Exercise and the Covid-19 pandemic
The purpose of this guide is to help older adolescent athletes (such as high school athletes), recreational adult athletes, laborers, and tactical personnel to safely return to previous levels of activity after being infected with Covid-19.
The state of exercise levels before, and during the pandemic
The pandemic due to the coronavirus disease 2019 (Covid-19), has impacted many factors of daily life, including physical activity. The Centers for Disease Control (CDC) recommends that adults perform 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week.2 Prior to the first noted cases of Covid-19, many US adults did not perform the recommended amounts of daily physical activity. With social distancing measures, and other precautions taken to help prevent the spread of Covid-19 levels of physical activity further declined. By some estimates, the exercise levels of adults in the United States decreased by 32%-48%3,9
Physical inactivity is linked to many chronic diseases such as obesity, diabetes, and heart disease. People with these comorbidities are at further risk of complications from Covid-19. Many people who have had Covid-19 may want to resume a particular level of physical activity. This may be due to the protective effect that exercise has against many chronic conditions, or because the individual was previously physically active, or both. However, there are many questions regarding how and when to resume physical activity after Covid-19.
Even mild cases of Covid-19 can leave one feeling weak, and with a loss of balance and endurance. These symptoms can in part be due to the pathology of the disease, as well as time off from regular activity to recover from disease symptoms.
The difficulty in constructing guidelines
As there is constantly new information regarding Covid-19, forming concrete guidelines can be difficult. Many of the available guidelines use a risk stratification approach to making recommendations on return to activity. That is, taking into account any previous co-morbidities as well as the severity of Covid-19 when guiding individuals on making a return to previous activity levels.
The duration of Covid-19 symptoms can also help to categorize individuals to help provide them with more appropriate information. Of concern with Covid-19 are those who suffer from either post-acute Covid-19 or chronic Covid-19. These individuals may be described as having long Covid.
Post-acute Covid-19 is defined as symptoms extending beyond 3 weeks from the first onset of symptoms. Chronic Covid- 19 is defined as symptoms extending beyond 12 weeks of the first onset of symptoms. Symptoms of post-acute and chronic Covid-19 can vary but may include:1
- Cough
- Low-grade fever
- Fatigue
- Shortness of Breath
- Chest pain
- Headache
- Neurocognitive difficulties
- Muscle pains and weakness
- GI upset
- Rashes
- Metabolic disruption (such as poorly controlled diabetes)
- Thromboembolic conditions
- Depression and other mental health conditions
- Skin rashes
Covid-19 can present with a multitude of symptoms, affecting various body systems. Some of the systems most commonly affected with Covid-19 include the cardiac, pulmonary, renal, and neurological systems. Return to activity should take into consideration the impact of Covid-19 on each of these systems.
Cardiac system
In patients hospitalized with Covid-19, cardiac morbidity is a significant concern. In earlier strains of Covid-19 up to 22% of hospitalized patients had demonstrated acute cardiac injury. Acute cardiac injury is defined as having troponin levels higher than the 99th percentile, electrocardiographic, and/or echocardiographic abnormalities. Other cardiac concerns include myocarditis, which is the inflammation of the middle layer of tissue surrounding the heart. Myocarditis could result in arrhythmias (irregular heartbeat), cardiac dysfunction, and death.7
Those with persistent dyspnea with activity, that is a shortness of breath with activity that persists three to six weeks after the first onset of symptoms may also benefit from an evaluation for myocarditis.
Pulmonary system
The lungs are most commonly affected by Covid-19. Individuals who survived severe disease may experience persistent pulmonary symptoms such as acute respiratory distress syndrome (ARDS), and Covid-19 pneumonia. Individuals who experienced severe pulmonary symptoms due to Covid-19 may want to consult with a pulmonologist or other clinician with experience in treating the pulmonary system. Some relevant tests may include imaging such as a chest x-ray, or computed tomography (CT); pulmonary function tests; or functional testing such as the six-minute walk test, or one-minute sit-to-stand test.6
Renal system
Acute kidney injury (AKI) has been noted in some Covid-19 patients. Many of these patients presented with symptoms such as hematuria (blood in the urine), proteinuria ( protein in the urine).
Proper hydration can help to recover from Covid-19 related acute kidney injuries. Avoidance of nephrotoxic medications can also help; however, one may need to follow medical guidance as some nephrotoxic medications include ACE-inhibitors (medication used to treat hypertension), antibiotics, and anti-virals.
While recovering athletes may also experience other complications such as fatigue, cognitive dysfunction, and blood clotting disorders, there are currently no guidelines specific to athletes.
There are no guidelines for return to sport or return to activity that are evidence-based. The available guidelines are based upon expert opinion. These consensus statements recommend a [risk stratification] approach to return to activity. That is, using factors such as the athletes’ age, prior comorbidities, and severity of Covid 19 disease to determine a progression for return to activity.6
Return to activity/ sport guidelines
For asymptomatic, or mild cases of Covid 19 without comorbidities of being a high-risk cardiac case, or having cardiac disease: Recommended return to exercise after at least seven days of being asymptomatic. Start with light exercise for the first 2 weeks. Individuals may use self-monitoring such as the Borg Rating of perceived exertion (RPE) scale.
| 6 | No exertion | 14 | |
| 7 | Extremely light | 15 | Hard (heavy) |
| 8 | 16 | ||
| 9 | Very light | 17 | Very hard |
| 10 | 18 | ||
| 11 | Light | 19 | Extremely hard |
| 12 | 20 | Maximal exertion | |
| 13 | Somewhat hard |
Those recovering are recommended to spend a minimum of 7 days in each phase. Individuals should only move to the next phase then progression criteria are met. One may drop back a phase if they find the current phase to be difficult.
- Phase 1: Preparation for return to exercise
Appropriate activities include breathing exercises, stretching/ flexibility exercises, balance exercises, and gentle walking.
RPE: 6-8
- Phase 2: Low-intensity activity
Appropriate activities include walking, light yoga, light household tasks, and light gardening
RPE: 6-11
Individuals may progress to the next phase when they can walk for 30 minutes at RPE 11
- Phase 3: Moderate-intensity aerobic activity and strength
Appropriate activities may include intervals. Starting with 2 intervals of 5 minutes of aerobic exercise with full recovery between intervals. One may add an interval per day as tolerated.
RPE 12-14
One may progress to the next phase after 7 days, and when they can perform a 30-minute session and feel recovered after an hour of rest.
- Phase 4: Moderate-intensity aerobic activity and strength with coordination and function skills
More vigorous activity than phase 3 with 2:1 ratio of days training to rest days.
Individuals may progress to the next phase after 7 days, and when fatigue levels return to normal.
RPE 12-14
- Phase 5: Return to baseline exercise.
Individuals may return to a regular exercise pattern of RPE >15 as tolerated.
With these guidelines, it is noted that one should only exercise if they feel recovered from the previous day’s activity, and have no new or return of symptoms. Individuals should seek medical advice if they experience shortness of breath that is abnormal for a specific activity level, a return of symptoms, or chest pain.8
Continued monitoring is important
As individuals return to their baseline activity levels, monitoring for “red flag” symptoms of Covid-19 complications as well as overtraining is important. The Australasian College of Sport and Exercise Physicians has recommended that the following be treated as “red flag symptoms,” and warrant referral to a cardiologist, or clinician with relevant experience:
- Chest pain or palpitations
- Breathlessness that is out of proportion with the level of exercise
- A swollen leg, tachycardia (rapid heartbeat), or dyspnea at rest as this may be associated with thrombosis or pulmonary embolism.6
Other factors such as general fatigue, quality of sleep, and muscle soreness should be monitored. These factors may be more indicative of overtraining. Monitoring resting the heart rate of individuals in the morning can also help to prevent overtraining. Increased resting heart rate in the morning by over 10 beats per minute may be a sign of overtraining.3
In addition to monitoring physiological markers, one’s mental health should also be taken into consideration. Some experts site psychological stress in athletes due to declines in physical activity, opportunities to compete, and opportunities to socialize with teammates.5 With this, it may be worthwhile to monitor the mental health of individuals as they return to activity, especially if they have known psychological risk factors such as depression.
Athletes can safely navigate their way back to previous levels of activity. According to the guidelines established thus far, a risk stratified approach is best. Many athletes may be able to follow these guidelines while self monitoring. Due to factors such as pre-existing comorbidities as well as the severity of the disease, some individuals may need to seek the advice of a healthcare provider due to any risks identified.
In time, studies may look more closely at Covid-19 in athletes and active individuals and provide more concrete results.
Citations:
1 (2021, Sept.16). Post-Covid Conditions. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html#print
2 (2022, Mar. 17). How much physical activity do adults need? Retrieved from: https://www.cdc.gov/physicalactivity/basics/adults/index.htm
3 Dressendorfer, R.H.; Wade, C.E.; Scaff Jr., J.H.; (1985) Increased Morning Heart Rate in Runners: A Valid Sign of Overtraining? Phys Sportsmed, 13(8), 77-86
4 Dunton, G.F.; Wang, S.D; Do, B.; Courtney, J. (2020). Early effects of the COVID-19 pademic on physical activity locations and behaviors in adults living in the United States. Preventive Medicine Reports, 20
5 Mehrsafar, A.M.; Gazerani, P.; Zadeh, A.M.; Jaenes Sanchez, J.C. (2020). Addressing potential impact of COVID-19 pademic on physical and mental health of elite athletes. Brain Behav Immun, 87, 147-148
6 O’Conner, F.G.; Franzos, M.A. (2021, Nov. 29). COVID-19: Return to play or strenuous activity following infection. Retrieved from: https://www.uptodate.com/contents/covid-19-return-to-play-or-strenuous-activity-following-infection#H2097903284
7 Phelan, D.; Kim, J.H.; Chung, E.H. (2020). A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection. JAMA Cardiol, 5(10), 1085-1086
8 Salman, D.; Vishnubala, D.; Le Feuvre, P.; Beaney, T.; Korgaonkar, J.; Majeed A.; McGregor, A.H. (2021). Returning to physical activity after covid-19. BMJ, 321
9 Wilke, J.; Mohr, L.; Tenforde, A.S.; Edouard, P. Fossati, C.; Gonzalez-Gross, M.; Sanchez Ramirez, C.; Laino, F.; Tan, B.; Pillay, J.D.; Pigozzi, F.; Jimenez-Pavon, D.; Novak,B.; Jaunig, J.; Zhang, M.; van Poppel, M.; Heidt, C.; Willwacher, S.; Yuki, G.; Lieberman, D.E.; Vogt, L.; Verhagen, E.; Hespanhol, L.; Hollander, K. (2021). A Pandemic within the Pandemic? Physical Activity Level s Substantialy Decreased in Countried Affected by COVID-19. Int J Environ Res Public Health, 18 (5), 2235
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