Effects of Pilates in Patients With Post- -COVID-19 Syndrome: Controlled and Randomized Clinical Trial
Phase: NA
Conditions: COVID-19
Sponsor: Michele de Aguiar Zacaria

 
 
 
AUGUSTO MOTTA UNIVERSITY CENTER 
Stricto Sensu Postgraduate Program in Rehabilitation Sciences 
Academic Master's in Rehabilitation Sciences 
 
 
 
MICHELLE DE AGUIAR ZACARIA 
 
 
 
 
 
 
 
EFFECTS OF PILATES ON PERIPHERAL MUSCLE STRENGTH, 
DYSPNEA AND FATIGUE IN PATIENTS WITH POST-COVID-19 
SYNDROME: CONTROLLED AND RANZOMIZED CLINICAL TRIAL 
 
 
 
 
 
 
 
 
 
 
RIO DE JANEIRO 
2022 
 

 
 
ii 
Summary 
 
Introduction: COVID-19 is an emerging pandemic disease caused by severe acute 
respiratory syndrome (SARS-CoV-2). Although most patients infected with SARS-
CoV-2 are asymptomatic or have mild symptoms, some patients develop severe 
symptoms that can long-term impair their quality of life and functional capacity. SARS-
CoV-2 is closely related to severe acute respiratory syndrome (SARS) with direct and 
indirect effects on several systems, especially the musculoskeletal system, in addition 
to the respiratory system. Some of these symptoms persist for a long time, called Post-
Covid-19 Syndrome, directly interfering with the functional capacity and quality of life 
of these patients. Pilates exercises focus on breathing, postural symmetry, trunk 
stabilization, flexibility, joint mobility and strengthening through the full range of motion 
of all joints and not isolated muscle groups. Objectives: The objective of this study will 
be to evaluate the clinical and functional effects of a Pilates exercise program for 
patients with Post-Covid-19 syndrome after a period of intensive care admission and 
invasive mechanical ventilation. Methods: The study will be a clinical, randomized and 
controlled trial. 48 patients of both sexes, over 18 years of age, who have developed 
the severe form of COVID-19 and required at least 7 days of invasive mechanical 
ventilation will be recruited. Patients who currently require supplemental oxygen at 
home and who present motor, cognitive or neurological alterations that prevent the 
practice of Pilates will be excluded . They will be previously randomized in a 1:1 ratio 
by electronic system and blindly allocated to the intervention group that will perform an 
exercise protocol based on the Pilates method , 2x/week, for 12 weeks in therapeutic 
sessions of identical protocols lasting 60 min. All patients will be evaluated before and 
after for peripheral muscle strength and endurance , post-Covid-19 functional status, 
dyspnea, fatigue and quality of life. Data analysis will be performed using the SPSS 
23.0 program ( Statistical Package for Social Sciences ). Descriptive analysis will be 
performed for all variables (mean and standard deviation). General Linear Model ( 
GLMs ) with mixed design will be performed to compare treatment effect size between 
groups. The pairwise comparison comparisons ) will be performed to verify the mean 
difference between the Pilates Group and the Control Group in all variables in each 
period independently. Intention-to-treat analysis was used using the Last method. 
observation Carried Forward (LOCF) for lost participant data. A significance level of 
0.05 and a confidence interval of 95% will be adopted. Results: The expected results 
are based on the alternative hypothesis that Pilates exercises are clinically effective, 
improving functional performance, exercise tolerance, balance , reducing symptoms 
and improving the quality of life of patients with symptoms of Post-Covid-19 Syndrome. 
 
Keywords: Covid-19; Pilates Method ; everyday activities; ( http://decs.bvs.br/ ). 
 
 
Abstract  
 
Introduction: COVID-19 is an emerging pandemic disease caused by severe acute 
respiratory syndrome (SARS-CoV-2). Although most patients infected with SARS-
CoV-2 are asymptomatic or have mild symptoms, some patients develop severe 
symptoms that can long-term impair their quality of life and functional capacity. SARS-

 
 
iii 
CoV-2 is closely related to severe acute respiratory syndrome (SARS) with direct and 
indirect effects on several systems, especially the musculoskeletal system, in addition 
to the respiratory system. Some of these symptoms persist for a long time, called Post-
Covid-19 Syndrome, directly interfering with the functional capacity and quality of life 
of these patients. Pilates exercises focus on breathing, postural symmetry, trunk 
stabilization, flexibility, joint mobility and strengthening through the full range of motion 
of all joints and not isolated muscle groups. Objectives: The objective of this study will 
be to evaluate the clinical and functional effects of a Pilates exercise program for 
patients with Post-Covid-19 syndrome after a period of intensive care admission and 
invasive mechanical ventilation. Methods: The study will be a clinical, randomized and 
controlled trial. 48 patients of both sexes, over 18 years of age, who have developed 
the severe form of COVID-19 and required at least 7 days of invasive mechanical 
ventilation will be recruited. Patients who currently require supplemental oxygen at 
home and who present motor, cognitive or neurological alterations that prevent the 
practice of Pilates will be excluded. They will be previously randomized in a 1:1 ratio 
by electronic system and blindly allocated to the intervention group that will perform an 
exercise protocol based on the Pilates method, 2x/week, for 12 weeks in therapeutic 
sessions of identical protocols lasting 60 min. All patients will be evaluated before and 
after for peripheral muscle strength and endurance, post-Covid-19 functional status, 
dyspnea, fatigue and quality of life. Data analysis will be performed using the SPSS 
23.0 program (Statistical Package for Social Sciences). Descriptive analysis will be 
performed for all variables (mean and standard deviation). General Linear Model 
(GLMs) with mixed design will be performed to compare treatment effect size between 
groups. Pairwise comparisons will be performed to verify the mean difference between 
the Pilates Group and the Control Group in all variables in each period independently. 
Intention-to-treat analysis was used using the Last Observation Carried Forward 
(LOCF) method for data on lost participants. The significance level of 0.05 and a 
confidence interval of 95% will be adopted. Results: The expected results are based 
on the alternative hypothesis that Pilates exercises are clinically effective, improving 
functional performance, exercise tolerance, balance, reducing symptoms and 
improving the quality of life of patients with symptoms of Post-Covid-19 Syndrome. 
 
Keywords: Covid-19; Pilates Method; everyday activities; (http://decs.bvs.br/). 
 
 
 
 
summary 
ABSTRACT  
II 
ABSTRACT  
II 
CHAPTER 1  
LITERATURE REVIEW  
6 
1.1  INTRODUCTION  
6 
1.1.1  COVID-19  
7 

 
 
iv
1.1.2  ETIOLOGY, PATHOGENESIS AND EPIDEMIOLOGY  
8 
1.1.3  DIAGNOSIS  
10 
1.1.4  CLINICAL PICTURE  
11 
1.1.5  ACUTE HYPOXEMIC RESPIRATORY FAILURE  
12 
1.1.6  SEVERE ACUTE RESPIRATORY SYNDROME DUE TO THE EVOLUTION OF COVID-19  
13 
1.1.8.1  NEUROLOGICAL DYSFUNCTIONS  
16 
1.1.8.2  MUSCULOSKELETAL DISORDERS  
17 
1.1.9.1  DYSPNEA  
18 
1.1.9.1.1  DYSPNEA ASSESSMENT  
19 
1.1.9.2  MUSCULOSKELETAL CHANGE IN COVID-19  
22 
1.1.9.2.1  PERIPHERAL MUSCLE ASSESSMENT  
24 
1.1.9.3  FATIGUE  
27 
1.1.9.4  FATIGUE ASSESSMENT  
29 
1.2  PILATES METHOD  
31 
1.2.1  RATIONALE FOR THE USE OF PILATES IN THE MANAGEMENT OF DYSFUNCTIONS CAUSED 
BY COVID-19  
35 
1.3  JUSTIFICATIONS  
35 
1.3.1  RELEVANCE TO REHABILITATION SCIENCES  
37 
1.3.2  RELEVANCE TO THE MINISTRY OF HEALTH'S PRIORITY AGENDA  
37 
1.3.3  RELEVANCE FOR SUSTAINABLE DEVELOPMENT  
37 
1.4  OBJECTIVES  
38 
1.4.1  PRIMARY/GENERAL  
38 
1.4.2  SECONDARY/SPECIFIC  
38 
1.5  ASSUMPTIONS  
38 
2.1  ETHICAL ASPECTS  
39 
2.2  STUDY DESIGN  
39 
2.2.1  LOCATION OF THE STUDY  
39 
2.2.2  PRE-REGISTRATION OF PROTOCOL  
39 
2.3  SAMPLE  
40 
2.3.1  PLACE OF STUDY RECRUITMENT  
40 
2.3.2  INCLUSION CRITERIA  
40 
2.3.3  EXCLUSION CRITERIA  
40 
PROPOSED PROCEDURES/METHODOLOGY  
41 
2.3.4  CLINICAL ASSESSMENT  
41 
2.4  OUTCOMES  
46 
2.4.1  PRIMARY OUTCOME  
46 
2.4.2  SECONDARY OUTCOME  
47 
2.5  DATA ANALYSIS  
47 
2.5.1  SAMPLE SIZE (CALCULATION OR JUSTIFICATION)  
47 
2.5.2  CONTROL VARIABLES  
48 
2.5.3  EXPOSURE VARIABLES  
48 
2.5.4 CONFOUNDING  
VARIABLES 
 
48 
2.5.5  STATISTICAL ANALYSIS PLAN  
48 
2.5.6  AVAILABILITY AND ACCESS TO DATA  
49 

 
 
v 
2.6  EXPECTED RESULTS  
49 
2.7  BUDGET AND FINANCIAL SUPPORT  
49 
2.8  SCHEDULE  
50 
REFERENCES  
52 
APPENDIX 1 - FREE AND INFORMED CONSENT FORM  
55 
APPENDIX 2 – PRELIMINARY ETHICAL CHECKLIST (CEPLIST)  
57 
APPENDIX 3 - TERM OF AUTHORIZATION FOR THE USE OF IMAGE  
60 
APPENDIX 4 - TERM OF CONSENT  
61 
ANNEX 1 - POST-COVID-19 FUNCTIONAL STATUS SCALE (PCFS)  
62 
ANNEX 2 – MODIFIED MEDICAL RESEARCH COUNCIL DYSPNEA SCALE  
63 
ANNEX 3 - PICTOGRAM OF FATIGUE  
64 
 
 

 
 
6
Capítulo 1 Literature review 
 
 
1.1 
Introduction 
 
Covid-19 has been described as a serious respiratory disease, which mainly 
affects the lower respiratory tract, coursing with pneumonia and SARS. In general, the 
course of the disease can range from mild (about 81% of cases) or moderate to severe 
(14% of cases) (MACHADO, et al. , 2020; RAGHU, WILSON, 2020) . However, about 
5% have critical clinical conditions combined with other systemic complications, as a 
result of the morbidities acquired in the process, which cause important impacts on the 
functional and cognitive capacities of recovered individuals (PAHO/WHO, 2020) 
In this context, the respiratory condition is one of the most affected in the 
process of infection by SARS-CoV-2, and such findings have been demonstrated by 
studies with very robust methodologies, that important fibrotic lung lesions emerged as 
the main consequences observed in individuals who had the most severe form of 
Covid-19 (GREVE, BRECH, et al. , 2020, HULL, et al. , 2020) . Still in this context, 
Raghu and Wilson (2020) were able to observe in their study that individuals, after 
hospital discharge, presented restrictive pulmonary sequelae, such as: the reduction 
of lung volumes and capacities, as well as diffusion alterations inherent to interstitial 
impairment, in addition to some important findings regarding small airway obstruction. 
Another consequence of SARS-Cov-2 infection on respiratory capacity is the damage 
generated in neural tissue by inflammatory events, causing loss of neuromuscular 
function, generating hypotrophy of the respiratory muscles (HADAYA;, BENHARASH, 
2020; ZOUFALY, POGLITSCH, et al. , 2020) . 
Another very important finding in post-Covid-19 individuals was also observed, 
is the musculoskeletal condition. In this sense, the authors Greve, Brech et al . (2020) 
will describe in their study that in the first week of hospitalization, a loss of up to 20% 
of quadriceps muscle mass can occur in septic individuals in the ICU. Among the main 
findings, the authors point out that just being in bed for a week can generate a 30% 
reduction in muscle strength, followed by an additional loss of 20% each following 
week. In view of this, it is concluded that the loss of muscle mass and strength is closely 

 
 
7
and directly associated with deficits in the functional capacity and daily activities of 
these individuals (CORRÊA, KARLOH, et al. , 2011; NUNES, HERVÉ, et al. , 2020) . 
Still in the scope of functional sequelae, we have that the systemic 
manifestations of the disease associated with the consequences, often iatrogenic, of 
prolonged hospitalizations and of the therapeutic measures implemented to support 
life, produce sequelae that not only limit exercise tolerance, but also affect the quality 
of life of individuals. Given this context, the objective of the present study is to present 
and evaluate the factors related to the persistence of symptoms in patients with post-
Covid-19 syndrome after hospital discharge. 
1.1.1 
COVID-19 
The so-called pandemic by the "Novo Corona Virus" and later named COVID-
19, has its emergence dated in 2019, having only been documented and announced 
to the world by the World Health Organization (WHO), after the observation of several 
cases of infection. severe respiratory infection of unknown origin (CHENG, JIAN, et al. 
, 2020;) .  
In this context, about a few days later, the identification of a virus found in an 
oropharyngeal swab sample with symptoms similar to those observed in the 
Coronaviridae family occurs , in this way, the “new coronavirus ” receives the name of 
SARS-CoV-2 and the disease caused by it from “ Coronavirus disease 2019” . Since 
then, it has been known as COVID-19, and later, from March 2020, the WHO would 
declare the pandemic by Covid-19, whose real context was already alarming, as it had 
more than 118,000 cases of infected people around the world. , having already caused 
almost 5,000 deaths (WEINBERGER, CHEN, et al. , 2020) . 
In the practical clinical and pathophysiological context, Covid-19 can be 
described as a serious respiratory disease, which mainly affects the lung parenchyma 
and the lower airways, triggering pneumonia and SARS. The course of the disease 
can range from mild (81% of cases) and moderate to severe (14% of cases), requiring 
urgent care in an intensive care unit. The remaining 5% have critical clinical conditions 
combined with other multisystem complications. ( MACHADO, Debora Mazioli, 
VIANNA, et al. , 2020, RAGHU, WILSON, 2020) . SULEYMAN, FADEL, et al. , 2020) 
. 

 
 
8
1.1.2 
Etiology, Pathogenesis and Epidemiology 
The so-called coronavirus received this designation in 1965 due to its 
microscopic profile, with a structure similar to a crown, and there are seven human 
coronaviruses identified today, namely: HCoV-229E and HCoV-NL63, of the genus 
Alfacoroanavirus and HCoV-OC43. , HCov-HKU1, SARS- CoV , MERS - CoV , SARS-
CoV-2, of the genus Betacoronavirus . The SARS -CoV-2 coronavirus, responsible for 
Covid-19, belongs to the order Nidovirales and the family Coronaviridae (DA SILVEIRA 
CESPEDES, DE SOUZA, 2020a, ZACHARIAH, JOHNSON, et al. , 2020) . 
Such a virus is structurally composed of a nuclecapsid and the viral envelope, 
formed respectively by genomic RNA , N protein ( nuclecapsid phosphorylated ) and 
four proteins (S – spike , M – membrane, E – envelope, HE – hemagglutinin esterase 
) (TOMAZINI, MAIA, et al. , 2020, WIERSINGA, RHODES, et al. , 2020) . 
Perhaps because it is a new presentation of the disease, the pathogenesis of 
Covid-19 is still not so clarified, however, it is understood that to enter the cell, the S 
protein of the viral complex tends to fix itself on the carboxypeptidase enzyme receptor 
correlated with angiotensin converting enzyme 2 (ACE2) (SANTOS, FINATTI, 2020, 
ZOUFALY, POGLITSCH, et al. , 2020) . 
Soon after, to result in viral replication, it is necessary that the genetic material 
of the virus is endocytosed , and soon after fusing with the cell membrane, the RNA is 
converted into DNA through reverse transcription (TOMAZINI, MAIA, et al. , 2020) . 
ACE2 receptors are categorical in cardiopulmonary tissues and hematopoietic cells, 
and cytokine release and T cell apoptosis may occur (DA SILVEIRA CESPEDES, DE 
SOUZA, 2020b, PUNTMANN, CARERJ, et al. , 2020, WIERSINGA, RHODES, et al. , 
2020) . 
Therefore, it is suggested that in severe cases of respiratory diseases, the effect 
of activating a cascade coagulation occurs, due to high levels of interleukin 6 (IL-6), 
intense lymphopenia and great disturbance of cytokines , generating in practice an 
increased risk of thromboembolic events (ARENTZ, YIM, et al. , 2020, DA SILVEIRA 
CESPEDES, DE SOUZA, 2020b, MERKLER, PARIKH, et al. , 2020, WARE, 2020, 
ZOUFALY, POGLITSCH, et al. , 2020) . 
 
Regarding the transmission of the virus, it was identified that this occurs via the 
mucous membranes of the human body, mainly through the airways, through close 

 
 
9
contact from individual to individual, and the main means of contamination is through 
respiratory droplets when talking, sneezing. or coughing (CHENG, JIAN, et al. , 2020, 
DA SILVEIRA CESPEDES, DE SOUZA, 2020a) . According to the WHO, the first three 
days, counting from the onset of symptoms, is considered the period of greatest 
transmissibility, considering that the virus is mainly found in the upper airways, a place 
that, due to the proximity of people, increases the risk of contamination. vertical and 
horizontal. 
However, transmission can still occur in the pre -symptomatic period, that is, 
between the first and third day before the onset of symptoms (TEICH, KLAJNER, et al. 
, 2020, WIERSINGA, RHODES, et al. , 2020) . When considering other forms of 
transmission, the literature says that human coronaviruses can persist viable 
contamination on object surfaces for up to nine days. However, these surfaces can be 
sanitized with 0.1% sodium hypochlorite solution and also concentrations between 62-
71% of ethanol. Finally, direct contact with bodily fluids from an infected individual also 
becomes a major means of transmission (CHENG, JIAN, et al. , 2020) . 
When referring to the incubation period of the SARS-CoV-2 virus, it should be 
noted that it can be considerably long, with an average between 5 and 6 days, with the 
possibility of variation from 2 to 14 days. Some authors point out that in 95% of cases, 
incubation occurs in 5.1 days, and 97.5% of infected individuals develop symptoms of 
Covid-19 around 11.5 days (MILLAR, BUSSE, et al. , 2020) . , PUNTMANN, CARERJ, 
et al. , 2020, WIERSINGA, RHODES, et al. , 2020) . Only 1%, in every ten thousand 
cases, develop symptoms after 14 days, and consequently, the long incubation period, 
the delay in the manifestation of symptoms and asymptomatic individuals, are 
determining factors to explain the high transmission rate of Covid-19. (GRASSELLI, 
TONETTI, et al. , 2020) . 
The WHO estimated that at the beginning of the pandemic, the fatality rate could 
vary between 5.1% and 5.6%, which would make the SARS-CoV- 2 situation high when 
compared to other different types of Influenza . Despite the evidence that we were 
facing a moderate to severe pandemic, the difficulty of having a real perspective of 
lethality at the beginning was very great (DA SILVEIRA CESPEDES, DE SOUZA, 
2020b, MILLAR, BUSSE, et al. , 2020 ) . After all, it is considered that it can be 
influenced by several factors such as demographic and socioeconomic conditions, 
mass testing capacity of the population involved, the services offered in providing 
diagnosis and adequate care at different levels of complexity, especially in therapy 

 
 
10 
units. intensive care unit (ICU) and health systems in each country (AMITRANO, 
MAGALHÃES, et al. , 2020, WILLIAMSON, WALKER, et al. , 2020) . 
 
 
1.1.3 
Diagnosis 
Diagnosis is based on detection of viral RNA through a molecular real-time 
polymerase chain reaction (RT-PCR) test, which is currently considered the gold 
standard. This test is performed by collecting respiratory samples, such as 
nasopharyngeal smear or bronchial aspirate, and has high sensitivity (ability to identify 
individuals with the disease) and specificity (ability to identify individuals without the 
disease) (BÖGER, FACHI, et al. , 2020, DA SILVEIRA CESPEDES, DE SOUZA, 
2020a, b, PUJADAS, CHAUDHRY, et al. , 2020, SURKOVA, NIKOLAYEVSKYY, et al. 
, 2020) . The WHO recommends that the RT-PCR test should be performed between 
the third and seventh day of the onset of symptoms and/or suspicion of the disease in 
order to obtain maximum precision in the results. However, both the long incubation 
time of the virus and the insufficient amount of viral genome can favor false negative 
results (SURKOVA, NIKOLAYEVSKYY, et al. , 2020) . 
IgM serological tests and antibody detection are another possibility used to 
identify the presence of Covid-19. Both work with responses to viral infection, such as 
the production of IgG in affected individuals, and such tests are considered simple, fast 
and easy to perform, making them the best option for large groups that need a quick 
and low-cost response. (PALLETT, RAYMENT, et al. , 2020, WIERSINGA, RHODES, 
et al. , 2020 ; THE LANCET RESPIRATORY MEDICINE, 2020) . However, this test 
has around 30% to 40% of possibility for false negative, in addition, it is recommended 
to optimize the results, that individuals must present symptoms, therefore, it is not 
immediately recommended to be performed in asymptomatic individuals. (BATISTA, 
DIÓGENES, et al. , 2020, BÖGER, FACHI, et al. , 2020, DA, CHAVES, 2013, 
PALLETT, RAYMENT, et al. , 2020, TEICH, KLAJNER, et al. , 2020) . 
For diagnostic purposes, imaging tests have been shown to be useful and 
differentiated, mainly to guide decision-making on therapeutic interventions. Among 
them, computed tomography (CT) of the chest stands out, which allows characteristic 
findings such as: irregular bilateral ground-glass opacity or consolidation in the 
peripheral areas of the lungs with septal and interlobular vascular thickening. (CHUA, 

 
 
11 
ARMSTRONG-JAMES, et al. , 2020, HAMMER, RAPTIS, et al. , 2020, POLISTINA, 
SIMIOLI, et al. , 2020, TEICH, KLAJNER, et al. , 2020) . Finally, although the findings 
change with the evolution of the disease, compatible with other forms of pneumonia, 
CT has not only shown good applicability and good clinical correlation, but also its fast 
scanning process makes it a valuable option in the diagnostic complement in patients 
with suspected Covid -19, and optimizes the therapeutic plan for the patient (BÖGER, 
FACHI, et al. , 2020, HAMMER, RAPTIS, et al. , 2020, PEGADO, SILVA-FILHO, et al. 
, 2020) . 
 
1.1.4 
Clinical condition 
In Covid-19, around 80% of individuals develop mild or uncomplicated disease, 
20% develop severe symptoms and will be at the mercy of treatment in an Intensive 
Care Unit (ICU). In the first week, symptoms are related to the spread of the virus in 
the body and are similar to those of common colds, in which the main symptoms 
include a runny nose, nasal congestion, fever, cough and sputum, and headache, 
tachypnea and myalgia or fatigue may also occur. (SANTOS, FINATTI, 2020 ; EL 
MOHEB, NAAR, et al. , 2020, PEGADO, SILVA-FILHO, et al. , 2020) . 
In the next phase, usually from the seventh day, events related to the activity of 
the so-called inflammatory storm occur, which can change the disease status from 
moderate to severe. At this stage, the persistence of initial symptoms is still observed, 
plus broader and systemic signs and symptoms, where individuals have prolonged 
fever, asthenia, dyspnea, tachycardia, cyanosis, hemoptysis, hypotension and angina 
(GEBERHIWOT, MADATHIL, et al. , 2020, MERKLER, PARIKH, et al. , 2020, TEICH, 
KLAJNER, et al. , 2020) . In this context, in approximately 20% of cases, the presence 
of gastrointestinal symptoms (nausea, vomiting and diarrhea), neurological symptoms 
( ageusia , digeusia , stroke, ataxia, convulsions, etc. ) and cutaneous manifestations 
( erythematous rash , urticaria) are also observed. and papillo-vesicular lesions ) ( EL 
MOHEB, NAAR, et al. , 2020) . In some cases, there is also a reduction in albumin 
levels, an increase in C-reactive protein and an increase in lactate dehydrogenase can 
be verified in laboratory tests, while in imaging tests, bilateral pneumonia is the main 
finding. (DA SILVEIRA CESPEDES, DE SOUZA, 2020a, TEICH, KLAJNER, et al. , 
2020) . Finally, during the tenth day of the disease, individuals end up needing 

 
 
12 
hospitalization for treatment and use of supplemental oxygen therapy (IOANNOU, 
LOCKE, et al. , 2020) . 
Not infrequently, some individuals who reach the most severe condition, 
approximately 5%, develop very uncomfortable systemic complications, conferring 
greater morbidity to the disease progression. According to Merkel et al. (2020) and 
Puntmann et al . (2020), such complications can be: severe pneumonia, progressive 
respiratory failure due to alveolar damage, ARDS, acute renal failure, heart failure, liver 
failure, sepsis and septic shock, thromboembolic events, bacterial or fungal infections 
, multiple organ failure , persistence of hyperthermia, decreased lymphocyte and 
leukocyte counts and new pulmonary infiltrates. 
Taking this context into account, complications from Covid-19 usually occur in 
individuals who have risk factors and previous comorbidities such as: age >60 years, 
diabetes mellitus, arterial hypertension, smoking, obesity (BMI > 40), COPD, disease 
chronic kidney disease, chronic liver disease, immunodeficiency and cerebrovascular 
disease. So much so that, in the study by Pegado (2020), it was observed that the 
exacerbation of adjacent diseases and the findings of respiratory rate >30 RM and 
SatO 2 < 93%, PaO2 / FiO2 < 300, represented a poor prognosis, accompanied by a 
rate of mortality from SARS around 10%. Therefore, it is suggested that there is a 
strong association that other unfavorable pre-existing clinical conditions combined with 
Covid-19 significantly favor the worsening of the clinical condition, and consequently, 
considerably increase the mortality rate of these individuals (IOANNOU, LOCKE, et al. 
, 2020, PUJADAS, CHAUDHRY, et al. , 2020) . 
 
1.1.5 
Acute hypoxemic respiratory failure 
Regarding the clinical and systemic manifestations of Covid-19, pneumonia can 
be characterized by pulmonary inflammation, where the presence of fluid in the 
pulmonary alveoli occurs, also being observed on CT with a predominance of alveolar 
changes, with up to 50% involvement. of total lung tissue (CHUA, ARMSTRONG-
JAMES, et al. , 2020) . From a structural point of view, there is resistance in the airways 
and in inspiratory movements due to the accumulation of secretions, which also 
contributes to an increase in symptoms such as fever, dyspnea, tachypnea , cough, 
angina and O 2 desaturation (CHAVES, 2013). ) .  

 
 
13 
The study by Araujo - Filho et al. (2020) suggests that, when considering 
imaging exams, most of the published studies highlight CT with more relevant findings, 
among which the main findings are: ground-glass opacity, focal consolidations 
accompanied by mixed opacities, among they have an inverted halo, multifocal and 
bilateral involvement with greater peripheral distribution, followed by predominance in 
the middle, lower and posterior lung fields. The author also reports that in individuals 
at a more advanced stage of the disease, it can be observed that the alveolar changes 
are superimposed by septal thickening and reticular changes, which suggests 
concomitant interstitial involvement. Finally, pleural effusion and incipient pulmonary 
fibrotic scars were also described, however, with greater evidence in the more 
advanced stage when compared to the initial stage of the disease (CHUA, 
ARMSTRONG-JAMES, et al. , 2020, TEICH, KLAJNER, et al. , 2020) . 
 
1.1.6 Severe acute respiratory syndrome due to the evolution of 
COVID-19 
 
The Severe Acute respiratory syndrome (SARS) or Severe Acute 
Respiratory Syndrome (SARS) is one of the most frequent causes of hospital 
admission followed by death in patients affected by Covid-19. According to the Ministry 
of Health, the definition of SARS is said to be an acute respiratory disease 
characterized by fever above 38°, cough, dyspnea, increased respiratory rate (>25 
breaths/minute), and may also present with hypotension and even, gastrointestinal 
signs and symptoms (LANA et al. 2020). 
Assuming the evolution of the disease, the clinical picture worsens as the 
process of acute hyperinflammation of the tissue and pulmonary edema occurs, 
resulting in exacerbated permeability due to the injury, and often disruption, of the 
alveolar capillary barrier. According to Almeida (2018), this process of pulmonary 
inflammation generates the release of inflammatory molecules such as cytokines , 
which are responsible, respectively, for the activation and recruitment of alveolar 
macrophages and neutrophils in the lungs, triggering the release of leukotrienes , 
oxidants, platelet activation and proteases. Ware ( 2020 ) explains that these 
substances cause damage to the capillary endothelium and alveolar epithelium, so the 
barriers between capillaries and air spaces are broken. As a result, the air spaces and 
the interstitium are flooded by edematous fluid, proteins and other cellular debris, 

 
 
14 
culminating in surfactant disruption, collapse of air spaces, misalignment between 
ventilation x perfusion and pulmonary hypertension (ALMEIDA, 2018, CORDIOLI, 
2012). ) . 
Ware (2020) also describes that, in the evaluation of lung mechanics in the first 
24 hours after admission to the ICU, it shows that lung compliance is decreased, along 
with a series of factors, suggesting a mortality of 40% to 60% in these individuals. This 
survival rate, evidenced in Covid-19, suggests a pathophysiology of pulmonary 
microvascular thrombosis due to coagulation deregulation and fibrinolysis , 
accompanied by lung injury, indicators of major deleterious effects in recovered 
individuals (CORDIOLI, 2012, REIS, LIMA, 2020, WARE, 2020) . In general, the 
consequences left in the body of individuals considered recovered represent persistent 
respiratory dysfunctions, mainly in the tissues and organs of the respiratory system, 
accompanied by important deficits not only directly linked to respiratory capacity during 
physical activities, but also, and perhaps mainly linked to BADL (basic activities of daily 
living), which involve basic self-care (ALMEIDA, 2018, DORNELES, 2018) . 
1.1.7 
Post-COVID-19 Syndrome 
 
According to the Ministry of Health's Surveillance System, the survival 
rate of individuals who have experienced the most severe form of Covid-19 is 
approximately 50%. Although there are few published studies on the sequelae left by 
SARS-CoV-2 in the body, it is already known that the disease leaves traces in many 
systems (LANA et al. 2020). In the study by Juárez-Belaúnde , Colorme font et al . 
(2020), in their report to the journal of Neurologia, states that the pathophysiological 
process of the disease comes from an inflammatory response that mainly affects the 
respiratory system. However, the author emphasizes that new studies have been 
identifying sequelae of great significance, also in the cardiovascular, neurological and 
musculoskeletal systems. As described by the WHO, the probability of deficits in these 
systems increases in individuals who have undergone periods of ICU stay, combined 
with the need to use respirators. As a result, the morbidities acquired in the process 
leave important impacts on the functional and cognitive capacities of recovered 
individuals (GREVE, BRECH, et al. , 2020, PAHO/WHO, 2020) . 
 
1.1.8 
respiratory disorders 

 
 
15 
fibrotic normalities , previously associated with the idiopathic cause, are the 
main consequences left by the passage of Covid-19, so that its manifestations can 
result from any stage, being evidenced more frequently in cases that have undergone 
the most severe form of the disease. illness. Consequently, the lung damage caused 
by SARS-CoV-2 infection in the acute phase results from the combination of some 
expected clinical manifestations, such as: edema formation, alveolar release of 
epithelial cells and deposition of hyaline material in alveolar membranes . 
POGLITSCH, et al. , 2020) . During the 2nd and 4th weeks, the lungs show signs of 
fibrosis, characterizing the next phase of the infection, where fibrin deposition occurs, 
infiltration of inflammatory cells and fibroblasts adjacent to the epithelial cells in the 
alveolar spaces (HULL, LLOYD, et al. , 2020) . 
A little further on, during the 6th to 8th week, the lung tissue becomes fibrotic , 
in addition, bilateral lesions tend to be observed. In this context, Raghu and Wilson 
(2020) observed in their study that individuals, after hospital discharge, present 
restrictive abnormalities such as reduced diffusion capacity and small airway 
obstruction. Some authors also suggest that these abnormalities may be common in 
lung function, especially in individuals who have reached the most severe form of 
Covid-19, due to high inflammatory rates and pulmonary fibrosis. 
Despite what is already evidence on the multisystem sequelae of Covid-19, 
several other studies are emerging around the sequelae left in the respiratory system 
after infection by the SARS-CoV-2 Coronavirus , suggesting that these may vary in 
individuals who have had it. mild, moderate or severe frames. The same authors also 
state that the resolution of the abnormalities may occur within the next 6 to 12 months 
after the infection, or even become permanent (HADAYA, BENHARASH, 2020) . 
 
Another consequence of SARS-Cov-2 infection on respiratory capacity is the 
damage generated in neural tissue by inflammatory events. This in turn receives 
information from mechanoreceptors and chemoreceptors in the lungs and/or provides 
innervation to organs, airway smooth muscle, glands and vasculature . Strike, Brech 
et al. (2020) report in their study that some complications and/or deficits left in 
respiratory capacity may be the result of cardiorespiratory arrest after damage to the 
innervations of the heart, lungs and other organs of the cardiorespiratory system, as 
well as loss of neuromuscular function and muscle trophism . . Thus, it can be 
considered that decreased cardiorespiratory function, decreased inspiratory muscle 
strength and, consequently, functional capacity are linked to the worsening of 

 
 
16 
symptoms resulting from SARS-Cov-2 infection in neural tissue linked to organs and/or 
structures in the system. respiratory system (HADAYA;, BENHARASH, 2020, 
ZOUFALY, POGLITSCH, et al. , 2020) . 
 
1.1.8.1 
Neurological Dysfunctions 
There are some hypotheses and speculations about the way in which the virus 
accesses the nervous system, the main one being the one that defends the idea that 
one of the transsynaptic pathways of the vagus nerve would be responsible (INCIARDI, 
LUPI, et al. , 2020) . , LU, LI, et al. , 2020) . This hypothesis is due to the fact that its 
innervation involves the lower part of the airways through the nasal and olfactory 
epithelium (GREVE, 2020; WEI, LIU, et al. , 2020) . But there are differences between 
the authors, so much so that some still discuss a second hypothesis, which the spread 
would occur via hematogenous , with the virus crossing the blood -brain barrier . 
(MATSCHKE, LÜTGEHETMANN, et al. , 2020) . However, when observing the neural 
tissue infected by SARS-CoV-2, the induction of cellular apoptosis by the virus was 
observed, where the mechanisms of apoptosis are similar to those of demyelinating 
diseases , which I could give more support to the first hypothesis (JUÁREZ-
BELAÚNDE , COLOMER FONT, et al. , 2020, MATSCHKE, LÜTGEHETMANN, et al. 
, 2020) . 
Taking into account individuals hospitalized due to severe Covid-19 infection, 
they may be susceptible to central and peripheral nervous system injuries, so that their 
inherent neurological sequelae are not limited to functional damage only, but 
complications such as confusional syndromes , vascular accident. cerebral palsy 
(CVA), encephalopathies, encephalitis, polyneuropathy and Guillan -Barre syndrome , 
confirming a significant functional impact and also quality of life (INCIARDI, LUPI, et 
al. , 2020, JUÁREZ-BELAÚNDE, COLOMER FONT, et al. , 2020) . 
 
Among the main neurological complications, it was observed that about 20% of 
individuals affected by Covid-19 had among the main signs and symptoms, namely: 
changes 
in 
consciousness, 
seizures 
or 
epileptic 
status, 
paralysis, 
CVA 
(cerebrovascular accident), infectious neuropathy, peripheral polyneuropathy , in 
addition to possible necrotizing myopathy (LU, LI, et al. , 2020, SHAHJOUEI, NADERI, 
et al. , 2020) . However, the author considers it pertinent to note that the so-called 
critically ill polyneuropathy , in general an infectious mixed sensorimotor neuropathy, 

 
 
17 
by itself already causes axonal degeneration , and necrotizing myopathy , in turn, can 
cause fatty degeneration, hypotrophy and fibrosis. Such conditions are frequently 
observed, respectively, in 46% and 48% to 96% of individuals who experience 
prolonged ICU stay (GREVE, BRECH, et al. , 2020) . 
 
1.1.8.2 
musculoskeletal disorders 
As is widely known, the condition of physical inactivity, caused by hospitalization 
in the ICU (or even social isolation), can significantly impact the muscle homeostasis 
of individuals. In this context, the inflammatory process caused by Covid-19 infection 
promotes musculoskeletal consequences that are often catastrophic, impacting and 
can last for a long period of patients' lives, drastically reducing their quality of life. This 
condition seems to be more evident in individuals who remain in hospital for long 
periods, however, the author explains that this process involves several conditions to 
which individuals are exposed, such as the inflammatory process, immobility, in 
addition to insufficient nutritional and caloric support, apart from The administration of 
corticosteroids is often carried out without such criteria, given the complex contexts in 
which patients are inserted (GREVE, BRECH, et al. , 2020) . 
Even before the Covid-19 pandemic, it was already widely known that patients 
who are exposed or subjected to long periods of immobility, precisely due to the 
absence of exposure to mechanical discharges, end up triggering an adaptive 
response, which, among other things, includes: of protein synthesis, increased 
degradation and apoptosis of muscle cells (sarcomeres), leading to the dreaded 
sarcopenia. When such a condition sets in, there is inevitably a loss of homeostasis in 
the renewal of muscle tissue, accelerating the process of hypotrophy and loss of 
muscle strength (NUNES, HERVÉ, et al. , 2020) . 
Strike, Brech et al . (2020) also describe in their study that in the first week of 
hospitalization, a loss of up to 20% of thigh muscle mass can already occur in septic 
individuals in the ICU. The author also points out that one week in bed can generate a 
30% reduction in muscle strength, followed by an additional 20% loss each following 
week. In view of this, it is concluded that the loss of muscle mass and strength will 
directly impact the physical capacity or even daily activities of these individuals, 
generating a significant negative impact on the quality of life of patients affected by 

 
 
18 
Covid-19, and who have experienced such a situation (CORRÊA , KARLOH, et al. , 
2011, NUNES, HERVÉ, et al. , 2020) . 
 
 
1.1.9 
Persistence 
of 
symptoms 
in 
Post-COVID-19 
Syndrome 
 
1.1.9.1 
dyspnea  
The dyspnea symptom, popularly known as shortness of breath, can be 
characterized as a form of subjective experience of uncomfortable breathing, 
consisting of qualitatively distinct sensations that may vary in intensity, and may also 
present a range of symptoms not only with multiple interactions of physiological origin. 
, but also with multidimensional factors, such as psychological, social and 
environmental, often culminating in the situation described by some authors as “ total 
dyspnea ” (MARTINEZ et al., 2004). However, expressions such as difficulty, effort, 
weight or discomfort to be able to breathe, sensation of shortness of breath, or hunger 
for air, feeling of oppression or tightness in the chest, are also widely used by patients 
in an attempt to describe the dyspnea symptom ( ZIEGLER, 2011) . 
 
Some specific literature data show that dyspnea is usually present in up to 20% 
of the general population, being directly associated with increased morbidity and 
mortality, also generating limitations in physical and social activities and in the quality 
of life of individuals, especially when related to problems cardiac, pulmonary or even 
neuromuscular disorders, often within a hospital setting or even prolonged 
hospitalization (IOANNOU, LOCKE, et al. , 2020, NUNES, HERVÉ, et al. , 2020) . 
 
In this context, it is common for individuals with cardiopulmonary complications 
to report dyspnea while performing physical activities, which can range from the mildest 
to the most strenuous, depending on the degree of punctual or systemic involvement 
involved (BOHN JÚNIOR, COSTA, et al. , 2020) . There are some plausible 
explanations found in the literature, based on the premise that during physical 
activities, there is greater consumption of oxygen and, consequently, greater 
production of CO 2 (carbon dioxide) (BOHN JÚNIOR, COSTA, et al. , 2020, CORRÊA 
, KARLOH, et al. , 2011) 

 
 
19 
Other authors also suggest that, in response to the detection of high 
concentrations of CO 2 and low concentrations of Oxygen, the bulbar respiratory center 
increases the respiratory rate as a way of compensating for homeostatic maintenance. 
In normal situations, this process does not generate discomfort, on the other hand, in 
the case of pathological contexts, where there is a deficit in cardiac or pulmonary 
functions, the respiratory rate and shortness of breath can be increased even in rest 
situations (DORNELES, 2018). ; SOUZA, VIEIRA et al., 2020) . 
 
Not infrequently, there may be situations in which dyspnea can cause so much 
discomfort that individuals feel incapable of breathing with adequate depth and speed 
due to exacerbated ventilatory demand, and it is quite common for them to frequently 
report the perception that chest expansion when breathing in this difficult and reduced, 
as well as expiration (which should be a practically passive process) demands greater 
efforts than normal (SIMSIC, 2016) . 
As an inevitable consequence, the increase in Respiratory Frequency (RR), 
together with shortness of breath, considerably affect the performance of physical and 
daily activities of individuals, generating a significant functional impact and directly 
implying in the reduction of the quality of life of the individuals involved (BOHN 
JÚNIOR, COSTA, et al. , 2020, ZIEGLER, 2011) . 
 
1.1.9.2 
Dyspnea assessment 
 
As already mentioned, dyspnea can be defined as a subjective perception of 
increased work of breathing, which generates a distressing sensation of shortness of 
breath, perceived as inadequate ventilation. Therefore, dyspnea, triggered when 
performing activities of effort, seems to be one of the most frequent complaints and 
tends to be more frequent among individuals who have impaired lung function, 
especially in the post-covid-19 period ( O'DONNELL et al . al ., 2007). 
The sensation of dyspnea in certain individuals during exertion leads to a 
progressive reduction in physical activity, and this condition can generate a vicious 
cycle, affecting not only the functional state and physical conditioning, but also the 
performance of their activities of daily living, having an impact. directly on the patient's 
quality of life (TROOSTERS et al., 2005). 
In this context, the literature provides a significant amount of instruments and 
scales to assess the degree of dyspnea in these individuals, whether through 

 
 
20 
subjective assessment, limitation of activities of daily living or functional disability 
(CABRAL, LOPES, et al. , 2017, PISSULIN, PACAGNELLI, et al. , 2018) . 
Therefore, we can consider that among the unidimensional scales, the 
multidimensional instruments, the most used in practice are: the visual analogue scale 
(VAS), the Borg scale, the modified scale of the British Medical Research Council 
(MRC), basal index of dyspnea (BDI), transitional dyspnea index (BTI), in addition to 
the PFSDQ ( pulmonary functional status and dyspnea questionnaire) ( VELLOSO, 
COSTA, OZEKI, 2002) 
The Visual Analog Scale (EVA), created by Scott Co. Laboratory , in 1920, 
has been used to measure different subjective aspects such as mood, pain, anxiety 
and dyspnea , and since then it has been widely used in clinical practice to measure 
dyspnea both at rest and during exercise (AITKENS, 1969). 
We have the modified Borg scale , which is characterized by being a subjective 
scale, adapted by BURDON, in 1982, to measure dyspnea both during exercise or in 
physical activities, since the measurement is made directly at the moment of that the 
patient is experiencing the sensation (BORG, 1998). The Borg scale seeks to assess 
the subjective sensation of exertion (also described as a sensation of respiratory 
fatigue), and covers a score from 0 to 10, where: 0 means no respiratory difficulty, 
while 10 represents maximum respiratory difficulty. 
Because it is an extremely subjective scale, over time, and in order to allow a 
better understanding of the perceived exertion by the evaluated individual, the insertion 
of quantitative expressions of intensity was established so that there was a direct 
correlation between the numerical categories. and verbal descriptors (HIGBEE, 
DODD, 2020, SILVA, DIAS, et al. , 2011) . It is worth mentioning that the Borg scale 
includes instructions for its use, together with the structure to be evaluated, seeking 
not only to facilitate the individual's understanding, but above all to increase the 
accuracy of the response in relation to the subjective perception of effort during the 
proposed activities (CABRAL , LOPES, et al. , 2017, GOMES, SHUJMANN, et al. , 
2019, LIMA DE, MAGALHÃES, et al. , 2019) . 
The assessment of dyspnea in relation to limitations in performing routine 
activities requires some intersection between uni and multidimensionality, so that it is 
possible to quantify it. In this context, the most cited scale in the literature is the 
Modified Scale of the British Medical Research Council ( MMRC - Modified Medical 
Research Council ), created by English pulmonologists in 1960, and since then it has 

 
 
21 
been used to measure breathing difficulty in ADLs (activities of daily living) and 
perceived respiratory incapacity (BESTALL et al ., 1999, DA CAPITAL et al. , 2018). 
MMRC scale is composed of only five items, with the patient choosing the item 
that corresponds to how much dyspnea limits their ADL, indicating their subjective 
degree of dyspnea by choosing a value between 1 and 5: 1 (only suffers from lack of 
breath during strenuous exercise), 2 (suffers from shortness of breath when walking 
quickly or walking up a gentle slope), 3 (walks slower than people of the same age 
because of shortness of breath or has to stop for breath even when walking slowly ), 4 
(breathing pause after walking less than 100 m or after a few minutes) and 5 (feeling 
so short of breath that you no longer leave the house, or feel short of breath when 
getting dressed) ( KOVELIS, DEMETRIA et al . , 2008). 
In practice, the MMRC scale is an instrument of easy applicability, 
understanding by the patient and reproducibility by the examiner, and consists of the 
correlated and adjective description of dyspnea during daily activities, which often fit 
the reality of individuals with breathing difficulties in basic activities. , how to leave the 
house, or even when dressing (CAMARGO, PEREIRA, 2010, KOVELIS, SEGRETTI, 
et al. , 2008, ZIEGLER, 2011; PISSULIN, PACAGNELLI, et al. , 2018) . 
Regarding the multidimensional instruments for dyspnea assessment, we have 
the Basal Dyspnea Index (BDI) ( developed by MAHLER et al ., 1984) has been used 
to assess and measure the direct and indirect impact caused by dyspnea on 
individuals' lives, being divided into three distinct domains, however, correlating the 
magnitudes: functional disability, tasks and effort, facilitating a more detailed and 
multidimensional assessment of the impact of dyspnea on each individual's life. The 
BDI also has some specific characteristics, as it correlates a grade from 0 to 4 for each 
aforementioned domain, in addition to a field that includes, in addition to the subjectivity 
of the symptom, it also allows the association of the dyspnea symptom with other 
physical, emotional or behavioral aspects. 
Regarding the use of multidimensional questionnaires for direct and correlated 
assessment of dyspnea, in the international literature, the following stand out: The -
Pulmonary Questionnaire Functional Status and dyspnea Questionnaire - Modified 
version (PFSDQ- M), in its translated, adapted and validated version for Portuguese. 
For clarification and specification purposes, we have that PFSDQ-M ( Modified version 
of Pulmonary Functional Status and dyspnea Questionnaire ) is composed of three 
domains: influence of dyspnea on ADL, influence of fatigue on ADL (5 general and 10 

 
 
22 
specific items for each domain) and change in ADL compared to the period prior to the 
disease (10 specific items). With regard to these domains, the patient is instructed to 
indicate how much dyspnea and fatigue interfere with the 10 specific ADL items, -
choosing a value between 0 and 10 for each activity, with the respective meanings: 0 
(no interference ), 1-3 (mild), 4-6 (moderate), 7-9 (severe) and 10 (very severe). In the 
third domain, the patient reports the impact on the change in ADL compared to the 
period before the disease, choosing for each activity a value between 0 and 10: 0 (as 
active as always in relation to this activity), 1 -3 (small change), 4-6 (moderate change), 
7-9 (extreme change) and 10 (no longer do this activity) ( KOVELIS, DEMETRIA et al, 
2008). 
After this personal and non-transferable stratification by the patient, not only is 
a partial score calculated , ranging from 0 to 100 for each of the three domains ( 
dyspnea , fatigue and change in ADL), and a total score is formed by the sum of the 
partial scores of the three domains, totaling a value that varies from 0 to 300. It is worth 
mentioning that there are five general questions in the dyspnea and fatigue domains 
that are merely informative and qualitative, and their answers are not counted in the 
questionnaire score . For purposes of interpretation, higher values on the scale indicate 
greater limitation in ADL ( LAREAU, MEEK, ROOS, 1998). 
 
 
1.1.9.3 
 Musculoskeletal Change in COVID-19 
Excessive production of pro-inflammatory cytokines in hypercatabolic 
conditions is associated with oxidative stress , which promotes the production of 
corrosive molecules that cause severe damage to myocytes (WELSCH C et al ., 2020). 
The exact dynamics underlying muscle wasting in COVID-19 are still unclear. 
However, the researchers suggest that muscle loss in COVID-19 patients is a result of 
a wide range of interrelated factors (Figure 1). 
Aging, as well as metabolic and inflammatory disorders (diabetes, obesity, 
cardiovascular disease, cancer, etc.), are associated with baseline states of protein-
energy malnutrition and hyperinflammatory systemic diseases that contribute to 
peripheral muscle dysfunction (PMD). In the context of COVID-19, these individuals 
are usually also the majority of affected patients and thus have ample possibilities of 
peripheral muscle dysfunction. Undoubtedly, elderly people affected by SARS-CoV-2, 

 
 
23 
especially the severe forms, are likely to express dramatic injuries to their muscle 
structure, especially in the late stages of the disease (PITSCHEIDER, L et al., 2020; 
JIN M et al. , 2020). 
The exact musculoskeletal consequences for patients with COVID-19 have not 
yet been fully established. Although the respiratory tract appears to be the primary site 
of infection, compromised alveolar epithelium in some COVID -19 patients can lead to 
the development of viremia , and cells in other tissues may be susceptible to direct 
viral infection . al., 2020; DISSER et al., 2020) . 
In addition to the potential direct viral infection, infection -induced 
proinflammatory cytokines and signaling molecules can lead to pathological changes 
in skeletal muscle tissue. C-reactive protein (CRP) is a biomarker commonly used to 
assess inflammatory processes in general, and current studies have shown that 
critically ill patients with COVID-19 have much higher CRP levels than healthy 
individuals. Several of the pro-inflammatory signaling molecules known to be elevated 
in COVID-19 patients can also affect musculoskeletal tissue (DISSER et al. , 2020) . 
Patients who needed to be admitted to an intensive care unit (ICU) or stayed in 
the hospital for long periods tend to have more musculoskeletal complications that 
require rehabilitation. The period of hospitalization is directly related to longer periods 
of hypomobility and/or immobility, resulting in fatigue, muscle weakness and 
polyneuropathy . (BARKER-DAVIES et al ., 2020; FELIPPE FELIX MEDIANO et al ., 
2020) . 
Myalgias and generalized weakness have been reported in symptomatic 
patients with COVID-19. Although some data have suggested that the occurrence of 
muscle pain does not increase with the severity of COVID-19, in patients with 
computed tomography (CT) or radiographic imaging of the abnormal lungs, myalgias 
were an important predictor of overall disease severity ( DISSER, et al., 2020) . 
Even after hospital discharge, some patients report difficulties in activities of 
daily living (ADL), such as walking and climbing stairs. This suggests that SARS 
infection leads to deficits in both muscle strength and endurance, probably due to the 
pro-inflammatory effects of the viral infection and the deconditioning that occurs during 
the period of convalescence. The reduction in the functional capacity and physical 
fitness of these patients corresponded to falls in several health-related quality of life 
indices (DISSER et al, , 2020; LAU et al , 2005) . 

 
 
24 
 
Figure 1: Pathophysiological hypothesis for peripheral muscle dysfunction in COVID-19. 
(Source: MOHAMED ALI A & HIROSHI K, 2020) 
1.1.9.4 
Peripheral muscle assessment 
As previously discussed, peripheral muscle dysfunction has a substantial contribution 
to peripheral muscle fatigue. The impact of this dysfunction on muscle performance is 
developed by abnormalities in muscle structure, bioenergetics and function. Some 
important clinical implications are related to changes in muscle structure (mass) and 
function (strength and endurance), such as reduced exercise capacity, quality of life, 
and survival in several pulmonary conditions, including COPD, which we could similarly 
to assume similar changes in the dysfunctions induced by COVID-19. The etiology of 
these abnormalities appears to be multifactorial, involving factors such as 
deconditioning , hypoxia and/or hypercapnia , oxidative stress , senescence, hormonal 
dysfunction, systemic inflammation, chronic or repetitive use of drugs (corticosteroids) 
and nutritional depletion. 

 
 
25 
The involvement of inflammatory mediators in PMD is suggested by the observation 
that systemic inflammatory markers are related to poor contractile muscle performance 
in several pulmonary conditions such as COPD, ASTHMA and interstitial lung diseases 
( RONDELLI RR et al., 2009) . For example, quadriceps strength was negatively 
associated with IL-8 levels during exacerbation of lung diseases (SPRUIT MA et al., 
2003) and with IL-6 and TNF-α levels in the elderly (YENDE S et al., 2006). In very 
critically ill patients, high CRP levels were associated with reduced strength, 
endurance and quality of life. On the other hand, in another study, it was evidenced 
that the marked weakness of the quadriceps was significantly related to the average 
daily dose of steroids used by the patients during the acute exacerbation of pulmonary 
diseases. The deleterious effects of steroids on skeletal muscle function have been 
attributed to the inhibition of protein synthesis and increased protein degradation. 
Other evidence suggests the role of oxidative stress in muscle dysfunction in 
hyperinflammatory lung diseases . COVID-19 is known to cause an inflammatory, 
multisystemic storm implicated over time in several peripheral dysfunctions, including 
muscle dysfunction. All determinants of muscle dysfunction in pulmonary diseases are 
summarized in Table 1. 
determinant trigger 
Abnormalities 
dysfunction 
hyperinflammatory stress 
 pro-inflammatory cytokines 
such as IL1, TNF-alpha, IL-8, 
IL-6 
muscle performance 
Use of corticosteroids  
protein synthesis and muscle 
catabolism 
muscle performance during 
exercise, worsening dyspnea 
and fatigue 
Acute 
and/or 
chronic 
hypoxemia 
inflammatory mediators, ATP 
and muscle glycogen 
muscular strength and 
endurance , muscle 
performance but activities of 
daily living. 
oxidative stress 
Oxidant and anti-oxidant 
imbalance 
muscular endurance 
Immobility and sedative and 
neuromuscular 
blocking 
agents 
type I fibers and oxidative 
enzymes 
IIx fibers ( hypotrophied ) 
muscular endurance and 
muscular performance 
during exercise 
Table 1: Metabolic and bioenergetic determinants of peripheral muscle fatigue in lung disorders and 
their consequences. (Modified from: RONDELLI RR et al., 2009) 

 
 
26 
Currently, there is a wide variety of models, tests and exercise protocols being used, 
aiming to obtain parameters indicative of muscle fatigue in patients with COPD ( 
Vøllestad NK et al., 1997). 
Functional assessment methods of peripheral muscle fatigue basically involve three 
basic components: 
I) the muscle activation strategy: voluntary effort or exogenous stimulation 
II) the condition of the exercise (isometric, isoinertial or isokinetic ) 
III) the exercise pattern: time and intensity, which may involve a single 
prolonged contraction or a series of repeated contractions 
Most of the methods used in this evaluation in patients with pulmonary or cardiac 
diseases preferentially focus on the muscles of the lower limbs. It should be noted, 
however, that the function of the upper limbs remains relatively preserved in these 
patients. 
maximum voluntary contraction 
The assessment of muscle strength and endurance can be obtained by maximal 
voluntary contraction (MVC). This assessment can be done by instructing the patient 
to generate as much voluntary force as possible without altering muscle length 
(symmetrical test) or by encouraging the patient to perform a full range of motion with 
the greatest possible load (1RM test). In this evaluation, equipment such as 
tensiometers or dynamometers can be used to quantify the generated isometric force 
(if there is no change in muscle length). In the case of the 1 RM test, the highest load 
imposed and that the patient can complete and repeat is considered. As these are 
volitional techniques, external complicating factors, such as the patient's functional 
ability and motivation, can generate submaximal contractions and thus underestimate 
the analysis. However, due to the ease of execution, verbal encouragement and 
technical experience, little variability has been described in our tests involving maximal 
voluntary contraction (MVC). In patients with chronic pulmonary dysfunction, the loss 
of the ability to generate or maintain MVC during knee extension exercise has been 
representative of muscle fatigue. (SWALLOW EB et al., 2007). Studies have used 
series of submaximal voluntary contractions in the evaluation of resistance and 
peripheral muscle fatigue. Usually, relative values of approximately 20-60% of MVC 
(1RM test or isometrically sustained maximal voluntary contraction ) are required to be 
sustained until exhaustion, maintaining cadence and rhythm constant or close to it. 
Resistance is measured by the time the task is maintained. The test should be stopped 

 
 
27 
when there is a failure to maintain the intensity of the contraction (5% drop) or inability 
to complete the range of motion or visually there are signs of muscle fatigue, such as 
fasciculations , for example. 
 
 
 
1.1.9.5 
Fatigue 
Within the spectrum of most common symptoms in post-COVID-19 patients, non-
specific chronic pain, cough, dyspnea, myalgia, arthralgia , and fatigue stand out 
(AZUMA et al., 2020). However, it is worth mentioning that in any chronic post-viral 
syndrome, it can present with a feeling of fatigue and lack of energy, in addition to 
nonspecific myalgia, which can also generate depression and even sleep disorders, 
as shown by the various characterizations of post-infection by the virus. SARS-CoV-2. 
Such long-term adverse effects, which are extremely similar to those experienced by 
patients with chronic fatigue syndrome (CFS) and fibromyalgia syndrome, indicate a 
significant burden of these ongoing symptoms in patients with COVID-19 
(MOLDOFSKY et al., 2011; MANDAL et al., 2011; MANDAL et al. al., 2020). 
Classically, muscle fatigue is conceptualized as the muscle's inability to generate 
or maintain levels of force required for a given rate of work (VØLLESTAD NK, 1997). 
Muscle fatigue can be divided into two components: central and peripheral. This 
terminology is given by the anatomofunctional sites involved in the fatigue process. In 
central fatigue, muscle activation from the central nervous system is compromised, 
whereas in peripheral or contractile fatigue, involvement is distal to the neuromuscular 
junction. Figure 2 shows a representative illustration of the structures involved in 
central and peripheral fatigue. 

 
 
28 
 
Figure 2: The main potential sites of muscle fatigue: Central fatigue relates to changes in (1) the 
excitatory command to the upper motor centers or (2) the lower motor neuron and (3) its degree of 
excitability, or (4) the transmission neuromuscular. Peripheral fatigue occurs when the alterations 
are related (5) to the excitability of the sarcolemma , or (6) to the release and reuptake of calcium by 
the T tubules and the sarcoplasmic reticulum, or (7) to contractile mechanisms, or even (8) to the 
supply of energy and/or accumulation of metabolites. (Source: RONDELLI RR et al., 2009) 
Most often described as a manifestation of tiredness, lack of energy or 
exhaustion associated with impairment in the performance of usual day-to-day 
activities, the current definition of fatigue describes it as a symptom resulting from an 
underlying pathophysiology or resulting from a specific treatment. performed, then 
fatigue is understood as a sequel, which proves to be refractory to the usual energy 
recovery strategies. The fatigue symptom is very prevalent in clinical situations such 
as oncological diseases, heart failure, fibromyalgia and chronic obstructive pulmonary 
disease, in addition to conditions related to the frailty of the elderly (MOTA et al., 2005; 
WINTER & FOWLER, 2009). 
In this context, a recent study found that while the symptom burden in individuals 
recovering from hospital admission with COVID-19 generally improved at initial follow-
up, 53% reported persistent shortness of breath, 34% persistent cough, and 69% 
persistent fatigue ( MANDAL et al., 2020). already Perrin et al. (2020) described these 
persistent symptoms as fatigue, diffuse myalgia, depressive symptoms and sleep 
disturbances comprising a broad spectrum called post-COVID-19 syndrome (PERRIN 
et al., 2020). 
In a recent review of the pathophysiological mechanisms of chronic fatigue in 
post-COVID-19 patients, the authors defend the premise that post-COVID-19 fatigue 
syndrome may result from damage to olfactory sensory neurons, causing an increase 
in resistance to flow. of cerebrospinal fluid (CSF), and further leading to congestion of 

 
 
29 
the lymphatic system with subsequent toxic accumulation. within the central nervous 
system (CNS) which could biologically explain the persistence of this symptom. The 
lymphatic system, described in recent works as a perivascular network, where a large 
proportion of subarachnoid cerebrospinal fluid circulates , responsible for the drainage 
of toxic residues from brain metabolism. This whole-brain pathway has been called the 
“lymphatic system”, based on its similarity in function to the peripheral lymphatic 
system, and its functions have been described in the pathophysiological scope of 
Alzheimer's Disease (JESSEN et al., 2015). 
Taking into account some clinical findings in practice, it has been suggested that 
chronic fatigue syndrome would be associated with idiopathic intracranial hypertension 
without pathologically elevated intracranial pressure, some authors have argued that 
chronic fatigue syndrome could have a clear neurophysiological explanation based on 
obstruction. of the lymphatic system (WOSTYN P, 2021). 
Among other biological hypotheses, it is assumed that post-viral infection fatigue 
syndrome is based on the inflammatory storm that COVID-19 as well as other 
syndromes previously presented. Furthermore, fatigue has been associated with 
infections, which often occur outside of an epidemic or pandemic scale, results that 
are not limited to just viral infections, but also bacterial infections (HICKIE et al., 2006; 
MOLDOFSKY et al. , 2011). 
Given this evidence, it was expected that some COVID-19 survivors would 
develop post-infectious fatigue, based on the hypothesis that the inflammatory storm 
caused by SARS-COV-2 infection may, by association with the findings already 
described in severe viral infections, explain the persistent and prolonged fatigue in the 
post-covid-19 (JOHNSON et al., 2020). 
 
1.1.9.6 
Fatigue Assessment  
 
The term fatigue is defined as '' extreme tiredness resulting from mental or 
physical exertion or illness '' and is also used to describe a nonspecific but debilitating 
symptom in a range of chronic diseases such as cancer, multiple sclerosis, stroke, and 
depression. The subjective nature and severity of fatigue are assessed using 
psychometric tools, such as self -report questionnaires and scales (ELBERS et al., 
2008; WHITEHEAD L, 2009; KRUPP et al., 2010; MITCHELL SA, 2010). 

 
 
30 
 
The relative merit of objective and subjective measures of fatigue is dependent 
on the clinical situation in which it is intended to be studied. For example, in a clinical 
population where fatigue can be chronic and have a devastating impact on quality of 
life (QOL) and/or physical function, specific instruments are multidimensional or not 
clearly justified. 
 
In a last Brazilian consensus document, fatigue is defined as a subjective and 
persistent feeling of tiredness, physical, emotional and/or cognitive exhaustion, 
disproportionate to recent activity, which does not improve with rest and sleep and 
which interferes with activities of daily living (DE FADIGA, 2010). 
 
Twenty-one instruments validated worldwide for fatigue assessment are 
described in the literature (Chart 2). In Brazil, there are 7 cross- culturally validated 
fatigue instruments (Chart 3). 
 
FATIGUE ASSESSMENT INSTRUMENTS WORLDWIDE 
Fatigue Severity scale 
visual analogue scale for fatigue 
Fatigue Assessment instrument 
Brief mental fatigue Questionnaire 
Chalder Fatigue Scale 
Fatigue Impact scale 
Multidimensional Fatigue Inventory 
Fatigue Symptom inventory 
Dutch Fatigue Scale 
Dutch Exertion Fatigue Scale 
Piper Fatigue Scale 
Revised-Piper Fatigue Scale 
Schwartz Cancer Fatigue Scale 
Brief Fatigue Inventory 
Cancer Fatigue Scale 
Schedule of Fatigue and Anergia for Chronic fatigue Syndrome 
Schedule of Fatigue and Anergia for General Practice 
Cancer-related Fatigue Distress Scale 
Fatigue Impact Scale for Daily Administration 
Fatigue Pictogram 
Fatigue Symptom Check list 
Table 2: International instruments for fatigue assessment (Modified from: Brazilian Consensus on 
Fatigue, 2010). 

 
 
31 
 
 
In this context, and in the face of so many instruments and scales available, 
based on the experience of specialists and available knowledge, the Brazilian 
Consensus on Fatigue (2010) suggests a flowchart for an adequate assessment of the 
fatigue symptom, as follows: at the time of diagnosis, the realization of three sequential 
questions. Once the presence of the fatigue symptom is identified, an initial 
assessment is carried out to quantify the symptom, using a numerical scale (score 
between 0 and 10;), the Fatigue Pictogram (MOTA, PIMENTA, FITCH, 2009). Having 
the interest and condition of making a more detailed assessment of the symptom, 
including seeking to know the dimensions of fatigue, we suggest the use of a 
multidimensional scale such as the Piper Fatigue Scale-Revised (MOTA, PIMENTA, 
PIPER, 2009) . After the initial evaluation of the symptom, one should investigate the 
causes of fatigue, mitigating and exacerbating factors, implement the treatment and 
periodically reassess the presence and intensity of the symptom (DE FADIGA, 2010). 
(Instruments and scales mentioned in the annex) 
 
FATIGUE ASSESSMENT INSTRUMENTS VALIDATED IN BRAZIL( *) 
Fatigue Severity Scale 
Chalder Fatigue Scale 
Fatigue Impact Scale 
Dutch Fatigue Scale 
Modified Dutch Fatigue Scale 
Piper's Revised Fatigue Scale 
Picogram of Fatigue 
Table 3: Instruments validated in Brazil for fatigue assessment *Modified from: Brazilian Consensus 
on Fatigue, 2010. 
 
1.2 Pilates Method 
 
Pilates has become one of today's buzzwords thanks to the influence of media and 
social media. Hundreds of new exercise videos added to the internet every day, 
including elite athletes and famous people, have made the pilates method (MP) even 
more popular (THOMPSON WR, 2017). Pilates is not an exercise approach that 
includes predetermined standard positions and movements, on the contrary, it is a 
training method that anyone can do that increases physical strength, flexibility and 

 
 
32 
coordination, balance, reduces stress and anxiety, improves well-being and mental 
focus (UNGARO A, 2011). The basic principle of the Pilates method is the technique 
of centering the body and mind based on providing and maintaining stability (ADAMS 
M et al., 2012). 
Pilates , which was introduced in the context of rehabilitation by medical units dealing 
with dance, has been the exercise-based method of choice in the dance and fitness 
world for a long time. Training based on the precepts of Pilates is used as part of 
rehabilitation programs for musculoskeletal disorders and patients with neurological 
disorders, postpartum, chronic pain, arthritis and many other movement disorders. It is 
also preferable in special groups such as children and the elderly, as well as in adults, 
for the protection and improvement of general health (BYRNES K et al., 2018). 
 
History of Pilates 
 
Joseph Hubertus Pilates , the founder of the Pilates concept , was born in 1880 in 
Düsseldorf, Germany. His childhood was spent with illnesses such as asthma and 
rickets. He majored in gymnastics, boxing, yoga and karate to improve his health. He 
was a circus performer, and self-defense instructor as a young man. Combining 
Eastern and Western philosophies, he began to develop his own system of exercises 
called Contrology . His method soon gained popularity in Germany. He 
immigrated to the United States in 1926 and quickly became popular while continuing 
his studies (OWSLEY A, 2005). Joseph Pilates died in 1967 at age 87. Since his death, 
his work has been continued by many students (LATEY P, 2001; WOOD S, 2018). The 
principles outlined by Joseph Pilates in his book Return to Life through Contrology are 
still valid today, and there are two more principles in modified forms of Pilates training 
. These eight principles previously described and adopted today in the context of 
musculoskeletal rehabilitation are: concentration, control, centering, fluency, precision, 
breathing, relaxation and resistance (WOOD S, 2018). 
 
Pilates training principles 
Concentration : Pilates training requires a mental focus on the target area of the body 
itself. Concentration draws attention to the working body segment, potentially 
improving functioning and, ultimately, improving the quality of movement 
(MUSCOLINO JE et al., 2004). 

 
 
33 
Control : Pilates training is aimed at contracting the right muscle at the right time so 
that proper movement can take place. Each stage from start to finish of the movement 
continues and ends under control. Controlled movement also reduces the risk of injury 
(IULIAN-DORU T et al., 2013). 
Centering : There are many muscles in the abdomen, lumbar region and hip complex, 
which is accepted as the center of our body and called the central region. Muscles 
such as the multifidus , quadratus lumborum, iliopsoas , transversus abdominis, and 
diaphragm in this are primarily involved in protecting the lower back. One 
strong and active core is an indication of a strong center. With centralization, 
movements of the head, shoulders, chest, pelvis and extremities are organized around 
a central base (MUSCOLINO JE et al., 2004; IULIAN-DORU T et al., 2013). 
Fluency : In Pilates training , the flow of movements is continued with a mind-body 
interaction. Movements and transitions must occur in a slow, fluid harmony to best 
achieve the training effects. Breathing and concentration are also included in this 
adaptation process (WOOD S, 2018). 
Precision : Pilates training is concerned with quality, not quantity. Perform the 
movements correctly instead of repeating a certain one 
sometimes increases the quality of movement. Activation and contraction of target 
muscles at the target time depends on this. In cases where this principle is not enough, 
training moves away from the integrity within itself (UNGARO A, 2011). 
Breathing : It is important to breathe properly during exercise. Breathing is believed to 
be a catalyst for core stability. Compared with other exercise methods, diaphragmatic 
breathing is used less in Pilates (LEMOS AQ et al., 2019) 
training . The reason for this is the view that increased intra-abdominal pressure during 
diaphragmatic 
breathing 
reduces 
transversus 
abdominis 
muscle 
activation 
(MUSCOLINO JE et al., 2004). 
Integrated Isolation : To learn correct posture and maximize the benefit to be gained 
from movement, daily activities must be continued within the framework of centering 
and other principles (LATEY P, 2001) 
Stabilization : Pilates training provides muscular resistance to the core muscles and 
other small stabilizing muscles. Muscular endurance is more important in spinal 
training than pure muscle strength because the deep spinal stabilizers are constantly 
at work. At the same time, it facilitates the formation of continuously functioning 

 
 
34 
memory muscles, which has become routine (LATEY P, 2001; MUSCOLINO JE et al., 
2004; LEMOS AQ et al., 2019) 
Pilates exercises were designed by Joseph Pilates in Germany in 1883. Pilates 
exercises can have the effect of increasing coordination, improving muscle fiber 
recruitment, stimulating proprioception and causing muscle co-contraction around 
large joints. This concept focuses on activating the specific muscle(s) at the correct 
speed, with quality, precision and conscious control of the movement. Pilates focuses 
on balance and strengthening of ligaments, joints, seniors have the opportunity to 
increase their level of functional strength and improve efficiency in daily life (LATEY P, 
2001). 
The technique, known today as “ Pilates ” is, basically, an approach of integrated 
and controlled exercises, with a main focus on body awareness, in which the body and 
mind mutually influence each other, and this characteristic is what sets the difference 
with others. other techniques or forms of physical exercise (ROSSI, 2014). 
Joseph H. Pilates , its creator, sought, through a system of movements called “ 
Contrology ”, to exercise as many muscles as possible in a conscious and controlled 
way. The Method integrates the Western approach - with its emphasis on movement, 
muscle tone and strength - and Eastern traditions by considering exercise a path to 
calm emphasizing stretching and flexibility (BARBOSA; et al., 2015 and ROSSI, 2014). 
Exercises based on the Pilates method have been used for prevention, 
rehabilitation, physical conditioning and improvement of mindfulness, associated with 
well-being (GIACOMINI, et al., 2015 and JUNGES, 2014). 
The MP is a comprehensive conditioning method that is based on six 
fundamental principles that must be performed simultaneously: centralization, 
concentration, control, precision, breathing and fluidity of movement (MUSCOLINO JE 
et al., 2004). 
Pilates exercises are divided into two broad categories: Mat Pilates and Pilates 
Apparatus. The first exercises developed on a mat on the floor, later, Pilates created a 
series of specific devices that make it possible to perform the exercises against 
resistance, which is provided by the use of springs and pulleys (MUSCOLINO JE et 
al., 2004). 
 

 
 
35 
1.2.1 
Rationale for the use of Pilates in the management of 
dysfunctions caused by Covid-19 
 
One of the fundamental principles of MP is breathing, and its control is 
fundamental during the execution of the exercises. An essential part of each exercise 
is learning to breathe correctly, through a full inhalation followed by a forced exhalation. 
Thus, adequate breathing helps to control movements and, therefore, the method can 
be considered an indirect strategy for respiratory muscle training. It is known that the 
incorrect breathing pattern can result in the compensation of lung volumes and 
respiratory muscle performance, with several factors involved (GIACOMINI, 2016 and 
IULIAN-DORU T et al., 2013). 
Recent studies have shown that PM leads to hypertrophy of the abdominal wall 
musculature, as assessed by MRI and ultrasound. In view of these findings, the 
hypothesis that even without the use of a specific training load for the respiratory 
muscles, the PM may favor an increase in respiratory muscle strength and its 
performance seems plausible (GIACOMINI, 2016). 
Pilates Method has positive results in tone and flexibility, in addition to improving 
respiratory efficiency. An observational study states that the practice of the Pilates 
Method improves ventilatory parameters, and may be associated with the stimulation 
of the ventilatory pattern that the method advocates. In addition, the improvement in 
VO2 max values is also described, suggesting that the Pilates program produces 
cardiovascular adjustments that can increase the vascular response to exercise, 
helping to regulate blood circulation in the musculoskeletal tissue (TINOCO-
FERNÁNDEZ et al., 2016) . 
 
1.3 Justifications 
 
 
Thousands of COVID-19 survivors have experienced the persistence of 
symptoms including fatigue, pain, dyspnea and musculoskeletal disorders that are 
known to reduce the functional capacity and, in turn, the quality of life of patients after 
SARS-COV viral infection - 2 ( AZUMA et al., 2020; GREVE, BRECH, et al. , 2020 
MANDAL et al., 2020). However, although the persistence of symptoms is the subject 
of recent publications on the post-COVID syndrome, the direct causal relationship 

 
 
36 
between which factors are associated with the chronification of these symptoms is still 
not so clear . 
 
Regarding the field of rehabilitation strategies for the management of these 
disorders, there still seems to be an even greater twilight zone regarding the clear 
identification of which therapeutic interventions offer real and sustained clinical benefits 
and are directly associated with the clinical evolution of the syndrome symptoms. post 
- COVID, or even if certain isolated interventions, using the Pilates method as a unique 
therapeutic intervention strategy would be effective as a therapeutic intervention for 
adults with post - COVID syndrome (or who knows post intensive care syndrome, 
already so well described in the literature and that present a strong intersection with 
the recently described post-COVID syndrome. 
Musculoskeletal disorders and symptoms of dyspnea and fatigue are the most 
prevalent among survivors of severe forms of COVID-19 and are described as those 
most common signs and symptoms of post-COVID-19 syndrome. In this syndrome, 
even after a long period of time elapsed from the acute phase, the presence of 
symptoms such as respiratory and peripheral muscle weakness , pain, fatigue, 
dyspnea, exercise intolerance, among others, is observed, in view of the negative 
repercussions of the systemic manifestations of the disease. COVID-19 with 
Regarding the quality of life, prognosis and survival of patients, we can say that they 
have a high use of the Unified Health System (SUS) as the disease progresses. 
Pilates exercises , in essence, have clinical and physiological plausibility to be 
used as a therapeutic tool for the pulmonary and musculoskeletal rehabilitation of 
these patients. 
As it is a new infectious disease with a high risk of severe evolution and 
hospitalization in an intensive care unit, it is particularly important to explore the clinical 
characteristics of COVID-19, which can help in the adequate management of its 
sequelae in the post-acute phase. 
Pilates Method exercise program as a rehabilitation tool for these patients 
affected by the systemic sequelae caused by the infection by COVID-19. 
With this, according to Agenda 2030, object 3 - Health and Well-being, we can 
reduce diseases and comorbidities associated with non-communicable diseases 
through effective treatment strategies, promoting mental health and well-being. 
 
 

 
 
37 
1.3.1 
Relevance to Rehabilitation Sciences 
Undoubtedly, the manifestations described in the scope of the post - COVID 
syndrome brought even more importance to the area of rehabilitation sciences, since 
thousands of people around the world, in a relatively determined interval, were 
contaminated by this viral infection, many even developed the severe form and have 
experienced and are experiencing persistent symptoms of the so-called post-COVID-
19 syndrome. Given this scenario, the search for effective, cost-effective and clinically 
relevant treatment strategies are emerging and fundamental themes for the area of 
rehabilitation sciences. that we are experiencing and the large number of people 
affected by COVID-19, the search for more functional rehabilitation resources is of 
paramount importance for improving the quality of life and adds another resource to 
our professional activity. 
 
1.3.2 
Relevance to the Ministry of Health's Priority Agenda 
Given the number of people affected by COVID-19 and thus by the post-COVID-
19 syndrome, clinical research involving functional rehabilitation rehabilitation 
strategies are of paramount importance for improving the population's quality of life 
and meets axis 4 of the agenda of priorities. of the MS on technological development 
and innovations in health, as well as meeting axis 9, since the clinical effects of the 
Pilates method , for example, could be incorporated into the roll of standardized 
assistance practices of the SUS and thus expand and democratize access to effective 
interventions and which, in turn, allow expanding the number of users served, since 
Pilates can and should be done in a group. 
 
1.3.3 
Relevance to sustainable development 
The most accepted definition of sustainable development is development 
capable of meeting the needs of the present generation without compromising the 
ability to meet the needs of future generations. It is development that does not exhaust 
resources for the future. Social concern is one of the axes of sustainable development 
and, therefore, clinical research that demonstrates, with solid results, that therapeutic 
strategies capable of ensuring the expansion of access to the population, have strong 
relevance for sustainable development. 
 

 
 
38 
1.4 Goals 
 
1.4.1 
Primary / General 
 
To evaluate the clinical and functional effects of a quarterly Pilates Method 
exercise program for patients with post-COVID syndrome. 
 
1.4.2 
Secondary/Specific 
- Evaluate the effects of pilates exercises on muscle strength and peripheral 
resistance; 
- To compare the effects of Pilates on the levels of fatigue and dyspnea in 
patients with post-COVID syndrome; 
- Correlate the effects of Pilates on peripheral muscle function and symptoms 
of fatigue and dyspnea in patients with post-COVID syndrome. 
- Evaluate the effects of Pilates on the quality of life of patients with post-COVID 
syndrome 
 
1.5 hypotheses 
 
1.5.1 NULL HYPOTHESIS (H0) 
Pilates Method exercise program has no clinical effect on peripheral muscle 
strength and endurance and does not reduce fatigue or dyspnea in patients with post-
COVID syndrome. 
 
1.5.2 ALTERNATIVE HYPOTHESIS (H1) 
A quarterly Pilates Method exercise program has clinical effects on peripheral 
muscle strength and endurance, reducing fatigue and dyspnea in patients with post-
COVID syndrome. 
 
 

 
 
39 
CHAPTER 2 - Participants and Methods 
 
 
2.1 Ethical aspects 
 
This clinical trial will be submitted to the Ethics and Research Committee of 
UNISUAM before the execution of the study, in accordance with resolution 466/2012. 
All voluntary participants, after all clarifications, will sign an informed consent form (ICF; 
Appendix 1) after being informed about the nature of the study and the protocol to be 
carried out. 
 
2.2 Study design 
 
The study will be a clinical trial previously randomized by electronic 
randomization system ( www.random.org ) and the allocation of volunteers in the study 
arms will be done without the participation of the researchers. The study will be double-
blind since neither the volunteers nor the professional who will perform the pilates 
protocol are aware of the objectives and clinical valences that will be measured by the 
study. 
 
2.2.1 Location of the study 
 
The clinical trial will be carried out at the Rehabilitation Center of the Military 
Police of the State of Rio de Janeiro 
 
2.2.2 Protocol pre -registration 
 
 
After approval by the UNISUAM Research Ethics Committee, the entire clinical 
trial protocol will be registered in the Brazilian Registry of Clinical Trials ( ReBEC - 
https://ensaiosclinicos.gov.br/ ) or in the Clinical trials ( https://clinicaltrials.gov/ ) 
 

 
 
40 
2.3 Sample 
 
The sample will consist of 60 participants, divided into two groups: an 
intervention group (n=30) that will do a 12-week program, 2x/week of Pilates method 
exercises , and a control group (n=30) that will not do any intervention for rehabilitation 
in the period. 
 
2.3.1 Study recruitment site 
 
Patients will be recruited at the Central Hospital of the Military Police and at the 
specialized multidisciplinary outpatient post-COVID-19 follow-up. 
 
 
2.3.2 Inclusion criteria 
 
1. Patients with a previous diagnosis of COVID-19, who required hospitalization 
and required invasive mechanical ventilation for at least 7 days and who were 
discharged between August and December 2021 to minimize regression to 
mean; 
2. Both sexes; 
3. Older than 18 years. 
 
2.3.3 Exclusion criteria 
 
1. Need for supplemental home oxygen; 
2. Motor or neurological or cognitive alteration that contraindicates the practice of 
Pilates . 
3. Persistence of clinical signs of deep vein thrombosis 
4. Upper limb dynamometry < 14 kg for men and < 7 kg for women would indicate 
very marked peripheral muscle weakness and would therefore contraindicate 
Pliates at the moment. 
 

 
 
41 
2.3.4 Risks and Benefits 
The possible risks of this research are, the increase in the sensation of 
shortness of breath during the execution of the exercises, the reduction of the 
saturation of O2 and, the possible muscular pains resulting from the practice of the 
Pilates Method . 
As benefits we can mention: the improvement of the disposition to carry out the 
activities of daily living, the improvement of the balance, in addition to obtaining gains 
in relation to the quality of life and the reduction of dyspnea. 
The research will be immediately suspended if any risk or damage to the health 
of the subject participating in the research is perceived, resulting from it, not provided 
for in the consent form (ICF). If it is proven that a group has benefited from the 
intervention of the protocol of this work, the same intervention will be offered to the 
other group, avoiding any harm to the patient. 
 
Proposed Procedures/Methodology 
 
2.3.5 clinical evaluation 
 
- Demographic and clinical characteristics: An initial assessment will be carried 
out, where personal data and clinical history will be collected. 
 
2.3.6 Peripheral Muscle Assessment 
 
2.3.6.1 Palm grip dynamometry 
 
Traditionally, handgrip strength (HGS) tests have been used in rehabilitation to 
assess the physical condition of the upper limbs, by measuring the strength of the hand 
and forearm muscles of patients with various disorders in the upper extremity resulting 
from arthritis. rheumatoid disease , carpal tunnel syndrome, lateral epicondylitis , 
stroke, traumatic injuries, myopathy , ICU-acquired muscle weakness, critical patient 
polyneuropathy and neuromuscular diseases (INNES E, 1999; KURILLO GA et al ., 
2004; MOREIRA D et al., 2004; MOREIRA D et al. al ., 2003) HGS measurement by 

 
 
42 
dynamometry presents a good correlation with the functional level of the upper limbs 
and general health status, being widely used in the selection of therapeutic procedures 
and monitoring of functional rehabilitation (INNES E, 1999). Manual dynamometry has 
wide applicability, as it is a low-cost, simple, fast and non-invasive method (GÜNTHER 
CM et al ., 2008) that provides, through HGS values, an indicator of the general health 
of the evaluated individuals. 
The HGS assessment will be performed by a single previously trained 
investigator, in the morning between 8 am and 12 noon, according to the 
recommendations of the Brazilian Society of Hand Therapists (SBTM, 2008). The 
individuals will be positioned seated with the arm adducted parallel to the trunk, 
shoulder in neutral rotation, elbow flexed at 90°, forearm in fundamental position. Wrist 
hyperextension of up to 30º and ulnar deviation of up to 15º will be allowed during the 
tests. Three measurements will be taken from both hands, with a minimum interval of 
30 seconds between them. The tests will be performed alternately between the 
dominant and non-dominant side, to minimize the influence of muscle fatigue. For data 
analysis, the highest value obtained for each hand will be considered. The dominant 
hand is defined as the preferred hand for carrying out daily activities. Volunteers will 
be asked which hand they prefer to carry out activities such as writing, eating and 
carrying objects. During the execution of the handgrip, the arm will remain immobile, 
with only permission for the movement of the wrist and finger joints. 
Will be used as prediction formulas (NOVAES RD et al., 2009): 
• HGS-D, kgf = 39.996 - (0.382 x age, years ) +(0.174 x weight, kg )+(13.628 x 
sex (men=1; women=0) 
• HGS-ND, kgf = 44.968 - (0.420 x age, years )+(0.110 x weight, kg )+(9.274 x 
sex (men=1; women=0) 
 
 
2.3.6.2 Quadriceps Maximum Load Test 
 
The one-repetition maximum test (1RM) is often used as a measure of muscle 
strength, whether in the context of physical rehabilitation. In this sense, there is a 
consensus that the basis for prescribing therapeutic exercises, especially those 

 
 
43 
performed against resistance TCR) is established through the relationship between the 
percentage of 1RM and the number of repetitions. 
The 1 RM Test will be performed in an extension chair, with adjustments that 
keep the hip and ankle flexed at 90º and the knee flexed to ensure an angular trajectory 
of 120º after extension. The 1RM tests will be conducted according to the protocol 
proposed by Brown and Weir (Brown & Weir, 2001). Before each test, free, light 
activities involving the tested muscle will be performed, followed by 1 min of stretching 
for the tested muscle ( in this case, the quadriceps will be tested). After stretching, 3 
repetitions were performed with moderate load and after 5min of rest and interval, the 
1RM test will be performed, adding weights when necessary, 0.4 to 5kg, totaling up to 
five attempts. We will record the maximum load as the greatest load lifted in a single 
movement of full knee extension in an open kinetic chain. 
For the reference values, the highest value among the three measures of 
maximum voluntary contraction in the 1RM test, normalized by the body weight of each 
individual tested, was used, according to the formula proposed by Magalhães in 2010: 
(Strength (Kg) /Weight x 100) 
 
 
2.3.6.3 Quadriceps Muscle Endurance Test 
 
The quadriceps muscular endurance test will be performed after 30 min of rest 
after the 1 RM test. We will use a load of 40% of the load obtained in the 1 RM test, 
rounding up to the next higher load in case of load fractions. 
The muscular endurance test will be performed in the same extension chair, with 
hips, ankle at 90º and knee flexed to ensure an angular velocity of 1'20º/s using the 
dominant lower limb ( LLd ). Volunteers will be instructed to count 1 second for LL 
extension and 1 second to return to flexion (angular velocity of 120º/s). The outcome 
of this test will be the time to exhaustion characterized by failure or inability to complete 
the range of motion. 
 
 
2.3.7 Post COVID functional scale (PCFS) 

 
 
44 
The Post-COVID-19 Functional Status Scale is a longitudinal patient 
assessment tool for identifying changes in post-COVID-19 functional status and their 
evolution. The PCFS scale covers the entire set of functional areas, in particular 
limitations in activities of daily living (ADL) and in the workplace, as well as changes in 
lifestyle. The scale can be administered to the patient by trained staff or conducted by 
the patient as a self-assessment. In the project, following the guidelines of the PCFS, 
which will be used for research purposes, it will be conducted by a trained evaluator 
and followed all the guidelines described for this purpose. This scale consists of six 
ordinal categories that reflect conditions of increasing severity, from 0 to 4. Death is 
coded as "D". Grade 0 implies the absence of any residual symptoms. If one or more 
residual symptoms are present but do not affect the patient's normal activities, grade 
1 will be assigned. If they are limited in intensity/frequency or occasionally avoided, 
grade 2 will be assigned; grade 3 implies limitations that force the patient to reprogram 
usual activities, reflecting the inability to perform some of them, which, in fact, must be 
performed by others. Grade 4, the most severe, is reserved for severe functional 
restrictions that require continuous assistance in daily activities (CORSI et al., 2020; 
KLOK et al., 2020) . 
 
 
2.3.8 Dyspnea assessment by the modified Medical Resource scale 
Council ( mMRC ) 
medical resource modified dyspnea scale council ( mMRC ): consists of only 
five items, and the patient chooses the item that corresponds to how much dyspnea 
limits their ADLs . The patient reports his subjective degree of dyspnea by choosing a 
value between 0 and 4, where 0 (suffers from shortness of breath only during intense 
exercise), 1 (suffers from shortness of breath when walking quickly, climbing stairs or 
ramps), 2 (walks slower than people of the same age because of shortness of breath 
or having to stop for breath even when walking slowly), 3 (to breathe after walking less 
than 100 m or after a few minutes) and 4 (feel so short of breath who doesn't leave the 
house anymore, or I need help dressing or bathing alone) (ANNEX 1). The mMRC 
dyspnea scale showed satisfactory reliability and validity (KOVELIS et al., 2008) . 
For the perception of effort during the exercises of the intervention group, the 
modified Borg scale will be used : which is a subjective scale to qualify the degree of 

 
 
45 
respiratory distress during exercise, where option 0 means no effort and 10 means 
maximum effort and will be used exclusively during Pilates sessions to control exercise 
intensity. 
 
2.3.9 Fatigue Assessment by the Fatigue Pictogram 
Fatigue assessment will be done by the Fatigue Pictogram. The Fatigue 
Pictogram (FITCH MI et al., 2003) is an illustrated instrument for the assessment of 
fatigue (ANNEX 2). It has two sets of figures that assess the intensity and impact of 
fatigue on usual activities and, as it is brief and easy to apply, it is useful for assistance 
and research. Aiming at comparability between world populations or populations with 
different diseases, and in view of the recommendations to make cultural adaptations 
of existing instruments instead of creating new ones, we chose to use it, assigning 
numbers to each of the images to facilitate quantitative analysis. This scale was 
validated in Brazil in relation to its psychometric properties in the Brazilian population 
( MOTA DD et al., 2009) 
 
 
2.3.10 
Quality of life assessment  
The assessment of quality of life will be carried out using a generic instrument 
of 36 items, validated in Brazil and called the SF-36 (Short Form Health Survey ). This 
instrument is a generic quality-of-life assessment questionnaire that is easy to 
administer and understand. Consisting of 36 items, subdivided into 8 domains, which 
are: functional capacity, physical aspects, pain, general health status, vitality, social 
aspects, emotional aspects and mental health. It presents a score that goes from 0 
(zero) to 100 (obtained by calculating the Raw Scale ), where zero corresponds to the 
worst general health status and 100 corresponds to the best health status. To calculate 
the domain (aspect to be analyzed), a specific formula is applied, according to the 
translated and validated SF-36 (Brazier et al. , 1992; Lins and Carvalho, 2016) 
2.3.11 
Pilates Method Exercise Protocol (MP) 
Pilates exercise protocol : was developed based on protocols contained in 
previously published clinical trials whose objective was muscle strengthening or 
improvement of muscle fatigue. Thus, the protocol developed will perform exercises 
from the classical repertoire of the Pilates Method , with the use of equipment exclusive 

 
 
46 
to the Method - such as Cadillac , Lader Barrel , Chair and Reformer . The sessions 
will take place twice a week, in groups of up to 3 participants, always in the morning 
and will last 60 min, with 10 min of warm-up, 40 min of exercises with load and 10 min 
of relaxation exercises and calm down. All sessions will be performed by a physical 
therapist specialized in the method, in a specific outpatient clinic. The professional who 
will conduct the Pilates sessions will execute the proposed protocol and is unaware of 
the outcomes studied by the project. In figure 3, we present the equipment that will be 
used in the study. 
 
 
Figure 3: Equipment that will be used. (a) Combo Chair , (b) Cadillac , (c) Universal Reformer 
, (d) Ladder barrel 
 
 
 
2.4 Outcomes 
 
2.4.1 primary outcome 
 
As variables for the primary outcome of this research, it will be the functional 
performance, resulting from the combination of the PCFS Scale with the Dynamometry 
of Pressure Para, Test of Strength and of Endurance of the quadriceps muscle. 

 
 
47 
 
2.4.2 secondary outcome 
 
Improved quality of life (Questionnaire SF36) and reduced perception of 
dyspnea during physical activities and ADLs ( mMRC and Borg ). 
 
 
2.5 Data analysis 
 
2.5.1 Sample size (calculation or justification) 
 
The sample size calculation was done with the “ pwr ” package (CHAMPELY S, 
2018) (R package , version 1.2-2, https://CRAN.R-project.org/package=pwr ). For the 
calculation, we considered the mean of 41.3, the standard deviation of 5.05 and a 
minimal clinically important difference of 4.7 kg between the means of maximum load 
in the maximal voluntary contraction test (OLIVEIRA IO, 2016) and power based on 
Cohen 's model of 0.8 with a standard deviation of 5.05. Assuming α = 0.05, β = 0.8, 
standard deviation = 5.05 and an effect size proposed by Cohen of 0.93. 
This effect size " d " is calculated by: 
d= [(Reference average + Minimum detected change) – reference average]/ deviation – standard 
d= [( 41.3 + 4.7) – 41.3]/5.05 => d= 0.93. 
pwr package . in R we have: 
n= pwr.t. test ( n=NULL, d=0.93, sig.level =0.05, power=0.8, type=" two.sample ", alternative=" 
two.sided ") 
n = 19.15925 
d = 0.93 
      sig.level = 0.05 
power = 0.8 
    alternative = two.sided 

 
 
48 
In this way, we use on=established and rounded up to the first integer 
immediately higher (n=20) + 20% to cover any losses. Thus, the minimum number of 
patients needed in each group will be 24 patients. 
 
2.5.2 control variables 
 
The control variables will be the peripheral muscle strength established by the 
handgrip test, by the maximum voluntary contraction test and by the peripheral muscle 
endurance test. In addition, we will use the mMRC , the quantified fatigue pictogram, 
the PCFS and the quality of life as control variables. 
 
2.5.3 Exposure variables 
 
The exposure variables will be the 12-week, twice-weekly exercise program 
based on the Pilates method . 
 
2.5.4 Confounding variables 
The length of stay and the degree of dysfunction acquired in the ICU may 
represent confounding variables. Thus, avoiding regression to the mean, inclusion in 
the study can only occur after 3 months (90 days) after hospital discharge. This is the 
time described to minimize eventual complications inherent to the immobility syndrome 
and homogenize the groups 
 
 
 
2.5.5 Statistical analysis plan 
 
Data analysis will be performed using the SPSS 23.0 program ( Statistical 
Package for Social Sciences ). Descriptive analysis will be performed for all variables 
(mean and standard deviation). General Linear Model ( GLMs ) with mixed design will 
be performed to compare treatment effect size between groups. The pairwise 
comparison comparisons ) will be performed to verify the mean difference between the 
Pilates Group and the Control Group in all variables in each period independently. 

 
 
49 
Intention-to-treat analysis was used using the Last method. observation Carried 
Forward (LOCF) for lost participant data. A significance level of 0.05 and a confidence 
interval of 95% will be adopted 
. 
2.5.6 Availability and access to data 
 
 
All data may be made available for consultation and full access at the clinical 
trial registration site. 
 
 
2.6  Expected results 
 
The hypotheses of this clinical trial hope to demonstrate the clinical effects of a 
Pilates program for the management of musculoskeletal disorders and persistent 
symptoms in patients with COVID-19. Studies involving other populations have already 
demonstrated the effects of Pilates on peripheral muscle strength and endurance in 
patients with chronic lung disorders, patients with chronic low back pain, patients with 
neurological syndromes, among others. Thus, it is hypothesized that similar effects 
may occur in the study population. 
 
2.7 Budget and financial support 
 
This study will be entirely with own resources and equipment available in the 
research laboratories of the teaching institution partner in conducting the study. There 
is no burden to study participants 
 
Table 3: Budget details. 
Budget identification 
Type 
Price R$) 
Physiotherapist 
specializing in Pilates 
execution team 
BRL 0.00 
reformer 
permanent material 
BRL 0.00 
Cadillac 
permanent material 
BRL 0.00 

 
 
50 
Chair 
permanent material 
BRL 0.00 
Lader barrel 
permanent material 
BRL 0.00 
pulse oximeter 
permanent material 
BRL 0.00 
stopwatch 
permanent material 
BRL 0.00 
palm grip dynamometer 
permanent material 
BRL 0.00 
Extension chair and load 
cell 
permanent material 
BRL 0.00 
Video camera 
permanent material 
BRL 0.00 
Reproduction of evaluation 
sheets 
Material consumption 
BRL 50.00 
A4 paper format 
Material consumption 
BRL 50.00 
 
Total in BRL BRL 100.00 
 
2.8 Timeline 
 
Table 4: Execution schedule. 
step identification 
Start 
(mm/yy) 
Term 
(mm/yy) 
Beginning of the course and designing the project 
August/20 
November/21 
Project submission to the Research Ethics 
Committee 
April/22 
April/22 
Methods training 
April/22 
April/22 
patient recruitment 
April/22 
May/22 
Execution of the Protocol 
April/22 
July/22 
Data collection and tabulation 
April/22 
July/22 
Data analysis 
July/22 
August/22 
Preparation of the manuscript(s) 
August/22 
August/22 
Final essay writing 
August/22 
August/22 
defense exam 
September/22 September/22 
Changes guided by the examining board 
September/22 September/22 
Submission of manuscript(s) 
September/22 
October/22 
Delivery of the final version of the final paper 
October/22 
October/22 
 

 
 
51 
 
 
 

 
 
52 
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Muscle force during an acute exacerbation in hospitalized patients with COPD and its 
relationship with CXCL8 and IGF-I. Thorax. 
SWALLOW EB, Reyes D, Hopkinson NS, Man WD, Porcher R, Cetti EJ, et al. 
Quadriceps strength predicts mortality in patients with moderate to severe chronic 
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Systematic review and meta-analysis. Journal of bodywork and movement therapies. 
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ACSM's Health & Fitness Journal. 2017;21:10 -19. 
TINOCO-FERNÁNDEZ, M. et al. The Pilates method and cardiorespiratory adaptation 
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TROOSTERS, T. et al. Pulmonary rehabilitation in chronic obstructive pulmonary 
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VELLOSO, Marcelo; COSTA, Cleude Pinheiro; OZEKI, Cristina Midori . Dyspnea 
measurement methods : a literature review. Conscientiae Saúde, v. 1, p. 35-39, 2002. 
VØLLESTAD NK. Measurement of human muscle fatigue. J Neurosci Methods. 
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WELCH, C.; GREIG, C.; MASUD, T.; WILSON, D.; JACKSON, TA COVID-19 and 
Acute Sarcopenia. Aging Dis. 2020, 11, 1345–1351. 
WOOD S. Pilates for Rehabilitation: Human Kinetics; 2018 
YENDE S, Waterer GW, Tolley EA, Newman AB, Bauer DC, Taaffe DR, et al. 
Inflammatory markers are associated with ventilatory limitation and muscle dysfunction 
in obstructive lung disease in well functioning elderly 

 
 
55 
Appendix 1 - Free and Informed Consent Form 
 
EFFECTS OF PILATES ON PERIPHERAL MUSCLE STRENGTH, DYSPNEA AND 
FATIGUE IN PATIENTS WITH POST-COVID-19 SYNDROME: CONTROLLED AND 
RANZOMIZED CLINICAL TRIAL 
Made from Res. nº 466 of 12/10/2012 of the National Health Council 
 
Brief justification and research objectives : We are daily in contact with the 
negative repercussions of the sequelae caused by the COVID-19 infection. Complaints 
such as shortness of breath, tiredness, body aches, joint pain and weakness, worsen 
the quality of life and make daily activities difficult. Pilates exercises can be used to 
reduce these discomforts, improving quality of life and maintaining independence. The 
objective of this research is to evaluate the clinical and functional effects of the Pilates 
Method exercise program for post-COVID patients. 
Procedures : In a first contact, a draw will be held to define which group you 
will be placed in. We will have two groups, in Group 1, the Pilates Method protocol will 
be applied , 2x/week in a period of 12 weeks with 60-minute sessions; Group 2 will 
only undergo initial and final assessments. After defining the group you will be a part 
of, we will make an initial assessment, where your personal data, disease history, 
medication use, life habits and information about the Covid-19 infection will be 
collected. After this assessment, you will answer 2 questionnaires, one specific about 
the consequences of Covid-19 and another about quality of life. In a third step, we will 
measure your blood pressure and check your oxygen saturation and heart rate, after 
these measurements we will do some physical tests to assess your tiredness and 
balance in carrying out some movements similar to your daily life, such as sitting and 
getting up. . We will always be monitoring your feeling of shortness of breath and 
tiredness, in addition to the vital signs measured in the second stage. After this 
evaluation, Pilates Apparatus sessions will be scheduled twice a week, for 3 months, 
where a Pilates exercise protocol will be applied in the specific equipment of the 
Method - Cadillac , Chair , Lader Barrel and Reformer . 
Potential risks and benefits : The possible risks are, increased sensation of 
shortness of breath during the execution of the exercises, drop in O2 saturation, 
possible muscle pain resulting from the practice of Pilates . As benefits we can 
mention: improved disposition to perform day-to-day functions, improved balance, in 
addition to obtaining gains in terms of quality of life and reducing the feeling of 
shortness of breath. If it is proven that a group has benefited from the intervention of 
the protocol of this work, the same intervention will be offered to the other group, 
avoiding any harm to the patient. 
Guarantee of secrecy, privacy, anonymity and access: Your privacy will be 
respected, that is, your name or any other data or element that can in any way identify 
you, will be kept confidential. Anonymity and privacy will be guaranteed. If there is 
interest, you will have access to the results. 
Ensuring clarification : Assistance is ensured throughout the research, as well 
as the guarantee of your free access to all information and additional clarifications 
about the study and its consequences. 
Assurance of responsibility and disclosure : The results of the exams and 
research data will be the responsibility of the researcher, and these results will be 
published in the scientific environment without citing any way that can identify their 
name. 

 
 
56 
Expense reimbursement guarantee : You will not incur personal expenses at 
any stage of the study, nor financial compensation related to your participation. In case 
of personal injury directly caused by the procedures proposed in this study, you will be 
entitled to medical treatment, as well as the legally established indemnities. However, 
if you have any expenses resulting from participation in the research, there will be 
reimbursement by means of a deposit in a checking account or check or cash. 
Likewise, if any damage occurs as a result of your participation in the study, you will 
be duly compensated, as determined by law. 
Responsibility of the researcher and the institution : The researcher and the 
proposing institution will be responsible for any personal or moral damages related to 
the physical and ethical integrity that the research may entail. 
Criteria for suspending or terminating the research :  
The study will be 
suspended in the event of any methodological or technical failure observed by the 
researcher, and the researcher is responsible for informing all participants of the 
reason for suspension. The study will also be suspended if any risk or damage to the 
health of the participating subjects is perceived, resulting from the research, which has 
not been foreseen in this term. When the necessary data collection is reached, the 
survey will be terminated. 
Infrastructure statement : The institution where the study will be carried out 
has the necessary infrastructure for the development of research with an adequate 
environment. 
Ownership of the information generated: There is no restrictive clause for 
the dissemination of research results, and the data collected will be used solely and 
exclusively to prove the experiment. The results will be submitted for publication, 
whether they are favorable or not to the hypotheses of the study. 
About the refusal to participate : If you wish, you may refuse to participate in 
the study, or withdraw your consent at any time, without having to justify yourself, not 
suffering any damage to the assistance you receive. 
Contact of the responsible researcher and the ethics committee : At any 
stage of the study, you can have access to the responsible professional, MICHELLE 
DE AGUIAR ZACARIA , who can be reached at (41) 98427-6132 . If you have any 
concerns or questions about research ethics, you can contact the Research Ethics 
Committee of Centro Universitário Augusto Motta (UNISUAM), located at Rua Dona 
Isabel, 94 – Bonsucesso, telephone (21)3882-9797 ( Extension: 9943), e-mail: 
comitedeetica@souunisuam.com.br. 
If this term is clear enough to provide you with all the information about the study 
and if you understand its purposes, the procedures to be carried out, its discomforts 
and risks, the guarantees of confidentiality and permanent clarification. You may 
declare your free consent to participate, being fully aware of the study proposals. 
 
Rio de Janeiro, _____ of ________________ of _______ 
 
_____________________________________ 
Signature of the participant or the person in charge 

 
 
57 
Appendix 2 - Preliminary Ethical Checklist ( CEPlist ) 
 
The List of Items for the Research Ethics Committee ( CEPlist ) was prepared 
based on Resolution of the National Health Council No. 466 of December 12, 2012 
with the aim of improving the quality of information in Research Protocols involving 
human beings that are submitted for consideration by the CEP/CONEP system. 
The CEPlist is completed by the main researcher of the project before its 
submission to be attached to Plataforma Brasil as “Other” documents. The researcher 
will fill in the number of the page where this information appears. If the item does not 
apply, it must be filled in with “NA”. 
 
a) Mandatory documents 
Pages 
a.1. Terms 
a) Term of Consent of the proposing institution 
written on letterhead, dated and signed by a 
representative 
 
 
b) Term(s) of Consent of the co-participating 
institution( s ) written on letterhead, dated and 
signed by a representative 
 
 
a) Free and Informed Consent Form 
 
 
b) Free and Informed Consent Term 
 
 
c) Term of Authorization for Use of Secondary 
Data 
 
a.2. Timeline 
a) Detailed schedule regarding the stages of the 
research project 
 
a.3. Budget 
a) Detailed budget regarding the application of 
resources 
 
 
b) Citation of the research sponsor(s) 
 
a.4. declarations 
a) Declaration of Institution and Infrastructure 
written on letterhead, dated and signed by a 
representative 
 
 
b) Declaration of Researchers 
 
 
c) Sponsor's Declaration 
 
a.5. waiver 
a) Justification for waiver of the Term requested 
by the responsible researcher to the 
CEP/CONEP System 
 
b) Research Project (PP) 
Pages 
b.1. Introduction 
a) Grounding on scientific facts, prior 
experimentation and/or assumptions 
appropriate to the specific area of research 
 
b.2. Materials and 
methods 
a) Appropriate methods to answer the questions 
studied, specifying them, whether qualitative, 
quantitative or quali -quantitative research 
 
 
b) Calculation and/or justification of sample size 
 
 
c) Well-defined inclusion and exclusion criteria 
 
 
d) Detailed procedure for recruiting participants 
 
 
e) Location( s ) of the research stage(s) 
 
 
f) Wash - out periods or use of placebo justified 
and with critical risk analysis 
 

 
 
58 
 
g) Detailed and justified explanation of the exams 
and tests that will be carried out 
 
 
h) Maintenance of research data in a file, physical 
or digital, under the custody and responsibility 
of the main researcher, for 5 years after the 
end of the research 
 
 
i) Detailed criteria for suspending and 
terminating the survey 
 
b.3. Appendices 
and Annexes 
a) Questionnaire(s) for data collection 
 
c) Free and Informed Consent Term (ICF) 
Pages 
c.1. Required 
information 
a) Project title below the Term title 
 
 
b) Information provided in clear and accessible 
language to the participant 
 
 
c) Justification and clear and well-defined 
objectives 
 
 
d) Detailed procedures and methods to be used 
in the research 
 
 
e) Possibility of inclusion (draw) in a control or 
experimental group 
 
 
f) Possible discomforts and risks arising from 
participation in the research 
 
 
g) Possible benefits arising from participation in 
the research 
 
 
h) Measures and precautions to be taken to avoid 
and/or reduce adverse effects and conditions 
that may cause damage 
 
 
i) Forms of follow-up and assistance to which 
research participants will be entitled to deal 
with complications and damages resulting, 
directly or indirectly, from the research 
 
 
j) Guarantee of full freedom to the research 
participant, to refuse to participate or withdraw 
their consent, at any stage of the research, 
without penalty 
 
 
k) Ensuring that the confidentiality and privacy of 
research participants is maintained during all 
phases of the research 
 
 
l) Guarantee that the research participant will 
receive a copy of the Term 
 
 
m) Guarantee of reimbursement and how the 
expenses incurred by the research participants 
and resulting from it will be covered 
 
 
n) It explains the guarantee of indemnity in the 
face of possible damages resulting from the 
research 
 
 
o) Clarification on the possibility of including the 
participant in a control or placebo group, 
 

 
 
59 
clearly explaining the meaning of this 
possibility 
 
p) Commitment to forward the research results for 
publication in the scientific environment 
 
 
q) Statement by the responsible researcher that 
expresses compliance with the requirements of 
Resolution No. 466/2012 
 
 
r) Declaration by the responsible researcher that 
the results of the exams and/or research data 
will be the responsibility of the researchers 
 
c.2. Researcher 
a) All pages and copies of the Term include the 
address and telephone or other contact 
information of those responsible for the 
research 
 
c.3. Ethics 
Committee 
a) On all pages and copies of the Term, the 
address and telephone or other contact 
information of the CEP 
 
c.4. Participant 
a) There is space for the name of the participant 
and/or legal guardian and place for their 
signature 
 
d) Free and Informed Assent Term (TALE) 
Pages 
d.1. Presentation 
a) There is a consent form for those responsible 
with the consent of minors or legally incapable 
persons. 
 
recommendations 
( ) Approved 
This project complies 
with Resolution 
466/2012 of the 
National Health Council 
and can be submitted to 
the CEP/CONEP 
( ) With pending 
A review of the 
suggestions proposed by 
the board is requested 
before consideration by 
the CEP/CONEP 
( ) Failed 
The project must be 
resubmitted after meeting the 
suggestions proposed by the 
BANK and the CEP/CONEP 
criteria 
 
 
 

 
 
60 
Appendix 3 - Image use authorization term 
 
 
I, 
____________________________________________________, 
nationality 
________________, minor, in this act duly represented by his (her) (legal guardian), 
____________________________________________, 
nationality 
________________, marital status ________________, bearer of Identity Card RG 
No. , resident at Av /Rua ________________________________, no. _________, 
municipality of Rio de Janeiro ________________________________/Rio de Janeiro, 
I AUTHORIZE the use of my image in any and all material including photos, videos 
and documents, to be used in didactic and scientific material arising from the EFFECTS 
OF PILATES ON PERIPHERAL MUSCULAR STRENGTH, IN DYSPNEA AND 
FATIGUE OF PATIENTS WITH POST-COVID-19 SYNDROME: CONTROLLED AND 
RANZOMIZED CLINICAL TRIALS. This authorization is granted free of charge, 
covering the use of the aforementioned image throughout the national territory and 
abroad, in the following ways: presentation folder; scientific articles in specialized 
magazines and newspapers; classes in training courses; informational posters; 
lectures at scientific meetings; congress banners; electronic media (panels, videos, 
television, cinema, radio program, among others), as long as they are related to the 
dissemination of the project and the research findings. As this is the expression of my 
will, I declare that I authorize the use described above without anything to be claimed 
as rights related to my image or any other, and I sign this authorization in 2 copies of 
equal content and form. I declare that I understand the objectives and benefits of 
using the research images and I authorize their use in the ways described above, 
for the dissemination of the project and the research findings. 
 
_________________________________________ Date: _____/_______/_______ 
Participant's signature 
 
________________________________________ _ Date : _____/_______/_______ 
MICHELLE DE AGUIAR ZACARIA 
 
 
 
 

 
 
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Appendix 4 – Research Consent Term 
 
 
The MILITARY POLICE PHYSIATRY AND REHABILITATION CENTER is in 
agreement with the execution of the project on the EFFECTS OF PILATES ON 
PERIPHERAL MUSCLE STRENGTH, DYSPNEA AND FATIGUE IN PATIENTS 
WITH POST-COVID-19 SYNDROME: CONTROLLED RANDIMIZED CLINICAL 
TRIAL, coordinated by researcher PROFESSOR DR. LUIS FELIPE DA FONSECA 
REIS AND BY MASTER STUDENT MICHELLE DE AGUIAR ZACARIA, from the 
Postgraduate Program in Rehabilitation Sciences at Centro Universitário Augusto 
Motta, and undertakes to support the development of said research in this Institution, 
ALLOWING THE PROJECT EXECUTION, WITHOUT ANY FINANCIAL OR EVEN 
ADMINISTRATIVE CHARGES IN THE ROUTINE OF THE UNIT. This institution is 
committed to ensuring the safety and well-being of participants in compliance with 
Resolution 466 of 2012 of the National Health Council and its complementary ones. 
 
 
Rio de Janeiro, March 30, 2022. 
 
 
_____________________________ 
TEN CEL PM MED SIRLEY DE MELLO FERNANDES 
RG 60686     ID FUNCTIONAL 2462256-7 
DIRECTOR OF THE PHYSIATRY AND REHABILITATION CENTER OF PMERJ 
 
 
( ) I authorize the realization of the Project on the premises of the CFRPM 
( ) I authorize to cite the name of the Institution 
 
 
 

 
 
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Annex 1 - Post-COVID-19 Functional Status Scale 
(PCFS) 
 
 
 

 
 
63 
Annex 2 - Medical Research Dyspnea Scale modified 
council 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
64 
Annex 3 - Fatigue Pictogram