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After COVID, When Can Young Athletes Resume Play

The question of returning to sports is significant because of the propensity for COVID-19 to cause cardiac damage and myocarditis.6 While the incidence of myocarditis is lower in the pediatric population compared to the adult population, myocarditis is known to be a cause of sudden death during exercise in the young athletic populations. Similar to other forms of myocarditis, providers caring for patients who have had a COVID infection should be confident there is no myocardial injury prior to clearing athletes to participate.7 When considering the question of return-to-play, we believe there are three variables to consider: (1) How recent was the COVID-19 infection? (2) How severe was the infection? (3) What is the physical activity or sport being considered?

After COVID, When Can Young Athletes Resume Play

While most pediatric patients will be asymptomatic, there certainly are severe presentations. Severe disease would be defined as someone who required hospitalization, had abnormal cardiac testing during the acute infection, and/or had the recently described multisystem inflammatory syndrome in children (MIS-C). The impact on the heart in MIS-C seems similar to the presentation of other acute viral myocarditis in pediatric patients8 and therefore it would be reasonable to treat pediatric patients who have had MIS-C as if they had myocarditis. These patients will have likely had cardiac testing during the acute phase (echocardiograms, ECGs, etc.). Depending on the results of these, based on care of athletes with myocarditis, the patient should be restricted for 3-6 months and only resume activities when/if cardiac testing (ECG, echocardiogram, 24-hour Holter monitor, exercise stress test and possibly cardiac magnetic resonance imaging [CMRI]) have normalized.7 We must emphasize that nothing is known about the long term history of pediatric patients with MIS-C. Although complete or near complete recovery of cardiac function is often seen in this population, even prior to hospital discharge, more frequent and longer monitoring of this population may be warranted. In the absence of any data, a conservative approach for return to activity is probably indicated for this small sub-population of COVID-19 patients.

In a JAMA Cardiology article in May, members of the American College of Cardiology's Sports and Exercise Cardiology Council outlined recommendations to determine when athletes who tested positive for COVID-19 could resume physical activity. For instance, an athlete with mild symptoms who didn't require hospitalization should rest and recover for two weeks after symptoms subside. Then the athlete should undergo further evaluation and medical testing, including an electrocardiogram; echocardiogram; and testing for high levels of the blood enzyme troponin, an indicator of heart damage.

On the other hand, athletes who test positive during routine screening but have no symptoms should rest for two weeks and be monitored carefully when they return to play. They don't necessarily need further evaluation if they remain asymptomatic.

The SARS-CoV-2 pandemic has provided a constant challenge to sport with varying protocols and regulations across the globe. In October 2020, we published a graduated return to play protocol 1 to aid colleagues and athletes resume safe exercising and training ahead of return to competition. With the imminent Tokyo Summer Olympic and Paralympic Games, it was considered that we could convey our experience of managing recently infected elite athletes during the early stages of the pandemic and showcase the evolution of best-practice for the safe return of athletes to sport.

In an excellent Editorial responding to the Big Ten study, Udelson et al summarized the available data on return to play after COVID-19 Infection. We agree with them that the current data support a conservative approach to cardiac testing as in the guidelines and that clinical judgement be applied to individual cases. We also emphasize the need for an athlete-centered, shared decision-making approach in the management of young athletes with myocarditis post COVID-19. These findings are consistent with our COVID-19 experience at Stanford Sports Medicine.

While there is no doubt that it will bring multiple benefits in terms of general health, returning to play sport should be gradual and preceded by an accurate physical examination in those young subjects previously affected by the coronavirus disease, especially when their heart and/or lungs and/or kidneys were affected.

Though COVID-19 represents and absolute and unpredictable novel situation, the current suggestions concerning resuming physical activity in children and adolescents are in accordance with that previously outlined in a number of documents on restarting playing sport following any injury or long-lasting inactivity [31, 32]. The two most important principles in the field are caution and graduality. Both are evidence-based and support the concept of post-injury vulnerability. In this respect, the GRTP protocol is an objective tool providing progressive tasks to the young athlete, although limited validation of the same is available. Additional research is needed to validate it, which is consistent with almost any previous documents on resuming exercise after different kinds of injuries [27, 33]. The approach to post-COVID athletes who are vulnerable because of comorbidities or who are suffering from long-COVID is similar to the way to manage those at risk of prolonged post-injury symptoms or other long-term complications. In fact, recovery from injury and medical care to full performance can be a lengthy and difficult process [34].

Overall, all the available scientific evidence suggests promoting physical activity resumption in young people after COVID-19. The proposed approach, however, should be cautious, gradual, and preceded by a physical examination done by a general paediatrician or general practitioner and sometimes by a specialist in Cardiology. This is with the goal of certifying that the young athlete is fit and ready to restart playing sport.

Athletes who undertake a high-level of training represent a particularly valuable cohort to understand the cardiovascular impact of milder SARS-CoV2 infections. Indeed, competitive athletes represent a unique population that may be at high risk for situational transmission of disease, and once infected, may be at risk for sudden cardiac death (SCD) during competitive training [12,13,14]. Asymptomatic viral myocarditis is a common cause of SCD, especially among young patients [15, 16]. The reported prevalence of CMR abnormalities in asymptomatic/mildly symptomatic athletes after SARS-CoV2 infection is also highly heterogeneous (0%-15%) [17,18,19,20,21,22,23]. Of note, some of these CMR studies did not involve imaging in control subjects. In this context, understanding the impact of COVID-19 has important implications, both in terms of risk stratification and development of guidelines to support the resumption of training.

The ASCCOVID study (; NCT04936503; =&term=NCT04936503&cntry=&state=&city=&dist=; date of registration; date of registration 23 June 2021) is a prospective, multicenter, nationwide cohort study which enrolled athletes from two distinct cohorts: professional athletes from the French National Rugby League (F-NRL, XV players rugby) and high-level sports students, whose sports profile is more representative of leisure sports in the general population. Written informed consent was obtained from all participants. The study was conducted in accordance with the Helsinki Declaration after the approval of the Ethics Committee (CPP Sud Ouest II, ID-RCB: 2020-A01196-33) and authorization of French Competent Authority (ANSM).

MRI scanning was not performed in the first 14 days after infection, but rather from the 2nd month following the diagnosis of COVID-19 (positive PCR in rugby players and in relation to the onset of symptoms in student athletes who were only diagnosed with a lag on serologies). This approach ensured that any evolving MRI abnormalities were detected. A detailed MRI protocol is included in Additional file 1 section. Briefly, anonymized images were analyzed in a core laboratory at the Bordeaux University Hospital for left ventricular wall dimensions, left and right ventricular volumes, ejection fraction, global longitudinal strain, regional wall motion and pericardial effusion. Analysis of LGE was performed to detect myocardial or pericardial injury. T1 and T2 images were analyzed to measure mean T1/T2 values.

Consistent with recent reports, troponin I and CRP levels were in the normal range in the majority of our cohort with mild/asymptomatic COVID-19 [17, 21, 31]. In the rugby F-NRL cohort, we observed a proportion of athletes with increased D-Dimer levels after COVID-19. Of note, the baseline values of these parameters have been reported to be significantly higher in some athletes compared to the general population [32,33,34]. Rugby players are regularly exposed to sport-related trauma, which could potentially contribute to even higher D-Dimer levels. Caution is therefore needed when interpreting these biomarkers in rugby players the context of COVID-19, with or without associated myocardial lesions.

Before returning to play, athletes who test positive for COVID-19 should consult with their physicians to determine if heart screening tests are needed. Although routine testing is not recommended for all asymptomatic individuals, a physician should determine on an individual basis when the risks are high enough.

Since the outbreak of the pandemic, the condition has become increasingly common in college athletes. In at least one case, a 20-year-old college football player, Jamain Stephens, died from myocarditis, which had developed after he had been infected with COVID-19.

Currently, sports programs around the United States have different guidelines about when athletes who get COVID-19 can return to play. Guidelines also differ on which students should be screened for heart damage. 041b061a72


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