An image of a person with a cloud-filled head is used to illustrate the concept of the feeling of being ill with COVID-19.

Long COVID is now considered a chronic condition and requires an innovative approach to care. Studies are showing that massage and other hands-on therapists can make a difference for people living with this oftentimes-challenging condition. Read the second article in this series, “The Long COVID Client, Part Two: Manual Therapy Protocol,” on on June 3.

About 11% of American adults who have had COVID-19 reported in January 2023 of having experienced Long COVID symptoms, according to the Kaiser Family Foundation. That equates to 25 million people in the U.S., or 7.5% of the U.S. population. Another report out in March indicated that 11% of the U.S. population is currently experiencing Long COVID. These people are referred to colloquially as long-haulers, and may experience a range of symptoms that might persist for weeks, months or years.

Long COVID was named in April 2020 by the U.S. Centers for Disease Control and Prevention (CDC) and in July 2021 became a condition recognized under the Americans with Disabilities Act. Long COVID is also called long-haul COVID, post-acute COVID-19, post-acute sequelae of SARS CoV-2 infection (PASC), long-term effects of COVID, or chronic COVID.

Long COVID is defined as conditions that go on after four weeks from infection and can have relapsing, overlapping qualities with varying risk factors. The CDC has published a list of symptoms. On the CDC’s list and of particular relevance to massage therapists are such conditions as fatigue, and muscle-and-joint pain:

General Effects of Long COVID

• Tiredness or fatigue that interferes with daily life

• Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”)

• Fever

• Difficulty breathing or shortness of breath

• Cough

• Chest pain

• Fast-beating or pounding heart (also known as heart palpitations)

• Difficulty thinking or concentrating (sometimes referred to as “brain fog”)

• Headache

• Sleep problems

• Dizziness when you stand up (lightheadedness)

• Pins-and-needles feelings

• Change in smell or taste

• Depression or anxiety

• Diarrhea

• Stomach pain

• Joint or muscle pain

• Rash

• Changes in menstrual cycles

Massage for Long COVID

If you suspect a client might have Long COVID but they do not reveal that during their intake, refer them to their physician. If the client states during the massage therapy intake that they have been diagnosed with Long COVID, you can share a study or two and explain how lighter massage treatments combined with anti-stress practices might be helpful.

Massage therapists who understand the role healthy, trained touch can play in the care of Long COVID clients are slowing down their strokes, lightening up their touch and following new protocols that may include lymphatic drainage and such stress-relieving methods as guided meditation in their sessions.

A study published in the International Journal of Environmental Research and Public Health in November 2022, “Rehabilitation of Post-COVID-19 Musculoskeletal Sequelae in Geriatric Patients: A Case Series Study,” for example, found “the musculoskeletal system is affected in over 40% of patients with Coronavirus disease 2019 (COVID-19)” and showed subjects’ motor skills improved after undergoing therapies, one of which included massage.

Although massage and other manual therapies are contraindicated when an active infection is present, it is interesting to note that laboratory studies have shown lymphatic drainage has a place post-infection, as the lymphatic system carries the immune cells that fight disease.

The study, “Reducing fatigue-related symptoms in Long COVID-19: a preliminary report of a lymphatic drainage intervention,” published in Cardiovascular Endocrinology & Metabolism in June 2022, suggested manual lymphatic drainage intervention might help reduce fatigue symptoms related to Long COVID.

Brigit Viksnins
Brigit Viksnins

The effects of lighter and slower massage techniques are benefiting clients. “We asked students to study the signs of returning health, or parasympathetic reregulation, and look for them in session,” massage therapist and educator Brigit Viksnins, LMT, BCTMB, MAT, RCST, SEP, said. “We trained them to become aware of the behaviors that elicited those cues. They regularly found that slow work in sync with the body security system brought about those cues, like a dry mouth becoming wet enough to swallow, full sinuses shifting to drain, eyes glistening, sighs or involuntary deep breaths happening, pale or pasty skin becoming more rosy with enhanced microcirculation, and more.”

Light Techniques for Long COVID Clients

Once trained in lighter and more subtle modalities that may be easier on the client, you can incorporate them into your session work with Long COVID clients. Examples of such therapies include:

Craniosacral therapy: CST helps drain the face and sinuses, is useful to address brain fog and has relaxation qualities.

• Lymphatic drainage massage: The human body is 65-75% water, and lymphatic drainage assists in the flow of migration of the immune cells and antigen transport.

• Visceral manipulation: Neck pain may come from where the lungs attach to the neck by way of the pleura. The intestines may be pulling on the back. Visceral manipulation brings soft-tissue work deeper and can improve posture.

Reflexology and acupressure: Deep, focused touch applied to organ points helps support vitality. You can also teach clients how to massage their feet for at-home integration.

• Energy work: Reiki, Polarity Therapy and Zero Balancing are options for energy balancing and for people who prefer little to no touch.

• Myofascial work: Ortho-Bionomy is good for approaching connections. For example, the piriformis can pull on the psoas, the psoas can be pulled by the diaphragm (from coughing), and that might pull the trapezius to the base of the head.

Anatomical Hubs

Massage therapists who see Long COVID clients are also focusing more on anatomical hubs they may have previously considered more integrative and less focal, as they typically have fewer symptoms:

• Head: The brain has recently been named an immune organ; it engages in a unique process of waste removal called the glymphatic system. The brain can benefit from relaxation, the movement of cerebrospinal fluid, and lymphatic drainage to help with brain fog.

• Belly: This area contains most of the immune system, which plays an important role in detoxification, and has the greater percentage of serotonin production and anti-inflammatory chemical messengers.

• Thoracic inlet and outlet: This is the area where the neck meets the upper shoulders, and the areas of the collarbones and sternum. Most of the lymphatic system (the system that carries the immune cells) drains here, the majority underneath the left side.

• Trapezius: The trapezius attaches from the sacrum and sacral iliac to the base of the skull. It can tighten, with lots of coughing, to relax the diaphragm. A complaint of a band-like pain that stretches across the lower back may be coming from the trapezius that is reacting to the upper thoracic and neck muscles tightening from inflammation of the lungs.

• Psoas and piriformis: The diaphragm attaches all the way down the lumbar spine and has a direct relationship with the psoas and piriformis muscles. Understanding the anatomy of the diaphragm and brushing up on the mechanics of the breath may provide answers for mysterious psoas issues that may be worsening.

• Fold areas, which include the armpits, hip creases and spaces behind the knees, are places where fluids can stagnate. Work the extremities from hand to shoulder, foot to hips. Use a very light, feather-like touch and keep strokes very superficial as though you are massaging the whole body lightly through that one contact area at the level of the skin.

Frederic Verswijver
Frederic Verswijver

“Restoring self- regulation in long Covid is paramount,” advised Frederic Verswijver, DO, PhD, LMT. “Treatment of the autonomic nervous system, the spinal ganglia, and reducing the cortisol and aldosterone [related to] the collective fear and the social.”

Light vs. Deep Touch

With chronic symptoms, especially fatigue, a massage therapist wants to work effectively while avoiding the therapeutic crash that can happen post-session. It is best not to ask too much of the body at first. Think of your Long COVID client’s capacity like a gas tank; how much gas have they used to get better? They may not have much left in their tank.

Consider supportive, non-inflammation-inducing pressure versus working out knots. Deep work may ask too much of the body, as people can sometimes be sore or inflamed after a deep tissue massage that seeks to repattern tissue.

For those who practice deep tissue massage, shorter and more frequent sessions with days in between for rest and hydration (drinking small amounts more regularly verses large glasses of water) may be indicated. Such a session schedule may also be more affordable for some clients who were hit by the financial impact of the pandemic.

If it’s within your scope of practice, remind clients to stretch and move regularly. (It is advised to move once every hour, even if for only several minutes, if a person is sedentary.)

Massage and Integrative Care

Integrative care is new territory and massage therapists are recognizing the importance of in-between session care—both online and in-person—They are also developing packages with shorter, more-frequent and affordable sessions that incorporate anti-stress practices including self-massage coaching, mindfulness, and movement exercises.

A literature review, “Mindfulness Meditation Interventions for Long COVID: Biobehavioral Gene Expression and Neuroimmune Functioning,” published in Neuropsychiatric Disease and Treatment in November 2022, for example, states: “Meditation has been found to reduce fatigue and unrefreshing sleep, and for those with post-viral infections, it has enhanced immunity, and reduced inflammatory-driven pathogenesis … It may apply to those with Long COVID … Evidence is reviewed suggesting effective and sustainable outcomes may be achieved for symptomatology and underlying pathology of post-viral fatigue.”

Massage therapists are sharing what has helped them stay afloat. One practitioner helped her clients by offering dance parties and group meditation sessions online. Creating in-person and online community can offer a container of support. (Remember scope of practice, client confidentiality and disclaimers also apply to online sessions.) Here are suggestions for between-session integration practices:

Visualization practices, meditation, mindfulness, calming videos, AMSR, EFT, ho’oponopono (wholeness and healing), manifestation, mindful nature walks

• Naps, micro naps, rest, downtime, sleep hygiene and decreased screen time

• Neuroplasticity exercises

• Sound or music therapy, tuning fork therapy, singing bowls, or toning, color therapy and hydrotherapy

• Pool work

• Breathing exercises and laughter yoga

• Vagus-nerve stretches and hug therapy

• ELDOA (postural self-normalizing techniques) and dynamic stretching

• Movement and dance practices (Nia and 5 Rhythms,) gentle yoga, qigong, Continuum

Movement and Feldenkrais

• Aromatherapy, essential oils and flower essences

• Still-point inducer, acupressure mats and Pulsed Electro-Magnetic Field (PEMF) t mats

Take time to develop a unique treatment plan for Long COVID clients, combining in-office sessions and care between sessions. Include your client in the planning process and find the anti-stress practices that interest them and will bring them moments of joy and bliss. This will help to instill confidence and hope for recovery.

The Emotional Impact of COVID-19

COVID-19 changed the paradigm of health care in that our medical system has needed to support specialists working s teams more than ever before.

We see in the list of symptoms related to COVID-19 that there can be digestive upset, headaches and pulmonary distress, among many other symptoms, and patients are seen by several specialists both in the hospital and during follow-up.

In the past there was little overlap of specialists working with one patient; now there is more of a team approach to care.

The field of massage therapy is also evolving due to COVID-19. During the pandemic, many people naturally complained of feeling fear, isolation and stress. Massage therapists are starting to recognize the emotional impact COVID-19 has had on the population. Some studies outline PTSD, depression and anxiety as contributing factors to the complications of COVID-19 recovery.

Kate White
Kate White

“Clients would often cry after feeling safe enough to just let down a little on my table,” said Kate White, BCTMB, RCST, CEIM, SEP, PPNE, PLC. “I remember one client burst into tears and said, ‘I’ve been holding it together for so long.’ I was glad to be there for her and affirm the truth of that.”

Science is directing massage therapists to consider the emotional aspect of the chronic conditions of Long COVID. In a more uncertain world, which the pandemic created, clients are more likely to experience an emotional release during a session. Enhanced stress-reduction methods are quickly becoming a new part of the massage therapist’s repertoire.

Massage therapists realize they can make a difference from the moment the client walks into the relaxing environment of the waiting room to the moment they leave—from the lowered light and gentle music to the confidence and hope inspired by providing a clear and thorough treatment plan.

It is also important to know when to refer out. Notably, massage therapists are starting to think in the terms of team care and are joining with doctors, nurse practitioners and psychologists who are recognizing the importance of anti-stress care in pain management.

Greer Bailey
Greer Bailey

“In my practice, I would say 80% of my clients now come in for reasons of anxiety, depression, and headaches [and] it has been a notable increase since COVID,” said Greer Bailey, LMT. “I have also noticed in my massage practice more people are coming in with the language, ‘I want help releasing this trauma from my body’ or ‘I would like help to better understand the trauma that lives in my body.’

“I strongly believe it is becoming even more important to work with doctors and psychologists, because there is more trauma coming to the table that is outside of our scope of practice,” Bailey said.

Flow is Key

Long COVID is a systemic condition, and a holistic approach to care is the optimal approach. COVID-19 has shifted the paradigm of practice, directing massage therapists to think more holistically, to seek new trainings and to understand the importance of supporting the emotional component that undeniably aligns with chronic physical symptoms.

Evidence in this evolution of massage practice is mirrored by the shift seen in curriculums of continuing education trainings. CE providers are starting to train their participants more in how to support both the physical and emotional components of a client’s treatment.

As clients with Long COVID go from specialist to specialist seeking solutions, massage therapists are able to provide support as massage is one of only a few modalities that offers care to the whole body. Massage therapists are taking into consideration the emotional impact the pandemic has had on clients’ bodies.

Flow is key as therapists slow down their pace, lighten their touch and embrace the importance of focusing on integration.

[Read “Massage for Long COVID: Part Two, A Manual Therapy Protocol.”]

Carey Beneson Taussig

About the Author

Carey Benenson Taussig, DO (IT), LMT, has practiced manual therapy since 2004. She teaches practitioners worldwide in working with clients online to apply self-massage and employ visualization, among other methods She teaches osteopathic manual therapy techniques to post-graduates in-person, both in the U.S. and Europe. Her articles for MASSAGE Magazine include “The MT’s 10-Step Guide to Offering Online Sessions.”