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 Table of Contents  
Year : 2023  |  Volume : 7  |  Issue : 1  |  Page : 45-48

Proposing an #EASIER cardiopulmonary rehabilitation protocol for coronavirus disease 2019 survivors

1 Department of Physiotherapy, Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, São Carlos, São Paulo, Brazil
2 Department of Physical Therapy, College of Applied Sciences, University of Illinois at Chicago; Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IL, USA
3 Department of Physical Therapy, College of Applied Sciences, University of Illinois at Chicago; Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IL, USA; Human Sciences Research Centre, University of Derby, Derby, UK
4 Department of Physiotherapy, Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, São Carlos, São Paulo, Brazil; Healthy Living for Pandemic Event Protection (HL – PIVOT) Network, Chicago, IL, USA

Date of Submission01-Aug-2022
Date of Acceptance04-Nov-2022
Date of Web Publication13-Mar-2023

Correspondence Address:
Dr. Audrey Borghi-Silva
Department of Physiotherapy, Cardiopulmonary Physiotherapy Laboratory, Federal University of São Carlos, Rod Washington Luis, Km 235, Jardim Guanabara, 13565-905, São Carlos, São Paulo, Brazil

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_28_22

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The economic and social impact that coronavirus disease 2019 (COVID-19) can bring is undeniable since high numbers of active workers in production and service provision are being contaminated. In addition, those infected may have long-term sequelae, impairing their functional capacity, and consequently, their work activities. It considers that intervention in cardiopulmonary rehabilitation is of great importance, especially in the recovery stage, and should be carried out mainly with the aim of improving dyspnea, severe muscle weakness, and fatigue, to promote functional independence, and increase quality of life. Based on the limitations demonstrated in COVID-19 survivors, we developed a protocol based on the acronym #EASIER, which is divided into six phases. Such a study will be able to early identify the impact of COVID-19 in different severities as well as provide subsidies to guide physiotherapists early, through the correct prescription of rehabilitative interventional measures.

Keywords: Cardiopulmonary rehabilitation, coronavirus disease 2019, exercise, rehabilitation program, rehabilitation

How to cite this article:
da Luz Goulart C, Silva RN, Oliveira MR, Back GD, Arena R, Faghy MA, Borghi-Silva A. Proposing an #EASIER cardiopulmonary rehabilitation protocol for coronavirus disease 2019 survivors. Heart Mind 2023;7:45-8

How to cite this URL:
da Luz Goulart C, Silva RN, Oliveira MR, Back GD, Arena R, Faghy MA, Borghi-Silva A. Proposing an #EASIER cardiopulmonary rehabilitation protocol for coronavirus disease 2019 survivors. Heart Mind [serial online] 2023 [cited 2023 May 29];7:45-8. Available from: http://www.heartmindjournal.org/text.asp?2023/7/1/45/371612

  Cardiopulmonary Rehabilitation Protocol Top

The current commentary is based on clinical, randomized, and controlled trials in patients with cardiopulmonary diseases and review articles in patients with coronavirus disease 2019 (COVID-19). Our aim is to propose a cardiopulmonary rehabilitation (CPR) protocol model for postacute COVID-19 patients [Figure 1], emphasizing the main components of rehabilitation based on a detailed assessment, based on “a thorough patient assessment, followed by a patient-tailored therapy.”[1] [Figure 2] illustrates the main items to be evaluated after hospital discharge.
Figure 1: Step by step for carrying out or not the recommended protocol. CPR=Cardiopulmonary rehabilitation, COVID-19=Coronavirus disease 2019, RPE=Rating of perceived exertion, SpO2=Oxygen saturation, CPET=Cardiopulmonary exercise test, HR=Heart rate

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Figure 2: Steps for an optimal assessment in patients on the postacute COVID-19 phase. COVID-19=Coronavirus disease 2019, QoL=Quality of life

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The CPR protocol should be performed based on the patient's need, focusing on the main limitations found during the initial assessment [Figure 2], and the patient's complaints. As previously reported by the World Health Organization,[2] adults across the lifespan should perform at least 150 min of physical exercise per week, depending on the patient's tolerability and symptoms. In this regard, three to five rehabilitation sessions of approximately 60 min each, should be prioritized each week. The effectiveness of rehabilitation is greater if started shortly after recovery from an acute medical event (e.g., COVID-19 infection); if the patient has no fever or disabling symptoms, rehabilitation can begin 72 h after hospital discharge.

Based on the limitations demonstrated in COVID-19 survivors thus far,[3] we developed a protocol with the acronym #EASIER, which is divided into six phases (totalizing 60 min/session), including: (1) exercises for warm-up, (2) aerobic training, (3) strength training, (4) improving respiratory muscle strength, (5) exercises for cognitive function and balance, and (6) recovery. The six phases are described in detail below; all of the exercises are suggestions that can be performed focusing on the patient's limitations and based on each rehabilitation center's capacity.

Calculating the proper intensity and volume of exercise in the COVID-19 patient population can be challenging, especially when group rehabilitation includes patients across a wide range of viral infection severity (i.e., mild-to-severe symptoms and pathophysiology). In this sense, the protocol proposed in this study has individualized load prescription as suggested by the American College of Sports Medicine (ACSM),[4] based on vital signs and also in subjective methods to assess patients' perceived effort. Thus, we suggest to use peak oxygen consumption (VO2peak) and ventilatory threshold (VT) assessed through cardiopulmonary exercise testing (CPET), when available or by some exercise test when CPET cannot be performed, such as the 6-min walk test. Symptoms can be assessed using well-established perceived exertion scales[5] as well as heart rate (HR), electrocardiography, and blood pressure (BP) to assess the cardiovascular response to exercise.[4] Based on the recommendations, we suggest performing the #EASIER CPR protocol three times per week.

Exercises for warm-up (5 min)

According to the ACSM, effective exercise programs typically include warm-up activities before aerobic and strength training.[4] For warm-up exercises, light intensity is recommended and must be performed reaching a perceived effort of 2 on a 0–10 point rating of perceived exertion (RPE) scale.[5] Thus, we suggest the following exercises:

  • Flexibility exercises including the range of motion, exercises to stretch the cervical and lumbar spine, and the upper and lower limbs (4 min);[6],[7],[8] or
  • Upper and lower limbs cycle ergometer (2 min for upper limbs and 2 min for lower limbs – 4 min in total); and
  • Up and down steps (1 min).

After completing the “exercises for warm-up≵ phase, a rest of 3–5 min may be required before proceeding to the next phase for patients with substantial fatigue and muscle weakness, or if RPE is ≥2 points.[5]

Aerobic training (15 min)

When VO2peak through CPET can be assessed, performing aerobic exercises from low (45% to 55% of VO2peak) to moderate intensity (≅60% of VO2peak) is recommended.[9],[10] In cases where it is not possible to assess VO2peak, we recommend using RPE (moderate intensity: 3–4 points)[5] and HR, the latter of which should be monitored to stay between 65% and 75% of age-predicted maximum HR.[5],[9]

In cases of well-conditioned patients, high intensity can be reached[4] 80% of VO2peak[9],[10] or 5–7 points on the 0–10 RPE scale,[5] never exceeding the age-predicted maximum HR.

Herein, we recommend the following exercises:

  • Lower limb cycle ergometer (15 min) or
  • Treadmill walking (15 min).

Strength training (20 min)

The inclusion of strength training in a rehabilitation program is recommended to increase HR, contributing to the functional independence of patients, as observed in other chronic cardiorespiratory conditions.[7],[11],[12],[13],[14]

For strength training exercises, as it is for warm-up and aerobic exercises, the load must be based on the limitations of the patient; VT, RPE, and HR can be used to prescribe training intensity.[4] However, it is also recommended to increment 5%–10% of maximum repetition (MR) per week, progressing from 20% to 85% of MR by muscle group.[7]

For both prescribed intensity and volume, it is important to mention that, according to the ACSM, “(…) no specific amount of time is recommended for muscle strengthening, but muscle-strengthening exercises should be performed to the point at which it would be difficult to do another repetition. When resistance training is used to enhance muscle strength, one set of 8–12 repetitions of each exercise is effective, although two or three sets may be more effective.”[4]

Thus, we suggest the following exercises based on patient limitations and assessment:

  • Squats (5 min)
  • 50%–85% of 1 MR, 3 sets, and 10–15 repetitions in the upper and lower limbs[15] (5 min)
  • Upper and lower limb exercises with resistance elastic bands or free weights (15 min).

The rest of 1–2 min between each set of 8 and 12 repetitions or between each 1 MR should be done. After the “strength training≵ phase, a rest of 3–5 min may be required to proceed if RPE is ≥2 points.

Improving respiratory muscle strength (10 min)

Respiratory muscle strength training and breathing exercises in a rehabilitation program are recommended to improve respiratory function, quality of life, and anxiety as well as facilitate chest expansion training and mobilization of the respiratory muscle groups of COVID-19 survivors.[16]

Thus, for respiratory muscle strength training, we suggest using linear devices as the most suitable, due to the possibility of changing the training load. If devices that make it possible to monitor training through software are available, they are recommended for their ability to provide feedback during training.

Thus, we suggest the following exercises based on patient limitations and assessment:

Volume: 3–5 sets of 8–10 breaths.

Intensity: Load must be based on the limitations of the patient, however, it is recommended to progress from 30% to 80% of maximum inspiratory pressure.[16]

A resting time of 1 min should be done between each set of respiratory muscle training (RMT). After the RMT phase, a rest of 3–5 min may be required to proceed if RPE is ≥2 points.

Exercises for cognitive function and balance (5 min)

The implementation of multicomponent exercises in a rehabilitation program, including balance and cognitive training, is recommended to improve motor and cognitive skills simultaneously, which are already known to be impaired by COVID-19. It is suggested that there should be a combination of exercises that include some difficulty in balancing or stimulating memory activities.[17],[18] Thus, we suggest 5 min of these activities to improve balance and cognitive skills, which could be:[17],[18]

  • Single leg support (1 min each leg – 2 min in total)
  • Stand with eyes closed on an unstable surface (1 min)
  • Memory games (2 min).

Recovery (5 min)

According to the ACSM, effective exercise programs typically include cooldown activities after the training protocol as a recovery phase.[4]

Recovery activities should be performed in a very low intensity, i.e., RPE of 1 point,[5] allowing a gradual decrease in HR and breathing,[4] such as:

  • Light walk (3 min)
  • Breathing exercises synchronizing abdominal and thoracic movements (2 min).

  Special Recommendations Top

As COVID-19 impairs pulmonary function, mainly decreasing the diffusion capacity of the lungs,[19] some patients may experience a drop in oxygen saturation (SpO2) requiring oxygen supplementation in the postacute COVID-19 phase.[20] For those patients, we recommend that the rehabilitation health professionals (for example: physiotherapist, nutritionist, psychologist, and physician) involved in the CPR program continuously monitor the SpO2 of every patient during exercise and recovery,[21] which can be easily and safely accomplished using a pulse oximeter, recommending the SpO2 to be ≥90%. It is important to emphasize that nicotine and alcohol dependence can delay the effects of rehabilitation. We also recommend to measure BP and the use of an electrocardiogram during the CPR session, especially in patients with cardiac and/or lung diseases. Rehabilitation may be contraindicated in cases of myocarditis and thromboembolic complications (both related to COVID-19) and also in cases that the doctor contraindicates.

  Final Considerations Top

With this protocol, we hope to guide rehabilitation health professionals on how to provide an #EASIER CPR protocol that can cover the cardiorespiratory and skeletal muscle impairments caused by COVID-19,[22] helping patients overcome the functional impairments brought about by COVID-19 infection.

Ethical Statement

The Ethical Statement is not applicable for this article.


The authors would like to thank São Paulo Research Foundation – FAPESP (Processes: #2018/03233-0 and #2015/26501-1) and the Ministry of Education/CAPES-Brazil.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official American Thoracic Society/European Respiratory Society statement: Key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13-64.  Back to cited text no. 1
WHO. Physical Activity. 2020: World Health Organization; 2020. p. 1-10. Available from: https://www.who.int/news-room/fact-sheets/detail/physical-activity, 05 de março de 2022.  Back to cited text no. 2
Dixit S, Borghi-Silva A, Bairapareddy KC. Revisiting pulmonary rehabilitation during COVID-19 pandemic: A narrative review. Rev Cardiovasc Med 2021;22:315-27.  Back to cited text no. 3
ACSM'S Guidelines for Exercise Testing and Prescription. 10th ed. 2018.  Back to cited text no. 4
Zuhl M. Tips for Monitoring Aerobic Exercise Intensity. American College of Sports Medicine: ACSM; 2020. p. 1.  Back to cited text no. 5
Karapolat H, Demir E, Bozkaya YT, Eyigor S, Nalbantgil S, Durmaz B, et al. Comparison of hospital-based versus home-based exercise training in patients with heart failure: Effects on functional capacity, quality of life, psychological symptoms, and hemodynamic parameters. Clin Res Cardiol 2009;98:635-42.  Back to cited text no. 6
Tsai LL, McNamara RJ, Moddel C, Alison JA, McKenzie DK, McKeough ZJ. Home-based telerehabilitation via real-time videoconferencing improves endurance exercise capacity in patients with COPD: The randomized controlled TeleR Study. Respirology 2017;22:699-707.  Back to cited text no. 7
Maddison R, Rawstorn JC, Stewart RA, Benatar J, Whittaker R, Rolleston A, et al. Effects and costs of real-time cardiac telerehabilitation: Randomised controlled non-inferiority trial. Heart 2019;105:122-9.  Back to cited text no. 8
Goulart CD, Silva RN, Oliveira MR, Guizilini S, Rocco IS, Mendez VM, et al. Lifestyle and rehabilitation during the COVID-19 pandemic: Guidance for health professionals and support for exercise and rehabilitation programs. Expert Rev Anti Infect Ther 2021;19:1385-96.  Back to cited text no. 9
Woods JA, Keylock KT, Lowder T, Vieira VJ, Zelkovich W, Dumich S, et al. Cardiovascular exercise training extends influenza vaccine seroprotection in sedentary older adults: The immune function intervention trial. J Am Geriatr Soc 2009;57:2183-91.  Back to cited text no. 10
Frederix I, Hansen D, Coninx K, Vandervoort P, Van Craenenbroeck EM, Vrints C, et al. Telerehab III: A multi-center randomized, controlled trial investigating the long-term effectiveness of a comprehensive cardiac telerehabilitation program – Rationale and study design. BMC Cardiovasc Disord 2015;15:29.  Back to cited text no. 11
Zhao HM, Xie YX, Wang C, Chinese Association of Rehabilitation Medicine; Respiratory Rehabilitation Committee of Chinese Association of Rehabilitation Medicine; Cardiopulmonary Rehabilitation Group of Chinese Society of Physical Medicine and Rehabilitation. Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019. Chin Med J (Engl) 2020;133:1595-602.  Back to cited text no. 12
Barker-Davies RM, O'Sullivan O, Senaratne KP, Baker P, Cranley M, Dharm-Datta S, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med 2020;54:949-59.  Back to cited text no. 13
Gentil P, de Lira CA, Coswig V, Barroso WK, Vitorino PV, Ramirez-Campillo R, et al. Practical recommendations relevant to the use of resistance training for COVID-19 survivors. Front Physiol 2021;12:637590.  Back to cited text no. 14
Borghi-Silva A, Krishna AG, Garcia-Araujo AS. Importance of functional capacity assessment and physical exercise during and after hospitalization in COVID-19 patients: Revisiting pulmonary rehabilitation. J Bras Pneumol 2021;47:e20210277.  Back to cited text no. 15
Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complement Ther Clin Pract 2020;39:101166.  Back to cited text no. 16
Brülhart Y. Does multicomponent physical exercise with simultaneous cognitive training boost cognitive performance in older adults? A 6-month randomized controlled trial with a 1-year follow-up. Physioscience 2016;10:124-5.  Back to cited text no. 17
Eggenberger P, Theill N, Holenstein S, Schumacher V, de Bruin ED. Multicomponent physical exercise with simultaneous cognitive training to enhance dual-task walking of older adults: A secondary analysis of a 6-month randomized controlled trial with 1-year follow-up. Clin Interv Aging 2015;10:1711-32.  Back to cited text no. 18
Mo X, Jian W, Su Z, Chen M, Peng H, Peng P, et al. Abnormal pulmonary function in COVID-19 patients at time of hospital discharge. Eur Respir J 2020;55:2001217.  Back to cited text no. 19
Daher A, Balfanz P, Aetou M, Hartmann B, Müller-Wieland D, Müller T, et al. Clinical course of COVID-19 patients needing supplemental oxygen outside the Intensive Care Unit. Sci Rep 2021;11:2256.  Back to cited text no. 20
Shenoy N, Luchtel R, Gulani P. Considerations for target oxygen saturation in COVID-19 patients: Are we under-shooting? BMC Med 2020;18:260.  Back to cited text no. 21
Silva RN, Goulart CD, Oliveira MR, Tacao GY, Back GD, Severin R, et al. Cardiorespiratory and skeletal muscle damage due to COVID-19: Making the urgent case for rehabilitation. Expert Rev Respir Med 2021;15:1107-20.  Back to cited text no. 22


  [Figure 1], [Figure 2]


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