Article
The Impact of Wearing Different Face Masks on Vigorous
Physical Exercise Performance and Perceived Exertion among
COVID-19 Infected vs. Uninfected Female Students
Nourhen Mezghani 1,†, Achraf Ammar 2,3,4,5,*,† , Omar Boukhris 6,7 , Liwa Masmoudi 4,8,
Mohamed Ali Boujelbane 2,4,9, Rayda Ben Ayed 10,11 , Turki Mohsen Alzahrani 1, Atyh Hadadi 1, Rihab Abid 5,
Ibrahim Ouergui 12,13 , Jordan M. Glenn 14, Khaled Trabelsi 4,8,‡ and Hamdi Chtourou 4,9,‡
1 Department of Sport Sciences, College of Education, Taif University, Taif 21944, Saudi Arabia;
mezghanni.nourhen@yahoo.fr (N.M.); tm.alzahrani@tu.edu.sa (T.M.A.); atyhhadadi@gmail.com (A.H.)
2 Department of Training and Movement Science, Institute of Sport Science,
Johannes Gutenberg-University Mainz, 55099 Mainz, Germany; dbouja@yahoo.com
3 Interdisciplinary Laboratory in Neurosciences, Physiology and Psychology: Physical Activity, Health and
Learning (LINP2), UFR STAPS (Faculty of Sport Sciences), UPL, Paris Nanterre University,
39200 Nanterre, France
4 High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax 3000, Tunisia;
liwa.masmoudi@yahoo.fr (L.M.); trabelsikhaled@gmail.com (K.T.); h_chtourou@yahoo.fr (H.C.)
5 Research Laboratory, Molecular Bases of Human Pathology, LR19ES13, Faculty of Medicine,
University of Sfax, Sfax 3029, Tunisia; isseps.rihababid@gmail.com
6 SIESTA Research Group, School of Allied Health, Human Services and Sport, La Trobe University,
Citation: Mezghani, N.; Ammar, A.; Melbourne 3086, Australia; omarboukhris24@yahoo.com
Boukhris, O.; Masmoudi, L.; 7 Sport, Performance, and Nutrition Research Group, School of Allied Health, Human Services and Sport,
Boujelbane, M.A.; Ben Ayed, R.; La Trobe University, Melbourne 3086, Australia
8
Alzahrani, T.M.; Hadadi, A.; Abid, R.; Research Laboratory, Education, Motricity, Sport and Health (EM2S), LR15JS01, High Institute of Sport and
Ouergui, I.; et al. The Impact of Physical Education of Sfax, University of Sfax, Sfax 3000, Tunisia
9 Physical Activity, Sport, and Health, UR18JS01, National Observatory of Sport, Tunis 1003, Tunisia
Wearing Different Face Masks on 10 National Institute of Agronomy of Tunisia (INAT), University of Carthage-Tunis, 43 Avenue Charles Nicolle,
Vigorous Physical Exercise El Mahrajène 1082, Tunisia; raydabenayed@yahoo.fr
Performance and Perceived Exertion 11 Laboratory of Extremophile Plants, Centre of Biotechnology of Borj-Cédria, B.P. 901,
among COVID-19 Infected vs. Hammam Lif 2050, Tunisia
Uninfected Female Students. Eur. J. 12 High Institute of Sport and Physical Education of Kef, University of Jendouba, El Kef 7100, Tunisia;
Investig. Health Psychol. Educ. 2023, ouergui.brahim@yahoo.fr
13, 2709–2723. https://doi.org/ 13 Research Unit, Sports Science, Health and Movement, University of Jendouba, El Kef 7100, Tunisia
14
10.3390/ejihpe13110187 Department of Health, Exercise Science Research Center Human Performance and Recreation,
University of Arkansas, Fayetteville, AR 72701, USA; jordan@neurotrack.com
Academic Editors: María del Mar * Correspondence: acammar.achraf@uni-mainz.de; Tel.: +49-15236403235
Molero Jurado, Carmen Galán † These authors contributed equally to this work as the first author.
Arroyo, Roxana Paola Palacios ‡ These authors contributed equally to this work as the last author.
Cartagena, José Carmelo Adsuar
and María Mendoza Muñoz Abstract: Under certain circumstances, masks are an effective and immediate solution to reduce the
spread of viral infection. However, the impact of masks on the ability to perform vigorous exercise
Received: 21 August 2023
Revised: 28 October 2023 remains an area of concern. Primarily, this impact has been explored in healthy subjects, yielding
Accepted: 12 November 2023 contradictory findings, and little is known of it among COVID-19-infected individuals. This study
Published: 15 November 2023 examined the effects of surgical masks, N-95 masks, and unmasked conditions on the performance
and perceived exertion (RPE) of infected vs. non-infected young women during high-intensity,
repeated sprint exercise (5mSRT). Following a familiarization session, eighty-three (42 COVID-19-
previously infected (PIG) and 43 non-infected (NIG)), female participants (age 20.02 ± 1.05 years, BMI
Copyright: © 2023 by the authors. 21.07 ± 2.1 kg/m2) were randomly assigned to one of three mask conditions: unmasked, surgical
Licensee MDPI, Basel, Switzerland.
mask, or N95 mask. All participants attended three test sessions (i.e., one session for each mask
This article is an open access article
condition) at least one week apart. At the beginning of each test session, data related to participants’
distributed under the terms and
conditions of the Creative Commons physical activity (PA) and sleep behaviours during the previous week were collected. In each test
Attribution (CC BY) license (https:// session, participants performed the 5mSRT, during which performance indicators (best distance (BD),
creativecommons.org/licenses/by/ total distance (TD), fatigue index (FI) and percentage decrement (PD)) were collected, along with RPE.
4.0/). ANOVA indicated no significant main effects of Groups and Masks, and no significant interaction
Eur. J. Investig. Health Psychol. Educ. 2023, 13, 2709–2723. https://doi.org/10.3390/ejihpe13110187 https://www.mdpi.com/journal/ejihpe
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2710
for Groups × Masks for BD, FI, PD, RPE and most sleep and PA behaviours (p > 0.05). For TD, the
Groups × Mask interaction was significant (p = 0.031 and ηp2 = 0.042). Posthoc analysis revealed, in
the unmasked condition, there was no difference in TD between PIG and NIG (p > 0.05). However,
when wearing a surgical mask, PIG covered lower TD compared to NIG (p < 0.05). Additionally,
different types of masks did not affect TD in NIG, while PIG performed the worst using the surgical
mask (p < 0.05). These results suggest post-COVID-19 individuals can maintain physical fitness
through regular exercise (i.e., sport science curricula) in unmasked conditions, but not when wearing
a surgical mask. Furthermore, the impact of different types of face masks on physical performance
seems to be minimal, particularly in uninfected populations; future research is warranted to further
explore this impact in post-COVID conditions.
Keywords: SARS; post-infection; exercise; physical activity; surgical mask; N95; performance;
intermittent exercise; student; sport science
1. Introduction
According to the World Health Organization (WHO), as of 1 September 2023, more
than 770 million confirmed cases of COVID-19 had been identified, resulting in approxi-
mately seven million deaths. Additionally, more than 13.5 billion vaccine doses have been
administered worldwide [1].
Recent research indicates the majority of COVID-19 cases worldwide develop the
long-COVID syndrome [2]. Long COVID encompasses multiple adverse effects, with new
common pathologies such as cardiovascular, thrombotic, and cerebrovascular disease [3],
where symptoms can last for years [4,5]. Long COVID is associated with all age groups
and all forms of acute disease severity [2]. Most patients with long-onset COVID were
not hospitalised at the time of their COVID-19 initial infection [2], and factors found to
be associated with a higher risk of long COVID include identifying as female [6]. Long
COVID is an area of ongoing research, with many open questions, particularly with regard
to preventive measures likely to enhance individuals’ immunity, while simultaneously
reducing the risk of infection. The WHO recommends revising old strategies against the
disease, such as avoiding crowds in open spaces, wearing masks, and opening windows
in enclosed indoor spaces, even for those who are vaccinated. The aim is to reduce both
individual infection risk and the risk of spreading the virus to others [7].
In conjunction, masks reduce the spread of influenza and severe acute respiratory
syndrome (SARS). Surgical masks and N95 respirators are equally effective in preventing
transmission and limiting disease spread [8], thereby controlling and containing infectious
outbreaks [9,10]. As a result, wearing a mask is still an immediate solution, assistive in all
circumstances of risk for protection from any subsequent viral pandemic [11].
The surgical mask (Figure 1A) is a disposable, high-quality medical mask providing
protection against the release of both large and small airborne particles. However, the
edges of this type of mask may not create a completely airtight seal, allowing for some
air leakage. N95 masks (Figure 1B), when used with respirators, are specifically designed
to filter out dangerous airborne particles. They are engineered to fit snugly around the
face, preventing air leaks. Prior research suggests N95 respirators offer higher degrees of
protection, resulting in fewer observed respiratory and influenza-like illnesses, compared
to surgical options [12,13]. Currently, numerous different standards exist worldwide,
delineating testing procedures for essential factors, including fluid resistance, breathability,
bacterial filtration efficiency (BFE), particle filtration efficiency (PFE), and other parameters
crucial for assessing the quality of face masks [14,15]. This underscores the significance of
studying the effects of various masks, as an enduring and critical subject of research.
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mask types on exercise performance in two distinct groups: “previously infected” (PIG) vs.
“non-infected” (NIG) groups, particularly during high-intensity, intermittent exercise such
  as the 5 m shuttle run test (5mSRT). To provide a better understanding of how mask usage
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2712
affects physical performance, the present study aims to compare the effects of surgical
masks (normal masks), N-95 masks and unmasked conditions on the performance of PIG
vs. NIG during high-intensity, repeated sprint exercise (5mSRT).
We hypothesize that, (i) compared to the unmasked condition, the performance and
the perceived exertion during 5mSRT would be altered using both surgical and N-95 masks,
with more pronounced alteration using the N-95, and (ii) compared to non-infected female
students, previously infected female students would exhibit greater alterations in the 5 m
shuttle run test performance and perceived exertion.
2. Materials and Methods
2.1. Participants
A group of female physical education students volunteered to take part in this study.
To be eligible, participants had to be physically active (e.g., through their studies in the
sport science department), with no contraindications for maximal exercise testing (i.e.,
cardiopulmonary, orthopaedic, or neurological conditions), as confirmed by a medical
doctor. They were requested to refrain from consuming caffeine or engaging in strenuous
exercise 48 h before all trials.
A participant was classified into the PIG if they had undergone COVID-19 testing at a
COVID-19 screening and investigation clinic affiliated with National Guard Health Affairs
and tested positive for the virus. The date of infection for each subject corresponds to the
day they received an SMS notification from the ‘syhatty’ application identifying them as
carriers of the virus. As mandated by the Saudi Arabian government, all candidates in both
the PIG and NIG groups received two doses of the COVID-19 vaccine prior to the start of
the trial procedure.
Prior to the study, all participants provided signed informed consent, and the study
was conducted according to the guidelines of the Declaration of Helsinki and approved by
the Ethics Committee of Taif University, Saudi Arabia.
2.2. Experimental Design
Participants visited the laboratory on a separate occasion, before the experiment.
During this session, they were informed of the study details and requirements; anthro-
pometric measurement and familiarization with the 5 m shuttle run test (5mSRT) were
also performed.
Following the familiarization session, participants randomly attended three test ses-
sions (i.e., without mask, with N95 (Figure 1A), and with surgical mask (Figure 1B),
separated by at least one week. There is no recommendation to wear a mask in the week
before the experiment began or in the weeks in between the test sessions.
Previous research demonstrates that sleep quality and physical activity level have a
substantial impact on physical performance [34–36]. We monitored these parameters using
the IPAQ-SF and the sleep-quality scale to ensure that our results were dependent solely
on mask type and whether or not the patient was infected.
At the beginning of each test session, data related to participants’ physical activity
and sleep behaviors during the last week were collected (i.e., background data for each
test session). In each test session, participants performed the 5mSRT. During the 5mSRT,
participants were asked to express their perceived exertion using the Rating of perceived
exertion (RPE) scale.
2.2.1. 5 m Shuttle Run Test (5mSRT)
In this test, participants were instructed to perform 6 repetitions of 30 s shuttle sprints
with an intermediate recovery of 35 s. Participants focused on performing a maximum
distance sprint by going and returning 5 m, then 10 m, then 15 m, then 20 m, etc., for 30 s.
After each 30 s repetition, a 35 s recovery was permitted. Distance was reported to the
nearest meter. During the recovery phase, participants returned to the starting position
in preparation for the subsequent repetition [37]. Participants performed the test in pairs
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2713
with two investigators to record the results. Based on the distance covered during each
repetition, the following indicators were calculated as suggested by Boukhris et al. [38]:
• BD (m) = the greatest distance covered during a 30 s shuttle,
• TD (m) = total distance covered during the six 30 s shuttles,
• FI (%) was calculated as follows:
FI (%) = [(((shuttle 1 + shuttle 2)/2) − ((shuttle 5 + shuttle 6)/2))/((shuttle 1 + shuttle 2)/2)] × 100.
Additionally, the percentage decrement (PD) during the 5mSRT was calculated as follows:
PD (%) = [((BD × number of sprints) − TD)/(BD × number of sprints)] × 100.
2.2.2. Rating of Perceived Exertion (RPE) Scale
After each repetition of 5mSRT, participants gave their subjective RPE score from 0
(very very light) to 10 (very very hard), according to the French version of the CR10 scale,
validated by Haddad et al. [39]. Immediately after the end of each 30 s repetition, the
participant was shown the RPE scale and asked to report the number from 0 to 10 that
best represented their feeling of exertion. The RPE scale is a reliable indicator of physical
discomfort, has good psychological measurement characteristics, and correlates closely
with several other physiological indicators of fatigue [34]. The following formula was used
to calculate the average RPE score during 5mSRT:
Sum of RPE scores of all repetitions
RPE(AU) =
Number of repetitions
2.2.3. International Physical Activity Questionnaire Short Form (IPAQ-SF)
The data from the IPAQ-SF were added within each item (i.e., vigorous intensity,
moderate intensity, and walking), in accordance with the official IPAQ-SF standards to
determine the overall amount of time spent engaging in weekly PA [40,41]. By adjusting
the reported time for each item by a MET value unique to each PA category, the total
weekly PA (MET-minweek-1) was calculated. According to the official IPAQ recommen-
dations for young and middle-aged adults (18–65 years old), MET values established
were the initial values (original IPAQ): vigorous PA = 8.0 METs, moderate PA = 4.0 METs,
and walking = 3.3 METs. As a fourth and fifth component, respectively, total PA (sum of
completed vigorous, moderate, and walking activities) and sitting time were calculated.
2.2.4. Sleep-Related Measures
Participants were asked about their sleeping hours during the previous night and
average hours of sleep per week, as well as the subjective quality of their sleep the night
before the test on a scale of 0 to 10, where “0” indicates “no sleep,” “5” indicates “some
sleep with a few interruptions,” and “10” indicates “deep, uninterrupted sleep” [35].
2.3. Statistical Analyses
All statistical tests were processed using STATISTICA 13.0 Software (Stat-Soft, Maisons-
Alfort, France). Mean and standard deviation (SD) values were calculated for each variable.
Normality of the distribution was confirmed using the Shapiro–Wilks W-test. A two-way
analysis of variance (ANOVA) (2 levels [group: with previous infection, without previous
infection] × (3 levels [mask conditions: without, N95, FFP2]). When appropriate, post hoc
comparisons were performed, and differences were interpreted using a Bonferroni correc-
tion. Effect sizes were calculated as partial eta-squared (ηp2) to estimate the meaningfulness
of significant differences for the normally distributed variables, with values of 0.01, 0.06
and 0.13 representing small, moderate, and large effect sizes, respectively [42]. Significance
was accepted for all analyses at the level of p < 0.05. Exact p-values are provided.
Eur. J. Investig. Health Psychol. Educ. 2023, 13, x FOR PEER REVIEW  6 
 
meaningfulness of significant differences for the normally distributed variables, with val-
Eur. J. Investig. Health Psychol. Educ. 2u02e3s, o1f3 0.01, 0.06 and 0.13 representing small, moderate, and large effect sizes, respectively  2714
[42]. Significance was accepted for all analyses at the level of p < 0.05. Exact p-values are 
provided. 
33.. RReessuultlst s
3.1. Participant Characteristics
3.1. Participant Characteristics 
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3.2. 5 m Shuttle Run Test and RPE
  Table 1 reports mean values for best distance (BD), total distance (TD), fatigue index
(FI), percentage decrement (PD), and Rating of perceived exertion scale (RPE) among the
different groups, as well as ANOVA results and effect sizes.
As shown in Table 1, the two-way ANOVA indicated no significant main effects of
Groups and Mask, and no significant interaction for Groups × Mask for BD, FI, PD and RPE
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2715
(p > 0.05). However, for the TD, the Groups × Mask interaction was significant (F = 3.566,
p = 0.031, ηp2 = 0.042). The post hoc Bonferroni test showed TD recorded for participants
wearing surgical masks was significantly higher in the NIG compared to the PIG (p < 0.05).
Additionally, for the PIG group, TD was significantly lower with a surgical mask compared
to without a mask (p < 0.05) and a N95 mask (p < 0.05).
3.3. Sleep Parameters
Table 2 reports mean values for sleeping hours in the previous night, average sleeping
hours in the previous week, and sleep quality among the different groups, as well as
ANOVA results and effect sizes.
Results showed sleeping hours during the previous night and sleep quality did not
differ significantly between groups (i.e., PIG and NIG) and conditions (i.e., without a mask,
with a surgical mask, and with a N95 mask).
However, for average sleep duration over the previous week, sleep duration recorded
for participants without a mask was significantly lower in the PIG than the NIG (p < 0.05).
Contrarywise, sleep duration recorded for participants with a N95 mask was significantly
higher in the PIG compared to the NIG (p < 0.05). For PIG, sleep duration was signifi-
cantly higher in participants with the N95 mask compared to participants without a mask
(p < 0.05).
3.4. Physical Activity Behaviors
Table 3 reports mean values for responses to the IPAQ-SF, as well as ANOVA results
and effect sizes.
Regarding vigorous intensity, the number of days/week recorded for participants
with a surgical mask and N90 mask were significantly higher in the PIG than the NIG
(p < 0.05). Additionally, for the PIG, the number of days/week were significantly higher in
participants with a surgical mask and N95 mask compared to participants without a mask
(p < 0.05). However, the number of hours/day and MET values did not differ significantly
between groups (i.e., infected and non-infected) and conditions (i.e., without a mask, with
a surgical mask, and with a N95 mask) (p > 0.05).
Regarding moderate intensity, walking, and all PA activities, the number of days/week
and hours/week, and MET values did not differ significantly between groups (i.e., PIG and
NIG) and conditions (i.e., without a mask, with a surgical mask, and with a N95 mask).
Regarding sitting, the number of hours/day were significantly lower in participants
with a N90 mask compared to participants without a mask in the PIG (p < 0.05). However,
the number of hours/day did not differ significantly between groups (i.e., PIG and NIG)
(p > 0.05).
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2716
Table 1. Best distance (BD), total distance (TD), fatigue index (FI), percentage decrement (PD) and rating of perceived exertion scale (RPE).
Means ± SD Groups Effect Mask Effect Groups × MaskInteraction
Parameters
NIG (N = 41) PIG(N = 42) All Groups (N = 83) F(1,81), p-Value, ηp
2 F(1,81), p-Value, ηp2 F(1,81), p-Value, ηp2
Without mask 100.4 ± 11.5 100.8 ± 18.9 100.6 ± 15.6
With surgical mask 101.2 ± 12.3 119.9 ± 97.6 110.6 ± 69.4 F(1,81) = 1.512, p = 0.222, F(1,81) = 2.072, p = 0.129, F(1,81) = 1.204, p = 0.303,BD (m) 2 2 2
With mask N95 98.3 ± 12.2 99.2 ± 12.1 98.7 ± 12.1 ηp = 0.018 ηp = 0.025 ηp = 0.015
Without mask 501.1 ± 73.6 522 ± 106.8 511.6 ± 91.4
With surgical mask 520.2 ± 95.7 479.2 ± 120.3 ab 499.7 ± 109 F(1,81) = 1.061, p = 0.306, F(1,81) = 0.794, p = 0.454, F(1,81) = 3.566, p = 0.031,TD (m) 2 2 2
With mask N95 516 ± 62.7 516.5 ± 77.2 c 516.2 ± 69.8 ηp = 0.013 ηp = 0.010 ηp = 0.042
Without mask 0.22 ± 0.23 0.18 ± 0.32 0.2 ± 0.28
With surgical mask 0.2 ± 0.27 0.28 ± 0.29 0.24 ± 0.28 F(1,81) = 1.997, p = 0.161, F(1,81) = 2.586, p = 0.078, F(1,81) = 2.086, p = 0.128,FI (%) 2 2 2
With mask N95 0.16 ± 0.09 0.17 ± 0.22 0.17 ± 0.17 ηp = 0.024 ηp = 0.031 ηp = 0.025
Without mask 0.12 ± 0.07 0.42 ± 1.87 0.27 ± 1.33
With surgical mask 0.11 ± 0.05 0.36 ± 1.63 0.24 ± 1.14 F(1,81) = 2.660, p = 0.107, F(1,81) = 0.153, p = 0.858, F(1,81) = 0.156, p = 0.856,PD (%) 2 2 2
With mask N95 0.12 ± 0.06 0.24 ± 0.84 0.18 ± 0.59 ηp = 0.032 ηp = 0.002 ηp = 0.002
Without mask 5.4 ± 1.81 5.11 ± 1.7 5.25 ± 1.76
With surgical mask 5.18 ± 1.76 5.08 ± 1.6 5.13 ± 1.68 F(1,81) = 1.524, p = 0.221, F(1,81) = 0.901, p = 0.408, F(1,81) = 0.932, p = 0.396,RPE (a. u.) 2 2 2
With mask N95 5.35 ± 1.77 4.67 ± 1.64 5.01 ± 1.73 ηp = 0.018 ηp = 0.011 ηp = 0.011
a significantly different from NIG at p < 0.05; b significantly different from “Without mask” at p < 0.05; c significantly different from “With surgical mask” at p < 0.05.
Table 2. Sleeping hours previous night, average hours of sleeping previous week and sleep quality for the two groups.
Means ± SD Groups Effect Mask Effect Groups × MaskInteraction
Parameters
NIG PIG
(N = 41) (N = 42) All Groups (N = 83) F(1,81), p-Value, ηp
2 F(1,81), p-Value, ηp2 F(1,81), p-Value, ηp2
Sleeping hours last Without mask 4.89 ± 2.99 5.32 ± 3.01 5.11 ± 2.99
night (hours) With surgical mask 4.74 ± 2.39 4.58 ± 2.43 4.66 ± 2.39
F(1,81) = 1.010, p = 0.922, F(1,81) = 0.837, p = 0.435, F(1,81) = 0.451, p = 0.638,
2 2 2
With mask N95 5.02 ± 2.23 4.67 ± 2.46 4.85 ± 2.34 ηp = 0.000 ηp = 0.010 ηp = 0.006
Average hours of Without mask 11.37 ± 11.37 7.68 ± 5.97 a 9.53 ± 9.21
sleeping last week With surgical mask 8.34 ± 7.36 9.07 ± 6.02 8.71 ± 6.7 F(1,81) = 0.031, p = 0.860, F(1,81) = 0.548, p = 0.579, F(1,81) = 5.384, p = 0.005,2 2 2
(Hours/week) With mask N95 7.88 ± 6.79 b 12.08 ± 14.89 ab 9.98 ± 11.63 ηp = 0.000 ηp = 0.007 ηp = 0.062
Without mask 5.46 ± 2.65 5.77 ± 2.77 5.62 ± 2.69
Sleep quality (a. u.) With surgical mask 5.66 ± 2.6 5.88 ± 2.43 5.77 ± 2.51 F(1,81) = 0.176, p = 0.676, F(1,81) = 0.341, p = 0.712, F(1,81) = 0.059, p = 0.943,2 2 2
With mask N95 5.37 ± 2.78 5.64 ± 2.57 5.5 ± 2.67 ηp = 0.002 ηp = 0.004 ηp = 0.001
a significantly different from NIG at p < 0.05; b significantly different from “Without mask” at p < 0.05.
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2717
Table 3. Responses to the physical activity questionnaire recorded without mask, with surgical mask and with mask N95 for the two groups.
Means ± SD Groups Effect Mask Effect Groups × Mask Interaction
Parameters
NIG (N = 41) PIG(N = 42) All Groups (N = 83) F(1,81), p-Value, ηp
2 F(1,81), p-Value, ηp2 F(1,81), p-Value, ηp2
Without mask 0.49 ± 1.45 0.68 ± 1.43 0.59 ± 1.44
(Days/week) With surgical mask 0.37 ± 0.7 1.22 ± 2.18 ab 0.79 ± 1.65 F(1,81) = 7.095, p = 0.009, F(1,81) = 0.952, p = 0.388, F(1,81) = 3.616, p = 0.029,
With mask N95 0.29 ± 0.54 1.32 ± 1.72 ab 0.8 ± 1.37 ηp
2 = 0.081 ηp2 = 0.012 ηp2 = 0.043
Without mask 0.29 ± 0.99 0.4 ± 0.65 0.34 ± 0.83
(Hours/week) With surgical mask 0.28 ± 0.64 0.61 ± 1.06 0.45 ± 0.88 F(1,81) = 3.899, p = 0.052, F(1,81) = 0.647, p = 0.525, F(1,81) = 2.494, p = 0.086,Vigorous Intensity 2
With mask N95 0.2 ± 0.46 0.73 ± 1.65 0.47 ± 1.24 ηp = 0.046 ηp
2 = 0.008 ηp2 = 0.030
Without mask 311 ± 915 371 ± 877 341 ± 891
(MET values) With surgical mask 145 ± 372 1274 ± 4060 709 ± 2904 F(1,81) = 3.204, p = 0.077, F(1,81) = 1.336, p = 0.266, F(1,81) = 2.663, p = 0.073,2 2 2
With mask N95 196 ± 355 1270 ± 3905 733 ± 2803 ηp = 0.038 ηp = 0.016 ηp = 0.032
Without mask 1.8 ± 1.48 1.71 ± 1.69 1.76 ± 1.58
(Days/week) With surgical mask 1.51 ± 1.82 1.37 ± 1.75 1.44 ± 1.78 F(1,81) = 0.419, p = 0.520, F(1,81) = 1.624, p = 0.200, F(1,81) = 2.513, p = 0.084,2 2 2
With mask N95 1.51 ± 1.53 2.2 ± 2.02 1.85 ± 1.81 ηp = 0.005 ηp = 0.020 ηp = 0.030
Without mask 0.82 ± 0.8 0.84 ± 0.94 0.83 ± 0.87
Moderate Intensity (Hours/week) With surgical mask 0.89 ± 0.96 1.06 ± 1.22 0.98 ± 1.09
F(1,81) = 0.021, p = 0.885, F(1,81) = 0.635, p = 0.531, F(1,81) = 1.103, p = 0.334,
2 2 2
With mask N95 1.03 ± 1.11 0.8 ± 1.07 0.92 ± 1.09 ηp = 0.000 ηp = 0.008 ηp = 0.013
Without mask 476 ± 555 439 ± 630 457 ± 590
(MET values) With surgical mask 483 ± 634 697 ± 1502 590 ± 1147 F(1,81) = 0.120, p = 0.730, F(1,81) = 0.714, p = 0.491, F(1,81) = 0.634, p = 0.532,2 2 2
With mask N95 563 ± 741 565 ± 987 564 ± 866 ηp = 0.001 ηp = 0.009 ηp = 0.008
Without mask 5.12 ± 2.29 5.12 ± 2.44 5.12 ± 2.35
(Days/week) With surgical mask 5.05 ± 1.97 4.98 ± 2.03 5.01 ± 1.99 F(1,81) = 0.191, p = 0.663, F(1,81) = 0.450, p = 0.638, F(1,81) = 0.150, p = 0.861,2 2 2
With mask N95 5 ± 2.03 4.83 ± 2.08 4.91 ± 2.04 ηp = 0.002 ηp = 0.006 ηp = 0.002
Without mask 2.01 ± 2.3 1.35 ± 1.59 1.68 ± 2
(Hours/week) With surgical mask 2.01 ± 2.2 1.4 ± 1.19 1.7 ± 1.8 F(1,81) = 3.979, p = 0.049, F(1,81) = 1.249, p = 0.290, F(1,81) = 0.070, p = 0.933,Walking 2 2 2
With mask N95 2.56 ± 3.79 1.68 ± 2.13 2.12 ± 3.1 ηp = 0.047 ηp = 0.015 ηp = 0.001
Without mask 2231 ± 2851 1600 ± 2189 1916 ± 2552
(MET values) With surgical mask 2202 ± 2881 1397 ± 1437 1799 ± 2310 F(1,81) = 4.068, p = 0.047, F(1,81) = 0.641, p = 0.528, F(1,81) = 0.257, p = 0.774,2 2 2
With mask N95 2751 ± 3827 1569 ± 1944 2160 ± 3087 ηp = 0.048 ηp = 0.008 ηp = 0.003
Without mask 5.95 ± 1.73 5.88 ± 1.92 5.91 ± 1.82
(Days/week) With surgical mask 5.68 ± 1.89 5.76 ± 1.81 5.72 ± 1.84 F(1,81) = 0.002, p = 0.965, F(1,81) = 0.368, p = 0.693, F(1,81) = 0.899, p = 0.409,2 2 2
With mask N95 5.78 ± 1.8 6.02 ± 1.8 5.9 ± 1.79 ηp = 0.000 ηp = 0.005 ηp = 0.011
Without mask 3.12 ± 2.86 2.59 ± 1.94 2.85 ± 2.45
(Hours/week) With surgical mask 3.18 ± 2.76 3.07 ± 2.41 3.13 ± 2.58 F(1,81) = 0.698, p = 0.406, F(1,81) = 1.543, p = 0.217, F(1,81) = 0.191, p = 0.827,All PA 2 2 2
With mask N95 3.79 ± 3.97 3.21 ± 3.93 3.5 ± 3.94 ηp = 0.009 ηp = 0.019 ηp = 0.002
Without mask 3019 ± 3205 2410 ± 2321 2714 ± 2804
(MET values) With surgical mask 2830 ± 3064 3368 ± 5702 3099 ± 4540 F(1,81) = 0.025, p = 0.876, F(1,81) = 1.214, p = 0.300, F(1,81) = 0.816, p = 0.444,
With mask N95 3509 ± 3968 3404 ± 5827 3457 ± 4942 ηp
2 = 0.000 ηp2 = 0.015 ηp2 = 0.010
Without mask 9.43 ± 4.89 9.2 ± 4.59 9.31 ± 4.72
Sitting (Hours/day) With surgical mask 8.65 ± 3.89 8.75 ± 5.55 8.7 ± 4.75 F(1,81) = 0.008, p = 0.930, F(1,81) = 4.585, p = 0.012, F(1,81) = 0.735, p = 0.481,
ηp2With mask N95 8.48 ± 3.99 7.63 ± 4.15 b 8.06 ± 4.06 b = 0.000 ηp
2 = 0.054 ηp2 = 0.009
a significantly different from NIG at p < 0.05; b significantly different from “Without mask” at p < 0.05.
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2718
4. Discussion
The present study investigated the effect of different mask types on high-intensity,
intermittent exercise performance in PIG vs. NIG. The first main finding revealed that
different mask types did not affect physical performance during the 5mSRT for NIG.
Although these results contradict our initial hypothesis, they are consistent with
Shaw et al.’s findings [44]. In their study, the authors found that wearing surgical fabric
masks or disposable masks had no appreciable impact on performance during intense
exercise in healthy young individuals, as measured by heart rate, arterial oxygen saturation,
tissue oxygenation, and perceived exertion during a cycling ergometry test to exhaustion.
Moreover, our results are consistent with previous studies showing that healthy individuals
tolerate wearing face masks, specially designed to put heavy strain on respiratory muscles,
while exercising for several weeks at high intensity without experiencing adverse effects.
This suggests using a face mask or respirator during exercise is unlikely to be harmful
for healthy people [45]. A review of the literature on the effects of various face masks on
the respiratory system during physical activity also indicates that the impact of masks on
cardiorespiratory responses to physical activity is minimal, and often imperceptible, even
during very intense exercise in healthy individuals [9]. The authors conclude that further
research is required to examine the impacts of different masks on the respiratory system
during exercise, across diverse populations [9].
However, our findings contrast with those of Driver et al. [46], who reported that
wearing cloth face masks increases shortness of breath and discomfort while decreasing
exercise time (−14%) and VO2 max (−29%) during high intensity treadmill running exercise.
Similarly, wearing surgical and FFP2/N95 face masks led to a decrease in maximum
power production during a progressive cycle ergometer test until exhaustion, in healthy
individuals [33]. In contrast to the present findings, another study reported that, compared
to a no-mask condition, individuals experienced higher RPE and a slightly elevated heart
rate while walking at 4 km/h for 6 min on a graduated treadmill (10% rating) while wearing
surgical face masks [47].
The second main finding of the present study indicates that, without a mask, there
was no significant difference in performance between PIG and NIG, which may indicate a
poor association between COVID-19 infection and reduced high-intensity performance in
the studied population.
These findings contrast with the study by Steibeis et al. [48], who reported a reduction
of <80% of predicted values of ventilatory capacity in 56% of infected young subjects
during a cardiopulmonary exercise test (CPET), conducted without masks. The study
identified reduced patients’ respiratory quality of life as a risk factor for adverse CPET
performance [48]. Furthermore, other studies found that COVID-19 convalescents expe-
rienced reduced exercise capacity up to six months after symptom onset, with changes
in respiratory efficiency and maximum oxygen consumption (VO2 peak) being the most
common anomalies [49–53]. Different studies suggest cardiac and respiratory sequelae,
as well as muscle deconditioning, as potential mechanisms underlying the reduction in
functional capacity [45,49,54].
The present lack of difference in physical performance between the PIG and NIG
in the unmasked condition may be explained by several factors. Firstly, it is important
to note our participants were young adults with an average age of 20 ± 1.2; none of
them required hospitalization or displayed severe symptoms during their acute phase of
COVID-19 infection. Reduced VO2 peak, a well-known risk factor of altered high-intensity
running performance, was shown to be associated with dyspnea, hospitalization, and
intensive medical care treatment [49,54] with younger subjects and those with lower BMI
having higher COVID resistance and less frequent hospitalization [48]. Secondly, it is worth
mentioning that all participants were involved, through their academic pursuits in the
sport science department, in regular physical activity, which is known to help maintain
respiratory and muscular function, even after a COVID-19 infection [19].
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2719
However, under the surgical mask condition, TD was significantly reduced in PIG
compared to NIG. These findings partially confirm our second hypothesis, as TD was at
least 7% lower in PIG in the surgical mask condition during the six 30 s shuttle runs. In
general, alterations in the 5mSRT have been previously linked to various factors such as
participants’ age, sleep pattern, and physical activity levels [36,38]. The present difference
between the PIG and NIG populations using the surgical mask is unlikely to be influenced
by any of the abovementioned factors. Age-matched participants showed no difference
in terms of 5mSRT performance using the unmasked condition. Additionally, while sleep
patterns (quantity and quality) did not differ between both groups in both free-mask and
surgical mask conditions, physical performance differed significantly between both groups
during the surgical mask condition. Furthermore, MET values for vigorous, walking,
moderate, and all PA did not differ between the PIG and NIG across all mask conditions.
Differences between both groups were observed in day/week vigorous activity, during
surgical and N95 mask conditions. However, while this difference exists under surgical
and N95 conditions, 5mSRT performance was only higher in NIG during the surgical mask
condition. It seems, therefore, unlikely that physical activity behaviour influenced the TD
performance of PIG while wearing a surgical mask.
Overall, our results suggest regular physical activity may be beneficial in preserving
respiratory and muscular function in young adults following a COVID-19 infection, as evi-
denced by the lack of differences between groups in the unmasked condition. However, the
cumulative effects of a prior COVID-19 infection plus the use of masks during exercise may
negatively impact the performance of PIG, particularly in outcomes requiring sustained
high-intensity exercise, such as the TD of the 5mSRT test.
According to present findings, TD was decreased in PIG using a surgical mask com-
pared to no mask and the N95 conditions by 8.23% and 7.17%, respectively.
The lower performance using the surgical mask compared to the unmasked condition
is understandable, as wearing a mask is known to make individuals uncomfortable, increase
their breathing resistance, and reduce their airflow, which can lead to fatigue and poorer
performance [30]. However, the poor performance using the surgical mask compared to the
N95 mask was surprising. Previous research indicates that, while N95 offers the greatest
protection and the highest filtration effectiveness, it has greater breathing resistance than
surgical masks [15,55–57].
Li et al. [56] reported that N95 masks had significantly higher rating for perceptions of
heat, humidity, breath resistance, and overall discomfort compared to surgical face masks.
However, in terms of carbon dioxide inhalation, a more recent study found wearing masks
during a moderate physical activity (walking at a speed of 5 km h–1), resulted in an average
carbon dioxide concentration of 2875 ppm, with no significant differences between surgical,
cloth, or N95 face masks [58]. Importantly, the authors concluded that, according to the
existing literature, this concentration could not have a toxicological effect.
Taken together, it seems that using a face mask makes exercising more difficult due
to CO2 rebreathing; the effect can be mainly attributed to the user’s feeling of greater
ventilation rather than a toxicological increase in PaCO2 [9]. This assumption can offer
insight into the poorer performance recorded in the present study using the surgical mask
compared to the unmasked and N95 mask conditions. Nevertheless, it is not possible
to provide a firm conclusion on this subject, as the present study lacks measurement of
ventilation perception and other physiological parameters.
This assumption is in line with the findings from a recent review on the effects of
different face masks and respirators on the respiratory system during physical activity.
This review encompassed data from several models, including fabric face covers and
surgical masks, N95 respirators, industrial respirators, and high-resistance or high-dead-
space applied breathing loads. Overall, the available information from the reviewed
studies indicates that, while activity may cause changes in perceived exertion and dyspnea,
the effects of face masks on breathing, blood gases, and other physiological parameters
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2720
during physical activity are minimal, too minimal to be noticed, even during very intense
exercise [9].
Limitations of the Study
This study represents a pioneer effort to compare high-intensity shuttle run perfor-
mance and perceived exertion using surgical, N95, and no masks among uninfected vs.
previously infected populations. However, the study group was small and only included
young female students. Therefore, results cannot be extrapolated to the general popula-
tion. Moreover, additional physiological measures are required to objectively explain the
reduction in TD observed only in the surgical mask condition among the PIG.
5. Practical Recommendation
In a post-pandemic scenario, even with zero cases and widespread vaccinations, the
lasting effects of the COVID-19 pandemic persist, underscoring the ongoing importance
of immune system building and preventive measures. The use of various masks is an
efficient preventive measure that does not hinder intense, intermittent physical activity
for individuals, whether they are previously infected or uninfected. It is crucial for both
infected and uninfected individuals to engage in regular physical activity, especially high-
intensity intermittent activities, as this contributes to the enhancement of the immune
system and overall physical health.
6. Conclusions
The present study showed that, under the unmasked condition, there were no differ-
ences in 5mSRT performance between previously infected and uninfected active female
students enrolled in sport science programs. However, when wearing a surgical mask, PIG
covered significantly lower TD compared to NIG. These results suggest post-COVID-19
individuals can maintain physical fitness through regular exercise (i.e., sport science cur-
ricula), when exercising without a mask. Additionally, different types of masks did not
seem to affect the 5mSRT performance of NIG, whereas PIG exhibited poorer performance
when wearing a surgical mask. Accordingly, the impact of different types of face masks on
physical performance is suggested to be minimal, particularly in the uninfected population.
Nonetheless, this impact remains an active area of research among post-COVID individuals.
Future large-scale research is warranted to gain further insight into the impact of differ-
ent masks on different physical performance indicators and the associated physiological
responses among post-COVID individuals.
Author Contributions: Conceptualization, N.M., A.A., K.T. and H.C.; Data curation, N.M.; Formal
analysis, A.A., O.B. and L.M.; Investigation, N.M. and A.A.; Methodology, N.M., A.A., O.B., M.A.B.,
R.B.A., T.M.A., A.H., R.A., I.O., J.M.G., K.T. and H.C.; Project administration, A.A.; Supervision, A.A.,
K.T. and H.C.; Validation, N.M., A.A., O.B., L.M., M.A.B., R.B.A., T.M.A., A.H., R.A., I.O., J.M.G.,
K.T. and H.C.; Writing—original draft, N.M. and A.A.; Writing—review & editing, A.A., O.B., L.M.,
M.A.B., R.B.A., T.M.A., A.H., R.A., I.O., J.M.G., K.T. and H.C. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The protocol was fully approved by the local scientific
research ethics committee of Taif University (HAO-02-T-105).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are available from the first author upon reasonable request.
Acknowledgments: The authors wish to thank the volunteer participants for their contribution and
valuable time throughout the experiment. The authors would like to thank Taif University, Saudi
Arabia for supporting this study.
Conflicts of Interest: The authors declare no conflict of interest.
Eur. J. Investig. Health Psychol. Educ. 2023, 13 2721
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