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Post COVID-19 Recovery: Implications & Program Adaptations for Aquatic Professionals


     by Patricia Benjamin Med



People who have had COVID show signs of debilitating fatigue that may linger for several weeks and even months post recovery. Although tests no longer indicate they have the virus, most still suffer from symptoms of fatigue and an intermittent cough for days, weeks, even months afterwards. Even those affected with mild symptoms are surprised by the slow recovery to a “healthy” normal. 

As aquatic professionals we will have many challenges before us in a post COVID-19 pandemic recovery. Working with and coaching those in differing stages of recovery will require informative decision making regarding our programming.  The following are some implications and aquatic adaptations for us to consider when programming, teaching, and coaching those clients.  

COVID-19 Symptoms Overlap with Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome

The number of post COVID infected persons still suffering from on-going symptoms is growing exponentially as recovery data is being collected.  SARS-CoV-2 (Coronavirus) can affect the brain causing neuroinflammation of several systems throughout the body, resulting in chronic fatigue (Pan, et al. 2020).   

In an international survey published in May of 2020, the most frequent symptoms reported were fatigue, post exertional malaise (PEM), and cognitive dysfunction or “brain fog”.  This condition is being called “Long COVID” by researchers and those afflicted called “long haulers” (Komaroff and Bateman 2021). 

“Long Haul” symptoms are quite similar to those who have been diagnosed with an illness called Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome or ME/CFS (Tucker 2021). The following have been found typical of “long haulers” who share similarities to persons diagnosed with ME/CFS. (Davis et al. 2020).

·       Cardio-respiratory inflammation, breathlessness (Naviaux 2016).. 

·       Chronic fatigue syndrome – unexplained muscle and joint pain, headaches, flu-like symptoms   

·       Post exertional malaise (PEM) – “Crash and Collapse” after doing too much

·       Psychological changes – mood, sleep, appetite, motivation

There are notable abnormalities in both “long COVID” and ME/CFS that diminish energy production within the cells’ organelles due to neuroinflammation within the brain (hypothalamus and pituitary glands) resulting in the reduction of transport of metabolic signaling cytokines used to fight the disease (Moldofsky and Patcai 2011). 

According to the Centers for Disease Control and Prevention (CDC), neuroinflammation produces impaired energy production, a characteristic of post-exertional malaise (PEM) in persons with ME/CFS.  Persons with ME/CFS may experience a “crash” or “collapse” for days, weeks or months. Among other immune and brain responses to inflammation, the mitochondria (powerhouse) in cells are afflicted by the disease, become dysfunctional, and ATP energy production becomes depleted during any type of physical exertion (Morris 2013). PEM is a marker on a continuum to both of these special populations (Tucker 2021).  

As with ME/CFS, return to physical activity is recommended as soon as PEM has subsided, and the person feels ready to participate. (Naviaux 30)  Coronavirus infection affects people differently with anywhere from mild to severe symptoms replicating ME/CFS.  Rate of recovery is dependent on the individual’s tolerance for physical overload (CDC).   A participant’s prior state of health and present physical condition should always be taken into consideration when an aquatic program is provided or recommended.  

Adaptations for Aquatic Professionals

The following adaptations are based on a model created by a panel of doctors, sports and exercise science medicine, and rehabilitation professionals from the United Kingdom (Salaman 2021).  The adaptations are provided as a pragmatic approach and a simplistic guide to help post COVID recovering participants in our aquatic classes regain stamina and return to healthy “normal” or “better” pre-COVID wellness. Recommended is a gradual increase in duration and frequency with intensity as tolerable by the participant.  Program modifications, regressions and progressions to water exercise movement and intensity can be adopted by the participant throughout each recovery phase.  

Adapted for water exercise (BORG Scale of intensity Rate of Perceived Exertion 1-10)   

·       Phase 1  

Focus:  Preparation for purposeful water movement with coordination such as water walking, breathing exercises, flexibility and ROM, and balance.  Very light intensity. RPE 1-3, as tolerated.

Pragmatic Approach: PNF 1&2, Bad Ragaz, Aqua Stretch, and simple stretching.  Shallow-water walking forward, backward, sideways. Simple arm patterns; slicing hand positions.  Aquatic yoga or Ai Chi for breathing exercises and balance. 

·       Phase 2  

Focus:   Prep and base with light intensity exercise preparing body for gradual water fitness acclimation and intensity continuum. Basic elements of moves, moving more water with purpose   RPE 3-5, as tolerated.

Pragmatic Approach:  Shallow water Level II & III and Grounded moves, jog, jack, ski, tuck, twist, Wavemaker 6-7 method, dynamic balance, 2-3 days a week for 10-30 minutes.   

  • ·       Phase 3  

Focus: Base to build. Light-moderate intensity with emphasis on cardiovascular and muscle endurance. 

Pragmatic Approach:  Longer intervals of work with equal amounts of rest/recovery, neuromotor challenges, simple choreography with resting movement sequences, buoyancy equipment balance challenges.  Shallow or deep formats.  RPE 5-7.  1-2 classes per week working up to a 30-45 minutes per class.

·       Phase 4

Focus:  Build to moderate-vigorous intensity, Gradual increases in cardiovascular load, endurance, and muscle strength.  

Pragmatic Approach: Various aquatic formats including, but not limited to, swimming, aquatic jogging, aquatic biking, aquatic pole, aquatic mat/board, circuits, HIIT (ratios 3:1, 2:1, 1:1), add-on and layered choreography, buoyancy and resistance equipment challenges.  RPE 6-8.  2-3 classes per week working up to 45-60 minutes.

·       Phase 5

Focus:  Return to healthy “normal” pre-COVID water exercise stamina.

Pragmatic Approach: Able to participate in a variety of water exercise formats.  Perceived rate of exertion ranging from very light to vigorous (PRE 1-10).  Shallow-water, dual depth, and deep-water exercise class participation,  2-5 days per week, 60 minutes or more.  


Aquatic fitness professionals have an opportunity to work with and help a very unique special population. As facilities continue to open, the number of post COVID recovery participants in our classes will grow in the months to come.   Researchers are currently looking at similarities between “Long-COVID” recovery and the chronic illness, ME/CFS.   Post-exertional malaise (PEM) is a marker to consider when teaching clients about RPE within each phase.  A panel of scientists and doctors from the UK created a model that I used to develop a pragmatic approach to lead recovering individuals in our classes on their journey to “normal” or “better” health with aquatic fitness.  


Center for Disease Control and Prevention (CDC).  Myalgic Enephalomyelitis/Chronic Fatigue Syndrome.  https://www.cdc.gov/me-cfs/index.html

Davis, H., Assaf, G., McCorkel, L., Wei, H., Low, R., Re'em, Y., et al. 2020. Symptomatic description of long COVID through 7 months in an international cohort.  Medrxiv. doi:https://doi.org/10.1101/2020.12.24.20248802


Komaroff, A.L. and Bateman, L. 2021. Will Covid-19 Lead to Myalgic Encephalomyelitis/Chronic Fatigue Syndrome? Frontiers in Medicine. https://www.frontiersin.org/articles/10.3389/fmed.2020.606824/full

Moldofsky H, Patcai J. 2011.  Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study. BMC Neurol. 11:37. doi: 10.1186/1471-2377-11-37

Morris, G. and Maes, M. 2014.  Mitochondrial dysfunctions in myalgic encephalomyelitis/chronic fatigue syndrome explained by activated immuno-inflammatory, oxidative and nitrosative stress pathways. Metab Brain Dis. 2014 Mar;29(1):19-36. doi: 10.1007/s11011-013-9435-x. Epub 2013 Sep 10. PMID: 24557875.

Pan R, Zhang Q, Anthony SM, Zhou Y, Zou X, Cassell M, et al. 2020. Oligodendrocytes that survive acute coronavirus infection induce prolonged inflammatory responses in the CNS. Proc Natl Acad Sci USA.117:15902–10. doi: 10.1073/pnas.2003432117

Salman, D., Vishnubala, D., Le Feuvre, P., Beaney, T., Korganonkar, J., Majeed, A., and McGregor, A. 2021. PRACTICE POINTER “Returning to physical activity after covid-19.   The BMJ.  BMJ 2021;372:m4721 


Tucker, M.E.  2021. COVID-19 “Long Haul” Symptoms Overlap with ME/CFS – Medscape – Mar 26, 2021  https://www.medscape.com/viewarticle/948223

Naviaux, R.K., Naviaux, J.C., Li, K., Bright, A.T., Alaynick, W.A,. Wang, L., et al. 2016. Metabolic features of chronic fatigue syndrome. Proc Natl Acad Sci USA. 113:E5472–80. doi: 10.1073/pnas.1607571113



Patricia Benjamin is a Wavemaker Academy Ambassador and Program Coach. She has over 25 years experience teaching and coaching aquatics and is AEA, ATRI, WSI, and PN1 Certified. As an enthusiast, her aim is to help people achieve optimal function for living a satisfying leisure lifestyle.  Patricia works as a personal trainer and nutrition coach for 50+ Lifestyle Health and lives in Post Falls, Idaho.