A New Type of Massage Client: COVID-19 “Long-Haul” Survivors

COVID-19 survivors who experience long-term symptoms—often called long-haulers, with the condition itself termed Long COVID Syndrome—are a type of client who could increasingly show up on your massage table.

Some research has indicated an estimated 10% of recovered COVID-19 infections produce longer-term symptoms, while other research puts that number at 30%. That latter study, from the University of Washington, states that close to one-third of COVID-19 survivors report “worse health and quality of life” than before their COVID-19 diagnosis, while 8% report they are no longer able to do such normal tasks as “lift heavy objects, or stand or walk unassisted for more than a short period of time.”

Typical long-haul symptoms range from mild to debilitating fatigue, headaches, breathing difficulties, coughing, heart palpitations, joint or muscle pains, loss of taste and smell, digestive issues, mood changes, dizziness and brain fog, according to the Centers for Disease Control and Prevention.

With Delta and other, newer COVID-19 variants emerging, there will likely be an even larger population of clients dealing with long-haul COVID-19 symptoms. 

I have worked with about 40 clients who had been infected with COVID-19. Of these, a dozen have complained of mild, lingering symptoms, and at least three have complained of debilitating long-term symptoms. While massage therapy cannot always help alleviate such symptoms, there are several that can be helped with massage. 

The obvious ones to look out for are joint-and-muscle pain and headaches. Clients presenting with these conditions are very likely to find relief with massage therapy. Breathing difficulties, coughing, digestive issues, dizziness and brain fog may also be helped. In my opinion, often these issues involve a protective stress response to the situation. Massage therapy can help re-teach the client’s nervous system so it can release the protection. 

Be on the lookout for clients complaining about any of these conditions and let them know you may be able to help. 

Functional vs. Structural Symptoms

When a client’s symptoms have largely functional sources (nervous system firing muscles inefficiently), massage therapists can provide great relief. If symptoms have largely structural sources (damaged or malformed tissues), massage might be able to help. However, massage may be contraindicated at first and clients will also need to work with physical therapists and other specialists. As with any client, if someone presents with a condition you don’t feel is within your scope or education, refer out.

Here are some examples of how symptoms can have functional sources. Many of these will be related to the stress response from getting and surviving COVID-19:

  • Joint and muscle pain from protective compression
  • Headaches due to jaw clenching and teeth grinding
  • Coughing due to tight sternocleidomastoid (SCM) muscles
  • Breathing difficulties due to overtired diaphragm and intercostal muscles

Here are some examples of symptoms that have structural sources:

  • Breathing difficulties due to damaged lung tissue
  • Headaches due to neurological damage or degeneration 
  • Loss of taste or smell due to neurological damage or degeneration
  • Digestive issues due to damage to GI lining 

Long-Haul Condition: Overworked Breathing Muscles

The COVID-19 virus replicates by fusing with ACE2 receptors and in the process destroys the healthy cells it invades. These receptors are found in many tissues in the body, including the lungs, heart, blood vessels, kidneys, liver and gastrointestinal tract. However, the easiest pathway into the body for the virus is through the air and into the lungs. 

As the lung tissues are damaged, they fill up with fluid and debris, causing pneumonia. This makes it harder and harder to process oxygen from the air you breathe. As difficulty increases and the diaphragm fatigues, you compensate by recruiting ancillary breathing muscles to inhale and exhale. These can include intercostals, scalenes, SCM, pectorals, trapezoids, abdominals and serratus sets.

As with any protective compensatory muscular pattern, the longer the pattern is used, the more the body treats it as “safe.” In this case, it learns to breathe using ancillary muscles as “safe.” Without intervention to teach the brain that normal, relaxed diaphragmatic breathing is OK, it may never return to fully relaxed breathing. 

Relaxed breathing should involve a noticeable expansion and contraction of the ribcage. It also does not always have to be deep, despite what we hear in wellness cultures. Efficient breathing is relaxed, doesn’t take conscious effort, and only takes as much air as is needed for whatever activity the person is engaged in. 

If you haven’t learned to work directly on diaphragm and intercostals, now is a great time to learn ways to release those muscles. In addition, releasing the ancillary muscles listed above is equally important. 

One technique I use a lot is light compression of the abdomen with my palms after working directly on the diaphragm. Lightly taking away the ability to use the abdominals for respiration makes the brain have to figure out another way to inhale and exhale. It should choose the diaphragm as the obvious muscle to recruit. This helps the brain relearn that diaphragmatic breathing is safe again.

However, if the brain isn’t ready to trust the diaphragm yet, this may induce feelings of panic and anxiety. Go easy at first and slowly increase the length of time you hold the abdominals in each session. It may take several sessions to restore easy movement in the ribcage. 

“I was having a very difficult time breathing deeply post-COVID-19 and had been unable to exercise,” related one long-haul client, David (name changed), whose symptoms included post-traumatic stress disorder and chronic stress. After receiving massage therapy and working with a respiratory therapist, he added, “I’m back in the gym. I’m not back to 100% yet, but am steadily improving and feel that I will make a full recovery.”

In Some Ways, We Are All COVID-19 Survivors

This crisis has affected every single client I’ve seen in the past 20 months, whether they contracted COVID-19 or not. Many clients are unaware they are exhibiting low-to-medium chronic stress and PTSD symptoms. These can show up as headaches, fatigue, brain fog, digestive problems and muscle hypertension. (Notice the overlap between chronic stress and PTSD symptoms and long-haul COVID-19 symptoms.)

Chronic stress and PTSD share many traits and symptoms. An easy distinction is that chronic stress is when a body is stuck in its sympathetic nervous system (fight or flight) and can’t easily switch to its parasympathetic system to restore. PTSD differs in that a client can swing from sympathetic to parasympathetic in uncontrollable and unpredictable ways. 

For clients who contracted COVID-19 and recovered, a PTSD or chronic stress reaction is even more likely. COVID-19 is still a new virus. While we are learning more and more about it, its short- and long-term effects are unpredictable. Contracting the virus means not only dealing with the physical symptoms, but also not knowing what the virus will do to you in the long term. In short, it can be super scary! 

Massage can assist clients to restore balance between their sympathetic and parasympathetic systems. Basic techniques that release muscle tension, promote circulation and soothe the nervous system all signal safety and give the body space to induce its parasympathetic responses. Advanced techniques such as direct psoas and diaphragm releases, ancillary breathing muscle releases, and breathwork can have even more profound results.

If you’ve been avoiding these more advanced techniques in your practice, now is a great time to learn some and start incorporating them into your work with clients. All of your clients will thank you and you will be able to serve a much wider pool of people in your area!

Long-Haul Condition: Compensating Muscle Patterning

A “mild” case of COVID-19 can mean days to weeks of grueling fatigue, breathing difficulty, fever and whole-body aches. If a client was hospitalized, at minimum they were bedridden for several days to weeks. At worst they might have been bedridden and intubated for weeks to months. 

For clients recovering from COVID-19 there will be all sorts of breathing compensations to address. Clients will favor ancillary breathing muscles due to an overworked diaphragm. Pay particular attention to the serratus anterior, posterior superior and posterior inferior. These muscles’ main function is for forced exhalation (i.e., coughing). These muscles will likely be stuck in hypertension due to long bouts of coughing and also being used for breathing. 

In addition, chronic hypertension is likely throughout the muscular system. The fight to expunge the virus results in long bouts of fever and sweating, dehydration, stress and inaction due to fatigue. There will be a lot to unwind, and it will take time for their system to fully recover.

I’m known for doing mostly focused work in my practice; however, I’ve had to adjust this predilection and start with more full-body sessions for stress reduction and relaxation. Most clients seem to need a full-body session or two to help get out of crisis mode before they can handle more focused work. 

We can follow up with sessions that involve more focused work on breathing musculature, hips, shoulders, neck and jaw. As clients ease back into a normal routine, including exercise, we also need to follow up with any injuries that crop up if they try to push too hard too fast in their recovery. 

Helping guide clients through the process step-by-step and supporting them taking time for their recovery to avoid new injuries is a particularly valuable service we can offer. 

Another client, Christina (name changed), said her massage team has “become an integral part of my support system in recovering from these long-haul symptoms”—not only due to the relief from fatigue, mysterious muscle soreness and general stress related to the illness, but also because of the therapeutic space that allowed her to feel comfortable talking about how difficult being sick has been.

Long-Haul Condition: Headaches

Headaches can come from a wide variety of sources, but are basically of two main types: tension headaches and migraines.

With tension headaches, the source comes from a functional pattern of muscle tension. These broadly include jaw muscles, neck muscles and shoulder muscles. Since the source is muscular, massage can be very helpful in not only relieving symptoms but also in relieving the root causes and providing a long-term solution. 

Migraines have a neurological source that triggers a severe tension headache. In general, massage can usually help relieve symptoms; however, the root cause needs a specialist to determine if medication or specialized therapy is warranted. Massage can help to raise the threshold before the migraine triggers, mostly by relieving the long-term buildup of tension from multiple episodes. 

With COVID-19, headaches might be simply due to muscle tension and chronic stress. However, COVID-19 has known neurological effects. Clients who never previously suffered from migraines may now be having them after contracting the virus. If a client is having severe headaches, definitely encourage them to speak to a neurologist. Even mild headaches that keep recurring despite multiple massage sessions are worth a visit to a specialist to rule out a neurological source. 

For all headache sufferers, basic muscular sources to look into can include the external jaw muscles, scalenes, SCM, traps, levator scapula, suboccipital and frontalis muscles. Any of these can either directly be causing achy pain or be referring pain to the head from trigger points or compressed nerves. 

More advanced techniques to learn and incorporate, where allowed by scope of practice, are inner mouth work on the medial and lateral pterygoids, release of the hyoid muscles, working behind the trachea on longus colli and capitis, and detailed rebalancing of cervical vertebrae rotatores and multifidus muscles.

Any of these advanced techniques will help you serve a much wider variety of client issues.

Expect COVID-19 Survivors in Your Practice

Too often in online discussions on whether we can “massage a client with _____,” I see many massage therapists immediately shying away from giving treatment—and sending clients away to more “established” medical professionals such as physical therapists and orthopedists before even considering working with them. 

We absolutely should be doing a thorough intake to rule out contraindications and sometimes massage really isn’t contraindicated. But I often hear massage therapists basically assuming massage is contraindicated when a client comes in with some medical-sounding term. 

We do ourselves and our clients a disservice when we rule out massage even though there aren’t any actual contraindications present.

Clients who have recovered from COVID-19 and are past the indicated quarantine period potentially have a host of issues that can be helped with massage therapy—and helping these people recover and return to normal activities can be highly rewarding. Given the wide-ranging spread of COVID-19, it’s likely you’ll run into clients who are recovering from long-haul COVID-19 symptoms. I highly encourage you to learn everything you can about working with this growing population and open your practice to this growing clientele. 

About the Author:

David Weintraub, LMT

David Weintraub, LMT, owns Bodyworks DW Advanced Massage Therapy, a pair of medical massage studios in New York, New York. Bodyworks DW, a National Certification Board for Therapeutic Massage & Bodywork-approved continuing education provider in New York and nationally, is designed to support talented new massage therapists in attaining the skills needed to be successful professional therapists. His courses offer training on advanced technique, assessment and treatment design, and rebooking practices. 


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