Returning to physical activity after covid-19
This is a summary of the returning to physical activity guidelines after contracting covid-19 published by the British Journal of Medicine. Covid-19 is a deadly disease leaving families devasted across the globe. It has been identified that after mild covid-19 a proportion of people experience a prolonged recovery, particularly when trying to return to exercise. There is increased recognition for the long term complications following covid-19 such as enduring illness, cardiopulmonary disease and psychological sequelae.
The health benefits of being physically active are long-established from cardiovascular to mental health. By contrast, we also know the harm of physical inactivity which is a major risk factor for non-communicable disease alongside cigarette smoking and obesity. Before the covid-19 pandemic, a 1/3 of the UK population were not physically active enough for good health. There is evidence demonstrating a decline in physical activity throughout the pandemic particularly in people with obesity and hypertension who have shown to have the worse outcomes from covid-19.
Physical activity encompasses more than just sport and should be part of everyday life. The current UK government guidelines are 150 minutes of moderate-intensity (can talk but not sing) or 75 minutes of vigorous-intensity (difficult to talk) per week in addition to muscle-strengthening activities at least twice per week. These targets can include exercise (planned physical activity with the aim of improving physical fitness) it can also include activities such as gardening, and carrying heavy shopping bags etc.
What are the risks of physical activity after covid-19?
The complete understanding of the risks after covid-19 is limited but there have been three main areas highlighted for concern.
Cardiac injury, including myocarditis. Exercising in the presence of myocarditis is associated with increased morbidity and mortality. Most of the data collected for myocarditis is from patients who were hospitalised this can not be extrapolated for those with a mild illness.
Thromboembolic complications such as pulmonary embolism. The long term effect of pulmonary function is not yet known but data from 2003 severe respiratory syndrome coronavirus (SAR-CoV) epidemic suggest persistent impairments in pulmonary function in exercise capacity in survivors.
Psychiatric phenomena such as psychosis have been identified as a potential presenting feature of covid-19 and psychological sequelae after infection can include post-traumatic stress disorder, anxiety and depression.
Without evidence from robust studies, all current guidelines to date are based on consensus and expert opinion.
How to know if someone can return to physical activity?
Using a risk stratification can help to maximise safety and mitigate risks.
Is the person physically ready to return to activity? Consensus agreement is that a return to exercise or sporting activity should only occur after an asymptomatic period of at least 7 days.
Activities of daily living should be easy and achievable i.e. able to walk 500m without feeling excessive fatigue or breathlessness (on the basis that the individual could walk 500m without fatigue to breathlessness prior to contracting covid-19) or their own previously baseline.
Figure 1, the return to physical activity pathway from the BMJs "‘Return to physical activity after covid-19’ article’
Ongoing symptoms may be indicative of a post-acute covid-19 illness. This will require assessment in the primary care initially and potentially liaison with local post-covid-19 rehabilitation services. At the moment physical activity is not considered as a treatment for covid-19.
People who were hospitalised are considered to be at a greater risk of cardiac complications. Those who did not need to be hospitalised but who did have symptoms during their illness of myocardial injuries such as chest pain, severe breathlessness, palpitations, symptoms or signs of heart failure, or syncope or pre-syncope should be assessed with a physical examination and considered from further investigations by a cardiology team.
Respiratory symptoms such as a persistent cough and breathlessness are expected to resolve after several weeks, however, non-resolving or worsening of symptoms may indicate pulmonary-vascular complications and patients should be referred to secondary care services.
Is the person psychologically ready to embark on a physical activity programme? Physical activity has a positive impact on mood and mental well-being and has a role in the prevention and treatment of mental health conditions. Ask about mood, sleep, appetite, and motivation. Further support may be needed through self-care resources, community services, and peer support.
Guiding the patient back to physical activity?
There is no clear, evidence-based approach to return to physical activity but a prudent approach is that it should be gradual, individualised and based on the subjective tolerance of the activity. Once the patient has been risk-stratified and symptom-free for 7 days a phased approach can be used to increase physical activity levels to either baseline, the governmental guidelines or beyond. If symptoms return or new symptoms develop including cough, abnormal breathlessness, palpitations, fever, indicate you should stop and seek medical advice and restart the process when symptom-free. People may expect to be more breathless after a period of illness a subjective assessment is necessary. A graduated progression includes an increase in volume and followed by load/intensity.
Discussions regarding physical activity in primary care can follow a modified 3As approach: ask, assess and advise.
Ask permission to discuss the topic and gauging the person’s current levels of activity.
Assess the perspectives and goals regarding physical activity.
Advise/assist in providing additional information and resources alongside their own health goals. Assist them by helping break down potential barriers.
How to start
Phase 1 - 2
Begin light intensity activities for at least 2 weeks. Using the borg Rating of Perceived Exertion (RPE) scale a subjective measure of how hard someone feels they are working can be helpful to guide people in choosing what activities to do and progressions. Rate their subjective feelings of exertion, shortness of breath, and fatigue on a scale of 6 (no extortion at all) to 20 (maximal exertion). Light intensity exercise is considered an RPE of under 11. They should be able to hold a conversation without any difficulty whilst performing activities such as light garden tasks, gentle walking, balancing or yoga. It is recommended to spend 7 days on extremely light intensity (RPE 6 - 8) for as long as the person feels able to do them. This is followed by another 7 days at phase 2 incorporate light-intensity activity (RPE 6 - 11) such as walking gradually increasing by 10 - 15 minutes per day at the same RPE.
Figure 2 an the Borg RPE scale used to monitor and gage exercise intensity.
Phase 3 - 4
Progressing to more challenging movements depends on pre-illness capacity. This could include two 5-minute intervals of activity such as brisk walking, going up and down the stairs, jogging, swimming, cycling separate by a block of recovery. The exercise should feel ‘hard’ an RPE of 12 - 14 (moderate intensity, not out of breath could hold a conversation). Progress by adding an interval per day.
Phase 4 would include more complex movements challenging coordination, strength, and balance, such as running with changes of direction, bodyweight exercises, intensity should not feel hard. After phase 4 the patient should be able to return to pre-baseline levels of activity.
A minimum of 7 days is recommended at each phase to prevent sudden increases in training load. However, people should stay in the training phase they feel comfortable with. Patients should monitor any inability to feel recovered after 1 hour of exercise and the day after abnormal breathlessness, abnormal heart rate, excessive fatigue or lethargy and markers of ill health. If any of these occur, or the person fails to progress as expected they should step back to an earlier phase and seek medical advice when unsure.
Keeping a diary of exercise progression, along with RPE, changes in mood, and heart rates can be helpful when monitoring progress.
Takeaways
If you have been hospitalised you should receive a covid rehab and cardiology review.
If you continue to experience cardiac symptoms i.e. shortness of breath, chest pain, palpitations you should seek medical advice.
Activities of daily living should be easy and achievable i.e. able to walk 500m without feeling excessive fatigue or breathlessness (on the basis that the individual could walk 500m without fatigue to breathlessness prior to contracting covid-19).
Advice to return to any physical activity only after 7 days symptom-free and a reduction in exercise intensity for the first 2 weeks.
If you have any questions or yourself or you know anyone who is struggling to recover from covid-19 I would love to help my email address is ben.duckett@pandhtherapy.co.uk. I am fully qualified to deliver cardiac prevention and rehabilitation should anyone need assistance in this area too.
References
Salman David, Vishnubala Dane, Le Feuvre Peter, Beaney Thomas, Korgaonkar Jonathan, Majeed Azeem et al. Returning to physical activity after covid-19 BMJ 2021; 372 :m4721
Sheldon Trevor A, Wright John. Twin epidemics of covid-19 and non-communicable disease BMJ 2020; 369 :m2618
Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985 Mar-Apr;100(2):126-31. PMID: 3920711; PMCID: PMC1424733.