Bjsports 2022 106681.full

Original research
Effects of a 16-week home-based exercise training
Br J Sports Med: first published as 10.1136/bjsports-2022-106681 on 10 May 2023. Downloaded from http://bjsm.bmj.com/ on May 10, 2023 by guest. Protected by copyright.
programme on health-related quality of life, functional
capacity, and persistent symptoms in survivors of severe/
critical COVID-19: a randomised controlled trial
Igor Longobardi ‍ ‍,1 Karla Goessler,1 Gersiel Nascimento de Oliveira Júnior,1
Danilo Marcelo Leite do Prado,1 Jhonnatan Vasconcelos Pereira Santos,1
Matheus Molina Meletti,1 Danieli Castro Oliveira de Andrade,2 Saulo Gil ‍ ‍,1
João Antonio Spott de Oliveira Boza,1 Fernanda Rodrigues Lima,2
Bruno Gualano ‍ ‍,1,2 Hamilton Roschel ‍ ‍1,2
► Additional supplemental ABSTRACT

material is published online Background Long-lasting effects of COVID-19 may WHAT IS ALREADY KNOWN ON THIS TOPIC
only. To view, please visit the ⇒ COVID-19 may cause multisystemic consequences
journal online (http://d x.doi. include cardiovascular, respiratory, skeletal muscle, metabolic,
org/1 0.1136/b jsports-2022- psychological disorders and persistent symptoms that can that continue or develop after acute SARS-CoV-2
106681). impair health-related quality of life (HRQoL). We investigated infection, which can negatively impact patients’
the effects of a home-based exercise training (HBET) health-related quality of life (HRQoL). In fact,
1
Applied Physiology and multiple sequelae and life-threatening events
programme on HRQoL and health-related outcomes in
Nutrition Research Group,
School of Physical Education survivors of severe/critical COVID-19. have already been documented even months
and Sport, School of Medicine, Methods This was a single-centre, single-blinded, parallel- after infection, particularly in those who had
University of Sao Paulo, SP, group, randomised controlled trial. Fifty survivors of severe/ severe/critical COVID-19. Exercise has a potential
Brazil critical COVID-19 (5±1 months after intensive care unit therapeutic role in a broad spectrum of diseases,
2
Rheumatology Division, with positive effects on different physiological
Hospital das Clínicas HCFMUSP, discharge) were randomly allocated (1:1) to either a 3 times a
Faculdade de Medicina, week (~60–80 min/session), semi-supervised, individualised, and psychological systems; however, its ability to
Universidade de Sao Paulo, SP, HBET programme or standard of care (CONTROL). Changes mitigate post-COVID-19 impact on HRQoL and
Brazil in HRQoL were evaluated through the 36-Item Short-Form health outcomes in survivors of severe/critical
Health Survey, and physical component summary was COVID-19 is unknown.
Correspondence to predetermined as the primary outcome. Secondary outcomes
Professor Hamilton Roschel, WHAT THIS STUDY ADDS
Applied Physiology and included cardiorespiratory fitness, pulmonary function,
functional capacity, body composition and persistent ⇒ A home-based exercise training programme
Nutrition Research Group,
School of Physical Education symptoms. Assessments were performed at baseline and specifically tailored to patients with severe/critical
and Sport, School of Medicine, after 16 weeks of intervention. Statistical analysis followed COVID-19 was safe and able to improve physical
University of Sao Paulo, 01246-
intention-to-treat principles. domains of HRQoL. Of relevance, exercise also
903, SP, Brazil; hars@usp.b r improved functional capacity and reduced the
Results After the intervention, HBET showed greater HRQoL
Accepted 8 April 2023 score than CONTROL in the physical component summary occurrence of persistent muscle weakness and
(estimated mean difference, EMD: 16.8 points; 95% CI 5.8 myalgia in this population.
to 27.9; effect size, ES: 0.74), physical functioning (EMD: HOW THIS STUDY MIGHT AFFECT RESEARCH,
22.5 points, 95% CI 6.1 to 42.9, ES: 0.83), general health PRACTICE OR POLICY
(EMD: 17.4 points, 95% CI 1.8 to 33.1, ES: 0.73) and vitality
⇒ Post-COVID-19 syndrome is a worldwide health
(EMD: 15.1 points, 95% CI 0.2 to 30.1, ES: 0.49) domains.
issue. The bespoke exercise intervention herein
30-second sit-to-stand (EMD: 2.38 reps, 95% CI 0.01 to
emerges as an effective, safe and relatively easy
4.76, ES: 0.86), and muscle weakness and myalgia were also
to escalate therapeutic strategy for patients
improved in HBET compared with CONTROL (p<0.05). No
recovering from severe/critical COVID-19. Future
significant differences were seen in the remaining variables.
multicentre studies with larger sample sizes should
There were no adverse events.
address the effectiveness of different exercise
Conclusion HBET is an effective and safe intervention to
interventions, as well as barriers and facilitators
© Author(s) (or their improve physical domains of HRQoL, functional capacity and
to their implementation, in cohorts of patients
employer(s)) 2023. No persistent symptoms in survivors of severe/critical COVID-19.
experiencing persistent symptoms of COVID-19.
commercial re-use. See rights Trial registration number NCT04615052.
and permissions. Published
by BMJ.
To cite: Longobardi I, condition, affecting approximately 39%–46%

Goessler K, de Oliveira
INTRODUCTION of survivors of COVID- 19 worldwide.1 It has
Júnior GN, et al.
Br J Sports Med Epub ahead COVID-19 pandemic has led to a growing number been defined as newly occurring and persistent
of print: [please include Day of survivors experiencing debilitating persistent symptoms (eg, fatigue, dyspnoea, muscle weak-
Month Year]. doi:10.1136/ symptoms long after infection. Post-COVID-19 ness, etc) lasting more than 12 weeks that cannot
bjsports-2022-106681 syndrome, or long COVID, is a frequent be explained by an alternative diagnosis.2 This
Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681 1

Original research
condition is usually associated with substantial health impair- by RT-PCR testing for SARS-CoV-2 from nasopharyngeal swabs
ments, including poor cardiorespiratory fitness, exertional and had been discharged from the intensive care unit (ICU)
intolerance, reduced functional capacity, lower muscle mass between 3 months and 6 months prior to their enrolment into
and psychological morbidities (eg, anxiety and depression).3–8 the study.
Available evidence suggests that patients who have had severe/ Patients who need oxygen supply or had resting oxygen
critical COVID-19 (eg, those admitted to an intensive care saturation <85% on room air, anaemia, pulmonary hyperten-
unit) may present with even worse outcomes.9 As a conse- sion, recent myocardial infarction (<12 months), severe valve
quence, survivors of severe/critical COVID- 19 commonly disease, unstable angina, untreated heart failure, uncontrolled
have poor health-related quality of life (HRQoL) scores, even arrhythmias, active oncological disease or recent malignancy
several months after the infection.8 10 11 (<5 years), transplant history, uncontrolled hypertension,
Therefore, there is an emergency for novel therapies uncontrolled type- 2 diabetes, autoimmune diseases, with
capable of recovering overall health in these patients. Exercise inability to walk, with severe cognitive dysfunction that could
training has been proven an effective non-pharmacological compromise any assessments, considered unstable due to any
therapy for a broad spectrum of diseases, showing positive other health condition, or already engaged in rehabilitation
effects on cardiovascular, respiratory, skeletal muscle, meta- programmes and/or exercise training programmes at baseline
bolic and mental disorders.12 In COVID-19, there is prelimi- were excluded.
nary data to suggest that exercise may be of clinical value to All participants provided written consent after being
individuals previously hospitalised (in wards) by improving informed of the purpose of the study, experimental proce-
cardiovascular (eg, pulse wave velocity) and respiratory (eg, dures and potential risks. Our study included participants
maximal inspiratory and expiratory pressures) parameters.13 from diverse ethnicities, sexual orientations, social status and
However, little is known about the effects of exercise inter- religions.
ventions on severe/critical patients, who may be prone to
post-exertional symptoms exacerbation. We hypothesised that
a home-based exercise training (HBET) programme would Outcomes
improve HRQoL, and physical and mental parameters in All outcomes of interest were assessed at baseline (ie, pre-
survivors of severe/critical COVID-19. intervention) and after 16 weeks (post-intervention) at the same
intrahospital laboratory.
MATERIALS AND METHODS

Study design Health-related quality of life
This was a single- centre, single-
blinded, parallel-
group, We assessed HRQoL through the Medical Outcomes Study
randomised, controlled trial. The study was pre-registered at 36-Item Short-Form Health Survey (SF-36).14 SF-36 yields an
Clinicaltrials.
gov (NCT04615052). The trial design is illus- 8-
scale profile of scores (physical functioning, role-physical,
trated in the online supplemental figure S1. The manuscript was bodily pain, general health, vitality, social functioning, role-
reported according to the Consolidated Standards of Reporting emotional and mental health). Physical component summary
Trials (CONSORT) guidelines. (primary outcome) and mental component summary were also
calculated. Scores range from 0 to 100 (higher scores indicate
Randomisation better HRQoL).
The allocation list was created using a specific software (https://
www.random.org/sequences) with a computer-generated block Cardiorespiratory fitness and pulmonary function
design stratified by post-COVID-19 Functional Status (PCFS) We carried out a maximal a graded cardiopulmonary exercise
score, which has five levels, ranging from Grade 0 to Grade testing on a treadmill (Centurion C200, Micromed, Brazil)
4. Participants who met the eligibility criteria were enrolled using a modified Balke protocol to the limit of tolerance; each
consecutively and those who successfully completed baseline patient performed the same protocol pre-intervention and post-
assessments were randomly assigned to either HBET or standard intervention. Heart rate (HR) was continuously recorded beat-
of care (CONTROL) group in a 1:1 ratio. The randomisation by-beat from the R–R interval using a 12-lead electrocardiograph
process was performed by an independent researcher, who had (ErgoPC Elite, Micromed, Brazil). Gas exchange and ventila-
no involvement in the trial. tory parameters were recorded breath by breath by continuous
sampling using a rapid response gas analyser (Metalyzer 3B,
Participants Cortex, Germany). System was calibrated immediately before
Survivors of COVID- 19 from a tertiary referral hospital each test following manufacturer’s specifications. Outcome vari-
(Hospital das Clínicas da Faculdade de Medicina da Univer- ables, including peak oxygen uptake (VO2peak), oxygen uptake
sidade de São Paulo) were identified and screened from their at ventilatory threshold (VO2VT), oxygen uptake efficiency slope
medical records between November 2020 and April 2022. (OUES), respiratory exchange ratio (RER), pulmonary ventila-
COVID- 19 status followed the WHO severity classification.2 tion (VE), ventilatory equivalent for carbon dioxide (VE/VCO2),
Patients were categorised either as severe (severe pneumonia, O2 pulse and chronotropic index were assessed as previously
resting oxygen saturation <90% on room air, signs of respira- described.3 15 16 Heart rate recovery was assessed during the first
tory distress, eg, respiratory rate ≥30 breaths/min) or critical (HRR1min), second (HRR2min) and fourth minute (HRR4min) of the
(defined by the criteria for acute respiratory distress syndrome, recovery phase.
sepsis, septic shock, acute thrombosis or other conditions that We assessed pulmonary function without bronchodilator,
would normally require life-sustaining therapies such as invasive in the upright position, by using a computer-based spirom-
or non-invasive mechanical ventilation or vasopressor therapy). etry system (Metalyzer 3B, Cortex, Germany) in accordance
Eligibility criteria for the study included patients aged 45 years with recommendations.17 Forced expiratory volume in the
or older, who had received a confirmed diagnosis of COVID-19 first second (FEV 1), forced vital capacity (FVC), FEV1/FVC
2 Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681

Original research
Figure 1 CONSORT flow diagram. CONSORT, Consolidated Standards of Reporting Trials; CONTROL, standard of care; CPX, cardiopulmonary
exercise testing; HBET, home-based exercise training; ICU, intensive care unit.
ratio, peak inspiratory flow and peak expiratory flow were version of the PCFS scale following previous recommen-
also assessed.17 dations. 23 It comprises 17 (yes/no) questions, with scores
An experienced physician blinded to the protocol conducted ranging between 0 and 4. Overall classification is based on
all tests. the highest-scoring answer (higher scores indicate greater
functional limitations).
Functional capacity and muscle strength
We performed a handgrip strength test using a handheld dyna-
Anthropometry and body composition
mometer (TKK 5101; Takei, Tokyo, Japan) on the dominant
hand with subjects standing and their elbow fully extended.18 We After an overnight fast, we performed a whole-body dual-energy
assessed lower-limb muscle function and strength through the X-ray absorptiometry scan using a Lunar iDXA equipment (GE
30-second sit-to-stand and the timed-up-and-go tests.19 20 The Healthcare, Madison, WI, USA) to evaluate the body compo-
same researcher blinded to the patients’ assignment performed sition. We measured the body weight using a calibrated digital
all tests. scale and the height using a stadiometer. We determined waist
We assessed functional status (broadly defines as the ability and hip circumferences by using an anthropometric measuring
to independently perform self-care and instrumental activi- tape. The same trained technician blinded to the patients’ assign-
ties of daily living)21 22 through the Brazilian Portuguese ment conducted all measurements.

Original research
Persistent symptoms
Table 1
Characteristics of the participants
We evaluated newly occurring and persistent symptoms
HBET (n=25) CONTROL (n=25)
through a self-reported checklist recalling since the onset of
Age, years 60.8±7.1 61.2±7.7 acute SARS-CoV-2 infection, in accordance with WHO defi-
Women, n (%) 13 (52) 12 (48) nition.2 In addition, fatigue severity was assessed in-depth
Height, cm 163.9±0.1 163.1±0.1 through the Fatigue Severity Scale (FSS). Beck Anxiety Inven-
Weight, kg 84.9±16.4 84.0±13.56 tory (BAI) and Beck Depression Inventory (BDI) were also
BMI, kg/m2 31.5±5.0 31.9±5.0 used to properly classify patients with symptoms of anxiety
Overweight, n (%) 9 (36) 10 (40) and depression.24
Obesity class I, n (%) 10 (40) 7 (28)
Obesity class II, n (%) 5 (20) 6 (24)
Obesity class III, n (%) 1 (4) 2 (8) Physical activity level
HR, bpm 75.8±9.4 75.0±11.0 We used the International Physical Activity Questionnaire–Short
Systolic blood pressure, mm Hg 125.6±16.1 125.0±14.5 Form to estimate physical activity level.25
Diastolic blood pressure, mm Hg 81.8±12.0 80.0±8.7
SpO2, % 96.7±1.2 97.0±1.3 Intervention and control
Smoking status The intervention was a 16-week, 3-times-a-week (~60–80 min/
Current smoker, n (%) 1 (4) 1 (4) session), semi- supervised, HBET programme. One weekly
Former smoker, n (%) 12 (48) 12 (48)
session was individually supervised through online live video-
Never smoked, n (%) 12 (48) 12 (48)
calls with an experienced physical trainer. The patients received
PAL, min/week 170 (160) 180 (155)
instructions to give feedback to the trainer immediately after
Comorbidities
completing the other 2 weekly unsupervised training session.
Hypertension, n (%) 15 (60) 13 (52)
In case of non- compliance, the missed training session was
Dyslipidaemia, n (%) 13 (52) 14 (56)
rescheduled within the same or next week. Supplementary mate-
Rheumatic disease, n (%) 9 (36) 7 (28)
rials containing exercise cards and videos, and educative infor-
Diabetes mellitus, n (%) 8 (32) 10 (40)
mation about how to rate their effort were provided (online
CVD, n (%) 5 (20) 5 (20)
supplemental figure S2). Patients were instructed to immediately
Psychological disease, n (%) 5 (20) 5 (20)
communicate the research team of any symptoms (including
Pulmonary disease, n (%) 4 (16) 4 (16)
post-exertional symptom exacerbation), or any adverse events
Hypothyroidism, n (%) 4 (16) 5 (20)
potentially related to the intervention. Adherence to the training
Others, n (%) 2 (8) 3 (12)
programme was verified by a training log.
Medications
Training volume and exercise complexity progressed as a
AT1 inhibitor, n (%) 13 (52) 7 (28)
function of patients’ functional capacity (based on PCFS score),
Diuretics, n (%) 7 (28) 3 (12)
which was reassessed every 2 weeks. Exercise volume for the
CCB, n (%) 1 (4) 5 (20)
aerobic training sessions ranged from multiple bouts of 10 min/
ACE inhibitor, n (%) 1 (4) 4 (16)
day of walking (PCFS Grade 4) to a single bout of ≥50 min/day of
β-blockers, n (%)
1 (4) 3 (12)
jogging (PCFS Grade 0) (online supplemental table S1). Strength
Insulin, n (%) 2 (8) 5 (20)
training sessions comprised 3–5 sets (depending on PCFS grade)
Metformin, n (%) 6 (24) 7 (28)
of 8–15 repetitions per exercise (online supplemental table S2).
Sulfonylureas, n (%) 4 (16) 6 (24)
A set of six strengthening exercises was designed for each PCFS
Statins, n (%) 7 (28) 7 (28)
grade. Training intensity progressed every 2 weeks based on RPE,
Levothyroxine, n (%) 4 (16) 4 (16)
and ranged from ‘very light’ to ‘fairly light’ (Borg Scale score
NSAIDs, n (%) 3 (12) 3 (12)
9–11) within the first 2 weeks of the protocol toward ‘hard’ to
SSRIs, n (%) 4 (16) 3 (12)
‘very hard’ (Borg Scale score 15–17) in the last 4 weeks (online
Atypical antidepressants, n (%) 3 (12) 1 (4)
supplemental table S3). Active stretching exercises for the major
Anticoagulants, n (%) 2 (8) 3 (12)
Others, n (%) 4 (16) 3 (12)
muscle groups were also prescribed. Online supplemental tables
Severity of COVID-19 illness
S1–S3 provides detailed information on training progression.
Severe, n (%) 6 (24) 6 (24)
Patients with hypertension were instructed to measure their
Critical, n (%) 19 (76) 19 (76)
blood pressure immediately before training sessions (sessions
Hospital LoS, days 18 (13) 19 (12)
were suspended if systolic or diastolic blood pressure were
ICU LoS, days 9 (7) 7 (8)
≥160 mm Hg or ≥105 mm Hg, respectively). Patients with
IMV, n (%) 13 (52) 12 (48)
type-2 diabetes were instructed to measure their blood glucose,
Time since discharge, days 160±35 157±33
with acceptable values between 90 mg/dL and 250 mg/dL before
Data expressed as mean±SD, median (IQR), or as frequency and percentage (%).
the training session.
AT1, angiotensin-1; BMI, body mass index; CCB, calcium channel blocker; CVD, cardiovascular disease; Standard of care included general advice for a healthy
HBET, home-based exercise training; ICU, intensive care unit; IMV, invasive mechanical ventilation;
LoS, length of stay; NSAIDs, non-steroidal anti-inflammatory drugs; PAL, physical activity level; SpO2,
lifestyle (eg, guideline- based recommendations for healthy
peripheral oxygen saturation; SSRI, selective serotonin reuptake inhibitors. dieting and physical activity), which was provided at the
beginning of the study. CONTROL patients were contacted
by phone or text message every 2 months (unless they reached
Laboratory analysis out to the research team sooner for any reason) for a general
We collected blood samples from the median or cephalic basilic check-up on their well-being and any medical needs. When-
vein after a 12-hour fast and analysed for complete blood count, ever necessary, patients from both groups received outpatient
glucose metabolism, lipid profile, skeletal and cardiac muscle care, consultation with a specialised physician and additional
damage and C reactive protein. diagnostic exams.

Original research
Figure 2 Radar chart of SF-36 health-related quality of life scores assessed pre-intervention (ie, baseline) and post-intervention (ie, 16 weeks)
in survivors of severe/critical COVID-19. ESs calculated from between-group mean differences of pre-to-post changes divided by the pooled pre-
intervention SD. BP, bodily pain; CONTROL, standard of care; ESs, effect sizes; GH, general health; HBET, home-based exercise training; MCS, mental
component summary; MH, mental health; PCS, physical component summary; PF, physical functioning; RE, role-emotional; RP, role-physical; SF, social
functioning; VT, vitality. *Indicate significant between-group difference after 16 weeks (p≤0.05).
Deviations from the protocol in case of a significant F value. Data are presented as mean±SD
Inflammatory cytokines and inspiratory muscular strength anal- for continuous variables or as frequency and percentage for
yses were originally planned, but sufficient financial resources categorical variables, except otherwise stated. Linear mixed-
were not available. model’s adjusted estimated mean difference (EMD) and 95% CI
are provided whenever the post hoc analysis indicated between-
Statistics group significant differences. An additional post hoc, complete-
Sample size was calculated a priori considering SF-36 physical case (per protocol), sensitivity analysis comprising only those
component summary as the primary outcome. Analyses were who did not drop out was performed using independent t-tests
conducted on G*Power (V.3.1.9.2) using a two-way analysis of to compare between-group delta changes (∆HBET−∆CONTROL). The
variance with two repeated measures for group by time interac- sensitivity analysis was conducted in order to assess the robust-
tion. Data from our pilot study resulted in a partial eta squared ness of the findings based on our intention- to-
treat primary
(η2p) of 0.051 and an effect size (ES) f of 0.23. Power was set analysis.
to 80% (β=0.2) and a two-sided α level of 0.05 was consid-
ered. Initial estimated sample size was 40 (n=20 per group);
however, we aimed for 25 participants per group due to poten- RESULTS
tial dropouts. Participants
Statistical analysis was performed on SAS V.9.2 software Fifty survivors of severe/critical COVID-19 were randomised.
using an intention-to-treat approach for the primary analysis. A Four patients in HBET and five in CONTROL group were lost
linear mixed-model with repeated measures was performed for during follow-up, none of them due to reasons related to the
longitudinal data using a restricted maximum likelihood algo- trial or training protocol (figure 1).
rithm to compare changes of outcomes in time between exper- Table 1 shows demographic and clinical characteristics of the
imental groups. ‘Group’ (HBET and CONTROL) and ‘time’ participants. Half of the patients required invasive mechanical
(pre-intervention and post-intervention) were included as fixed ventilation, while the other half required non-invasive mechan-
factors and ‘patients’ as a random factor with assumed normal ical ventilation (eg, continuous positive airway pressure or high
distribution. Kenward-Roger degrees-of-freedom adjustment flow nasal cannula oxygen therapy). No patient included in
was used to adjust for data imbalance eventually generated by this study required extracorporeal membrane oxygenation. All
missing data. Data normality and homoscedasticity was visually patients met current diagnostic criteria for the various case defi-
checked with histogram of the studentized residuals and residual nitions in use for post-COVID-19 syndrome.27 The proportion
plots. Nonnormal data were log transformed. The absence of of patients classified in PCFS scale as having severe (Grade 4),
extreme observations (outliers) was guaranteed through stan- moderate (Grade 3), mild (Grade 2), very mild (Grade 1) or
dard visual inspection. For the primary outcome, baseline values absence (Grade 0) of functional limitations were: 20%, 24%,
were used as covariates. ESs were calculated from between- 28%, 20% and 8%, respectively.
group mean differences of pre-to-post changes divided by the At baseline, laboratory markers were within normal range
pooled pre-intervention SD, as previously described.26 Changes on average, except for blood glucose, total cholesterol and
in frequency outcomes were determined by using either χ2 test triglycerides levels which were slightly altered; there were no
or Fisher’s exact test when necessary. Significance level was set at between-group differences after 16 weeks (online supplemental
p ≤0.05. A post hoc test with Tukey’s adjustment was performed table S4). Physical activity level increased in HBET but not

Original research
Table 2 Effects of HBET intervention and standard of care (CONTROL) on cardiorespiratory fitness and pulmonary function parameters in survivors
of severe/critical COVID-19 pre-intervention (ie, at baseline) and post-intervention (ie, after 16 weeks)
HBET CONTROL Post-intervention between-group differences
Baseline 16 weeks Baseline 16 weeks EMD 95% CI P value ES
Cardiorespiratory fitness n=25 n=21 n=25 n=20
Time to exhaustion, s 640.2±145.8 715.2±157.0 605.4±197.7 631.1±186.6 81.6 (–58.9 to 222.2) 0.406 0.24
VO2peak, L/min 1.72±0.57 1.91±0.61 1.76±0.61 1.79±0.62 0.12 (–0.34 to 0.58) 0.892 0.27
VO2peak, mL/kg/min 20.5±5.2 22.2±4.3 20.6±6.0 21.3±6.0 1.57 (–2.71 to 5.86) 0.757 0.32
VO2peak, % pred. 70.9±17.9 78.5±16.1 71.5±18.4 74.6±19.5 4.06 (–10.2 to 18.3) 0.869 0.20
VO2VT, L/min 1.07±0.33 1.13±0.34 1.01±0.28 1.09±0.34 0.03 (–0.24 to 0.30) 0.991 –0.17
VO2VT, mL/kg/min 12.5±2.1 13.4±3.1 11.8±3.0 12.5±3.9 0.53 (–2.12 to 3.17) 0.951 0.25
VO2VT, % pred VO2peak 44.6±9.2 46.6±10.8 44.5±14.1 45.4±15.0 0.74 (–10.5 to 12.0) 0.998 0.21
OUES, L/min 2.06±0.60 2.19±0.69 1.94±0.57 1.90±0.56 0.34 (–0.13 to 0.82) 0.239 0.41
RERpeak 1.06±0.07 1.07±0.11 1.07±0.08 1.07±0.09 0.00 (–0.07 to 0.07) 1.000 0.13
VE, L/min 70.5±25.5 72.9±27.3 68.9±19.8 68.2±23.2 6.89 (–12.0 to 25.8) 0.762 0.25
VE/VCO2 slope 34.6±4.9 33.2±5.3 34.6±6.0 33.5±4.0 –0.11 (–4.49 to 4.27) 0.999 0.11
VE/VCO2nadir, L/min 32.0±3.2 30.7±4.1 31.5±4.8 30.5±4.2 0.11 (–3.59 to 3.80) 0.999 0.07
O2 pulse, mL/bpm 11.6±3.7 12.3±3.6 11.4±2.2 11.7±3.1 0.69 (–1.88 to 3.25) 0.888 0.20
O2 pulse, % pred. 73.3±13.9 81.8±19.2 76.3±13.7 79.1±17.6 2.74 (–10.7 to 16.2) 0.946 0.47
HRmax, bpm 144±14 154±17 143±19 143±14 10.5 (–3.16 to 24.14) 0.183 0.52
∆HR, bpm 60±18 76±17 61±19 66±20 7.95 (–6.67 to 22.56) 0.470 0.41
Chronotropic index, % 80.4±18.7 94.0±19.2 80.0±22.2 80.2±16.7 11.1 (–5.02 to 27.25) 0.266 0.46
HRR1min, bpm 9.5 (11) 20 (10) 13 (11) 17 (6) 1.55 (–5.29 to 8.41) 0.929 0.19
HRR2min, bpm 26±10 40±13 31±9 35±13 5.11 (–4.45 to 14.68) 0.488 0.85
HRR4min, bpm 44±10 53±11 47±11 47±12 4.33 (–5.25 to 13.91) 0.621 0.61
Pulmonary function test n=25 n=21 n=25 n=20
FEV1, L 2.56±0.84 2.51±0.81 2.73±0.73 2.63±0.77 –0.16 (–0.77 to 0.44) 0.881 0.06
FVC, L 2.75±0.84 2.71±0.81 2.86±0.77 2.78±0.81 –0.16 (–0.79 to 0.46) 0.893 0.05
FEV1/FVC, % 93.8±3.5 93.8±4.3 95.5±3.2 94.8±3.9 –0.71 (–4.01 to 2.60) 0.938 0.20
Peak inspiratory flow, L/s 5.27±2.59 5.91±1.93 5.17±1.88 6.03±2.66 –0.08 (–1.97 to 1.81) 0.999 –0.09
Peak expiratory flow, L/s 7.34±3.15 7.48±2.80 6.84±1.96 7.08±2.52 0.20 (–1.88 to 2.28) 0.994 –0.04
Data expressed as unadjusted mean±SD or median (IQR).
bpm, beats per minute; EMD, adjusted estimated mean difference; ES, effect size; FEV1, forced expiratory volume in the first second; FVC, forced vital capacity; HBET, home-
based exercise training; HRR, heart rate recovery; OUES, oxygen uptake efficiency slope; pred, predicted; RERpeak, peak exercise respiratory exchange ratio; VE/VCO2, ventilatory
equivalent for carbon dioxide; VO2peak, peak oxygen uptake; VO2VT, oxygen uptake at the ventilatory threshold.
in CONTROL after the intervention (EMD: 328 min/week; Cardiorespiratory fitness, pulmonary function, functional
95% CI 161 to 494; p<0.001; ES: 2.78). capacity and muscle strength
Eleven patients (HBET: n=6; CONTROL: n=5) required No significant between- group differences were detected for
outpatient care during the follow-up period due to malnutrition, cardiorespiratory or pulmonary function variables (all p>0.05;
osteonecrosis, bedsores, gout crisis, suspected peripheral arterial table 2). Significant between-group differences were observed
disease, hypertensive crisis, depressive crisis, household accident for 30-second sit-to-
stand performance at post- intervention
and acute infection (common cold and non-specified respiratory (EMD: 2.38 repetitions; 95% CI 0.01 to 4.76; p=0.048; ES:
tract infection). No adverse events potentially associated with 0.86; table 3). There were no between- group differences in
the intervention were reported according to our medical staff. handgrip strength, timed-up-and-go or PCFS (all p>0.05) after
Among patients who completed the study, adherence to HBET 16 weeks.
protocol was 71.2% (81.0% in supervised and 66.5% in non-
supervised sessions).
Anthropometry and body composition
No significant between-group differences were detected for any
Health-related quality of life
measurement after 16 weeks (all p>0.05) (table 3).
After 16 weeks, the score of physical component summary
(primary outcome) was higher in HBET compared with
CONTROL (EMD: 16.8 points; 95% CI 5.8 to 27.9; p<0.001; Persistent symptoms
ES: 0.74) (figure 2). Further analysis also revealed other Self-
reported presence of persistent symptoms was similar
between-group differences in favour of HBET for physical func- between groups at baseline (all p>0.05, table 4). After 16
tioning (EMD: 22.5 points; 95% CI 6.1 to 42.9; p=0.005; ES: weeks, the proportion of patients with muscle weakness (4.8%
0.83), general health (EMD: 17.4 points; 95% CI: 1.8 to 33.1; vs 35.0%) and myalgia (19.0% vs 55.0%) was significantly
p=0.024. ES: 0.73) and vitality (EMD: 15.1 points; 95% CI 0.2 different in HBET versus CONTROL (p<0.05). No signif-
to 30.1; p=0.015; ES: 0.49). No statistically significant between- icant between-group differences could be observed in total
group differences could be observed for any other SF-36 domain number of symptoms per patient or the presence of any other
(all p>0.05). persistent symptom (all p>0.05). However, the proportion of

Original research
Table 3 Effects of HBET intervention and standard of care (CONTROL) on functional capacity, anthropometry and body composition in survivors of
severe/critical COVID-19 pre-intervention (ie, at baseline) and post-intervention (ie, after 16 weeks)
HBET Control Post-intervention between-group differences
Baseline 16 weeks Baseline 16 weeks EMD 95% CI P value ES
Functional capacity n=25 n=21 n=25 n=20
Handgrip strength, kg* 30.0 (19.5) 32.0 (15.0) 28.5 (19.5) 29.2 (17.5) 2.42 (–6.33 to 11.15) 0.879 0.17
30-second sit-t o-stand, repetitions 12.2±2.3 14.9±3.4 12.2±2.9 12.4±3.2 2.38 (0.01 to 4.76) 0.048 0.86
Timed-up-and-g o, s* 7.33 (2.37) 6.79 (1.41) 6.81 (1.47) 6.88 (1.10) –0.04 (–1.10 to 1.03) 0.997 0.36
PCFS 2.0 (2.0) 1.0 (1.0) 2.0 (2.0) 2.0 (3.0) –0.66 (–1.63 to 0.31) 0.275 0.55
Anthropometry n=25 n=21 n=25 n=20
Waist circumference, cm 104.0±11.0 101.9±10.3 103.8±10.6 105.3±9.4 –4.49 (–13.91 to 4.93) 0.579 0.34
Hip circumference, cm 105.9±10.2 105.7±9.9 105.9±9.8 106.9±9.9 –0.99 (–8.67 to 6.67) 0.985 0.14
WTH circumference, cm 0.98±0.07 0.97±0.08 0.99±0.07 1.01±0.06 –0.03 (–0.09 to 0.02) 0.342 0.26
Body composition n=25 n=17 n=22 n=12
Lean body mass, kg 48.7±10.8 49.4±10.1 47.8±6.7 49.1±6.8 0.71 (–6.66 to 8.08) 0.993 –0.03
Leg lean mass, kg 16.6±4.3 17.0±4.4 15.8±2.4 16.6±2.5 0.56 (–2.38 to 3.49) 0.935 –0.06
Arms lean mass, kg 6.1±1.9 6.1±1.7 5.6±1.1 5.8±1.2 0.31 (–0.98 to 1.60) 0.909 –0.07
Appendicular lean mass, kg 22.6±6.1 23.0±5.9 21.4±3.4 22.4±3.5 0.87 (–3.22 to 4.96) 0.934 –0.07
Body fat mass, kg 33.1±8.8 32.2±8.9 31.9±9.4 31.2±9.2 –1.17 (–8.59 to 6.24) 0.927 0.27
Android fat mass, kg* 2.89 (1.56) 2.98 (1.15) 2.83 (1.61) 2.84 (1.53) –0.18 (–0.99 to 0.63) 0.929 0.31
Gynoid fat mass, kg 5.2±1.6 5.0±1.7 4.9±1.8 4.7±1.7 –0.12 (–1.52 to 1.28) 0.995 0.21
Visceral adipose tissue, kg* 1.71 (0.99) 1.58 (0.87) 1.82 (0.86) 1.97 (0.69) –0.19 (–0.71 to 0.32) 0.732 0.34
Data expressed as unadjusted mean±SD or median (IQR).
*Indicate that statistical analysis was performed on log-transformed data due to nonnormal distribution.
EMD, adjusted estimated mean difference; ES, effect size; HBET, home-based exercise training; PCFS, post-covid functional status; WTH, waist-to-hip.
patients with fatigue (76.0% vs 28.6%) and dyspnoea (36.0% vs depression (either self-reported or assessed by BAI/BDI) were
9.5%) remarkably decreased in HBET, although it did not reach comparable between the two groups at baseline, with no signifi-
between-group statistical significance. Symptoms of anxiety and cant changes in either group after 16 weeks (all p>0.05).
Table 4 Effects of HBET intervention and standard of care (CONTROL) on persistent symptoms in survivors of severe/critical COVID-19 pre-
intervention (ie, at baseline) and post-intervention (ie, after 16 weeks)
HBET CONTROL Post-intervention between-group differences
Baseline 16 weeks Baseline 16 weeks
(n=25) (n=21) (n=25) (n=20) EMD 95% CI P value ES
Self-reported persistent symptoms
Symptoms per patient 6.0 (5.0) 3.0 (5.0) 7.0 (4.0) 5.0 (6.0) –2.19 (–4.79 to 0.41) 0.126 0.90
Fatigue, n (%) 19 (76.0) 6 (28.6) 17 (68.0) 10 (50.0) 0.159
Anxiety/depression, n (%) 16 (64.0) 10 (47.6) 17 (68.0) 13 (65.0) 0.262
Muscle weakness, n (%) 13 (52.0) 1 (4.8) 14 (56.0) 7 (35.0) 0.020
Myalgia, n (%) 13 (52.0) 4 (19.0) 13 (52.0) 11 (55.0) 0.025
Loss of memory, n (%) 11 (44.0) 12 (57.1) 12 (48.0) 10 (50.0) 0.646
Joint pain, n (%) 10 (40.0) 8 (38.1) 12 (48.0) 12 (60.0) 0.161
Headache, n (%) 11 (44.0) 4 (19.0) 6 (24.0) 4 (20.0) 1.000
Dry mouth/eyes, n (%) 11 (44.0) 5 (23.8) 5 (20.0) 7 (35.0) 0.431
Dyspnoea, n (%) 9 (36.0) 2 (9.5) 8 (32.0) 6 (30.0) 0.123
Paresthesia, n (%) 9 (36.0) 8 (38.1) 8 (32.0) 8 (40.0) 0.900
Anosmia/ageusia, n (%) 8 (32.0) 5 (23.8) 4 (16.0) 2 (10.0) 0.410
Dizziness, n (%) 6 (24.0) 6 (28.6) 6 (24.0) 3 (15.0) 0.454
Palpitations, n (%) 5 (20.0) 1 (4.8) 5 (20.0) 4 (20.0) 0.184
Chest discomfort/pain, n (%) 4 (16.0) 1 (4.8) 5 (20.0) 1 (5.0) 1.000
Others, n (%) 13 (52.0) 4 (19.0) 11 (44.0) 6 (30.0) 0.484
FSS, score 3.85±1.61 2.59±1.60 3.45±1.90 3.46±1.95 –1.08 (–2.47 to 0.30) 0.173 0.71
BAI >7 points, n (%) 8 (32.0) 5 (23.8) 8 (32.0) 7 (35.0) 0.431
BDI >13 points, n (%) 6 (24.0) 3 (14.3) 6 (24.0) 6 (30.0) 0.224
Data expressed as unadjusted mean±SD, median (IQR), or frequency and percentage (%).
BAI, Beck anxiety inventory; BDI, Beck depression inventory; EMD, adjusted estimated mean difference; ES, effect size; FSS, Fatigue Severity Scale; HBET, home-based exercise
training.

Original research
Complete-case (per protocol), sensitivity analysis phase, better functional state at baseline and differences in the
HBET resulted in greater pre-to-post changes in scores than training protocol, with a less active supervision and unreported
CONTROL for the primary outcome (physical component adherence in Amaral et al’s study when compared with the
summary) and the following SF- 36 domains: physical func- present one.13
tioning, bodily pain, general health, vitality, role-emotional, Exertional intolerance is a common feature following COVID-
mental health and mental component summary (all p<0.05). 19, especially in severe forms of the disease.3 4 Potential mech-
Changes in absolute and relative VO2peak, OUES, VE, ∆HR and anisms for reduced exercise capacity include altered central
HRR2min were also significantly different across groups (all (cardiac, pulmonary and autonomic) and peripheral (meta-
p<0.05) in favour of HBET. Improvements in 30-second sit- bolic) parameters. In general, intention-to-treat analysis did not
to-stand performance and in PCFS scores were also greater in reveal between-group differences for cardiopulmonary exercise
HBET than in CONTROL (both p<0.05). HBET also showed testing variables. These results could indicate either a low effi-
greater decreases in waist circumference and total and android cacy of our HBET or an insufficient power for these secondary
fat mass, as well as in the total number of persistent symptoms outcomes. Our sensitivity analysis considering only completers
and FSS (both p<0.01) (online supplemental table S5). suggest that the latter might be the case, by showing greater
improvements in several cardiopulmonary exercise testing
parameters (eg, VO2peak, OUES, VE and chronotropic responses)
DISCUSSION in favour of HBET. Importantly, these variables were previously
To the best of our knowledge, this is the first randomised found to be impaired in survivors of COVID-19.3 36 37 Incre-
controlled trial to investigate the effects of an HBET programme ments in VO2peak (~8.3%) following HBET were slightly lower
on health outcomes in patients previously admitted to ICU due than mean improvements reported for individuals with chronic
to COVID-19. The main finding was the positive effect of the diseases undergoing exercise training.38–40 This is not unex-
intervention on the physical domains of HRQoL, namely, phys- pected as we opted for a less intensive aerobic component within
ical functioning, general health, vitality and physical component the programme considering the known and unknown potential
summary (the primary outcome). In addition, 30-second sit-to- risks associated with remotely training survivors of severe/crit-
stand performance and some persistent symptoms (ie, muscle ical COVID-19. Although VO2VT and VE/VCO2 did not change
weakness and myalgia) were also improved following HBET. In in the sensitivity analysis either, HBET increased oxygen uptake
contrast, our primary analysis did not show statistically signifi- efficiency (as indicated by OUES), which is related to pulmonary
cant improvements in the mental domains of HRQoL, cardio- and metabolic factors.16 38 These findings collectively suggest
respiratory fitness, pulmonary function and body composition. that HBET may have a therapeutic value to improve cardiore-
HRQoL is determined by a variety of physical (eg, symp- spiratory fitness in these patients, although further interventions
toms and functional status) and mental (eg, psychological primarily focused on improving cardiorespiratory parameters
status) factors that influence self-perceived health status.28 Truf- are warranted.
faut et al observed that decreased HRQoL 3 months after ICU An association between physical conditioning and post-
discharge was associated with a variety of COVID-19 severity COVID-19 syndrome seems to exist.41 Notably, HBET decreased
parameters during hospital stay.29 In line with this, at baseline, the presence of persistent muscle weakness and myalgia. As
our patients had scores below normative values for the Brazilian seen in previous studies,8 41 fatigue was the major persistent
population in almost all SF-36 domains.30 HBET had heterog- symptom reported by our patients. Despite the lack of between-
enous ES (ranging from 0.43 to 0.83) on multiple domains of group difference, the proportion of patients with self-reported
SF-36 related to physical health, indicating that it can be an fatigue and dyspnoea remarkably diminished among exercised
effective strategy in enhancing HRQoL in survivors of severe/ patients. Furthermore, our exercise intervention was found to
critical COVID- 19. Importantly, the effect of HBET on the have a moderate-to-large effect on the total number of persistent
physical component summary of SF-36 (ES: 0.74) was beyond symptoms and fatigue severity (ES: 0.90 and 0.79, respectively),
the minimally important difference,31 supporting the potential corroborated by our complete-case sensitivity analysis showing
clinical relevance of the intervention. This could be explained, greater reductions in both parameters following training. These
at least partly, by the meaningful improvements observed in the improvements may have been translated into better SF-36 scores,
secondary outcomes. especially in physical domains (eg, vitality and general health).
It has been reported that muscle wasting and dynapenia occur These results are of clinical relevance considering the still
rapidly in ICU patients with severe COVID- 19.32 We have growing number of individuals with post-COVID-19 syndrome
recently demonstrated that survivors of COVID-19 who suffered worldwide.
the greatest muscle wasting during hospital care present with Conversely, between-group differences were not found in any
persistent reduction in muscle cross-sectional area and handgrip psychological symptoms (eg, anxiety and depression), which
strength 6 months after hospital discharge.6 These parameters may account for the somewhat smaller ES (ranging from 0.37
have already been shown to be determining factors for patients’ to 0.66 in favour of HBET) observed in the mental domains of
prognosis.33 34 Even though HBET was unable to increase muscle SF-36. The proportion of patients classified as having anxiety/
lean mass and strength during follow-up, presumably due to depression symptoms when assessed by specific psychometric
insufficient training volume load,35 we observed improvements tools (ie, BAI and BDI) was in line with values reported in the
in some functional capacity parameters. HBET yielded a large literature following critical illness and COVID-197 42; however,
effect on 30-second sit-to-stand performance (ES: 0.86), whereas the presence of self-reported anxiety/depression symptoms was
PCFS also improved (only in the complete-case analysis) with much higher, suggesting a mismatch between these inductive,
a moderate magnitude (ES: 0.55). Our results contrast with a and self-reported questionnaire methods. One may not rule out
previous randomised controlled trial which did not observe any the possibility that exercise training programmes performed in
effect of HBET on functional capacity in individuals recovering groups or other environments (eg, outdoors) according to indi-
from COVID-19 hospitalisation.13 Discrepancies in results may vidual preference may have more positive results on psycholog-
be related to the lower severity of the disease during the acute ical symptoms.43

Original research
The strengths of this study include the assessment of a well- 31303720.7.0000.0068). Participants gave informed consent to participate in the
characterised sample of individuals who had severe/critical study before taking part.
COVID- 19 (all patients with confirmed RT- PCR for SARS- Provenance and peer review Not commissioned; externally peer reviewed.
CoV- 2 test and admitted to the ICU of a tertiary referral Data availability statement All data relevant to the study are included in the
hospital according to WHO criteria), the delivery of a well- article or uploaded as online supplemental information.
monitored HBET intervention, and the use of broad, valid Supplemental material This content has been supplied by the author(s).
and gold-standard measures to assess primary and secondary It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not
outcomes. Nevertheless, this study is not without limitations. It have been peer-reviewed. Any opinions or recommendations discussed are
solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all
was not possible to identify SARS-CoV-2 variant during acute liability and responsibility arising from any reliance placed on the content.
phase infection; still, most patients were recruited during the Where the content includes any translated material, BMJ does not warrant the
first and second waves of COVID-19 in Brazil, during which accuracy and reliability of the translations (including but not limited to local
Gamma P.1 prevailed and vaccines against SARS-CoV-2 were regulations, clinical guidelines, terminology, drug names and drug dosages), and
not available. We cannot extrapolate our results to other clin- is not responsible for any error and/or omissions arising from translation and
adaptation or otherwise.
ical populations; for instance, patients who had milder disease
(eg, ward patients or outpatients) could respond differently to This article is made freely available for personal use in accordance with BMJ’s
website terms and conditions for the duration of the covid-19 pandemic or until
this type of intervention. Furthermore, it was not possible to otherwise determined by BMJ. You may download and print the article for any lawful,
blind the participants to the intervention; therefore, the bene- non-commercial purpose (including text and data mining) provided that all copyright
fits may be partially explained by placebo effects. Adherence to notices and trade marks are retained.
the training programme was suboptimal, which may have miti-
ORCID iDs
gated the magnitude of change in some outcomes. Measurement Igor Longobardi http://orcid.org/0000-0001-6669-9553
bias in intention-to-treat estimates, selection bias due to missing Saulo Gil http://orcid.org/0000-0001-9050-0073
outcome data and random confounding could be limitations in Bruno Gualano http://orcid.org/0000-0001-7100-8681
our models, which were unable to be further adjusted owing Hamilton Roschel http://orcid.org/0000-0002-9513-6132
to potential insufficient power. In fact, our sample size may be
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BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med
Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681



Home-based EXERCISE Training

Progression
Training intensity progression based on the Borg RPE scale.
Week 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16
Borg
9-11 11-13 12-14 13-15 14-16 14-16 15-17 15-17
RPE
RPE: rate of perceived exertion
• The table above indicates the progression of exercise intensity

throughout the training program.
• This progression is for both aerobic and strengthening exercises.
• Specific and individualized instructions for each type of exercise will

be provided by your trainer each week.
• On the next two pages are presented general tables related to the
prescription of aerobic and strength training.
• In case of any doubt or intercurrence, contact the research team for

further instructions.

Aerobic Training Program
PCFS Grade Level Bouts Duration (min) Exercise
1 2 10
4 2 3 10 Walk
3 2 15
1 2 15
3 2 3 15 Walk
3 2 20
1 1 >30
2 2 1 >35 Walk
3 1 >40
1 1 >40
0/1 2 1 >45 Walk/Jog
3 1 >50

Strengthening Training Program
PCFS Grade Level Sets Repetitions
1 12-15
4 2 3 10-12
3 8-10
1 12-15
3 2 3 10-12
3 8-10
1 12-15
2 2 4 10-12
3 8-10
1 12-15
0/1 2 5 10-12
3 8-10


PCFS Grade: 4
WARM-UP
WRIST ROTATIONS
Instructions: Keep both your arms and shoulders relaxed. Then, rotate your
wrists outward and then inward for 30 seconds. Perform two sets of
controlled movements in both directions.
HIP ROTATION
Instructions: In an upright and relaxed position, look straight ahead and place
your hands upon your hips. Perform controlled two sets of circular movements,
rotating your hips 3 times to each side for 30 seconds. If necessary, place
both hands on the wall to maintain balance.


PCFS Grade: 4
STRENGTHENING EXERCISES
1. STANDING KNEE LIFTS
Instructions: In an upright position, raise your knee as high as you can and
hold it for 2 seconds. Then return to the starting position and repeat the
movement with the same leg. If necessary, place both hands on the wall for
greater balance and safety while performing the exercise.
2. LYING SINGLE-LEG HIP FLEXION
Instructions: Lie down on a stable surface. Support your lumbar with both
hands for greater comfort. Lift one leg, bringing it toward your torso. Then
return to the starting position and perform the movement with the same leg.


PCFS Grade: 4
3. SEATED CALF-RAISES
Instructions: In a sitting position, place a weight (e.g., 2kg package) on your

knees. Then, lift your heels at the same time as you push the floor with your toes.
Hold your calves contracted for 2 seconds before return to the starting position.
Place the chair against a wall before starting the exercise for safety.
4. SEATED ELBOW FLEXION
Instructions: In a sitting position, hold a weight (e.g., 500ml bottle) in each

hand and then flex your elbows to lift it. Keep your elbows stable, next to your
waist. Hold the lifted weight for 2 seconds before returning to the starting
position. Place the chair against a wall before starting the exercise for safety.


PCFS Grade: 4
5. LYING DIAPHRAGMATIC BREATHING
Instructions: Lie down on a stable and comfortable surface. Hold a weight

(e.g., 2kg package) on your belly and place both hands upon it. Inhale as much
air as possible in a single and deep breath for lift the package. Hold this
position for 2 seconds before slowly exhaling.
6. SEATED ISOMETRIC HIP FLEXION
Instructions: In a sitting and slightly reclined position, hold the front of the chair
firmly for greater stability. Thereafter, try to lift both legs (bringing the knees and
feet toward your torso). Hold them up for 15 to 30 seconds until you return to the
starting position. If you can't sustain them raised for so long, do it for as long as
you can. For safety, place the chair against a wall before start the exercise.


PCFS Grade: 4
COOL-DOWN
NECK STRETCH
Instructions: In an upright position (keep your spine erect and stable), gently
pull your head to one side and hold it for 20 to 30 seconds. Then, repeat it for
the other side. Finally, with both hands, gently pull your head down. This exercise
should be relaxing, so don't use excessive force!
ARMS STRETCH
Instructions: With your spine straight and stable, interlace your fingers and turn
your palms outward. Raise your arms above your head (or as high as you can)
and extend them for 20 to 30 seconds.


PCFS Grade: 3
WARM-UP
ARM SWINGS
Instructions: In an upright and relaxed position, swing both arms parallel to

the floor for 30 seconds. Your arms shall cross in front of your body and,
then, return to the side of your body. Perform two sets.
HIP ROTATION
Instructions: In an upright and relaxed position, look straight ahead and place
your hands upon your hips. Perform controlled two sets of circular movements,
rotating your hips 3 times to each side for 30 seconds. If necessary, place
both hands on the wall to maintain balance.


PCFS Grade: 3
1. HIP RAISES
Instructions: Lie down on a stable and comfortable surface. Bend your knees
and place both feet firmly on the floor. Rest both hands at your sides for
greater stability. Lift your hip by contracting your glutes and legs' muscles. Hold
your hip raised for 2 seconds and, then, return to the starting position. If
necessary (e.g., 2kg package), hold a weight on your hips.
2. KNEE EXTENSION
Instructions: In a sitting position, extend your knee by contracting the front

muscles of your leg. Hold your foot raised for a few seconds before returning
to the starting position. If necessary, you can attach a weight (e.g., 2kg
package) to your ankle [please, consult your trainer]. Place the chair against a
wall before starting the exercise for safety.


PCFS Grade: 3
3. HIP ABDUCTION
Instructions: Lie on your side on a stable and comfortable surface. Bend the
knee closer to the floor and extended the corresponding arm in front of your
body for greater stability. Then, lift the other leg, moving it sideways. Hold your
leg up for 2 seconds before returning to the starting position. If necessary, you
can attach a weight (e.g., 2kg package) to your ankle [please, consult your
trainer].
4. LATERAL RAISES
Instructions: In an upright position, hold a weight (e.g., 500ml bottle) in each

hand. Then lift both arms at your sides, bringing them up to the shoulder height.
Hold the weight lifted for 2 seconds before returning to the starting position.


PCFS Grade: 3
5. LYING TRICEPS EXTENSION
Instructions: Lie down on a stable and comfortable surface. Initially, with both
arms extended towards the sky (i.e., perpendicular to the ground), hold firmly a
weight (e.g., 5kg package) with both hands. In a controlled manner, slowly
bend your elbows to bring the weight towards your forehead. Then, extend your
elbows once again, returning to the starting position.
6. CRUNCHES
Instructions: Lie down on a stable and comfortable surface. Bend your knees and
place your feet firmly on the floor. With both arms extended by your sides,
contract your abdominal muscles to lift your torso while bringing your hands
toward your heels. Hold your torso lifted for 2 to 3 seconds before returning to
the starting position.


PCFS Grade: 3
COOL-DOWN
GLUTE STRETCH
Instructions: Lie down on a stable and comfortable surface. Bend your knees
and place your feet firmly on the floor. Embrace one of your knees and bring it
towards your upper body. Hold it in a stretch position for 20 to 30 seconds.
Then, return to the starting position and perform the movement with the
opposite leg. This exercise should be relaxing, so don't exert excessive force!
SIT AND REACH
Instructions: In a sitting position, extend one of your knees and, in a slow

movement, try to reach your toes with your hand on the same side. Stretch as
much as you can and hold this position for 20 to 30 seconds [if necessary, you
can hold on to the shin]. Then, return to the starting position and perform the
movement with the opposite leg. Place the chair against a wall or stable
structure before start the exercise for safety. This exercise should be relaxing, so
don't exert excessive force!


PCFS Grade: 3
NECK STRETCH
Instructions: In an upright position (keep your spine erect and stable), gently
pull your head to one side and hold it for 20 to 30 seconds. Then, repeat it for
the other side. Finally, with both hands, gently pull your head down. This exercise
should be relaxing, so don't use excessive force!
ARMS STRETCH
Instructions: With your spine straight and stable, interlace your fingers and turn
your palms outward. Raise your arms above your head (or as high as you can)
and extend them for 20 to 30 seconds.


PCFS Grade: 2
WARM-UP
ARM SWINGS
Instructions: In an upright and relaxed position, rotate your arms at your

side. Perform two sets of three forward and three backward circular
movements for 30 seconds.
STANDING KNEE LIFT
Instructions: In an upright position, look straight ahead and place both hands
upon your hips. Lift your knees alternately as high as you can for 30 seconds.
Perform two sets.


PCFS Grade: 2
1. SIT-TO-STAND
Instructions: In a sitting
position, place your feet close
to the base of the chair. Lean
your torso slightly forward and
then lift your body in a single
movement by using the
strength of your leg muscles.
Keep both hands resting upon
your shoulders. Place the chair
against a wall before starting
the exercise for safety.
2. STEP-UP
Instructions: To perform this

exercise, use a ladder or proper
box (consult your trainer). Place a
foot over the object while keeping
the other leg on the floor. Lift your
body in a single movement by using
the strength of your leg muscles, as
if climbing it. Thereafter, return to
the starting position and repeat the
movement with the same leg. Place
one hand on the wall or handrail for
satefy [but don't use the strength of
your arms].


PCFS Grade: 2
3. FARMER WALK
Instructions: To perform this

exercise, you will need two bags
loaded with objects of same
known weight (e.g., 5kg
packages). Hold the bags, while
you contract the muscles in your
abdomen and forearm, and walk
for 100 to 200m.
4. SINGLE ARM ELBOW FLEXION
Instructions: In an upright
position, hold a weight (e.g.,
bucket full of water) with a single
hand. Then lift the weight by
flexing your elbow. Bring the
object nearly to shoulder height,
while keeping your elbows stable,
next to your waist. Hold the lifted
weight for two seconds before
returning to the starting position.
Rest the opposite hand upon your
hip for greater stability.


PCFS Grade: 2
5. OVERHEAD SHOULDER PRESS
Instructions: In an upright
position, hold a weight (e.g.,
5kg package) with both hands
at chest level (as shown in the
picture). Then lift it, by pushing
the weight up and hold it
raised above your head for 2
seconds before returning to
the starting position.
6. LYING HIP FLEXION
Instructions: Lie down on a stable, comfortable surface. Support your lower back
with both hands for greater comfort. Bend your knees and move them towards
your upper body by contracting your abdominal muscles. When returning to the
starting position (i.e., knees fully extended and parallel to the floor), keep your
ankles elevated, without resting them on the floor before the next repetition.


PCFS Grade: 2
COOL-DOWN
SHOULDER STRETCH
Instructions: In an upright and relaxed position, cross one arm in front of your
upper body at shoulder height. Then, pull your elbow with your other arm. Hold
this position for 20 to 30 seconds. Then, return to the starting position and
perform the same movement with the other side. During the movement, rotate
your neck, turning your head toward the opposite side. The exercise should be
relaxing, so don't exert excessive force!
SIT AND REACH



PCFS Grade: 2
DORSAL STRETCH
Instruction: In an upright position, stand at a distance of approximately 1m from

the wall. Place both hands on the wall at eye level and then slowly move your
hip backwards, bringging your lower body backward. Stretch your back muscles
for 20 to 30 seconds and then return to the starting position. The exercise
should be relaxing, so don't exert excessive force!
QUADRICEPS STRETCH
Instructions: Standing next to a stable structure (e.g., wall or chair), flex one
knee and pull your ankle toward your lower back. Hold it for 20 to 30 seconds.
opposite leg.


PCFS Grade: 1/0
WARM-UP
ARM SWINGS
Instructions: In an upright and relaxed position, rotate your arms at your

side. Perform two sets of three forward and three backward circular
movements for 30 seconds.
STANDING KNEE LIFT
Instructions: In an upright position, look straight ahead and place both hands
upon your hips. Lift your knees alternately as high as you can for 30 seconds.
Perform two sets.


PCFS Grade: 1/0
1. HALF SQUAT
Instructions: In an upright position, place your feet at shoulder width and

extend your arms in front of your body, placing one hand over the other. Gently,
bend your knees and evenly move your hips backwards. Keep your spine straight
throughout the whole movement. Squat as low as you can without getting off
balance and then return to the starting position.
2. LUNGES
Instructions: In an upright position, step forward with one of your legs. Bend the
knee of the front leg and slowly lower your body until the knee of the hind leg
almost touches the floor. Then, extend your knees to lift back your body. During
the exercise, try to focus the effort on your front leg. Use a chair (positioned
against a wall) or a stable structure (e.g., handrail) as support for greater
stability.


PCFS Grade: 1/0
3. CALF-RAISES
Instructions: In an upright position, stand close to a wall and place both hands
lightly upon it for greater stability during the exercise. In a single movement, lift
your body weight by pushing your toes against the floor and contracting your
calves to raise your heels. Then return to the starting position in a controlled
movement.
4. WALL PUSH-UP
Instructions: Stand approximately 1 meter away from a wall. Place both hands
upon the wall, below the shoulder line, and slightly lean your body forward. In a
controlled manner, flex both elbows. After getting closer to the wall, extend your
elbows by pushing the wall to return to the starting position. [PCFS Grade 0
should perform "push ups" on the floor].


PCFS Grade: 1/0
5. STANDING ONE-ARM ROW
Instructions: Stand approximately 1 meter away from a wall and step back
with one of your legs. Place the hand of the same side as your front leg on the
wall, at shoulder height, slightly leaning your upper body. Hold a weight (e.g.,
bucket full of water) perpendicular to the ground with your free hand (same
side as the back leg). Pull the weight, bringing your elbow toward your waist
and hold it lifted for 2 seconds before returning to the starting position.
Perform the exercise for both sides of the body.
6. PLANK
Instructions: Place forearms on the floor with elbows aligned below shoulders
and arms parallel to your body at about shoulder width. Lift your hip and keep
your body straight, by contraction your abdominal muscles and keeping your
weight evenly distributed between your toes and forearms. Hold this position for
30 seconds before rest.


PCFS Grade: 1/0
COOL-DOWN
SHOULDER STRETCH
Instructions: In an upright and relaxed position, cross one arm in front of your
upper body at shoulder height. Then, pull your elbow with your other arm. Hold
this position for 20 to 30 seconds. Then, return to the starting position and
perform the same movement with the other side. During the movement, rotate
your neck, turning your head toward the opposite side. The exercise should be
relaxing, so don't exert excessive force!
SIT AND REACH



PCFS Grade: 1/0
DORSAL STRETCH
Instruction: In an upright position, stand at a distance of approximately 1m from

the wall. Place both hands on the wall at eye level and then slowly move your
hip backwards, bringging your lower body backward. Stretch your back muscles
for 20 to 30 seconds and then return to the starting position. The exercise
should be relaxing, so don't exert excessive force!
QUADRICEPS STRETCH
Instructions: Standing next to a stable structure (e.g., wall or chair), flex one
knee and pull your ankle toward your lower back. Hold it for 20 to 30 seconds.
opposite leg.

Supplementary Table 1. Aerobic training prescription.

PCFS Grade Level Bout(s) Duration Exercise
4 1 2 10 min Walk
2 3 10 min
3 2 15 min
3 1 2 15 min Walk
2 3 15 min
3 2 20 min
2 1 1 ≥30 min Walk
2 1 ≥35 min
3 1 ≥40 min
1/0 1 1 ≥40 min Walk/Jog
2 1 ≥45 min
3 1 ≥50 min
Abbreviations: PCFS: post-COVID functional status.

Supplementary Table 2. Strengthening training prescription.

PCFS Grade Level Sets Repetitions Exercises
4 1 3 12-15 1) Standing knee lifts

2) Lying single-leg hip flexion
2 10-12 3) Seated calf-raises
4) Seated elbow flexion
3 8-12 5) Lying diaphragmatic breathing
6) Seated isometric hip flexion*
3 1 3 12-15 1) Hip raises
2) Knee extension
2 10-12 3) Hip abduction
4) Lateral raises
3 8-12 5) Lying triceps extension
6) Crunches
2 1 4 12-15 1) Sit-to-stand
2) Step-up
2 10-12 3) Farmer Walk
4) Single arm elbow flexion
3 8-12 5) Overhead shoulder press
6) Lying hip flexion
1/0 1 5 12-15 1) Half squat
2) Lunges
2 10-12 3) Standing calf-raises
4) Wall push up/Push up
3 8-12 5) Standing one-arm row
6) Plank*
Abbreviations: PCFS: post-COVID functional status. * indicate isometric contraction (30/45/60
seconds) exercises.
Supplementary Table 3. Home-based exercise training intensity progression.

Weeks 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16
RPE 9-11 11-13 12-14 13-15 14-16 14-16 15-17 15-17
Abbreviations: RPE: rate of perceived exertion.

Supplementary Table S4. Effects of home-based exercise training (HBET) intervention and standard of care (CONTROL) on biochemical markers in survivors of severe COVID-19 pre-
intervention (baseline) and post-intervention (16 weeks).
HBET CONTROL Post intervention between-group differences
Baseline 16 weeks Baseline 16 weeks EMD 95%CI P value ES
Biochemical markers n = 25 n = 21 n = 25 n = 20
Erythrocytes, 1012/L 4.93±0.47 4.93±0.48 5.00±0.50 5.00±0.42 –0.15 (–0.59; 0.29) 0.792 0.00
Hematocrit, % 42.7±3.1 43.7±3.3 41.8±4.2 42.0±3.8 1.11 (–2.48; 4.70) 0.831 0.17
Hemoglobin concentration, g/dL 14.3±1.2 14.6±1.2 13.6±1.5 13.7±1.1 0.71 (–0.52; 1.95) 0.401 0.19
White blood cell count, ×109/L 6.75±1.78 6.99±1.80 7.28±1.54 7.39±1.19 –0.41 (–1.95; 1.12) 0.880 0.05
Neutrophil count, ×109/L 3.57±1.11 3.93±1.46 4.30±1.20 4.22±1.05 –0.36 (–1.50; 0.78) 0.823 0.27
Lymphocyte count, ×109/L 2.12±0.53 2.26±0.64 2.24±0.59 2.33±0.42 –0.06 (–0.60; 0.49) 0.991 0.11
Monocyte count, ×109/L 0.51±0.12 0.51±0.14 0.52±0.15 0.54±0.15 –0.05 (–0.19; 0.08) 0.690 –0.14
Platelet count, ×109/L 239.1±25.9 253.3±40.3 251.1±50.0 256.8±47.9 0.23 (–41.8; 42.3) 1.000 0.42
MPV, fL 10.3±1.0 10.4±0.8 10.3±0.8 10.5±0.6 0.07 (–0.68; 0.82) 0.995 0.12
Blood glucose, mg/dL 102.6±11.6 100.7±9.3 104.2±13.3 100.5±11.7 –1.02 (–11.48; 9.45) 0.993 0.03
HbA1c, % 5.8±0.4 5.8±0.3 5.6±0.4 6.2±1.1 –0.32 (–0.92; 0.27) 0.461 0.08
Total cholesterol, mg/dL 210.8±37.9 218.3±43.4 215.3±43.3 228.5±44.1 –11.7 (–46.7; 23.2) 0.806 0.26
HDL-c, mg/dL 46.6±7.5 50.2±8.2 49.9±13.3 50.9±14.3 –1.0 (–10.3; 8.3) 0.991 0.59
LDL-c, mg/dL 135.2±25.5 137.5±37.0 133.8±44.2 141.6±39.2 –4.2 (–34.9; 26.5) 0.983 0.15
Triglycerides, mg/dL 173.4±70.2 143.1±46.8 166.3±79.6 153.4±70.0 –21.6 (–79.5; 36.2) 0.747 0.95
Creatine phosphokinase, U/L 105.0 [103.0] 124.5 [113.5] 89.0 [116.0] 119.0 [76.0] –7.52 (–64.15; 49.12) 0.984 0.11
Troponin-T, pg/mL 7.5 [6.0] 6.0 [6.0] 8.0 [4.0] 9.5 [7.5] –2.67 (–6.47; 1.13) 0.245 0.68
C-reactive protein, mg/L 2.6 [4.3] 3.0 [3.3] 3.2 [3.6] 4.6 [4.0] –0.81 (–3.77; 2.14) 0.873 0.30
Data expressed as unadjusted mean±SD or median [IQR]. Abbreviations: EMD: adjusted estimated mean difference; 95%CI: 95% confidence interval; ES: effect size; MPV: mean platelet
volume; HbA1C: glycated hemoglobin. a indicate significant within-group difference from pre- to post-intervention (P≤0.05).

Supplementary Table S5. Case-complete sensitivity analysis

∆HBET−∆CONTROL 95%CI P Value
HRQoL - SF-36
Physical functioning, points 21.9 (10.6; 33.2) <0.001
Role−physical, points 15.5 (−6.4; 37.4) 0.157
Bodily pain, points 14.7 (2.6; 26.9) 0.018
General health, points 16.0 (6.6; 25;4) <0.001
Vitality, points 10.8 (2.9; 18.8) 0.008
Social functioning, points 11.1 (−1.4; 23.6) 0.080
Role−emotional, points 19.6 (3.1; 36.1) 0.021
Mental health, points 9.1 (1.8; 16.3) 0.016
Physical component summary, points 16.5 (8.5; 24.4) <0.001
Mental component summary, points 13.1 (4.1; 22.2) 0.005
Cardiorespiratory fitness
Time-to-exhaustion, s 57.5 (−20.7; 135.7) 0.115
VO2peak, L·min−1 0.16 (0.04; 0.28) 0.011
VO2peak, mL·kg−1·min−1 1.71 (0.32; 3.11) 0.017
VO2peak, % pred 4.6 (−1.0; 10.3) 0.106
VO2VT, L·min−1 −0.04 (−0.20; 0.12) 0.654
VO2VT, mL·kg−1·min−1 −0.66 (−2.73; 1.40) 0.518
VO2VT, % pred VO2peak 3.1 (−7.2; 13.4) 0.566
OUES, L·min−1 0.23 (0.03; 0.43) 0.028
RERpeak 0.04 (−0.01; 0.08) 0.112
VE, L·min−1 7.14 (1.04; 13.23) 0.023
VE/VCO2 slope −0.99 (−3.81; 1.82) 0.479
VE/VCO2nadir, L·min−1 −0.39 (−3.09; 2.31) 0.773
O2 pulse, mL·bpm−1 0.34 (−0.56; 1.25) 0.444
O2 pulse, % pred 3.52 (−3.66; 10.69) 0.327
HRmax, bpm 7.8 (−0.9; 16.5) 0.076
∆HR, bpm 7.7 (0.8; 14.6) 0.028
Chronotropic index, % 9.5 (−0.8; 19.7) 0.068
HRR1min, bpm 1.2 (−5.8; 8.2) 0.725
HRR2min, bpm 10.2 (3.2; 17.2) 0.005
HRR4min, bpm 5.2 (−1.6; 12.1) 0.133
Pulmonary function test

FEV1, L −0.10 (−0.32; 0.12) 0.359
FVC, L −0.05 (−0.25; 0.16) 0.658
FEV1/FVC, % 2.85 (−0.81; 6.51) 0.123
PIF, L·s−1 0.38 (−0.62; 1.39) 0.443
PEF, L·s−1 −0.06 (−1.12; 1.00) 0.907
Functional capacity
Handgrip strength, kg 1.22 (−1.37; 3.82) 0.345
30-s sit-to-stand, repetitions 2.56 (0.79; 4.32) 0.006
Timed-up-and-go, seconds −0.63 (−1.67; 0.41) 0.217
PCFS −0.74 (−1.31; −0.18) 0.011

Anthropometry
Waist circumference, cm −3.07 (−4.85; −1.29) <0.001
Hip circumference, cm −1.57 (−3.46; 0.32) 0.101
WTH circumference, cm −0.02 (−0.04; 0.00) 0.094
Body composition
Lean body mass, kg −0.93 (−2.25; 0.40) 0.163
Leg lean mass, kg −0.42 (−1.05; 0.20) 0.175
Arms lean mass, kg −0.11 (−0.33; 0.11) 0.312
Appendicular lean mass, kg −0.66 (−1.48; 0.17) 0.115
Body fat mass, kg −2.76 (−4.61; −0.91) 0.005
Android fat mass, kg −0.38 (−0.65; −0.10) 0.008
Gynoid fat mass, kg −0.19 (−1.22; 0.82) 0.688
Visceral adipose tissue, kg −0.14 (−0.33; 0.05) 0.143
Persistent symptoms
Symptoms per patient −3.1 (−4.9; −1.2) 0.001
FSS, points −1.15 (−1.97; −0.33) 0.007
Data expressed as mean difference. Abbreviations: HBET: home-based exercise training; 95%CI: 95%
confidence interval; HRQoL: health-related quality of life; bpm: beats per minute; HRR: heart rate
recovery; VE/VCO2: ventilatory equivalent ratio for carbon dioxide; RERpeak: peak exercise respiratory
exchange ratio; VO2peak: peak exercise oxygen uptake; VO2VT: oxygen uptake at the ventilatory
threshold; pred: predicted; FEV1: forced expiratory volume in the first second; FVC: forced vital
capacity; PIF: peak inspiratory flow; PEF: peak expiratory flow; PCFS: post-covid functional status;
WTH: waist-to-hip; FSS: fatigue severity scale. Sample size was HBET n=21 and CONTROL n=20 for
all variables except for body composition parameters (HBET n=17 and CONTROL n=12).

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Original research

Effects of a 16-­week home-­based exercise training

► Additional supplemental ABSTRACT

To cite: Longobardi I, condition, affecting approximately 39%–46%

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681 1

MATERIALS AND METHODS

2 Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681 3

4 Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681 5

6 Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681 7

8 Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681 9

10 Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi:10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Training intensity progression based on the Borg RPE scale.

Week 1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16

RPE: rate of perceived exertion

• The table above indicates the progression of exercise intensity

• This progression is for both aerobic and strengthening exercises.

• Specific and individualized instructions for each type of exercise will

• In case of any doubt or intercurrence, contact the research team for

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Aerobic Training Program

PCFS Grade Level Bouts Duration (min) Exercise

0/1 2 1 >45 Walk/Jog

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Strengthening Training Program

PCFS Grade Level Sets Repetitions

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

2. LYING SINGLE-LEG HIP FLEXION

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Instructions: In a sitting position, place a weight (e.g., 2kg package) on your

4. SEATED ELBOW FLEXION

Instructions: In a sitting position, hold a weight (e.g., 500ml bottle) in each

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

5. LYING DIAPHRAGMATIC BREATHING

Instructions: Lie down on a stable and comfortable surface. Hold a weight

6. SEATED ISOMETRIC HIP FLEXION

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Instructions: In an upright and relaxed position, swing both arms parallel to

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Instructions: In a sitting position, extend your knee by contracting the front

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

Instructions: In an upright position, hold a weight (e.g., 500ml bottle) in each

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Home-based EXERCISE Training

5. LYING TRICEPS EXTENSION

Longobardi I, et al. Br J Sports Med 2023;0:1–10. doi: 10.1136/bjsports-2022-106681

Effects of a 16-week home-based exercise training