Return to Play after COVID-19

We know a lot more about COVID-19 now than at this same point last year. At the same time, a lot more athletes have survived infection. So our question turns from “What is COVID-19?” toward “How do I safely return to physical activity after recovering from COVID-19?”

Olympic bronze medalist Henri Schoeman was one of the more prominent triathletes to get COVID-19 and recover from it to log some respectable results towards the end of 2020, while Ironman world champion Anne Haug tested positive before she was set to compete at the PTO Championships at Challenge Daytona. Competitive elite athletes will have a team of medical professionals evaluating their condition and assessing their return to sport.

However, many recreational athletes are left to their own devices. One of our members said: “I had COVID at Christmas… Symptoms were flu-like but lasted a bit longer, say a month. I have been struggling to get back to the top end ever since. Realistically I've lost about 10% off my top end, but more frustratingly I just need much more rest than ever before. And I've had to take 4- to 5-day breaks thrice because I've overdone it, despite taking it relatively steady compared to previous. I haven't had any medical advice... I reckon now, 5 months on I'm starting to feel better again, though in fairness I've learned not to do any speed work so as not to need too much rest.”

So in response, we’ve prepared an easy reference based on published guidelines from World Triathlon, the BASES (British Association of Sport and Exercise Sciences) expert statement and Gradual Return to Play infographic, as well as Considerations for Return to Exercise following Mild-to-Moderate COVID-19 in the Recreational Athlete by Metzl et. al.

(Please note that this document must not be considered a substitute for medical advice. It’s always good practice to consult with a medical professional prior to partaking in strenuous physical activity, regardless of but also considering any history of infection with COVID-19.)

What parts of our bodies does COVID-19 affect?

COVID-19 most visibly affects the pulmonary system (lungs), and due to the strain it puts on the body also the cardiac system (heart and circulation). But it can actually leave a mark even on your musculoskeletal (muscles and bones), gastrointestinal (stomach and intestines), hematologic (blood), phrenic (kidney), and even nervous (brain, spinal, and peripheral nerves) systems. It can leave not only severe acute damage, but also chronic damage. Even in asymptomatic patients there is a risk of myocarditis (inflammation of the heart muscle) and sudden cardiac death.

Due to this wide range of how the disease affects the body and the broad scope of severity, it’s recommended that a medical doctor should oversee or sign off on the return of an athlete to training. In particular, those who have recovered from more severe COVID-19 must take a more gradual return to activity.

When can I return to exercise?

Most of us are used to trying to exercise through a cold or a mild cough but strictly speaking, return to exercise after recovering from any viral illness should be gradual.

The severity of COVID-19 disease, particularly fatigue, can affect the duration of recovery. World Triathlon recommends the athlete must be evaluated by a medical professional when returning to activity and competitive sport.

If you’re still symptomatic (experiencing symptoms such as but not limited to: persistent fever, shortness of breath at rest, cough, chest pain, or palpitations), you should not resume exercising.

Here are some key considerations from the UK Home Countries Institutes of Sport guidance for healthcare professionals for a Graduated Return to Play:

  • Athletes should not start to return until at least 10 days following onset of symptom and should be 7 days symptom-free. (Some athletes take over 3 weeks to recover and a few take many weeks, even after mild symptoms.)
  • In most cases, 7 days is the minimum time to progress to full training, especially in sports of an aerobic nature. Less physically intense sports, like golf or lawn bowls, may progress quicker.
  • Before considering a return to training, the athlete must be able to complete all activities of daily living without excessive fatigue and/or breathlessness and walk a minimum of 500 m on the flat without getting breathless.
  • The athlete must have stopped all treatments that may mask symptoms, e.g. paracetamol.

How do I “Return to Play” after COVID-19?

Much of the current guidance on return to activity after COVID-19 has been developed on the basis of mild to moderate symptoms. If your experience with COVID-19 required hospitalisation, your Return to Play should be managed by a multi-disciplinary team including medical specialists who will be better able to judge what you need to help you progress back into normal activity.

Mild symptoms: anosmia (loss of or impairment of sense of smell), ageusia (loss of or impairment of sense of taste), headache, mild fatigue, mild upper respiratory tract illness, and mild gastrointestinal illness.

Moderate symptoms: persistent fever greater than 38°C, chills, cough, myalgia (body pain), lethargy, dyspnea (shortness of breath) and chest tightness, SpO2 (blood oxygen saturation) greater than 94%

The following infographic was created by the UK Home Countries Institutes of Sport, showing a six-stage protocol for a graduated return to play. Progression should be based on the response to training at each stage. Any negative response necessitates a return to the previous symptom-free level of activity. Ongoing symptoms or failure to progress through the rehabilitation programme should trigger a medical review and further investigation.

Monitoring the following may help to assess response:

  • Resting heart rate (RHR)
  • Rated Perceived Exertion (RPE)
  • Sleep, stress, fatigue and muscle soreness
  • Fatigue and breathlessness
  • Injury-Psychological Readiness to Return to Sport (I-PRRS) scale
  • Where relevant, monitoring using specific medical tests such as oxygen saturations, blood and lung function tests may be necessary. Other allied disciplines such as nutrition, physiology and technical coaches should also usually be involved.

Here are World Triathlon’s guidelines for return to competitive sport after recovery from COVID-19 infection. While this is for elite athletes to accomplish to return to competing on the world circuit, you can use this information in consultation with your medical doctor guiding your return to activity.

1. Athlete with positive COVID-19 test, but asymptomatic:

  • 10 days self-isolation, rest and no exercise for two weeks after first positive test result
  • Diagnostics required: medical history, physical examination, resting electrocardiogram (ECG) without abnormalities

2. Athlete with positive COVID-19 test, mild/moderate symptoms but without pneumonia:

  • 10 days self-isolation, rest/recovery with no exercise while symptomatic; 2 weeks of convalescence without resumption of exercise
  • Return to play can begin only after symptoms resolve.
  • Diagnostics required: medical history, physical examination, laboratory (differential blood count, PCR, CK, CK MB, hs-cTn, D-dimer), resting and exercise ECG with O2 saturation, echocardiography, spirometry without abnormalities

3. Athlete with positive COVID-19 test with pneumonia:

  • No sport for at least 4 weeks.
  • Return to training only after symptoms resolution, under doctor’s supervision.
  • Diagnostics required: medical history, physical examination, laboratory, resting and exercise ECG, cardiopulmonary exercise test (CPX) with BGA, echocardiography, spirometry without abnormalities. Consider adding CMRI (cardiac magnetic resonance imaging).

4. Athletes with positive COVID-19 test with myocarditis (suspected/confirmed) with or without pulmonary involvement:

  • No sport for at least 3-6 months.
  • Return to training under supervision of a cardiologist.
  • Diagnostics required: according to “Guidelines myocarditis”, consider adding CMRI. In case of pneumonia, perform all exams under point 3.

While these guidelines may continue to evolve as we learn more about COVID-19 and how our bodies recover from infection, the common refrain is: take your time, listen to your body, and let it heal. Sport is only one part of your life, and you want to make sure you can continue to enjoy it long-term.

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