Original Research

Exploring the influence of long-COVID on physical activities

Talmay T. Nadesan, Meluleki S. Thethwayo, Stacy Maddocks, Verusia Chetty

Received: 20 June 2025; Accepted: 22 Sept. 2025; Published: 07 Nov. 2025

Copyright: © 2025. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: People living with long-COVID (PLWLC) experience a broad range of persistent coronavirus disease 2019 (COVID-19) symptoms extending beyond 4 weeks. Long-term, multi-organ damage in the body negatively impacts physical activity, which is vital to improving mental well-being and quality of life. People living with long-COVID experiment with self-management strategies, and this can have damaging outcomes.

Objectives: Our study explored the influence of the 2019 coronavirus on physical activity, through the lived experiences of PLWLC, to inform future rehabilitation initiatives for this population.

Method: A qualitative research study design involving semi-structured interviews was utilised to gather the experiences of 17 purposively selected participants who have long-COVID at a private facility in KwaZulu-Natal, South Africa. Data collected from the interviews were transcribed verbatim and thematically analysed.

Results: Four main themes emerged, namely, perceptions of pre-COVID and post-COVID physical activities in daily life, approaches to coping strategies with physical activity limitations, perceptions of physical activity’s influence in recovery and progressive informal exercise therapy.

Conclusion: Our study reveals long-COVID’s complex and multifactorial nature, which imposes challenges on PLWLC’s individual functioning and daily activities, community participation and societal roles. Individuals perceived poor, mixed or beneficial effects with the uptake of physical activity and resorted to self-taught management strategies. Further research on safe, tailored and contextualised rehabilitation advice and interventions for the common debilitating symptoms of long-COVID is needed.

Clinical implications: Inform future rehabilitation considerations for healthcare professionals and provide insight for further interventional explorative studies for long-COVID rehabilitation.

Keywords: long-COVID; COVID-19; physical activity; long-COVID recovery; post-COVID conditions; long hauler; post-acute COVID syndrome; long-COVID rehabilitation.

Introduction

The persistence of coronavirus disease 2019 (COVID-19) symptoms beyond 4 weeks post-initial infection is referred to as long-COVID (Humphreys et al. 2021; Ladds et al. 2020; Shelley et al. 2021). The common debilitating long-COVID symptoms are fatigue, breathlessness and cognitive dysfunction, among others (Davis et al. 2021; Jassat et al. 2023; Logue et al. 2021; Lopez-Leon et al. 2021). These persistent symptoms have negatively impacted individuals’ physical activity and quality of life (QoL) (Delbressine et al. 2021; Jassat et al. 2023).

Physical activity refers to any movement of the body generated by skeletal muscles that requires energy expenditure (World Health Organization [WHO] 2024). It plays a vital role in reducing the risk of comorbidities, non-communicable diseases and sedentary behaviour (SB), while also enhancing mental well-being and overall QoL (Le Roux et al. 2022; WHO 2024). However, the presence of long-COVID poses a substantial barrier to both the uptake and resumption of physical activity (Brown et al. 2022; Chuang et al. 2024; Vélez-Santamaría et al. 2023). These activities include sport and leisure events and activities of daily living (ADLs) such as walking, washing dishes, showering and engaging in other personal and household responsibilities (Burton et al. 2022; Buttery et al. 2021; Shelley et al. 2021; Wright, Astill & Sivan 2022). Furthermore, participation in broader life roles, such as returning to work or engaging with family, has become personally and socially challenging for many people living with long-COVID (PLWLC). This challenge is often compounded by difficulties with concentration, breathlessness and persistent physical and mental exhaustion (Burton et al. 2022; Buttery et al. 2021). The progression of long-COVID is frequently characterised as non-linear, with recurrent and unpredictable symptom relapses. This unpredictability contributes to heightened frustration and emotional distress, as individuals struggle with the uncertainty of the disease’s trajectory and its fluctuating nature (Burton et al. 2022).

People living with long-COVID perceive recovery as slow and difficult with limited improvements, which are worsened by the lack of adequate information and guidance from healthcare professionals regarding long-COVID (Hossain et al. 2023). Consequently, many individuals have turned to self-management strategies, with ‘pacing’ frequently reported in the literature as a widely adopted approach (Baz et al. 2021; Perumal, Shunmugam & Naidoo 2023; Wright et al. 2022). These findings support the need for multidisciplinary rehabilitation strategies that are tailored to the specific needs of individuals while cautioning against the use of graded exercise therapy (GET), which has been shown to be potentially harmful in this population (Décary et al. 2021; D’Souza 2021; Vink & Vink-Niese 2022). Physiotherapists are central to the rehabilitation of individuals with chronic and debilitating physical conditions. Their role in long-COVID management is increasingly recognised, particularly in supporting physical activity engagement, alleviating persistent symptoms and potentially contributing to improved overall well-being in PLWLC (Sánchez-García et al. 2023). Nevertheless, despite their critical involvement, there remains a lack of standardised rehabilitation protocols specifically designed for long-COVID, highlighting an urgent need for further research and consensus in this area.

While the literature pertaining to long-COVID and physical activity is growing, there is inadequate knowledge and underestimation of the illness sequelae and its impact on physical activity. This is compounded by the lack of qualitative studies to understand PLWLC’s challenges in daily activities and participation. Consequently, care for patients from a clinical perspective may be insufficient and poorly managed. Thus, our study explored the influence of long-COVID on physical activity, through the lived experiences of PLWLC, to inform future rehabilitation initiatives for this population.

Research methods and design

Design

Our study utilised a phenomenological qualitative design using semi-structured interviews, allowing personal accounts to be shared about the common phenomenon and providing valuable insight into participants’ first-hand experiences (Creswell 2014). Open-ended questions explored the lived experiences of PLWLC on the influence of long-COVID on physical activities. This encouraged participants to construct meaning and create discussions about their sickness trajectory, physical activity experiences and course of recovery.

Research setting

Data were collected during the COVID-19 pandemic in 2022 and conducted in an outpatient private healthcare facility in a lower-to-middle income area in the eThekwini district, South Africa. This facility provided follow-up consultation services to PLWLC and services residents within a 5-km radius. Depending on the patient’s financial status, the facility consults at discounted rates or free.

Study population and sampling strategy

Our study population included males and females living with long-COVID in a low-to-middle income area from diverse ethnic groups and aged from 24 to 80 years.

Purposive maximum variation sampling was used by selecting participants over 18 years old who accessed care at our study site, experienced persistent COVID-19 symptoms for 4 weeks post-diagnosis that affected their pre-COVID physical activity levels, were not dependent on assistance to carry out ADLs pre-COVID and did not have underlying cognitive disorders that would hinder comprehension and communication abilities. These cognitive disorders were screened by the facility’s doctors and psychologists. At the time of recruitment, the facility’s staff contacted long-COVID patients who were diagnosed with COVID-19 between 2020 and 2022 from their medical records and acquired permission for the authors’ involvement for further screening. Of the 42 patients contacted, 10 did not meet all the inclusion criteria, nine did not respond and six did not consent. Only 17 participants were included in our study.

Data collection

Research tool

The interview guide was informed by published literature (Humphreys et al. 2021) and adapted by the authors from discussions with academic researchers who had a wealth of knowledge in qualitative studies. The semi-structured interviews included open-ended questions to encourage participants to share feedback in their own words without limiting their thoughts. These questions probed their sickness trajectory, physical activity experiences and course of recovery.

Procedure

Data collection commenced after obtaining ethical approval and continued for a period of 8 weeks. Fifteen participants chose Zoom interviews from home, while two preferred face-to-face at the medical facility. Interviews lasted approximately 45 to 60 min and were performed in English by the primary researcher, a female physiotherapy master student who has experience treating COVID-19 patients. On Zoom, although cameras were turned on, only audio was recorded by the software’s embedded digital recorder. Connectivity problems were experienced with three participants; however, restarting the software enabled continuity. Face-to-face interviews were conducted in a pre-arranged room at the facility using one digital tape recorder. During all interviews, the authors observed and recorded participants’ non-verbal cues in a notebook. Two individuals who expressed emotional concerns were offered free follow-up consultations with the facility’s practitioners. Data saturation was reached by the 15th interview (Hossain, Alam & Ali 2024).

Data analysis

Within 48 h following the interviews, audio recordings were transcribed verbatim using the software REV (2022). The accuracy of the transcription was verified by the authors listening to the audio recording while reading the transcript for each participant. Participants verified their transcripts and approved the information without changes, and this ensured trustworthiness (Lim 2025). An inductive conventional thematic data analysis was performed, using a step-wise approach (familiarisation; coding; initial theme generation; theme review; defining and naming themes) to produce the report (Nowell et al. 2017). Digital transcripts were read repeatedly to obtain an overall impression of the material collected, and subsequently, initial codes were identified and ideas were extracted into themes through an inductive process. Dependability was achieved by peer evaluation of the authors’ generated themes and quotes by research supervisors (Lim 2025). The authors discussed and deliberated until a consensus on final themes was reached. Transferability was attained by documenting our study’s process and methodology (Lim 2025).

Ethical considerations

Ethical approval was obtained from the University of KwaZulu-Natal’s Research Ethics Committee (reference number: HSSREC/00004323/2022). All processes adhered to the approved ethics guidelines. Participants completed and signed a written information sheet with an informed consent form detailing the intent and purpose of our study, its voluntary nature, the right to withdraw at any moment and permission to be audiotaped in the interviews. Pseudonyms were used to ensure anonymity in the data. The data were kept in encrypted electronic devices, accessible to the authors only, to ensure confidentiality.

Results

Seventeen participants, between 10 months and 27 months post-COVID, across all four South African ethnic groups, and who experienced long-COVID, participated in our study (Table 1).

Themes

From the data collected, four major themes emerged: perceptions of pre-COVID and post-COVID physical activities in daily life, approaches to coping strategies with physical activity limitations, perceptions of physical activity’s influence on recovery and progressive informal exercise therapy.

Theme 1: Perceptions of pre-COVID and post-COVID physical activities in daily life

In our study, PLWLC led active lives before COVID-19, engaging regularly in ADLs, leisure activities, transportation and occupation activities. They expressed frustration in their post-COVID state because of their inability to adequately perform individual functions, essential daily duties and societal roles. Fatigue, dyspnoea, muscle weakness, joint pains, dizziness, headaches and brain fog were commonly reported as causes of physical disruptions.

Activities of daily living and domestic activities: Participants experienced reduced exercise capacity and increased fatigue when performing household duties, including gardening, cooking, washing, cleaning and house maintenance. This led to prolonged and fewer chores being completed:

‘… [T]o sweep, to mop, dust and tidy up, [takes] normally an hour … Today it took me two and a half hours because I get tired and I wanna sit, sweep a bit, and I’ll sit on another couch …’ (Timothy, 48 years old, 23 months post-COVID)

Long-COVID impacted a participant’s self-care ability of toileting and bathing, leading to loss of self-identity roles involving multitasking and carrying out domestic duties:

‘I’m dizzy and [I] just fall … [I] take the bucket to [urinate] … I’m bathing from the dish outside the bath … because I can’t [make it to the bathroom]. You know, us women, [we] can put the pots [away] and clean and do washing at the same time. So it is really frustrating me.’ (Buhle, 60 years old, 19 months post-COVID, unemployed)

Leisure activities: Leisure activities, like shopping, sports and socialising, were greatly impacted by the physical symptoms that affected family roles and interactions:

‘I can’t even play with my child for long periods, like outside kicking a ball and not getting tired … So that has impacted on a lot as well [as] being a mother.’ (Imbali, 40 years old, 10 months post-COVID)

There are a combination and an interlinking of physical and psychological symptoms, where anxiety, stress and fear of reinfection from people triggered physical symptoms. Their physical incapacitation also resulted in mental health implications (depression and antisocial behaviour), further deterring participants from their usual activities and community engagements:

‘I was heavily involved in our church where we went to feed the poor. [I] did a lot of walking … and all of that has come to a complete halt. Reason being … I fear socialising … I get stressed out now and I get anxious … I’m breathless.’ (Timothy, 48 years old, 23 months post-COVID)

Transportation activities: Some participants found difficulty when walking to work, the clinic, the shop or to taxi ranks, which discouraged future attempts. Those who use private transport were unable to drive long distances or opted to not drive at all because of long-COVID symptoms:

‘… Before COVID, I would take a walk to [the store] and I would be fine. But now when I get back, I’m completely out of breath … I just don’t do it anymore.’ (Michaela, 35 years old, 22 months post-COVID, experienced relapse 8 months post-COVID)

‘I was so tired … I only drive to the [school] and back home. I don’t do any longer distances than that.’ (Priyanka, 55 years old, 27 months post-COVID, had COVID-19 twice, caterer)

Occupation activities: Occupational disruptions were apparent, with deterioration in focus during meetings, work performance, mobility and communication with clients or colleagues because of long-COVID symptoms:

‘Before COVID we were quite fit … I would walk up 10 flights of stairs during load-shedding, no problem. Now I’m not gonna go to that meeting ‘cause I’m not gonna be able to.’ (Daniella, 49 years old, 23 months post-COVID, risk manager)

Long-COVID impairments led to fewer work targets being reached compared to pre-COVID, which, to some participants, meant reduced salaries and, to another, early retirement. One participant expressed that long-COVID worsened underlying symptoms, which led to job loss:

‘[Arthritis] treatment is not responding as before. I’ve got very, [severe] pains in my whole body, especially the joints and I’m self-employed … I was sewing many things, but now I can’t even touch the machine … I’m doing nothing now and I can’t live with this grant.’ (Buhle, 60 years old, 19 months post-COVID, unemployed)

Theme 2: Approaches to coping strategies with physical activity limitations

From the fear of dying in hospitals, participants turned to self-management initiatives influenced by family, friends, online resources and mass media. Initiatives included assistance and support, energy conservation strategies and positive psychological changes. These were used to minimise post-exertional malaise (PEM), debilitating symptoms and relapses, with the hope of participants returning to work and meeting their daily goals.

Assistance and support: Most PLWLC utilised assistance and support from family, neighbours and colleagues to complete their duties to cope with their physical activity limitations. One participant required assistive devices for walking to combat muscle weakness and balance impairments, while others resorted to ordering food and paying for services to complete ADLs:

‘… [My husband] helps me with normal household chores and does most of my daughter’s homework … So, he’s actually been a great support post-COVID.’ (Imbali, 40 years old, 10 months post-COVID)

Energy conservation strategies: Participants took naps, planned activities ahead of time and prioritised tasks by starting with small, essential duties before slowly progressing to bigger goals that required more energy. They described arriving earlier to events, parking their cars closer to the buildings and rehearsing tasks in advance to manage time and energy levels more effectively. Pacing was the most common strategy used. This entailed completing a task in parts during the day to avoid physical exertion or relapses:

‘When I’m cooking a meal for somebody, then I just pace myself and give myself time. I will cook, cut the onions and the tomatoes … and then I’ll have a break … and then I do the next thing.’ (Priyanka, 55 years old, 27 months post-COVID, had COVID-19 twice, caterer)

Positive psychological changes impacting physical symptoms: Positive thinking, meditation and distraction helped overcome participants’ physical activity limitations, allowing them to undertake activities for longer periods of time as they perceived symptoms as less intensive. Tenacity and sheer willpower to surmount mental obstacles and fatigue were fuelled by a survival instinct and desperation to provide for loved ones and not become a burden. Some PLWLC changed their physical activity expectations by accepting and adjusting to their body’s new norm, instead of trying to overcome it:

‘I think it’s my fighting spirit, my mental state … I have to tell myself that I have to do it in order to survive and not be a burden to other people.’ (Zanele, 80 years old, 16 months post-COVID)

Theme 3: Perceptions of physical activity’s influence in recovery

Most participants were familiar with the general benefits of physical activity for regular health, especially those who engaged in competitive sporting activities or had highly active lifestyles before COVID-19. However, participants shared contrasting opinions on their engagement in physical activity on recovery, while navigating through the various long-COVID symptoms.

Poor associations: Some participants had poor associations with physical activity uptake as no changes were observed, fear of unknown adverse effects, symptom relapses and readmission to hospital. Participants who expressed being overwhelmed by their current situation or did not contemplate physical activity to recover described more sedentary lives before COVID-19. They would often emphasise resting and letting their body naturally recover without the uptake of physical activity:

‘When I do partake in any activity, it’s still the same, little [or] no changes at all. The more I’m active then I just feel like my chest gets painful and then I get sick to the point where I end up going to hospital.’ (Michaela, 35 years old, 22 months post-COVID, experienced relapse 8 months post-COVID)

Mixed responses: Some participants recognised improvements with physical activity uptake; however, these participants were discouraged by the exacerbation of symptoms that resulted in prolonged resting periods. This led to inconsistent efforts at physical activity uptake, regardless of physical activity’s possible long-term health benefits. Other mixed views described fluctuating presentations, where the same symptoms improved and worsened at different stages with the same physical activity uptake:

‘It’s just like a yo-yo at the moment, like the repetitive sickness or lethargy comes in, and now I’ve gotta start all over again.’ (Daniella, 49 years old, 23 months post-COVID, risk manager)

Improvements in health and well-being: Participants with positive perceptions of physical activity expressed improvements with their physical and mental health, sleep quality, or used it to measure their body’s recovery process and level of participation, despite experiencing worsening of symptoms at first. Triggering of symptoms was accepted as part of the recovery process:

‘… I think more exercise has improved my lung capacity, has improved my overall health. I think my physical strength has improved … doing smaller duties initially. I’ve come to a point where I’m okay now, much better than I was.’ (Jan, 64 years, 22 months post-COVID)

Theme 4: Progressive informal exercise therapy

Despite the difficulties, most participants reported substantial improvement in long-COVID symptoms, ADLs, sports participation, physical activity and social inclusion, in the first 3-to-6 months post-COVID. One participant living with long-COVID reported reduced chest pain and improved breathing, 10 months post-COVID. After the second wave, PLWLC who were re-infected reported quicker recovery times than from previous infections. Nevertheless, most participants perceived very slow, gradual changes in their recovery after 1-year post-COVID, irrespective of acute COVID-19 severity and pre-COVID fitness levels.

Participants attempted self-experimentation through sport or unknowingly engaged in ADLs that incorporated anaerobic, aerobic or gradually graded activities. Swimming, active breathing exercises (particularly pursed-lip breathing and breath holding), yoga and walking were frequently reported to reduce fatigue and improve breathing, muscle strength, balance, mobility, endurance and mental health:

‘I started with the swimming, like 20 metres, eventually went to 100 metres of swimming every morning, which I think that really helped a lot … You pout your lips and you blow out … I didn’t stop after [three months], and I went on for another three months afterwards [to] continuously improve my lung capacity.’ (Jan, 64 years old, 22 months post-COVID)

Discussion

This section will present an interpretation of the results and elaborate how the themes addressed the objective of our study, namely, to explore the influence of the 2019 coronavirus on physical activity, through the lived experiences of PLWLC, to inform future rehabilitation initiatives for this population.

The influence of debilitating symptoms of long-COVID on physical activities

The greatest challenge related to long-COVID is its extensive and crippling symptom profile (Hayes, Ingram & Sculthorpe 2021; Thomas et al. 2023). Joint pains, muscle weakness, dizziness, PEM and exacerbation of underlying conditions were examples of some of the debilitating symptom profiles that our study’s participants experienced, leading to reduced exercise capacity and impaired mobility. These symptoms are aligned with the long-COVID symptom profiles, recognised in global and national studies (Davis et al. 2023; Jassat et al. 2023; Tziolos et al. 2023). Participants described fatigue and dyspnoea as the most common debilitating symptoms, which reinforce findings by Jassat et al. (2023) and Hossain et al. (2023). In support of recommendations to create long-COVID-specific rehabilitation strategies, our study highlights the need for interventions by rehabilitation regimes specifically targeted for fatigue and dyspnoea in PLWLC (Hawke et al. 2023; Vélez-Santamaría et al. 2023).

Physical activity changes pre- and post-COVID

Impaired communication, mobility and essential work skills resulted in fewer work targets being reached, meeting absenteeism and reduced engagement with clients post-COVID. Participants attributed their poor work performance to long-COVID symptoms (e.g. breathlessness), challenging structural environments (e.g. stairs and long corridors) and functional impairments (e.g. inability to sew and communicate). This is concerning as those who could not meet pre-COVID productivity levels experienced a poor return to work and faced a threat to their financial stability, such as reduced income, early retirement or job losses, especially to those who did not have formalised job protection (Faghy et al. 2022; McNabb et al. 2023). Ottiger et al. (2024) assert that approximately 60.9% of PLWLC successfully return to work post-COVID. This draws attention to the need for modifications to PLWLC’s workspace and a review of their working hours to aid recovery and occupational reintegration.

To live independently, ADLs are essential skills needed and commonly used to evaluate physical functioning (Humphreys et al. 2021). As reflected in our study population, all participants pre-COVID were independent and could carry out their daily activities timeously. Most participants described themselves as highly involved in leisure activities pre-COVID, participating in sports, walking to work or shops or physical engagement in family activities and social events. However, post-COVID, participants expressed challenges and frustration when undertaking these activities. Consequently, individuals utilised assistive devices or required assistance from loved ones to complete the rest of their duties. This is similar to Hawke et al. (2023), Vélez-Santamaría et al. (2023) and Faghy et al. (2022), where PLWLC relied on others when executing ADLs, and some required canes or wheelchairs for mobility. Pre-COVID activities that were once considered low intensity were now activities that exacerbated symptoms and led to prolonged resting periods. Thus, participants did not take up ADLs, leisure activities or work activities that consumed too much energy or time. Likewise, in Humphreys et al. (2021), participants found self-care and domestic duties difficult, with formal exercise inconceivable, resulting in house confinement for months. These findings reflect the profound and lasting impact of long-COVID on functional independence and suggest a pattern consistent with the limitations observed in our study.

Humphreys et al. (2021) indicate that psychological and physical impacts of long-COVID were interconnected. On the one hand, stress triggered physical symptoms; on the other hand, the prolonged and unanticipated physical impairments led to frustration, lowered self-esteem and shame for not fulfilling daily responsibilities. Our study reinforces the interlinking effects of psychological and physical impacts on physical activity, leading to fear-avoidance, depression, despondency and withdrawal from family roles and community engagements. This demonstrates the significance of ADLs and leisure activities to PLWLC’s sense of identity, family roles and mental health.

Post-COVID inactivity and sedentary behaviour

Our study indicated prolonged morbidity and reduced daily activities as a result of, or in an attempt to avoid, PEM, leading to a decline in QoL and an increase in SB (Vélez-Santamaría et al. 2023; Wright et al. 2022). Sedentary behaviour and physical inactivity are both independent contributors to various adverse health conditions, including depression, cardiovascular disease, reduced QoL and, ultimately, mortality (Cunningham et al. 2020; Wright et al. 2022). Given the results of our study, PLWLC are exposed to the detrimental effects of prolonged SB and physical inactivity, and therefore there is a need to advocate for their safe return to physical activity. Their return to independence should be of paramount concern to healthcare practitioners and future rehabilitation initiatives to avoid secondary complications because of the loss of physical activity (Lippi, Mattiuzzi & Sanchis-Gomar 2024; Wright et al. 2022).

Wright et al. (2022) suggest that because of risks from physical inactivity and a sedentary lifestyle, physical activity levels did not improve through the course of long-COVID. This was deduced by PLWLC not reaching their pre-COVID activity levels. However, despite the current participants’ inability to reach pre-COVID levels, most expressed significant physical activity improvements, particularly between 3 and 6 months post-COVID, and in those who engaged with physical activity earlier in the recovery phase. This is similar to findings by Chuang et al. (2024), where PLWLC also experienced a downward trend of long-COVID symptoms over time. This should be interpreted with caution, as long-COVID is multifaceted, and recovery is influenced by long-COVID phenotypes and participants’ mental states (Baz et al. 2021; Thomas et al. 2023).

Perceptions of physical activity uptake and its influence in recovery

The idea of recovery, and attitudes to physical activity uptake, differed between participants, despite all experiencing similar debilitating symptoms and the inability to reach pre-COVID physical levels.

Participants who experienced prolonged recuperation periods, relapses, fluctuating or stagnant outcomes after physical activity, and who had lived more sedentary lives pre-COVID, were overwhelmed and uncertain. They tended not to attempt physical activity to improve their function. Their perception of the adverse effects outweighed their perception of its benefits. Those who had mixed or negative perceptions of the uptake of physical activity to improve recovery emphasised their reliance on rest and assistance from others, working within their comfort zone and waiting for their bodies to heal. Participants who were not certain of long-COVID’s unpredictable nature and patterns, and who had not regained control over their symptoms, perceived stagnation in their recovery, together with loss of purpose, self-identity and worsening of mental health, which if not resolved could lead to a negative reinforcing loop (Skilbeck, Spanton & Paton 2023).

Skilbeck et al. (2023) report that positive attitudes to physical activity uptake occur once PLWLC gain an understanding of their symptom patterns, mastery over relapses and control over their lives and the condition. In our study, participants who lived active lifestyles pre-COVID, whether through sport or occupation, perceived the uptake of physical activity more positively. These participants were more likely to be experimental and were disciplined to use physical activity to achieve physical goals, despite the risk of exertion. They exhibited positive mindsets, resilience and survival instincts when dealing with long-COVID repercussions and perceived improvements in physical and mental health. Individuals who used physical activity to self-rehabilitate understood how far they could exert their bodies and therefore established boundaries. This is congruent with the findings of Humphreys et al. (2021), where participants whose physical activity formed part of their core-identity pre-COVID are more likely to take up physical activity, risk relapses and view symptom exacerbation as constructive. Moreover, PLWLC who viewed physical activity uptake as positive, as Skilbeck et al. (2023) describe, redefined their sense of recovery in terms of fulfilling duties and roles, and accepting that recovery may require more time and help. It is therefore recommended that PLWLC should fully understand symptoms, goals and management as better knowledge may assist with more positive perceptions. In addition, education on the benefits of physical activity, understanding an individual’s body and contributing conditions should be addressed by physiotherapists to support PLWLC to manage their symptoms independently.

Coping strategies and informal progressive physical activity rehabilitation

Almost all participants resorted to energy conservation strategies to prevent exertion and fatigue. Although studies commonly indicate pacing as a self-rehabilitation strategy to preserve energy in PLWLC (Humphreys et al. 2021; McNabb et al. 2023; Wright et al. 2022), arguably ‘ineffective outcomes’ of pacing are reported by Thomas et al. (2023) because of limited tolerance in which pacing can help in certain activities (p. 6). This necessitates more research into interventions used by PLWLC in relation to various symptom profiles, versus the intensity and capacity of activity, for better energy conservation advice.

Participants described low-to-moderate intensity exercises or ADLs, containing elements of aerobic, anaerobic and gradually progressive loading, which improved their perceived respiration, balance, muscle strength, mobility, endurance and fatigue levels, especially in the first 6 months post-COVID. While GET had been discouraged in past studies because of damaging outcomes from unpredictable physical, cognitive and emotional triggers of post-exertional malaise or relapse (Décary et al. 2021; D’Souza 2021; Vink & Vink-Niese 2022), our study’s participants perceived improvements with informal graded activities, which warrants investigation on how PLWLC can cautiously engage in physical activity with gradual increasing intensities.

Pouliopoulou et al. (2023) indicate that exercise-based rehabilitation and respiratory training interventions were more effective on functional exercise capacity in PLWLC than physical activity in home settings, suggesting close monitoring by clinicians to ensure safe treatment. This raises concerns, considering South Africa’s overburdened clinical facilities and the low levels of general health service availability and affordability in poor and rural settings (Burger & Christian 2020; Jassat et al. 2023), However, a key limitation to the finding of Pouliopoulou et al. (2023) is that treatment not contextualised to a person’s particular setting can face the risk of rejection (Thomas et al. 2023). Therefore, it would be more feasible and appropriate for physiotherapists in South Africa to incorporate PLWLC’s daily activities and lifestyle as a rehabilitation starting point to improve physical activity levels in low- middle-income communities. Encouraging family activities and the initiation of community exercise and support groups to increase social interaction and QoL can be included, which may also reduce fear-avoidance. Therefore, intervention studies developed in the future need to incorporate personal accounts of PEM, coping and self-monitoring strategies within a patient’s setting, to reduce the risk of rejection and promote sustainability and safety. Our study advocates patient involvement, experience and personalised approaches, which are lacking in previous studies that seek to develop rehabilitation regimes.

Limitations

Our study may be subject to response bias, as the participants were likely those with a particular interest in physical activity, potentially influencing the findings. Consequently, the results may not be generalisable to the broader population of PLWLC, particularly those who are less inclined towards physical activity or who face greater barriers to participation. Additionally, our study was conducted within a single healthcare facility in KwaZulu-Natal, South Africa, which presents a unique context and set of characteristics that may not reflect other settings or populations.

Furthermore, most interviews were conducted via Zoom, which, while practical during times of restricted in-person contact, may have limited the ability to capture non-verbal cues. This could have affected the depth and richness of the qualitative data, potentially constraining the interpretation of participants’ experiences and perspectives.

Recommendations

Further research is needed to explore the impact of long-COVID on physical activity among PLWLC in the South African context. This would enhance the generalisability of findings and contribute to a more comprehensive understanding of the condition’s implications within diverse local populations. Future studies should consider incorporating more face-to-face interviews, which may enrich data collection through the observation of non-verbal cues and facilitate deeper engagement with participants.

It is also recommended that a pilot study be conducted to evaluate the effectiveness and clarity of the interview questionnaire, ensuring that it is well-suited to capturing the complex experiences of PLWLC. Moreover, expanding the scope of future research to include interviews with medical practitioners and key stakeholders such as employers and caregivers would provide a broader perspective. This could inform the development of more effective, multisectoral rehabilitation and support plans tailored to the needs of PLWLC in South Africa.

Conclusion

This research found various persistent symptoms of COVID-19 that impose challenges on PLWLC. Long-COVID symptoms are extensive, with fatigue and breathlessness being the most commonly experienced. Both long-COVID’s manifestations and its inconsistent and oscillating characteristics disrupt daily physical activity levels and negatively impact QoL and mental health. Previous COVID-19 physical activity levels were not reached by the participants, regardless of improvements perceived by some. Others attribute poor and mixed views of, and outcomes from, physical activity uptake, influencing their self-rehabilitation attempts and perceptions of recovery. People living with long-COVID resorted to self-management strategies, emphasising energy conservation approaches. Positive perceptions of a gradual increase in physical activity uptake suggest that a cautious, individualised approach to GET is justified. However, further research on tailored management advice for long-COVID rehabilitation and recovery is required.

Acknowledgements

This article is based on research originally conducted as part of Talmay Tehillah Nadesan’s master’s thesis titled ‘Exploring the influence of the coronavirus disease on physical activity in people living with long coronavirus disease in KwaZulu-Natal, South Africa’, submitted to the Faculty of Health Sciences, Department of Physiotherapy, University of KwaZulu-Natal in 2024. The thesis is currently unpublished and not publicly available. The thesis was supervised by Meluleki Thethwayo, Stacy Maddocks and Verusia Chetty. The manuscript has been revised and adapted for journal publication. The authors confirm that the content has not been previously published or disseminated and complies with ethical standards for original publication.

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. V.C. serves as an editorial board member of this journal. The peer review process for this submission was handled independently, and V.C. had no involvement in the editorial decision-making process for this manuscript. V.C. has no other competing interests to declare.

T.T.N. and S.M. conceptualised the topic of our study and analysed and wrote up our study results. M.S.T. and V.C. provided expert critiques during the writing process and contributed to the finalisation of the article.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The data that support the findings of our study are not openly available because of reasons of sensitivity and are available from the corresponding author, M.S.T., upon reasonable request.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or publisher. The authors are responsible for this article’s results, findings and content.

References