key: cord-0839778-c7bsmllc authors: Amaral, V. T. d.; Viana, A. A.; Heubel, A. D.; Linares, S. N.; Martinelli, B.; Witzler, P. H. C.; Oliveira, G. Y. O. d.; Zanini, G. d. S.; Silva, A. B.; Mendes, R. G.; Ciolac, E. G. title: Cardiovascular, respiratory and functional effects of tele-supervised home-based exercise training in individuals recovering from COVID-19 hospitalization: A randomized clinical trial date: 2022-01-28 journal: nan DOI: 10.1101/2022.01.24.22269745 sha: d056afdfe53575110abaa7ba4d274582853361f5 doc_id: 839778 cord_uid: c7bsmllc Our aim was to test the hypothesis that tele-supervised home-based exercise training (exercise) is an effective strategy for improving cardiovascular, respiratory, and functional capacity parameters in individuals that were hospitalized due to coronavirus disease 2019 (COVID-19). Thirty-two individuals (52 {+/-} 10 years; 17F) randomly assigned to exercise (N = 12) and control groups (N = 20), had their anthropometric (weight, body mass index), hemodynamic (brachial and central blood pressure), vascular (arterial stiffness), ventilatory (pulmonary function and respiratory muscle strength), and functional parameters (handgrip strength, five-time sit to stand [FTSTS], timed up and go test [TUG] and six-minute walking test [6MWT]) assessed at baseline (30 to 45 days of hospital discharged) and after 12 weeks of follow-up. Both groups similarly increased (P < 0.001) forced vital capacity (absolute and % of predicted), forced expiratory volume in the first second (absolute and % of predicted), and handgrip strength during follow-up. However, only exercise group reduced carotido-femoral pulse wave velocity (-2.0 {+/-} 0.6 m/s, P = 0.048), and increased (P < 0.05) resting oxygen saturation (1.9 {+/-} 0.6 %), mean inspiratory pressure (24.7 {+/-} 7.1 cmH2O), mean expiratory pressure (20.3 {+/-} 5.8 cmH2O) and % of predicted mean expiratory pressure (14 {+/-} 22 %) during follow-up. No significant changes were found in any other variable during follow-up. Present findings suggest that tele-supervised home-based exercise training can a potential adjunct therapeutic to rehabilitate individuals that were hospitalized due to COVID-19 The pandemic of coronavirus disease 2019 (COVID- 19) is an unprecedented public health emergency, with the exponential increase of cases overloading the health systems worldwide 1 . Although most COVID-19 cases are mild or even asymptomatic, nearly 20% of patients require hospitalization due to severe manifestations 2 . The long-term effects of COVID-19 on respiratory, cardiovascular and functional systems is not completely known. However, even under adequate medical treatment, the pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may cause an injury to the lung parenchyma, with permanent structural damage 3 . Studies have also shown a direct relationship between COVID-19 and poor cardiovascular outcomes, such as increased arterial stiffness and association between overweight and endothelial dysfunction 4, 5 . Initial investigations showed that SARS-CoV-2 is able to infect the endothelial cells, which are responsible for regulating vascular tone 6 harming the vascular function of these individuals 7 . To avoid further damage in the long term, interventions aiming to rehabilitate and/or promote the health of COVID-19 patients after hospital discharge are welcome. Exercise training is a wellknown first-line intervention for preventing and treating different diseases 8, 9 . Tele-supervised homebased exercise programs have been recommended for promoting health and rehabilitation in different conditions during COVID-19 pandemic 10 , and may also be a suitable strategy for rehabilitating COVID-19 patients 10 . However, randomized clinical trials investigating the benefits of telesupervised home-based exercise training in individuals that were hospitalized due to COVID-19 are still lacking. Thus, our aim was to test the hypothesis that tele-supervised home-based exercise training is an effective strategy for improving cardiovascular, respiratory, and functional capacity parameters in individuals that were hospitalized due to COVID-19. . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint 4 This is a randomized, single center and single-blinded clinical trial (Brazilian Register of Clinical Trials identifier: RBR-9y32yy) that analyzed the effect of a 12-week tele-supervised homebased exercise training on anthropometric, respiratory, cardiovascular and functional parameters in individuals hospitalized due COVID-19. We investigated patients of both sex that were hospitalized at the Bauru State Hospital (São Paulo, Brazil), with age ≥ 18 years, and with laboratory-confirmed COVID-19 diagnosis detected by reverse transcriptase-polymerase chain reaction (RT-PCR) test. Pregnant or lactating women, individuals with contraindications for physical activity (i.e., recent myocardial infarction, unstable angina or arrhythmias or other uncontrolled heart disease), and individuals with decompensated metabolic, pulmonary, hepatic or renal diseases were not included. All volunteers who met inclusion criteria were randomly assigned to perform a 12-week telesupervised home-based exercise training (exercise) or control follow. Sixty-three individuals who had been hospitalized (in ward setting) due COVID-19 from July 2020 to February 2021, accepted to participate in the study. Two individuals were not included due to decompensated comorbidities. Six-one individuals were then randomly assigned to exercise (N = is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint All individuals were invited, by telephone call, to attend Exercise Chronic Disease Laboratory (ECDR) at UNESP/Bauru (SP) to perform both baseline (30 to 45 days after hospital discharge) baseline and follow-up clinical assessments. All measurements were performed in a controlled room temperature (20-22ºC) by the same and experienced evaluator, who was blinded to participant's group assignment. Clinical assessment included anamnesis (to obtain demographic and health characteristics, persistent symptoms and medications used), body mass and height (Ramuza™ anthropometric scale; Ramuza Indústria e Comércio de Balanças Ltda., Santana do Parnaíba-SP, Brazil), and vital signs, respectively. Current smokers were defined as patients who were smoking at the time of study or had stopped smoking during the last month prior its beginning. BMI was calculated using the formula body mass/height² (kg/m²) 13 . Vital signs measurements were performed at seated position, after 10 min of rest, and included pulse oxygen saturation (SpO2) (G-Tech™ Led finger oximeter; Accumed Produtos Médico Hospitalares Ltda., Duque de Caxias-RJ, Brazil), respiratory rate, BP (Omron HEM 7200™, Omron Healthcare Inc., Dalian, China) and HR (Polar™ H10 heart rate sensor; Polar Electro Inc, Kempele, Finland). SpO2 and respiratory were measured once, and BP and HR were measured in triplicated (the average was considered the resting BP and HR), as previously described 14 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint transit time), augmentation index (AIx, ratio of augmentation pressure expressed as the difference between the second and first pressure peaks in the pulse wave) and central pressure (assessed directly from the carotid pressure waveform, using mean and diastolic pressures to calibrate the carotid signal) were automatically calculated 15 . Pressure waveforms were measured during 10 to 15 cardiac cycles, and the mean was used for the final analysis 15 . All measurements were performed by an experienced observer that was blinded to participants' group assignment. The pulmonary function testing (spirometry) was performed without bronchodilator, using a calibrated and validated portable spirometer (SpiroPro®, Jaeger, Höchberg, Germany), and with participants seated at rest. Forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak expiratory flow were obtained by asking the individual for inspiration until total lung capacity and a quick and intense expiration for at least 6 seconds. At least three trials were performed and the largest values of FVC and FEV1 were determined. All maneuvers were checked for acceptability and reproducibility criteria 16 . FVC and FEV1 were adjusted to predicted values (FVC % pred and FEV1 % pred) according to the Brazilian Guidelines for Pulmonary Function Testing 17 . Respiratory muscle strength was measured by analog manovacuometer (Commercial Médica™, São Paulo-SP, Brazil), after pulmonary function testing, and with participants seated at rest. The maximal inspiratory pressure (MIP) was measured with a scale of ± 120 cmH2O from residual volume up to the total lung capacity. The maximal expiratory pressure (MEP) was assessed from the total lung capacity, with the individual being instructed to fully inhale and exhale with maximum effort. At least three consecutive trials were carried out, with an interval of one minute between them. The value considered was the highest among the three measurements (except if it was the last), and the predicted values (MIP % pred and MEP % pred) were also calculated 18 . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint Handgrip strength was measured using a hydraulic dynamometer (Jamar™ hydraulic hand dynamometer, Sammons Preston, Bolingbrook, Illinois, USA) with the individuals in the sitting position, with the elbow flexed at 90º and a neutral wrist. Three measurements were made for the dominant hand. The mean was calculated and the highest value was used for analysis 19 . Lower limb muscle strength/power was measured by the FTSTS test, after handgrip strength assessment, as previously described 20 . Balance/agility was measured by the TUG test, after the FTSTS test, as previously described 20 . Finally, the 6MWT was assessed on a 30 m length flat surface, using cones and tape measure to mark the ground, and following the recommendations of the European Respiratory Society/American Thoracic Society 21 . BP was measured before, immediately after and after 2 min of recovery. HR and SpO2 were measured before, every 2 min of exercise (2, 4 and 6 min), and at 1 min of recovery. The average of HR and SpO2 measured every 2 min of exercise were considered exercise heart rate and exercise SpO2, respectively. Absolute (total distance walked during test) and relative (percentage of predicted distance) 22 values were used to assess walking performance. The prevalence of partial oxygen desaturation during the exercise phase was measured as a reduction ≤ 4 % in SpO2 during any moment of walking when compared to pre-exercise levels. Participants of the exercise group underwent a 12-week (tele-supervised and home-based) exercise training protocol. At the end of baseline evaluations, exercise group participants received instructions by a trained researcher (an exercise specialist) on how to safely perform the recommended exercise at home. The researcher demonstrated and oriented the participants on how to execute each proposed exercise properly. During this session, the participants were familiarized with each exercise and with the 6 to 20 rating of perceived exertion scale (RPE), which was used to control the exercise intensity 23 . If necessary, exercise adaptations to properly execute the exercise . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint 8 and/or to meet intensity were made during this session. Supplementary material containing exercise cards, with illustrations and instruction on how to perform each exercise adequately, how to meet the adequate workload (number of repetitions/sets, duration, rhythm, rest interval…) and how to progress workload throughout the follow-up, were sent by mobile app (WhatsApp) immediately after the instructional session. An instructional video about how to properly perform each exercise was also made available on the YouTube platform, and the participants were instructed to watch it as many times as necessary. All participants were contacted individually every Friday (by phone call or WhatsApp messages, according to participants' preference) to check the exercise frequency, which was noted in a spreadsheet. Verbal encouragements and orientations (if needed) were also performed during the weekly contact. All participants were instructed to perform both resistance (thrice-weekly in alternated days) and aerobic (five times-a-week) exercises. Participants were also instructed to perform a 5 min warmup (joint mobility and stretching exercises) and 5 min of cool-down (stretching and relaxing exercises) before and after each exercise session (both resistance and/or aerobics). Resistance training included nine multi-and single-joint exercises (bodyweight squat, push-up on the wall, bodyweight lunge, one-arm row, deadlift, side lateral raise or shoulder press, elbow flexion, calf raise, and abdominal crunch in chair) using bodyweight and/or rubber bands/plastic bottles (with water or sand) as resistance. Participants were instructed to perform 1 set of 10-15 reps at week 1, 2 sets of 10-15 reps at weeks 2 to 3, 3 sets of 10-15 reps at weeks 4 to 6), and 3 sets of 15-20 reps at weeks 7 to 12. Participants were also instructed to maintain 1 min of rest between sets and exercises, and to maintain the intensity at 14-17 points of RPE scale throughout the follow-up. For aerobic training, participants were instructed to perform walking and/or cycling (depending on preference and equipment available) five times a week, and they may choose to perform part of the sessions after the resistance training or to perform all the sessions in separate days. Aerobic sessions consisted of 10-15 min at week 1 (depending on participant's capacity), 20 min at weeks 3 to 4, and 30 min at weeks 5 to 12. Exercise intensity should be maintained at 11 to 13 of . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint RPE throughout the follow-up. During weeks 3 to 12, participants could choose to perform the aerobic exercise in a single session (20 or 30 min in a single session) or to accumulate in multiple sessions throughout the day (i.e.; 2 sessions of 10 min at weeks 3 to 4, and 2 sessions of 15 min or 3 sessions of 10 min at weeks 5 to 12). Statistical analysis was performed using the Statistical Package for the Social Sciences version 19 .0 (SPSS Inc., Chicago, IL, USA) for Windows. The Shapiro-Wilk and Levene tests were used to assess normality and homoscedasticity of data, respectively. Data were expressed as mean ± SD (parametric data) or as N (%) (categorical data). Unpaired Student's t test and Chi-square were used to indicate difference between groups in parametric and categorical variables at baseline. Two-way analysis of variance (ANOVA) with repeated measures (group vs. time) was used to indicate betweenand within-group differences in the variables measured before and during follow-up. The Bonferroni post-hoc test was used to identify the significant differences indicated by ANOVA. The level of significance was set at P < 0.05. Characteristics of the participants included in the study were not different between groups at baseline ( Table 1) . Seventy-five percent and 85% of exercise and control group had at least one comorbidity, respectively, and the most prevalent were obesity and hypertension. The tele-supervised home-based exercise program was well tolerated by all participants and there were no adverse events during follow-up. The prevalence of subjects with at least one persistent COVID-19 related symptom was not different between groups both at baseline (exercise = 83%; control = 85%; P = 0.900) and is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. Table 2) . Post hoc analysis identified that exercise group, but not control group, increased resting SpO2 (1.9 ± 0.6; P = 0.015) ( Table 2) is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. (Table 3) . Post hoc analysis identified that both groups increased (P < 0.05) handgrip strength (exercise: 4.5 ± 1.3 kgf; control: 4.6 ± 1.0 kgf) and SpO2 at exercise phase of 6MWT during follow-up, while SpO2 at pre 6MWT increased (P = 0.018) only in exercise (Table 3) . Post hoc analysis also identified that HR at exercise and recovery phases of 6MWT were higher (P < 0.05) in exercise than control group (both at baseline and during follow-up). No significant differences during follow-up were identified in FTSTS, and no significant difference between groups were identified in TUG (Table 3) . The major finding of the present study was that tele-supervised home-based exercise training was effective to reduce PWV in individuals recovering from COVID-19 hospitalization. In addition, is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint cardiovascular risk 25 . For example, a 1 m/s of increase in PWV is associated with a 14 % increased risk in cardiovascular events, and a 15 % increased risk in cardiovascular and all-cause mortality 26 . Previous studies showed that PWV is increased in individuals infected with SARS-CoV-2 when compared to a control group 7, 27 . The present 2.0 ± 0.6 m/s PWV reduction in exercise group and no significant change in control suggest that tele-supervise home-based exercise training is effective for improving arterial stiffness in survivors from COVID-19 hospitalization, which may impact cardiovascular prognosis and mortality in the long term 25, 26 . Previous systematic reviews assessing the effect of face-to-face exercise training on arterial stiffness showed an average reduction of only 0.6 m/s in PWV after exercise programs with durations similar to ours (12 weeks) 28, 29 . It can be speculated that the higher PWV decrease found in the present study may be associated with an increased inflammatory process 30 caused by COVID-19. Inflammatory process deteriorates vascular integrity, inducing hyperinflammation and release of cytokines 30 , reducing the bioavailability of nitric oxide and consequently increasing arterial stiffness 27, 30 . This inflammatory process activation is associated with serious damage to target organs, in addition to disruption of endothelial cells 27 . In accordance, COVID-19 survivors showed increased PWV after four months of infection, which was associated with oxidative stress and endothelial dysfunction markers 31 . Thus, it is possible that the well-known anti-inflammatory benefits of exercise training 8 may revert the COVID-19 inflammatory process, resulting in the present large PWV reduction. Future studies assessing this hypothesis are then welcome. Evidence about pulmonary function after COVID-19 hospital discharge is currently limited to cross-sectional studies 32 , where disease severity correlated with reduced pulmonary function 4 months after acute infection 33 . In the present study, we found similar FVC and FEV1 (absolute and relative levels) improvements during follow-up in both exercise and control groups. Considering that these patients had a disease that affects the respiratory system 32 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint 13 respiratory muscle strength (MIP and MEP) after hospital discharge among COVID-19 patients 33-35 , which is similar to the lower baseline levels of MIP % pred and MEP % pred found in the present study (both exercise and control groups). Thus, individuals hospitalized due to COVID-19 appear to have long-lasting pulmonary parenchymal dysfunction that results in changes in mechanical properties of the chest wall and respiratory muscles. On the other hand, tele-supervised home-based exercise was effective to improve MIP (24.7 ± 7.1 cmH2O), MEP (20.3 ± 5.8 cmH2O), MEP % pred (14.3 ± 22.6 %), and resting SpO2 (1.9 ± 0.6 %). It is important to note that prevalence of inspiratory or expiratory muscle strength impairment (MIP or MEP levels lower than 80 % of the predicted levels) in exercise group reduced from 8 (67%) and 9 (75%) individuals to 3 (25%) and 5 (42%) for MIP and MEP, respectively. Average levels of MIP and MEP (both absolute and % pred) also increased in the control group during follow-up; however, the increase was of lower magnitude and not statistically significant. Although the present exercise program was not focused on training the respiratory muscles, these muscles are indistinctly activated during exercise, which probably caused the greater respiratory pressures increases in exercise than control group. Accordingly, resistance 36 and aerobic 37 exercise training programs similar to present study showed to be effective for improving MIP and MEP in other populations. Regarding resting SpO2 improvement found only in exercise group, it can be speculated that it is a result of a greater O2 delivery and, consequently, availability due to the vascular and respiratory strength improvements induced by the exercise program. It is also important to note that there was a similar increase in handgrip strength, and no significant changes in FTSTS, TUG and 6MWT distance during follow-up in both groups. In addition, the exercise-induced increase in resting SpO2 did not result in improved exercise SpO2 when compared to control follow-up. Findings from a previous study assessing the effect of different faceto-face exercise programs (using exercise similar to those used in the present study) in older individuals suggest that a higher aerobic exercise intensity or resistance exercise volume may be . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint 14 required to increase these functional capacity parameters 38 . Future studies assessing this hypothesis in individuals recovering from COVID-19 are thus welcome. The small sample size with only non-critical hospitalized individuals does not allow us to extrapolate the present results to all individuals recovering from COVID-19. Although the power and effect sizes were adequate for most of the assessed variables, future studies assessing the effects of exercise in other COVID-19 populations (i.e.; critical and mild disease) are required. The high dropout rate is also a limitation that should be addressed. When asked by phone, the main reasons for dropping-out included lack of time, to work overtime (to replace co-workers infected by SARS-CoV-2), to take care of family members, and fear of leaving their house and being re-infected by SARS-CoV-2. Future studies and exercise programs addressing to overcome these barriers are thus welcome. In summary, both groups similarly increased pulmonary function and handgrip strength during follow-up. However, only exercise group reduced carotid-femoral pulse wave velocity, and increased respiratory muscle strength and SpO2. These findings suggest that tele-supervised home-based exercise training can be a potential adjunct therapeutic to rehabilitate individuals that were hospitalized due to COVID-19. All authors have no competing interest to declare. The data used to support the findings of this study are available through the corresponding author upon reasonable request. ACKNOWLEDGEMENT . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. VTA, AAV, ADH, BM, RGM and EGC participated in the study conception and design. Material preparation and data collection were performed by VTA, AAV, GYOO, PHCW, ADH, and SNL. Data analysis and interpretation was performed by EGC, and VTA participated in data interpretation. The first manuscript draft was performed by VTA, AAV, GSZ, BM and EGC. All authors contributed to manuscript draft improvement. Final revision was made by VTA and EGC. All authors read and approved the final version of the manuscript. . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint Data are presented as mean ± SD. SpO2: oxygen saturation. Asterisk denotes significant difference from baseline at the same group (*: P < 0.05). . CC-BY 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint Table 3 . Functional capacity at baseline and during follow-up. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint Impact of the COVID-19 pandemic on working students: Results from the Labour Force Survey and the student lifestyle survey Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China Features, Evaluation, and Treatment of Coronavirus (COVID-19) Determinants of endothelial dysfunction in noncritically ill hospitalized COVID-19 patients: A cross-sectional study Clinical guidance of severe SARS when Covid19 disease is suspected Endothelial cell infection and endotheliitis in COVID-19 Vascular alterations among young adults with SARS-CoV-2 Physical Exercise as an Immunomodulator of Chronic Diseases in Aging Exercise as a prescription for patients with various diseases Telerehabilitation During the COVID-19 Pandemic in Outpatient Rehabilitation Settings: A Descriptive Study Post-COVID-19 Syndrome and the Potential Benefits of Exercise Home confinement during COVID-19 pandemic reduced physical activity but not health-related quality of life in previously active older women. medRxiv Hypotensive Effect of Heated Water-based Exercise in Older Individuals with Hypertension Expert consensus document on arterial stiffness: Methodological issues and clinical applications Standardization of Spirometry 2019 Update. 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CC-BY 4.0 International license associations with clinical outcome Effects of exercise modalities on arterial stiffness and wave reflection: A systematic review and meta-analysis of randomized controlled trials Effects of moderate combined resistance-and aerobic-exercise for 12 weeks on body composition, cardiometabolic risk factors, blood pressure, arterial stiffness, and physical functions Acute systemic inflammation increases arterial stiffness and decreases wave reflections in healthy individuals Association of COVID-19 with impaired endothelial glycocalyx, vascular function and myocardial deformation 4 months after infection Respiratory function in patients post-infection by COVID-19: a systematic review and meta-analysis Medium-term impact of COVID-19 on pulmonary function, functional capacity and quality of life Lung function of patients hospitalized with COVID-19 at 45 days after hospital discharge: first report of a prospective multicenter study in Brazil Data are presented as mean ± SD; FTSTS: five-time sit to stand; SpO2: oxygen saturation; TUG:timed up and go test. Asterisk denotes significant difference from baseline at the same group (**: P < 0.01; ***: P < 0.001). Dagger denotes significant difference from exercise at the same moment ( † : P < 0.05; † † : P < 0.01).. CC-BY 4.0 International license It is made available under a perpetuity.is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint It is made available under a perpetuity.is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint It is made available under a perpetuity.is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted January 28, 2022. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprintThe copyright holder for this this version posted January 28, 2022. ; https://doi.org/10.1101/2022.01.24.22269745 doi: medRxiv preprint