ROLE OF MODERATE INTENSITY AEROBIC EXERCISE ON IMMUNITY AND IMROVING OUTCOME IN

COVID 19 PATIENT

INTRODUCTION:

The development of a drug to treat patients with COVID-19 might take several months, thus the
need for quick and safe interventions is a must to decrease its spreading and death rates

COVID-19 is a self-limited infection, in which the strength of the host’s immune strength plays a
significant role against it [1]. Increasing the aerobic capacity can produce immediate effects on the
immune system activity. It has been shown that aerobic exercises significantly increase the function
of the immune system in short periods and sometimes this increase occurs after only one session.
The effect of increasing the aerobic capacity on improving the immune functions can be mainly
produced through two mechanisms.

1. Firstly, it can increase the level and function of Tlymphocytes, neutrophils, macrophages,
and monocytes, which are essential elements in the body’s defence against infections
[2,3,4,5,6,7]
2. Secondly, it can increase the level of immunoglobulins (IgA, IgM, IgG), particularly IgA
because of its vital role against lung infections [8,9,10,11].

LITERATURE REVIEW:

A review conducted by Ayman A. Mohammed et al. summarizes that increasing the aerobic capacity
is recommended in covid patients because it has potential of improving immune and respiratory
functions which would help counter COVID-19. This can decrease the morbidity and mortality rates
of COVID-19.

A recent study that has been published on March 13, 2020 [19] has demonstrated that risk factors
linked with the occurrence of COVID-19 and its progression to death include aging, hypertension,
diabetes, and heart problems. All these risk factors have been previously shown to be immediately
or shortly improved by increasing the aerobic capacity [20,22,23,24,25,26].

An aerobic exercise program of moderate intensity which can be determined using Borg's scale,
rating of perceived exertion (RPE) 6–20 (fairly light to somewhat hard) as it has a very good
correlation with the physiological measure of exercise intensity [9]. Borg's RPE has a real-world
applicability and also seems to be an authentic tool for monitoring and prescribing exercise intensity,
which is self-governing in regards of gender, age, previous physical activity level and coronary artery
disease . It is also stated in some researches that exercising at an RPE of 11–13 is suggested for
sedentary individuals, and an RPE of 13–15 may be recommended for those who have been
previously exercising [27]

Martin et al in 2009 [28] had provided evidence to support the hypothesis that moderate intensity
exercise reduces inflammation and improves the immune response to respiratory viral infections.
They hypothesized that acute and chronic moderate exercise induces a level of stress hormones that
down-regulates excessive inflammation within the respiratory tract and aids in activating innate anti-
viral immunity shifting the immune response towards a Th2 profile, thereby balancing the Th1/Th2
responses to prevent an excessive Th1 immune reaction to these pathogens. Further research is
necessary to examine cellular and molecular mechanisms through which exercise modulates
immune function. They suggested that moderate intensity exercise training should be used as an
adjunct to other preventative measures against respiratory tract viral infection.
Walsh et a l[29] in their review suggest that immune health may actually be enhanced by regular
intermittent exposures to environmental stress (for example, intermittent hypoxia training).

OBJECTIVES:

To determine level of immunological markers- T lymphocytes, neutrophils, monocytes, macrophages

and immunoglobulins in blood and saliva of covid 19 patients undergoing moderate intensity aerobic
exercise for 30 minutes thrice a week for 4 weeks.

I.To determine effect of 4 weeks moderate intensity aerobic exercise on increase in the number of
following cells in blood
1.lymphocytes
2. neutrophils
3. monocytes
4.IgG
5.IgM
6.IgA (blood and saliva)
II. To determine percentage of patients progressing to need for supplemental oxygen in 4 weeks
exercise group as compared to that in standard therapy group
METHODS

Randomized controlled trial with experimental group undergoing moderate intensity aerobic
exercises 30 minutes thrice a week for 4 weeks in addition to standard treatment and control group
undergoing standard treatment. LAB TESTS at 0 and 15 days of exercise intervention.

INCLUSION CRITERIA

COVID 19 POSITIVE PATIENTS AGED 18- 50 YEARS WITH BORG DYSPNOEA SCALE<3 AND NO
SEVERE COMORBIDITY LIMITING EXERCISE PERFORMANCE

Inclusion criteria
a) covid positive

b) borg dyspnea scale score <1

c) no co morbidity decreasing ability to stand

Exclusion criteria
a) body temperature>38degree Celsius
b) blood oxygen saturation< 95%

c) bp <90/60 mm hg
>140/90 mm hg

Control(s)
patients undergoing standard treatment

REFERENCES

1. Cascella M., Rajnik M., Cuomo A., Dulebohn S.C., Di Napoli R. 2020. Features, Evaluation and
treatment coronavirus (COVID-19)

2. Gonçalves C.A.M., Dantas P.M.S., dos Santos I.K. Effect of acute and chronic aerobic exercise
on immunological markers: a systematic review. Front Physiol. 2020;10(January):1–
11. [Google Scholar]
3. Lippi G., Banfi G., Montagnana M., Salvagno G.L., Schena F., Guidi G.C. Acute variation of
leucocytes counts following a half-marathon run. Int J Lab Hematol. 2010;32(1 PART.2):117–
121. [PubMed] [Google Scholar]
4. Lippi G., Salvagno G.L., Danese E. Mean platelet volume (MPV) predicts middle distance
running performance. PloS One. 2014;9(11):8–13. [Google Scholar]
5. Li T.L., Cheng P.Y. Alterations of immunoendocrine responses during the recovery period
after acute prolonged cycling. Eur J Appl Physiol. 2007;101(5):539–546. [PubMed] [Google
Scholar]
6. Lira F.S., dos Santos T., Caldeira R.S. Short-term high- and moderate-intensity training
modifies inflammatory and metabolic factors in response to acute exercise. Front
Physiol. 2017;8(OCT):1–8. [PMC free article] [PubMed] [Google Scholar]
7. Reis Gonçalves C.T., Reis Gonçalves C.G., de Almeida F.M. Protective effects of aerobic
exercise on acute lung injury induced by LPS in mice. Crit Care. 2012;16(5):R199. [PMC free
article] [PubMed] [Google Scholar]
8. Rodríguez A., Tjärnlund A., Ivanji J. Role of IgA in the defense against respiratory infections:
IgA deficient mice exhibited increased susceptibility to intranasal infection with
Mycobacterium bovis BCG. Vaccine. 2005;23(20):2565–2572. [PubMed] [Google Scholar]
9. Hines M.T., Schott H.C., Bayly W.M., Leroux A.J. Exercise and immunity: a review with
emphasis on the horse. J Vet Intern Med. 1996;10(10):280–289. [PubMed] [Google Scholar]
10. Cunningham-Rundles C. vol. 157. Wiley-Blackwell; 2009. Lung disease, antibodies and other
unresolved issues in immune globulin therapy for antibody deficiency; pp. 12–16. (Clinical
and experimental immunology). [Google Scholar]
11. Mohamed G., Taha M. Comparison between the effects of aerobic and resistive training on
immunoglobulins in obese women. Bull Fac Phys Ther. 2016;21(1):11. [Google Scholar]
12. Pedersen B.K., Hoffman-Goetz L. Exercise and the immune system: regulation, integration,
and adaptation. Physiol Rev. 2000;80(3):1055–1081. [PubMed] [Google Scholar]
13. Marklund P., Mattsson C.M., Wåhlin-Larsson B. Extensive inflammatory cell infiltration in
human skeletal muscle in response to an ultraendurance exercise bout in experienced
athletes. J Appl Physiol. 2013;114(1):66–72. [PubMed] [Google Scholar]
14. De Gonzalo-Calvo D., Dávalos A., Montero A. Circulating inflammatory miRNA signature in
response to different doses of aerobic exercise. J Appl Physiol. 2015;119(2):124–
134. [PubMed] [Google Schol
15. Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A rapid advice guideline for the
diagnosis and treatment of 2019 novel coronavirus (2019-nCoV) infected pneumonia
(standard version). Vol. 7, Military Medical Research. BioMed Central Ltd.; 2020. [PMC free
article] [PubMed]
16. Nieman DC, Pedersen BK. Exercise and Immune Function Recent Developments. Vol. 27,
CURRENT OPINION Sports Med. 1999. [PubMed]
17. Channappanavar R., Zhao J., Perlman S. T cell-mediated immune response to respiratory
coronaviruses. Immunol Res. 2014;59(1–3):118–128. [PMC free article] [PubMed] [Google
Scholar]

18. Gonçalves C.A.M., Dantas P.M.S., dos Santos I.K. Effect of acute and chronic aerobic exercise
on immunological markers: a systematic review. Front Physiol. 2020;10(January):1–11. [Google
Scholar]

19.Wu C., Chen X., Cai Y. Risk factors associated with acute respiratory distress syndrome and
death in patients with coronavirus disease 2019 pneumonia in wuhan, China. JAMA Intern
Med. 2020:1–10.

20. Bacchi E., Negri C., Trombetta M. Differences in the acute effects of aerobic and resistance
exercise in subjects with type 2 diabetes: results from the RAED2 randomized trial. PloS
One. 2012;7(12) [Google Scholar]

21. Yardley J.E., Kenny G.P., Perkins B.A. Resistance versus aerobic exercise. Diabetes
Care. 2013;36(3):537–542. [PMC free article] [PubMed] [Google Scholar]

22. Yokoyama H., Emoto M., Fujiwara S. Short-term aerobic exercise improves arterial stiffness
in type 2 diabetes. Diabetes Res Clin Pract. 2004;65(2):85–93. [PubMed] [Google Scholar]

23.Chapman S.B., Aslan S., Spence J.S. Shorter term aerobic exercise improves brain, cognition,
and cardiovascular fitness in aging. Front Aging Neurosci. 2013;5(NOV) [Google Scholar]

24. Giallauria F., Del Forno D., Pilerci F. Improvement OF heart rate recovery after exercise
training IN older people. J Am Geriatr Soc. 2005;53(11):2037–2038. [PubMed] [Google Scholar]

25. Tao L., Bei Y., Lin S. Exercise training protects against acute myocardial infarction via
improving myocardial energy metabolism and mitochondrial biogenesis. Cell
PhysiolBiochem. 2015;37(1):162–175. [PubMed] [Google Scholar]

26. Wisløff U., Loennechen J.P., Currie S., Smith G.L., Ellingsen Ø. Aerobic exercise reduces
cardiomyocyte hypertrophy and increases contractility, Ca2+ sensitivity and SERCA-2 in rat after
myocardial infarction. Cardiovasc Res. 2002;54(1):162–174. [PubMed] [Google Scholar]

27.Scherr J., Wolfarth B., Christle J.W., Pressler A., Wagenpfeil S., Halle M. Associations between
Borg’s rating of perceived exertion and physiological measures of exercise intensity. Eur J Appl
Physiol. 2013;113(1):147–155. [PubMed]
 28.Martin, Stephen & Pence, Brandt & Woods, Jeffrey. (2009). Exercise and Respiratory Tract
Viral Infections. Exercise and sport sciences reviews. 37. 157-64. 10.1097/JES.0b013e3181b7b52

29. Exercise, immune function and respiratory infection: An update on the influence of training
and environmental stress.Walsh NP, Oliver SJ.Immunol Cell Biol. 2016 Feb;94(2):132-9. doi:
10.1038/icb.2015.99. Epub 2015 Nov 13.PMID: 26563736 Review.

PARUL CHAUHAN
PHYSIOTHERAPIST, JPNATC