Exercising with a Surgical Mask is Safe but Decreases Performance in Both Athletic and Non-Athletic Individuals
1Department of Sports Medicine, İstanbul University Faculty of Medicine, İstanbul, Türkiye
2Clinic of Sports Medicine, Başakşehir Çam ve Sakura City Hospital, İstanbul, Türkiye
3Department of Public Health, İstanbul University Faculty of Medicine, İstanbul, Türkiye
4Department of Pulmonary Medicine, İstanbul University Faculty of Medicine, İstanbul, Türkiye
5Department of Physiology, İstanbul University-Cerrahpaşa, İstanbul, Türkiye
Keywords: Mask; oxygen consumption; exercise; athlete
Introduction: Upper respiratory tract infections (URTI) are common medical problems in athletes. Many athletes with URTI continue to train at high-levels and even compete. Using a mask as an additional measure may be beneficial to prevent the spreading of infection among teammates. However, there are many concerns about the effects of mask use on exercise safety and performance. Although some studies have investigated the effects of masks on performance in healthy individuals, studies in athletes are even more limited. Thus, we aimed to evaluate the impact of surgical masks on performance and safety during a cardiorespiratory exercise test (CPET) test applied to both athletes and non-athletes.
Patients and Methods: A cross-over, non-randomized study was designed. The study was conducted in two phases. In phase 1, the CPET was performed without using a surgical mask. In phase 2, CPET was performed with a surgical mask in addition to the spiro mask 48 hours after the first test. Thirty participants aged 18-35 were included in the study. They were further divided as athletes (n= 17) and non-athletes (n= 13) subgroups.
Results: Significant decreases were observed in some parameters of submaximal exercise [VEan, BFan, VE/ VO2 , VE/VCO2 (p< 0.001)] and in maximal exercise [VEmax, BFmax, TVmax, VE/VO2 , VE/VCO2 (p< 0.001)]. There were also significant decreases in VO2 levels (VO2 an, VO2 max) when compared with and without a surgical mask in both submaximal and maximal exercise (p< 0.001). Additionally, PETO2 decreased, and PETCO2 increased in maximum exercise (p< 0.001), whereas no significant changes were detected at the submaximal level. In subgroup analysis, VEan, VEmax, VO2 an, VO2 max parameters were decreased in athletes compared to non-athletes in surgical masked tests.
Conclusion: Surgical masks for athletes and non-athletes decrease performance but have no detrimental effect on cardiorespiratory parameters. Athletes should be aware of this negative effect when high-level performance is demanded.
However, many hypotheses about the effects of using a mask during exercise have been put forward. One of these hypotheses is that respiratory air trapping and rebreathing of carbon dioxide may lead to hypercapnic hypoxia, especially during high-intensity exercise. Another is that the mask will increase the respiratory workload by creating resistance during breathing(7). How the use of masks affects exercise performance is another question, especially in the minds of athletes. Because athletes have expressed worries about their physiologic performance while wearing a face mask, as anything that covers the mouth and/or nose can theoretically increase the resistive work of breathing(8).
To date, some studies have investigated the effects of masks on physiological and physical performance in healthy individuals. Studies in the athlete population are even more limited.
Therefore, our study aimed to examine the impact of surgical masks on maximal and submaximal exercise using the cardiopulmonary exercise test (CPET) applied to both athletic and non-athletic individuals. In this context, we primarily evaluated the following parameters: maximum oxygen consumption (VO2 max), exercise test duration, maximum heart rate (HRmax), maximum minute ventilation (VEmax), and end-tidal carbon dioxide pressure (pETCO2 ).
Patients and Methods
A non-randomized, cross-over study was conducted in two phases. In phase 1, the CPET was performed without using a surgical mask. In phase 2, CPET was performed with a surgical mask in addition to the spiro mask 48 hours after the first test. The participants were asked not to consume caffeine and alcohol, to avoid strenuous physical activity, and to have at least 6-8 hours of night sleep before the tests.
The study included 30 participants, aged 18-35, without any health problems related to cardiopulmonary, orthopedic, or neurological systems. They were further divided into athletic (n= 17) and non-athletic physically active (n= 13) subgroups, according to their sport activity level. All participants underwent a detailed physical examination before enrolment in the study. The demographics of the participants were recorded.
Participants provided written informed consent prior to the study. The study was registered at ClinicalTrials.gov (NCT05282472,15.03.22).
This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of İstanbul University, İstanbul Faculty of Medicine (File no: 2021/659).
Cardiopulmonary Exercise Test (CPET)
Surgical Mask and CPET Mask Compatibility
The metabolic test device was first put on the mask (Rudolph Mask 2 way 7910) during the test. Participants were instructed to exhale forcefully, and the presence of an air leak was subsequently assessed. Following this, a 3-layer surgical mask (UNL mask, Türkiye) was applied over the original mask and secured using a CPET turbine (Figure 1).
CPET Test Protocol
The resting arterial blood pressure, heart rate, oxygen saturation (SpO2 ) (EDAN Vital Sings Monitor M3A, Edan Instruments, China), and electrocardiography (ECG) measurements were performed. CPETs were carried out using the Q 5000 (Quinton 5000, USA) stress test system and the ergospirometric test system (Metalyzer 3B system, Metasoft 2.7 software, Cortex, Germany) on the Quinton 65 treadmill. O2 and CO2 gases were analyzed with the breath by breath method during the test, and O2 consumption (VO2 ) and CO2 production (VCO2 ) values were determined.
Bruce protocol was used and blood pressure, SpO2 and ECG were monitored throughout the test. The test was terminated when the participants reached the maximum exercise level.
The criteria for reaching the maximum included:
1) A respiratory exchange ratio (RER) value above 1.10,
2) The age-related target heart rate reaching ± 10 beats per minute, or
3) A plateau in VO2 . Participants who met two of these three criteria were considered to have reached their maximum(9). Active recovery was performed with a three-minute walk after the test was terminated. The highest VO2 value analyzed within the 15-second period in the maximum phase of CPET was considered VO2 max.
Descriptive and Outcome Data
The values for heart rate (HR), target heart rate percent (HRpred%), systolic blood pressure (SBP)-diastolic blood pressure (DBP), oxygen consumption (VO2 ), RER value, minute ventilation (VE), ventilation/carbon dioxide curve (VE/ VCO2 slope), ventilation/oxygen curve (VE/VO2 slope), oxygen pulse (VO2 /HR), respiratory frequency (BF), tidal volume (TV), end-tidal oxygen pressure (pETO2 ) and end-tidal carbon dioxide pressure (pETCO2 ) for anaerobic threshold and maximum level were recorded during the CPET. The anaerobic threshold was calculated using the V-slope method (slope of the linear relationship between VCO2 and VO2 ) (10).
Data were analyzed using SPSS 26 package software. The mean and standard deviation were calculated for the numerical data; nominal and original data were expressed as numbers and percentage distributions. The distribution of normality was tested using the Kolmogorov-Smirnov test. According to the result, the analysis of dependent groups before and after was performed with the paired sample t-test. p-value of <0.05 was considered significant. The differences between the subgroups of physically active individuals and athletes were revealed by the Linear Model Anova review.
A total of 30 people were included in the study. 50% (n= 15) of the participants were women, 56.7% (n= 17) were athletes. The mean ± Std age of all participants was 23.1 ± 3.5, height 174.5 ± 8.68 cm, weight 68.4 ± 10.2 kg, and BMI 22.46 ± 2.72. The demographics of the participants are given in Table 1.
There were no significant differences in the following CPET parameters; HRrest (p= 0.64), HRan (p= 0.69), HRmax (p= 0.95), HRmax/HRpred% (p= 0.84), HRrec (p= 0.96), SBPrest (p= 0.27), SBPmax (p= 0.45), SBPrec (p= 0.92), DBPrest (p= 0.10), DBPmax (p= 0.54) and DBPrec (p= 0.21), when comparing the tests with and without surgical masks in the study group (Table 2).
When the ventilation parameters were evaluated; significant decreases were observed in Vean (p< 0.001), Vemax (p<0.001), Bfan (p< 0.001), Bfmax (p< 0.001) and TVmax (p<0.001) parameters during CPET tests performed with surgical masks compared to CPET tests performed without a surgical mask (Table 2). There was no significant difference in the TVan (p= 0.48) parameter (Table 2).
The VO2 values at both the anaerobic threshold and the maximum exercise level during the CPET tests with a surgical mask were significantly lower than those obtained during the CPET tests without a surgical mask (p< 0.001 and p< 0.001, respectively). However, no significant change was identified in the CPET duration (p= 0.11) (Table 2).
When the VE/VCO2 slope and VE/VO2 slope results obtained from the CPET tests with surgical masks were compared to CPET tests without surgical masks, significant decreases were detected in both the anaerobic threshold level (p= 0.01 and p= 0.01, respectively) and the maximum exercise level (p< 0.001 and p< 0.001, respectively) (Table 2).
Considering the gas pressure parameters, there was a significant decrease in pETO2 at the maximum level (p< 0.001), but no significant difference was observed at the anaerobic threshold of the CPET tests (p= 0.17) when comparing tests conducted with surgical masks to those without (Table 2). The pETCO2 did not show a significant change in the anaerobic threshold level (p= 0.18), in the same way as pETO2 . However, the pETCO2 value increased significantly at the maximum exercise level (p< 0.001), unlike pETO2 (Table 2).
When the subgroups were analyzed using Linear Model Anova, it was revealed that VEan (p= 0.005), VEmax (p= 0.002), VO2 an (p= 0.001), VO2 max (p= 0.001) (Figure 2) parameters were decreased significantly after the use of surgical masks in athletes compared to physically active nonathletes. Also, it was observed that the alterations in the maximal pETCO2 values in the CPET tests with and without masks were not significant between the subgroups (p= 0.282).
From a physiological standpoint, the level of oxygen consumption (VO2 ) results from the pulmonary, cardiovascular, and hematological systems and the aerobic ATP production capacity of the muscles. VO2 max stands as the most prominent indicator of aerobic capacity.
VO2 max measurement is accepted as the gold standard in the evaluation of the aerobic capacity of individuals, especially athletes, and these measurements are performed with CPET. These tests can be carried out for clinical purposes, not only for healthy individuals such as athletes but also for those with pathologies of respiratory and circulatory systems. In one phase of our study, a 3-layer surgical mask was used during CPET. This way, the effect of the mask on the aerobic capacity and anaerobic threshold levels of individuals was determined. In addition, other cardiopulmonary parameters monitored during the test were also evaluated.
Alterations in Maximum Exercise Level
Our results showed that surgical masks used during CPET significantly decreased VO2 max, and VEmax values, while significantly increasing pETCO2 max, similar to some studies in the literature (Table 2)(7). Alkan et al. reported a decrease in VO2 max as a performance output when a surgical mask is used during maximal exercise in both young and older adult groups(11). Similar results were obtained in later studies, and two hypotheses were proposed. The first is the increase in airway resistance and, accordingly, the ventilatory workload due to the structure of the surgical mask. The other is that it traps a certain level of the exhaled air on the face area covered by the surgical mask, and CO2 can be re-inspired, causing hypercapnic hypoxia(7,9). Another study by Driver et al. reported that using cloth masks decreased VO2 max, VEmax as well as exercise duration and HRmax. Even though no direct association with the cardiovascular system has been reported in this study, due to the decrease in pulmonary function and mask discomfort, the exercise had to be terminated early(12).
Shaw et al. claimed that the spirometer mask placed separately on the surgical mask causes the surgical mask to stick to the face and eventually impairs its external permeability. They claimed that this situation might cause discomfort. Although they did not perform any ergospirometric evaluation or gas analysis, the same researchers reported that the use of surgical masks and cloth masks did not cause any significant changes in parameters such as exercise time, HRmax, SpO2 , and peak power(13).
On the other hand, Epstein et al. did not detect a significant difference in tissue oxygenation parameters, but they found a slight increase in pETCO2 value. Despite this increase, they stated that the use of surgical masks during exercise remains safe(14).
In our study, unlike the previous ones, we applied a 3-layer surgical mask on the spirometer and fixed it with a CPET turbine(13,14). We believe that this method provides the opportunity to evaluate gas exchange in conditions similar to surgical masks in daily life.
In our findings,
1) There was no statistically significant difference between CPET durations with and without a surgical mask,
2) None of the participants wished to terminate the test due to ventilation-related difficulties,
3) In terms of cardiovascular parameters, our results were in line with the studies conducted by Epstein and Shaw, which did not involve the use of a spirometry mask (Table 2).
However, the detection of a decrease in VO2 max during CPET performed with a surgical mask in our study suggests that masking individuals during maximal exercise may cause a reduction in their exercise capacity and performance. This finding distinguishes our study from the two studies above that did not directly assess aerobic capacity(13,14).
Alterations in Submaximal Exercise (Anaerobic Threshold) Level
The anaerobic threshold level is a frequently used marker for exercise prescribing, especially in endurance sports. Determination of the anaerobic threshold provides the opportunity to evaluate the metabolic response to exercise directly. It reveals the intensity of an exercise to be planned more reliably and more personalized than the calculations made on the VO2 max and HRmax percentages(15).
An exercise performed at the anaerobic threshold level is known as submaximal exercise. In a typical aerobic exercise session, activity is mostly performed at submaximal intensity. For this reason, it is crucial to know whether using a surgical mask during this type of exercise affects the anaerobic threshold level and cardiopulmonary parameters during exercise.
Many studies in the literature evaluate the effects of the mask during submaximal exercise. Lässing et al. stated that using a surgical mask during submaximal exercise, similar to maximal exercise, causes an increase in airway resistance and a decrease in maximum oxygen consumption, but no difference in endurance performance and perceived stress was observed(16). On the other hand, Bar-on et al. stated that brisk walking with a mask for five minutes causes a significant increase in pETCO2 and a slight decrease in oxygen saturation and that the situation may have clinical significance in the elderly and comorbid populations during longer exercise periods(17).
Studies evaluating the effect of surgical mask use on the anaerobic threshold and parameters during the anaerobic threshold are limited. Egger et al., by using a bicycle ergometer in their study, found that with well-trained athletes, the use of surgical masks did not change the anaerobic threshold and exercise parameters during the anaerobic threshold(18).
In our study, although changes were observed in ventilation parameters at the maximum exercise level, no significant change was found in pETCO2 at the anaerobic threshold level. In line with these findings, we can say that possible re-inspiration of exhaled CO2 during a submaximal exercise with a mask may not cause additional metabolic load.
In light of these findings, we think that submaximal exercise can be performed safely with a mask in crowded open areas such as parks and in closed areas such as gyms where the risk of URTI transmission is higher. In the medical literature thus far, we have not come across any study that reports the pETCO2 value at the anaerobic threshold level during exercise with a surgical mask.
Differences Between the Sub-Groups
The results of both subgroups showed similar alterations in the evaluated parameters, but these changes were statistically significant in the athlete group.
Most of the studies we encountered in the literature were conducted with healthy and physically active volunteers(12-14). Egger et al. suggested that the exercise test can be terminated early without complete physical exhaustion due to leg fatigue, lack of motivation, and pain intolerance in poorly trained individuals. They stated that the mask used by individuals in this population might be less deformed(18,19).
They also observed that as the duration of exercise increases in well-trained individuals, there is an increase in sweating and mouth breathing. Furthermore, individuals can achieve higher minute ventilation, which results in more water vapor retention in the surgical mask, leading to deformation of the mask. This effect may adversely affect the maximum exercise performance by causing an increase in respiratory resistance.
Based on these findings and our study results, we believe that a surgical mask has a comparable impact during exercise in individuals with varying physical activity levels, but it appears to have a more pronounced effect on the performance of athletes.
Our data has revealed that surgical masks have a detrimental impact on CPET parameters at the maximum exercise level for both athletes and physically active healthy individuals, but they can still be considered safe. In this regard, athletes and coaches should be mindful of this detrimental effect, especially in situations where peak performance is crucial, such as competitive sports and competitions. In accordance with the findings, we believe that using surgical masks during submaximal exercise does not impose an additional metabolic burden and can be considered safe. We believe that wearing masks while exercising in locations where there is a risk of transmission will have no negative consequences for physically active healthy people. In our opinion, using a surgical mask may also be safe for individuals who have chronic diseases such as diabetes, obesity, and hypertension and who exercise regularly while performing a submaximal exercise. However, further studies with relevant populations are needed to reveal the effects of surgical mask use during exercise in individuals with chronic diseases.
Cite this article as: Yakal S, Taşdemir EN, Dinçer Ş, Devran S, Günver MG, Şahinkaya T, et al. Exercising with a surgical mask is safe but decreases performance in both athletic and non-athletic individuals. Koşuyolu Heart J 2023;26(3):107-114.
This study was approved by the İstanbul University Faculty of Medicine Ethics Committee (Decision no: E-29624016-050.99-196051, Date: 03.05.2021).
This is retrospective study, we could not obtain written informed consent from the participants.
Concept/Design - SY, MA; Analysis/Interpretation - SD, GM; Data Collection - ENT, ŞD; Writing - ŞD, ENT; Critical Revision - GM, ME; Final Approval - TŞ, SY; Statistical Analysis -ŞD, MGG; Overall Responsibility - SY.
The authors have no conflicts of interest to declare.
The authors declare that this study has received no financial support.
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