Condition Recovery for Athletes Post-Covid
How Can Physical Therapy Help Athletes Return to Play Post-COVID?
There is no question that the COVID-19 pandemic has had a significantly negative impact on the lifestyles of people across the globe. Athletes, from the recreational to elite levels, have, without a doubt, been adversely affected due to the unfortunate lockdowns and extended closures that occurred due to efforts to reduce the spread of COVID-19.
Despite the fact that athletes of all levels have made reasonable adjustments to work-out routines via home-gym set-ups and other covid-free alternatives, these training variations are drastically different from the norm, and they fail to meet the pre-covid competition demands. As one considers return to sport during the pandemic, it is crucial to investigate the inevitable post-covid health-related limitations and risks.¹ It is vitally important to develop a safe and effective return to sport training methods. The following considerations should be taken into account: the duration of time the athlete followed quarantine and/or lockdown; the athlete’s current health status as a result of having COVID-19; the demands of the sport the respective athlete is returning to; and the overall training parameters the athlete is following throughout the home/lock-down training.¹ Although there are some generic return to sport principles one can follow, including sport-specific training is encouraged to promote ideal recovery outcomes.
Safely Return to Sport
In order to protect public health throughout the pandemic, the strategy of promoting reduced or no access to sporting facilities was implemented. This ultimately led to significantly reduced training sessions and sporting competitions. As a result, a careful eye should be given on how to facilitate return to safe and effective return to sport while considering optimal performance levels and still reducing the risk of injury and other health complications. In absence of routine sports training, it will most likely cause a decline in the performance of sport-specific tasks.² According to Webster’s dictionary, de-training is the “partial or complete loss of training-induced adaptations in response to cessation of training or a substantial decrease in training load.”² The following factors would influence the condition an athlete would likely return to:
- Pre-covid level of athletic activity the athlete
- Intensity and type of training
- Diet and nutrition habits maintained during quarantine
- The severity of COVID-19 symptoms the athlete experienced.
- Presence of other factors: altered sleep patterns, the uncertainty of returning to training, and feelings of depression.³
Long-term Effects of COVID-19
Although much has been learned throughout the pandemic, there is still much unknown regarding the potential long-term effects of COVID-19. In general, research supports the negative impacts on various body systems associated with the heart, brain, lungs, and kidneys. In addition, people experience various combinations of symptoms such as shortness of breath, muscle aches, fever, chills, and exhaustion when tested positive for COVID-19.⁴ One of the most challenging aspects of this is that there is no definitive set of symptoms and there is a wide range of health-related complications; some will be asymptomatic and be able to return to full functional capacity for desired sport, while others will present with compromised and reduced athletic performance. In general, the majority of athletes will most likely need to return to sport in a slow, gradual manner that will require utmost patience. It will be therefore important to consult with a primary care physician to ensure monitoring of symptoms throughout the process.
Although COVID-19 is most commonly associated with pulmonary complications, it has also proven to negatively affect the cardiovascular system. One of the most common cardiac abnormalities is myocarditis, as it has shown in patients hospitalized for COVID-19. As recent literature has shown that myocarditis is associated with the unfortunate and sudden mortality in athletes, attention has been driven to the risks of myocarditis following COVID-19 in the athletic population. Furthermore, major emphasis has been placed on the cardiac evaluation process and ultimately the athletes return to play. As myocarditis has become the leading cause of sudden cardiac death amongst athletes, it has become crucial to evaluate athletes post-COVID for myocarditis using MRI as an essential tool.⁴
As shown in a study⁵, MRI scans were taken of 26 elite athletes testing positive for COVID-19. Of those 26, a total of 12 displayed mild symptoms, and 14 were asymptomatic. Lastly, none of the symptomatic athletes were hospitalized. Of all participants, the cardiac MRI results identified myocarditis in 15% of the sample, and 31% showed signs of cardiac tissue fibrosis. Although a conclusion cannot be made in regards to the long-term effects of myocarditis on athletes, it still does become a useful tool in identifying high-risk athletes from those who are safe to return to sport and/or training. In their report, the doctors within this study now implement a risk assessment tool for universities and other professional sports agencies in hopes to balance the athlete’s risk against a desire to resume play safely.
Following the analysis of this study, the American College of Cardiology developed a tool to guide safe and effective return-to-play for athletes; those with mild to moderate symptoms with positive COVID-19 test should only resume following the complete absence of symptoms and normal MRI scan. According to the CDC, other serious long-term complications have been reported: lung function abnormalities, acute kidney injury, rash, hair loss, smell and taste problems, sleep issues, difficulty with concentration, memory problems, depression, anxiety, and changes in mood.⁶
Addressing Physical Impairments & Functional Limitations
As returning to exercise and training post-COVID is a challenge, it is important to address physical impairments and functional limitations in a slow, gradual manner. Should symptoms such as shortness of breath, lightheadedness, muscle aches, weakness, and fatigue be persistent, it is best to avoid the higher intensity of training until these are resolved. “Light physical demand” activities of daily living such as cleaning, walking, stair negotiation, cooking, lifting, and reaching should not produce any adverse symptoms prior to beginning training or higher-level activities.
A useful exercise formula recommended by the American College of Sports Medicine (ASCM)⁷ can help determine how the intensity of activity based on one’s heart rate. Because age impacts aerobic capacity, using a simple calculation can help guide appropriate levels of exercise. Simply take 220 – age =. Maximum Heart Rate. (HR). We should not exercise at our max HR. The recommendation is to determine appropriate intensity by a percentage of Max HR. Scientific evidence supports exercising at moderate intensity as 50-70% of Max HR for 10-30 minutes, 5 times a week. As conditioning occurs, a greater effort will be needed to reach the desired HR.
Example: 30 year old; Max HR is 220 – 50 = 190. The goal would be to exercise at a level that keeps the HR at 133 for 20-30 minutes in the early stages of restoring activity levels.
Physical Therapy Can Help Safely Guide Athletes to Their Physical Pre-COVID Condition
With athletes returning to the sport, think safety first. Cardiac symptoms may go undetected until activity levels are increased. Consider consulting a physical therapist who can guide the athlete through training the cardiovascular system, as well as musculoskeletal conditioning, keeping injury risk very low, while returning the athlete to the sport that he or she loves.
Article by: Russ Zeiss
Ivy Rehab Physical Therapy, New Rochelle
Russell Zeiss is a licensed Physical Therapist in New York, and currently the Clinical Director at Ivy Rehab Physical Therapy in New Rochelle, NY. After earning his Bachelor’s Degree in Exercise Science at SUNY Buffalo in May 2011, Russell continued his professional education at Daemen College and received his Doctoral Degree in Physical Therapy in May 2014.
Russell works with a multidisciplinary approach, treating patients presenting with musculoskeletal, neurological, surgical, and cardiopulmonary pathology. Throughout his career with Ivy Rehab Physical Therapy, he continues to develop clinical and leadership skills in order to advance to his current role as Area Director. Individualized patient care, collaboration with a multidisciplinary team of physicians and other PTs, and utilization of time management skills have been paramount in his overall work ethic. Russell uses a combination of manual therapy techniques, specific impairment-based exercises, and patient education in order to assist patients toward full recovery and restoration of function.
Russell is currently in training for his MDT certification and will eventually pursue OCS certification. In the height of the pandemic in March 2020, Russell also developed the Healthy Lungs Program in order to help patients post-COVID recover as they present with mobility restrictions, breathing impairments, and overall deconditioning.
- Aspetar Clinical Guideline. Safe Return to Sport during the COVID-19 Pandemic.June 2020
- Mujika I, Padilla S. Detraining: loss of training-induced physiological and performance adaptations. Part I. Sports Medicine. 2000 Aug 1;30(2):79-87.
- Pillay L, van Rensburg DC, van Rensburg AJ, Ramagole DA, Holtzhausen L, Dijkstra HP, Cronje T. Nowhere to hide: the significant impact of coronavirus disease 2019 (COVID-19) measures on elite and semi-elite South African athletes. Journal of Science and Medicine in Sport. 2020 May 19.
- Phelan D, Kim JH, Chung EH. A game plan for the resumption of sport and exercise after coronavirus disease 2019 (COVID-19) infection. JAMA Cardiol. Published online May 13, 2020. doi:1001/jamacardio.2020.2136
- Rajpal S, Tong MS, Borchers J, et al. Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection.JAMA Cardiol. Published September 11, 2020. doi:10.1001/jamacardio.2020.4916
- Long-Term Effects of COVID-19: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects.html
- American College of Sports Medicine, Riebe, D., Ehrman, J. K., Liguori, G., & Magal, M.(2018). ACSM’s guidelines for exercise testing and prescription (Tenth edition.). Philadelphia: Wolters; Kluwer