COVID-19 Return to Play Guidelines
The COVID-19 pandemic has resulted in the postponement or cancellation of sports and athletics across the world. As we enter 6 months since the beginning of the first outbreaks, some professional sports are starting to return with strict protocols to prevent COVID-19 infections among players and staff.
The NBA and NHL had both adopted an isolation/bubble strategy for the remaining playoff teams while the NFL has focused on testing and isolating players from non-essential team personnel, media and fans.
Many colleges and universities have deferred the 2020 fall sports season until the spring of 2021 in hopes that a COVID-19 vaccine will be available before then. These institutions are also struggling with high rates of positive COVID-19 test results as students return to campus.
Most high schools have also deferred or cancelled the fall sports seasons in an attempt to follow local, state and CDC guidelines for large gatherings.
NATA COVID-19 Return To Play Guidelines
The National Athletic Trainers Association has published a series of helpful guidelines for COVId-19 return to sport considerations and the important role that athletic trainers should have in ensuring a successful return to sports.
The NATA COVID-91 guidelines recommend setting up s COVID-19 Response Team that would be focused on preventing COVID-19 infections among athletes as well as diminishing the risk of infection to other athletes if an athlete should test positive.
One recommendation made in the NATA COVID-19 Guidelines is a one-year extension of valid 2019-20 season Pre-participation Physical Exam into the 2020-21 season with the following caveats:a
If your state activity association accepts the extension o f2019-20 pre-participation physical examinations, it is recommended that the school:
▪ Obtain updated medical history for all returning athletes. Schools should consider adding COVID-19 symptomology and exposure questions to their medical history forms.
▪ Athletes with underlying, pre-existing conditions, injuries or illnesses must obtain an updated pre-participation physical examination or appropriate clearance from treating physician based upon situation.
Require all new athletes (i.e., first-time athletic participants in the school’s athletic program) to obtain pre-participation physical examination.NATA COVID-19 Guidelines
The NATA COVID-19 Guidelines also recommend maintaining adequate supplies of personal protection equipment and supplies:
As health care professionals, athletic trainers should have access to appropriate supplies and equipment to protect their patients and themselves. ATs are encouraged to:
Take stock of current inventory of personal protective equipment and cleaning and sanitization supplies. Determine additional needs based on projected increase in use. Items to consider include:
Schools may be asked or required to provide additional masks for:
Athletes (e.g., conditioning, practices, games, meetings, etc.)
Staff (e.g., conditioning, practices, games, meetings, etc.)
Game and event personnel
Cleaning and sanitization supplies. Work with school custodial services to assess and coordinate fulfillment.NATA COVID-19 Guidelines
Post COVID-19 Return to Play Clearances for Athletes with COVID-19 infections
Athletes with documented COVID-19 infection should be evaluated to determine their need for medical clearance prior to returning to sports activities.
Return to Sports Algorithm after COVID-19 Infection
The Journal of the American Medical Association has published a post-COVID-19 guideline for return to play after COVID-19 infection ((https://jamanetwork.com/journals/jamacardiology/fullarticle/2766124))
Which Athletes Need Medical Clearance for Sports?
This current guideline recommends two weeks of no exercise after diagnosis with COVID-19 followed by a slow and controlled return to exercise for athletes that had no symptoms with their positive COVID-19 test.
Sports Clearance for Positive COVID-19 Athlete with Mild Symptoms
For positive COVID athletes with mild symptoms not requiring hospitalization, these athletes should also follow a rest/recovery period for the 2 weeks following the positive COVID-19 test. These symptomatic athletes should then also continue to recover for 2 weeks following the last day of COVID-19 symptoms.
These mildly symptomatic, positive COVID athletes should then have medical evaluation for clearance to return to sports including:
- High sensitivity Troponin T
- 12-lead EKG
- Cardiac Echocardiogram
Other testing based on symptoms. Cardiac MR may be indicated if there are cardiac or pulmonary complaints since a recent study demonstrated that some post-COVID athletes can have normal labs, EKG and cardiac echo but findings of plueral effusions and myocarditis on cardiac MR. ((https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645))
Athletes hospitalized with COVID-19 should have cardiac evaluation while hospitalized and if they have an elevated high-sensitive troponin or abnormal cardiac study should follow American College of Cardiology/American Heart Association athlete myocarditis guidelines for return to play after discharged from the hospital and medically cleared for sports participation.
Hospitalized athletes without cardiac findings should follow the guidelines for mildly symptomatic athletes once discharged; rest/recovery for 2 weeks following resolution of symptoms and then medical evaluation for further testing before starting a supervised return to sports activity program.
What type of medical clearance do athletes need post-COVID-19 infection?
All positive COVID-19 athletes, once cleared for return to sports should follow a supervised return to sports/exercise program. Any symptomatic athletes that test positive for COVID-19 regardless of if they were hospitalized or not should have follow-up medical clearance including lab work for hs-Troponin, EKG and cardiac echo.
Evolving research on athletes after COVID-19 infection and possible cardiac issues
JAMA Cardiology published a study in July 2020 that evaluated 100 German patients recovering from COVID-19 infections with cardiac imaging including cardiac magnetic resonance imaging (cardiac MRI). ((https://jamanetwork.com/journals/jamacardiology/fullarticle/2768916)) The study looked at potential long-term cardiac changes after COVID-19 infection. The test subject group was significantly older that high-school and college athletes with a average age of 49 years old, but the concerning finding which could also affect younger and healthy athletes was that 78 of the 100 patients had abnormal cardiac MRIs, with 60% (60 of 100) of the patients having cardiac inflammation The cardiac MRIs were done on average, 71 days after the patient was diagnosed with COVID-19 (ranging between 64-92 days after diagnosis with COVID-19).
In September 2020, a research letter was publishing in JAMA Cardiology ((https://jamanetwork.com/journals/jamacardiology/fullarticle/2770645)) that detailed the results of an Ohio State University study of college athletes with prior COVID-19 infection that had cardiac MRI done as part of a return to play medical evaluation.
Out of 26 college athletes studied, a total of 4 (15%) college athletes had abnormal cardiac MRI findings. Only two of the four athletes were symptomatic with complaints of mild shortness of breath while the other two athletes had no symptoms.
The researchers did not think that the findings were indicative of an exercise response since the T2 phase of the cardiac MRI demonstrated an increase of from 52 to 59 milliseconds. This increase in the T2 phase on cardiac MRI would indicate the possibly of inflammation of the heart consistent with myocarditis ((https://www.karger.com/Article/Fulltext/478901))
One issue with the Ohio State study could be the short duration between diagnosis of COVID-19 and the cardiac MRI. In most cases, the cardiac MRI was done around 2 to 3 weeks after diagnosis, but in some cases, as soon as 11 days after diagnosis. (Table We don’t yet know if this cardiac inflammation seen on the cardiac MRI is an acute phase reaction due to viral load and ACE-2 receptors on the heart or if this is an indication of possible longer term issues in these athletes. The four athletes that had cardiac MRIs consistent with myocarditis were tested at days 11,12, 17 and 23 from diagnosis of COVID-19.
Follow up cardiac MRIs would be helpful to determine the need for long-term follow up of these athletes.
Late Gadolinium Enhancement (LGE) in Athletes after COVID-19
The Ohio State also demonstrated that 12 of the 26 athletes had some evidence of late gadolinium enhancement on cardiac MRI. The positive LGE group included the 4 athletes with myocarditis changes on cardiac MRI as well as 8 additional athletes.
Late gadolinium enhancement on cardiac MRI is thought to be an indication of myocardial damage as the damaged heart cells take up the gadolinium dye while healthy heart cells don’t take up the gadolinium. ((https://www.ahajournals.org/doi/10.1161/CIRCIMAGING.113.001144))