Returning to Sports after Covid 19
It is hard to know what to write about in a world that changes so often right now. Some of us are working like crazy now and some have more time for running, even though due to a job loss or other circumstances. I have had several questions about recovering and getting back to our sports after a disease like Covid 19. My column reflects only what we know up to the time it is written.
One of my patients, an elite triathlete, made an appointment to help decide how to return to training. In mid March, he had 2 weeks of shortness of breath, fevers and chills, but not a bad cough. He had no other medical conditions. At the time I saw him, he still had shortness of breath and body aches when running or biking a few miles, but his fevers were gone. He had no place to swim. So, when should an athlete normally return to training after an illness such as this?
Endurance athletes usually train at least 3-5 days a week, and the resulting fitness level is associated with less risk in respiratory diseases. (Nieman). Elite endurance athletes train at a much higher intensity. Some have postulated this decreases immunity, but it isn’t necessarily associated with risk if illness as long as they do not increase their intensity suddenly. (Campbell)
Covid 19 is unique in many ways. One issue is the varying severity of illness. Some athletes may never even know they are infected, and others can have symptoms lasting many weeks. Many athletes will have worsening symptoms between days 7-9 of the illness, including shortness of breath and possibly clotting issues in the lungs and elsewhere. In addition, many of the hospitalized with Covid 19 showed an elevation in the cardiac enzymes raising the possibility of heart damage happening.
In the general population, the CDC recommends return to work after Covid 19 symptoms are completely gone for 3 days and it is more than 7 days from the start of symptoms. Is it safe to resume training then? We often discus the “neck rule” meaning that symptoms above the neck are fine to run with but lower symptoms are not. But this is not a simple cold virus. Recommendations for a more conservative return would be 7 days after symptoms resolve and at least 10 days after the start of symptoms. (Hull)
The athlete mentioned above had started training on his own as soon as symptoms stopped. He had terrible workouts and felt body aches and shortness of breath throughout. After our visit, he waited another week so it was 10 days after symptom resolution. He started slowly again and still experienced more mild shortness of breath with training. He continued lower intensity workouts for the next 2 weeks and slowly started advancing At the time of writing this, about 4 weeks after symptoms stopped, he is training at about 60% of his usual and still experiencing a little shortness of breath and slight fatigue with workouts. We discussed taking some more time off, but he felt it was best for his mental health to keep going as he could. There is no evidence that another week off would have helped as his current symptoms only occur with workouts. His main race this year has been canceled so he has some time to work up to his normal baseline.
This situation is rapidly revolving and hopefully we will know more soon. If you have access to a heart rate monitor and/or pulse oximeter, they may be useful. Here are some guidelines I have given to the athletes in my practice:
● Don’t attempt to start training until your resting HR is within 5 BPM of your normal and if you have a pulse oximeter it is above 96
● Reduce the distance and intensity to half normal. If that was successful, we slowly added distance and intensity, but not both on the same day
● Monitor your HR and if it won’t stay in your target zone, back off the intensity and/or duration.
● If your pulse oximeter shows less than 90, stop your workout and rest. If it is consistently in the low 90s back off in intensity and/or duration.
Hope you are able to get back to all your favorite activities!
Nieman DC, Wentz LM. The compelling link between physical activity and the body's defense system. J Sport Health Sci. 2019;8(3):201–217. doi:10.1016/j.jshs.2018.09.009
Campbell, JP, Turner, JE, Debunking the Myth of Exercise-Induced Immune Suppression: Redefining the Impact of Exercise on Immunological Health Across the LifespanFront Immunol. 2018 Apr 16;9:648. doi: 10.3389/fimmu.2018.00648. eCollection 2018.
Hull, Loosemore et all. Respiratory Health in Athletes Facing the Covid 19 Challenge. The Lancet April 8, 2020