How to manage the return to training after illness
Issue: Volume 27 Number 4
A commonly asked question by athletes and coaches refers to the guidelines and recommendations for planning the return to full training and competition after illness. Almost every athlete at some point in his or her career experiences the frustration of illness which interferes with training or competition performance. Once the symptoms of illness have subsided, the critical issues are how quickly an athlete can resume full training and competition, and the guidelines for managing the training process through this period.
The most common forms of illness experienced by athletes are viral syndromes of the upper respiratory tract. The majority of viral illnesses appear to be those related to the common cold. Less common is the influenza virus. In teenage and young adult athletes, about 70–90 per cent of individuals have come into contact with Epstein Barr Virus, which causes infectious mononucleosis or glandular fever. Many individuals will not present with symptoms because their immune system is sufficiently robust to deal with the virus. However, in a small number of cases Epstein Barr Virus can manifest as glandular fever, characterised by fatigue and swollen glands. This particular condition can produce moderate to severe symptoms in some individuals and may take several weeks to months for a full recovery.
Some athletes also suffer from exercise-induced asthma or allergies, particularly during spring when seasonal pollen counts can be high. The physician’s examination (and blood tests if needed) will assist the process of identifying the underlying cause or origin of illness, and the most appropriate treatment and management strategy.
A primary consideration for athletes (and coaches) is the timing of return to training and competition. The amount of time off training will depend on the nature and severity of the illness and the rate of recovery for individual athletes. A simple three-step approach has been developed at the Australian Institute of Sport (Pyne et al. 1995; Young 1999) to assist physicians, coaches and athletes.
In essence, the order in which various elements of training are prioritised is:
- Frequency of training.
- Duration of training.
- Intensity of training.
In this approach, the first step is for the athlete to resume training after the layoff, and start increasing the frequency or number of sessions in the process of returning to full training. Once that is achieved, the second step is to gradually increase the duration or volume of individual training sessions. The final step is to increase the intensity of training so that full training and competition can be resumed. The process may take only one or two days for a mild illness, days to weeks for a moderate illness, and occasionally weeks to months for a severe illness.
The recommendations for the initial return centre on low-intensity aerobic sessions of 20–30 minutes duration. This typically involves a short individual session outside of the regular training program, particularly in team sports. The intensity of the sessions should be light to moderate with a heart rate of approximately 60–65 per cent of maximum. This would equate to a level of 120–130 beats per minute for an athlete with a maximum heart rate of 200 beats per minute. Exercise can be repeated the next day if recovery is complete and there has been no recurrence of symptoms.
Once the athlete can exercise and recover safely over several consecutive days, it is appropriate to increase the frequency of exercise to twice daily and eventually the regular pattern of training. Depending on the severity of illness and rate of recovery, a typical pattern of training might involve a single session on the first and second day of recovery, two sessions on the third day, a single session on the fourth, and then resumption of the normal pattern. For a more moderate to severe illness, the pattern might involve one session on the first day, then a rest day, followed by another single session, another rest day, then two consecutive days of a single session, and so on.
At this point, the athlete can start to increase the duration of exercise until full training duration and frequency are reached. The duration or volume of sessions depend on the long-term background of the athlete, the length of any lay-off or absence from normal training, and the severity of the illness. Athletes with an extensive training background and a high level of fitness, who only miss one or two days of training with mild symptoms of illness, can increase the duration or volume of training reasonably quickly. In contrast, younger or older athletes with a smaller training background and lower level of fitness, or athletes who have missed several days or weeks of training with a moderate to severe illness, may require several days to weeks to resume their full training volumes. One rule of thumb is that the length of the rehabilitation and return to full training is similar to the number of days of training missed through illness; for example, three days off sick would require another three days of modified training before resuming full training.
The final step is to increase the intensity of training in small increments until full training and competitive capacities are reached. A common mistake is to increase the intensity of exercise too quickly. The immune system can be sensitive to sudden increases in training intensity or load. A good idea is to increase volume and intensity in small 5–10 per cent increments rather than larger increases that can stress an athlete and lead to a relapse of the illness. A periodised approach involving lower and higher intensity sessions and plenty of recovery is recommended. It is also suggested the athlete be given more rest between high-intensity efforts to allow for extra recovery. For example, a set of sprints normally completed with 20 seconds rest could be modified to 40–60 seconds of rest, so as not to overload the athlete.
The athlete should be encouraged to carefully monitor training performance and wellbeing for several days after an illness to ensure recovery is complete. A checklist is shown in Table 1. These details can be recorded in a training diary. The athlete and coach should be in close consultation during this period to ensure that the recovery is proceeding in line with expectations. Some symptoms can reappear and the athlete should be reminded that occasional relapses can be experienced and are part of the normal rehabilitation process. A physician should be consulted if fatigue and symptoms of illness persist or recur, particularly after periods of reduced training. Remember also that during this period of resumption of training it is important to maximise healthy eating habits and hydration.
Table 1 Checklist for signs and symptoms of illness when resuming training or competition after an illness
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References
1. Pyne, DB, Gray, AB and McDonald, WA 1995. ‘Exercise, training and immunity’. In: Textbook of Science and Medicine in Sport. J Bloomfield, P Fricker and K Fitch (eds) Melbourne: Blackwell Science, pp. 602–15.
2. Young, M 1999. ‘How I treat: return to sport after post-viral fatigue’, British Journal of Sports Medicine, 33:173.
