COVID-19: Getting it is one thing, recovering is another.

PART 1
Helping you manage your return to normal life and exercise.
Hayd’n Hill, Phillipa Kirschner and Fiona Brenninkmeijer

The recovery of Covid-19 has proven to be nonlinear. Just as when Covid-19 is contracted, some do not display symptoms, some display mild to moderate symptoms and others are really ill and even hospitalised (4). We once thought it was just the elderly and those with predisposing conditions that would be hit hard, but now we know it infects people of all ages, shapes and sizes. This is similar when it comes to recovering from Covid-19. There is no rhyme or reason as to why one person struggles to recover and return to normal activity, when someone else does not struggle to return to activity at all (1). The assumption is that the sicker you are while you are infected, the longer you will take to recover. This is not always the case, as the return to activity protocols were created due to mild Covid cases struggling to return to exercise (1). Although there may be a link between time spent in an intensive care unit (ICU) and a delayed recovery due to secondary complications (1,3,4).
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Fortunately, guidelines and recommendations have come out to aid the recovery of those who have, and have had, Covid-19 (1,2,4,5). These guidelines are based on current research, expert opinions and consensus statements. What is important here, is that we become aware of strategies that can be used to aid your recovery from Covid-19, and in turn, help you safely return to doing what you want to do. A structured approach to managing your recovery is helpful in this regard (1,4). It is not as simple as telling someone to get off the couch and push through their fatigue and to simply try harder. The struggles post Covid-19 are real and it is something that we all need more awareness of.

There are other aspects to be aware of post Covid, such as Long Covid, but that will be revealed in our next Blog (Part 2). In this blog, we will take you through the journey of Covid-19 and the self-management of this condition in the early phases to later phases, as well as how we at Optimal Therapy can assist you (1,2). We will present to you a phased approach to return to normal activity and provide helpful links and resources from the world's top institutions (1).

During Covid, it is really important to make sure that you rest; allowing your body to recover. Understanding what the body is trying to do can be very helpful and allow you to put your mind at ease, as well as do everything you can to support your body's function. Here is a short video explaining our bodies response to a virus: https://www.youtube.com/watch/gVdY9KXF_Sg

​There are a few other important aspects to keep in mind while you are sick, to help you recover, and to minimise complications once you are asymptomatic include:

Nutrition: The aim here is to reduce inflammation and therefore oxidative stress on your body (6,7). Diet and nutrition have a direct impact on your immune system (8). During the initial stage as you lose appetite it's ok not to eat too much(when you are eating, follow a more keto or low carb diet – eliminate refined carbs/sugars as they depress the immune system and are pro-inflammatory). When you are able to eat, eat nutrient dense foods which are easy to digest (soups) and protein as these are the building blocks for your immune cells. Vitamin D can also be helpful, take 50,000 IU daily for the first three days. VitaminC metabolism is altered when you are sick, take 1000mg three times a day, then once you are feeling back to normal, taper the dose. Zinc is important for taste and smell, you can take up to 60mg/day for up to a month as high doses interfere with the absorption of other minerals (6,7,8). https://www.yourcovidrecovery.nhs.uk

Breathing exercises: This will help to maintain your lung capacity and help your
recovery in the long run. This may also help in the fight of getting secondary
complications such as Pneumonia (1,5). https://covidpatientsupport.lthtr.nhs.uk/#/

Positioning: Due to this virus being respiratory in nature, you may experience bouts of shortness of breath. There are resting positions which help your lungs to expand further, easing this symptom when the attack comes (5).
https://www.euro.who.int/en/health-topics/Life-stages/disability-andrehabilitation/publications/support-for-rehabilitation-self-management-after-covid-19-related-illness-2020-produced-by-whoeurope

Gentle movement of the thoracic spine (mid and upper back) may also help with
breathing difficulties as well as helping you later on when wanting to return to normal
activity. Whole body low intensity movement can also reduce the risk of developing a
DVT or pulmonary embolism (deep vein thrombosis/blood clot) (1,4,5).
https://www.csp.org.uk/public-patient/covid-19-road-recovery
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After Covid, your initial infection, returning to exercise is not only helpful for your general health, but it can play an important role in fighting off secondary health issues and complications (1). There are a few complications of having Covid that you should be aware of that have led health care professionals to recommend a slow phased approach. These complications were originally noted in sports professionals until they realised that many people with mild symptoms actually struggled to return to exercise. (1,4,5). Having ongoing cardiac involvement, even after mild covid-19 symptoms, has been found to be one of the highest risk factors (3). This includes myocarditis which is inflammation of the heart muscle (1,3). If you experience ongoing chest pain, shortness of breath and palpitations while trying to exercise, you should seek help from your doctor. Ongoing shortness of breath and decreased lung capacity is a common respiratory complication (1,2). Finally there have been some cases of patients developing a DVT (deep vein thrombosis) in the calf or pulmonary embolism in the lungs (1,4). Those thought to be at higher risk for Cardiac complications and thromboembolic events are those who were severely ill and hospitalised for an extended period of time (1,4).

Recovery time is person dependent and has not necessarily been linked to the severity of your symptoms. In fact, the gradual return to activity was suggested after coming to the realisation that many of those with mild Covid struggled to return to exercise (1). Even with mild Covid, it is important to remember that you have been in isolation for an extended period of time. This means that you have had a lack of movement leading your body to become deconditioned to movement and exercise(4). The consensus suggests starting your journey of becoming active again after 7 days of being asymptomatic (no symptoms)(1,4). In the following two weeks you should commence with minimal exertion activities (still able to converse). It is important to note that moderate strength and aerobic activity only commence in phase 3, this is roughly 3 weeks after having no symptoms. The English and Scottish Institute of Sport guidance suggests that activities of daily living should be easily achievable and the person should be able to walk 500m on a flat without feeling excessive fatigue or breathlessness before commencing with baseline exercises. However, your pre-illness baseline should be considered as we are not all athletes and do not exercise at the same intensities (1). This can be considered before moving onto phase 4.

While a lot of the resources help you with self management techniques, at Optimal therapy we can help you with Risk Stratification so you may know if it is safe to return to physical activity and or if a further clinical assessment is necessary beforehand (1). Here is an example of this:

Once it has been determined that you are safe to commence the return to activity protocol, you can go through the following phased approach as a guideline:

It is important to note that each phase takes 7 days, only moving on to the next phase once certain criteria are met. You should monitor your symptoms and drop back a phase if your condition is worsening or you start to display symptoms again. Following the phased approach may help you avoid the risk of developing Long Covid or secondary complications, however there is no guarantee (1). For Phase 1, the self-management links throughout the text provide good information on what you can do. As you get to phase 2-3 it may be beneficial to join one of our THERAPY pilates classes to get you moving more under guidance of one of our Physiotherapists. Moving further into phase 3-4 you can come in to see one of our Rehab trainers for individualised exercises at the right level for where you are at in your recovery. If you require further assistance at phase 5, please contact reception to book an appointment with one of our Personal Trainers to continue your exercise journey.
In the table below you can see when it may be important to seek medical advice. You can also see the Borg Rating of Perceived Exertion (RPE) scale which will help you know if the activity that you are doing may be too intense for the phase that you are in. The perceived exertion score is important to keep track of so that if symptoms arise, you know you may have been moving along too quickly. Self monitoring is very important throughout the process, you can use devices that track your heart rate (watches), your oxygen levels (Sats monitor) and your blood pressure (BP cuff). Our team at Optimal can also help you to monitor these as well as do other screening tests to help you individualise your plan and progression. It is important to note your
mood, sleep, appetite and motivation as they will play a large role in your performance and recovery from exercise (1). These could be affected by the stress of returning to work or school and by financial pressure to name a couple factors.

In the next blog, Part 2, we will discuss the psychosocial effects of having Covid, the
psychological sequelae (can include post-traumatic stress disorder, anxiety, and depression), the importance of nutrition, as well as the Long Covid phenomenon. Long Covid is a syndrome that involves prolonged symptoms and potentially months of struggle (2). Not everyone struggles with this, but awareness may help you understand what is happening to yourself or to your friendly neighbor who could be struggling for a prolonged period of time. We will also be diving a bit deeper into the nutrition side of things. If you have any questions or queries on how to start your exercise journey after having Covid, please feel free to drop us an email and we will be happy to help you and be a part of your journey as a mulit-disciplinary team at Optimal Therapy.
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More helpful Links from the practice pointer in the British Medical Journal (1):
• Department of Health and Social Care. UK chief medical officers’ physical activity guidelines: infographics.
https://www.gov.uk/government/publications/physical-activity-guidelines-infographics
‐ Infographics with physical activity guidance across the lifespan, including for older adults, children, and during pregnancy/postpartum period.
• Couch to 5k (https://www.nhs.uk/live-well/exercise/couch-to-5k-week-by-week/)
‐ A graded programme to help people gradually ease into running.
• OneYou (https://www.nhs.uk/oneyou/)
‐ Tools and support to help guide and advise on physical activity
• Sport England. Join the movement (https://www.sportengland.org/jointhemovement)
‐ Physical activity advice and example workouts, including “Stay In Work Out” for exercise during lockdowns or when in isolation
• Chartered Society of Physiotherapists. Helping older people stay active at home.
(https://www.csp.org.uk/public-patient/keeping-active-and-healthy/staying-healthy-you-age/staying-strong-you-age/strength)
‐ Simple exercises to help people, in particular older adults, to stay active at home

​References:
1. Salmon et al (2021). Practice pointer: Returning to physical activity after covid-19. BMJ 2021;372:m4721 | doi: 10.1136/bmj.m4721
2. www.nice.org.uk/guidance/ng188
3. Puntmann, O., et al (2019). Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19), JAMA Cardiol. 2020;5(11):1265-1273. doi:10.1001/jamacardio.2020.3557.
4. Metzl, D., et al (2020), Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete, Sports Medicine Institute, Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021, USA, HSSJ (2020) 16 (Suppl 1):S102–S107, https://doi.org/10.1007/s11420-020-09777-1.
5. World Health Organization, Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark.
https://www.euro.who.int/en/health-topics/Life-stages/disability-and-rehabilitation/publications/support-for-rehabilitation-self-management-after-covid-19-related-illness-2020-produced-by-whoeurope.
6. Zabetakis, I., et al (2020). COVID-19: The Inflammation Link and the Role of Nutrition in Potential Mitigation. Nutrients 2020, 12, 1466; doi:10.3390/nu12051466.
7. Iddir, M., et al (2020). Strengthening the Immune System and Reducing Inflammation and Oxidative Stress through Diet and Nutrition: Considerations during the COVID-19 Crisis. Nutrients 2020, 12, 1562; doi:10.3390/nu12061562.
8. Butler, M.J., and Barrientos, R.M. (2020). The impact of nutrition on COVID-19 susceptibility and long-term consequences. Elsevier: Brain, Behavior, and Immunity - Volume 87, July 2020, Pages 53-54. https://doi.org/10.1016/j.bbi.2020.04.040.