Post-Covid-19 rehab for athletes: start with pulmonary function

Minsk, Belarus, April 3, 2020. Staff check the temperature of a fan before the match, despite most sport being cancelled around the world as the spread of coronavirus disease (COVID-19) continues, REUTERS/Vasily Fedosenko

The coronavirus shows no partiality in it’s spread. While devastating to the elderly population, it infects even the fittest athletes. Though those with underlying medical conditions fare worse when infected, the virus causes even previously healthy people to become quite ill. On the other hand, the disease is barely noticeable in some people. The tricky thing is that there is no way to predict how a person will react to the virus.

Knowing that responses to the virus are unpredictable, the chances are still high that athletes who fall ill with the coronavirus will need rehabilitation to return to sport. The coronavirus attacks all bodily systems, but primarily affects the lower respiratory tract. While the disease process presents with a variety of symptoms, including fatigue, sore throat, fever, diarrhea, and vomiting, shortness of breath is the hallmark complaint. The compromise that occurs in the lungs during the active disease may have lasting effects after the patient gets well.

Doctors in Hong Kong recently (March 13, 2020) reported the findings of the first follow-up clinics of recovered Covid-19 patients(1). They suppose that some recovered patients have lost between 20% to 30% of their previous lung function(1). These reports come after a review of a small population, about a dozen or so patients, of which around one-quarter had shortness of breath during functional activities despite disease resolution. The doctors report that lung scans of recovered patients also reveal substantial lung damage. There was no mention as to whether these patients were previously mechanically ventilated or not.

Any organ damage is possibly due to the cytokine storm experienced by many patients with Covid-19. This mechanism is still under investigation, and researchers have yet to understand why some patients, who were previously healthy, present with this severe immune reaction. Either the coronavirus continues to replicate, necessitating a more massive immune response, or the virus alters the immune response and the usual triggers that stop it. Thus the body’s immune system may damage, more than protect, the lungs.

In other patients, injury to the lungs could come from acute respiratory distress syndrome (ARDS) due to the development of viral pneumonia. For some sufferers, the very thing that might save them, the mechanical ventilator, can cause damage to the delicate lung tissue. No matter the cause, impairment of the lung tissue or the underlying capillaries may take time to heal even after the virus has resolved. In the worst case scenario, the damage may be permanent and lead to the development of pulmonary fibrosis.

The recovered Hong Kong patients would be referred for physiotherapy to rehabilitate their lungs, and the presenting physicians suggested swimming as a means of gradually increasing lung function. While recommended for rehabilitation, clinicians avoid traditional respiratory physiotherapy in the acute management of Covid-19. Firstly, patients present with a dry cough; thus, clearing secretions through percussions and positioning isn’t warranted. Secondly, the use of spirometers, the facilitation of diaphragmatic breathing, and other similar strategies tax the already compromised lungs and lower oxygenation. Therefore, during acute care, practitioners avoid stressing the pulmonary system with aggressive respiratory therapy(2).

Post-acute pulmonary rehab

Athletes who contract the coronavirus may suffer pulmonary compromise through direct organ damage or the inactivity from a prolonged disease process, and need rehabilitation during their recovery. Clinicians should be aware that the acuity of patients discharged from the hospital may be higher than under typical circumstances since hospitals will want to free up beds as quickly as possible. Because the point in the recovery at which a person is no longer contagious is still in question, many patients may be discharged home rather than a rehab facility where isolation is more difficult. Keep this continued contagion in mind if treating patients in their homes or bringing them to an outpatient facility. The safest way to treat post-Covid-19 patients at this time is via telehealth.

Using telehealth with athletes recovering from coronavirus requires the athlete to provide the therapist with information as to their response to exercise. A pulse oximeter, stopwatch to measure pulse and respiratory rate, and a way to engage in a stationary activity like a stationary bike or treadmill are helpful. If the patient is still quite weak and gets winded easily, start with chair exercises to strengthen the respiratory muscles. Encourage expanded inspiration through diaphragmatic breathing and expiration through pursed lips. Again, percussion and positional drainage aren’t likely needed in this population.

If endurance equipment isn’t available, progress activities to sit to stand, marching in place, and walking around the house for a specified time. During the activity, have the patient report their response via pulse rate, respiratory rate, and oxygen saturation (if accessible). If they’re unable to give these measurements, determine activity intensity as you would during sports training, by relying on the talk test. There aren’t any current guidelines about how much activity is enough or too much. Therefore, rely on your sports training knowledge. In this phase of building up endurance, keep the athlete in an activity range that allows them to talk comfortably, especially if they’ve been very ill. Once they’ve recovered their strength, try bumping up the intensity for brief intervals.

Telehealth is a proven and highly-effective modality to administer pulmonary rehabilitation(3). Allowing the athlete to self-monitor and learn to adjust their activity accordingly empowers them and improves self-confidence after a stressful illness(3). As endurance and pulmonary function return, implement resistance training, and develop a plan for return to sport.


  1. South China Morning Post.
  2. Monaldi Archives for Chest Disease. 2020;90:1285
  3. Chronic Respiratory Diseas. 2018;15(1):41-47
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