In your words

COVID-19: How to optimize your immune system with prehabilitation

Take a page from the physical medicine and rehabilitation playbook and prepare your mind, body and spirit to withstand this pandemic as best as you can.

Editor’s note: This is an opinion piece; the views expressed are the authors’ own and do not necessarily represent the views of The DO or the AOA.

Depending on the individual, outcomes from novel coronavirus disease (COVID-19) infection range from asymptomatic to severe illness that can progress to pneumonia, acute respiratory distress and death. The elderly tend to have worse outcomes, but all are susceptible to complications. Social distancing—to avoid exposure to potentially infected individuals—has become the mainstay of prevention. 

In physical medicine and rehabilitation, the ultimate goal of a physician is to help patients return to a healthy, high-functioning life. However, there is also another aspect to the field called “prehabilitation.” This concept is similar to the sports pre-season. It is a time to prepare the body, mind and spirit to optimize for a sports season, an upcoming surgery or in this case, a viral pandemic.  

What changes can we make individually that could improve our immune system and ameliorate outcomes? What can we do while social distancing without fancy equipment, special foods or organized classes?


Exercise is highly effective in preparing our bodies for potential illness. However, prolonged, intense exercise has been shown to suppress the immune system, while moderate-intensity exercise reduces inflammation in the body—thereby, reducing the risk of infection. The “talk test” is a good measure for moderate pace. You should be able to hold a conversation but not sing a song.

Moderate exercise that can be done during social distancing includes brisk walking, heavy cleaning around the home (mopping, vacuuming), hiking (on an empty trail) and light biking.

The American Heart Association and CDC recommend 150 minutes of moderate-intensity exercise weekly.  Remember, exercise is a personal journey that works best when you listen to cues from your body. 


Malnutrition is the most common cause of immunodeficiency worldwide. Maintaining an optimal level of protein is the best prehabilitation for illness. The dietary reference intake is 0.36 grams of protein per pound of body weight, which is 56 grams per day for the average sedentary man and 46 grams for the average woman. We need protein in our diet to help the body repair and regenerate cells and tissues as well as make enzymes, hormones and other body chemicals. 

Even mild protein deficiency can alter immune response and negatively affect our ability to overcome illness, regardless of age or health status. High-quality foods to promote optimal protein status include salmon, lima beans, eggs, beef, chicken, tuna, tempeh, legumes, hemp seeds, chickpeas, quinoa and Greek yogurt.  

Stress reduction

When under stress, the body expresses cortisol and adrenaline to raise heart rate and blood pressure. It slows down digestion and releases blood glucose to efficiently produce more energy. 

Unfortunately, many of us normally live with chronically elevated stress hormone levels.  Over time this can lead to weight gain, hypertension, sleep and mood disturbances and reduced energy; all of which can impair the immune system.

Meditation is a way of achieving stress reduction through deep, relaxed breathing. Sit in a chair or lay down. Breathe. Slow down your thoughts. Concentrate on one relaxing word or phrase. A review of studies published in JAMA Internal Medicine found that meditation can reduce psychological stress by easing anxiety, depression and pain.


Effective sleep is associated with a reduced infection risk and can improve outcomes. A 2015 study demonstrated that prolonged sleep makes us more resistant to the common cold, many of which are caused by coronavirus variations. The study found that people who slept less than six hours before infection had a four times higher risk of developing a cold than subjects who had slept seven-plus hours per night. 

So how many hours is best? Seven to nine hours for an adult. Some of us barely get five to six hours and expect our bodies to carry the load of a typical day.  During this pandemic, we need sleep more than ever.  

Go outside

Spending time in nature may affect health by reducing heart rate and decreasing body inflammation. A study that placed groups of people in the forest and in the city for two nights found that those in the forest had less cortisol, a decrease in signs of inflammation and an increase in ‘vigor.’ Spending time in forests has been shown to decrease blood pressure and stress levels and strengthen immune response

Phytoncides are natural compounds emitted from plants and trees. This natural essence protects trees from harmful germs and insects. Inhaling phytoncides may enhance humans’ immune system function

Studies have even found that observing videos of the forest or waterside scenes can be beneficial.

Be sure to follow social distancing guidelines while outdoors.

Self-manual treatment

While DOs use osteopathic manipulative treatment (OMT) to diagnose, treat and prevent illness and injury, in the current environment, patients may not have access to OMT.

However, there are self-manipulation exercises patients can complete at home to encourage optimal lung function. Detailed information, including an instructional video, on self-manipulation exercises for immune system support is available here.

Take-home points: How we can “prehab” COVID-19

  • Practice social distancing
  • Get moderate exercise
  • Get protein in your diet
  • Meditate
  • Sleep seven to nine hours per night
  • Spend time outdoors taking in the phytoncides
  • Practice self-manipulation to encourage optimal lung function

About the authors: Denice Franco, DO, is an assistant professor in the department of osteopathic manipulative medicine at New York Institute of Technology College of Osteopathic Medicine (NYITCOM). Nikki Petrocelli is a registered dietician and certified dietitian nutritionist. Taner Celebi, OMS III, attends NYITCOM. Ravi Chinsky, OMS III, attends NYITCOM.


  1. Jayme D Mancini

    Thank you for sharing. All of these are good ways to optimize immune system health. The self-manipulation and exercises are helpful.

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