Shared-Decision Making: The Risks Vs. Benefits of Returning to Sports During COVID-19

Ambassador Hailey Merk, MSM, MMS, PA-C, a Physician Assistant in Sports Medicine and Orthopedic Surgery from Chicago, has experienced how the COVID-19 pandemic is affecting athletes of all ages, especially our youth. Here she shares insight into discussing the risks vs. benefits of returning to sports and guidelines to follow to assist in this shared decision-making discussion with players and parents.

Shared-decision making is a crucial discussion in all fields of medicine that she learned how to construct working as a consultant at a healthcare education and technology company that provided decision aids to support the consent process and during Business and PA school at Wake Forest University through inquiry based learning classes.

Professional sports organizations are designing creative solutions to keep the 2020 seasons in action including utilizing quarantine bubbles and rapid and frequent COVID-19 saliva testing to keep players, coaches, and staff safe while continuing to face frequent challenges. Using these teams as a model, youth sports players, parents and coaches are questioning how to balance risks vs. benefits when deciding to return to sports. It is our role as healthcare providers to provide guidance based on the most current and ever-changing data and guidelines available to us.

The three-talk model of shared decision making emphasizes the patient at the center of the discussion and can be applied to the question of returning to sports amidst the COVID-19 pandemic. Team talk supports patient to discuss choices and their goals for the decision. Option talk provides risks, benefits and alternatives of the decision. Decision talk guides patients to make the decision based on their individual preferences. Below are examples of each discussion point to motivate the conversation and are not meant to be comprehensive:

 

  • Team Talk
    • What sport(s) do you play? If multiple, which sport is your favorite?
    • What season is your sport played? How frequently will you have practice, scrimmages, games?
    • What are your goals with playing this sport? Do you have a goal to continue play into high school/college?
    • Will the sport require travel with the team? What locations?
    • What safety precautions have been put in place by the school/club team/coaches?

 

  • Option Talk
    • Risks
      • Have you ever had symptoms of COVID-19 or tested positive for COVID-19? If the answer is yes, a sports physical and medical clearance from a pediatrician/PCP is recommended due to the risk of developing myocarditis that can cause sudden cardiac death after COVID-19 infection
      • Risk is lowest with sports drills and conditioning at home and increased with team practice, competition, and games with teams from a geographic location
      • Winter sports played indoors can increase risk in comparison to outdoor sports that allow social distancing of six feet apart
      • Direct contact sports increase risk in comparison to non-contact sports and drills
      • *Take a thorough past medical history to share risks of pre-existing conditions

 

  • Benefits
    • Improved cardiovascular health and musculoskeletal strength and less likely to develop obesity or type 2 diabetes
    • Increased opportunity for scholarships and advancements in education and career
    • Organized routine to look forward to and build healthy habits each week that are more likely to continue into adulthood
    • Broadened socialization and play time with friends that is fundamental to development and mental health
    • Applied leadership roles and skills in future education and career

 

  • Return to Play Guidelines
    • American Academy of Pediatrics (AAP)
      • COVID-19 testing prior to team participation in sports is discouraged in an asymptomatic player who has not had a recent exposure
    • American College of Cardiology (ACC)
      • Patients should be asymptomatic for two weeks with medical clearance that shows no cardiac involvement prior to return to play after COVID-19 symptoms or a positive test
      • If severe symptoms or abnormal cardiac testing, treat per myocarditis guidelines
    • Centers for Disease Control and Prevention (CDC)
      • Masks may be difficult for youth to wear during sports play while coaches, officials, staff and spectators should wear masks
      • Cloth face masks can reduce risk when social distancing guidelines cannot be maintained

 

  • Decision Talk
    • As your healthcare provider, taking into account your goals, the risks, benefits, alternatives and the guidelines we discussed, I recommend _______.
    • Open up the discussion to ensure the patient and parent preferences align with the final decision including how to return to sport safely, to add any modifications, or to avoid returning to the sport at this time.

This discussion will continue to evolve as we see updates in COVID-19 and return to play guidelines. Checking in on updates every week from AAP, ACC, AAFP, CDC and sports medicine and orthopedic organizations AAOS and AOSSM empowers you as the provider to lead this discussion and ensure your patients are safely returning to sports when possible. While our youth sports teams may not have the resources of the big leagues, we can get them back in the game too!

Follow up with me on Instagram @thesporty_pa for further discussion and posts on this topic!

Watch the news interview with my collaborating physician Dr. Nikhil Verma @nikhilvermamd Lead Physician for the Chicago White Sox on this topic: https://www.youtube.com/watch?v=YDErZCoDRkg

Watch this Osmosis video that simplifies the shared decision making process into a short three minute clip: https://www.youtube.com/watch?v=4ueDJEFytMI

References

American Academy of Pediatrics. (2020, September 18). COVID-19 Interim Guidance: Return to Sports. American Academy of Pediatrics. Retrieved October 06, 2020, from https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/

Centers for Disease Control and Prevention. (2020, May 29). Considerations for Youth Sports. Centers for Disease Control and Prevention. Retrieved October 06, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/youth-sports.html

Dean, P., MD, Jackson, L., MD, & Paridon, S., MD. (2020, July 14). Returning To Play After Coronavirus Infection: Pediatric Cardiologists' Perspective. American College of Cardiology. Retrieved October 06, 2020, from https://www.acc.org/latest-in-cardiology/articles/2020/07/13/13/37/returning-to-play-after-coronavirus-infection

Elwyn, G., Durand, M. A., Song, J., Aarts, J., Barr, P. J., Berger, Z., . . . Weijden, T. V. (2017). A three-talk model for shared decision making: Multistage consultation process. BMJ. doi:10.1136/bmj.j4891

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