GUIDELINES FOR RETURN TO SPORT POST COVID-19 INFECTION

The World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic in 2020 and this has affected almost everyone in one way or another. A nationwide lockdown was the only way to control the spread of the infection in a densely populated country like India. Prolonged lockdown has made people physically and functionally inactive leading to deconditioning.

Many people were infected and recovered within a few weeks. However, a majority of the population experienced residual effects and unusual medical symptoms even 4 weeks after initial diagnosis of COVID. These post -COVID and long COVID effects (persisting 4weeks post COVID) makes the return to sport very tricky for COVID affected athletes.

Therefore, it is important to introduce guidelines for an injury free return to activities and improve the quality of living of people post COVID-19. A pre-participation medical & physical evaluation of the population preparing to get back to their physical activities should be performed. The aim of the evaluation is to identify any systemic abnormalities consisting of cardiovascular, pulmonary & physical complications, injury prevention and to initiate a safe and progressive return to play protocol.

Possible complications after recovering from COVID-19 Infection:

A. Cardiovascular complications

Myocarditis is one of the leading causes of medical emergencies under 35 years old athletes. Experts believe that exercising while infected with the virus increases the risk of developing myocarditis as the immunity is low. There is a risk of developing myocarditis post infection for 8-12 weeks.

Early symptoms are chest pain, rapid or abnormal heart beats and shortness of breath. People having mild cases of myocarditis might remain asymptomatic.[1]

Athletes frequently present with non- specific symptoms such as fatigue, malaise, reduced performance, muscle soreness or increased resting heart rate, which often gets misinterpreted in context of other differential diagnosis e.g overtraining, depression or psychosomatic disorders. As soon as the athlete presents with chest pain or tightness or breathlessness while exercising, immediate cardiac assessment should be done to prevent an emergency. [4]

Assessment may include:

1. Electrocardiogram (ECG)
2. Cardiac biomarkers (e.g., high sensitivity troponin)
3. Echocardiogram

Heart Attack: COVID-19 is an inflammatory disease. [1] It produces inflammation in the blood vessels, which makes the blood cells clump up and form clots. The clots block the tiny blood vessels in the heart muscles, causing heart attack. People who have underlying diabetes, high blood pressure are more vulnerable, hence should be more cautious.[4]

Plan of action:

• Every individual should be screened for cardiac abnormalities post COVID as myocarditis can go undetected in asymptomatic populations or people who had mild symptoms. It is advisable to undertake 12 lead ECG and Echocardiogram in athletes post COVID infection to diagnose any underlying occult heart conditions.
• Constant monitoring for symptoms like chest pain, fatigue, shortness of breath not relating with the intensity of exercise should be done while returning to physical activity.
• Emphasis on following a progressive return to activities program.

B. Pulmonary Complications

Pneumonia associated with COVID-19 infection can cause irreversible damage to the air sacs (alveoli) in the lungs, the resulting scar tissue can lead to long-standing breathing problems. Guidelines by British thoracic society recommend chest radiograph 3months after discharge from hospital post COVID infection and pulmonary function test.

Persistent Breathlessness: Athletes who have persistent dyspnea for more than 6 weeks should get evaluated for myocarditis, further pulmonary evaluations might be done to find out the cause.[1]

Asthma: Patients may develop asthma or if the asthma gets worsened by COVID-19, long- term bronchodilation therapy is recommended as per physician advice. [1]

Acute respiratory distress syndrome secondary to COVID-19 is a substantial risk factor of death in athletes.

Plan of action:

• Prior to beginning the return to activities, if there are significant respiratory symptoms (cough, breathlessness or asthmatic episodes etc), then pulmonary function test and pulmonologist clearance to be consideredto rule out pulmonary complications.
• Functional assessment: 6-minute walk or 12-minute walk test, one- minute sit to stand, Kasch pulse recovery, get up and go test for older people should be done. Cardiopulmonary exercise testing may be performed for elite athletes.
• Monitor for symptoms like chest congestion, cough, breathlessness, wheezing etc.

C. Musculoskeletal Complications

Detraining: is the loss of physiological performance gains. Prolonged inactivity is the reason for decline in mean maximum oxygen uptake, which is an indication of detraining. [2]

Fatigue: Feeling tired all the time, not relieved by sleep or rest. Fatigue develops because of prolonged inactivity of muscles, the muscles need time to rebuild their strength. [2]

Reduced Performance: because of reduced energy levels, athletes are not able to perform optimally.

Reduced Strength: Decrease in muscle mass and inflammation in the body after COVID-19 infection.

All the above mentioned complications lead to biomechanical changes in the musculoskeletal system, which predisposes the athlete to injury. Compensatory mechanisms develop in the body due to lack of strength and proprioception, hindering the performance of the athlete.

Plan of action:

• Consult your physiotherapist and get the musculoskeletal screening and initiate preventive rehabilitation
• Start with bodyweight exercises instead of using weights straightaway.
• Work on mobility and flexibility of muscles and range of motion of joints.
• Progressively increase the load on ligaments and joints by increasing the frequency of exercise first, followed by increasing the duration and lastly increasing the intensity of the exercises.
• Maintain optimal hydration and nutrition and quality of sleep.
• Progressive conditioning for endurance training

D. Neuromuscular Complications

Myalgia: Muscle pain caused by viral infection or inflammatory conditions which may involve a localised area or a group of muscles.

Neuropathy: SARS- COV-2 has higher affinity for angiotensin converting receptor-2, which is expressed on endothelial cells and neurons. [3]

Plan of action:

• Proprioception training should be initiated to increase awareness of the nervous system.[2]
• Focus on the breath to bring the body in a state of rest and digest.
• Motor control training to improve neuromuscular coordination.

Key considerations for progressive return to play:

 The athlete must be able to complete activities of daily living and walk 500m continuously without excessive fatigue or breathlessness.

• They should take at least 10 days rest and be 7 days symptomfree before starting training.
• Athletes belonging to less aerobically intense sports like golf may recover quickly. Some athletes might take over 3 to 6 weeks to recover.
• Keep monitoring the resting heart rate, rated perceived exertion, sleep, stress, fatigue and muscle soreness and injury- psychological readiness to return to sport.

 

 

 

Disclaimer: The above mentioned information is based on the expert opinion and scientific literature as there is lack research publication on COVID-19 infections and return to sports.

References: 

1. Francis G O’ Connor, MD, MPH, FACSM, M Alaric Franzos, MD, MPH, FACC, FACP( 2021, apr29). COVID-19: Return to play or strenuous activity following infection.
2. Caterisano, A, Decker, D, Snyder, B, Feigenbaum, M, Glass, R, House, P, Sharp, C, Waller, M, and Witherspoon, Z. 2019. CSCCa and NSCA Joint Consensus Guidelines for Transition Periods. Strength and Conditioning Journal, 41(3), 1-23.
3. Paliwal, V. K., Garg, R. K., Gupta, A., & Tejan, N. (2020). Neuromuscular presentations in patients with COVID-19. Neurological sciences: official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 41(11), 3039–3056. https://doi.org/10.1007/s10072-020-04708-8
4. Kulkarni, S., Jenner, B. L., & Wilkinson, I. (2020). COVID-19 and hypertension. Journal of the Renin-Angiotensin-Aldosterone System. https://doi.org/10.1177/1470320320927851

Compiled by:

 Dr. Akanksha Saini (PT), Dr. Srikanth Narayanaswamy, Dr. Arun Kumar Rawal (PT)

YOS Sports Health Specialists,

Bangalore

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