Long COVID remains a major challenge for many patients, especially when symptoms persist long after the acute infection. The editorial by Puhan and Dalla Lana (2025) in the European Respiratory Journal presents and discusses the results of an important new study: For patients without pronounced PEM, rehabilitation can still be effective and safe more than a year after COVID-19.
What was studied?
The PHOSP-R study, a randomized controlled trial, compared two forms of rehabilitation – in-person (in the clinic) and remote (at home) – to usual care. Participants were patients who had been hospitalized for COVID-19 and still suffered from long COVID more than a year after infection.
Key findings
Physical performance: In-person rehabilitation improved the incremental shuttle walk test distance by an average of 52 meters compared to the control group – a value well above the clinically relevant threshold for chronic lung diseases. Remote rehabilitation also showed a positive, though somewhat smaller, effect (34 meters).
Muscle strength and immune markers: There were indications of improved muscle strength. In addition, the number of certain immune cells (naive and memory CD8+ T cells) increased after in-person rehabilitation – a known effect of exercise, though its significance for long COVID needs further study.
Patient-reported outcomes: Most patient-reported outcomes (such as quality of life or fatigue) did not improve significantly. Possible reasons: more general questionnaires were used, and many participants were already in a very chronic phase, where changes are harder to achieve.
Safety: Rehabilitation was safe – no particular risks or side effects were observed. This is consistent with experience from rehabilitation in other chronic diseases.
Important: Patients with moderate to severe post-exertional malaise (PEM) were excluded. The results therefore mainly apply to long COVID patients without PEM. For people with PEM, more research and individually tailored rehabilitation plans are needed.
Structured planning: The 5-phase plan
Altea developed a structured five-phase plan for long COVID rehabilitation (“Back to Sport”):
Phases 1–2: Daily activities and light exercise, with particular attention to pacing – careful energy management.
Phases 3–5: Gradual increase of endurance and strength training, only advancing after at least seven days without setbacks or new symptoms.
Outpatient vs. inpatient
Since the process takes time, outpatient rehabilitation is often better suited than a short inpatient stay.
IMPORTANT: Rehabilitation must always be adapted to the individual's condition. Exceeding limits can lead to a crash. Pacing is key here as well.
Conclusion
The PHOSP-R study shows: Even more than a year after severe COVID-19, targeted rehabilitation can improve physical performance – safely and effectively, as long as there is no PEM. For long COVID rehabilitation, an individual, structured, and patient approach is essential. For people with PEM, developing suitable and safe training concepts remains a challenge.
