What We Know About Returning to Exercise After COVID-19

What We Know About Returning to Exercise After COVID-19

For the most up-to-date news and facts about the coronavirus in the United States, refer to the Centers for Disease Control and Prevention Coronavirus website here. Information for other countries should refer to the World Health Organization’s site here. Article originally publised on 12/15/2020, updated as of 2/11/2021, incorporating new guidelines that have been released with regards to safely returning to exercise after recovering from COVID-19.



Many questions are still up-in-the-air regarding the long-term effects of the coronavirus. While we are more knowledgeable about the short-term and intermediate effects of the virus on multiple body systems, the long-term and chronic effects remain to be seen. 

As of right now, we are not sure who might develop complications that will affect exercise capacity. In August 2020, experts released guidelines for returning to physical activity for recreational (non-professional) athletes. Since this was the first set of guidelines of its kind, it offers valuable information for those who are recovering from COVID-19 and wondering when it is okay to resume physical activity. 

Food for thought: guidelines are simply that - recommendations to guide you about a particular topic. Since most of our knowledge regarding COVID-19 is still evolving, it is possible that these guidelines will be updated as more information is uncovered. 

What do the activity guidelines say?
There are five guidelines based upon each body system that can be affected by COVID-19. The sixth guideline contains recommendations for returning to activity that were created by the National Strength and Conditioning Association and Collegiate Strength and Conditioning Coaches Association Joint committee. 

Cardiac system
We are well aware of the effects of COVID-19 on the cardiovascular system, which includes your heart and blood vessels. Unfortunately, the risk of developing a new heart condition in those who were not hospitalized for COVID-19 is unknown at this time. 

For individuals without pre-existing heart conditions who have completely recovered from mild-to-moderate symptoms due to COVID-19, experts recommend resuming moderate intensity physical activity after resting for at least 10 days after symptom onset and 7 days after symptom resolution. Other experts take a more conservative approach and recommend waiting 2-3 weeks to begin exercise after symptoms are gone. 

People with a known history or new onset of heart problems following recovery from COVID-19 should seek medical advice prior to resuming any physical activity. 

Pulmonary system
In otherwise healthy individuals, lingering pulmonary complications from COVID-19 can range from mild, like shortness of breath, to more severe, like pneumonia. While young and healthy adults may recover well, we are not certain what the recovery course will look like for individuals who suffered with severe pulmonary complications from COVID-19.

Generally, experts state that you should avoid intense physical activity for two weeks following infection. A gradual return to exercise, beginning with low intensity and low impact exercise, is recommended. 

Once you resume activity, perform low intensity exercise everyday, for 10-15 minutes per day, and only increase in intervals of 2-3 minutes if you are symptom-free. Breathing exercises, like diaphragmatic breathing, pursed lip breathing, Yoga, Tai Chi, and singing, can be helpful in retraining your lungs and breathing muscles. 

What is diaphragmatic breathing? Place your hand on your stomach, slightly above your navel. Now inhale for a two-count and focus on expanding your stomach into your hand. Exhale for a three-count as your stomach sinks back to the resting position. Your shoulders should not elevate during proper breathing. Expanding your rib cage and abdomen forces you to use your diaphragm, which is a muscle located at the bottom of your rib cage. 

Still stuck in that no-activity period? Focus on maintaining healthy lifestyle habits such as: 

  • Getting enough sleep every night
  • Drinking enough water (daily recommendation is half of your body weight in ounces)
  • Eating well-balanced meals at least 3-4 times per day

For more recommendations, check out, Dealing with Setbacks — How to Stay Fit While Injured or Sick.

Musculoskeletal system
During recovery from COVID-19, two of the most common lingering complaints are muscle and joint pain.

If this sounds like you, then use your pain level and symptoms to guide your return to physical activity. Once the pain has resolved, a gradual progression to normal activity can begin. Always start with low intensity, low impact exercise for one week before amping up the intensity level. 

Being inactive during your recovery places you at risk for deconditioning and musculoskeletal injuries. Refer to the recommendations below from the National Strength and Conditioning Association and Collegiate Strength and Conditioning Coaches Association Joint Committee regarding the 50/30/20/10 rule for returning to exercise.

Hematological system
Not much is known about the risk factors for blood clots in individuals who were not hospitalized for COVID-19. A blood clot, known as a deep venous thrombosis, is dangerous if left undiagnosed and untreated. It can present as calf pain, with or without swelling, and should always be immediately addressed by a medical expert. 

Usually, physical activity and avoiding periods of prolonged sitting are recommended as protection against developing blood clots. However, since exercise is not recommended for someone who is recovering from acute COVID-19, avoiding sitting for periods greater than one hour may be the best solution thus far. 

Gastrointestinal system
The main considerations for individuals who have had gastrointestinal complications (nausea, vomiting, diarrhea) from COVID-19 should not exercise until medically cleared to do so. Once you are able to resume activity, monitor fluid and calorie intake to avoid dehydration and nutritional deficiencies.

Considerations for returning to activity
Studies have shown lingering deficits at six months in COVID-19 survivors, specifically in regards to exercise capacity. Because of this, the National Strength and Conditioning Association and Collegiate Strength and Conditioning Coaches Association Joint Committee created guidelines for those returning to exercise after recovering from a mild-to-moderate infection. 

The 50/30/20/10 rule refers to reducing one’s exercise volume by at least 50%, followed by  30%, 20%, and 10% over the next 3 weeks. These guidelines are based upon the assumption that someone has been symptom-free, for at least 7 days, without an underlying cardiopulmonary condition. 

Any new symptoms that develop during that time period warrants further medical attention prior to continuing with physical activity.

What we know about returning to exercise after the coronavirus
Everyone’s immune system recovers at a different rate, regardless of the type of disease or infection, which makes it difficult for experts to make recommendations on when it is safe to return to exercise after the coronavirus. 

Currently, we think that those with mild-to-moderate symptoms from COVID-19 can resume physical activity without fear of complications, unless they have a history of heart problems. 

Returning to exercise after COVID-19 should be guided in a stepwise fashion, beginning with low intensity/low impact for 10-15 minutes per day, and based upon your symptoms. Consider using the 50/30/20/10 rule over a four week period prior to resuming your normal workout schedule. 

UPDATED 2/11/21: 

Since the original publication of this article, new guidelines have been released with regards to safely returning to exercise after recovering from COVID-19. Here’s what the new guidelines have to say. 

During the first few days of being symptom-free, practice small modifications in your daily activities that help reintroduce movement (like carrying a load of laundry up the stairs). Refrain from exercise until you are symptom-free for at least seven days and then gradually follow these four phases. You should remain in each phase for at least seven days and only progress once the activity load becomes easy. 

Phase 1: Do light-intensity activity for two weeks. Activities might include household chores and gardening, leisure walking, and balance or yoga exercises. Progress to Phase 2 after spending at least seven days in Phase 1. 
Phase 2: Continue with light intensity activity, gradually increasing by 10-15 minutes per day if you can tolerate it. 
Phase 3: Progress to more challenging activities, depending on your level of fitness before infection. Begin with intervals of two 5-minute blocks of activity such as brisk walking, going up and down stairs, jogging, swimming, or cycling. Be sure to rest between intervals. Increase your tolerance by adding one interval per day. 
Phase 4: Add complex movement for coordination, strength, and balance. After seven days of Phase 4, you should be able to return to their baseline level of activity. 

Considerations for exercising: 

  • Exercise is safe as long as you feel recovered from the previous day without any new (or return of) symptoms. 
  • Experts strongly urge you to perform a warm-up and cooldown as part of your workout. 
  • Shortness of breath, especially in the lighter stages of activity, is not normal and should be taken seriously. If you feel as if your shortness of breath is disproportionate to your level of activity, then stop exercising and seek medical attention. 

Written for Fitness Blender by Kayla C, PT, DPT
Board-Certified Neurological Clinical Specialist

*The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a physician or other qualified health provider regarding any questions you may have about a medical condition or health objectives.

References

  1. Wang, T. J., Chau, B., Lui, M., Lam, G. T., Lin, N., & Humbert, S. (2020). Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19. American journal of physical medicine & rehabilitation, 99(9), 769–774. 
  2. Metzl, J. D., McElheny, K., Robinson, J. N., Scott, D. A., Sutton, K. M., & Toresdahl, B. G. (2020). Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete. HSS journal : the musculoskeletal journal of Hospital for Special Surgery, 1–6. Advance online publication. 
  3. Gentil, P., de Lira, C., Souza, D., Jimenez, A., Mayo, X., de Fátima Pinho Lins Gryschek, A. L., Pereira, E. G., Alcaraz, P., Bianco, A., Paoli, A., Papeschi, J., & Carnevali Junior, L. C. (2020). Resistance Training Safety during and after the SARS-Cov-2 Outbreak: Practical Recommendations. BioMed research international, 2020, 3292916.