Physical Activity and COVID-19

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk and Kim Jackson  

Introduction

The COVID-19 pandemic is an unprecedented time all across the world. Worldwide, extensive social distancing policies are put into place, restricting people’s daily activities and worldwide pleas from governments asking people to stay safe and stay at home. This of course means that most people will spend much of their time (if not all) at home.

These social distancing measures mean that people have far fewer opportunities to be physically active, especially if activities such as walking or cycling as transportation means or taking part in a leisurely sports activity (i.e. jogging, walking the dog, going to the gym) are being restricted. Furthermore, these drastic measures also make it so much easier to be sedentary at home for long periods of time.[1] The impact of this physical inactivity may very likely be seen in many areas such as health and social care and the mental well-being of people all across the globe.

Although these social distancing measures are important and needed in a time such as now, our bodies and minds still need physical activity and the many benefits thereof.

Definition of Physical Activity

Physical Activity (PA) is defined as any bodily movement produced by skeletal muscles that require energy expenditure.[2] There are two components to physical activity that needs to considered:

  • Aerobic fitness: this usually includes moderate to vigorous activity that makes you feel a bit warm, causes your breathing to increase and your heart rate to increase.
  • Strength and balance: This is often the forgotten component of physical activity, but it is an essential part and has many benefits.

Physical activity may include[3]:

  • Active recreation
  • Sports participation
  • Cycling
  • Walking
  • Play
  • Dance
  • Gardening
  • House cleaning
  • Carrying heavy shopping

During the COVID-19 pandemic it is even more important for all people to be physically active. Even if it is only a short break from sitting at your desk and doing some walking or stretching. Doing something simple as this will[3]:

  • ease muscle strain
  • relief mental tension
  • improve blood circulation
  • improve muscle activity
  • It also helps to give some routine to a day in these unprecedented times.

Benefits of Physical Activity

Health-benefits-of-physical-activity.png

There are many benefits of physical activity. These include:

  • Physical activity benefits infographic for adults and older people.png
    Strengthening and maintaining your immune system strength - being less susceptible to infections[4]
  • Reduces high blood pressure
  • Weight management
  • Reduces the risk of  heart disease
  • Reduces the risk of diabetes
  • Reduces the risk of stroke
  • Reduces the risk of certain cancers
  • Improves bone and muscle strength
  • Improves balance
  • Improves flexibility
  • Improves fitness
  • Improves mental health
  • Reduces the risk of depression
  • Reduces the risk of cognitive decline
  • Delays the onset of dementia
  • Improves overall feeling of well-being
  • In children physical activity may:
    • support healthy growth and development
    • reduce the risk of disease in later life
    • help in development of fundamental movement skills

Benefits of Strength and Balance Training

Often, strength and balance training is forgotten as being part of physical activity and many people only focus on the aerobic fitness component and the benefits thereof. The benefits of strength and balance training include[5][6]:

  • Benefits of Strength and Balance Training[7]
    Improves blood liquid profile
  • Improves vascular function
  • Improves immune function
  • Builds and maintain muscle mass
  • Increases oxidative capacity
  • Helps to maintain independence and functional status
  • Improves the ageing trajectory
  • Improves blood glucose sensitivity
  • Improves blood pressure and is a healthy way to manage blood pressure
  • Improves body composition - this helps to maintain a healthy weight over time

Despite all these many benefits, physical inactivity costs 5.3 million lives per year globally.[8] It is important therefore to find ways to limit the impact of the COVID-19 pandemic as well as the wider impact it will have on long term chronic diseases.[1]

Physical Activity Guidelines

The WHO Guidelines on the amount of physical activity include[9]:

  • Infants under the age  of 1 year need to be physically active several times a day.
  • Children under 5 years of age should spend at least 180 minutes a day in physical activities, with 3-4 year-old's being moderately or vigorously active for an hour a day.
  • Children and adolescents aged 5-17 years
    • all children and adolescents should do at least 60 minutes a day of moderate to vigorous-intensity physical activity, including activities that strengthen muscle and bone, at least 3 days per week.
  • Adults aged 18 - 64 years
    • should do a total of at least 150 minutes of moderate-intensity physical activity throughout the week, or at least 75 minutes of vigorous-intensity physical activity throughout the week, including muscle-strengthening activities 2 or more days per week.
  • Adults aged 65 years
    • should do a total of at least 150 minutes of moderate-intensity physical activity throughout the week, or at least 75 minutes of vigorous-intensity physical activity throughout the week, including muscle-strengthening activities 2 or more days per week.
    • older adults with poor mobility should do physical activity to enhance balance and prevent falls on 3 or more days per week

Important: Any physical activity is better than none!!!

During the COVID-19 pandemic being physically active will be a challenge for all of us, but it is critical that we find and plan ways to be active and reduce our sedentary time. Although our movement around our neighbourhood, town, city, country and the world might be restricted, it remains critical that we all move more and sit less.

The Importance of Physical Activity during the COVID-19 Pandemic

In light of the current situation worldwide, certain benefits of physical activity may be specifically pertinent to the COVID-19 Pandemic. These benefits are[10]:

  • Physical activity enhances immune function and reduces inflammation, it could therefore reduce the severity of infections.
  • Physical activity improves common chronic conditions that increase the risk for severe COVID-19 (i.e. Cardiovascular Disease, Diabetes).
  • Physical activity is a great stress management tool through reducing symptoms of anxiety and depression.
  • Physical activity helps bring cortisol levels in balance - Stress and distress (such as during a pandemic) creates an imbalance in cortisol levels and this negatively influences immune function and inflammation.
[10]

Physical (In)Activity during Lockdown

As already iterated, we are living in unprecedented times and we are learning as we go of the effects and impact of this pandemic. With regards to physical activity and periods of lockdown or restricted and regulated movement, there is some evidence emerging, but it is still in the early stages of this pandemic and we won't fully understand the impact of "lock down" for many months.[11]

Insights from data sets

Anecdotal evidence

Exercise photo.jpg

Many countries in the world are currently in some or other form of lockdown or restricted movement policy and practicing social distancing. Some countries have stricter measures in place with regards to exercise and only allow people to exercise outside/away from their homes once a day or only allow people to exercise outside/away from their homes within a specific time frame or even not allowing any exercise outside/away from home. These restrictions and constraints are specific to each country and the the extent of the COVID-19 outbreak in that specific country. In the media it is publicised that these various measures of lock down may have a positive effect on people's activity levels, with reports of more people being seen outside running, walking, cycling etc. We should be cautious of thinking that this implies that people are now adapting a more active and healthy lifestyle. Physical activity is accrued over a period of 24 hours in many different ways. Organised or structured sport/exercise is merely a small part of physical activity. Most people accumulate their "active minutes" by doing various other activities such as housework, walking the dog, walking/cycling to and from work, walking between tube/train stations, etc. All these activities are part of people's daily lives and contribute to their physical activity minutes. During periods of lockdown, many of these activities are restricted or not even taking place and it is extremely difficult to build in these levels of activity when people's daily movements are restricted.[11]

Wearable Technology

Garmin data Average Daily Steps[12]
Garmin data: Virtual Cycling[13]

Data from wearable technology companies such as Garmin also paints an interesting picture of the type of physical activities people engage in during these times. This data, however, is not really representative or cross sectional,but from people who are using wearable technology such as smartwatches and fitness trackers. Interesting to note is that during the month of March there was a global reduction in the daily average amount of steps taken - which is indicative of people being restricted in their movements. Virtual cycling has increased in countries, such as Italy and Spain with severe lockdown restrictions. In other countries, such as the UK and Sweden, where outdoor exercise is allowed there is a significant increase in outdoor cycling activities, compared to the same time in 2019.[14] People are finding ways to still be active even in extreme lockdown situations, but this data still does not provide a credible idea of a person's cumulative physical activity levels over a 24 hour period.

Early Research Findings

University College London launched a social study on the psychological and social experience of people in the UK during the Covid-19 pandemic.[15] During the second week of the study the researchers looked into exercise and social behaviours of over 47 000 participants.This is app-based and self-reported data. Early stage findings from this study include[15][16]:

  • 1 out of 4 people say that they have had no exercise or even gentle physical activity in the past 7 days.
  • 85% of study participants reported that they did not engage in any moderate or strenuous exercise at all.
  • 40% of study participants reported that they had not done any gentle exercise such as going for a walk.
  • Even in younger participants (18 - 30 years) four out of five people report not engaging in any moderate or high intensity activity.
  • People with diagnosed mental and physical health conditions are doing the least physical activity.
  • Older people are engaging in more gentle activity, but the least in in exercise at home or moderate to strenuous exercise overall.
  • People living alone are engaging less in all kinds of physical activity.
  • People from lower income levels are engaging less in all kinds of physical activity.

These are early findings and these results will most likely change over time and as lockdown measures eases.

From the various data sets, it is clear that people are finding ways to exercise, but that is not a true reflection of their accrued physical activity over a 24 hour period. Many people also engage in no moderate or strenuous physical activity during lockdown measures - the implications of this will only be evident later on.

Implications of Physical Inactivity during COVID-19

Health and Social Care

There are a couple of things to consider when looking at the implications of physical inactivity during COVID-19 on health and social care[11]:

  • It is impossible to predict the outcomes currently
  • At best we can try and make educated guesses
  • There are global variations to consider such as the time frame around going into lockdown and easing of restrictions in countries as well as differences in health and social systems in countries.
Health footprint of Pandemic[17]
First wave: Population of people who experience COVID-19

This population of people who experience COVID-19 and recovery from it will still have ongoing needs. They would have had an enforced period of physical inactivity due to the illness. These people will have specific rehabilitation needs. Currently this is the obvious population of people that receives focus and attentions.[11]

See also: Role of the Physiotherapist in COVID-19 and Respiratory Management of COVID-19

Second wave: People with urgent non-COVID-19 conditions

Although, we are dealing with a pandemic at the moment, people all over the world still need healthcare for their existing mental and physical health conditions. Especially during periods of lockdown, this population will still have ongoing needs in terms of self management of their condition. In a scenario where healthcare services and systems are under stress and resources limited it is critical to support people in self-management of their condition. Physical activity and the benefits thereof is one important way of supporting this population of people to self-manage their conditions so that they are able to cope effectively with symptoms such as pain, stiffness, fatigue or breathlessness. As physiotherapists we can play a critical role in supporting people to stay active so that they are healthy enough to self-manage their condition during this time.[11]

Third wave: Impact of interrupted care on chronic conditions

During periods of lockdown, routine healthcare services have been put on hold or paused in many countries around the world. Services such as routine screenings, diagnostics and elective surgeries have been put on hold. This will have an impact on this population of people as many people who have thought that there would have been progress in the diagnosis or management of their condition. Even after healthcare services resume for this population, it may still take some time for services to clear the backlog caused by periods of lockdown. This may have far-reaching effects. Again, physiotherapists can make a difference with this population by advocating physical activity as a way to self-manage their conditions.[11]

See also: Physical Activity and Non-Communicable Diseases

Mental Well-Being

The link between physical activity and mental well-being is clear. Physical activity is a key, critical way to manage mental health well-being and it is important that we as physiotherapists promote this to people, regardless of them having been diagnosed with a mental health condition or not. Studies have reported that enforced sedentary behaviour has led to depressive feelings and low moods in healthy people within seven days[18]. Taking into consideration the current situation worldwide with countries in enforced periods of lockdown and isolation, this may potentially have a mammoth impact on the mental well being of many people and even more so if they do not engage in any form of physical activity!

[19]

See also: Mental Health Stress and Resilience in Times of COVID-19, Mental Health, Physical Activity and Physical Therapy and Physical Activity and Mental Health

Musculoskeletal Deconditioning

With decreased physical activity there is the likelihood of musculoskeletal deconditioning.[20] During periods of lockdown where many people's daily activity movements are restricted, musculoskeletal deconditioning is likely to happen in most people. In fit and healthy people this will be less noticeable, but in older people, people with diagnosed health conditions or people who functions very close to the functional threshold, musculoskeletal deconditioning will be more pronounced. This musculoskeletal deconditioning may have a significant impact on these vulnerable populations and may potentially increase the risk of injuries related to falls, such as hip fractures.[21] This will in turn have implications for health and social care services already under stress.

A Call to Action for Physiotherapists

Physiotherapist with patient.png

Considering the possible impact of physical inactivity during lockdown, there are ways that physiotherapists can make a significant difference in the lives of their patients:

  1. Clinicians need to be mindful of the impact of lockdown on the mental and physical well -being of people. Now, more than ever the holistic aspects of our assessments need to be emphasised, especially considering the stress on the mental well-being of so many people.[11] People are uncertain, anxious, worried and isolated during lockdown.
  2. Clinicians need to consider the aspects of muscle strength and deconditioning when assessing their patients.[11] Although this is "usually" considered in assessments, it might need to be prioritised and physiotherapists need to find ways to support their clients to:
    • regain muscle strength
    • regain joint range
    • optimise well-being
    • if areas of musculoskeletal deconditioning are not addressed it may affect a person's ageing trajectory and their overall well-being.
  3. During lockdown, physiotherapists can be active and effective as a global workforce through supporting people to stay physically active.[11]

Ways Physiotherapists can Promote Physical Activity during Lockdown

  1. Encourage people to break their periods of inactivity
  2. Encourage people to engage in aerobic activity on a daily basis - even very short periods of exercise have been reported to have real health benefits[22]
  3. Encourage people to engage in strength and balance exercises two to three times a week
    • Focus on major functional muscle groups
    • Think about and find ways for people to incorporate these exercises every week during lockdown and beyond
    • By doing this there is the potential to change physical activity behaviour in the long term
  4. Physiotherapists need to focus on effective messaging during lockdown. This may include positive messages about the benefits of physical activity aligned with the concerns that people have during lockdown and pandemic.[11] These may be:
    • Physical activity during lockdown may improve mental health
    • Physical activity during lockdown may help in improving sleep patterns.
    • Physical activity during lockdown helps you stay healthy.
    • Physical activity during lockdown helps reduce the demand on health systems.

Ways to Stay Physically Active during COVID-19

Staying physically active during self-isolation[23]

How to Stay Safe while Exercising during COVID-19

  • Do not exercise if you have a fever, cough or difficulty breathing (symptoms of COVID-19).[24]
  • Practice social distancing when exercising outdoors and practice good hand hygiene before and after.[24]
  • If you are not use to physical activity, start slowly with low intensity activities such as walking or low impact exercises for shorter periods of time and gradually build up over time.[24]
  • Choose the right activity to reduce the risk of injury - the intensity of the exercise should match your fitness levels and health status.[24]

Resources

[25]

References

  1. 1.0 1.1 The Conversation.How to stay fit and active at home during the coronavirus self-isolation. Published on 25 March 2020. Available from https://theconversation.com/how-to-stay-fit-and-active-at-home-during-the-coronavirus-self-isolation-134044 (last accessed 9 May 2020)
  2. World Health Organisation. Physical Activity. Avalaible at: https://www.who.int/dietphysicalactivity/pa/en/ [last accessed 6 April 2020]
  3. 3.0 3.1 World Health Organisation. Be Active During COVID-19. Available from https://www.who.int/news-room/q-a-detail/be-active-during-covid-19 [last accessed 6 April 2020]
  4. Nieman DC, Henson DA, Austin MD, et al. Upper respiratory tract infection is reduced in physically fit and active adults. British Journal of Sports Medicine 2011;45:987-992.
  5. Public Health England. Muscle and bone strengthening and balance activities for general health benefits in adults and older adults. Summary of a rapid evidence review for the UK Chief Medical Officers’ update of the physical activity guidelines. Published July 2018. (last accessed 9 May 2020)
  6. Mcleod JC, Stokes T and Phillips SM (2019) Resistance Exercise Training as a Primary Countermeasure to Age-Related Chronic Disease. Front. Physiol. 10:645. doi: 10.3389/fphys.2019.00645
  7. Mcleod JC, Stokes T and Phillips SM (2019) Resistance Exercise Training as a Primary Countermeasure to Age-Related Chronic Disease. Front. Physiol. 10:645. doi: 10.3389/fphys.2019.00645
  8. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. The Lancet. 2012 Jul 21;380(9838):219-29.
  9. World Health Organisation. Physical Activity. Published on 23 February 2018. Available from https://www.who.int/news-room/fact-sheets/detail/physical-activity. (last accessed 8 May 2020).
  10. 10.0 10.1 Sallis, JF. Physical activity + COVID-19. Lecture to UC San Diego medical students. March 2020. Published on 1 April 2020. Available from https://www.youtube.com/watch?v=F4mcbi9tD-M. [last accessed 10 April 2020]
  11. 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 Lowe, A. Physical Activity and COVID-19. Course. Physioplus, 2020.
  12. Wareable. Garmin data reveals how the world is working out during the lockdown. Published on 11 April 2020. Available from https://www.wareable.com/garmin/garmin-data-lockdown-7940. (last accessed 9 May 2020)
  13. Wareable. Garmin data reveals how the world is working out during the lockdown. Published on 11 April 2020. Available from https://www.wareable.com/garmin/garmin-data-lockdown-7940. (last accessed 9 May 2020)
  14. Wareable. Garmin data reveals how the world is working out during the lockdown. Published on 11 April 2020. Available from https://www.wareable.com/garmin/garmin-data-lockdown-7940. (last accessed 9 May 2020)
  15. 15.0 15.1 University College London. More people are worried about food, friends and family than getting ill from COVID-19. Published on 6 April 2020. Available from https://www.ucl.ac.uk/news/2020/apr/more-people-are-worried-about-food-friends-and-family-getting-ill-covid-19-0. (last accessed 9 May 2020)
  16. March Network.COVID-19 Social Study. Available from https://www.marchnetwork.org/research. (last accessed 11 May 2020)
  17. Victor Tseng. Health Footprint of Pandemic. Published on 30 March 2020. Available from https://twitter.com/VectorSting/status/1244671755781898241/photo/1. (last accessed 9 May 2020)
  18. Endrighi R, Steptoe A, Hamer M. The effect of experimentally induced sedentariness on mood and psychobiological responses to mental stress. Br J Psychiatry. 2016;208(3):245‐251.
  19. Dr Cullen Hardy. Emotional and Mental Benefits of Exercise. Published on 14 March 2016. Available from https://www.youtube.com/watch?time_continue=17&v=OK_vnVbxBXE&feature=emb_logo (last accessed 9 May 2020)
  20. Kramer A, Gollhofer A, Armbrecht G, Felsenberg D, Gruber M. How to prevent the detrimental effects of two months of bed-rest on muscle, bone and cardiovascular system: an RCT. Scientific reports. 2017 Oct 13;7(1):1-0.
  21. Low ST, Balaraman T. Physical activity level and fall risk among community-dwelling older adults. Journal of physical therapy science. 2017;29(7):1121-4.
  22. UK Chief Medical Officers' Physical Activity Guidelines. Published on 7 September 2019. Available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity-guidelines.pdf (last accessed 9 May 2020)
  23. Victor Tseng. Health Footprint of Pandemic. Published on 30 March 2020. Available from https://twitter.com/VectorSting/status/1244671755781898241/photo/1. (last accessed 9 May 2020)
  24. 24.0 24.1 24.2 24.3 World Health Organisation. Be Active during COVID-19. Published on 27 March 2020. Available from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/be-active-during-covid-19. (last accessed 9 May 2020)
  25. World Health Organisation.Q&A on physical activity at home during COVID-19. Published on 16 April 2020. Available from https://www.youtube.com/watch?v=xeN-BRRAi2k. (last accessed 9 May 2020)