The physical inactivity public health emergency has been brought to light and further fueled by the COVID-19 pandemic.[i] [ii] There is a need for evidenced-based recommendations on safely returning to physical activity after a COVID-19 infection. ACSM was among the first organizations to offer guidance on planning for physical activity taking the effects of COVID-19 into consideration.
There is increasing awareness of potential long-term cardiopulmonary sequelae of COVID-19, also known as “post-acute” or “long” COVID.[iii] These persistent symptoms, including cough, elevated resting heart rate and extreme fatigue, can last for weeks to months after COVID-19 infections.[iv] Cardiac damage has been seen in about one quarter of patients with severe COVID-19 illness.[v] [vi]
Myocarditis, inflammation in the middle layer of the heart wall, has likely always been a potential complication of viral syndromes for athletes returning to sport. COVID is somewhat unique however, in that we can test for and diagnose the specific virus and then monitor its progress. Despite this unique opportunity, the prevalence of injury to the heart is unknown in those with asymptomatic infections or mild symptoms, but is likely to be low.[vi]
Based on expert opinion and some emerging data, it is important to assign levels of risk to those diagnosed with COVID-19 infections in order to provide specific recommendations on how each group can safely return to exercise.[vii] Individuals under the age of 50, who had an asymptomatic infection or mild respiratory symptoms that resolved within seven days and would like to resume recreational exercise are considered low risk. This group can follow a gradual return to exercise without further evaluation. [viii]
Those with symptoms or fatigue lasting for more than seven days, or prolonged shortness of breath or chest pain that did not require hospitalization, are deemed intermediate risk. High risk patients are defined as those who required hospitalization or who experienced shortness of breath or chest pain at rest or while performing activities of daily living.
Both intermediate and high-risk patients should be evaluated with an electrocardiogram (EKG) and troponin (a type of protein found in the heart muscle) test if experiencing chest pain or shortness of breath or have an abnormal EKG. Ideally, a multi-disciplinary team comprised of specialists in cardiology, pulmonology and sports medicine will collaborate to create a personalized exercise prescription for these patients.[viii]
Expert panels agree on several general principles for gradual return to exercise. Low-risk patients should rest for at least ten days after being diagnosed with COVID-19. If asymptomatic for seven days, they can begin a gradual return to physical activity.[ix]
Firstly, one should return to their normal routine (work/school) and sleep patterns. Individuals should ensure they are able to easily perform activities of daily living and walk 500 meters on a flat surface without experiencing excessive fatigue or shortness of breath. Initial physical activity should consist of light exercise for 15 minutes. If post-COVID energy levels are achieved, activity time duration can be increased, followed by resumption of bodyweight exercise, such as yoga or resistance training with sufficient rest. Heavier resistance and sports-specific training can follow.[x]
Athletes should engage in at least two weeks of minimal exertion before resuming their sport. Increases in volume (time performing activity) and load (intensity) should be gradual. Pre-illness capacity should dictate progressing to more physically demanding activity. If there is an occurrence of any red-flag symptoms, such as chest pain, severe shortness of breath or rapid/irregular heartbeat, the athlete should be evaluated by a primary care provider, and possibly referred to a cardiologist or pulmonologist.[xi]
The COVID-19 infection can affect the global population through multiple clinical symptoms, varying from mild to severe. It is clear that a gradual approach to returning to physical activity mitigates risk. We must continue to gather data to develop an evidence-based, cost-effective pathway to safely return to exercise after COVID-19.
ACSM Call to Action Statement | COVID-19 Considerations for Sports and Physical Activity
Infographic | COVID-19: Considerations for Sports and Physical Activity
Website: | ACSM's COVID-19 Updates and Resources
Resources | COVID-19 Reopening and Return to Play Resources
Meredith N. Turner, M.D. was born in the Bahamas and resided there until she moved to the U.S. to attend Emory University in Atlanta, where she obtained a Bachelor’s of Science in Biology. She then received her medical degree at Thomas Jefferson Medical College in Philadelphia. She completed her residency in Family Medicine at the University of Miami/Jackson Memorial Hospital, where she also completed her Sports Medicine fellowship in Primary Care Sports Medicine. She is American Board Certified in both Family Medicine and Sports Medicine, and practices in Nassau, Bahamas.
[i] Fitzpatrick, J., Castricum, A., Seward, H., Tulloh, L., & Dawson, E. (2020). Infographic. COFIT-19: let's get moving through the COVID-19 pandemic!. British Journal of Sports Medicine, 54(22), 1360–1361.
[ii] Hamer, M., Kivimäki, M., Gale, C. R., & Batty, G. D. (2020). Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: A community-based cohort study of 387,109 adults in UK. Brain, behavior, and immunity, 87, 184–187.
[v] Baggish, A., Drezner, J. A., Kim, J., Martinez, M., & Prutkin, J. M. (2020). Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes. British Journal of Sports Medicine, 54(19), 1130–1131.
[viii] Bhatia, R. T., Marwaha, S., Malhotra, A., Iqbal, Z., Hughes, C., Börjesson, M., Niebauer, J., Pelliccia, A., Schmied, C., Serratosa, L., Papadakis, M., & Sharma, S. (2020). Exercise in the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) era: A Question and Answer session with the experts Endorsed by the section of Sports Cardiology & Exercise of the European Association of Preventive Cardiology (EAPC). European Journal of Preventive Cardiology, 27(12), 1242–1251.
[ix] Elliott, N., Martin, R., Heron, N., Elliott, J., Grimstead, D., & Biswas, A. (2020). Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine, 54(19), 1174–1175.
[x] Kingstone, T., Taylor, A. K., O'Donnell, C. A., Atherton, H., Blane, D. N., & Chew-Graham, C. A. (2020). Finding the 'right' GP: a qualitative study of the experiences of people with long-COVID. BJGP open, 4(5), bjgpopen20X101143. Bottom of form.