Asian J Sports Med. 2020 March; 11(1):e102630. doi: 10.5812/asjsm.102630.

Published online 2020 March 17. Editorial

COVID-19 Epidemic: Exercise or Not to Exercise; That is the Question!

1
Farzin Halabchi , Zahra Ahmadinejad 2, 3 and Maryam Selk-Ghaffari 1, *
1
Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
2
Department of Infectious Disease, Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
3
Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
*
Corresponding author: Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Email: selk1360@gmail.com

Received 2020 March 12; Accepted 2020 March 13.

Keywords: Exercise, COVID-19, Coronavirus, Public Health, Epidemic

In December 2019, a public health emergency was in- life (7). However, prolonged high intensity physical activity
duced by an outbreak of novel beta coronavirus termed leads to immunosuppression (6, 8).
2019-novel coronavirus (SARS-CoV-2) in Wuhan City, Hubei Experts have expressed a J-shaped connection between
Province, China, which is going to be a worldwide epi- physical activity and respiratory tract viral infection. Mod-
demic with high mortality and morbidity (1, 2). In the erate intensity physical activity boosts immune system
time of writing this editorial (March 10, 2020), more than and the risk of respiratory track viral infections are re-
100000 persons from more than 100 countries have been duced. However, high intensity physical activity with long
infected with more than 4000 deaths reported. Clini- durations weakens the immune system for several hours
cal manifestations of COVID-19 consist of fever, cough, following the exercise and the risk of inspiratory track in-
dyspnea, myalgia, headache and diarrhea (3). Fatal pul- fection are increased in this period (8).
monary involvement and multi-organ failure has occurred As a conclusion, moderate- intensity (and not high- in-
in a portion of infected individuals (4). The virus is an tensity) exercise may be helpful for healthy asymptomatic
enveloped RNA coronavirus which is mainly transmitted people and should be recommended. However, as men-
from person-to-person respiratory spread (people who are tioned earlier, due to high risk of spread (by person to
in close contact with each other or respiratory droplets person or contaminated surfaces), exercise in private en-
produced when an infected person coughs or sneezes) and vironments (for example in home) with good ventila-
to a lesser extent from contact with contaminated surfaces tion and use of personal equipment may be more rea-
or objects (1, 2). Preventive strategies may efficiently limit sonable. A home exercise program using different safe,
the rapidly expanding outbreaks of 2019-nCoV, globally (5). simple, and easily implementable exercises is suitable to
The main question in the field of sports and exercise avoid the airborne coronavirus and preserve fitness levels.
medicine is that whether physical activity is suitable dur- This program may include aerobic (walking in the house),
ing this viral respiratory tract epidemic or not. strengthening, stretching and balance exercises, or a com-
First, let us discuss the existing evidence regarding the bination of these (9).
effects of exercises with different intensities on immune Also, moderate intensity aerobic exercise (such as brisk
system responses. Present studies have shown that mod- walking) in outdoor environments with special attention
erate intensity physical activity has positive enhancing ef- to maintaining safe distance with others and surfaces may
fects on immune system responses against viral respira- be a proper alternative. However, the hazards of high-
tory infections (6). Following moderate intensity physi- intensity exercise in public gyms and crowded environ-
cal activity, increase in neutrophil and natural killer (NK) ments may outweigh the benefits and should be avoided.
cell counts is detected and salivary IgA concentrations is Similarly, we have important challenges for competi-
enhanced (6, 7). Moderate intensity physical activity in- tive sport events. Firstly, athletes in this setting should do
creases stress hormones, which leads to reduction in ex- strenuous exercise to compete, which may be immunosup-
cessive inflammation (7). This leads to a boost in immu- pressive. Secondly, the majority of competitive sports man-
nity against viral infections via a change in Th1/Th2 cell re- date close contact of athlete with teammates, opponents,
sponses (6). Twenty to thirty percent reduction of upper environment (for example pool water in swimming or div-
respiratory tract infections is reported in individuals per- ing) or equipment (for example barbells in weight lifting
forming moderate levels of physical activity in their daily or power lifting, javelin, shot put or discus in field sports)

Copyright © 2020, Asian Journal of Sports Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0
International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the
original work is properly cited.
 Halabchi F et al.

which may be hazardous due to the very high contagious- The proposed recommendations regarding physical
ness of COVID-19. Furthermore, the most organized com- activity and sport in a COVID-19 epidemic are summarized
petitions are held in big sport stadiums with a great num- in Table 1.
ber of spectators, which increases the risk of spread. An- Well-designed studies are warranted to determine the
other concern is regarding international competitions in benefits and hazards of exercise in COVID-19 patients, es-
which asymptomatic carrier athletes (especially from the pecially in afebrile patients with mild symptoms over the
countries with high prevalence) may spread the virus to neck.
the opponents, match executives and spectators and cause
an outbreak in the host country. This can accelerate the in-
Footnotes
ternational or intercontinental transmissions. Therefore,
strict 2-week isolation out of camps and matches is highly Conflict of Interests: We declare no conflict of interests.
recommended to any athlete or coach with suspected or es-
Funding/Support: None declared by authors.
tablished COVID-19 disease.
Therefore, it is rational to cancel or postpone these
competitions. However, when the cancellation is not pos- References
sible due to the sensible reasons, the matches should be or-
1. Pradhan P, Pandey AK, Mishra A, Gupta P, Tripathi PK, Menon MB, et al.
ganized without spectators and with full consideration of Uncanny similarity of unique inserts in the 2019-nCoV spike protein
protection and sanitary principles. Due to these considera- to HIV-1 gp120 and Gag. bioRxiv. 2020. doi: 10.1101/2020.01.30.927871.
tions, a big concern exists regarding the largest mass gath- 2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical charac-
teristics of 2019 novel coronavirus infection in China. MedRxiv. 2020.
ering sport events (Tokyo 2020 Olympic and Paralympic
doi: 10.1101/2020.02.06.20020974.
Games). This event is anticipated to take place this summer 3. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical
with the participation of more than 200 countries, 15000 characteristics of 138 Hospitalized patients with 2019 novel
athletes and 20 million visitors and the great question for coronavirus-infected pneumonia in Wuhan, China. JAMA. 2020.
doi: 10.1001/jama.2020.1585. [PubMed: 32031570]. [PubMed Central:
responsible authorities such as the International Olympic
PMC7042881].
Committee (IOC) and World Health Organization (WHO) is 4. Zahra Syeda M, Diabakte K, Geng X, Ji F, Ouyang L, Pan S, et al. The on-
whether to hold, postpone or even cancel these important going epidemic of 2019 novel coronavirus (SARS-CoV-2): Infection and
games (10). fatality trends in Wuhan, Hubei and across China. SSRN. 2020.
5. Xiong H, Yan H. Simulating the infected population and spread trend
Another important question is about continuing or re- of 2019-nCov under different policy by EIR model. SSRN. 2020. doi:
turning to physical activity during or following an upper 10.1101/2020.02.10.20021519.
respiratory tract infection. It is generally guided by the 6. Martin SA, Pence BD, Woods JA. Exercise and respiratory tract
viral infections. Exerc Sport Sci Rev. 2009;37(4):157–64. doi:
“neck check rule”. If the symptoms of upper respiratory 10.1097/JES.0b013e3181b7b57b. [PubMed: 19955864]. [PubMed Central:
tract infection are limited over the neck including cough, PMC2803113].
sneezing and sore throat, the individual is asked to jog for 7. Harris MD. Infectious disease in athletes. Curr Sports Med Rep.
2011;10(2):84–9. doi: 10.1249/JSR.0b013e3182142381. [PubMed:
10 minutes. If the general condition and signs are deteri-
21623289].
orated, he or she should be prohibited from physical ac- 8. Ahmadinejad Z, Alijani N, Mansori S, Ziaee V. Common sports-
tivity until full recovery. If the condition of the individual related infections: a review on clinical pictures, management
did not change following the 10 minutes jogging, he or she and time to return to sports. Asian J Sports Med. 2014;5(1):1–9.
doi: 10.5812/asjsm.34174. [PubMed: 24868426]. [PubMed Central:
is allowed to return to low to moderate physical activity
PMC4009082].
below 80% of VO2 max . However, if the symptoms are be- 9. Chen P, Mao L, Nassis GP, Harmer P, Ainsworth BE, Li F. Coron-
low the neck including myalgia, fever and gastrointestinal avirus disease (COVID-19): The need to maintain regular physical
symptoms, physical activity should be prohibited until full activity while taking precautions. J Sport Health Sci. 2020;9(2):103–4.
doi: 10.1016/j.jshs.2020.02.001. [PubMed: 32099716]. [PubMed Central:
recovery (7, 11). In patients with pneumonia, return to phys-
PMC7031771].
ical activity is much slower and should be gradually during 10. Gallego V, Nishiura H, Sah R, Rodriguez-Morales AJ. The COVID-19 out-
4 weeks (8). break and implications for the Tokyo 2020 Summer Olympic Games.
Travel Med Infect Dis. 2020:101604. doi: 10.1016/j.tmaid.2020.101604.
Nevertheless, it seems that the rule applies to healthy [PubMed: 32112859].
active people with intact immunity and may not be gen- 11. Eichner ER. Infection, Immunity, and Exercise. Phys Sportsmed.
eralizable to the general population. Otherwise, due to the 1993;21(1):125–35. doi: 10.1080/00913847.1993.11710319. [PubMed:
novel characteristics of COVID-19 and its potential negative 27414832].

impact on the immune system and rare cardiac complica-

tions including myocarditis, being more cautious regard-
ing continuing exercise in symptomatic patients seems
reasonable.

2 Asian J Sports Med. 2020; 11(1):e102630.

 Halabchi F et al.

Table 1. Recommendations for Doing Physical Activity and Sport in People with Different Conditions During COVID-19 Epidemic

Condition Low to Moderate-Intensity Exercise High-Intensity Competitive Sport

Exercise
√
× ×
Healthy or asymptomatic persons
Exercise in private environment with good Cancel or postpone or (if not possible)
ventilation; Use of personal equipment organize without spectators and with
full consideration of protection
√
URI with symptoms limited to over /× × ×
the neck
10-minute jog test: If the general condition and
signs are deteriorated: prohibit physical activity
until full recovery; If not changed: allow low to
moderate physical activity (< 80% of VO2 max )
URI with symptoms below the neck
× × ×
(myalgia, fever and GI symptoms), or
pulmonary or multi-organ Physical activity should be prohibited until full
involvement recovery

Abbreviations: GI, gastrointestinal; URI, upper respiratory tract infection.

Asian J Sports Med. 2020; 11(1):e102630. 3