COVID-19 in German Competitive Sports: Protocol for a Prospective Multicenter Cohort Study (CoSmo-S)

COVID-19's Impact on Athletes: Reduced Cardiorespiratory Fitness after a SARS-CoV-2 Infection

OBJECTIVE

This study aimed to identify potential changes in cardiorespiratory fitness among athletes who had previously been infected with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2).

METHODS

In this prospective observational multicenter hybrid study (CoSmo-S), cardiopulmonary exercise testing on treadmills or bicycle ergometers involving 2314 athletes (39.6% female) was conducted. German federal squad members (59.6%) and non-squad athletes were included in the study. A total of 1170 (37.2% female) subjects were tested positive for SARS-CoV-2 via polymerase chain reaction from which we had pre-SARS-CoV-2 infection examinations available for 289 subjects. Mixed-effect models were employed to analyze, among others, the following dependent variables: power output at individual anaerobic threshold (PO IAT ·kg -1 ), maximal power output (PO max ·kg -1 ), measured V̇O 2max ·kg -1 , heart rate at individual anaerobic threshold (HR IAT ), and maximal heart rate (HR max ).

RESULTS

A SARS-CoV-2 infection was associated with a decrease in PO IAT ·kg -1 (-0.123 W·kg -1 , P < 0.001), PO max ·kg -1 (-0.099 W·kg -1 , P = 0.002), and measured V̇O 2max ·kg -1 (-1.70 mL·min -1 ·kg -1 , P = 0.050), and an increase in HR IAT (2.50 bpm, P = 0.008) and HR max (2.59 bpm, P < 0.001) within the first 60 d after SARS-CoV-2 infection. Using the pandemic onset in Germany as a longitudinal reference point, the healthy control group showed no change over time in these variables and an increase in PO max (+0.126 W·kg -1 , P = 0.039) during the first 60 d after the reference point. Subgroup analyses showed that both squad members and endurance athletes experienced greater decreases in cardiorespiratory fitness compared with non-squad members respectively athletes from explosive power sports.

CONCLUSIONS

A SARS-CoV-2 infection is associated with a decline in cardiorespiratory fitness in athletes for approximately 60 d. Potential factors contributing to this outcome seem to be cardiopulmonary and vascular alterations in consequence of SARS-CoV-2. A minor effect on cardiorespiratory fitness has training interruption due to acute symptoms and/or quarantine.

Cardiac Function and Structure before and after Mild SARS-CoV-2 Infection in Elite Athletes Using Biventricular and Left Atrial Strain

BACKGROUND/OBJECTIVES

Myocardial involvement has been observed in athletes following SARS-CoV-2 infection. It is unclear if these changes are due to myocardial damage per se or to an interruption in training. The aim of this study was to assess cardiac function and structure in elite athletes before and after infection (INFAt) and compare them to a group of healthy controls (CON).

METHODS

Transthoracic echocardiography was performed in 32 elite athletes, including 16 INFAt (median 21.0 (19.3-21.5) years, 10 male) before (t0) and 52 days after (t1) mild SARS-CoV-2 infection and 16 sex-, age- and sports type-matched CON. Left and right ventricular global longitudinal strain (LV/RV GLS), RV free wall longitudinal strain (RV FWS) and left atrial strain (LAS) were assessed by an investigator blinded to patient history.

RESULTS

INFAt showed no significant changes in echocardiographic parameters between t0 and t1, including LV GLS (-21.8% vs. -21.7%, p = 0.649) and RV GLS (-29.1% vs. -28.7%, p = 0.626). A significant increase was observed in LA reservoir strain (LASr) (35.7% vs. 47.8%, p = 0.012). Compared to CON, INFAt at t1 had significantly higher RV FWS (-33.0% vs. -28.2%, p = 0.011), LASr (47.8% vs. 30.5%, p < 0.001) and LA contraction strain (-12.8% vs. -4.9%, p = 0.050) values.

CONCLUSIONS

In elite athletes, mild SARS-CoV-2 infection does not significantly impact LV function when compared to their pre-SARS-CoV-2 status and to healthy controls. However, subtle changes in RV and LA strain may indicate temporary or training-related adaptions. Further research is needed, particularly focusing on athletes with more severe infections or prolonged symptoms.

Return to play of young and adult professional athletes after COVID-19: A scoping review

Background/objective

Given the persistence of COVID-19 under various facets and mutations, there is an urgent need to understand the debate on a safe return to play for professional athletes (young and adults) recovering from the infection. This work offers a scoping and comprehensive review on the topic during the first two years of the pandemic event by providing an identification of main clusters of research, relevant gaps and significant insights for future investigation.

Methods

The literature is selected using the search engines of: PubMed®, SCIENCEDIRECT, and SCOPUS. Further criteria for selection are: Time range of 2020-2022; Scope: Return to play of professional athletes recovering from COVID-19 infection; 3) Types of publications: Research papers, reviews, practice guidelines, case reports; 4) Language: English. Two independent researchers performed a quality check on a random sample (n = 30%) of publications.

Results

Main results reveal four research clusters deepening the analysis on: myocarditis, cardiac diseases and return to play, training and rehabilitation, mass screening and risk assessment, and sport and bio-psycho-social sphere for a safe return to play. Major collaborations occur between UK-South Africa, UK-USA, USA-Canada, and USA-Australia.

Conclusions

Important gaps refer to a lack of investigation on a safe return to play for female athletes in mostly all sports disciplines; on the other hand, sport and the bio-psycho-social sphere of the athlete is a fast-growing topic. Both deserve further attention in the immediate future to improve ad-hoc sport and exercise practices.

COVID-19 in Female and Male Athletes: Symptoms, Clinical Findings, Outcome, and Prolonged Exercise Intolerance-A Prospective, Observational, Multicenter Cohort Study (CoSmo-S)

BACKGROUND

An infection with SARS-CoV-2 can lead to a variety of symptoms and complications, which can impair athletic activity.

OBJECTIVE

We aimed to assess the clinical symptom patterns, diagnostic findings, and the extent of impairment in sport practice in a large cohort of athletes infected with SARS-CoV-2, both initially after infection and at follow-up. Additionally, we investigated whether baseline factors that may contribute to reduced exercise tolerance at follow-up can be identified.

METHODS

In this prospective, observational, multicenter study, we recruited German COVID elite-athletes (cEAs, n = 444) and COVID non-elite athletes (cNEAs, n = 481) who tested positive for SARS-CoV-2 by PCR (polymerase chain reaction test). Athletes from the federal squad with no evidence of SARS-CoV-2 infection served as healthy controls (EAcon, n = 501). Questionnaires were used to assess load and duration of infectious symptoms, other complaints, exercise tolerance, and duration of training interruption at baseline and at follow-up 6 months after baseline. Diagnostic tests conducted at baseline included resting and exercise electrocardiogram (ECG), echocardiography, spirometry, and blood analyses.

RESULTS

Most acute and infection-related symptoms and other complaints were more prevalent in cNEA than in cEAs. Compared to cEAs, EAcon had a low symptom load. In cNEAs, female athletes had a higher prevalence of complaints such as palpitations, dizziness, chest pain, myalgia, sleeping disturbances, mood swings, and concentration problems compared to male athletes (p < 0.05). Until follow-up, leading symptoms were drop in performance, concentration problems, and dyspnea on exertion. Female athletes had significantly higher prevalence for symptoms until follow-up compared to male. Pathological findings in ECG, echocardiography, and spirometry, attributed to SARS-CoV-2 infection, were rare in infected athletes. Most athletes reported a training interruption between 2 and 4 weeks (cNEAs: 52.9%, cEAs: 52.4%), while more cNEAs (27.1%) compared to cEAs (5.1%) had a training interruption lasting more than 4 weeks (p < 0.001). At follow-up, 13.8% of cNEAs and 9.9% of cEAs (p = 0.24) reported their current exercise tolerance to be under 70% compared to pre-infection state. A persistent loss of exercise tolerance at follow-up was associated with persistent complaints at baseline, female sex, a longer break in training, and age > 38 years. Periodical dichotomization of the data set showed a higher prevalence of infectious symptoms such as cough, sore throat, and coryza in the second phase of the pandemic, while a number of neuropsychiatric symptoms as well as dyspnea on exertion were less frequent in this period.

CONCLUSIONS

Compared to recreational athletes, elite athletes seem to be at lower risk of being or remaining symptomatic after SARS-CoV-2 infection. It remains to be determined whether persistent complaints after SARS-CoV-2 infection without evidence of accompanying organ damage may have a negative impact on further health and career in athletes. Identifying risk factors for an extended recovery period such as female sex and ongoing neuropsychological symptoms could help to identify athletes, who may require a more cautious approach to rebuilding their training regimen.

TRIAL REGISTRATION NUMBER

DRKS00023717; 06.15.2021-retrospectively registered.

Assessment of myocardial function and cardiac performance using left ventricular global longitudinal strain in athletes after COVID-19: a follow-up study

Background

It has not yet been conclusively determined whether reduced left ventricular global longitudinal strain (LV GLS) after COVID-19 contributes to a reduction in exercise capacity. Our own studies showed a possible mild myocardial involvement in the form of reduced LV GLS in athletes after COVID-19 compared with healthy athletes. The aims of this prospective follow-up study were to investigate the development of LV GLS over a 3-month period in athletes after COVID-19 and the possible relationship between LV GLS and physical performance.

Methods

LV GLS was determined in four-, two-, and three-chamber views and assessed offline by a blinded investigator in 96 recreational athletes (mean age 33.15 ± 12.40 years, 53 male, peak VO2 38.82 ± 11.14 ml/min/kg) at a median of two (t0) and five months (t1) after COVID-19. Cardiopulmonary exercise testing (CPET) was performed on a bicycle ergometer on both examination dates.

Results

LV GLS improved significantly between t0 and t1 (t0 -18.82 ± 2.02 vs. t1 -19.46 ± 2.05, p < 0.001). Echocardiographic and spiroergometric parameters were within the normal clinical reference range. Maximum power increased significantly from t0 to t1 (t0 283.17 ± 83.20 vs. t1 286.24 ± 85.22 Watt, p = 0.009) and there was a trend toward increased peak oxygen uptake (t0 36.82 ± 11.14 vs. t1 38.68 ± 10.26 ml/min/kg, p = 0.069). We found no correlation between LV GLS and performance parameters, except for the respiratory exchange ratio (RER) [ρ -0.316, (-0.501; -0.102), p < 0.050].

Conclusions

Significant improvement in LV GLS approximately five months after COVID-19 may be due to mild myocardial involvement during or shortly after COVID-19, which seems to recover. There was no correlation between LV GLS and performance parameters, except for an inverse correlation of LV GLS and RER, suggesting insufficient exercise intolerance at lower GLS values. Further studies on the development of GLS in athletes or in the general population with moderate and severe disease courses would be informative as well as the comparison of pre-COVID-19 with post-COVID-19 echocardiography to evaluate the effects of COVID-19 on cardiac function.

Blood Profiling of Athletes after COVID-19: Differences in Blood Profiles of Post-COVID-19 Athletes Compared to Uninfected Athletic Individuals-An Exploratory Analysis

Blood profiling data in athletic populations and their respective responses to SARS-CoV-2 infection are lacking. Thus, this exploratory pilot study aimed to analyze and compare clinical blood markers in previously infected trained athletes (ATH; 30 m/29 f) and a not previously infected healthy athletic control group (HC; 12 m/19 f). The ATH group undertook a sports medical examination which included extended blood analyses. Blood profiles with a total of 74 variables were assessed (blood counts, pro-/inflammatory and immunological markers, and micronutrients), and the ATH group was compared to the age-matched, vaccinated HC group with comparable athletic back grounds, though without previous SARS-CoV-2-infections. The ATH group showed lower IgG, Troponin-T levels, and they had a lower complement/acute-phase protein activation. Furthermore, Vitamin D levels were lower and electrolyte/micronutrient concentrations were higher in ATH. Soluble transferrin receptor as a marker of erythrocyte turnover was decreased whereas PTT as a coagulation marker was increased. Subgroup analyses according to sex revealed more differences between the women of the ATH and HC groups (for 25 different variables) than between the men (for 5 different variables), especially for immunological and metabolic variables. In particular, the immune system and electrolyte/micronutrient status should be observed frequently and sex-specifically in this athletic cohort.

Former SARS-CoV-2 Infection Was Related to Decreased VO2 Peak and Exercise Hypertension in Athletes

The impact of former COVID-19 infection on the performance of athletes is not fully understood. We aimed to identify differences in athletes with and without former COVID-19 infections. Competitive athletes who presented for preparticipation screening between April 2020 and October 2021 were included in this study, stratified for former COVID-19 infection, and compared. Overall, 1200 athletes (mean age 21.9 ± 11.6 years; 34.3% females) were included in this study from April 2020 to October 2021. Among these, 158 (13.1%) athletes previously had COVID-19 infection. Athletes with COVID-19 infection were older (23.4 ± 7.1 vs. 21.7 ± 12.1 years, p < 0.001) and more often of male sex (87.7% vs. 64.0%, p < 0.001). While systolic/diastolic blood pressure at rest was comparable between both groups, maximum systolic (190.0 [170.0/210.0] vs. 180.0 [160.0/205.0] mmHg, p = 0.007) and diastolic blood pressure (70.0 [65.0/75.0] vs. 70.0 [60.0/75.0] mmHg, p = 0.012) during the exercise test and frequency of exercise hypertension (54.2% vs. 37.8%, p < 0.001) were higher in athletes with COVID-19 infection. While former COVID-19 infection was not independently associated with higher blood pressure at rest and maximum blood pressure during exercise, former COVID-19 infection was related to exercise hypertension (OR 2.13 [95%CI 1.39-3.28], p < 0.001). VO₂ peak was lower in athletes with compared to those without COVID-19 infection (43.4 [38.3/48.0] vs. 45.3 [39.1/50.6] mL/min/kg, p = 0.010). SARS-CoV-2 infection affected VO₂ peak negatively (OR 0.94 [95%CI 0.91-0.97], p < 0.0019). In conclusion, former COVID-19 infection in athletes was accompanied by a higher frequency of exercise hypertension and reduced VO₂ peak.

Effectiveness of patient triage at the orthopedic hospital and the hygiene concept in a professional handball team in the first year of the SARS-CoV-2 pandemic

The first severe acute respiratory syndrome coronavirus type 2 (SARS-CoV‑2) pandemic wave in Germany in spring 2020 challenged the largely unprepared healthcare system. A prevention concept was implemented to protect the vulnerable patient group at our orthopedic department. The patient triage during the pre-admission process included screening for symptoms and obtaining information on travel, occupation, contact and cluster (TOCC) [16].In March 2020, all sporting events were also cancelled or postponed [12]. Mitigation strategies for sport activities were necessary to restart training and competition. For the professional handball team of the Sport Club Magdeburg (SCM), a hygiene concept including strict mitigation measures combined with a polymerase chain reaction (PCR) test regime was implemented.We reviewed 15,739 patient contacts in a 12-month period at orthopedic department during the SARS-CoV‑2 pandemic. This epidemiological, retrospective study presents the results of patient triage detecting cases with suspected SARS-CoV‑2 infections when entering the clinic. We also considered 2328 inpatient PCR test results and the infection rates among the medical staff. At the same period, professional athletes underwent 1428 PCR tests as a part of the hygiene concept.During the triage process, 333 cases (2.12%) with suspected SARS-CoV‑2 infections were detected at the orthopedic outpatient department. Three patients had a positive PCR test result after triage. Another four positive PCR tests were found among the inpatient group and one positive result among the medical staff. In the athletes' cohort, none of the 1428 PCR tests was positive.Patient triage as a part of the preadmission process is an effective tool to protect the maximum-care hospital from a SARS-CoV‑2 mass outbreak. A hygiene concept with a defined PCR test regime protects a professional athlete team from SARS-CoV‑2 infections during international competition and training.

Inflammation and severity of depressive symptoms in physically active individuals after COVID-19 – An exploratory immunopsychological study investigating the effect of inflammation on depressive symptom severity

Background

SARS-CoV-2 infection is a risk factor for the development of depressive symptoms such as lack of energy, loss of interest, and depressed mood. Inflammatory processes might underline this association. The aim of this study was to investigate the association between inflammatory markers and the severity of depression after SARS-CoV-2 infection, and the predictive effect of inflammatory markers on the severity of depressive symptoms. Lifestyle factors and lifestyle-related diseases can influence inflammation and depressive symptoms. As these lifestyle factors and lifestyle-related diseases are less common in physically active individuals, they are a suitable population for investigating this research question.

Methods

We investigated 61 at least moderate physically active individuals on average ∼6 months (SD = 4.22, range = 0.5–19 months) after SARS-CoV-2 infection (t₀) and performed a follow-up after 3 months (t₁). Depressive symptoms and biomarkers of inflammation (interleukin [IL]-1β, IL-8, IL-10, Ferritin, Lipopolysaccharide-binding-protein [LBP], neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], lymphocyte-to-monocyte ratio [LMR]) and kynurenine [KYN] were measured at both time points. Concentrations of inflammatory markers at t₀ were used to predict the severity of depressive symptoms at t₀ and t₁.

Results

Concentrations of KYN were negatively related to the severity of depressive symptoms at t_0. Concentrations of LMR predicted higher depressive symptoms at t₀ as well as at t₁. Furthermore, individuals with lower concentrations of LBP at t₀ showed a higher severity of depressive symptoms at t₁. No correlation was found between severity of depressive symptoms and IL1β, IL-8, IL-10, ferritin, NLR, and PLR at both time points.

Conclusions

KYN, LBP and LMR might be useful as a predictive factor of depressive symptoms in physically active individuals after SARS-CoV-2 infection. While the results for KYN confirm the current scientific evidence, our results highlight the importance of the innovative inflammatory markers LMR and LBP. LMR and LBP might be interesting targets for predicting the development of depressive symptoms in SARS-CoV-2 infected populations and should be further investigated in future studies.

Relationship between physical performance and perception of stress and recovery in daily life post COVID-19-An explorative study

INTRODUCTION

COVID-19 is a multi-systemic disease which can target the lungs and the cardiovascular system and can also affect parts of the brain for prolonged periods of time. Even healthy athletes without comorbidities can be psychologically affected long-term by COVID-19.

OBJECTIVE

This study aimed to investigate athletes' perceived mental stress and recovery levels in daily life, and their maximal aerobic power, at three different time points, post COVID-19.

METHODS

In total, 99 athletes (62.6% male), who had been infected by COVID-19, filled out the Recovery Stress Questionnaire for Athletes (REST-Q-Sport) and completed cardiopulmonary exercise testing (endpoint maximal aerobic power output (Pmax)) at the initial screening (t1: 4 months after infection). Follow-up assessments occurred three (t2, n = 37) and seven months after t1 (t3, n = 19).

RESULTS

Subgroup means from the Recovery category were significantly below the reference value of four at all three time points, except "General Recovery" (3.76 (± 0.96), p = 0.275, d = 0.968) at t3."Overtiredness" (2.34 (± 1.27), p = 0.020, r = 0.224) was significantly above the reference value of two at t1, while all other Stress subgroups were not significantly different from the reference value or were significantly below the maximum threshold of two at t1, t2 and t3. Spearman's ρ revealed a negative association between Pmax and the subcategories of stress (ρ = -0.54 to ρ = -0.11, p < 0.050), and positive correlations between Pmax and "Somatic Recovery" (ρ = 0.43, p < 0.001) and "General Recovery" (ρ = 0.23, p = 0.040) at t1. Pmax (t1: 3.83 (± 0.99), t2: 3.78 (± 1.14), β = 0.06, p < 0.003) increased significantly from t1 to t2. In addition, REST-Q-Sport indicated a decrease in "Sleep" (t2 = 2.35 (± 0.62), t3 = 2.28(± 0.61), β = -0.18, p < 0.023) at t3, when compared to t2.

CONCLUSION

The perceived recovery seems to be negatively affected in post COVID-19 athletes. Physical performance post COVID-19 correlates with both "Emotional and Somatic Stress" and "Somatic and General Recovery", indicating potential mental and physical benefits of exercise. While it is evident that COVID-19, like other viral infections, may have an influence on physical performance, monitoring stress and recovery perceptions of athletes is critical to facilitate their return-to-sports, while minimizing long-term COVID-19 induced negative effects like the athletic objective and subjective perceived recovery and stress levels.

Recovery of performance and persistent symptoms in athletes after COVID-19

INTRODUCTION

After the acute Sars-CoV-2-infection, some athletes suffer from persistent, performance-impairing symptoms, although the course of the disease is often mild to moderate. The relation between cardiopulmonary performance and persistent symptoms after the acute period is still unclear. In addition, information about the development of this relationship is lacking.

OBJECTIVE

To assess the prevalence of persistent symptoms over time and their association with the performance capability of athletes.

METHODS

We conducted two cardiopulmonary exercise tests (CPET) in a three months interval with 60 athletes (age: 35.2±12.1 years, 56.7% male) after infection with Sars-CoV-2 (t0: study inclusion; t1: three months post t0). At each examination, athletes were asked about their persistent symptoms. To evaluate the change of Peak VO2/BM (Body Mass) between the time before infection and the first examination, the VO2/BM (predVO2) before infection was predicted based on anthropometric data and exercise history of the athletes. For data analysis, athletes were grouped according to their symptom status (symptom-free, SF; persistent symptoms, PS) and its progression from the first to the second examination 1) SF-SF, 2) PS-SF and 3) PS-PS.

RESULTS

Comparing the SF and PS groups at t0, significant differences for Max Power/BM, Max Power/lbm (lean body mass), Peak VO2, Peak VO2/BM, Peak VO2/lbm, Peak VO2/HR, Peak VE, Peak Vt and VE/VCO2-Slope were observed. Regarding the progression over three months, an increase in Max Power/BM was shown in SF-SF and PS-SF (tendency). Max Power/lbm increased in SF-SF and PS-PS (tendency). A decrease of VE/VCO2-Slope in PS-PS was found.

CONCLUSION

COVID-19 led to a decline in performance that was greater in PS than in SF. Additionally, PS had decreased ventilatory parameters compared to SF. Furthermore, an improvement over time was observed in some CPET parameters and a partial recovery was observed judging by the decrease in various symptoms.