A comprehensive interdisciplinary view at the Return to Sport after COVID-19 infection

Czech version

Authors: Filip Hrdlička ^1,2; Jaroslav Větvička ^3,4; Vendula Bendová ¹; Jiří Beran ⁵; Bohuslav Bunganič ⁶; Petr Krejčí st. ^4,6; Lumír Kroček ³; Václav Monhart ⁶; Jan Mühlfeit ⁷; Přemysl Rákosník ⁸; Pavel Stejskal ⁹; Michal Šafář ¹⁰; Josef Veselka ¹¹; Libor Vítek ¹²
Authors‘ workplace: 3. lékařská fakulta, Univerzita Karlova, Praha ¹; SK Slavia Praha – fotbal, a. s. ²; Centrum zdravotnického zabezpečení sportovní reprezentace z. s. ³; Lékařská komise, Český olympijský výbor ⁴; Institut postgraduálního vzdělávání ve zdravotnictví ⁵; Interní klinika, 1. LF UK a ÚVN, Praha ⁶; INSEAD, Fontainebleau, France ⁷; Alergologie, Plicní, Praha ⁸; Fakulta sportovních studií, Masarykova Univerzita, Brno ⁹; Fakulta tělesné kultury, Univerzita Palackého, Olomouc ¹⁰; Kardiologická klinika 2. LF UK a FN Motol, Praha ¹¹; IV. interní klinika a Ústav lékařské biochemie a laboratorní diagnostiky, VFN a 1. LF UK, Praha ¹²
Published in: Vnitř Lék 2021; 67(1): 14-21
Category:

Overview

The COVID-19 pandemic has affected the whole world. It applies to all age and social groups. It is no different with athletes. So far, we cannot say for sure what the long-term consequences of SARS-CoV-2 infection are. Recent evidence, however, suggests that we should be very careful when returning to sports. After self-isolation, the athlete should undergo a Preparticipation Physical Examination and then pay attention to the gradual dosing of the load to prevent complications. Lifestyle changes and care for the mental health of athletes are also necessary during the illness.

In this work, we present a comprehensive methodology for returning to sports after COVID-19 for medical and coaching teams caring for athletes divided according to the course of the disease. In scientific literature, similar algorithms are called "Return to Play" or "Return to Sport". Creating an exact algorithm can make the Return to Play process more efficient and safer. However, increased attention still needs to be paid to certain organ systems and specific symptoms that could indicate long-term consequences to the new type of coronavirus.

Keywords:

algorithm – COVID-19 – guideline – infection – preparticipation physical evaluation – return to play – return to sport

Sources

1. Gandhi RT, Lynch JB, Rio CD. Mild or Moderate COVID-19. New England Journal of Medicine. 2020; 383(18): 1757–1766. doi:10.1056/nejmcp2009249.

2. Al -Sadeq DW, Nasrallah GK. The incidence of the novel coronavirus SARS -CoV-2 among asymptomatic patients: A systematic review. International Journal of Infectious Diseases. 2020; 98: 372–380. doi:10.1016/j.ijid.2020. 06. 098.

3. Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS -CoV-2; COVID-19): A systematic review and meta -analysis of 148 studies from 9 countries. Plos One. 2020; 15(6). doi: 10.1371/journal.pone.0234765.

4. Wilson MG, Hull JH, Rogers J, et al. Cardiorespiratory considerations for return -to -play in elite athletes after COVID-19 infection: a practical guide for sport and exercise medicine physicians. British Journal of Sports Medicine. 2020; 54(19): 1157–1161. doi: 10.1136/bjsports-2020-102710.

5. The Football Association. COVID-19 Safeguarding Risk Assessment Guidance. www.thefa.com. https://www.thefa.com/-/media/thefacom -new/files/get -involved/2020/COVID19-risk -assessment -guidance -and -template.ashx. Published September 17, 2020. Accessed October 29, 2020.

6. Chun JY, Baek G, Kim Y. Transmission onset distribution of COVID-19. International Journal of Infectious Diseases. 2020; 99: 403–407. doi:10.1016/j.ijid.2020. 07. 075.

7. Ren X, Li Y, Yang X, et al. Evidence for pre-symptomatic transmission of coronavirus disease 2019 (COVID-19) in China. Influenza and Other Respiratory Viruses. 2020. doi: 10.1111/irv.12787.

8. He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and transmissibility of COVID-19. Nature Medicine. 2020; 26(5): 672–675. doi: 10.1038/s41591-020-0869-5.

9. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet. 2020; 395(10223): 497–506. doi: 10.1016/s0140-6736(20)30183-5.

10. Kim JH, Levine BD, Phelan D, et al. Coronavirus Disease 2019 and the Athletic Heart. JAMA Cardiology. 2020. doi: 10.1001/jamacardio.2020.5890.

11. Verwoert GC, Vries STD, Bijsterveld N, et al. Return to sports after COVID-19: a position paper from the Dutch Sports Cardiology Section of the Netherlands Society of Cardiology. Netherlands Heart Journal. 2020; 28(7–8): 391–395. doi: 10.1007/s12471-020-01469-z.

12. Carfì A, Bernabei R, Landi F. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020; 324(6): 603. doi:10.1001/jama.2020.12603.

13. Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiology. 2020. doi: 10.1001/jamacardio.2020.3557.

14. Rajpal S, Tong MS, Borchers J, et al. Cardiovascular Magnetic Resonance Findings in Competitive Athletes Recovering From COVID-19 Infection. JAMA Cardiology. 2020. doi:10.1001/jamacardio.2020.4916.

15. Rubin R. As Their Numbers Grow, COVID-19 „Long Haulers“ Stump Experts. Jama. 2020;324(14):1381. doi:10.1001/jama.2020.17709

16. Ahmadian E, Khatibi SMH, Soofiyani SR, et al. COVID-19 and kidney injury: Pathophysiology and molecular mechanisms. Reviews in Medical Virology. 2020. doi: 10.1002/rmv.2176.

17. Beauchamp LC, Finkelstein DI, Bush AI, Evans AH, Barnham KJ. Parkinsonism as a Third Wave of the COVID-19 Pandemic? Journal of Parkinson’s Disease. 2020; 10(4): 1343–1353. doi: 10.3233/jpd-202211.

18. Ayres JS. A metabolic handbook for the COVID-19 pandemic. Nature Metabolism. 2020; 2(7): 572–585. doi: 10.1038/s42255-020-0237-2.

19. Kümpel P, Holub M, Roháčová H, Plíšek S. Doporučený postup SIL ČLS JEP léčby pacientů s onemocněním COVID-19. Společnost infekčního lékařství ČLS JEP. https://www. infekce.cz/zprava20-93.htm. Published August 28, 2020. Accessed November 1, 2020.

20. Beran J, Šalapová E, Špajdel M. Inosine pranobex is safe and effective for the treatment of subjects with confirmed acute respiratory viral infections: analysis and subgroup analysis from a Phase 4, randomised, placebo -controlled, double -blind study. BMC Infectious Diseases. 2016; 16(1). doi: 10.1186/s12879-016-1965-5.

21. Baladia E, Pizarro AB, Ortiz -Muñoz L, Rada G. Vitamin C for COVID-19: A living systematic review. Medwave. 2020; 20(06). doi: 10.5867/medwave.2020. 06. 7978.

22. Elliott N, Martin R, Heron N, Elliott J, Grimstead D, Biswas A. Infographic. Graduated return to play guidance following COVID-19 infection. British Journal of Sports Medicine. 2020; 54(19): 1174–1175. doi: 10.1136/bjsports-2020-102637.

23. Phelan D, Kim JH, Chung EH. A Game Plan for the Resumption of Sport and Exercise After Coronavirus Disease 2019 (COVID-19) Infection. JAMA Cardiology. 2020; 5(10): 1085. doi:10.1001/jamacardio.2020.2136.

24. Schellhorn P, Klingel K, Burgstahler C. Return to sports after COVID-19 infection. European Heart Journal. 2020. doi: 10.1093/eurheartj/ehaa448.

25. Hull JH, Lloyd JK, Cooper BG. Lung function testing in the COVID-19 endemic. The Lancet Respiratory Medicine. 2020; 8(7): 666–667. doi:10.1016/s2213-2600(20)30246-0.

26. Löllgen H, Bachl N, Papadopoulou T, et al. Recommendations for return to sport during the SARS -CoV-2 pandemic. BMJ Open Sport & Exercise Medicine. 2020; 6(1). doi: 10.1136/ bmjsem-2020-000858.

27. Henry BM, Oliveira MHSD, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta -analysis. Clinical Chemistry and Laboratory Medicine (CCLM). 2020; 58(7): 1021–1028. doi: 10.1515/cclm-2020-0369.

28. Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis. Circulation. 2015; 132(22). doi: 10.1161/ cir.0000000000000239.

29. Malone S, Owen A, Newton M, Mendes B, Collins KD, Gabbett TJ. The acute:chonic workload ratio in relation to injury risk in professional soccer. Journal of Science and Medicine in Sport. 2017; 20(6): 561–565. doi: 10.1016/j.jsams.2016. 10. 014.

30. Murray NB, Gabbett TJ, Townshend AD, Blanch P. Calculating acute:chronic workload ratios using exponentially weighted moving averages provides a more sensitive indicator of injury likelihood than rolling averages. British Journal of Sports Medicine. 2016; 51(9): 749–754. doi: 10.1136/bjsports-2016-097152.

31. Gabbett TJ. The training—injury prevention paradox: should athletes be training smarter and harder? British Journal of Sports Medicine. 2016; 50(5): 273–280. doi: 10.1136/bjsports-2015-095788.

32. Gabbett TJ, Nielsen RO, Bertelsen ML, et al. In pursuit of the ‘Unbreakable’ Athlete: what is the role of moderating factors and circular causation? British Journal of Sports Medicine. 2018; 53(7): 394–395. doi:10.1136/bjsports-2018-099995.

33. Gabbett TJ. Debunking the myths about training load, injury and performance: empirical evidence, hot topics and recommendations for practitioners. British Journal of Sports Medicine. 2018; 54(1): 58–66. doi: 10.1136/bjsports-2018-099784.

34. Gabbett TJ. How Much? How Fast? How Soon? Three Simple Concepts for Progressing Training Loads to Minimize Injury Risk and Enhance Performance. Journal of Orthopaedic & Sports Physical Therapy. 2020; 50(10): 570–573. doi:10.2519/jospt.2020.9256.

35. Schwellnus M, Soligard T, Alonso J -M, et al. How much is too much? (Part 2) International Olympic Committee consensus statement on load in sport and risk of illness. British Journal of Sports Medicine. 2016; 50(17): 1043–1052. doi: 10.1136/bjsports-2016-096572.

36. Soligard T, Schwellnus M, Alonso J -M, et al. How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury. British Journal of Sports Medicine. 2016; 50(17): 1030–1041. doi:10.1136/bjsports-2016-096581.

37. Windt J, Gabbett TJ, Ferris D, Khan KM. Training load -injury paradox: is greater preseason participation associated with lower in -season injury risk in elite rugby league players? British Journal of Sports Medicine. 2016; 51(8): 645–650. doi: 10.1136/bjsports-2016-095973.

38. Windt J, Gabbett TJ. How do training and competition workloads relate to injury? The workload—injury aetiology model. British Journal of Sports Medicine. 2016; 51(5): 428– 435. doi: 10.1136/bjsports-2016-096040.

39. Stokes KA, Jones B, Bennett M, et al. Returning to Play after Prolonged Training Restrictions in Professional Collision Sports. International Journal of Sports Medicine. 2020. doi: 10.1055/a-1180-3692.

40. Hoang A, Chorath K, Moreira A, et al. COVID-19 in 7780 pediatric patients: A systematic review. EClinicalMedicine. 2020; 24: 100433. doi:10.1016/j.eclinm.2020.100433.

41. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatrica. 2020; 109(6): 1088–1095. doi: 10.1111/apa.15270.

42. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics. 2020; 145(6). doi: 10.1542/peds.2020-0702.

43. Cruz AT, Zeichner SL. COVID-19 in Children: Initial Characterization of the Pediatric Disease. Pediatrics. 2020; 145(6). doi: 10.1542/peds.2020-0834.

44. Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. New England Journal of Medicine. 2020; 383(4): 334–346. doi: 10.1056/nejmoa2021680.

45. Yonker LM, Neilan AM, Bartsch Y, et al. Pediatric Severe Acute Respiratory Syndrome Coronavirus 2 (SARS -CoV-2): Clinical Presentation, Infectivity, and Immune Responses. The Journal of Pediatrics. 2020. doi: 10.1016/j.jpeds.2020. 08. 037.

46. Belhadjer Z, Méot M, Bajolle F, et al. Acute Heart Failure in Multisystem Inflammatory Syndrome in Children in the Context of Global SARS -CoV-2 Pandemic. Circulation. 2020; 142(5): 429-436. doi: 10.1161/circulationaha.120.048360.

47. Dean PN, Jackson LB, Paridon SM. Returning To Play After Coronavirus Infection: Pediatric Cardiologists‘ Perspective. American College of Cardiology. https://www.acc.org/latest -in -cardiology/articles/2020/07/13/13/37/returning -to -play -after -coronavirus -infection. Accessed October 19, 2020.

48. Canter CE, Simpson KE. Diagnosis and Treatment of Myocarditis in Children in the Current Era. Circulation. 2014 ;129(1): 115-128. doi: 10.1161/circulationaha.113.001372

49. Calder PC, Kew S. The immune system: a target for functional foods? British Journal of Nutrition. 2002; 88(S2). doi: 10.1079/bjn2002682.

50. Nieman DC, Bishop NC. Nutritional strategies to counter stress to the immune system in athletes, with special reference to football. Journal of Sports Sciences. 2006; 24(7): 763– 772. doi:10.1080/02640410500482982.

51. Singer P, Shapiro H. Enteral omega-3 in acute respiratory distress syndrome. Current Opinion in Clinical Nutrition and Metabolic Care. 2009; 12(2): 123–128. doi: 10.1097/ mco.0b013e328322e70f.

52. Grant WB, Lahore H, Mcdonnell SL, et al. Evidence That Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. 2020. doi: 10.20944/ preprints202003.0235.v2.

53. Yousfi N, Bragazzi NL, Briki W, Zmijewski P, Chamari K. The COVID-19 pandemic: how to maintain a healthy immunesystem during the lockdown – a multidisciplinary approach withspecial focus on athletes. Biology of Sport. 2020; 37(3): 211–216. doi: 10.5114/biolsport.2020.95125.

54. Fronso SD, Costa S, Montesano C, et al. The effects of COVID-19 pandemic on perceived stress and psychobiosocial states in Italian athletes. International Journal of Sport and Exercise Psychology. 2020: 1–13. doi:10.1080/1612197x.2020.1802612.

55. Vaughan RS, Edwards EJ, Macintyre TE. Mental Health Measurement in a Post COVID-19 World: Psychometric Properties and Invariance of the DASS-21 in Athletes and Non -athletes. Frontiers in Psychology. 2020; 11. doi: 10.3389/fpsyg.2020.590559.

56. Andreou E, Alexopoulos EC, Lionis C, et al. Perceived Stress Scale: Reliability and Validity Study in Greece. International Journal of Environmental Research and Public Health. 2011; 8(8): 3287–3298. doi: 10.3390/ijerph8083287.

57. Brabcová DB, Kohout J. Psychometrické ověření české verze Škály vnímaného stresu. E -psychologie. 2018; 12(1): 37–52. doi:10.29364/epsy.311.

58. Schinke R, Papaioannou A, Maher C, et al. Sport psychology services to professional athletes: working through COVID-19. International Journal of Sport and Exercise Psychology. 2020; 18(4): 409–413. doi: 10.1080/1612197x.2020.1766182.

59. Samuel RD, Tenenbaum G, Galily Y. The 2020 Coronavirus Pandemic as a Change -Event in Sport Performers’ Careers: Conceptual and Applied Practice Considerations. Frontiers in Psychology. 2020; 11. doi: 10.3389/fpsyg.2020.567966.

60. Lafferty M, Breslin G, Britton D, Butt J, Lowry R, Morris R, Barker J, Slater M, & Eubank M. Supporting Youth Athletes During COVID-19: Advice for Parents and Guardians: Supporting Youth Athletes During COVID-19. British Psychological Society. https://www.bps.org.uk/sites/www. bps.org.uk/files/Policy/Policy%20-%20Files/Supporting%20youth%20athletes%20during%20 COVID-19.pdf Published July 07, 2020. Accesed November 2, 2020.

61. Schinke R, Papaioannou A, Henriksen K, Si G, Zhang L, Haberl P. Sport psychology services to high performance athletes during COVID-19. International Journal of Sport and Exercise Psychology. 2020; 18(3): 269–272. doi:10.1080/1612197x.2020.1754616.

62. Rio CD, Collins LF, Malani P. Long -term Health Consequences of COVID-19. Jama. 2020; 324(17): 1723. doi:10.1001/jama.2020.19719.