Exercising During the Pandemic Presentation by Dr Goh Ping Ping Cardiologist, Echocardiologist Clinical Exercise Specialist Asian Heart & Vascular Centre www.ahvc.com.sg

1. Exercising During the
Pandemic
Dr Goh Ping Ping
Asian Heart & Vascular Centre

2. Benefits of Exercise
Regular physical activity in the correct intensity:
• Reduces risk of heart disease by 40%
• Lowers risk of stroke by 20%
• Reduces incidence of diabetes by almost 50%
• Reduces incidence of hypertension by almost 50%
• Can reduce risk and recurrence of breast cancer by almost 50%
• Can reduce risk of colon cancer by almost 60%
• Can reduce risk of developing Alzheimer’s disease by one third
• Can decrease risk of depression as effective as Prozac or behavioural therapy
“ Tremendous health benefits are seen with even low levels of exercise;
Amount of exercise needed to benefit health is much lower than amount needed for fitness ”

3. Another Earlier Pandemic
Physical Inactivity is the fourth leading cause of death worldwide
Evidence of health benefit of physical activity available since 1950s
Efforts to promote PA to improve population health has lagged behind
(Ref: Kohl HW et al. The Pandemic of Physical Inactivity: global action for public health
Lancet. 2012;380(9838):294–305)
Ref:
The Global Obesity Pandemic: shaped by global drivers and local
environments
Prof Boyd A Swinburn, WHO Collaborating Centre for Obesity
Prevention. The Lancet. August 27, 2011

4. Benefits of Exercise Hold True Even During Pandemic
• Individuals, especially those at higher risk of COVID
complications, should exercise at home or outdoors
while remaining socially distanced
• Those choosing to exercise inside a fitness facility
should follow appropriate safety guidelines
• Moderate-intensity physical exercise is a/w better
immune function
-- Exercise Is Medicine
American College of
Sports Medicine
Greatest risk for severe COVID complications:
• older adults (>=age 65)
• people with chronic diseases (e.g. diabetes,
heart disease and lung disease)
• compromised immune systems (e.g. going
through cancer treatment or with HIV)

5. Adverse Prognostic Factors in COVID-19 Patients
(Literature review of 51 articles on physical exercise and
COVID-19 in PUBMed, April –June 2020)
increased risk of hospitalization and mortality in COVID-19 patients
• overweight/obesity
• diabetes mellitus and insulin resistance
• arterial hypertension and its comorbidities
• coronary heart and cerebrovascular disease
• sedentary behaviour, poor dietary habits, and physical inactivity
(characterized by chronic and high inflammation, leading to more
serious forms of COVID)

6. Exercise has benefits in immunity
• moderate levels of physical exercise has positive effects on many immune markers and
could provide an immuno-protective effect
• High cardiorespiratory fitness boost Immunity and attenuate the proinflammatory state
induced by COVID-19
• ? reduce severity of cytokine storm
• Animal studies – exercise reduces lung damage caused by COVID binding to ACE2 receptors.
marked increases in potent anti-inflammatory cytokines such as
IL-10, IL-1 receptor antagonist, IL-6 (“myokine”) and IL-37
Downregulation of the expression/activation of proinflammatory
TLRs (Toll-like receptors)
8
8
8
.
Obesity (2020) 28, 1378-1381

7. Physical Activity a/w Better Outcome in Severe COVID Infection
• 48,440 adults from Kaiser Permanente Southern California
• Diagnosed COVID in 2020
• Consistently meeting physical activity guidelines vs consistently inactive
• Inactive group had a greater risk of hospitalisation (OR 2.26;95% CI 1.81 to 2.83),
admission to the ICU (OR 1.73; 95% CI 1.18 to 2.55) and death (OR 2.49; 95% CI
1.33 to 4.67) due to COVID-19
• Similar benefit in patients who were doing some physical activities vs inactive
Sallis R, et al. Br J Sports Med 2021;55:1099–1105

8. 3 categories of PA based on The Physical
Activity Guidelines for Americans
consistently meeting
guidelines
EVS >150 min/week at all assessments
during the study period
consistently inactive
EVS 0–10 min/week at all assessments
some activity
EVS 11–149 min/week or those
with variability in EVS measures.
EVS = Exercise Vital Sign
days per week and number of minutes per day engaged in moderate to strenuous exercise
Ref: The Physical Activity Guidelines for Americans (JAMA 2018;320:2020-8)
Highest risk of Hospitalisation
ICU admission
Death

9. Physical Activity a/w Better Outcome in Severe COVID Infection
(Kaiser Permanente Study)
Conclusions:
1. Consistently meeting physical activity guidelines was strongly associated with a
reduced risk for severe COVID-19 outcomes among infected adults
2. Recommend efforts to promote physical activity be prioritised by public health
agencies and incorporated into routine medical care.
Sallis R, et al. Br J Sports Med 2021;55:1099–1105

10. Vigorous exercise may suppress immune system?
• High exercise training workload, competitive events linked to physiological,
metabolic and psychological stress
• Early exercise immunology studies reported that heavy exertion was a/w
elevated inflammatory markers and upper respiratory infections.
• preliminary data suggest that transient immune dysfunction from exercise-
induced suppression of metabolic function of immune cell (may be countered
by increased intake of carbohydrate and polyphenols.)
• Moderate and vigorous exercise bouts of < 60 minutes a/w enhanced
immunosurveillance
Journal of Sport & Health Science 8 (2019) 201-207

11. Vigorous exercise may suppress immune system?
Journal of Sport & Health Science 8 (2019) 201-207
Comparison of magnitude of immune responses between
30- to 45-min walking bout and 42.2-km marathon race
J curve relationship between exercise and URTI

12. How Much To Exercise During the Pandemic?
• 150-300 minutes per week
• Cardio/aerobic physical activity:
• moderate-intensity exercise 5 times a week
• High-intensity exercise 3 times a week
• 2 sessions per week of muscle strength training (5-20 min/session)
– upper body/lower body/core

13. Moderate Intensity Physical Exercise
Indoor Activities
• Put some music on and walk briskly
around the house or up and down
the stairs for 10- 15 minutes, 2-3
times per day
• Dance to your favourite music
• Jump rope
• Exercise video
• Home cardio machines
Outdoor Activities
• Walk or jog around your neighbourhood
with safe distancing
• Spending time in nature
• Bicycle ride
• Gardening and lawn work
• racket games, golf
6
665555555

14. Moderate Intensity Physical Exercise
Peak Heart Rate
= 220 minus age
Resting Heart Rate
6
665555555
.
220
-50
170
Heart Rate Reserve
= Peak - Resting
Target Heart Rate
= 50-70% of HRR
Add back to Resting
HR
170
-60
110
110
X 0.6
66
60
+ 66
126

15. Negative Impact of COVID on Exercise –
A Vicious Cycle?
Boston Marathon postponed for first time in history in 2020,
returned in early October 20210000
postponed
grounded

16. Reduced Level of Physical Activity during COVID-19 Pandemic is a/w
Depression and Anxiety Levels
(Puccinelli et al. BMC Public Health (2021) 21:425)
• Internet survey of 2140 Brazilians, both gender, mean age 38.6 yrs
• March to June 2020, Brazilian government adopted emergency measures nationwide, including closure of
schools and universities, parks, commercial activities and non-essential services
Results:
• reduction of physical activity level (IPAQ) due to social distancing compared to pre-pandemic
• 30% of participants exhibit moderate to severe symptoms of depression (PHQ-9), 23% moderate to severe
symptoms of anxiety (GAD-7) compared to pre-pandemic prevalence of 5-10%
• More symptoms of depression and anxiety is a/w reduction in physical activity, greater adherence to social
distancing measures, lower income and younger age (? Greater exposure to social media)

17. How Did Pandemic Affect Exercise?
Generally decrease in Physical Exercise
• Work from home
• Gym closure
• Safe distancing
• Mask wearing
More physically and mentally vulnerable
Negative impact on fighting infection

18. Perception and Behaviour of “Fitness Freaks” during Lockdown in COVID-19 Pandemic
(Harleen Kaur et al. Frontiers in Psychology. October 2020, vol 11)
22 subjects, mostly male, mean age 26, frequent gym goers
• Initial negative situational perception and lack of motivation for fitness exercise
• psychological health concerns and overdependence on social media in spending free time
• Followed by gradual increase in positive self-perception and motivation to overcome dependence on gym and
fitness equipment and to continue fitness exercises at home
• Common activities - yoga and meditation, high-intensity workout, lifting heavy buckets/ big water bottles, and
skipping
• listening to music and social media help adherence to home workout.
• regular home workout during lockdown greatly helped to overcome psychological issues and fitness concerns

19. Sedentary behaviour is an independent risk factor
• any waking behaviour characterized by an energy expenditure ≤ 1.5 METs,
while in a sitting, reclining or lying posture
• “screen time” (TV viewing, videogame playing, computer use), car-driving,
and reading

20. Sedentary Behaviour is a/w Adverse Outcomes
• meta-analysis of 34 studies (up to 2016)
• 1,331,468 community-dwelling participants
• total sitting time > 6 - 8 h/day ; TV viewing
time > 3–4 h/day were associated with
increased risk of all-cause death and CV
death in PA adjusted analyses
Patterson R et al. Sedentary behaviour and risk of all-cause,
cardiovascular and cancer mortality, and incident type 2 diabetes:
a systematic review and dose response meta-analysis.
Eur J Epidemiol. (2018) 33:811–29

21. If you are homebound (QO) or need to sit for long period (WFH)
• Get up and walk around the house or do some active chore
• 5 minutes after every hour of sitting
• During every commercial break if watching TV
• Build a Home-based Physical Activity Routine
Need to increase Physical Activity, but also decrease Sedentary Behaviour!

22. Setting up a Home Based Routine (I)
Strengthening Activity
• squats, single-leg balancing, push-ups, sit-ups and side planks
• Can be done using own body weight
• Equipment: barbells, ankle weights and exercise bands
Conditioning Activity
• Calisthenics, such as jumping jacks, jogging in place
• Dancing to fast music
• stationary exercise bike
• YouTube exercise videos

23. Setting up a Home Based Routine (II)
Flexibility Activity
• Daily stretching exercise
• 2-3 times a week after aerobic/strength
exercises
Sport-specific exercise
• skills used in running track, soccer, basketball and other sports
√
x

24. Home-based exercises recommended by WHO
Knee to elbow
• 1-2 minutes, rest 30-60 sec, repeat up
to 5 times
Plank
• Hold at least 20-30 sec, rest 30-60 sec,
repeat up to 5 times

25. Home-based exercises recommended by WHO
Back extension
• 10-15 times or more, rest 30-60 sec,
repeat up to 5 times
Squats
• 10-15 times or more, rest 30-60 sec,
repeat up to 5 times

26. Home-based exercises recommended by WHO
Side knee lifts.
• 1-2 min, rest 30-60 sec, repeat up to 5
times
Superman
• 20-30 times or more, rest 30-60 sec,
repeat up to 5 times

27. Home-based exercises recommended by WHO
Bridge
• 10-15 times, rest 30-60 sec, repeat up
to 5 times
Chair dips
• 10-15 times or more, rest 30-60 sec,
repeat up to 5 times

28. Home-based exercises recommended by WHO
Chest opener
• hold 20-30 sec
• Stretches chest and shoulder
Seated meditation
• Straight back, close eyes, relax body
• Concentrate on breathing and progressively deepen breathing
• 5 minutes
Legs up the wall
• Concentrate on breathing and progressively deepen breathing
• 5 minutes
• Relax, destressing

29. Post-Pandemic: Easing Back into Exercise Safely
• Avoid .rapid change in activity level
• Ensure regular work on flexibility, strength and conditioning at home before
jumping back into a sport
• Introduce outdoor activities such as jogging or biking to prepare for more
intensive sports activity
• Ease in: start slowly and work up to the prepandemic level
• Apply the “10 percent rule” to avoid overuse/excessive stress on bone, muscle or
joint e.g. if someone is running 10 km per week, increase the distance to 11 km
the following week
• Listen to your body: any type of pain is a sign to take a break

30. Returning to the Gym after Lockdown
There is likely a difference from pre-COVID fitness level
1. less is more: be prepared to take 1-2 days break in between
2. start slow, focus on movement quality over quantity, address muscle imbalances
Able to engage your core and maintain a neutral spine when performing a plank?
Able to keep your hip, knee, and ankle aligned when balancing on one leg?
Able to get your thighs parallel to the ground when doing a squat?
Able to bring your arms overhead without arching through your lower back?
3. Plan ahead – strength/ conditioning/ flexibility
4. Seek help from fitness professional

31. General advice for patients about exercising outdoors
• Avoid crowded area
• Keep 2 m from others, assume everyone is potentially infectious
• Solo exercising is preferred
• Avoid making conversation during exercise
• Do not travel for exercise – start from your front door
• At-risk group, exercise inside or in own compound
• Limit hand-to-face contact
• When outdoors, minimise touching common surfaces e.g. left hand to press crossing button, right
hand to hold towel/water bottle/ adjust glasses etc, wash hands thoroughly when reach home
• Do not take risk, avoid busy road and risky form of exercise

32. Does wearing face mask affect exercise performance
• Randomised trial to study effect of cloth mask, surgical mask and no mask during
bicycle ergometry
• 7 men and 7 women, young healthy subjects
• No difference in time to exhaustion, peak power, blood oxygen saturation, tissue
oxygenation index, perceived exertion, heart rate during exercise
• Conclusion - wearing a face mask during vigorous exercise had no discernable
detrimental effect on blood or muscle oxygenation, and exercise performance in
young, healthy participants
Shaw et al. Int. J. Environ. Res. Public Health 2020, 17, 8110

33. Take Home Points
• Encourage your patients to exercise
• Exercise benefits health even without achieving high fitness level
• Moderate-intensity physical exercise is a/w better immune function

34. Exercising During the
Pandemic
Dr Goh Ping Ping
Asian Heart & Vascular Centre