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Moderate intensity exercise helps in boosting the immune system in population with cardiorespiratory disease.
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Exercise and nutrition are important aspect in cardiopulmonary rehabilitation.
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Cardiopulmonary rehabilitation will be important for population with the disease undergoing rehabilitation during the pandemic due its immune boosting and anti-inflammatory effect.
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Long term effect of cardiorespiratory program during the pandemic is yet not clear.
Abstract
Background
Patients with cardiorespiratory problems often suffer from systemic inflammation. Stress due to the disease and continuous inflammation can undermine the success of the rehabilitation program.
Objective
This review has been undertaken primarily to understand the effectiveness of exercise training on the immune system in individuals undergoing cardiorespiratory rehabilitation and its implications for further management during the COVID-19 pandemic.
Methods
Assessors analyzed related studies identified in the MEDLINE, PROQUEST, PUBMED, Cochrane Library, CINAHL, EMBASE, Google Scholar, Physiotherapy Evidence, and Science Direct databases. The studies were divided into groups focused on the effect of exercise on blood leukocytes, the anti-inflammatory effect, and the role of nutrition and exercise in resolving inflammation.
Results
Twenty-eight studies were included in this review. The number of studies included in each section was as follows: the effects of exercise training on leukocytes in cardiorespiratory conditions (n = 8), anti-inflammatory effect (n = 6), and the role of nutrition and exercise in resolving inflammation (n = 14). The bias risk assessment showed poor internal validity; most included studies were assigned no and unclear descriptors.
Conclusions
Substantive evidence is presented that emphasizes the role of moderate-intensity exercise in boosting the immune system in patients with cardiorespiratory diseases. Exercise has anti-inflammatory effects that are vital for overall well-being and resolving longstanding inflammation. Individuals with an active lifestyle had a better pathogen immune response than more sedentary individuals. Our findings highlight the current need to investigate the long-term effects of cardiorespiratory rehabilitation programs.
The health-related economic burden cardiovascular disease (CVD) imposes on individuals remains unknown, including the personal liabilities of their families
The burden of pulmonary diseases has also increased in recent years worldwide. Chronic obstructive pulmonary disease (COPD) and asthma contribute significantly to a population's mortality rate.
Rehabilitation is an integral part of remediation for disabling sequelae of cardiorespiratory diseases. The rehabilitation path for cardiorespiratory diseases involves acute care continued in outpatient and community settings based on the complexity of the patient's need. Recently, the global coronavirus disease 2019 (COVID-19) outbreak has posed unprecedented challenges in providing rehabilitation, including for cardiorespiratory diseases.
Impact of COVID-19 outbreak on rehabilitation services and Physical and Rehabilitation Medicine physicians’ activities in Italy. An official document of the Italian PRM Society (SIMFER).
Eur J Phys Rehabil Med [Internet].2020 Jul; 56 (Available from)
Additionally, an optimized exercise workout provides a cohesive physiological response, improving the exercise tolerance capacity of cardiorespiratory disease survivors.
Moreover, decreased exercise capacity is an independent indicator and predictor of numerous noncommunicable diseases, such as cardiovascular and chronic respiratory diseases.
Endothelial function is a vital factor in cardiorespiratory health, a major determinant of which is the immune system. A growing body of evidence shows that exercise and nutrition can influence immune system function.
The body's defenses mainly encompass the inborn (innate) and adaptive immune responses.
The innate immune system remains active from birth, with physical barriers, macrophages, and natural killer (NK) cells as primary constituents. The adaptive immune system relies more on cellular and humoral responses.
The immune system is sensitive to short- and long-term exercise training. It has become evident that moderate-intensity exercises enhance immunosurveillance with several health benefits.
Therefore, current evidence support the connection between regular physical activity and increased immunosurveillance capacity, enhancing the body's defense mechanism against infection.
Short- and long-term systematic exercises can considerably modulate an individual's immune protection with additional benefits such as psychological motivation and reductions in weight and any pre-morbid inflammatory status.
Studies have previously shown the effectiveness of pulmonary rehabilitation (PR) programs on biomarkers such as fibrinogen and albumin, which have predictive ability for the postoperative outcome of lung-related problems.
Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial.
Exercise's anti-inflammatory and antioxidative effects on the skeletal muscles, adipose tissue, cardiovascular system, and immune system have already been shown. It has also been postulated that exercise reduces redox-sensitive transcription factors, proinflammatory cytokine profiles, and activator protein-1.
In addition, some studies have reported that the degree of inflammation in cardiorespiratory-related problems is related to workout intensity. However, there remains uncertainty in these results.
A systematic review reported that regular fruit and vegetable consumption over long periods positively affects lung function in COPD individuals. Some nutritional studies have also shown the effects of dietary interventions on health-related quality of life, systemic inflammation, and physical functions.
While disparities in clinical trials remain, there continues to be a need to examine the long-term effects of dietary interventions.
This integrative literature review primarily focuses on understanding the effectiveness of exercise in modulating the immune responses of individuals undergoing cardiorespiratory rehabilitation and its implications for patient management during the COVID-19 pandemic.
Methods
We performed a comprehensive and thorough search of the MEDLINE, PROQUEST, Cochrane Library, PUBMED, CINAHL, EMBASE, Physiotherapy Evidence (PEDro), Google Scholar, and Science Direct electronic databases. We used search strings combining keywords and medical subject headings terms related to exercise, nutrition, impact on the immune system, blood parameters, anti-inflammatory effects, and cardiorespiratory diseases. Studies explicitly discussing the antioxidative anti-inflammatory role of exercises and the effects of exercise on blood parameters, nutrition, and acute and chronic immune responses were included in this review. Evidence was retrieved on exercise's role, which was then used to devise a plan for its management and practice with cardiorespiratory diseases during the COVID-19 pandemic. A graphical abstract for the current review is presented in Fig. 1. Bias risk was assessed using Cochrane's risk of bias tool in Review Manager v.5.4.1 to rate the quality of articles included in this study (Fig. 2). The Risk of bias evaluation was divided into domain allocation concealment, random sequence generation, blinding of participants, blinding of outcome data, incomplete outcome data, selective reporting, and other biases. Yes, no, and unclear descriptors were used to report each domain.
Fig. 1Summarizing the effect of exercise in cardiorespiratory disease.
Twenty-eight studies were included in this review. This study is divided into four themes: the impact of exercise training on blood parameters, high and moderate-intensity exercise training in cardiorespiratory diseases and their immune responses (Tables 1 and 3), anti-inflammatory effects of exercise training in cardiorespiratory diseases (Table 3), and the role of nutritional interventions in cardiorespiratory rehabilitation (Table 2). The number of studies included in each section was as follows: the effects of exercise training on leukocytes in cardiorespiratory conditions (n = 8), anti-inflammatory effect (n = 6), and the role of nutrition and exercise in resolving inflammation (n = 14). Furthermore, facts supporting exercise's involvement in modulating the immune response were also examined.
Table 1Effects of exercise training on Leukocytes in cardiorespiratory conditions.
Single session bicycle ergometer With initial2 min without loading later gradual increments in the load till exhaustion
Pre
Post Post 2 h Post 24 h
Neutrophils,% Eosinophils,% Macrophages,%
Short term session of incremental exercise, causes increased eosinophils, phlegm in patients with COPD, with no noteworthy variations in other inflammatory cells
Moderate intensity exercises followed by high intensity exercises, providing 30 min interval between two modes of exercise
Single session of moderate-intensity exercise characterized by 2 sessions of exercises done at 50% of maximal power with 6 min of rest period between each session. Whereas high intensity exercise comprises of 6 short sessions done at 100% of maximal power with 1 min of rest between each session
Pre
post
Leukocytes Neutrophils Lymphocytes Monocytes
The prescribed exercise pattern couldn't notice any changes in leukocytes but, reported increase in growth hormones
Combined aerobic exercise and upper body resistance training. Aerobic exercise consisted of (treadmill walking, cycling, or rowing) with intensity 60–85% of maximal heart rate
0 wk.
12 wk.
CRP, Intercellular adhesion molecule-1 (ICAM-1), (IL-6), and TNF-α
Gender based-CR and Traditional CR were effective in reducing inflammatory biomarkers
The bias risk assessment showed poor internal validity; most included studies were assigned no and unclear descriptors in most domains. The details of the bias risk assessment are shown in Fig. 2.
Impact of exercise training on blood parameters
While moderate-intensity exercises enhance the immune system, vigorous exercises can suppress the immune system.
Acute training leads to increased neutrophil concentration during and after exercise. Similarly, moderate exercise can increase lymphocyte counts. Intense exercise did not affect lymphocyte count.
Physical activity induces neutrophilia under cortisol's influence. Neutrophil chemotaxis is substantially decreased without a reduction in bactericidal activity during the post-exercise period (nearly 24 h) .
This decrease in neutrophil chemotaxis reverses within 48 h post-exercise. However, it should be noted that infectious microorganism activity can increase during this period.
Finally, an eight-week structured exercise program resulted in a temporary increase in circulating plasma volume and plasma erythropoietin concentration and a gradual increase in red blood cell volume.
This multidimensional system acts on unrecognized foreign bodies or molecules (e.g., parasites, bacteria, viruses, fungi, and infected cells) to eliminate them from the body.
The body's defense or immune system can be divided into innate and adaptive immunity.
Innate immunity
This immune system is typically the primary defense mechanism against foreign pathogens. It typically comprises immune cell-like monocytes, macrophages, granulocytes, and NK cells.
In contrast, acute high-intensity or regular, intense exercise can disrupt the defense mechanism, increasing the risk of upper respiratory tract infection.
Evidence suggests that intense training sessions increase the likelihood of infection, relapse, and myocarditis. Macrophages, NK cells, and neutrophils are relatively responsive to acute exercise sessions. With chronic exercise training, the NK cells show increased inactivity. In contrast, opposite or suppression inactivity is observed in neutrophil functions with intense sessions. Evidence suggests that acute moderate exercise sessions with a duration <60 min and intensity <60% of VO2 max (oxygen uptake) are associated with reduced immune system stress.
Intermittent training is an aerobic training strategy that uses either rest or low-intensity-exercise periods between high-intensity periods. The primary concept behind this strategy is to allow more rigorous exercise periods than continuous high-intensity exercise.
Acute high-intensity interval training usually destabilizes the immune system, but chronic functional bouts may lead to immune system adaptations without altering leukocyte count.
Classically, high lymphocyte counts are observed throughout continuous training and immediately afterward, with fewer cells post-workout during the early recovery phase. This typical cell orchestration is commonly observed for T cells and, to a lesser extent, B cells.
An increase in both CD4+ and CD8+ lymphocytes is observed post-exercise. Despite high CD3+ cell accumulation, lymphocyte production is often reduced in the aged. Therefore, exercise-induced leucocytosis is observed in younger and older individuals but less often in the aged.
This hypothesis advocates that medium-intensity workouts can enhance the body's defense mechanism in inactive individuals, while high-intensity workouts may weaken the body's defense mechanism.
Niemen et al. previously used this hypothesis to explain the 2–6-fold increase in the risk of developing respiratory infections among marathon runners.
After long periods of intensive exercise, the immune system may experience physiological stress and suppression. This period is called an “open window” and usually lasts 3 to 72 h. Therefore, the host remains vulnerable to microbes and pathogens such as bacteria and viruses, with a greater likelihood of contracting infections.
Therefore, advocating exercise training in cardiorespiratory disease, especially high-intensity exercises, may require caution and knowledge about the J curve theory since patients with cardiorespiratory diseases are already susceptible to infections. However, if the exercise training program does not attain the desired intensity, it may fail to produce the required effects on the body's inflammatory state.
Role of nitric oxide (NO) in inflammation and exercise
NO plays a key role in defense systems protecting against infections by various organisms. It differentiates the growth and death of immune and inflammatory cells, which include mast cells, macrophages, neutrophils, NK cells, and T lymphocytes.
One study found that four weeks of home-based exercise training enhanced the release of endothelium-derived NO in hypercholesterolemic patients without altering risks for other comorbidities. Therefore, current evidence indicates that exercise training has both cardioprotective and blood pressure normalizing effects.
The anti-inflammatory effects of exercise training in cardiorespiratory diseases
It is well-known that chronic build-up of inflammatory biomarkers, such as fibrinogen, C-reactive protein (CRP) and cytokines, may develop and progress toward cardiorespiratory disease.
Skeletal muscles generally interconnect with other tissues through peptides called myokines which are secreted by the myocytes during muscle contractions.
The exercising muscle usually produces and discharges several peptides, including leukemia inhibitory factor and interleukins (IL)−4, IL-6, IL-7, and IL-15.
Studies exploring exercise's role also specifically reported that exercise induces the release of myostatin inhibitors usually released from wasted or disuse muscles, which act on myostatin and negatively affect muscle mass and hypertrophy.
The first cytokine released from active skeletal muscle cells into the blood during exercise is IL-6. Exercise increases the amount of muscle-derived IL-6 in the blood.
Therefore, longer workout periods lead to a more distinctive total IL-6 release. This release of IL-6 is primarily related to workout intensity, approximately around 70%–85% of VO2 max.
In contrast, tumor necrosis factor-alpha (TNF-α) in the arteries may promote the atherosclerosis process via specific adhesion factors. Additionally, inflammatory cytokines modify skeletal muscle histology and deleteriously affect cardiac contractility and left ventricular remodeling.
Notably, while a structured exercise training regime can adversely affect plasma IL-6 levels, muscular IL-6 receptor levels are increased, indicating improved IL-6 signaling in expert compared to amateur individuals.
Some studies discussing the resolutory effects of exercise training in cardiac and pulmonary conditions are discussed in Table 3. It should be noted that most studies listed in Table 3 report the beneficial effects of exercise.
Table 3A qualitative view of anti-inflammatory effect of exercise training in cardiorespiratory conditions.
Downregulated hs-CRP and MAD, upregulated GSH and TAC, and improved metabolic status following combined exercise and turmeric supplementation: a clinical trial in middle-aged women with hyperlipidemic type 2 diabetes.
RCT (Exc+TS (n= 11), Exc+placebo (Exc; n= 10), TS (n= 11), and Con (C; n= 10)
HT2DM
hs-CRP levels, HDL, cholesterol, and TG
Exc + TS is recommended as a conclusive lifestyle approach to manage metabolic status, oxidative stress biomarkers, and CRP in middle-aged females with T2DM
Effect of endurance exercise training on endothelial function and arterial stiffness in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial.
Effect of exercise training on skeletal muscle fibre characteristics in men with chronic heart failure. Correlation between skeletal muscle alterations, cytokines and exercise capacity.
Plasma levels of amino-terminal pro-brain natriuretic peptide (NT-proBNP), high- sensitivity C-reactive protein (hs-CRP), and cardiac troponin T (cTnT)
A 12-week exercise training program did not lead to improvements in plasma concentrations of cytokines nor NT-proBNP, when compared with usual care
Muscle Biopsies, TNFa, C-reactive protein (CRP), tumor necrosis factor-a (TNFa) and (C) interleukin-6 (IL-6)
Pulmonary rehabilitation induced muscle adaptations and skeletal muscle hypertrophy without decreasing the levels of systemic or local muscle inflammation
TNF-a, soluble TNF receptors (sTNFRs: sTNFR55 and sTNFR75) and interleukin (IL)−6 and TNF-a mRNA
Moderate-intensity exercise increases plasma tumor necrosis factor-a levels in COPD without exercise-induced upregulation of the tumor necrosis factor-a gene in skeletal muscle
High Intensity, Intermittent exercise of adequate intensity can increase GH in children with CF, without affecting systemic inflammation, whereas Continuous mode of moderate-intensity exercise is associated with significant increase in IL-6 levels
Index of lipid peroxidation, thiobarbituric acid reactive species (TBARS), total radical-trapping antioxidant parameter (TRAP) and xanthine oxidase (XO) activity
PR program is associated with decreased systemic exercise-induced oxidative damage
combine to create a persistent secondary exacerbated condition in the whole body. Ancillary studies support the direct association between sedentariness and visceral fat deposition.
Studies have identified important factors concerning the harmful outcomes of visceral fat deposition in the liver and skeletal muscles that may further accelerate systemic inflammation.
This anti-inflammatory effect further attenuates chronic heart failure progression. However, there remains a dearth of studies on the anti-inflammatory potential of exercise training in PR in COPD cases.
A prominent reason for this could be the failure to reach the optimum intensity to produce the desired blood parameter effects. In addition, most studies failed to calculate exercise adherence for participants (Tables 1 and 2).
Role of nutritional interventions in cardiorespiratory rehabilitation
The surveillance ability of the immune system can be increased through a mild to moderate intensity exercise training regime.
In contrast, the lower immune response in the upper airway after high-intensity exercises may be due to decreased salivary and nasal release and a reduction in nasal neutrophil numbers.
The results of nutrition and exercise interventions for cardiorespiratory problems in decreasing inflammation are discussed in Table 2. It is perhaps already known that exercise capacity is inversely associated with the body's inflammatory status.
Patterns of dietary intake and serum carotenoid and tocopherol status are associated with biomarkers of chronic low-grade systemic inflammation and cardiovascular risk.
Br J Nutr [Internet].2014 Oct 28; 112 (Available from): 1341-1352
Patterns of dietary intake and serum carotenoid and tocopherol status are associated with biomarkers of chronic low-grade systemic inflammation and cardiovascular risk.
The American Heart Association Nutrition Committee and the European Society of Cardiology have reported that the daily consumption of vegetables and fruits can decrease CVD risk.
An analysis of 83 studies (two cohort studies and12 observational, 10 cross-sectional, and 71 clinical trials) showed that greater vegetable and fruit consumption was inversely associated with decreases in TNF-α and CRP levels and total airway inflammation.
Another study comprising 792 participants with a mean age of 70 years found that plant-based diets appeared superior and were associated with lower plasma fibrinogen and CRP levels.
Nut consumption and risk of cardiovascular disease, total cancer, all-cause and cause-specific mortality: a systematic review and dose-response meta-analysis of prospective studies.
BMC Med [Internet].2016 Dec 5; 14 (Available from): 207
Moreover, a recent meta-analysis of 23 randomized control trials assessing the effectiveness of nuts in reducing inflammation markers found that dietary management with nuts could meaningfully decrease intercellular adhesion molecule-1 and inflammatory biomarker levels.
Nevertheless, research has shown the various benefits of a vegetable-based diet. However, there remains a dearth of studies evaluating the long-term effects of dietary management programs.
Consequently, the long-term effects of exercise and nutrition on inflammatory and immune biomarkers must be assessed as an indicator of its long-term efficacy, simultaneously evaluating the effects on several adverse events, hospitalizations, and adherence to exercise programs (Table 2).
A conceptual basis for rehabilitation programs: their theoretical foundation in practice
Cardiac rehabilitation and PR programs are essential for people recovering from cardiac surgery, myocardial infarction, heart failure, or transplants.
There is increasing evidence that cardiac rehabilitation (CR) effectively decreases morbidity and mortality, increasing mental well-being, quality of life, and exercise capacity.
The American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association have reported that the essential core rehabilitation program components help reduce cardiovascular risk, augment healthy behaviors, and decrease cardiovascular-related morbidity and mortality.
Therefore, it is essential to design programs that effectively modify risky health behaviors and immunomodulation.
Similarly, PR has proven beneficial in patients with lung diseases, breathlessness, reduced functional capacity, decreased quality of life, and frequent hospital admissions.
D.ose–response relationship between physical activity and mortality in adults with noncommunicable diseases: a systematic review and meta-analysis of prospective observational studies.
Int J Behav Nutr Phys Act [Internet].2020 Dec 26; 17 (Available from): 109
However, the exact dose-response providing anti-inflammatory effects in cardiorespiratory disease remains unknown. Moreover, some animal studies have reported enhanced acute immunosurveillance, the effect of which remains unknown in healthy and diseased populations.
The specific concepts discussed in the current review will enhance the decision-making process when designing CR or PR programs. It is believed that exercise causes an acute increase in IL-6, which is known for its anti-inflammatory effects.
Over time, this effect can be vital for interventions focusing on patients suffering from cardiac or pulmonary diseases.
The cytokine storm in COVID-19
In moderate to severe COVID-19 infection, a destructive inflammatory reaction is often observed in which enormous quantities of proinflammatory cytokines are discharged, called a cytokine storm.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; also known as 2019-nCoV) infected individuals show an enhanced response leading to an unwarranted adverse reaction in the body. Greater cytokine quantities are released in severe COVID-19 cases, including interferon-gamma IL-1β, IL-2, IL-6, IL-8, IL-10, IL-17, TNF-α, gamma-induced protein 10, monocyte chemoattractant protein 1 (MCP1), macrophage inflammatory protein 1 alpha, and granulocyte-colony stimulating factor. This enhanced response can cause an auto-immunological attack, causing extensive damage to the primary organs such as the heart, lung, brain, and kidneys, eventually leading to multiple organ failures.
Recent data suggests that around 20% of individuals infected with SARS-CoV-2 may suffer from serious symptoms for over 12 weeks postdiagnosis. While studies have begun exploring this novel condition, the best practice for management in this field remains to be determined.
It has been reported that COVID-19 has severely obstructed CR care worldwide. A survey evaluating the impact of the COVID-19 pandemic on healthcare in 70 countries reported that it caused a temporary interruption in approximately 75% of CR programs.
Specific tests such as the one-minute sit-to-stand test can be used to remotely assess aerobic capacity and leg strength since they are quite sensitive to changes, particularly pulmonary problems in COPD patients.
Evaluation of exercise responses can be made using a pulse oximeter to measure oxygen desaturation, a common finding that may become complex with COVID-19. Electronic blood pressure monitors can similarly be used. Exercise intensity can be self-evaluated using a rating of perceived exertion scale and a modified Borg dyspnea scale.
A walking test can also be used to evaluate cardiorespiratory fitness in patients with CVD by remotely monitoring them after administering a structured exercise program.
Evidence suggests that CR using a walking test and telemonitoring using a heart rate monitor can efficiently administer and increase cardiorespiratory fitness in cardiac patients with mild-to-moderate risk factors.
Self-management approaches are another core aspect in the remote management of COPD and asthma, which requires the patient to have sufficient knowledge and self-care skills.
An organized self-management strategy can decrease the number of episodes of exacerbations requiring hospitalization, improving the patient's mental, social and physical health
Anxiety and depression could reflect different aspects of the same situation. After an appropriate referral process, the rehabilitation process should consider an appropriate support system to manage them.
Goal setting in the rehabilitation program should be patient-centered and individually tailored rather than generally applied for a specific intensity to provide beneficial results. Structured home-based PR also has beneficial effects that will be vital for remotely managing complex clinical scenarios, such as individuals with pre-existing pulmonary or cardiac problems isolating due to COVID-19.
While clinically assessing affected patients, comorbidities should be assessed as part of good practice to rule out absolute contraindications to the treatment sessions. Moreover, the exercise sessions should be modified per the assessment status in relative contraindication cases. In addition to good practices, it is essential to acquire patient suggestions and feedback to further develop the program.
Guidelines for minimizing the risk of COVID-19 infection and transmission and optimizing rehabilitation sessions
Patients with pre-existing cardiorespiratory disease exposed to COVID-19 may have a combination of complex sequelae with signs of myocardial injury, arrhythmias, and heart failure. Such patients often remain at a higher risk of mortality and morbidity.
Patients with heart failure have reported low immune status, especially heart transplant recipients. Therefore, vaccination is a must in these patients
Noncommunicable diseases such as diabetes and hypertension may further exacerbate the situation. Nevertheless, heart failure in recovering patients might be a potent indicator of the impending danger of death.
Therefore, minimizing infection or reinfection in existing patients with comorbidities is vital. It will be essential to prevent disease transmission by using a well-ventilated room, personal protective equipment (PPE), and frequently checking for temperature and symptoms. A separate room with outpatient facilities for patients already infected with COVID-19 requiring rehabilitation
Faghy M.A., Arena R., Stoner L., Haraf R.H., Josephson R. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect, the company ’ s public news and information . 2020;(January).
will be of paramount importance. A high-efficiency particulate air filtration system should be used for COVID-19-infected patients, particularly during transportation. However, wearing PPE is recommended in all circumstances as the second line of control in system failure.
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
When preparing the patient for discharge, oxygen saturation, need for oxygen therapy, baseline respiratory function, and exercise capacity should be determined both at rest and during activity. A structured exercise program should always be pursued post-discharge for at least 6–8 weeks.
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
Additionally, mild-to-moderate exercises should be pursued at home with patient education, self-evaluation, and management skills with access to remote monitoring of vitals for immediate assistance, if required.
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
Once the impairments in the cardiorespiratory system are identified among the COVID-19 survivors, they should receive a complete rehabilitation program per the standards.
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
Baseline evaluation of mental and physical health will also be essential since they may also hinder the rehabilitation program. In addition, COVID-19 survivors with disuse atrophy post-discharge should receive nutritional support.
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
This review clearly outlines the anti-inflammatory effects of exercise-based interventions. Therefore, future trials should focus on both the short- and long-term implications of interventions in patients with cardiorespiratory diseases. Well-controlled trials are needed to understand the optimal regimen required to produce immune system effects.
Conclusions
A structured exercise program appears a prudent approach for elevating the immune status among patients with cardiorespiratory diseases. The use of exercise in these patients for its anti-inflammatory and immune-protective effects is recommended. However, high-intensity exercises should be used with caution as they can temporarily increase susceptibility to infection post-exercise. It should be noted that moderate-intensity exercises should be performed for <60 min with <60% oxygen consumption to attain maximum benefits from the rehabilitation program. While sufficient trials highlight exercise's positive effects, there remains a need to investigate the long-term effects of cardiorespiratory rehabilitation programs in pandemic situations with a better methodological design.
Funding
King Khalid University, RGP.2/134/43
Authors’ contributions
The authors confirm their contributions to the paper as follows: Study conception and design: SD. Conceptualization: SD; Data curation: SD and KG; Formal analysis: SD, RR, and VN; Investigation: SD, KG, and RR; Methodology: SD, VN, and SL; Project administration: SD; Resources: SD; Supervision: SD; Writing-original draft: SD, VN, and RR.; Writing-review and editing: SD, KG, and SL. All authors reviewed the results and approved the final version of the manuscript.
Declaration of Competing Interest
None
Acknowledgment
King Khalid University for providing the resources required to fulfill the completion of the review
Impact of COVID-19 outbreak on rehabilitation services and Physical and Rehabilitation Medicine physicians’ activities in Italy. An official document of the Italian PRM Society (SIMFER).
Eur J Phys Rehabil Med [Internet].2020 Jul; 56 (Available from)
Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial.
Patterns of dietary intake and serum carotenoid and tocopherol status are associated with biomarkers of chronic low-grade systemic inflammation and cardiovascular risk.
Br J Nutr [Internet].2014 Oct 28; 112 (Available from): 1341-1352
Patterns of dietary intake and serum carotenoid and tocopherol status are associated with biomarkers of chronic low-grade systemic inflammation and cardiovascular risk.
Nut consumption and risk of cardiovascular disease, total cancer, all-cause and cause-specific mortality: a systematic review and dose-response meta-analysis of prospective studies.
BMC Med [Internet].2016 Dec 5; 14 (Available from): 207
D.ose–response relationship between physical activity and mortality in adults with noncommunicable diseases: a systematic review and meta-analysis of prospective observational studies.
Int J Behav Nutr Phys Act [Internet].2020 Dec 26; 17 (Available from): 109
Faghy M.A., Arena R., Stoner L., Haraf R.H., Josephson R. Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19 . The COVID-19 resource centre is hosted on Elsevier Connect, the company ’ s public news and information . 2020;(January).
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- And American Thoracic Society-coordinated international task force.
Downregulated hs-CRP and MAD, upregulated GSH and TAC, and improved metabolic status following combined exercise and turmeric supplementation: a clinical trial in middle-aged women with hyperlipidemic type 2 diabetes.
Effect of endurance exercise training on endothelial function and arterial stiffness in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial.
Effect of exercise training on skeletal muscle fibre characteristics in men with chronic heart failure. Correlation between skeletal muscle alterations, cytokines and exercise capacity.
- yes, 
- No, 
- Unclear).
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