Impact of High-Intensity Interval Training on Disease Activity and Disease in Patients With Psoriatic Arthritis: A Randomized Controlled Trial

Increased physical activity promotes skin clearance, improves cardiovascular and psychological health, and increases functional capacity in patients with psoriasis

Background

Patients with psoriasis are less physically active compared to age-matched controls, due to psoriasis-specific barriers, which significantly limits their ability to benefit from health-promoting levels of physical activity (PA). In addition, long-term health outcomes for people with psoriasis are poor and include depression, metabolic syndrome and cardiovascular disease (CVD); presenting a significant challenge to healthcare services.

Objectives

We designed a PA intervention in partnership with patients with psoriasis hypothesising this may have therapeutic utility in the management of psoriasis.

Methods

Participants with chronic plaque psoriasis were recruited to a single-centre, 20-week, prospective cohort study. A wrist-worn accelerometer (GENEActiv Original; Activinsights Ltd) and a hip-worn pedometer (Onwalk 900; Decathlon Group) were used objectively measure levels of PA. Our 10-week PA intervention comprised twice weekly 60-min walks within three different greenspaces in Greater Manchester, each led by a Sports and Exercise Scientist to deliver a pre-specified volume/dose of activity. During weeks-11-20 of the study, participants followed independent activities. Clinical evaluation, including assessment of psoriasis severity, cardiometabolic parameters, psychological wellbeing and functional capacity was made at baseline, week-10 and -20.

Results

Sixteen patients with psoriasis completed the study. We observed significantly reduced Psoriasis Area and Severity Index at week-10 (p = 0.01) and -20 (p = 0.001) compared to baseline, with 50% of participants achieving PASI-50 at week-20. Dermatology Life Quality Index (DLQI) was significantly reduced at week-20 (p = 0.04), compared to baseline. Significant reduction in blood pressure at week-10 (systolic: -7.4 mmHg, p = 0.002; diastolic: -4.2 mmHg, p = 0.03) and -20 (systolic: -8.8 mmHg, p = 0.001; diastolic: 4.1 mmHg, p = 0.008) was observed and pulse wave velocity was significantly reduced by week-20 (p = 0.02), suggesting improvement in cardiovascular health. Despite high prevalence of anxiety and depression at baseline, we documented a significant improvement in wellbeing and psychological health. Functional capacity was significantly enhanced following completion of the study.

Conclusion

Increasing PA constitutes a promising therapeutic intervention in the management of psoriasis. Evaluation of our intervention in a clinical trial would help determine clinical utility and establish PA guidelines for patients with psoriasis.

Combined associations of obesity and physical activity with pain, fatigue, stiffness and anxiety in adults with spondyloarthropathies: UK Biobank study

Objective

Inflammatory spondyloarthropathies are associated with pain, fatigue, stiffness and anxiety. The National Institute for Health and Care Excellence and the EULAR provide limited lifestyle guidance for managing symptoms with inflammatory spondyloarthropathies. We investigated the combined associations of obesity and physical activity with symptom severity in inflammatory spondyloarthropathies.

Methods

The relationship between BMI, physical activity and symptom severity (spinal and general pain, fatigue, anxiety, mobility) was examined in people with ISpAs (n = 1577). BMI categories were normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2) and obese (≥30 kg/m2). Physical activity was assessed via the International Physical Activity Questionnaire (low < 600 metabolic equivalent of task (MET)-min/week, moderate ≥ 600 METs, high ≥ 3000 METs). Statistical models adjusted for confounders, including medication, estimated the likelihood (odds ratios, OR) of higher symptom severity across BMI and physical activity categories.

Results

Overweight and obesity, compared with normal weight, were linked to higher severity of all symptoms, with stronger associations for obesity (OR ≥ 2.34, P < 0.001) than overweight (OR ≥ 1.37, P ≤ 0.032). Moderate activity, compared with low, was associated with lower severity of all symptoms (OR ≤ 0.77, P ≤ 0.032). High activity, compared with low, was associated with lower severity of fatigue, anxiety and mobility issues (OR ≤ 0.74, P ≤ 0.029), but associations with spinal and general pain were not significant (OR ≤ 0.80, P ≥ 0.056). No BMI-by-physical activity combinations were detected, indicating physical activity benefits all BMI groups to a similar extent.

Conclusion

National Institute for Health and Care Excellence and EULAR guidance for inflammatory spondyloarthropathies should emphasize maintaining a normal weight. Moderate physical activity is optimal for reducing symptom severity and should be promoted in lifestyle guidance.

High-quality research on physical therapy in psoriatic arthritis is needed: a systematic review

Objectives

Although physical therapy is recommended as part of the non-pharmacological management of patients with psoriatic arthritis (PsA), the evidence is still unclear. Therefore, this study aimed to systematically review and appraise the quality of research on physical therapy in the management of patients with PsA.

Methods

In June 2024, a systematic literature search using four different databases (Medline, Embase, Web of Science and the Cochrane Library) was performed to include interventional and observational studies examining physical therapy in patients with PsA (PROSPERO ID 255501). A risk of bias assessment was conducted. Due to the wide variety of interventions and outcomes, a narrative synthesis was used.

Results

Of 9442 abstracts, 15 papers examining physical therapy uptake in clinical practice (N = 2) and different physical therapy interventions (N = 13) were included: cardiorespiratory exercises (N = 5), resistance exercises (N = 2), therapeutic modalities (N = 4) and mixed rehabilitation programs (N = 2). A low risk of bias was scored in only one RCT assessing cardiorespiratory exercises. The well-tolerated 11-week high-intensity interval training resulted in a long-term increase in peak oxygen uptake and a short-term decrease in truncal fat percentage in patients with low disease activity. Resistance training in patients with active disease did not increase muscle strength, but improved functional capacity, disease activity, pain and general health after the intervention. Evidence for other modalities was inconclusive.

Conclusion

High-quality evidence on physical therapy in PsA was scarce. Cardiorespiratory and resistance exercises demonstrated promising results to positively influence cardiometabolic risk as well as disease-related outcomes. Future research on physical therapy in PsA with adequate methodological quality is needed.

Analysis of physical activity in psoriatic arthritis: relationship with clinical and analytical parameters and comorbidity-description of the sedentary patient

Objective

This study aimed to relate physical activity and a sedentary lifestyle to clinical, biological, functional, and comorbid parameters in a cohort of patients with psoriatic arthritis (PsA).

Methods

A cross-sectional study was conducted with 232 PsA patients. Physical activity and sedentary lifestyle were obtained using the International Physical Activity Questionnaire (IPAQ) questionnaire. The demographic, clinical, and biological variables measured were age, time since PsA diagnosis, smoking, type of treatment used, clinical form, presence of enthesitis, dactylitis (present or past), fatigue, tumor necrosis factor (TNF)-alpha, and interleukin 6 (IL-6). Activity and functionality were measured using the Disease Activity Index for Psoriatic Arthritis (DAPSA) and Health Assessment Questionnaire (HAQ) in peripheral forms, while the Ankylosing Spondylitis Disease Activity Score (ASDAS-PCR) and Bath Ankylosing Spondylitis Functional Index (BASFI) were measured in axial forms. Disease impact was assessed using the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire. Alongside comorbidities, obesity, anxiety, depression [Hospital Anxiety and Depression Scale (HADS)], and sleep quality [Insomnia Severity Index (ISI)] were assessed.

Results

The mean age was 54.6 (SD: 11.4) years, with 54.3% being male. A total of 25.6% of patients were sedentary. Physical activity and sedentary lifestyle were inversely correlated with fatigue, activity, functionality, and disease impact. Within comorbidities, they correlated with anxiety, depression, and insomnia. In addition, physical activity was inversely correlated with obesity. In linear regression analysis, physical activity was found to be related to body mass index (BMI) with a ß coefficient of -0.1 (p < 0.04; 95%CI: -194.1--4.5), and an R2 value of 0.11. In logistic regression analysis, a sedentary lifestyle was found to be related to pain, with an odds ratio (OR) of 1.5 (p < 0.001; 95%CI:1.1-1.8) and an R2 Nagelkerke value of 0.36.

Conclusion

A quarter of the patients were sedentary. Lack of physical activity correlated with worse parameters of clinical activity, functionality, disease impact, and the presence of comorbidities.

Effect of high-intensity interval training in physiotherapy primary care for patients with inflammatory arthritis: the ExeHeart randomised controlled trial

OBJECTIVES

To assess the effect of high-intensity interval training (HIIT) delivered in physiotherapy primary care on the primary outcome of cardiorespiratory fitness (CRF) in patients with inflammatory arthritis (IA). Additionally, to explore the effects of HIIT on secondary outcomes, including cardiovascular disease (CVD) risk factors and disease activity.

METHODS

Single-blinded randomised controlled trial with 60 patients randomly assigned to either a control group receiving usual care or an exercise group receiving usual care and 12 weeks of individualised HIIT at 90%-95% peak heart rate. Outcomes were assessed at baseline, 3 months and 6 months post baseline and included CRF measured as peak oxygen uptake (VO2peak), classic CVD risk factors, disease activity, anthropometry and patient-reported physical activity, pain, fatigue, disease impact and exercise beliefs and self-efficacy.

RESULTS

Intention-to-treat analysis demonstrated a significant between-group difference in VO2peak at 3 months (2.5 mL/kg/min, 95% CI 0.9 to 4.0) and 6 months (2.6 mL/kg/min, 95% CI 0.8 to 4.3) in favour of the exercise group. A beneficial change in self-reported physical activity in favour of the exercise group was observed at 3 and 6 months. The HIIT intervention was well-tolerated with minimal adverse events and no apparent impact on disease activity. Differences in secondary outcomes related to CVD risk factors, disease impact, pain, fatigue and exercise beliefs and self-efficacy were generally small and non-significant.

CONCLUSION

After 12 weeks of supervised HIIT delivered in physiotherapy primary care, patients with IA demonstrated a favourable improvement in CRF, with sustained effects at 6-month follow-up.

TRIAL REGISTRATION NUMBER

NCT04922840.

Effectiveness of functional training versus resistance exercise in patients with psoriatic arthritis: randomized controlled trial

OBJECTIVE

This study aims to evaluate the effect of functional versus resistance exercise training on the functional capacity and quality of life of psoriatic arthritis patients.

METHODS

Forty-one psoriatic arthritis patients (18 to 65 years old) were randomized into two groups: functional training group and resistance exercise group. The functional training group underwent functional exercises with elastic band and the functional training group underwent machine resistance exercise twice a week for 12 weeks. Outcome measures were: The Bath Ankylosing Spondylitis Functional Index (BASFI) and Health Assessment Questionnaire for the Spondyloarthropathies (HAQ-S) for functional capacity and functional status, one-repetition maximum test for muscle strength, the Short Form 36 health survey questionnaire (SF-36) for quality of life, and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Disease Activity Score 28 (DAS-28) for disease activity. Analyzes were performed by a blinded evaluator at baseline (T0), six (T6) and twelve (T12) weeks after the beginning of the exercise.

RESULTS

At baseline, the groups were homogeneous in the clinical and demographic characteristics. There was a statistical intra-group improvement for both groups in the BASFI, BASDAI, HAQ-s, and DAS-28. In the quality-of-life assessment, both groups showed statistical intra-group improvements for all domains except the "emotional aspect" domain in the resistance exercise group. In the muscle strength, there was a statistical improvement for all exercises in both groups, except for the "alternate biceps (bilateral)" exercise.

CONCLUSION

Functional training and resistance exercise are similarly effective in improving functional capacity, functional status, disease activity, general quality of life, and muscle strength in patients with psoriatic arthritis.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04304326. Registered 11 March 2020, https://clinicaltrials.gov/ct2/show/NCT04304326?term=NCT04304326&draw=2&rank=1 .

Impact of different types of exercise programs on ankylosing spondylitis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis of controlled studies aimed to assess the efficacy of different types of exercise programs (EP) on ankylosing spondylitis (AS) activity, function and mobility.

METHODS

We searched PubMed/Medline, Cochrane Library and Embase databases for reports of controlled trials of patients with AS published up to May 2022. The studies were classified by intervention into categories defined by the 4 exercise domains established by the American College of Sports Medicine and then adopted by the European League Against Rheumatism: aerobic, muscle strength, flexibility, neuromotor performance.

RESULTS

We found a moderate effect of EP as a whole on BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) (-0.60, 95% CI -0.95, -0.25, p < 0.001), BASFI (Functional) (-0.63, 95% CI -0.84, -0.42, p < 0.0001) and BASMI (Metrology) (-0.52, 95% CI -0.88, -0.15, p < 0.01). The effect of "flexibility + muscle strength" EP was large for BASMI, moderate for BASDAI and BASFI. The effect of "flexibility + muscle strength + aerobic" EP was large for BASFI, moderate for BASDAI.

CONCLUSIONS

EP, regardless of the specific type of exercise, have a moderate effect on AS activity, function and mobility. EP including flexibility and muscle strength exercises may have a large effect, especially for mobility. Programs including aerobic exercise showed significant efficacy for function.IMPLICATIONS FOR REHABILITATIONIn ankylosing spondylitis (AS), any exercise program (EP), regardless of the type of exercises involved, showed a moderate effect on disease activity, function and spinal mobility.In AS, EP combining flexibility and strength exercises showed the largest effect on spinal mobility and should be encouraged.In AS, EP combining flexibility, muscle strength and aerobic exercises may be particularly effective on patient function.

Regular Exercise Improved Fatigue and Musculoskeletal Pain in Young Adult Psoriatic Patients without Psoriatic Arthritis

Fatigue and musculoskeletal pain are also frequent in patients with psoriasis (PsO) without arthritis (PsA). The current study aimed to assess the impact of an intervention program based on aerobic training to reduce fatigue and musculoskeletal pain in patients with PsO without PsA. A total of 118 male patients with PsO volunteered in the current interventional study and were randomly allocated to the experimental (n = 59) or control group (n = 59). The intervention consisted of a 16-week aerobic training program on a treadmill, three sessions per week, consisting of a warm-up, 35-50 min treadmill exercise (increasing 5 min/4 weeks) at a work intensity of 50-65% of peak heart-rate (increasing 5%/4 weeks), and cooling-down. The functional assessment of chronic illness therapy fatigue scale (FACIT-Fatigue), health assessment questionnaire disability index (HAQ-DI), and visual analog scale (VAS) were compared pre and post intervention. Nutritional intake, maximal aerobic power, lipid profile, serum markers of muscle damage, and body composition were also assessed. When compared to baseline, FACIT-Fatigue, HAQ-DI, and VAS scores were significantly improved without increasing markers of muscle damage. Fat mass percentage, lipid profile, and maximal oxygen consumption were also improved. In conclusion, a 16-week aerobic training program at moderate intensity was safe, well tolerated, and effective in psoriatic patients without PsA. Long-term follow-up studies are required to examine whether these promising results may improve clinical outcomes.

The effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis - A systematic review with meta-analysis

This systematic review aimed to systematically investigate the literature on the effectiveness of exercise and physical activity programs on fatigue and sleep in people with arthritis. For that, seven databases were searched for relevant randomized controlled trials. After the searches, 36 studies investigating 2281 participants were included. Risk of bias assessments were done by two independent reviewers using the Cochrane Risk of Bias tool 2. Random-effects meta-analyses were performed, and the Grading of Recommendations Assessment, Development and Evaluation framework was used to judge the certainty of evidence. The evidence on benefits of exercise and physical activity programs on fatigue and sleep parameters in people with osteoarthritis and psoriatic arthritis was either lacking or inconclusive. There was very low to low certainty evidence for a slight benefit of exercise and physical activity programs on fatigue at short-term in people with ankylosing spondylitis and rheumatoid arthritis. However, the evidence was very uncertain for the medium- and long-term as well as for any sleep parameters. The results indicate that exercise and physical activity programs may offer some benefits on fatigue for people with arthritis in the short-term, although the best type of exercise remains uncertain. The available evidence on improvements in sleep was insufficient to draw strong conclusions.

Changes of inflammation in patients with psoriatic arthritis after high intensity interval training assessed by ultrasound and MRI, a randomized controlled trial

BACKGROUND

In psoriatic arthritis (PsA) there is a theoretical risk of increased disease activity related to strenuous physical activity, including exercise. We evaluated the effect of high intensity interval training (HIIT) on objective measures of inflammation in PsA assessed by ultrasound (US) of peripheral joints and entheses, and by bone marrow edema (BME) on MRI of the sacroiliac joints (SIJ) and spine.

METHODS

We randomly assigned 67 PsA patients to an intervention group that performed structured HIIT for 11 weeks, or to a control group instructed not to change their physical exercise habits. Outcome measures included US evaluation of the total cohort and MRI in a subgroup of 41; both assessed at 3 months. We calculated the proportions with an increased US B-mode and power-doppler (PD) signal of joints and entheses and Spondyloarthritis-Research-Consortium-of-Canada (SPARCC)-BME score of the SIJ and spine for both groups.

RESULTS

Proportions with an increased US B-mode score of the joints were 32% and 28% in HIIT and control groups, respectively. Corresponding proportions of PD scores of the joints were 7% and 10% and PD scores of entheses were 32% and 31%. The proportions with increased MRI BME of the SIJ were 6% in the HIIT group and 10% in the control group. Corresponding proportions were 6% and 5% for the MRI BME of the spine.

CONCLUSION

In PsA patients with a low to moderate disease activity, there was no clear evidence of objectively measured increased inflammation after HIIT, as evaluated by US and MRI.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02995460 (16/12/2016).

Difficult to treat psoriatic arthritis - how should we manage?

Psoriatic arthritis (PsA) is a chronic, multi-domain immune-mediated inflammatory arthritis with a high disease burden. PsA patients have significant co-morbidities like obesity, depression, fibromyalgia which can impact disease activity assessment. The management of PsA has undergone a paradigm shift over the last decade due to the availability of multiple biologic and targeted synthetic disease modifying anti-rheumatic drugs. Despite the availability of multiple therapeutic agents, it is not uncommon to find patients not responding adequately and continuing to have active disease and/or high disease burden. In our review, we propose what is "difficult to treat PsA", discuss differential diagnosis, commonly overlooked factors, co-morbidities that affect treatment responses, and suggest a stepwise algorithm to manage these patients.

Lifestyle Modifications and Nonpharmacologic Interventions to Improve Outcomes in Psoriatic Arthritis: A Systematic Review

PURPOSE

Psoriatic arthritis (PsA) is a multisystem inflammatory disorder associated with significant mortality and morbidity, including functional impairment and psychological disability. Although evidence-based treatment recommendations are available for the use of drug treatments in PsA, there is little guidance for health professionals on nonpharmacologic and psychological interventions that may be useful in PsA. The objective of this systematic review (SR) was to identify how lifestyle modifications and the use of nonpharmacologic and psychological interventions may improve the outcomes of patients with PsA.

METHODS

Studies were included if they evaluated adults diagnosed with PsA and included exposure to nonpharmacologic interventions, psychological interventions, and lifestyle modifications. The outcomes used needed to have been validated in PsA. A systematic literature search was run on May 28, 2021, in the Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), EMBASE, Global Health, MEDLINE, and PsycINFO databases to identify articles related to lifestyle modifications and nonpharmacologic or psychological interventions for adults with PsA published between 2010 and 2021. Two review authors independently screened and selected full-text studies for inclusion in the SR. Risk of bias was assessed with either the Risk of Bias 2 (ie, RoB 2) tool or Critical Appraisal Skills Program checklist depending on the study type.

FINDINGS

The search strategy identified 26,132 references. Eight studies examining lifestyle modifications and the effect on PsA were eligible to be included in the SR. Three of the 8 studies were randomized controlled trials, and 5 were nonrandomized studies. Three studies assessed physical activity, 3 assessed diet, 1 study assessed smoking, and another study assessed mud bath therapy. There was large heterogeneity between studies, and the measures of disease activity, and psychological and functional outcomes varied widely between studies.

IMPLICATIONS

Although this SR identified 8 relevant studies, these studies did not provide high-quality evidence to guide patients for non-drug treatments of PsA. The effectiveness of these interventions has therefore not been established. We found that physical activity seems to have a positive impact on disease activity and psychological well-being. Further well-designed research studies are needed to develop treatment recommendations. PROSPERO identifier: CRD42021257404.

Efficacy of non-pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVE

To identify the best evidence on the efficacy of non-pharmacological interventions in reducing fatigue in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and to summarise their safety in the identified studies to inform European Alliance of Associations for Rheumatology recommendations for the management of fatigue in people with I-RMDs.

METHODS

Systematic review of randomised controlled trials (RCTs) including adults with I-RMDs conducted according to the Cochrane Handbook. Search strategy ran in Medline, Embase, Cochrane Library, CINAHL Complete, PEDro, OTseeker and PsycINFO. Assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. Data were pooled in meta-analyses.

RESULTS

From a total of 4150 records, 454 were selected for full-text review, 82 fulfilled the inclusion criteria and 55 RCTs were included in meta-analyses. Physical activity or exercise was efficacious in reducing fatigue in rheumatoid arthritis (RA) (standardised mean differences (SMD)=-0.23, 95% CI=-0.37 to -0.1), systemic lupus erythematosus (SLE) (SMD=-0.54, 95% CI=-1.07 to -0.01) and spondyloarthritis (SMD=-0.94, 95% CI=-1.23 to -0.66); reduction of fatigue was not significant in Sjögren's syndrome (SMD=-0.83, 95% CI=-2.13 to 0.47) and systemic sclerosis (SMD=-0.66, 95% CI=-1.33 to 0.02). Psychoeducational interventions were efficacious in reducing fatigue in RA (SMD=-0.32, 95% CI=-0.48 to -0.16), but not in SLE (SMD=-0.19, 95% CI=-0.46 to 0.09). Follow-up models in consultations (SMD=-0.05, 95% CI=-0.29 to 0.20) and multicomponent interventions (SMD=-0.20, 95% CI=-0.53 to 0.14) did not show significant reductions of fatigue in RA. The results of RCTs not included in the meta-analysis suggest that several other non-pharmacological interventions may provide a reduction of fatigue, with reassuring safety results.

CONCLUSIONS

Physica activity or exercise and psychoeducational interventions are efficacious and safe for managing fatigue in people with I-RMDs.

Actigraphy-derived physical activity levels and circadian rhythm parameters in patients with psoriatic arthritis: relationship with disease activity, mood, age and BMI

Background

Psoriatic arthritis (PsA) is associated with sleep disturbance, depression and a lifetime risk of obesity and cardiovascular disease. To date, there have been no studies investigating the relationship between objectively-measured physical activity (PA) levels and circadian rhythm disturbance with disease activity, daily symptoms and mood in patients with PsA.

Objective

This pilot study aimed to investigate the relationship between disease activity, daily symptoms and mood on PA and circadian rhythm in PsA.

Design

A prospective cohort study recruiting adults with PsA from rheumatology clinics at a single centre in the UK.

Methods

Participants wore an actigraph and recorded their symptoms and mood on a daily basis via a smartphone app for 28 days. Time spent in sedentary, light and moderate-to-vigorous physical activity (MVPA) and parameters reflecting the circadian rhythm of the rest-activity pattern were derived. This included the onset time of the least active 5-h (L5) and most active 10-h (M10) daily consecutive periods and the relative amplitude (RA). The relationship factors between baseline clinical status, daily symptoms, PA and circadian measures were examined using linear mixed effect regression models.

Results

Nineteen participants (8/19 female) were included. Participants with active PsA spent 63.87 min (95% CI: 18.5-109.3, p = 0.008) more in inactivity and 30.78 min (95% CI: 0.4-61.1, p = 0.047) less in MVPA per day compared to those in minimal disease activity (MDA). Age, body mass index and disease duration were also associated with PA duration. Participants with worse functional impairment had an M10 onset time 1.94 h (95% CI: 0.05-3.39, p = 0.011) later than those with no reported functional impairment. No differences were detected for L5 onset time or RA. Higher scores for positive mood components such as feeling energetic, cheerful and elated were associated with less time in inactivity and greater time spent in MVPA overall.

Conclusion

Our study highlights differences in PA and circadian rest-activity pattern timing based on disease activity, disability and daily mood in PsA. Reduced PA levels in patients with active disease may contribute to the observed increased risk of cardiovascular and metabolic sequelae, with further studies exploring this need.

Management of Enthesitis in Patients With Psoriatic Arthritis: An Updated Literature Review Informing the 2021 GRAPPA Treatment Recommendations

OBJECTIVE

Enthesitis is a key pathological and clinical feature of psoriatic arthritis (PsA) in children and adults. Enthesitis is typically assessed clinically using several validated enthesitis scoring systems that have been used in clinical trials. Enthesitis treatment response has been reported as change in the total enthesitis score or the proportion of patients who achieved complete resolution. The majority of trials in PsA did not require patients to have enthesitis at study entry since enthesitis was evaluated only as a secondary outcome. Despite the inherent limitations of the clinical assessment of enthesitis, imaging of the entheses using ultrasound or magnetic resonance imaging has rarely been used in clinical trials to assess response to treatment of enthesitis. This systematic review summarizes existing evidence regarding pharmaceutical and nonpharmaceutical interventions for enthesitis in patients with PsA to facilitate an evidence-based update of the Group for Research and Assessment in Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations for PsA.

METHODS

We performed a systematic literature review to identify 41 randomized clinical trials that reported enthesitis treatment response in patients with PsA. For each intervention, the response effect size was summarized and the quality of evidence was graded. Recommendations were then formulated for the various pharmacological and nonpharmacological therapies.

RESULTS

We included 41 randomized clinical trials in our review and graded each intervention.

CONCLUSION

Several classes of systemic conventional and advanced therapies and local measures were recommended for active enthesitis in patients with PsA.

High-Intensity Interval Training (HIIT) on Biological and Body Composition Variables in Patients with Musculoskeletal Disorders: A Systematic Review and Meta-Analysis

In order to assess the impact of high-intensity interval training (HIIT) on biological and body composition variables in patients with musculoskeletal disorders (MSKD), a systematic search on PubMed (Medline), CENTRAL, CINAHL, Web of Science, SPORTDiscus, and Scopus was conducted. Standardized mean differences (SMD) and 95% confidence intervals were calculated and pooled in a meta-analysis using the random-effects model. The effectiveness of HIIT on waist circumference, muscle mass, resting heart rate, resting systolic and diastolic blood pressure, C-reactive protein, body weight, and body fat were determined. GRADE, risk of bias 2, and PEDro scales were employed. HIIT compared to no intervention, minimal intervention, or usual care did not show significant results in its favor on any of the variables studied, except for the resting heart rate when compared with no intervention (SMD = -0.33; 95% CI: -0.63, -0.04; heterogeneity Q value: 0.14; p = 0.93; I² = 0%). In addition, HIIT also does not seem to be more effective than moderate-intensity continuous training. Based on the results, it seems that HIIT has almost no significant effects on biological and body composition variables, except for resting heart rate, in patients with MSKD.

Effects of High-Intensity Interval Training (HIIT) on Patients with Musculoskeletal Disorders: A Systematic Review and Meta-Analysis with a Meta-Regression and Mapping Report

The aim was to assess the impact of high-intensity interval training (HIIT) on patients with musculoskeletal disorders. We conducted a search of Medline, Embase, PEDro, and Google Scholar. We conducted a meta-analysis to determine the effectiveness of HIIT on pain intensity, maximal oxygen consumption (VO2 max), disability, and quality of life (QoL). We employed the GRADE and PEDro scales to rate the quality, certainty, and applicability of the evidence. Results showed significant differences in pain intensity, with a moderate clinical-effect (SMD = -0.73; 95% CI: -1.40--0.06), and in VO2 max, with a moderate clinical-effect (SMD = 0.69; 95% CI: 0.42-0.97). However, the meta-analysis showed no statistically significant results for disability (SMD = -0.34; 95% CI: -0.92-0.24) and QoL (SMD = 0.40; 95% CI: -0.80-1.60). We compared HIIT against other exercise models for reducing pain intensity and increasing VO2 max. The meta-analysis showed no significant differences in favour of HIIT. Meta-regression analysis revealed that pain intensity scores were negatively associated with VO2 max (R2 = 82.99%, p = 0.003). There is low-moderate evidence that the HIIT intervention for patients with musculoskeletal disorders can reduce pain intensity and increase VO2 max but has no effect on disability and QoL. Results also showed that HIIT was not superior to other exercise models in reducing pain intensity and increasing VO2 max.

Evaluating the Impact of High Intensity Interval Training on Axial Psoriatic Arthritis Based on MR Images

High intensity interval training (HIIT) has been shown to benefit patients with psoriatic arthritis (PsA). However, magnetic resonance (MR) imaging has uncovered bone marrow edema (BME) in healthy volunteers after vigorous exercise. The purpose of this study was to investigate MR images of the spine of PsA patients for changes in BME after HIIT. PsA patients went through 11 weeks of HIIT (N = 19, 4 men, median age 52 years) or no change in physical exercise habits (N = 20, 8 men, median age 45 years). We acquired scores for joint affection and pain and short tau inversion recovery (STIR) and T1-weighted MR images of the spine at baseline and after 11 weeks. MR images were evaluated for BME by a trained radiologist, by SpondyloArthritis Research Consortium of Canada (SPARCC) scoring, and by extraction of textural features. No significant changes of BME were detected in MR images of the spine after HIIT. This was consistent for MR image evaluation by a radiologist, by SPARCC, and by texture analysis. Values of textural features were significantly different in BME compared to healthy bone marrow. In conclusion, BME in spine was not changed after HIIT, supporting that HIIT is safe for PsA patients.

Effect of high-intensity exercise on cardiorespiratory fitness, cardiovascular disease risk and disease activity in patients with inflammatory joint disease: protocol for the ExeHeart randomised controlled trial

INTRODUCTION

Inflammatory joint disease (IJD) is associated with increased risk of cardiovascular disease (CVD) fostered by systemic inflammation and a high prevalence of CVD risk factors. Cardiorespiratory fitness (CRF) is an important health parameter and CRF-measures are advocated in routine health evaluations. CRF associates with CVD risk, and exercise modalities such as high intensity interval training (HIIT) can increase CRF and mitigate CVD risk factors. In IJD, exercise is rarely used in CVD risk management and the cardioprotective effect of HIIT is unclear. Furthermore, the clinical applicability of HIIT to primary care settings is largely unknown and warrants investigation. The primary aim is to assess the effect of a HIIT programme on CRF in patients with IJD. Second, we will evaluate the effect of HIIT on CVD risk and disease activity in patients with IJD, feasibility of HIIT in primary care and validity of non-exercise algorithms to detect change in CRF.

METHODS AND ANALYSIS

ExeHeart is a single-blinded, randomised controlled trial. Sixty patients with IJD will be recruited from the Preventive Cardio-Rheuma clinic at Diakonhjemmet Hospital, Norway. Patients will be assigned to receive standard care (relevant lifestyle advice and cardio-preventive medication) or standard care plus a 12-week HIIT intervention by physiotherapists in primary care. HIIT sessions will be prescribed at 90%-95% of peak heart rate. Outcomes include CRF (primary outcome), CVD risk factors, anthropometric measures, disease activity and patient-reported outcomes related to pain, fatigue, disease, physical activity and exercise and will be assessed at baseline, 3 months (primary endpoint) and 6 months postbaseline.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Regional Committee for Medical and Health Research Ethics (201227). Participants are required to sign a written informed consent form. Results will be discussed with patient representatives, submitted to peer-reviewed journals and presented at relevant platforms.

TRIAL REGISTRATION NUMBER

NCT04922840.

Brazilian Society of Rheumatology 2020 guidelines for psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic and systemic immune disease characterized by inflammation of peripheral and/or axial joints and entheses in patients with psoriasis (PsO). Extra-articular and extracutaneous manifestations and numerous comorbidities can also be present. These recommendations replace the previous version published in May 2013. A systematic review of the literature retrieved 191 articles that were used to formulate 12 recommendations in response to 12 clinical questions, divided into 4 sections: diagnosis, non-pharmacological treatment, conventional drug therapy and biologic therapy. These guidelines provide evidence-based information on the clinical management for PsA patients. For each recommendation, the level of evidence (highest available), degree of strength (Oxford) and degree of expert agreement (interrater reliability) are reported.

Efficiency of an Optimized Care Organization in Fibromyalgia Patients: The From Intent to Move (FIMOUV) Study Protocol of a Randomized Controlled Trial

Introduction: Fibromyalgia (FM) is characterized by multiple symptoms including pain, fatigue, and sleep disorders, altering patient's quality of life. In the absence of effective pharmacological therapy, the last European guidelines recommend a multidisciplinary management based on exercise and education. Thus, our main objective was to measure the effectiveness of a healthcare organization offering a specific program of adapted physical activity combined with a therapeutic education program for FM patients.

Methods and Analysis: The From Intent To Move (FIMOUV) study will recruit 330 FM patients randomized into two groups: test and control. The test group will benefit from a 1-month mixed exercise training program supervised at the hospital, followed by 2 months in a community-based relay in a health-sport structure. In addition, each of the two groups will benefit from therapeutic patient education sessions. The main endpoint is the measurement of the level of physical activity by accelerometry at 1 year. The secondary endpoints concern adherence to the practice of physical activity, impact on lifestyle, state of health, and physical capacity, as well as an estimate of the budgetary impact of this management strategy.

Discussion: This interventional research will allow us to assess the evolution of behaviors in physical activity after an FM syndrome management based solely on patient education or based on a supervised and adapted practice of physical activity associated with this same therapeutic education program. It seems to be the first study evaluating the impact of its intervention on objective data for measuring physical activity and sedentary behavior via accelerometry among FM patients.

Trial registration:ClinicalTrials.gov NCT04107948.

Psoriatic arthritis and physical activity: a systematic review

INTRODUCTION

The positive effects of physical activity in both rheumatoid arthritis and ankylosing spondylitis have been proven, but no clear data is yet published regarding psoriatic arthritis (PsA). The aims of this study were (i) to assess the level of physical activity (PA) in these patients and (ii) to review the effects of PA on articular disease, extra articular symptoms, and overall well-being.

METHODS

The research strategy was performed on Pubmed, Cochrane, PEDro databases using the following keywords: "psoriatic arthritis AND physical activity" without restriction. The PRISMA methodology was used to select and analyze articles. We searched for all studies published online and in English before January 2021.

RESULTS

A total of 319 studies were retrieved by our search but only 13 could be included. Two reports showed that 17 and 68% of patients reported practicing regularly physical activity. Exercise improved the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), the general symptoms (pain and fatigue), and the quality of life. Muscle strength and some of cardiovascular comorbidities were also improved. While the studies concerning the risk of enthesitis or flare induced by physical activity are conflicting, recent clinical trials did not mention any adverse event. Finally, rehabilitation programs were associated with a reduction mainly of pain and fatigue.

CONCLUSION

Studies show clear beneficial effects of exercise in PsA on disease activity, on well-being, and on comorbidities, and they seem to outweigh the risk of enthesitis induced by mechanical stress. Further investigations are necessary to confirm these results and to precise the modalities of exercise. Key Points • Psoriatic arthritis patients have a sedentary lifestyle • Physical activity has beneficial effects on disease activity, well-being and reduced some cardiovascular risk factor in psoriatic arthritis • Risk of enthesitis and flares is low with exercise in psoriatic arthritis.

New Insights in Physical Therapy and Rehabilitation in Psoriatic Arthritis: A Review

Psoriatic arthritis (PsA) is a complex, multiform and chronic inflammatory disease characterized by the association of psoriasis and arthritis with other musculoskeletal and extra-articular manifestations. The treatment of PsA is rapidly evolving due to the introduction of new biologic and small-molecule drugs, and the aim of treatment is to induce a condition of remission or low disease activity in all disease domains. However, unmet treatment needs still persist for those patients with impaired function, reduced quality of life or comorbidities. In this context, physical therapy and rehabilitation could provide additional benefits by reducing disease activity and improving function. Although a large number of studies have assessed the role of physical therapy and exercise in other forms of chronic inflammatory arthritis, such as axial spondyloarthritis and rheumatoid arthritis, evidence on their effect on persons with PsA is still lacking. However, some studies have reported the potential positive role of physical therapy on the different disease domains of PsA, in helping to improve disease activity, prevent or improve articular impairment, improve pain management and improve quality of life. Here, we review current evidence on physical therapy, exercise and rehabilitation in patients with PsA. In particular, we review the literature focusing on each domain, to provide evidence of efficacy and effectiveness of exercise and rehabilitation on skin, peripheral arthritis, axial involvement, dactylitis, enthesitis and comorbidities.

Cardiovascular Disease in Spondyloarthritides

The spondyloarthritides are a group of chronic systemic inflammatory joint diseases, the main types being ankylosing spondylitis (AS) and psoriatic arthritis (PsA). Evidence accumulating during the last decades suggests that patients with AS or PsA carry an increased risk for cardiovascular disease and cardiovascular death. This risk appears to be mediated by systemic inflammation over and above classical cardiovascular risk factors. The excess cardiovascular risk in those patients has been formally acknowledged by scientific organizations, which have called physicians' attention to the matter. The application by Rheumatologists of new effective anti-rheumatic treatments and treat-to-target strategies seems to benefit patients from a cardiovascular point of view, as well. However, more data are needed in order to verify whether anti-rheumatic treatments do have an effect on cardiovascular risk and whether there are differences among them in this regard. Most importantly, a higher level of awareness of the cardiovascular risk is needed among patients and healthcare providers, better tools to recognize at-risk patients and, ultimately, commitment to address in parallel both the musculoskeletal and the cardiovascular aspect of the disease.

Physical and Psychosocial Burden of Psoriatic Arthritis: Longitudinal Data From a Population-Based Study in Norway

OBJECTIVE

Psoriatic arthritis (PsA) can have a significant impact on health-related quality of life (HRQoL). Data on the timing of changes in the HRQoL of patients with PsA are limited. The present study was undertaken to explore associations between sleep disturbance, fatigue, pain, anxiety, depression, general health status, and satisfaction with life before and after a diagnosis of PsA compared to the general population.

METHODS

Patients diagnosed with PsA between the Nord-Trøndelag Health Study (HUNT2 [1995-1997] and HUNT3 [2006-2008]) surveys were compared to the general population. The adjusted odds ratio (OR_adj ) with 95% confidence interval (95% CI) was estimated at both time points.

RESULTS

Among 36,507 individuals participating in both the HUNT2 and HUNT3 surveys, 160 were diagnosed with PsA between the surveys. The prevalence of sleep disturbances and fatigue was higher in PsA patients after diagnosis compared to the general population (OR_adj 2.24 [95% CI 1.55-3.25] and OR_adj 1.94 [95% CI 1.27-2.98], respectively). The prevalence of pain and poor health status were higher in patients with PsA compared with the general population even before PsA was diagnosed (OR_adj 2.81 [95% CI 1.96-4.02] and OR_adj 3.08 [95% CI 2.19-4.35], respectively) and increased after diagnosis of PsA (OR_adj 12.87 [95% CI 6.27-26.40] and OR_adj 5.63 [95% CI 3.99-7.95], respectively). For anxiety, depression, and life satisfaction, patients who developed PsA were comparable to the general population both before and after the diagnosis of PsA.

CONCLUSION

Compared to the general population, PsA patients reported a higher prevalence of pain and poorer health status before diagnosis. Increased prevalence of sleep disturbances and fatigue in PsA patients was only found after the PsA diagnosis, and no differences between patients with PsA and the control group were found for anxiety and depression.

Psoriatic arthritis: exploring the occurrence of sleep disturbances, fatigue, and depression and their correlates

Introduction

Sleep disturbances, fatigue, and anxiety/depression in psoriatic arthritis (PsA) may be influenced by skin and musculoskeletal manifestations. All of these in turn affect the psychosocial impact of disease. The objective was to explore the occurrence of sleep disturbances, fatigue, and anxiety/depression in psoriatic arthritis (PsA) patients, and their correlates.

Methods

A broad data collection was performed in 137 Norwegian PsA outpatient clinic patients including demographics, disease activity measures for both skin and musculoskeletal involvement, and patient-reported outcome measures. Sleep disturbances and fatigue were defined present if the numeric rating scale (0–10) score was ≥ 5. Anxiety/depression was assessed using a questionnaire (1–3; 1 defined as no anxiety/depression). Descriptive statistics was applied, and associations were explored using univariate and adjusted linear regression analysis.

Results

The mean age was 52.3 years, PsA disease duration 8.8 years; 49.6% were men and 54.8% were currently employed/working. The prevalence of sleep disturbances was 38.0%, fatigue 44.5%, and anxiety/depression 38.0%. In adjusted analysis, pain, fatigue, and higher mHAQ were associated with sleep disturbances. Sleep disturbances, pain, and anxiety/depression were associated with fatigue, whereas only fatigue was associated with anxiety/depression.

Conclusions

The prevalence of sleep disturbances, fatigue, and anxiety/depression was frequently reported by PsA patients. No measures reflecting skin involvement or objective measures of musculoskeletal involvement were independently associated with sleep disturbances, fatigue, or anxiety/depression. Our data suggest that patients’ perceptions of musculoskeletal involvement (pain or mHAQ) play an important role causing sleep disturbances and fatigue, whereas fatigue in PsA patients is strongly associated with anxiety/depression.

Strategies to Improve Outcomes in Psoriatic Arthritis

PURPOSE OF REVIEW

The therapeutic response to biologic agents in psoriasis is significantly higher than observed in psoriatic arthritis (PsA). In this review, specific actions to improve treatment outcomes in PsA are discussed.

RECENT FINDINGS

Increased understanding of disease pathogenesis derived from improved preclinical models and advances in cell-based and molecular technologies provide new tools to identify therapeutic targets. In addition to the important contributions of metabolic comorbidities, chronic pain and the lack of a diagnostic biomarker signal the need for new strategies to improve outcomes. Potential strategies include the following: (1) discover a novel pathway or cellular subset, (2) apply stratification biomarkers to individualize therapy, (3) preclinical intervention, (4) combination therapy, (5) lifestyle modification, (6) address chronic pain and fatigue, and (7) multidisciplinary care. The future holds great promise for enhanced treatment responses in PsA based on improved understanding of individual variation in disease pathophysiology coupled with comprehensive and integrated treatment programs.

Effect of high-intensity interval training on cardiovascular disease risk factors and body composition in psoriatic arthritis: a randomised controlled trial

Background

Psoriatic arthritis (PsA) is associated with an accumulation of cardiovascular disease (CVD) risk factors. The aim of this study was to evaluate the effect of high-intensity interval training (HIIT) on CVD risk factors in patients with PsA.

Methods

We randomly assigned 61 patients with PsA (41 women and 20 men) to an intervention group performing HIIT for 11 weeks or a control group who were instructed to not change their physical exercise habits. Outcomes were assessed at 3 and 9  months with measures on maximal oxygen uptake (VO_2max), fat percentage and Body Mass Index (BMI). We used linear mixed models to calculate mean difference with 95% CI between the groups according to the intention-to-treat principle.

Results

At 3  months, the HIIT group had a 3.72  mL/kg/min (95%  CI 2.38 to 5.06) higher VO_2max and a 1.28 (95% CI −2.51 to −0.05) lower truncal fat percentage than controls. There was also some evidence that the HIIT group had lower total fat percentage (−0.80; 95%  CI −1.71 to 0.10) and slightly lower BMI (−0.31; 95%  CI −0.78 to 0.17) than the control group. At 9  months, the HIIT group had still a higher VO_2max (3.08; 95%  CI 1.63 to 4.53) than the control group, whereas the difference in other factors were small.

Conclusion

In patients with PsA, 3  months with HIIT was associated with a substantial increase in VO_2max and a reduction in truncal fat percentage compared with controls. The beneficial effect on VO_2max was also sustained through 9  months.

Trial registration number

NCT02995460.