Would-be athletes, exercisers and amateur sports people are obsessed with metrics — miles covered, kilos lifted, points scored. Performance is measured, targets are set, goals are reached.
nd so the thousands who have tested positive in recent weeks may be pencilling in their first post-Covid run, game or swim, imagining a recovery that can be planned and measured. When it comes to Covid, though, there is little certainty; some will resume their previous regimes with minimal effort, but for others, it will be more complex.
Dr Julie Broderick, assistant professor of physiotherapy at Trinity College, explains: “There is a spectrum of physical recovery experienced by people after Covid and recovery does not appear to be related to the severity of initial symptoms experienced.
“At one end of the spectrum, many people will recover very easily after Covid. Some people can feel exhausted with low energy levels for some time afterwards although most people feel recovered by 12 weeks, but not everyone.”
Those who have been in critical care may require more intensive rehabilitation. “For some people it will be a huge effort to sit or stand up afterwards and physiotherapists in the hospital setting will deliver a specific rehabilitation programme,” she adds.
Recovery won’t look the same for everyone, but there are some who may have suffered a more severe disease from Covid than others. This is because they had already been experiencing what is described by Niall Moyna, professor of clinical exercise physiology at DCU, as “meta-inflammation” or “persistent low-grade inflammation” suffered by those who are overweight, have high blood pressure, diabetes or cardiovascular disease, sometimes referred to as “comorbidities”.
These conditions “consistently release pro-inflammatory cytokines. Sars does exactly the same thing.”
A cytokine, explains Professor Moyna, is fine, as long as it’s regulated. “It’s a normal response to inflammation. If you get a cut, or an infection, these pro- and anti-inflammatory cytokines are hovering around, looking for damage, and clearing it up, unbeknownst to us.” But when the process is “dysregulated”, these cytokines can run amok.
“It initiates within the cell. When those pro-inflammatory cytokines are released, they activate another class of cell called dendritic cells which activates another class called macrophages and they release even more pro-inflammatory cytokines.
“This is exacerbated in people who have comorbidities, and who have this meta-inflammation.”
Eurostat figures published in July found that 26pc of Irish adults were obese and 56pc were overweight. These factors notwithstanding, the big issue with mapping a recovery exercise plan is the “heterogeneity” of Covid and its symptoms, adds Professor Moyna.
“We could probably give general guidelines, but from amnesia to headaches, fatigue, shortness of breath, insomnia, vomiting, dizziness — it varies tremendously.”
Humans like specifics. Covid has had few of them. And for those struggling to recover, the pattern only persists.
“For people who have had a relatively mild illness, there is a substantial number — between five and 10pc — who will have prolonged symptoms,” says Dr Noel McCaffrey, consultant in sport and exercise medicine at Cappagh Hospital and founder of ExWell Medical, a community-based rehabilitation programme.
“These symptoms are broken down into the main categories — the brain fog, the cardiac dysfunction — inappropriately elevated heart rate at rest or in response to mild exercise — then there’s the fatigue, which is the overwhelming one.
“Fatigue by definition is the inability to generate or sustain muscular effort, so you can’t lift a weight or hold it up for a long time. Or you can’t do a given exercise intensity, say walking at 4km per hour pace, and you cannot sustain that, that is fatigue.”
The fatigue can be exacerbated by muscle deconditioning. Anyone who has played a sport or trained even half seriously knows what this feels like and it is terrible, like your new personal best is your previous poor-to-middling.
Even if you’ve just been laid up on the couch, there may be an impact. “Part of the heavy breathing could be due to the fact they’re a bit deconditioned from lying up for 10 days,” says Niall Moyna.
“If you’re over 60 and you’re lying in bed for a week, your muscles could age a decade. If you’re younger, your muscles could age a year from a week lying in bed. So it’s understandable that you may feel weaker. And you could feel a shortness of breath from a decrease in your cardiovascular fitness.”
This means taking a cautious approach to exercise, at least initially. “It’s like starting all over again. What’s your age, what’s your gender, what’s your current state of fitness, what’s your history of exercising, what are your injuries,” says Professor Moyna.
“People need to be aware that you can’t go back to where you left off. You have to be very cautious.”
Top tips to start exercising after Covid
Note: Individuals are advised to get in touch with their GP before resuming exercise after Covid if they have any concerns, or where there are persistent symptoms attend a Covid clinic to check for heart inflammation.
Start with strength work
This induces less breathlessness than aerobic exercise, says Dr McCaffrey. “This could be simply sitting in your chair, lifting light dumbbells, doing bicep curls. Maybe five or six repetitions on each side and do that two or three times.
“Or maybe stand beside the chair and just lift the heels off the ground — literally on your tippy toes — up and down, shrinking the calf muscle. Do five or six of those, no more.
“You can take different muscle exercises and add very minimal stress by choosing either a small number of repetitions or a very low weight.
“Start off gently, you’ll be doing no more than two to three minutes at a time, maybe every second day. Then once a day, and twice a day.
“As time passes, and if there’s no setback, you might add in a modest amount of walking. By which I mean walking out the door and walking for one minute and turning back and then coming home.
“Build it up slowly. It all hinges on not having a reaction to it.”
Be honest with yourself
Ignoring or denying symptoms could lead to a significant setback, so be honest about your progress.
“Give it two weeks to wean yourself back and ask, ‘What am I capable of doing?’ It might be five minutes the first day, eight minutes the second. Within two weeks you could be doing 20 minutes,” says Professor Moyna.
“If you had pericarditis you would get a terrible sensation when you’re breathing and you should consult your GP.
“After two or three sessions, you have to be honest with yourself.
“If you’re going out to exercise and you’re going, ‘God I’ve a splitting headache, I can hardly breathe, I can’t get air in, obviously you’re not ready to start exercising.
“Look at the signs yourself. Be smart. Be prudent. And most of all, start very slowly.”
Log your progress
(“Once it has been established there is nothing persistent going on like lung clots,” Dr McCaffrey stresses.) Monitoring your progress and logging any symptoms will help to assess your recovery.
“If you go for a five-minute walk and you recover an hour later, then you can stick at that level for four or five sessions before trying to progress.
“You could progress by going a little faster or a little longer or by doing it twice a day instead of once a day.
“Keeping a diary is good, and introducing objective testing. If there’s a stretch of road in the avenue in the park, record how long it takes you to walk.
“Some degree of measurement can help and a sensible approach to grading the exercise — don’t jump in too quickly.”
Less is more… for now at least
Dr McCaffrey acknowledges this may be hard for those who enjoy physical exercise, but it’s important.
“The approach we take is to be careful. That means prescribing less rather than more because if we overdo it, there might be nasty consequences, in terms of a period when you can’t get out of bed.
“We’re all afraid of that. It’s awful to have to say that to people whose lifestyle previously was built on exercise and a lot of their enjoyment in life is built around being active. It’s a really difficult situation. The best advice will become clearer as time passes, but we’re just not there yet.”
If you haven’t exercised before, now is a good time to start
Meeting the minimum physical activity guidelines reduces your risk of being infected with Covid by two-and-a-half times, but it also reduces the risk of severe disease.
“We think we can just give ourselves a drug that is going to solve all of our chronic diseases,” adds Professor Moyna. “In fact we, already have a drug which solves them. It’s called activity.”
‘Exercise, especially outdoor exercise, is essential for kids’
AS with adults, there are no hard-and-fast rules for children returning to activity. The recovery period depends on the severity of illness, defined as mild and moderate to severe.
Mild infection is “a temperature, a slight increase in breathing that does not interfere with the child’s activity or feeding, particularly in the smaller ones,” explains Professor Basil Elnazir, Consultant in Paediatric Respiratory Medicine at the Beacon Hospital.
“Usually, it should pass within 24 to 48 hours, and the child will recover.
“Some of those children will move into moderate to severe. This is extreme difficulty breathing and inability to feed. The child becomes uninterested in feeding, leading to interference with hydration. There may be some audible noise, a wheeze or cough, what we call a Stridor.
“Also, any change in the colour — the child becoming pale or becoming a bit dusky, with fast breathing. This is moderate to severe illness and needs to be seen by a doctor.”
The child should be over the symptoms with a mild illness by 72 hours.
“The child would bounce back, maybe not 100pc, but become interested in food again, and the cough abates or becomes reduced, and there’s no increased breathing.
“Anything that persists beyond the 48 to 72 hours, particularly other systemic signs such as persistent temperature or persistent work of breathing and persistent lack of interest in food and drinking. That’s taking longer than usual, and it’s not mild anymore.”
Where a child has seen a doctor or been to a hospital, parents should always follow the medic’s advice.
“The vast majority of children — aside from around five to ten per cent — will be able to resume activities relatively soon after their symptoms subside,” explains Aoife McCarthy, Specialist Paediatric Physiotherapist at The Children’s Physio Ireland.
McCarthy doesn’t advise parents quiz their children about how they’re feeling — but instead monitor for symptoms.
“First and foremost, they need to get back to their daily activities. You’re checking whether they’re getting up, getting dressed, getting their breakfast, heading off to school. Are they more tired than usual when they get home? Are they falling asleep? Is there any wheezing?
“I would let them go to school and get home for a few days before adding anything back in.
“If you’re happy to proceed, then integrate activities slowly as a family. Take a walk together. If they play Gaelic football, have a kick around with them yourself so you can assess how they’re getting on.
“From there, I would advise starting one activity at a time and continuing to monitor the progress.”
Red flags would be breathlessness, wheezing, headaches or dizziness.
Try to strike a balance between the natural impulse to be protective during Covid and the importance of activity for children’s growth, development and mental health, Professor Elnazir advises.
“Exercise, especially outdoor exercise, is essential while being supervised and well-wrapped-up,” Professor Elnazir says.
“These children can become deconditioned, and their basal metabolic rate is reduced. The next thing their energy expenditure, aerobic and anaerobic ability would be affected.
“Now, the child that was walking to school before now finds walking to school is a bit of a struggle. Now, he needs to take a ride to school.
“So we must work on these things, and try to encourage them gradually.
“Otherwise, we can end up with a lot of problems.
“Exercise is a wonder drug with benefits reaching far across physical and mental growth and development.”