Relaxation Exercise in Patients With COVID-19
Condition: Covid19
MeSH terms: COVID-19
Study type: Interventional

Summary: 
      the aim of this study is to investigate the effect of relaxation techniques on immune
      biomarkers and disease severity and progression in patients with COVID-19 and the period to
      which these changes last.
    

Detailed description: 
      Study procedures A randomized controlled design was used. The study was double-blinded in
      which both patients and assessors were blinded to study procedures. Each patient was asked to
      sign an informed consent before participation in this study. This study was approved by the
      ethics committee of our university (blinded). Patients were recruited from December 2020 to
      April 2021. The patients were collected by reviewing the hospital's data (blinded). Then, we
      called patients with COVID-19 to ask them about their welling to participate in this study.
      Patients who accepted to participate were interviewed through video calls using Zoom App to
      discuss study procedures with them. Patients who accepted to engage in this study were
      visited by a researcher at their home while they are in quarantine. Through the initial
      visit, the consent form was signed, and blood samples were taken. Any patient must have
      permission to perform our intervention from the physician who supervises him/her. The
      clinical protocol of this study was retrospectively registered at
      https://www.clinicaltrials.gov/ platform with this registration number NCT04998708. The study
      was registered retrospectively because of the vulnerability of the research team to have
      COVID-19 which may affect the dates and data of the trial. There were no deviations from the
      registered trial protocol.

      The suitable sample size for this study was determined using a priori power test. The G*POWER
      program (ver. 3.1.9.2, Heinrich-Heine-University, Düsseldorf, Germany) was used. The criteria
      entered into the program included a MANOVA test using 2 groups, 2 measurements, a power level
      of 80%, a significance level of .05, and medium effect size (dz= .25)(Faul et al., 2007).
      Based on the previous assumptions, the total sample size needed for this study was 30
      patients. A minimum power of 80% or more is acceptable in most studies(Kadam & Bhalerao,
      2010). The flow of patients throughout the study is shown in Figure 1.

      Initially, forty-five patients accepted the participation in this study. Ten patients did not
      meet the study inclusion criteria and additional five patients did not complete the whole
      study because they did not like doing exercise. Finally, thirty patients with COVID-19
      completed the whole study (2-weeks intervention and 3-weeks post-intervention "follow-up").
      The patients' age ranged from 25 to 45 years old. The inclusion criteria included that the
      patient has a recent mild or moderate COVID-19 with no or low-grade fever 99.5- 100.94 °F
      (37.5-38.3 °C) (Affronti et al., 2010; Zhuang et al., 2020). Mild grade COVID-19 was
      determined by having symptoms of acute upper respiratory tract infection (fever, cough,
      myalgia, runny nose, fatigue, sore throat, sneezing) or gastrointestinal symptoms (nausea,
      vomiting, abdominal pain, diarrhea). Moderate grade COVID 19 was determined by having mild
      symptoms plus pneumonia (cough, frequent fever) with no obvious hypoxemia, the presence of
      lesions on chest CT(Yuki et al., 2020). The exclusion criteria included that the patient is
      indicated for being hospitalized, has high-grade fever <100.94 °F (<38.3 °C), or other
      chronic diseases such as heart problems, hypertension, or diabetes. Women on contraceptives
      were excluded because contraceptives decrease immune function increase the risk of various
      autoimmune disorders(Williams, 2017).

      Evaluative procedures There were three main dependent variables including blood immune
      markers, salivary immunoglobulin A, and Wisconsin Upper Respiratory Symptom Survey. These
      measurements were collected at the baseline, 2-weeks post-intervention, and 1-week as a
      follow-up.

      A lab technician and one researcher were asked to visit the patient at home during the
      quarantine. The technician collected blood and saliva samples and the researcher conducted
      the Wisconsin Upper Respiratory Symptom Survey. They wore special protective equipment
      recommended by WHO(WHO, 2020b; World Health Organization (WHO), 2020). Three visits were
      performed including the beginning of the research procedures, 24-h post-intervention (2
      weeks), and 1-week as a follow-up.

      Blood sample collection Blood samples were taken in the morning (8:30-9:30) by collecting
      10mL of venous blood. Patients were asked to stop any exercise for at least 24 hours before
      blood sampling. Also, patients were asked to stop eating or drinking 8 hours before
      collecting samples. Samples were collected in vacutainer tubes with sodium
      ethylenediami-netetraacetic acid (EDTA) for plasma separation. The blood was centrifuged at
      3,000 rpm for 15 min at 4◦C. The total lymphocytes, leukocytes, and monocytes were measured
      utilizing a multichannel hemocyte analysis system (SE-9000; Sysmex Corp, Hyogo, Japan)(Lira
      et al., 2017; Shimizu et al., 2011). The concentrations of IL-6, IL-10, and TNF-α were
      analyzed by using ELISA commercial kits assay (R&D Systems, Minneapolis, USA). The
      manufacturer's instructions for analysis of IL-6, IL-10, and TNF-α on an EZ-Reader microplate
      reader at 450 nm were followed(de Souza et al., 2018; Lira et al., 2017). The samples were
      stored at -20◦C for further analysis.

      Saliva sample collection The saliva sample was taken without any saliva stimulation methods.
      The patient was asked to rinse their mouths with distilled water and evacuate their mouth
      just before the collection. We used the passive drainage method for this collection. The
      patient slightly flexed their head forward to allow the saliva to move into a sterilized and
      pre-weighed Falcon tube for 5 min. The weight of tubes was measured again following the
      collection to estimate the volume and the saliva flow rate. The tubes were weighed with 0.1mg
      accuracy with the proposed saliva density proposed at 1.0 g. mL-1. The samples were stored at
      -80◦C for further analysis. The S-IgA concentration was analyzed utilizing commercial ELISA
      kits (IgA Salivary, DRG, Minneapolis, USA). The IgA-S secretion rate (ng/min) was measured by
      multiplying the whole concentration of IgA-S present in the mucosal surface per unit of time
      by the saliva flow rate (mL/min) (de Souza et al., 2018).

      Wisconsin Upper Respiratory Symptom Survey The Wisconsin Upper Respiratory Symptom Survey is
      an empirically derived patient-oriented illness-specific quality-of-life evaluative outcomes
      instrument(A. W. Barrett & Barrington, 2005). The development process of this survey was
      described in detail by Barrett et al(B. Barrett et al., 2018). The Wisconsin Upper
      Respiratory Symptom Survey is designed to evaluate the negative effect of acute upper
      respiratory infection on the quality of life. It is a validated and reliable measurement for
      evaluating the change in the quality of life over time including influenza-like illness
      symptoms of headache, body aches, and fever(B. Barrett et al., 2018). The patients were asked
      to fill the survey at the baseline, 2-weeks post-intervention, and 1-week as a follow-up.

      Treatment Procedures Patients were assigned randomly into intervention, and control groups.
      Patients were randomly allocated to 4 permuted blocks using computer software to have 2 equal
      sample sizes. The randomization was performed by a college staff member who was not involved
      in this study. All patients in the groups followed the WHO procedures of quarantine(WHO,
      2020a) and took standardized medications administered by the Turkish Ministry of Health
      (Hydroxychloroquine Sulphate 200 Mg).

      The intervention group performed an integrated intervention combining CBSM and PMRs. We used
      these two interventions because it has been shown their positive effects on immune function.
      The two relaxation techniques included progressive muscle relaxation training (PMR)(Xiao et
      al., 2020) and cognitive-behavioral stress management (CBSM)(McGregor et al., 2004). We used
      two types of relaxation techniques to produce maximum effects of relaxation techniques within
      the limited period of COVID-19 quarantine (2 weeks). The control groups did not receive any
      relaxation techniques during the study.

      Progressive Muscle Relaxation Training Progressive muscle relaxation training has been
      reported to decrease anxiety, negative emotions, and enhance sleep quality in patients with
      COVID-19 (Özlü et al., 2021; Xiao et al., 2020). The patients performed PMR in their bed for
      30 minutes in the morning after waking up and at night before sleeping. We recorded a
      detailed video for PMR to be watched by all patients before participating in this study. The
      PMR order was initiated by doing isometric contractions of muscles with a concentration on
      the sensation of tension for 3 to 5 sec. Then, they take a rest for 10 to 15 sec. Next, the
      patients were instructed to perform the PMR in this sequence foot, leg, hip and waist, chest,
      arm, shoulder, and face. The specific instructions for each exercise were demonstrated in the
      study of Özlem et al(Özlü et al., 2021). The patient should at least complete 12 days of PMRs
      to be included in the statistical analysis.

      Cognitive-Behavioral Stress Management (CBSM) Cognitive-Behavioral Stress Management has been
      reported to significantly decrease depression, anxiety, and stress in patients with COVID-19
      (Li et al., 2020). All included patients were taken a 2-h structured group session to
      illustrate the CBSM in detail before starting the study. All sessions were conducted by a
      hired psychologist who was blinded to study procedures. The CBSM consisted of a 2-h
      structured group session performed 2 times/week. Each session focused on various CBSM
      techniques (e.g., coping skills training, cognitive restructuring, assertion training, and
      stress management). The patients also were asked to do homework assignments (e.g., relaxation
      monitoring cards and a cognitive restructuring worksheet) given each week. The patient should
      attend all 2-h structured group sessions and do all assignments to be included in the
      statistical analysis.

      Data analysis Patients' files were encoded by a university administrator who did not join
      this study(Taylor & Murphy, 2010). Intention-to-treat and general linear models of analysis
      were followed. A multivariate analysis of repeated measurements (MANOVA) test was used to
      measure within--each group interactions, while an independent MANOVA test was used to measure
      between-groups comparisons. The outcome measures were measured at the baseline, 2-weeks
      post-intervention, and 1-week as a follow-up. All results were compared to the baseline
      results. The baseline characteristics of patients in both groups were compared using Pearson
      chi-squared tests for categorical variables (gender, previous lung infection history) and
      t-test for continuous variables (age and body mass index). The significance level was set at
      p<.05. The SPSS (ver. 25, IBM Inc., Armonk, NY, USA) was used for statistical analysis.
    

Intervention name(s): Relaxation technique
Intervention type(s): Other
Intervention description(s): The intervention group performed two types of relaxation techniques, that have shown their positive effects on immune functions, including progressive muscle relaxation exercise (PMRs)16 and cognitive-behavioral stress management (CBSM)32. We used two types of relaxation techniques to produce maximum effects of relaxation techniques within the limited period of COVID-19 quarantine (2 weeks). the control groups did not receive any treatment during the study; however, they were treated afterwards.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment