Abstract
Objectives
The study investigated the longitudinal association between physical activity and the risk of long COVID in patients who recovered from COVID-19 infection.
Study design
We analyzed longitudinal data of the Prospective Study About Mental and Physical Health cohort, a prospective cohort study with adults living in Southern Brazil.
Methods
Participants responded to an online, self-administered questionnaire in June 2020 (wave 1) and June 2022 (wave 4). Only participants who self-reported a positive test for COVID-19 were included. Physical activity was assessed before (wave 1, retrospectively) and during the pandemic (wave 1). Long COVID was assessed in wave 4 and defined as any post-COVID-19 symptoms that persisted for at least 3 months after infection.
Results
A total of 237 participants (75.1% women; mean age [standard deviation]: 37.1 [12.3]) were included in this study. The prevalence of physical inactivity in baseline was 71.7%, whereas 76.4% were classified with long COVID in wave 4. In the multivariate analysis, physical activity during the pandemic was associated with a reduced likelihood of long COVID (prevalence ratio [PR]: 0.83; 95% confidence interval [CI]: 0.69–0.99) and a reduced duration of long COVID symptoms (odds ratio: 0.44; 95% CI: 0.26–0.75). Participants who remained physically active from before to during the pandemic were less likely to report long COVID (PR: 0.74; 95% CI: 0.58–0.95), fatigue (PR: 0.49; 95% CI: 0.32–0.76), neurological complications (PR: 0.47; 95% CI: 0.27–0.80), cough (PR: 0.40; 95% CI: 0.22–0.71), and loss of sense of smell or taste (PR: 0.43; 95% CI: 0.21–0.87) as symptom-specific long COVID.
Conclusion
Physical activity practice was associated with reduced risk of long COVID in adults.
Keywords: Physical activity, Long COVID, COVID-19, Cohort, Symptoms
Introduction
More than 671 million have been diagnosed with COVID-19 since March 2020.1 However, the World Health Organization has noticed that many survivors may suffer from a long, persistent form of the disease known as long COVID.2 Long COVID condition refers to patients with probable or confirmed SARS-CoV-2 infection whose symptoms persisted for at least 3 months.3 Recent estimates suggested a prevalence as high as 75% of long COVID in the general population. The most common symptomology is fatigue, followed by respiratory and neurological complications.4 Identifying protective mechanisms to reduce the risk of this condition is an emerging priority in public health to reduce the projected burden of long COVID.
Physical activity is associated with reduced risk of infection, hospitalization, and mortality related to COVID-19.5 , 6 However, the levels of physical activity were drastically disrupted during social distancing restrictions.7, 8, 9 A body of evidence demonstrates the deleterious impact of physical inactivity on cardiovascular, muscular, respiratory, neurological, and immune systems, which are all affected by COVID-19 infection.10 , 11 Previous studies have suggested an association between physical inactivity and the risk of long COVID.12 , 13 Although these investigations suggested a higher prevalence of long COVID-19 in physically inactive adults, the association between different trajectories of physical activity from before to during the pandemic is scanty. Therefore, this study aimed to investigate the longitudinal association between physical activity and the risk of long COVID.
Methods
Study design
We analyzed data from the Prospective Study About Mental and Physical Health (PAMPA) cohort, a prospective study that evaluates the effects of the COVID-19 pandemic on health parameters in Southern Brazil. The ethics board approved the study from the Physical Education Faculty (Universidade Federal de Pelotas, Brazil; CAAE: 31906920.7.0000.5313). More details about study design and recruitment can be found elsewhere.14
Participants recruitment and sample
Adults (aged ≥18 years) living in the Rio Grande do Sul state were recruited by a four-arm approach aiming to reach participants in all state regions. Researchers spread the questionnaire's weblink via (1) messages to their personal and professional contacts over the state, (2) social media campaigns, (3) local media and state agencies, and (4) universities' staff and students.14 For this study, we used data from wave 1 (assessed in June and July 2020) and wave 4 (assessed in June and July 2022), as we first included questions on persistent symptoms after COVID-19 infection in the latest wave. Wave 1 assessed two periods: before (retrospectively) and during the first months of the pandemic (present). A total of 2239 participants were recruited in wave 1, and 462 participants were followed up in wave 4. Overall, 237 participants reported a positive COVID-19 test and were included in the study (Fig. 1 ).
Fig. 1.
Study sampling process.
Outcome
Participants who reported a positive test for COVID-19 were asked to indicate for how long they had COVID-related symptoms. A list of symptoms was displayed (e.g. fatigue, cough, headache), and for each one, there were the following answering options: (1) did not have, (2) 3 months, (3) 6 months, (4) 12 months, (5) 15 months, and (6) ≥18 months. Based on this information, two outcome variables were built, as follows: (1) presence of general long COVID symptoms (any COVID-related symptoms that lasted at least 3 months) and (2) duration of long COVID symptoms (<6 months, >6 and <12 months, and 12 or more months). We also analyzed the association between physical activity and the presence of each persistent symptom, henceforward referred to as symptom-specific long COVID. Only symptoms with a prevalence ≥20% were analyzed for analysis purposes. Memory and concentration problems, irritability, depression, and anxiety were grouped as neurological complications in these analyses.
Exposure
Physical activity was assessed on wave 1, with two-time references: before (retrospectively) and during the pandemic (at survey's week). Participants were asked if they engaged in regular physical activities before the pandemic and in the last 7 days. Those who answered yes were asked about the frequency (days per week) and time (minutes per day) the activities lasted.15 Two main exposure variables were built. Participants were considered inactive if they engaged in <150 min/week and active if they engaged in ≥150 min/week.13 The trajectory of physical activity from before (retrospectively) to during wave 1 (baseline) was examined using a four-category variable that classified participants based on their physical activity status in both periods as follows: remained inactive, became inactive, remained active, or became active.
Potential confounders
Sex, age, educational level, ethnicity, marital status, comorbidities, body mass index (BMI), pandemic routine behavior (stayed at home always, left home to essentials only, left home all days), family income, and vaccination status (unvaccinated, one to four doses) were used as possible confounders. Self-reported weight and height were assessed to calculate BMI, which was categorized as follows: normal (<25 kg/m2), overweight (≥25 and <30 kg/m2), and obese (≥30 kg/m2). Participants reported their daily routine during wave 1 and were categorized as follows: stayed at home always, left home to essentials only, and left home all days. Negative economic impact of COVID-19 was assessed, with participants reporting whether monthly income decreased from before to during the social distancing restrictions (wave 1). Finally, participants were asked about the number of vaccine doses they took until wave 4 (June 2022).
Data analyses
Descriptive data are presented as total and relative frequencies. A Chi-square test was used to check for associations between outcomes and exposures, and when necessary, the Fisher exact test was used. Robust Poisson regression models were used to evaluate the association between physical activity assessed in wave 1 and the presence of general and specific long COVID symptoms 2 years later in wave 4. Data are presented as prevalence ratio (PR) with their respective 95% confidence interval (95% CI). Ordinal logistic regression models were used for the association between physical activity and duration of general and specific long COVID symptoms, with data presented as odds ratio (OR) with their respective 95% CI. Because of our low follow-up rate (51.3%), we conducted inverse probability weights models for successful follow-up for general and specific long COVID symptom and physical activity variables. This method is used in situations with unequal selection probabilities to avoid censoring or non-response bias.16 All models were adjusted for age, sex, education, ethnicity, income, presence of comorbidities, and vaccination status. In addition, we used structural equation modeling to examine the possible mediation role of income and education in the association between physical activity and the long COVID.17
Results
We included 237 participants with a mean age of 37.1 ± 12.3 years, with most being women, White, and with at least one university degree (Table 1 ). The prevalence of physical inactivity increased from before (49.8%) to during (71.7%) the pandemic (wave 1). Three in four participants had general long COVID (76.4%; 95% CI: 70.5%, 81.4%). The most common symptomatology was fatigue (53.2%), followed by neurological complications (40.1%), cough (39.7%), headache (35.9%), and loss of sense of smell or taste (27.8%). Symptoms lasted from 3 to 6 months in 38.5% and more than 6 months in 37.5% of the included participants.
Table 1.
Characteristics of the included participants (N = 237).
| Variables | Overall, n (%) | Long COVID, n (%) |
P-value | |
|---|---|---|---|---|
| No (n = 56) | Yes (n = 181) | |||
| Sex | 0.074a | |||
| Male | 59 (24.9) | 19 (33.9) | 40 (22.1) | |
| Female | 178 (75.1) | 37 (66.1) | 141 (77.9) | |
| Age in years | 0.937b | |||
| 18–30 | 92 (38.8) | 23 (41.1) | 69 (38.1) | |
| 31–59 | 131 (55.3) | 30 (53.6) | 101 (55.8) | |
| ≥60 | 14 (5.9) | 3 (5.4) | 11 (6.1) | |
| Skin color | 0.086b | |||
| White | 213 (89.9) | 46 (82.1) | 167 (92.3) | |
| Mixed | 14 (5.9) | 6 (10.7) | 8 (4.4) | |
| Black | 10 (4.2) | 4 (7.1) | 6 (3.3) | |
| Highest education achievement | 0.632a | |||
| High school or less | 66 (27.8) | 17 (30.4) | 49 (27.1) | |
| University degree or higher | 171 (72.2) | 39 (69.6) | 132 (72.9) | |
| Conjugal situation | 0.387a | |||
| Living with partner | 158 (66.7) | 40 (71.4) | 118 (65.2) | |
| Living alone | 79 (33.3) | 16 (28.6) | 63 (34.8) | |
| Daily routine during pandemic | 0.161b | |||
| Stayed at home always | 11 (4.6) | 3 (5.4) | 8 (4.4) | |
| Left home to essentials only | 160 (67.5) | 43 (76.8) | 117 (64.6) | |
| Left home all days | 66 (27.8) | 10 (17.9) | 56 (30.9) | |
| Chronic conditions, yes (%) | 141 (59.5) | 29 (51.8) | 112 (61.9) | 0.179a |
| Reduced income during pandemic, yes (%) | 100 (42.2) | 20 (35.7) | 80 (44.2) | 0.261a |
| COVID-19 vaccine | 0.866b | |||
| Two doses | 19 (8.0) | 4 (7.1) | 15 (8.3) | |
| Three doses | 131 (55.3) | 33 (58.9) | 98 (54.1) | |
| Four doses | 87 (36.7) | 19 (33.9) | 68 (37.6) | |
| Physical activity before pandemic | 0.035a | |||
| No | 118 (49.8) | 21 (37.5) | 97 (53.6) | |
| Yes | 119 (50.2) | 35 (62.5) | 84 (46.4) | |
| Physical activity during pandemic | 0.015a | |||
| No | 170 (71.7) | 33 (58.9) | 137 (75.7) | |
| Yes | 67 (28.3) | 23 (41.1) | 44 (24.3) | |
| Change in physical activity status | 0.017b | |||
| Sustained inactive | 95 (41.5) | 17 (31.5) | 78 (44.6) | |
| Become inactive | 67 (29.3) | 14 (25.9) | 53 (30.3) | |
| Become active | 15 (6.6) | 2 (3.7) | 13 (7.4) | |
| Sustained active | 52 (22.7) | 21 (38.9) | 31 (17.7) | |
Physical activity before the pandemic was assessed retrospectively during wave 1 (June 2020).
Physical activity during the pandemic was assessed during wave 1 (June 2020).
Pearson's Chi-squared.
Fisher exact.
Participants who reported being physically active during the pandemic showed a lower likelihood of general long COVID as well as fatigue, neurological complications, and cough as symptom-specific long COVID (Table 2 ). Participants who were active before the pandemic showed a lower likelihood of fatigue, neurological complications, and headache as symptom-specific long COVID. Structural equation modeling indicated that income (P = 0.834 for indirect effect) and education (P = 0.849 for indirect effect) do not mediate the association between physical activity and the likelihood of long COVID.
Table 2.
Association of physical activity before and during the pandemic with the presence of general and symptoms specific long COVID in adults (N = 237).
| Outcome | Before pandemic |
During pandemic |
||
|---|---|---|---|---|
| PR (95% CI) | P-value | PR (95% CI) | P-value | |
| Long COVID | 0.88 (0.76, 1.02) | 0.090 | 0.83 (0.69, 0.99) | 0.041 |
| Symptom-specific long COVID | ||||
| Fatigue | 0.67 (0.52, 0.86) | 0.002 | 0.66 (0.48, 0.92) | 0.015 |
| Neurological complications | 0.71 (0.51, 0.97) | 0.032 | 0.48 (0.30, 0.77) | 0.002 |
| Cough | 0.73 (0.53, 1.01) | 0.056 | 0.58 (0.38, 0.89) | 0.013 |
| Loss of sense of smell or taste | 0.72 (0.47, 1.10) | 0.131 | 0.63 (0.37, 1.09) | 0.097 |
| Headache | 0.57 (0.40, 0.82) | 0.003 | 0.75 (0.49, 1.16) | 0.197 |
CI, confidence intervals; PR, prevalence ratio.
General long COVID was defined as any post-COVID-19 symptoms that persisted for at least 3 months.
Symptom-specific long COVID were based on individual symptoms.
Physical activity before the pandemic was assessed retrospectively during wave 1 (June 2020).
Physical activity during the pandemic was assessed during wave 1 (June 2020).
PR was estimated using robust Poisson regression models adjusted for age, sex, education, skin color, income, presence of comorbidities, and vaccination status.
We also investigated the association between changes in physical activity status and long COVID, as described in Table 3 . Participants who were physically active before and during the pandemic showed a lower probability of long COVID than those who remained physically inactive. This protective association was also observed for persistent fatigue, neurological complications, cough, loss of sense of smell or taste, and headache. In addition, those who became active showed a lower likelihood of neurological complications after COVID-19 infection. Physical activity before the pandemic was associated with a lower probability of fatigue as symptom-specific long COVID, even in participants who became inactive during the pandemic.
Table 3.
Association between change in physical activity status and the presence of general and symptoms specific long COVID in adults (N = 237).
| Outcome | Persisted inactive | Became inactive |
Became active |
Persisted active |
|---|---|---|---|---|
| PR (95% CI) | PR (95% CI) | PR (95% CI) | ||
| Long COVID | Ref | 0.98 (0.83, 1.15) | 1.06 (0.85, 1.33) | 0.74 (0.58, 0.95) |
| P-value | 0.811 | 0.581 | 0.016 | |
| Symptom-specific long COVID | ||||
| Fatigue | Ref | 0.74 (0.56, 0.99) | 0.87 (0.56, 1.33) | 0.49 (0.32, 0.76) |
| P-value | 0.035 | 0.519 | 0.001 | |
| Neurological complications | Ref | 0.75 (0.53, 1.07) | 0.34 (0.13, 0.88) | 0.47 (0.27, 0.80) |
| P-value | 0.112 | 0.025 | 0.006 | |
| Cough | Ref | 0.99 (0.69, 1.41) | 1.17 (0.69, 1.97) | 0.40 (0.22, 0.71) |
| P-value | 0.956 | 0.566 | 0.002 | |
| Loss of sense of smell or taste | Ref | 0.85 (0.53, 1.36) | 1.00 (0.47, 2.11) | 0.43 (0.21, 0.87) |
| P-value | 0.452 | 0.988 | 0.018 | |
| Headache | Ref | 0.65 (0.43, 0.99) | 1.14 (0.68, 1.92) | 0.48 (0.27, 0.86) |
| P-value | 0.049 | 0.579 | 0.015 | |
CI, confidence interval; PR, prevalence ratio.
General long COVID was defined as any post-COVID-19 symptoms that persisted for at least 3 months.
Symptom-specific long COVID were based on individual symptoms.
Physical activity before the pandemic was assessed retrospectively during wave 1 (June 2020).
Physical activity during the pandemic was assessed during wave 1 (June 2020).
PR was estimated using robust Poisson regression models adjusted for age, sex, education, skin color, income, presence of comorbidities, and vaccination status.
Finally, physical activity was associated with a shorter duration of symptoms (Table 4 ). Physical activity before the pandemic was associated with briefer fatigue, neurological complications, and headache as symptom-specific long COVID. Participants who became physically inactive from before to during the pandemic were less likely to report persistent fatigue and headache, whereas neurological complications were less likely in those who became active in the same period (Table 5 ). Persistent fatigue, neurological complications, and cough after COVID-19 infection were briefer in participants who were physically active during the pandemic than in inactive participants in the same period (Table 4). General and symptom-specific long COVID was less likely in participants who remained physically active during the pandemic (Table 5).
Table 4.
Association of physical activity before and during the pandemic and duration of general and symptoms specific long COVID in adults (N = 237).
| Outcome | Before pandemic |
During pandemic |
||
|---|---|---|---|---|
| OR (95% CI) | P-value | OR (95% CI) | P-value | |
| Long COVID | 0.62 (0.38, 1.00) | 0.051 | 0.44 (0.26, 0.75) | 0.003 |
| Symptom-specific long COVID | ||||
| Fatigue | 0.35 (0.21, 0.59) | <0.001 | 0.41 (0.23, 0.74) | 0.003 |
| Neurological complications | 0.53 (0.31, 0.90) | 0.018 | 0.30 (0.15, 0.59) | 0.001 |
| Cough | 0.60 (0.35, 1.03) | 0.064 | 0.39 (0.21, 0.74) | 0.004 |
| Loss of sense of smell or taste | 0.60 (0.33, 1.08) | 0.087 | 0.54 (0.27, 1.08) | 0.081 |
| Headache | 0.39 (0.22, 0.68) | 0.001 | 0.61 (0.32, 1.15) | 0.124 |
CI: confidence interval; OR: odds ratio.
OR >1 indicates higher odds for persistent symptoms lasting longer.
General long COVID was defined as any post-COVID-19 symptoms that persisted for at least 3 months.
Symptom-specific long COVID were based on individual symptoms.
Physical activity before the pandemic was assessed retrospectively during wave 1 (June 2020).
Physical activity during the pandemic was assessed during wave 1 (June 2020).
OR were estimated using proportional ordinal logistical regression models adjusted for age, sex, education, skin color, income, presence of comorbidities, and vaccination status.
Table 5.
Association between change in physical activity status and duration of general and symptoms specific long COVID in adults (N = 237).
| Outcome | Persisted inactive | Became inactive |
Became active |
Persisted active |
|---|---|---|---|---|
| OR (95% CI) | OR (95% CI) | OR (95% CI) | ||
| Long COVID | Ref | 0.76 (0.42, 1.37) | 0.58 (0.23, 1.49) | 0.33 (0.17,0.64) |
| P-value | 0.364 | 0.227 | 0.001 | |
| Symptom-specific long COVID | ||||
| Fatigue | Ref | 0.42 (0.23, 0.78) | 0.68 (0.24, 1.88) | 0.20 (0.09, 0.41) |
| P-value | 0.025 | 0.494 | <0.001 | |
| Neurological complications | Ref | 0.60 (0.32, 1.12) | 0.21 (0.05, 0.79) | 0.26 (0.12, 0.58) |
| P-value | 0.110 | 0.016 | 0.002 | |
| Cough | Ref | 1.01 (0.53, 1.92) | 1.18 (0.41, 3.43) | 0.23 (0.10, 0.53) |
| P-value | 0.953 | 0.799 | 0.001 | |
| Loss of sense of smell or taste | Ref | 0.72 (0.36, 1.43) | 0.98 (0.31, 3.09) | 0.30 (0.13, 0.75) |
| P-value | 0.313 | 0.882 | 0.009 | |
| Headache | Ref | 0.45 (0.23, 0.88) | 1.14 (0.39, 3.30) | 0.28 (0.12, 0.64) |
| P-value | 0.022 | 0.836 | 0.003 | |
CI: confidence interval; OR, odds ratio.
OR >1 indicates higher odds for persistent symptoms lasting longer.
General long COVID was defined as any post-COVID-19 symptoms that persisted for at least 3 months.
Symptom-specific long COVID were based on individual symptoms.
Physical activity before the pandemic was assessed retrospectively during wave 1 (June 2020).
Physical activity during the pandemic was assessed during wave 1 (June 2020).
OR were estimated using proportional ordinal logistical regression models adjusted for age, sex, education, skin color, income, presence of comorbidities, and vaccination status.
The association between physical activity and long COVID remained significant after inverse probability weighting for successful follow-up (Supplementary Table 1). In this sensitivity analysis, cough and headache were associated with physical activity before the pandemic. In contrast, loss of sense of smell or taste was associated with physical activity during the pandemic. Remaining physically active from before to during the pandemic was consistently associated with long COVID, although becoming physically inactive was no longer related to long COVID (Supplementary Table 2).
Discussion
Our findings demonstrate the protective association between physical activity and long COVID. Adults who persisted physically active during the COVID-19 pandemic showed a lower likelihood of long COVID, including long-lasting fatigue, neurological complications, cough, loss of sense of smell or taste, and headache. Up to 80% of COVID-19 survivors live with persistent symptoms after SARS-CoV-2 infection.4 , 10 , 18 Considering the 640 million cases of COVID-19 since the pandemic's beginning, physical activity has been shown as a potential non-pharmacological strategy to reduce the forecasted burden of long COVID-19 worldwide. Consequently, public policies focused on reducing the risk of long COVID, especially in those at higher risk, are urgently needed.
We demonstrated that people who survived COVID-19 and were physically active before and during the pandemic showed a lower likelihood of respiratory sequelae after SARS-CoV-2 infection. Fatigue was the most common long COVID symptomatology, with previous corroborating studies on COVID-19, SARS-CoV-1, and MERS-COV.4 , 18, 19, 20 Most patients with decreased respiratory function after SARS-CoV-1 infection also presented muscle wasting and fatigue.27 In addition, Ahmed et al.19 estimated a reduction of 461 m in a six-minute walking test, an indicator of exercise capacity, in patients who survived SARS-CoV-1 and MERS-COV. Decreased exercise tolerance may also be associated with modifications in peripheric oxygen uptake. After COVID-19 infection, patients showed preserved oxygen availability with reduced peripheral oxygen extraction rate and increased venous saturation, which may explain the lower cardiorespiratory fitness in these patients compared with healthy controls.21 On the other hand, physical activity can improve mitochondrial activity and oxygen uptake, preserving energy production during cellular respiration.22 , 23 For example, a previous study revealed that eight weeks of endurance and resistance training was safe and more effective than self-care recommendations and inspiratory muscle training alone to regain cardiovascular and muscular fitness and improve symptom severity and health status in adults with long COVID.24 Thus, physical activity maintenance before and during the COVID-19 pandemic may have promoted cellular and systemic protective mechanisms, preserving pulmonary function in COVID-19 survivors.
Our findings suggest that physical activity was associated with a lower likelihood of neurological complications after COVID-19. Neurological complications were among the most common symptomatology of long COVID, known as brain ‘fog’.4 , 18 Different mechanisms have been suggested for the beneficial effects of physical activity on brain function. For example, regular physical activity seems to preserve brain health through the upregulation of neurotrophic factors and anti-inflammatory cytokines,25 , 26 resulting in the generation of new astrocytes and promotion of neurogenesis and synaptic plasticity. These physical activity–induced modifications can improve cognitive function and reduce the risk of neurological complications and degenerative processes. Also, previous evidence suggests the critical role of astrocytes in this complication.27, 28, 29 Astrocytes are the most abundant cells in the central nervous system and perform various functions, such as regulating the concentration of neurotransmitters and other substances with the potential to interfere with neuronal functioning, the integrity of the blood–brain barrier, and helping to maintain cerebral homeostasis.
Physical activity before and during the pandemic was associated with shorter lengths of long COVID symptoms. A previous cross-sectional, population-based analysis suggested an inverse association between physical activity and the duration of symptoms.30 However, to our knowledge, this is the first study to assess the longitudinal association of physical activity with the presence and duration of long COVID. Exposure to physical activity across the life course results in long-term benefits in different body systems. For example, physical activity during adolescence showed a lower risk of depression31 and improved cognitive function32 in adulthood. However, during the more restricted phases of the COVID-19 pandemic, physical activity practice in sports clubs, gyms, and public spaces were limited to control virus spreading. Alternative methods, such as online platforms, surged as options to preserve physical activity levels. Unfortunately, inequity in opportunities to continue physical activity practice during these stages may lead to an increased burden of long COVID in some population groups. Based on the available scientific literature and our findings, physical activity surges as a potential strategy to reduce the likelihood of long COVID in adult populations.
Despite this being the first study to assess the longitudinal association between physical activity and long COVID in Brazil, an epicenter of the COVID-19 pandemic, our study presents some limitations. First, physical activity, persistent symptoms, and COVID-19 infection were self-reported. However, the local ethics committee did not allow in-person research activities during baseline assessments. Also, we acknowledged the low response rate from baseline to wave 4. Data collection for wave 4 occurred between June and August 2022, simultaneously with political campaigns for the Brazilian Presidential Election. The anti-science movement that arose in Brazil during the pandemic resulted in offenses of some eligible participants against the research.33 In addition, the results may be biased by the limited number of non-long COVID people, explained as a result of loss of follow-up. However, the results were robust after sensitivity analysis with inverse probability weighting to account for losses to follow-up.
Conclusions
In conclusion, physical activity was associated with a lower likelihood of long COVID in adults. Although experimental studies are needed to confirm our findings, public policies focused on reducing the risk of long COVID, especially in those at higher risk, are urgently needed.
Author statements
Acknowledgments
A.J.R. and F.M.D. was supported by the National Council for Scientific and Technological Development (CNPq). T.A.B. was supported by Research Initiation Scholarship Program - Affirmative Actions (PBIP-AF/UFPEL). J.S.L., I.A.P., L.S.S., J.Q.S.R., and Y.P.V. were financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001.
Ethical approval
The ethics board approved the study from the Physical Education Faculty (Universidade Federal de Pelotas, Brazil; CAAE: 31906920.7.0000.5313).
Funding
This study was financed in part by the Fundação de Amparo à Pesquisa do estado do Rio Grande do Sul (FAPERGS) (21/2551-0002071-7) and the National Council for Scientific and Technological Development – CNPq (405496/2021-4).
Competing interests
None declared.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.puhe.2023.05.011.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
References
- 1.Dong E., Du H., Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20(5):533–534. doi: 10.1016/S1473-3099(20)30120-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rajan S., Khunti K., Alwan N., Steves C., MacDermott N., Morsella A., et al. European Observatory on Health Systems and Policies; Copenhagen (Denmark): 2021. In the wake of the pandemic: Preparing for Long COVID.https://www.ncbi.nlm.nih.gov/books/NBK569598 [Internet] [PubMed] [Google Scholar]
- 3.Organization WH . World Health Organization; 2021. A clinical case definition of post COVID-19 condition by a Delphi consensus, 6 October 2021. [Google Scholar]
- 4.Di Gennaro F., Belati A., Tulone O., Diella L., Fiore Bavaro D., Bonica R., et al. Incidence of long COVID-19 in people with previous SARS-Cov2 infection: a systematic review and meta-analysis of 120,970 patients. Intern Emerg Med. 2022;30:1–9. doi: 10.1007/s11739-022-03164-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Lee S.W., Lee J., Moon S.Y., Jin H.Y., Yang J.M., Ogino S., et al. Physical activity and the risk of SARS-CoV-2 infection, severe COVID-19 illness and COVID-19 related mortality in South Korea: a nationwide cohort study. Br J Sports Med. 2022;56(16):901–912. doi: 10.1136/bjsports-2021-104203. [DOI] [PubMed] [Google Scholar]
- 6.Sallis R., Young D.R., Tartof S.Y., Sallis J.F., Sall J., Li Q., et al. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. Br J Sports Med. 2021;55(19):1099–1105. doi: 10.1136/bjsports-2021-104080. [DOI] [PubMed] [Google Scholar]
- 7.Ammar A., Brach M., Trabelsi K., Chtourou H., Boukhris O., Masmoudi L., et al. Effects of COVID-19 home confinement on eating behaviour and physical activity: results of the ECLB-COVID19 international online survey. Nutrients. 2020;12(6):1583. doi: 10.3390/nu12061583. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Caputo E.L., Reichert F.F. Studies of physical activity and COVID-19 during the pandemic: a scoping review. J Phys Act Health. 2020;1(aop):1–10. doi: 10.1123/jpah.2020-0406. [DOI] [PubMed] [Google Scholar]
- 9.Wunsch K., Kienberger K., Niessner C. Changes in physical activity patterns due to the COVID-19 pandemic: a systematic review and meta-analysis. Int J Environ Res Public Health [Internet] 2022;19(4):2250. doi: 10.3390/ijerph19042250. https://www.mdpi.com/1660-4601/19/4/2250/htm [cited 2022 Dec 7]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Lopez-Leon S., Wegman-Ostrosky T., Perelman C., Sepulveda R., Rebolledo P.A., Cuapio A., et al. More than 50 long-term effects of COVID-19: a systematic review and meta-analysis. Sci Rep. 2021;11(1):1–12. doi: 10.1038/s41598-021-95565-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Thompson E.J., Williams D.M., Walker A.J., Mitchell R.E., Niedzwiedz C.L., Yang T.C., et al. Long COVID burden and risk factors in 10 UK longitudinal studies and electronic health records. Nat Commun. 2022;13(1):1–11. doi: 10.1038/s41467-022-30836-0. https://www.nature.com/articles/s41467-022-30836-0 [Internet] 2022 [cited 2022 Sep 24];13(1). Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Delbressine J.M., Machado F.V.C., Goërtz Y.M.J., Van Herck M., Meys R., Houben-Wilke S., et al. he impact of post-COVID-19 syndrome on self-reported physical activity. Int J Environ Res Public Health. 2021;18(11):6017. doi: 10.3390/ijerph18116017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Wright J., Astill S.L., Sivan M. The relationship between physical activity and long COVID: a cross-sectional study. Int J Environ Res Public Health [Internet] 2022;19(9):5093. doi: 10.3390/ijerph19095093. https://www.mdpi.com/1660-4601/19/9/5093/htm [cited 2022 Dec 7]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Feter N., Caputo E.L., Doring I.R., Leite J.S., Cassuriaga J., Reichert F.F., et al. Cold Spring Harbor Laboratory Press; 2020. Longitudinal study about low back pain, mental health, and access to healthcare system during COVID-19 pandemic: protocol of an ambispective cohort Short title: PAMPA cohort: study protocol. [Google Scholar]
- 15.Milton K., Bull F.C., Bauman A. Reliability and validity testing of a single-item physical activity measure. Br J Sports Med. 2011;45(3):203–208. doi: 10.1136/bjsm.2009.068395. [DOI] [PubMed] [Google Scholar]
- 16.Mansournia M.A., Altman D.G. Inverse probability weighting. BMJ [Internet] 2016:352. doi: 10.1136/bmj.i189. https://www.bmj.com/content/352/bmj.i189 [cited 2022 Dec 17]. Available from: [DOI] [PubMed] [Google Scholar]
- 17.Kyan A., Takakura M. Socio-economic inequalities in physical activity among Japanese adults during the COVID-19 pandemic. Public Health. 2022;207:7–13. doi: 10.1016/j.puhe.2022.03.006. [DOI] [PubMed] [Google Scholar]
- 18.Rochmawati E., Iskandar A.C., Kamilah F. Persistent symptoms among post-COVID-19 survivors: a systematic review and meta-analysis. J Clin Nurs [Internet] 2022:1–11. doi: 10.1111/jocn.16471. https://onlinelibrary.wiley.com/doi/10.1111/jocn.16471 Available from: [DOI] [PubMed] [Google Scholar]
- 19.Ahmed H., Patel K., Greenwood D.C., Halpin S., Lewthwaite P., Salawu A., et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome coronavirus (MERS) outbreaks after hospitalisation or ICU admission: a systematic review and meta-analysis. J Rehabil Med. 2020;52(5):1–11. doi: 10.2340/16501977-2694. [DOI] [PubMed] [Google Scholar]
- 20.Herridge M.S., Cheung A.M., Tansey C.M., Matte-Martyn A., Diaz-Granados N., Al-Saidi F., et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003;348(8):683–693. doi: 10.1056/NEJMoa022450. [DOI] [PubMed] [Google Scholar]
- 21.Singh I., Joseph P., Heerdt P.M., Cullinan M., Lutchmansingh D.D., Gulati M., et al. Persistent exertional intolerance after COVID-19: insights from invasive cardiopulmonary exercise testing. Chest. 2022;161(1):54–63. doi: 10.1016/j.chest.2021.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Apabhai S., Gorman G.S., Sutton L., Elson J.L., Plötz T., Turnbull D.M., et al. Habitual physical activity in mitochondrial disease. PLoS One [Internet] 2011;6(7):e22294. doi: 10.1371/journal.pone.0022294. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0022294 [cited 2022 Dec 5]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Zoll J., Sanchez H., N'Guessan B., Ribera F., Lampert E., Bigard X., et al. Physical activity changes the regulation of mitochondrial respiration in human skeletal muscle. J Physiol [Internet] 2002;543(1):191–200. doi: 10.1113/jphysiol.2002.019661. https://onlinelibrary.wiley.com/doi/full/10.1113/jphysiol.2002.019661 [cited 2022 Dec 5]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Jimeno-Almazán A., Buendía-Romero Á., Martínez-Cava A., Franco-López F., Sánchez-Alcaraz B.J., Courel-Ibáñez J., et al. Effects of a concurrent training, respiratory muscle exercise, and self-management recommendations on recovery from post-COVID-19 conditions: the RECOVE trial. J Appl Physiol (1985) [Internet] 2023;134(1):95–104. doi: 10.1152/japplphysiol.00489.2022. https://journals.physiology.org/doi/10.1152/japplphysiol.00489.2022 [cited 2023 May 1]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Hamer M., Kivimäki M., Gale C.R., Batty G.D. Lifestyle risk factors, inflammatory mechanisms, and COVID-19 hospitalization: a community-based cohort study of 387,109 adults in UK. Brain Behav Immun. 2020;87:184–187. doi: 10.1016/j.bbi.2020.05.059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Feter N., Alt R., Dias M.G., Rombaldi A.J. How do different physical exercise parameters modulate brain-derived neurotrophic factor in healthy and non-healthy adults? A systematic review, meta-analysis and meta-regression. Sci Sports [Internet] 2019;34(5):293–304. http://www.sciencedirect.com/science/article/pii/S0765159719300309 Available from: [Google Scholar]
- 27.Andrews M.G., Mukhtar T., Eze U.C., Simoneau C.R., Ross J., Parikshak N., et al. Tropism of SARS-CoV-2 for human cortical astrocytes. Proc Natl Acad Sci USA. 2022;119(30) doi: 10.1073/pnas.2122236119. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Aceti A., Margarucci L.M., Scaramucci E., Orsini M., Salerno G., Di Sante G., et al. Serum S100B protein as a marker of severity in Covid-19 patients. Sci Rep. 2020;10(1):1–8. doi: 10.1038/s41598-020-75618-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Huang S., Fishell G. In SARS-CoV-2, astrocytes are in it for the long haul. Proc Natl Acad Sci USA. 2022;119(30) doi: 10.1073/pnas.2209130119. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Jimeno-Almazán A., Martínez-Cava A., Buendía-Romero Á., Franco-López F., Sánchez-Agar J.A., Sánchez-Alcaraz B.J., et al. Relationship between the severity of persistent symptoms, physical fitness, and cardiopulmonary function in post-COVID-19 condition. A population-based analysis. Intern Emerg Med. 2022;17(8):2199–2208. doi: 10.1007/s11739-022-03039-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Redig L., Feter N., Dumith S.C., Domingues M.R., Rombaldi A.J. Physical inactivity from childhood to adolescence and incident depression. Am J Prev Med. 2021;62(2):211–218. doi: 10.1016/j.amepre.2021.09.001. [DOI] [PubMed] [Google Scholar]
- 32.Dregan A., Gulliford M.C. Leisure-time physical activity over the life course and cognitive functioning in late mid-adult years: a cohort-based investigation. Psychol Med. 2013;43(11):2447–2458. doi: 10.1017/S0033291713000305. [DOI] [PubMed] [Google Scholar]
- 33.Hallal P.C. SOS Brazil: science under attack. Lancet. JULY 30, 2022;400(10349):355. doi: 10.1016/S0140-6736(22)01196-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
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