Therapeutic pulmonary telerehabilitation protocol for patients affected by COVID-19, confined to their homes: study protocol for a randomized controlled trial

Background In December 2019, 27 cases of pneumonia, of unknown cause, were identified in the province of Hubei (China). The WHO declared the situation as a Public Health Emergency of International Concern, and it was finally declared a global pandemic on March 11, 2020. The Spanish Government obliges the entire population to remain confined to their homes, with the exception of essential basic services, to stop the spread of COVID-19. Home isolation implies a notable physical deconditioning. Telerehabilitation methods have reported positive experiences, and we propose to study in affected patients of COVID-19, due to the general house confinement of the entire Spanish population. Methods Patients will be recruited in the regions of Andalusia, Murcia, and Valencia (Spain). Patients will remain confined to their homes, and there, they will carry out their assigned exercise program, which will be controlled telematically. Evaluators will attend to carry out all measurements at the beginning, during, and end of the study, telematically controlled. The patients will be randomly divided into three groups, two of them will perform a home exercise program (breathing exercises or non-specific exercises for muscle toning) and the third group will perform sedentary activities, using mental activation techniques, and will act as a sham group. We will evaluate respiratory variables and other variables of the physical state through physical tests, effort, and perceived fatigue. The data will be statistically analyzed, and the hypotheses will be tested between the groups, using the SPSS software, v.24, considering a 95% confidence interval. Discussion We will analyze the results, in terms of the level of fatigue and perceived exertion, physical health, and maintenance of respiratory activity of two types of exercise programs, toning and respiratory, applied in patients affected by COVID-19 during the period of home confinement. We intend to investigate a field not previously studied, such as the repercussion of carrying out a toning and respiratory exercise program in these patients, in historical circumstances that no one had previously observed in Spain, since the general population has never been forced to remain confined in their homes, due to a pandemic infection, by a coronavirus (COVID-19). Observing the effects that these two home exercise programs could produce in patients infected with COVID-19, we will try to better analyze and understand the mechanisms that are associated with the worsening of breathing in this type of patient. Trial registration Brazilian Clinical Trial Registry RBR-6m69fc. Registered on March 31, 2020.


 EXERCISE 2. Reeducation of right hemidiaphragm
The patient will be layed in lateral decubite over right side, with a pillow under thoracic wall. Both low limbs will be semiflexioned and upper limbs in a confortable position. At first, the patient will perform an expiration with pursed lips until produce an abdominal wall contraction. Later, the patient will perform a deep nasal inspiration with the mouth closed. With this maneuver, the aim is to bring the air to the belly; when plenty of aire, the aire will be expulsed while the abdomen is contracted. 10-15 repetitions in the morning and 10-15 in the evening.

 EXERCISE 3. Reeducation of left hemidiaphragm
The patient will be layed in lateral decubite over left side, with a pillow under thoracic wall. Both low limbs will be semiflexioned and upper limbs in a confortable position. At first, the patient will perform an expiration with pursed lips until produce an abdominal wall contraction. Later, the patient will perform a deep nasal inspiration with the mouth closed. With this maneuver, the aim is to bring the air to the belly; when plenty of aire, the aire will be expulsed while the abdomen is contracted. 10-15 repetitions in the morning and 10-15 in the evening.

 EXERCISE 4: Reeducation of the anterior region of the diaphragm
The patient will be layed in prone position with a pillow between pelvic región and abdomen. Hands will be placed under the head, with the head rotated. The exercise starts with a slight expiration with abdominal contraction at the end, followed by a slow and prolonged inspiratory phase  EXERCISE 5: Reeducation of the anterior region of the diaphragm The patient will be in a 4 point kneeling position doing the same breathing phases. At first, the patient will perform an expiration with pursed lips until produce an abdominal wall contraction. Later, the patient will perform a deep nasal inspiration with the mouth closed. With this maneuver, the aim is to bring the air to the belly; when plenty of aire, the aire will be expulsed while the abdomen is contracted. 10-15 repetitions in the morning and 10-15 in the evening. .  EXERCISE 6: Exercise of positive expiratory pressure Through this exercise, an expiratory brake is performed, what improves bronchial stability and prevents collapse. A delay in the air outlet occurs, maintining a distension in upper aire passages. It favors the opening of colateral ventilation, what makes the air to reach peripheral areas that can not be reached because of obstruction. It improves the elimination of secretions in a secondary way 15 . Through a home made device, the patient will perform a deep inspiration and, following that, a slow expiration blowing through the tube introduced in a bottle of water, not achieving a complete expiration. The secuence will be repeated 10-15 times, twice a day.
Picture from College of Physical Therapists, Community of Madrid  EXERCISE 7: costal breathing exercise in supine position The patient will be layed in supine position over a hard surface with a pillow under the head and knees. An increase in inspiration and expiration volumen will be performed.
The patient will place a hand on the abdomen, and it will work as a brake. For the abdomen. At first, an inspiration with mouth closed will be done, and the air will arrive to lungs. Later, with pursed lips, the patient will empty the lungs in a forced expiration.