A Safe Return to Sports amid the COVID-19 Pandemic

After professional sports and other sporting activities had been drastically limited to prevent COVID-19 spread, training facilities are now reopening to welcome recreational and competitive athletes. However, due to the ongoing pandemic, restrictions are still in place to lower the risk of human infection. The European Federation of Sports Medicine Association or EFSMA presents recommendations on a uniform approach to keeping athletes safe.

In this MEDICA.de interview, Professor Löllgen explains these recommendations in more detail.

Professor Löllgen, which groups of athletes need a sports medical examination before they may resume regular sports activities?

Prof. Herbert Löllgen: Athletes need a medical checkup if they have exhibited any symptoms, signs, or faced a particular risk of COVID-19 virus disease in any way, shape or form, or if they have tested positive for COVID-19. Athletes who have no symptoms, risks, or pending COVID-19 genetic PCR tests may resume sports again.

The primary goal is to identify whether someone who has tested positive has either undergone the disease or is still sick since we know that the test only detects the virus a few days after infection. That’s why people are often already contagious prior to testing and carry the virus. Our objective pertaining to the individual athletes is to prevent someone from testing positive and being physically active, only to develop symptoms a few days later. At this point, the common aspects of COVID-19 assist with the assessment of risk and support the examination. This includes three key factors pertaining to whether the athlete has been exposed to an area with increased infections, whether he or she was in close contact with other athletes who have tested positive, and whether he/she exhibits symptoms such as fever or chills.

What does EFSMA recommend specifically for people who are at higher risk before or when they resume regular sports activities?

Löllgen: We recommend a preventive medical screening by a sports medicine physician for people who are at a higher risk of severe illness. This screening should also include cardiac testing and a neurological exam.  We advise a physical exam that includes an electrocardiogram (ECG) and an echocardiogram for athletes with a cardiovascular history or if heart disease is suspected. Pulmonary function tests should be taken for monitoring purposes and chest X-rays in borderline cases.

We are often asked where persons should go to get tested. Most German cities have so-called COVID-19 virus testing centers. Local health departments can subsequently refer recreational or competitive athletes to these centers. After the risk assessment, the decision becomes whether the athlete must be home quarantined or whether he/she requires an inpatient hospital stay for observation to prevent community transmission. In my view, this aspect is still wrought with uncertainty, as it remains unclear what will happen three or four days after testing. Monitoring via telehealth platforms or phone calls is strongly advised. If physicians at the COVID-19 virus testing center see an increased risk, the disease progression can also be monitored via an inpatient hospital stay.

What precautionary measures are taken with exams and medical devices to prevent the spread of the disease?

Löllgen: Safety of physicians, medical technical assistants, and staff members is paramount to protect all parties and prevent the spread of infection. All devices must be disinfected between uses. However, devices should only be wiped after a 20-30 minute waiting period to allow for respiratory droplets to settle. Respiratory devices feature special filters that can trap the virus. These filters must be regularly changed or sanitized to promote decontamination and reuse. Examination rooms can be small, making it important to ensure proper ventilation. Sports medicine facilities face a somewhat different scenario as large institutes examine entire teams, making it essential to follow strict hygiene measures.

What are the timeline recommendations for the resumption of sports activities based on as it relates to the respective groups?

Löllgen: The timelines are based on empirical findings and prior experience gained from infectious diseases, colds or influenza infection. One problem when it comes to COVID-19 is that findings and insights slightly change every week. For example, the previous recommendation stated that quarantine should last for a period of 14 days. Meanwhile, a U.S. study indicates that 11 days is a sufficient quarantine period. The pivotal question is how long athletes should wait to resume sports after they have been infected or exposed. The rule of thumb is about two to four weeks in this case. Moderate non-intensive endurance training may be resumed after two weeks. Some parameters are associated with the severity of infection and can be monitored for this purpose. This includes NT-proBNP and hsTroponin for cardiac settings or immune-inflammatory markers. High-resolution CTs (HRCT) can be used to detect changes in pulmonary structure. Generally, it is always recommendable to slowly start up again after any disease and gradually increase the intensity after a week or two.

How often should team sports athletes undergo testing?

Löllgen: The decision is up to medical consultants and the local health department. From time to time, it makes sense to repeat testing two or three times successively if there are symptoms present. It is imperative to test every 24 days, especially if a member of the team has tested positive for COVID-19.

How do the various sports and leisure facilities address the relevant physical distancing and equipment requirements?

Löllgen: Sports medicine facilities have adapted their conduct and equipment to meet the hygiene criteria. Club presidents or trainers are in charge of regulatory compliance in the respective sports clubs. They must ensure that social distancing measures are implemented in the locker rooms and warrant that athletes wear face masks and avoid physical contact if possible. If someone has become infected despite these precautions, the entire sports club is locked down for the time being. By now, medical practices also use point-of-care testing. These tests should also see increased application in sports facilities. According to the manufacturers, the test has a 99 percent specificity rate.

How will COVID-19 be highlighted at the MEDICA Medicine + Sports Conference (MMSC) 2020 as it relates to sports?

Löllgen: COVID-19 will be addressed as part of the "infectious diseases and implications for professional and recreational sports" outline. A special Session is dedicated to this subject.