Journal of Science and Medicine in Sport 23 (2020) 670–679

Contents lists available at ScienceDirect

Journal of Science and Medicine in Sport

journal homepage: www.elsevier.com/locate/jsams

Nowhere to hide: The significant impact of coronavirus disease 2019

(COVID-19) measures on elite and semi-elite South African athletes夽
Lervasen Pillay a,∗ , Dina C. Christa Janse van Rensburg a,b , Audrey Jansen van Rensburg a ,
Dimakatso A. Ramagole a , Louis Holtzhausen a,c , H. Paul Dijkstra c,d , Tanita Cronje e
a
Section Sports Medicine & Sport Exercise Medicine Lifestyle Institute (SEMLI), Faculty of Health Sciences, University of Pretoria, South Africa
b
International Netball Federation, UK
e
Department of Statistics, Faculty of Natural and Agricultural Sciences, University of Pretoria, South Africa
c
Aspetar Orthopaedic and Sports Medicine Hospital, Qatar
d
Department for Continuing Education, University of Oxford, UK

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To describe the perceptions of South African elite and semi-elite athletes on return to sport
Available online 19 May 2020 (RTS); maintenance of physical conditioning and other activities; sleep; nutrition; mental health; health-
care access; and knowledge of coronavirus disease 2019 (COVID-19).
Keywords: Design: Cross- sectional study.
COVID-19 Methods: A Google Forms survey was distributed to athletes from 15 sports in the final phase (last week
Return to sport
of April 2020) of the level 5 lockdown period. Descriptive statistics were used to describe player demo-
SARS-CoV-2 virus
graphic data. Chi-squared tests investigated significance (p < 0.05) between observed and expected values
Athletes
Lockdown impact
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 1–6 months. Most
athletes trained alone (61%; p < 0.0001), daily (61%; p < 0.0001) at moderate intensity (58%; p < 0.0001) and
for 30–60 min (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 exces-
sive 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 fed-
erations must support athletes and develop and implement guidelines to reduce the risk in a COVID-19
environment.
© 2020 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Practical implications 3. Reduce the injury risk by implementing a progressive training

load and allowing for maximum adaptation before competition
1. Implement a culture of education for athletes and support is re-introduced.
staff regarding hygiene, wearing masks, social distancing mea- 4. Sleep hygiene and its effects on performance should become an
sures and self-isolation to improve health literacy and promote imperative part of athletic education.
required behaviours. 5. Athletes returning to sport should require thorough medical
2. Consider health, nutritional and psychological support and edu- assessment including nutrition assessment prior to resumption
cation during the remainder of the lockdown period. of high intensity sporting activity.
6. Mental health aspects form an important part of athlete perfor-
mance and should be recognised and acted on timeously through
life/performance coaches or psychologists.
夽 Rapid response papers and have not undergone the full peer review process.
7. Stimulate athletes to become saving and investment-wise, and
∗ Corresponding author. plan their future in time for a career/business/life after sport.
E-mail address: [email protected] (L. Pillay).

https://doi.org/10.1016/j.jsams.2020.05.016
1440-2440/© 2020 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679 671

1. Introduction 3. Results

The coronavirus disease 2019 (COVID-19) caused by the severe From a total of 1080 distributed surveys, 692 athletes
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) resulted responded. The response rate was 64% and respondents consisted of
in a global pandemic with unprecedented consequences. Many sci- 67% males (Table 1). Some (presumably university level semi-elite
entific articles (peer-reviewed and non-peer reviewed) have been athletes, n = 55; 8%) reported participation in two or more sports.
published regarding epidemiology,1 pathogenesis,2 complications3 Four respondents preferred not to reveal their sex.
and treatment.4 The COVID-19 pandemic forced governments to Most respondents were from soccer (26%), followed by hockey
implement unparalleled measures to curb the rapid spread of the (16%) and rugby (13%). Most males participated in soccer (37%),
disease including strict lockdown, banning of all organised and while most females played netball (31%).
social gatherings (including sports events) and restricting non- Regarding return to competitive sport, 35% athletes expected to
essential travel, with a significant effect on the sports industry RTS within 1–3 months whilst 31% felt unsure, and no sex differ-
and athletes. In South Africa, level 5 lockdown measures were ence was observed (p = 0.0740). Only 50% athletes were comfortable
enforced from 26 March to 30 April (5 weeks). Only essential with RTS when allowed by authorities, and results are comparable
services, travel and shopping were allowed and exercise outside between males and females (p = 0.6901). The athletes are willing to
individual property boundaries was not allowed,5 likely having a compete behind closed doors (p < 0.0001), while male athletes are
psychological impact on all, including athletes.6 Our current under- more willing than females (p < 0.0001) (Table 2).
standing of these lockdown measures on training, nutrition and For exercise maintenance and other activities, more athletes
mental health of athletes are limited. This study aims to investi- trained alone (p < 0.0001), compared to those training alone but
gate the perceptions of South African elite and semi-elite athletes digitally directed by a trainer, or a medical person or using technol-
on (1) return to sport (RTS); (2) maintenance of physical condi- ogy like Zoom together with other athletes. More males used Zoom
tioning and other activities; (3) sleep; (4) nutrition; (5) mental to train with other athletes than females (p < 0.0001). Most ath-
health; (6) healthcare access; and (7) knowledge of the COVID-19 letes trained daily vs alternative days or ≤3× a week (p = 0.0001).
disease. More males trained daily compared to females (p = 0.0059). Ses-
sions consisted mainly of own body weight (males 73%) and
cardio exercises (females 70%). Athletes could train outside with-
out breaking the law (p < 0.0001) (male vs female p = 0.3779),
2. Methods at a reduced training intensity (p < 0.0001) (male vs female
p = 0.6972) and sessions lasted mostly 30–60 min (males vs females
A cross-sectional study was designed, based on input from p = 0.6351). Sports specific equipment is used significantly more
researchers and clinicians looking after athletes, regarding the (p < 0.0001) than treadmills, steppers, stationary bikes, swimming.
challenges they experienced during the lockdown period. Survey Males and females had comparable results (p = 0.0899). Sedentary
questions were adapted from validated questionnaires on main- behaviour above active behaviour was preferred during leisure
tenance of activity,7 nutrition8 and mental state.9 The survey was time (p < 0.0001). Sedentary behaviour largely favoured watching
piloted by 20 healthcare workers including sports physicians, phys- television, and males significantly favoured electronic gaming com-
iotherapists and biokineticists. Following ethics approval from the pared to females (p < 0.0001) (Table 3).
Ethical Committee of the University of Pretoria (REC 274/2020), More athletes reported changes in sleep-wake times during
a link to the online Google Form survey was distributed to a the lockdown period (p < 0.0001), but they still experienced rest-
convenience sample of athletes via WhatsApp. Athletes were ful sleep (p < 0.0001) and did not experience constant fatigue
asked to read the description and need for the study and click (p < 0.0001). There were no sex differences in sleep-wake times
on the link to proceed after giving consent. Participants from (p = 0.6045) and restful sleep (p = 0.2455), however, a signifi-
15 sports (soccer, hockey, rugby, cricket, athletics, netball, bas- cantly larger proportion of females felt more fatigued than males
ketball, endurance running, cycling, track and field, swimming, (p = 0.0213) (Table 4).
squash, golf, tennis, karate) were recruited through the databases Even though not statistically significant, more than half of the
of the researchers, sports medicine healthcare professionals and athletes admitted to the worsening of their diet (p = 0.1486), with
administrators affiliated with the research team. The inclusion cri- females significantly more than males (p < 0.0001). Excessive car-
teria was (1) elite and semi-elite athletes based in South Africa, bohydrate consumption was significantly more (p < 0.0001) than
(2) >18 years of age. Recreational athletes were excluded. The excessive fizzy drinks, poor hydration during and after exercise,
survey was live for 72 h during the level 5 lockdown period, processed foods, and red meat (Table 4).
from 28 April to 30 April 2020 and took 10–15 min to com- Observing mental state, 52% of the athletes felt depressed
plete. Data were collected from Google Forms and exported to at some time (p = 0.3230), and females reported a significantly
a csv file for data analysis. The data consisted of categorical (p < 0.0001) higher rate. While 54% of all athletes did not report
feedback, hence the descriptive statistics consisted of frequen- energy loss, and 55% struggled to keep motivated; female athletes
cies and percentages which described the feedback received. We reported higher energy loss (p = 0.0084) and lack of motivation
used the Chi-square goodness of fit test to investigate if a sig- (p = 0.0358) compared to males. Most felt they adapted to the
nificant difference, tested at a 5% level of significance, existed new routine (males vs females p = 0.0765). Libido stayed the
between the observed and expected values. The Chi-square test same for most respondents, but significantly more males reported
of independence was used to explore sex specific associations. increased libido compared to females (p < 0.0001). Many ath-
Post hoc analyses were included with a Bonferroni adjustment letes were not aware of online psychological and mental health
where applicable. As questions were single or multiple choice programmes, however, females are significantly more mindful
options. It should be noted that proportions do not add up to (p = 0.0020) (Table 4).
100% for the questions with multiple responses. Multiple choice A significant number of athletes had access to healthcare
options on risk reduction behaviour were listed as per the World (p < 0.0001; males vs females p = 0.5934). Both males and females
Health Organization (WHO)10 and National Institute for Communi- accessed telehealth opposed to physical consultations (p < 0.0001),
cable Diseases (NICD)11 documents regarding the most important via WhatsApp (65% males vs 52% females) or telephone (60% males
aspects. vs 56% female). More athletes had access to general practition-
672 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679

Table 1
Athlete demographics: sex and sport involvement.

Type of sport Total surveys Female n = 225 Male n = 463 Responses n = 769 Response rate
involvement distributed (33%) (67%) (Respondents n = 692) within each sport
n = 1080

n % % % %
Soccer 250 5 37 26 72
Hockey 150 19 14 16 74
Rugby 130 4 17 13 69
Cricket 110 4 16 12 77
Athletics 100 15 8 10 72
Netball 80 31 – 10 86
Basketball 80 17 6 9 81
Endurance running 50 10 4 6 78
Cycling 20 4 2 3 90
Track and field 30 3 1 2 43
Swimming 30 3 1 2 37
Squash 15 0 1 1 40
Golf 15 0 1 1 33
Tennis 10 1 – 0.5 30
Karate 10 1 – 0.3 20

Respondents n = 692: completed responses received back.

Responses n = 769: athletes reported participation in two or more sports.

ers and physiotherapists for medical assistance compared to other cardio workouts, and functional sport-specific training, resembling
healthcare professionals (p < 0.0001). Males and females differed appropriate active rest phase modalities.18 Only a small number
significantly towards choice of health access (p < 0.0001) (Table 5). of athletes included proprioception in their programmes. Good
Television news, news websites, social media and government proprioception plays an important role in accurate movement pat-
sites were the sources of knowledge on COVID-19 used as opposed terns and can prevent injuries and recurrence of injuries.19 Such
to radio, friends, doctors, community forums, physiotherapists and exercises are easy to do indoors and even in confined spaces,
bankers (p < 0.0001) and no sex difference was observed. Hand- and should be recommended. Athletes had considerable access to
washing with soap and water and hand sanitising with >70% alcohol equipment, including sports specific equipment, treadmills, step-
content were rated as the most important (p < 0.0001; males vs pers, free weights, swimming pools and stationary bikes, providing
females p = 0.8127). Most athletes were aware that shortness of good opportunities for cross-training, which we also recommend
breath, fever, dry cough and sore throat were the main symptoms to assist with whole-body maintenance and to add variety.20
of COVID-19 (p < 0.0001; males vs females p = 0.8402). Shortness Leisure time activities with possible lifestyle changes dur-
of breath was identified by 85% male vs 78% female athletes as the ing lockdown were of concern. The majority chose sedentary
main symptom of COVID-19. Most athletes knew how to proceed on behaviour, especially watching television. Males engaged more in
symptom development (p < 0.0001; males vs females p = 1.000). On electronic and cell-phone gaming, possibly contributing to sleep
suspicion of COVID-19 symptoms, a significant difference existed alteration and feelings of fatigue. Few partook in alcohol-related
in accessing healthcare via contacting their doctors, or opting for activities during this period. The detrimental effects of seden-
contacting the National Institute of Communicable Diseases (NICD) tary behaviour on both physical and mental health is beyond
hotline, as opposed to going to a laboratory for testing, searching dispute.21,22 Realistic changes to decrease sedentary behaviour
the web or social media or going to the doctor’s rooms (p < 0.0001). during the lockdown needs to be advocated by health care pro-
Both males and females knew proceedings (p = 1.000), and would fessionals. Athletes are also exposed to the negative psychological
contact a doctor (Table 5). consequences of COVID-19 like anxiety and stress reported across
the wider society, where people are overwhelmed by the constantly
changing alerts and media reports about the virus spread. Home
4. Discussion
confinement not only affect the physiological status of athletes,23,24
but the inability to compete may also influence athlete mental
The COVID-19 pandemic lockdown measures significantly
health.25 We found that one in two athletes was depressed, with
impacted elite and semi-elite athletes in South Africa. One of our
energy loss and lack of motivation to train. Females are more
key findings is that despite high levels of uncertainty regarding
affected in all these spheres, with potentially profound adverse
RTS guidelines, most athletes are continuing to train daily. Two
effects on their mental health.26,27 A recent consensus document
out of three athletes trained alone with only a minority of ath-
on athlete mental health stressed the importance of mental well-
letes using digital guidance by a professional. There are certain
being for optimal performance.25 Access to psychological support
risks to unsupervised training,12 including an inadvertent lapse
to maintain their mental health during and after lockdown is
into poor technique and posture, which may predispose athletes
paramount. A significant proportion of athletes reported a change
to injuries.13 Solo training and a lack of sport- specific training
in sleep routine, even though still restful. Nevertheless, almost half
may also be challenging for athletes who participate in team and
of the respondents reported feeling chronically fatigued. Quality
very technical (e.g. pole vault) sports. More than half of the ath-
and quantity of sleep have a significant impact on injury inci-
letes were training at a moderate exercise intensity for 30–60 min
dence and recovery post-exercise.28 Sleep allows for the immune
per day, at a lower training load than normal. Moderate train-
system to regenerate and recuperate.29 Compromised immunity
ing loads allow for recovery14 and this is important during the
increases the risk of viral illness (including COVID-19), this is
COVID-19 pandemic to avoid blunting of the immune system.15–17
particularly important given the imminent winter of the south-
Even though the additional recovery time came at an opportune
ern hemisphere. Social isolation, exercise reduction, sedentary
time (e.g. Olympics was 4 months away), deconditioning is bound
behaviour, and changes in nutrition have a psychological conse-
to occur, posing challenges in reconditioning and safe RTS.12 The
quence and can impact sleep and fatigue. Athletes need to be
majority of athletes engaged in own bodyweight strength training,
 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679 673

Table 2
Athlete responses to return to competitive sport during the lockdown period.

Return to competitive sport during lockdown

When do you think you will be competing again? Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
% % % %
1 montha 8 11 – 10 <0.0001*
1–3 monthsb 30 38 – 35
3–6 monthsc 24 19 50 21
>6 monthsd 4 3 – 3
Unsureb 34 29 50 31

As you are aware, the SARS-CoV-2 virus will not Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
simply “disappear” and maybe around for
some time. Should regulations and authorities
allow return to sport, would you be
comfortable to return to your sport?
Yesa 48 51 25 50 <0.0001*
Nob 16 14 50 15
Maybec 36 35 25 35

If you answered “No” or “Maybe”, please say

what would make you comfortable to return
to sport
Maybe Female n = 82 Male n = 160 PNTS n = 1 Total n = 430 (% of 243) p- value
I am assured that protocols have been put in place 59 53 – 54 <0.0001*
to significantly reduce my chances at contracting
the virus
Risks must be reduced by 100% 40 39 100 40
My sporting federation and government must be 44 36 – 38
happy with guidelines to protect athletes
The international sporting world must be moving 24 32 – 29
in the same direction
I am enabled financially or equipment-wise by my 9 13 – 12
federation to take the precautionary measures
implemented

No Female n = 35 Male n = 65 PNTS n = 2 Total n = 174 (% of 102) p- value

Risks must be reduced 100% 54 62 100 60 <0.0001*
I am enabled financially or equipment-wise by my 11 9 – 43
federation to take the precautionary measures
implemented
The international sporting world must be moving 17 34 – 27
in the same direction
My sporting federation and government must be 23 29 – 26
happy with guidelines to protect athletes
I am assured that protocols have been put in place 49 40 50 10
to significantly reduce my chances at contracting
the virus

Would you compete behind closed doors but Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
televised?
Yes 72 86 50 82 <0.0001*
No 28 14 50 18

PNTS: Prefer not to say.

ab
When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These
represent the post hoc results.
*
Significant difference p < 0.05.

educated regarding the psychological impact on sleep and fatigue20 guidance by a sports nutritionist, both during the lockdown and
and re-adjust their sleeping patterns on RTS. afterward.
More than half of the athletes reported deterioration in eating The majority of athletes had access to healthcare professionals,
habits, especially a significant increase in carbohydrate ingestion. mostly through telehealth. With the implementation of the lock-
Impaired nutrition may result in a myriad of issues upon RTS down and dangers of COVID-19, the Health Professionals Council of
including deteriorated performance, lifestyle-related concerns and South Africa relaxed its regulations on the use of telehealth, mak-
affecting weight category sport.30 Athletes are generally believed ing it more accessible.33 Only one in four had access to a sports
to consume substantial amounts of supplements,31 but a large per- physician, perhaps due to financial or travelling constraints. The
centage of athletes in our study did not consume supplements. Only athletes accessed traditional and social media to gain knowledge
one in three athletes used a combination of vitamin C, multivita- on COVID-19 demonstrating the ability of these platforms to reach
mins, zinc, vitamin B, protein and other unclassifiable supplements. wide audiences to deliver key public health messages. It appears
During the COVID-19 pandemic some authors have advised taking that doctors or other evidence-based platforms were poorly utilised
supplements including vitamin C, zinc and vitamin D for immune for this purpose possibly because healthcare professionals did not
enhancement.4,20 Most athletes can train outside without break- reach out to the athlete population. Nevertheless, athletes had good
ing regulations, exposing them to natural light to allow vitamin knowledge about COVID-19 preventative measures and present-
D synthesis.32 Given the significant inadequacies in nutrition dur- ing symptoms. They identified handwashing with soap and water
ing the lockdown, it seems appropriate to implement nutritional or the use of alcohol-based hand sanitisers as a priority in reduc-
674 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679

Table 3
Athlete responses to exercise maintenance and other activities during the lockdown period.

Exercise maintenance during lockdown

How are you maintaining activity during Female n = 225 Male n = 463 PNTS n = 4 Total n = 897 (% of 692) p- value
lockdown?#
% % % %
Alonea 57 63 75 61 <0.0001*
Directed digitally by a Fitness or Personal trainerb 31 23 25 25
Directed digitally by a medical person 30 20 25 24
(Physiotherapist/Biokineticist/Sports Scientist)b
Using technology like Zoom etc. with other 10 24 – 20
athletesb

How often do you train in a week? Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
Dailya 53 65 75 61 <0.0001*
Every alternate dayb 27 23 25 24
3× or less a weekc 20 12 – 15

What do your sessions consist of? # % of Female % of Male % of PNTS Total n = 2031(% of 692) p- value
Own body weight strengtha 66 73 50 71 <0.0001*
Cardio (running/stepper/cycle/treadmill) a 70 65 25 67
Sport specific exercises that are functionalb 62 48 50 52
Resisted strength work (use of elastics and/or 43 52 25 49
weights)b
Flexibilityc 31 30 25 31
Proprioception (balance)c 24 24 25 24

Are you able to exercise outside without Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
breaking the law? (e.g. in your backyard)
Yes 85 82 25 83 <0.0001*
No 15 18 75 17

Have you reduced your training load and Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
intensity during this lockdown period?
Yes 76 74 75 75 <0.0001*
No 24 26 25 25
At what intensity do you exercise? Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
Higha 36 36 25 36 <0.0001*
Moderateb 57 58 75 57
Lowc 7 6 – 7

When you do exercise, how long are your Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
sessions?
<30 mina 11 12 50 11 <0.0001*
30–45 minb 35 31 25 33
45–60 minb 40 39 – 39
>60 minc 14 18 25 17

Do you have any of the following equipment you % of Female % of Male % of PNTS Total n = 1609(% of 692) p- value
use at home to assist you with exercise?#
Sports specific equipment (soccer ball/rugby 56 67 75 63 <0.0001*
ball/tennis ball, etc.)a
Resistance bandsab 53 52 75 52
Free weightsb 41 48 50 46
Swimming poolc 31 28 – 29
Stationary bike (or any equipment to allow for 28 20 – 23
indoor cycling)c
Stepperd 8 11 25 10
Treadmilld 10 9 – 10

Other activities during lockdown

Aside from exercise, what else do you do to keep % of Female % of Male % of PNTS Total n = 2693(% of 692) p- value
busy during the lockdown?#
Active <0.0001*
Fix things at home or spring cleana 58 49 50 52
Games outdoors (playing with kids, etc.) b 21 28 25 25
Sedentary
Watch televisiona 72 71 75 72
Social mediaa 61 57 75 58
Read a bookbc 50 41 75 44
Electronic gaming (play station etc.) bcde 11 51 75 38
Cell phone gamingcde 29 40 25 36
Work remotely on your other business venturesde 37 27 – 30
Board gamese 24 31 – 29
Drink alcoholf 3 5 – 4

PNTS: Prefer not to say.

ab
When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These
represent the post hoc results.
#
Questions were open to select more than one option i.e. percentages may add up to >100.
*
Significant difference p < 0.05.
 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679 675

Table 4
Athlete responses to sleep, nutrition and mental state during the lockdown period.

Sleep during lockdown

Have you been sleeping and waking up at your Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
normal times as before the lockdown?
% % % %
Yes 20 22 – 21 <0.0001*
No 80 78 100 79

Is your sleep restful? Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
Yes 70 75 25 73 <0.0001*
No 30 25 75 27

Are you feeling constantly fatigued during the Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
lockdown?
Yes 48 38 100 42 <0.0001*
No 52 62 – 58

Nutrition during lockdown

Has your diet worsened or improved during the Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
lockdown?
Improved 36 53 25 47 0.1486
Worsened 64 47 75 53

If your diet has worsened, in what way?# Female n = 143 Male n = 219 PNTS n = 3 Total n = 686 (% of 365) p- value
Excessive carbohydrates (includes 80 73 100 76 <0.0001*
sweets/chocolates/rice/bread etc.)a
Fizzy drinksb 24 41 67 34
Poor hydration during exercise and after exerciseb 34 33 67 34
Excessive processed foodsc 16 22 33 20
Excessive red meatcd 10 17 67 15
Alcohold 12 8 33 10

Are you using any supplements to assist in Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
boosting your immune system?
Yes 36 30 – 32 <0.0001*
No 64 70 100 68

If yes to the above question, what Female n = 82 Male n = 173 PNTS n = 0 Total n = 219 p- value
supplements?#
Multivitamina 39 27 – 36 <0.0001*
Vitamin Cb 46 23 – 36
Otherab 24 17 – 23
Proteinb 10 14 – 15
No information suppliedc 1 6 – 5
Zincc 5 2 – 4

Mental state during lockdown

Do you feel depressed? Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
Yes 60 48 75 52 0.3230
Yes, all of the time 4 2 – 3
Yes, on very few occasions 29 27 – 27
Yes, sometimes 27 19 75 22
No 40 52 25 48
No 40 52 25 48

Do you feel you have a loss of “energy” daily? Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
Yes 53 42 100 46 0.0275*
No 47 58 – 54

Do you struggle to keep yourself motivated to Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
exercise?
Yes 60 52 75 55 0.0150*
No 40 48 25 45

Have you re-adapted to developing a new Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
routine daily with lockdown?
Yes 62 69 50 66 <0.0001*
No 38 31 50 34

Has your libido (sexual appetite)...during Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
lockdown
Decreaseda 14 13 25 13 <0.0001*
Increasedb 13 38 25 30
Stay the samec 73 49 50 57

Are you aware of several psychological and Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
mental health programmes available online
and via skype should you need it?
676 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679

Table 4 (Continued)

Yes 60 47 50 51 0.6483
No 40 53 50 49

Have you been sleeping and waking up at your Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
normal times as before the lockdown?
% % % %
Yes 20 22 – 21 <0.0001*
No 80 78 100.00 79

Is your sleep restful? Female n = 225 Male n = 463 PNTS n = 4 Total p- value
Yes 70 75 25 73 <0.0001*
No 30 25 75 27

Are you feeling constantly fatigued during the Female n = 225 Male n = 463 PNTS n = 4 Total p- value
lockdown?
Yes 48 38 100 42 <0.0001*
No 52 62 – 58

PNTS: Prefer not to say.

ab
When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These
represent the post hoc results.
#
Questions were open to select more than one option i.e. percentages may add up to >100.
*
Significant difference p < 0.05.

ing their risk of contracting the virus. Applying respiratory hygiene activation and sport-specific conditioning following this period of
was rated high while only one in two athletes recognised social dis- lockdown, is recommended.40–42 Further, nutrition, sleep, mental
tancing of >2 m as important. Even though athletes were aware of and general health issues related to restriction of movement should
how to mitigate the risk, they lacked awareness of the priorities of be addressed40–42 and supported through the RTS process.43 It is
risk modification.10 The timing of the survey may have contributed also important to control the possible spreading of the virus dur-
to athletes favouring the use of surgical and FFP1/FFP2/N95 masks ing RTS, as well as managing the progress of the pandemic by early
(which should be reserved for healthcare professionals), instead of detection and management of new cases in the sports community
a cloth mask. Cloth masks have shown some potential to reduce to mitigate a second wave.23,38
the risk of viral transmission.34 This information was shared by the The majority of our study participants were males, with the
government shortly before the start of the survey, which may have sex distribution of our participants being representative of the
biased the responses.35 The athletes also correctly recognised the current South African athlete population.44 Convenience sam-
most significant symptoms of COVID-19 as communicated by the pling was used and team sports were overrepresented, thus
World Health Organisation,10 NICD11 and National Department of the findings may not be generalisable to individual sports. We
Health,36 being shortness of breath, fever, dry cough and a sore did not require athletes to report pre-lockdown sleep pat-
throat. Almost all athletes knew how to proceed if they suspected terns, mental status or supplement use thus findings cannot be
having contracted the SARS-CoV-2 virus. Three out of four athletes comparable to pre-lockdown habits. We did not specifically dif-
know they should either contact their doctors, or the NICD toll- free ferentiate between guided or unguided training programmes, even
number for guidance. These findings underline the vital role and though there was an option to indicate guidance by profession-
efficacy of high quality messaging in traditional and social media als. The study was open for only 72 h and may have limited
in a pandemic. the response rate. This short access period was necessary to
Athletes are keen to RTS, and the majority of athletes are even allow timely data analyses and planning of implementation mea-
prepared to do so behind closed doors.37 However, one in three sures and advice before RTS. Additionally owing to availability
athletes were unsure when to RTS, possibly owing to global uncer- of resources, we were unable to verify the level of evidence of
tainty about the pandemic, lack of communication by national and websites, social media platforms or other sources of information
international federations and sport governing bodies. One out of used by athletes. We also did not specifically ask why athletes
two athletes were comfortable to RTS when advised, the other opted for advice from non-medical experts or how finances were
half was unsure or would not return. Established protocols, risk affected.
mitigation strategies, guidance from sports federations and gov-
ernment following international trends, and financial support from
federations and/or provision of protective equipment were some 5. Conclusion
of the requirements identified by the athletes. Continuous athlete
education to promote required behaviours, preparing the envi- COVID-19 has significant physical and mental effects on athletes
ronment and health screening to evaluate COVID-19 status prior including physical deconditioning, altered sleep patterns, wors-
to RTS is needed.38 Physiological readiness to RTS should include ening nutrition, uncertainty on RTS and feelings of depression.
re-evaluating weight, blood pressure, liver function, glucose, gly- Athletes are well informed on the COVID-19 disease, however,
cated haemoglobin and lipid profiles.39 Then a stepwise and the need remains to provide them with easy access to reliable
sport-specific return to training, synchronised with the expected evidence-based resources. Closer medical, nutritional and psycho-
gradual lifting of restrictions of movement and social distancing is logical support during and after the lockdown is recommended.
advised.38 Further, lost opportunities and uncertain financial and sport-
High load, training load fluctuations that negatively impact ing futures may have long-lasting effects on both athletes and
acute:chronic load ratios are known injury risk factors.13,14 Accel- the sports industry. Re-adjustment to normal life and RTS will
erated RTS after the lockdown of NFL athletes in 2011, subsequently undoubtedly be challenging. Even though the international focus
lead to high injury rates.12 Ongoing monitoring of training loads, seems to be on RTS, this study shows that there are many other
injury and illness upon RTS and addressing any deficits regarding lifestyle challenges needing to be overcome prior to returning
the level of conditioning, strength, proprioception, neuromuscular to a pre-COVID-19 normality. Governments and sporting federa-
tions should develop and implement regional and sport-specific
 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679 677

Table 5
Athlete responses to healthcare and knowledge on COVID-19 during lockdown.

Questions on healthcare during lockdown

Do you have easy access to your healthcare Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
professionals?
% % % %
Yes 81.33 79.27 75.00 79.91 <0.0001*
No 18.67 20.73 25.00 20.09

Is your access via# % of Female % of Male % of PNTS Total n = 1246(% of 692) p- value
Telehealth <0.0001*
Whatsappa 52 65 50 61
Telephonea 56 60 25 59
Social mediab 15 19 – 17
Other electronic meansb 13 13 25 13
Physical
Physical consultations 40 25 25 30

Which professionals do you have access to?# % of Female % of Male % of PNTS Total n = 1168(% of 692) p- value
General Practitionera 52 44 50 47 <0.0001*
Physiotherapista 30 46 25 41
Otherb 39 23 – 28
Biokineticistb 27 28 50 28
Sports Physicianb 16 30 – 26

Knowledge on COVID-19 during lockdown

Where do you gain your knowledge from regard % of Female % of Male % of PNTS Total n = 2265(% of 692) p- value
COVID-19?#
Television newsb 73 74 25 73 <0.0001*
News websitesab 72 68 100 70
Social mediabc 59 58 25 58
Official government websites and social media 60 48 75 52
sitesc
Radiod 27 24 – 25
A friendefg 15 14 25 15
My doctorefg 9 16 – 14
Community forumsfg 13 9 25 10
My physiog 2 12 – 9
My bankerb 1 2 – 2

What are the most important aspects in % of Female % of Male % of PNTS Total n = 4181(% of 692) p- value
reducing risk at contracting the coronavirus?#
Social distancing of 2 md 61 57 50 58 <0.0001*
Handwashing with soap and watera 89 83 100 85
Coughing/sneezing into a flexed elbowcd 72 70 100 71
Not rubbing eyes/nose/mouthbc 80 75 100 77
Cloth masksij 20 25 – 23
Hand sanitising with alcohol content 70ab 84 84 100 84
Sneezing/coughing into a handkerchiefefh 38 40 50 40
Wearing glovesefg 43 43 50 43
Social distancing of 1 mfgh 33 41 50 39
Surgical masksfgh 38 39 – 39
FFP1/FFP2/N95 masksghi 31 30 50 31
Disposing of clothes when returning from shops 17 15 25 16
etc.j

What are the main symptoms of the coronavirus % of Female % of Male % of PNTS Total n = 1980(% of 692) p- value
that should prompt you to get a medical
opinion?#
Fevera 79 79 100 79 <0.0001*
Dry Coughb 61 65 100 64
Shortness of breathc 78 85 100 83
Sore throatb 56 63 75 61

Should you think you have coronavirus Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
symptoms do you know how to proceed?
Yes 92 92 100 92
No 8 8 – 8

If your answer is yes to the above question how % of Female % of Male % of PNTS Total n = 1190(% of 692) p- value
would you proceed?#
Contact a doctora 71 74 75 73 <0.0001*
Phone the toll-free NICD numberb 52 50 50 51
Go to a lab and ask them for testing for COVID-19c 24 24 – 24
Search on google or social mediad 7 10 – 9
Just arrive at a doctors rooms for a consultatione 1 2 – 2
Speak to your pharmaciste 0 2 – 2

Do you have easy access to your healthcare Female n = 225 Male n = 463 PNTS n = 4 Total n = 692 p- value
professionals?
Yes 81.33 79.27 75.00 79.91 <0.0001*
678 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679

Table 5 (Continued)

No 18.67 20.73 25.00 20.09

Is your access via #

% of Female % of Male % of PNTS Total n = 1246(% of 692) p- value
Telehealth <0.0001*
Whatsappa 52 65 50 61
Telephonea 56 60 25 59
Social mediab 15 19 – 17
Other electronic meansb 13 13 25 13
Physical
Physical consultations 40 25 25 30

Which professionals do you have access to?# % of Female % of Male % of PNTS Total n = 1168(% of 692) p- value
General Practitionera 52 44 50 47 <0.0001*
Physiotherapista 30 46 25 41
Otherb 39 23 – 28
Biokineticistb 27 28 50 28
Sports Physicianb 16 30 – 26

PNTS: Prefer not to say.

ab
When significance tests indicated that differences existed between the counts within each question, the superscripts indicate which options reported similar results. These
represent the post hoc results.
#
Questions were open to select more than one option i.e. percentages may add up to >100.
*
Significant difference p < 0.05.

evidence-based guidelines for safe RTS in a COVID-19 environment Rayno Rayepen, Dr Janesh Ganda, Fanie de Klerk, Dr Abdul-
to minimise risk of community transmission and preserve public lah Moola, Elana Meyer, Nolene ConradJacques Durand, Steven
health. Ball, Marianne Viljoen, Jason Fyfer, Setty Ndaba, Siphesihle
Mthembu, Non Pongolo, Ryan Rickelton, Mangaliso Mosehle,
Funding Nolene Conrad, Rene Kalmer, Raisibe Ntokizane, Craig Cynkin,
Shannon Naidoo, Granald Scott, Rooi Mahamutsa, Ludwe Mpaku-
No funding received. paku.
The authors would like to express their gratitude to Mrs
Authors’ contribution Madeleen Scheepers for the upload of all publications to Endnote
library.
LP: responsible for the overall content as guarantor, study con-
cept, study planning, data collection, content contribution, data
interpretation, manuscript (first draft), manuscript editing. DCJvR: References
study planning, manuscript planning, content contribution, data
interpretation, manuscript (first draft), manuscript editing. AJvR: 1. Zhou P, Yang X-L, Wang X-G et al. A pneumonia outbreak associated with a new
coronavirus of probable bat origin. Nature 2020; 579(7798):270–273. http://dx.
manuscript planning, content contribution, data interpretation, doi.org/10.1038/s41586-020-2012-7.
manuscript (first draft), manuscript editing. DAR: data inter- 2. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus
pretation, manuscript (first draft), manuscript editing. LH: data disease (COVID-19) outbreak. J Autoimmun 2020:102433. http://dx.doi.org/10.
1016/j.jaut.2020.102433.
interpretation, manuscript (first draft), manuscript editing. HPD: 3. Jiang F, Deng L, Zhang L et al. Review of the clinical characteristics of coronavirus
data interpretation, manuscript (first draft), manuscript editing. TC: disease 2019 (COVID-19). J Gen Intern Med 2020:1–5.
manuscript planning, data analysis including statistical analysis, 4. Richards G, Mer M, Schleicher G et al. COVID-19 and the rationale for pharma-
cotherapy: a South African perspective. Wits J Clin Med 2020; 2(1):11–18.
data interpretation, manuscript editing. 5. President Cyril Ramaphosa: South Africa’s response to Coronavirus COVID-19
pandemic. South Africa: South Africa Government Newsroom Speeches; 2020.
Conflict of interest Available at: https://www.gov.za/speeches/president-cyril-ramaphosa-south-
africas-response-coronavirus-covid-19-pandemic-23-apr-2020.
6. Qiu J, Shen B, Zhao M et al. A nationwide survey of psychological distress
The authors report no conflict of interest pertaining to this among Chinese people in the COVID-19 epidemic: implications and policy rec-
manuscript. ommendations. Gen Psychiatry 2020; 33(2). http://dx.doi.org/10.1136/gpsych-
2020-100213.
7. Thomas S, Reading J, Shephard RJ. Revision of the physical activity readiness
Data sharing statement questionnaire (PAR-Q). Can J Sport Sci 1992; 17(4):338–345.
8. Segal-Isaacson C, Wylie- Rosett J, Gans KM. Validation of a short dietary assess-
ment questionnaire: the Rapid Eating and Activity Assessment for Participants
No additional data are available. short version (REAP-S). Diabetes Educ 2004; 30(5):774–781. http://dx.doi.org/
10.1177/014572170403000512.
9. Krueger RF, Derringer J, Markon KE et al. Initial construction of a maladap-
Acknowledgements
tive personality trait model and inventory for DSM-5. Psychol Med 2012;
42(9):1879–1890. http://dx.doi.org/10.1017/S0033291711002674.
The authors made available all contact numbers and data-free 10. World Health Organization. Coronavirus. Available at: https://www.who.int/
websites for the DOH, NICD as well as several pharmaceutical and health-topics/coronavirus#tab=tab 3.
11. Guidelines for case-finding, diagnosis, management and public health response
private based companies providing telephonic support for depres- in South Africa, Centre for Respiratory Diseases and Meningitis and Out-
sion. break Response, National Institute for Communicable Diseases (NICD)
The authors would like to thank the following medical col- of the National Health Laboratory Services (NHLS) and the National
Department of Health, South African Government, South Africa, 2020.
leagues, athletes and sport administrators for distributing the Available at: https://www.nicd.ac.za/wp-content/uploads/2020/03/NICD DoH-
survey: Dr Kevin Subbhan, Cheryl Roos, Zac van Heerden, COVID-19-Guidelines-10March2020 final.pdf.
Lance Stevens, Belinda Waghorn, Denise Polson, Calvin Ship- 12. Myer GD, Faigenbaum AD, Cherny CE et al. Did the NFL lockout expose the Achilles
heel of competitive sports?, JOSPT, 1033 North Fairfax Street, Suite 304, Alexan-
ley, Nick Brink, Josh Smith, Tim Vadachallam, Denis Riehbok, dria, VA, JOSPT, Inc., 2011.
Kelvin Ndhlomo, John Williams, Warren Engelbrecht, Kutlwano 13. Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: a comprehensive
Molefe, Christy Cronin, Neline Hoffman, Bernadette Costons, overview. J Orthop Surg Res 2018; 13(1):1–11.
 L. Pillay et al. / Journal of Science and Medicine in Sport 23 (2020) 670–679 679

14. Maupin D, Schram B, Canetti E et al. The relationship between acute: chronic 31. Maughan RJ, Depiesse F, Geyer H. The use of dietary supplements by
workload ratios and injury risk in sports: a systematic review. Open Access J athletes. J Sports Sci 2007; 25(S1):S103–S113. http://dx.doi.org/10.1080/
Sports Med 2020; 11:51. 02640410701607395.
15. Matthews CE, Ockene IS, Freedson PS et al. Moderate to vigorous physical activ- 32. Grant WB, Lahore H, McDonnell SL et al. Evidence that vitamin D supplementa-
ity and risk of upper-respiratory tract infection. Med Sci Sports Exerc 2002; tion could reduce risk of influenza and COVID-19 infections and deaths. Nutrients
34(8):1242–1248. 2020; 12(4):988.
16. Soligard T, Steffen K, Palmer D et al. Sports injury and illness incidence in the Rio 33. Kwinda MA. Guidance on the application of telemedicine guidelines during the
de Janeiro 2016 Olympic Summer Games: a prospective study of 11,274 athletes covid-19 pandemic, South Africa, Health Professions Council of South Africa,
from 207 countries. Br J Sports Med 2017; 51:1265–1271. 2020. Available at: https://www.hpcsa.co.za/Uploads/Events/Announcements/
17. Schwellnus M, Soligard T, Alonso J-M et al. How much is too much? (Part 2) APPLICATION OF TELEMEDICINE GUIDELINES.pdf.
International Olympic Committee consensus statement on load in sport and 34. Greenhalgh T, Schmid MB, Czypionka T et al. Face masks for the public during
risk of illness. Br J Sports Med 2016; 50(17):1043–1052. the covid-19 crisis. BMJ 2020; 369:m1435.
18. de Oliveira Neto L, Elsangedy HM, de Oliveira Tavares VD et al. Training in home – 35. National Department of Health, COVID-19, online resource and news portal, South
home-based training during COVID-19 (SARS-COV2) pandemic: physical exer- Africa, 2020. Available at: http://www.health.gov.za/index.php/component/
cise and behavior-based approach. Revista Brasileira de Fisiologia do Exercício phocadownload/category/631.
2020; 19(2). 36. COVID-19 Corona Virus South African Resource Portal, 2020. Available at: https://
19. Ogard WK. Proprioception in sports medicine and athletic conditioning. Strength sacoronavirus.co.za/.
Cond J 2011; 33(3):111–118. http://dx.doi.org/10.1519/SSC.0b013e31821f3ae. 37. Lillicrap S. Behind closed doors: what impact can these coronavirus hit games
20. Jukic I, Calleja-González J, Cos F et al. Strategies and solutions for team sports ath- have on players?, England, Sportsman HQ, 2020. Available at: https://www.
letes in isolation due to COVID-19, Multidisciplinary Digital Publishing Institute, thesportsman.com/articles/behind-closed-doors-what-impact-can-these-
2020. coronavirus-hit-games-have-on-players.
21. Farren GL, Zhang T, Gu X et al. Sedentary behavior and physical activity pre- 38. Hughes D, Saw R, Perera NKP et al. The Australian Institute of sport framework
dicting depressive symptoms in adolescents beyond attributes of health-related for rebooting sport in a COVID-19 environment. J Sci Med Sport 2020. Available
physical fitness. J Sport Health Sci 2018; 7(4):489–496. at: https://www.jsams.org/article/S1440-2440(20)30527-2/fulltext.
22. de Oliveira R.G, Guedes DP. Physical activity, sedentary behavior, cardiorespi- 39. Varaeva YR, Livantsova EN, Polenova NV et al. Characteristics of blood lipid
ratory fitness and metabolic syndrome in adolescents: systematic review and profiles of professional athletes: a literature review. Curr Pharm Des 2020;
meta-analysis of observational evidence, Public Library of Science, 2016. 26(1):98–102. http://dx.doi.org/10.2174/1381612825666191213115232.
23. COVID-19 and Sporting Activity. AIS framework for rebooting sport, Australia, 40. Soligard T, Schwellnus M, Alonso J-M et al. How much is too much? (Part 1)
The Australian Institute of Sport, 2020. Available at: https://ais.gov.au/health- International Olympic Committee consensus statement on load in sport and
wellbeing/covid-19#ais framework for rebooting sport. risk of injury. Br J Sports Med 2016; 50(17):1030–1041.
24. Sarto F, Impellizzeri F, Spörri J et al. Impact of potential physiological changes due 41. Gabbett TJ. The training – injury prevention paradox: should athletes be training
to COVID-19 home confinement on athlete health protection in elite sports: a call smarter and harder? Br J Sports Med 2016; 50(5):273–280.
for awareness in sports programming, 2020. Available at: https://osf.io/preprints/ 42. Carmody S, Borodina MA, Gouttebarge M et al. When can profes-
sportrxiv/4zb3a/. sional sport recommence safely during the COVID-19 pandemic? Risk
25. Reardon CL, Hainline B, Aron CM et al. Mental health in elite athletes: Interna- assessment and factors to consider. Br J Sports Med 2020. Available at:
tional Olympic Committee consensus statement (2019). Br J Sports Med 2019; https://blogs.bmj.com/bjsm/2020/04/30/when-can-professional-sport-
53(11):667–699. recommence-safely-during-the-covid-19-pandemic-risk-assessment-and-
26. Trojian T. Depression is under-recognised in the sport setting: time for pri- factors-to-consider/.
mary care sports medicine to be proactive and screen widely for depression 43. AIS Whitepaper on load, Prescription of training load in
symptoms. Br J Sports Med 2016; 50:137–139. relation to loading and unloading phases of training. Execu-
27. Tolentino JC, Schmidt SL. DSM-5 criteria and depression severity: implications tive Summary, Version 1, 4 May 2015, 2020. Available at:
for clinical practice. Front Psychiatry 2018; 9:450. http://dx.doi.org/10.3389/ http://runpure.com.au/wp- content/uploads/2016/02/AIS White paper -
fpsyt.2018.00450. Loads and risks following troughs250615.pdf.
28. Nédélec M. Recovery strategies in elite sport: focus on both quantity and quality 44. Eminent Persons Group on Transformation in Sport (EPG), Sport
of sleep. Rev Med Liege 2020; 75(1):49. transformation status report. A comparative & sport code specific
29. Haspel JA, Anafi R, Brown MK et al. Perfect timing: circadian rhythms, sleep, and assessment & introduction to school sport structure, Published by the
immunity – an NIH workshop summary. J Clin Invest Insight 2020; 5(1). http:// Department of Sport & Recreation, South Africa, 2016/2017. Avail-
dx.doi.org/10.1172/jci.insight.131487. able at: https://www.srsa.gov.za/sites/default/files/Transformation
30. Thomas DT, Erdman KA, Burke LM. Nutrition and athletic performance. %20Status%20Report%20-%202016-2017%20EPG%20-FINAL.pdf.
Med Sci Sports Exerc 2016; 48:543–568. http://dx.doi.org/10.1249/MSS.
0000000000000852.