Gradual return to physical activity after recovering from COVID-19

Gradual return to physical activity after recovering from COVID-19

OVERVIEW

  • People with persistent symptoms or who have had a severe form of COVID-19 or who may have a history of cardiopathy should consult a doctor before resuming physical activity.
  • People who have had a mild form of COVID-19 and want to resume physical activity should do so very gradually.
  • Do not resume exercise until at least seven days without symptoms and start with at least two weeks of minimal exercise.
  • Use daily self-monitoring to track your progress and determine when to seek additional medical help if needed.

Here we provide a summary of guidelines and advice from public health organizations for returning to exercise after COVID-19 (see hereherehere and here).

After a mild form of COVID-19, some people have a prolonged recovery, especially when trying to resume exercise. In addition, many affected people may have long-term complications from COVID-19, including chronic COVID syndrome (post-COVID syndrome or long COVID), cardiopulmonary disease, and, in some people, psychological sequelae (1234). This article presents a pragmatic approach to help people safely return to physical activity after symptomatic SARS-CoV-2 infection, focusing on those who have lost their physical condition or have had a prolonged period of inactivity but who do not have chronic COVID syndrome.

The health benefits of physical activity, for cardiovascular as well as mental health, are well established (56). Conversely, the harms of physical inactivity make it a major risk factor for noncommunicable diseases around the world, as are smoking and obesity (7). Before the COVID-19 pandemic, the majority of adult Canadians (82.5%) did not meet physical activity guidelines (at least 150 minutes of moderate-intensity physical activity per week at a rate of at least 10 minutes per session) and were sedentary for most of the day (9.6 hours) (8). There has been a further decline in physical activity since the start of the pandemic among people with chronic conditions like obesity and hypertension (9), conditions that are associated with severe forms of COVID-19 (10). Brief advice can help people engage in physical activity, with the associated positive health effects, and help those recovering from illness to return to previous levels of physical activity or beyond (11). Some people may not know how and when to resume physical activity after COVID-19, and if it is safe. Some may have tried returning to their baseline exercise and found that they were unable to do so.

You should consult a doctor before exercising after having COVID-19 when:

  • The illness required treatment in the hospital.
  • Myocarditis has been diagnosed.
  • You experienced heart symptoms during the illness (chest pain, palpitations, severe shortness of breath or syncope).
  • You experience persistent symptoms (respiratory, gastrointestinal, rheumatic or other).

If you had no complications during the illness and have had no symptoms for 7 days, you can gradually resume physical activity (Figure 1):

Resuming in four phases (minimum of 7 days for each phase):

Phase 1: Very low intensity physical activity, such as flexibility and breathing exercises.

Phase 2: Low-intensity physical activity such as slow walking, light yoga, light housework and gardening, gradually increasing the duration to 10–15 minutes per day, when the exercise is well tolerated.

At both phases 1 and 2, the person should be able to hold a normal conversation without difficulty while doing the exercises.

Phase 3: Aerobic and strength exercises of moderate intensity, such as brisk walking, jogging, swimming, cycling, going up and down stairs. You shouldn’t feel like the exercise is “hard”. It is recommended to do two 5-minute intervals of exercise separated by a recovery block. People should add one interval per day if exercise is well tolerated.

Phase 4: Aerobic and strength exercises of moderate intensity with control of coordination and functioning skills, such as running with changes of direction, side steps, but without it feeling too difficult. Two days of training followed by a day of recovery.

Phase 5: Return to regular exercise (pre-COVID).

 

Figure 1. Suggested return to physical activity after COVID-19. Adapted from Salman et al., BMJ, 2021.

 

It is proposed to devote a minimum of 7 days to each phase to avoid sudden increases in training load. However, people should stay at the stage they feel comfortable with for as long as necessary. Watch for any inability to recover 1 hour after exercise and the next day, for abnormal shortness of breath, abnormal heart rate, excessive fatigue or lethargy, and markers of poor mental health. If this happens or if you are not progressing as planned, you should return to a previous phase and seek medical attention if in doubt. Keeping a journal of exercise progress, as well as the intensity of exertion, any changes in mood and, for those who are used to measuring it, objective fitness data such as heart rate, can be useful in tracking progress.

Association between chronic stress and heart attacks

Association between chronic stress and heart attacks

OVERVIEW

  • Cortisol concentration in recent hair growth was measured in middle-aged people shortly after suffering a heart attack, and in people of the same age group who were in apparent good health.
  • The median concentration of cortisol in the hair of people with a myocardial infarction was 2.4 times higher than that measured in the control group.
  • The risk of myocardial infarction was approximately 5 times higher in people with high cortisol levels compared to those with normal cortisol levels.
  • These results indicate that chronic stress appears to be an important risk factor for myocardial infarction.

It is well established that acute physical and/or emotional stress (accident, anger, fear) is a risk factor for heart attack (see our article on the subject). However, it is not clear whether high levels of chronic stress also contribute to the risk of myocardial infarction. One of the reasons that little is known about this potential risk factor is that until recently, it was only possible to measure acute stress, not chronic stress. The stress response involves activation of the corticotropic axis (or hypothalamic-pituitary-adrenal axis) and the autonomic nervous system, including the secretion of cortisol, one of the main stress hormones. Chronic stress can now be objectively and conveniently assessed in people by measuring cortisol levels in hair. As the hair grows, an amount of cortisol proportional to the blood concentration is incorporated into the hair. A 1 cm hair cut at the base of the scalp will have taken 4 to 6 weeks to grow, and its cortisol content will reflect the level of chronic stress the person has experienced during that time. The last 5–10 days of hair growth is in and under the scalp.

In a retrospective study of women and men under the age of 65 in Sweden, the levels of cortisol in the hair of 174 people who had suffered a myocardial infarction were compared to those of 3156 people in apparent good health. The median concentration of cortisol in the hair of people with a myocardial infarction was 2.4 times higher (53.2 pg/mg) than that measured in the control group (22.2 pg/mg).

Analysis of the data shows a very clear dose-response relationship, i.e. that the higher the levels of cortisol detected in the participants’ hair, the greater the risk of a heart attack. This dose-effect relationship is not linear, as can be seen in Figure 1: the cortisol levels of the first 3 quintiles are not associated with a significantly higher risk of myocardial infarction, but this risk increases very significantly for cortisol levels in quintiles 4 and 5.

Figure 1. Relative risk of myocardial infarction as a function of the concentration of cortisol in the hair of the participants. *Very significant (p <0.001). From Faresjö et al., 2020.

 

This retrospective study shows an association between high cortisol levels and myocardial infarction, but this type of study does not establish a causal link. Results from other studies also suggest that cortisol may cause myocardial infarction. For example, the elevated cortisol levels seen in people with Cushing’s syndrome or in patients receiving glucocorticoid therapy are linked to an increased prevalence of cardiovascular risk factors and myocardial infarction. It is therefore plausible that increased cortisol levels cause metabolic disorders that lead to atherosclerosis and, in the long term, to coronary artery blockage and myocardial infarction. Increased blood cortisol levels also have direct effects on the cardiovascular system, including increased contractility of blood vessels, inhibition of angiogenesis, and increased platelet activation, which can lead to thrombosis.

Exposure to chronic stress is typical of our modern societies and can be the cause of many illnesses. We have to learn to manage this chronic stress, for example by practicing cardiac coherence or meditation. I encourage readers to learn more on this subject; there are many very accessible books: Christophe André: Looking at Mindfulness, Matthieu Ricard: The Art of Meditation, Jon Kabat-Zinn: Full Catastrophe Living, and Rick Hanson: Hardwiring Happiness.