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Rece ved / Gel ş: 24.05.2020 · Accepted / Kabul: 05.08.2020 · Publ shed / Yayın Tar h : 10.11.2020

Correspondence / Yazışma: Pel n Aksen Ceng zhan · Kırıkkale Ün vers tes Spor B l mler Fakültes , Antrenörlük Eğ t m Bölümü, Kırıkkale, Turkey · pel naksen@hotma l.com

Rev ew Art cle / Derleme

Soc al nsulat on dur ng COVID-19: The mportance of phys cal act v ty COVID-19 sürec nde sosyal zolasyon: F z ksel akt v ten n önem

Al Ahmet Doğan , Pel n Aksen Ceng zhan

Department of Coach ng Educat on, Faculty of Sport Sc ences, Kırıkkale Un vers ty, Kırıkkale, Turkey ABSTRACT

Concerns about the increasing spread of COVID-19 have raised and the global epidemic has led virtually all countries around the world to take quick protective measures. Staying at home against infection risks has been a key safety step that can limit the spread of infections to a wider population.

However, this measure resulted in sedentary behaviors, such as playing games on the digital media, watching television, spending excessive time on mobile devices, and decreased physical activity. In this study, the following issues are addressed: importance of physical activity, which has a positive effect on health protection and immune system strengthening, anxiety, and depression reduction during the COVID-19 outbreak; informing people about the available opportunities to be active; the beneﬁts of being active; the amount of activity one should do; and, how safe performing physical activity is. During the pandemic, it is vital to disseminate appropriate messages to encourage the public to engage in physical activity, and to provide information about the beneﬁts of adopting an active lifestyle.

Keywords: Coronavirus, COVID-19, outbreak, pandemic, physical activity ÖZ

COVID-19'un artan yayılımıyla ilgili endişeler artmış, küresel salgın birçok ülkenin hızlı ve koruyucu önlemler almasına yol açmıştır. Enfeksiyon riskine karşı evde kalma, enfeksiyonların geniş kitlelere yayılmasını sınırlandırabilen temel bir güvenlik adımı olmuştur. Uzun süre evde kalmak; dijital ortamda oyun oynamak, televizyon izlemek, mobil cihazlar kullanarak yapılan aktivitelere aşırı miktarda zaman harcamak gibi hareketsiz davranışlara, ﬁziksel ak‐

tivitenin azalmasına yol açmıştır. Bu çalışmada, pandemi süresince ﬁziksel aktivitenin, sağlığın korunması ve bağışıklık sisteminin güçlenmesi, kaygı ve depresyonun azaltılmasında olumlu etkisi olduğuna dikkat çekmek, insanları aktif olmaları için hangi fırsatların var olduğu konusunda bilgilendirmenin yanı sıra, aktif olmanın ne gibi yararları olduğu, kişinin ne kadar aktivite yapması gerektiği ve ﬁziksel aktivitenin ne kadar güvenli olduğu bilgisi sunul‐

maktadır. Pandemi süresince toplumu ﬁziksel aktivite yapmaya teşvik etmek, aktif yaşam tarzı hakkında bilgi vermek için uygun mesajların oluşturulma‐

sı hayati önem taşımaktadır.

Anahtar Sözcükler: Koronavirüs, COVID-19, salgın, pandemi, ﬁziksel aktivite

INTRODUCTION

A publ c health emergency began n Wuhan, Ch na, n De- cember 2019, when a new beta coronav rus, named 2019- new coronav rus (SARS-CoV-2), w th a h gh morb d ty and mortal ty, broke out (1,2). The World Health Organ zat on (WHO) has announced that the v rus caus ng the d sease s named as "COVID-19" (3,4). On January 30, 2020, WHO declared the outbreak as “publ c health emergency of nterna- t onal concern”, and on March 11, as a pandem c (5).

Symptoms of COVID-19 nclude fever, cough, shortness of breath, muscle pa n, headache, and d arrhea (6). The v rus s an RNA coronav rus that spreads from person to person through nd v duals who are n close contact w th each other; by means of resp ratory droplets that occur a er an n- fected person coughs or sneezes; or by contact w th a contam nated person (1,2). Although no vacc ne or drug s ava- lable for the treatment of th s v rus-borne d sease, many researchers around the world have been conduct ng nten-

s ve research on the source of the v rus and ts extens ons.

On the other hand, quest ons such as the ncubat on per od of the v rus, r sk assessment, and e ect ve treatment met- hods have not been answered yet (7).

Health eﬀects of inactive life due to the pandemic The global ep dem c has led many countr es around the world to take qu ck protect ve measures. In Ch na, c t es were completely locked up, travel bans were enforced, and schools and un vers t es were completely closed (8). These measures started w th soc al d stanc ng and self-quarant ne pract ces, mandatory quarant nes, travel restr ct ons, can- cellat on of nternat onal ghts, followed by travel restr ct - ons w th n the country, and f nally curfews were declared.

On the other hand, educat on and tra n ng act v t es have been phys cally nterrupted, and ex ble and home-o ce appl cat ons have started n the workplace wh le onl ne educat on has been n t ated.

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WHO reported that, n 2008, approx mately 31% of adults aged 15 years and over globally, were found to fulf l nsu - c ent phys cal act v ty. It s est mated that approx mately 3.2 m ll on deaths each year result from nsu c ent phys cal act v ty. It was determ ned that the prevalence of nadequate phys cal act v ty was h ghest n the USA and the Eastern Med terranean Reg on. In both reg ons, wh le 50% of women were su c ently act ve, the frequency of nadequate phys cal act v ty n men was 40% n the USA and 36% n the Eastern Med terranean. It was reported that the South- East As a Reg on has the lowest percentages (15% for men and 19% for women) (9). A er COVID-19, a total of 19,144,639 steps/day measured by 455404 people n 187 d f- ferent countr es, worldw de; then, a 5.5% reduct on n ave- rage steps (287 steps) w th n 10 days a er the pandem c declarat on and a 27.3% decrease w th n 30 days (1432 steps) were reported. The max mum decrease of 48.7% was recorded n Italy, and a max mum decrease of 6.9% was recorded n Sweden. In countr es such as Italy and Iran, n wh ch reg onal COVID-19 outbreaks occurred prev ously, earl er decl nes n the number of steps were observed. In US c t es, the number of step trends revealed s m lar t es, des- p te the w de nternat onal var ab l ty. Stud es to demonst- rate the real mpact of worldw de solat on on phys cal act - v ty levels proceed (10).

In a prev ous study, nd v duals' phys cal act v ty levels were compared v rtually n all countr es n the same per od last year w th a wearable dev ce that track phys cal act v ty levels of 30 m ll on users n the quarant ne process, and t was found that there was a 7% to 38% reduct on n the ave- rage number of steps. Th s showed that quarant ne caused a s gn f cant drop n phys cal act v ty levels (11). In stud es on the e ects of quarant ne, negat ve psycholog cal e ects such as post-traumat c stress symptoms, confus on, and an- ger were reported. Restr ct on of movement, loss of the usu- al rout ne, and reduced soc al and phys cal contact w th ot- hers are o en sa d to cause boredom, frustrat on, and a fe- el ng of solat on. It has been shown that there s ser ous concern about the harmful e ects of phys cal nact v ty, espec ally w th l m tat on of movement (12,13).

COVID-19 s a new v rus that causes a resp ratory d sease (14), a ect ng the mmune cells (15). SARS-CoV-2 causes an nfect on n the alveolar ep thel al cells v a the ACE2 receptor. The destruct on of ep thel al cells and ncreased perme- ab l ty causes the release of the v rus, wh ch tr ggers natural mmun ty. Natural mmune cells, such as macrophages and neutroph ls, both capture the v rus and secrete nume- rous cytok nes and chemok nes. These cytok nes and chemok nes also allow monocytes and T lymphocytes to accu- mulate n the nfected area. CD4 + helper T cells st mulate B

cells to prol ferate, d erent ate, and produce v rus-spec f c ant bod es. CD8 + T cells, on the other hand, l m t the nfec- t on w th the r cytotox c e ects. If the nfect on cannot be cleared completely, t causes hyper n ammat on. Hyper nf- lammat on and cytok ne storm syndrome are also observed n pat ents w th severe COVID-19. Cytok ne storm has been reported to cause secondary hemophagocyt c lymphoh st - ocytos s and s assoc ated w th mult ple organ fa lure and death. Strong phys cal exerc se leads to the act vat on of the mmune system, wh ch ncludes cells capable of produ- c ng ROS, such as neutroph ls, monocytes and macrophages (16,17).

Phys cal act v ty, wh ch s one of the ma n components of healthy l fe (18), causes an ncrease n mmune system cells, thereby strengthen ng the mmune system (19). Ex- perts recommend appropr ate phys cal act v t es that w ll ncrease the protect ve e ect of our mmune system aga nst the v rus before the v rus gets act vated n the body and makes us s ck (20) The general consensus n the l terature on exerc se mmunology s that the mmune system responds pos t vely to exerc se, but th s response depends on the sever ty, durat on, and the type of the exerc se (19-21). Card - ovascular exerc se makes mportant contr but ons to the development of the mmune system as t a ms to strengthen the muscles attacked by the v rus (22). Ep dem olog cal stu- d es suggest that regular phys cal act v ty s assoc ated w th a decrease n the nc dence and mortal ty of n uenza and pneumon a (23). In add t on, Woods et al. (24) reported that regular exerc ses mproved responses to vacc nes.

G ven the concerns about the ncreased spread of COVID-19, stay ng at home has been a key measure aga nst the r sk of nfect on, wh ch can l m t the spread of nfect ons to large masses (25). However, stay ng at home causes sedentary behav ors such as spend ng too much t me play ng d g tal games, watch ng telev s on, spend ng excess ve t me on mob - le dev ces, and ly ng down (26). COVID-19 s a d sease m- pos ng h gher r sk for obese nd v duals (15). L m tat ons that prevent part c pat on n outdoor act v t es and trave- l ng freely cause long per ods of nact v ty at home, and these cond t ons that l m t phys cal act v ty cause several health problems, such as anx ety, depressed mood, boredom, anx ety and depress on (27).

The occurrence of quarant ne-related stress and ncreased stress-related nutr ent ntake cause the nd v dual to enter a v c ous c rcle, wh ch results n the deter orat on of sleep patterns. Therefore, t s mportant to consume foods that conta n or promote the synthes s of seroton n and melato- n n at d nner. Melaton n act vates the mmune system cells e ther d rectly through melaton n receptors or nd rectly v a changes n stero d hormones (28).

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Table 1. Examples of home-based bodyweight training exercises

Exercise Frequency Beneﬁts

Dynam c warm-up: High-knee skips, butt kicks, high kicks, lateral shuﬄes

Bodyweight squats 1-2 sets of 10 reps-beginner Lower-body strength and power

2-3 sets of 20 reps-advanced Functional outcomes

Push-ups 1-2 sets of 10 reps-beginner Upper-body strength and endurance

2-3 sets of 20 reps-advanced

Walking lunges 1-2 sets of 5 reps-beginner Hamstring strength and running speed

Planks 1-2 sets of 20 s -beginner Posture, upper+lower body iso. strength

2-4 sets of 40 s -advanced

Jumping jacks 1-2 sets of 15 reps-beginner Endurance and core strength

Sit-ups 1-2 sets of 15 reps-beginner Abdominal and core strength

Cool-down: Static stretching and ﬂexibility exercises

Table 2. Intensity categories of home-based aerobic exercise training for various target groups Trained/Active Sedentary Patients/Elderly

Intensity % HRmax RPE % HRmax RPE % HRmax RPE Additional intensity clues

Low 65

(50-80%) 2 (1-3)

60 (50-75%)

2 (1-3)

60 (50-70%)

2

(1-3) Easy, breath is moderate Moderate 80

(70-90%) 4 (3-5)

75 (70-85%)

4 (3-5)

70 (65-80%)

3 (2-4)

Somewhat hard, breath quickens, talking is possible, but not singing

High 90

(85-100%) 6 (5-10)

85 (80-95%)

5 (4-8)

80 (70-90%)

5 (3-7)

Challenging, breath is deep and rapid, only few words can be said without pausing for breath

HRmax: heart rate % of maximal heart rate (estimated as 220-age); RPE: rating of preceived exertion during aerobic training (scale relates to following intensity; 0:

rest, 2: easy, 3: moderate, 5: hard, 7: very hard, 10: max)

Increased eat ng frequency, ncreased use of alcohol c be- verages, and decreased energy consumpt on cause we ght ga ns (12). Decreased phys cal act v ty negat vely a ects the mmune system act v ty, worsen ng the cond t on of people w th chron c d seases such as heart problems, d abetes, and h gh blood pressure (29,30).

Enter ng the quarant ne per od suddenly, and thus stop- p ng exerc se abruptly causes nsul n res stance to n t ate rap dly n muscle t ssue, and thereby the use of muscle gly- cogen starts to decrease, result ng n muscle atrophy. Meta- bol c and card ovascular adaptat ons can lead to mpa red aerob c capac ty and ncreased blood pressure a er an exerc se break, even just for two weeks. Unused muscles lead to reduced energy consumpt on, ncreased atherogen c l poprote n product on, and relocat on of metabol c subst- rates n the l ver; thus, by accelerat ng atherosclerot c d sease, t causes obes ty and l p d accumulat on n blood ves- sels (31). Abrupt d scont nuat on of phys cal act v ty can lead to decreased venous blood c rculat on and coronary perfus on, wh ch may make nd v duals suscept ble to dete- r orat on n health when they restart exerc s ng. Rest ng heart rate ncreases a er the acute cessat on of phys cal act - v ty, and the r sk of card ovascular d sease and mortal ty may ncrease even more (32,33).

Physical activity and immune system relationships in the pandemic process

Dur ng COVID-19, perform ng s mple, safe, and easy exerc - ses s very mportant to ma nta n the f tness level. Exerc ses can be performed n quarant ne cond t ons s nce they requ- re no spec al place and tools. In terms of ndoor exerc ses, very modern aud o-v sual tools, such as soc al med a, e-health, ndoor exerc se pract ces, and phys cal act v ty v deos, are used over the nternet, such as YouTube. A large number of dance, aerob cs, yoga, p lates, and strength tra n ng programs are ava lable. Examples of home exerc ses are:

yoga, walk ng n the house, ndoor runn ng, cl mb ng sta- rs, home exerc se b kes, and treadm lls. S mple household tems such as f lled water bottles and cans or food packages can be useful as we ght exerc ses. The h gh number of repe- t t ons dur ng exerc se can stra n the person, even when work ng w th low we ghts. Exerc ses that do not requ re equ pment, such as push-ups and s t-ups performed w th one's own body we ght, and that can be pract ced at all t - mes are also useful (25,34).

Table 1 presents aerob c tra n ng categor es for tra ned and untra ned nd v duals, w th exclus ve ntens ty data related to heart rate, rat ng of perce ved exert on (RPE), and nten- s ty data regard ng the extent of breathlessness dur ng exerc se.

Body-we ght exerc ses nvolv ng the upper and lower body are push-ups, pull-ups, squats, lunges, box jumps, jump ng rope, burpees, etc (Table 2).

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A most mportant quest on n the f eld of sports and exerc - se med c ne s whether t s appropr ate to perform phys cal act v ty dur ng a v ral resp ratory outbreak (35). There s currently no sc ent f c data on the e ects of exerc se on coronav rus, but n ep dem olog cal stud es conducted a er the 2009 H1N1 n uenza ep dem c, phys cal act v ty before nfect on has been shown to be e ect ve n reduc ng the n- c dence, durat on, or sever ty of the cond t on (36). S gn f - cant reduct ons n mortal ty r sk were reported n pat ents w th resp ratory d sease, pneumon a and asp rat on pneumon a n runners, nclud ng those w th d abetes (37).

Exerc se s the most e ect ve therapy to reduce symptoms of depress on (38). Aerob c exerc se has a pos t ve e ect on pat ents d agnosed w th anx ety d sorder (39). COVID-19 d - sease can be asymptomat c for several days. H gh ntens ty exerc ses can cause the exacerbat on of the COVID-19 v rus, espec ally n obese people, due to the product on of ox - dants and suppress on of the mmune system. The most conven ent way to deal w th the COVID-19 v rus are moderate- ntens ty aerob c exerc ses and phys cal act v t es, such as br sk walk ng (40-42). It has been reported that exerc ses last ng for at least 150 m n per week, nclud ng muscle strengthen ng act v t es for 20 m n a day (25), at least two days a week, w th appropr ate rest ntervals, s e ect ve n prevent ng chron c d seases (43). Phys cal act v ty s known to reduce the r sk of system c n ammat on, excess body mass, and d seases endanger ng mmune funct on (22,44).

The eﬀect of pandemic on mass sports

Compet t on sports, h gh- ntens ty exerc ses n publ c gyms, and crowded env ronments should be avo ded as they can be very dangerous than benef c al (35). Because of the h gh r sk of v rus spread ng from person to person, or through contam nated surfaces, exerc se env ronments should be well vent lated and the use of personal equ pment should be preferred. Safe, s mple, and pract cal home exer- c ses are su table for th s purpose to prevent th s a rborne coronav rus and ma nta n f tness levels. Th s program can nclude aerob c (walk ng at home), strengthen ng, stretc- h ng, and balance exerc ses, or a comb nat on of these (25).

All k nds of act v t es nvolv ng large aud ence n crowded ndoor fac l t es, sw mm ng pools, barbell bars, shot put, and javel n ncrease the r sk of transm ss on of COVID-19.

Another concern regard ng the r sks s mposed by athletes, execut ves, and spectators part c pat ng n nternat onal compet t ons, espec ally from countr es where the v rus s h ghly prevalent. Th s can speed up nternat onal or nter- cont nental transfers. Athletes or tra ners w th suspected COVID-19 d sease are strongly recommended for two weeks of sol tary solat on before camps and games/matches. The-

refore, t makes sense to cancel or postpone these compet - t ons (35).

It s very mportant that compet t ons wh ch cannot be can- celed due to certa n reasons should be carr ed out w th ma- x mum attent on to san tary pr nc ples to protect the aud - ence. There ex sts a huge danger wa t ng for us at the Tokyo 2020 Olymp c Games and Paralymp c Games, wh ch w ll ac- commodate very large masses. Tokyo 2020 Olymp c Games are expected to take place th s summer w th the part c pat - on of more than 200 countr es, 15,000 athletes, and 20 m l- l on v s tors. Author t es such as the Internat onal Olymp c Comm ttee (IOC) and the WHO are expected to postpone or cancel these mportant games (35). For nstance, the Inter- nat onal Olymp c Comm ttee announced on 24 March 2020 that the Tokyo 2020 Olymp c and Paralymp c Games w ll be postponed to the summer of 2021. In support of th s dec s - on, the mportance of protect ng the athlete's health has been emphas zed n var ous statements reported by nternat onal sports organ zat ons (45).

In the face of th s new coronav rus pandem c, the WHO, the Centers for D sease Control and Prevent on, and other pub- l c health counsel ng organ zat ons encourage regular par- t c pat on n phys cal act v ty, as long as they rema n com- m tted to publ c health and commun ty safety rules, and are not contra nd cated n part cular nd v duals (4,46-48).

L m t ng nd v duals' freedom of travel, and pract ces such as quarant ne should not y eld n the prevent on of nd v - duals from engag ng n phys cal act v ty. Many stud es show that phys cal act v ty contr butes pos t vely to the health of nd v duals w th d erent d seases (29). Ch ldren, the elderly, and nd v duals w th chron c llnesses must al- ways seek med cal adv ce before start ng any phys cal act - v ty program.

CONCLUSION

To conclude, t s very mportant to perform phys cal act - v ty dur ng the COVID-19 outbreak n order to protect the health and strengthen the mmune system. Any dec s on taken by the author t es and restr ct ng the nd v dual's ab - l ty for outdoor mob l ty should not prevent phys cal act - v ty. Phys cal act v ty has a pos t ve e ect on reduc ng anx - ety and depress on that occur dur ng the quarant ne per od caus ng nact v ty.

Ma nta n ng a regular phys cal act v ty rout ne n a fa rly safe env ronment s cons dered to be an appropr ate stra- tegy for healthy l v ng and f tness dur ng the coronav rus pandem c. In th s research, these top cs are presented: n- door act v ty opt ons ava lable for the general publ c, bene- f ts of be ng act ve, how much act v ty a person should perform, and how safe phys cal act v ty s. It s v tal to d ssem

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nate appropr ate messages to encourage the soc ety to engage n phys cal act v ty and to prov de nformat on about act ve l festyles.

Conﬂict of Interest / Çıkar Çatışması

The authors declared no con cts of nterest w th respect to authorsh p and/or publ cat on of the art cle.

Financial Disclosure / Finansal Destek

The authors rece ved no f nanc al support for the research and/or publ - cat on of th s art cle.

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