Aerobic Versus Anaerobic Exercise on Immune Functions and Disease Severity in Patients With COVID-19

Evaluative procedures There were two main dependent variables including blood immune
markers and severity of respiratory symptoms. These measurements were collected at the
baseline after one week and 24 h after the end of the exercise program (two weeks).

A lab technician was asked to visit the patient at home (quarantine). The lab technician
wore special protective equipment recommended by WHO. Two visits were performed, one at
the beginning of the research procedures, and the last visit at the 24 hours after the
end of the exercise program (two weeks). The technician collected blood and saliva
samples to be analyzed.

Blood sample collection Blood samples were taken in the morning (8:30-9:30). 10mL of
venous blood was collected. Participants were asked to stop any exercise for at least 24
hours before blood sampling. Also, participants were asked to stop eating any food or
liquid from 22:00 the prior day of measurement. Samples were collected in vacutainer
tubes with sodium ethylenediaminetetraacetic acid (EDTA) for plasma separation. The blood
was centrifuged at 3,000 rpm for 15 min at 4◦C. The investigators measured total
lymphocytes, leukocytes, and monocytes from total-blood samples utilizing a multichannel
hemocyte analysis system (SE-9000; Sysmex Corp, Hyogo, Japan). The concentrations of
IL-6, IL-10, and TNF-α were analyzed by using ELISA commercial kits assay (R&D Systems,
Minneapolis, USA) following the manufacturer's instructions for analysis on an EZ-Reader
microplate reader at 450 nm. The samples were stored at -20◦C for further analysis.

Saliva sample collection A saliva sample was collected to measure the salivary IgA-S
concentration. The saliva sample was taken without any saliva stimulation methods, the
participant was asked to rinse their mouths with distilled water and to evacuate their
mouth just before collection. The investigators used the passive drainage method for the
collection, in which the participant slightly flexed their head forward to allow the
saliva to move into a sterilized and pre-weighed Falcon tube for 5min. The weight of
tubes were measured again following collection, to estimate the volume and the saliva
flow rate. The tubes were weighed with 0.1mg accuracy with proposed saliva density as 1.0
g.mL-1. The samples were stored at -80◦C for further analysis. The S-IgA concentration
were analyzed utilizing commercial ELISA kits (IgA Salivary, DRG, Minneapolis, USA). The
IgA-S secretion rate (ng/min) was measured by multiplying the whole concentration of
IgA-S present in the mucosal surface per unit of time by the saliva flow rate (mL/min).

Wisconsin Upper Respiratory Symptom Survey the Wisconsin Upper Respiratory Symptom Survey
(WURSS) is an empirically derived patient-oriented illness-specific quality-of-life
evaluative outcomes instrument. The development process of this survey was described in
detail by Barrett et al. WURSS-24 is designed to evaluate the negative effect of acute
upper respiratory infection, presumed viral (the common cold). It is a valid and reliable
measurement tool to evaluate the measure items and domains that change over time
including influenza-like illness symptoms of headache, body aches, and fever. The
participants were asked to fill the survey before starting the study and the 2
times/week.

Treatment Procedures Participants were assigned randomly into two groups, exercise and
control groups. All participants in both groups followed the WHO guidelines of quarantine
and used standardized medications given by the physician according to the Turkish
Ministry of Health, including the Hydroxyclorocin Sulphate 200 Mg Film Tablet (Plaquenil
200 Mg Film Tablet). The dose was 2 times/ day, 200Mg/time, for 5 days Besides, the
exercise group performed a moderate-intensity aerobic exercises for 40 min/ 3
sessions/week, 40 minute/session.

Participants in the aerobic exercise group performed a two weeks aerobic exercise
program. The exercise program consisted of walking/running on a treadmill or bicycling on
a stationary bicycle. Each session is composed of five-minute warm-up slow walking or
bicycling. Then the main intervention which composed of thirty-minutes of
moderate-intensity aerobic exercises (walking/running or bicycling). Lastly, a
five-minute of cool-down exercise (walking/running or bicycling). The exercise intensity
was 60-75% of the predicted MHR (calculated as MHR=210-age).

The resistance exercises program consists of 3 sessions/week, 60 min/session for 2 weeks.
The two-way body part split protocol was used during the resistance exercises (legs, back
and biceps on one day; chest, shoulders and triceps on a separate day) alternatively.
During each session group of 5 exercises have been performed using both multi-joint and
single joint exercises. A 5 - 10 min of warm up exercises have been before the beginning
of each session, warm up exercises consist of moderate speed walking and stretching
exercises. Three set of exercises have been performed with 1 - 2 min rest between sets.
During the first week the resistance exercises intensity has been adjusted to be eight
repetitions for each exercise at 70% of 1RM, During the second week, the intensity was
increased to 80% of 1 RM.

The Borg Rating of Perceived Exertion (RPE) scale was used to control the exercise
intensity. PRE is a reliable and validated scale to allow individuals to monitor and
guide the exercise intensity by rating their level of exertion during exercise. After
explaining the scale in detail for the patients, investigators asked them to keep the
exertion rating level between 12 to 14 (light - somewhat hard) on the Borg Scale, which
suggests that the patient is exercising on a moderate exercise level. The exercise was
stopped if the patients experienced any of the following signs and symptoms: chest pain,
shortness of breath, fainting, claudication, fatigue, ataxia, dizziness, cyanosis, or
pallor.