Clinical Guidelines for Return to Play Following COVID-19 Infection

Abstract

The emergence of COVID-19 has impacted all areas of clinical practice, and to those working with elite athletes pose some unique challenges. Return to play (RTP) following an illness has received considerable research interest over the years, yet COVID-19 has forced consideration of strategies to govern safe RTP from a novel virus for which many unknowns remain. Cardiopulmonary complications seen with COVID-19 infection require careful consideration and thorough clinical evaluation to ensure RTP is conducted in a safe manner. Several advisory panels have convened and set forth guidelines to govern RTP for athletes following COVID-19 infection. This review will assimilate the recommendations of these various advisory panels and attempt to consolidate a practical comprehensive set of recommendations clinicians can call upon to minimize potential harms associated with athletic performance following COVID-19 infection.

Introduction

Working in primary care, naturopathic doctors encounter athletic patients who have experienced a COVID-19 infection. Patients that compete in a sport and/or exercise with the intent of improving their performance can be defined as athletes. Vasiliadis and Boka (2021) defined athletes as those fulfilling the following three criteria: intent of the exercise, participation in sport events, and registration in a sports federation. For the purposes of this article, the last criterion is not recommended to define an athlete as it excludes patients that may require guidance about return to exercise post infection. Several publications exist suggesting a variety of guidelines for return to play (RTP) protocols after COVID-19 infection (Gluckman et al 2022, Elliott et al 2020, Halle et al 2021, Nieß et al 2020, Vasiliadis and Boka 2021). The aim of this article is to assist clinicians in simplifying the variety of recommendations into a concise, easily applied clinical tool.

Return to Play (RTP) Guidelines

In the current guidelines for RTP protocols post COVID-19 infection in athletes, the biggest variability is in the objective measurements (lab testing, imaging, and other investigations) that are recommended prior to graded return to sport. Earlier publications suggest more investigations including cardiac magnetic resonance imaging (CMR), electrocardiogram (ECG), and echocardiography, likely due to the paucity of available information about severe complications arising from mild or moderate COVID-19 infection (Halle et al 2021, Vasiliadis and Boka 2021). Later publications propose fewer objective investigations to guide RTP protocols (Casasco et al 2022, Gluckman et al 2022) likely due to the relatively unlikely occurrence of severe complications such as myocarditis in athletes not experiencing cardiac symptoms (Modica et al 2022). In a systematic review and meta-analysis of available literature studying athletes recovered from COVID-19, the event rates for myocarditis in the athletic population ranged from one to 4% (Modica et al 2022).

Athletes with severe COVID-19 infection requiring hospitalization should be followed by a multidisciplinary team to determine individualized RTP with exercise rehabilitation specialists (Casasco et al 2022, Gluckman et al 2022, Vasiliadis and Boka 2021) and are beyond the scope of this document. Patients with self-limiting COVID-19 infection, including those who are asymptomatic, or have mild or moderate symptoms without cardiac involvement, are included in the guidelines proposed.

Upon testing positive for COVID-19, an athlete should rest until symptoms resolve (Elliott et al 2020). The British Journal of Sports Medicine (BJSM) infographic for RTP, originally published in October 2020, recommends a minimum of 10 days rest (Elliott et al 2020), however updated guidelines indicate that athletes with mild or moderate non-cardiopulmonary symptoms can resume exercise after their symptoms resolve (Gluckman et al 2022). Another set of guidelines recommends the introduction of low-intensity exercise 72 hours after the resolution of symptoms, citing that high-intensity exercise may increase the risk of upper respiratory tract infection and/or complications while low-to-moderate intensity exercise may improve immune function (Vasiliadis and Boka 2021). The authors did not define high or low-intensity exercise based on an objective measure, making this guideline difficult to apply practically. The BJSM infographic recommends the athlete be able to participate in the activities of daily living (e.g. walk 500m) without aggravating respiratory symptoms or causing excessive fatigue prior to initiating their graduated RTP protocol. They also clearly define their RTP recommendations with objective heart rate measures (Elliott et al 2020). In an asymptomatic athlete who has tested positive for COVID-19, the guideline is exercise abstinence for three days (Gluckman et al 2022). One important consideration in RTP guidelines is that longer periods of physical inactivity may increase the risk of injury (Gluckman et al 2022, Puga et al 2022). Guidelines need to balance cardiopulmonary event risk and injury prevention.

The overall risk of myocarditis following COVID-19 infection in otherwise healthy athletes appears to be relatively low with studies citing an event rate of one to 4% (Modica et al 2022). A large multicentre Italian study of 4000 athletes who tested positive for COVID-19 from a variety of sport disciplines included objective cardiovascular measurements in their RTP protocol (Casasco et al 2022). This study used the NIH classification for COVID-19 patients, separating athletes into three categories by severity of disease. Professional athletes were included in the most severe category regardless of symptomatology and received more investigations than non-professional athletes. Mildly symptomatic patients received a 12-lead ECG at rest and during maximal exercise with continuous O2 saturation monitoring and an echocardiogram. Moderately symptomatic individuals and those requiring hospitalization received the previous investigations in addition to a 24 hour ECG on a training day and CMR. Professional athletes and those with severe/critical disease received all previously mentioned investigations in addition to a cardiopulmonary exercise test. Additional testing was on a case-by-case basis determined by the sports medicine doctors and included but was not limited to pulmonary imaging and CMR. All athletes in the study received blood work including complete blood count, liver function tests, kidney function tests, lactate dehydrogenase, clotting factors, protein electrophoresis, d-dimer, and ferritin testing. With this extensive monitoring of a variety of athletes, cardiac complications were very rare: myocarditis was detected in 0.12% of the total population, and a variety of arrhythmic events were the most common finding (Casasco et al 2022). The authors concluded that safe RTP may include an ECG-monitored exercise test, but they do not propose a schedule for returning to exercise (Casasco et al 2022).

Other guidelines also recommend objective screening measures in athletes returning to exercise post-infection including ECG, c-reactive protein (CRP), creatinine, complete blood count, and creatine kinase (Halle et al 2021). If all findings are normal, the authors suggest returning to exercise gradually after two weeks of complete clinical recovery. The graded return should be two to three days for each training day lost to illness (Halle et al 2021). Practically, this guideline agrees with both the American College of Cardiology Consensus Statement and the Infographic published by the BJSM (Gluckman et al 2022, Elliott et al 2020); In the case of an athlete who is symptomatic with COVID-19 infection for five to seven days, a graduated RTP would be approximately 10-15 days (Halle et al 2021).

Adverse cardiac event outcomes appear to be relatively low in athletes in their recovery from COVID-19 infection (Casasco et al 2022, Modica et al 2022). A study looking at total injuries in the 2020 National Football League Season showed muscular-skeletal injury risk may increase following a reduction in training time (Puga et al 2022). A study based on a survey of competitive runners suggests that runners that reported having COVID-19 have a slightly higher incidence of injury compared to those that did not have COVID-19 (Toresdahl et al 2022). It is unclear if COVID-19 infection causes pathophysiologic changes that increase the likelihood of injury, but it is possible that reduction in training load combined with lack of graduated RTP may be a risk factor for injury (Puga et al 2022, Toresdahl et al 2022).

A graduated RTP protocol is recommended for all athletes suffering a COVID-19 infection, regardless of severity of symptoms. To pool and summarize the available evidence, the following schedule is recommended:

• Initial Rest: Minimum five days, until complete symptom resolution

1. Athletes must tolerate activities of daily living without excessive fatigue or respiratory symptoms prior to moving to step B
2. Athletes tolerating activities of daily living may integrate range of motion activities into their daily routine
3. Athletes experiencing cardiac symptoms should be referred to undergo screening including ECG

• Introduction of Exercise: Duration 15 minutes, less than 70% of heart rate maximum

1. This may include sport specific drills and skills
2. Athletes should stay at this phase for a minimum of one day
3. Athletes must not experience any excessive fatigue or return of any symptoms following their effort prior to moving to the next phase

• Increased Intensity and Duration: 30 minutes of activity, less than 80% of heart rate maximum

1. May include normal training activities, but duration and intensity remain limited
2. Minimum two days
3. Athletes must not experience any excessive fatigue or return of any symptoms following their effort prior to moving to the next phase

• Increased Duration: 45 minutes, less than 80% of heart rate maximum

1. May include normal training activities, but duration and intensity remain limited
2. Minimum two days
3. Athletes must not experience any excessive fatigue or return of any symptoms following their effort prior to moving to the next phase

• Resume all normal training activities

Discussion

The above suggested protocol is a minimum of 10 days but may be longer depending on an individual athlete’s progression. Athletes should be educated about the possibility of increased injury risk following a period of convalescence as well as the importance of seeking care for any cardiac symptoms. Clinicians can reassure athletes that adverse cardiac event risks are relatively low and that a graduated RTP may reduce the risk of injury and/or other adverse events. This guideline is limited by the evolving understanding of COVID-19 and possibly long-term consequences of this relatively novel virus. As more data emerge there will likely be changes to our RTP protocols. Conservative and graduated RTP is most responsible to mitigate injury risk, despite the relatively low risk of cardiac complications of COVID-19.

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