^[1] Symptoms can fluctuate or relapse over time.^[1]

Other symptoms include sleep problems, pain, anxiety or low mood, and many other organ-related symptoms.^{[3, 4]} More than half of people with long COVID in a meta-analysis had post-exertional malaise, a worsening of symptoms after physical or mental effort.^[5]

Causes and risk factors

The exact causes are not settled. Researchers are studying several possible mechanisms, and long COVID overlaps with other post-viral conditions such as ME/CFS and postural tachycardia syndrome.^{[2, 4]}

Long COVID symptom clusters were more common in women than in men in a global analysis, and symptoms lasted longer on average after hospitalization.^[6] A review of post-COVID fatigue also named older age, female sex, a severe acute illness, more medical conditions and prior depression or anxiety as risk factors.^[7]

How it is diagnosed and treated conventionally

Long COVID is diagnosed by a physician after other explanations for the symptoms are ruled out.^[1] Current care is largely symptomatic and supportive, and a physician may order tests for the heart, lungs and other systems depending on symptoms.^[4]

A living systematic review of 24 trials found moderate-certainty evidence that an online cognitive behavioral therapy program probably reduces fatigue and improves concentration. It also found that a supervised physical and mental health rehabilitation program probably improves overall health, and that many other treatments tested had no compelling evidence of benefit.^[8]

Why Long COVID calls for a whole-person approach

Long COVID affects several body systems at once, and a one-size-fits-all approach is unlikely to fit.^[3] A "treatable traits" review grouped common problems into neurological, chest, psychological, pain, fatigue, sleep and functional clusters, each of which can be addressed separately.^[3]

Complementary care aims at several of these clusters, such as sleep, stress and fatigue, and sits next to the medical evaluation of each one.

Fatigue and post-exertional malaise

Fatigue is one of the most common and limiting symptoms.^{[1, 7]} Because many people have post-exertional malaise, activity is usually added slowly and with rest, and plans are worked out with the treating team.^{[5, 8]}

Breathing and the chest

Ongoing respiratory problems are one of the three major symptom clusters in a global analysis, with shortness of breath a core symptom.^{[1, 6]} Chest and breathing symptoms need medical evaluation to rule out lung or heart disease.^[4]

Brain, mood and sleep

Cognitive problems, anxiety, depression and sleep impairment are among the common symptom groups.^[3] The treatable traits review notes that further high-quality trials are needed for the fatigue, psychological, pain and sleep clusters.^[3]

Pain and autonomic symptoms

Pain is a recognized trait cluster in long COVID.^[3] Overlap with postural tachycardia syndrome suggests that some people also have problems with heart rate and blood pressure regulation, which need medical assessment.^[2]

Acupuncture for Long COVID

What the research shows

Acupuncture is being studied for long COVID, but the evidence is limited and there are no large, well-controlled trials in people with long COVID. Reviews cover mainly symptoms and related conditions.

A systematic review of 110 trials found acupuncture improved fatigue, depression, cognitive, headache and sleep scores compared with medication or sham. Those trials were in people with other conditions, not long COVID, and the authors say studies in long COVID are needed.^[9]

For loss of smell, a systematic review of mostly low-quality studies found that acupuncture and acupoint injection may help after viral infection.^[10] A sham-controlled trial of 40 patients with COVID-related loss of smell compared a frequency-guided ear acupuncture protocol with switched-off laser sessions. Smell scores improved in the treated group but not the control group, and both groups used nasal steroid drops.^[11]

Otherwise there are only case-level reports. One patient with post-COVID syndrome recovered after 7 acupuncture sessions combined with graded exercise, which makes the role of acupuncture unclear.^[12] In a retrospective survey of 79 patients treated by TCM physicians in Germany and Austria, fatigue and exertional breathlessness improved on physician ratings, but with no control group.^[13]

How acupuncture may work

How acupuncture might help in long COVID is not known. Researchers have proposed that it modulates nerve signaling and inflammation, and one case report suggested effects through the vagus nerve and gut-brain pathways.^[14] These are hypotheses, not settled facts.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the body, scalp and sometimes ears, usually left in place for about 20 to 40 minutes. We reassess after a short course of visits, and tell us if treatment leaves you more tired.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or bruising, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Long COVID

The Ayurvedic view

Ayurveda has no classical name for long COVID. Practitioners may describe lingering fatigue and weakness after illness as depleted strength and weak digestion (agni), with imbalance of the doshas that is understood for each person. These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Easily digested warm meals and a regular daily routine with consistent sleep
• Gentle breathing practices and rest, paced to your energy
• Gentle oil massage
• Herbs prescribed individually by a qualified practitioner

Panchakarma procedures are not appropriate during acute illness, frailty, pregnancy or severe exhaustion, and they are not a substitute for medical evaluation of ongoing symptoms.

What the research shows

We found no clinical trials of Ayurvedic treatment for long COVID.

A review of integrative care in long COVID notes that interest in complementary therapies has surged because established treatments are lacking, and describes what has been studied rather than endorsing particular therapies.^[16] Daily routine, sleep and stress care may reasonably support recovery, since rehabilitation and behavioral programs have shown benefit for fatigue and concentration.^[8] No study shows that Ayurveda changes the course of long COVID.

Herbal medicine for Long COVID

Herbs and formulas that have been studied

The research is on Chinese herbal formulas, which have been tested in China. One example is Qingjin Yiqi granules, studied in people with post-COVID-19 condition.^[17] A meta-analysis pooled 10 trials of Chinese herbal medicine for post-COVID syndrome.^[18]

What the research shows

The evidence is limited. A randomized trial of 388 patients found that 14 days of Qingjin Yiqi granules plus standard rehabilitation improved breathlessness and fatigue scale scores more than rehabilitation alone, with no treatment-related adverse events. Symptom score and walking distance did not differ, and there was no placebo.^[17]

A meta-analysis of 10 randomized trials (2,401 patients) found Chinese herbal medicine did not significantly lower overall symptom scores, although it improved chest tightness and insomnia. Trends for fatigue and shortness of breath did not reach significance, heterogeneity was high, and the authors urged caution.^[18] A systematic review of post-COVID fatigue also found that treatments, including a Chinese herbal formula, were mostly tested in small, uncontrolled studies.^[7]

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. A literature review, mostly of case reports, found enhanced warfarin effect or bleeding with herbs such as dan shen (Salvia miltiorrhiza), garlic and ginkgo, and bleeding when ginkgo was combined with aspirin.^[19] People taking blood thinners or other long-term medicines need a practitioner's review before using herbs.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes lingering fatigue and breathlessness after infection as deficiency of qi and yin, with lingering pathogenic factors in the lungs. Researchers instead study immune activation, inflammation, nervous system regulation and the gut-brain axis in long COVID.^{[2, 14]}

Ayurveda's depleted strength and weak digestion describe exhaustion and gut symptoms, which loosely parallel the fatigue and digestive symptoms that people report.^[4] No study has shown that a dosha or a TCM pattern corresponds to a specific biological process in long COVID.

How this care fits with your medical care

Integrative care for long COVID is complementary. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Do not stop or change prescribed medicines or rehabilitation without your prescriber.

We do not diagnose long COVID or decide its cause, and new or worsening symptoms need a medical evaluation. Please bring your diagnosis, recent test results, a list of medicines and supplements, and any rehabilitation plan.

When to seek urgent medical care

Long COVID can overlap with serious heart, lung and blood clot problems, so some symptoms need prompt evaluation.^[4]

• Chest pain or pressure, or a racing, pounding or irregular heartbeat with faintness
• Severe or worsening shortness of breath
• Fainting or near-fainting
• Sudden weakness, numbness, trouble speaking, confusion or severe headache
• Swelling and pain in one leg, or coughing up blood
• Thoughts of harming yourself; call or text 988, the Suicide and Crisis Lifeline

If any of these occur, call 911 or go to the nearest emergency department.