Professional sport players recover from coronavirus and return to competition: hopes for resuming a normal life after COVID-19 for older people| JOURNAL OF GERONTOLOGY AND GERIATRICS

Abstract

On June 2020, many professional soccer athletes of Italian teams re-started playing League A. Some of them recovered from COVID-19, resumed their sports at a competitive level declaring to have struggled for a long time during recovering period.

Most COVID-19 survivors (especially older people) are not professional athletes; these persons cannot generally benefit from a dedicated staff during recovery. This is why it is really important to provide rehabilitation and physical exercise protocols for adults and/or older people who have recovered from COVID-19.

To this aim, the post-COVID-19 service of Fondazione Policlinico Universitario A. Gemelli (Rome, Italy) has developed specific physical activity programmes. The physical activity protocol of “SPRINTT”, a European project aimed at preventing mobility disability in frail older people with sarcopenia, has been re-shaped to adapt it to COVID-19 survivors. This personalized program includes aerobic, strength, flexibility, and balance training. Accumulating evidence supports regular physical activity, in combination with appropriate nutritional support, as the most effective strategy for improving sarcopenia and physical function. More studies are needed to determine if this may be more valid in COVID-19 patients.

INTRODUCTION

On June 17, 2020, professional athletes started their soccer activity playing the Italian Cup final. In particular, some of them had recovered from COVID-19 one month earlier, after testing positive on different occasions, the first of which in mid March. They admitted coronavirus had taken a huge toll on their health and even left struggling to breathe.

Few days later many other professional soccer athletes of other Italian teams re-started playing League A. Similarly, other professional athletes who have suffered from COVID-19 slowly recovered and resumed their sports at a competitive level declaring to have struggled for a long time during recovering period.

The stories of many professional athletes around the world have attracted particular attention from the media. However, most COVID-19 survivors are not professional athletes, but a number of them were practicing physical activity on a regular basis before illness. Differently from professional athletes, these persons cannot generally benefit from a dedicated staff during recovery. This is why it is really important to provide rehabilitation and physical exercise protocols for adults and/or older people who have recovered from COVID-19.

PERSISTENCE OF COVID-19 SYMPTOMS

Symptoms of COVID-19 vary from individual to individual, from asymptomatic infection to severe respiratory failure. Infection commonly presents as a flu-like syndrome with symptoms such as fever, cough, asthenia, headache, conjunctivitis, frequently associated with anosmia, dysgeusia, and gastrointestinal symptoms such as vomiting, nausea and diarrhoea. Severe lung injury has been described at all ages, more frequently in high-risk individuals, such as the elderly with multimorbidity, in whom severe interstitial pneumonia, acute respiratory distress syndrome (ARDS) and subsequent death are more common ^1,2. According to the WHO recommendation, patients with SARS CoV-2 infection are considered microbiologically cured after obtaining a double negative RT - PCR nasal and throat swab results ³. This allows them to regularly resume the activities of daily living, dissolving their isolation. This generally happens when the symptoms of the acute phase are gone. However, data collected at the Fondazione Policlinico Agostino Gemelli IRCCS (Rome, Italy) post-acute care COVID-19 service from SARS-CoV-2 infection survivors ⁴ indicate that a strikingly high number of them complain of several characteristic disease symptoms weeks after testing negative. As of today, more than 350 adults (mean age: 56.5 ± 14.6 years; range: 18-86 years; 37% women) have being followed at our centre. It is important to highlight that two months after disease onset (60.3 ± 13.6 days), more than 50% of COVID-19 survivors experience persistent fatigue, 43% suffer from dyspnoea, and 27% complain joint pain ⁵. The rate of these symptoms is higher among adult and older people. For this reason, it is extremely important to develop rehabilitation services to address the impact of COVID-19 in older people who survive the SARS-CoV-2 infection.

REHABILITATION AND PHYSICAL EXERCISE FOR COVID-19

Physical activity, in its various blends, increases aerobic capacity, muscle mass, strength and endurance by ameliorating aerobic conditioning and/or strength. Indeed, according to the most recent WHO recommendations, people of all ages have to include a minimum of 30 min of moderate intensity physical activity (such as brisk walking) on most, if not all, days of the week. For most people, greater health benefits can be obtained by engaging in physical activity of more vigorous intensity or longer duration.

In COVID-19 patients, the long-term persistence of fatigue deserves adequate evaluation and appropriate interventions. For those who “struggle” to resume their usual activities of daily living and/or are unable to return usual activities and/or playing their favourite sport, tailored physical activity protocols should be implemented.

It is also essential to provide the same service to patients who, during to the long period of isolation or the long hospitalization, have reduced physical activity or in whom, especially if elderly, this inactivity has turned into a decrease of autonomy condition.

Furthermore, it is necessary to consider the positive impact of resuming physical activity on healed patients who have remained in isolation for some time, deprived of daily life and routine activities, which are essential for their psychophysical well-being.

To this aim, the post-COVID-19 service of Fondazione Policlinico Universitario A. Gemelli (Rome, Italy) has developed specific physical activity programmes. The physical activity protocol of “SPRINTT” ⁶, a European project aimed at preventing mobility disability in frail older people with sarcopenia, has been re-shaped to adapt it to COVID-19 survivors. The programme is also offered to those, never hospitalized, who remained physically inactive during the two-month lockdown issued in Italy E-mail: (@longevity_run).

COMPONENTS OF TRAINING

The physical activity program includes aerobic, strength, flexibility, and balance training. The program focuses on walking and fast walking as the primary mode of physical activity, given its widespread popularity and ease of administration across a broad segment of the sedentary population. Each session is preceded by a brief warm-up and followed by a short cool-down period. Following each bout of walking (30 minutes), participants perform flexibility exercises.

INTENSITY OF TRAINING

Participants are introduced to the physical activity program in a structured way such that they begin with lighter intensity and gradually increase intensity over the first 2 weeks of the intervention. Walking for physical activity is promoted at a moderate intensity and tailored for each participant. The rating of perceived exertion (RPE) is used as a method to regulate physical activity intensity. Using the Borg’s scale (range 6-20), participants are asked to walk at an intensity of 13 (activity perception of “somewhat hard”). They are instead discouraged from exercising at levels that approach or exceed 15 (“hard”) or drop to a rating of 11 (“fairly light”) or below. Lower extremity strengthening exercises are performed at an intensity of 15-16 (“hard”).

FREQUENCY AND DURATION OF TRAINING

The physical activity program comprises of continuing twice- per-week center-based group exercise sessions and a progression of home-based physical activity to other 2–3 times per week. The intervention comprises a general weekly walking goal of 150 min. This is consistent with the public health message from the Physical Activity Guidelines for Americans report that states that moderate physical activity should be performed for 30 min on most if not all days of the week (150-210 total minutes) ().

AEROBIC COMPONENT OF THE PHYSICAL ACTIVITY INTERVENTION

Walking is the primary mode of physical activity in post COVID-19 SPRINTT protocol. Participants have been trained to assess their RPE using the Borg’s scale. Walking pace is encouraged at a moderate intensity (RPE = 13). A characteristic physical activity session is composed of a 5-min warm-up consisting of low intensity walking (RPE < 9) or, when walking cannot be performed at an RPE < 9, stationary cycling. Participants then complete walking and strength training at the target RPE for each activity for the amount of time prescribed. At the end of each physical activity session, there are 3 minutes of cool down in which the walking speed is gradually reduced.

STRENGTH TRAINING COMPONENT OF THE PHYSICAL ACTIVITY INTERVENTION

Strength training focuses primarily on lower extremity exercises. Adjustable ankle weights have been provided to all participants. The goal is to include three sessions of strength training (RPE = 15-16) throughout the intervention. Each strength exercise includes two sets of ten repetitions each, with 1-min rest in between. The target intensity is approached in a progressive manner over a 4-week period depending on the progress of each participant. At each exercise session, participants complete one strength training exercise from all of the five groups, for a total of five exercises.

BALANCE TRAINING PROTOCOL

Participants perform balance training according to five different levels of difficulty. Progression to the next level occurs when all exercises of a certain level can be performed correctly. Balance exercises are performed once a day every day throughout the intervention.

UPPER BODY EXERCISES

Upper body exercises are incorporated at the end of the session. Each week, one upper body exercise is chosen by the trainer and performed at the end of the group session.

CONCLUSIONs

Physical activity increases aerobic capacity, muscle mass, strength and endurance by ameliorating aerobic conditioning and/or strength. According to the most recent WHO recommendations people of all ages have to include a minimum of 30 min of moderate intensity physical activity on most, if not all, days of the week ⁷.

Accumulating evidence supports regular physical activity, in combination with appropriate nutritional support, as the most effective strategy for improving sarcopenia and physical function. Exercise protocol should be patient-centered and tailored to individual patient needs; any program should take into account comorbidities that may affect a patient’s progress or ability to participate the activities ^8,9. As COVID-19 is a novel disease, education about the implications of the disease and potential consequences will need to be discussed with patients.

The successful story of the professional athletes brings a message of hope: close medical counselling and adapted physical activity may allow COVID-19 survivors to faster resume their pre-infection lives and daily habits. More studies are needed to determine if this may be more valid in COVID1-19 patients. There is a lack of evidence-based guidelines regarding exercise protocol and specific training following COVID-19. There is a need for further research around sequelae of and the long-term impact COVID-19 may have on survival subjects.

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