A consensus statement from sports clinicians of the European Federation of Sports Medicine Associations from July 2020 recommends a review with a sports and exercise medicine physician after mild symptomatic infection, and investigations including echocardiography and lung function testing where cardiopulmonary symptoms were present.24 Guidance from the Netherlands Society of Cardiology states that, for those with systemic features including fever, electrocardiography testing should be considered before resumption of activity.25 However, the incidence of myocardial injury (box 1) or thromboembolic complications after mild or moderate covid-19 in the community is currently unknown but thought to be low. Therefore, a balance is needed between obstructing an already inactive population from undertaking physical activity at recommended levels beneficial for their health, and the potential risk of cardiac or other consequences for a small minority. There is no perfect solution given the current uncertainties and the varying availability of resources globally, such as cardiopulmonary investigations or dedicated sports and exercise medicine services. We advocate a pragmatic approach that enables a gradual return to physical activity while mitigating risks.How do I know if my patient can safely return to physical activity?A risk-stratification approach can help maximise safety and mitigate risks, and a number of factors need to be taken into account. First, is the person physically ready to return to activity? In the natural course of covid-19, deterioration signifying severe infection often occurs at around a week from symptom onset. Therefore, consensus agreement is that a return to exercise or sporting activity should only occur after an asymptomatic period of at least seven days,21242627 and it would be pragmatic to apply this to any strenuous physical activity (fig 1). English and Scottish Institute of Sport guidance suggests that, before re-initiation of sport for athletes, activities of daily living should be easily achievable and the person able to walk 500 m on the flat without feeling excessive fatigue or breathlessness.27 However, we recommend considering the person’s pre-illness baseline, and tailoring guidance accordingly. Some may not have been able to walk 500 m without breathlessness before their covid-19 illness, and they should not be precluded from starting physical activity at a level tolerable for them (see fig 1, phases 1 to 3).Fig 1 Suggested return to physical activity after covid-19: risk stratification to exclude features suggestive of myocarditis or post-acute covid-19 and phased resumption of physical activity after 7 days without symptoms28Download figure
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The second factor is that ongoing symptoms, regardless of system, may be indicative of a post-acute covid-19 illness. This will require assessment in primary care initially, and potentially liaison with local post-covid-19 rehabilitation services.121 Assessment and management of post-acute covid-19 illness is covered elsewhere.1 Whether there is a role for graded physical activity as a treatment for this condition is currently unclear.People who had more severe covid-19 illness, such as those who were hospitalised, are thought to be at higher risk of cardiac complications121321242527 and thromboembolic events.1520 We recommend that their graduated rehabilitation be managed in conjunction, or after discussion and liaison, with local post-covid-19 services. People who did not require hospital treatment but who had symptoms during their illness suggestive of myocardial injury, such as chest pain, severe breathlessness, palpitations, symptoms or signs of heart failure, or syncope and pre-syncope, should be assessed with a physical examination and considered for further investigations. Depending on the severity of the symptoms encountered, investigations may include 12-lead electrocardiography, with abnormal findings prompting referral to cardiology or post-covid-19 services.25 The cardio-respiratory examination may reveal signs suggestive of costochondritis or musculoskeletal pain, which can be safely managed in primary care. Discuss findings indicating pulmonary oedema, fibrosis, pleural effusion, added heart sounds, ongoing hypoxia, or new arrhythmias with local post-covid-19 rehabilitation or cardiology services. Investigations in secondary care may include serum troponin levels, electrocardiography, and echocardiography (fig 1).121325 Both European and US guidelines advocate restrictions on exercise for three to six months in cases of myocarditis confirmed by cardiac magnetic resonance imaging or endomyocardial biopsy.1317212529Third, with regards respiratory symptoms, persistent cough and breathlessness are expected to resolve after several weeks,115 but progressive, non-resolving or worsening symptoms may indicate pulmonary-vascular complications such as pulmonary embolism, concomitant pneumonia or
