Efficacy of Dao Yin in patients with 2019 novel coronavirus pneumonia: study protocol for a randomized controlled trial

Background The epidemic of 2019 novel coronavirus (2019-nCoV) pneumonia has become a focused public health event in world. The authorities have taken prompt medical action in China, which contained strict isolation measures and potential symptomatic supportive care. Dao Yin, a traditional Chinese exercise, combines limb movements and breathing exercises. Previous researches showed that it can activate the immune system and improve the lung function and the mental state of patients. Therefore, there may be a potential effect of Dao Yin on the physical and mental health of patients with 2019-nCoV. The aim of this trail is to verify whether conventional therapy plus Dao Yin could show better effects for 2019-nCoV than conventional therapy alone. Methods/design The study is a multicenter randomized controlled trial with parallel-group design including two intervention groups: a conventional therapy group and a conventional therapy plus Dao Yin group. A total of 186 eligible participants will be randomly assigned to the groups in a 1:1 ratio. The routine treatment of the two groups is performed daily according to guideline, and Dao Yin is performed once a day until the patient is out of the hospital. The primary outcome is the Length of Hospital Stay (LHS). Secondary outcomes include the vital signs, respiratory symptoms, questionnaire of mental health and the quantity of immune cells. The outcomes will be assessed at five points including the baseline, 3th, 6th, 9th day during hospitalization and the discharge day. The significance level is 5%. This study will focus on the value of a conventional therapy plus Dao Yin as the treatment for 2019-nCoV and will explore any potential connection among the outcomes. Discussion This study may evaluate the efficacy of conventional therapy plus Dao Yin for 2019-nCoV, which can contribute to provide a solid evidence of Dao Yin therapy for the nationwide emergence.

shown to improve dyspnea and health status and reduce medical expenses 11. Dao Yin, a low-risk traditional Chinese exercise, which is widely used to prevent heart and lung disease. It can be performed regardless of previous sports experience and age. At the same time, Dao Yin does not require expensive equipment, and can be practiced individually or in groups12, which is suitable for home practicing. It includes a series of physical and mental activities including Ba Duan Jin, Yi Jin Jing, Tai Chi, Wu Qin Xi, and Liu Zi Jue. Previous studies showed that traditional Chinese exercises have been widely used in clinical practice, which can promote mental and physical health, such as improving cardiopulmonary function, reducing high-risk factors for heart and cerebrovascular diseases, enhancing immune function to fight viruses [13][14][15][16] . Therefore, a randomized controlled clinical trial is being carried out to compare the clinical efficacy of the conventional therapy compared with conventional therapy plus Dao Yin. To explore the changes in respiratory function, immune function, and mental health of patients with 2019-nCoV after Dao Yin interventions and to analysis the potential correlation of these outcomes.

Methods/design
Study design This is a multicenter randomized controlled trial with two parallel arms. Recruiting blinded. It is planned to recruit 186 patients and randomly assign them to the conventional treatment group and the conventional treatment plus Dao Yin group at a 1: 1 ratio. Dao Yin intervention is conducted once a day lasting from admission to cure discharge. The assessor, who was masked to the group assignment, will perform evaluation and analysis of outcome at five points (before treatment, 3rd, 6th, 9th day during hospitalization and the discharge day). All patients are provided with informed consent at the time of recruitment, and the trial protocol was approved by the Ethics Committee of Yue yang Hospital of Integrated Traditional Chinese and Western Medicine (item number:2020-002). The study was registered with the China Clinical Trial Registry (ChiCTR2000029978). The trial flow chart and research design are shown in Figure 1 and Inclusion criteria (1) The age of patients is between 18 and 60, and is not limited to male or female; (2) Patients diagnosed with mild pneumonia (slight clinical symptoms, no pneumonia manifestations on imaging), general pneumonia patients (with fever, respiratory tract symptoms, etc., imaging showed pneumonia but no multiple organ damage) 17 (3) Hospitalized patients; (4) Volunteer to join the trial and sign the "informed consent". case data are incomplete and affect the judgement of curative effect; (4) unbearable adverse events; (5) patients voluntarily withdrew on their own. It is worth noting that the trial will be immediately terminated with poor clinical efficacy or severe adverse events such as respiratory failure, severe acid-base balance disorders, sepsis and even shock.

Randomization
Clinical researchers will get a random sequence number which is automatically generated by a random number generator (SPSS21.0, SPSS Inc., Chicago, Illinois, USA), and sequentially number them in an opaque envelope. Researchers will open random allocation envelopes and assign participants accordingly. Eligible patients will be randomly divided into a conventional treatment group and a conventional treatment plus exercise training group, with 93 patients in each group.

Blinding
Participants and Dao Yin trainers are unable to be blind about group assignments due to the specific intervention, but the trainers will not know the assessment of outcomes. To reduce the risk of bias, evaluators, data managers, and statisticians were unaware of group assignments in the outcome evaluation process and data analysis.

Interventions
Both groups of participants will receive routine treatment. Based on this, the experimental group will perform Dao Yin once a day until the discharge day. The daily routine treatment plan must be recorded in the electronic medical record by the doctor's system. In order to avoid cross-infection and ensure the identity of the training content, the training method will be presented to the subjects in text and video, including exercise action essentials, time, intensity, and precautions. It should be emphasized that during the test, other exercise rehabilitation methods, including aerobic exercise, stretching exercise, yoga and other sports therapy will be prohibited. If the subject receives any other exercise regimen, the changes should be recorded on the Clinical Report Form (CRF) each time. Researchers will start a remote video conference to monitor and correct the exercises throughout the whole trail process. When officially begin, patients will perform Dao Yin every day at 9 am, which mainly includes 2 minutes of warm-up exercise, 8 minutes of traditional exercise combined with breathing and stretching, and 2 minutes of cool down. Exercise training will be performed until patients discharged. The 7 steps detailed movement is shown in Figure 3. The study showed that certain exercise intensity can reach patient benefit goals 18

Outcome measurements
All outcome will be managed by researchers masked to the group assignment, which include five points (before treatment, 3rd, 6th, 9th day during hospitalization and the discharge day) Outcomes included the patient's general vital signs, length of hospital stays, evaluation of dyspnea degree, mental health and immune cells.

Length of Hospital Stay (LHS)
The key to treating pneumonia is to access if it can shorten the hospitalization time and reach the discharge standard. So, we treat length of hospital stays as the primary outcome.
Secondary outcome measurement

Vital signs 19
Blood pressure, heart rate, respiration, and blood oxygen saturation will be monitored three times a day by the nurse and then an average data will be obtained.

Mental health
The Motivation Assessment Scale (MAS) 20 and Self Rating Depression Scale (SDS) 21

Main elements of the immune system
Under the effect of exercise stress, T lymphocytes will be redistributed in large quantities in lymphoid and non-lymphoid organs. These stress-induced immune profiles will increase immune surveillance and vigilances 24 . T-cell and Natural Killer cell will be detected in peripheral blood with the Flow cytometry 25 method to gain more insights into the underlying connection between exercise and immune respond.

Safety evaluation
The doctors should focus on the vital signs of patients with 2019-nCoV strictly to decrease the incidence of adverse events, which is refer to the unexpected responses that occur during or after treatment. Record and analyze them whether the adverse events are related to the treatment. If a serious adverse reaction occurs, the researchers should immediately take appropriate medical measures according to the situation. Liver function and renal function tests and lung CT imaging tests also need to be monitored.

Data collecting and monitoring
During the recruitment phase, screeners will collect demographics of the participants. The data assessor will record the baseline characteristics of the patient, the length of hospital stays, general vital signs, the questionnaire to evaluate respiratory function and psychological status, and the levels of immune cells through a CRF. Next, two third-party personnel who have received strict data management training will receive data in the form of an excel database, and then they will enter the real-time data into the China Clinical Trial Registration Center. This electronic data management system will be used in the Ministry of Science and Technology of Yue yang Hospital of Integrated Traditional Chinese and Western Medicine to collect and monitor test data in real time.

Statistical analyses
Statisticians will use SPSS Windows version 21.0 software to perform the data analysis within group and between groups. Data will be expressed as mean ± standard deviation.
The data between groups will be compared by Student's t test when the continuous variables can meet a normal distribution or T distribution. Otherwise, Mann-Whitney test or Wilcoxon test will be used. For categorical data, the Fisher's exact or the Chi-square test will be adopted. We will conduct an intention-to-treat analysis if participants are lost to follow-up and perform a simple correlation analysis or simple regression analysis to determine the potential correlation between the outcome measurements. Adverse events in each group will be documented as percentage (%) for safety assessments using the chisquare test or Fisher's exact test. All statistical analyses will be conducted in a two-sided manner, with a significance level of 5%.

Sample size calculation
The trial takes the LHS as the primary efficacy outcome. With reference to the latest literature 3 , it is assumed that the average length of stay in the control group of this study is 10 days, the standard deviation is 3 days, and the average length of stay in the treatment group is 8.5 days, α = 0.05 , β = 0.10. Considering the 10% drooping rate, it was calculated that 93 subjects were needed in each group, and a total of 186 cases were required to be recruited.

Quality control
Professional trial methodology should be trained before the researchers participate in the trial which can ensure the consistency of methods. Quality control will be conducted during the processing of the trail under the management of the steering committee.
Supervisors will review the quality control of the trials via remote video surveillance, frequency is once every 2 weeks and recorded. Anything modification in the study protocol happen will inform the steering committee and ethics committee.

Discussion
The epidemic of 2019-nCoV has become a worldwide public health problem 26 28 . Therefore, mental health and autoimmunity should be focused on, which may play an antiviral role at early stage. Dao Yin, as part of traditional Chinese medicine, has been proven in many ways to significantly improve lung function and physical and mental health, and is closely related to the human immune system [29][30][31] .
The Yellow Emperor's Canon of Internal Medicine states that " a body full with healthy Qi energy will let the evil Qi energy go away ". Dao Yin can increase the body's ability to resist external evil through activities. Dao Yin breathing improve chest movement and lung ventilation as well as improve overall health by improving diaphragm muscle movement, which is the most important breathing muscles in the body. It is suitable for frail patients and seniors in the hospital status with the characterization of slow motion and respiration and relaxation. By training in body posture and movement, regulating breathing patterns and maintaining mental calmness, a variety of natural self-regulation and self-repair mechanisms in body can be activate to stimulate the balanced release of

Study Limitations
There is an inevitable limitation that it is difficult to control the methodology of blinding during the physical intervention. In this study, Dao Yin as a physical therapy is impossible to be blind for the participants and therapist. We have not conducted a comparison of efficacy between two different exercises.

Trial Status
This protocol is version 2.0 February 16, 2020. The participants will be recruited from February 24, 2020 to May 31, 2020. But no one will be enrolled until this paper is submitted. This trial was registered in Chinese Clinical Trial Registry on 18 February 2019.
The registration number is ChiCTR2000029978.