BACKGROUND: Long COVID, characterized by persistent multi-organ symptoms post-SARS-CoV-2 infection, poses a substantial global health burden. While diverse therapeutic interventions have been proposed, their comparative efficacy remains uncertain due to fragmented evidence and methodological heterogeneity in prior studies. METHODS: In this meta-analysis, we searched PubMed, Cochrane Library, Embase, and Web of Science from inception to February 22, 2025, for randomized controlled trials (RCTs) evaluating exercise training, respiratory muscle training, telerehabilitation, transcranial direct current stimulation (tDCS), olfactory training, percutaneous electrical acupuncture-lumbar traction (PEA-LUT), and steroid sprays in adults with Long COVID. Primary outcomes included cardiopulmonary function, exercise capacity, fatigue, and olfactory recovery. Data were pooled using random-effects models, with sensitivity analyses (leave-one-out method) and Egger's test to assess robustness and publication bias. GRADE criteria evaluated evidence certainty. RESULTS: We identified a total of 48 eligible trials, comprising 3558 participants. Significant differences were observed in the following outcomes in the context of exercise training: 6-minute walk test (6MWT) (MD 88.92; 95% CI 56.91 to 120.92), 30-second sit-to-stand test (STS) (MD 3.05; 95% CI 1.96 to 4.13), SF-12 Mental Component Summary (SF-12-MCS) (MD 3.10; 95% CI 0.78 to 5.43), VO2 peak (% predicted) (MD 6.00; 95% CI 0.45 to 11.54), VO2 peak (L/kg/min) (MD 1.65; 95% CI 0.30 to 3.01), VO2 peak (L/min) (MD 0.14; 95% CI 0.03 to 0.25), modified Medical Research Council (mMRC) dyspnea scale (MD -1.39; 95% CI -2.08 to -0.7), and the Multidimensional Functional Assessment of Daily Living Scale (MBDS) (MD -4.34; 95% CI -6.90 to -1.78). Furthermore, significant differences were also found in the following key outcomes: 6MWT (MD 89.54; 95% CI 9.86 to 169.23), maximal inspiratory pressure (MIP) (% predicted) (MD 15.79; 95% CI 2.73 to 28.84), MIP (cm H2O) (MD 19.69; 95% CI 10.14 to 29.24), and mMRC (MD -1.02; 95% CI -1.86 to -0.18) in respiratory muscle training; MFIS-physical (MD -2.29; 95% CI -4.36 to -0.22) in transcranial direct current stimulation (tDCS); and TDI Score (MD 4.66; 95% CI 2.16 to 7.15) in percutaneous electrical acupuncture-lumbar traction (PEA-LUT). INTERPRETATION: Exercise training should be prioritized for improving cardiopulmonary function and exercise capacity in Long COVID, supported by high-certainty evidence. Respiratory muscle training and PEA-LUT offer targeted benefits for respiratory strength and anosmia, while tDCS may address fatigue. In contrast, telerehabilitation and steroid sprays lack efficacy, highlighting the need for personalized, symptom-specific approaches. These findings advocate for updated clinical guidelines integrating multimodal therapies and underscore the urgency of large-scale trials to optimize dosing and long-term outcomes.

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