Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes an infectious disease (COVID-19) that has spread to more than 200 countries and affected more than 6 million people. SARS-CoV-2 is a highly transmissible virus that is primarily spread through airborne droplets when infected individuals congregate with others in enclosed spaces (1). Based on clinical observations and autopsy data, the virus attacks vascular tissue throughout the body causing ischemic injury and inflammatory reactions that destroy cells and tissues (2). The virus also causes direct tissue damage, and the body's immune system can “over respond,” resulting in a “cytokine storm” capable of significant destruction. We do not know if the virus will express a seasonal variation, like influenza, or be a constant year-round threat. This alone will challenge planning for a variety of events, including personal and group physical activities. Although this call to action focuses on individual fitness and physical activity, team sports are recognized as a vital activity for many. It is important to recognize for those returning to team sports that the risk for COVID-19 transmission may be higher in high-contact sports, such as football and soccer, as compared with low-contact sports, such as baseball and softball. Accordingly, diagnostic testing is likely to become more important in high-risk contact sports and should be adapted based on local guidelines.
Regular physical activity benefits both physical and mental health in the long- and short-term. Risk factor analysis for the most severe COVID-19 cases indicates a link to obesity, obesity-related conditions, such as hypertension and type 2 diabetes mellitus, older age, racial and ethnic minority status, and physical inactivity (1,3). The diseases of inactivity, including obesity and hypertension, will flourish without an effort to maintain fitness. Moderate-to-vigorous physical activity (MVPA) decreased during the early phases of the COVID-19 pandemic (4), and a gradual return is encouraged while following mitigation guidelines (1,5). During this pandemic, it is essential for those with normal health and chronic disease to activate, maintain, and advance physical activity to 30 min to 60 min most days of the week within the confines of social distancing. This may not be the time to train for peak performance. How to achieve this physical activity goal will vary for well and COVID-19-recovered individuals; and COVID-19-recovered individuals may face the challenges of infection-related organ damage, especially those convalescing from severe illness. Anecdotes from these individuals suggest that even the very fit going into the disease take weeks and possibly months to restore exercise tolerance. Until there is an effective vaccine, finding the time and place to exercise safely will likely be a challenge for many.
The magnitude of exercise-induced physiological stress has an influence on immune function (1,5–7). MVPA bouts of 30 min to 60 min stimulate the exchange of immune cells between lymphoid tissues and the circulation. MVPA repeated on a near-daily basis enhances pathogen surveillance activity and reduces acute respiratory illness (ARI) morbidity and mortality (1). In contrast, participating in unusually high exercise workloads with the associated physiological stress is linked to transient immune dysfunction and an elevated ARI risk (7). Socially induced stress has direct effects on immune function, disease susceptibility, and life span (8).
A critical concern for both highly active individuals and competitive athletes is the potential for cardiac injury from SARS-CoV-2 (9,10). Acute cardiac injury and myocarditis have been observed in a significant proportion of hospitalized patients with COVID-19, and exercise could accelerate viral replication and cardiac damage. Another concern for competitive athletes is the safe return to competitive events that involve varying degrees of travel and mass gatherings (11,12).
The COVID crisis requires a flexible approach to physical activity based on the need for social distancing combined with changes to personal demands and environments. This may include incorporating physical activity in unaccustomed ways with outdoor activities, family groupings, or alternate off peak times. Creativity is even more crucial for those affected by negative social determinants of health such as individuals living in areas where the outdoor environment is not safe or is too crowded for social distancing. Overcoming obstacles to physical activity, using behavioral innovation specific to one's situation, is key to optimizing overall physical, mental, and emotional well-being. The COVID pandemic should be viewed as an opportunity to expand our approach to prescribing physical activity.
Physical activity improves mental health and reduces anxiety and depression (13). However, social distancing removes the unique social environment of group physical activity. For many individuals, group sport activities are critical social networks that provide opportunity for children to develop personal and social skills and for adults to maintain such skills (14,15). Participating in fitness and sport groups creates a sense of belonging and cohesion that will be lost during the social distancing required to stem the pandemic. The lack of group engagement may affect mood, self-esteem, and cognitive function. The absence of this community can be devastating to those vulnerable populations that rely on these activities for socialization and communication, like cognitively and physically impaired athletes (i.e., Special Olympics). Policies are needed to reintroduce group exercise while maintaining safe social distancing practices.
The COVID-19 pandemic has imposed significant restrictions on in-person elective medical care, shifting much of sports medicine practice to telehealth. Recent reports describing the orthopedic video-assisted virtual visit suggest strategies for effectively performing a remote physical examination (16,17). In the related fields of behavior change and mental health, increasing use of digital platforms has improved health care delivery and patient engagement (18,19). Sports medicine providers can similarly use telehealth to connect with patients on issues relating to wellness and physical activity during the COVID-19 pandemic. Through existing, easily accessible digital platforms, providers can advise on physical activity recommendations for those striving to start or maintain optimal exercise regimens and coach those struggling with musculoskeletal injuries on easily accessible home treatments and therapeutic exercise programs. The current limited availability of diagnostic studies and procedural interventions encourages a greater reliance on patient-provider communication to solve sports- and physical activity-related health issues.
In summary, activating the general population for the health benefits of physical activity may be challenging as we emerge from COVID-19. Increasing physical activity will require individuals and groups to walk a fine line between benefit and risk. The main vehicle for spread of the virus is airborne droplets from breathing, talking, coughing, and sneezing. Breathing hard appears to increase the amount of airborne virus (20). Physical activity in groups or spaces where adequate social distancing cannot be maintained will require masking to reduce transmission. For the general public, evidence shows that physical distancing of more than 1 m can be effective and that face masks (disposable or reusable 12- to 16-layer cotton type) are associated with some protection, even in nonhealth care settings (21). Widespread surveillance testing may be needed to track transmission prior to resuming team sports and contact activities (22). Athletes and active people cannot be the collateral damage in our quest to achieve herd immunity, and group spectator sports may not return in the short term. Decision making should be driven by scientific data and not competing financial interests.
We suggest the following call to action items:
- Encourage well individuals to start or continue moderate physical activity for 150 min·wk−1 to 300 min·wk−1, although smaller amounts are still beneficial.
- Individuals who have contracted COVID-19 should contact their primary care physician to determine if any evaluation is necessary to ensure a safe return to exercise.
- Perform MVPA in personal homes or outside while maintaining the proper physical distance from others, using face coverings when needed to minimize droplet spread.
- Maintain immune health by participating in 150 min to 300 min MVPA per week and keeping body weight at recommended levels.
- Individuals at high risk for SARS-CoV-2 exposure should refrain from exhaustive exercise, overreaching, and overtraining (2,4).
- Determine evidence-based recommendations for return-to-exercise after resolution of COVID-19. In the meantime, advise rest and no exercise for 2 wk from resolution of mild or moderate COVID-19 or from a positive test result, followed by a slow resumption of physical activity with close monitoring for clinical deterioration under the guidance of a health care team (9,10).
- Apply and adapt the World Health Organization interim guidelines, COVID-19 mitigation checklists, and risk assessment tool kit to each sport discipline (11).
- Use innovative strategies in the approach to promote physical activity during the COVID-19 pandemic.
- Develop policies to safely reintroduce group activities that augment physical and mental health in close consideration of social determinants of health.
- Optimize sports medicine telehealth to have broad appeal and reach across diverse populations.
- Ensure equal access to telehealth across all communities and focus on reaching vulnerable populations, the economically disadvantaged, and those with language barriers.
- Implement the use of masking and testing to reduce spread and avoid close contact when masking fails. When universal masking cannot occur (e.g., high intensity exercise, competitions), diagnostic testing and effective contact tracing protocols become increasingly important, especially in high-contact risk sports.
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