Should I Lift When I am Sick?

ILLNESS AND ATHLETIC PERFORMANCE

(With Particular Emphasis on Viral Illnesses)

“When you are sick you need to start to learn, what is the most beneficial thing to getting back to 100% health quicker. Is it staying home and resting, or a light work out doing what ever you can. I started to feel quite sick, very achy muscles and joints, and felt like spewing. I felt for me the best thing was to do was whatever I could. I managed 3 sets before I could not continue, even those 3 sets it felt good to get my body moving as it felt quite sore and stiff. If all you can do is 3 sets, then do 3 sets.... This is not a 'waste of a workout'. These days are some of the most valuable for development and becoming a better athlete.”

The above is a statement that was posted recently (2016) on a popular social media site by a weightlifter of some significant ability and experience. The philosophy of “training through an illness” is perhaps something that is not an uncommonly held belief in the athletic world. There is, however, evidence to suggest that under certain circumstances, it is possibly the worst advice that could be given to any athlete.

The following discussion represents a very limited retrospective review of the scientific literature on the subject of training and competing in the presence of an infective illness – particularly viral.

Bacterial and Viral Infections

Bacterial and viral infections have many things in common. Both types of infections are caused by microbes - bacteria and viruses, respectively - and spread by things such as:

Coughing and sneezing.
Contact with infected people, especially through kissing and sex.
Contact with contaminated surfaces, food, and water.
Contact with infected creatures, including pets, livestock, and
insects such as fleas and ticks.

Microbial infections can be:

Acute - which are short-lived.
Chronic - which can last for weeks, months, or a lifetime.
Latent - which may not cause symptoms at first but can reactivate over a period of months and years.

Bacterial and viral infections can cause similar symptoms such as coughing and sneezing, fever, inflammation, vomiting, diarrhea, fatigue, and cramping. Differentiating the cause of the illness is therefore often difficult. However, typical symptoms of a viral illness include:

Fever
Headache
Myalgia – muscle pain
Arthralgia – joint pain
Respiratory/gastrointestinal distress
Exanthem – skin rash
Lymphadenopathy – “swollen glands”

Exercise and Infection

Athletes are subject to the same infections suffered by the rest of the community, with certain circumstances increasing the susceptibility of athletes to infections – team sports, prolonged close contact with fellow team members, the sharing of food and drink etc.(1) Most acute infections in athletes are viral in nature, such as upper respiratory tract infections and gastroenteritis. Over 200 viruses are implicated in the cause of upper respiratory tract infections.

After acute, intense physical activity there is a decrease in the activity and quantum of the various mediators of immunity, and this is known as the “immunological window” during which an athlete may be more susceptible to infection – both bacterial and viral. There is evidence to suggest that physical exercise prior to bacterial infection enhances the production of antibodies, and increases resistance to infection. There is however, some evidence that intense training is associated with a higher level of viral infection in athletes, and particularly within 10 days after a spike in training loads.(2) Viral infection is commonly used to explain poor athletic performance, due to compromise of muscle enzyme activity, metabolism and strength. Exercise during illness also requires greater cardiopulmonary effort.

The remainder of this discussion centres on viral illness and its effects.

Acute infectious viral illness is often associated with a fever and in general it is recognized that fever impairs:

muscle strength
aerobic power
endurance
coordination
fluid/temperature regulation
concentration

Acute viral illnesses can hinder exercise capacity by the direct effects of fever – anorexia, malaise, muscle and joint pains etc – but also by causing muscle protein catabolism, tissue wasting and negative nitrogen balance. This of course results in decreased muscle performance, the full recovery from which may take weeks or even months (3).

Some of the specific concerns with athletes include:

Intense exercise during the incubation phase of the viral infection may

result in a more severe illness

Intense exercise whilst infected with the Coxscakie B virus – a common

cause of a “cold” - may increase the risk of contracting myocarditis which

has been known to cause sudden death

Although not clearly understood, rhabdomyolsis has been reported in

athletes performing intense exercise during or just after the acute phase of a viral illness3

Should an Athlete Train During Illness?

It is important to determine if an athlete is suffering from a viral illness or not. A viral illness will usually be preceded by a period of time (48 hours or so) in which the athlete will feel generally unwell – the prodrome. Once the viral illness is present it is very important to differentiate those athletes into two groups:

those with symptoms restricted to one system – usually the upper respiratory tract
those with generalized symptoms

The differentiation between the two groups is known as the “neck check”(4,5). Athletes with systemic symptoms such as general malaise, excessive fatigue,muscle and/or joint pains and tenderness, body temperature above 38degC, or resting pulse rate greater than 10 beats above normal should avoid athletic activity until the systemic symptoms and signs return to normal. Engaging in

intense exercise during a viral infection has been associated with increased risk of heat exhaustion, post viral fatigue syndrome, viral myocarditis, ventricular fibrillation and even death. The risks associated with strenuous physical activity during the acute phase of viral infection are potentially serious, and there are reports of sudden death and serious complications occurring in previously fit young adults who undertake vigorous exercise when in the acute phase of a viral illness. (4,6,7,8)

For example, the Coxsackie B virus causes symptoms of the common cold but has a tendency to invade cardiac muscle and cause myocarditis – a serious and potentially fatal disease. There is also evidence to suggest that exercise during a viral illness may delay the return to peak performance in training and competition. (9,10)

The “Neck Check” If symptoms are above the neck- runny nose, nasal congestion, sore throat - and not associated with symptoms below the neck – fever, malaise, muscle aches, joint pain, severe cough, gastrointestinal – the athlete may commence training at 50% intensity for 10 minutes. If symptoms do not worsen then training can continue as tolerated. In other words, if the symptoms of a viral illness are generalized, an athlete should not train or compete.

As a general rule, for all but mild common colds, it is advised that the athlete avoids hard training for the first month after a viral infection (11)

Prevention of Spread

Viral infections – particularly URTI’s – can occur throughout the year, although there are seasonal peaks in autumn and spring. Transmission occurs through aerosol and droplet spread, direct and indirect saliva, and skin to skin contact. Viral gastroenteritis is commonly caused by improperly prepared food, drinking contaminated water, or through close contact with an infected individual. In an athletic situation in which there is close contact amongst team members it is therefore important to isolate the illness sufferer from other team members during the acute phase of the illness – ie. until symptoms have abated. It is also very important that the sufferer does not use team equipment during this acute phase of the illness. When teams travel to countries in which hygiene standards are less than ideal it is important to follow strict guidelines to avoid contracting gastroenteritis. Good hygiene will help limit the risk of spread of illness amongst fellow team members. The most vital preventative measure is the frequent washing of hands by athletes and coaches – ready access to hand sanitizers is important. Other important measures include:

avoid rubbing of nose and eyes
avoidance of sharing water bottles and towels
proper hydration
carbohydrate replacement before, during and after exercise

In order to reduce the risk of developing an infectious viral illness the following guidelines may be important (12):

avoidance of overtraining
reduction in general life-stressors
sufficient recovery time
well balanced diet sufficient to maintain a positive nitrogen balance
consider yearly influenza vaccination

Conclusions

Although athletes are subject to the same infections as other community members, there is evidence that they are subject to increased risk of viral upper respiratory tract and gastroenteric illnesses, particularly during heavy training and immediately after competition because of the added psychological stress of the event itself. In general, regular moderate training improves immunosurveillence, increases resistance and decreases the duration of an infectious disease – particularly to bacterial illness; but intense training and in particular, when combined with competition, may impair the immune response, and render the athlete more susceptible to viral illness. Intensive physical activity immediately before or during an infective illness – particularly viral – may increase the severity and morbidity of the infection, and prolong recovery and return to training and competition. If an athlete has symptoms of an acute infective illness “below the neck” they should be excluded from training and competition until the acute phase of illness passes (possibly for 2 to 4 weeks). There are several means by which athletes and coaches can reduce the risk of developing acute infections, and if they do develop, there should be rigorous measures put in place to reduce the effect of the illness and prevent its spread.