Cardiac considerations for post-COVID-19 rehabilitation

3/2020 A jogger runs in Brockwell Park, as the spread of COVID-19 continues, London. REUTERS/Hannah McKay

Each day brings new information about the effects of the coronavirus. As patients who survive go home from the hospital, more details about their rehabilitation needs are revealed. Many will suffer from deconditioning due to lengthy hospitalizations, or worse, prolonged organ damage. News reports that home deaths are on the rise lead one to believe that patients managing at home may be sicker than we suspect. Therefore, just because someone weathered the virus without hospitalization doesn’t mean they weren’t significantly ill.

As mentioned in the last newsletter, COVID-19 doesn’t play favorites. The virus attacks both young, old, sick, and well. Therefore, athletes aren’t immune. Though their assumed good health and lack of co-morbidities likely serve them well, even the fittest of folks can succumb to the devastation of COVID-19.

The good news is that doctors are removing more and more patients from ventilators. While mechanical ventilation isn’t a positive indicator of outcomes, the medical management is improving, and the tide is turning. The move to other methods of oxygenation instead of intubation may improve the pulmonary outcomes and avoid the secondary effects of prolonged ventilation.

Besides the bewildering hypoxia seen in COVID-19, there is significant cardiac involvement in critically ill patients. They can suffer myocardial damage similar to a heart attack but possibly due to myocarditis. Present in both patients with and without previous cardiovascular disease (CVD) or pathology, the cardiac injury appears more often in patients over 50-years-old. Master’s level athletes, simply due to their age, may be more vulnerable to the CVD effects of the coronavirus. The long-term outcomes from these coronary insults are unknown. Athletes will likely want to return to their previous activity level, therefore a thoughtful and careful cardiac rehabilitation program is needed.  For those who endure a mild case of COVID-19, the micro effects and CVD impact are yet unknown.

Cardiac rehabilitation

The status of recovery and contagion in COVID-19 positive patients is still under investigation. Researchers don’t know for certain that having it once protects one from catching it again. Some early evidence from China suggests variance in the antibody protection, but these results need more scrutiny and peer review(1). Therefore, unless referred to an inpatient rehabilitation unit, post-COVID-19 patients will likely return home, requiring rehabilitation via telehealth rather than outpatient clinics.

Telehealth is an effective means of delivering cardiac rehabilitation. A systematic review and meta-analysis conducted in New Zealand found telehealth delivery of cardiac rehabilitation as good or better than center-based models or usual care(2). The technological advances since the study, performed in 2016, make telehealth even more accessible to a greater number of clinicians and patients.

In the study, those who received telehealth based rehab performed statistically better in markers such as VO2 Max, than the center-based cohort at 1.5 and 7.2 years follow-up(2). Telehealth delivery improved exercise adherence as well, with patients participating in their program with higher frequency. The authors suggest that the individualized treatment and close monitoring of the telehealth model gave the participants the confidence to perform their treatment activities. This personalized aspect might be particularly beneficial for those recovering from COVID-19 and dealing with the psychological as well as the physical stress of the disease.

For athletes, telehealth is a useful stepping stone to transition back to the gym and playing field. By utilizing the information technology (IT) athletes already use and know, clinicians can monitor and progress their program from home. Most athletes use a wearable activity tracking device, but for those who don’t, a smartphone will suffice. Wearable tech enables heart rate monitoring, and apps such as Strava, allow clinicians to analyze activity in near real-time. Knowing heart and respiratory response to exercise will help determine exercise capacity.

For the time being, disregard the athlete’s previous norms. Start from scratch by determining their max heart rate. Since there aren’t any protocols for post-COVID-19 heart rate training, use what you know from sport’s training. The heart rate response to moderate exercise should be around 50% to 75% of the maximum heart rate. The athlete should be able to continue to talk but not sing. Breathing quickens, but they aren’t breathless. Vigorous exercise, on the other hand, requires more concentration to maintain breathing while talking. Sentences are breathy and broken. The heart rate response is usually 70% to 85% of the maximum heart rate. Of course, if they have a pulse oximeter available, measure the oxygen saturation during exercise sets and delay the next set until the oxygen saturation returns to 98% or more.

The length and course of the disease will impact the progression of heart rate training. Athletes in the home can march in place, walk through the house or outside, or cycle if a trainer or stationary bike is available, to increase their heart rate. Record the heart rate response to activity intervals and try to keep the bulk of the activity in the moderate zone for the first couple of weeks.

Things to watch for include:

  • arrhythmia and tachycardia
  • significant shortness of breath or difficulty returning to baseline respiratory rate
  • extreme fatigue

Recovering patients may tolerate frequent short bursts of activity rather than longer sessions. Add resistance activities when able. Implement a chair sitting workout at first to work arms and legs without stressing the entire body. Continue to monitor vital signs and responses to activity and progress as tolerated.

Sample Program:

Day 1:

  • Baseline vital sign assessment
  • March in place for 3-5 minutes, holding on to a countertop if needed for balance. Rest 2-4 minutes. Repeat for 3 sets, 2 times per day.
  • Active range of motion of all limbs through all planes of movement in sitting if needed. Perform 5-10 reps for 2-3 sets.

Day 2-5:

  • Progress duration and frequency of marching in place, recording vital sign responses.
  • Progress active range of motion to 2 times per day.

Day 7-14

  • Progress walking to measured distances with recorded rests.
  • Begin resistance exercises using household items (or weights if available).
  • Perform bodyweight activities as able such as squats, planks, and lunges.

Day 14-21

  • If endurance allows, begin walk/jog intervals.
  • Progress resistance program to more assertive sport-specific strengthening as tolerated.
  • Begin basic sport-specific drills, balance, and plyometric activities.


  1. medRxiv 2020.03.30.20047365; doi:
  2. 2016;102:1183
  3. JAMA Cardiol. doi: 10.1001/jamacardio.2020.1017
  4. JAMA Cardiol.2020 Mar 25. doi: 10.1001/jamacardio.2020.0950
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