ReCOVery: Post-Exertional Malaise and other challenges after COVID-19

Category: Community Corner, Education, Latest News, Learning Centre, Patient Education


There is a growing population of individuals experiencing a range of debilitating and long-lasting effects after having COVID-19. For these individuals, the effects are greater than the expected weakness and fatigue that others may experience after being sick for a few weeks, be it with COVID-19 or another illness. In these cases, a slower and modified version of the ReCOVery program is vital to help them recover, in contrast to a fast-paced program that could exacerbate their symptoms.

Post-Exertional Malaise

After engaging in physical or cognitive tasks that should not be very challenging, some individuals feel extreme fatigue that can last for days and is not alleviated by rest. This is known as Post-Exertional Malaise (PEM). PEM is often part of a condition known as Chronic Fatigue Syndrome or Myalgic Encephalomyelitis, which can develop after having a virus, among other causes. This condition can also include other symptoms, such as changes to one’s thinking and sleeping. There is a debate in the medical community as to whether people are developing this specific condition after having COVID-19 or something that appears similar.


After having COVID-19, some are experiencing changes in blood pressure, heart rate, breathing, and other body functions, known generally as dysautonomia. Dysautonomia is an umbrella term for several conditions involving dysfunction of the autonomic nervous system. The autonomic nervous system maintains equilibrium in the body and controls many functions, including heart rate, blood pressure, breathing, digestion, sweating, pupil dilation, and others.

ReCOVery for PEM and Dysautonomia

The key to helping you recover after having COVID-19 is to ensure that we know what challenges you are experiencing and, based on that, how these challenges need to be rehabilitated. Therefore, as part of the ReCOVery assessment, we screen for PEM, Dysautonomia, and other health concerns that can arise after COVID-19. When appropriate, we may communicate with your physician or specialist to ensure that it is safe for you to participate in the ReCOVery program. The ReCOVery program is then tailored to your individual needs.


For individuals with PEM, a significant focus of the ReCOVery program is on pacing. Pacing involves tracking your daily activities and energy levels, prioritizing what is important and urgent to you, and balancing the activities you do with rest periods so that you do not exacerbate your symptoms. It can be tempting to get a lot done on a day you feel good, but it is essential not to overdo it. In the early stages of rehabilitation, it is especially important to pace yourself. Pacing will allow your energy systems to heal rather than be further strained. As you recover, your “energy envelope,” i.e., the available energy you have in a given day, should slowly increase. However, there will be good and challenging days as part of your recovery, which is perfectly normal.

Symptom-Based Physical Activity

Additionally, for individuals experiencing PEM, rather than focusing on a progressively more challenging exercise program, the exercise component of ReCOVery will be symptom-based. This means that physical activities will be adjusted daily based on symptoms. Additionally, the program may include more functional physical activities, such as a trip to the grocery store or going for a walk, rather than a typical regimen of exercises.

Heart Rate Monitoring and Breathing

When living with PEM or dysautonomia, heart rate changes are common. If your heart rate becomes very elevated, it can be a sign that the activity you are doing is too challenging and may result in an episode of PEM. If you have dysautonomia, you may be prone to atypical fluctuations in heart rate. In both cases, it is valuable to monitor your heart rate. Therefore, we may incorporate this into your ReCOVery program. When applicable, we may set a target heart range to stay within and teach you how to rest and breathe in a manner that helps lower your heart rate when it gets high.

Dysautonomia and PEM can also contribute to breathlessness. This breathlessness is in addition to the typical breathlessness associated with COVID-19. Therefore, a thorough cardiorespiratory / breathing assessment and specific breathing exercises are integral to the ReCOVery program to help improve dysfunctional breathing.

If you are experiencing extreme fatigue, heart rate changes, breathlessness, or other challenging long-lasting effects of COVID-19, please reach out to Bella at Pro Motion Physiotherapy.

Phone: 905-731-1991


We look forward to helping you in your recovery!

Written by Bella Levi, Registered Physiotherapist