Matt Long discusses some of the current thinking around returning to running post COVID-19 infection
For a coach rather than a medical practitioner to pen a piece about the pandemic may seem akin to proverbially boxing off the back foot and a quick way to find oneself backed up against the ropes in danger of facing a flurry of social media punches. My disclaimer is of course that one should continue to follow the latest national guidance, seek the counsel of your GP and comply with appropriate quarantine, test, track and trace systems.
This article is meant to engender debate amongst the athletic community, many of who may have succumbed to the milder forms of Covid which have not required hospitalisation or the intervention of mechanical ventilation. Return to exercise amongst those who have been hospitalised and who may have ongoing and apparent health conditions always requires close medical supervision.
The above being said, as a coach I sense somewhat of a wall of silence in recent months with very few people being willing to offer advice on how athletes should return to running post Covid. There is a difference between rightfully giving primacy to the voice of physicians on this matter yet at the same time not allowing such a debate to be monopolised by them.
NHS Heroes they undoubtedly are but begging the pardon of the odd handful reading this, your local GP tends not to be the coach standing trackside or roadside who is seeing the athlete struggling in ways which may be imperceptible to the medical stethoscope in the sanitised environment of the doctor’s surgery. So let’s start with matters of the medical and morph into the discourse of coaching pedagogy as we proceed.
In their work on Graduated Return To Play (GRTP), Elliot et al. (2019) emphasise the need not only for passive rest during Covid itself, but for the athlete to be symptom free for 7 days before re-commencing exercise.
In the early months of the pandemic, the European Federation of Sports Medicine Association (July 2020) recommended that athletes undertake a review with a medical practitioner after recovery from the milder forms of Covid, suggesting that echocardiology and lung function testing were advisable. This is fine from a medical perspective but in terms of socio-economics, given the massive strain which the NHS is still under and the difficulties many have in accessing their GP for appointment it may be unrealistic for those suffering the milder forms of Covid who have perhaps been asymptomatic.
Individual centred coaching response
Ahmed and Tumi (2020) stress that coaches and athletes should always take an individual centred approach in coming back to the sport from Covid particularly because symptoms can be episodic, intermittent and refractory both in terms of the physiological and psychological, for example fatigue and dysphoria.
Salman et al. (2021) advocate phased return post Covid based on the following guidance:
Phase 1. Very light activity involving breathing and static stretching.
Phase 2. Yoga for flexibility and light aerobic activity e.g. walking.
Phase 3. Combination of weight bearing and non weight bearing aerobic activity including cycling, swimming and jogging.
Phase 4. Return to running and body weight exercises.
The length of the above will differ according to state of fitness of the athlete prior to Covid as well as factors like biological and training age but it is worth coaches and athletes building the above into microcycles over a number of days for each phase.
Monitoring the return
Vasiliadis and Boka (2021) counsel that, “as athletes of all levels return to exercise after a viral infection, special consideration should be given to the intensity and volume of exercise”. A mixture of quantitative and qualitative measures can be simultaneously employed to assess readiness to return to running. The former could include assessment of resting heart rate and quality of sleep, whereas the latter my be facilitated by rate of perceived exertion (RPE) during exercise itself and the undertaking of a regular Psychological Readiness Inventory.
It is well established in the sports science literature that physical inactivity can impair insulin sensitivity and lipid metabolism as well potentially leading to an increase in visceral fat (see Metzl et al. 2020). Simultaneously, loss of muscle mass and a decline in muscle strength are likely to have occurred to some extent as a result of self-isolation during Covid (see Vasilidas and Boka, 2021). Return to running activity should focus on aerobically dominant work as its accepted that regular moderate exercise leads to a decrease in the risk of respiratory infection.
The above doesn’t mean that one has to be stuck just doing long steady distance running for weeks on end after returning to running. Out and back running at two differential but aerobically dominant paces can be evolved into progression running at a series of consecutively aerobically dominant paces as two examples of modes of sessions that will move you through the gears without over stressing the lactate system.
A cautionary note on high intensity training
Vasiliadis and Boka (2021) caution that, “Returning to high intensity exercise training while the body is still experiencing a systemic infection with a persistent cough, fever and dyspnoea is strongly associated with a significant risk of major complications such as myocarditis”. This may hardly be surprising but significantly some coaches have reported to this author that worryingly, weeks and even months after original infection, and whilst presenting as asymptomatic, some athletes seem to struggle to transition between the comfortability of aerobic base building work and higher end speed endurance work which is more lactate based. Through the observational method, one coach for instance reported that short repetition sessions effected over 300m or 400m which afford a generous passive recovery (ordinarily between 2-3 mins) were witnessing some athletes struggling to recover after 4 or 5 minutes.
To make the mistake of being too ready to attribute the above to a simple cause and effect relationship between Covid infection and the deterioration in an ability to handle speed endurance would evidence guilt of the worst kind of reductionism. This phenomenon has been spoken about by several coaches of teenage athletes who have different training and biological ages and their chronological ages are not reliable indicators of their status as pre or post pubescent athletes. We know, for instance, that pre-pubsecent athletes tend to have less well developed lactate energy systems compared to when they transition to post pubescent athletes. So the ‘Covid factor’ may in some cases be an extraneous variable which should not be confused with causation.
The above being said even if a tenuous correlative link is suspected between having Covid and struggling to handle subsequent training intensities which go beyond the upper end of one’s aerobic capacity, surely this is worth coaches and athletes factoring into their periodisation planning.
A sensible way forward may be for athletes to spend slightly longer this Spring on what could be referred to as ‘bridging’ sessions. Sessions which are aerobically dominant but which dip into the lactate system without over stressing it. One classic example would be the traditional unstructured Holmer style fartlek where athletes move through the gears more steadily than in a traditional repetition session – the analogy being that the motor vehicle is test driven up and down through the gears without the accelerator being pushed firmly to the floor and the engine given the proverbial thrashing. A second mode of session which is common where the author coaches at Birmingham University AC is where speed endurance work is interspersed as the middle ‘filling’ of a sandwich, whose two slices of bread at either end consist of tempo based work which is aerobically dominant.
If one embraces the philosophy that bridging sessions can be a safer way to build back into higher intensity work that stresses the lactate system as a stimulus then both coach and athlete retain a sense that they are in control of their response post Covid, rather having Covid controlling them.
The above leaves us with a number of questions for self reflection:
1. In what ways was I or my athlete symptomatic during Covid?
2. Why do I need to give primacy to the medical model and try and seek advice and testing where possible?
3. Why do I need to recognise that my return to training and racing after Covid may need to be shaped differently in comparison with another returning athlete who has different needs?
4. How am I or my athlete phasing a return to training and competition?
5. Which modes of training do I struggle with post Covid?
6. When can I use bridging sessions to work my way back from aerobically dominant work to speed endurance work?
7. In what ways am I monitoring how my body responds to training and competition post Covid.
Ahmed, I., & Tumi, A. (2020). When is it safe to return to exercise post-COVID-19?. The British journal of general practice : the journal of the Royal College of General Practitioners, 70(701), 580–581. https://doi.org/10.3399/bjgp20X713609
Elliott N, Martin R, Heron N, et al (2020). Infographic. Graduated return to play guidance following COVID-19 infection (2020) British Journal of Sports Medicine;54:1174-1175.
Metzl JD, McElheny K, Robinson JN, Scott DA, Sutton KM, Toresdahl BG. Considerations for Return to Exercise following Mild-to-Moderate COVID-19 in the Recreational Athlete. (2020) HSS Journal; 16(1_suppl):102-107. doi:10.1007/s11420-020-09777-1
Salman D, Vishnubala D, Le Feuvre P, Beaney T, Korgaonkar J, Majeed A et al. (2021) Returning to physical activity after covid 19 BMJ 2021; 372 :m4721 doi:10.1136/bmj.m4721
Vasiliadis, A. V., & Boka, V. (2021). Safe Return to Exercise after COVID-19 Infection. Sultan Qaboos University medical journal, 21(3), 373–377. https://doi.org/10.18295/squmj.8.2021.124
Matt Long has served as both an England Team Manager and Coach and welcomes contact for coaching support through firstname.lastname@example.org