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.