Recommendations by presentation of symptoms:
Anosmia and dysgeusia (loss of taste and smell)
The VA recommends smell/olfactory training as the main treatment for the loss of taste and smell. The olfactory training regimen outlined by the VA is as follows:
Actively smell or sniff four familiar scents. Think about your memory of the odor while smelling the odor. In random order, sniff for a total of 20-60 seconds for each odor. Rest for 30 seconds between each scent. Sniff the four scents 2 to 4 times daily, each, for 24-36 weeks. Change the odorants used every 12 weeks. The stimulating smells used are often in commercially available smell kits [and] are often selected from major smell categories, such as aromatic, flowery, fruity, and resinous.
Unless there are other nasal symptoms (congestion, rhinitis), they do not recommend intranasal steroids; they recommend against the use of antibiotics and vitamin A drops.
The AAPM&R also recommends olfactory training, with the addition of mouth moisturization and referral to an ENT if symptoms persist for more than three months. The WHO also recommends olfactory training, but they are clear that there is little evidence of its efficacy, though also little risk.
Autonomic Nervous System Dysregulation
The VA and AAPM&R suggest treatment for POTS as such: hydration (64 oz of water daily), limiting alcohol, increasing sodium intake (between 3000-5000 mg daily), compression stockings, slowly getting out of bed, taking care when standing, small frequent meals, and biofeedback.
The VA advises against strenuous activity in hot weather but encourages a gradual return to exercise, starting with recumbent activities such as rowing, swimming, and cycling and progressing to upright activities, walking, jogging, and using an elliptical. Working with a cardiologist, physical therapist, and occupational therapist may be needed.
The AAPM&R suggests medication (low-dose beta blockers, fludrocortisone, midodrine, pyridostigmine, ivabradine, clonidine, methyldopa, modafinil, methylphenidate, SSRIs, or SNRIs) for patients whose symptoms do not improve with the measures outlined above.
Once other causes of chest pain (cardiac, gastrointestinal, etc.) have been ruled out, the VA recommends diaphragmatic breathing, stretching, and one or two weeks of low-dose non-steroidal anti-inflammatory drugs (NSAID). Working with a cardiologist, physical therapist, or chiropractor may also be needed.
Fatigue and Activity Intolerance
The VA, AAPM&R, and WHO suggest a titrated return to activity and patient education on strategies for conserving energy. The VA also recommends dietary supplementation with B12, vitamin D, fish oil, and Cognitive Behavioral Therapy for insomnia and diaphragmatic breathing. Consults with physical therapy, occupational therapy, Cardiology, Pulmonology, and mental health can also be helpful.
Dyspnea (difficulty breathing)
The VA and AAPM&R recommend supplemental oxygen and consultation with a pulmonologist if needed. The VA also advises working with cardiology, pulmonary rehabilitation, ENT or speech-language pathology, physical therapy, and/or occupational therapy. The Asthma and Allergy Association of America recommends focused deep breathing exercises, relaxation techniques, pulmonary rehabilitation, and consultation with a pulmonary or asthma specialist if symptoms persist.
The VA recommends diaphragmatic breathing, occupational therapy, and consultation with a neurologist. The AAPM&R recommends consulting with an occupational therapist, speech-language pathologist, and/or neuropsychologist. They also suggest counseling patients on sleep hygiene and gradually returning to activity and aerobic exercise. The WHO recommends cognitive exercises as well as environmental modifications to improve the ease of everyday activities. The SAMHSA recommends cognitive rehabilitation, cognitive behavioral therapy, metacognitive strategies, attention processing training, mindfulness-based stress reduction, and modifications to routines such as recording lectures and minimizing distractions.
The VA and AAPM&R suggest using albuterol as needed, inhaled corticosteroid (ICS), and ICS/long-acting beta-agonist (LABA) medications for two or three months. They also suggest hydration, expectorants, and other airway-clearing devices if needed. The VA also recommends diaphragmatic breathing. Consultation with a pulmonologist is recommended.
The AAPM&R recommends over-the-counter painkillers, acupuncture, relaxation therapies, deep breathing exercises, and biofeedback. They suggest supplementing with magnesium, melatonin, coenzyme Q10, riboflavin, and/or feverfew as a preventative measure. Referral to a neurologist is specified as important for managing migraines.
The VA suggests over-the-counter and/or prescription painkillers, hydration (64 oz. of water daily) as well as counseling on lifestyle factors such as sleep, exercise, and nutrition, regulating glucose, supplementing with Riboflavin and Magnesium Oxide, and diaphragmatic breathing. They also suggest referral to a neurologist if symptoms persist.
Mental Health (Anxiety, Depression, Obsessive Compulsive Disorders, Substance Use Disorders, Psychotic Disorders, PTSD)
The VA suggests patient education on stress management and sleep, guided meditation, and supplementation with fish oil. Antidepressants are not a blanket recommendation but should be considered in specific cases. They also recommend attending long Covid support groups (see ‘Where can I find Long Covid resources?’ section below). The WHO recommends psychological support, mindfulness, exercise, and support groups. The Substance Abuse and Mental Health Services Administration advises Individual and/ or group psychotherapy, peer support groups, and the use of SSRIs for certain patients with OCD or PTSD. They also advise referral to a psychiatrist.
The WHO recommends dietary modifications and swallowing exercises. The AAPM&R recommends referral to speech therapy.