Return to Exercise after COVID–19

The COVID-19 pandemic has brought to the surface the importance of engaging in healthful decisions regarding nutrition and exercise do reduce the risk of worse outcomes after infection. Young athletes and middle-aged athletes do have the same risk to contract COVID-19 with lower risk of complication, but cardiovascular effects have been reported. Inflammation from the disease can lead to heart damage. Athletes are not immune to these effects. Returning to the activities you love takes a step-by-step progression to return to full activity. Before we talk about return to activity, here are some complications that should be considered when thinking about returning to activity.


The current scientific evidence is limited in this area but there are some significant effects that need to be considered:

1) Myocarditis – an inflammation of the heart muscle that can affect the electrical system of the heart. This has been demonstrated in student athletes in a low percentage (1.9%).

2) Inflammation of the heart muscle has been shown in 60% people that were hospitalized 71 days out from their initial diagnosis. Ongoing inflammation can extend the return to activity of an individual. As an addition, presence of inflammation does not mean that you have myocarditis.

3) Blockages in the blood vessels in the lungs (Thromboembolism) – Has been demonstrated in survivors that can negatively affect return to sport and can be a serious complication that can lead to serious injury to your lung or in the worst cases, death.


This is only a general recommendation, and not a substitute for medical advice.


If you have been severely affected with COVID -19 symptoms and do want to return to activity, I highly recommend you having a discussion with your primary care physician and attending physical therapy for supervised and guided progression.


So, how do I know if I am ready to return to activity? Severe infection is shown to present about seven days after onset of symptoms. The current recommendation is that return to activity should only occur after you become asymptomatic for a period of at least seven days.


Using a pulse oximeter can help to give you a safe reading to check how much oxygen is in your red blood cells. This can give you an idea of how you are responding to activity. Normal range is >95%.


Ask yourself questions this before initiating sport activity:

1) Are you able to perform your normal activity of daily living without difficulty, coughing, breathlessness, fatigue, and is your pulse oximetry >95%?

2) Are you able to walk for a mile without coughing, breathlessness or fatigue, pulse oximetry normal >95%? - This low-level activity should be graded based on previous activity level.

3) Are you ready to return to physical activity? Do you remain lethargic, lack motivation, sleepy, moody? - These are things to consider, they do not prevent initiation of activity, in fact, getting back to some low-level activity may improve these areas.


The study referenced here has a terrific flow chart to help guide progress:

Guidelines to progress activity

The first few weeks 0 – 1 weeks. Begin with very easy intensity. I use the rating of perceived exertion, or RPE scale, with my athletes on each of their workouts to assess on how hard an activity feels. This is located on the bottom right-hand corner of the graphic above.


Perform the same activities for most days of the week, you should be able to make full recovery later that day with no new symptoms. After 1 week with no symptoms you can move to the next phase. If you find this too taxing, then stay in the level where you respond the best, only move up when you feel you can without symptom production.


Week 0 – 1

Recommended activity:

- RPE 6 - 8 – Extremely light to light

- Light housework

- Stretching, light yoga

- Easy walks in 10-20 minutes in duration < 3.0 mph


Week 2 – 3

Same as above but adding in increased walking duration by 5-10 minutes until you can reach light walking intensity for a duration of 30 minutes. You can also substitute bike riding also in the active recovery range < 56% of your FTP (functional threshold power) if you train with a power meter.


Week 3 – 4

Add in some aerobic activity. Start with two – three intervals of 3-5 minutes in duration, separated by 3-5 minutes of recovery level riding. Walking, you can increase to a fitness walking intensity 3-3.5 mph on the treadmill.

If you use power on your bike, then keep it on the low end 57%-65% of your functional threshold power FTP, RPE 11-12. If this feels easy and doable, your pulse ox remains >95%, add an additional interval the next day.


Weeks 4 – 5

Increase intensity of your walking to 10 minutes of a fitness walk at 3.5 mph followed up by short intervals of light jogging, if running is your thing, again keeping your HR low and breathing controlled. Begin with 3- 5-minute blocks for 2-4 repetitions. RPE should be moderately challenging 12 - 13.


For cycling, you can increase the duration of your aerobic blocks from 5 to 8-10 minutes or move to the middle of the endurance level 65-72% of your FTP.


Add in some body weight strengthening exercise for 1-2 sets of 10 repetitions. Pushups, squatting, lunging, and rowing work well.