The SARS-CoV-2 pandemic has provided a constant challenge to sport with varying protocols and regulations across the globe.
As the pandemic progressed, additional research was published describing the typical presentation of SARS-CoV-2 infection, the impact on athletes and more detailed outcomes from cardiac and respiratory assessment.
In elite sport, one of the biggest challenges is keeping care patient-centred yet advising coaching colleagues on relevant medical information, within the boundaries of patient confidentiality. The creation of an easy-to-follow graduated return to play (GRTP) plan helps inform all involved in the care and support of an athlete. It provides easily accessible guidance on what would be deemed normal to expect in the resumption of physical activity and training reflecting case management experience and the relevant published research. It has been our experience that sharing the GRTP with athletes and non-clinical colleagues has created greater understanding on how to manage novel respiratory infections in elite sport settings.
We continue to learn as the pandemic ebbs and flows across the globe. Published evidence from our elite athlete cohort 2 suggests that COVID-positive athletes who are either asymptomatic or only experience ‘above neck’ symptoms (e.g. cough, loss of taste or smell) tend to recover more quickly and thus may be able to safely resume full training quicker than athletes who experience ‘below neck’ or more systemic symptoms (including, but not limited to: fever, shortness of breath, chest pains or palpitations). In addition, other studies have shown that cardiac complications arising from SARS CoV-2 infection are usually associated with the presence of symptoms that signpost or localise to the lower chest during the acute illness and with ongoing lower chest symptoms and abnormal cardiovascular findings (e.g. increased HR) on return to exercise. We were keen, with both the original GRTP and these updated protocols, to highlight symptoms of possible concern that should be brought to the attention of the supervising clinician (figure 2).
Before commencing this updated GRTP protocol (figure 1), all athletes must be able to complete all activities of daily living without excessive fatigue and/or breathlessness and be able to walk on the flat without getting breathless. This guidance is not appropriate for athletes who have been hospitalised or required acute emergency care; in this scenario clinician led case-by case GRTP planning is recommended.
For athletes who experience any ‘below neck’ symptoms, their GRTP protocol starts at STAGE 1 with a minimum of 10 days to completion. It involves complete rest for at least 5 days to optimise the initial recovery and protect the cardio-respiratory system. After this initial 5 days of rest, if symptoms are improving satisfactorily, and the supervising clinician approves, the GRTP can continue into STAGE 2 (a minimum of 48hrs of light activity), then progresses through STAGE 3 over a minimum of 48hrs. As such, STAGE 4 (normal training resumption) could, in theory, be achieved as soon as day 10, and then STAGE 5 (return to competition) thereafter, at the discretion of the supervising clinician and wider support team.
For athletes who have mild above neck symptoms only it is recommended that the GRTP has a minimum of 5 days to completion. Their GRTP protocol starts at STAGE 2 (i.e. an athlete can continue to undertake light activity). After 48hrs, this progresses through STAGE 3 over a minimum of another 48hrs. As such, STAGE 4 (normal training resumption) could, in theory, be achieved as soon as day 5, and then STAGE 5 (return to competition) thereafter. The mandatory self-isolation period- should be fully adhered to (e.g. even if STAGE 4 commences before the end of the self-isolation), and all of these progressions are at the discretion of the supervising clinician and wider support team. Athletes that test positive yet are asymptomatic should start at STAGE 3 and be closely monitored throughout the GRTP for the development of signs (HR, HRV, RPE etc) and symptoms that may be associated with Covid-19. If they develop symptoms, they should return to STAGE 1 or STAGE 2 depending on clinical presentation.
In all cases, if any of the ‘red flag’ symptoms manifest (figure 2) or if the athlete or anyone else supporting them has any concerns, the supervising clinician should be consulted immediately, and the GRTP should be ceased. A questionnaire can be used to formally document the absence of any warning features (see figure 3 as an example). Some people take over 3 weeks to recover and return to full training, and some mild symptoms may also persist (e.g. mild breathlessness, fatigue, reduced or altered smell / taste), which may extend the return to training process.
