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Introduction: climbing towards a new normality (and opportunity for new perspectives)
Flatanger in the middle of Norway is known for some of the hardest climbing routes in the world. The spectacular Hanshelleren cave (figure 1) is referred to as the ‘crown jewel’ in this area, attracting climbers from all over the world to test their physical and mental strength on high-quality rock. When you stand at the bottom, the massive overwhelming granite structure may appear frightening and entirely insurmountable. However, if you climb up and inside the cave, the perspective changes, revealing a stunning view of the fiords and the surroundings.
The COVID-19 pandemic may have seemed as scary and frightening to us as standing at the bottom of the Hanshelleren cave. We have taken a significant fall:
Professional sport has been postponed or cancelled.
Gyms have been closed.
Children and youth sports and activities have been put on hold.
Now, we are standing at the bottom of the cave facing a steep climb ahead. At the time of writing, the society in Norway is about to reopen. The athletic population is gradually returning to their sporting activities, in the setting of a new kind of normality.
In this issue, we therefore focus on returning to sport from a variety of perspectives. We place particular emphasis on the athlete’s heart, as the evidence regarding cardiorespiratory complications and/or consequences following COVID-19 is yet unclear.
Sit less, move more and more often!
Lockdown and quarantine life have had a negative impact on global physical activity, according to Fitbit data,1 and future research needs to determine the long-term consequences. Now it may be more crucial than ever to use our sports and exercise medicine (SEM) voices to promote the undeniable benefits of exercise for physical and mental health and encourage everyone to keep moving! According to Professor Eklund at the Norwegian School of Sport Sciences and his colleagues, it is as simple as: ‘Sit less, move more and more often!’ In their editorial (see page 1125) , they highlight that an easily achievable goal for most people is to reduce sedentary time and subsequently increase total physical activity in small doses.
Returning safely to sport
The return to sport (RTS) concept presently covers a broader meaning than ever. As SEM physicians and physiotherapists, we are now facing the challenge of supporting our athletes in returning safely to high-intensity training and competitions from an entire period of significant changes in training workload and daily life. We have to simultaneously balance the risk of virus spread and handling the unanswered questions regarding the consequences the new virus may have had on athletes with COVID-19 symptoms. It is therefore timely that Matt Wilson and colleagues have prepared a comprehensive practical guide on returning to play (RTP) in elite athletes during the COVID-19 pandemic (see page 1157) . However, it is worth mentioning that the recommendations must be subject to adjustments as new evidence becomes available. Sticking with the theme of RTP after COVID-19, we also recommend reading the cardiologist’s views in the editorials by Dores and Cardim (see page 1132) and by Baggish et al (see page 1130) . How a gradual RTP programme could look like is elegantly illustrated in the infographic by Elliott et al (see page 1174) , and a football-specific RTP programme after COVID-19 is proposed by the Royal Spanish Football Federation (see page 1133) . Moving on to RTS following specific injuries, we are fortunate to present a conceptual framework for on-pitch rehabilitation in elite football in Taberner’s PhD Academy Awards. This article (see page 1176) describes an innovative ‘control-chaos continuum’, which can be adapted to the type of injury and guide us in the RTS process. Concerning specific injuries in professional football players, isolated syndesmosis injuries are less common, yet cause substantial injury burden. We are therefore enlightened by the new original research by Pieter D’Hooge et al (see page 1168) on RTP times after surgery for unstable syndesmotic ankle injuries. Interestingly, the average time to RTP was relatively quick. However, three specific injury characteristics (West Point grade III injury, concomitant talar cartilage lesion and age >25) were associated with longer RTP times; valuable findings to inform the players and the medical support staff better about RTP. In the systematic review by Linda Truong et al (see page 1149), the scope on recovery stages and RTS is expanded from physical factors to exploring the role of psychological, social and contextual factors following sport-related knee injuries. Although high-quality research is needed in this field, the read is truly an awakening and a reminder that ‘non-physical’ factors are present and can profoundly influence and play an essential role in all stages of recovery. Moreover, individualised considerations of these factors should be essential components of an evidence-based management approach.
Cardiology: considering the athlete’s heart
Individual considerations and shared decision-making that value patients’ goals and preferences are also encouraged in the editorial by Li et al (see page 1126) . It addresses the difficult question about when to play or not to play in athletes with inherited heart rhythm disorders. This brings us to the critical review by Corrado et al (see page 1142) , which discusses how to evaluate premature ventricular beats (PVB) in the athlete, and the informative educational review by Jong et al (see page 1178) , teaching us how to recognise sudden cardiac arrest (SCA) on the pitch. These two articles provide valuable information and practical tips for health professionals in how to recognise and managing athletes with PVBs and SCA, respectively.
Enhancing communication in SEM and Skadefri.no
One possible positive (?) side effect of the pandemic may be the awareness of the high potential for enhanced communication through virtual communication. Increased necessity for new ways of communicating has drawn our attention towards embracing telehealth approaches and other digital solutions in healthcare. Ahmed et al highlight in their editorial (see page 1128) the benefits of using WhatsApp by SEM clinicians for a quicker and more efficient communication between colleagues and patients/athletes. However, concerning ethics and general data protection regulations, it is important to be aware that the area is yet not perfect.
In this context, we also want to direct a spotlight towards the Norwegian innovative platform Skadefri.no. This is an evidence-based resource including a website and a free app, and is developed at the Oslo Sports Trauma Research Center aimed to address the gaps in access to sport-specific injury prevention resources and make them available in one platform for athletes, coaches, parents, clinicians and anyone else involved in sports. The website is translated into English,2 and the Get Set–Train Smarter app is translated into seven different languages. The platform provides among many things videos and images of specific injury prevention exercises for all the Olympic sport codes, and the latest sport added to the app is the new Olympic sport climbing. We encourage you to check it out and to follow Skadefri.no on Facebook and Instagram!
With that, we wish all our colleagues good luck with the climb towards new normality, hopefully with an enlightened view and new perspectives from the top.
Thanks to Stian Christophersen for assisting with obtaining the cover picture.
Twitter @arnlaugw, @HildeMBerge
Contributors AW and HMB drafted the manuscript and approved the final version.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.