Gradual return to physical activity after recovering from COVID-19

Here we provide a summary of guidelines and advice from public health organizations for returning to exercise after COVID-19 (see here, here, here 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 (1, 2, 3, 4). 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 (5, 6). 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.