{"id":10300,"date":"2022-11-18T06:00:43","date_gmt":"2022-11-18T05:00:43","guid":{"rendered":"https:\/\/blogs.bmj.com\/bjsm\/?p=10300"},"modified":"2022-11-16T11:09:58","modified_gmt":"2022-11-16T10:09:58","slug":"lets-play-ball-covid-19-graduated-return-to-play-guidlelines","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bjsm\/2022\/11\/18\/lets-play-ball-covid-19-graduated-return-to-play-guidlelines\/","title":{"rendered":"Let’s Play Ball: COVID-19 Graduated Return to Play Guidlelines"},"content":{"rendered":"

Keywords:\u00a0<\/strong>Basketball, COVID-19, return to play<\/p>\n

The outbreak of Coronavirus disease (COVID-19) resulted in suspension of youth, academic and professional sport in New Zealand, and around the world.\u00a0 Following resumption of domestic and international competition there have been several reports of an increased number of athletes testing positive for COVID-19 after returning to competition (1).<\/span> In light of these concerns, it is essential that sporting organisations provide \u2018informative, consistent and specific guidance for safe return to training and competition\u2019 (2),<\/span> delivered in context to the sport. This blog presents an overview of the Basketball New Zealand COVID-19 Graduated Return to Play (GRTP) Guidelines and is written to assist athletes resume safe training ahead of return to competition that promotes health and performance in an easy-to-follow GRTP infographic.<\/span><\/p>\n

Guidance Scope\u00a0<\/b><\/p>\n

In light of recent concerns surrounding the return to play of athletes following COVID-19 disease, this document has been prepared by the Basketball New Zealand Coronavirus (COVID-19) Framework Project Team to provide guidelines for coaches and athletes, taking into consideration the New Zealand Public Health guidelines regarding COVID-19 at the time of publication (3).<\/span>\u00a0\u00a0<\/span>As public health guidelines will continue to change as greater levels of evidence are published (<\/span>4-6),<\/span> these changes need to be considered before advising athletes.<\/span><\/p>\n

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Target audience and applicability of guidelines<\/b><\/p>\n

The guidelines are ONLY applicable to those who have had mild to moderate illness (or are asymptomatic), and not requiring hospital care. The guidelines are <\/span>NOT<\/span> suitable for those who are not being closely supervised by a healthcare practitioner. In such cases, it is recommended that you seek guidance from appropriate physician.<\/span><\/p>\n

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Expert Opinion<\/b><\/p>\n

The guidance is based on expert opinion of leading medical, academic and high-performance personnel, taking into consideration the current available literature on Graduated Return to Play (GRTP) outlining experiences of athletes who are known to have contracted COVID-19. This has resulted in published guidelines moving closer to a \u2018symptoms\u2019 as opposed to \u2018time-course\u2019 based approach (<\/span>7-10).<\/span><\/p>\n

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Athlete Progression<\/b><\/p>\n

As athletes may unintentionally detrain as a result of self-isolation periods following COVID-19 infection due to the illness and\/or lack of facilities to maintain their fitness (<\/span>11, 12)<\/span> it is recommended that athlete training progressions follow a linear step-type loading principle with incremental increases in training load (<\/span>13, 14). <\/span>The GRTP guidelines outline that the athlete can advance to the next stage <\/span>ONLY<\/span> if there are <\/span>NO<\/span> worsening of symptoms at rest, and at the level of physical activity achieved in the previous GRTP stage without a worsening of\u00a0 symptoms. The concepts of training load, progression, and recovery are key considerations for coaches, performance staff and team physicians supporting athletes (<\/span>15),<\/span> and have been previously addressed (<\/span>13).<\/span>\u00a0<\/span><\/p>\n

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50\/30\/20\/10 Rule\u00a0\u00a0<\/b><\/p>\n

The <\/span>\u201c50\/30\/20\/10\u201d rule<\/span><\/i> serves as a useful approach to individual and team load progression, as outlined in the Joint Consensus Paper by the National Strength and Conditioning Association (NSCA) and Collegiate Strength and Conditioning Coaches Association (CSCCa) (<\/span>16).<\/span>\u00a0 With the reintegration of players into the training environment, it is recommended to reduce the overall training volume by 50% of the uppermost planned volume initially. This is followed by a 30% reduction in uppermost planned volume, then 20%, and 10%.<\/span> Such an approach to progressive overload may assist with the successful reintegration into the training environment. Follow this link <\/a><\/span>for more detail of the 50\/30\/20\/10 rule (13).<\/span><\/p>\n

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Recovery Strategies<\/b><\/p>\n

Recovery is defined as a <\/span>\u2018multifaceted (e.g., physiological and psychological) restorative process relative to time\u2019 (<\/span><\/i>17). <\/span>From a basketball-specific perspective, recovery should target the physiological and psychological stress associated with the return to training and competition (<\/span>18).<\/span> Common recovery strategies include sleep, cold water immersion, massage, compression, nutrition and hydration interventions (<\/span>19-21).<\/span>\u00a0 It is also important that psychological and emotional wellness is not be overlooked during this process (<\/span>22).<\/span> As there is no<\/span> \u2018one-size-fits-all\u2019<\/span><\/i> approach to recovery (<\/span>20),<\/span> it is important to educate athletes about the importance of individualised, self-initiated, proactive recovery strategies (<\/span>19-21).<\/span><\/p>\n

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Protocol Commencement<\/b><\/p>\n

This GRTP protocol should only commence when the athlete is:<\/span><\/p>\n

    \n
  1. Free from all but the mildest \u2018above neck\u2019 symptoms (e.g., mild headache, loss of taste or smell); and<\/span><\/li>\n
  2. Off treatments that may mask symptoms (e.g., paracetamol).<\/span><\/li>\n<\/ol>\n

    NOTE: In the case that a symptomatic athlete tests negative for COVID-19 they should continue to consult with their physician during their recovery, as per any viral illnesses.<\/span><\/p>\n

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    Red Flag Indicators<\/b><\/p>\n

    If any of the \u2018red flags\u2019 indicators outlined in Table 1 or other concerning symptoms occur, a medical practitioner should be consulted immediately, and as a minimum the athlete should rest and reattempt the previous stage after at least 24 hour without symptoms. It is recommended that a medical practitioner be consulted at any stage if there are concerning symptoms or indications (i.e., \u2018red flags\u2019).<\/span><\/p>\n

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    Table 1. Red Flags Indications<\/b><\/p>\n\n\n\n\n\n\n\n\n\n\n\n
    Indicator<\/b><\/td>\nDescriptor<\/b><\/td>\n<\/tr>\n
    Severe or increasing breathlessness<\/b><\/td>\nDisproportionate to the amount of effort.<\/span><\/td>\n<\/tr>\n
    Thromboembolic events<\/b><\/td>\nUnusual, sharp, pain or discomfort in chest or abdomen, muscle pain +\/- limb swelling.<\/span><\/td>\n<\/tr>\n
    Exertional light-headedness<\/b><\/td>\nNot just when standing up from a sitting position<\/span><\/td>\n<\/tr>\n
    Syncope<\/b><\/td>\nFainting \/ passing out<\/span><\/td>\n<\/tr>\n
    Unusually high heart rate<\/b><\/td>\nDuring exercise or slow HR recovery on cessation of exercise.<\/span><\/td>\n<\/tr>\n
    Unusually high RPE<\/b><\/td>\nFor a given exercise intensity (compared with previous known RPE responses.<\/span><\/td>\n<\/tr>\n
    Psychological<\/b><\/td>\nIncreased mental health \/ anxiety-related difficulties<\/span><\/td>\n<\/tr>\n
    Athlete illness perception<\/b><\/td>\nIncreased perception of moderate \/ severe illness symptoms<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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    Adapted from the UK Home Countries Institutes of Sport (<\/span>10)<\/span> and Elliott and colleagues (<\/span>23).<\/span><\/p>\n

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    GRTP descriptions and progressions\u00a0<\/b><\/p>\n

    Table 2 describes GRTP actives and progression of stages for athletes who experience any \u2018below neck\u2019 symptoms. While Table 3 outlines GRTP actives and progression of stages for athletes who are either asymptomatic or have mild above neck symptoms only. These stages are outlined in the accompanying infographic at the bottom of this blog.<\/span><\/p>\n

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    Table 2. GRTP descriptions and progressions: \u2018below neck\u2019 symptoms<\/b><\/p>\n\n\n\n\n\n\n\n\n\n
    Stage<\/b><\/td>\nDescriptor<\/b><\/td>\n<\/tr>\n
    STAGE 1<\/b><\/td>\n\n
      \n
    • Involves minimum rest period during 7-days self-isolation (<\/span>19)<\/span> in order to optimise the recovery and protect the cardio-respiratory system.\u00a0<\/span><\/li>\n
    • Household activities and light exercise when feeling well enough.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    STAGE 2<\/b><\/td>\n\n
      \n
    • If symptoms are improving, and physician approves, progression to stage 2.\u00a0<\/span><\/li>\n
    • Light aerobic activity. Keep the intensity low (RPE 1-2).\u00a0<\/span><\/li>\n
    • <70% HR max working for 15 minutes only.\u00a0<\/span><\/li>\n
    • Monitor how you feel the next day.<\/span><\/li>\n
    • Progression over a minimum of 2 days.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    STAGE 3a<\/b><\/td>\n\n
      \n
    • Increase the intensity of the activities working at <80% HR max (RPE 3-4).\u00a0<\/span><\/li>\n
    • Complete <50% uppermost training load. <\/span><\/li>\n
    • Progression over a minimum of 2 days.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    STAGE 3b<\/b><\/td>\n\n
      \n
    • Progress to more complex training drills at RPE 5-6 for 45 minutes.\u00a0<\/span><\/li>\n
    • Perform conditioning activities at a heart rate <80% HR max.\u00a0<\/span><\/li>\n
    • Introduce competitive drills <20% of session time.\u00a0<\/span><\/li>\n
    • Complete <70% uppermost training load.<\/span><\/li>\n
    • Progression over a minimum of 2 days.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    STAGE 4<\/b><\/td>\n\n
      \n
    • Resume team training<\/span><\/li>\n
    • Complete <80% uppermost training load.\u00a0<\/span><\/li>\n
    • Keep heart rate <80% HR max and train for 60 minutes.\u00a0<\/span><\/li>\n
    • Competitive and contact work <30% of session time.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    STAGE 5<\/b><\/td>\n\n