The Effect of the Physical Fitness and Breathing Training Program in COVID-19 patients in Wuhan, China: prospective study

Background Corona Virus Disease 2019 (COVID-19) has adverse effects on patients’ respiratory system. Therefore the pulmonary rehabilitation is particularly necessary for COVID-19 patients. A recent qualitative study indicated that patients perceived the impact of fatigue on their daily lives to be a key factor in decreasing their quality of life. This study aimed to investigate the knowledge and needs of physical tness and breathing training, and to explore the impact of physical tness and breathing training on COVID-19 patients. Methods From Feb 16, 2020 to Apr 6, 2020, a self-designed questionnaire was used to investigate the knowledge and needs of physical tness and breathing training in COVID-19 inpatients. And then the participants received an intervention about physical tness and breathing training which lasted 2 weeks. The 9-item Functional Assessment of Chronic Illness Therapy-Fatigue scale (FACIT-F) was used to measure COVID-19 related fatigue before and after the intervention.


Introduction
Corona Virus disease 2019 (COVID-19) is a severe acute respiratory disease caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) [1] . The population is generally susceptible because the transmission route of COVID-19 is mainly spread by respiratory droplets [2] , and the epidemic quickly spreads to the whole world. At March 12th, World Health Organization (WHO) characterized it as a global pandemic [3] .
COVID-19 has adverse effects on patients' respiratory system, physical function and psychological function, therefore the pulmonary rehabilitation is particularly necessary for COVID-19 convalescent patients. It may be of value for all patients in whom respiratory symptoms are associated with diminished functional capacity or reduced health-related quality of life (HRQL) [4] . Furthermore, emerging evidence supports the use and bene ts of the program in other chronic respiratory diseases, such as idiopathic pulmonary brosis, interstitial lung disease, and others. The previous studies have shown that pulmonary rehabilitation can stabilize or improve the functional status of patients [5,6] .
The National Health Commission of the People Republic of China (NHC) has published the General O ce of the National Health Commission on printing and distributing rehabilitation plans for discharged patients with COVID-19 (Trial) [7] . The document emphasized the importance of COVID-19 patients for pulmonary rehabilitation, which hospital medical personnel should pay attention to it to improve patient's dyspnea and dysfunction, reduce the complications, recovery the greatest possible ability of daily life activities.
Fatigue is identi ed as the most commonly detected. It is demonstrated that fatigue played a strongly negative effect on COPD patients. COPD-related fatigue is acknowledged to associate with COPD patients' worse health status [8][9][10] , and also exerts a negative impact on daily lives, physical functioning and emotional well-being [9,11,12] .
This study aimed to investigate the knowledge and needs of physical tness and breathing training, and to explore the impact of physical tness and breathing training on COVID-19 patients.

Materials And Methods
Objectives This was a prospective study. The present study aimed to investigate the knowledge and needs of physical tness and breathing training, and to explore the impact of physical tness and breathing training on fatigue in COVID-19 patients.

Participants
The inclusion criteria were as follows: (1) Age older than 18 years; (2) Informed consent form was signed; (3) Patients was diagnosed of COVID-19. The exclusion criteria were as follows: (1) Patients with psychotic disorder or dementia; (2) Patients didn't have smart phones. The data for demographic information and clinical data were collected.

Assessment of knowledge and needs for physical tness and breathing training
The self-designed questionnaire, including the general condition of patients, the knowledge of physical tness and breathing training, the frequency of actual physical tness and breathing training and the needs for teaching methods. The physical tness and breathing training knowledge and needs scale referred to the General O ce of the National Health Commission on printing and distributing rehabilitation plans for discharged patients with COVID-19 (Trial) [7] and recommendations for respiratory rehabilitation of COVID-19 in adult [13] . There were 5 kinds of pulmonary rehabilitation programs, included breathing training apparatus, abdominal breathing, pursed-lip breathing, breathing rehabilitation physical tness, aerobic physical tness and strength training. The scale included four aspects: whether the patients know the relevant knowledge of pulmonary rehabilitation, whether they have mastered the training methods of pulmonary rehabilitation, the training frequency of patients who have mastered pulmonary rehabilitation, and the expected teaching ways. Patients' understanding are according to a 5point Likert scale were assigned according to "very much", "relatively", "uncertain", "not really" and "not at all". The higher score, the better the patients' understanding. Through the "mastered" and "not mastered" options we can understand whether the patient can carry out pulmonary rehabilitation training independently.

Assessment of Chronic Illness Therapy-Fatigue scale
The 9-item Functional Assessment of Chronic Illness Therapy-Fatigue scale (FACIT-F) was demonstrated to be reliable and valid for measuring COPD-related fatigue [14,15] .The 9-item FACIT-F scale consists of three components: general fatigue (5 items), functional ability (2 items) and psychological fatigue (2 items). Each item is rated from 0 to 4 and the overall score ranges from 0 to 36, with a higher score signifying less fatigue [16] .We applied the cut-off of 12 and 24 points, thus patients' fatigue degree was classi ed as mild (FACIT-F score 24 to 36), moderate (12 to 23) and severe (0 to 11). The Cronbach's alpha of the 9-item FACIT-F scale was 0.89 in this study.

Intervention
The Physical tness and Breathing Training Program (appendix 1) for COVID-19 The training content was presented using instructional video materials teaching and face-to-face interactive reminder. The instructional video materials were conducted by Wechat in personal mobile phone. This was a 2 weeks program.

Statistical analyses
The patient's characteristics were presented as mean ± SD for continuous variables, and showed as interquartile range (IQR) for non-normally distributed continuous variables. Categorical variables were showed as percentages. For categorical variables, Chi-square test was used. Mann-Whitney U test was applied to compare if there were any signi cant differences in the mean scores between the two groups.
All calculation was performed with SPSS 22.0. A P value of less than 0.05 was considered to be signi cant.

The knowledge of pulmonary rehabilitation
The patients who knew the breathing training apparatus was the least (19 14.29%), and those who knew the aerobic physical tness accounted for 64 48.12% , which was better than other items. Measured on a 5-point Likert scale, the total understanding degree of physical tness and breathing training (2.47±1.17) had only "not really" and "uncertain". In terms of the understanding degree of aerobic physical tness (3.05±1.09) is between "uncertainty" and "relatively", the understanding degree of pursed-lip breathing (2.23±1.11), abdominal breathing (2.72±1.23), breath rehabilitation physical tness (2.36±1.11), and strength training (2.41±1.12) is between "not really" and "uncertain". Breathing training apparatus (1.93±0.25) is between "not at all" and "not really" (shown in Table 2 Table 4).
The healthcare professionals and exposure There were 130 healthcare professionals took part in this program. None of them reported covid-19 related symptoms during the deployment period in Wuhan. When they returned home, none of the nasopharyngeal swabs collected from them tested positive for nucleic acids on the reverse transcriptase polymerase chain reaction assay for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). None of the serum samples of healthcare professionals tested positive for SARS-CoV-2 speci c IgM or IgG antibodies (95% con dence interval 0.0 to 0.7%) [17] .

Discussion
Our investigation used the self-designed questionnaire to determine the knowledge and needs of patients with COVID-19 in physical tness and breathing training for pulmonary rehabilitation. The nding from this study indicated that patients generally had a low level of knowledge of physical tness and breathing training, such as breathing training apparatus, pursed-lip breathing, and breath rehabilitation physical tness. The reason may be the patients have few respiratory basic diseases, and during the outbreak period, rehabilitation medical personnel do not recommend to carry out physical therapy and rehabilitation training in the ward of patients with COVID -19 lest they get infected [18] . In this study, the training content was presented using instructional video materials teaching combined with face-to-face interactive reminder. It should be bene t for the patients to improve their knowledge level.
The prevalence of moderate to severe fatigue was 48.88% in COVID-19 patients, which was consistence with the COPD patients admitted to hospitals with an acute exacerbation, which is a more severe group of patients [15] .
The American Thoracic Society (ATS) and the European Respiratory Society (ERS) pointed out that physical tness and breathing training was the cornerstone of pulmonary rehabilitation. The core of pulmonary rehabilitation is physical tness training, patients should gradually transfer from the early respiratory muscle training to the whole body physical tness training, aerobic physical tness, and then according to the rehabilitation assessment to the strength training, nally to the appropriate form of physical tness and intensity training [4,19] . Physical tness training program had identi ed it improved both the cardiorespiratory and musculoskeletal tness in patients recovering from SARS [20] .
In this study, the training program which gradually transferred from the early respiratory muscle training to the whole body physical tness training, aerobic physical tness , and according to the rehabilitation assessment, nally to the appropriate form of physical tness and intensity training. The signi cant differences were observed in fatigue, SpO2 and oxygen ow after the intervention, moderate degree alleviated to mild degree. According to recommendations for respiratory rehabilitation of COVID-19 in adult [13] , patients should have aerobic physical tness for 3~5 times a week, 20~30min each time, strength training for 2~3 times a week, training for 6 weeks, abdominal breathing, pursed-lip breathing, breathing rehabilitation physical tness s for 2 times a day, 15~45min each time. However, most of the patients in the survey practice breathing training apparatus, abdominal breathing, respiratory rehabilitation physical tness s and aerobic physical tness for 2 weeks, which were less than the recommended physical tness time for the participants discharged.
Most of the patients expect to be taught by video. Video and picture text teaching can simultaneously guide multiple groups and it is convenient, it also can reduce the people contact in special periods. Not only saves medical resources, reduces the workload of medical staff, but bene ts a wide range of people.
Besides sports training, it also includes the comprehensive measure such as the psychological intervention and health education. Therefore, professional clinicians, clinical nurses, rehabilitation physicians and psychological therapists should make promotional videos or graphics which related to pulmonary rehabilitation together. In terms of increasing the completion degree of patients' pulmonary rehabilitation training, patients' compliance can be improved through WeChat group punch, family member supervision, online mutual supervision between patients and online supervision of medical staff. Some scholars guided respiratory rehabilitation can be conducted by providing video and remote telephone guidance to COVID-19 patients [21] .
In our study, all healthcare workers were responsible for Physical Fitness and Breathing Training Program, which included face to face training procedures on a routine basis. We implemented a more stringent protocol for our participants as a necessary precaution, which included wearing N95 respirators and surgical masks at the same time. In addition, they were well trained in hand hygiene, putting on and taking off personal protective equipment. During training procedures, healthcare workers were equipped with standards personal protective equipment, including protective suits, masks, gloves, goggles, face shields, and gowns [17] (shown in table5).
Several potential limitations should be mentioned regarding the present study. First, participants were recruited convenience sampling only from the inpatient department.
So the generalization of the ndings might be limited. Future research among patients from different settings (eg, inpatient, outpatient, community) and with different status is advised. Second, this study adopted fatigue rather than details of FEV1 to measure bene t of training program, the correlation between fatigue score and COVID-19 severity may be weak.

Conclusions
This study investigated the knowledge and needs of COVID-19 convalescent patients for pulmonary rehabilitation. Most patients have insu cient knowledge of pulmonary rehabilitation and hope to be guided by video teaching. We should not only pay attention to guide the knowledge and operation of pulmonary rehabilitation for COVID − 19 convalescent patients, but supervise in many ways in order to enhance the patient's compliance.

Declarations Ethical Approval and Consent to participate
The study protocol was approved by the Ethics Committee of XXX Hospital, XXX University. The COVID-19 patients were recruited between Feb 16, 2020 and Apr 6, 2020. In the form of online survey, questionnaires were sent to the study population through WeChat group to complete. Each WeChat ID can only be answered once to avoid duplication of information collected. All respondents provided informed consent. Obesity (BMI ≥ 28.0) 9 6.57 Note: very much includes "very much" and "relatively", not at all includes "not really" and "not at all".  Table 4 Comparison of FACIT-F and vital signs before and after intervention in COVID-2019 patients