Resuming physical activity after having COVID-19 has an extra layer of complexity because of the potential of complications, such as myocarditis (inflammation of the heart muscle), for those individuals known as long haulers, who experience prolonged symptoms of the virus, says Michael Fredericson, MD, professor of physical medicine and rehabilitation in the department of orthopedic surgery at Stanford Medicine in Palo Alto, California. “I think the best advice about exercising after having COVID-19 is to be very careful — this is a challenging disease,” says Dr. Fredericson, adding that no matter your age or your fitness level, it’s a good idea to discuss any physical activity plans with your doctor and proceed with caution. Here’s an overview of the current guidelines and recommendations. RELATED: Tips for Getting Back Into a Workout Routine if the Pandemic Disrupted Yours
Returning to Exercise Should Be Individualized
Sports medicine physicians at the Hospital for Special Surgery (HSS) in New York City issued recommendations for recreational athletes returning to physical activity after being infected with COVID-19. The list of considerations and recommendations was published in August 2020 in the HSS Journal. The authors note that each patient with COVID-19 is unique, and there can be a wide variance of how each person experiences the virus. The guidelines also note that each person recovers from COVID-19 at a unique rate, and there is currently no algorithm to determine exactly how and when an individual should return to activity. “There isn’t a clear, uniform response in people that recover from COVID-19,” says James Borchers, MD, a sports medicine doctor at the Ohio State University Wexner Medical Center in Columbus. It makes sense for everyone — even people who had only mild to moderate symptoms or even no symptoms at all — to connect with their healthcare provider so that they can have some discussion about how to begin to return to exercise appropriately as well as how to increase intensity appropriately, says Dr. Borchers. Other recommendations from the HSS Journal paper:
Exercise should not resume if a patient with COVID-19 has persistent fever, dyspnea (breathlessness) at rest, cough, chest pain, or palpitations.Any COVID-19 patient with an underlying cardiovascular or pulmonary condition should consult a physician prior to resumption of exercise, even if asymptomatic.An otherwise healthy patient with a self-limited course of COVID-19 who has been asymptomatic for seven days may begin resuming physical activity at 50 percent of normal intensity and volume.Consultation with a physician is recommended if patients who have had COVID-19 develop chest pain, fever, palpitations, or dyspnea on the resumption of exercise.
“These guidelines make sense and are appropriate as long as we keep in mind that every individual is unique, and the activity that they’re returning to is unique,” says Borchers. “For some people, starting at 50 percent of what did before they were infected with the virus may prove too challenging.” Further modification may be needed. These guidelines were written before the emergence of the delta variant of COVID-19 (and several others), but they still apply to cases caused by the various variants, says James N. Robinson, MD, a primary sports medicine doctor at HSS in New York City and a co-author of the paper. “It is important to wear masks and practice social distancing when exercising indoors around others,” Dr. Robinson says. The Centers for Disease Control and Prevention advises that outdoor activities are still safer than indoor ones (particularly when it comes to exercising indoors at a gym or in a fitness studio), and masking in indoor public spaces can help lower COVID-19 transmission risk. RELATED: COVID-19 and the Gym: Is It Safe to Go?
Tips for Everyone Getting Back to Exercise After Moderate or Mild COVID-19
When you do restart your workout routine, here are some tips you should keep in mind.
1. Don’t Exercise While You Still Have Symptoms of COVID-19
“The most important thing for people to remember is not to exercise while still having symptoms — fever, fatigue, shortness of breath,” says Robinson. Instead, he recommends that people wait until they are symptom-free for 7 to 10 days before resuming exercise. “It’s never good to exercise when you’re sick or symptomatic with an active infection,” Borchers adds. If you exercise while you have an active viral infection, that may cause the infection to get worse, which could lead to additional complications, he explains. RELATED: How to Recover From COVID-19 at Home
2. Start Slow and Gradually Up the Intensity
How you should start exercising after COVID-19 depends on what level of activity you were doing before, says Fredericson. “For most people, you’d want to start off with just a walking program and gradually build up your walking tolerance. Once you’ve done that over a couple week period, then you could add in more intense cardio, but not too intense — just so your heart rate is going up a little more than it was with walking,” he says. A good way to get started would be with a stationary bike or elliptical machine, or engaging in an activity like swimming, says Fredericson. “If you could do a gradual build of intensity over a period of a couple weeks, tolerate it and continue to feel good, then you can return to your typical workouts,” he says. For more serious fitness enthusiasts who may plan out their workouts to certain heart rate zones or perceived exertion metrics, the recommendations set out by the National Strength and Conditioning Association might be a good fit (after discussing with your doctor), says Fredericson. It’s a four-week program to get you back to your usual fitness level. “The first week you reduce your activity by 50 percent of what you were previously doing. If that goes well, then you do a week at a 30 percent reduction, then a 20 percent reduction, and then a 10 percent reduction,” he says. Over these four weeks of gradually upping your workload, you’ll safely get back to your pre-illness workouts, adds Fredericson. But it’s important to only continue the program if you’re feeling okay after each increase. Because each person’s recovery and return to exercise is an individual experience, you’ll have to monitor your progress closely and pay attention to your symptoms when you work out. RELATED: A Complete Guide to Working Out at Home
3. Listen to Your Body — Especially if You Have Any Existing Heart Issues
“Since our guidelines were published, there has been increasing concern about the risk of myocarditis after COVID-19. This is all the more reason people should take it slow and pay attention to their bodies,” says Robinson. According to Fredericson, some cases of COVID-19 create intense inflammation throughout the body, and part of that inflammation can affect the cardiac muscle, causing myocarditis. “You can develop an arrhythmia, where the heart beats irregularly, or it can sometimes lead to a ventricular arrhythmia, where you could have a heart attack,” he says. It’s been observed in people with severe and moderate cases of COVID-19, adds Fredericson. Research published in the January-February 2021 issue of Cardiovascular Pathology suggests that COVID-19 myocarditis may be relatively rare. The authors used data from 277 autopsy cases used in 22 published papers and estimated that the rate of myocarditis was between 1.4 and 7.2 percent. The bottom line: “If patients have underlying prior heart or pulmonary conditions, it is important they consult their physician before returning to strenuous work or exercise,” says Robinson. RELATED: Why Being Fit Helps You Manage Chronic Diseases
Returning to Exercise if You Have Long COVID-19
The safest and best way to return to exercise will look different for people with prolonged symptoms, says Borchers. “What we’ve seen so far is that these people start to feel better, but they never quite get over the hump; they seem to plateau and don’t improve. COVID-19 long haulers can have excessive fatigue with normal daily activities, experience daily headaches, and find themselves out of breath doing things like going up and down the stairs or walking to the mailbox,” he says. “It seems to take a prolonged time for these people to get better, and they certainly should not try to get back to exercising while they’re feeling that way,” says Borchers. Any return to physical activity for these people should only happen after they are symptom-free and with the guidance of their physician, he says. RELATED: Meet the COVID-19 ‘Long Haulers’ With additional reporting by Carmen Chai.
