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Clinical Implications of Mask Wearing During Exercise in Inpatient Rehabilitation Setting During COVID-19 Global Pandemic

Published:December 25, 2021DOI:https://doi.org/10.1016/j.apmr.2021.10.012
      Wearing a face mask offers protection against the SARS-CoV-2 infection, yet experts are unsure about the effects of mask wearing while exercising on those with health conditions who require inpatient rehabilitation (IPR). Although there is no doubt of the importance of mask wearing for the safety of both the clinician and patient, those who work with people in IPR should be aware of the physical, mental, and emotional effects of mask wearing.

      Summary of Exercise and Mask Research

      Current research tells us that exercise performance in healthy people is lower when wearing a mask (table 1). The effect of face masks on exercise and vital signs varies across studies, but important findings include (1) higher ratings of perceived exertion, (2) increased shortness of breath, and (3) feeling claustrophobic while wearing a face mask during exercise.
      Table 1Summary of Face Mask Research in Healthy Populations
      AuthorsStudy Design and Type of MaskParticipantsAge of Participants (y), mean ± SDExercise TestResults
      Driver et al
      • Driver S
      • Reynolds M
      • Brown K
      • et al.
      Effects of wearing a cloth face mask on performance, physiological and perceptual responses during a graded treadmill running exercise test.
      Randomized crossover design: cloth face mask vs

      no mask
      N=31

      (14 healthy female participants, 17 male participants)
      23.2±3.1Graded treadmillFace masks led to reduced performance (ie, reduced exercise time) and changes in physiological (eg, reduced oxygen consumption, amount of air moved, heart rate, oxygen carried in the blood) and perceptual variables (ie, RPE, dyspnea) during low-, moderate-, and high-intensity exercise.
      Epstein et alCrossover design: surgical, N95, vs no maskN=16 male participants34±4Graded bikeFace masks did not reduce performance (exercise time) or change physiological variables (heart rate, SAO2, blood pressure). Partial pressure of carbon dioxide at the end of an exhaled breath during the N95 mask condition was higher than the surgical mask and no mask.
      Fikenzer et alCrossover design: surgical, N95, vs no maskN=12 male participants38.1±6.2Graded bikeFace masks (surgical and N95) reduced ventilation, maximal oxygen uptake, and comfort compared with no mask.
      Li et alRandomized: surgical vs N95 maskN=10

      (5 female participants, 5 male participants)
      28.0±6Treadmill testParticipants’ heart rate was lower while wearing the surgical mask, and they rated them less favorably on perceived humidity, heat, and breath resistance than N95 masks.
      Shaw et alRandomized crossover design: surgical, cloth face mask, vs no maskN=14

      (7 female participants

      7 male participants)
      28.2±8.7Graded bikeFace masks did not affect exercise time, peak power, SAO2, RPE, or heart rate.
      Abbreviations: RPE, rating of perceived exertion; SAO2, arterial blood oxygen saturation.
      Driver et al
      • Driver S
      • Reynolds M
      • Brown K
      • et al.
      Effects of wearing a cloth face mask on performance, physiological and perceptual responses during a graded treadmill running exercise test.
      found that masks affected physical and mental outcomes at low-, moderate-, and high-intensity exercise. Presumably, people with health conditions may also experience reduced exercise performance because of mask wearing. Thus, clinicians should monitor, manage, and adapt the rehabilitation environment to enhance the patient's ability to exercise safely.
      • Marler H
      • Ditton A.
      “I'm smiling back at you”: exploring the impact of mask wearing on communication in healthcare.

      What This Means for Populations With Neurologic Conditions

      People with neurologic conditions do not have normal oxygen consumption at rest or with exercise.
      • Driver S
      • Reynolds M
      • Brown K
      • et al.
      Effects of wearing a cloth face mask on performance, physiological and perceptual responses during a graded treadmill running exercise test.
      ,
      • Epstein D
      • Korytny A
      • Isenberg Y
      • et al.
      Return to training in the COVID-19 era: the physiological effects of face masks during exercise.
      Therefore, clinicians should expect mask wearing to affect (1) oxygen uptake during aerobic exercise, (2) fatigue levels during exercise, and (3) physiological and autonomic responses during exercise.
      Clinicians should consider the effect of wearing a mask in the context of individual needs. They should keep in mind that impairments in language, cognition, and mood, as well as some medications may also affect patients’ participation in IPR, which may likely be exacerbated by wearing a mask. Such impairments can affect patients’ ability to accurately determine and state perceived effort at rest and with exercise.
      • Marler H
      • Ditton A.
      “I'm smiling back at you”: exploring the impact of mask wearing on communication in healthcare.
      Considering the issues regarding mask wearing, clinicians should incorporate the following actions into standard care: (1) Routinely assess physiological markers (heart rate, respiratory rate, oxygen saturation, blood pressure) in patients before, during, and after exercise. Symptoms that do not abate within 1 hour may be a sign that the patient is unable to tolerate current exercise intensity while wearing a mask.
      • Salman D
      • Vishnubala D
      • Le Feuvre P
      • et al.
      Returning to physical activity after COVID-19.
      (2) Observe tolerance to exercise through various means, such as technology, illustrations, and common gestures, to maximize communicative success and safety in mask wearers.
      • Marler H
      • Ditton A.
      “I'm smiling back at you”: exploring the impact of mask wearing on communication in healthcare.

      Clinical Implications for the Interdisciplinary Team

      Recommendations to meet these challenges have been suggested by multiple sources (fig 1). This information is based on current research and clinical expertise because specific guidelines have not been developed for this patient population.
      Fig 1
      Fig 1Quick reference guide for clinicians in inpatient rehabilitation settings.
      As guidelines from the Centers for Disease Control and Prevention evolve, it is unlikely that the practice of mask wearing in hospital settings will be eliminated soon. As such, it is up to the clinician to determine whether the mask hinders the patient's ability to safely exercise and communicate. Some examples of ways in which masks can affect treatment sessions are loss of nonverbal cues to monitor exercise tolerance, reduced intelligibility of speech to communicate perceived effort, and inability of the clinician to provide verbal cues to patients about exercise technique.

      American Speech-Language-Hearing Association. Using masks for in-person service delivery during COVID-19 pandemic: what to consider. Available at: https://www.asha.org/Practice/Using-Masks-for-In-Person-Service-Delivery-During-COVID-19-What-to-Consider/. Accessed May 17, 2021.

      Additionally, clinicians will need to use modified communication strategies for patients with impaired language and cognitive skills during exercise. Such strategies should be consistently discussed, used, and shared among the interdisciplinary team in the IPR. Modifications may include

      American Speech-Language-Hearing Association. Using masks for in-person service delivery during COVID-19 pandemic: what to consider. Available at: https://www.asha.org/Practice/Using-Masks-for-In-Person-Service-Delivery-During-COVID-19-What-to-Consider/. Accessed May 17, 2021.

      (1) use of masks with clear panels for patients and clinicians, (2) use of images or videos for demonstration of exercise technique, (3) using thumbs up/thumbs down gestures to indicate patients’ tolerance to exercise, (4) reducing background noise when conducting exercise testing or treatments, and (5) facing the patient when asking about exercise tolerance and effort.

      Authorship

      This page was developed by Kayla Covert, PT, DPT (email address: [email protected] ); Chad Swank, PT, PhD; Megan Reynolds, MS; and Simon Driver, PhD.

      Disclaimer

      This information is not meant to replace the advice of a medical professional and should not be interpreted as a clinical practice guideline. Statements or opinions expressed in this document reflect the views of the contributors and do not reflect the official policy of ACRM unless otherwise noted. Always consult your health care provider about your specific health condition. This Information/Education Page may be reproduced for noncommercial use for health care professionals and other service providers to share with their patients or clients. Any other reproduction is subject to approval by the publisher.

      Acknowledgment

      This material is the result of work supported with resources and the use of facilities at the Baylor Scott and White Health Foundation.

      References

        • Driver S
        • Reynolds M
        • Brown K
        • et al.
        Effects of wearing a cloth face mask on performance, physiological and perceptual responses during a graded treadmill running exercise test.
        Br J Sports Med. 2021 Apr 3; ([Epub ahead of print])
        • Marler H
        • Ditton A.
        “I'm smiling back at you”: exploring the impact of mask wearing on communication in healthcare.
        Int J Lang Commun Disord. 2021; 56: 205-214
        • Epstein D
        • Korytny A
        • Isenberg Y
        • et al.
        Return to training in the COVID-19 era: the physiological effects of face masks during exercise.
        Scand J Med Sci Sports. 2021; 31: 70-75
        • Salman D
        • Vishnubala D
        • Le Feuvre P
        • et al.
        Returning to physical activity after COVID-19.
        BMJ. 2021; 372: m4721
      1. American Speech-Language-Hearing Association. Using masks for in-person service delivery during COVID-19 pandemic: what to consider. Available at: https://www.asha.org/Practice/Using-Masks-for-In-Person-Service-Delivery-During-COVID-19-What-to-Consider/. Accessed May 17, 2021.