Exercises for long COVID — pacing-first, NOT graded escalation

The 2022 NICE guidelines for long COVID (and the WHO post-COVID classification before it) made a critical reversal of traditional fitness advice: pacing-first, NOT graded exercise therapy escalation. The reason is post-exertional symptom exacerbation (PESE) — push too hard on a good day and crash for days to weeks. This is the same mechanism that drove harm in ME/CFS when GET (graded exercise therapy) was the standard, and long COVID has substantial overlap with ME/CFS. So the rules are inverted: start at 30-40% of perceived capacity, increase by ≤10% per week MAXIMUM, and the SYMPTOM day dictates intensity — not the calendar plan. A bad day calls for seated march and breathing work, full stop. A POTS subset (postural orthostatic tachycardia syndrome) needs recumbent or seated-only cardio plus salt loading and compression — coordinate with cardiology.

Volya's catalogue carries the pacing-friendly foundation: diaphragmatic-breathing and pursed-lip-breathing for the breathing rehabilitation Liu 2020 RCT validated, seated-march for upright cardio when standing fatigues, slow-arm-swing-walk for low-intensity outdoor cardio, supine-knee-to-chest for tension release, scapular-retraction for desk-worker posture, cat-cow for gentle spinal mobility. The AI coach also knows the nutrition side — Mediterranean anti-inflammatory pattern, histamine intolerance trial (mast cell activation overlap is common — low-histamine 4-6 weeks with reintroduction), vitamin D test-first, B-vitamins (B1/B6/B12/folate depletion common), omega-3 (algae for vegans, anticoagulant flag), hydration 30 ml/kg + salt loading for POTS subset (coordinate with cardiology), magnesium glycinate, alcohol elimination trial. This is NEVER a replacement for medical care — long COVID specialty clinics exist; refer there for severe or persistent presentations.