Recent updates on COVID-19 include a successful rehabilitation pacing program for people with postexertional symptom exacerbation (PESE) as the result of physical, cognitive, or emotional exertion in patients with long COVID, a possible blood marker of postvaccine myocarditis, and the launch of the first at-home test-to-treat program.

Pacing Protocol Reduces Long COVID Symptoms

Patients with long COVID showed a clinically significant reduction in crashing episodes using a 6-week structured pacing protocol for rehabilitation, according to findings from a prospective study published in the Journal of Medical Virology.1,2

The researchers investigated whether using the World Health Organization (WHO) Borg CR-10 5-phase pacing protocol for 6 weeks could reduce PESE that occurs as the result of physical, cognitive, or emotional exertion in patients with long COVID. The goal of the pacing protocol is to manage the intensity of daily activities to avoid triggering PESE by returning to normal exercises gradually through 5 weekly phases that start with breathing exercises, gentle stretches, and balance exercises. 

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The study included 31 people (mean age, 47 years; 71% female; 90% White) who had experienced long COVID symptoms for a median of 17 months at baseline. Participants were provided with the pacing protocol and received weekly telephone calls from a clinician who administered a PESE questionnaire. Based on the questionnaire responses, the clinician advised each patient on their target activity level for the next week. The most commonly reported long COVID symptoms were fatigue, cognitive dysfunction, breathlessness, headache/migraine, palpitations, and musculoskeletal aches/pains/weakness.

The participants showed a significant reduction in the average number of PESE episodes (from 3.4 to 1.1) by Week 6. An average decrease in PESE episodes of 16% (95% CI, 9%-24%; P <0.001) was found each week, and reduction across all 3 exertional triggers (physical, cognitive, and emotional) was reported. Improvements in physical activity levels and quality of life were also noted.

“When patients get a crash, they experience feelings of complete exhaustion and wipe out and are unable to resume activities for hours or sometimes days,” explained coauthor Manoj Sivan, MD, associate clinical professor in the School of Medicine at the University of Leeds. “The findings of this research are exciting because this is the first time that crashing episodes have been used as a marker for the condition and a structured pacing program has now been shown to substantially reduce symptoms and improve quality of life.” 

Potential Blood Marker of Myocarditis Post-COVID-19 Vaccination Identified

Elevated levels of spike protein were found among adolescents and young adults who developed myocarditis after receiving the COVID-19 vaccine, according to data from a prospective study published in Circulation.3 The findings may lead to new strategies to improve outcomes in patients with the rare complication of postvaccination myocarditis, the study authors noted.

“Understanding the mechanisms that drive postvaccine myocarditis could guide vaccine development in the future and give us important insights about the immune response,” said coauthor David Walt, PhD, a professor in the Department of Pathology at Brigham and Women’s Hospital.4 “This was a precious sample set because these cases are so rare. We studied them in great depth, which led to an interesting finding that could guide treatment strategies to reverse postvaccine myocarditis.”

Researchers prospectively collected blood from 16 patients hospitalized at Massachusetts General for Children or Boston Children’s Hospital for myocarditis after SARS-CoV-2 vaccination. The analysis showed no differences in mRNA vaccine-induced antibody and T cell responses among patients who developed myocarditis compared with 45 healthy asymptomatic, age-matched vaccinated patients (control group).

The only difference between the groups was that patients with myocarditis showed free full-length spike protein (33.9±22.4 pg/mL) in their plasma that was unbound by antibodies; free spike protein was not found among patients in the control group (unpaired t test; P <0.0001). “Thus, the spike antigen itself, which evades antibody recognition rather than invoking immune hyperactivation, may contribute to myocarditis in these individuals,” the study authors wrote.

Myocarditis is estimated to occur in 18 out of every 1 million vaccine doses administered, typically in adolescent and young adult men within several days of mRNA COVID-19 vaccination. Most cases are mild and self-limited. The risk for heart complications (myocarditis plus multisystem inflammatory syndrome) is markedly higher following COVID-19 infection compared with after vaccination in both adolescent boys (2 to 6 times higher) and young men (7 to 8 times higher).

“While this finding helps us better understand this potential complication, it does not alter the risk-benefit ratio of receiving the COVID vaccines,” said lead author Lael Yonker, MD, a pediatric pulmonary medicine specialist at Mass General for Children.4 “The incidence of myocarditis and other heart-related complications among children infected with SARS-CoV-2 is much higher than the risk of postvaccination myocarditis.”

The findings are limited by the small sample size and the inability to draw cause-and-effect conclusions.

COVID-19 At-Home Test-to-Treat Program Launched

The National Institutes of Health launched the first at-home test-to-treat program that will provide free COVID-19 health services — at-home rapid tests, telehealth sessions, and at-home treatments — in selected communities.5 The program will make antiviral treatment available for eligible individuals who receive a positive COVID-19 test result.

Berks County, Pennsylvania, will be the first to pilot the home test-to-treat program in January 2023. Up to 8000 eligible residents are anticipated to participate in the program.

“At-home testing for COVID-19 is now widely available in the United States, as are antiviral treatments, and this program combines easy home access to both,” said Bruce Tromberg, PhD, director of the National Institute of Biomedical Imaging and Bioengineering (NIBIB) at the National Institutes of Health and leader of the Rapid Acceleration of Diagnostics (RADx®) Tech program. “The Home Test-to-Treat program allows those who are sick an alternative to venturing out for testing or treatment, potentially reducing the spread of COVID-19 in the community.”

Telehealth services provider eMed will implement the program by hosting a website where participants can sign up for the program, report symptoms, and coordinate telehealth-enabled test kits, and receive telehealth and antiviral treatment delivery.


1. Parker M, Sawant HB, Flannery T, et al. Effect of using a structured pacing protocol on post-exertional symptom exacerbation and health status in a longitudinal cohort with the post-COVID-19 syndrome. J Med Virol. 2023;95(1):e28373. doi:10.1002/jmv.28373

2. Impressive results with long COVID pacing trial. News release. University of Leeds; December 17, 2022. Accessed January 9, 2023.

3. Yonker LM, Swank Z, Bartsch YC, et al. Circulating spike protein detected in post-COVID-19 mRNA vaccine myocarditis. Circulation. 2023 Jan 4. doi: 10.1161/CIRCULATIONAHA.122.061025

4. Researchers study immune response, proteins in blood of young adults who develop rare complication after COVID vaccination. News Release. Mass General Brigham; January 4, 2023. Accessed January 9, 2022.

5. NIH launches Home Test to Treat, a pilot COVID-19 telehealth program. News release. National Institutes of Health; January 5, 2023. Accessed January 9, 2023.