Post-COVID Exercise Planning

Jan 3

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Takeaway Points:

Post-COVID, the risk of various health issues is increased, and it is not a good idea to directly return to high activity levels right away.
In this post, I cover some of the most important elements to avoid in training to ensure that you have a smooth transition back to full ability.

Before I start this post I will remind everyone that I am not a doctor and this is not medical advice. Please consult your doctor for clearance before returning to activity.

Recently, I was unfortunate to come down with COVID. My wife and I are able to work from home and have been very cautious all year, to the extent that we’ve barely left our house. Unfortunately, our children were still required to attend in-person classes at school, and as a result, one of them brought it home in early December and we all quickly came down with symptoms.

Luckily, we all had relatively mild cases, and have been able to recover without any necessary hospitalization. Unfortunately, the symptoms are surprisingly long-lasting, and even now (about three weeks since the start of symptoms), we’re still feeling it.

One factor which I don’t think there has been enough discussion of, is the risk of developing myocarditis, an inflammation of the heart which increases the risk of heart attacks and other adverse health effects.

While athletic populations are generally expected to be healthier, one study on athletes post-recovery showed that 4 of the 26 athletes (15%) had evidence of myocarditis, 2 of which had no symptoms (and thus no reason to suspect needing to be careful). They also found that 12 of the 26 athletes (46%) had late gadolinium enhancement (LGE), which denotes scarring of the heart tissue and is a predictor of adverse cardiovascular outcomes. This shows us that even in athletic populations, we need to be careful when assessing health and returning to activity, post-recovery.

(There are also some caveats to the above study on athletes - however, a discussion of the merits of that study are a bit beyond the scope of this post. Still, it is important to understand that the risks do exist and are serious.)

Sadly, these are also not the only negative effects which can persist long term, including the possibility of deep vein thrombosis and pulmonary embolism.

In the short term, exercise places a great deal of stress on the body, and this temporarily increases the risk of adverse effects, like a heart attack. However, since most of us have healthy heart muscle, that stress is usually not a serious concern. Over time, exposure to the stress of exercise further strengthens the body’s various capabilities, which make it more resilient to the further stress of harder and harder exercise, making it a long-term net positive. However, in populations with compromised function - for example, with COVID-induced myocarditis, or the general weakening of the body that occurs with aging - the acute stress of exercise could potentially induce serious negative events.

In the situation of having recovered from COVID, the most prudent approach would be to first see if it is possible to get testing done through your doctor to determine the presence of such risk factors before resuming exercise. Unfortunately, this is likely difficult in the current climate, where the general strain of COVID on health care means that they are overrun in the US and UK, and would likely not have much ability to devote testing and imaging to the average exerciser looking to return to full activity.

That said, here are some general guidelines which I am following myself, and which I would recommend to anyone returning to activity post-COVID. These guidelines should not be considered medical advice, and you should still consult your doctor to get cleared before returning to activity.

Four major factors in exercise are excessively likely to cause cardiac events, due to the ways in which they affect the body. They are: extreme intensity, the valsalva maneuver, isometric exercise, and inverted positions.

Intensity

Intensity is a relative measure of how hard you’re working out. If you’re performing a light jog at a consistent pace, this is generally of moderate intensity, while a sprint at maximum speed for a short duration would be considered to be maximum intensity.

Likewise, a single repetition maximum (1RM), the heaviest weight that you can lift for a single repetition, is as intense as it gets in lifting weights, compared to a weight that you can comfortably lift for 10 or 15 reps. You can also up the intensity of an exercise by trying to push to complete failure, the point at which you cannot perform any more reps and fail the proceeding rep attempt.

Extreme intensity represents your body working at its absolute limits, so it is no surprise that it will also put excess strain on your heart. Exercise should be limited in intensity for a decent period of time following recovery, so that you can ensure that you give your body more than adequate time to return to such levels of effort. This also means that lifters should likely limit their sets and train a bit further away from failure so that there is less risk of overdoing it.

It may also be difficult to start up an exercise habit for the first time, given that your body would be less accustomed to exercise than the experienced exerciser. Newer exercisers should be doubly careful to keep intensity low and avoid pushing intensity too aggressively in their training.

Valsalva Maneuver

The valsalva maneuver is a method for bracing the body. In this maneuver, the airway is forcibly shut while attempting to exhale, which causes a lot of muscle to tense up simultaneously, helping to stabilize the core and enabling the lifter to lift a bit more weight.

The maneuver tends to happen naturally at heavier weights as intensity increases, and is a common part of powerlifting, strongman, weightlifting, and other sports where very heavy weights are regularly lifted.

However, this also causes blood pressure to skyrocket, which is why it is not recommended for those with preexisting blood pressure issues or heart conditions.

Avoiding the valsalva maneuver is largely in line with the guidelines for avoiding intensity above, as it is primarily a technique for allowing a lifter to lift more weight at extreme intensities. Focusing on even, consistent breathing during exercise helps to keep the circulation functioning normally, and if you find that you’re exercising heavily enough that you need to use the valsalva maneuver, it is likely too heavy.

Heavy Isometric Exercises

Isometric exercises are exercises in which effort is generated not by lifting a weight and then lowering it, but instead by holding a position and resisting against the external force of gravity, preventing movement. The classic example of an isometric exercise is the plank, a core exercise in which the plank position is held against the force of gravity. Many other core exercises would also qualify as isometric exercises, and some isometric variations exist of other exercises.

You can likely imagine the reason this is forbidden - because in a similar way, the high necessity for stability against heavy external resistance is likely to invoke the valsalva maneuver, spike blood pressure, and thus cause issues.

Light isometric exercises are likely ok - for example, a short duration plank is a relatively easy core exercise for advanced exercisers - but taking them very heavily, or with very extreme durations, is likely to cause problems and should be avoided.

Inverted Positions

An inverted position is any position in which the head is lower than the torso, causing blood to rush to the head. The most common example of this position is a handstand, though other exercises (hyperextensions, glute ham raises, pike pushups, feet elevated planks, etc.) also involve an inverted head position.

Inverted positions can naturally affect your circulation as well, and possibly make it harder for your heart to pump blood to the peripheries of your body. This effect is increased with longer durations, and so inverted positions should generally not be done for excessively long periods anyway.

This isn’t ideal when you’re dealing with potential heart or blood pressure issues, and can even potentially be dangerous. As a result, any exercise which uses an inverted head position should be entirely avoided for a while.

My Recovery

Anyone who knows me knows that I’ve been a huge fan of walking for cardio lately. The low intensity of this method also means that it works well for assisting in my post-COVID recovery.

About one and a half weeks after the start of symptoms, I was largely feeling better able to get around without getting winded, and was able to return to walking in the neighborhood. I avoided the hills for a few days, focusing on mostly flat ground and building into the hills as I was feeling better.

After about a week of cardio and feeling better with my cardiovascular ability, I returned to very light workouts. Before COVID, I was doing lots of very-high-rep bodyweight exercises, heavy exercises loaded with my flywheel box, and more advanced gymnastics/calisthenics moves, so doing more basic bodyweight exercises (pushups, squats, pullups) is light enough to me that it works well.

The plan from here is to focus on adding volume via additional sets and reps of these exercises, with larger than normal rest periods, instead of adding weight. I will likely wait another month or so before I start trying some of the more advanced/heavier exercises I was used to. In this way, I can keep the stress relatively low and ensure a smooth recovery.

The above outlined approach is also in keeping with the one paper I could find on the topic, a position paper from the Dutch Sports Cardiology Section of the Netherlands Society of Cardiology. Correspondingly, they recommend limiting intensity and getting tested for long-duration symptoms, and not resuming activity for a minimum of 10 days after the onset of symptoms, with a gradual return to exercise afterward. They also emphasize the high importance of further testing, especially if intending to return to high activity levels.

About Adam Fisher

Adam is an experienced fitness coach and blogger who's been blogging and coaching since 2012, and lifting since 2006. He's written for numerous major health publications, including Personal Trainer Development Center, T-Nation, Bodybuilding.com, Fitocracy, and Juggernaut Training Systems.

During that time he has coached hundreds of individuals of all levels of fitness, including competitive powerlifters and older exercisers regaining the strength to walk up a flight of stairs. His own training revolves around bodybuilding and powerlifting, in which he’s competed.

Adam writes about fitness, health, science, philosophy, personal finance, self-improvement, productivity, the good life, and everything else that interests him. When he's not writing or lifting, he's usually hanging out with his cats or feeding his video game addiction.

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