medicina

Case Report
Effects of High Intensity Plank Exercise on Physical Fitness and
Immunocyte Function in a Middle-Aged Man: A Case Report
Sang-Kyun Park 1 , Ki-Soo Lee 1 , Seung-Jae Heo 1, * and Yong-Seok Jee 2,3, *

1 Department of Physical Education, Chungnam National University, Daehak-ro, Yuseong-gu,

Daejeon 34134, Korea; [email protected] (S.-K.P.); [email protected] (K.-S.L.)
2 Department of Exercise Immunity for Cancers, Seoul Songdo Hospital, Dasan-ro, Jung-gu, Seoul 04597, Korea
3 Department of Leisure and Marine Sports, Hanseo University, Hanseo 1-Ro, Haemi-myeon,
Seosan 31962, Korea
* Correspondence: [email protected] (S.-J.H.); [email protected] (Y.-S.J.); Tel.: +82-41-660-1028 (Y.-S.J.)

Abstract: Background and Objectives: Although the plank exercise is difficult to perform for untrained
people, it does not require money, special equipment, or much space. However, it is not known how
plank exercises affect physical fitness and immunocyte function. This study analyzed the changes in
physical fitness and immune cells of a middle-aged man after performing 4 weeks of elbow plank
exercise. Materials and Methods: Elbow plank exercise was performed for approximately 20 min
(resting time, around 10 min) a day, 5 days a week for 4 weeks. The intensity was checked daily
with ratings of perceived exertion (RPE). When the participant reached an intensity of RPE 15, RPE
16, and RPE 17 of the RPE 20 scale, 1 min of rest was given before repeating the process. Results:
Compared with the pre-values, (1) all the physical fitness factors (muscle strength, muscle endurance,





 flexibility, and cardiopulmonary fitness) were increased after 4 weeks; (2) body weight, skeletal
muscle mass, and the basal metabolic rate were increased, whereas body fat mass and fat percentage
Citation: Park, S.-K.; Lee, K.-S.; Heo,
S.-J.; Jee, Y.-S. Effects of High Intensity
were decreased; and (3) although the variables of complete blood count were changed positively,
Plank Exercise on Physical Fitness some were not. Specifically, CD3, CD8, and CD56 were increased, whereas CD4, CD4/CD8, and
and Immunocyte Function in a cytotoxicity were decreased. These results show that elbow plank exercise can improve all factors of
Middle-Aged Man: A Case Report. physical fitness and improve some of the immunocyte functions of a middle-aged man. Conclusions:
Medicina 2021, 57, 845. https:// This study confirmed that, although the elbow plank exercise of vigorous intensity for 4 weeks
doi.org/10.3390/medicina57080845 improved physical fitness, it was not effective in improving some immunocyte functions. Therefore,
the exercise intensity of plank exercises for improving immunocyte functions should be reconsidered.
Academic Editors: Marcin Kurowski
and Radosław Gawlik Keywords: plank exercise; physical fitness; muscle mass; CD56; cytotoxicity

Received: 25 July 2021

Accepted: 17 August 2021
Published: 20 August 2021
1. Introduction
Publisher’s Note: MDPI stays neutral
The Korea Disease Control and Prevention Agency reported that 35.4% of the nation’s
with regard to jurisdictional claims in
population lacked physical activity (PA) [1]. This lack of PA is of increasing interest because
published maps and institutional affil- it also affects the high mortality rate [2]. Recently, social distancing has become mandatory
iations. due to the COVID-19 pandemic, so outdoor activities have decreased, and sedentary
lifestyles have increased, resulting in a relative decrease in the amount of PA. In most cases,
but not in all cases, lack of PA leads to obesity and impairs the function of immune cells to
defend against foreign cells, such as the coronavirus [3].
Copyright: © 2021 by the authors.
Exercise is a helpful way to reduce body weight and can prevent obesity by main-
Licensee MDPI, Basel, Switzerland.
taining and/or increasing the muscle mass and basal metabolic rate [4]. Moreover, it
This article is an open access article
can improve immune cell function [5–11]. In other words, during the present COVID-19
distributed under the terms and pandemic, exercise is a necessity, not an option [12]. Considering the recent mandatory
conditions of the Creative Commons social distancing, it is important to find and perform exercises that can be done alone at
Attribution (CC BY) license (https:// home [13]. Recently in Korea, home training is trending since it allows individuals to
creativecommons.org/licenses/by/ exercise by themselves in the comfort of their own homes. Since it requires little time, space,
4.0/). and cost, many studies are being conducted on its efficacy [14].

Medicina 2021, 57, 845. https://doi.org/10.3390/medicina57080845 https://www.mdpi.com/journal/medicina

Medicina 2021, 57, 845 2 of 10

Plank exercise is a movement derived from Pilates, yoga, and stretching, and can be
performed by anyone with minimal spatial requirements. Since plank exercise can be used
as a whole-body exercise, it is possible to expend a large amount of calories and develop
muscles in a short period of time [14]. Some studies have shown that plank-type exercises
are effective in developing strength and endurance [15,16], in reducing low back pain [17],
and in preventing falls [18]. Though past studies have shown plank exercise to be effective
in engaging the core muscles of the human body, it is not known what kind of change it
provides to the immune cells of the human body. Therefore, this study was conducted
to observe changes in physical fitness and immunocyte function in a male subject after
performing plank exercises at home.

2. Materials and Methods

2.1. Participant
A 43 year-old male, who had no experience performing plank exercises, voluntarily
participated in the study. Before the start of the experiment, his height and body weight
were measured at 168.6 cm and 80.4 kg, respectively. He played basketball on a regular
basis 10 years ago, but now his main physical activity is only walking for 30 min twice a
day. He had no cardiac or metabolic disease, but his father had hypertension. He has been
smoking a pack of cigarettes a day and drank moderately about three days a week. He had
not been taking any medication. Of course, we recommended abstaining from exercise,
smoking, and alcohol consumption for one month during the experiment.

2.2. Experimental Design

This prospective case study compared pre-values with post-values and was conducted
at Seoul Songdo Hospital from May 28 to 26 June 2021. It followed the principles of the
Declaration of Helsinki and received approval from the institutional ethics committee (Sah-
myook Univ. 2-1040781-A-N-012020085HR). Prior to the study, the principal investigator
explained all the procedures to the participant before he read and signed an informed
consent form. He completed a self-report questionnaire about his health status and learned
how to record the ratings of perceived exertion (RPE) in a diary. The assessments were
performed at Week 0 (baseline) and at Week 4. Plank exercises were used as the intervention
program, which were conducted for 4 weeks, 5 days a week, for 20 min (+ a rest time of
10 min) a day. The physical fitness variables measured were body composition, muscle
strength, muscle endurance, flexibility, and cardiopulmonary fitness. Other dependent
variables included complete blood count (CBC), lymphocytes, and granulocytes.

2.3. Measurement Methods

2.3.1. Blood Sampling and Immunocyte Measures
This study investigated the changes of CBC, lymphocyte, and granulocytes subsets.
The percentage (%) and absolute cell counts of peripheral blood cell subsets were analyzed
as described below: 50 µL of blood were stained with anti-human antibodies against anti-
CD3, anti-CD4, anti-CD8, and anti-CD56 from BD Biosciences (Franklin Lakes, NJ, USA).
After incubation for 15 min at room temperature (RT) in the dark, the red blood cells (RBC)
were lysed by adding 450 µL of FACS lysing solution to each test tube for 15 min at RT in
the dark. Another intracellular staining step was required for analysis of regulatory T cells,
cytotoxic T cells, and immune checkpoint molecules. After the lysis of RBC, the remaining
cells were washed in 2 mL of permeabilization buffer. After staining was completed, cells
were analyzed using FACS Canto II (BD Bioscience) and Flowjo software (Treestar, Ashland,
OR, USA) and are presented as percentages. Absolute cell counts of the lymphocyte subsets
were obtained using an automatic hematology analyzer (Sysmex Corp., Kobe, Japan). The
analyzed CBC subsets consisted of white blood cells (WBC), RBC, hemoglobin, hematocrit,
platelets, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean
corpuscular hemoglobin concentration (MCHC), erythrocyte sedimentation rate (ESR), red
cell distribution width (RDW), and platelet distribution width (PDW). Percentage analysis
 the lymphocyte subsets were obtained using an automatic hematology analyzer (Sysmex
Corp., Kobe, Japan). The analyzed CBC subsets consisted of white blood cells (WBC), RBC,
hemoglobin, hematocrit, platelets, mean corpuscular volume (MCV), mean corpuscular
hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), erythrocyte
Medicina 2021, 57, 845 sedimentation rate (ESR), red cell distribution width (RDW), and platelet distribution 3 of 10
width (PDW). Percentage analysis for granulocytes were composed of neutrophils, lym‐
phocytes, monocytes, eosinophils, and basophils. The analyzed immunocytes were a lym‐
phocyte subset of immunophenotypes, which were CD3, CD4, CD8, CD56, and CD4/CD8.
for
Thegranulocytes
cytotoxicitywere composed
refers of neutrophils,
to the volume of naturallymphocytes, monocytes,
killer (NK) cells eosinophils,
against viral, andor
bacterial,
basophils. The
cancerous cells.analyzed immunocytes were a lymphocyte subset of immunophenotypes,
which were CD3, CD4, CD8, CD56, and CD4/CD8. The cytotoxicity refers to the volume of
natural killer (NK)
2.3.2. Physical cellsMeasures
Fitness against viral, bacterial, or cancerous cells.

2.3.2. In this study,

Physical theMeasures
Fitness health‐related physical fitness components included body compo‐
sition, muscle strength, muscular endurance, flexibility, and cardiopulmonary endurance,
In this study, the health-related physical fitness components included body composi-
which was measured using a graded exercise test. Firstly, body composition was meas‐
tion, muscle strength, muscular endurance, flexibility, and cardiopulmonary endurance,
ured using a bioelectrical impedance analysis method with a body composition analyzer
which was measured using a graded exercise test. Firstly, body composition was measured
(Inbody 770, Biospace, Seoul, Korea). The variables of body composition in this study were
using a bioelectrical impedance analysis method with a body composition analyzer (In-
height,
body weight,
770, skeletal
Biospace, muscle
Seoul, Korea).mass,Thefatvariables
mass, body masscomposition
of body index (BMI), in fatthis
percentage,
study were and
basal metabolic rate (BMR) [19]. Secondly, muscle strength
height, weight, skeletal muscle mass, fat mass, body mass index (BMI), fat percentage,was measured using a grip
strength
and basaltest with a Smedley
metabolic rate (BMR) dynamometer (TKK‐5401,
[19]. Secondly, muscleTakei Inc.,was
strength Tokyo, Japan). The
measured using sub‐
a
ject strength
grip held the dynamometer
test with a Smedley whiledynamometer
his arms did not contact the
(TKK-5401, body.
Takei After
Inc., bothJapan).
Tokyo, hands wereThe
alternately
subject held measured twice, the
the dynamometer maximum
while his arms value
did was recorded,
not contact theand theAfter
body. meanboth
value from
hands
both hands was used [20]. Thirdly, muscle endurance was
were alternately measured twice, the maximum value was recorded, and the mean value measured using a sit‐up test
for 60 s [21]. The subject lay down with his back on the floor,
from both hands was used [20]. Thirdly, muscle endurance was measured using a sit-up bended his knees at right
angles,
test for 60fixed hisThe
s [21]. feetsubject
on thelay sit‐up
downboard,
withand placed
his back on his
the hands behind his
floor, bended hisknees
head atwith his
right
fingersfixed
angles, crossed. The on
his feet total
thenumber of completed
sit-up board, and placedsit‐ups
hiswas
handsrecorded.
behindFourthly,
his head flexibility
with his
was measured
fingers crossed. Theusing a sit‐and‐reach
total test that sit-ups
number of completed measured wasthe degree Fourthly,
recorded. to which flexibility
the upper
was measured using a sit-and-reach test that measured the degree to which the uppersubject
body bends forward in a sitting position with both legs fully outstretched. The body
took off
bends his shoes
forward in aand sat position
sitting with his with
kneesboth
straightened
legs fullybefore bendingThe
outstretched. his subject
upper body
took offfor‐
ward
his shoesandandextending
sat with hishis head
kneestoward the scale
straightened above
before a flexibility
bending meter
his upper body(TKK1859,
forwardTakeiand
Inc., Tokyo,
extending hisJapan). The maximum
head toward the scale value
aboveof two measurements
a flexibility was recorded
meter (TKK1859, [22].Tokyo,
Takei Inc., Lastly,
this study
Japan). The assessed
maximum thevalue
maximalof two oxygen uptake (VO
measurements was 2max) for cardiopulmonary
recorded fitness
[22]. Lastly, this study
using a the
assessed graded exercise
maximal oxygen test.uptake
The devices
(VO2 max) usedforincluded an electrocardiogram
cardiopulmonary fitness using a (Q‐4500,
graded
SunTechtest.
exercise Medical, Inc., Morrisville,
The devices used included NC,anUSA), automatic sphygmomanometer
electrocardiogram (Q-4500, SunTech Medical,(M‐412),
gas Morrisville,
Inc., tester (QMC4200),
NC, USA), and automatic
treadmill (Q65‐90, Quinton, New
sphygmomanometer Kent County,
(M-412), gas tester VA, USA). The
(QMC4200),
Bruce
and protocol
treadmill was used,
(Q65-90, whichNew
Quinton, consisted of StageVA,
Kent County, 1 (5USA).
metabolic equivalents;
The Bruce protocol METs),
was
Stagewhich
used, 2 (7 METs), Stage
consisted of3Stage
(9 METs), Stage 4 (11
1 (5 metabolic METs), andMETs),
equivalents; subsequent
Stage stages that followed
2 (7 METs), Stage 3
(9similar
METs),increases.
Stage 4 (11 TheMETs),
subjectand subsequent
continued stagesorthat
to walk runfollowed similaran
until reaching increases. The
all‐out level,
subject
which is continued to walk
their maximal RPE.or The
run VO
until reaching
2max an all-outusing
was calculated level,body
which is their
weight at amaximal
peak test
RPE.
stageThe VO2 max was calculated using body weight at a peak test stage [23].
[23].

2.4.
2.4.Exercise
ExerciseProgram
Program
Elbow
Elbow plankexercise
plank exercisewas wasperformed
performed forfor
thethe
study. Lying
study. stretches
Lying werewere
stretches performed for
performed
5for
min before and after the plank exercise. In the work-out phase, the participant maintained
5 min before and after the plank exercise. In the work‐out phase, the participant main‐
atained
straight, strong line
a straight, from
strong linehead
fromtohead
toestowith
toesno lowering
with of theof
no lowering hips
thewith the shoulders
hips with the shoul‐
and elbows flexed at 90 ◦ , as shown in Figure 1.
ders and elbows flexed at 90°, as shown in Figure 1.

Figure 1. Elbow plank exercise at home.

In this study, Borg’s 20-scale RPE chart for deciding his plank intensity was copied to
the size of the palm of the hand and provided to the participant. By referring to various
studies in the literature [14,24,25], the plank exercise was conducted with the goal of
reaching an extremely high intensity. The exercise intensities for elbow plank ranged
from RPE 15 (feeling hard) and RPE 17 (feeling extremely hard). Each 30-min session was
divided into three 10-min stages, each with increasing intensity. In other words, elbow
Medicina 2021, 57, 845 4 of 10

plank exercises were performed until reaching RPE 15 (hard) in the first 10 min, RPE 16
(hard to very hard) in the second 10 min, and RPE 17 (very hard) in the third 10 min.
The same posture was maintained until reaching the target RPE for each stage. When the
target RPE was reached, the subject took rested for 1 min and then restarted throughout
the approximate 30-min duration. In other words, if each intensity was exceeded and the
correct plank posture was not achieved, 1 min was allowed to rest, to then re-execute.
As shown in Table 1, the average plank exercise time performed by the subject in the
first week was 17.22 min, and the rest time was 14 min, making the total program 31.22 min
long. On the other hand, the average plank exercise time of Week 2 was 16.81 min, and
the rest time was 13.4 min, giving a total of 30.21 min. The average plank exercise time of
the 3rd week was 17.68 min, and the rest time was 13 min, for a total of 30.68 min. Finally,
the average plank exercise time of Week 4 was 18.07 min, and the rest time was 12.6 min,
which gave a total of 30.67 min. That is, in this study, the set time at RPE 15 and RPE 16
was adjusted to match the total program time to around 30 min, and the time at RPE 17
was not adjusted for high-intensity plank exercise.

Table 1. Plank exercise time and resting time of the participant.

Plank Exercise Resting Time

Days Total (Minutes)
Seconds Minutes Seconds Minutes
Day 1 1079.00 17.98 840.00 14 31.98
Day 2 1049.00 17.48 840.00 14 31.48
Day 3 1026.00 17.10 840.00 14 31.10
Week 1
Day 4 1028.00 17.13 840.00 14 31.13
Day 5 985.00 16.42 840.00 14 30.42
Mean 17.22 14.00 31.22
Day 1 1052.00 17.53 840.00 14 31.53
Day 2 1034.00 17.23 780.00 13 30.23
Day 3 1023.00 17.05 780.00 13 30.05
Week 2
Day 4 983.00 16.38 780.00 13 29.38
Day 5 951.00 15.85 840.00 14 29.85
Mean 16.81 13.40 30.21
Day 1 1108.00 18.47 780.00 13 31.47
Day 2 1051.00 17.52 780.00 13 30.52
Day 3 1066.00 17.77 780.00 13 30.77
Week 3
Day 4 1079.00 17.98 780.00 13 30.98
Day 5 999.00 16.65 780.00 13 29.65
Mean 17.68 13.00 30.68
Day 1 1071.00 17.85 720.00 12 29.85
Day 2 1085.00 18.08 780.00 13 31.08
Day 3 1029.00 17.15 720.00 12 29.15
Week 4
Day 4 1106.00 18.43 780.00 13 31.43
Day 5 1130.00 18.83 780.00 13 31.83
Mean 18.07 12.6 30.67

2.5. Data Analyses

Microsoft Excel (Microsoft, Redmond, WA, USA) was used to organize the data. In
order to observe changes before and after the plank exercises, the delta percentage (∆%)
was calculated using the formula of ‘{(post data − pre data)/pre data} × 100’ for all data.

3. Results
3.1. Effect of Plank Exercise on Complete Blood Count
As shown in Table 2, the WBC, RBC, hemoglobin, hematocrit, and platelets increased,
whereas MCV, MCH, and MCHC decreased after 4 weeks. Meanwhile, the ESR showed
no changes after 4 weeks of plank exercise. In addition, although the RDW decreased, the
Medicina 2021, 57, 845 5 of 10

PDW increased. These results indicate that elbow plank exercise may change the blood
components in middle-aged men after 4 weeks.

Table 2. Changes in complete blood counts.

Baseline Week 4 ∆%
White blood cell (×103 /µL) 6.1 6.7 9.84
Red blood cell (×106 /µL) 4.8 5.1 6.25
Hemoglobin (g/dL) 15.4 16.2 5.19
Hematocrit (%) 43.4 45.9 5.76
Platelets (×103 /µL) 266 274 3.01
Mean corpuscular volume (fL) 89.9 89.5 −0.44
Mean corpuscular hemoglobin (pg) 31.9 31.6 −0.94
Mean corpuscular hemoglobin
35.5 35.3 −0.56
concentration (g/dL)
Erythrocyte sedimentation rate (mm/hr) 4 4 0
Red cell distribution width (%) 11.6 11.4 −1.72
Platelet distribution width (%) 13.4 16.6 23.88
All values are expressed as original data. ∆% means changed ratio, which get from {(post data − pre data)/pre
data} × 100.

3.2. Effect of Plank Exercise on Lymphocytes and Granulocytes

As shown in Table 3, although the neutrophil and basophil increased, the lymphocytes,
monocytes, and eosinophils decreased after 4 weeks. Meanwhile, although the CD3, CD8,
and CD56 increased, the CD4, CD4/CD8, and cytotoxicity decreased. These results indicate
that elbow plank exercise may affect the immunocyte function in middle-aged men. In
particular, when looking at the changes in NK cell-related functions, it appears that the
plank exercises led to notable improvements after just 4 weeks.

Table 3. Changes in granulocytes and immunocytes.

Baseline Week 4 ∆%
Neutrophil (%) 53.9 55.7 3.34
Lymphocyte (%) 34.8 34.5 −0.86
Monocyte (%) 7.7 6.4 −16.88
Eosinophil (%) 3.3 3 −9.09
Basophil (%) 0.3 0.4 33.33
CD3 (%) 67.5 68 0.74
CD4 (%) 38.4 33.7 −12.24
CD8 (%) 29.1 34.3 17.87
CD56 (%) 7.26 7.33 0.96
CD4/CD8 (%) 1.32 0.98 −25.76
Cytotoxicity (%) 25.54 7.71 −69.81
All values are expressed as original data.

3.3. Effect of Plank Exercise on Body Composition

As shown in Table 4, body weight, skeletal muscle mass, BMI, and BMR increased,
whereas body fat mass and body fat percentage decreased after 4 weeks. These results
show that elbow plank exercise can change the body composition of middle-aged men. In
particular, performing plank exercises for 4 weeks showed an increase in total body weight
due to an increase in skeletal muscle mass (3.10%) and a change in body fat mass (−2.98%).
Medicina 2021, 57, 845 6 of 10

Table 4. Changes in body composition.

Baseline Week 4 ∆%
Weight (kg) 80.4 81.5 1.37
Skeletal muscle mass (kg) 32.3 33.3 3.1
Body fat mass (kg) 23.5 22.8 −2.98
Body mass index (kg/m2 ) 28.6 28.7 0.35
Body fat percentage (%) 29.2 28.6 −2.05
Basal metabolism rate (kcal) 1599 1638 2.44
All values are expressed as original data.

3.4. Effect of Plank Exercise on Physical Fitness Levels

As shown in Table 5, muscle strength, muscle endurance, flexibility, and maximum
oxygen uptake increased after 4 weeks of plank exercise. These results indicate that 4 weeks
of elbow plank exercise can improve the health physical fitness of middle-aged men.

Table 5. Changes in health physical fitness components.

Baseline Week 4 ∆%
Muscle strength (kg) 41.75 42.65 2.16
Muscle endurance (reps) 28 35 25
Flexibility (cm) −6 3 150
VO2 max (ml/kg/min) 35.6 36.3 9.84
All values are expressed as original data.

4. Discussion
This study found that elbow plank exercise improved the body composition and
increased the health-related physical fitness in a middle-aged man, leading to desirable
changes in immunocyte function. In the health-related fitness results of this study, plank
exercise was associated with a decreasing tendency in body weight, including fat levels, and
maintaining or enhancing skeletal muscle mass and the basal metabolism rate. Furthermore,
this study found that the body weight, skeletal muscle mass, BMI, and BMR increased,
whereas body fat mass and fat percentage decreased after 4 weeks. These results show
that plank exercise can improve the body composition of middle-aged men. In particular,
4 weeks of elbow plank exercises led to an increase in total body weight due to an increase
in skeletal muscle mass (+3.10%) and a change in body fat mass (−2.98%).
Innate immunity involves macrophages, neutrophils, dendritic cells, and NK cells.
The acquired immune response involves B cells and T cells (CD4+ and CD8+) [26]. In the
aspect of immunocyte functions in this study, although the neutrophils, basophils, and
NK cells (CD56) increased, the lymphocytes, monocytes, and eosinophils decreased after
4 weeks. Meanwhile, the total T cell (CD3) and cytotoxic T cell (CD8) increased, while the
helper T cell (CD4), CD4/CD8, and cytotoxicity decreased. These results show that ‘hard’
to ‘very hard’ plank exercise changed the immunocyte functions in a middle-aged man. In
particular, when looking at the reduced cytotoxicity related to NK cell functions, it appears
that 4 weeks of plank exercises were effective.
It has been reported that exercise should be a part of a treatment program for treating
chronic disease. Recently, the coronavirus has disrupted the immunocytes of many people
as a result from mid- to long-term isolation [12]. In this respect, the results of this study
are considered to be meaningful for the current global situation. The purpose of this
study was to understand how the plank exercise, an exercise that can be performed alone
at home, affects the immunocyte function and physical strength of a single subject. For
immunocyte function, Pedersen [27] reported that exercise influences both innate and
acquired immunity. Inkabi et al. [28] reported that different immunocyte types are affected
differently by physical exercise. In this study, the lymphocyte percentage, which is related
to innate immunity, somewhat decreased from the baseline (34.8%) to Week 4 (34.5%).
Moreover, similar to lymphocyte percentage, this study observed a reduction in NK cell
Medicina 2021, 57, 845 7 of 10

percentage and cytotoxicity percentage. This result indicates that although regular exercise
leads to positive changes in innate immune function, vigorous exercise may cause negative
changes. Previously, Gleeson [29] and Pedersen and Hoffman-Goetz [30] reported that
NK cells increase in abundance during exercise, while the NK cell count drops to below
half of the normal level after exercise. Del Giacco et al. [26] also indicated that an increase
in NK cells, as measured as a percentage of lymphocytes in peripheral blood, enhances
cytolytic capacity. A decrease in the level of NK cells results in suppression of cytolytic
activity, which may indicate an enhanced period of susceptibility to infections [31]. NK
cells are remarkably sensitive to the stress induced by physical exercise, which promotes
their redistribution from the peripheral blood to other tissues after physical exercise [26].
There is an increase in the number of NK cells in the peripheral blood that are transported
to other tissues during physical exercise due to induced stress signals; the target tissues
should be reached before the cessation of physical exercise, with the blood serving as a
highway to traffic NK cells to the sites of stress signaling [32]. Similarly, the results of this
study showed that the NK cell levels, which are related to innate immunity, tended to
decrease with exercise. In other words, the hard to intense plank exercise in this study did
not change the levels of NK cells, whereas the levels of cytotoxicity in the peripheral blood
decreased due to overstressed signals. Similar to the results of this study, Pedersen [27]
reported that a moderate amount of exercise provides an overall “boost” to the immune
system, but strenuous exercise results in dampening of the immune system.
Previous studies suggest that physical exercise is important for innate immune func-
tion, but more important for acquired immune function. Taking the above studies into
account, Fabbri et al. [33] showed that a crucial consequence of defective T cell function is
an increased incidence of viral infections. B cells produce antibodies, which are released
to destroy invading viruses and bacteria [34]. CD4+T cells function to activate cells of
the innate immune system, such as B lymphocytes and cytotoxic T cells. CD4+T cells
are also involved in the suppression of immune reactions [35]. Similarly, the results of
this study showed that the helper T cell count (CD4), a marker of adaptive immunity,
decreased in the participant, whereas the CD4/CD8 ratio decreased −25.76% at Week 4
compared to the baseline. In other words, regular plank exercise produced a decrease in
the helper T cell population while suppressing cytotoxic immune cells. In addition, this
study showed that the CD8 T cell percentage increased. These changes in adaptive immune
cells significantly increased cytotoxicity, revealing that the apoptotic activity of NK cells
and WBC can actively contribute to the killing of bad cells. During physical exercise, CD4+
and CD8+T cells, also known as helper and cytotoxic T cells, respectively, were recruited to
the peripheral blood, resulting in increased concentrations of lymphocytes. In general, it is
known that the functions of B cells are suppressed after intense, long-duration exercise,
while lymphocyte concentrations have been shown to increase during acute exercise and
fall below the pre-workout values after long-term endurance exercise [26,36]. However,
Pedersen and Nieman [37] reported that the total lymphocyte concentration declines after
acute exercise and the proliferation response is unchanged compared to the response before
exercise. Physical exercise induces a greater early increase in catecholamines that affects
different types of lymphocytes, resulting in their mobilization in the blood [38]. In other
words, this study implies that changes in immunocyte function occur simultaneously with
changes in fitness-related variables.
Strenuous exercise, but not moderate exercise, is followed by a decreased concentration
of lymphocytes in the bloodstream, which results in low lymphocyte levels in tissues [39].
In light of these results, we can infer that the plank exercise performed in this study was
maintained at a high intensity by the participant. In the aspect of physical fitness, the
strength, muscle endurance, flexibility, and VO2 max were increased after 4 weeks of plank
exercise. These results indicate that plank exercise can improve health-related physical
fitness in middle-aged men, though it seems that this plank exercise made negative changes
in NK cell-related functions due to the high intensity. In other words, the results of this
study showed that high-intensity plank exercise can increase the number of NK cells but
Medicina 2021, 57, 845 8 of 10

reduce its cytotoxicity. Normally, when the number of NK cells increases, cytotoxicity also
increases, but cytotoxicity decreases when there is a specific cause, such as having cancer
cells, when exposed to excessive stress, or when exercising excessively [40,41]. In other
words, it can be concluded that the subject who completed 4 weeks of plank exercises
had increased NK cells, but showed no changes in its function due to the negative results
of high-intensity exercise. Meanwhile, immune cells, as well as physical fitness, were
measured one day before the start of the plank exercises and on the day after the four-week
period. As a result, a clear change could be observed in the physical fitness variables, but a
constant change pattern could not be observed in the variables that had sensitive responses,
such as immune cells. Therefore, based on the data derived from the current case study,
we suggest that future studies should not only look at the changes before and after the
experiment to observe the changes in immune cells but rather in the middle of the course
of the experiment, 7 days after the experiment, or one month after the experiment.

5. Conclusions
This study confirmed that high- to very-high-intensity plank exercise can improve
immunocyte function and physical fitness in a healthy man. However, our study has some
limitations. First, the participant consisted entirely of only one middle-aged man, which is
a small sample size. Second, although there are hundreds of types of immune cells, this
study only observed a few specific immunocytes. Third, a careful approach is required
because plank exercises performed at less than moderate intensity or high intensity can
cause shoulder joint or back pain. Considering these limitations, further studies that
investigate the effectiveness of plank exercise on a greater number of participants with
diverse demographic backgrounds, and on multiple immune cell tests, are encouraged.

Author Contributions: S.-K.P. and Y.-S.J. conceived the idea; S.-J.H. developed the background and
performed the calibration of different devices used in the tests; K.-S.L. and Y.-S.J. verified the methods
section; all authors discussed the results and contributed to the final manuscript; S.-K.P. performed
the tests; Y.-S.J. wrote the manuscript with support from S.-J.H.; all authors contributed to the final
version of the manuscript; S.-K.P. and Y.-S.J. contributed to the interpretation of the results and data
analysis, and they drafted the manuscript and designed the figures and tables; all authors provided
critical feedback and helped shape the research, analysis, and manuscript. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study received approval from the institutional ethics
committee (Sahmyook Univ. 2-1040781-A-N-012020085HR).
Informed Consent Statement: Written informed consent has been obtained from the S.-K.P.
Data Availability Statement: Data and material are available on reasonable request.
Acknowledgments: The authors wish to thank the participant of this study.
Conflicts of Interest: The authors declare no competing interests.

References
1. Korea Disease Control and Prevention Agency. 2017 Korea National Health and Nutrition Examination Survey; Korea Disease Control
and Prevention Agency: Cheongju-si, Korea, 2017.
2. World Health Organization. Global Recommendations on Physical Activity for Health; World Health Organization: Geneva, Switzer-
land, 2010.
3. Nieman, D.C.; Wentz, L.M. The compelling link between physical activity and the body’s defense system. J. Sport Health Sci. 2018,
8, 201–217. [CrossRef]
4. Stiegler, P.; Cunliffe, A. The Role of Diet and Exercise for the Maintenance of Fat-Free Mass and Resting Metabolic Rate During
Weight Loss. Sports Med. 2006, 36, 239–262. [CrossRef] [PubMed]
5. Jee, Y.-S. Exercise is an antigen for vaccination: First series of scientific evidence. J. Exerc. Rehabil. 2019, 15, 339–340. [CrossRef]
[PubMed]
6. Jee, Y.-S. How much exercise do we need to improve our immune system? Second series of scientific evidence. J. Exerc. Rehabil.
2020, 16, 113–114. [CrossRef] [PubMed]
Medicina 2021, 57, 845 9 of 10

7. Jee, Y.-S. Influences of acute and/or chronic exercise on human immunity: Third series of scientific evidence. J. Exerc. Rehabil.
2020, 16, 205–206. [CrossRef] [PubMed]
8. Jee, Y.-S. Physical exercise for strengthening innate immunity during COVID-19 pandemic: 4th series of scientific evidence. J.
Exerc. Rehabil. 2020, 16, 383–384. [CrossRef]
9. Jee, Y.-S. Acquired immunity and moderate physical exercise: 5th series of scientific evidence. J. Exerc. Rehabil. 2021, 17, 2–3.
[CrossRef]
10. Jee, Y.-S. Cancer and exercise immunity: 6th series of scientific evidence. J. Exerc. Rehabil. 2021, 17, 151–152. [CrossRef] [PubMed]
11. Peake, J.; Nosaka, K.; Suzuki, K. Characterization of inflammatory responses to eccentric exercise in humans. Exerc. Immunol. Rev.
2005, 11, 64–85. [PubMed]
12. Nyenhuis, S.M.; Greiwe, J.; Zeiger, J.S.; Nanda, A.; Cooke, A. Exercise and Fitness in the Age of Social Distancing During the
COVID-19 Pandemic. J. Allergy Clin. Immunol. Pr. 2020, 8, 2152–2155. [CrossRef]
13. Schultz, D.; Jones, S.S.; Pinder, W.M.; Wiprovnick, A.E.; Groth, E.C.; Shanty, L.M.; Duggan, A. Effective Home Visiting Training:
Key Principles and Findings to Guide Training Developers and Evaluators. Matern. Child. Heal. J. 2018, 22, 1563–1567. [CrossRef]
[PubMed]
14. Park, D.-J.; Park, S.-Y. Which trunk exercise most effectively activates abdominal muscles? A comparative study of plank and
isometric bilateral leg raise exercises. J. Back Musculoskelet. Rehabil. 2019, 32, 797–802. [CrossRef]
15. Akuthota, V.; Ferreiro, A.; Moore, T.; Fredericson, M. Core Stability Exercise Principles. Curr. Sports Med. Rep. 2008, 7, 39–44.
[CrossRef]
16. Behm, D.G.; Drinkwater, E.J.; Willardson, J.M.; Cowley, P.M. Canadian Society for Exercise Physiology position stand: The use of
instability to train the core in athletic and nonathletic conditioning. Appl. Physiol. Nutr. Metab. 2010, 35, 109–112. [CrossRef]
[PubMed]
17. Kline, J.B.; Krauss, J.R.; Maher, S.F.; Qu, X. Core strength training using a combination of home exercises and a dynamic sling
system for the management of low back pain in pre-professional ballet dancers: A case series. J. Dance Med. Sci. 2013, 17, 24–33.
[CrossRef] [PubMed]
18. Granacher, U.; Gollhofer, A.; Hortobágyi, T.; Kressig, R.W.; Muehlbauer, T. The Importance of Trunk Muscle Strength for Balance,
Functional Performance, and Fall Prevention in Seniors: A Systematic Review. Sports Med. 2013, 43, 627–641. [CrossRef] [PubMed]
19. Cha, J.-Y.; Kim, J.-H.; Hong, J.; Choi, Y.-T.; Kim, M.-H.; Cho, J.-H.; Ko, I.-G.; Jee, Y.-S. A 12-week rehabilitation program improves
body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom. J.
Exerc. Rehabil. 2014, 10, 35–44. [CrossRef] [PubMed]
20. Bohannon, R.W. Muscle strength: Clinical and prognostic value of hand-grip dynamometry. Curr. Opin. Clin. Nutr. Metab. Care
2015, 18, 465–470. [CrossRef] [PubMed]
21. Bianco, A.; Jemni, M.; Thomas, E.; Patti, A.; Paoli, A.; Roque, J.R.; Palma, A.; Mammina, C.; Tabacchi, G. A systematic review to
determine reliability and usefulness of the field-based test batteries for the assessment of physical fitness in adolescents—The
ASSO Project. Int. J. Occup. Med. Environ. Health 2015, 28, 445–478. [CrossRef]
22. Park, S.; Park, J.; Yoo, J.; Jee, Y.-S. Effect of playing soccer on stress, sociality, and physical fitness in alienated youth: A retrospective
study. J. Exerc. Rehabil. 2020, 16, 154–161. [CrossRef]
23. Jee, Y.-S. The efficacy and safety of whole-body electromyostimulation in applying to human body: Based from graded exercise
test. J. Exerc. Rehabil. 2018, 14, 49–57. [CrossRef]
24. Calatayud, J.; Casaña, J.; Martín, F.; Jakobsen, M.D.; Colado, J.C.; Gargallo, P.; Juesas, A.; Muñoz, V.; Andersen, L.L. Trunk muscle
activity during different variations of the supine plank exercise. Musculoskelet. Sci. Pract. 2017, 28, 54–58. [CrossRef] [PubMed]
25. Choi, J.-H.; Kim, D.-E.; Cynn, H.-S. Comparison of Trunk Muscle Activity Between Traditional Plank Exercise and Plank Exercise
with Isometric Contraction of Ankle Muscles in Subjects with Chronic Low Back Pain. J. Strength Cond. Res. 2019. [CrossRef]
[PubMed]
26. Giacco, S.R.; Tocco, F.; Melis, F.; Crisafulli, A.; Gessa, M.; Santoboni, U.; Caria, M.; Tavéra, C.; Giacco, S.G.; Concu, A. Respon-
siveness of human natural killer cells during acute, incremental exercise up to exhaustion. Sport Sci. Health 2004, 1, 36–40.
[CrossRef]
27. Pedersen, B.K. Special feature for the Olympics: Effects of exercise on the immune system: Exercise and cytokines. Immunol. Cell
Biol. 2000, 78, 532–535. [CrossRef] [PubMed]
28. Inkabi, S.E.; Pushpamithran, G.; Richter, P.; Attakora, K. Exercise immunology: Involved components and varieties in different
types of physical exercise. Scientect. J. Life Sci. 2017, 1, 31–35. Available online: http://www.scientect.com/journals/index.php/
SJLS (accessed on 10 July 2021).
29. Gleeson, M. Immune function in sport and exercise. J. Appl. Physiol. 2007, 103, 693–699. [CrossRef]
30. Pedersen, B.K.; Hoffman-Goetz, L. Exercise and the Immune System: Regulation, Integration, and Adaptation. Physiol. Rev. 2000,
80, 1055–1081. [CrossRef] [PubMed]
31. Timmons, B.W.; Cieslak, T. Human natural killer cell subsets and acute exercise: A brief review. Exerc. Immunol. Rev. 2008, 14,
8–23. [PubMed]
32. Lee, H.Y.; Baek, J.O.; Lee, J.R.; Park, S.H.; Jeon, I.S.; Roh, J.Y. Atypical Hydroa Vacciniforme-Like Epstein-Barr Virus Associated
T/NK-Cell Lymphoproliferative Disorder. Am. J. Dermatopathol. 2012, 34, e119–e124. [CrossRef] [PubMed]
33. Fabbri, M. T lymphocytes. Int. J. Biochem. Cell Biol. 2003, 35, 1004–1008. [CrossRef]
Medicina 2021, 57, 845 10 of 10

34. McLeod, I.X.; He, Y. Roles of autophagy in lymphocytes: Reflections and directions. Cell. Mol. Immunol. 2010, 7, 104–107.
[CrossRef] [PubMed]
35. Luckheeram, R.V.; Zhou, R.; Verma, A.D.; Xia, B. CD4+T Cells: Differentiation and Functions. Clin. Dev. Immunol. 2012, 2012,
1–12. [CrossRef]
36. Pedersen, B.K. Effects of exercise on lymphocytes and cytokines. Br. J. Sports Med. 2000, 34, 246–251. [CrossRef]
37. Pedersen, B.K.; Nieman, D.C. Exercise immunology: Integration and regulation. Immunol. Today 1998, 19, 204–206. [CrossRef]
38. Petersen, A.M.W.; Pedersen, B.K. The anti-inflammatory effect of exercise. J. Appl. Physiol. 2005, 98, 1154–1162. [CrossRef]
39. Northoff, H.; Weinstock, C.; Berg, A. The Cytokine Response to Strenuous Exercise. Int. J. Sports Med. 1994, 15, S167–S171.
[CrossRef]
40. Shephard, R.J.; Shek, P.N.; DiNubile, N.A. Exercise, Immunity, and Susceptibility to Infection: A j-shaped relationship? Physician
Sportsmed. 1999, 27, 47–71. [CrossRef] [PubMed]
41. Natale, V.M.; Brenner, I.K.; Moldoveanu, A.I.; Vasiliou, P.; Shek, P.; Shephard, R.J. Effects of three different types of exercise on
blood leukocyte count during and following exercise. Sao Paulo Med. J. 2003, 121, 9–14. [CrossRef] [PubMed]