Lutz Graumann is medical coordinator at the Deutscher Eishockey-Bund and speaks in an interview about the implementation of the "return to play" protocol at the U20 World Championships in Canada after a Covid-19 infection. The sports doctor from Rosenheim explains which individual stages have to be completed on the way back to competition, how these are monitored and on what basis decisions are ultimately made.
The path back to training and competition after a Covid-19 infection is currently a topic of discussion, and this question is also being raised in relation to the U20 World Cup in Canada following the positive cases in our German team. What exactly does the term include, what is a return-to-play protocol in principle?
Lutz Graumann: “It basically means that once a health problem has been identified, one considers an objective plan as to how an athlete can return to sport without causing any health risks. It is a standardized protocol for returning to competition and varies depending on what is involved. With regard to the corona pandemic, we learn something new here every day; there are the first somewhat longer reports of experiences that are around six months old. So we are now quickly learning about the complexity and are constantly learning more about it due to the many cases in ice hockey.”
What exactly does this protocol look like in relation to a Covid-19 infection?
Grauman: “In relation to the corona pandemic, it is only used for confirmed Covid-19 infections confirmed by PCR tests. It is done to protect the athletes from themselves too. A ten-day rest period is initially prescribed - whether there are symptoms or not. There are different phases within the infection. In the first phase there is an absolute ban on sports except for walking and everyday activities, that's it. Phase two is an introduction to lighter to medium loads; in phase three the load is further increased and varied. Finally, in our case, load checks follow on the ice and only then is approval given. This way we can understand every single step. All processes are then discussed in the team between athletic trainer Christian Bachmann, the national science and training coach Karl Schwarzenbrunner, the team doctor Claudia Frenz and me - and then also with the sports management.
How did phase one go for the players at the U20 World Cup in Canada?
Grauman: "For the boys in Canada, a symptom diary was kept and their resting pulse was recorded every day, as well as their temperature and blood pressure. Phase one is completed after at least seven symptom-free days, and only then does phase two begin. We stick strictly to the scheme here and look closely at the symptom diary. Some mobilization was possible in Canada, something like yoga or something similar for very light activation. We also used a new type of 24-hour ECG and checked how the cardiovascular system and breathing were reacting - because the symptoms also include an increased resting pulse and faster breathing."
How is phase two characterized?
Grauman: “For the U20, 15 minutes on a spinning bike were used to see how the body reacts to stress. The load was increased up to a maximum of 70 percent of the maximum heart rate. In order to have a good comparison, preliminary values are necessary here, but we have all of them from the training. Each player's heartbeat was measured precisely and the values were determined. In addition, the one-minute regeneration of the pulse was observed, because the fitter and healthier someone is, the faster the pulse calms down. All of this was then combined with a subjective assessment of the athlete, for which the so-called Borg scale is used as a reference. At the end, it is evaluated whether the 70 percent maximum heart rate actually corresponds to a 70 percent load. This phase lasted two days. If it works, the athlete moves on to the next phase, if not, he stays there or may even be demoted.”
And in phase three the load is increased further...
Grauman: “Exactly, here there is phase 3a for one day and phase 3b for one day. 3a is exercise over 30 minutes with a maximum heart rate of 80 percent, 3b is exercise for 45 minutes. This was always carried out in the hotel room or in the training room with the same monitoring over and over again. The 45-minute load was not uniform, but was carried out at intervals in order to get closer to the load typical for ice hockey. It was always observed how the athlete is feeling, how fast the pulse is going down and does this correspond to the subjective feeling. Whenever there are abnormalities somewhere, things don’t go any further.”
Then it's off to the ice once phase three has been successfully completed. Is the decision about deployment made here?
Grauman: “After consultation with the IIHF, we were able to shorten this process to one day. After this phase the athlete is ready for the game, in total it is an eleven-day return-to-play protocol including the illness from the day of the last symptoms. The load on the ice lasts less than 60 minutes and is never used to its full capacity; the load is also 80 percent. We're trying to do it so that the players have another day where they can really push themselves in the pre-game skate. Christian Bachmann monitors the load during training, we always do this with our partner Firstbeat. We also monitor with the Nambaya system because it helps us enormously with early detection. Here we have the option of a 12-channel ECG, which offers the highest level of detail in heart analyzes that can currently be done. The overall document for the World Cup was developed by the IIHF, we decided to do even more diagnostics than was required.”
What happens if an athlete seems fit to play and then problems arise again?
Grauman: “If an athlete gets symptoms again after a game and shortly before, then the team decides again what the problem is and what measures we need to take. We look very carefully to make sure we don't miss anything. Even when the athletes are out of the protocol, there is routine constant monitoring. The resting heart rate is checked every day, we communicate every day, we collect data every day.”
How did the return-to-play protocol go at the U20 World Cup in Canada?
Grauman: “The process was completely transparent because it was accompanied by neutral observers, both the IIHF and the Canadian health authorities monitored it. All based on data that was also collected by a neutral body. As I said, we did more – including more monitoring – than we should have done. But it is also clear that monitoring can only be rated as good if there are preliminary values from the players (resting heart rate, stress data, resting ECG for comparison). There are examples where we were able to clarify certain things immediately. This approach would be important for all leagues, also with a view to the coming months. We always see how the body reacts to work.”
So, under these circumstances, is it responsible to reinstate players relatively quickly after a Covid-19 infection?
Grauman: “It is not irresponsible because we go through and follow all the steps that are currently recommended according to current literature and because we have already had an overview of the athletes' condition several days in advance. There are always numbers and data that can be used as a comparison and prove that he is ready for the next level. This is viewed and assessed from different perspectives in a very interdisciplinary manner. Everyone is worried about possible heart problems and we have to make it clear how important diagnostics are in this regard, and the clubs all have to understand that too.”
What remains is concern about long-term consequences. How do you deal with this?
Grauman: "Our entire medical team has enormous respect for the late effects and long-term consequences of the coronavirus. At the moment, we are concentrating primarily on the cardiovascular system in diagnostics, not least because these complications have already occurred in professional ice hockey. Nevertheless, we are constantly busy exchanging ideas with experts at home and abroad in order to protect our athletes as best as possible. Therefore, our current strategies are not set in stone and will certainly be critically questioned again in the coming months."