Exercising after COVID-19: What doctors need to know

By Naveed Saleh, MD, MS
Published January 13, 2022

Key Takeaways

For many people, the pandemic made an already-fraught relationship with fitness even worse–especially for those who’ve suffered a decline in fitness following a bout with COVID-19. Even after mild COVID-19 illness, many people need time to recover.

As a physician, it’s important to encourage your patients to return to exercise when they’re ready. But, when is the right time to return to exercise? The experts are weighing in.

What are the risks?

Emerging research has focused on several health issues linked to the return to exercise after COVID-19 infection.

First, COVID-19 can lead to cardiac injury, including viral myocarditis, which can increase the risk of disease and death, according to the authors of guidance published in the BMJ.[]

The authors highlighted the results of a study suggesting ongoing myocardial inflammation as demonstrated by serum troponin levels and cardiovascular MRI findings at 71 days post-diagnosis. Although 67% convalesced at home, 33% needed hospitalization.

Other risks include throwing clots, with pulmonary emboli linked to COVID-19. To date, it is unclear what the long-term pulmonary implications are, but data from the 2003 SARS-CoV epidemic indicated long-lasting impairments in pulmonary function and exercise capacity in survivors.

One last concern that could interfere with function is psychiatric repercussions, such as psychosis. Psychosis can even crop up as a presenting symptom of COVID-19, with PTSD, anxiety, and depression also on the table further into the illness.

What are the benefits?

According to research, between 10% and 20% of those infected with SARS-CoV-2 develop long-haul COVID-19 symptoms 12 weeks after the acute symptomatic phase. This manifestation is challenging to diagnose, with no gold standard in place. This lack of diagnostic measures makes therapy unsure. Based on evidence from other chronic conditions, however, exercise may help

The authors of a narrative review published in the International Journal of Environmental Research and Public Health support the prospect of using exercise to counter the ill effects of long-haul symptoms.[]

“There is sufficient evidence suggesting that tailored and supervised exercise training may be an effective multisystemic therapy for post-COVID-19 syndrome that suits the diversity of the cases and symptoms,” wrote the authors.

“A multidisciplinary and integrative approach including exercise sciences is essential where clinical conditions are addressed, but must integrate neurocognitive and psychological aspects into the assessment, as well as the social impact that this pathology entails,” they added.

Further research needs to be done to understand which types of exercise, as well as the intensity and load, are required to combat COVID-19.

On a related note, physical deconditioning is the most common cause of impaired VO2max in those experiencing severe pneumonitis secondary to COVID-19, according to the results of a study published in the European Respiratory Journal.[] The authors wrote that these findings “underscore the importance of an early rehabilitative intervention in survivors of severe COVID-19 pneumonitis.”

How should you monitor?

The authors of the aforementioned BMJ article suggested a stepwise approach to ensuring safety and decreasing the risk associated with returning to exercise.

  1. The patient should be ready to return to exercise following an asymptomatic stretch of 7 days. However, activities of daily living should be handily accomplished before a return to strenuous activity. There should also be no signs or symptoms of myocarditis or myocardial injury, such as chest pain, shortness of breath, heart failure, etc.

  2. A primary care physician should evaluate the patient for ongoing symptoms, with rehabilitation services involved as necessary. It is not yet known whether graded physical activity is advisable, but graduated rehabilitation may be advisable in those who were hospitalized for COVID-19. Physical examination and diagnostic evaluation—including ECG, serum troponin levels, and echocardiography—could compel a referral to cardiology, although findings such as costochondritis could be managed by primary care. Findings of concern include additional heart sounds, edema, fibrosis, pleural effusion, and novel arrhythmias.

  3. Cough and breathlessness should dissipate after a few weeks, but persistent, progressive, or decompensating symptoms could indicate pulmonary embolism, pneumonia, or post-inflammatory bronchoconstriction. These patients should be referred out accordingly.

  4. Although exercise can boost mood and well-being, the patient should be psychologically ready for the endeavor. Mood, sleep, inclination, and appetite should all be assessed. Systems of support may be useful, such as self-care resources, community services, and peer support, as well as counseling and rehabilitation services.

How do you counsel?

To date, no clear, evidence-based guidance regarding a return to physical activity has been specified.

Nevertheless, a good strategy could be a gradual and personalized approach rooted in subjective tolerance. If the patient has been asymptomatic for at least 7 days and has been stratified for risk, phasing in fitness may be prudent. This may also be a great opportunity to encourage exercise in those who were previously sedentary.

“People might be expected to be more breathless for a given activity after a period of illness or inactivity,” wrote the authors of the BMJ article. “However, a degree of subjective assessment is needed to assess if this is consistent with the given activity and level of fitness, and if it is improving.”

The authors proposed that discussion in the primary care setting should involve a modified “3As” approach: Ask, assess, and advise/assist.

It’s important to ask whether it is okay to discuss exercise and determine the patient’s views and goals with respect to physical activity and whether they want to increase levels.

Try recommending goals and consider monitoring progress, including the use of a diary. You can also surmount challenges by making physical activity accessible and bearable, such as recommending walking to destinations or doing work in a garden.

Final note

Resuming exercise following infection with COVID-19 is highly idiosyncratic and depends on many factors.

Nevertheless, it’s likely a good idea to direct your patients to resume this healthy lifestyle choice as soon as feasible.

As explained by University of Iowa Health Care, exercise helps with lung recovery following illness, prevents blood clots, helps the arms/legs maintain strength, and improves mental well-being. The University also offers additional tips on exercise in the context of COVID-19.

Related: Targeting long-haul COVID: An exclusive interview on the latest research
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