About 10% of Covid-19 sufferers continue to have symptoms three months or more after the initial disease. But what are the causes of Long Covid symptoms? Scientists are scratching their heads over who is at risk of Long Covid and why, what is going on in the physiology that explains the wildly diverse and strange symptoms and how best to help people improve their health. We don’t have all the answers yet but here’s our take on it from an osteopathic perspective, having read a ton of research and treated a number of Long Covid patients.

Immune System

The way the immune system reacts to the SARS-CoV-2 virus is unusual and complex. It seems to trigger an over-reaction and this is more exaggerated in women than men, making them twice as likely to get Long Covid. It’s more like an allergic reaction or an autoimmune response, where the immune system attacks things that are harmless or that are part of us. This provokes body-wide inflammation and causes Long Covid symptoms such as coughing, fatigue, aches and pains, abdominal pain and skin rashes.

Antihistamines (such as cetirizine or fexofenadine) may be useful in helping to improve these symptoms but there haven’t been any large scale trials yet. Always check with your GP or pharmacist to make sure any new medication you want to take isn’t going to affect your existing medications. Ordinary ways to support your immune system include a healthy diet, with plenty of fresh fruit and veg, and supplements such as vitamin C and zinc.

Lining of the blood vessels

The vascular endothelium – the lining of every blood (and lymphatic) vessel from inside the heart to the tiniest capillaries in your brain or your foot and everything in between – is irritated by Covid-19 and this disturbs its normal activity. Normally it acts like another nervous system in your body, deciding what needs to be exchanged between the vessels and tissues, regulating blood supply and drainage, preventing clotting and working with the immune system, the gut and the autonomic nervous system to manage your physiology. It all starts to go wrong when there is inflammation everywhere and that’s why in Long Covid we see micro clots and symptoms affecting any and every part of your body. Brain fog, fatigue, heart problems, lung and kidney problems, etc. most likely stem from endothelial inflammation.

To support blood vessel health cut your sugar intake (it’s the biggest single cause of inflammation) and eat a healthy diet as mentioned above. Did you know that one of the founding principles of osteopathy, stated in 1874, is that “the rule of the artery is supreme”? It’s a quaint way of saying that if your blood vessels are unhealthy that is the start of all ill health. We’re just catching up with this idea today!


Dysbiosis is a term meaning ill health in the gut microbiome – those friendly bacteria that make up the majority of cells in our body. They don’t just aid digestion, they are intimately involved in the immune system, endothelial health and even our mental health. Did you know you also have a microbiome in your lungs? And the bacteria in the lungs and the gut talk to each other? Lots of exciting discoveries recently! Anyway, our poor little friends are attacked by SARS-CoV-2 and that disrupts all their amazing activity. This contributes to the already disturbed state of the immune system and endothelium as described above.

Eat healthy food, take a multi-strain probiotic, breathe fresh air. You know those veg that make you fart? The brassicas – sprouts, broccoli, cauliflower, cabbage – they really help your gut because that awful smell they produce (hydrogen sulphide) helps the endothelium to do its job AND they’re fibrous which helps the microbiome.


Well, the thoracic diaphragm to be precise – that great dome of muscle that divides your chest from your abdomen. It’s as important to your gut below it as it is to your lungs above it, allowing the lungs to fill and empty and gently massaging the gut with every breath. In Long Covid patients it doesn’t seem to be working very well, and that means the lungs don’t work properly and neither does the gut. See how interconnected it all is? Your oxygen uptake is reduced (because of the diaphragm and because lung cells are attacked by the virus) so it feels like you are trying to function at high altitude AND the blood vessel lining is damaged so the transfer of oxygen and nutrients is impaired. No wonder you feel fatigued and can’t concentrate!

One way to exercise the diaphragm without tiring your whole body is to breathe out for longer than you breathe in –  try counting to 3 as you inhale and counting to 5 as you exhale. Lengthen the breath to counts of 7 ‘in’ and 11 ‘out’ if you can. Another exercise is to breathe out through a straw in a glass of water. Try it a few times and see if that helps your breathing and energy level.

Autonomic Nervous System (ANS)

The ANS is the thing that does all the background jobs like regulating blood pressure, heart rate, temperature, blood supply, immune response, digestion, etc. so that you don’t have to think about it consciously. But it’s more than that – it’s a safety system that operates from ‘fight or flight’ at one end of the spectrum to ‘rest, digest and repair’ at the other end. (Have a look at the work of Stephen Porges for more on this). You might have heard of the vagus nerve – the wanderer? It starts in the brain and then extends down through the body. It has a sensory aspect that picks up on safety cues in the environment – smiling faces, hugs, reassuring voice tone, pleasant aromas and such like. It also has an action side, affecting our response to these cues, raising or lowering blood pressure, sending blood to the large muscles or to the gut depending on whether it’s safe to rest, among many other physiological responses. Covid-19 messes with the ANS, contributing to symptoms such as dizziness, headaches, fatigue, taste and smell alterations, swallowing difficulty, bladder and bowel problems, feeling faint when you get up (orthostatic hypotension), racing heart rate (orthostatic tachycardia), palpitations, shortness of breath, change in voice and anxiety.

The ANS interacts with all the other systems in the body, including the hormones, immune system, blood vessels, organs, muscles, joints and skin. So, when it is disturbed, the whole person is affected.

Balancing the ANS can be helped by the measures already mentioned above, plus mindfulness meditation and slowing your breathing. Focus on using the diaphragm to breathe, rather than the muscles in your upper chest. You can put a hand on your chest and a hand on your belly and then breathe so that only your belly hand moves with the breath. You could also try massaging those little muscles that connect the back of your skull to the top of your neck (suboccipital muscles) which stimulates the vagus nerve. They’re often really tight, due to poor posture at our desk when we sit forward and poke our chins out. Sit up, with your back against the chair back, and drop your chin down to give these muscles a break. You can also massage the tragus and the cymba conchae of the ear to stimulate the vagus nerve.

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