Review Article

Psychophysiological Adaptations to Exercise Training in COVID-19 Patients: A Systematic Review

Table 3

Characteristics of the included studies.

ReferencePopulation and sample SizeParticipants/ageGenderIntervention (type of exercise, duration, intensity, sets, and reps.)Time of intervention & study durationStudy designParameter/the outcome measurePRO measure instrumentResultsConclusion

Ahmed et al. [36]Pakistan ()COVID-19 patients
Age: years old
Male and femaleAll participants underwent (3 S/WK) of AE (20–60 M/S) and breathing exercises for (10 M/S)In postdischarge COVID-19 patients
5 weeks
A prospective interventional study(1) HRQOL
(2) Breathlessness
(3) Cardiorespiratory fitness
(4) Pulmonary function
(1) SF-36
(2) Modified Borg Dyspnoea Scale
(3) 6MWT test
(4) FVCs
Significant improvement in the following:
(1) Dyspnoea: pre-EX: and post-EX: ()
(2) Physical function: pre: and post: ()
(3) QOL: pre: and post: ()
(4) No significant result for pulmonary function: pre: and post: ()
In COVID-19-recovered individuals, cardiorespiratory fitness and health-related QOL were substantially improved. As a result, an early Rb training program should be implemented in COVID-19-recovered patients to increase cardiorespiratory fitness and QOL. Greater improvement in general health and body pain domains of health-related QOL
Xia et al. [47]China ()
EX ()
CO ()
Hospitalized COVID-19 survivors with remaining dyspnoea
Age: years old
Male and femaleParticipants were subjected to 6 WK of telerehabilitation program (unsupervised home program) 3–4 S/WK. Included: breathing control and thoracic expansion, AE, and lower limb muscle strength EXIn postdischarge COVID-19 patients
6 weeks
RCT(1) Physical function
(2) Peripheral muscle performance of lower limp
(3) Pulmonary function
(4) QOL
(5) Dyspnoea
(1) 6MWT
(2) Squat time in seconds
(3) Spirometry
(4) SF-12
(5) —
Significant improvement in the following:
(1) Physical function: pre: and post ()
(2) Peripheral muscle performance of lower limp: pre: and post: ()
(3) QOL: pre: and post: ()
(4) Dyspnoea: pre: 1.27 (0.88 to 1.82), after 4 WK: 1.08 (0.82 to 1.42) (), and after 6 WK: 1.46 (1.17 to 1.82) ()
(5) No significant different in pulmonary function: pre: and post: ()
However, there was no significant difference in the control group ()
Self-reported dyspnoea and maximal voluntary breathing had short-term effects. Otherwise, the intervention’s benefits on pulmonary function are doubtful, and its impacts on the mental elements of QOL are minimal. No serious adverse events were recorded
Liu et al. [40]China ()
EX ()
CO ()
Elderly patients with COVID-19
Comorbidities (HTN, T2DM, and osteoporosis)
Age: years old
MaleParticipants were subjected to respiratory Rb of 2 S/WK for 10 M. The intervention includes respiratory muscle EX, cough EX, diaphragmatic EX, stretching EX, and home EX at 60% of the individual’s maximal expiratory mouth pressureWith a definite diagnosis of COVID-19
6 weeks
RCT(1) PFT
(2) Functional tests
(3) QOL
(4) Mental status tests
(1) DLCO
(2) 6MWT
(3) SF-36
(4) SAS anxiety and SDS depression scores
Significant improvements the following:
(1) Pulmonary function: pre: and post:
(2) Physical function: pre: and post:
(3) QOL: pre: and post:
(4) Decreased SAS: pre: and post:
(5) SDS scores: pre: and post: ()
However, there was no significant difference in the control group ()
RB program can improve QOL, respiratory function, anxiety, and depression of elderly patients with COVID-19
Kong et al. [39]China ()
EX ()
CO ()
COVID-19 patients
Age: years old
Male and femalePatients undergo breathing exercises for 20 M every D, the EX was based on Yoga breathing methods, and it aims to stimulate nasal and diaphragmatic breathing, increase expiratory duration, reduce respiratory flow, and regulate breathing rhythmDuring diagnosed with COVID-19
10 days
RCT(1) Depression and anxiety
(2) QOL
(1) HADS-A and HADS-D
(2) PSSS
Significant reduction in the following:
(1) HADS scores of depressions (pre: and post: ) and anxiety (pre: and post: )
(2) QOL: pre: and post: ()
There was no significant difference in the control group ()
Breathing EX proper intervention and critical element for COVID-19 patients’ treatment as well as having a beneficial effect on COVID-19 patients’ mental health and better life quality
Spielmanns et al. [45]Switzerland ()COVID-19 patients
Age: years old
Reported comorbidities
Male and femalePulmonary rehabilitation program including a total of 25–30/S for 5–6 WK/D. Endurance (cycling and treadmill) 5-6/WK for 10–30/M/S, gymnastics 5–6/WK for 45 M/S, outdoor walking 2–3/W for 45 M/S, strength training 3–4/WK for 30 M/S, relaxation 2/WK for 45 M/S, and respiratory therapy 3/for 30 M/SPost-COVID-19 patients
3 weeks
Observational study(1) Physical function(1) 6 MWTSignificant improvements in the following:
(1) Physical function: pre: and post: ()
Pulmonary Rb has been linked to significant clinical and functional gains in those who have had severe COVID-19
Zampogna et al. [48]Italy ()COVID-19 patients
Age: 71.0 (61.5–78.0) years old
Male and femaleThe EX (1 depends on the patient’s ability) were mobilization, active exercises and free walking, peripheral limb muscle activities, shoulder, and full arm circling for 30 M/daily/S. The EX (2 depends on the patient’s ability) was strengthening, callisthenic, cycling, balance EX, and paced walkingRecovered COVID-19 patients

Between April 1 and August 15, 2020. Short
Retrospective study(1) Pulmonary function
(2) Performance of lower extremity function
(3) Exercise tolerance
(1) Barthel Index
(2) SPPB
(3) 6MWT
Significant improvement in the following:
(1) Pulmonary function: 55.0 (30.0–90.0) to 95.0 (65.0–100.0) ()
(2) SPPB: post: 0.5 (0–7) ()
(3) Physical function: pre: and post: ()
Pulmonary Rb is effective and successful in COVID-19 survivors, including those who require assisted breathing or oxygen management. It may also be valuable to guide physicians caring for COVID-19 survivors and enhance their quality of life
Abodonya et al. [35]Saudi Arabia ()
EX ()
CO ()
COVID-19 patients
Age: years old
Male and femaleThe IMT group was utilizing a threshold inspiratory muscle trainer at 2/S/D for 5/D/WK. Each S consisted of six inspiratory cycles, each lasting about 5 M of resisted inspiration followed by a 60-second rest period. The inspiratory threshold pressure was set at 50% of the maximum inspiratory pressure (MIP)Recovered COVID-19 patients
2 weeks
Pilot control clinical study(1) Pulmonary function test (FVC%, FEV1%)
(2) Dyspnoea Severity Index
(3) QOL
(4) Functional capacity
(1) Spirometer
(2) DSI questionnaires
(3) Euro Quality-5 Dimensions-3 Levels (EQ-5D-3L) questionnaire
(4) 6MWT
No significant difference in the following:
(1) Pulmonary function: pre: and post: ()
Significant improvements in the following:
(2) DSI score: pre: and post: ()
(3) QOL: pre: and post:
(4) Physical function: pre: and post: ()
After consecutive weaning from mechanical ventilation, a 2 WK of IMT improves pulmonary functions, dyspnoea, functional performance, and QOL in recovered ICU COVID-19 patients. In the COVID-19 treatment program, the IMT should be emphasized, especially with ICU patients
Amini et al. [31]Iran ()COVID-19 patients
Age: years old
Elderly maleMotor training was standing on the support platform, walking between obstacles, striking the ball, and walking on a narrow support surface while holding an object. The cognitive training was a countdown, reverse spelling, and poem reading. The intensity and duration were 1 to 5 h dual-task training programs (motor and cognitive training). Each training S lasted an average of 45 M and included 6 EX in 2 to 3 sets (5–10 repetitions/set). Participants completed a 10-M/S. The EX was 2S/WKRecovered from the COVID-19
4 weeks
A quasiexperimental repeated measure(1) Anxiety and depression(1) GHQ-2Significant improvement in the scores of anxiety (pre: and post: ) and depression (pre: and post: )This study contributes to the existing knowledge about the usefulness of cognitive-motor training in regaining cognitive health in older individuals who have recovered from COVID-19, and it corroborates cognitive-motor training as a feasible therapeutic strategy
Curci et al. [26]Italy ()COVID-19 patients
Age: years old
Reported comorbidities
Male and femaleThe Rb program included passive mobilization, posture changes, clapping and vibration, breathing EX, with diaphragm recruitment and chest-abdomen coordination EX; passive muscle stretching and pumping EX. All patients underwent Rb intervention (30 M/set, 2/D)
Patients completed balancing and coordination EX such as one-legged stance, static heel/toes, and walking for escalating distances at the end of the Rb program
Postacute COVID-19 patients
 D
Real-practice retrospective study(1) Disability status
(2) Dyspnoea in activities of daily living
(3) Physical function
(4) Effort and exertion, breathlessness, and fatigue during physical work
(5) Oxygen saturation
(6) CRP
(1) Barthel Index
(2) Dyspnoea Scale (mMRC)
(3) 6MWT
(4) RPE
(5) SpO2
(6) Serum levels of laboratory markers
Significant improvement in the following:
(1) B1: pre: and post: ()
(2) Dyspnoea: pre: and post: ()
(3) Physical function: pre: and post: ()
(4) Fatigue: pre: and post: ()
(5) Oxygen saturation: pre: and post: ()
(6) Reduced in the levels of CRP: pre: and post: ()
Postacute COVID-19 patients can benefit from the motor and respiratory Rb therapy
Gloeckl et al. [37]Germany ()Mild/moderate and severe/critical COVID-19 patients
Age: 60–71 years old
Male and femalePulmonary Rb which included cycle endurance training for 10–20 M/S at 60–70% of peak work rate 5D/WK, strength training which included leg press, knee extension, and other EX such as back extension and abdominal trainer three sets/EX at an individual intensity 15–20 repetitions. RT for 30 M/S 5D/WK, patient education 2 S/WK, respiratory physiotherapy 2-4 times/WK for 30 M, activities of daily living training 4-5/WK for 30 MA mild to critical COVID-19 patients
3 weeks
Prospective, observational cohort study(1) Physical function
(2) Pulmonary function
(3) QOL
(4) Dyspnoea
(5) Laboratory parameters
(6) Oxygen saturation
(7) Leukocytes
(8) D-dimer
(1) 6MWT
(2) FVC
(3) SF-36
(4) Borg scale
(5)
(6) Handgrip strength kg peak quadriceps strength % pred and five-rep STST
(7) SPO2
Significant improvement in the following:
(1) Physical function: pre: 509 (426–539) and post: 557 (463–633) ()
(2) Pulmonary function: pre: 80.0 (59.2–90.9) and post: 87.7 (67.0–98.9) ()
(3) QOL: no significant difference; in severe COVID-19 patients: pre: 30.2 (22.7–36.8) and post: 34.7 (30.2–41.3) ()
(4) Dyspnoea: pre: 5 (4–6) and post: 5 (3–6) ()
(5) CRP: pre: 2.6 (1.5–5.4) and post: 2.0 (1.3–3.9) ()
(6) Oxygen saturation: pre: 92.0 (87.8–94.2) and post: 93.0 (85.5–94.5) ()
(7) There were no significant improvements in leukocytes: pre: 7.2 (6.0–9.7) and post: 7.0 (6.0–9.7) ()
(8) D-dimer: pre: 726 (367–982) and post: 428 (307–807) ()
Pulmonary Rb is practicable and with a high rate of adherence, safe (no adverse events), and helpful in improving EX performance, lung function, and quality of life in patients with mild/moderate and severe/critical COVID-19
Gobbi et al. [50]Italy ()COVID-19 patients
Age: years old
Male and femaleRb program includes EX for body conditioning such as sit to stand, simple bed EX, limb muscle strengthening (8-12 reps, 1-3 sets with 2 M rest between sets), and AE with cycle and arm ergometer for 45 M/S for 5D/W at moderate intensity (65%VO2M)After discharge from acute COVID-19Observational study(1) Physical function
(2) Laboratory findings
(1) Timed-up and-go
(2) Serum blood
(1) Physical function: pre: and post: ()
Significant reduction in the following:
(2) CRP: pre: and post: ()
(3) Lymphocyte: pre: and post: ()
(4) D-dimer: pre: 1435.8 (1441.9) and post: 776.6 (778.0) ()
In post-SARS-CoV-2 patients, a dietary intervention aerobic and strengthening EX improved functional status, CRP, and D-dimer
Gonzalez-Gerez et al. [38]Spain ()
EX ()
CO ()
Mild to moderate symptomatology in the acute-stage COVID-19 patients
Age: years old
Male and femalePulmonary Rb program, the breathing EX was 1/D for 7 D at home; based on the assessment of the RPE, patients underwent 4 (RPE 7–10) for 10 M), 8 (RPE 5–7) for 20 M), or 12 (RPE <5) reps/EX/D for 30 M)In confined COVID-19 patients in the acute phase
1 week
Randomized, controlled, parallel, double-blind, two-arm(1) Physical function
(2) Peripheral muscle performance of lower limbs
(3) Multidimensional nature of dyspnoea
(4) Physical activity intensity level
(1) 6MWT
(2) Thirty-second STST
(3) Multidimensional dyspnoea-12
(4) RPE
Significant improvement in the following:
(1) Physical function: pre: and post: ()
(2) Peripheral muscle performance of lower limbs: pre: and post: ()
(3) Dyspnoea: pre: and post: ()
(4) Physical activity intensity level: pre: and post: ()
There was no significant difference in the control group ()
Breathing EX by telerehabilitation was a viable method for improving physical condition, dyspnoea, and perceived effort in persons with mild to severe COVID-19 symptoms in the acute phases, suggesting therapeutic benefits, compliance, and a safe approach
Imamura et al. [51]Brazil ()COVID-19 patients
Age:
years old
Male and femaleRb program included stretching, muscle strengthening, mobilization, functional, and RT, including active cycle ergometer 2-3 times/W K using RPE to monitor intensity, activities for the lower limbs; functional electrical stimulation-assisted training; sensory stimulation; orthostatic positioning; balance, gait, and body awareness training; and safety guidance for performing activities of daily living independentlyAfter recovered from COVID-19
 D
Retrospective study(1) Muscle strength
(2) Physical function
(1) Medical Research Council sum score
(2) The short physical performance battery (SPPB)
Significant improvement in the following:
(1) Muscle strength: pre: and post: ()
(2) No significant difference in physical function: pre: and post:
Rb improves patients’ functional status following COVID-19 recovery and should be addressed in postacute COVID-19 patients
Liu et al. [41]China ()
EX ()
CO ()
Patients with mild COVID-19 infections
Age: 28 (40.00%)
Male and femalePulmonary RB, included five-tone breathing EX (five-step breathing EX and two-section motion EX, combining a five-element music therapy). A set of Baduanjin EX for 1 D is 30 M, and a course of treatment lasts for 7 DDuring COVID-19 infections
RCT(1) Anxiety state
(2) QOL
(1) SAI
(2) PQSI
Significant improvement in the following:
(1) SAI: ()
(2) QOL: ()
However, there was no significant difference in the control group ()
Pulmonary Rb had a significant effect on anxiety and sleep disorders in patients with mild COVID-19 infections
Maniscalco et al. [12]Italy ()COVID-19 patients
Age: years old
Reported comorbidities
Male and femaleAll patients performed pulmonary Rb program for 6 S/WK, including physical EX training at moderate to high intensities (strengthening muscles in the upper and lower extremities, treadmill walking and cycling)After discharge
5 Weeks
(1) Pulmonary function
(2) Physical function
(3) Dyspnoea
(4) Fatigue
(5) 6MWT was also performed in accordance with the ATS/ERS guidelines
(6) Dyspnoea and fatigue
(1) Single-breath method
(2) Automated equipment (Vyasis, Milan, Italy, according to American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines)
(3) —
(4) —
(5) —
(6) —
No significant improvements in the following:
(1) Respiratory function: pre: 326.3 mL (95% CI: -130.6–783.3) and post 430.9 mL (95% CI: -20.6–882.5) ()
(2) Physical function: pre: 42.0 m (95% CI: -1.9–85.8) and post: 39.7 m (95% CI: -2.5–81) ()
(3) Dyspnoea score was reduced to 0.4 (95% CI: 0.03–0.8 ()
(4) Reduced fatigue 0.6 (95% CI: 0.1–1.1) ()
The multidisciplinary Rb program is highly beneficial in post-COVID-19 patients, regardless of the underlying cardiorespiratory comorbidity. No adverse events were recorded
Martin et al. [42]Belgium ()
EX ()
CO ()
Severe or critical COVID-19 patients
Age: years old
Male and femaleThe pulmonary Rb was carried out at home 2/WK. Each S comprised 30 M of endurance EX and upper and lower body muscle strengthening. The RPE score was used to determine the intensity of the endurance exercise. The upper and lower body muscular training was done using items found in the participants’ homes (bottles of water and a chair). For each exercise, the participants were told to perform 2–3 series of 8–12 repsPatients hospitalized with COVID-19
6 weeks
Prospective observational study(1) Functional exercise capacity
(2) Dyspnoea
(3) HR and SPO2
(1) STST
(2) Visual analog scale
(3) Finger pulse oximeter
No significant different in the following:
(1) physical function: (15.1; 20.0) ()
(2) Dyspnoea: 0 (0–3), 2 (0–5) ()
(3) SPO2: (90.0; 93.5) ()
Patients in the hospital with COVID-19 had limited functional discharge ability and poor recovery after three months. The feasibility and efficacy of a basic telerehabilitation program have been confirmed, and the functional recovery after three months has significantly improved
Medica, Edizioni Minerva [34]Turkey ()
EX ()
CO ()
Acute respiratory distress syndrome patients with COVID-19
Age: 64–78 years old
Reported comorbidities
Male and femaleRb program includes a passive range of motion EX being carried out. Each joint in the extremities was moved passively for 10-15 reps, for a total of 15 M/D, for 6 D/WKDuring hospitalization
Admission median 1-14 D
Observational study(1) Muscle strength
(2) HRQOL
(3) Laboratory findings
(1) Medical Research Council (MRC) Scale
(2) SF-36
(3) Serum blood
No significant different in the following:
(1) Muscle strength: 58 (50–60), 48–60 ()
(2) QOL: 90 (38–100) ()
(3) CRP: 280 (146–331), 68–412 ()
(4) IL 6: 138 (71–2593), 28–20 276 ()
(5) Lymphocyte: 0.40 (0.20–0.53), 0.00–0.90 ()
(6) IL6: 138 (71–2593), 28–20,276 ()
(7) D-dimer: 8515 (2735–10,108), 1420–13,666 ()
(8) Ferritin: 280 (146–331), 68–412 ()
The findings did not support the idea that early intensive care unit Rb improves muscular strength. More individuals in the rehab group with pulmonary and neurologic disorders may reduce the effect of Rb on outcomes. These comorbidities, on the other hand, highlight the need for Rb. When appropriate measures are followed, it is safe for both patients and healthcare professionals
Piquet et al. [43]France ()COVID-19 patients with 49% had hypertension, 29% had diabetes, and 26% had more than 50% pulmonary damage on computed tomographic scans
Age: years old
Male and female2 S/D was given for each patient as part of the Rb program but was short (<20 M). The program consisted of body weight EX (sit-to-stand, tiptoe stands, squats), elastics, and weights, with each EX consisting of 3 series of 10 reps. Respiratory Rb was associated with controlled diaphragmatic breathing. AE comprised submaximal intensity cycling ergometer sessionsPatients hospitalized with COVID-19
Retrospective chart review(1) Activities of daily living
(2) Physical function
(3) Muscle strength
(1) Barthel activities of daily living index
(2) —
(3) Dynamometry
Significant improvement in the following:
(1) QOL: pre: and post: ()
(2) Physical function: pre: and post: ()
(3) Muscle strength: pre: and post: ()
Inpatient Rb for COVID-19 patients was linked with significant motor, respiratory, and functional improvement, particularly in severe instances, but modest chronic autonomy loss persisted after discharge. COVID-19, mainly a respiratory illness, may progress to a motor disability as time in critical care increases
Puchner et al. [13]Austria ()COVID-19 patients
Age: years old
Reported comorbidities
MaleBreathing therapy, individual respiratory muscle training, mobilization and breathing perception therapy, endurance and strength training, speech therapy and swallow evaluation, occupational therapy, neuropsychological therapy, nutritional counselling, and passive therapy session (massages) training were conducted in S of 25 to 50 MCOVID-19 survivors
3 weeks
Observational cohort study.(1) Pulmonary function
(2) Physical function
(1) FVC
(2) 6MWT
Significant improvements
(1) Pulmonary function: pre: and post: ()
(2) Physical function: pre: and post: ()
Individuals discharged from the hospital after a severe COVID-19 infection often have persistent physical and cognitive dysfunctions. Multidisciplinary inpatient Rb is significantly effective for these individuals
Rodriguez-Blanco et al. [44]Spain ()
EX ()
CO ()
COVID-19 patients with mild to moderate symptomatology
Age: years old
Telerehabilitation program with nonspecific conditioning EX included 10 EX based on nonspecific toning EX of resistance and strength, 1 S/D for 7 D, depending on RPE, at home. Patients completed 4 (RPE 7_10), 8 (RPE 5_7), or 12 (RPE 15) reps/EX/D for 10, 20, and 30 M, respectively. Patients also received a text message every DConfined patients affected by COVID-19 in the acute phase
1 week
A randomized, controlled, parallel, double-blind, two-arm clinical trial(1) Physical function
(2) Peripheral muscle performance of lower limbs
(3) Physical activity intensity level
(1) 6MWT
(2) 30STST
(3) RPE
Significant improvements in the following:
(1) Physical function: pre: and post: ()
(2) Peripheral muscle performance of lower limbs: pre: and post: ()
(3) Physical activity intensity level: pre: and post: ()
However, there was no significant difference in the control group ()
90% adherence was found in the program
In COVID-19 patients with mild to moderate symptoms in the acute stage, a 1 WK telerehabilitation program based on respiratory EX is effective, safe, and practical
Stavrou et al. [22]Greece ()COVID-19 survivor, being smokers (10%) and with COPD (10%), hypertension (65%), diabetes mellitus (20%), and CVD (10)
Age: years old
Male and femaleUnsupervised pulmonary Rb program; each patient participated in 3 S/WK. Each training S lasted about 100 M. Each training S comprised (i) flexibility and mobility EX warm-up and 5 M, (ii) recover set (5 M), (iii) the AE set with walking (50 M), (iv) the set with yoga EX for breathing and/or proprioception (20 M), and (v) the set with multijoint strength M (20 M). The patients in the AE set walked on a level, hard surface, and every 5 M patients measured their HR and SPO2After recovery
8 weeks
(1) Pulmonary function
(2) QOL
(3) Physical function
(4) Peripheral muscle performance of lower limbs
(5) Oxygen saturation
(6) Dyspnoea
(1) FVC
(2) PSQI
(3) 6MWT
(4) 30 STST
(5) Nonin 9590 Onyx Vantage, USA
(6) Borg Scale CR10
No significant Improvement in the following:
(1) Pulmonary function: pre: and post: ()
(2) Significant improvements in QOL: pre: and post: ()
(2) Physical function: pre: and post: ()
(3) Peripheral muscle performance of lower limbs: pre: and post: ()
(4) Oxygen saturation: pre: and post: ()
(5) Dyspnoea: pre: and post: ()
The research results recommend using unsupervised pulmonary Rb programs in patients who have recovered from COVID-19, to improve several aspects of long-term COVID-19 syndrome
Tang et al. [32]China ()Mild/moderate severe/critical COVID-19 patients
years old
Male and femaleLiuzijue EX routine was 1/D for 20 MAfter discharge survivor over 4 WKMulticentre prospective self-controlled s(1) Pulmonary function
(2) Physical function
(3) QOL
(1) POWERbreathe inspiratory muscle assessment system (POWERbreathe International Ltd., UK)
(2) 6MWT
(3) SF36
Significant improvements in the following:
(1) Pulmonary function: post: ()
(2) Physical function: post: ()
(3) QOL:
Liuzijue EX is a safe and effective home exercise program that improves functional capacity and quality of life in COVID-19 patients who were discharged. These results also demonstrated the need for Rb for COVID-19 individuals who have been cured
Xiao et al. [33]China ()
EX ()
CO ()
COVID-19 patients
years old
Male and femalePatients were given progressive muscular relaxation training in bed for 30 M before waking up and 30 M before going to bed. The following information was provided: to begin, exert muscular tension and focus on the sensation of tension; attempt to maintain this sensation of tension for 3 to 5 seconds, then relax for 10 to 15 seconds. Following that, the patient should feel a sense of muscular relaxation. Patients were then taught how to relax in the following order: foot, leg, hip and waist, chest, arm, shoulder, and face training. Each S lasted 15 M for 1 WKDuring isolation treatment
1 WK
A clinical observational study(1) Anxiety status of patients
(2) Depression status
(3) QOL
(1) GAD-7
(2) PHQ-9
(3) PSQI
Significant difference in the following:
(1) Anxiety: pre: and post: ()
(2) Depression: pre: and post: ()
(3) QOL: pre: and post: ()
In isolation therapy, progressive muscle relaxation training in COVID-19 patients can significantly decrease anxiety and sadness and enhance sleep quality. Advanced muscle relaxation training has been proven to improve patient care and is worthy of clinical support
Zhu et al. [49]China ()
EX ()
CO ()
Patients with COVID-19
years old
Male and femalePulmonary Rb includes the following EX: (1) allowing patients to maintain regular mobility in the isolation ward, such as chest expansion and ambulation, for at least 1 hour/D; (2) providing respiratory control training; (3) purse-lip breathing: allow the patients to breathe deeply through their nose, hold their breath for 2 seconds, and then breathe deeply from their abdomen for 3–5 seconds with their mouth pursed as if whistling; the patients were taught for 10–15 M each and 4 times/DDuring hospitalization between February 1, 2020, to March 31, 2020A prospective observational study(1) Physical function
(2) Pulmonary function
(3) Laboratory findings
(1) 6MWT
(2) Spirometry
(3) Serum blood
(1) Physical function: pre: , post (one week of intervention): ()
(2) Pulmonary function: pre: , post (one week of intervention): and after (24 W of interventions): ()
(3) CRP: ()
(4) D-dimer: pre: ()
(5) White blood cell: ()
(6) Lymphocyte: ()
Pulmonary Rb may accelerate the improvement of pulmonary function in COVID-19 patients
Hermann et al. [21]Switzerland ()Reported comorbidities; 66 years oldMale and femaleThe patients underwent a multimodal 2 to 4 WK inpatient cardiopulmonary Rb. This program was for 25–30 therapy S, for 5–6 D/WK, including AE and strength training. The intensity for AE was determined by a 6 MW. Strength training was done 3 times for a total of 20 repsAfter severe COVID-19
2 to 4 WK
A mean duration of 20 D
(1) Physical function
(2) Oxygen saturation
(1) 6MWT
(2) SPO2
No significant improvement in the following:
(1) Physical function: ()
(2) Oxygen saturation: ()
Following COVID-19, complete cardiopulmonary Rb is safe, practical, and successful. Physical performance and subjective health condition improved independently of previous ventilation
Sun et al. [46]China ()Patients with COVID-19
years old
Male and femalePulmonary Rb EX included (I) breathing exercises, (II) respiratory muscle training, (III) stretching training, and (IV) psychotherapy. Patients can perform pulmonary Rb (2 S/D for 3 WK) in the isolationInpatients confirmed COVID-19.
3 weeks
A self-pre- and postcontrol prospective clinical trial(1) Dyspnoea
(2) CRP
(3) QOL
(4) Laboratory findings
(1) Modified Medical Research Council (mMRC) dyspnoea scale
(2) —
(3) Using activity of daily living score
(4) Serum blood
Significant improvements in the following:
(1) CRP ()
(2) Dyspnoea ()
(3) QOL ()
(4) Lymphocyte: pre: and post: ()
In severe COVID-19 patients, PR can relieve symptoms, improve health-related quality of life, improve respiratory muscle function, and reduce disease-related anxiety and stress. PR should be given throughout the primary health management process, whether the patient is in the hospital or at home
Mohamed and Alawna [30]Turkey ()
EX ()
CO ()
Mild or moderate COVID-19 patients
years old
Male and femaleModerate-intensity AE for 40/S, 3/S/WK for 30 M, including treadmill walking/running or stationary bicycle riding. A 5 M warm-up slow walking or biking is followed by a 5 M cooldown EX (walking/running or bicycling) for each S. The EX intensity was 60-75% of the maximal HR estimated (—age). The exercise intensity was controlled using the RPE scaleCOVID-19 patients during home quarantine
2 weeks
Observational study(1) IL6 and TNF-α
(2) Leucocytes and lymphocyte
(1) ELISA commercial kits assay (R&D Systems, Minneapolis, USA)
(2) Lymphocytes and leukocytes from total-blood samples utilizing a multichannel hemocyte analysis system (SE-9000; Sysmex Corp, Hyogo, Japan)
Significant improvements in the following:
(1) IL-6: pre: ()
(2) TNF-α: pre: and post: ()
(3) Leucocytes: pre: and post: ()
(4) Lymphocytes: pre: and post: ()
2 WK of moderate-intensity AE reduced the severity and progress of COVID-19-related diseases, improved quality of life, and improved immunological function by elevating leucocytes, lymphocytes, and immunoglobulin A levels