Exercise-based rehab improves exercise capacity in long COVID patients

Results from the PHOSP-R* trial show that exercise-based rehabilitation (EBR) improves short-term exercise capacity in individuals with post-COVID syndrome (long COVID) following an acute hospitalization.

“In this fully powered randomized controlled trial, we demonstrated that both face-to-face (F2F) and remote EBR significantly improve exercise capacity compared with usual care (UC) alone in those previously hospitalized with COVID-19,” the investigators said.

In the primary adjusted analysis, there were statistically significant improvements in the primary outcome of change in Incremental Shuttle Walking Test (ISWT) between the F2F rehab and UC groups (mean difference, 52 m; p<0.01) and the remote and UC groups (mean difference, 34 m; p=0.05) after 8 weeks of intervention.

The F2F rehab arm improved from 285 m to 312 m (p<0.001), while the remote rehab arm improved from 353 m to 388 m (p<0.01). [Eur Respir J 2025;65:2402152]

The per-protocol analysis (n=140) still favoured both rehab interventions over UC (mean differences, 66 m; p<0.001 [F2F] and 42 m; p=0.021 [remote]). Half of the participants in the F2F and remote intervention arms achieved >35-m improvement (56 percent and 50 percent, respectively); in the UC arm, only 19 percent were able to achieve this outcome.

“These between-group improvements exceed the established minimal clinically important difference of 35 m, highlighting improvements of clinical relevance in those with long COVID,” said the researchers.

Secondary outcomes, safety

Compared with UC, the F2F rehab programme led to clinically important improvements in SPPB** (median 1.2), 4MGS*** (mean 0.12 ms⁻¹), QMVC^# (3.33 kg), and handgrip strength (2.06 kg).

Save for the handgrip strength, similar improvements were seen with remote rehab vs UC (median 1.5 [SPPB], mean 0.04 ms⁻¹ [4MGS], and 3.35 kg [QMVC]).

Two serious adverse events were reported during the study period, but none were related to the interventions. One was resolved the same day, while the other was a death.

Post-COVID hospitalization rehab recommended

Individuals with long COVID experience a range of symptoms leading to functional impairment, reduced exercise capacity, and difficulty performing activities. [Lancet Respir Med 2021;9:1275-1287] These impairments may be due to an interaction of ongoing pathology, including acute treatment complications, immune system dysregulation and ongoing inflammation, compounded by the effects of hospitalization. [Chest 2024;166:461-471; Eur Respir Rev 2023;32:230110; Nat Commun 2024;15:17]

Eligible participants were 181 adults (mean age 59 years, 55 percent men) who were admitted to a hospital during a confirmed acute COVID-19 episode and had ongoing symptoms lasting >12 weeks, resulting in self-described functional impairment. Thirty percent were classified as critical per the WHO Severity Index, requiring ventilatory support at admission.

Participants were randomized 1:1:1 to either F2F EBR, remote EBR, or UC for 8 weeks. F2F rehab comprised twice-weekly sessions (∼90–120 min/session) involving symptom-titrated exercise training (aerobic, resistance), three home exercise programme sessions, and educational sessions. Remote rehab participants completed a remotely monitored exercise training on a web platform and were followed by a healthcare professional through fortnightly phone calls or the web messaging service as needed. UC was offered to all groups.

Forty-eight percent of the participants were able to attend the EBR sessions, but about a quarter were unable to due to other commitments (29 percent in the F2F group) or limited access to digital technologies (23 percent in the remote group).

“The results demonstrate that two modes of delivery are efficacious at improving exercise capacity in those with long COVID following hospitalization,” said the researchers.

Adults should thus be referred to an appropriate rehab programme after hospitalization from COVID-19 to address their ongoing symptoms and functional/exercise impairment. The regimens should be titrated to cater to individual patient needs.

“Improving exercise capacity may have important secondary beneficial effects on the immune system in long COVID,” they concluded.