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September 18, 2020
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Returning to sports amid COVID-19: What PCPs need to know

Source/Disclosures
Disclosures: Jones reports no relevant financial disclosures.
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After prolonged breaks due to the COVID-19 pandemic, patients are returning to exercise and competitive sports.

“The situation remains very fluid and decisions to return to sport should be guided by evidence-based data and not politics,” Nathaniel Jones, MD, a primary care sports medicine specialist at Loyola Medicine, told Healio Primary Care. “Until an effective treatment and/or vaccine is available, we will likely see a back and forth of easing of restrictions based on local infection numbers.”

Quote from Jones on activity restrictions in COVID-19

This “back-and-forth” has already been observed, with some professional, collegiate and high school-level leagues reversing their decisions to cancel or postpone a season. For instance, the Big Ten conference announced that it would resume its football season in late October after initially canceling in hopes of resuming in Spring 2021.

Multiple professional medical societies, including the American College of Sports Medicine (ACSM) and the Hospital for Special Surgery (HSS) Sports Medicine Institute have released considerations and guidance on what to tell high-level athletes and average patients who are returning to recreational activity after prolonged breaks during the pandemic and after COVID-19 illness.

Resuming sports and exercise

In a call-to-action, researchers from ACSM provided physicians with physical activity recommendations for the average healthy person, rather than just for patients who are high-level athletes.

“The short- and long-term impact of inactivity negatively influences physical and mental health,” William O. Roberts, MD, MS, FACSM, co-author of the call-to-action and past ACSM president, said in a press release. “Physical activity is critical to health outcomes and an essential component of weathering the pandemic.”

In the paper, ACSM noted that risk factors for severe COVID-19 include obesity, hypertension, diabetes and physical inactivity. They explained that conditions like obesity and hypertension can “flourish” when efforts are not made to maintain fitness.

Therefore, ACSM recommends that physicians encourage healthy people to engage in moderate physical activity for 150 minutes to 300 minutes each week. In addition to staying in shape, ACSM said this activity can help patients maintain immune health and keep their body weight to recommended levels.

Jones said that athletes who took a break from physical activity “should engage in a period of exercise acclimatization, where they undergo a gradual return to activity.”

In a study published in the International Journal of Sports Medicine, researchers explained that restricted access to training may negatively impact physical attributes that protect against injury in sports. For instance, they noted that a 2011 shutdown of the National Football League led to a 4-fold increase in Achilles tendon ruptures in the 29 days after returning to competition and an increase in soft-tissue injuries throughout the subsequent season.

“It is important to consider strategies to mitigate losses in physical function and to develop appropriate reconditioning strategies,” Keith A. Strokes, MD, professor in the department for health at the University of Bath, and colleagues wrote.

Stokes and colleagues wrote that a preparation period of 6 weeks should be sufficient enough for most athletes to be ready to return to competition, but that this time frame “will ultimately depend on the length of governmental social distancing policies, which differ by country.”

Jones said that PCPs should not advise patients undergoing pre-season physicals against participating in sports. Instead, PCPs should remind patients about the importance of masking, physical distancing, frequent hand hygiene and engaging in outdoor activities when possible.

“The only restriction on activity would be based on an inability to social distance, especially without masks in an enclosed space,” Jones said. “If at all possible, outdoor exercise with social distancing would be ideal.”

If the weather is not suitable for outdoor activity, people should use spaces with good indoor ventilation and practice infection prevention measures.

“Otherwise, I encourage patients to choose physical activity that they enjoy and will be able to stick to,” Jones said.

Returning to sports after recovering from COVID-19

For patients who recovered from COVID-19, returning to physical activity is more difficult.

“I believe it’s important to emphasize the novelty of COVID-19, and that we are still learning on daily basis both the short- and long-term effects of the virus,” Jones said. “In early research, there is concern for possible long-term cardiac effects which could affect exercise tolerance.”

Therefore, Jones said that PCPs should consider having patients who are high-level athletes or who engage in intense physical activity undergo EKGs and other assessments before returning to exercise.

ACSM recommends that patients who contracted COVID-19 consult their PCP to determine whether they can safely return to exercise.

In its considerations for clinicians treating athletes with mile to moderate COVID-19, HSS stated that decisions on returning to physical activity should be guided by a body-system approach that involves the cardiac, pulmonary, hematologic, musculoskeletal and gastrointestinal systems.

HSS recommends that athletes with mild or moderate COVID-19 should not resume exercise if they have a persistent fever, dyspnea while resting, cough, palpitations or chest pains. The agency also stated that if patients who had COVID-19 develop these symptoms after resuming activity, they should talk to their physician.

In addition, if these patients have an underlying cardiovascular or pulmonary condition, they should discuss returning to exercise with a physician before resuming activity, even if they are asymptomatic.

According to HSS, patients with mild to moderate COVID-19 who are otherwise healthy can begin resuming physical activity at half intensity and volume after being asymptomatic for 7 days.

“For the average patient, a gradual, progressive return to activity is of vital importance, with the understanding that if any symptoms such as chest pain, shortness of breath, palpitations arise, further evaluation by the PCP should occur before continuation of activity,” Jones said.

References:

Big Ten. The Big Ten Conference Adopts Stringent Medical Protocols; Football Season to Resume October 23-24, 2020. https://bigten.org/news/2020/9/16/the-big-ten-conference-adopts-stringent-medical-protocols-football-season-to-resume-october-23-24-2020.aspx. Accessed September 16, 2020.

Denay KL, et al. Curr Sports Med Rep. 2020;doi:10.1249/JSR.0000000000000739.

PRNewswire. ACSM Publishes Call To Action Addressing COVID-19 And Return To Sports And Physical Activity. https://www.prnewswire.com/news-releases/acsm-publishes-call-to-action-addressing-covid-19-and-return-to-sports-and-physical-activity-301108524.html. Accessed September 16, 2020.

Metzl JD, et al. HSS J. 2020;doi:10.1007/s11420-020-09777-1.

Stokes K, et al. Int J Sports Med. 2020;doi:10.1055/a-1180-3692.