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Mask Use for Athletes: A Systematic Review of Safety and Performance Outcomes

Context: With the current Centers for Disease Control and Prevention recommendations for mask use to minimize transmission of coronavirus 2019 (COVID-19) coupled with concern for future pandemics that would require mask wearing, providing data-driven guidance with respect to athletic performance is essential. Objective: The purpose of this study was to perform a systematic review of existing literature on the use of face masks while exercising to assess the physiologic effects of face masks worn during athletic activities. Data Sources: A systematic review was conducted of studies on face mask use during exercise according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Potential studies were identified through searches of MEDLINE, Embase, Cochrane CENTRAL and CINAHL databases. Study Selection: Screening was completed independently by 2 coauthors who sought to identify studies that described the effects of oronasal mask use, if any, on sports/exercise/physical activity, for any age, gender, or level of sport. Articles describing mask effects without exercise, articles published before 1980, and non-English language studies were excluded. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: Data extraction focused on physiologic parameters measured during physical activity performed while wearing a face mask. Results: Twenty-two articles met all inclusion criteria. Study analysis revealed that the use of masks in healthy volunteers during exercise had no significant effect on physiologic parameters measured including heart rate (HR), respiratory rate (RR), oxygen saturation, and perceived exertion. Of the studies that investigated N95 masks in the healthy adult population, 2 reported modest changes in RR and maximum power output indicative of decreased athletic performance when subjects were exercising at maximum effort. Similar findings were seen in studies of subpopulations including children and pregnant women. Conclusion: Available data suggest that healthy individuals can perform moderate-to-vigorous exercise while wearing a face mask without experiencing changes in HR, RR, and oxygen saturation that would compromise individual safety or athletic performance. In the specific situation in which an N95 mask is worn, maximum power generated may be impaired. What is known about the subject: To date, there has been no systematic review of the existing literature to provide a clear consensus on whether face mask use significantly impacts athletic performance. Mask use has been demonstrated safe in the workplace; however, the use of face masks during exercise has not been examined on a large scale, particularly with respect to physiologic parameters. What this study adds to existing knowledge: This analysis highlights that available data suggest that healthy individuals can perform heavy exercise in face masks with minimal physiologic changes. This is the first systematic review of studies analyzing exercise use wearing masks. With the evidence presented here commonly cited concerns about both safety and performance decrements with mask use during physical activities may be allayed.