Abstract
A 23-year-old male competitive athlete performed a maximal cardiopulmonary exercise test on a cycle ergometer with a concurrent cognitive test on an iPad 6 days before and 19 weeks after a nonhospitalized COVID-19 illness. Results indicated reductions in time to exhaustion (−3.25 min), peak oxygen consumption (–1.68 mL/kg/min), and accuracy (–8%) during peak exertion despite his return to prior levels of activity. Reductions in functional or cognitive performance in competitive athletes may elicit noticeable differences in athletic performance; therefore, fitness specialists should consider the assessment of both cognitive function as well as aerobic capacity in athletes following COVID-19, regardless of severity, to facilitate safe and effective return to activity.
Keywords: Cardiopulmonary exercise testing, cognition, COVID-19, SARS-CoV-2
COVID-19 can lead to impaired functional exercise capacity (FEC) and cognitive dysfunction1–4 despite presence or severity of symptoms.5,6 In competitive athletes, both physical ability and cognitive performance play key roles in their successful engagement in athletic activities,7 and even small reductions in functional or cognitive performance may elicit noticeable differences in athletic performance. As recovered athletes resume activity, assessment strategies and guidelines are continually revised to facilitate safe and effective return to play.8–12 We present a case describing the change in FEC and cognitive performance, measured by maximal cardiopulmonary exercise testing (CPET) with concurrent cognitive assessment, prior to and after COVID-19 illness in a competitive male athlete in order to inform future health and fitness professionals when developing return to play protocols.
CASE DESCRIPTION
A 23-year-old male competitive athlete completed a CPET with concurrent cognitive testing (Figure 1) 6 days before and 19 weeks after nonhospitalized COVID-19 as part of a research study. During the first assessment, he screened negative for exposure, signs, or symptoms of COVID-19 and endorsed regular participation in vigorous anaerobic and aerobic exercise 5 days per week as well as recreational and competitive sports. Six days after the initial assessment, he reported a positive polymerase chain reaction test indicating COVID-19, and his CPET was deferred until after recovery. No involved health professional developed COVID-19. During his acute illness, he reported mild symptoms of headache, anosmia, and dysgeusia, which persisted 3, 28, and 35 days, respectively. He also reported palpitations for which he was referred to cardiology but was cleared with no intervention. After 2 weeks of rest, he began to self-progress his activity, starting with light-intensity exercise, and was able to increase intensity and duration until he returned to his prior level of exercise intensity, occupation as a fitness specialist, and sport after 8 weeks. He was able to maintain this level of activity until his second assessment 19 weeks after diagnosis; however, he did experience a 3.5 kg weight loss during his recovery.
Figure 1.
Cardiopulmonary exercise testing with concurrent cognitive testing on a cycle ergometer in a 23-year-old competitive athlete.
CPET and cognitive performance outcomes are detailed in Table 1. Despite returning to his prior level of activity, reductions in FEC and cognitive performance were observed. Time to exhaustion decreased by 3 minutes and 15 seconds and peak oxygen consumption decreased from 40.48 to 38.80 mL/min/kg. Cognitive performance testing, which consisted of a simple reaction time task on an iPad completed during the last 30 seconds of each 3-minute stage, showed a decrease in accuracy of 8% during peak exertion (96.2% to 88.5%) despite similar reaction times (0.279 to 0.270 s). Following 4 minutes of active recovery, accuracy remained lower (96.4% compared to 100%).
Table 1.
Peak cardiopulmonary and cognitive performance outcomes before and after COVID-19 infection in a 23-year-old athlete
| Parameter | Pre–COVID-19 | Post–COVID-19 |
|---|---|---|
| Weight (kg) | 92.6 | 89.1 |
| Exercise performance | ||
| Duration (mm: ss) | 37:45 | 34:30 |
| Power (W) | 275 | 250 |
| Rate of perceived exertion (6–20) | 19 | 17 |
| Dyspnea (0–10) | 9 | 8 |
| Cardiovascular | ||
| Systolic blood pressure (mm Hg) | 202 | 208 |
| Diastolic blood pressure (mm Hg) | 86 | 70 |
| Oxygen pulse (mL/beat) | 21.5 | 19.7 |
| Heart rate (bpm) | 174 | 171 |
| Ventilatory | ||
| Oxygen saturation (%) | 99 | 98 |
| Respiratory frequency (1/min) | 47.9 | 40.4 |
| Tidal volume (L) | 3.081 | 2.923 |
| VE/VCO2 slope | 37.5 | 25.6 |
| Breathing reserve (%) | 29.9 | 43.6 |
| Minute ventilation (L/min) | 147.6 | 118.5 |
| Metabolic | ||
| VO2 (mL/min) | 3745.6 | 3456.2 |
| VCO2 (mL/min) | 3734.7 | 3530.1 |
| Respiratory exchange ratio | 0.995 | 1.025 |
| Metabolic equivalents | 11.6 | 11.1 |
| Predicted VO2 (%) | 100.5 | 94 |
| VO2 (mL/min/kg) | 40.48 | 38.80 |
| Gas exchange | ||
| PET O2 (mm Hg) | 114 | 113.5 |
| PET CO2 (mm Hg) | 30.5 | 34 |
| VE/VO2 | 38.6 | 33.4 |
| VE/VCO2 | 38.6 | 32.7 |
| Cognitive performance | ||
| Accuracy (%) | 96.2 | 88.5 |
| Reaction time (s) | 0.279 | 0.270 |
PET indicates partial pressure of end tidal; VCO2, carbon dioxide production; VE, ventilatory equivalent; VO2, oxygen consumption.
DISCUSSION
To our knowledge, this case report is the first to provide baseline measures of cognitive performance and CPET outcomes in a competitive athlete before and after COVID-19. This participant demonstrated a reduction in FEC (>100% to 94% predicted peak oxygen consumption); however, this does not meet the threshold for impairment (<80%–85% predicted oxygen consumption) that has been observed in more severe COVID-19 cases.13–15 Breathing reserve remained >15%, suggesting no ventilatory limitation during exercise, and his ventilatory efficiency of CO2, which is often impaired in individuals hospitalized with COVID-19,13–16 was normal. It is important to note, however, that his time to exhaustion was reduced by a full CPET stage following COVID-19, which, coupled with weight loss, may be attributed to muscular impairment.16 This participant demonstrated a reduction in cognitive performance, as measured by accuracy on a simple motor task, at peak exertion and following a 4-minute recovery period, which is consistent with the literature describing the impact of COVID-19 on cognition.3,4
The potential for changes in functional and cognitive performance, such as those observed in this case, may impact competitive athletic performance and should be investigated further to understand if there are implications for return to play protocols and training programs. Additionally, the results of this case describe relatively minor changes in FEC, but this may not be representative of the impact of COVID-19 on clinical or untrained populations, which may be more likely to experience significant impairment. This case not only describes novel information regarding a trained athlete’s functional and cognitive change following recovery from COVID-19 but highlights the utility of providing similar postinfection assessments to guide exercise progression for adults recovering from COVID-19 in the community.
ACKNOWLEDGMENTS
The authors wish to acknowledge the Gatorade Sports Science Institute for its support in completing the cardiopulmonary exercise tests.
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