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COVID-19 RECOVERY IN ATHLETES: THE UK WORLD CLASS OLYMPIC AND PARALYMPIC EXPERIENCE FEATURE / CRAIG RANSON & JAMES HULL Introduction The COVID-19 pandemic has had and continues to have a devastating impact on global health. Within elite sport, there are typically three main considerations for health practitioners when assessing the athlete who has been infected with COVID-19. Firstly, the risk of illness to an athlete’s immediate health. During the early part of the pandemic, there was major concern over reports relating to a high incidence of COVID-19-related myocarditis in young athletes. Fortunately, subsequent well conducted studies provided some reassurance that this is not a common phenomenon in those with a previous diagnosis of COVID-19. Secondly, the nature of any guidance on acute management and subsequent return activity and duration recommendations. Thirdly, the identification of factors that indicate the likelihood of a prolonged recovery or ‘long COVID’ illness. What have we learnt from the UK World Class Olympic and Paralympic Sport experience? Practitioners from UK Home Country Sports Institutes (HCSI) in England, Scotland, Wales and Northern Ireland have closely monitored COVID-19 related illness in World Class Programme (WCP) Olympic and Paralympic Sport athletes, assessing the aforementioned factors. Since the onset of the pandemic in 2020 to the present time, there have been 410 recorded cases of COVID-19 related illness in 357 athletes (Figure 1). This equates to approximately one quarter of the WCP population experiencing over 10,000 time-loss days (restricted or unavailable to train). The context of that time-loss was particularly pertinent given the preparatory cycle for the Tokyo summer and Beijing Winter Olympic and Paralympic games, disrupted not only by widespread illness, but also the mandatory training and travel restrictions imposed as part of the global public health strategy to manage the pandemic. For the most part, COVID-19-related illness in the WCP cohort has been a relatively mild illness (i.e., not required hospital care or specific treatments). On balance, duration appears to be shorter lived as the pandemic progresses, with the median
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Figure 1. WCP athlete COVID-19 cases recorded per month of incidence
number days of restricted training reducing from 18 days during the first year (to end Feb 2021) to 13 days in the second year. In late 2021 we published our experience of the impact of COVID-19 illness within the WCP1. In this analysis, we evaluated the pattern of symptoms at presentation (Box 1) and used this phenotype-based approach to provide insight regarding symptom clusters and how they might inform return to sport. The analysis found that whilst most infected athletes returned to full sport participation within two to three weeks, one quarter (23%) experienced restricted athlete training for over 28 days. Four percent of infected athletes were restricted for more than 100 days and a couple of those have been unable to return to elite sport participation. The phenotype prevalence was different in each of the first two waves. During the first wave (Feb 2020 – July 2020), 86% of cases were from one of three respiratory phenotypes and 26% had a specific lower respiratory focus e.g., dyspnoea and chest pain. However, during the second wave (Aug 2020 – Jan 2021) only 72% of cases were from a respiratory phenotype, with just 7% of all cases having a lower respiratory focus. This means that proportionally fewer athletes presented with respiratory symptoms and more athletes presented with general viral symptoms, such as headache and fatigue. Across the board, those with a lower respiratory phenotype were approximately twice as likely to result in more than 28 days time-loss. Our finding that approximately 1 in 4 athletes diagnosed with COVID-19 did not return to
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full training within 28 days was compared to our historical data that showed only 1 in 25 athletes diagnosed with a viral URTI had more than 28 days time-loss. Whilst HOW COVID-19 PRESENTED: THE 5 SYMPTOM PHENOTYPES
1. Upper respiratory focus (UR); sore throat +/- change in smell or taste or sinus problems reported +/- a cough +/- fever. 2. Lower respiratory focus (LR); presence of dyspnoea +/- chest pain +/- cough +/- fever +/- other lower respiratory tract symptoms; e.g. wheeze. 3. Cough only (CO); cough as the predominant symptom recorded and in the absence of co-existing dyspnoea and without other UR symptoms. 4.
Gastrointestinal (GI); with predominant symptoms being diarrhoea +/- nausea +/- abdominal pain.
5. Non-specific (NS); main clinical feature was fever, fatigue +/- headache +/myalgia but a lack of any prominent respiratory or GI symptoms. symptom duration was associated with training time-loss, another factor that may have contributed to this comparatively long impact on participation was the production of a HCSI COVID-19 Return to Play Protocol2. This protocol recommended a minimum of 17 days before full training or competition participation. This might now appear conservative, however in
