Infographic. Clinical recommendations for return to play during the COVID-19 pandemic

344 LöllgenH, etal. Br J Sports Med March 2021 Vol 55 No 6 Infographic. Clinical recommendations for return to play during the COVID-19pandemic Herbert Löllgen,1,2 Norbert Bachl,1,3,4,5 Theodora Papadopoulou,1,3,6,7 Andrew Shafik,7 Graham Holloway,7 Karin Vonbank,8 Nigel Edward Jones,7,9 Xavier Bigard,1,10 David Niederseer ,11 Joachim Meyer,12,13 Borja MunizPardos,14 Andre Debruyne,1,3 Petra Zupet,1,15 Jürgen M Steinacker ,1,3,16 Bernd Wolfarth,3,17 James Lee John Bilzon ,3,7,18 Anca Ionescu,1,19 Michiko Dohi ,3,20 Jeroen Swart,3,21 Victoriya Badtieva,3,22,23 Irina Zelenkova,14,22 Maurizio Casasco,1,3,24 Michael Geistlinger,3,25 Luigi Di Luigi,3,26 Nick Webborn,27 Patrick Singleton,28 Mike Miller,28 Fabio Pigozzi,1,3,29,30 Yannis P Pitsiladis 1,3,31 Infographic COVID-19 AND RETURN TO PLAY The world of sport has recently returned to training and competition following suspension due to the COVID-19 pandemic. It is concerning that a number of athletes have tested positive for COVID-19 after returning to competition.1 Numerous authors have attempted to address return to play given the importance and complexity of the issue, with notable attention on possible cardiac implications.2–6 SCOPE OF THE INFOGRAPHIC The specific recommendations shown in the present infographic (figure 1) have been generated by a panel of international experts and represent a compilation of the numerous approaches used to inform resumption of regular sports during the COVID-19 pandemic. Despite the different regulations around the world and the particular characteristics of each sport, it is essential to provide informative, consistent and specific guidance for safe return to training and competition at this most difficult time. RECOMMENDATIONS COVID-19 is a systemic disease affecting the endothelium and all organs, especially the heart and lungs with more severity and clinical significance. Therefore, our recommendations for safe return to sport are based on a comprehensive clinical evaluation (ie, cardiac and respiratory) and have been designed for six different groups according to the level of exposure to COVID-19. These groups are based on a previous report by Phelan et al,3 which are applicable to both leisure time and professional athletes. It is imperative that group allocation is determined beforehand through a medical examination performed in cooperation with a respiratory physician and/or cardiologist. Specific recommendations for each group are provided based on current evidence and expert opinion (see table 1). SPECIAL CONSIDERATIONS The resumption of sporting activity should be determined on a casebycase basis and consider the individual situation of the athlete, including preexisting conditions, as well as the type of sport and the risk of infection from other athletes (eg, increased risk in contact/team sports). Ideally, the final decision to return to play will be based on the results of the individual assessment in consultation with the sport and exercise medicine physician, specialists in pulmonary medicine and sport Figure 1 Recommendations for return to sport during the COVID-19 pandemic. BNP, brain natriuretic peptide; CRP, Creactive protein. Protected by copyright. on March 3, 2021 at Universidad de Zaragoza. Biblioteca.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2020-102985 on 3 September 2020. Downloaded from 345 LöllgenH, etal. Br J Sports Med March 2021 Vol 55 No 6 Infographic cardiologists (or extended multidisciplinary team), coaches and training specialists. After a prolonged period of interruption in sport caused by more severe health issues, increments in training should be gradual, individualised and supervised by periodic monitoring of cardiac and respiratory markers to detect potential signs and symptoms. Although the present recommendations are focused primarily on pulmonary and cardiac assessments, given the wider healthrelated issues caused by COVID-19, more comprehensive evaluation including psychological status, examination of muscular function and other suspected collateral issues should be considered to provide more detailed and thorough information for safe return to play. FURTHER ESSENTIAL READING For more detailed description of the risk factors and symptoms that could inform the decision to return to sport as safely as possible, consult Baggish et al,5 Carmody et al7 and Niess et al.8 1European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland 2Cardiology Practice, Remscheid, Germany 3International Federation of Sports Medicine (FIMS), Lausanne, Switzerland 4Institute of Sports Science, University of Vienna, Vienna, Austria 5Austrian Institute of Sports Medicine, Vienna, Austria 6Lower LimbsADMR Hip & Groin, Defence Medical Rehabilitation Centre Headley Court, Loughborought, UK 7British Association of Sport and Exercise Medicine, Doncaster, UK 8Department of Pulmology, Medical University of Vienna, Vienna, Austria 9University of Liverpool, Liverpool, UK 10Union Cycliste Internationale (UCI), Aigle, Switzerland 11Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland 12German Respiratory Society (DGP), Berlin, Germany 13Lungenzentrum (BogenhausenHarlaching), München Klinik, Munich, Germany 14GENUD (Growth, Exercise, Nutrition and Development), Department of Physiatry and Nursing, University of Zaragoza, Zaragoza, Spain 15Institute for Medicine and Sport, Ljubljana, Slovenia 16Division of Sports and Rehabilitation Medicine, Ulm University Hospital, Ulm, Germany 17Department of Sport Medicine, Humboldt University and Charité University School of Medicine, Berlin, Germany 18Department for Health, University of Bath, Bath, UK 19Sports Medicine, "Carol Davila" University of Medicine, Bucharest, Romania 20Sport Medical Center, Japan Institute of Sports Sciences, Tokyo, Japan 21UCT Research Unit for Exercise Science and Sports Medicine, Universisty of Cape Town, Cape Town, South Africa 22I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, 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 25Department of Public, International and European Law, Unit of International Law, University of Salzburg, Salzburg, Austria 26Movement, Human and Health Sciences, University of Rome Foro Italico, Rome, Italy 27School of Sport and Service Management, University of Brighton, Eastbourne, UK 28World Olympians Association, Lausanne, Switzerland 29Sports Medicine Unit, University of Rome Foro Italico, Rome, Italy 30FIFA Medical Center of Excellence, Villa Stuart Sport Clinic, Rome, Italy 31Collaborating Centre of Sports Medicine, University of Brighton, Eastbourne, UK Correspondence to Professor Yannis P Pitsiladis, Collaborating Centre of Sports Medicine, University of Brighton, Eastbourne BN20 7SN, UK; Y. Pitsiladis@ Brighton. ac. uk Correction notice This article has been corrected since it published Online First. Ref 8 has been corrected. Twitter Theodora Papadopoulou @Dora_Sportmed, James Lee John Bilzon @JBilzon, Michiko Dohi @rinsho and Patrick Singleton @PSingleton33 Contributors All authors contributed significantly and in line with the instructions to authors to merit publication. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or notforprofit sectors. Competing interests None declared. Patient consent for publication Not required. Provenance and peer review Not commissioned; externally peer reviewed. This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, noncommercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained. © Author(s) (or their employer(s)) 2021. No commercial reuse. See rights and permissions. Published by BMJ. To cite LöllgenH, BachlN, PapadopoulouT, etal. Br J Sports Med 2021;55:344–345. Accepted 22 August 2020 Published Online First 3September2020 Br J Sports Med 2021;55:344–345. doi:10.1136/bjsports-2020-102985 ORCID iDs DavidNiederseer http:// orcid. org/ 0000000330891222 Jürgen MSteinacker http:// orcid. org/ 0000000162102449 James Lee JohnBilzon http:// orcid. org/ 0000000267017603 MichikoDohi http:// orcid. org/ 0000000211267849 Yannis PPitsiladis http:// orcid. org/ 0000000162102449 REFERENCES 1 Fuller R. Novak Djokovic must ’feel responsibility’ at coronavirus at Adria Tour, says Evans - BBC Sport. 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Return to play after COVID-19: a sport cardiologist’s view. Br J Sports Med 2020;54:1132–3. 7 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;54:946–8. 8 Nieß AM, Bloch W, FriedmannBette B, etal. Position stand: return to sport in the current coronavirus pandemic. Dtsch Z SportMed2020;71:E1–4. Table 1 Clinical recommendations for testing individual groups Recommendations Groups 123456 Tested randomly or by finding antibodies. Only possible PPE or standard exam X Need for usual checkup including ECG and echo X Tested following contact with somebody who was positive or tested because having typical signs and symptoms and out of hospital treatment X Inhospital treatment but quarantine at home XX For diagnosis only X Treatment with close monitoring due to symptoms but normal ward with isolation and quarantine X Need thorough preparticipation exam, CPET, echo and other necessary assessments XX Serious illness with difficult progression and intensive care unit without artificial ventilation X X Artificial ventilation X Need thorough examination before discharge (eg, MRI) X X CPET, cardiopulmonary exercise testing; PPE, preparticipation evaluation. Protected by copyright. on March 3, 2021 at Universidad de Zaragoza. Biblioteca.http://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2020-102985 on 3 September 2020. Downloaded from