Clinician perspectives on Long-COVID physical rehabilitation: challenges, uncertainty, and semantics, 2026, Reeves

[rvallee]

Clinician perspectives on Long-COVID physical rehabilitation: challenges, uncertainty, and semantics

https://www.tandfonline.com/doi/full/10.1080/09638288.2026.2682998

Spoiler: Authors

Jack M. Reeves, Justin McNab, Lissa M Spencer, Ling-Ling Tsai, Andrew J. Baillie & Jennifer A. Alison

Abstract​

Purpose​

To understand the perspectives of clinicians who provided rehabilitation services to people with Long-COVID or referred people to such services.

Methods​

Clinicians involved with Long-COVID rehabilitation were recruited via email and interviewed. Recruitment continued until thematic saturation on physical rehabilitation approaches was reached. Semi-structured interviews were recorded, deidentified, and transcribed. Reflexive thematic analysis was used to develop themes from codes.

Results​

Twenty-one clinicians were interviewed about their perceptions of Long-COVID rehabilitation. Clinicians were physiotherapists, exercise physiologists, clinical psychologists, respiratory physicians, rehabilitation physicians, an infectious disease physician, and a general practitioner. Four overarching themes were identified. (1) “Long-COVID is hard to characterise,” including Subtheme 1.1 “Naming Long-COVID: opinions and impacts of differing terminology”; and 1.2 “Framing Long-COVID: one syndrome, experienced as many.” (2) “Challenges of diagnosis in a novel condition.” (3) “Management of a novel condition – Who knows what to do?” (4) “Exercise therapy is complex,” including Subtheme 4.1 “Graded exercise therapy – semantic discordance despite alignment in approach” and 4.2 “Clinicians question public opposition to exercise.”

Conclusion​

Clinicians described Long-COVID as a heterogenous condition which challenges traditional rehabilitation frameworks. This study highlights how uncertainty with rehabilitation methods leads to fragmented approaches to rehabilitation and inconsistencies in care.

Implications for rehabilitation​

• Long-COVID rehabilitation should be framed around a heterogenous and largely “invisible” condition where validation of symptoms and careful assessment is prioritised.
• Where appropriate, exercise should be prescribed as highly individualised, symptom-titrated physical activity rather than rigid, pre-set incremental exercise programmes regardless of terminology employed.
• Discrepancies in terminology can undermine engagement; clinicians should aim for consistent and patient-friendly language (typically Long-COVID) while still aligning with formal terminology.
• Knowledge gaps and variable beliefs about models of care contribute to inconsistencies in patient management.

 

[Hutan]

Australian authors - the University of Sydney

Regardless, there is a long history of those with “invisible illnesses” (i.e., conditions without outwardly visible signs) receiving poor support and late or minimal recognition from healthcare systems and society, often due to ambiguity in the mechanism or measurability of symptoms [Citation10]. This discrimination, sometimes borne through sexism or ableism, can leave sufferers feeling dismissed due to medical scepticism, with symptoms inappropriately attributed primarily to psychological causes.

Given the recency of Long-COVID, there is inadequate evidence to guide best practice in rehabilitation, and initially clinicians relied on expert advice through well-regarded health organisations [Citation11,Citation12]. There has existed and persists a concern over the safety of some rehabilitation interventions being provided, namely, of exercise interventions for people exhibiting post-exertional malaise (PEM) or post-exertional symptoms exacerbation (PESE) [Citation12]. This may stem from controversies surrounding the use of graded exercise therapy in people with myalgic encephalitis/chronic fatigue syndrome (ME/CFS) [Citation13–15] given the similar symptom profile with Long-COVID [Citation16]. Proponents of graded exercise therapy in ME/CFS have suggested that carefully supervised activity may help to reduce deconditioning [Citation17]. Critics of graded exercise therapy highlight the lived experience of those with ME/CFS demonstrating lack of benefit and that the studies that support graded exercise therapy are methodologically weak [Citation14,Citation18].

Reasonably neutral statements of the situation regarding graded exercise therapy, although I suggest that proponents of graded exercise therapy for ME/CFS are not primarily trying to reduce deconditioning. They are in fact trying to cure the person of ME/CFS, as a result of correcting various issues perceived by the clinician e.g. the patient's fear of movement or over-reaction to normal aches following exercise.

The sample consisted of seven physiotherapists, five exercise physiologists, two clinical psychologists, three respiratory physicians, two rehabilitation physicians, an infectious disease physician, and a general practitioner.

If you ask physiotherapists and exercise physiologists providing services to people with Long Covid what services are best, you are probably going to get replies along the lines of 'exercise, but carefully supervised by physiotherapists and exercise physiologists'. 'Have hammer, see nails.'

The research team consisted of clinicians with experience of providing rehabilitation services for people following COVID infection (JR, LS, LLT), researchers who have previously published on rehabilitation for people with Long-COVID (JR, LS, LLT, AB, JA), researchers with experience in qualitative research methods (JR, JM, LS, LLT, JA), and researchers who convene a collaboration of clinicians, researchers, and consumers (Long-COVID Australia Collaboration; AB, JA).

They acknowledged the impact their professional backgrounds in physiotherapy (JR, LS, LLT, JA), clinical psychology (AB), and social anthropology (JM) would have on analysis and interpretation. For example, physiotherapists tended to focus on aspects of physical rehabilitation and how they were perceived while those with a background in psychology and anthropology brought attention to cultural context, navigating the health system, and how opinions align with alternate health contexts.

The bias is not going to be helped by most of the researchers also having a background in physiotherapy. 'Also have hammers, so applaud the seeing of nails...'

 

[Trish]

They even have the jargon: 'symptom titrated physical activity'.
Yet from what I have read on this thread, they seem to think this requires a clinician to prescribe it and oversee it as a program of treatment. Surely it means inform the patient about PEM and pacing, and don't prescribe exercise or rehab. programs.

 

[Sean]

Clinicians involved with Long-COVID rehabilitation were recruited via email and interviewed.​

How were the recipients selected for the email in the first place?

Where appropriate,​

That 'appropriate' is doing a lot of heavy lifting. Who decides what is appropriate, particularly given the abysmal track record of rehabilitation pros on this matter so far?

 

[Hutan]

How were the recipients selected for the email in the first place?

Participants included clinicians who provided outpatient rehabilitation for Long-COVID or medical practitioners who referred people with Long-COVID to rehabilitation. Researchers used existing networks to identify Australian-based clinicians who had provided such services within the prior 12 months.

One of the respondents is an exercise physiologist in Melbourne. I assume that is Nathan Butler (who much earlier in life was part of PACE).

I only read a bit before I got bored, but it's quite a mixed bag. Some of the clinicians sound reasonable, at least about some things. Some do not. I'm not sure this study tells us much other than there's a lot of uncertainty, with many clinicians making things up as they go along. Which we already knew.

Perceptions of illness and symptoms involve a complex interplay of physiological and psychological components for many different health conditions, especially PAIS. Clinicians believed that the manifestation of COVID-sequelae in those with Long-COVID stemmed from an underlying physiological mechanism which contributed to symptoms, but often suspected symptoms were exacerbated by psychological factors, making references to “anxiety,” “trauma,” “mental health,” “burn out,” “not coping,” “depression,” and “pre-existing health concerns.”

They expressed disappointment when other health professionals denied Long-COVID as a medical condition or when they were disinterested in providing healthcare services for those attempting to access care.

Yeah, I still have colleagues – we still have people make dumb a** comments about, ‘this is all fairy dust, it doesn’t actually exist. Why have we even got it on our agenda? Why aren’t we talking about real, proper disease or real evidence-based stuff’ - really sad to hear. – Participant 18 (General Practitioner, male)​

​

I think that’s - well, smacks of discrimination and ignorance [referring to medical practitioners avoiding Long-COVID patients]. […] It’s a new disease and everyone wants it to be over, but it’s not. It’s got a chronic phase and people have to learn about it. – Participant 21 (Rehabilitation Physician, male)​

​

If we’re going to apply one of these brands of Long-COVID or PCC or PASC, then the symptom set that’s being complained of should be medically unexplained. If you’re going to get to the point of saying it’s medically unexplained, you have to have done a structured medical assessment both for physical health issues and for mental health issues that might explain the symptom set, and that includes some investigations to make sure you’ve crossed all the T’s and dotted the I’s. – Participant 11 (Infectious Disease Physician, male)​

Others felt Long-COVID patients were “quite resource intensive” for clinicians such as general practitioners and that numerous investigations into all a patient’s symptoms, of which there are commonly multiple, unnecessarily pathologised their unexplained symptoms.

Some of that is actually going through a whole lot of investigations to rule out problems and it does put them into a system of sort of medicalising and pathologising a lot of issues that don’t require those sort of investigations. – Participant 19 (Respiratory Physician, female)​

Others sat in the middle of these opposing perspectives on the importance of exhaustive investigations, suggesting a core set of tests may be appropriate, but not continuing with an extensive list as a part of a routine evaluation.

We [speaking of multidisciplinary clinic] probably take a more holistic view of things […] make sure everyone has had blood tests and that all other sorts of causes have been ruled out, at least most of the broad causes. Then, yeah, kind of seeing what happens from there, but not then pursuing further sort of investigations, like brain MRIs and all of the other stuff. – Participant 4 (Exercise Physiologist, male)​

 

[bobbler]

One of the respondents is an exercise physiologist in Melbourne. I assume that is Nathan Butler (who much earlier in life was part of PACE).

I only read a bit before I got bored, but it's quite a mixed bad. Some of the clinicians sound reasonable, at least about some things. Some do not. I'm not sure this study tells us much other than there's a lot of uncertainty, with many clinicians making things up as they go along. Which we already knew.

​

Yes to last para. Perhaps this is most useful (studying the staff and who ends up in this area instead of the patients, because there’s an issue isn’t there for certain conditions with what they get lumbered with and the services should be in the lookout) - and needs to mark the beginning of more research focusing on this issue - as an insight into what ‘types’ can end up magnetized into certain types of things and the motivations that they give away (rather than what they claim).

These quotes are trope bingo with people arguing over which harmful trope should supersede the other and are focused on ‘[their] opinions of’ the patient not it seems about care or being scientific or medical minded. They brought silent tears to my eyes. They don’t know how vicious and callous it makes them by that they think this because they think they’ve learned code terms that somehow softens that.

A different turn of phrase doesn’t change who that makes them that they do and think what they do and doesn’t make what they do softer or less harmful. It’s just more dishonest when they attempt to disguise it and reveals their denial.

Who all unlucky patients end up having to put up with. And the standard of their ‘thinking’ - inverted commas because I bet this stuff just fell out as rote from their own bigotry rather than what they like to think is a thought through considered answer on a problem that should be the one about how to solve the illness and give the patients the best long term health (not their ‘problem’ of what to make their job and how to sell their wares)

But saying (I doubt anyone does mri anyway so it’s a straw man probably for blood tests that anyone with such ism labels would have done as normal) you don’t want to put someone thru everything under the sun for the sake of it but do look at each person and what differentials are worth checking given this could be decades or rest of their lives before they get access to any medicine again is different to ‘don’t want to medicslise by ruling out’.

Which is just nasty ‘belief systems’ using that term - and says a lot about what they really mean. And in my mind no person working in a health system should keep their job when that crap falls out of their mouth but they got that habit that it’s ok to think and say out loud from some other person sadly.

I think medicine just as other areas have had to in certain things but ducked doing well needs to stop pretending it can’t see the issue of populations it makes vulnerable and then leaves such to all types of bad behaviour whether that’s inadvertent or not. Any industry has to be wary of creating attractive easy access unmonitored (properly) places for predators. Even where such predators believe they are helping or wanted, or wish they were that type.

Sadly such issues go along with allowing someone to just cite nonsense beliefs of any kind no matter how distasteful, delusional and harmful to others based on one-liners - which evidence-based medicine seemed happy to be invented as a ‘means the opposite in detail of what it conveys in claimed intention’

I can see the different types here that sadly I’m used to seeing and probably other medical departments might have to deal with the odd one of every x number of years or so .

What makes me sad is there perhaps are a few thinking straight (where in normal medical departments it’s the opposite way round where they are the majority) who are being thrown in to be suffocated by larger numbers of those seeking not to learn or get better for the patients (but at best make the patient and /or their illness fit with what they want to do each day and how they wish that could mean they get praised for the outcome of that at the same time). Who then develop a language and myths for cognitive dissonance etc. And drown out those trying to bring in basic standards who I guess have to give up to not suffer the penalties for not changing to fit in.

There’s a lot of pat phrases here and I feel so sad at how effective bs propaganda from I guess the years of the mus awfulness give people blather to say thinking it replaces being competent and talking in terms of what they actually do and don’t know terms. It does make it sound like a super dodgy combining of various religious movements all jockeying for their own way - not one of these really talking symptoms or about patients in ways other than pawns or objects but certainly getting their designation of slurs on them will be lifelong.

Some seem to revel in what I guess is permission/lack of oversight they think is given to them by naming myths of others who apparently think even worse things about the illness. So it’s ok. If what you do is harm that actively charting as claims it would cure vs someone who didn’t want to acknowledge existing. They aren’t getting it that they might be worse and certainly are neither neutral or benevolent if they aren’t one of these few checking up with open eyes long term on the actual patient outcome rather than being callous to take your slot doing what you want to believe and choosing to not look at what it did to someone in truth.

 

[Hutan]

I only read a bit before I got bored, but it's quite a mixed bad.

Thanks @bobbler. I see I had a typo there, 'mixed bad' where I meant 'mixed bag', which probably was apt.

years of the mus awfulness

Yes, it was probably not so much me getting bored, and more my reaction to the awfulness that made me not finish this paper. I think I didn't want to get to the Discussion section and see for sure that there was no censure when ignorance produced prejudice.

Knowledge gaps and variable beliefs about models of care contribute to inconsistencies in patient management.

The abstract is vague - it is not clear in what way the inconsistencies in patient management should be cleaned up, although I can guess. Some days, there's only so much bashing of one's sense of self that can be tolerated.