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Stages of return to play after COVID-19 infection

Stages of return to play after COVID-19 infection
Stage Activity level Objectives Percent of maximum HR permitted Duration of exercise session Exercise intensity and examples
Stage I Initial rest Allow time for recovery N/A N/A Activities of daily living.
Stage II Light activity Gradual increase in heart rate <70% <15 minutes

Begin light exercise (eg, walking, light jogging, light stationary bicycle).

No resistance training.
Stage III Moderate activity Increase in exercise frequency and duration <80% <45 minutes

More challenging aerobic activities (eg, 2- to 3-km run at 12 to 15 minutes/mile [7 to 9 minutes/km] or at easy pace for elite runners; stationary bicycle at 50 to 125 watts; other activity at RPE 9 to 12).

Begin resistance training (eg, bodyweight exercises that can be performed for 15 to 20 repetitions without difficulty; weight training at 50% of 1RM or less).
Stage IV Advanced activity Increase in exercise intensity; restoration of functional skills <80% <60 minutes

More intense aerobic activities (eg, 3- to 5-km run at 10 to 15 minutes/mile [6 to 9 minutes/km] or at moderate but not fast pace for elite runners; stationary bicycle at >150 watts; other activity at RPE 11 to 14).

More intense resistance training (eg, full bodyweight exercises; weight training at 70% of 1RM or less).
Stage V Normal training Gradual resumption of standard fitness routine N/A N/A

Normal training*.

Re-introduction of sprints, interval training, and agility (multi-directional) training*.

Full resistance training*.
The table provides a general scheme for progressing to full play following infection with COVID-19. The duration of each stage will vary widely depending upon a range of patient factors, including severity of infection, comorbidities, age, baseline fitness, and goals. Clinicians must monitor patients appropriately and modify activity based on patient response and any symptoms or signs that may develop.
HR: heart rate; N/A: not applicable; 1RM: one repetition maximum; RPE: rate of perceived exertion.
* Training volume and intensity should be increased gradually. A good rule of thumb is that increases should not exceed 10% each week. For aerobic activities, increases in volume should precede increases in intensity.
References:
  1. Elliott N, Martin R, Heron N, et al. Infographic. Graduated return to play guidance following COVID-19 infection. Br J Sports Med 2020; 54:1174.
  2. Metzl JD, McElheny K, Robinson JN,et al. Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete. HSS J 2020; 16(Suppl 1):1.
  3. Jewson J, McNamara A, Fitzpatrick J. Life after COVID-19: The importance of a safe return to physical activity. Aust J Gen Pract 2020; 49.
  4. Coronavirus Disease 2019: Readiness Guide Version 2. Navy Bureau of Medicine and Surgery 2021.
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