This past week has been a frustrating one for me. Marathon training was coming along nicely when out of nowhere came the mother of all colds. It was like the bubonic plague and SARS had a viral love child! I normally fight off the odd sniffle but this brute had me beaten. As I sniffed and coughed in my death bed I wondered, “what is the evidence based management of a cold?” and “should I get dressed today or just stay in bed?”. This article looks to answer those important questions, well the first one at least…

A cold is usually a viral upper respiratory tract infection. It starts with a sore throat, malaise and fever. Nasal congestion, rhinorrhea (runny nose) and coughing usually develop within 24-48 hours. Symptoms peak at day 3-4 with an increase in 'nasal discharge' and start to resolve by day 7 but can last up to 4 weeks.

Treating a cold

In terms of treatment there are a host of different options but minimal strong evidence to support them. There is an old saying for this,

“A treated cold lasts 7 days and an untreated cold lasts a week”

One thing that the literature does agree on though is that antibiotics have no role in treating colds. The infection isn't likely to be bacterial and research has shown antibiotics do not reduce the duration or severity of symptoms. Other treatment options are aimed largely at relieving symptoms rather than treating the underlying infection.

Simasek and Blandino (2007) discuss the literature on treating the common cold. They found no evidence to support the use of echinacea or vitamin C during a cold. However, they did suggest that vitamin C used prophylactically may reduce duration and severity of the common cold and reduce incidence in people exposed to physical and environmental stresses.

Summary of findings from Simasek and Blandino (2007)

Table Source

A Cochrane review found that decongestants may help symptoms, however they should be used for a maximum of 7 days as they may make symptoms worse with prolonged use. Recent research has suggested Zinc may reduce duration of symptoms if used within the first 24 hours following onset. Cochrane reviews have found minimal evidence to support the use of garlic, humidified air or nasal saline. A review of Chinese Medicine found a high risk of bias in the research and did not support their usage for common colds.

There is some evidence to support the use of paracetamol or aspirin but a recent systematic review in the use of paracetamol was inconclusive. NSAIDs have been found to be effective in reducing pain but not other cold symptoms and have potential side effects and contra-indications. Medications combining paracetamol and decongestant or anti-histamine and decongestant appear to be effective but side effects of anti-histamines have been reported. As a result anti-histamines are not generally recommended in the treatment of common colds.

NHS choices provide straight forward advice of rest, drink fluids and eat healthily. As there appears to be minimal quality evidence of benefit from any over the counter medication then cost versus benefit needs to be considered in each case. Symptoms from cold vary so it may be best to treat based on the most troublesome symptom.

Return to sport

For many athletes the question isn't, how do I treat this cold? But rather when can I get back to training/ competing? There is some useful guidance from the literature on this but it's also worth asking if missing a week or 2 of training would really be that bad a thing. If you're in the off season with no competition on the immediate horizon a week of rest until symptoms settle might well be the most sensible course of action. However if, like me, you're mid marathon training, you'll want to return as soon as is safe to do so.

The most practical advice from the research is the 'neck check';

“If symptoms are above the neck (eg, runny nose, nasal congestion, or sore throat) and not associated with below the neck symptoms (eg, fever, malaise, severe cough, gastrointestinal symptoms), then the athlete may train at half intensity for 10 minutes. If symptoms do not worsen, then the workout can continue as tolerated. If the symptoms worsen in the initial 10-minute period, the workout should end and training should not resume until symptoms improve. Exercise should be delayed until all symptoms below the neck have resolved. When resuming training after recovering from an illness, the athlete should start at a moderate pace and gradually increase his or her training intensity to the pre-illness level over 1 to 2 days for every training day missed.” Metz (2003)

The aim of this approach us to reduce the likelihood of training with systemic symptoms (e.g. fever or muscle pain) or lower respiratory tract infection (e.g. a chest infection rather than a cold) as this has been associated with an increase risk of myocarditis. In addition training with a fever is to be avoided as fevers place a considerable strain on the body including impaired muscle strength, reduced pulmonary perfusion and increased oxygen and fluid requirements.

It's debatable whether the body can adapt positively to training stimulus while the immune system responds to an infection. There is also thought to be an 'open window' acutely after exercise where immune system protection is reduced. That said, 2 studies have demonstrated that continuing moderate exercise during cold did not increase symptom severity or duration (Weidner et al. 1998, Weidner and Schurr 2003).

Despite research findings whether your run or rest is likely to be determined by how you feel. Many of us will run with a minor sniffle but with a full on man-flu-megadeath-cold the only thing capable of running continuously is our nose! And yes ladies, “man flu” is worse for us men! Look a scientist says so!

On a practical note, colds do seem to follow a pattern with peak symptoms at day 3-4. It's probably best to avoid training in this period and consider returning as symptoms improve.

The Bigger Picture

It's important to ask yourself, why do I have this cold? Did your charming God-Daughter sneeze all over you, as in my case, or could it be due to overtraining? Research has identified a relationship between amount of exercise and risk of a cold. There appear to be a J-shaped curve, showing reduced risk with moderate exercise (versus no exercise) but highest risk with high levels of training;

J curve, described by Neiman (1994) [left] and demonstrated by Spence et al. (2007) [right]

If your cold is as a result of overtraining or a recent rapid increase in training volume or intensity then rest is arguably your best option. Think about your training schedule and consider if you're having enough rest and have the right mix of training volume, frequency and intensity. A lot of training adaptation is thought to occur during rest so it is a vital part of your training. There's more information in our article on training error and John Feeney discusses how to avoid overtraining here. In addition stress may play a part as it is known to effect immune response. It's potential role in upper respiratory tract infections is discussed by Cohen (1995).

Remember, no one else wants your cold so avoid training with others and take care to prevent passing it on to loved ones. There are also other causes of cold symptoms, such as influenza, glandular fever or pneumonia. If in doubt seek medical advice. The NHS choices website has a useful article on when to see your GP and how to prevent spreading your cold.

And finally…a light hearted poem I wrote on surviving man flu…

I hope you all stay cold free, I'm feeling better….time for a run I think…better get dressed first!