We are by now all familiar with the symptoms of COVID-19, and the precautions we need to take in order to keep ourselves as safe as possible. However, despite precautions, many of us have been ill or may still become infected with this virus.

Its also apparent that a subset of people who have “recovered” from COVID-19 will go on to experience symptoms that linger well beyond testing negative for the virus. These individuals are sometimes referred to as “COVID long-haulers,” and experts are searching for answers about this condition that’s now being termed post-COVID syndrome. 

This syndrome is a unique phenomenon, and we’re still learning about its presentation. However, most of us are becoming aware that its symptoms, particularly fatigue, can have debilitating effects on quality of life. Lingering fatigue, muscle and body aches, difficulty concentrating or focusing, inability to exercise, shortness of breath and difficulty sleeping, seem to be especially common amongst COVID-19 survivors. This constellation of symptoms has been likened to the better known chronic fatigue syndrome (CFS). 

“Why people experience fatigue is not well understood, but it likely has to do with immune system dysregulation, ongoing inflammation in the body, and direct damage to the brain or spinal cord that can interrupt flow between neurons,” says Esther Melamed, MD, PhD, assistant professor of neurology at Dell Medical School at The University of Texas.

Other more severe symptoms reported by survivors of the virus are lingering respiratory and cardiovascular trouble, such as weakening of the heart muscle. Unfortunately joint pain, rashes, muscle aches, dizziness, confusion, vision changes, depression, and anxiety are also relatively common. In the case of some patients who have recovered, there can be a resurgence of symptoms, or even brand-new symptoms, believed to be linked to the virus. Flare-ups of asthma and reflux in one patient, for example, were ailments she had pre-COVID. It’s therefore possible that this virus can reactivate previous health problems that were previously under control.

There seems no way to predict exactly how someone will react to the virus, but it’s becoming clear that survival doesn’t always equal recovery. Some who only present with mild symptoms of COVID-19 can take many weeks to get back to full strength, leading to a possible relapse or post-viral fatigue episode. Paradoxically, those who have endured significant symptoms may recover more rapidly.

Implications for dancers 

Understandably, all this information is particularly worrying for dancers wanting to return to the level of performance training they experienced before COVID-19. Physicians, trainers, coaches, league officials, and those responsible for the welfare of dancers and athletes, have also been faced with substantial uncertainty about the safety of returning to training and competition during this trying time. There is specific concern for dancers who are COVID-19 positive and younger than 15 years, because there is generally a lack of medical and performance resources to monitor safe return to performance in this population.

Recovery Protocols

Since early March 2020, performance and medical professionals who support athletes at various levels have attempted to construct training environments and practices based on emerging yet inconsistent science on the ramifications of contracting COVID-19. 

I believe these protocols are highly relevant for dancers, and that the ballroom dance world can benefit from taking note of scientific data which provide recommendations for physical performance and recovery during this time. 

Some questions for dancers presenting with post-COVID syndrome to consider: 

*How soon can I resume training?

*What exercise should I begin with?

*How hard and how often should I be training?

*How should I progress my training?

*What are the warning signs I need to look out for if I’m pushing too hard?

These are important questions to answer because COVID-19 is known to increase the risk of cardiovascular, kidney, respiratory and haematological complications following illness. All of these systems undergo extra loading during exercise. Allowing the dancer to self monitor and adjust their activity accordingly, is empowering and improves self-confidence after a stressful illness. In addition, self monitoring helps those at risk not suffer a relapse.

Some examples of self monitoring include: 

*Resting heart rate (a rise in RHR may indicate too much too soon)

*Rated perceived exertion (if perceived exertion increases for a given workload/speed, dancers may need to back off).

*Sleep, stress, fatigue and muscle soreness (poorer sleep quality or an increase in any of the other factors indicates too much loading).

As endurance and pulmonary function returns, a more cohesive plan for return to performance can be developed. Dancers must also be psychologically ready to return to performance. This can be gauged using a standardized questionnaire such as the I-PPRS scale. An example of this questionnaire for athletes can be found here: https://www.momsteam.com/injury-psychological-readiness-return-sport-scale.

Every patient should be regarded as a snowflake, but in general most people who have this syndrome appear to be improving. Shortness of breath appears to be the the hallmark complaint, as the compromise that occurs in the lungs during the active disease may have lasting effects. Although there remains uncertainty, it has been observed that nearly all dancers and athletes who recover from mild COVID-19 infection do not develop significant cardiovascular pathology. For coaches who need to get dancers back into training and competition, this is somewhat comforting.

-Jodie-

Corresponding Author: James E. Udelson, MD, The CardioVascular Center, Division of Cardiology, Tufts Medical Center, 800 Washington St, PO Box 70, Boston, MA 02111 (judelson@tuftsmedicalcenter.org).