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Physical Activity for Improving the Immune System of Older Adults During
the COVID-19 Pandemic

Article  in  Alternative Therapies in Health and Medicine · November 2020

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 REVIEW ARTICLE
Physical Activity for Improving the Immune
System of Older Adults During the COVID-19
Pandemic
Shahnaz Shahrbanian, PhD; Shahla Alikhani, Mina Ahmadi Kakavandi, Anthony C. Hackney, PhD, DSc
ABSTRACT
Context • COVID-19 has spread rapidly around the world
and reached pandemic proportions. With no definitive
treatment to date, prevention is critical, and strengthening
the immune system is a valuable tool in reducing the risk
of infection. While the aging process can weaken the
immune system, physical activity may boost it.
Objective • The review intended to examine the interaction
between the changes in the immune system during aging
and the development of a COVID-19 infection, focusing
on pathophysiological factors, and to evaluate whether
regular physical activity can strengthen the immune
system in older adults.
Design • The research team performed a narrative review
by searching databases.
Shahnaz Shahrbanian, PhD, Assistant professor, and Mina
Ahmadi Kakavandi, PhD student, Department of Sport
Science, Faculty of Humanities, Tarbiat Modares University,
Tehran, Iran. Shahla Alikhani, PhD student, Department
of Physical Education and Sport Sciences, Sanandaj Branch,
Islamic Azad University, Sanadaj, Iran. Anthony C.
Hackney, PhD, DSc; Professor, Department of Exercise &
Sport Science, University of North Carolina, Chapel Hill,
NC, USA.
Corresponding author: Shahnaz Shahrbanian, PhD
E-mail address: sh.shahrbanian@modares.ac.ir
INTRODUCTION
Severe Acute Respiratory Syndrome Coronavirus 2
(SARS-CoV-2), or Coronavirus disease‐2019 (COVID-19),
was first observed in Wuhan, China in December 2019. It has
spread rapidly around the world, causing the World Health
Organization (WHO) on March 11, 2020 to declare that it
had reached a pandemic level.1 Since then many countries
have declared national health emergencies to mitigate its
Shahrbanian—Physical Activity for Improving the Immune System
During COVID-19
Results • During the COVID-19 pandemic, older people
can stay active and healthy through playing sports such as
yoga, walking, jogging, and cycling. Also, they can use
online or virtual yoga and Pilates classes and videos,
perform resistance exercises with minimal facilities at
home, and do daily housework, such as gardening.
Conclusions • In general, due to the positive role of
regular exercise training on the immune system of the
older adults as well as the involvement of the immune
system in COVID-19, it’s necessary to guide and implement
home-based exercises for older adults. (Altern Ther Health
Med. 2020;26(S2):##-##)
spread. While the virus is new, the major aspects of its
mechanism of spread and its debilitating effects have been
documented by the scientific community.
COVID-19 can affect people in all age groups, but severe
COVID-19, acute respiratory distress syndrome (ARDS),
and death are more common among older adults compared
to people in other age groups.2 WHO classifies people
60 years and over as older adults.3 The immune system
becomes less robust with age due to biological factors, such
as genetics, and environmental factors, such as exposure to
infectious agents, the imposition of metabolic changes due to
unhealthy lifestyles—inactivity, poor diet—and long-term
physiological pressures.4
Immunosenescence, the gradual decline in the immune
system associated with aging, is related to a variety of
biological events—physiological and morphological—
including an altered immune function, increased
inflammation and oxidation, and the production and release
of autoantibodies that lead to autoimmune diseases.5,6
Systemic inflammation, caused by decreased antioxidant
function and anti-inflammatory cytokines, can cause older
adults to experience the condition Inflamm-aging, which
ALTERNATIVE THERAPIES, VOL. 26 NO. S2 117
weakens the immune system.7 This phenomenon plays an
important role in creating cytokine storms that cause ARDS
in older adults with COVID-19, which is related to the
pathophysiological factors of the aging process and includes
changes in the expression of the angiotensin-converting
enzyme 2 (ACE2) receptor,8 increases in reactive oxygen
species (ROS) levels,9 cell autophagy changes,10 and vitamin-D
deficiency.11 When the COVID-19 virus reaches the alveoli, it
produces uncontrollable responses due to disruption of the
anti-inflammatory system.12 An increase in cytokines
generally and in pro-inflammatory cytokines particularly,
such as interleukin-6 (IL-6) and interleukin-1 beta (IL-1β),
has been reported in older adults.13
Aging primarily affects the immune system by altering
the structure and activity of the thymus gland and reducing
the formation of primary lymphatic tissues.14 Thymus atrophy
in older adults affects and reduces naive T cells and is
associated with accumulation of memory T cells and
decreased production of antibodies.15
During aging, macrophages that produce
anti-inflammatory agents are reduced, including fibroblast
growth factor (FGF), vascular endothelial growth factor
(VEGF), nitric oxide (NO), and transforming growth factor-β
(TGF-β).16 In addition, aging decreases the levels of natural
killer (NK) cells; they are the innate immune system and
have a potent ability to activate cytotoxic activity, protecting
the body against viral infections and cancers by preventing
their spread and killing them.17
One of the most important cytokines for the cytotoxic
activity of NK cells is interleukin-2 (IL-2), which can cause
interferon (IFN) secretion and which is less effective in older
adults.18 Schouten et al reported that the development of
ARDS in older adults is associated with an increase in pro-
inflammatory cytokines in aging.19 These changes in the
immune system of the older adults have made them more
vulnerable to COVID-19 and increased its severity.
The adaptive immune system, providing the antigen-
specific immune response, is associated with the evolution of
2 types of B cells, with a source in bone marrow, and of
thymus (T) cells that form the primary lymphocyte CD3+.
Early CD3+ lymphocytes include 2 subsets of CD4+, which
have an auxiliary role, and of CD8+, which show cytotoxicity,
all of which are also affected by age.20
The current review intended to examine the interaction
between the changes in the immune system during aging and
the development of a COVID-19 infection, focusing on
pathophysiological factors, and to evaluate whether regular
physical activity can strengthen the immune system in older
adults.
Methods
Procedures
The research team performed a narrative review by
searching databases. To assure the validity of the data, the
research team reviewed all the information based on citation
and language.
118 ALTERNATIVE THERAPIES, VOL. 26 NO. S2
Results
Immunological Changes in COVID-19
Innate Immunity. The innate immune system is the
body’s first defense against viral infections. This system
detects a viral infection with pattern recognition receptors
(PRRs), which are receptors in the host cells, such as the toll-
like receptor (TLR).21 By activating these receptors, the RNA
of COVID-19 triggers signaling pathways that lead to the
production of pro-inflammatory cytokines, such as tumor
necrosis factor alpha (TNF-α) and IL-8 and IFN-1 and IFN-3
(In healthy people,IFN-1 and IFN-3 protect the body against
infections, but overactive immune system has caused them
to play a pro-inflammatory role.) They are not only the most
important antiviral defenses inherent in immunity but also
are effective in the adaptive immune system. IFN-I can limit
the COVID-19 infection.22
Loss of the antiviral abilities of IFN-1 and IFN-3 has
been observed in cells infected with COVID-19 from
critically ill patients. Activation of TLR and retinoic
acid-inducible gene-I-like receptors [RIG-I  like (RLR)]
causes phosphorylation of transcription factors, such as
nuclear factor kappa-light-chain-enhancer of activated B
cells (NF-κB) and interferon-regulatory factor (IRF) and
leads to the production of pro-inflammatory cytokines and
interferon.23 COVID-19 impairs IFN-1 production22 and
may cause an increase in ACE2 regulation in airway epithelial
cells.24
The production of proinflammatory cytokines, such as
IL-6 may be involved in cytokine storm syndrome, which is
seen in patients with COVID-19.25 Mehta et al found that
lymphopenia and increased IL-6 levels are associated with
severe COVID-19 in some patients.26 Elevated IL-6 levels
may be associated with high levels of IFN-γ, IL-7, and IL-2
pro-inflammatory cytokines.26 Subsequently, viral infections
and antiviral dysfunction of IFN-1 and IFN-3 can lead to
inflammation and activation of the pathological pathway of
T helper 1 (Th1) and Th17 and the invocation of immune cell
effectors, such as C-reactive protein (CRP).27
Several studies have also reported a reduction in the
number of NK cells in the peripheral blood of patients with
COVID-19.28,29 NK cells regulate their cytotoxic activity by
regulating activating or inhibiting receptors, such as NKp46,
which is an NK activator receptor.30
T-cell response. T cells play a key role in controlling
viral infections. CD4 T cells are involved in the production
of antibodies and other immune cells, and CD8 T cells
reduce viral infections by killing infectious cells. Wang et al
showed a reduction in CD4 and CD8 levels in patients with
moderate to severe COVID-19.31 Increased proliferative
cytokines, such as TNF-α and IL-6, appear to cause
lymphopenia.32
T-regulatory (Treg) cells. Treg levels are reduced in
critically ill patients with COVID-19.33 Upregulation of
CD154 is associated with Treg cells.34 Loss of these cells may
contribute to the development of pulmonary
immunopathology in patients with COVID-19.35
Shahrbanian—Physical Activity for Improving the Immune System
During COVID-19
Humoral immunity response. Humoral immunity is critical
to fighting viral infections, activating B cells to produce
antibodies against specific pathogens. COVID-19 has a
strong response to B cells, leading to the production of IgM,
IgA, and IgG immunoglobulins.36 In general, in the intense
type of COVID-19, T cells show greater activity than in less-
intense COVID-19, which can lead to fatigue in patients and
reduced cytotoxic effects.37
Impact of Aging on the Immune System
Immune-system aging is associated with a progressive
decline in immune-system effects, which depend on the
normal functioning of the innate immune system and the
interaction of mediated cells. This decline in turn can affect
the health of older people.4
Macrophages. In the aging process, not only is the
number of macrophages reduced, but their phagocytic and
cytotoxic functions decrease as do those of the major
histocompatibility class (MHC), which interacts with the
immune cells in innate immunity.16 An imbalance between M1
and M2 macrophages may be the cause of age-related disease.38
Th1 and Th2 function. Dendritic cells (DCs) are one of
the components of the innate immune system that are
normally immature, but after evolution, they cause MHC
expression and monitor Th1 and Th2 function, reducing the
regulation of adhesive molecules and modulating
inflammation responses.39 Panda et al observed an increase
in the predisposing cytokines of DCs in older adults.40
In the aging process, T cells overproduce inflammatory
cytokines, which leads to immune-system pathology.41 In
addition, CD28+ levels are reduced the older adults.42 It has
been shown that in the aging process, the Th2 profile that has
an anti-inflammatory effect—IL-4 and IL-10—changes to a
Th1 profile with an inflammatory effect type—IL-2 and IFN-γ,
leading to moderate systemic inflammation in older adults.
Also, the ratio of Th17 to the anti-inflammatory aspect of
Tregs with an anti-inflammatory function increases with
age.43 Under normal conditions, a balance exists between
Th17 and Treg.44
Tregs. CD25 expression and forkhead box P3 (FOXP3)
transcription factor are essential for Treg differentiation.45
Tregs have an anti-inflammatory function by detecting their
own antigens, which are pathological factors associated with
aging due to the shortening of lymphocyte telomere due to
aging.46 Inflammatory status in the aging process
(inflammaging), including the existence of inflammatory
cytokines such as TNF-α, is a strong stimulant for the aging
of CD4+ T cells and the differentiation of T cells, and also, B
cell dysfunction associated with aging.47 The aging process
reduces the quality and quantity of B lymphocyte reserves.48
T cells. During aging, a significant decrease occurs in
naive T cells and immunoglobulins and memory T cells.49
The function of T-cell-dependent lymphocytes is also
reduced.50 Conversely, a decrease occurs in antibody
production,51 and the immature myeloid cells of the bone
marrow increase.52
Shahrbanian—Physical Activity for Improving the Immune System
During COVID-19
TLRs. Through TLRs, host cells are able to detect
antigens of external factors called pathogen-associated
molecular patterns (PAMPs). Diagnosis of PAMPs by TLRs is
made in membranes, endosomes, lysosomes,
endocytolysosomes, and other parts of the cell. PAMPs are
made of lipids, lipoproteins, and proteins that can produce
various cytokines by activating TLRs21 and are coordinators
of cellular effects, the expression and signals of which are
disrupted in older adults.53 Increased TLR-4 regulation in
monocyte-derived DCs causes inflammation in older adults.54
NK cells. IL-2 is one of the mediators that has a positive
effect on the function of cytotoxic NK cells and causes IFN
secretion, which is reduced in older adults.18 Aging can
change the phenotype of NK cells by increasing CD56dim
and decreasing CD56bright cells as well as by increasing the
CD57 index.55
Effects of Exercise
The review of the literature by Hwang et al found that
the positive effects of exercise, such as Pilates, on improving
the effects of aging, were obvious.56 Exercise is considered to
be an immunotherapy intervention.57 Regular exercise, with
its positive effects on the immune system, can be used as a
strategy to strengthen older adults’ immune systems against
COVID-19.58 An active lifestyle has positive effects on the
aging of the immune system.59
NK cells. Regular exercise, such as walking, can improve
NK cells’ function60 and the efficiency of neutrophils and
support their migration to IL-8.61 In a study with older adult
runners with 17 years of experience, Shinkai et al examined
the role that exercise can play in enhancing the differentiation
of T cells and found that the runners underwent an
improvement in their immune system.62
Autophagy performance. Mejías-Peña et al has reported
improved autophagy performance after 8 weeks of resistance
training.63 Those same researchers also showed a positive
effect on autophagy after 8 weeks of aerobic exercise.64 Raso
et al, however, observed no changes in lymphocyte phenotypes
in healthy older women after 12 months of moderate-
intensity resistance training.65
Lymphocyte. Like the 2 studies by Mejías-Peña et al,
Abd El-Kader and Al Shreef reported that 6 months of
resistance and aerobic exercise in older adults significantly
increased CD3+, CD4+, CD8+, and IL-10 (Anti-inflammatory
and Tcells) and significantly reduced pro-inflammatory IL-6
and TNF-α in both groups; however, greater improvements
were observed in the aerobic-exercise group.66
Also, Shimizu et al found a significant increase for older
adults in CD28+ CD8+ in the exercise group compared to
the control group’s after 12 weeks of resistance and aerobic
exercise.67 CD28+ actually can cause the expression of T-cell
walls, which decrease(s) as age increases.68
Effects of excessively strenuous exercise. Contrarily,
strenuous exercise with excessive volume may increase the
risk of upper respiratory tract infection (URTI) due to a
weakened immune systems.69 In response to an exercise
ALTERNATIVE THERAPIES, VOL. 26 NO. S2 119
session, lymphocytosis was observed to invoke leukocytes
from the vascular and tissue walls, and then immediately
after stopping the exercise session, lymphocytopenia and
neutrophil depletion occurred rapidly, which may lead to
decreased immune function. In addition, Simpson et al
found that acute exercise can have the greatest impact on
cytotoxic NK cells and T cells. An exercise session has also
been shown to increase aging in T naive and apoptotic
lymphocyte cells.71
Moderate Exercise. Prolonged exercise weakens the
immune system, but moderate exercise improves immune
responses.72 In physical activities, the type, intensity, and
volume of exercise are involved in physiological responses,
and an acute session of intense sports activity may weaken
the immune system due to the open window phenomenon.73
Otherwise, regular exercise can eliminate disorders caused
by aging that affect the function of cytotoxic CD8+ T cells.74
Duggal et al reported that regular cycling exercise in people
over the age of 55 caused a significant decrease in the number
of old T cells compared to those of people who were less
active. Therefore, it has been suggested that regular exercise
can reduce the destructive effects of aging on the immune
system.75 McFarlin et al observed lower TLR receptor
expression following resistance training for older women, 65
to 80 years.76 Lower expression of this receptor is associated
with improved blood pressure and systemic inflammation.
Resistance and strength training. Conversely, a number
of studies have shown that resistance training in healthy
older adults subjects doesn’t affect the number and
differentiation of immune cells.78,79 Timmerman et al reported
that participants, after 12 weeks of combined resistance and
aerobic exercise, showed lower levels of monocytes—CD14+,
CD16+—and no change in the TLR4 receptor, which plays
an important role in innate immunity in the diagnosis of
microorganisms.80
Bermon et al also showed that 8 weeks of strength
training in older adults over 70 years of age had no effects on
NK cells,79 while Fairey et al observed improvements in NK
cells after 10 weeks of resistance training in menopausal
women, aged 65 to 85 years, with breast cancer.81
In general, combined exercises are probably effective on
the immune system of older adults.
Protective Effects of Exercise
Myokines. Skeletal muscle tissue is a regulator of the
immune system because it can produce anti-inflammatory
cytokines from macrophages and monocytes to improve the
immune system’s function.82 A myokine that is affected by
exercise is called meteorin-like, which causes browning of
adipose tissue and an increase in eosinophil-related IL-4,
eventually leading to improved macrophage polarization 2.83
A myokine is a cytokine or peptide that is released by
skeletal muscles in response to muscle contractions.84 After
exercise, the muscles secrete a lot of IL-17, which is essential
for the development of thymus cells.85 IL-15 and IL-17 are
essential for the proliferation of lymphocytes, especially
120 ALTERNATIVE THERAPIES, VOL. 26 NO. S2
T-naive cells,86 for which serum levels decrease during
aging.75 IL-15 is essential for the development and toxicity
effects of NK cells.87
Lymphocytes. High levels of cardiorespiratory readiness
is one defense mechanism for preventing aging of the body’s
immune system in relation to viral infections; it sensitizes the
viral antigen of CD8+ cells and reduces viral infections.88
After physical activity, lymphocytes become sensitive to
catecholamines through the adrenergic-β receptor,89
increasing the number of NK cells in the peripheral blood by
4 to 5 times and causing leukocytes to move in the blood and
tissues.90 Friedenreich et al studied the effects of 12 months
of aerobic exercise on 200 menopausal women and observed
an improvement in the shortening of leukocyte telomeres.91
Enhancement of catecholamine receptors. One
adaptation derived from exercise that improves the immune
cells is the enhancement of catecholamine receptors, which
are downregulated by aging.92 In acute physical activities, the
secretion of noradrenaline triggers immune-cell changes,
including the activation of NK cells and T cells.93 The
increase in neutrophils due to the increased catecholamines,
growth hormone, and amino acid glutamine in the muscles
following exercise, in turn increases the differentiation and
proliferation of lymphocytes. However, blood glucose and
glutamine depletion that occur during intense exercise can
weaken the immune system.94
Recommendations for Physical Activity
Physical activity is very important for maintaining the
health and independence of older adults.95 affecting the
immune system and fighting viruses.96 Radak et al found that
regular exercise improves the immune system by reducing
inflammatory factors and increasing antioxidant capacity.97
Effects of COVID-19. After the closure of parks, clubs,
fitness centers, and other public places due COVID-19, the
opportunity for physical activity has decreased, especially for
people who are unable to exercise at home. In addition, the
need to maintain social distance between people has a great
impact on their ability to exercise. Under normal
circumstances, a distance of 2 meters is considered for social
distance, but during outdoor physical activities, it’s necessary
to observe a distance of 5 to 20 meters between people.98
Concerns about COVID-19 can affect eating habits and
cause greater caloric intake, leading potentially to overweight
and obesity. In addition, most people experience fear, anxiety,
stress, economic worries, sadness, boredom, isolation, and
withdrawal from others that negatively affects their diets and
physical and mental health. Therefore, the need for exercise
originates from the necessity to maintain good health, reduce
stress, prevent becoming overweight, strengthen the immune
system, and improve sleep quality.99 Older people are much
more vulnerable to disease progression and cognitive decline
because of spending all their time at home so that they may
be safe from COVID-19, with monotony and inactivity being
the result. Sitting and not moving for a long time is dangerous
and harmful for anyone at any age; this condition is especially
Shahrbanian—Physical Activity for Improving the Immune System
During COVID-19
common in older adults and induces many health-and-
wellness problems, including a decreased immune system,
muscle wasting, osteoarthritis, an increased risk of falls,
cardiovascular disease, diabetes, osteoporosis, chronic pain,
anxiety, and depression.100
Problematically, older people are also among the most
vulnerable groups to the pandemic COVID-19. The incidence
and severity of the disease are higher among them in
comparison to other age groups.101 The importance of
observing social distance and home quarantine has caused
older adults not to have an appropriate amount of physical
activity and to be exposed to the effects of inactivity, including
obesity and the development of underlying diseases. These
effects subsequently weaken the immune system, leading to an
increase in the risk of developing COVID-19.102
Improved physical condition. Research has clearly
shown that exercise can reduce weaknesses and frailty in
older adults. A 2015 review showed that home-based exercise
programs improved physical activity, mobility, muscle
strength, and balance in older adults.103 Also, physical activity
can regulate the composition of the gut microbiome, which
leads to a decrease in physical frailty.104
A 2015 systematic review found a 22% reduction after
home- based exercise in older adults’ risk of having a fall.105
Home-based exercise stabilizes movements and reduces
physical weakness to an acceptable level (mobility of physical
in older adults)106 One systematic review has suggested use of
low-intensity exercises, including resistance training, to
increase muscular strength in the arms and legs; functional
movements such as climbing stairs and overcoming obstacles;
balance movements such as walking on a straight line,
transferring weight from heel to toe and from one foot to
another foot; and endurance movements such as walking.107
Other studies have shown that home-based exercises,
including a combination of 3 moves to strengthen the hands,
7 moves to strengthen the legs, and 5 balance and coordination
movements, for 4 days a week improves can reduce physical
weakness fivefold.108
Types of exercise. The American Society on Aging has
recommended 4 types of exercise to improve health and
fitness as well as reduce boredom and risk of injury.109
Exercise and physical activity are not only useful for
maintaining the mental and physical health of older adults
but also can help them maintain independence.110
Strengthening activities such as lifting weights to maintain
muscles and prevent atrophy are required at least twice a
week. The guidelines also suggests using combination
exercises as part of weekly workouts.
Compliance originating from endurance training has
been studied for most of the body’s organs, but in particular,
endurance training can cause biochemical changes in the
diaphragm and play a protective role against the challenges
of the mechanical ventilation system used for patients with
COVID-19.111
According to the Physical Activity Guidelines for
Americans from WHO and the Centers for Disease Control
Shahrbanian—Physical Activity for Improving the Immune System
During COVID-19
and Prevention (CDC), it’s helpful to do at least 150 minutes
of aerobic exercise a week, 3 days a week, such as brisk
walking or dancing, to stay healthy during quarantine.110
The American College of Sports Medicine (ACSM)
guidelines recommend physical activity for older adults
includes all the components of physical fitness, including
cardiorespiratory fitness, muscle strength, balance,
coordination, and agility.112 They recommend walking 5 days
a week under normal conditions. However, in quarantine
conditions, due to reduced physical activity, it’s better to walk
for 5-10 minutes and 5-7 days a week in the form of walking
fast at home or going up and down stairs (in the case of no
joint problems). In addition, 2-3 sessions of resistance
training per week are recommended.
Theou et al,in their systematic review indicate that
exercise for older adults should be done for 30 to 45 minutes
and 3 to 4 times a week to influence muscle improvement,
balance, and physical weakness.113
Cadore et al’s study of older adults with physical
disabilities recommended that resistance exercises be
performed 2 to 3 times a week with 8 to 12 repetitions for
daily activities, such as sitting down and standing up. Some
exercises, such as walking, climbing stairs, and using a
stationary bike, were also recommended for endurance
training.107
In sedentary people, Angels indicated that exercise
should be started slowly with moderate intensity for 5 to 10
minutes and gradually be increased in duration.114 To enjoy
the benefits of exercise, the researchers indicate that it should
be done regularly and according to a schedule. The purpose
of these exercises is to maintain the necessary mobility to
increase blood circulation and provide oxygen to the brain
and other organs. 114
Home-based exercise. An example of a suggested type
of exercises is home-based exercise that can be done with
online and video guidance.115 As mentioned, moderate-
intensity exercise is very effective in improving the immune
system in older adults. Overall, home-based exercise
protocols, while maintaining necessary mobility, preventing
muscle atrophy, and improving the quality of life of older
adults, can strengthen their immune systems to help keep
them healthy against COVID-19.
In home-quarantine conditions, guiding older people
online or through recorded videos of exercise, can be very
effective in maintaining their muscles. Before starting the
main exercises, Hill et al indicate that it’s necessary to
perform stretching movements for each limb; then the main
movements can proceed and finally the stretching movements
to cool down.115 For example, those researchers recommend
a basic 10-minute program without any special equipment,
to interrupt the cycle of sitting and reduce disease progression.
These movements include movements to stimulate the
muscles of the legs, knees, hips, and trunk to provide balance;
squats to strengthen the quadriceps and hips; plank and
push-ups to strengthen the muscles of the shoulders and
neck and chest; shoulder stretches for stretching the muscles
ALTERNATIVE THERAPIES, VOL. 26 NO. S2 121
Table 1. Safety Tips for Older Adults During Exercise

Safety Items Description

Conversation testing Test your level of effort using conversation testing, meaning that you always practice at a level where you can speak.
Environmental awareness Be aware of your environment and have access to a firm bench or chair if you lose your balance.
Hydration Drink water before, during, and after exercise, even if you don’t feel thirsty.
Suitable shoes and clothes Choose the shoes and clothes that fit the activity and the ambient temperature.
Motivation • Find simple ways to have fun and enjoy sports.
• Adapt the type of exercise to your daily activities.
• Turn exercise into a social activity that keeps you motivated during sports activities.
Suitable environment for Exercise in a flat environment because exercise is best done in flat areas due to the fact that walking and exercising on
exercise the uphill may cause injury.
Notifying someone when It’s necessary to inform someone when leave the house to exercise so that you can receive help if needed.
leaving the house

of the shoulder and waist as well as the hamstrings; stretching
the calf muscles (calf raise); and finally walking to strengthen
the cardiovascular fitness.
Encouraging people to do such activities will help keep
them healthy. However, all of these exercises are recommended
with moderate intensity and under the supervision of a
physician.100 In addition, other activities that can be done at
home include stretching the upper limbs, pulling the knee
into the chest, push-ups using the wall, stepping up and
down stairs, performing Pilates and yoga using online
programs, walking, and resistance training.116
If people prefer high-intensity exercise, they should
exercise for at least 75 minutes a week.117 Using online
exercise-training courses and the minimum activities
available at home, such as jumping ropes and climbing stairs,
and practicing yoga and Pilates can also be helpful.118
In the pandemic situation of COVID-19 and the
observance of social distance, the key role of virtual exercise
training classes is prominent. Participating in video
conferences can also enable individuals to engage and
interact with other people while exercising at home and not
only motivates them to continue exercising, but also prevents
them from becoming depressed and lonely.119
Exercise intensity. To stay safe during exercise, it’s
important point for individuals to start exercising with low
intensity and according to their level of physical fitness.
Excessive exercise can cause injury and lead to permanent
stoppage of exercising. For this reason, the best approach is
continual and gradual progress.110 To stay safe during
exercise, older adults should always consider safety tips,
some of which Table 1 shows. Following these tips can help
older adults overcome common barriers to exercise and
move toward better health.109,120
Other benefits. Research has shown that exercise, in
addition to its physical benefits, is also beneficial for a
person’s mental and emotional health. It reduces stress,
anxiety, and depression; improves mood and emotions;
increases energy levels; improves sleep; and empowers people
to feel more in control. In addition, exercise and physical
activity may improve some aspects of cognitive function,
such as a person’s ability to quickly switch between tasks,
plan an activity, and ignore irrelevant information.110
Motivation. Studies have shown that having a high
motivation can help older adults continue to participate in
physical activities and to be independent.106,121 Selecting
enjoyable activities and sports that have a recreational
aspect,122 setting goals for when and where physical activity is
performed, and controlling and tracking exercise by taking
notes or by participating in telephone follow-ups with
friends, family, mentors, or home caregivers121 are among the
factors that encourage older adults to continue doing physical
activities.
Safety. With COVID-19, it may not be possible to
participate in group exercises; however, exercise is important
to older people to maintain muscle strength, balance, and
flexibility and to increase the quality of life.109 Older adults
may be concerned about safety when exercising at home;
however, research has shown that the dangers of exercising at
home, in comparison with group exercises, aren’t greater for
older adults.109 One type of appropriate and safe exercise
during the COVID-19 crisis is home-based exercise.
According to the literature, a home-based exercise history
improves the quality of life of older adults and reduces the
risk of a fall.103,123 It’s important to note that the positive
results of these exercises on increasing mobility and reducing
the risk of falls are certainly associated with improved muscle
condition and prevention of muscle atrophy.
Decreased anxiety and depression. Using social and
virtual networks to communicate can help reduce anxiety
and depression in older adults. Internationally recommended
exercise programs can be effective in controlling and treating
physical weakness in older adults.124 Weakness and frailty
exacerbate the likelihood of reduced performance and quality
of life and increased mortality. Weakness can begin at age 65
but become more severe after age 70; its risk factors include
overweight and obesity, inactivity, cardiovascular problems,
and alcohol consumption.125
Conclusions
During the COVID-19 pandemic, older people can stay
active and healthy through playing sports such as yoga,
walking, jogging, and cycling. Also, they can use online or
virtual yoga and Pilates classes and videos, perform resistance
exercises with minimal facilities at home, and do daily

122 ALTERNATIVE THERAPIES, VOL. 26 NO. S2 Shahrbanian—Physical Activity for Improving the Immune System
During COVID-19

housework, such as gardening. In general, due to the positive
role of regular exercise training on the immune system of the
older adults as well as the involvement of the immune system
in COVID-19, it’s necessary to guide and implement home-
based exercises for older adults. Due to the proven
physiological role of these exercises, these or similar exercises
can be used to minimize the effects of inactivity and home
quarantine as well as strengthen the immune system of the
older adults.
Author’s disclosure statement
The research team declares that they have no financial or other relationships that might
lead to a conflict of interest.
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