The impact of the COVID-19 pandemic on the global sporting community has been immense, disrupting fixtures, contracts, training schedules and those mass-participation events once thought to be immovable and untouchable, such as the London Marathon and the 2020 Olympic Games. But it is the impact – both physiological and psychological – on individual participants that is coming under greater scrutiny as a gradual loosening of the international lockdown starts to see training and competition slowly reintroduced. And with this, comes many pertinent questions and concerns from club doctors and athletes alike.

Whilst for the general population it is possible during the lockdown to maintain physical activity with the promotion of daily walks, runs, and exponential growth in sign-ups to online work-outs and sales of home gym equipment and bikes, little has been discussed about the effect of “detraining” on an elite athlete – and conversely, to what level it is safe to train at – during the current pandemic.

In answer to these questions, a new published paper is helping all stakeholders in professional and elite sport to navigate evolving research and advice and to effectively and safely prepare for a return to competitive sport in the current and post-pandemic era.

The publication originated from a team of Research Fellows funded by the charity Cardiac Risk in the Young (CRY) and is led by Dr Michael Papadakis and Professor Sanjay Sharma from the unit of Sports Cardiology and Inherited Cardiac Diseases at St George’s University, London.

Prof Sharma has worked alongside CRY for the past two decades as the charity’s Consultant Cardiologist. Prof Sharma is also the appointed Cardiologist for the Virgin Money London Marathon and regularly oversees the assessment of the heart health of professional footballers and elite athletes across many sports (including tennis, rugby, and athletics).

He explains; “One of the first things to highlight from this paper – whether an elite or recreational or even a beginner athlete – is that is still ‘safe’ to exercise during this COVID-era. There is evidence that moderate exercise performed for 20-30 minutes, 3-4 times per week strengthens the immune system and reduces the risk of viral infection. Scientific studies have shown that this regular moderate exercise prior to developing a potentially serious viral infection such as flu protects people dying from it.

“Interestingly, previous research has shown that people who continued to remain active during the 1998 Hong Kong flu were more likely to survive compared to people who did not perform any exercise.

“It goes without saying that professional athletes and those competing at club level need to maintain fitness before a full return to competition. Remote exercise programmes set during the lockdown may not fully reflect your sport, particularly contact sports such as football or rugby. Full match fitness is unlikely with most team sports and it is anticipated that a mini pre-season training will be organised by clubs before formal competition recommences – something we now expect to see being reintroduced over the coming weeks and months.”

Although athletes are accustomed to exercising much more intensively than the general population, it is recognised that rigorous exercise can cause stress on the body, leading it to become run down and more prone to infections. The new publication states there is currently no evidence to suggest that athletes are especially susceptible to COVID-19 infection, but the pragmatic position remains that athletes should not try to exceed the intensity of their usual training programme in regions of the world where the pandemic is still at its peak.

From the early days of the pandemic, there was concern of a small percentage of patients who required hospital admission displaying signs of inflammation of the heart muscle – a condition known as myocarditis.

It is unlikely that a COVID-19 patient’s heart will be affected if they are only presenting mild symptoms and are adopting self-care at home – but patients do need to be aware of chest pain that may be made worse by breathing in deep, increasing breathlessness and palpitations (racing heart). In such cases, patients should contact their GP, Club Doctor or emergency services – and athletes should not exercise if experiencing any of these symptoms.

Dr Papadakis explains; “COVID-19 may affect the heart in a number of different ways. One of the most serious implications is myocarditis, which can be diagnosed by measuring levels of a protein termed cardiac troponin in the blood, which is released by damaged heart muscle. In the case of an elite athlete, this blood test may now be performed by the club doctor or a recommended medical institution or clinic that has the facilities and capacity to test without the risk of anyone else becoming infected.

“If the cardiac troponin level in blood is increased, the doctor will also arrange an electrical tracing of the heart (ECG) and a heart scan and an appointment (potentially still via video conferencing) with a cardiologist.”

“Myocarditis can become very serious, especially if people continue to exercise. This can cause the heart to become damaged permanently and may even cause sudden death.

“So, all guidance states that all exercise should be stopped completely for at least 3 months, to rest the heart. Depending on the results of the follow-up heart scan, the cardiologist may also prescribe medications if the heart appears to have been weakened by the infection. The patient will have another assessment after 3 months to determine if their heart is strong enough to return to sport; some athletes may need to rest for another 3 months.

“Our publication includes an algorithm to guide athletes, club doctors and sporting bodies as to when evaluation by a heart specialist is necessary to ensure safe return to training in those with confirmed or suspected COVID-19. It provides a realistic approach which balances the concerns of the impact of COVID-19 on the heart versus subjecting athletes to unnecessary investigations, taking into consideration available resources for the elite but also for the millions of recreational exercisers.”

The new publication, supported by CRY’s research programme, highlights myriad issues and questions including; specific advice for Marathon runners (who will have seen training regimes disrupted across the world with the cancelled of numerous high profile events); concerns about whether all athletes should be tested for COVID-19 before returning to their season; if they are more or less susceptible to becoming infected or experiencing serious side effects; and does management of the virus differ in athletes to the general population?

To address and discuss these many issues, Dr Papadakis and Professor Sharma will be hosting a unique, live webinar on Monday 15^th June at 3pm. There will be no charge made to those wishing to attend the session (whether they are athletes, Club officials and medics, general public, or members of the media) but there will be an opportunity to make a donation to help support CRY’s research programme through the COVID-19 crisis.

If you would like to register for the webinar go to www.c-r-y.org.uk/covid19

Dr Steven Cox, CRY’s Chief Executive, adds; “We are pleased that our research team have been able to provide the most up to date advice for both patients and the medical community, as well as young people who want to stay as fit and healthy as possible throughout this crisis. This is an incredibly challenging time for everyone, and this guidance will help to give people some confidence in their decisions when they are surrounded by so much uncertainty.”