This is an article by invitation. Doctors Arati and Pravin Gaikwad are experienced pediatricians who have also been endurance athletes for a long time. In Navi Mumbai, they are co-founders of the runners group, LifePacers. This blog contacted them for inputs on how best a runner recovered from COVID-19 may handle his / her return to the sport. They paraphrased their response to questions sent, by first pointing out that COVID-19 is a new disease and since guidelines are still evolving, they should not be considered as mandates. The guidelines are based on expert opinion and available data.

In general, the quest for every runner when it comes to injury (an illness is similar to it) is to stay within the repairable realm and not provoke irreparable damage.  So, to begin with, even if used to an active lifestyle, asymptomatic patients should stop exercising for at least two weeks. This would anyway coincide with the isolation and quarantine period they are advised once they test positive. Mild activity to keep a sense of movement going is alright. Anything vigorous, which puts strain on the body or elevates heart rate needlessly, should be avoided. Exercising intensely may increase the risk of viral replication along with increased risk of myocardial involvement. Also, deep inhalation during exercise may help the virus to settle in the lower lobes of the lungs causing respiratory compromise.

Most active people turn to physical activity to boost circulation and feel better when they are feeling a bit low. But with COVID-19 in the equation, the results may not play out as hoped for. Being healthy, fit and strong may help you avoid some of the more severe symptoms of COVID-19 like Acute Respiratory Distress Syndrome (ARDS), but it doesn’t make you immune to some of the more insidious effects of the disease like myocarditis. A German study published in JAMA Cardiology, dealing with a sample of people who had formerly come down with COVID-19, showed 60 per cent of individuals to have myocarditis after two to three months of recovery. Eighteen per cent of these had been asymptomatic individuals.

Individuals who had been COVID-19-positive with any degree of symptoms should seek a physician’s opinion before resuming physical activity. Symptomatic athletes – recreational to professional – have been surprised by the potency of the disease. They have struggled to reestablish old workout regimens; some have had a lingering battle with lung issues, muscle weakness and unsettling anxiety about whether they would be able to match their old physical peaks.  The physician will decide depending upon the severity of infection endured, the treatment availed and the accompanying ailments the individual has. Herein, the biggest concern at present seems to be myocarditis (seven to twenty three per cent as per various studies).  Therefore, in symptomatic COVID-19 patients, the recommended tests before a return to active lifestyle may include Cardiac MRI, 2D Echo, ECG and Serum Troponin plus lung function tests in individuals who underwent extended ventilation support. As many recreational runners are above 40 years of age and a lot of them have obesity, high blood pressure, diabetes and even asthma, it’s advisable to get at least a 2D Echo done and get a cardiologist’s opinion before the workout regimen is restarted.

During this period, as the return to workout is planned, some form of movement, even fast paced walking – if the physician permits – will help to prevent the possibility of blood clots in the legs. Endurance runners tend to have lower heart rate. This makes pooling of blood in the legs easier; the tendency increases with COVID-19 infection. Further, individuals placed on ventilators and confined to bed, often lose between two and ten per cent of their muscle mass per day. Resorting to resistance training as the runner returns to his regular regimen would be a prudent step in this regard.

A general consensus seems to be the 50/30/20/10 rule as per the Joint Committee of the National Strength and Conditioning Coaches Association. This is a four week-plan. After recovering from infection and ensuring that one is up to resuming physical activity, upon return to running, it is recommended that in the first week only 50 per cent of the previously followed peak mileage and pace be pursued. In the following week, depending on how the runner is feeling, the load may be raised to 30 per cent less from peak level; over the two weeks thereafter the gap with peak level may be further reduced to 20-10 per cent. All this, provided there is no adverse feedback from the body to the phased increase of workout.  In general, pay attention to how you feel. You need to be good at listening to your body. Chest pain and dizziness are the two symptoms where one should stop immediately and take a physician’s opinion. Shortness of breath and palpitations can also be due to the erosion of physical fitness caused by muscle loss and lack of training. Persistent muscle pain, unexplained fatigue, hitting peak heart rate unusually early in your run or having a hard time bringing the heart rate down – these must be evaluated by a physician.

(The authors, doctors Arati and Pravin Gaikwad, are experienced pediatricians who have also been endurance athletes for a long time. They have their own clinic and are co-founders of the Navi Mumbai-based runners group, LifePacers.)