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36 exercise COVID-19 controlled studies
https://c19early.com/exmeta.html
0
0.5
1
1.5+
All studies 40% 36
1,464,894
Improvement, Studies, Patients Relative Risk Mortality 44% 13
1,437,929
Ventilation 46% 2
43,773
ICU admission 41% 4
708,149
Hospitalization 38% 9
666,393
Recovery 57% 2
66
Cases 20% 14
77,841
Peer-reviewed 40% 35
1,464,894
Prophylaxis 40% 36
1,464,894
Exercise for COVID-19 c19early.com/ex Aug 2022
Favors exercise Favors inactivity after exclusions
• Results are robust — in exclusion sensitivity analysis 31 of 36
studies must be excluded to avoid finding statistically significant efficacy
in pooled analysis.
• Results are consistent with the overall risk of all cause mortality based on cardiorespiratory fitness —
[Laukkanen ] show RR 0.55 [0.50-0.61] for the top vs. bottom tertiles.
0
0.5
1
1.5+
All studies 40% 36
1,464,894
Improvement, Studies, Patients Relative Risk Mortality 44% 13
1,437,929
Ventilation 46% 2
43,773
ICU admission 41% 4
708,149
Hospitalization 38% 9
666,393
Recovery 57% 2
66
Cases 20% 14
77,841
Peer-reviewed 40% 35
1,464,894
Prophylaxis 40% 36
1,464,894
Exercise for COVID-19 c19early.com/ex Aug 2022
Favors exercise Favors inactivity after exclusions
• Studies analyze exercise/physical activity levels before infection, comparing regular/moderate exercise vs. lower/no exercise. Note that risk may increase with more extreme activity levels.
• No treatment, vaccine, or intervention is 100%
available and effective for all variants. All practical, effective, and safe
means should be used.
Denying the efficacy of treatments increases mortality, morbidity, collateral
damage, and endemic risk.
• All data to reproduce this paper and
sources are in the
appendix .
Other meta analyses for exercise can be found in
[Li , Rahmati ] , showing significant improvements for mortality, ICU admission, and hospitalization.
Highlights
We show traditional outcome specific analyses and combined
evidence from all studies.
A
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Hamer 28%
0.72 [0.61-0.87]
hosp.
n/a
n/a
Improvement, RR [CI] Treatment Control Brawner 74%
0.26 [0.11-0.58]
hosp.
n/a
n/a
Zhang 26%
0.74 [0.48-1.14]
death
n/a
n/a
Tavakol 69%
0.31 [0.10-1.02]
severe case
3/64
19/124
Yates 45%
0.55 [0.38-0.79]
death
72/163,912
62/30,119
Holt 17%
0.83 [0.63-1.09]
cases
n/a
n/a
Cho 53%
0.47 [0.26-0.87]
death
case control
Sallis 59%
0.41 [0.22-0.76]
death
11/3,118
170/6,984
Christensen 63%
0.37 [0.16-0.85]
death
543 (n)
529 (n)
Latorre-Román 76%
0.24 [0.05-1.04]
hosp.
n/a
n/a
Marcus 42%
0.58 [0.48-0.71]
symp. case
240/10,627
134/3,708
Yuan 91%
0.09 [0.01-1.65]
death
0/61
6/103
Brandenburg -6%
1.06 [0.23-4.79]
hosp.
102 (n)
39 (n)
Bielik 30%
0.70 [0.40-1.21]
mod. case
775 (n)
365 (n)
af Geijerstam 50%
0.50 [0.31-0.81]
death
318,902 (n)
336,271 (n)
Lee 74%
0.26 [0.07-0.99]
death
2/11,072
32/41,293
Maltagliati 52%
0.48 [0.25-0.87]
hosp.
n/a
n/a
Baynouna AlKetbi 98%
0.01 [0.00-0.44]
death
n/a
n/a
Ahmadi 30%
0.70 [0.54-0.89]
death
160/232,613
112/95,221
Nguyen 20%
0.80 [0.72-0.88]
symp. case
904/2,836
483/1,111
Lin 47%
0.53 [0.12-2.33]
cases
n/a
n/a
de Souza 73%
0.27 [0.07-1.06]
ventilation
3/611
6/327
Mohsin 19%
0.81 [0.66-0.99]
severe case
86/258
224/544
Ekblom-Bak 48%
0.52 [0.30-0.92]
severe case
n/a
n/a
Lengelé 74%
0.26 [0.07-0.80]
cases
23/229
4/12
Saadeh 9%
0.91 [0.56-1.43]
symp. case
362 (n)
225 (n)
Hamrouni 29%
0.71 [0.55-0.92]
death
138/106,006
109/47,827
Huang 47%
0.53 [0.23-1.22]
severe case
7/74
16/90
Steenkamp 42%
0.58 [0.50-0.68]
death
29,469 (n)
13,366 (n)
Gilley -42%
1.42 [0.60-3.35]
cases
172/1,917
5/79
Beydoun 43%
0.57 [0.32-1.01]
cases
1,710 (n)
448 (n)
Salgado-Aranda 83%
0.17 [0.05-0.56]
death
4/223
41/297
Paul 38%
0.62 [0.30-1.20]
no recov.
n/a
n/a
Kontopoulou 66%
0.34 [0.24-0.47]
recov. time
42 (n)
24 (n)
Malisoux 63%
0.37 [0.14-0.98]
progression
115 (n)
108 (n)
Antunes 80%
0.20 [0.03-1.41]
ICU
1/14
9/25
Tau2 = 0.06, I2 = 67.5%, p < 0.0001
Prophylaxis 40%
0.60 [0.53-0.67]
1,826/885,655
1,432/579,239
40% improvement All studies 40%
0.60 [0.53-0.67]
1,826/885,655
1,432/579,239
40% improvement 36 exercise COVID-19 studies c19early.com/ex Aug 2022
Tau2 = 0.06, I2 = 67.5%, p < 0.0001
Effect extraction pre-specified (most serious outcome, see appendix) Favors exercise
Favors inactivity
B
C
Figure 1. A. Random effects
meta-analysis. This plot shows pooled effects, discussion can be found in the heterogeneity section,
and results for specific outcomes can be found in the individual outcome analyses.
Effect extraction is pre-specified, using the most serious outcome reported.
For details of effect extraction see the
appendix .
B. Scatter plot showing the
distribution of effects reported in studies.
C. History of all reported
effects (chronological within treatment stages).
Introduction
We analyze all significant studies
reporting COVID-19 outcomes as a function of physical activity levels.
Search methods, inclusion criteria, effect
extraction criteria (more serious outcomes have priority), all individual
study data, PRISMA answers, and statistical methods are detailed in
Appendix 1 . We present random effects meta-analysis results for all
studies, for studies within each treatment stage, for individual outcomes, for
peer-reviewed studies, for Randomized Controlled Trials (RCTs), and after
exclusions.
Physical Inactivity
Insufficient physical activity is a risk factor for many
diseases and is common around the world
[Guthold ] , as shown in
Figure 2 .
[Guthold ] found that prevalence in high-income
countries was over twice as high, and has increased over time.
Figure 2. Prevalence of insufficient
physical activity around the world as of 2016, from
[Guthold ] (top: female,
bottom: male).
For upper respiratory tract infections, research shows lower risk
for moderate activity vs. a sedentary lifestyle, however risk increases with more
extreme activity levels
[Nieman ] .
Figure 2. Risk may increase with more
extreme activity levels, as seen with upper respiratory tract infections
[Nieman ] .
Results
Figure 3 shows a visual overview of the results, with details in
Table 1 and
Table 2 .
Figure
4 ,
5 ,
6 ,
7 ,
8 ,
9 ,
10 ,
11 , and
12
show forest plots for a random effects meta-analysis of
all studies with pooled effects, mortality results, ventilation, ICU admission, hospitalization, progression, recovery, cases, and peer reviewed studies.
0
0.5
1
1.5+
ALL STUDIES
MORTALITY
VENTILATION
ICU ADMISSION
HOSPITALIZATION
RECOVERY
CASES
PEER-REVIEWED
After Exclusions
ALL STUDIES
All
Prophylaxis
Exercise for COVID-19
C19EARLY.COM/EX AUG 2022
Treatment time Number of studies reporting positive effects
Total number of studies Percentage of studies reporting positive effects
Random effects meta-analysis results
Prophylaxis
34
36
94.4%
40% improvement
All studies
34
36
94.4%
40% improvement
Table 1. Results by treatment stage.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Hamer 28%
0.72 [0.61-0.87]
hosp.
n/a
n/a
Improvement, RR [CI] Treatment Control Brawner 74%
0.26 [0.11-0.58]
hosp.
n/a
n/a
Zhang 26%
0.74 [0.48-1.14]
death
n/a
n/a
Tavakol 69%
0.31 [0.10-1.02]
severe case
3/64
19/124
Yates 45%
0.55 [0.38-0.79]
death
72/163,912
62/30,119
Holt 17%
0.83 [0.63-1.09]
cases
n/a
n/a
Cho 53%
0.47 [0.26-0.87]
death
case control
Sallis 59%
0.41 [0.22-0.76]
death
11/3,118
170/6,984
Christensen 63%
0.37 [0.16-0.85]
death
543 (n)
529 (n)
Latorre-Román 76%
0.24 [0.05-1.04]
hosp.
n/a
n/a
Marcus 42%
0.58 [0.48-0.71]
symp. case
240/10,627
134/3,708
Yuan 91%
0.09 [0.01-1.65]
death
0/61
6/103
Brandenburg -6%
1.06 [0.23-4.79]
hosp.
102 (n)
39 (n)
Bielik 30%
0.70 [0.40-1.21]
mod. case
775 (n)
365 (n)
af Geijerstam 50%
0.50 [0.31-0.81]
death
318,902 (n)
336,271 (n)
Lee 74%
0.26 [0.07-0.99]
death
2/11,072
32/41,293
Maltagliati 52%
0.48 [0.25-0.87]
hosp.
n/a
n/a
Baynouna AlKetbi 98%
0.01 [0.00-0.44]
death
n/a
n/a
Ahmadi 30%
0.70 [0.54-0.89]
death
160/232,613
112/95,221
Nguyen 20%
0.80 [0.72-0.88]
symp. case
904/2,836
483/1,111
Lin 47%
0.53 [0.12-2.33]
cases
n/a
n/a
de Souza 73%
0.27 [0.07-1.06]
ventilation
3/611
6/327
Mohsin 19%
0.81 [0.66-0.99]
severe case
86/258
224/544
Ekblom-Bak 48%
0.52 [0.30-0.92]
severe case
n/a
n/a
Lengelé 74%
0.26 [0.07-0.80]
cases
23/229
4/12
Saadeh 9%
0.91 [0.56-1.43]
symp. case
362 (n)
225 (n)
Hamrouni 29%
0.71 [0.55-0.92]
death
138/106,006
109/47,827
Huang 47%
0.53 [0.23-1.22]
severe case
7/74
16/90
Steenkamp 42%
0.58 [0.50-0.68]
death
29,469 (n)
13,366 (n)
Gilley -42%
1.42 [0.60-3.35]
cases
172/1,917
5/79
Beydoun 43%
0.57 [0.32-1.01]
cases
1,710 (n)
448 (n)
Salgado-Aranda 83%
0.17 [0.05-0.56]
death
4/223
41/297
Paul 38%
0.62 [0.30-1.20]
no recov.
n/a
n/a
Kontopoulou 66%
0.34 [0.24-0.47]
recov. time
42 (n)
24 (n)
Malisoux 63%
0.37 [0.14-0.98]
progression
115 (n)
108 (n)
Antunes 80%
0.20 [0.03-1.41]
ICU
1/14
9/25
Tau2 = 0.06, I2 = 67.5%, p < 0.0001
Prophylaxis 40%
0.60 [0.53-0.67]
1,826/885,655
1,432/579,239
40% improvement All studies 40%
0.60 [0.53-0.67]
1,826/885,655
1,432/579,239
40% improvement 36 exercise COVID-19 studies c19early.com/ex Aug 2022
Tau2 = 0.06, I2 = 67.5%, p < 0.0001
Effect extraction pre-specified (most serious outcome, see appendix) Favors exercise
Favors inactivity
Figure 4. Random effects meta-analysis for all studies with pooled effects.
This plot shows pooled effects, discussion can be found in the heterogeneity section,
and results for specific outcomes can be found in the individual outcome analyses.
Effect extraction is pre-specified, using the most serious outcome reported.
For details of effect extraction see the
appendix .
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Zhang 26%
0.74 [0.48-1.14]
n/a
n/a
Improvement, RR [CI] Treatment Control Yates 45%
0.55 [0.38-0.79]
72/163,912
62/30,119
Cho 53%
0.47 [0.26-0.87]
case control
Sallis 59%
0.41 [0.22-0.76]
11/3,118
170/6,984
Christensen 63%
0.37 [0.16-0.85]
543 (n)
529 (n)
Yuan 91%
0.09 [0.01-1.65]
0/61
6/103
af Geijerstam 50%
0.50 [0.31-0.81]
318,902 (n)
336,271 (n)
Lee 74%
0.26 [0.07-0.99]
2/11,072
32/41,293
Baynouna AlKetbi 98%
0.01 [0.00-0.44]
n/a
n/a
Ahmadi 30%
0.70 [0.54-0.89]
160/232,613
112/95,221
Hamrouni 29%
0.71 [0.55-0.92]
138/106,006
109/47,827
Steenkamp 42%
0.58 [0.50-0.68]
29,469 (n)
13,366 (n)
Salgado-Aranda 83%
0.17 [0.05-0.56]
4/223
41/297
Tau2 = 0.03, I2 = 41.7%, p < 0.0001
Prophylaxis 44%
0.56 [0.48-0.66]
387/865,919
532/572,010
44% improvement All studies 44%
0.56 [0.48-0.66]
387/865,919
532/572,010
44% improvement 13 exercise COVID-19 mortality results c19early.com/ex Aug 2022
Tau2 = 0.03, I2 = 41.7%, p < 0.0001
Favors exercise
Favors inactivity
Figure 5. Random effects meta-analysis for mortality results.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
de Souza 73%
0.27 [0.07-1.06]
3/611
6/327
Improvement, RR [CI] Treatment Control Steenkamp 45%
0.55 [0.47-0.64]
29,469 (n)
13,366 (n)
Tau2 = 0.01, I2 = 3.4%, p < 0.0001
Prophylaxis 46%
0.54 [0.43-0.68]
3/30,080
6/13,693
46% improvement All studies 46%
0.54 [0.43-0.68]
3/30,080
6/13,693
46% improvement 2 exercise COVID-19 mechanical ventilation results c19early.com/ex Aug 2022
Tau2 = 0.01, I2 = 3.4%, p < 0.0001
Favors exercise
Favors inactivity
Figure 6. Random effects meta-analysis for ventilation.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Sallis 42%
0.58 [0.40-0.85]
32/3,118
195/6,984
Improvement, RR [CI] Treatment Control af Geijerstam 40%
0.60 [0.46-0.80]
318,902 (n)
336,271 (n)
Steenkamp 41%
0.59 [0.52-0.66]
29,469 (n)
13,366 (n)
Antunes 80%
0.20 [0.03-1.41]
1/14
9/25
Tau2 = 0.00, I2 = 0.0%, p < 0.0001
Prophylaxis 41%
0.59 [0.53-0.65]
33/351,503
204/356,646
41% improvement All studies 41%
0.59 [0.53-0.65]
33/351,503
204/356,646
41% improvement 4 exercise COVID-19 ICU results c19early.com/ex Aug 2022
Tau2 = 0.00, I2 = 0.0%, p < 0.0001
Favors exercise
Favors inactivity
Figure 7. Random effects meta-analysis for ICU admission.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Hamer 28%
0.72 [0.61-0.87]
hosp.
n/a
n/a
Improvement, RR [CI] Treatment Control Brawner 74%
0.26 [0.11-0.58]
hosp.
n/a
n/a
Sallis 53%
0.47 [0.38-0.58]
hosp.
99/3,118
732/6,984
Latorre-Román 76%
0.24 [0.05-1.04]
hosp.
n/a
n/a
Brandenburg -6%
1.06 [0.23-4.79]
hosp.
102 (n)
39 (n)
af Geijerstam 27%
0.73 [0.64-0.83]
hosp.
318,902 (n)
336,271 (n)
Maltagliati 52%
0.48 [0.25-0.87]
hosp.
n/a
n/a
de Souza 34%
0.66 [0.43-0.99]
hosp.
49/611
42/327
Antunes 43%
0.57 [0.34-0.95]
hosp. time
14 (n)
25 (n)
Tau2 = 0.07, I2 = 80.0%, p < 0.0001
Prophylaxis 38%
0.62 [0.50-0.78]
148/322,747
774/343,646
38% improvement All studies 38%
0.62 [0.50-0.78]
148/322,747
774/343,646
38% improvement 9 exercise COVID-19 hospitalization results c19early.com/ex Aug 2022
Tau2 = 0.07, I2 = 80.0%, p < 0.0001
Favors exercise
Favors inactivity
Figure 8. Random effects meta-analysis for hospitalization.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Malisoux 63%
0.37 [0.14-0.98]
115 (n)
108 (n)
Improvement, RR [CI] Treatment Control Tau2 = 0.00, I2 = 0.0%, p = 0.045
Prophylaxis 63%
0.37 [0.14-0.98]
0/115
0/108
63% improvement All studies 63%
0.37 [0.14-0.98]
0/115
0/108
63% improvement 1 exercise COVID-19 progression result c19early.com/ex Aug 2022
Tau2 = 0.00, I2 = 0.0%, p = 0.045
Favors exercise
Favors inactivity
Figure 9. Random effects meta-analysis for progression.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Paul 38%
0.62 [0.30-1.20]
no recov.
n/a
n/a
Improvement, RR [CI] Treatment Control Kontopoulou 66%
0.34 [0.24-0.47]
recov. time
42 (n)
24 (n)
Tau2 = 0.11, I2 = 60.7%, p = 0.0036
Prophylaxis 57%
0.43 [0.24-0.76]
0/42
0/24
57% improvement All studies 57%
0.43 [0.24-0.76]
0/42
0/24
57% improvement 2 exercise COVID-19 recovery results c19early.com/ex Aug 2022
Tau2 = 0.11, I2 = 60.7%, p = 0.0036
Favors exercise
Favors inactivity
Figure 10. Random effects meta-analysis for recovery.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Zhang 18%
0.82 [0.69-0.96]
cases
n/a
n/a
Improvement, RR [CI] Treatment Control Holt 17%
0.83 [0.63-1.09]
cases
n/a
n/a
Cho 10%
0.90 [0.86-0.95]
cases
case control
Christensen 23%
0.77 [0.52-1.15]
cases
55/543
77/529
Marcus 42%
0.58 [0.48-0.71]
symp. case
240/10,627
134/3,708
Bielik -9%
1.09 [0.69-1.73]
cases
775 (n)
365 (n)
Lee 16%
0.84 [0.73-0.98]
cases
291/11,072
1,293/41,293
Nguyen 20%
0.80 [0.72-0.88]
symp. case
904/2,836
483/1,111
Lin 47%
0.53 [0.12-2.33]
cases
n/a
n/a
Lengelé 74%
0.26 [0.07-0.80]
cases
23/229
4/12
Saadeh 9%
0.91 [0.56-1.43]
symp. case
362 (n)
225 (n)
Huang 66%
0.34 [0.17-0.70]
cases
n/a
n/a
Gilley -42%
1.42 [0.60-3.35]
cases
172/1,917
5/79
Beydoun 43%
0.57 [0.32-1.01]
cases
1,710 (n)
448 (n)
Tau2 = 0.02, I2 = 69.4%, p < 0.0001
Prophylaxis 20%
0.80 [0.72-0.89]
1,685/30,071
1,996/47,770
20% improvement All studies 20%
0.80 [0.72-0.89]
1,685/30,071
1,996/47,770
20% improvement 14 exercise COVID-19 case results c19early.com/ex Aug 2022
Tau2 = 0.02, I2 = 69.4%, p < 0.0001
Favors exercise
Favors inactivity
Figure 11. Random effects meta-analysis for cases.
0
0.25
0.5
0.75
1
1.25
1.5
1.75
2+
Hamer 28%
0.72 [0.61-0.87]
hosp.
n/a
n/a
Improvement, RR [CI] Treatment Control Brawner 74%
0.26 [0.11-0.58]
hosp.
n/a
n/a
Zhang 26%
0.74 [0.48-1.14]
death
n/a
n/a
Tavakol 69%
0.31 [0.10-1.02]
severe case
