ArticlePDF AvailableLiterature Review

Recommendations for return to sport during the SARS-CoV-2 pandemic

  • Deutsche Gesellschaft für Sportmedizin und Prävention (Deutscher Sportärztebund) e.V.


In this viewpoint we make specific recommendations that can assist and make the return to sport/exercise as safe as possible for all those impacted – from the recreational athlete to the elite athlete. We acknowledge that there are varying rules and regulations around the world, not to mention the varying philosophies and numerous schools of thought as it relates to return to sport/exercise and we have been cognisant of this in our recommendations. Despite the varying rules and circumstances around the world, we believe it is essential to provide some helpful and consistent guidance for return to training and sport for sport and exercise physicians around the world at this most difficult time. The present viewpoint provides practical and medical recommendations on the resumption to sport process.
LöllgenH, etal. BMJ Open Sp Ex Med 2020;6:e000858. doi:10.1136/bmjsem-2020-000858 1
Open access Viewpoint
Recommendations for return to sport
during the SARS- CoV-2 pandemic
Herbert Löllgen,1 Norbert Bachl,1,2,3,4 Theodora Papadopoulou,1,4,5,6
Andrew Shak,7,8 Graham Holloway,5 Karin Vonbank,9 Nigel Edward Jones,5,10,11
Xavier Bigard,1,4,12 David Niederseer ,13 Joachim Meyer,14
Borja Muniz- Pardos ,15 Andre Debruyne,1,4 Petra Zupet,1,4,16
Jürgen M Steinacker ,1,4,17 Bernd Wolfarth,4,18 James Lee John Bilzon ,4,5,19
Anca Ionescu,1 Michiko Dohi ,4,20 Jeroen Swart ,4,21
Victoriya Badtieva ,4,22,23 Irina Zelenkova,15,22 Maurizio Casasco,1,4,24
Michael Geistlinger,4,25 Luigi Di Luigi ,4,26 Nick Webborn,27,28 Patrick Singleton,29
Mike Miller,29 Fabio Pigozzi,1,4,30,31 Yannis P Pitsiladis 1,4,32
To cite: LöllgenH, BachlN,
PapadopoulouT, etal.
Recommendations for return
to sport during the SARS-
CoV-2 pandemic. BMJ Open
Sport & Exercise Medicine
2020;6:e000858. doi:10.1136/
For numbered afliations see
end of article.
Correspondence to
Dr Yannis P Pitsiladis;
Y. Pitsiladis@ Brighton. ac. uk
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
In this viewpoint we make specic recommendations that
can assist and make the return to sport/exercise as safe
as possible for all those impacted – from the recreational
athlete to the elite athlete. We acknowledge that there
are varying rules and regulations around the world, not to
mention the varying philosophies and numerous schools
of thought as it relates to return to sport/exercise and
we have been cognisant of this in our recommendations.
Despite the varying rules and circumstances around the
world, we believe it is essential to provide some helpful
and consistent guidance for return to training and sport
for sport and exercise physicians around the world at
this most difcult time. The present viewpoint provides
practical and medical recommendations on the resumption
to sport process.
The COVID-19 pandemic and the restrictive
measures adopted internationally in order to
contain the virus has led to a disruption of
organised sport at all levels. During the lock-
down period, outdoor exercise was forbidden
or partly restricted in some cases without
access to sports facilities including gyms or
sports centres. As the number of infections
and hospitalisations decreased, the strict lock-
down was gradually lifted. Team sports have
commenced reintroducing their training
routines in groups, and the Bundesliga reac-
tivated the professional league behind closed
doors on 16 May 2020 despite serious concerns
raised by some in the scientific community.1
Additional sporting competitions such as
boxing, Ultimate Fighting Championship
and Formula 1 are also scheduled to resume.2
It is worth noting that social distancing is
possible in some sports (eg, tennis, swimming,
athletics and golf) whereas this is not always
possible in other cases (eg, football, rugby,
basketball, cycling and boxing), and careful
measures of hygiene and control are espe-
cially needed for these more at risk sports to
regulate the safety of sport resumption and to
avoid possible infections. For more thorough
information about the risk factors and symp-
toms to be considered to make the return to
sport as safely as possible, consult Carmody
et al3 and Nieß et al.4 The present viewpoint
provides practical and medical recommenda-
tions on the resumption to sport process.
During the resumption to sport process, the
following groups must be distinguished (indi-
viduals below refer to both leisure time and
professional athletes or persons starting new
with regular physical activities). This group
classification is a more developed version of
that recently published by Phelan et al.5:
1. Individuals without symptoms and signs
that never have been tested positive for se-
vere acute respiratory syndrome coronavi-
rus 2 (SARS- CoV-2).
2. Individuals with a positive SARS- CoV-2 test
without any COVID-19 symptoms but iso-
lating at home (quarantine) under close
medical observation (telephonic or video).
3. Individuals who experienced COVID-19
with mild symptoms, only needing outpa-
tient treatment and quarantine for 14 days.
4. Individuals with moderate symptoms but
had inpatient treatment due to an in-
creased risk derived from pre- existing con-
ditions (eg, asthma, diabetes).
5. Individuals with severe symptoms, inpa-
tient treatment, including intensive care
without artificial respiration.
copyright. on July 14, 2020 by guest. Protected by Open Sport Exerc Med: first published as 10.1136/bmjsem-2020-000858 on 13 July 2020. Downloaded from
2LöllgenH, etal. BMJ Open Sp Ex Med 2020;6:e000858. doi:10.1136/bmjsem-2020-000858
Open access
6. Individuals with severe symptoms, inpatient treatment
in intensive care and on artificial respiration.
It is imperative that a medical examination is performed
in cooperation with a respiratory physician and/or cardi-
ologist, if suspicious findings of the pulmonary and/or
cardiovascular systems arise.
Group 1
In individuals without symptoms and signs of COVID-19
and without any pre- existing medical condition(s), risk
stratification to safely resume to sport has to be evalu-
ated through questionnaires compiling data related to
personal and medical history, close contact with people
with positive SARS- CoV-2 test, or contact with people of
high risk of having been infected without being tested
positive, or in so called hotspots. The individual has to
confirm being free of any symptoms and this must be
documented. Exercise testing is likely to be necessary in
some sports due to the expected detraining after lock-
down,6 and exercise testing must be performed according
to the latest COVID-19/SARS- CoV-2 health and safety
Group 2
Resumption after 14 days quarantine. Examinations
ought to include medical history, physical examination,
12- channel ECG, lung function assessment with typical
respiratory signs and symptoms, and ECG stress test.5 7–9
Echocardiography if clinically indicated.
Group 3
Resumption after a quarantine period of 2 weeks and
strict social distancing for another 2 weeks.
A medical examination by a sport and exercise medi-
cine physician with medical history, physical examination,
blood test focused on critical markers (eg, C- reactive
protein, high sensitivity troponin- I, natriuretic peptides),
and resting ECG (eg, changes of Q- wave, ST- stretch,
T- wave).8 Additional lung function assessment and stress
test with ECG, blood gas analysis and spiroergometry as
well as echocardiography are recommended if symptoms
have involved respiratory or cardiac impairment. Return
to regular sport is possible 3–4 weeks after beginning of
the symptoms under medical surveillance for 6 months
after return to sport if any symptoms are present but not
limiting return to sport.
Group 4
Same procedure as for group 3 but including compulsory
ergometry with blood gas analysis and/or spiroergom-
etry.3–5 10 Chest X- ray examination and depending on
the findings obtained during the inpatient stay, high-
resolution CT of the thorax in the most severe cases always
in consultation with a lung specialist. Cardiac examina-
tions depending on medical history, symptoms and signs,
cardio- MRI after consultation with a cardiologist. Return
to sport will vary from 2 to 6 months depending on the
severity of respiratory (lung) and/or cardiac (myocar-
ditis) involvement.
Groups 5 and 6
Following SARS- CoV-2 discharge, rehabilitation is recom-
mended. A complete pulmonary and cardiological
examination is necessary (‘cardiac markers’ such as high
sensitivity troponin- I or natriuretic peptides) including
resting ECG, lung function, echocardiography, stress test
with ECG and blood gas analysis.8 10–13 Return to sport
will be after several months depending on the severity
and completeness of recovery.
Depending on previous findings in heart rate, CT of
the thorax and cardiac MRI examination in consultation
with a respiratory physician and cardiologist, hospital
discharge can take place. A final medical check and
sports statement is mandatory.
Resumption of sport can occur 10–14 days after
complete recovery from SARS CoV-2 infection for
athletes included in groups 1 and 2. In patients with more
severe organ involvement, pneumonia, myocarditis or
neurological signs, an individualised plan is necessary.4 5
Testing for SARS CoV-2 can be carried out to support a
return to play decision but is not essential unless stipu-
lated (eg, National/International Sports Federation,
An adequate assessment of the resumption of sporting
activity is based on a case- by- case decision that must
consider the individual situation of the athlete including
pre- existing conditions, the type of sport and the risk
of infection from other athletes (eg, increased risk in
contact/team sports). The recommendation to return to
play will be based on the results of the examination and
individual assessment in consultation with the sport and
exercise medicine physician, specialists in pulmonary
medicine and sport cardiology (or extended multidisci-
plinary team), coaches and training specialists. After a
contact ban, an athlete should be provided with recom-
mendations on sports resumption that are in accordance
with national and regional guidelines. After a longer
period of interruption in sport caused by more severe
health issues, increases in training should be gradual and
individualised by monitoring signs and symptoms of the
health issue.
Author afliations
1European Federation of Sports Medicine Associations (EFSMA), Lausanne,
2Institute of Sports Science, University of Vienna, Vienna, Austria
3Austrian Institute of Sports Medicine, Vienna, Austria
4International Federation of Sports Medicine (FIMS), Lausanne, Switzerland
5British Association of Sport and Exercise Medicine, Doncaster, UK
6Defence Medical Rehabilitation Centre, Loughborough, UK
7South Tyneside NHS Foundation Trust, Sunderland, UK
8Newcastle Thunder Rugby, Newcastle, UK
9Department of Pneumology, Pulmonary Function Laboratory, Medicine Clinic
(KIMII), University of Vienna, Vienna, Austria
10British Cycling, Manchester, UK
copyright. on July 14, 2020 by guest. Protected by Open Sport Exerc Med: first published as 10.1136/bmjsem-2020-000858 on 13 July 2020. Downloaded from
LöllgenH, etal. BMJ Open Sp Ex Med 2020;6:e000858. doi:10.1136/bmjsem-2020-000858
Open access
11University of Liverpool, Liverpool, UK
12Union Cycliste Internationale (UCI), Aigle, Switzerland
13Heart Centre, University of Zurich, Zurich, Switzerland
14Lung Center, Clinic Bogenhausen, Munich, Germany
15GENUD (Growth, Exercise, Nutrition and Development), University of Zaragoza,
Zaragoza, Spain
16Institute of Medicine and Sports, Ljubljana, Slovenia
17Division of Sports and Rehabilitation Medicine, Ulm University Hospital, Ulm,
18Department of Sport Medicine, Humboldt University and Charité University School
of Medicine, Berlin, Deutschland, Germany
19Department for Health, University of Bath, Bath, UK
20Sport Medical Center, Japan Institute of Sports Sciences, Tokyo, Japan
21UCT Research Unit for Exercise Science and Sports Medicine, University of Cape
Town (UCT), Cape Town, South Africa
22I.M. Sechenov First Moscow State Medical University (Sechenov University),
Moscow, Russian Federation
23Moscow Research and Practical Centre for Medical Rehabilitation, Restorative
and Sports Medicine, Moscow Healthcare Department, Moscow, Russian Federation
24Italian Federation of Sports Medicine (FMSI), Rome, Italy
25Unit International Law, Department of Constitutional, International and European
Law, University of Salzburg, Salzburg, Austria
26Unit of Endocrinology, Department of Movement, Human and Health Sciences,
University of Rome “Foro Italico”, Rome, Italy
27School of Sport and Service Management, Eastbourne, UK
28School of Sport, Exercise and Health Sciences, Loughborough University,
Loughborough, UK
29World Olympians Association, Lausanne, Switzerland
30University of Rome “Foro Italico”, Rome, Italy
31FIFA Medical Center of Excellence, Villa Stuart Sport Clinic, Rome, Italy
32Collaborating Centre of Sports Medicine, University of Brighton, Eastbourne, UK
Twitter David Niederseer @DavidNiederseer
Contributors All authors contributed signicantly to merit publication and in
accordance with the BJSM instructions to authors.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
DavidNiederseer http:// orcid. org/ 0000- 0003- 3089- 1222
BorjaMuniz- Pardos http:// orcid. org/ 0000- 0002- 9191- 9033
Jürgen MSteinacker http:// orcid. org/ 0000- 0001- 8901- 9450
James Lee JohnBilzon http:// orcid. org/ 0000- 0002- 6701- 7603
MichikoDohi http:// orcid. org/ 0000- 0002- 1126- 7849
JeroenSwart http:// orcid. org/ 0000- 0001- 7098- 0313
VictoriyaBadtieva http:// orcid. org/ 0000- 0003- 4291- 679X
LuigiDi Luigi http:// orcid. org/ 0000- 0002- 2522- 126X
Yannis PPitsiladis http:// orcid. org/ 0000- 0001- 6210- 2449
1 Corsini A, Bisciotti GN, Eirale C, etal. Football cannot restart soon
during the COVID-19 emergency! A critical perspective from the
Italian experience and a call for action. Br J Sports Med 2020.
doi:10.1136/bjsports-2020-102306. [Epub ahead of print: 24 Mar
2 Coronavirus and sports: what happened in April 2020 | Sports|
German football and major international sports news | DW |
01.05.2020. Available: https://www. dw. com/ en/ coronavirus- sports-
cancellations/ a- 52569936 [Accessed 8 May 2020].
3 Carmody S, Murray A, Borodina M, etal. When can professional
sport recommence safely during the COVID-19 pandemic? risk
assessment and factors to consider. Br J Sports Med 2020.
doi:10.1136/bjsports-2020-102539. [Epub ahead of print: 07 May
4 Nieß AM, Bloch W, Friedmann- Bette B, etal. Position stand: return
to Sport in the Current Coronavirus Pandemic (SARS- CoV-2/
COVID-19). Ger J Sport Med 2020;71:E1–4.
5 Phelan D, Kim JH, Chung EH. A game plan for the resumption
of sport and exercise after coronavirus disease 2019 (COVID-19)
infection. JAMA Cardiol 2020. doi:10.1001/jamacardio.2020.2136.
[Epub ahead of print: 13 May 2020].
6 Pillay L, Janse van Rensburg DCC, Jansen van Rensburg A, etal.
Nowhere to hide: the signicant impact of coronavirus disease 2019
(COVID-19) measures on elite and semi- elite South African athletes.
J Sci Med Sport 2020;23:670–9.
7 Schellhorn P, Klingel K, Burgstahler C. Return to sports after
COVID-19 infection. Eur Heart J 2020. doi:10.1093/eurheartj/
ehaa448. [Epub ahead of print: 20 May 2020].
8 Bhatia RT, Marwaha S, Malhotra A, etal. Exercise in the Severe
Acute Respiratory Syndrome Coronavirus-2 (SARS- CoV-2) era: A
Question and Answer session with the experts Endorsed by the
section of Sports Cardiology & Exercise of the European Association
of Preventive Cardiology (EAPC). Eur J Prev Cardiol 2020;20474873
9 Kirkpatrick JN, Mitchell C, Taub C, etal. Ase statement on protection
of patients and echocardiography service providers during the 2019
novel coronavirus outbreak: endorsed by the American College of
cardiology. J Am Coll Cardiol 2020;75:3078–84.
10 Atri D, Siddiqi HK, Lang JP, etal. COVID-19 for the cardiologist:
basic virology, epidemiology, cardiac manifestations, and potential
therapeutic strategies. JACC basic to transl Sci 2020;5:518–36.
11 Barker- Davies RM, O'Sullivan O, Senaratne KPP, etal. The Stanford
Hall consensus statement for post- COVID-19 rehabilitation. Br J
Sports Med 2020. doi:10.1136/bjsports-2020-102596. [Epub ahead
of print: 31 May 2020].
12 Szekely Y, Lichter Y, Taieb P, etal. The Spectrum of Cardiac
Manifestations in Coronavirus Disease 2019 (COVID-19) - a
Systematic Echocardiographic Study. Circulation 2020. doi:10.1161/
CIRCULATIONAHA.120.047971. [Epub ahead of print: 29 May 2020].
13 Dores H, Cardim N. Return to play after COVID-19: A sport
cardiologist’s view. Br J Sports Med 2020.
copyright. on July 14, 2020 by guest. Protected by Open Sport Exerc Med: first published as 10.1136/bmjsem-2020-000858 on 13 July 2020. Downloaded from
... The current recommendation of the Journal of the American Medicine Association for asymptomatic or mild symptomatic patients is to have a minimum of 2 weeks of rest after COVID-19 infection (Phelan et al., 2020). Others suggested that return to exercise should only occur after an asymptomatic period of at least 7 days (Barker-Davies et al., 2020;Lollgen et al., 2020), while the return-to-play guidelines for hospitalized or more severely ill patients are even more cautious (Phelan et al., 2020;Salman et al., 2021). Moreover, physical complications of the COVID-19 infection or anxiety to restart exercise activities may further decrease physical activity levels in COVID-19 patients. ...
... Potentially, athletes could feel anxious to restart exercise after a COVID-19 infection, which could further reduce exercise and sports performance levels. Alternatively, the return to physical activity guidelines and advice from physicians could have lowered exercise levels post-COVID-19 infection (Barker-Davies et al., 2020;Lollgen et al., 2020;Phelan et al., 2020). These guidelines state that an athlete may restart exercise after an asymptomatic period of at least 7 days (Barker-Davies et al., 2020;Lollgen et al., 2020). ...
... Alternatively, the return to physical activity guidelines and advice from physicians could have lowered exercise levels post-COVID-19 infection (Barker-Davies et al., 2020;Lollgen et al., 2020;Phelan et al., 2020). These guidelines state that an athlete may restart exercise after an asymptomatic period of at least 7 days (Barker-Davies et al., 2020;Lollgen et al., 2020). This may have lowered the exercise levels in athletes 1-month post-COVID-19, but less likely explains the lower physical activity level at 3 months post-COVID-19 infection. ...
Full-text available
We examined the effect of a COVID-19 infection on changes in exercise levels in recreational athletes in the first three months after infection, and identified personal factors associated with a larger change in exercise level and recovery time. Recreational athletes (n=4360) completed an online questionnaire on health and exercise levels. 601 Athletes have had a diagnostically confirmed COVID-19 infection, while 3479 athletes did not (non-COVID-19 group). Exercise levels (in MET-min/week) were examined prior to (2019) and during the COVID-19 pandemic (2020) for the non-COVID-19 group, and in 2019, 1-month pre-COVID-19 infection, 1-month post-COVID-19 infection and 3 months post-COVID-19 infection in the COVID-19 group. Median exercise level at baseline in the COVID-19 group was 3528 (IQR=1488-5760) MET-min/week. One-month post-COVID-19 infection, exercise level dropped 58% (2038 MET-min/week), which partly stabilized to 36% (1256 MET-min/week) below baseline values 3 months post-COVID-19 infection. Moreover, in both the COVID-19 (pre-COVID-19 infection) and non-COVID-19 group exercise levels during the pandemic decreased with ~260 MET-min/week. These results illustrate that even a relatively physically active population of recreational athletes is significantly affected by a COVID-19 infection, particularly those athletes who are overweight. COVID-19 disease burden, age, sex, comorbidities and smoking were not associated with reduced exercise levels.
... Although most competitive athletes have an asymptomatic or mildly symptomatic SARS-CoV-2 infection course and are a low-risk population to develop cardiac and other complications after SARS-CoV-2 infection [8,14], a post-COVID-19 screening strategy primarily based on symptoms should detect cardiac involvement and other complications from SARS-CoV-2 infection and should enable the safe and early return to sports of affected athletes after infection [11,12,[14][15][16]. ...
... Although in most young athletes, an asymptomatic or mildly symptomatic SARS-CoV-2 infection course has been observed, and these patients have to be considered a low-risk population for developing cardiac and other complications after SARS-CoV-2 infection [8,14], a post-COVID-19 screening strategy to enable a safe and early return to sports primarily based on symptoms was implemented in the German sports system to face the fear regarding the development of cardiac involvement and other complications from SARS-CoV-2 infection [11,12,[14][15][16]31]. ...
Full-text available
The impact of former COVID-19 infection on the performance of athletes is not fully understood. We aimed to identify differences in athletes with and without former COVID-19 infections. Competitive athletes who presented for preparticipation screening between April 2020 and October 2021 were included in this study, stratified for former COVID-19 infection, and compared. Overall, 1200 athletes (mean age 21.9 ± 11.6 years; 34.3% females) were included in this study from April 2020 to October 2021. Among these, 158 (13.1%) athletes previously had COVID-19 infection. Athletes with COVID-19 infection were older (23.4 ± 7.1 vs. 21.7 ± 12.1 years, p < 0.001) and more often of male sex (87.7% vs. 64.0%, p < 0.001). While systolic/diastolic blood pressure at rest was comparable between both groups, maximum systolic (190.0 [170.0/210.0] vs. 180.0 [160.0/205.0] mmHg, p = 0.007) and diastolic blood pressure (70.0 [65.0/75.0] vs. 70.0 [60.0/75.0] mmHg, p = 0.012) during the exercise test and frequency of exercise hypertension (54.2% vs. 37.8%, p < 0.001) were higher in athletes with COVID-19 infection. While former COVID-19 infection was not independently associated with higher blood pressure at rest and maximum blood pressure during exercise, former COVID-19 infection was related to exercise hypertension (OR 2.13 [95%CI 1.39-3.28], p < 0.001). VO2 peak was lower in athletes with compared to those without COVID-19 infection (43.4 [38.3/48.0] vs. 45.3 [39.1/50.6] mL/min/kg, p = 0.010). SARS-CoV-2 infection affected VO2 peak negatively (OR 0.94 [95%CI 0.91-0.97], p < 0.0019). In conclusion, former COVID-19 infection in athletes was accompanied by a higher frequency of exercise hypertension and reduced VO2 peak.
... Data collection took place on the same day as the study inclusion (4.4 ± 4.6 months after infection). Athletes were advised to follow current return to sport guidelines at this time [12,13]. ...
Full-text available
Introduction Fatigue is a common symptom in post-COVID-19 patients. Individuals with fatigue often perform less well compared to healthy peers or without fatigue. It is not yet clear to what extent fatigue is related to the inability to reach maximum exhaustion during physical exercise. Methods A symptom-based questionnaire based on the Carruthers guidelines (2003) was used for reporting the presence of fatigue and further symptoms related to COVID-19 from 85 participants (60.0% male, 33.5 ± 11.9 years). Cardiopulmonary exercise testing (CPET) and lactate measurement at the end of the test were conducted. Objective and subjective exhaustion criteria according to Wasserman of physically active individuals with fatigue (FS) were compared to those without fatigue (NFS). Results Differences between FS and NFS were found in Peak V̇O 2 /BM ( p < 0.001) and Max Power/BM ( p < 0.001). FS were more likely to suffer from further persistent symptoms ( p < 0.05). The exhaustion criterion Max. lactate was reached significantly more often by NFS individuals. Conclusion Although the aerobic performance (Max Power/BM) and the metabolic rate (Peak V̇O 2 /BM and Max. lactate) of FS were lower compared to NFS, they were equally able to reach objective exhaustion criteria. The decreased number of FS who reached the lactate criteria and the decreased V̇O 2 peak indicates a change in metabolism. Other persistent post-COVID-19 symptoms besides fatigue may also impair performance, trainability and the ability to reach objective exhaustion. Trial registration Trial registration: DRKS00023717; date of registration: 15.06.2021 (retrospectively registered).
... Dette betydde videre at erfaring og utviklede støttestrategier på hvordan man skulle håndtere den nye situasjonen manglet. Under den første fasen av pandemien var en stor del av fokuset på hvordan begrensningene og lockdown påvirket idrettsutøvere og hvordan treningsmuligheter kunne gjenopprettes på en trygg og organisert måte (Löllgen et al., 2020). Senere ble spørsmålene flyttet til å gjelde for eksempel hvordan eliteidrettsutøvere som hadde hatt covid-19 kunne gå tilbake til trening og konkurranse (Elliott et al., 2020), og hvordan konkurranser kunne starte opp igjen og samtidig ta hensyn til smittevern (Löllgen et al., 2021). ...
Full-text available
The Tokyo Summer Olympics 2020 were postponed by a year due to Covid-19. This postponement came as a surprise to both athletes and support staff. How did the pandemic affect the Olympic preparations and the mental health of the athletes? Twelve athletes, both Norwegian and Swedish medal candidates from nine sports, were interviewed. Norwegian and Swedish athletes had different training options, but they tried to adapt as best they could to current situations and what they were allowed to do. This resulted in different set of goals as they adapted to the conditions.
... The decision to return to PA after COVID-19 should take into account the duration of the disease, the severity of respiratory or cardiac symptoms (138), as well as the presence of comorbidities, and the capacity and the intensity of the planned exercise (139). In 2022, the Scientific Council of the Deutsche Gesellschaft fur Sportmedizin und Pravention (DGSP) published guidelines for returning to sports after COVID-19 that was addressed to elite athletes (140). ...
Full-text available
The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.
... These results show that sport activities had positive consequences both physically and mentally, as it was revealed during this pandemic, but we must mention that 90% of the participants were affected at physical level and they struggled to adapt to the conditions of the collective preparation at mental level, where 66.8% reported a moderate to very high level of anxiety; the ANOVA test confirming the statistical significance at respondents answer items (Parm, et al., 2021;Fiorilli et al., 2021;Hossain et al., 2020;Löllgen et al., 2020;Tayech et al., 2020;. ...
Full-text available
The pandemic COVID-19 has globally affected the physical activity behavior, forcing many people to isolate themselves for a long period of time. These actions caused and increased sedentary behaviors such as excessive sitting or using mobile devices. The lockdown and sedentary behavior have affected the health status and decreased the physical fitness, weakening one’s body and inducing a low immunological response. The aim of the study was to determine how elite handball players were affected at physical and mental during the restrictions imposed by the spreading of the SARS - CoV - 2 virus. A questionnaire-based survey was used to conduct the study. For the questionnaire design we used Likert style with three or five level items. The participants voluntarily consented to anonymously participate in our study before completing the questionnaire. The participants were informed that the data would be used only for scientific purpose. The results of our study suggest that pandemic negatively influenced the sport preparation of the handball players due the fact that subjects trained themselves for a period of over 2 months and that meant a reduction of the physical activity (influencing the physical fitness level) to half comparing to a collective preparation for competition. At mental level more than 2/3 felt an increased level of anxiety due to the pandemic, the way that their life was changed and worries concerning their personal and professional future. This period of incertitude had a negative impact at mental level confirming our hypothesis.
... To be able to provide information on how performance develops over time, long-term monitoring is necessary. Recent published studies and recommendations also state the need for long time monitoring [21,40,41]. Studies with long-term monitoring and repeated examinations of patients and athletes are rare. ...
Full-text available
Introduction After the acute Sars-CoV-2-infection, some athletes suffer from persistent, performance-impairing symptoms, although the course of the disease is often mild to moderate. The relation between cardiopulmonary performance and persistent symptoms after the acute period is still unclear. In addition, information about the development of this relationship is lacking. Objective To assess the prevalence of persistent symptoms over time and their association with the performance capability of athletes. Methods We conducted two cardiopulmonary exercise tests (CPET) in a three months interval with 60 athletes (age: 35.2±12.1 years, 56.7% male) after infection with Sars-CoV-2 (t 0 : study inclusion; t 1 : three months post t 0 ). At each examination, athletes were asked about their persistent symptoms. To evaluate the change of Peak VO 2 /BM (Body Mass) between the time before infection and the first examination, the VO 2 /BM (predVO 2 ) before infection was predicted based on anthropometric data and exercise history of the athletes. For data analysis, athletes were grouped according to their symptom status (symptom-free, SF; persistent symptoms, PS) and its progression from the first to the second examination 1) SF-SF, 2) PS-SF and 3) PS-PS. Results Comparing the SF and PS groups at t 0 , significant differences for Max Power/BM, Max Power/lbm (lean body mass), Peak VO 2 , Peak VO 2 /BM, Peak VO 2 /lbm, Peak VO 2 /HR, Peak VE, Peak Vt and VE/VCO 2 -Slope were observed. Regarding the progression over three months, an increase in Max Power/BM was shown in SF-SF and PS-SF (tendency). Max Power/lbm increased in SF-SF and PS-PS (tendency). A decrease of VE/VCO 2 -Slope in PS-PS was found. Conclusion COVID-19 led to a decline in performance that was greater in PS than in SF. Additionally, PS had decreased ventilatory parameters compared to SF. Furthermore, an improvement over time was observed in some CPET parameters and a partial recovery was observed judging by the decrease in various symptoms.
Introduction: Data regarding echocardiographic findings during follow-up of asymptomatic or pauci-symptomatic coronavirus disease 2019 (COVID-19) are scarce in pediatric patients. The aim of the present study is to assess post-COVID-19 sequelae through echocardiography in children who have experienced mild SARS-CoV-2. Methods: This single-center, retrospective, observational study enrolled a cohort of 133 pediatric outpatients, born between 2005 and 2022, with a history of asymptomatic or paucisymptomatic SARS-CoV-2 infection, who underwent transthoracic echocardiographic (TTE) evaluation at an outpatient pediatric clinic in Northern Italy. Results: The percentage of the pediatric activity of the clinic which was focused on post-COVID evaluation was not negligible, representing almost 10% of the ∼1500 pediatric patients examined from 1 January 2021 to 31 August 2022. According to ACEP classification, children enrolled in this study had previously experienced in 72.9% (97) asymptomatic COVID-19 and nearly 27% (36) a mild illness. Clinical and instrumental examinations did not show any relevant abnormality in the functional [left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP)] or structural [interventricular septum diameter (IVSd), left ventricular internal diameter (LViD, end-diastolic volume (EDV), left atrium volume (LAV)] parameters examined related to SARS-CoV-2 infection in the total of 133 children. Conclusion: According to our results, children who experienced an asymptomatic or mild SARS-CoV-2 infection should not be systematically investigated with second-level techniques, such as TTE, in the absence of clinical suspicion or other risk conditions such as congenital heart diseases, comorbidities or risk factors.
Objective: This systematic review aims to understand the problems associated with lockdown and the various conditions of Covid-19 infection and to help prepare athletes and exercise enthusiasts for the safe resumption of sport in a manner that promotes wellness, healthy competition, and a sports industry that survives the current situation. This systematic review was carried out, following the recommendations of the currently pre-established reporting elements for systematic reviews and meta-analyses. The following databases were consulted: ISI Web of Science (WOS), Scopus and Google Scholar. This review includes a total of 19 articles. News: The results are presented based on three predominant themes: (1) psychological impact produced by SARS-CoV-2; (2) post-Covid-19 cardiac abnormalities and (3) protocols for an adequate return to physical practice. Prospects and projects: Most of the protocols shown by the various papers are consistent in terms of duration and number of phases. Based on this, the safe return to practice protocol can be divided into four stages of seven days in each phase in order to progress according to the symptoms perceived. In each phase, the physiological demand and efforts necessary to cover the proposed activities are increased until optimal physical condition is recovered.
Full-text available
After SARS-CoV-2 infection, strict recommendations for return-to-sport were published. However, data are insufficient about the long-term effects on athletic performance. After suffering SARS-CoV-2 infection, and returning to maximal-intensity trainings, control examinations were performed with vita-maxima cardiopulmonary exercise testing (CPET). From various sports, 165 asymptomatic elite athletes (male: 122, age: 20y (IQR: 17-24y), training:16 h/w (IQR: 12–20 h/w), follow-up:93.5 days (IQR: 66.8–130.0 days) were examined. During CPET examinations, athletes achieved 94.7 ± 4.3% of maximal heart rate, 50.9 ± 6.0 mL/kg/min maximal oxygen uptake (V̇O2max), and 143.7 ± 30.4L/min maximal ventilation. Exercise induced arrhythmias (n = 7), significant horizontal/descending ST-depression (n = 3), ischemic heart disease (n = 1), hypertension (n = 7), slightly elevated pulmonary pressure (n = 2), and training-related hs-Troponin-T increase (n = 1) were revealed. Self-controlled CPET comparisons were performed in 62 athletes: due to intensive re-building training, exercise time, V̇O2max and ventilation increased compared to pre-COVID-19 results. However, exercise capacity decreased in 6 athletes. Further 18 athletes with ongoing minor long post-COVID symptoms, pathological ECG (ischemic ST-T changes, and arrhythmias) or laboratory findings (hsTroponin-T elevation) were controlled. Previous SARS-CoV-2-related myocarditis (n = 1), ischaemic heart disease (n = 1), anomalous coronary artery origin (n = 1), significant ventricular (n = 2) or atrial (n = 1) arrhythmias were diagnosed. Three months after SARS-CoV-2 infection, most of the athletes had satisfactory fitness levels. Some cases with SARS-CoV-2 related or not related pathologies requiring further examinations, treatment, or follow-up were revealed.
Full-text available
Regular exercise has multiple benefits for physical and mental health, including the body's ability to combat infections. The current COVID-19 pandemic and the social distancing measures employed to curtail the impact of the infection are likely to reduce the amount of usual physical activity being performed by most individuals, including habitual exercisers. The uncertainties relating to the impact of the SARS-CoV-2 virus on the heart may cause increased anxiety, particularly in athletes who need to sustain a vigorous exercise regime in order to maintain their skills and fitness in preparation for return to competition after a short retraining period. The aim of this document is to provide practical answers to pertinent questions being posed by the sporting community, in an attempt to offer reassurance, promote safe participation in exercise during as well as after the COVID-19 pandemic and provide a framework of management for physicians caring for athletes.
Full-text available
The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0–10. Substantial agreement (range 7.5–10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.
Full-text available
Background: Information regarding the cardiac manifestations of COVID-19 is scarce. We performed a systematic and comprehensive echocardiographic evaluation of consecutive patients hospitalized with COVID-19 infection. Methods: 100 consecutive patients diagnosed with COVID-19 infection underwent complete echocardiographic evaluation within 24 hours of admission and were compared to reference values. Echocardiographic studies included left ventricular (LV) systolic and diastolic function, valve hemodynamics and right ventricular (RV) assessment, as well as lung ultrasound. A second exam was performed in case of clinical deterioration. Results: Thirty two patients (32%) had a normal echocardiogram at baseline. The most common cardiac pathology was RV dilatation and dysfunction (observed in 39% of patients), followed by LV diastolic dysfunction (16%) and LV systolic dysfunction (10%). Patients with elevated troponin (20%) or worse clinical condition did not demonstrate any significant difference in LV systolic function compared to patients with normal troponin or better clinical condition, but had worse RV function. Clinical deterioration occurred in 20% of patients. In these patients, the most common echocardiographic abnormality at follow-up was RV function deterioration (12 patients), followed by LV systolic and diastolic deterioration (in 5 patients). Femoral vein thrombosis (DVT) was diagnosed in 5 of 12 patients with RV failure. Conclusions: In COVID-19 infection, LV systolic function is preserved in the majority of patients, but LV diastolic and RV function are impaired. Elevated troponin and poorer clinical grade are associated with worse RV function. In patients presenting with clinical deterioration at follow-up, acute RV dysfunction, with or without DVT, is more common, but acute LV systolic dysfunction was noted in ≈20%.
Full-text available
Objective To describe the perceptions of South African elite and semi-elite athletes on return to sport (RTS); maintenance of physical conditioning and other activities; sleep; nutrition; mental health; healthcare access; and knowledge of coronavirus disease 2019 (COVID-19). Design Cross-sectional study Methods A Google Forms survey was distributed to athletes from 15 sports in the final phase (last week of April 2020) of the level 5 lockdown period. Descriptive statistics were used to describe player demographic data. Chi-squared tests investigated significance (p < 0.05) between observed and expected values and explored sex differences. Post-hoc tests with a Bonferroni adjustment were included where applicable. Results 67% of the 692 respondents were males. The majority (56%) expected RTS after 1-6months. Most athletes trained alone (61%; p < 0.0001), daily (61%; p < 0.0001) at moderate intensity (58%; p < 0.0001) and for 30-60 min (72%). During leisure time athletes preferred sedentary above active behaviour (p < 0.0001). Sleep patterns changed significantly (79%; p < 0.0001). A significant number of athletes consumed excessive amounts of carbohydrates (76%; p < 0.0001; males 73%; females 80%). Many athletes felt depressed (52%), and required motivation to keep active (55%). Most had access to healthcare during lockdown (80%) and knew proceedings when suspecting COVID-19 (92%). Conclusions COVID-19 had physical, nutritional and psychological consequences that may impact on the safe RTS and general health of athletes. Lost opportunities and uncertain financial and sporting futures may have significant effects on athletes and the sports industry. Government and sporting federations must support athletes and develop and implement guidelines to reduce the risk in a COVID-19 environment.
Full-text available
The coronavirus disease-2019 (COVID-19), a contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), has reached pandemic status. As it spreads across the world, it has overwhelmed healthcare systems, strangled the global economy and led to a devastating loss of life. Widespread efforts from regulators, clinicians and scientists are driving a rapid expansion of knowledge of the SARS-CoV2 virus and the COVID-19 disease. We review the most current data with a focus on our basic understanding of the mechanism(s) of disease and translation to the clinical syndrome and potential therapeutics. We discuss the basic virology, epidemiology, clinical manifestation, multi-organ consequences, and outcomes. With a focus on cardiovascular complications, we propose several mechanisms of injury. The virology and potential mechanism of injury form the basis for a discussion of potential disease-modifying therapies.
The cardiovascular effects and long-term consequences of COVID-19 are currently unclear. The question of eligibility for sport and the point of return to sport following both asymptomatic and symptomatic COVID-19 with or without suspected involvement of the myocardium is currently becoming more and more important in leisure as well as in competitive sports. Fortunately, from previous studies and registries of acute myocarditis, it has been known that athletes with a complete recovery have a very good prognosis. Nevertheless, to optimize counselling and treatment of athletes in the future, prospective data collection on the current corona pandemic is urgently needed. To this end, the non-evidence-based recommendations for a return to sports presented herein might serve as a first guideline.