The long road back to fitness after COVID
A pulse oximeter, debilitating fear, and one writer's slow climb back to working out.
I remember the moment my partner, my elderly parents, and I knew for sure we had COVID-19. It was a gloomy evening in April 2021, and I was battening down my mental hatches against whispers insisting the persistent full-body ache I’d begun to feel was the infamous new coronavirus. Anything but that, I begged. My city, New Delhi, India, was eerily empty. Black plumes of crematory smoke billowed high above the skyline, and ambulances screeched through the night. We were in the middle of a full-blown apocalypse: Everyone I knew was sick, in the hospital, or dying.
Penned up in a 30-building apartment complex with at least 2,000 other families, we checked a popular COVID-tracking app and saw 400 active cases nearby. By the time we finally managed to coax an overworked clinic worker to swab our throats and noses, we’d added four more.
To add to my anxiety, I immediately had to stop exercising upon our diagnosis. I was 31 and had long used fitness to distract from the stress of everyday life, but it would not be able to help me through this. So much of what I’d read pointed to how terrifying physical exertion could be while infected: The disease attacks lung tissue and can cause inflammation in the heart and other organs, making even the most mundane movements exhausting and potentially dangerous. And it’s still unclear how long it takes the human body to recover once the virus is gone. When and to what extent would I be able to be active again?
Today, almost two years into the pandemic, the answer to that question remains shaky—but new COVID research is guiding my informed approach to fitness each day. If you’re in similar straits, perhaps my experience will help you find your footing in recovery.
Days 1 to 14 of COVID
After my positive test result, there was little time to separate my illness from the struggles of my loved ones. But I soon realized that I thankfully had a mild case. My symptoms did not last beyond the seventh day, and they largely involved a sore throat, congestion, diarrhea, fatigue, and although not a direct symptom of the virus, a pervasive sense of terror. Shaken by how stretched medical resources were, I started to obsessively map routes to nearby hospitals and sleep with a pulse oximeter under my pillow.
Meanwhile, my workout equipment gathered dust. I’d stopped going to the gym long before the pandemic, choosing to buy exercise gear for the apartment and making home workouts a bonding exercise for me and my partner. I posted pictures of our dumbbell sets and deadlift bars all the time; I couldn’t get enough of it. I felt like I was losing a vital piece of my life when our physician advised us to “take it easy” for a couple of weeks.
He wasn’t exaggerating. Medical experts have been warning athletes and other active individuals about the risks of COVID since early in the pandemic. Among them was Cleveland Clinic Sports medicine physician Marie Schaefer, whose recommendations were among the first I read during my isolation.
“Anyone, including young athletes, could experience a severe case or have long-term damage, which is why it’s so important to take this seriously,” Schaefer noted. “This is especially true with active individuals, as it can be difficult to tell what long-term effects someone is going to have after they recover from the virus. Some people might fare just fine and will be able to jump back into their old training regiment, while others will find that their athletic performance just isn’t what it used to be.”
Her words were particularly alarming because I read them at the same time that three 30-year-old former colleagues had been hospitalized with severe COVID. One eventually died. As India’s second wave of cases rolled on, we realized the virus was hitting younger people hard—many between 21 and 40 years old ending up succumbing. Doctors said this was expected for a country that did not vaccinate anyone under the age of 45 until late 2021, but for minds socially conditioned to equate youth with strong health, this was disheartening.
Schaefer’s advice was succinct: Active individuals, like myself, needed to understand that our return to exercise would be determined by how serious our infection was.
I would wait it out, then.
Days 1 to 5 after COVID
Someone posted to my high school alumni group on Facebook that our vivacious middle-aged commerce teacher had gasped for oxygen, then died. Next came an aunt. A younger friend. People I used to know. People I didn’t know.
I stopped thinking about morbidity and focused wholly on our individual recoveries. We were all over the hump. Our symptoms had been mild and dissipated long before the 14th day that generally marks the end of COVID’s transmissibility. The flickering green line of our pulse oximeter was holding steady between 94 to 100 percent, the normal oxygen saturation range. Anything below 94 percent can be a reliable indicator of significant lung impairment. I ached to squeeze into my sneakers, lift a weight heavier than the load of my head off the bed.
Had I gotten lucky? In mid-April 2021, the British Journal of Sports Medicine (BJSM) published wide scale data that said statistically, my mild case was not just random. Eight US-based researchers studied nearly 50,000 adults who were treated for COVID in California between January 1 and October 21 of 2020—and found the more active people were, the less likely they were to be hospitalized or die from COVID. Patients who exercised fewer than 10 minutes per week experienced the highest risk, while those who consistently met the World Health Organization’s standard of 150 minutes fared best.
“We hope that being physically active results in a faster recovery and lower risk of long COVID, but we have not examined these questions yet,” says study co-author Deborah Young, head of the behavioral research division at the Kaiser Permanente Southern California Department of Research and Evaluation. “The public health message for COVID outcomes as well as cardiovascular, cancer, mental health, and other outcomes is to be physically active. Thirty minutes on most days is enough to reduce risk.”
The research was thorough, but none of it dealt with activity after a diagnosis. For that, recommendations vary vastly for “recreational athletes,” meaning those who aren’t professional or elite athletes.
For example, Schaefer from the Cleveland Clinic recommended a minimum rest period of 10 days for all active individuals, regardless of whether they’re symptomatic or not. That countdown begins on the first day they experience symptoms, or on the day they test positive. She also said that any athlete with moderate or severe illness, or any athlete who had to be hospitalized, should be evaluated by a health care provider before restarting any form of exercise. She further advised all active people to follow a graduated, supervised return to activity.
For many adults, supervision simply means having someone watch your workout. In my case, this was my partner and exercise buddy—and our trusty oximeter.
The graduated process is slightly more complicated, but a guidance document for COVID recovery published in BJSM lays it out nicely. The first week, for example, should be slow, beginning with just 15 minutes of movement for each of the first two days, at no more than 70 percent of your maximum heart rate. If that goes well, the guidelines say to start increasing activity, but never by more than 15 minutes per day.
Another BJSM study suggests an additional seven days of rest on top of the 10-day period, and says athletes should try to walk about a third of a mile (500 meters) on flat ground. If they feel breathless or fatigued, they should reduce their exercise load and not do anything until they’ve rested at least 24 hours without complications.
In the end, everyone knows their body best. In a world with ever-evolving developments and still-nascent science about how the deadly new virus could affect humans, I realized I needed to be the primary gatekeeper of my health. Did I really think I was fit enough to lift weights and run again? Did it hurt to turn on the shower, engage in foreplay, experience a particularly crushing hug?
I asked myself questions, repeatedly. Monitored. Monitored. Monitored. I spoke to my physician on the phone, who advised that I start slow and stop if I felt uncomfortable. He also told me to check my pulse and oxygen saturation every time I finished a workout. I promised I would. While it is natural for blood-oxygen levels to decrease slightly from exercise, they should bounce back quickly afterward (this, of course, can vary according to fitness levels.)
Yoga was my first choice when I returned to activity. It would be gradual, and I thought I would find it easier to limit to under 20 minutes if I chose a set of Hatha moves (a slower-paced style that focuses on holding poses). Ideally, it would serve to regulate my breathing, while also giving me that “post-exercise” feeling I’d been craving.
Finally, 17 days after my symptoms first appeared, I dusted off a navy blue yoga mat, a pair of resistance bands, and lay down, supine and cautious. As I flowed through my practice, I paid close attention to my body’s reaction to every move.
Months later, I would come across an article by Jordan D. Metzl, a sports medicine physician at the Hospital for Special Surgery in New York. “As doctors, we can run tests, but you know your own body better than anyone else,” he wrote. “You know how you normally feel when you walk up the stairs, when you run, when you bike. If you’ve had COVID-19, are those things harder for you? Are you noticing a change in your body? If the answer is ‘yes,’ it’s important to speak with your doctor.”
I felt vindicated. But long before he put those words in print, I was stretching my weakened body on the floor, hoping I was doing everything I could for my mental and physical health.
Days 6 to 14 after COVID
Mentally, progress was slow. I felt more encumbered than ever by the daily headlines, vaccine inequity, and survivor’s guilt. While my 70-year-old parents had fully recovered, many others’ had not been so fortunate. Swathes of friends disappeared from social media, hunkering down to take care of ailing family. The virus consumed people in their 30s and 20s, but I remained, holding up my bruised mental health as a relic of the illness.
The urgent desire to exercise following a traumatic experience is natural. More than one study has found PTSD, or at least long-term anxiety or depression, to be common among COVID survivors, family members, and front-line workers. In such instances, the mind seeks out the high from endorphins—neurotransmitters released in abundance post-workout.
I sought it out frequently during my recovery. But to what end? Keen to shed light on any hurdles COVID might pose on physical exertion, researchers from the Sports Medicine Institute in New York analyzed a study conducted after the last SARS-CoV-1 pandemic in 2003. It followed 109 coronavirus patients as they returned to exercise, and found many were struggling with unprecedented long-term health complications. The authors of the 2020 paper concluded that athletes who had survived COVID-19 should be tracked the same way, at least for the first three to six months following infection.
Another publication by a team of sports medicine scientists, this time from Germany, suggests recreational athletes get a resting ECG and blood analysis in that same three- to six-month period to assess the unknown lingering effects of today’s disease. But the key word here is, still, “unknown.” When will we know? Even the German study confesses that many young athletes have few or no symptoms, so individualized guidance might be more meaningful.
For me, the second week of activity was an amalgamation of what I’d read, so I scaled up my workouts slightly. I now wanted the “runner’s high” of a fruitful cardio session, or the quick release of endorphins after a high-intensity resistance training session. I decided to apply the 50/30/20/10 rule developed by the US National Strength and Conditioning Association and the Collegiate Strength and Conditioning Coaches Association for athletes returning from a period of inactivity. This approach has been endorsed by some physicians for COVID recovery too. As such, I would reduce my normal exercise load by 50 percent the first week back, 30 percent less than normal the next week, then 20 and 10 percent the following weeks—as long as my body was comfortable at the end of each one. According to the creators of the rule, others might need to adjust those numbers based on the severity of their disease, or stretch the process over months rather than weeks.
Six days into my self-designed training module, I considered increasing my training time and intensity. I continued to work out at home with my partner five or six days a week, but scaled up from 20 to 30 minutes per day. I also added resistance training, but instead of lifting for both strength and hypertrophy (muscle size) as I always had, I aimed to merely get my muscles accustomed to doing the work again.
So there I was, squatting less than half my body weight, keeping to slow movements over longer periods to avoid accelerating my heart too quickly. The moment I hit 30 minutes, I’d clip my trusty pulse oximeter to the tip of my index finger and wait for the verdict. I’d feel a little fatigued, but I’d chalk it up to the exercise-hiatus. My oximeter always concurred.
Days 14 to 30 after COVID
By early June of 2021, there were not nearly as many ambulances or oxygen tanks on the streets of New Delhi. Collectively, we were coping. My partner was ready to take on the last leg of our recovery process, in a bid to assess whether we were truly symptom-free.
A month earlier, a team of doctors in Italy had found that the reason many people stopped exercising while recovering from COVID was not due to problems with their lungs, but rather, issues with muscular performance and anemia. While those doctors specifically looked at patients who’d been admitted to hospitals, other research has shown that sarcopenia (loss of skeletal muscle mass) can be an “unavoidable consequence,” even when recovering from the disease in bed at home.
To scale up my workouts, I started to focus on hypertrophy—doing more reps per set than one would for conventional strength training, while also increasing the weights and time my muscles were held under tension. I was doing a full-body routine only three to four days a week to make it easier for me to recover and avoid wearing any one muscle out too much. I could handle it. I was getting through it.
As for cardio, I chatted with my physician to chart a slow buildup, as I had with everything else. Low Intensity Steady State cardio like paced walks and jogs became staples as I looked to gradually raise my VO2 max, the greatest amount of oxygen my body could use during exercise. Interval training, like HIIT, is usually a better VO2 max facilitator, but I wasn’t back at my pre-COVID ability yet.
… and today
Thankfully, my post-COVID activity has followed a linear progression: I’ve gradually lifted heavier loads and advanced from walking to running, listening to my body through it all. I received both doses of the vaccine when they were available, but have continued to exercise at home rather than at the gym.
It has now been nearly nine months since the onset of my COVID symptoms and I continue to raise the bar on my workouts, while mixing in plenty of stretches and rest. Maybe you have been on a similar path of recovery. If so, I cannot stress how important it is to have a primary care physician guide you through the process. There is no substitute for expert medical care while dealing with COVID, but there are small steps you can take on your own; through my infection I monitored blood pressure, glucose, and inflammation markers on my doctor’s advice.
At the outset of this COVID-initiated fitness journey, I had no idea how much I could or should do, or what my body would even allow. If you’re looking for at least some information on what to expect, this is me, talking to you.