Physical exercise in the control of pain or fatigue associated with viral infections: systematic review

Rios, Mônica Andrade; Goes, Bruno Teixeira; Baptista, Abrahão Fontes; Oliveira, Leonardo Santana Ramos de; Sá, Katia Nunes

doi:10.5935/2595-0118.20220048-en

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REVIEW ARTICLE • BrJP 5 (3) • Jul-Sep 2022 • https://doi.org/10.5935/2595-0118.20220048-en copy

Physical exercise in the control of pain or fatigue associated with viral infections: systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES:

Individuals after viral infections remain with persistent symptoms such as pain and fatigue. Physical exercises have been described as a promising alternative for the control of these symptoms, but there are no systematic reviews that verify the effectiveness of this therapy and that assess the quality of these studies. The aim of this study was to investigate the effect of physical exercise on pain or fatigue associated with viral infections.

METHODS:

Systematic review registered with PROSPERO (CRD42021265174). Data collection was carried out between July 2021 and January 2022. Randomized clinical trials that addressed the practice of exercises, in individuals over 18 years of age, diagnosed with viral infection associated with the presence of pain or fatigue for more than 3 months were included. The search was carried out in the Pubmed, EMBASE, LILACS and Scielo databases, and the paired selection was carried out in the software (rayyan.ai); risk of bias analysis was assessed using the Cochrane risk-of-bias tool for randomized trials 2; certainty of evidence through GRADE; and for the construction of the meta-analysis, the Review Manager software.

RESULTS:

Eleven clinical trials were selected in populations with acquired immunodeficiency virus (HIV), human T-cell lymphotropic virus (HTLV), chikungunya and poliomyelitis. For both pain and fatigue, the combination of aerobic exercise with resistance training, lasting 40 to 60 minutes, two to three times a week, was effective and safe. The methodological quality of the studies showed a high risk of bias in six studies due to the following domains: bias due to deviations from the intended interventions, bias due to lack of outcome data and bias in the selection of the reported outcome; rated as some concerns in one study due to the domain bias due to deviations from intended interventions; and the others were assessed as low risk of bias. The meta-analysis showed a result in favor of the intervention group on pain intensity in the studies for Chikungunya and in a study for HTLV, which points to a positive effect in favor of the active groups.

CONCLUSION:

Exercises for the treatment of fatigue have very low evidence, while resistance exercises have moderate evidence for pain outcome. These are low-risk, low-cost resources with promising effects that should be better tested in people after viral infections.

Keywords:
Pain; Physical exercise; Fatigue; Viral infections

Authors	Population/Sample	Intervention	Comparator	Primary Outcome/Measurement	Main results	Conclusion
Smith et al.³⁴34 Smith BA, Neidig JL, Nickel JT, Mitchell GL, Para M F, Fass RJ. Aerobic exercise: effects on parameters related to fatigue, dyspnea, weight and body composition in HIV-infected adults. AIDS. 2001;15(6):693-701.	HIV/ n = 60 (8 women and 52 men)	Warm-up + aerobic (30’’) with 60-80% of max HR + relaxation. 3x/week, totaling 12 weeks	Usual activities	Fatigue: Time on the treadmill	Aerobic training had a sig-nificant effect on treadmill time (p: 0.01)	Supervised aerobic training safely decreases fatigue in HIV-1 infected individuals
Oncu, Durmaz and Karapolat³⁵35 Oncu J, Durmaz B, Karapolat H. Short-term effects of aerobic exercise on functional capacity, fatigue, and quality of life in patients with post-polio syndrome. Clin Rehabil. 2009;23(2):155-63.	Post-polio syndrome/ n= 28 (12 men and 16 women)	Flexibility + aerobic exercises (50-70% VO2 max., 13-15 on the Borg Scale). 3x/week, for 8 weeks and duration of 90 minutes per session	Exercises at home	Fatigue: FSS and FIS	Significant improvement in fatigue observed in the supervised exercise group compared to the home group, in the total FSS (p:0.002) and total FIS (p<0.001) scores	The physical exercise performed under supervision leads to more functional improvement in people later after polio than a similar program taught and conducted in home, unsupervised
Borges et al.³⁸38 Borges J, Baptista A F, Santana N, Souza I, Kruschewsky RA, Galvão-Castro B, Sá KN. Pilates exercises improve low back pain and quality of life in patients with HTLV-1 virus: a randomized crossover clinical trial. J Bodyw Mov Ter. 2014;18(1):68-74.	HTLV-1/ n= 22 (16 women and 6 men)	Pilates method: 1 hour session, 2 times a week, totaling 30 sessions	Usual activities	Pain Intensity: VAS	There was a significant reduction in pain intensity after the protocol of Pilates exercises (p< 0.001)	Pilates proved to be a useful tool to reduce self-reported low back pain
Jaggers et al.³⁶36 Jaggers JR, Hand GA, Dudgeon WD, Burgess S, Phillips KD, Durstine JL, Blair SN. Aerobic and resistance training improves mood state among adults living with HIV. Int J Sports Med. 2015;36(2):175-81.	HIV/ n= 49 (37 men and 12 women)	Aerobic (30’’ with 50-70% HR max.) + Resistance training (20’’). 2 times a week/ for 6 weeks	Sedentary habits	Fatigue: POMS-30 – fatigue sub-scale	The exercise group compared to the control group showed a significant difference in the fatigue subscale (p<0.05)	Routine aerobic and resistance training at a moderate intensity may serve as a viable fatigue option
Koopman et al.³⁷37 Koopman FS, Voorn EL, Beelen A, Bleijenberg G, de Visser M, Brehm MA, Nollet F. No reduction of severe fatigue in patients with postpolio syndrome by exercise therapy or cognitive behavioral therapy: results of an RCT. Neurorehabil Neural Repair. 2016;30(5):402-10.	Post polio syndrome/n = 67 (30 men and 37 women)	Home aerobic training (60-70% of Fcmax, 28 to 38’’, 3 times a week) + Muscle strengthening and functional exercises, 1 hour, 1 time a week	Usual care and CBT	Fatigue: CIS20-F	There were no differences between the groups	Neither the exercise group nor CBT was superior to usual care in reducing fatigue or improving activities in severely fatigued post-polio syndrome patients
Parker Jelsma and Stein³⁹39 Parker R, Jelsma J, Stein DJ. Managing Pain in Women living with HIV/AIDS: a randomized controlled trial testing the effect of a six-week peer-led exercise and education intervention. J Nerv Ment Dis. 2016;204(9):665-72.	HIV/AIDS / n= 27 (all women)	Education program + aerobic exercise and muscle strengthening (20 minutes weekly for 16 weeks) + guided relaxation (2 hours total)	Education program	Pain Intensity: BPI	There were no significant differences between groups in the reduction of the PSS primary outcome at each time point between Week 0 and Week 16. There was no improvement in PIS during the 15 months of normal care between Baseline and Week 0, but the PSS reduced significantly for all participants between Week 0 and Week 4, Week 8, Week 12 and Week 16	Both supervised exercise and educational intervention or educational intervention alone appear to be a viable and effective method of treating pain in women living with HIV
Maharaj and Yakasai²⁷27 Maharaj SS, Yakasai AM. Does a rehabilitation program of aerobic and progressive resisted exercises influence HIV-induced distal neuropathic pain? Am J Phys Med Rehabil. 2018;97(5):364-9.	HIV/ n= 136 (79 women and 57 men)	AE= 20 minutes with 40 Fc max. in the first 6 weeks and 65% in the following PRE= 40% of 1 RM, 2 sets of 10 repetitions, 3-5 second interval; after 6 weeks 65% of 1 RM in 3 sets of 10 repetitions, 2-3 second interval. HR (40-65%) for 30 minutes, every other day, 3 times/week, for 12 week	HIV talks, video presentations and counseling	Pain Intensity: NRS	There were significant differences between the intervention and control groups (p<0.001)	Moderate-intensity aerobic and progressive resistance exercise is safe and effective for reducing neuropathic pain
Macêdo et al.²⁴24 Macêdo MC, Mota RS, Patrício NA, Baptista A F, Andrade Filho AS, Sá KN. Pain and quality of life in human t-cell lymphotropic virus type 1-associated myelopathy or tropical spastic paraparesis after home-based exercise protocol: a randomized clinical trial. Rev Soc Bras Med Trop. 2019;52:e20180270.	HTLV-1/ n= 49 (31 women and 18 men)	Stretching and muscle strengthening: 1 to 3 sets of 10 repetitions with a 1-minute interval between sets. 2 times a week/45-50 minutes	Exercise booklet-guided protocol and control group	Pain Intensity: BPI	There were no differences between the groups	The exercise protocol tested generated a small degree of pain relief, but did not affect aspects of pain reactions or quality of life
De Oliveira et al.⁴⁰40 de Oliveira BFA, Carvalho PRC, de Souza Holanda AS, Dos Santos RISB, da Silva FAX, Barros GWP, de Albuquerque EC, Dantas AT, Cavalcanti NG, Ranzolin A, Duarte ALBP, Marques CDL. Pilates method in the treatment of patients with Chikungunya fever: a randomized controlled trial. Clin Rehabil. 2019;33(10):1614-24.	Chikungunya/ n= 42 (39 women and 3 men)	Pilates: 12 weeks with 2 sessions/week, 50’’, light to moderate intensity	Clinical care	Pain Intensity: VAS	In the intragroup analysis, a significant improvement in pain intensity was observed after 24 Pilates sessions	Patients in the chronic phase of Chikungunya fever who participated in Pilates training have reduced pain, improved functional capacity and quality of life without the emergence of adverse effects
Patrício et al.²⁵25 Patrício NA, Vidal DG, Pinto EB, Sá KN, Baptista A F. Efectiveness of virtual reality games for falls, postural oscillations, pain and quality of life of individual HAM/TSP: a randomized, controlled, clinical trial. J Neurovirol. 2020;26(5):676-86.	HTLV-1/ n= 28 (9 men and 17 women)	GCT: Sensory-motor exercises applied through a virtual game coupled to Nintendo Wii® (20’’/ 2 times a week, totaling 10)	CTG: protocol started after 10 weeks	Pain Intensity: BPI	There were no differences between the groups	Virtual game training did not improve pain intensity
Neumann et al.⁴¹41 Neumann IL, de Oliveira DA, de Barros EL, da S Santos G, de Oliveira LS, Duarte AL, Marques CD, Dantas AT, Dantas D, de Siqueira GR, da Silva Tenório A. Resistance exercises improve physical function in chronic Chikungunya fever patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2021;57(4):620-9.	Chikungunya/ n= 31 (28 women and 3 men)	Progressive resistance exercises: 2 sets of 8 repetitions totaling eight exercises per session, 2 times/week, for 50’’	Phone call about symptoms and drug use	Pain Intensity: VAS	Significant decrease in pain intensity after the intervention (p: 0.01)	Pain intensity is significantly reduced for patients in the chronic stage of Chikungunya who have performed progressive resistance exercises for 12 weeks

	Summary of findings					Summary of findings
Nº of participants (studies)	Risk of bias	Inconsistency	Indirectness	Imprecision	Overall certainty of evidence	Summary of findings
Fatigue 2 RCT Aerobic exercise group: n= 34 Control group n = 43	Serious^a a Study evaluated at high risk of bias in a domain of Rob2.	Serious^b b Without statistic difference between groups	Not serious	Very serious^c c Small sample size	⊕◯◯◯ VERY LOW	There is very low quality of evidence that aerobic exercise is effective in controlling fatigue after viral infection.
Fatigue 2 RCT Resistance exercise group: n = 46 Control group n = 42	Serious^a a Study evaluated at high risk of bias in a domain of Rob2.	Serious^b b Without statistic difference between groups	Not serious	Very serious^c c Small sample size	⊕◯◯◯ VERY LOW	There is very low quality of evidence that resistance exercise is effective in controlling fatigue after viral infection.
Pain 1 RCT Aerobic exercise group: n = 12 Control group n = 15	Serious^a a Study evaluated at high risk of bias in a domain of Rob2.	Serious^b b Without statistic difference between groups	Not serious	Serious^c c Small sample size	⊕⊕◯◯ LOW	There is low quality of evidence the aerobic exercise is effective in controlling pain after viral infection.
Pain 4 RCT Resistance exercise group: n = 82 Control group n = 61	Not serious	Serious^b b Without statistic difference between groups	Not serious	Serious^c c Small sample size	⊕⊕⊕◯ MODERATE	There is moderate quality of evidence the resistance exercise is effective in controlling pain after viral infection.
Pain 1 RCT Aerobic + resistance exercise group: n = 89 Control group n = 47	Not serious	Serious^b b Without statistic difference between groups	Not serious	Serious^c c Small sample size	⊕⊕◯◯ LOW	There is low quality of evidence the aerobic and resistance exercise is effective in controlling pain after viral infection.
Pain 1 RCT Exercise of control group: n = 13 Control group n = 13	Not serious	Serious^b b Without statistic difference between groups	Not serious	Serious^c c Small sample size	⊕⊕◯◯ LOW	There is low-quality evidence that exercise control by the virtual reality method is effective in controlling pain after viral infection.

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[1] Correspondence to: Mônica Andrade Rios E-mail: monicandrader1@gmail.com