key: cord-1052354-j3he9u76
authors: Pillay, Lervasen; Janse van Rensburg, Dina C. Christa; Jansen van Rensburg, Audrey; Ramagole, Dimakatso A.; Holtzhausen, Louis; Dijkstra, H. Paul; Cronje, Tanita
title: Nowhere to hide: the significant impact of coronavirus disease 2019 (COVID-19) measures on elite and semi-elite South African athletes
date: 2020-05-19
journal: J Sci Med Sport
DOI: 10.1016/j.jsams.2020.05.016
sha: 5cd6e5f8bb630750da503e5e0212b377920e2dba
doc_id: 1052354
cord_uid: j3he9u76

Abstract Objective To describe the perceptions of South African elite and semi-elite athletes on return to sport (RTS); maintenance of physical conditioning and other activities; sleep; nutrition; mental health; healthcare access; and knowledge of coronavirus disease 2019 (COVID-19). Design Cross-sectional study Methods A Google Forms survey was distributed to athletes from 15 sports in the final phase (last week of April 2020) of the level 5 lockdown period. Descriptive statistics were used to describe player demographic data. Chi-squared tests investigated significance (p<0.05) between observed and expected values and explored sex differences. Post-hoc tests with a Bonferroni adjustment were included where applicable. Results 67% of the 692 respondents were males. The majority (56%) expected RTS after 1-6months. Most athletes trained alone (61%; p<0.0001), daily (61%; p<0.0001) at moderate intensity (58%; p<0.0001) and for 30-60min (72%). During leisure time athletes preferred sedentary above active behaviour (p<0.0001). Sleep patterns changed significantly (79%; p<0.0001). A significant number of athletes consumed excessive amounts of carbohydrates (76%; p<0.0001; males 73%; females 80%). Many athletes felt depressed (52%), and required motivation to keep active (55%). Most had access to healthcare during lockdown (80%) and knew proceedings when suspecting COVID-19 (92%). Conclusions COVID-19 had physical, nutritional and psychological consequences that may impact on the safe RTS and general health of athletes. Lost opportunities and uncertain financial and sporting futures may have significant effects on athletes and the sports industry. Government and sporting federations must support athletes and develop and implement guidelines to reduce the risk in a COVID-19 environment.

The coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted in a global pandemic with unprecedented consequences. Many scientific articles (peer-reviewed and non-peer reviewed) have been published regarding epidemiology 1 , pathogenesis 2 , complications 3 and treatment. 4 The COVID-19 pandemic forced governments to implement unparalleled measures to curb the rapid spread of the disease including strict lockdown, banning of all organised and social gatherings (including sports events) and restricting non-essential travel, with a significant effect on the sports industry and athletes. In South Africa, level 5 lockdown measures were enforced from 26 March to 30 April (5 weeks). Only essential services, travel and shopping were allowed and exercise outside individual property boundaries was not allowed, 5 likely having a psychological impact on all, including athletes. 6 Our current understanding of these lockdown measures on training, nutrition and mental health of athletes are limited. This study aims to investigate the perceptions of South African elite and semi-elite athletes on (1) return to sport (RTS); (2) maintenance of physical conditioning and other activities; (3) sleep; (4) nutrition;

(5) mental health; (6) healthcare access; and (7) knowledge of the COVID-19 disease.

A cross-sectional study was designed, based on input from researchers and clinicians looking after athletes, regarding the challenges they experienced during the lockdown period. Survey questions were adapted from validated questionnaires on maintenance of activity, 7 nutrition 8 and mental state. 9 The survey was piloted by 20 healthcare workers including sports physicians, physiotherapists and biokineticists. Following ethics approval from the Ethical Committee of the University of Pretoria (REC 274/2020), a link to the online Google Form survey was distributed to a convenience sample of athletes via WhatsApp. Athletes were asked to read the description and need for the study and click on the link to proceed after giving consent.

Participants from 15 sports (soccer, hockey, rugby, cricket, athletics, netball, basketball, endurance running, cycling, track and field, swimming, squash, golf, tennis, karate) were recruited through the databases of the The inclusion criteria was (1) elite and semi-elite athletes based in South Africa, (2) >18 years of age.

Recreational athletes were excluded. The survey was live for 72 hours during the level 5 lockdown period, from 28 April to 30 April 2020 and took 10 -15 minutes to complete. Data were collected from Google Forms and exported to a csv file for data analysis. The data consisted of categorical feedback, hence the descriptive statistics consisted of frequencies and percentages which described the feedback received. We used the Chi-Square goodness of fit test to investigate if a significant difference, tested at a 5% level of significance, existed between the observed and expected values. The Chi-Square test of independence was used to explore sex specific associations. Post-hoc analyses were included with a Bonferroni adjustment where applicable. As questions were single or multiple choice options. It should be noted that proportions do not add up to 100% for the questions with multiple responses. Multiple choice options on risk reduction behaviour were listed as per the World Health Organization (WHO) 10 and National Institute for Communicable Diseases (NICD) 11 documents regarding the most important aspects.

From a total of 1080 distributed surveys, 692 athletes responded. The response rate was 64% and respondents consisted of 67% males (Table 1 ). Some (presumably university level semi-elite athletes, n=55; 8%) reported participation in two or more sports. More athletes reported changes in sleep-wake times during the lockdown period (p<0.0001), but they still experienced restful sleep (p<0.0001) and did not experience constant fatigue (p<0.0001). There were no sex differences in sleep-wake times (p=0.6045) and restful sleep (p=0.2455), however, a significantly larger proportion of females felt more fatigued than males (p=0.0213). (Table 4 ). 12 Even though not statistically significant, more than half of the athletes admitted to the worsening of their diet (p=0.1486), with females significantly more than males (p<0.0001). Excessive carbohydrate consumption was significantly more (p<0.0001) than excessive fizzy drinks, poor hydration during and after exercise, processed foods, and red meat. (Table 4) .

Observing mental state, 52% of the athletes felt depressed at some time (p=0.3230), and females reported a significantly (p<0.0001) higher rate. While 54% of all athletes did not report energy loss, and 55% struggled to keep motivated; female athletes reported higher energy loss (p=0.0084) and lack of motivation (p=0.0358) compared to males. Most felt they adapted to the new routine (males vs females p=0.0765).

Libido stayed the same for most respondents, but significantly more males, reported increased libido compared to females (p<0.0001). Many athletes were not aware of online psychological and mental health programs, however, females are significantly more mindful (p=0.0020). (Table 4 ) 

The COVID-19 pandemic lockdown measures significantly impacted elite and semi-elite athletes in South Africa. One of our key findings is that despite high levels of uncertainty regarding RTS guidelines, most athletes are continuing to train daily. Two out of three athletes trained alone with only a minority of athletes using digital guidance by a professional. There are certain risks to unsupervised training, 12 including an inadvertent lapse into poor technique and posture, which may predispose athletes to injuries. 13 Solo training and a lack of sport-specific training may also be challenging for athletes who participate in team and very technical (e.g. pole vault) sports. More than half of the athletes were training at a moderate exercise intensity for 30-60min per day, at a lower training load than normal. Moderate training loads allow for recovery and this is important during the COVID-19 pandemic to avoid blunting of the immune system. [15] [16] [17] Even though the additional recovery time came at an opportune time (e.g. Olympics was 4 months away), deconditioning is bound to occur, posing challenges in reconditioning and safe RTS. 12 The majority of athletes engaged in own bodyweight strength training, cardio workouts, and functional sport-specific training, resembling appropriate active rest phase modalities. 18 Only a small number of athletes included proprioception in their programs. Good proprioception plays an important role in accurate movement patterns and can prevent injuries and recurrence of injuries. 19 Such exercises are easy to do indoors and even in confined spaces, and should be recommended. Athletes had considerable access to equipment, including sports specific equipment, treadmills, steppers, free weights, swimming pools and stationary bikes, confinement not only affect the physiological status of athletes, [23] [24] but the inability to compete may also influence athlete mental health. 25 We found that one in two athletes was depressed, with energy loss and lack of motivation to train. Females are more affected in all these spheres, with potentially profound adverse effects on their mental health. [26] [27] A recent consensus document on athlete mental health stressed the importance of mental wellbeing for optimal performance. 25 Access to psychological support to maintain their mental health during and after lockdown is paramount. A significant proportion of athletes reported a change in sleep routine, even though still restful. Nevertheless, almost half of the respondents reported feeling chronically fatigued. Quality and quantity of sleep have a significant impact on injury incidence and recovery post-exercise. 28 Sleep allows for the immune system to regenerate and recuperate. 29 The athletes also correctly recognised the most significant symptoms of COVID-19 as communicated by the World Health Organisation 10 , NICD 11 and National Department of Health 36 , being shortness of breath, fever, dry cough and a sore throat. Almost all athletes knew how to proceed if they suspected having contracted the SARS-CoV-2 virus. Three out of four athletes know they should either contact their doctors, or the NICD toll-free number for guidance. These findings underline the vital role and efficacy of high quality messaging in traditional and social media in a pandemic.

Athletes are keen to RTS, and the majority of athletes are even prepared to do so behind closed doors. 37 However, one in three athletes were unsure when to RTS, possibly owing to global uncertainty about the pandemic, lack of communication by national and international federations and sport governing bodies. One out of two athletes were comfortable to RTS when advised, the other half was unsure or would not return.

Established protocols, risk mitigation strategies, guidance from sports federations and government following international trends, and financial support from federations and/or provision of protective equipment were some of the requirements identified by the athletes. Continuous athlete education to promote required behaviours, preparing the environment and health screening to evaluate COVID-19 status prior to RTS is needed. 38 Physiological readiness to RTS should include re-evaluating weight, blood pressure, liver function, glucose, glycated haemoglobin and lipid profiles. 39 Then a stepwise and sport-specific return to training, synchronised with the expected gradual lifting of restrictions of movement and social distancing is advised. 38 High load, training load fluctuations that negatively impact acute:chronic load ratios are known injury risk factors. [13] [14] Accelerated RTS after the lockdown of NFL athletes in 2011, subsequently lead to high injury rates. 12 Ongoing monitoring of training loads, injury and illness upon RTS and addressing any deficits regarding the level of conditioning, strength, proprioception, neuromuscular activation and sport-specific conditioning following this period of lockdown, is recommended. [40] [41] [42] Further, nutrition, sleep, mental and general health issues related to restriction of movement should be addressed [40] [41] [42] and supported through the RTS process. 43 It is also important to control the possible spreading of the virus during RTS, as well as J o u r n a l P r e -p r o o f 23 managing the progress of the pandemic by early detection and management of new cases in the sports community to mitigate a second wave. 23, 38 The majority of our study participants were males, with the sex distribution of our participants being representative of the current South African athlete population. 44 Convenience sampling was used and team sports were overrepresented, thus the findings may not be generalisable to individual sports. We did not require athletes to report pre-lockdown sleep patterns, mental status or supplement use thus findings cannot be comparable to pre-lockdown habits. We did not specifically differentiate between guided or unguided training programs, even though there was an option to indicate guidance by professionals.

The study was open for only 72 hours and may have limited the response rate. This short access period was necessary to allow timely data analyses and planning of implementation measures and advice before RTS.

Additionally owing to availability of resources, we were unable to verify the level of evidence of websites, social media platforms or other sources of information used by athletes. We also did not specifically ask why athletes opted for advice from non-medical experts or how finances were affected.

COVID-19 has significant physical and mental effects on athletes including physical deconditioning, altered sleep patterns, worsening nutrition, uncertainty on RTS and feelings of depression. Athletes are well informed on the COVID-19 disease, however, the need remains to provide them with easy access to reliable evidence-based resources. Closer medical, nutritional and psychological support during and after the lockdown is recommended. Further, lost opportunities and uncertain financial and sporting futures may have long-lasting effects on both athletes and the sports industry. Re-adjustment to normal life and RTS will undoubtedly be challenging. Even though the international focus seems to be on RTS, this study shows that there are many other lifestyle challenges needing to be overcome prior to returning to a pre-COVID-19

normality. Governments and sporting federations should develop and implement regional and sport-specific 

1. Implement a culture of education for athletes and support staff regarding hygiene, wearing masks, social distancing measures and self-isolation to improve health literacy and promote required behaviours.

2. Consider health, nutritional and psychological support and education during the remainder of the lockdown period.

3. Reduce the injury risk by implementing a progressive training load and allowing for maximum adaptation before competition is re-introduced. 4 . Sleep hygiene and its effects on performance should become an imperative part of athletic education. 5 . Athletes returning to sport should require thorough medical assessment including nutrition assessment prior to resumption of high intensity sporting activity.

6. Mental health aspects form an important part of athlete performance and should be recognised and acted on timeously through life/performance coaches or psychologists.

7. Stimulate athletes to become saving and investment-wise, and plan their future in time for a career/business/life after sport.

No funding received.

LP: responsible for the overall content as guarantor, study concept, study planning, data collection, content contribution, data interpretation, manuscript (first draft), manuscript editing DCJvR: study planning, manuscript planning, content contribution, data interpretation, manuscript (first draft), manuscript editing. editing DAR: data interpretation, manuscript (first draft), manuscript editing.

LH: data interpretation, manuscript (first draft), manuscript editing.

HPD: data interpretation, manuscript (first draft), manuscript editing.

TC: manuscript planning, data analysis including statistical analysis, data interpretation, manuscript editing.

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The authors made available all contact numbers and data-free websites for the DOH, NICD as well as several pharmaceutical and private based companies providing telephonic support for depression.The authors would like to thank the following medical colleagues, athletes and sport administrators for