Advertisement

Moving Together While Staying Apart: Practical Recommendations for 24-Hour Home-Based Movement Behaviours for Those With Cardiovascular Disease

  • Carley D. O’Neill
    Affiliations
    Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
    Search for articles by this author
  • Sol Vidal-Almela
    Affiliations
    Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Institut du savoir Montfort, Hôpital Montfort, Ottawa, Ontario, Canada

    School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa Ontario, Canada
    Search for articles by this author
  • Tasuku Terada
    Affiliations
    Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
    Search for articles by this author
  • Kimberley L. Way
    Affiliations
    Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Institute for Physical Activity and Nutrition, Deakin University, Geelong, Victoria, Australia
    Search for articles by this author
  • Kentaro Kamiya
    Affiliations
    School of Allied Health Sciences, Kitasato University, Kanagawa, Japan
    Search for articles by this author
  • Billy Sperlich
    Affiliations
    Department of Sports Sciences, University of Wuerzburg, Wurzburg, Bavaria, Germany
    Search for articles by this author
  • Peter Duking
    Affiliations
    Department of Sports Sciences, University of Wuerzburg, Wurzburg, Bavaria, Germany
    Search for articles by this author
  • Jean-Phillipe Chaput
    Affiliations
    School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa Ontario, Canada

    School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

    Healthy Active Living and Obesity Research Group, CHEO Research Institute, Ottawa Ontario, Canada
    Search for articles by this author
  • Stephanie A. Prince
    Affiliations
    School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

    Centre for Surveillance and Applied Research, Public Health Agency of Canada, Ottawa Ontario, Canada
    Search for articles by this author
  • Andrew L. Pipe
    Affiliations
    Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
    Search for articles by this author
  • Jennifer L. Reed
    Correspondence
    Corresponding author: Dr Jennifer Reed, Exercise Physiology and Cardiovascular Health Lab, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada.
    Affiliations
    Exercise Physiology and Cardiovascular Health Lab, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

    School of Human Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa Ontario, Canada

    School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
    Search for articles by this author
Open AccessPublished:August 27, 2021DOI:https://doi.org/10.1016/j.cjco.2021.08.010

      Abstract

      The novel coronavirus disease 2019 is a global public health crisis that disproportionately affects those with preexisting conditions. Cardiovascular disease (CVD) is the leading cause of death worldwide and many key CVD risk factors are modifiable (e.g., physical inactivity, sedentary behaviour, obesity). To limit the spread of coronavirus 2019, most governments have implemented restrictions and recommended staying at home, reducing social contact to a select and exclusive few, and limiting large gatherings. Such public health constraints may have unintended, negative health consequences on 24-hour movement behaviours. The primary purpose of this review is to provide practical at-home recommendations for sedentary time, sleep, and physical activity in those living with CVD. Adults with CVD will benefit from practical recommendations to reduce sedentary time, increase purposeful exercise, and maintain optimal sleep patterns while being at home and adhering to public health restrictions. Our recommendations include the following: (i) self-monitoring sitting time; (ii) engaging in 2-3 days per week of purposeful exercise for those with low exercise capacity and > 3 days per week for those with moderate-to-high exercise capacity; (iii) self-monitoring exercise intensity through the use of scales or wearable devices; (iv) maintaining a regular sleep schedule; and (v) moving daily. Clinicians should be aware that clear communication of the importance of limiting prolonged sedentary time, engaging in regular physical activity and exercise, and ensuring optimal sleep in association with the provision of clear, comprehensible, and practical advice is fundamental to ensuring that those living with CVD respond optimally to the challenges posed by the pandemic.

      Résumé

      La nouvelle maladie à coronavirus 2019 représente une crise de santé publique mondiale qui touche de manière disproportionnée les personnes présentant des pathologies préexistantes. Les maladies cardiovasculaires (MCV) constituent la principale cause de décès dans le monde et de nombreux facteurs de risque majeurs de MCV sont modifiables (par exemple, le manque d'activité physique, un comportement sédentaire, l'obésité). Pour limiter la propagation du coronavirus 2019, la plupart des gouvernements ont mis en place des restrictions et recommandé de rester à la maison, de réduire les contacts sociaux à un nombre de personnes restreint et exclusif, et de limiter les grands rassemblements. Ces contraintes de santé publique peuvent involontairement entraîner des conséquences sanitaires négatives sur les habitudes de déplacement sur 24 heures. L'objectif principal de cette étude est de fournir des recommandations pratiques, réalisables à domicile, en rapport avec le temps de sédentarité, le sommeil et l'activité physique chez les personnes atteintes de MCV. Les adultes atteints de MCV tireront avantage de recommandations pratiques dans le but de réduire le temps de sédentarité, augmenter l'activité physique volontaire et maintenir des habitudes de sommeil optimales, tout en restant à la maison et en respectant les restrictions sanitaires. Nos recommandations sont les suivantes: (i) autosurveillance du temps passé assis; (ii) pratique d'une activité physique volontaire 2 à 3 jours par semaine pour les personnes ayant une faible capacité d'exercice et > 3 jours par semaine pour les personnes ayant une capacité d'exercice modérée à élevée; (iii) autosurveillance de l'intensité de l'activité par l'utilisation de barème ou de dispositifs portatifs; (iv) maintien d'horaires de sommeil réguliers; et (v) action de bouger quotidiennement. Les cliniciens doivent être conscients qu'une communication claire quant à l'importance de limiter le temps de sédentarité prolongée, de pratiquer régulièrement de l'exercice ou une activité physique, et d'assurer un sommeil optimal, associée à la préconisation de conseils clairs, compréhensibles et pratiques, est fondamentale pour garantir une réponse optimale de la part des personnes vivant avec des MCV quant aux défis posés par la pandémie.
      The novel coronavirus disease 2019 (COVID-19) is a highly contagious, viral respiratory illness that has afflicted ≥ 254 million people globally and resulted in ≥ 5.1 million deaths as of November 16, 2021.

      COVID-19 Coronavirus Pandemic. 2020. Available at: https://www.worldometers.info/coronavirus/. Accessed November 16, 2021.

      Adults with cardiovascular disease (CVD) have an increased risk of morbidity and premature mortality from COVID-19 (approximately 10% of those with preexisting CVD who contract COVID-19 will die).
      • Wang L.
      • He W.
      • Yu X.
      • et al.
      Coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up.
      ,
      • Liu H.
      • Gai S.
      • Wang X.
      • et al.
      Single-cell analysis of SARS-CoV-2 receptor ACE2 and spike protein priming expression of proteases in the human heart.
      To limit the spread of COVID-19, public health authorities have implemented mobility restrictions (eg, quarantine, self-isolation) and commercial closures, including many fitness facilities. The closure of in-person cardiac rehabilitation programs resulted in the transition to virtual program offerings
      • Moulson N.
      • Bewick D.
      • Selway T.
      • et al.
      Cardiac rehabilitation during the COVID-19 era: guidance on implementing virtual care.
      ; not all programs or patients, however, have access to the necessary resources (eg, funds, technology, Internet connection) to transition effectively. There is therefore a need to provide patients with the tools required to ensure healthy, 24-hour movement behaviours (ie, limit sedentary time, optimal, and regular physical activity; any movement carried out by the muscles that requires energy). Most governments had recommended staying home, reducing social contact, and limiting large gatherings, but subsequent surges of infections caused a return to earlier restrictions. Such public health constraints may have unintended negative health consequences as 24-hour movement behaviours were altered globally, with increased sedentary time,
      • Hall G.
      • Laddu D.R.
      • Phillips S.A.
      • Lavie C.J.
      • Arena R.
      A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.
      reduced physical activity and purposeful exercise,
      • Hall G.
      • Laddu D.R.
      • Phillips S.A.
      • Lavie C.J.
      • Arena R.
      A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.
      ,
      • Lippi G.
      • Henry B.M.
      • Sanchis-Gomar F.
      Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (COVID-19).
      and unhealthy (eg, too much or too little) sleeping patterns.
      • Cellini N.
      • Canale N.
      • Mioni G.
      • et al.
      Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy.
      These changes pose significant risk to the health of individuals and can contribute to declines in physical and mental health during the pandemic.
      • Meyer J.
      • McDowell C.
      • Lansing J.
      • et al.
      Changes in physical activity and sedentary behaviour due to the COVID-19 outbreak and associations with mental health in 3052 US adults.
      COVID-19 public health restrictions have increased sedentary behaviour.
      • Hall G.
      • Laddu D.R.
      • Phillips S.A.
      • Lavie C.J.
      • Arena R.
      A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.
      ,
      • Colley R.C.
      • Bushnik T.
      • Langlois K.
      Exercise and screen time during the COVID-19 pandemic.
      Strong evidence supports a positive relationship between greater sedentary behaviour and type 2 diabetes, metabolic syndrome,
      • Edwardson C.L.
      • Gorely T.
      • Davies M.J.
      • et al.
      Association of sedentary behaviour with metabolic syndrome: a meta-analysis.
      heightened levels of anxiety
      • Teychenne M.
      • Costigan S.A.
      • Parker K.
      The association between sedentary behaviour and risk of anxiety: a systematic review.
      and depression,
      • Teychenne M.
      • Ball K.
      • Salmon J.
      Sedentary behavior and depression among adults: a review.
      and all-cause mortality.
      • Patterson R.
      • McNamara E.
      • Tainio M.
      • et al.
      Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis.
      Amid the COVID-19 pandemic, sedentary time has increased substantially, and low-intensity physical activity and step counts have declined significantly.
      • Faulkner G.
      • Rhodes R.E.
      • Vanderloo L.M.
      • et al.
      Physical activity as a coping strategy for mental health due to the COVID-19 virus: a potential disconnect among Canadian adults?.
      These findings are of particular significance for those living with CVD, as pre-pandemic sedentary time was already shown to be higher among these individuals.
      • Evenson K.R.
      • Butler E.N.
      • Rosamond W.D.
      Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States.
      Recommendations for replacing sedentary time with physical activity while adhering to pandemic public health recommendations are warranted to help reduce the burden of CVD.
      • Ekelund U.
      • Tarp J.
      • Steene-Johannessen J.
      • et al.
      Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis.
      Regular aerobic and resistance exercise (ie, planned, structured, intentional movement with the aim of maintaining or improving physical fitness and health) are associated with numerous physical (eg, lower blood pressure, higher cardiorespiratory fitness, enhanced sleep quality) and mental (eg, lower levels of anxiety and depression) health benefits among adults with CVD.
      • Warburton D.E.R.
      • Bredin S.S.D.
      Health benefits of physical activity: a systematic review of current systematic reviews.
      ,
      • Dibben G.O.
      • Dalal H.M.
      • Taylor R.S.
      • et al.
      Cardiac rehabilitation and physical activity: systematic review and meta-analysis.
      Moderate-intensity aerobic exercise is associated with a reduction in respiratory infection rates, respiratory symptom burden, and mortality,
      • Lee H.K.
      • Hwang I.H.
      • Kim S.Y.
      • et al.
      The effect of exercise on prevention of the common cold: a meta-analysis of randomized controlled trial studies.
      • Nieman D.C.
      • Henson D.A.
      • Austin M.D.
      • et al.
      Upper respiratory tract infection is reduced in physically fit and active adults.
      • Brawner C.A.
      • Ehrman J.K.
      • Bole S.
      • et al.
      Maximal exercise capacity is inversely related to hospitalization secondary to coronavirus disease 2019.
      underscoring the importance of maintaining an active lifestyle during the COVID-19 pandemic. Those infected with COVID-19 who are consistently inactive have been shown to be at an increased risk of hospitalization, admission to an intensive-care unit, and death as a result of the virus, in comparison to counterparts who participated in some physical activity and those who met the physical activity guidelines (≥ 150 minutes of moderate–vigorous physical activity per week).
      • Sallis R.
      • Young D.R.
      • Tartof S.Y.
      • et al.
      Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients.
      Aerobic and resistance-training exercise have additional benefits that aid in reducing the severity and burden of CVD, including improved cardiorespiratory and functional fitness and mental health, minimized age-related decline in muscle mass, reduced risk of experiencing a second cardiac event, and reduced mortality.
      • Anderson L.
      • Taylor R.S.
      Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews.
      ,
      • Yohannes A.M.
      • Doherty P.
      • Bundy C.
      • et al.
      The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life.
      Access to exercise facilities has been limited during the pandemic, and those with preexisting health conditions are urged to take additional precautions by reducing time outside the home. These restrictions have led to a marked increase in web searches for community and “at-home” exercise guidance,
      • Ding D.
      • del Pozo Cruz B.
      • Green M.A.
      • Bauman A.E.
      Is the COVID-19 lockdown nudging people to be more active: a big data analysis.
      underscoring the need for accessible, informative, and “pandemic-relevant” exercise recommendations.
      Several authors have reinforced the importance of regular physical activity/exercise during the pandemic.
      • Hall G.
      • Laddu D.R.
      • Phillips S.A.
      • Lavie C.J.
      • Arena R.
      A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.
      ,
      • Lippi G.
      • Henry B.M.
      • Sanchis-Gomar F.
      Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (COVID-19).
      ,
      • King A.J.
      • Burke L.M.
      • Halson S.L.
      • et al.
      The challenge of maintaining metabolic health during a global pandemic.
      They do not, however, provide practical recommendations as to how individuals living with CVD can engage in exercise and improve their 24-hour movement behaviours. Adults living with CVD will benefit from the application of 24-hour movement behaviour and exercise recommendations given that they are more: (i) susceptible to experiencing complications of CVD
      • Krittanawong C.
      • Virk H.U.H.
      • Narasimhan B.
      • et al.
      Coronavirus disease 2019 (COVID-19) and cardiovascular risk: a meta-analysis.
      ; (ii) likely to be confined at home; and (iii) vulnerable to the detrimental effects of inactivity, sedentariness, and sleep disturbances on cardiovascular health.
      • Morin C.M.
      • Carrier J.
      • Bastien C.
      • et al.
      Sleep and circadian rhythm in response to the COVID-19 pandemic.
      Healthy sleep (broadly defined as sleep of adequate duration, quality, and timing) plays a fundamental role in physical and mental health.
      • Chaput J.-P.
      • Dutil C.
      • Featherstone R.
      • et al.
      Sleep duration and health in adults: an overview of systematic reviews.
      Insufficient sleep (< 7 hours per night) is a global public health concern and is associated with CVD.
      • St-Onge M.-P.
      • Grandner M.A.
      • Brown D.
      • et al.
      Sleep duration and quality: impact on lifestyle behaviors and cardiometabolic health: a scientific statement from the American Heart Association.
      A U-shaped relationship exists between sleep duration and CVD morbidity and mortality
      • Kuehn B.M.
      Sleep duration linked to cardiovascular disease.
      — too little or too much sleep has an impact on CVD.
      • Kuehn B.M.
      Sleep duration linked to cardiovascular disease.
      The incidence of reported sleep disturbances has markedly increased during the COVID-19 pandemic.
      • Morin C.M.
      • Carrier J.
      • Bastien C.
      • et al.
      Sleep and circadian rhythm in response to the COVID-19 pandemic.
      Stress, anxiety, changes in daily routines, and reduced daylight exposure are key disruptors of sleep and circadian rhythms, and these have been more prominent during the pandemic.
      • Morin C.M.
      • Carrier J.
      • Bastien C.
      • et al.
      Sleep and circadian rhythm in response to the COVID-19 pandemic.
      Conversely, some people have reported improved sleep amid the pandemic, owing to reduced rigidity in work/school schedules.
      • Advani I.
      • Gunge D.
      • Banks S.
      • et al.
      Is increased sleep responsible for reductions in myocardial infarction during the COVID-19 pandemic?.
      There is a need to adapt daily regimens during the COVID-19 pandemic to ensure that adults living with CVD can achieve optimal 24-hour movement and exercise profiles while following public health restrictions for COVID-19. The primary purpose of this paper is to provide healthcare professionals and patients with a comprehensive resource with practical recommendations for achieving, maintaining, and monitoring healthy 24-hour movement behaviours for adults living with stable CVD during a pandemic. Educational resources have also been provided for physicians, physiotherapists, kinesiologists, and exercise physiologists/scientists to share widely with their patients. Figure 1 illustrates the interconnectedness of the 24-hour movement behaviours amid the pandemic.
      Figure thumbnail gr1
      Figure 1The interconnectedness of the 24-hour movement behaviours and exercise amid the pandemic is shown. PA, physical activity; RPE, Borg Rating of Perceived Exertion.

      24-Hour Movement Behaviour Recommendations

      Table 1 provides a summary of the 24-hour movement behaviour recommendations discussed within this review. At a minimum, any movement is better than no movement, prolonged bouts of sedentary behaviour should be reduced, and regular light-intensity movement should be encouraged.
      Table 124-hour movement behaviour recommendations
      Sedentary behaviourPhysical activitySleep
      Recommendations≤ 8 h/d, including ≤ 3 h recreational screen time
      • Breaking up long periods of sitting as often as possible
      150 min moderate-to-vigorous physical activity per week
      • Muscle- strengthening activities using major muscle groups at least twice a week
      • Several hours of light physical activities, including standing
      7-9 h optimal sleep per night, with consistent bed and wake-up times

      Sedentary Behaviour

      Greater mortality risks have been associated with > 9-10 hours of device-assessed sedentary time,
      • Ekelund U.
      • Tarp J.
      • Steene-Johannessen J.
      • et al.
      Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis.
      > 7-8 hours of self-reported sitting time,
      • Patterson R.
      • McNamara E.
      • Tainio M.
      • et al.
      Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis.
      and > 3 h/d of television viewing.
      • Grøntved A.
      • Hu F.B.
      Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis.
      The risks are comparable among those living with CVD.
      • Koster A.
      • Caserotti P.
      • Patel K.V.
      • et al.
      Association of sedentary time with mortality independent of moderate to vigorous physical activity.
      ,
      • Bakker E.A.
      • van Bakel B.M.A.
      • Aengevaeren W.R.M.
      • et al.
      Sedentary behaviour in cardiovascular disease patients: risk group identification and the impact of cardiac rehabilitation.
      There is evidence that moderate-to-vigorous–intensity physical activity (MVPA) may reduce or negate the effects associated with prolonged television viewing and total sitting time (30-40 to 60-75 min/d).
      • Ekelund U.
      • Tarp J.
      • Fagerland M.W.
      • et al.
      Joint associations of accelerometer-measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44,000 middle-aged and older individuals.
      This finding is troubling given that, globally, very few adults (27.5%) currently meet such physical activity guidelines.
      • Guthold R.
      • Stevens G.A.
      • Riley L.M.
      • et al.
      Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants.
      Important to note is evidence showing that the total volume of sedentary time is not solely responsible for placing individuals at greater risk for poor health outcomes; the pattern in which this time is accrued also plays a role.
      • Owen N.
      • Healy G.N.
      • Matthews C.E.
      • et al.
      Too much sitting: the population health science of sedentary behavior.
      Individuals who frequently break up their sedentary time (ie, accrue sedentary time in bouts < 30 minutes) have a lower risk of mortality, compared to those who spend more time in longer sedentary bouts.
      Patterns of sedentary behavior and mortality in U.S. middle-aged and older adults.
      Experimental studies have also found that breaking up sitting time with standing and movement can result in favourable metabolic changes and improve cardiovascular risk factors (eg, reduced weight, waist circumference, and blood pressure).
      • Kallings L.V.
      • Sierra Johnson J.
      • Fisher R.M.
      • et al.
      Beneficial effects of individualized physical activity on prescription on body composition and cardiometabolic risk factors: results from a randomized controlled trial.
      ,
      • Dunstan D.W.
      • Thorp A.A.
      • Healy G.N.
      Prolonged sitting: Is it a distinct coronary heart disease risk factor?.
      The public health response to the COVID-19 pandemic (eg, social distancing, closing of many recreational and occupational venues) has resulted in an increase in sedentariness (eg, screen usage/watching).
      • Hall G.
      • Laddu D.R.
      • Phillips S.A.
      • Lavie C.J.
      • Arena R.
      A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.
      In Canada, survey data revealed that during the pandemic’s first wave, most adults reported spending more time on the Internet (68%), watching television (63%), and playing video games (22%).
      • Colley R.C.
      • Bushnik T.
      • Langlois K.
      Exercise and screen time during the COVID-19 pandemic.
      Maintaining and decreasing screen time related to television and video game usage were associated with superior self-rated physical and mental health.
      • Colley R.C.
      • Bushnik T.
      • Langlois K.
      Exercise and screen time during the COVID-19 pandemic.
      Global movement data collected using smartphone technology identified that daily step counts decreased sharply during the first 10 days of the pandemic declaration; these reductions were sustained over a 30-day period.
      • Tison G.H.
      • Avram R.
      • Kuhar P.
      • et al.
      Worldwide effect of COVID-19 on physical activity: a descriptive study.
      The declines varied regionally, with more dramatic reductions among countries with stricter social-distancing protocols.
      • Tison G.H.
      • Avram R.
      • Kuhar P.
      • et al.
      Worldwide effect of COVID-19 on physical activity: a descriptive study.
      Steps are highly correlated with sedentary behaviour, as they reflect ambulatory and sporadic daily movement.
      • Tudor-Locke C.
      • Craig C.L.
      • Thyfault J.P.
      • Spence J.C.
      A step-defined sedentary lifestyle index: < 5000 steps/day.
      During the COVID-19 pandemic, the World Health Organization (WHO) released a guidance document addressing physical activity and sedentary behaviour during self-quarantine for those without symptoms or diagnosis of acute respiratory illness.

      World Health Organization. WHO Guidelines on Physical Activity and Sedentary Behaviour. 2020. Available at: https://www.who.int/publications/i/item/9789240015128. Accessed August 10, 2021.

      The tips provided for remaining active and reducing sedentary behaviour include the following: (i) take short active breaks during the day; (ii) follow an online exercise class; (iii) walk, even in small spaces; (iv) stand up, to reduce sedentary time, and consider creating a standing desk; and (v) relax using meditation and deep breathing. These recommendations are consistent with the recent release from the Canadian Society for Exercise Physiology, including a new 24-hour movement guideline for adults (18-64 years and 65+ years).

      Canadian Society for Exercise Physiology. 24-hour movement guideline for adults (18-64 years and 65+ years). Available at: https://csepguidelines.ca/guidelines/adults-18-64/. Accessed August 10, 2021.

      Our additional practical tips for reducing sedentary behaviour during the COVID-19 pandemic among those with CVD include the following: (i) self-monitor movement behaviours by using a wearable device or recording the time you spend sitting; being aware of how much you sit and when you sit for long periods (eg, working at a computer, watching television) is important, to understand where you can make changes; (ii) set up the home environment to encourage movement (eg, move your wastebasket away from your home office, leave the remote controls across the room); (iii) drink water regularly—this promotes frequent trips to the bathroom; (iv) set up external cues/idle alerts through the use of wearables, smart phone apps, or activity alarms to prompt you to stand every 20-30 minutes; (v) create habit reminders by standing or moving during routine habits (eg, choose to stand when having a drink, lap your home every time you use the washroom, or take phone calls standing); and (vi) engage in no more than 8 hours of sedentary time per day, including no more than 3 hours of recreational screen time. A review of techniques for reducing sedentary behaviour found that self-monitoring, problem solving, and restructuring the social or physical environment were the most promising techniques.
      • Gardner B.
      • Smith L.
      • Lorencatto F.
      • et al.
      How to reduce sitting time? A review of behaviour change strategies used in sedentary behaviour reduction interventions among adults.
      Use of wearable devices and prompts and cues to get up and move can help promote reductions in time spent being sedentary in adults and among patients with CVD.
      • Prince S.A.
      • Reed J.L.
      • Cotie L.M.
      • et al.
      Results of the sedentary intervention trial in cardiac rehabilitation (SIT-CR Study): a pilot randomized controlled trial.
      Establishing sedentary-behaviour breaks during routine events will help form habits more easily.
      • Rosenberg D.E.
      • Lee A.K.
      • Anderson M.
      • et al.
      Reducing sedentary time for obese older adults: protocol for a randomized controlled trial.
      Evidence supports the interruption of sedentary bouts every 20-30 minutes, with 2 minutes or more of light-intensity physical activity.
      • Dunstan D.W.
      • Kingwell B.A.
      • Larsen R.
      • et al.
      Breaking up prolonged sitting reduces postprandial glucose and insulin responses.

      Exercise

      Aerobic exercise

      Pre-exercise considerations

      Medical condition(s), risk factors, medications, and previous exercise history should be considered prior to providing exercise advice. National risk screening tools are readily available (eg, Canadian Society for Exercise Physiology, Get Active Questionnaire

      Canadian Society for Exercise Physiology, Get Active Questionnaire. Available at: https://csep.ca/wp-content/uploads/2021/05/GETACTIVEQUESTIONNAIRE_ENG.pdf. Accessed August 10, 2021.

      ; American College of Sports Medicine, Exercise Preparticipation Health Screening

      American College of Sports Medicine, Exercise Preparticipation Health Screening. Available at: https://www.acsm.org/blog-detail/acsm-certified-blog/2018/02/01/exercise-preparticipation-screening-removing-barriers-initiating-exercise. Accessed August 10, 2021.

      ) to ensure patients are cleared for exercise participation. It must be recognized, however, that the majority of patients can safely increase their normal levels of physical activity, and a little is much better than none! These tools can be completed virtually, or in-person via interaction between the healthcare provider and patient. It must be acknowledged that, during a pandemic, the introduction of exercise testing schema should reflect a practical, straightforward approach appropriate for the challenge of helping the sedentary become more active and supporting the development of increasing levels of regular physical activity for all.

      Safety

      Adults living with stable CVD are considered to be at moderate-to-high risk from exercise participation, according to the American College of Sports Medicine.
      • Riebe D.
      • Franklin B.A.
      • Thompson P.D.
      • et al.
      Updating ACSM's Recommendations for Exercise Preparticipation Health Screening.
      Walking at a comfortable, self-limited pace, however, is safe for CVD patients. Prior to prescribing exercise, individuals should be made aware of symptoms that could occur during exercise and how to address them. Table 2 provides a summary of potential symptoms and how they can be managed during exercise at home, for those with stable CVD.
      Table 2Symptoms to self-monitor during exercise
      • Riebe D.
      • Franklin B.A.
      • Thompson P.D.
      • et al.
      Updating ACSM's Recommendations for Exercise Preparticipation Health Screening.
      SymptomsRecommendation
      Dizziness or lightheadednessReduce intensity; hydrate with water or a sports drink; sit or lie down
      Excessive shortness of breathReduce intensity; remain calm
      NauseaReduce intensity; cool down
      Chest painReduce intensity; remain calm; call or have a family member/friend call 911

      Principles of exercise prescription: frequency, intensity, time, type

      Exercise prescription is composed of 4 principles: (i) frequency (number of sessions per week); (ii) intensity (exertion during exercise); (iii) time (duration of session); and (iv) type (mode of exercise) (FITT). For exercise to be safe and effective in improving physical and mental health, appropriate guidance incorporating all 4 principles is of paramount importance.
      The current Canadian Association of Cardiovascular Prevention and Rehabilitation clinical guidelines recommend that patients with CVD engage in 20-60–minute exercise sessions at an intensity ranging from 40% to 85% heart rate (HR) reserve (HRR), 3-5 days per week.
      • Stone J.A.
      Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention are available.
      These recommendations may seem arbitrary or complicated for patients aiming to exercise without supervision and lacking knowledge of how to monitor their physical activity behaviours. Consequently, specific, comprehensive, and practical recommendations for each exercise prescription principle are summarized below.

      Frequency

      Frequency refers to the number of days per week a person engages in exercise. Age, exercise capacity, and cardiovascular risk factors (eg, hypertension, diabetes, overweight/obesity, lipid profile, and mental health status) are important considerations prior to recommending or prescribing exercise frequency; most guidelines emphasize simply moving toward increased physical activity most days of the week or more.

      Exercise capacity considerations

      Low exercise capacity at baseline: patients who have a low level of fitness (< 5 metabolic equivalents [METS]) should begin exercising 2 days per week and increase to 3 days per week as fitness improves. Individuals who present with low exercise capacity may experience improvements and better adherence with < 3 sessions per week; however, higher frequencies are likely to elicit greater improvements.
      • Ismail H.
      • McFarlane J.R.
      • Dieberg G.
      • et al.
      Exercise training program characteristics and magnitude of change in functional capacity of heart failure patients.
      ,
      • Nieuwland W.
      • Berkhuysen M.A.
      • van Veldhuisen D.J.
      • et al.
      Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.
      Moderate or high exercise capacity at baseline: Adults who have moderate-to-high levels of fitness (> 5 METS) should exercise at least 3 days per week and gradually increase to 5 days per week as fitness improves; the greatest exercise capacity improvements will occur with higher frequency of sessions.
      • Nieuwland W.
      • Berkhuysen M.A.
      • van Veldhuisen D.J.
      • et al.
      Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.

      Considerations for patient’s age

      Higher exercise frequency reduces the risk of CVD among older adults (aged > 60 years)
      • Kim K.
      • Choi S.
      • Hwang S.E.
      • et al.
      Changes in exercise frequency and cardiovascular outcomes in older adults.
      and improves exercise capacity regardless of age; yet, some age-related considerations pertaining to exercise frequency have been suggested. Younger patients (aged < 50 years) tend to have greater increases in fitness with a higher frequency of weekly aerobic exercise; older individuals (aged > 50 years) may still achieve improvements in exercise capacity with a low frequency of sessions.
      • Nieuwland W.
      • Berkhuysen M.A.
      • van Veldhuisen D.J.
      • et al.
      Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.

      Additional considerations

      A single bout of exercise elicits acute benefits, including a reduction in post-exercise blood pressure
      • Carpio-Rivera E.
      • Moncada-Jiménez J.
      • Salazar-Rojas W.
      • et al.
      Acute effects of exercise on blood pressure: a meta-analytic investigation.
      and blood glucose,
      • Terada T.
      • Friesen A.
      • Chahal B.S.
      • et al.
      Exploring the variability in acute glycemic responses to exercise in type 2 diabetes.
      and enhanced mood.
      • Basso J.C.
      • Suzuki W.A.
      The effects of acute exercise on mood, cognition, neurophysiology, and neurochemical pathways: a review.
      These acute changes experienced regularly can substantially improve the CVD risk-factor profile. For example, MVPA performed 3-5 times per week lowers blood pressure by an average of 3.4/2.4 mm Hg.
      • Fagard R.H.
      Exercise characteristics and the blood pressure response to dynamic physical training.
      Less-frequent (2-3 days per week) sessions of longer duration (see time recommendations below) are successful for improving fitness levels; sustained, increased exercise frequency produces additional health benefits (eg, improved lipid profile,
      • Mann S.
      • Beedie C.
      • Jimenez A.
      Differential effects of aerobic exercise, resistance training and combined exercise modalities on cholesterol and the lipid profile: review, synthesis and recommendations.
      glucose control,
      • Umpierre D.
      • Ribeiro P.A.
      • Schaan B.D.
      • et al.
      Volume of supervised exercise training impacts glycaemic control in patients with type 2 diabetes: a systematic review with meta-regression analysis.
      quality of life,
      • Berkhuysen M.A.
      • Nieuwland W.
      • Buunk B.P.
      • et al.
      Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life.
      and reduced levels of anxiety and depression).
      • Broman-Fulks J.J.
      • Abraham C.M.
      • Thomas K.
      • et al.
      Anxiety sensitivity mediates the relationship between exercise frequency and anxiety and depression symptomology.
      Patients with time constraints, or those who prefer shorter exercise sessions, will benefit from a higher frequency of short-duration activity.
      • Nieuwland W.
      • Berkhuysen M.A.
      • van Veldhuisen D.J.
      • et al.
      Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.
      Increasing the frequency of exercise sessions or incidental physical activity during the week can improve fitness levels.

      Intensity

      Intensity refers to the physical effort required for a given exercise bout. Current recommendations suggest engaging in physical activity within the moderate-to-vigorous range.
      • Stone J.A.
      Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention are available.
      Yet, sedentary patients can gain considerable health benefits from being active at lower levels of intensity on a regular basis. Thus, low-intensity physical activity is the preferred recommendation for patients who are unscreened for engaging in exercise participation in an unsupervised setting. For patients with CVD who have been encouraged by their clinician to participate in exercise, low-to-moderate–intensity physical activity is safe to recommend. Those patients interested in progressing to higher-intensity exercise should do so only after proper screening by a clinician. For those patients eager to progress from moderate- to high intensity exercise, consultation with their clinician and an exercise stress test to ensure safety, if recommended and available, should precede the progression. Important to recognize, however, is that cardiovascular health can be significantly and very safely enhanced by walking regularly at a comfortable pace.
      Several methods can be used to monitor unsupervised exercise intensity.
      • Hansen D.
      • Abreu A.
      • Ambrosetti M.
      • et al.
      Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology.
      Valid and reliable scales such as the Borg Rating of Perceived Exertion (RPE),
      • Stamford B.A.
      Validity and reliability of subjective ratings of perceived exertion during work.
      monitoring of heart rate (HR), the talk test,
      • Reed J.L.
      • Pipe A.L.
      The talk test: a useful tool for prescribing and monitoring exercise intensity.
      and wearable technologies can all be used with minimal equipment or expertise. Table 3 summarizes recommended methods for prescribing and monitoring low- and moderate-intensity exercise.
      Table 3Prescribing and monitoring exercise intensity among patients with stable cardiovascular disease in an unsupervised setting
      ToolExercise intensity level
      LowModerateVigorous
      Borg Rating of Perceived Exertion9–1112–1314–17
      Gellish equation, % heart rate peak< 57–6364–7576–95
      Talk testAble to singUnable to sing but can maintain conversationConversation is not possible

      RPE scale

      Prescribing and monitoring exercise intensity using the RPE scale is a simple and inexpensive option for patients. The Borg RPE scale is a 14-point Likert scale ranging from 6 (no exertion at all) to 20 (maximal exertion).
      • Borg G.A.
      Psychophysical bases of perceived exertion.
      RPE during exercise highly correlates with objective relative indices of exercise intensity (% maximum oxygen uptake, % maximum HR) in women and men, regardless of training status.
      • Faulkner J.
      • Eston R.
      Overall and peripheral ratings of perceived exertion during a graded exercise test to volitional exhaustion in individuals of high and low fitness.
      RPE may be particularly useful for patients with CVD taking HR blunting medications (ie, beta-blockers),
      • Faulkner J.
      • Eston R.
      Overall and peripheral ratings of perceived exertion during a graded exercise test to volitional exhaustion in individuals of high and low fitness.
      as they limit the ability to use other methods to monitor exercise intensity, such as HR equations.

      Talk test

      The talk test is an easy-to-use, inexpensive, and valid tool to monitor exercise intensity among patients with CVD.
      • Reed J.L.
      • Pipe A.L.
      The talk test: a useful tool for prescribing and monitoring exercise intensity.
      ,
      • Petersen A.K.
      • Maribo T.
      • Hjortdal V.E.
      • et al.
      Intertester reliability of the talk test in a cardiac rehabilitation population.
      • Zanettini R.
      • Centeleghe P.
      • Franzelli C.
      • et al.
      Validity of the talk test for exercise prescription after myocardial revascularization.
      • Voelker S.
      • Foster C.
      • Porcari J.
      • et al.
      Relationship between the talk test and ventilatory threshold in cardiac patients.
      The talk test can be used when exercising at home with a partner, by self-determining whether comfortable speech is possible, difficult, or not possible, corresponding to light-, moderate-, and high intensity, respectively. During at-home exercise without a partner, the talk test can be implemented by self-reflecting or actively determining whether comfortable speech is possible. When prescribing intensity using the talk test, those with CVD should be encouraged to exercise at a moderate intensity (ie, maintaining conversation is possible). The talk test has particular applicability during a pandemic. Advice regarding the use of this “instrument” can be provided simply; it requires little instruction and does not rely on calculations of HR or estimations of exertion (which can be perplexing and troublesome for many patients).

      Heart rate equations

      Exercise intensity is frequently prescribed and monitored using HR or oxygen uptake (V̇O2) values. This measure is based on the observed direct and proportional increase in HR and V̇O2 during dynamic, aerobic exercise in women

      COVID-19 Coronavirus Pandemic. 2020. Available at: https://www.worldometers.info/coronavirus/. Accessed November 16, 2021.

      and men.
      • Wang L.
      • He W.
      • Yu X.
      • et al.
      Coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up.
      This approach may lead to an under- or over-prescription of exercise intensity in patients taking medications (eg, β-blockers) that blunt HR responses, or when the exercise session leads to a disproportionate increase in HR (eg, aerobic dance exercise, high intensity exercise).
      • Liu H.
      • Gai S.
      • Wang X.
      • et al.
      Single-cell analysis of SARS-CoV-2 receptor ACE2 and spike protein priming expression of proteases in the human heart.
      Table 4 highlights our recommended HR equation for patients with CVD and provides additional equations that may be used to predict HR during exercise.
      Table 4Heart rate prediction equations for monitoring exercise intensity
      EquationPopulation/method used to develop equationNumber of men/women in studyStrengthsLimitations
      Our recommended equation
      Gellish et al.
      • Gellish R.L.
      • Goslin B.R.
      • Olson R.E.
      • et al.
      Longitudinal modeling of the relationship between age and maximal heart rate.
      (207 − 0.7 × age)
      Middle-aged participants with a good level of fitness (n = 132)100/32No sex differencesNot validated among patients with CVD
      Additional heart rate prediction equations for monitoring exercise intensity
      Fox et al.
      • Fox 3rd, S.M.
      • Haskell W.L.
      Physical activity and the prevention of coronary heart disease.
      (220 – age)
      Men, age < 65 yearsMen onlyEasy to useOverestimates heart rate peak among older adults age ± 40 years
      • Tanaka H.
      • Monahan K.D.
      • Seals D.R.
      Age-predicted maximal heart rate revisited.
      ,
      • Gulati M.
      • Shaw L.J.
      • Thisted R.A.
      • et al.
      Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project.
      Tanaka et al.
      • Tanaka H.
      • Monahan K.D.
      • Seals D.R.
      Age-predicted maximal heart rate revisited.
      (208 − 0.7 × age)
      Meta-analysis (n = 18,712 healthy adults) along with a prospective study (514 healthy adults)Not reportedCan predict heart rate peak among older adults regardless of sex
      • Tanaka H.
      • Monahan K.D.
      • Seals D.R.
      Age-predicted maximal heart rate revisited.
      Not validated among patients with CVD
      Karvonen et al.
      • Karvonen J.
      • Vuorimaa T.
      Heart rate and exercise intensity during sports activities. Practical application.


      (220 – age – resting heart rate)
      Males, age 20 to 23 years (n = 6)6/0Helped establish exercise training intensities:

      Light = 30%–40% HRR

      Moderate = 40%–60% HRR

      Vigorous = 60%–90% HRR
      Can over- or underestimate exercise intensity in certain patients
      CVD, cardiovascular disease; HRR, heart rate reserve.

      Wearable technologies

      Wearables are available in a variety of modes (eg, smartwatches, smart patches, smart phones). These technologies provide an easy-to-use method of monitoring and receiving feedback on numerous physical activity parameters including HR, heart rhythm, walking/running distance, walking/running speed, and steps taken.
      • Düking P.
      • Holmberg H.C.
      • Sperlich B.
      Instant biofeedback provided by wearable sensor technology can help to optimize exercise and prevent injury and overuse.
      ,
      • Hosseinpour M.
      • Terlutter R.
      Your personal motivator is with you: a systematic review of mobile phone applications aiming at increasing physical activity.
      The reliability, validity, cost-effectiveness, and features of these technologies vary; thus, interpretation of the results produced by such devices, especially HR, should be performed cautiously.
      • Duking P.
      • Giessing L.
      • Frenkel M.O.
      • et al.
      Wrist-worn wearables for monitoring heart rate and energy expenditure while sitting or performing light-to-vigorous physical activity: validation study.
      ,
      • Düking P.
      • Hotho A.
      • Holmberg H.C.
      • et al.
      Comparison of non-invasive individual monitoring of the training and health of athletes with commercially available wearable technologies.
      During a period when many challenges exist, not the least of which may be financial, the cost of such technologies may be a barrier to their use.

      Time

      Time refers to minutes spent engaging in exercise per session and/or throughout 1 week. Exercise guidelines recommend at least 150 minutes of MVPA per week, which aligns with 5,400-7,900 steps per day.
      American College of Sports Medicine
      Emerging evidence has demonstrated that any level of activity is superior to being sedentary, and that frequent, short-duration sessions of high intensity may effectively and efficiently enhance health.
      • Ekelund U.
      • Tarp J.
      • Steene-Johannessen J.
      • et al.
      Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis.
      ,
      • Piercy K.L.
      • Troiano R.P.
      • Ballard R.M.
      • et al.
      The physical activity guidelines for Americans.
      ,
      • Dempsey P.C.
      • Strain T.
      • Khaw K.-T.
      • et al.
      Prospective associations of accelerometer-measured physical activity and sedentary time with incident cardiovascular disease, cancer, and all-cause mortality.
      A higher total volume of MVPA is associated with many health benefits, including improvements in anxiety, depression, quality of life, cardiorespiratory fitness, blood pressure, and blood lipid levels.
      • Terada T.
      • Friesen A.
      • Chahal B.S.
      • et al.
      Exploring the variability in acute glycemic responses to exercise in type 2 diabetes.
      Shorter bouts of exercise (eg, < 10 minutes) may initially be more feasible for those who are less fit, can elicit the aforementioned improvements in mental and physical health, and contribute to increasing the total volume of exercise.
      • Piercy K.L.
      • Troiano R.P.
      • Ballard R.M.
      • et al.
      The physical activity guidelines for Americans.
      Short bouts of exercise throughout the day can also promote the interruption of prolonged sitting. Interval training is a time-efficient mode of structured exercise comprised of short bouts of increased-intensity activity followed by intermittent recovery periods. Intervals can vary in length (eg, 1 minute at an increased intensity, 2 minutes of active recovery; 1 minute at an increased intensity, 4 minutes of active recovery). Important to note is that exercise sessions of varying lengths (eg, long moderate-intensity continuous exercise, long/short high intensity interval training) have been shown to elicit similar physiological responses
      • von Korn P.
      • Keating S.
      • Mueller S.
      • et al.
      The effect of exercise intensity and volume on metabolic phenotype in patients with metabolic syndrome: a randomized controlled trial.
      ; therefore, patient preferences merit careful consideration.

      Type

      Prescribing the type of exercise for those living with CVD should be, whenever possible, a collaborative process between the clinician and patient. Exercise enjoyment is a strong predictor of exercise participation, and greater exercise enjoyment is associated with more-frequent MVPA.
      • Lewis B.A.
      • Williams D.M.
      • Frayeh A.
      • et al.
      Self-efficacy versus perceived enjoyment as predictors of physical activity behaviour.
      “Fun” and “feasibility” are important determinants of sustained patterns of physical activity, so clinicians must be particularly aware of the dangers of “medicalizing” physical activity and provide physical activity guidance that is realistic, comprehensible, and in keeping with the circumstances and preferences of their patients. During the pandemic, creativity may be required to ensure appropriate and enjoyable physical activity (eg, virtual activity sessions with a friend, or time-limited challenges such as holding a wall-sit for the duration of 2 television commercials). Listening to music and watching television can be done during exercise at home and have been associated with superior mood and greater exercise enjoyment.
      • Murrock C.J.
      The effects of music on the rate of perceived exertion and general mood among coronary artery bypass graft patients enrolled in cardiac rehabilitation phase II.
      ,
      • Rider B.C.
      • Bassett D.R.
      • Strohacker K.
      • et al.
      Psycho-physiological effects of television viewing during exercise.
      During the COVID-19 pandemic, various exercise classes and cardiac rehabilitation programs have transitioned to online platforms. Virtual exercise classes (eg, those offered through cardiac rehabilitation programs, such as the University of Ottawa Heart Institute Heart Wise Exercise,
      • Reed J.L.
      • Harris J.M.
      • Midence L.
      • et al.
      Evaluating the Heart Wise Exercise program: a model for safe community exercise programming.
      community programs, or local fitness centres) may allow for those living with stable CVD to participate in structured programs with a trained instructor and permit social interaction (eg, viewing others on the screen, chatting after the class online). An example of an exercise prescription for patients with CVD is provided in Supplemental Material S3. Supplemental Tables S1 and S2 provide examples of exercise prescription for those with low and moderate levels of fitness and can be modified based on individual needs. Supplemental Table S3 provides an example of a physical activity log for tracking daily and weekly activity.

      Resistance, flexibility, and balance training

      Muscular strength and endurance, flexibility, and balance are integral elements for improving and maintaining functional fitness, reducing CVD risk factors, and managing chronic diseases.
      • Pollock M.L.
      • Evans W.J.
      Resistance training for health and disease: introduction.
      For many patients with CVD, an emphasis on “repetition” rather than “resistance” may be appropriate to ensure safety during muscular strength and endurance exercise. Patients with CVD should aim to complete 10-15 repetitions and 2-3 sets using a weight or resistance that can be comfortably repeated with proper form, with ≤ 90-second rest intervals between sets, on 2 to 3 occasions per week.
      • Fleck S.J.
      Body weight strength-training exercises can be modified to suit individuals of varying fitness levels (eg, wall push-ups, sit-to-stand, or chair squats). Additional exercises, and flexibility- and balance-training activities and instructions, can be found for free via the Osteoporosis Canada website.

      Osteoporosis Canada website. Available at: https://osteoporosis.ca/exercise-recommendations/. Accessed August 10, 2021.

      The use of common household items, such as soup cans and water bottles, can be incorporated into strength-training exercises for added resistance (eg, bicep curls with soup cans). For patients with access to resistance bands or free-weights, strength-training exercises can be prescribed based on appropriate tension (resistance bands) and weight (free-weights) that allows for the completion of 10-15 repetitions and 2-3 sets of the exercise with proper technique (eg, appropriate range of motion, avoiding the Valsalver maneuver). For many who may be unfamiliar with the practice or precepts of resistance training, the provision of simple guidelines and examples regarding home-based activities may be a practical approach during a pandemic to ensuring that the benefits of such activities are more generally available.

      Sleep

      A regularly physically active lifestyle is key for sleep health. Recent systematic reviews and meta-analyses have shown that exercise improves many sleep outcomes.
      • Dolezal B.A.
      • Neufeld E.V.
      • Boland D.M.
      • et al.
      Interrelationship between sleep and exercise: a systematic review.
      ,
      • Vanderlinden J.
      • Boen F.
      • van Uffelen J.G.Z.
      Effects of physical activity programs on sleep outcomes in older adults: a systematic review.
      Physical activity interventions involving middle-aged and older adults showed strong positive effects on sleep efficiency and duration (regardless of the intensity and mode of activity) among those suffering from disease, such as CVD, and reporting unhealthy sleep.
      • Dolezal B.A.
      • Neufeld E.V.
      • Boland D.M.
      • et al.
      Interrelationship between sleep and exercise: a systematic review.
      Practical recommendations or strategies to manage sleep disturbances during COVID-19 include the following: (i) prioritizing sleep and striving for 7-9 hours per night of sleep; (ii) maintaining a sleep routine, with consistent go-to-bed and wake-up times; (iii) ensuring as much daylight exposure as possible; (iv) avoiding use of digital devices (eg, a cellphone) in the bedroom or near bedtime; and, (v) exercising regularly.
      • Morin C.M.
      • Carrier J.
      • Bastien C.
      • et al.
      Sleep and circadian rhythm in response to the COVID-19 pandemic.
      If some of these behavioural sleep recommendations are challenging during the COVID-19 pandemic, adaptations to fit the needs of different individuals have recently been published.
      • Altena E.
      • Baglioni C.
      • Espie C.A.
      • et al.
      Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy.
      Sleep health can be monitored easily at home using simple tools such as sleep diaries (ie, paper or electronic notebooks for recording hours of sleep and time in bed per day; Supplemental Appendix S2) or wearable technology. Examples of simple and validated questions to assess sleep health have recently been published.
      • Chaput J.-P.
      • Shiau J.
      Routinely assessing patients' sleep health is time well spent.
      These questions can be answered in less than 2 minutes and provide information on key sleep health characteristics, such as sleep duration, sleep quality, sleep timing, daytime alertness, and absence of a sleep disorder (with desired answers).

      Discussion

      This review highlights the impact the COVID-19 pandemic continues to have on 24-hour movement behaviours and exercise, discusses how these changes negatively impact those living with CVD, and provides practical recommendations that can be provided to patients during these unprecedented times. An understanding of the tools available to each patient (eg, access to technologies, diaries/logs) will aid in recommending and monitoring exercise, sedentary behaviour, and sleep. The Supplementary Material S3 provided in this article can be used to guide low- to moderate-intensity exercise prescription for those with CVD who should reduce sedentary time, aim to get 7-9 hours of sleep per night, and accumulate at least 150 minutes of MVPA per week. Of note, evidence is emerging regarding the long-term symptoms associated with a previous COVID-19 infection that could have a negative impact on achieving and maintaining healthy 24-hour movement behaviours (eg, fatigue, breathlessness,);
      • Aucott J.N.
      • Rebman A.W.
      Long-haul COVID: Heed the lessons from other infection-triggered illnesses.
      greater efforts to individualize recommendations regarding sedentary behaviour, sleep, and physical activity may therefore be warranted. Sedentary behaviour has increased amid the pandemic
      • Faulkner G.
      • Rhodes R.E.
      • Vanderloo L.M.
      • et al.
      Physical activity as a coping strategy for mental health due to the COVID-19 virus: a potential disconnect among Canadian adults?.
      and is recognized as an independent risk factor for several CVDs, CVD risk factors (eg, atrial fibrillation, hypertension, dyslipidemia), and premature mortality.
      Patterns of sedentary behavior and mortality in U.S. middle-aged and older adults.
      ,
      • Pandey A.
      • Salahuddin U.
      • Garg S.
      • et al.
      Continuous dose-response association between sedentary time and risk for cardiovascular disease: a meta-analysis.
      Healthcare professionals working with those living with CVD can recommend breaking up sedentary time with movement of any intensity, and specific recommendations on MVPA should be provided. Monitoring sedentary time using technologies or diaries/logs can also be encouraged and reviewed by the patient and healthcare provider to ensure healthy 24-hour movement and exercise profiles during the pandemic.

      Conclusion

      Lamentably, COVID-19 and many of its consequences are a part of the foreseeable future. Recommendations for 24-hour movement behaviours and exercise need to take into consideration both the current health climate and the unique challenges faced within clinical settings and our communities (eg, time, space, and/or financial restraints). Clinicians should be aware that communication of the importance of physical activity and the provision of clear, comprehensible, and practical advice are fundamental to responding to the challenges posed by the pandemic for those living with CVD.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      The authors have no conflicts of interest to disclose. The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

      Supplementary Material

      References

      1. COVID-19 Coronavirus Pandemic. 2020. Available at: https://www.worldometers.info/coronavirus/. Accessed November 16, 2021.

        • Wang L.
        • He W.
        • Yu X.
        • et al.
        Coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up.
        J Infect. 2020; 80: 639-645
        • Liu H.
        • Gai S.
        • Wang X.
        • et al.
        Single-cell analysis of SARS-CoV-2 receptor ACE2 and spike protein priming expression of proteases in the human heart.
        Cardiovasc Res. 2020; 116: 1733-1741
        • Moulson N.
        • Bewick D.
        • Selway T.
        • et al.
        Cardiac rehabilitation during the COVID-19 era: guidance on implementing virtual care.
        Can J Cardiol. 2020; 36: 1317-1321
        • Hall G.
        • Laddu D.R.
        • Phillips S.A.
        • Lavie C.J.
        • Arena R.
        A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?.
        Progr Cardiovasc Dis. 2021; 64: 108-110
        • Lippi G.
        • Henry B.M.
        • Sanchis-Gomar F.
        Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (COVID-19).
        Eur J Prevent Cardiol. 2020; 27: 906-908
        • Cellini N.
        • Canale N.
        • Mioni G.
        • et al.
        Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy.
        J Sleep Res. 2020; 29e13074
        • Meyer J.
        • McDowell C.
        • Lansing J.
        • et al.
        Changes in physical activity and sedentary behaviour due to the COVID-19 outbreak and associations with mental health in 3052 US adults.
        Int J Environ Res Public Health. 2020; 17: 6469
        • Colley R.C.
        • Bushnik T.
        • Langlois K.
        Exercise and screen time during the COVID-19 pandemic.
        Health Rep. 2020; 31: 3-11
        • Edwardson C.L.
        • Gorely T.
        • Davies M.J.
        • et al.
        Association of sedentary behaviour with metabolic syndrome: a meta-analysis.
        PloS One. 2012; 7e34916
        • Teychenne M.
        • Costigan S.A.
        • Parker K.
        The association between sedentary behaviour and risk of anxiety: a systematic review.
        BMC Public Health. 2015; 15: 513
        • Teychenne M.
        • Ball K.
        • Salmon J.
        Sedentary behavior and depression among adults: a review.
        Int J Behav Med. 2010; 17: 246-254
        • Patterson R.
        • McNamara E.
        • Tainio M.
        • et al.
        Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis.
        Eur J Epidemiol. 2018; 33: 811-829
        • Faulkner G.
        • Rhodes R.E.
        • Vanderloo L.M.
        • et al.
        Physical activity as a coping strategy for mental health due to the COVID-19 virus: a potential disconnect among Canadian adults?.
        Front Commun. 2020; : 5:571833
        • Evenson K.R.
        • Butler E.N.
        • Rosamond W.D.
        Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States.
        J CardiopulmRehabil Prevent. 2014; 34: 406-419
        • Ekelund U.
        • Tarp J.
        • Steene-Johannessen J.
        • et al.
        Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: systematic review and harmonised meta-analysis.
        BMJ. 2019; 366: l4570
        • Warburton D.E.R.
        • Bredin S.S.D.
        Health benefits of physical activity: a systematic review of current systematic reviews.
        Curr Opin Cardiol. 2017; 32: 541-556
        • Dibben G.O.
        • Dalal H.M.
        • Taylor R.S.
        • et al.
        Cardiac rehabilitation and physical activity: systematic review and meta-analysis.
        Heart. 2018; 104: 1394-1402
        • Lee H.K.
        • Hwang I.H.
        • Kim S.Y.
        • et al.
        The effect of exercise on prevention of the common cold: a meta-analysis of randomized controlled trial studies.
        Korean J Fam Med. 2014; 35: 119-126
        • Nieman D.C.
        • Henson D.A.
        • Austin M.D.
        • et al.
        Upper respiratory tract infection is reduced in physically fit and active adults.
        Bri J Sports Med. 2011; 45: 987-992
        • Brawner C.A.
        • Ehrman J.K.
        • Bole S.
        • et al.
        Maximal exercise capacity is inversely related to hospitalization secondary to coronavirus disease 2019.
        Mayo Clin Proc. 2021; 96: 32-39
        • Sallis R.
        • Young D.R.
        • Tartof S.Y.
        • 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: 1099-1105
        • Anderson L.
        • Taylor R.S.
        Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews.
        Cochrane Database Syst Rev, 2014: Cd011273
        • Yohannes A.M.
        • Doherty P.
        • Bundy C.
        • et al.
        The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life.
        J Clin Nurs. 2010; 19: 2806-2813
        • Ding D.
        • del Pozo Cruz B.
        • Green M.A.
        • Bauman A.E.
        Is the COVID-19 lockdown nudging people to be more active: a big data analysis.
        Br J Sports Med. 2020; 54: 1183-1184
        • King A.J.
        • Burke L.M.
        • Halson S.L.
        • et al.
        The challenge of maintaining metabolic health during a global pandemic.
        Sports Med. 2020; 50: 1233-1241
        • Krittanawong C.
        • Virk H.U.H.
        • Narasimhan B.
        • et al.
        Coronavirus disease 2019 (COVID-19) and cardiovascular risk: a meta-analysis.
        Progr Cardiovasc Dis. 2020; 63: 527-528
        • Morin C.M.
        • Carrier J.
        • Bastien C.
        • et al.
        Sleep and circadian rhythm in response to the COVID-19 pandemic.
        Can J Public Health. 2020; 111: 654-657
        • Chaput J.-P.
        • Dutil C.
        • Featherstone R.
        • et al.
        Sleep duration and health in adults: an overview of systematic reviews.
        Appl Physiol Nutr Metab. 2020; 45: S218-S231
        • St-Onge M.-P.
        • Grandner M.A.
        • Brown D.
        • et al.
        Sleep duration and quality: impact on lifestyle behaviors and cardiometabolic health: a scientific statement from the American Heart Association.
        Circulation. 2016; 134: e367-e386
        • Kuehn B.M.
        Sleep duration linked to cardiovascular disease.
        Circulation. 2019; 139: 2483-2484
        • Advani I.
        • Gunge D.
        • Banks S.
        • et al.
        Is increased sleep responsible for reductions in myocardial infarction during the COVID-19 pandemic?.
        Am J Cardiol. 2020; 131: 128-130
        • Grøntved A.
        • Hu F.B.
        Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis.
        JAMA. 2011; 305: 2448-2455
        • Koster A.
        • Caserotti P.
        • Patel K.V.
        • et al.
        Association of sedentary time with mortality independent of moderate to vigorous physical activity.
        PloS One. 2012; 7e37696
        • Bakker E.A.
        • van Bakel B.M.A.
        • Aengevaeren W.R.M.
        • et al.
        Sedentary behaviour in cardiovascular disease patients: risk group identification and the impact of cardiac rehabilitation.
        Int J Cardiol. 2021; 326: 194-201
        • Ekelund U.
        • Tarp J.
        • Fagerland M.W.
        • et al.
        Joint associations of accelerometer-measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44,000 middle-aged and older individuals.
        Br J Sports Med. 2020; 54: 1499-1506
        • Guthold R.
        • Stevens G.A.
        • Riley L.M.
        • et al.
        Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants.
        Lancet Glob Health. 2018; 6: e1077-e1086
        • Owen N.
        • Healy G.N.
        • Matthews C.E.
        • et al.
        Too much sitting: the population health science of sedentary behavior.
        Exerc Sport Sci Rev. 2010; 38: 105-113
      2. Patterns of sedentary behavior and mortality in U.S. middle-aged and older adults.
        Ann Intern Med. 2017; 167: 465-475
        • Kallings L.V.
        • Sierra Johnson J.
        • Fisher R.M.
        • et al.
        Beneficial effects of individualized physical activity on prescription on body composition and cardiometabolic risk factors: results from a randomized controlled trial.
        Eur J Cardiovasc Prevent Rehabil. 2009; 16: 80-84
        • Dunstan D.W.
        • Thorp A.A.
        • Healy G.N.
        Prolonged sitting: Is it a distinct coronary heart disease risk factor?.
        Curr Opin Cardiol. 2011; 26: 412-419
        • Tison G.H.
        • Avram R.
        • Kuhar P.
        • et al.
        Worldwide effect of COVID-19 on physical activity: a descriptive study.
        Ann Intern Med. 2020; 173: 767-770
        • Tudor-Locke C.
        • Craig C.L.
        • Thyfault J.P.
        • Spence J.C.
        A step-defined sedentary lifestyle index: < 5000 steps/day.
        Appl Physiol Nutr Metab. 2013; 38: 100-114
      3. World Health Organization. WHO Guidelines on Physical Activity and Sedentary Behaviour. 2020. Available at: https://www.who.int/publications/i/item/9789240015128. Accessed August 10, 2021.

      4. Canadian Society for Exercise Physiology. 24-hour movement guideline for adults (18-64 years and 65+ years). Available at: https://csepguidelines.ca/guidelines/adults-18-64/. Accessed August 10, 2021.

        • Gardner B.
        • Smith L.
        • Lorencatto F.
        • et al.
        How to reduce sitting time? A review of behaviour change strategies used in sedentary behaviour reduction interventions among adults.
        Health Psychol Rev. 2016; 10: 89-112
        • Prince S.A.
        • Reed J.L.
        • Cotie L.M.
        • et al.
        Results of the sedentary intervention trial in cardiac rehabilitation (SIT-CR Study): a pilot randomized controlled trial.
        Int J Cardiol. 2018; 269: 317-324
        • Rosenberg D.E.
        • Lee A.K.
        • Anderson M.
        • et al.
        Reducing sedentary time for obese older adults: protocol for a randomized controlled trial.
        JMIR Res Protoc. 2018; 7: e23
        • Dunstan D.W.
        • Kingwell B.A.
        • Larsen R.
        • et al.
        Breaking up prolonged sitting reduces postprandial glucose and insulin responses.
        Diabetes Care. 2012; 35: 976-983
      5. Canadian Society for Exercise Physiology, Get Active Questionnaire. Available at: https://csep.ca/wp-content/uploads/2021/05/GETACTIVEQUESTIONNAIRE_ENG.pdf. Accessed August 10, 2021.

      6. American College of Sports Medicine, Exercise Preparticipation Health Screening. Available at: https://www.acsm.org/blog-detail/acsm-certified-blog/2018/02/01/exercise-preparticipation-screening-removing-barriers-initiating-exercise. Accessed August 10, 2021.

        • Riebe D.
        • Franklin B.A.
        • Thompson P.D.
        • et al.
        Updating ACSM's Recommendations for Exercise Preparticipation Health Screening.
        Med Sci Sports Exerc. 2015; 47: 2473-2479
        • Stone J.A.
        Canadian guidelines for cardiac rehabilitation and cardiovascular disease prevention are available.
        J Cardiopulm Rehabil. 2001; 21: 344-345
        • Ismail H.
        • McFarlane J.R.
        • Dieberg G.
        • et al.
        Exercise training program characteristics and magnitude of change in functional capacity of heart failure patients.
        Int J Cardiol. 2014; 171: 62-65
        • Nieuwland W.
        • Berkhuysen M.A.
        • van Veldhuisen D.J.
        • et al.
        Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease.
        J Am Coll Cardiol. 2000; 36: 202-207
        • Kim K.
        • Choi S.
        • Hwang S.E.
        • et al.
        Changes in exercise frequency and cardiovascular outcomes in older adults.
        Eur Heart J. 2020; 41: 1490-1499
        • Carpio-Rivera E.
        • Moncada-Jiménez J.
        • Salazar-Rojas W.
        • et al.
        Acute effects of exercise on blood pressure: a meta-analytic investigation.
        Arq Bras Cardiol. 2016; 106: 422-433
        • Terada T.
        • Friesen A.
        • Chahal B.S.
        • et al.
        Exploring the variability in acute glycemic responses to exercise in type 2 diabetes.
        J Diabetes Res. 2013; 2013: 591574
        • Basso J.C.
        • Suzuki W.A.
        The effects of acute exercise on mood, cognition, neurophysiology, and neurochemical pathways: a review.
        Brain Plast. 2017; 2: 127-152
        • Fagard R.H.
        Exercise characteristics and the blood pressure response to dynamic physical training.
        Med Sci Sports Exerc. 2001; 33 (discussion S93-S94): S484-S492
        • Mann S.
        • Beedie C.
        • Jimenez A.
        Differential effects of aerobic exercise, resistance training and combined exercise modalities on cholesterol and the lipid profile: review, synthesis and recommendations.
        Sports Med. 2014; 44: 211-221
        • Umpierre D.
        • Ribeiro P.A.
        • Schaan B.D.
        • et al.
        Volume of supervised exercise training impacts glycaemic control in patients with type 2 diabetes: a systematic review with meta-regression analysis.
        Diabetologia. 2013; 56: 242-251
        • Berkhuysen M.A.
        • Nieuwland W.
        • Buunk B.P.
        • et al.
        Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life.
        J Cardiopulm Rehabil. 1999; 19: 22-28
        • Broman-Fulks J.J.
        • Abraham C.M.
        • Thomas K.
        • et al.
        Anxiety sensitivity mediates the relationship between exercise frequency and anxiety and depression symptomology.
        Stress Health. 2018; 34: 500-508
        • Hansen D.
        • Abreu A.
        • Ambrosetti M.
        • et al.
        Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology.
        Eur J Prev Cardiol. 2021 Jun 2;
        • Stamford B.A.
        Validity and reliability of subjective ratings of perceived exertion during work.
        Ergonomics. 1976; 19: 53-60
        • Reed J.L.
        • Pipe A.L.
        The talk test: a useful tool for prescribing and monitoring exercise intensity.
        Curr Opin Cardiol. 2014; 29: 475-480
        • Borg G.A.
        Psychophysical bases of perceived exertion.
        Med Sci Sports Exerc. 1982; 14: 377-381
        • Faulkner J.
        • Eston R.
        Overall and peripheral ratings of perceived exertion during a graded exercise test to volitional exhaustion in individuals of high and low fitness.
        Eur J Appl Physiol. 2007; 101: 613-620
        • Petersen A.K.
        • Maribo T.
        • Hjortdal V.E.
        • et al.
        Intertester reliability of the talk test in a cardiac rehabilitation population.
        J Cardiopulm Rehabil Prev. 2014; 34: 49-53
        • Zanettini R.
        • Centeleghe P.
        • Franzelli C.
        • et al.
        Validity of the talk test for exercise prescription after myocardial revascularization.
        Eur J Prev Cardiol. 2013; 20: 376-382
        • Voelker S.
        • Foster C.
        • Porcari J.
        • et al.
        Relationship between the talk test and ventilatory threshold in cardiac patients.
        Clin Exerc Physiol. 2002; 4: 120-123
        • Düking P.
        • Holmberg H.C.
        • Sperlich B.
        Instant biofeedback provided by wearable sensor technology can help to optimize exercise and prevent injury and overuse.
        Front Physiol. 2017; 8: 167
        • Hosseinpour M.
        • Terlutter R.
        Your personal motivator is with you: a systematic review of mobile phone applications aiming at increasing physical activity.
        Sports Med. 2019; 49: 1425-1447
        • Duking P.
        • Giessing L.
        • Frenkel M.O.
        • et al.
        Wrist-worn wearables for monitoring heart rate and energy expenditure while sitting or performing light-to-vigorous physical activity: validation study.
        JMIR Mhealth and Uhealth. 2020; 8e16716
        • Düking P.
        • Hotho A.
        • Holmberg H.C.
        • et al.
        Comparison of non-invasive individual monitoring of the training and health of athletes with commercially available wearable technologies.
        Front Physiol. 2016; 7: 71
        • American College of Sports Medicine
        ACSM’s Guidelines for Exercise Testing and Prescription. Wolters Kluwer, Philadelphia, PA2018: 160
        • Piercy K.L.
        • Troiano R.P.
        • Ballard R.M.
        • et al.
        The physical activity guidelines for Americans.
        JAMA. 2018; 320: 2020-2028
        • Dempsey P.C.
        • Strain T.
        • Khaw K.-T.
        • et al.
        Prospective associations of accelerometer-measured physical activity and sedentary time with incident cardiovascular disease, cancer, and all-cause mortality.
        Circulation. 2020; 141: 1113-1115
        • von Korn P.
        • Keating S.
        • Mueller S.
        • et al.
        The effect of exercise intensity and volume on metabolic phenotype in patients with metabolic syndrome: a randomized controlled trial.
        MetabSyndr Relat Disord. 2021; 19: 107-114
        • Lewis B.A.
        • Williams D.M.
        • Frayeh A.
        • et al.
        Self-efficacy versus perceived enjoyment as predictors of physical activity behaviour.
        Psychol Health. 2016; 31: 456-469
        • Murrock C.J.
        The effects of music on the rate of perceived exertion and general mood among coronary artery bypass graft patients enrolled in cardiac rehabilitation phase II.
        Rehabil Nurs. 2002; 27: 227-231
        • Rider B.C.
        • Bassett D.R.
        • Strohacker K.
        • et al.
        Psycho-physiological effects of television viewing during exercise.
        J Sports Sci Med. 2016; 15: 524-531
        • Reed J.L.
        • Harris J.M.
        • Midence L.
        • et al.
        Evaluating the Heart Wise Exercise program: a model for safe community exercise programming.
        BMC Public Health. 2016; 16: 190
        • Pollock M.L.
        • Evans W.J.
        Resistance training for health and disease: introduction.
        Med Sci Sports Exerc. 1999; 31: 10-11
        • Fleck S.J.
        Designing Resistance Training Programs. 2nd ed. Human Kinetics, Champaign, IL1997
      7. Osteoporosis Canada website. Available at: https://osteoporosis.ca/exercise-recommendations/. Accessed August 10, 2021.

        • Dolezal B.A.
        • Neufeld E.V.
        • Boland D.M.
        • et al.
        Interrelationship between sleep and exercise: a systematic review.
        Adv Prev Med. 2017; 2017: 1364387
        • Vanderlinden J.
        • Boen F.
        • van Uffelen J.G.Z.
        Effects of physical activity programs on sleep outcomes in older adults: a systematic review.
        Int J Behav Nutr Phys Activ. 2020; 17: 11
        • Altena E.
        • Baglioni C.
        • Espie C.A.
        • et al.
        Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy.
        J Sleep Res. 2020; 29e13052
        • Chaput J.-P.
        • Shiau J.
        Routinely assessing patients' sleep health is time well spent.
        Prev Med Rep. 2019; 14: 100851
        • Aucott J.N.
        • Rebman A.W.
        Long-haul COVID: Heed the lessons from other infection-triggered illnesses.
        Lancet. 2021; 397: 967-968
        • Pandey A.
        • Salahuddin U.
        • Garg S.
        • et al.
        Continuous dose-response association between sedentary time and risk for cardiovascular disease: a meta-analysis.
        JAMA Cardiol. 2016; 1: 575-583
        • Gellish R.L.
        • Goslin B.R.
        • Olson R.E.
        • et al.
        Longitudinal modeling of the relationship between age and maximal heart rate.
        Med Sci Sports Exerc. 2007; 39: 822-829
        • Fox 3rd, S.M.
        • Haskell W.L.
        Physical activity and the prevention of coronary heart disease.
        Bull N Y Acad Med. 1968; 44: 950-967
        • Tanaka H.
        • Monahan K.D.
        • Seals D.R.
        Age-predicted maximal heart rate revisited.
        J Am Coll Cardiol. 2001; 37: 153-156
        • Gulati M.
        • Shaw L.J.
        • Thisted R.A.
        • et al.
        Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project.
        Circulation. 2010; 122: 130-137
        • Karvonen J.
        • Vuorimaa T.
        Heart rate and exercise intensity during sports activities. Practical application.
        Sports Med. 1988; 5: 303-311