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COVID-19 Pandemic Negatively Impacted Mental Health and Sports Participation of High School and Collegiate Athletes

With current knowledge of the impact of social isolation and detraining, we sought to understand the impact of restrictions of the COVID-19 pandemic they to competitive student majority of collegiate and high school athletes anticipated returning to sport at a lower level of play, upon lifting of COVID-19 restrictions. Clinical Relevance: Understanding how the COVID-19 pandemic impacts student athletes can lead to improvements in medical care for these athletes.


Introduction
In December of 2019 in Wuhan, Hubei Province, China, there arose an outbreak of a novel coronavirus (SARS-CoV-2) referred to as COVID- 19. This virus quickly spread throughout the world causing a global health crisis [1,2]. In response to this pandemic, governments worldwide began to impose travel restrictions and quarantine of their citizens [3]. As this novel coronavirus and its mutants continue to spread rapidly, recommendations for its containment and prevention continue to develop [4]. Numbers of those tested and diagnosed with the illness continues to rise [5].
Not only has the pandemic created organizational and financial turmoil, but it has also had unprecedented effects on athletes and the world of sports [6,7]. With widespread social isolation measures in place, sporting events, team practices, and training facilities have largely been suspended or temporarily shut down [8]. The anticipated Olympic Games in Tokyo has also been postponed [8,9].
With continuing widespread restrictions, the athletes are unable to participate in their typical training regimens or competition [8].
These limitations can cause a negative impact on the mental and physical health of the competitive athlete [10][11][12][13] as many athletes are deprived of access to the needed equipment, facilities, and space to complete training regimens. Those who participate regularly at a high level of exercise and training are especially prone to exhibit negative mental health impacts [14]. The potential negative mental health effects of such disruption of daily life by quarantines and widespread social isolation on athletes include anxiety [15], depression [16,17], and insomnia [1]. In addition, athletes experience negative physical effects from being unable to participate in typical exercise routines. These include deconditioning [18,19], development of comorbid conditions [20], and decreased bone and muscular health [21]. Increased body fat percentage and rapid loss of exercise performance adaptations also occur in athletes who undertake a detraining period [22,23].
The effects of the COVID-19 pandemic and their impact on mental and physical health has been a largely speculated and intently studied topic since the pandemic began. Several studies have been performed assessing the COVID-19 pandemic's impact on mental health relating to various geographic populations [24][25][26][27][28], in those with pre-existing mental health challenges [24], and in some specific populations such as college students [29,30].
Studies have been performed prior to the pandemic but there is limited literature on evaluating athletes especially high-school and collegiate during the pandemic while social restrictions were in place. The purpose of this study was to retrospectively evaluate and highlight the impact of the COVID-19 pandemic and its accompanying widespread restrictions on the mental and physical health of the competitive high school and college student athletes using an in-house survey. We hypothesized that CDC restrictions and limited sports activity will significantly impact the athlete's mental health and level of play upon return.

This was a HIPAA Compliant Local Institutional IRB Approved Study. The Survey was Anonymous and Voluntary
Survey: A REDCAP survey ( Figure 1) was prospectively sent to 424 college/graduate students and 1200 high school students.
Questions about demographics, sports participation, mental health, and physical activity were included in the survey. In addition, further questions regarding compliance with CDC guidelines were included.
Likert scales were used in compiling the results of the survey. A 3-point scale was used to measure responses as either "lower level", "same level", or "higher level" when asked about anticipated level of play upon return to sport. Similarly, A 5-point Likert scale was used for questions about adherence to CDC guidelines, home exercise programs, mental health, impact on future in their respective sports as seen in Figures 1-3. Survey participants were not involved in the design or dissemination plans of our research. All responses were completely anonymous for athlete privacy.

Statistics:
All results were collated on a Microsoft Excel file (Windows 10, Redwood, Seattle). Statistical analysis was performed using IBM SPSS software, with t-test and ANOVA used to determine significance. P-value less than 0.05 was considered statistically significant.
Among all class years of high school athletes, most were high school freshmen (n=106/267, 40%). Table 1 Table 2 lists details of all demographics and different sports participations. Response rates for the survey were approximately 33% (142) for college graduates and 22% (267) for high school students.

Adherence to CDC Guidelines
The vast majority of high school (83.1%) and college (81%) student athletes reported that they follow CDC guidelines "frequently" or "all the time". There was a statistically significant difference between male and female college student athletes who reported on their adherence levels to the CDC guidelines(P<.05) with males (3.98) reporting lower levels of adherence than females (4.29). to continue using their current home exercise programs. Females

Discussion
Maintenance of a structured workout program for high level athletes is paramount for continued success in sport. It is not surprising to these authors that most athletes surveyed were in discussions with team staff members about a home exercise program during the pandemic. With limited access to advanced training equipment, it is understandable why 27% of collegiate and 29% of high school athletes felt they would return to their sport at a lower level than their previous training would have allowed.
Knowledge and experience of these structured programs with specific training facilities would also explain the class discrepancy in perception of home training programs. A unique perspective from this study was on the mental health of the athletes surveyed. It is unfortunate that most collegiate athletes surveyed (63%) noted a negative impact on their collegiate athlete experience. It is possible that for most of these athletes, their participation in this level of athletics is limited and each season spent without competition is a season lost. However, it should be noted that the NCAA has made some accommodations to help reclaim these seasons by issuing a policy that seniors missing the season from last spring may regain their eligibility.
It is also with saddened understanding that we see high school seniors reporting the pandemic's effect on their experience negatively as many of them will have a premature end to their athletic career. Although the high school athletes surveyed were more optimistic regarding their future in athletics when compared to collegiate athletes, there is no question that the COVID 19 pandemic has had an impact on the mental health of both athlete populations. This would be an ideal area for additional research in the Sports Medicine community. The majority of both athlete populations seem to have adhered to the CDC recommendations with only minimal deviation for sports related activities. This is in contrast to a perception that members of this age group were routinely disregarding CDC guidelines for selfish benefit. A possible explanation is that the athletes surveyed were more disciplined than their non-athletic counterparts. Another is that the initial perception of disobedience in these young men and women is inaccurate and should not be applied to them en masse. It is, however, comforting to know that despite wavering confidence in medical leadership throughout this pandemic that many of the young athletes surveyed were practicing measures to keep their community safe. One of the potential sources for bias in this study is that of selection.
Although attempts were made to encourage the athletes to participate through two separate email reminders and the anonymous nature of the survey itself, the study is only subject to those participants that chose to respond. With a n=4, it is unlikely that the results evaluated for graduate students would yield enough power to make specific analysis accurate to that group. Additionally, all of the athletes survived were in the Dallas Metroplex region. Further analysis would be needed in other areas (either nationally or internationally) to give a more general understanding of COVID 19 repercussions on athletes. Another potential bias includes that of recall as CDC recommendations were adapting to the prevalence of the pandemic. Although the majority of athletes felt they were compliant with CDC guidelines during the pandemic, they may have been evaluating their previous activity with updated recommendations. It should also be noted that the survey was taken after the first surge in the Dallas area. Further analysis may need to be done to see if these trends hold to this population especially after the second surge was noted in Texas during the summer months. Finally, as the authors do not have any financial interests to disclose, we do not feel there was bias in the analysis of this data.

Conclusion
To conclude, COVID-19 pandemic negatively impacted mental health of young athletes with most of collegiate and high school athletes anticipated returning to sport at a lower level of play, upon lifting of COVID-19 restrictions.