Is physical activity detrimental to recovery from Coronavirus disease (COVID-19)?

Physical Activity During COVID-19 Recovery: Guidelines and Recommendations

Physical activity should be restricted during the acute inflammatory phase of COVID-19, particularly if there are signs of myocarditis or pericarditis, but carefully structured exercise programs are beneficial during recovery once inflammation has resolved. 1, 2

Cardiac Considerations During COVID-19 Recovery

Myocarditis and Exercise Restriction

• During active inflammatory phase of myocarditis, all sporting activities should be avoided due to:
  • Risk of exercise-induced disease progression
  • Potential to trigger malignant arrhythmias in electrically unstable myocardium 1
• Recommendations for myocarditis:
  • Restrict from competition and strenuous training for 3-6 months
  • Return to play only after:
    1. Normalization of left ventricular systolic function
    2. Normalization of cardiac/inflammatory biomarkers
    3. Absence of clinically relevant arrhythmias 1

Pericarditis and Exercise Restriction

• Exercise appears to exacerbate inflammation in the pericardium and precipitate recurrences
• Athletes with pericarditis should avoid competitive sports during the acute phase
• Return to activity only after normalization of inflammatory biomarkers and resolution of any effusion 1

Rehabilitation Approach After Acute Phase

When to Begin Rehabilitation

• Start rehabilitation only after:
  • Acute inflammatory phase has resolved
  • Patient is no longer infectious
  • Active myocarditis has been ruled out 1
• Implement rehabilitation care as early as possible once these conditions are met 2

Pulmonary Rehabilitation

• Begin with pulmonary rehabilitation training which improves:
  • Pulmonary function (forced vital capacity)
  • Exercise capacity (6-minute walking distance)
  • Overall health-related quality of life 2

Structured Exercise Programs

• Implement carefully structured exercise programs:
  • Combined aerobic with strength training
  • Combined exercise with specific respiratory exercises
  • Aerobic exercise with specific respiratory muscle training 2
• Use a conservative, graded exercise approach for those recovering from myocarditis 1

Special Considerations for Different Patient Groups

Athletes and Physically Active Individuals

• For athletes with confirmed COVID-19-associated myocarditis:
  • Exercise testing should be performed after 3-6 month convalescence period
  • Primary goal is to identify clinically significant ventricular arrhythmia 1
• For asymptomatic athletes with complete resolution of myocardial inflammation and no arrhythmias:
  • Use conservative, graded exercise approach for return to play 1

Patients with Post-Acute Sequelae (PASC/Long COVID)

• Decision-making regarding return to exercise should be informed by presence of cardiopulmonary symptoms
• If cardiopulmonary symptoms are present:
  • Perform triad testing
  • Consider cardiac MRI if appropriate
  • Limit strenuous physical activity 1
• For those with PASC but without cardiovascular disease:
  • Structured and individualized graded exercise should be performed throughout recovery 1, 2

Common Pitfalls and Caveats

• Premature return to exercise: Returning to exercise too soon during active myocarditis or pericarditis can worsen inflammation and trigger arrhythmias 1
• Lack of individualization: Treatment must be tailored to specific symptom clusters and severity; lack of individualization can worsen outcomes 2
• Ignoring psychological aspects: Undertreatment of psychological symptoms can worsen patient outcomes; mental health aspects require equal attention to physical rehabilitation 2
• Excessive exercise intensity: Based on indirect evidence, moderate physical activity is recommended during recovery, while high-intensity exercise requires further consideration 3

By following these evidence-based guidelines, patients can safely recover from COVID-19 while minimizing cardiovascular risks and optimizing rehabilitation outcomes.