Making a Return to Sports Post COVID-19
Eramosa Physiotherapy Associates is dedicated to supporting the safe and successful transition to returning to sport following COVID-19 infection. COVID-19 is an illness that can affect many organs of the body including the heart and lungs. In addition, there is evidence of athletes reporting symptoms that may persist weeks to months after COVID-19 infection.
It is therefore important that immediately after testing positive for COVID-19 to
- FIRST: rest and self-isolate according to public health guidelines, and
- SECOND: receive medical clearance to begin a gradual return to regular sports activities once the infection has cleared.
What are the risks to athletes to return to play after COVID-19?
Current evidence on the effects of COVID-19 is evolving rapidly and stems mainly from preliminary research, consensus statements and clinical expertise. One main concern for the cardiovascular system is the potential for cardiac injury either directly due to viral myocarditis or indirectly through the development of cytokine storms (isolated to severe cases). The majority of data on cardiac injury from COVID-19 is from severely ill patients who were hospitalized. The incidence of myocarditis in those who were asymptomatic or had mild to moderate cases of COVID-19 is unclear. Nevertheless, this is important as exercising in the presence of myocarditis is associated with increased morbidity and mortality.
The long-term respiratory effects of COVID-19 are not currently known; however, it is important to note that survivors of the 2003 SARS-CoV epidemic reported persistent complications in lung function and exercise capacity. There have been many instances of athletes, including those with mild cases of COVID-19, reporting prolonged symptoms such as a persistent cough and dyspnea, made worse by exercise. In the majority of mild to moderate cases, symptoms typically resolve within weeks, but may indicate pulmonary-vascular complications such as pulmonary embolism, concomitant pneumonia or post-inflammatory bronchoconstriction should they be “progressive, non-resolving or worsening”.
How do I know when an athlete can safely return to training?
The current understanding of protocols for return to play following COVID-19 infection is quickly evolving. The recommendations are subject to change as more information on recovery from COVID-19 for athletes becomes available. After COVID-19 infection, there is concern of potential cardiac injury and respiratory effects for athletes, depending on the severity of the illness. Any return to play considerations must be accompanied by a medical doctor’s approval and will also require your team trainer’s approval in coordination with a registered health professional. Below is a summary of what to expect over the next few weeks:
- Return to Play Stages*: There are 6 stages that will be monitored by your medical doctor and/or physiotherapist. Before beginning the return to play program, it is important that you no longer test positive for COVID-19 and that you have been symptom free and met your local public health guideline symptom-free quarantine period. It is recommended that you have at minimum 10 days of symptom free rest, with only gentle activities (e.g. walking, household chores) before proceeding into the stages of activity. Receiving medical clearance from your doctor to begin the program will work towards your rest period.
- Each stage requires a minimum of 24-48 hours before moving on to the next stage. Any return of symptoms (including excessive fatigue) results returning to the previous stage and progress again after a minimum of 24 hours’ period of rest with no reoccurrence of symptoms.
It is recommended for competitive athletes who tested positive for COVID-19, regardless of symptoms, to complete a medical history and physical examination. Athletes who experienced more severe cardiac symptoms during their illness such as chest pain, palpitations, severe breathlessness or syncope warrant further cardiac and pulmonary tests (i.e. 12-lead ECG, spirometry). Those who have had more severe infections and/or required hospitalization should have a full medical assessment before beginning any return to sport program, which may include blood testing for inflammatory markers and/or renal hematological monitoring, other cardiac monitoring such as an ECHO or cardiac MRI, and further pulmonary tests such as a chest x-ray. Athletes with other medical conditions such as diabetes, cardiovascular disease or renal disease should also have a medical assessment before starting any return to sport program.
What are the stages to return to play after COVID-19?
Similar to any return to play protocol, the program after COVID-19 should be progressive and include monitoring of symptoms at every stage. Following medial clearance, the athlete may begin a stepwise program that increases in training frequency, duration, and intensity. If any symptoms return, including excessive fatigue, the athlete should return to the previous stage and only progress after a minimum of 24 hours of rest without symptoms. See the infographic below for current recommendations for athletes by Elliott et al. 2020.
General COVID-19 Resources
London Health Science. London, ON- https://www.lhsc.on.ca/urgent-covid-19-care-clinic
Activity Guide for Transitioning Home, British Columbia- https://vch.eduhealth.ca/PDFs/FG/FG.226.C66.pdf
UK COVID Recovery Guide- https://www.yourcovidrecovery.nhs.uk/
Canadian COVID research:
World COVID research:
- Long COVID Support (UK)
- We are Body Politic COVID-19 Support Group
- Facebook: COVID Long Haulers Support GroupCanada
- Long COVID Physio Podcast
Acknowledgment to ReActive Physiotherapy for compiling and mentoring physiotherapists in community settings. For more information visit- https://reactivephysio.com/specialty-services/covid-19-survivorship/