Symptom cluster is associated with prolonged return-to-play in symptomatic athletes with acute respiratory illness (including COVID-19): a cross-sectional study-AWARE study I

Background: There are no data relating symptoms of an acute respiratory illness (ARI) in general, and COVID-19 specifically, to return to play (RTP).

Objective: To determine if ARI symptoms are associated with more prolonged RTP, and if days to RTP and symptoms (number, type, duration and severity) differ in athletes with COVID-19 versus athletes with other ARI.

Design: Cross-sectional descriptive study.

Setting: Online survey.

Participants: Athletes with confirmed/suspected COVID-19 (ARI_COV) (n=45) and athletes with other ARI (ARI_OTH) (n=39).

Methods: Participants recorded days to RTP and completed an online survey detailing ARI symptoms (number, type, severity and duration) in three categories: 'nose and throat', 'chest and neck' and 'whole body'. We report the association between symptoms and RTP (% chance over 40 days) and compare the days to RTP and symptoms (number, type, duration and severity) in ARI_COV versus ARI_OTH subgroups.

Results: The symptom cluster associated with more prolonged RTP (lower chance over 40 days; %) (univariate analysis) was 'excessive fatigue' (75%; p<0.0001), 'chills' (65%; p=0.004), 'fever' (64%; p=0.004), 'headache' (56%; p=0.006), 'altered/loss sense of smell' (51%; p=0.009), 'Chest pain/pressure' (48%; p=0.033), 'difficulty in breathing' (48%; p=0.022) and 'loss of appetite' (47%; p=0.022). 'Excessive fatigue' remained associated with prolonged RTP (p=0.0002) in a multiple model. Compared with ARI_OTH, the ARI_COV subgroup had more severe disease (greater number, more severe symptoms) and more days to RTP (p=0.0043).

Conclusion: Symptom clusters may be used by sport and exercise physicians to assist decision making for RTP in athletes with ARI (including COVID-19).