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Treatment & Procedure

Long Covid & Post-Vac

Focus topic

Still being exhausted, short of breath or foggy months after a coronavirus infection is not imagination. Long Covid is now recognized as a condition in its own right, with its own definition, its own guideline and its own care pathway with the statutory health insurers. A therapy that addresses the cause does not exist yet, but some building blocks demonstrably help.

In short

Long Covid or post-Covid refers to symptoms that are present usually 3 months after an infection, last at least 2 months and cannot be explained otherwise; typical are exhaustion, shortness of breath and difficulty concentrating. Best supported, with moderate certainty, are cognitive behavioral therapy, combined physical and mental rehabilitation and carefully dosed training. Anyone who experiences a crash after exertion needs pacing instead of pushing through. For device-based procedures such as hypoxia training or hyperthermia there are first signals but no randomized trials, and a therapy that regenerates mitochondria is not supported.

What Long Covid is

According to the World Health Organization’s definition, a post-Covid condition is present when, after a probable or confirmed infection, symptoms are present usually 3 months after onset, last at least 2 months and cannot be explained otherwise. The symptoms can be new or remain from the infection, and they can fluctuate or return.

A large review from 2023 estimates that Long Covid occurs after at least 10 percent of infections; worldwide at least 65 million people are affected, and more than 200 symptoms have been described. In some of those affected, the picture resembles that of ME/CFS, a condition with pronounced exertion intolerance.

Exertion intolerance: the decisive point

The cardinal symptom of many severely affected people is post-exertional malaise, PEM for short: after physical or mental exertion the condition worsens, often with a delay and for days. A study from 2024 made this visible. In 25 affected people, muscle samples showed reduced mitochondrial performance, and after an exercise test muscle damage and metabolic disturbances increased.

The German guideline therefore recommends preventing overexertion through well-dosed, if necessary supervised, activity and personal energy management, known as pacing. Training is not forbidden, but it must stay below the individual exertion limit.

Post-Vac

Post-Vac syndrome is the term for persistent symptoms in temporal connection with a Covid vaccination. The symptoms resemble those after an infection, especially the exhaustion. A representative survey in Germany from 2025 shows how difficult it is to separate the two, and urges that other causes such as an undetected depression also be checked. Controlled treatment trials specifically on post-Vac were not found; care follows the same principles as for Long Covid.

How to recognize a reputable offer

It starts with a thorough diagnostic workup that rules out other causes of the symptoms. A good concept asks specifically about exertion intolerance, plans activity below the limit and includes psychological support, without dismissing the symptoms as psychological. Be careful with packages that promise expensive device-based treatments as a cure or increase exertion without regard to PEM.

What is well supported

The best overview is a living systematic review in the BMJ from 2024 with 24 randomized trials and 3,695 patients. With moderate certainty, an online program of cognitive behavioral therapy improved exhaustion and concentration, and a combined physical and mental rehabilitation program led to a meaningful improvement or recovery in an additional 161 of 1,000 patients. Interval training improved physical function more than continuous training.

A second review on exercise programs found short-term improvements in shortness of breath, exhaustion and physical function in 8 randomized trials. Only 1 of 252 participants stopped training because of intolerance. For people without pronounced PEM, dosed training is thus a well-supported building block.

What the studies show

Treatments compared, BMJ 2024

Zeraatkar and colleagues summarized 24 randomized trials on medicines, exercise, behavioral therapy, nutrition and devices. Supported with moderate certainty are online behavioral therapy, combined rehabilitation and interval training. For hyperbaric oxygen, coenzyme Q10, probiotics, respiratory muscle training, brain stimulation and several medicines, no convincing evidence was found.

Muscles after exertion, Nature Communications 2024

Appelman and colleagues deliberately triggered PEM in 25 Long Covid patients and compared them with 21 recovered controls. The patients had lower mitochondrial function in the muscle; after exertion, muscle damage and metabolic values worsened. This explains the exertion intolerance better, but it is not a treatment study.

Hypoxia training in rehabilitation, 2024

Doehner and colleagues gave 145 patients in inpatient rehabilitation either additional intermittent hypoxia-hyperoxia training or standard rehabilitation only. Walking distance in the 6-minute test increased by 91.7 versus 32.6 meters; shortness of breath and exhaustion also improved. Allocation was neither randomized nor blinded.

Where the data stop

A therapy that addresses the cause does not exist; the German S1 guideline states that no causal therapy is known for the exhaustion. For many advertised procedures there are only case series or open-label studies. Hypoxia training lacks randomization; for whole-body hyperthermia there is a retrospective case series from a multimodal clinic program without a control group, whose authors themselves call for randomized trials. For immunoadsorption, lipid apheresis and hyperbaric oxygen, the guideline strongly advises against general use outside of trials.

The reduced mitochondrial function is a real finding, but a treatment that demonstrably regenerates it in Long Covid does not exist. It is also unclear which measures help people with severe PEM. Most studies are small, short and use different definitions.

Status, approval and legal

Since 2023 there has been a Long COVID directive of the Federal Joint Committee (G-BA), which explicitly also includes ME/CFS, similar conditions and post-Vac syndrome. It regulates coordinated care: usually the general practice is the first point of contact, draws up an individual treatment plan and involves specialists; specialized outpatient clinics look after the most severely affected. This has been billable since January 1, 2025. In addition, since June 11, 2026 four active substances recommended by an expert group have been included in the Pharmaceuticals Directive for use outside their marketing authorization. Device-based treatments such as hyperthermia or hypoxia training, by contrast, are usually paid out of pocket.

Safety

The greatest avoidable risk is overexertion. Anyone who crashes with a delay after exertion should plan activity according to the pacing strategy and build up training only carefully and under supervision. Every treatment should be preceded by a medical workup that checks other causes of the symptoms, including depression. For expensive treatment packages without study evidence, a second opinion is worthwhile, especially when a quick cure is promised.

Frequently asked questions about Long Covid & Post-Vac

When is it called Long Covid?

According to the World Health Organization’s definition, when symptoms are present usually 3 months after an infection, last at least 2 months and cannot be explained otherwise. Typical are exhaustion, shortness of breath and difficulty concentrating.

Which treatment helps with Long Covid?

Best supported are cognitive behavioral therapy, combined physical and mental rehabilitation and carefully dosed interval training. A therapy that addresses the cause does not exist yet. Treatment is guided by the symptoms.

What is PEM and why is pacing important?

PEM means that the condition worsens after exertion, with a delay and often for days. Pacing means dividing up one’s own energy so as to stay below this limit. The German guideline recommends exactly that.

Does hyperthermia or hypoxia training help with Long Covid?

There are first positive signals, for hypoxia training from a non-randomized study with 145 patients, for hyperthermia from a case series. Randomized trials are missing; the procedures are experimental and mostly paid out of pocket.

What is post-Vac syndrome?

This is the term for persistent symptoms in temporal connection with a Covid vaccination. They resemble Long Covid and are difficult to distinguish from it. The statutory health insurers’ Long COVID directive explicitly includes post-Vac syndrome.

Does health insurance pay for Long Covid treatment?

Yes, since January 1, 2025 there has been coordinated care via the general practice, with a treatment plan and specialized outpatient clinics for the most severely affected. In addition, since June 2026 four active substances have been approved for use outside their marketing authorization. Device-based treatments are mostly paid out of pocket.

Related

Sources

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Information only, not medical advice and not a usage or dosage recommendation. Prescription-only and unapproved substances belong in the hands of a physician. Last updated: 2026-09-30.