e frontiers in Physiology OPEN ACCESS Ecited by: Pte Unversity or Navare, Spa ‘Reviewed by: Ham Ara, Universi oF Gun, Fan Pate Oe, vert of Now Sac, Sati sles Franco Lp Gt Unversiy or trcia Soa “Correspondence "Paulo Gent pauogentenotmalcom Speciaty section: verso Physio, secon ofthe joura Frontiers in rysiooay Received: 9 December 2020 ‘Rovepted: 26 fru 2021 Pubiished: 03 rc 2021 Citation Gant Pde Lea CAB, Cos Barroso WKS, Vicrno PLEO, Ramee Corio R, Main W ard ‘Sea 0 2021) Practical ‘Recommandtos Peart othe (Use at Resstance Facing fer COND-19 Sinwors Front tysot 12697590 tt 1. ase 2027697590 HYPOTHESIS AND THEORY ished O3 Mar 20 ext 103 Practical Recommendations Relevant to the Use of Resistance Training for COVID-19 Survivors Paulo Gentil, Claudio Andre Barbosa de Lira', Victor Coswig?, Weimar Kunz Sebba Barroso”, Priscila Valverde de Oliveira Vitorino*, Rodrigo Ramirez-Campillo**, Wagner Martins” and Daniel Souza’ Coleg of sical Educator and Dance Fecal Unversity of Gots, Gana, Gaz,“ Mpertenson Leave, Fecrat Luweraty of Gis, Ging, Ban * Cale of ys! Eavesto, Fecal Umar of Pa Catan, Eazy, Si) ‘Sconces and Heath Schon Pica Cathe Unversty of Gs, Gata, Evan, *Labartary ef Human Peoomance, ‘Qinty of Lie ans Wethees Reseach Groyp, Dapriment of Physical Act Scences,Unverstiac de Los Lagos, Osama, ‘Ci, " Cant do vestgncon an son de arco, Facutad de Cenc, Uersad Mayer Santiago, Cie, Prysiceray Calege Unversty of rasta, asta, Bast ‘The novel coronavirus disease (COVID-19) has emerged at the end of 2019 and caused a global pandemic. The disease predominantly affects the respiratory system; however, there is evidence that itis a mutisystem disease that also impacts the cardiovascular system. Although the long-term consequences of COVID-19 are not well-known, evidence from similar diseases alerts for the possibilty of long-term impaired physical function and reduced quaity of life, especially in those requiring critical care. Therefore, rehabilitation strategies are needed to improve outcomes in COVID-19 survivors. Among the possible strategies, resistance training (RT) might be particularly interesting, since it has been shown to increase functional capacity both in acute and chronic respiratory conditions and in cardiac patients. The present article aims to propose evidence-based and practical suggestions for RT prescription for people who have been diagnosed with COVID-19 with a special focus on immune, respiratory, and cardiovascular systems Based on the current literature, we present RT as a possible safe and feasible activity that can be time-efficient and easy to be implemented in different settings Keywords: resiatance exercise, rehabitaton, strength traning, pulmonary rehabitation, cardiaerehabitation, ‘coronavirus THE PROBLEM The novel coronavirus disease (COVID-19) pandemic has posed a great threat to public health concern and safety (Wu et al, 2020; Zu et al, 2020). Caused by acute respiratory syndrome coronavirus 2 (or SARS-CoV-2}, COVID-19 is characterized by respiratory distress and multisystem disease, which is frequently severe and might result in death (Kreutz et al, 2020). Many COVID-19 survivors who requited critical care may develop psychological, physical, and cognitive impairments (Barker-Davies et al, 2020), There is evidence that coronaviruses may induce neurological impairments by invading the central nervous system and some patients may have symptoms like severe muscle pain (Li Y.C. etal, 2020). COVID results in elevant morbidity for 3-6 months (intermediate phase), and rehabilitation services and medical care might be needed for more than 12 months (chronic phase) (Barker-Davies eta, 2020) Previous studies showed that survivors of acute respiratory diseases might have persistent functional disability and psychological symptoms for as much as 1 year after discharge Fronts in Prysicogy | wrironorsinrg 1 ‘March 2021 | Woume 12 | Atco 657590cenit (Herridge et al, 2003; Tansey et al, 2007), with most of them showing extrapulmonary conditions, with muscle wasting and ‘weakness being most frequent (Herridge etal, 2003). Moreover, many COVID-19 patients will need to be on intensive care units, which is associated with symptoms like dyspnea, anxiety, depression, impaired physical function, and poor quality of life for up to 12 months after discharge (Ocyen et al., 2010; Denehy and Elliot, 2012; Jackson et al, 2012). Among them, physical function is one of the factors least likely to recover to normal values as it is heavily affected by critical illness (Gerth et al, 2019). The cardinal manifestations include limb ‘muscle weakness, muscle atrophy, and impairments in deep tendon reflexes (Li Z. et al 2020), Neuromuscular weakness in the intensive care units can prolong the patient’s mechanical ventilation time and hospitalization. Therefore, rehabilitation should commence in the critical care setting, since early exercise prevents neuromuscular complications and improves functional status in critical illness, being considered effective, safe, and feasible (Sosnowski et al, 2015; Barker-Davies et al, 2020). Moreover, rehabilitation programs starting within the post-acute phase (<30 days) seem to bring the most benefits (Barker-Davies et al, 2020) Besides all the knovledge about intensive care management and recovery, there is a paucity of evidence-based recommendations regarding rehabilitation following COVID-19. Among the possible strategies for rehabilitating COVID-19 patients survivors, resistance training (RT) that conventionally consists of the voluntary muscle contractions against some kind of external resistance might be particularly interesting, since it has been shown to be a safe and feasible strategy to increase functional capacity in both acute and chronic respiratory conditions (Troosters et al, 20105 Liao et al, 2015: Li et al, 2019; Rice etal, 2020), Based on the current scientific evidence, RT can be safe, time-efficient, and easy to be implemented in almost anywhere and with minimal resources (Gentil et al. 2020b; Souza etal, 2020). Therefore, the present article aims t0 propose evidence-based and practical suggestions for the use of RI for people who have been diagnosed with COVID-19 during different phases of disease, with a special focus on immune, respiratory, and cardiovascular systems, IMMUNE SYSTEM Te immune system works through the coordinated functions cof many cells to protect the organism against opportunistic infections (Pedersen and Holfan-Goetz, 2000). Therefore, preserving or improving its function is important for people ‘who were affected by COVID-19. There are evidences of ether immune survellance of immunodepression in response to exercise (Pedersen et al, 1998; Peake et al, 2017; Nieman and Wentz, 2019); however, the specifc effects of RT on immune function have not being extensively studied (Freidenreich and Volek, 2012). Interestingly, people involved in endurance training are more commonly affected by immunodepression and illness (Nieman, 2007) when compared to strength and power sports (Alonso et al, 2010, 2012; Horn et al, 2010; Fronts in Prysicogy | wrironorsinrg essence Tang for COVD-19 Sunmors Timpka et al, 2017), which might be a favorable point to ART (Natale etal, 2003; Gentil et al, 20206). In general, the association between exercise and body immune defenses follows a J-shaped curve (Pedersen et al, 1998; Peake et al, 20175 Nieman and Wentz, 2019), improving with moderate amounts of physical exercise anc decreasing with excessive or low amounts of exercise (Pedersen et al, 1998; Peake et al, 2017; Nieman and Wentz, 019). This complex relation i negatively inluenced by many factors, such as higher energy expenditure (Spence et al, 2007; Rama etal, 2013), inereased exercise volume (Peters and Bateman, 1983; Gleeson et al, 2013; Siedik et al, 2016), and metabolic stress (Pedersen and Hofiman-Goetz, 2000). In this sense, an acute bout of exercise might induce a suppressive effect on lymphocyte proliferative sesponses, with long-duration (longer than 1) and high-intensity exercise exhibiting a moderate suppressive effect (Scdlik et al, 2010) ‘A study by Davis et al. (1997) analyzed the effects of physical exercise on susceptibility to respiratory infection by using @ murine model. The exercise design was composed of three groups: no exercise, moderate short-term exercise (G0 min), and prolonged exercise to voluntary fatigue (25 35h). According to the results, exercising to fatigue resulted in greater mortality rate (410) than either no exercise or shor term moderate exercise. Although morality rate tended to be lower after short-term moderate exercise (9%) than no exercise (16%), there was no significant difference between conditions. The results also showed a decrease in antiviral resistance alter strenuous exercise within the lungs, in coxjunetion with increased susceptibility to respiratory infection in vivo. Although there is paucity of data linking the transitory immune suppression after strenuous exercise with chronie immune system impairment and subsequently infection risk (Niemanand Wentz, 2019), itis reasonable to suggest that exerise-induced immune suppression may impair the clearance of pathogen in acute illness COVID-19 patients. Therefore, even after the acute phase of the disease, physical exercise should ensure the adequate restoration of immune defense. For these reasons it might be advisable to avoid strenuous activities and adopt a reduced total training RT volume/duration ((<45 min) to preserve immune function and decrease the risk cof complications, particularly when the immune response is stil compromised (Gleeson etal, 2013; Peake eal, 2017). With that in mind, low-volume RT should be recommended. Here, itis important to note that taining sessions lasting a few minutes have been suggested to promote muscle strength and size gains in diferent populations (Fisher J. et al, 20175 Souza et al, 2020). From a practical standpoint, previous studies showed that, ‘untrained youngaand older adults can obtain many health benefits (es increased functionality and cardiovascular improvements) fom minimal dose RT protocols involving two sets of theee to four basic exercises with a training frequency of one or to sessions per week (Fisher etal, 2014 de Barbalho et al, 20175 Seguro et al, 2019; Souza eta, 2019; Dias et al, 2020) It is important to consider that rises in epinephrine, cortisol, and sympathetic modulation seem to be related to immunosuppression induced by exercise (Pedersen and Hoffiman-Goetz, 2000; Nieman and Wentz, 2019). In this March 202 | Youre 12 | Ace 697890cenit regard, previous studies have shown an association between elevated metabolic stress, cortisol levels, and immunosuppression in response to RT (Miles et al, 2003; Ramel et al, 2003; Kraiger etal, 2011). Therefore, it might be interesting to avoid such responses in COVID-19 survivors under rehabilitation According to previous studies, RT protocols witha few number of repetitions (<6 repetitions) and long between-sts rest intervals (3 min) result in less pronounced increases in sympathetic activity, cortisol, and lactate levels (Kraemer etal, 1990; Smilios, al, 2008, 2007; Vale et al, 2018). Moreover, low-volume RT with few repetitions is less glycolytic (Kauiman et al, 20 Therefore, it could provent the concurrency for energy substrate and subsequent immunosuppresson, since glucose isthe main fue of immune cells (Palmer etal, 2015). Regarding time of the day, studies involving endurance activities showed that the acute increases in leukocytes were higher when exercise was performed during the night (6 PM) ‘when compared to morning (9 AM), and it remained high for 1h alter exercise ina hot and humid weather (Boulkelia el, 2018) ‘When comparing exercise during the morning and afternoon (9 AM vs. 4 PM) in a cold envionment, Boukela etal (2017) found higher immune function and es pulmonary inslammation during afternoon exercise, We could not find specific studies with RR however, it has been previously shown that plasma cortisol levels are increased duising the morning (Hayes et al, 2010), ‘which could suggest an impaired immune function. Therefore, the suggestion isto train in the afternoon or carly night. The basis of COVID-19 pathogenesis is associated with 4 delayed antiviral response followed by an. immunological ‘overreaction that results in an excessive proinflammatory state (Castelli etal, 2020). The levels of systemic inflammation might explain the severity ofthe disease, with the mos affected patients presenting higher serum levels of proinflammatory cytokine, as well as reduced T lymphocytes count (Chen et al, 2020) Regulatory T lymphocyte (Treg) is also reduced in severely ill patients and seems to play an important role in COVID-19 pathogenesis, since i is associated with controlling autoimmune and proinflammatory response (Gladstone etal, 2020; Stephen Vietoret al, 2020). In this context, RT may contribute to control proinflammatory state (Chupel etal, 2017; Santiago etal, 2018; Lammers etal, 2020) Despite the fat that studies investigating the effect of RT on Treg cells are scarce (Dorneles etal, 2020), previous study in murine model showed that RT can upregulate this immune marker (Souza et al, 2017). Moreover, regular practice of RT increases the levels of interleukin-10, an ant inflammatory cytokine that is mainly produced by Treg cells (Chupel et al, 20175 Lammers et al, 2020). RESPIRATORY SYSTEM. ‘The high evel of proinflammation mediators and histopathological changes in the lungs in response to SARS: CoV-2 might induce apoptosis in pulmonary endothelial and epithelial cells, leading to impaired respiratory function such as acute respiratory distress (Castelli et al, 2020). Additionally, persistent proinflammatory state in severe COVID-19 patients Fronts in Prysicogy | wrironorsinrg Fessance Tang for COVD-19 Sunmors is associated with fibroblast proliferation in the alveolar septum, resulting in pulmonary interstitial fibrosis (Zhang et al, 2020). Pulmonary diseases are commonly associated with loss of muscle ‘mass and function (Steiner, 2007; Bone etal, 2017). The analysis fof previous outbreaks of severe acute respiratory syndrome (SARS) revealed that 6-20% of the patients showed mild or moderate restrictive Tung function consistent with muscle weakness 6-8 weeks after hospital discharge (Chan et al, 2003). This scems to persist for an even longer period as persistent pulmonary function impairment was present in 37% of the patients aller recovery from SARS and their health status was also significantly worse compared with healthy subjects (Ong ct al, 2005). Results from a cohort study showed significant impairment in lung capacity in 23.7% of SARS survivors I year after illness onset (Hui et al, 2005). Moreover, health status and exercise capacity were remarkably lower than those found in the normal population (Hui etal, 2005). Previous studies showed that, in people with pulmonary diseases, low muscle strength is associated with physical inactivity (Osthoif et al, 2013) and is an independent predictor of morbidity and mortality independent of the degree of respiratory Timitation (Swallow et al, 2007). Consequently, the Key target in rehabilitation for pulmonary diseases should be improving Tocomotor muscle structure and function, as exercise results in reduced benefits on exertional ventilation, operating lang volumes, and respiratory muscle performance (Marilier etal, 2020), Moreover, the performance of physical exercise is advised as adjuvant non-pharmacological treatment during pulmonary fibrosis rehabilitation (Spruit etal, 2009). RT has been suggested as an successful strategy for pulmonary rehabilitation, either performed alone or in conjunction with aerobic training, since it brings important increases in functional capacity (Liao et al, 2015; José and Dal Corso, 2016; Li et al, 2019). It is also important to highlight that exercise training «luring hospitalization due to acute respiratory conditions seems to bring important health and functional benefits, is. well tolerated, and the adverse events are infrequent (Troosters etal, 2010; Rice et al, 2020). RT can be successfully performed as a stand-alone exercise strategy, without increasing adverse c obstructive pulmonary disease patients under pulmonary rehabilitation (Liao etal, 2015). Considering that most people infected with SARS-CoV-2 could experience breathing diflculties, it is recommended to control the respiratory responses to exercise. One advantage ‘of RI is that it might promote less cardiorespiratory stress (ie, oxygen consumption and pulmonary ventilation) than aerobic exercise, even during maximal exercise testing (Houchen: Wolloff et al, 2014; Garnacho-Castano et al, 2015; Albesa Albiol et al, 2019), The manipulation of RT variables might further reduce the respiratory stress. Pulmonary ventilation and ‘oxygen consumption increase with increased volume/duration (Haddock and Wilkin, 2006; Mookerjee etal, 2016; Garnacho: Castano et al, 2018), lower rest intervals (Ratamess et al, 2007; Farinatti and Castinheiras Net, 2011), higher movement velocities (Mazzetti et al, 2011; Mukaimoto and Ohno, 2012; Buitrago et al, 2014), and higher number of repetitions (Scott et al, 2011; Ratamess et al, 2014). Therefore, training with events in chron March 202 | Youre 12 | Ace 697890cenit lower number of repetitions, higher interval between sets, and controlled movement velocity might be recommended (Buitrago et al, 2013). CARDIOVASCULAR SYSTEM Similar to other coronavirus infections, COVID-19 i associated vith cardiac complications, especially arrhythmias, hear faire, and myocardial injury (Kochi ct al, 2020; Madd et aly 20, Wang et al, 2020). Acute cardiac injury is higher in those with increased mortality, with severe dssose, and requiring. ventilatory support (Kochi et al 20205. Madjid ct al, 2020), Cardiac complications have been suggested to be multifactorial. It-may be caused by hypoxia, via ryocarial njry, hypotension, ACE2-reeptor downregulation, drug toxicity, or elevated systemic inflammation (Kochi et 2020), The proinflammatory mediators associated with COVID- 19 can result in vascular inflammation, myocarditis, and nic complications (Kochi et al, 2020: Madid et als 2020). Another complication regarding cardiovascular system is the increased risk of thromboembolism asa consequence of coagulopathy and endothelial vascular dysfunction in critical illness COVID-19 patents (Goshua et 2020) Patients diagnosed with COVID-19 should be flly assessed and, if necessary, additional investigations may include resting clectrocardiogram (ECG), blood exams, 24 h ECG, cardiopulmonary, echocardiogram, cardiovascular magnetic resonance imaging, and exercise testing with the involvement of a cardiologist (Darker Davies el, 2020), In case of myocarditis, 4 period of 3-6 months of complete rest from strenuous exercise might be necessary, depending on the clinical severity illness duration (Pelicia et al, 201% Schellhorn et al, 2020). After Teturming, itis advisable to conduct periodic reassessment in the first2 years due to an increased rskof silent clinical progression (Pelco etal, 2019), RT has been shown to be safe and effective for several cardiac patients from different cardiac diseases and has been recommended as a core component of cardiac rehabilitation for many decades (McKelvie and McCartney, 1990, Veril ct al, 1992; Yamamoto ct al, 2016). Some studies suggested that RT might be even safer than actobic exercise, since it results in less myocardial stress and reduced hemodynamic tesponses in patients with heart diseases like controled heart failure (Karksdottir etal, 2002; Levinger et al, 2005), coronary arterial disease (Karisdotir etal, 2002), and chemi ‘cardiomyopathy (McKelve etal, 1995) and in patents in cardia rehabilitation after myocardial infarction and percutaneous coronary intervention (Adams et sl, 2010), Moreover, RT lads to improvements in cardiac’ autonomic control of diseased individuals (Bhati et al., 2019). Cardiovascular stress might be more relatd tothe deraton of the exercise than with the load used, granting the use of higher Toads and Tower numberof repetitions In this regard Lamatte etal. (2005) reported higher levels of blood pressure and heart rate in response to RT using lower external loads tnd higher repeiions four sets of 17 repetitions at 40% of Fronts in Prysicogy | wrironorsinrg essence Tang for COVD-19 Sunmors the one-repetition maximum strength (IRM)] when compared with higher external loads and lower repetitions (four sets of 10 repetitions at 70% of IRM) in 14 patients who participated in a rehabilitation program (eg. bypass surgery, percutaneous coronary angioplasty, or valvular surgery). Similarly, Gjovaag etal. (2016) reported higher levels of blood pressure and heart rate in patients with coronary arterial disease after performing 15RM with lower external loads than performing 4RM with higher external loads. Regarding autonomic modulation, Vale et al, (2018) showed that hypertensive women training with lower repetitions and higher external loads (6RM) showed less sympathetic activation and higher parasympathetic activation ‘when compared to training with lower external loads and more repetitions (15RM). Therefore, in order to reduce cardiovascular stress during exercise, the recommended RT program should involve lower number of repetitions regardless ofthe load used, (One important feature in previous studies is that blood pressure and heart rate progressively increase over the seis, especially when the rest between sets is shorter (Gotshall et a, 1999; Lamotte et al, 2005; Gjovaag et al. 2016). This suggests that one should consider performing a lower number of sets (one or two) and using higher rest between sets (23 min). Other additional strategies to reduce cardiovascular stress is to give short pauses (ie.,5 s) in the middle of the ses (da Silva et al, 2007; Réia~Alonso eta, 2020), avoid performing repetitions until ‘muscle failure (MacDougall et al, 1992), and exercise during the aftemoon, since cardiac reactivity is lower (Jones et al, 2006; Boukelia etal, 2018) and there i a better blood pressure control (ones et al, 2008) at this period ofthe day. PRACTICAL RECOMMENDATIONS: RT might be performed in many settings, including acute hospitalization and rehabilitation scenarios, Previous studies have shown that RT performed during intensive care units ‘ight bring important benefits either alone (Morris et al, 2016; Barbalho et al. 2019; Veldema et al, 2019) or combined with other activities (Eggmann et al, 2018). Interestingly, the benefits of RT in intensive care unit patients have been reported even in the presence of mechanical ventilation (Eggmann etal, 2018). Another important concern with COVID-19 is the neuropsychiatric sequalae. In addition to pandemic-associated psychological distress, the direct and indirect effects of the coronavirus on the human central nervous system might be related to neuropsychiatric disorders such mood changes, sleep disorders, depression, and anxiety (Khatoon et al, 2020; Steardo et al, 2020; Troyer et al, 2020). Studies investigating COVID-19 patients found a high level of post-traumatic stress and depressive symptoms in comparison with non: infected people (Vindegaard and Eriksen Benros, 2020). In this regard, there are consistent evidence that RT is associated with improvements in depression (Gordon et al., 2018), anxiety (Gordon et al,, 2017), and sleep disorders (Kovacevic et al, 2018), including patients with chronic diseases (Ferreira et al, 2020) and during rehabilitation (McCartney, 1998; Vincent and Vincent, 2012; Chan and Cheema, 2016; Andrade et al, 2018; March 202 | Youre 12 | Ace 697890cenit Seguro et al, 2019). The potential benefits of RT for COVID-19 patients are illustrated in Figuee 1. RT programs commonly involve many exercises with the addition of isolated exercises for specific muscles, which might be too time-consuming. However, multi-joint exercises seem 10 be sufficient to improve muscle strength and hypertrophy in the muscles involved in the exercises (Gentil etal, 2015, 2017s Paoli et al, 2017; Barbalho et al, 2020a,b) and there is no additional benefits in using single-joint exercises (Gentil et al, 2013; de Franga et al, 2015; Barbalho et al, 2020b). This allows the use ‘of multi-joint exercises combined with low-volume programs, increasing feasibility and safety for most of the patients affected by COVID-19, hospitalized ot not, including individuals with cardiometabolic diseases and frail elderly. Patients with COVID: 19 that present severe body aches, sore throat, shortness of breath, chest pain, general fatigue, cough, or fever should avoid exercis between 2 and 3 weeks after the cessation of these symptoms, Its also recommended to avoid prolonged exhaustive or high- intensity exercise, These current restrictions to RT practice could bbe reviewed after cessation of the symptoms. COVID-19 patients that are asymptomatic should continue to exercise, as they would do normally. A pulmonary rehabilitation approach should be combined in the case on return from mild/moderate COVID-19 illness (Barker-Davies etal, 2020), RT using non-traditional equipment such as elas which are low cost and portable, and can be performed in almost anywhere, might contribute to increase the possibilities for RT performance in many different settings, including intensive care units. Previous studies reported that RT using clastic bands or tubes resulted in similar muscle activation and mechanical stress (Aboodarda et al, 2011, 2016), strength gains (Martins et al, 2013), and improvements in functional capacity (Colado et al, 2010; Souza et al, 2019) when compared to traditional RT. Furthermore, RT might also be performed using body weight exercises as it promotes gains in c devices, Improved eeneral health and quality of FIGURE 1 | Mister berets of resistance ating Fronts in Prysicogy | wrironorsinrg Fessance Tang for COVD-19 Sunmors muscle strength, hypertrophy, and body composition similar to traditional RT for many different populations, like middle aged people with non-alcoholic fat liver disease (Takahashi et al, 2015, 2017), elderly people (Tsuzuku et al, 2017), and even young trained practitioners (Calatayud et al., 201 Kikuchi and Nakazato, 2017). ‘Another possible limitation in rehabilitation settings is the belief that RT has to be performed with moderate to high loads (ACSM, 2009; Kraemer etal, 2002), as it is commonly suggested that it would be necessary to use loads 60% of 1RM for optimal gains in strength and muscle mass (McDonagh and Davies, 19845 ACSM, 2009), However, previous studies have shown that low external load RT might bring inereases in muscle fitness and hypertrophy that are similar to conventional approaches, when effort is high (Fisher J.P. etal, 2017; Steele et al, 2019). Previous studies in both trained (Morton etal, 2016) and untrained people (Mitchell etal, 2012; Assungio et al, 2016) reported that RT with low external load resulted in similar increase in muscle strength and hypertrophy when compared to high external load, ‘This is particularly evident when the strength tests not similar to the situations trained (Fisher J. P. et al, 2017). The caveats for using low external load are that it would require a higher umber of repetitions and longer exercise times, which can result in more negative impact on the immune system and a higher stress on respiratory and cardiovascular systems, as suggested above, Therefore, the cost-benefit of such adaptations might be analyzed individually, Significant physiological stimulus can also be obtained with maximal or near-maximal voluntary muscle contractions performed without external load. In this regard, previous studies reported high levels of muscle activation when performing RI with the intention to maximally contract the muscles and. no external load (Gentil et al 20173; Alves et al 2020), A previous study reported equivalent gains in arm muscle hypertrophy aiter traditional and no external load RY in young ‘men and women, using a contralateral training design (Counts et al, 2016). Positive outcomes in terms of hypertrophy and functionality have also been reported in intensive care units patients (Barbalho etal, 2019). Particularly in aging people, the performance of high-velocity, RY might be considered as an alternative strategy when the performance of high or low external load RT with high effort is not possible or recommended (Fragala et al, 2019). High: velocity RT may provide superior increases on functional capacity in comparison with conventional RT (Bottaro et al, 20075 Nogueira et al, 2009; Ramirez-Campillo et al, 2014), A previous study suggested that high-velocity RT might be a feasible and safe strategy to revert or prevent functional decline during acute hospitalization (Martinez-Velilla et al, 2019). Thus, the performance of few repetitions using high-velocity concentric muscle action combined with long rest intervals and/or intra set short pauses could provide significant gains on functionality while preventing higher cardiovascular stress (Lamotte et al, 2010; Dias et al., 2020). Considering that the use of light to ‘moderate loads (eg, 30-60% of IRM) are recommended to optimize muscle power (Fragala et al., 2019), this might be easily achieved with small implements such light dumbbells or March 202 | Youre 12 | Ace 697890cenit essence Tang for COVD-19 Sunmors “ining volume/ Repetions/ exercise duration set duration Restintenals Movement veloty Daytime jmmune system + + 7 NA Respiratory system + + * + ariovasculr 2 ‘Overall commendation: reduced training volume (3-6 sets per muscle group per week) to perfor preferentially multjint ‘exercises, exercise session no longer than 45 min, low numberof repetitions (6) long intervals between sets (23 min), controled ‘movement velocty (2 in both concentric and excentric phase) and Preferential inthe aftermoon/begering ofthe night FIGURE 2 | Practical recommendations errestance rang in COVID-19sunivers. the: wer: NA, not valle, clastic devices, Therefore, equipment and implements should rot be a barrier to implement RT programs during COVID- 19 rehabilitation, RT progression should be based on individual analysis, considering performance parameters and clinical symptoms. Initially, itis recommended that progression should be performed through increases in load, since higher number of sets and repetitions and lower rest intervals might impose unwanted risks. Therefore, the recommendation isto establish a repetition margin (ie, 4-6RM) and increase load when the participant reaches the upper limit. When the patient reaches pre-COVID. physical capacity, it would be interesting to re-examine for the possibility of restoring normal routine (Phelan etal, 2020) FINAL CONSIDERATIONS Itis important to observe some general precautions for returning, to exercise post-COVID-19, like monitoring temperature before ‘raining, starting with a muscle strengthening program prior to cardiovascular work, keeping social distancing, observing hygiene, adequate ventilation, and the use of masks when necessary (So etal, 2004; Gentil etal, 2020a). Another relevant point is the need to carefully evaluate clinical status and supervise patients that have been diagnosed with COVID-19, especially people with cardiac injuries (Barker-Davies et al, 2020), highlighting the need of a multidisciplinary approach. ‘A sublinical myocardial injury may be present after clinical recovery from mild infections, even without cardiac symptoms ‘or hospital admission, While the present article addresses RT for rchabilitation purposes, medical clearance is roquired. Therefore, a medical evaluation is recommended to exclude subclinical diseases before resuming high-intensity training or competition, eventually with exams such as transthoracic echocardiogram, ‘maximal exercise testing, and 24h Holter monitoring (Dores and Cardim, 2020; Wilson etal, 2020). Considering the negligible chance of cardiac sequelae after asymptomatic infection or local symptoms of COVID-1S, it is not necessary to perform pre-participation screening if a Fronts in Prysicogy | wrironorsinrg critical evaluation of signs and symptoms is negative and shows a complete recovery (Verwoert et al,, 2020; Wilson et al, 2020). However, a pre-participation screening and cardiologist consultation may be considered for specific groups, including, but not limited to, people with pre-existent cardiovascular disease, elite athletes, and those with impaired recovery of exercise capacity. For those with regional or symptoms not requiring, hospitalization, it is strongly recommended to perform a pre-participation screening that includes physical examination, critical evaluation of symptoms, and a 12-Iead ECG (Verwoert et al, 2020; Wilson et al, 2020). A cardiologist experienced in reading athletes’ ECG should be consulted to differentiate between ECG changes due to exercise adaptation and ECG abnormalities suggestive of cardiac disease. This is necessary because 12-Lead ECG is not the gold standard for the detection of myocarditis. It is also recommended to use cardiac biomarkers to detect myocarditis (Verwoert et al, 2020; Wilson et al, 2020). However, caution should be taken when using this strategy because mast people do not have previously documented baseline measurements to compare with, and exercise might clevate the levels of these biomarkers, without clear-cut clinical implications (Verwoert et al, 2020). RT may be done after myocarditis if serum biomarkers of myocardial injury and Teft ventricular systolic function are normal and if 24 h ECG. ‘monitoring or exercise testing rules out relevant arrhythmias (Barker-Davies eta, 2020). It is worthy to note that most of these screening recommendations refer to competitive athletes and high intense activities (Dores and Cardim, 2020; Verwoert eta. 2020; Wilson et al, 2020), Therefore, the specific limitations for performing RT should be individually analyzed and consider the specificities ‘of each protocol. In this contest, RT might be designed to be especially safe for people who have been diagnosed with COVID- 19, in different stages of disease and recovery, by decreasing the risk of immunosuppression and reducing respiratory stress and cardiovascular risk. Interestingly, when combining the evidence fin immune, pulmonary, and cardiovascular systems, the use ‘of low volumefduration approaches and the manipulation of March 202 | Youre 12 | Ace 697890cenit training variables (moderate to high loads, short set duration, low number of sets, exercise choice, high rest intervals, and/or intra-set rest) might be particularly safe (Figure 2) RT might be also convenient as it can be performed with different implements (traditional machines, elastic devices, body weight exercises, or with no external load) and settings (in-hospital, exercise facilities, or home based), increasing its feasibility Finally, RT as an approach of the rehabilitation treatment should be individualized according to the patient’s need, taking into consideration their comorbidities, symptoms of dyspnea, and psychological distress. 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Radiology 296. 15-25, ‘Conf of Interest The authors dlc thi the research ws sont in the sbsence of any commercial or fnancilelatonships tat could be construc potent eat of teres “The hang eto declared a pst co-authorsip with neo th author Copyright © 2021 Gent, de Lin, Cmwig, Baron, Vitorna, Ramires Campll, Martine and Sousa Ths isa open acres arte dried nde the terms ofthe Creative Commane Atrbaton Liens (CC BY). The ws drbuton or reproduction in other forms sprites povided the origina author(s) andthe ‘apyight owner(s) ave credited and thatthe ail publication in this ournal ‘seed. n accordance with accepted academic prate. No ws, distin ar reproduction ts perited hich des not comply with hese tem. March 202 | Youre 12 | Ace 697890