CrossFit

CrossFit and Post- Covid-19

Meyken Houppermans
Founder and Head Coach
The recommendations for recreational athletes who return to sports after a Covid-19 infection and athletes with ongoing and relapsing symptoms are limited. In this article we describe the few to be aware of. Additionally we give observations on post- Covid from our own practice at CrossFit Eudokia.

What is post- Covid?

Covid-19 infection is a multi-organ disease, which may cause long-term structural damage of different organ systems including the lung, heart, vasculature, brain, liver, kidney, or intestine.[i]

Covid 19 symptoms can be divided into three stages. The first stage is the acute Covid-19 in which symptoms last up to four weeks. The second stage is ongoing symptomatic Covid-19 in which symptoms last four to twelve weeks. The third stage is post- Covid 19 syndrome in which symptoms last longer than twelve weeks.[ii]

Post- Covid refers to symptoms such as fatigue, breathlessness, muscle soreness, chest pain, difficulty concentrating, anxiety, and depression. These symptoms develop after acute Covid 19 and include a combination of ongoing symptomatic COVID-19 and post‑COVID-19 syndrome.[iii]

Prevalence

The prevalence of post- Covid is high. According to the WHO approximately 10 to 20% of people who had a Covid-19 infection experience symptoms and effects that last for at least two months.[iv] Other studies show a far higher prevalence rate.[v]

In a worldwide study with 3762 participants in 56 countries, over 91% of participants reported it took over 35 weeks to recover from a Covid-19 infection. The most frequent symptoms after six months were fatigue, post-exertional malaise, and cognitive dysfunction. Even after seven months, many patients did not fully recover or return to previous levels of work and continued to suffer from symptoms and limitations in daily activities.[vi]

Active disease

Post- Covid has been identified as potentially an active disease, with an inflammatory response and viral activity, and occasionally blood clotting disorders.[vii] Relevant, especially in the context of returning to sports after a Covid-19 infection, is that over 85% of respondents recovering from Covid-19 experienced relapses of symptoms primarily triggered by exercise, physical or mental activity, and stress.[viii] 

The importance of a healthy lifestyle

According to the World Health Organization at this date, there have been over 520 million confirmed cases of Covid-19 worldwide, including over 6 million deaths.[ix] People with underlying medical conditions; older people; and those who are overweight have a higher risk of becoming seriously ill from a Covid-19 infection, and of developing complications. Besides following general guidelines to prevent and slow down the transmission of the virus, as well as getting vaccinated, the risk of infection and of becoming seriously ill from Covid-19 seems to be reduced by being in good physical, mental and emotional health. What does that mean? [x]

Being in good physical, mental and emotional health

This means for one:

- Meeting at least the WHO Recommendations for Exercise and prevent sitting down a lot [xi];

- Eating a wholesome non- Western diet consistently and in moderation [xii];

- Reducing stress to a minimum by having a good night of sleep, going outdoors in a green environment regularly, meditate or whatever clears the mind;

- Seeking medical treatment if needed;

- Invest in social connections;

- And having fun and laughing a lot.

The weakest were hit the hardest

Worldwide over 28% of adults and 81% of adolescents between 11 and 17 years are insufficiently active.[xiii] Worldwide, over 3% of adults are overweight[xiv].Worldwide non-communicable diseases such as heart attacks, cancer, chronic respiratory diseases, diabetes, obesity and depression kill 41 million people each year, this is 71% of all deaths globally.[xv] Numbers that can be significantly reduced with a healthy lifestyle and exercise.The importance of this has been made painfully clear by the Covid-19 pandemic.

The pandemic has had a negative impact on physical activity; on the prevalence of mental health issues such as depression and anxiety; on eating behavioral changes such as snacking, increased food consumption, and the re-emerge of eating disorders; and on unhealthy eating patterns especially in populations with a higher risk of obesity, such as those living in poor neighborhoods.[xvi] The weakest were possibly hit the hardest.

The importance of regular and consistent exercise

Exercise is part of a healthy lifestyle and important for physical, mental and emotional health. Exercising regularly and consistently are necessary conditions to achieve health benefits, such as improvement of muscular and cardio respiratory fitness and of bone and functional health; reduction of the risk of chronic diseases such as cancer and diabetes; and maintenance of a healthy bodyweight. It also helps to reduce the risk of mental and emotional health problems.[xvii]

Exercising regularly and consistently at moderate intensity helps to reduce the risk of severe infections, and for patients recovering from COVID-19 to reduce the impact of physical de-conditioning associated with the disease. It is particularly beneficial in the recovery of the musculoskeletal system, such as from fatigue, following COVID-19 infection.[xviii]

Not exercising is associated with poorer health outcomes such as increased all-cause mortality; poorer cardiometabolic health; increased risk of respiratory tract infections; higher risk of chronic diseases; weight gain; and reduced sleep duration. It can also affect mental health, mood and self-esteem. Furthermore, not exercising can reduce social connections and pro-social behavior, which in return can affect emotional health.[xix]

Relapse of symptoms after exercise and stress

Good physical, mental and emotional health enhances immune system.[xx] Exercising regularly and consistently at moderate intensity and meeting the WHO Recommendations for Exercise are key. As mentioned above, relapses of symptoms be triggered by exercise, physical or mental activity, and stress.[xxi]

It is known that very high intensity training sessions that far exceed the WHO Recommendations for Exercise, such as at the level of competitive professional athletes, may increase the risk of further COVID-19 complications, when executed by non- competitive recreational athletes.[xxii] Very high intensity training sessions have been associated with disruptions of the immune system, inflammation, oxidative stress, and muscle damage.[xxiii]

Balancing act

This raises the question whether relapses of Covid-19 symptoms are triggered by too much physical, mental and emotional stress on an individual level? It also raises the question on how to find that individual threshold, that delicate balance between exercising sufficiently to achieve health gains and going too far, resulting in a relapse of symptoms?[xxiv]

Obviously monitoring athletes in their return to sports is essential. This requires a balancing act between returning to exercise and an active lifestyle as soon as possible; having enough energy for daily activities such as work and family; and dealing with the mental struggle of recovery and acceptance. All at an adequate intensity that does not trigger the relapse of symptoms.

How to do that?

Return to exercise after Covid-19 infection

Guidelines for professional athletes

The overall guideline for professional athletes is to have a thorough medical history, physical and psychological examination conducted by a medical professional before returning to sports after Covid-19 infection; and to monitor and record their own physical and psychological markers of health.[xxv]

More precise:

- All athletes are recommended to undertake a medical history and physical examination, with cardiac, pulmonary and blood tests, clinical neurological and musculoskeletal tests and a mental health screening since anxiety and depression are common in people suffering from post- Covid.

- On returning gradually to sports athletes should be able to complete activities of daily living and walk 500 m without excessive breathlessness or fatigue, should have rested for ten days; do not have any organ- damage; and should be symptom free for 7 days without any treatment or medication which could mask COVID-19 symptoms.

- Gradually means a 2–3 days graded return for every day lost to illness. The focus should be on increasing frequency first, then duration of the training session, and last in increasing the intensity. The first week(s) of training should consist of low level stretching and light muscle strengthening activities.

- Monitoring of the athlete’s physical and psychological state and in female athletes the menstrual cycle, is important to determine the adequate levels of training versus recovery and energy, and for stress management: By analogy of the procedures in athletes with overtraining syndrome.

- If symptoms return, it may be an indication that the athlete is experiencing continued inflammation and viral load as a result of post- Covid. This requires suspension of training and evaluation of symptoms and organ damage status.[xxvi]

Guidelines for recreational athletes

Although there are hardly any evidence-based recommendations for recreational athletes, it is safe to assume that what applies to professional athletes might also apply to recreational athletes, since current recommendations for professionals are well assured of thorough medical checks.

In both athletes, it is a matter of thorough medical checks, self- monitoring of physical, mental and emotional health and energy balance; and individual tailor-made training programs that include a gradual return to sports, starting with exercises that focus on stretching and light muscle strengthening at low intensity. The gradual return should consist of first an increase in frequency, then duration and last in intensity. All with close monitoring of the athlete's physical, mental and emotional health.[xxvii]

Observations from practice

It is clear that more research is needed into the (long- term) effects of Covid-19 infections. More research can lead to new medical insights and practical recommendations as well as recognition of symptom burden with which patients sometimes struggle for years. Scientific knowledge and tacit knowledge needs to be brought together via a multidisciplinary approach and from the perspective of physical, mental and emotional health on an individual as well as on a global level.

Our tacit knowledge on this topic is based on our observations at CrossFit Eudokia and on self-reports from our members at CrossFit Eudokia.

Observations

- Some members have up to date not been infected with Covid-19 while others have been infected repeatedly, sometimes up to five times. Whether this is a new infection or a relapse of symptoms is unknown.

- The majority of members who experienced a Covid-19 infection reported that strength training went better than cardiovascular training. They noticed less loss in strength than expected.

- Coincidence or not, those who report repeated infections and/or relapse of symptoms often also mention experiencing a lot of stress or psychological pressure, for various reasons such as work or personal issues.

- The minority of members with repeated infections and/or relapse of symptoms was in good physical health, exercised regularly and consistently and met the WHO Recommendations for Exercise. The majority was not.

- The majority of members with repeated infections and/or relapse of symptoms are either overweight, or they have an unhealthy level of body fat combined with a healthy bodyweight according the BMI standard.

- For the majority of members with repeated infections and/or relapse of symptoms, it is a mental challenge to pick up their pre- Covid exercise regime with an individual tailor-made training program at low intensity. The mental challenge for many athletes is to train at low intensity, because it feels like they are ‘doing nothing’. Setting process oriented goals for every training session can help in this process. For example: the goal is to try to maintain nasal breathing throughout the whole training session.

The general guideline at CrossFit Eudokia is to first schedule set training days to get back in the routine of regular exercise. For the first weeks, training sessions are at low intensity. Nasal breathing is the indicator for low intensity. The athlete participates in the regular CrossFit WODs in a group setting to stimulate community bonds. Exercises are being modified to the low intensity equivalent of the regular WOD. For example static instead of dynamic exercises, and without time pressure. After every training session the athlete is askes to report how it went, and what they have experienced during and after the session. This stimulates self- management from the perspective of recovery. After four weeks an evaluation takes place focussng on the physical, mental and emotional health of the athlete, which forms the base for the next steps to take.[xxviii]

- Some members who experienced a Covid-19 infection recovered after a few weeks and remained free of symptoms. Others kept experiencing fever strokes and fatigue after training sessions. Relapses seem to happen more often after cardiovascular training compaired to strength training. It also seemed to happen in cases where the athlete could not resist increasing the intensity a bit more because during the training session that felt good. Or because both the athlete and the coach estimated that the athlete was ready to increase the intensity a little. This indicates that how an athlete feels during a training session is not always a good indicator for progress; and progress can take an erratic course.  

Overall, these are only a few rough observations of a small population, unworthy of well- founded conclusions. The one thing these observations show is the importance of an individual tailor made approach and ongoing close monitoring of and cooperation with the athlete.

Concluding

Post- Covid refers to symptoms such as fatigue, breathlessness, muscle soreness, chest pain, difficulty concentrating, anxiety, and depression. It is an active disease, with an inflammatory response and viral activity, and occasionally blood clotting disorders. Relapse of Covid-19 symptoms is very commonand is primarily triggered by exercise, physical or mental activity, and stress.[xxix]

Recreational athletes who want to return to sports after a Covid-19 infections should follow the general guidelines for professional athletes. Coaches should offer individual tailor made training programs, be aware of relapse of symptoms ands should closely monitor the athlete and work together to ensure a safe return to exercise.

Although CrossFIt is a high intensity sport, it also offers perfect options for scaling and modifying exercises and training sessions to individual’s needs. Everyone can do CrossFit, regardless of age, fitness or impairment. Key is a holistic approach and cooperation between all medical and health professionals involved with the athlete, as well as with the athlete itself, such as done in NL Actief Prevention Centers in The Netherlands (including CrossFit Eudokia in Rotterdam) specialized in training with athletes recovering from Covid-19.[xxx] This is crucial in guiding the athlete back to exercise and in stimulating self-management in athletes in the light of physical, mental and emotional health.

 

Resources

[i] Halle M, Bloch W,Niess AM, Predel HG, Reinsberger C, Scharhag J, Steinacker J, Wolfarth B,Scherr J, Niebauer J. Exercise and sports after COVID-19-Guidance from aclinical perspective. Transl Sports Med. 2021 May;4(3):310-318. doi:10.1002/tsm2.247. Epub 2021 May 4. PMID: 34230908; PMCID: PMC8250714.); LindsayRK, Wilson JJ, Trott M, Olanrewaju O, Tully MA, López-Sánchez GF, Shin JI,Pizzol D, Allen P, Butler LT, Barnett Y, Smith L. What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms? AnnMed. 2021 Dec;53(1):1935-1944. doi: 10.1080/07853890.2021.1992496. PMID:34726085; PMCID: PMC8567919.)

[ii] Lindsay RK,Wilson JJ, Trott M, Olanrewaju O, Tully MA, López-Sánchez GF, Shin JI, PizzolD, Allen P, Butler LT, Barnett Y, Smith L. What are the recommendations fo rreturning athletes who have experienced long term COVID-19 symptoms? Ann Med.2021 Dec;53(1):1935-1944. doi: 10.1080/07853890.2021.1992496. PMID: 34726085;PMCID: PMC8567919.)

[iii] Lindsay RK,Wilson JJ, Trott M, Olanrewaju O, Tully MA, López-Sánchez GF, Shin JI, PizzolD, Allen P, Butler LT, Barnett Y, Smith L. What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms? Ann Med.2021 Dec;53(1):1935-1944. doi: 10.1080/07853890.2021.1992496. PMID: 34726085;PMCID: PMC8567919.)

[iv] https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-(covid-19)-post-covid-19-condition

[v] Chen, C., Haupert, S. R., Zimmermann,L., Shi, X., Fritsche, L. G., & Mukherjee, B. (2022). Global Prevalence of Post COVID-19 Condition or Long COVID: A Meta-Analysis and Systematic Review. The Journal of infectious diseases, jiac136. Advance online publication.https://doi.org/10.1093/infdis/jiac136

[vi] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00299-6/fulltext;Chen, C., Haupert, S. R.,Zimmermann, L., Shi, X., Fritsche, L. G., & Mukherjee, B. (2022). Global Prevalence of Post COVID-19 Condition or Long COVID: A Meta-Analysis andSystematic Review. The Journal of infectious diseases, jiac136. Advance online publication; Lindsay RK,Wilson JJ, Trott M, Olanrewaju O, Tully MA, López-Sánchez GF, Shin JI, PizzolD, Allen P, Butler LT, Barnett Y, Smith L. What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms? Ann Med.2021 Dec;53(1):1935-1944. doi: 10.1080/07853890.2021.1992496. PMID: 34726085;PMCID: PMC8567919.)

[vii] Lindsay, R. K., Wilson, J. J., Trott,M., Olanrewaju, O., Tully, M. A., López-Sánchez, G. F., Shin, J. I., Pizzol,D., Allen, P., Butler, L. T., Barnett, Y., & Smith, L. (2021). What are the recommendations for returning athletes who have experienced long term COVID-19symptoms?. Annals of medicine53(1), 1935–1944.https://doi.org/10.1080/07853890.2021.1992496

[viii] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00299-6/fulltext

[ix] https://covid19.who.int/

[x] https://www.who.int/health-topics/coronavirus#tab=tab_1

[xi] Adults should do at least 150–300 minutes of moderate-intensity aerobic physical activity; or at least 75–150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week; should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits; may increase moderate-intensity aerobic physical activity to more than 300 minutes; or do more than 150 minutes of vigorous-intensity aerobic physical activity; or an equivalent combination of moderate- and vigorous-intensity activity throughout the week for additional health benefits;should limit the amount of time spent being sedentary. Replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits, and to help reduce the detrimental effects of high levels of sedentary behaviour on health, all adults and older adults should aim to do more than the recommended levels of moderate- to vigorous-intensity physical activity. (https://www.who.int/news-room/fact-sheets/detail/physical-activity)

[xii] A Western diet is low in fruits and vegetables, high in fat and sodium and consists of processed foods. It consists of large portions, high calories, and excess sugar, is high in saturated and trans fats.A healthy non Western diet is plant based and animal based and includes minimally processed foods, fruits, vegetables, whole grains, and fat-free or low-fat dairy, lean protein (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721435/)

[xiii] https://www.who.int/news-room/fact-sheets/detail/physical-activity

[xiv] https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight#:~:text=Worldwide%20obesity%20has%20nearly%20tripled,over%20650%20million%20were%20obese.

[xv] https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

[xvi] Puccinelli, P.J., daCosta, T.S., Seffrin, A. et al. Reduced level of physical activity during COVID-19 pandemic is associated withdepression and anxiety levels: an internet-based survey. BMC Public Health 21, 425 (2021); Constandt,B., Thibaut, E., De Bosscher, V., Scheerder, J., Ricour, M., & Willem, A.(2020). Exercising in Times of Lockdown: An Analysis of the Impact of COVID-19on Levels and Patterns of Exercise among Adults in Belgium. International journal of environmental research and public health, 17(11), 4144; Ashby NJS. Impact of the COVID-19 Pandemic on Unhealthy Eating in Populations with Obesity. Obesity (Silver Spring). 2020Oct;28(10):1802-1805. doi: 10.1002/oby.22940. Epub 2020 Aug 20. PMID: 32589788;PMCID: PMC7361200.

[xvii] https://www.who.int/news-room/fact-sheets/detail/physical-activity;Hull, J. H., Loosemore, M., & Schwellnus,M. (2020). Respiratory health in athletes: facing the COVID-19 challenge. The Lancet. Respiratory medicine, 8(6), 557–558.https://doi.org/10.1016/S2213-2600(20)30175-2

[xviii] (Hull, J. H., Loosemore, M., & Schwellnus,M. (2020). Respiratory health in athletes: facing the COVID-19 challenge. The Lancet. Respiratory medicine, 8(6), 557–558.https://doi.org/10.1016/S2213-2600(20)30175-2)

[xix] Hull, J. H., Loosemore, M., & Schwellnus,M. (2020). Respiratory health in athletes: facing the COVID-19 challenge. The Lancet. Respiratory medicine, 8(6), 557–558.https://doi.org/10.1016/S2213-2600(20)30175-2

[xx] https://www.who.int/news-room/fact-sheets/detail/physical-activity;Sallis R, Young DR, Tartof SY,et al Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients British Journal of Sports Medicine 2021;55:1099-1105.

[xxi] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00299-6/fulltext

[xxii] Lindsay RK,Wilson JJ, Trott M, Olanrewaju O, Tully MA, López-Sánchez GF, Shin JI, PizzolD, Allen P, Butler LT, Barnett Y, Smith L. What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms? Ann Med.2021 Dec;53(1):1935-1944. doi: 10.1080/07853890.2021.1992496. PMID: 34726085;PMCID: PMC8567919.)

[xxiii] Hull, J. H., Loosemore, M., & Schwellnus,M. (2020). Respiratory health in athletes: facing the COVID-19 challenge. The Lancet. Respiratory medicine, 8(6), 557–558.https://doi.org/10.1016/S2213-2600(20)30175-2

[xxiv] Anyone who required hospitalisation due to COVID-19 infection should be managed by a multi-disciplinary team including medical specialists (Lindsay et al, 2021)

[xxv] Lindsay RK,Wilson JJ, Trott M, Olanrewaju O, Tully MA, López-Sánchez GF, Shin JI, PizzolD, Allen P, Butler LT, Barnett Y, Smith L. What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms? Ann Med.2021 Dec;53(1):1935-1944. doi: 10.1080/07853890.2021.1992496. PMID: 34726085;PMCID: PMC8567919.)

[xxvi] Lindsay, R. K., Wilson, J. J., Trott,M., Olanrewaju, O., Tully, M. A., López-Sánchez, G. F., Shin, J. I., Pizzol,D., Allen, P., Butler, L. T., Barnett, Y., & Smith, L. (2021). What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms?. Annals of medicine53(1), 1935–1944.https://doi.org/10.1080/07853890.2021.1992496

[xxvii] Lindsay, R. K., Wilson, J. J., Trott, M., Olanrewaju, O.,Tully, M. A., López-Sánchez, G. F., Shin, J. I., Pizzol, D., Allen, P., Butler,L. T., Barnett, Y., & Smith, L. (2021). What are the recommendations for returning athletes who have experienced long term COVID-19 symptoms?. Annals of medicine, 53(1), 1935–1944; Vasiliadis AV, Boka V. Safe Return to Exercise after COVID-19Infection. Sultan Qaboos Univ Med J. 2021 Aug;21(3):373-377. doi:10.18295/squmj.8.2021.124. Epub 2021 Aug 29. PMID: 34522401; PMCID: PMC8407897

[xxviii] https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-(covid-19)-post-covid-19-condition

[xxix] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00299-6/fulltext

[xxx] NL Actief is the Dutch professional association for health and fitness. NLActief Prevention Centers, including CrossFit Eudokia, are specialized in lifestyle guidance for people with (an increased risk of) a chronic condition such as diabetes, non-congenital brain injury, obesity and people recovering from Covid-19.