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COVID-19: The Return To Activity

We find ourselves in a time of global uncertainty, locked in a battle with an invisible enemy which is changing the way we live, work, travel and socialise. And that is without even contracting the virus and the changes it may have to our physiological and psychological state. 

So what if we have had the Corona-Virus? How can we get over the symptoms, the lasting effects and how can we return to activity and sport?

Whether you have had symptoms or not, if you have tested positive then the likelihood is you have had to self-isolate and by this fact a prolonged period of inactivity. This means there has to be some form of graded return to activity. If you have had symptoms, this becomes even more important. 

We don’t have a lot, but experience that is building suggests that after mild covid-19 a proportion of people experience prolonged recovery and certainly people I have had the pleasure of working with are not sure when and how they should return to physical activity after covid-19. 

Risks

Early research is limited on what may be the risks of returning to activity following infection but it is important to recognise these. First is the potential for cardiac injury and in particular viral myocarditis which is inflammation of the heart muscle. Most data is from those who were hospitalised so we can’t generalise to those with only mild to moderate symptoms of which we have no data on (Salman et al, 2021). It is clear though that if you have been hospitalised with covid-19 or had severe symptoms then a cardiac assessment should be carried out prior to return to activity or sport. 

Pulmonary function can also be effected with pulmonary embolism a risk factor noted from the 2003 SARS-CoV outbreak and early research suggesting fibrosis and pleural effusion present in covid-19 (Salman et al, 2021). Again, we do not currently know the long term effects from covid-19 currently but awareness is required. The persistent cough and breathlessness are expected to resolve after several weeks so if these persist then further investigations will be required. 

For those medical professionals working with individuals and teams, physical signs may be few so give particular attention to tachycardia, added heart sounds, bibasal crackles, or signs of pleural effusion (Wilson et al, 2020)

If the presence of cardiac and pulmonary complications are discovered, both European and US guidelines advocate restrictions on exercise for 3-6 months. This will need to be managed in conjunction with the medical multidisciplinary team along with the patient / athlete and their surrounding support structure. 

Finally there are psychological impacts to consider and post traumatic stress disorder, anxiety and depression have all been identified as a feature of covid-19. 

How do I know when I can return to activity or sport?

Are you physically ready to return to activity? 

Consensus is that a return to exercise or sporting activity should only occur after at least 7 days of being asymptomatic (Salman et al, 2021).

English and Scottish Institute of Sport guidance suggests that activities of daily living should be easily achievable first, ie. a person should be able to walk 500m on the flat without feeling excessive fatigue or breathlessness. However, this should be considered on a individual basis as of course some might not have been able to do that before when we consider all activity and not just sporting endeavours. 

The British Journal of Sports Medicine (BJSM) produced this nice infographic to monitor readiness in relation to symptoms of which they created six groups (Lollgen et al,  2020)

Are symptoms persisting? 

Preliminary reports indicate some patients may develop a so called “post-acute covid-19 syndrome” in which they may experience persistent symptoms after recovering from their initial illness. This can occur in any measure of covid-19 symptoms from mild to moderate and severe. 

Are you psychologically ready to return to activity? 

Do you want to go back? Are you fearful of returning? How is your mood, sleep, appetite and motivation? 

All important questions, which are are important features of being able to complete and recovery from physical exertion and if your answers aren’t conducive to creating the correct environment around physical activity then these may need to be addressed prior to returning. 

Of course physical activity can help with some of these things ie. have a positive impact on mood and mental well being and should be discussed with a return to activity plan. 

So you think your ready….how do you get back? 

The simple way is to follow the phases below, listen to your body and just take your time with it. For a more in-depth approach with timings and heart rate zones, check out the BJSMs infographic below (Elliot et al, 2020). However please note this is designed as guidance for medical professionals aiding athletes back to training /competition who have had mild – moderate symptoms. But I think nicely highlights the time demands that it takes with elite athletes with mild symptoms needing at least 17 days but often 3 weeks to recover. 

Phase 1

  • Light intensity activity for 1-2 weeks, use of Rate of Perceived Exertion Scale (RPE) can help with this, 0-2. 
  • This is where you should be able to hold a full conversation without difficulty during the activity. 
  • Activities here can involve walking, yoga, gardening, household tasks.
  • Start with approx 10-15 minutes and build from there 

Phase 2 

  • Moderate activity for 1-2 weeks, 1-3 on the RPE scale. 
  • This can involve brisk walking, cycling, jogging, going up and down stairs 
  • Still shouldn’t be out of breath initially 
  • A post injury return to running programme would begin with 3-5 minutes jogging and increase by 3-5 minutes every other day. The same principles could be applied here. 
  • Intervals can be useful to provide rest breaks 
  • Couch to 5k is an excellent resource 
  • Light weights can utilised 

Phase 3 

  • The inclusion of more complex movements that challenge strength and balance 
  • Increase in distance / time and intensity of activity 
  • Increase in resistance for strength training 
  • It shouldn’t feel hard (3-4) and you should recover within 1 hour with no abnormal breathlessness, fatigue or heart rate. 
  • This phase is prepping you for a re-introduction back to normal activity and should last 1-2 weeks 

Phase 4

  • Return to normal activity 
  • NO big jumps in activity 
  • Yes we are back to “normal” training but it should be seamless transition from Phase 3. Ie. if you are used to running 10k but have only completed 5k in Phase 3 then your next run should be 6k, then 7k and not jump to 10k.
  • With sport, this is your re-introduction to training sessions which might involve 30-60 minutes of work with planned increases during the week.  

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