Four Phases Help COVID Patients Ease Back Into Exercise

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Once patients who have had COVID-19 are symptom-free for at least 7 days, clinicians can assess their risk for beginning an exercise regimen and help them start slowly, new research advises.

Guidance on how clinicians can lead patients safely to exercise after COVID-19 was published online in the BMJ by David Salman, MBBS, academic clinical fellow in primary care at the Imperial College of London, United Kingdom, and colleagues in January.

They recommend a four-phase approach for those who have had mild to moderate COVID-19.

The authors focus on patients who have had prolonged inactivity but who do not have an enduring post-acute COVID-19 illness.

Patients who have ongoing symptoms or who had severe COVID-19 or a history of heart complications would need further clinical assessment, the authors note. But otherwise, exercise can generally begin with at least 2 weeks of minimal exertion.

The paper is based on analysis of current evidence, consensus statements, and the practice experience of the researchers in sports and exercise medicine, rehabilitation, and primary care.

Incidence of myocardial injury or thromboembolic complications after mild or moderate COVID-19 in the community "is currently unknown but thought to be low," they say.

"Therefore, a balance is needed between obstructing an already inactive population from undertaking physical activity at recommended levels beneficial for their health, and the potential risk of cardiac or other consequences for a small minority," the authors write.

Light Intensity for First 2 Weeks

Authors suggest a phased-in approach with a minimum 7 days in each phase beginning with light intensity for at least 2 weeks.

Using the Borg Rating of Perceived Exertion (RPE) scale, the authors note, can help patients monitor how hard they're working and help them choose activities. Patients rate shortness of breath and fatigue on a scale from 6 (no exertion at all) to 20 (maximal exertion).

The authors recommend 7 days in phase 1 on "extremely light intensity activity (RPE 6-8)," with flexibility and breathing exercises. Activities might include household tasks and light gardening, walking, light strengthening, stretching, and balance or yoga exercises.

Phase 2 should include 7 days of light intensity activities (RPE 6-11) such as walking and light yoga, increasing 10-15 minutes per day at the same RPE level as tolerance allows. At these two levels a person should be able to hold a full conversation without difficulty during the exercises, the authors note.

Phase 3 may include intervals of two 5-minute blocks of brisk walking, going up and down stairs, jogging, swimming, or cycling — separated by a block of recovery. RPE of 12-14 is recommended in this phase and patients should be able to hold a conversation during the activities. Patients should add an interval per day as tolerance allows.

Last Phase Works Coordination, Strength

Phase 4 movement should challenge coordination, strength, and balance — activities such as running but with varied directions (eg, shuffling sideways). This phase could also include body weight exercises or circuit training, but exercises should not feel hard.

In any of the phases, the authors write, "They should monitor for any inability to feel recovered at 1 hour after exercise and on the day after, abnormal breathlessness, abnormal heart rate, excessive fatigue or lethargy, and markers of mental ill health."

Psychiatric complications, such as psychosis, have been identified as a potential feature of COVID-19 and sequelae can include posttraumatic stress disorder, anxiety, and depression, the authors note.

If any of these signs occur, the person should return to an earlier phase and seek medical advice.

After completing the four phases, patients may be ready to return at least to their pre-COVID-19 level of activity, the authors write.

However, the authors caution full recovery may take longer than patients expect.

The article includes perspective from a patient who was able to walk and swim for at least 90 minutes before getting COVID-19 in April. The patient, a healthcare assistant, said COVID-19 "was debilitating for me."

The patient said stretching helped the most: "This helped to expand my chest and lungs, so the more intense exercises got easier. It helped to be able to do these stretches prior to a more intense exercise such as walking, as my lungs felt they could hold more air. The breathing techniques were particularly helpful and something I do regularly. I found walking to also be most beneficial as it was an exercise I could control. I could walk at a speed and for a distance that was manageable for me and gradually increase this while using a 'fitbit' to check my heart rate and recovery time."

Ten weeks since the first symptoms, the patient reported being up to 70% of pre-COVID-19 fitness.

Salman told Medscape Medical News the exercise plans in the paper were meant to help guide physicians "and to interpret in the context of the patient in front of them, rather than for general use, particularly given the wide spectrum of illness and recovery trajectory following COVID-19 infection."

"Respect the Disease"

Sam Setareh, MD, a cardiology fellow at Mount Sinai in New York City, told Medscape Medical News the paper's basic message is a good one: "Respect the disease."

He agrees with the approach to wait a full week after the last symptoms and start getting back to exercise very slowly after COVID-19.

"The disease comes with inflammation, and it takes time to recover," he said.

Most of the cardiac risk data so far has been based on athletes and on hospitalized patients, so there is little information on cardiac risk for those who are returning to or starting exercise after mild to moderate COVID-19.

Setareh, who is affiliated with the post-COVID-19 cardiac clinic at Mount Sinai, said if patients had severe COVID-19 and if they had positive cardiac imaging, activity should be resumed under a post-COVID center cardiologist.

If patients are not able to return to their baseline exercise activity or have chest pain, they should get evaluated by a physician. Severe chest pain, heart racing, or palpitations need to be escalated to a cardiologist or post-COVID clinic, he said.

Setareh said that although too much exercise too soon after COVID-19 could be harmful, too much time without exercise could be harmful as well.

"Obese people did worse with COVID," he notes.

A report released Wednesday from the World Obesity Federation found that rates of dying from COVID-19 were 10 times higher in countries where more than half the population is overweight.

"This could be an opportunity in itself to resume activity and start exercising," he said.

Setareh said wearable devices and trackers, which shouldn't substitute for medical visits, can help people track progress and intensity levels.

The trends over the weeks will be more important than individual points in time, he said.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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