December 02, 2021 5 min read


People with COVID exhibit signs of debilitating fatigue, shortness of breath or cough, muscle or joint aches and pains, reduced balance, chest pain/palpitations and low mood, brain fog, and difficulty with focus and attention that can linger for several weeks and even months. Although a negative test indicates they no longer have the virus, most still suffer from symptoms for days, weeks, and even months afterward. Even those with mild symptoms are surprised by the slow recovery to a 'healthy' normal.

As water specialists, we have been facing many challenges in a post-COVID-19 pandemic recovery. Working with and coaching those in differing stages of recovery requires informative decision-making regarding our programming. The following are some implications and aquatic adaptations for us to consider when programming, teaching, and coaching those clients.


Research shows that most will have at least one symptom that seems to linger, even months later. These may include:

  • Fatigue
  • Shortness of breath or cough
  • Muscle or joint aches and pains
  • Reduced balance
  • Chest pain/palpitations
  • Low mood, brain fog, difficulty with focus and attention


The number of post-COVID-infected persons still suffering from ongoing symptoms is growing exponentially as recovery data is being collected. SARS-CoV-2 (Coronavirus) can affect the brain, causing neuroinflammation of several systems throughout the body, resulting in chronic fatigue (Pan et al. 2020).

In an international survey published in May 2020, the most frequent symptoms reported were fatigue, post-exertional malaise (PEM), and cognitive dysfunction, otherwise known as brain fog. Researchers call This condition 'Long COVID,' and those affected are called 'long haulers.' Long COVID describes signs and symptoms lasting longer than four weeks after contracting COVID-19, with many people having symptoms for far longer.

Long Covid symptoms are quite similar to those diagnosed with Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome or ME/CFS. The following are typical of long covid and share similarities to persons diagnosed with ME/CFS.

  • Cardio-respiratory inflammation and breathlessness
  • Chronic fatigue syndrome – unexplained muscle and joint pain, headaches, flu-like symptoms
  • Post-exertional malaise (PEM) – "Crash and Collapse" after doing too much
  • Psychological changes – mood, sleep, appetite, motivation

There are notable abnormalities in both long COVID and ME/CFS that diminish energy production within the cells' organelles due to neuroinflammation within the brain (hypothalamus and pituitary glands), resulting in the reduction of transport of metabolic signaling cytokines used to fight the disease. According to the Centers for Disease Control and Prevention (CDC), neuroinflammation produces impaired energy production, a post-exertional malaise characteristic in persons with ME/CFS. Persons with ME/CFS may experience a crash or collapse for days, weeks, or months. Among other immune and brain responses to inflammation, the mitochondria (powerhouse) in cells are afflicted by the disease, become dysfunctional, and ATP energy production depletes during physical exertion.

Muscle Weakness

A return to physical activity is recommended when Post-exertional malaise has subsided and the person feels ready to participate, as in Chronic Fatigue Syndrome. Coronavirus infection affects people differently, from mild to severe symptoms replicating ME/CFS. The recovery rate depends on the individual's tolerance for physical overload (CDC). A participant's prior health and present physical condition should always be considered when an aquatic program is provided or recommended.


One of the main symptoms of long Covid is breathlessness. This can happen even if you were not treated in hospital. Controlled, rhythmical breathing can support lung function and help mindfulness as well as relieve anxiety common during this pandemic.


  • Revitalise muscle function
  • Improve respiratory capacity
  • Lower the risk of mental health issues arising from restricted mobility
  • Facilitate individuals in resuming their regular lifestyles


A few of the benefits of practicing water therapy during post Covid-19 recovery include:

1. Water's natural viscosity provides resistance to body movements and chest expansion, expediting the strengthening of breathing muscles and limb and trunk muscles.

2. The buoyancy and fluidity properties of water ensure smooth and effortless movements.

3. The constant hydrostatic pressure exerted by water aids in enhancing blood circulation.

4. Aquatic settings accommodate individuals with mobility or balance issues on land, granting them the freedom to move more independently.

5. Buoyancy creates a weightless sensation in water, reducing the impact of gravity and resistance on body movements, thereby improving mobility.

5. For those experiencing breathlessness, swimming can assist in better breath control. Swimming can expand lung capacity and improve the efficiency of oxygen processing, which is beneficial for individuals with long COVID, characterized by chronic inflammation affecting the respiratory system. Swimming, known to benefit those with asthma, is now recognised as a valuable activity for long COVID patients seeking to enhance their post-COVID breathing function.


In a new study, researchers sought to explore the difference in rehabilitation effects between water and land-based aerobic exercise. After reviewing 1311 cases, it was concluded that water-based aerobic exercise significantly improved endurance exercise capacity compared to land-based aerobic exercise. Compared with land-based aerobic exercise, water-based aerobic exercise had a significant additional effect in enhancing the endurance exercise capacity of patients. Thus assisting greatly in post-COVID recovery and long Covid management and rehabilitation.


The following adaptations are based on a model created by a panel of doctors and sports and exercise science, medicine, and rehabilitation professionals. The adaptations are provided as a pragmatic approach and a simplistic guide to help post-COVID recovering participants in our aquatic classes regain stamina and return to healthy normal or better pre-COVID wellness. Recommended is a gradual increase in duration and frequency with intensity tolerable by the participant. The participant can adopt program modifications, regressions, and progressions to water exercise movement and intensity throughout each recovery phase.

Adapted for water exercise (BORG Scale of Intensity Rate of Perceived Exertion 1-10)

Phase 1

Focus: Preparation for purposeful water movement with coordination such as water walking, breathing exercises, flexibility and ROM, and balance. Very light intensity. RPE 1-3, as tolerated.

Pragmatic Approach:  Simple stretching. Shallow water walking forward, backward, sideways. Simple arm patterns slicing hand positions. Aquatic breathing and balance exercises.

Phase 2

Focus: Prep and base with light-intensity exercise, preparing the body for gradual water fitness acclimation and intensity continuum. Basic elements of moves, moving more water with purpose RPE 3-5, as tolerated.

Pragmatic Approach:  Shallow water Level II & III and Grounded moves, jog, jack, ski, tuck, twist, Wavemaker 6-7 method, dynamic balance, 2-3 days a week for 10-30 minutes.

Phase 3

Focus: Base to build. Light-moderate intensity with emphasis on cardiovascular and muscle endurance.

Pragmatic Approach:  Longer work intervals with equal amounts of rest/recovery, neuromotor challenges, simple choreography with resting movement sequences, and buoyancy equipment balance challenges. Shallow or deep formats. RPE 5-7. 1-2 classes per week, working up to 30-45 minutes per class.

Phase 4

Focus: Build to moderate-vigorous intensity, Gradual increases in cardiovascular load, endurance, and muscle strength.

Pragmatic Approach: Various aquatic formats including, but not limited to, swimming, aquatic jogging, aquatic biking, aquatic pole, aquatic mat/board, circuits, HIIT (ratios 3:1, 2:1, 1:1), add-on and layered choreography, buoyancy and resistance equipment challenges. RPE 6-8. 2-3 weekly classes, BUILDING up to 45-60 minutes.

Phase 5

Focus:Return to healthy 'normal' pre-COVID water exercise stamina.

Pragmatic Approach:  Able to participate in a variety of water exercise formats. Perceived Rate of Exertion ranging from Very Light to Vigorous (PRE 1-10). Shallow-water, dual depth, and deep-water exercise class participation, 2-5 days per week, 60 minutes or more.


Now borders have opened, the number of post-COVID recovery participants in our classes will grow in the coming months, with most of the population getting COVID at least once. A pragmatic staged approach is required to lead recovering individuals in our classes on their recovery journey to normal or better health with aquatic exercise. In the case of long COVID sufferers, Aquatic professionals can work with and help a unique population and work through individual cases with medical professionals to help these sufferers manage the symptoms and improve their quality of life.

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