Neurorehabilitation of neurological symptoms in post-COVID syndrome

In this review article, the authors from Switzerland discussed the neurorehabilitation of neurological symptoms in post-COVID syndrome. They focused on treating the three most common neurological symptoms: fatigue, pain, and sleep disorders.

More than two years after the global COVID-19 pandemic, it is evident that infection with SARS-CoV-2 can result in a new disease known as post-acute COVID syndrome or long COVID. The most frequent, persistent and disabling symptoms of long COVID are neurological. These symptoms include headaches, visual and olfactory dysfunction, gait disturbances, paresthesia, coordination problems, and cognitive impairments, such as concentration and memory problems and confusion. Their presence results in a long-term impairment of functional ability.

Neurorehabilitation can take place in an outpatient or inpatient setting. Multimodal therapy approaches such as inpatient rehabilitation can be advantageous due to the variability of post-COVID syndrome.

About the therapy


1. Occupational Therapy

The authors emphasized that occupational therapy is a cornerstone of post-COVID syndrome rehabilitation. They suggested that patients with long COVID should use therapies that have been successfully used for fatigue in patients with multiple sclerosis, such as an inpatient energy management education program, and energy management education. Furthermore, the patients should use the 3Ps: planning, prioritization, and pause management in everyday life.

These therapies are designed to help patients to better manage their symptoms in activities of daily living (fatigue, pain, cognitive impairment, etc.). An inpatient energy management education program integrates the principles of patient education, the trans-theoretical model of behavior change, social cognitive theory, energy conservation strategies, and cognitive behavioral technique.

The scientists said that a recent multicenter randomized controlled trial (ReCOVer study) evaluated the efficacy of the “Fit after COVID-19” program which incorporates cognitive behavioral techniques in patients experiencing severe fatigue following COVID-19 infection. The program consists of 9 modules, including goal setting, sleep–wake pattern, helpful thinking, social support, graded activity, processing the acute phase of COVID-19, fear and worries regarding COVID-19, coping with pain, and achieving goals. The results have not yet been published.

2. Physiotherapy


Graduated Exercise Therapy

The NICE guidelines do not recommend graduated exercise therapy because it is considered to be ineffective and harmful based on evidence from patient surveys and qualitative studies. Due to the choice of analyzed studies, this decision has been widely criticized by the scientific community. However, a systematic review of graduated exercise therapy for chronic fatigue syndrome found that patients with this syndrome experience reduction in fatigue, and their sleep and physical function improve after completing graduated exercise therapy.

The authors recommended that physical activity must be adjusted to the individual’s limits to avoid causing severe post-exertional malaise. It is therefore essential to determine the limits of each patient before starting physiotherapy treatment. Activity management or pacing and heart rate monitoring may be effective rehabilitation approaches to support the self-management of symptoms in the presence of post-exertional malaise.


Pacing is the process of establishing the optimal and individual balance between rest and activation periods (physical, cognitive, and emotional). The sustained stabilization of symptoms, which often fluctuate, could guide how activities and rest are modified in response to individual and often subjective symptoms. Pacing is a strategy for minimizing the worsening of symptoms after exertion. It is often used as part of a set of energy conservation strategies called the “Principle of Three P’s”, namely, prioritization, planning, and pause management.

Treatment of Sleep Disorders

The scientists said that cognitive behavioral therapy is an effective alternative and should therefore be offered to patients suffering from insomnia.

Treatment of Headaches

In the treatment of headaches, the authors suggested non-pharmacological measures such as progressive muscle relaxation, biofeedback, and patient education. In particular, progressive muscle relaxation as defined by Jacobsen has shown positive effects on headaches, e.g., migraines. During this technique, a 16 muscle groups of the body are identified and slightly tensed for a few seconds. Then, the muscles are relaxed for 30 to 40 s seconds. The practitioner focuses on the differences between tension and relaxation. In this way, the whole body is relaxed.

This review article was published in Clinical and Translational Neuroscience.

Journal Reference

Diem, L. et al. The Role of Neurorehabilitation in Post-COVID-19 Syndrome. Clin. Transl. Neurosci. 2023, 7, 13.