Intensive aerobic and muscle endurance exercise in patients with systemic sclerosis: a pilot study

Impact of a resilience-building energy management intervention for people with systemic sclerosis: a mixed methods study

Objectives

People with SSc often experience fatigue, which significantly affects daily life functioning and quality of life. We aimed to explore participants' experiences of a peer health-coached resilience-building energy management to enhance well-being (RENEW) intervention on symptoms and well-being and to use mixed methods to compare how SSc duration influenced the experiences of participants who had clinically significant fatigue improvement vs those who did not.

Methods

Semi-structured interviews were conducted with 21 participants from the parent clinical trial randomized to the RENEW intervention. Data were analysed using the rigorous and accelerated data reduction technique combined with thematic content analysis. A mixed methods approach used a joint display to identify themes related to the impact of SSc duration on fatigue improvement status. Participants were categorized into short/improvement, short/limited improvement, long/improvement, and long/limited improvement.

Results

Our team generated four themes: participant and peer health-coach relationship, physical and psychological well-being improvement, need for a tailored approach and easy program access through technology. Mixed methods analysis revealed that, regardless of SSc duration, participants with improved fatigue reported increasing self-awareness of SSc-related symptoms and learning coping strategies to manage fatigue. Participants in the short/improvement group reported preferences for slower pacing of the program and pairing with a coach with similar symptom severity. Participants in the long/limited improvement group sought SSc-specific symptom management information.

Conclusion

Incorporating peer health coaches and technology is beneficial for self-management interventions for people with SSc. Future tailoring of RENEW based on SSc duration and symptom severity is needed.

Clinical trial registration number

clinicatrials.gov, NCT04908943.

Effects of a telerehabilitation-based exercise program in patients with systemic sclerosis

BACKGROUND

This study aimed to evaluate the effect of telerehabilitation-based exercise programs in systemic sclerosis (SSc) patients.

METHODS

Forty-six SSc patients were randomly separated into two groups as telerehabilitation and control. Videos comprising clinical Pilates-based exercises were designed and uploaded to YouTube™ for the telerehabilitation group by physiotherapists. A video interview was conducted with the SSc patients once a week and an exercise program was performed twice daily for 8 weeks in the telerehabilitation group. The same exercise programs were printed on paper brochures and patients were instructed on their application in the form of a home exercise program to be continued for 8 weeks in the control group. Pain, fatigue, quality of life, sleep, physical activity, anxiety, and depression were assessed in all patients at the beginning and end of the study.

RESULTS

The clinical and demographic characteristics were similar in both groups (p > 0.05). Fatigue, pain, anxiety, and depression decreased in both groups, while quality of life and sleep quality increased after the exercise program (p < 0.05). However, the improvements in the telerehabilitation group were statistically more significant than in the control group for all studied parameters (p < 0.05).

CONCLUSION

The results of our study demonstrate the superior efficacy of telerehabilitation-based treatment programs over home exercise programs, hence, we suggest widespread use of this innovative treatment program in SSc patients.

Clinical Features Associated With Rate of Fractures in Patients With Systemic Sclerosis: A US Cohort Study

OBJECTIVE

Systemic sclerosis (SSc) is associated with several specific risk factors for fracture due to the complications of the disease and related medications. The present study was undertaken to examine the relationship between SSc-associated clinical features and fracture rate in a large US cohort.

METHODS

Participants with SSc in FORWARD, The National Databank for Rheumatic Diseases, were included (1998-2019). Age- and sex-matched individuals with osteoarthritis (OA) from the same database were included as comparators. The primary end point was self-reported major osteoporotic fracture. Cox proportional hazards models were used to study the associations between risk factors and fractures.

RESULTS

The study included 922 individuals (SSc patients, n = 154; OA patients, n = 768). Eighty-seven percent were female, with a mean age of 57.8 years. Fifty-one patients developed at least 1 fracture during a median of 4.2 years (0.5-22.0 years) of follow-up. Patients with SSc had more frequent fractures compared to OA comparators (hazard ratio [HR] 2.38 [95% confidence interval (95% CI) 1.47-3.83]). Among patients with SSc, a higher Rheumatic Disease Comorbidity Index score (HR 1.45 [95% CI 1.20-1.75]) and a higher Health Assessment Questionnaire disability index score (HR 3.83 [95% CI 2.12-6.93]) were associated with more fractures. Diabetes mellitus (HR 5.89 [95% CI 2.51-13.82]) and renal disease (HR 2.43 [95% CI 1.10-5.37]) were independently associated with fracture among SSc patients relative to SSc patients without these comorbidities.

CONCLUSION

Our findings highlight factors associated with fracture among patients with SSc. Disability as measured by the HAQ DI is a particularly strong indicator of fracture rate in SSc. Improving SSc patients' functional status, where possible, may lead to better long-term outcomes.

Myopathy in systemic sclerosis

PURPOSE OF REVIEW

Systemic sclerosis associated myopathy (SSc-AM) is a complex, heterogenous disease that is associated with poor outcomes. SSc-AM lacks a clear definition, and continues to be poorly recognized. The purpose of this review is to provide a contemporary overview of the clinical, serological and pathophysiologic findings in SSc-AM to guide optimal recognition and management of this challenging disease manifestation.

RECENT FINDINGS

There have been several advances in diagnostic techniques to facilitate characterization of SSc-AM, including muscle MRI, in which findings were correlated to distinct histopathologic categories of muscle involvement in SSc, histopathologic findings of prominent fibrosis or inflammation on biopsy, and the identification of novel autoantibodies associated with SSc-AM, which may be associated with distinct clinical phenotypes. In one of the largest studies to date, 17% of a well phenotyped SSc cohort were found to have myopathy, which was an independent risk of death, even after adjusting for potential confounders, further highlighting the importance of timely recognistion and management of SSc-AM.

SUMMARY

There is increasing recognition of the importance of SSc-AM. Novel diagnostic tools provide the opportunity for more detailed insights into pathophysiologic mechanisms, which may facilitate the development of a rigorous consensus definition of SSc-AM.

Minimal Clinically Important Differences (MCID) for the Functional Assessment of Chronic Illness Therapy Fatigue Scale in Patients with Systemic Sclerosis

(1) Background: Systemic sclerosis (SSc) is characterized by significant fatigue, causing diminished quality of life (QoL). The aim of this study was to examine fatigue levels and their associations with clinical factors and determine the minimal clinically important difference (MCID) value for the Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-FS). (2) Methods: A total of 160 SSc patients and 62 individuals without SSc were followed-up over a 12-month period by measuring the FACIT-FS and the Visual Analogue Scale and the Short Form 36 Vitality Score analyzing changes in exhaustion. (3) Results: Fatigue was strongly correlated with HRQoL, level of pain, emotional disorders, physical capability and functionality. The MCID values for FACIT-FS were calculated as -3 for deterioration and +4 for improvement after a 12-month follow-up. The predictors of improvement of fatigue from baseline parameters were the significant disease activity, the patients' poorer functionality and the short disease duration. Patients with scleroderma-related interstitial lung disease at baseline had approximately tripled risks for worsening fatigue. The independent influential factors regarding the changing of FACIT-FS were improving or worsening in the same direction in reference to physical condition, gastrointestinal and emotional factors. (4) Conclusions: Fatigue is a multi-dimensional symptom, which is strongly correlated to HRQoL. MCID values of FACIT-FS can be useful tools in monitoring the changes of HRQoL in clinical trials and in daily practice among patients with SSc.

Exploring the effects of a combined exercise programme on pain and fatigue outcomes in people with systemic sclerosis: study protocol for a large European multi-centre randomised controlled trial

Background

Pain, related to Raynaud’s phenomenon or digital ulceration, has been identified as very prevalent and debilitating symptoms of systemic sclerosis (SSc), both significantly affecting patients’ quality of life (QoL). Pharmacological therapeutic strategies were found not to be sufficiently effective in the management of SSc-induced pain and fatigue, and evidence for exercise is scarce. As yet, the effects of a long-term, tailored exercise programme on pain and fatigue in patients with SSc have not been explored. In addition to pain and fatigue, this study aims to evaluate the effects of exercise on QoL, physical fitness, functional capacity, and vascular structure in people with SSc (PwSSc).

Methods

This will be a multicentre (n = 6) randomised controlled clinical trial to assess the effect of a previously established, supervised 12-week combined exercise programme on pain and fatigue as compared to no exercise in PwSSc. The study will recruit 180 patients with SSc that will be allocated randomly to two groups. Group A will perform the exercise programme parallel to standard usual care and group B will receive usual care alone. Patients in the exercise group will undertake two, 45-min sessions each week consisting of 30-min high-intensity interval training (HIIT) (30-s 100% peak power output/30-s passive recovery) on an arm crank ergometer and 15 min of upper body circuit resistance training. Patients will be assessed before as well as at 3 and 6 months following randomisation. Primary outcomes of the study will be pain and fatigue assessed via questionnaires. Secondary outcomes include quality of life, structure of digital microvasculature, body composition, physical fitness, and functional capacity.

Discussion

Data from this multi-centre research clinical trial will primarily be used to establish the effectiveness of a combined exercise protocol to improve pain and fatigue in SSc. In parallel, this study will be the first to explore the effects of long-term exercise on potential microvascular alterations assessed via NVC. Overall, this study will provide sufficient data to inform current clinical practice guidelines and may lead to an improvement of QoL for patients with SSc.

Trial registration

ClinicalTrials.gov NCT05234671. Registered on 14 January 2022

The Preventive Role of Physical Activity in Systemic Sclerosis: A Cross-Sectional Study on the Correlation with Clinical Parameters and Disease Progression

Although exercise is associated with improved health in many medical conditions, little is known about the possible influences of physical activity (PA) habits pre- and post- a diagnosis of systemic sclerosis (SSc) on disease activity and progression. This cross-sectional study assessed, for the first time, self-reported pre- and post-diagnostic PA levels with the aim to verify if changes in these levels were correlated with demographic/anthropometric data (e.g., weight, height, gender, age, BMI), disease duration, diagnostic/clinical parameters (e.g., skin involvement, pulmonary hemodynamic/echocardiographic data, disease activity) related to disease activity and progression, and quality of life in a population-based sample of patients with SSc. Adult participants (n = 34, age 56.6 ± 13.3 years) with SSc (limited cutaneous SSc, lcSSc, n = 20; diffuse cutaneous SSc, dcSSc, n = 9; sine scleroderma SSc, n = 5) were enrolled at the Division of Rheumatology and Clinical Immunology of the Humanitas Research Hospital. All medical data were recorded during periodic clinical visits by a rheumatologist. Moreover, all subjects included in this study completed extensive questionnaires to evaluate their health-related quality of life (HRQOL), and others related to health-related physical activity performed before (PRE) and after (POST) the diagnosis of disease. The linear regression analysis has shown that either a high Sport_index or Leisure_index in the PRE-diagnostic period was correlated with lower disease duration in dcSSc patients. Physical load during sport activity and leisure time accounted for ~61.1% and ~52.6% of the individual variation in disease duration, respectively. In lcSSc patients, a high PRE value related to physical load during sporting activities was correlated with a low pulmonary artery systolic pressure (sPAP) and the POST value of the Work_index was positively correlated with the left ventricular ejection fraction (LVEF), and negatively with creatine kinase levels (CK). Interestingly, the univariate analysis showed that Work_index accounts for ~29.4% of the variance in LVEF. Our analysis clearly reinforces the concept that high levels of physical load may play a role in primary prevention-delaying the onset of the disease in those subjects with a family history of SSc-as well as in secondary prevention, improving SSc management through a positive impact on different clinical parameters of the disease. However, it remains a priority to identify a customized physical load in order to minimize the possible negative effects of PA.

A comprehensive framework for navigating patient care in systemic sclerosis: A global response to the need for improving the practice of diagnostic and preventive strategies in SSc

Systemic sclerosis (SSc), the most lethal of rheumatologic conditions, is the cause of death in >50% of SSc cases, led by pulmonary fibrosis followed by pulmonary hypertension and then scleroderma renal crisis (SRC). Multiple other preventable and treatable SSc-related vascular, cardiac, gastrointestinal, nutritional and musculoskeletal complications can lead to disability and death. Vascular injury with subsequent inflammation transforming to irreversible fibrosis and permanent damage characterizes SSc. Organ involvement is often present early in the disease course of SSc, but requires careful history-taking and vigilance in screening to detect. Inflammation is potentially reversible provided that treatment intensity quells inflammation and other immune mechanisms. In any SSc phenotype, opportunities for early treatment are prone to be under-utilized, especially in slowly progressive phenotypes that, in contrast to severe progressive ILD, indolently accrue irreversible organ damage resulting in later-stage life-limiting complications such as pulmonary hypertension, cardiac involvement, and malnutrition. A single SSc patient visit often requires much more physician and staff time, organization, vigilance, and direct management for multiple organ systems compared to other rheumatic or pulmonary diseases. Efficiency and efficacy of comprehensive SSc care enlists trending of symptoms and bio-data. Financial sustainability of SSc care benefits from understanding insurance reimbursement and health system allocation policies for complex patients. Sharing care between recognised SSc centers and local cardiology/pulmonary/rheumatology/gastroenterology colleagues may prevent complications and poor outcomes, while providing support to local specialists. As scleroderma specialists, we offer a practical framework with tools to facilitate an optimal, comprehensive and sustainable approach to SSc care. Improved health outcomes in SSc relies upon recogntion, management and, to the extent possible, prevention of SSc and treatment-related complications.

Exercise as a multi-modal disease-modifying medicine in systemic sclerosis: An introduction by The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis (G-FoRSS)

Systemic sclerosis (SSc) is a heterogeneous multisystem autoimmune disease whereby its main pathological drivers of disability and damage are vascular injury, inflammatory cell infiltration, and fibrosis. These mechanisms result in diffuse and diverse impairments arising from ischemic circulatory dysfunction leading to painful skin ulceration and calcinosis, neurovascular aberrations hindering gastrointestinal (GI) motility, progressive painful, incapacitating or immobilizing effects of inflammatory and fibrotic effects on the lungs, skin, articular and periarticular structures, and muscle. SSc-related impairments impede routine activities of daily living (ADLs) and disrupt three critical life areas: work, family, social/leisure, and also impact on psychological well-being. Physical activity and exercise are globally recommended; however, for connective tissue diseases, this guidance carries greater impact on inflammatory disease manifestations, recovery, and cardiovascular health. Exercise, through myogenic and vascular phenomena, naturally targets key pathogenic drivers by downregulating multiple inflammatory and fibrotic pathways in serum and tissue, while increasing circulation and vascular repair. G-FoRSS, The Global Fellowship on Rehabilitation and Exercise in Systemic Sclerosis recognizes the scientific basis of and advocates for education and research of exercise as a systemic and targeted SSc disease-modifying treatment. An overview of biophysiological mechanisms of physical activity and exercise are herein imparted for patients, clinicians, and researchers, and applied to SSc disease mechanisms, manifestations, and impairment. A preliminary guidance on exercise in SSc, a research agenda, and the current state of research and outcome measures are set forth.

Effects of supervised exercise program and home exercise program in patients with systemic sclerosis: A randomized controlled trial

AIM

To compare the effects of supervised exercise and home exercise program in patients with systemic sclerosis (SSc).

METHODS

Thirty-seven SSc patients were included. Patients with SSc were allocated into 2 groups as supervised and home exercise. Breathing, aerobic and resistance exercises were performed with a physiotherapist for 12 weeks in the supervised exercise group. Breathing, posture and aerobic exercises were given to the home exercise group as a home program for 12 weeks. All patients were assessed at baseline and 12 weeks later in terms of functional capacity, pulmonary functions, respiratory-peripheral muscle strength, dyspnea severity, health-related quality of life (HRQoL) and fatigue level.

RESULTS

Significant improvements were observed in the functional capacity, measured by 6 minute walking test in the supervised exercise group (before = 376.21 ± 65.50, after = 518.78 ± 75.84 m) and home exercise group (before = 384.44 ± 68.14, after = 432.7 ± 70.8 m; (P < .05). Respiratory-peripheral muscle strength (with the exception of inspiratory muscle strength and upper limb strength in the home exercise group) and HRQoL were significantly increased and fatigue level was significantly decreased in the supervised exercise and home exercise groups (P < .05). However, pulmonary functions and dyspnea severity were significantly improved only in the supervised exercise group (P < .05). The supervised exercise program was found superior to the home exercise program for change in all parameters (P < .05).

CONCLUSION

This study suggests that exercise interventions should be applied in addition to the medical treatments of patients with SSc as supervised and home exercise programs play an important role in the functionality and health status of these patients.

Neck treatment compared to aerobic exercise in migraine: A preference-based clinical trial

Objectives:

The main objective of this study was to compare the effectiveness of aerobic exercise with physiotherapy. A second objective was to evaluate whether patients with pain referred to the head during manual palpation will benefit more from physiotherapy than patients with local or no pain.

Methods:

A total of 103 patients with migraine received physiotherapy ( n = 79) or supervised aerobic exercise ( n = 24) according to their preference as an add-on treatment. Both groups had the same contact time with a specialized physiotherapist. The primary outcome measure was headache frequency during the 4 weeks after the intervention. Eighty-seven patients were analyzed at the primary end point ( n = 69 in the physiotherapy group; n = 18 in the aerobic exercise group). A follow-up assessment was conducted 3 months after the final intervention.

Results:

During the initial assessment of the upper cervical spine, 17 patients reported no pain, 45 local pain, and 25 referred pain to the head. Patients in the physiotherapy group had a mean reduction of 1.8 days (standard deviation (SD) 6.07), while patients in the aerobic exercise group had a mean reduction of 1.2 days (SD 4.27) at the primary end point. This difference was not statistically significant ( p = 0.8). The largest improvement was noted in the group that showed referred pain to the head and received physiotherapy (2.13 days (SD 7.82)). Only patients in the physiotherapy group reported a subjectively perceived general improvement.

Conclusions:

Patients had a strong preference for physiotherapy. Both groups showed small reductions in headache frequency. Effects were superior after physiotherapy but not statistically significant. Patients with pain referred to the head responded best to a physiotherapy intervention.

The effect and safety of exercise therapy in patients with systemic sclerosis: a systematic review

Given the shortcomings of previous literature reviews evaluating the effect and safety of exercise therapy in SSc, we aimed to carry out a systematic review of the literature specifically on this topic. A structured search strategy was performed in Medline (via PubMed) and other electronic databases from 1990 to 3 September 2019. Randomized controlled trials, observational designs, conference abstracts and trial registrations were included if they concerned SSc patients ≥18 years of age, exercise therapy and reported outcomes related to physical functioning. Nine articles were included. Four randomized controlled trials compared (a) hand exercises, (b) orofacial exercises, (c) aerobic exercises or (d) aerobic exercises plus resistance training with no exercise, demonstrating effects on hand function (a), maximum mouth opening (b), peak oxygen uptake (c + d) and quality of life. All five observational studies concerning hand, orofacial, aerobic and/or strengthening exercises reported improvements of hand function, mouth opening, aerobic capacity and/or muscle strength. In conclusion, the evidence on the effect and safety of exercise therapy in SSc is scanty.

Investigating the effectiveness and feasibility of exercise on microvascular reactivity and quality of life in systemic sclerosis patients: study protocol for a feasibility study

Background

Raynaud’s phenomenon is one of the first clinical manifestations observed in systemic sclerosis (SSc). This microvasculature disorder affects mostly the digits in over 95% of SSc patients, significantly affecting their health-related quality of life (HRQoL) and incurring higher hospital admissions and other healthcare costs. Exercise is known to improve both micro- and macrovascular function – aerobic exercise and resistance training, separately or combined, have been demonstrated to lead to significant vasculo-physiological improvements in conditions that present vasculopathy. However, the effects of a combined exercise programme on microcirculation in SSc patients has yet to be investigated. Therefore, the purpose of this study is to assess the effects of high-intensity interval training (HIIT) combined with circuit resistance training on the microvascular function in the digital area of SSc patients.

Methods

This will be a randomised controlled, feasibility trial with two arms, wherein 30 patients with SSc in receipt of medical treatment will be randomly assigned to usual care (medical treatment) or to a 12-week supervised exercise programme. Patients in the exercise group will undertake two, 45-min sessions each week consisting of 30 min HIIT (30 s 100% peak power output/30 s passive recovery) on the arm crank ergometer and 15 min of upper body circuit resistance training. Patients will be assessed before as well as at 3 and 6 months following randomisation. Primary outcomes of the study will be recruitment and retention rate, intervention acceptability and adherence to the exercise programme. Secondary outcomes include the digital area cutaneous microvascular function (laser Doppler fluximetry combined with iontophoresis), physical fitness, functional ability, upper back transcutaneous oxygen tension, body composition and quality of life (EQ-5D-5L). Selected interviews with a subsample of patients will be undertaken to explore their experiences of having Raynaud’s phenomenon and the acceptability of the exercise intervention and study procedures.

Discussion

Data from this study will be used to identify the feasibility of a combined exercise programme to be implemented in SSc patients, the acceptability of the intervention and the study design, and to determine the effects of exercise on the microvasculature. Overall, this study will provide sufficient data to inform and support a full multicentre clinical trial.

Trial registration

ClinicalTrials.gov (NCT number): NCT03058887, February 23, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2980-1) contains supplementary material, which is available to authorized users.

Physical activity in patients with systemic sclerosis

OBJECTIVES

To compare self-reported levels of physical activity (PA) of systemic sclerosis (SSc) patients with the general population. To evaluate in SSc patients factors associated with PA levels and needs and preferences regarding PA.

METHODS

Fifty nine SSc patients completed the Short QUestionnaire to ASsess Health-Enhancing PA. The proportion of patients meeting the Dutch Recommendation for PA (= moderate PA for 30 min on ≥ 5 days/week) and total minutes of PA per week were calculated and compared with similar data from the Dutch population. Characteristics were univariately and multivariately compared between patients with low and high PA levels (either ≤ or > mean minutes/week of the Dutch population). Needs and preferences regarding PA promotion and guidance related to exercise were assessed by questionnaires.

RESULTS

Stratified for age (< 55 or ≥ 55 years) and gender, the proportion SSc patients meeting the Dutch recommendation for PA was not significantly different from the Dutch population. The total minutes of PA per week was significantly lower among SSc patients (1704 vs. 2614, P < 0.001). Multivariable analyses showed that in SSc patients the male gender, scleroderma health assessment questionnaire (SHAQ) and lack of energy were significantly associated with lower PA levels (P = 0.007; P = 0.042; P = 0.025). Two-third of patients required more information about PA.

CONCLUSION

In SSc patients, the total minutes of PA per week are significantly lower compared to the general population. The male gender, functional ability as reflected by SHAQ and lack of energy seem to interfere with PA. These results might guide health professionals in providing their patients with appropriate information on PA.

Clinical significance and usefulness of rehabilitation for systemic sclerosis

Systemic sclerosis is a multisystem connective tissue disorder characterized by excessive fibrosis of the skin and internal organs. Impairments in skin, the musculoskeletal system, and respiratory system require rehabilitation therapy because they may lead to disabilities and reduce the quality of life in daily activities. Rehabilitation for systemic sclerosis mainly comprises two distinct approaches that include local and global rehabilitation. Local rehabilitation is applied to maintain and/or improve hand and face functions, while global rehabilitation includes aerobic and resistance exercises. Although few high-quality randomized clinical trials have been conducted to date, previous studies indicated the effectiveness of rehabilitation therapy for decreasing local and systemic disabilities, resulting in improved quality of life. Rehabilitation for systemic sclerosis needs to be regularly and constantly performed at home as well as in hospitals. Physicians involved in the treatment of systemic sclerosis need to consider rehabilitation, and skilled physiotherapists and occupational therapists also play a crucial role in evaluating and treating systemic sclerosis patients.

Aerobic and resistance exercise in systemic sclerosis: State of the art

INTRODUCTION

Patients with systemic sclerosis (SSc) experience reduced exercise capacity and muscle strength compared with healthy subjects. There are also indications of reduced levels of physical activity.

OBJECTIVE

To present the current knowledge of physical exercise in SSc.

RESULTS

Most studies presently available [three case studies, one single subject experimental design, one study comparing patients with healthy controls, one quasi experimental design (pre-post), two clinical trials and two random controlled trials] have included small samples of patients, mostly composed of patients with and without pulmonary involvement. It seems that patients with SSc without pulmonary involvement are able to perform and benefit from aerobic exercises of at least moderate intensity. Exercise tolerance, aerobic capacity, walking distance, muscle strength and muscle function as well as health-related quality of life (HRQL) have been found to be improved after participation in programmes including aerobic exercise and aerobic exercise combined with resistance exercises. Improvements seem to be only partially retained at follow up. Patients with pulmonary involvement may also experience improved muscle strength, physical and aerobic capacity, as well as HRQL following exercise.

CONCLUSIONS

Patients with SSc without pulmonary involvement can be recommended to be as physically active as the general population. Patients with mild pulmonary involvement can be recommended to be physically active by engaging in exercises of moderate intensity and to participate in moderate-load resistance exercises. Health professionals should inform patients with SSc about the importance of physical activity and avoidance of a sedentary lifestyle.

Physical activity and autoimmune diseases: Get moving and manage the disease

Physical activity, by definition, is any skeletal muscle body movement that results in energy expenditure. In the last few decades, a plethora of scientific evidences have accumulated and confirmed the beneficial role of physical activity as a modifiable risk factor for a wide variety of chronic diseases including cardiovascular diseases (CVDs), diabetes mellitus and cancer, among others. Autoimmune diseases are a heterogeneous group of chronic diseases, which occur secondary to loss of self-antigen tolerance. With the advent of biological therapies, better outcomes have recently been noted in the management of autoimmune diseases. Nonetheless, recent research highlights the salient role of modifiable behaviors such as physical inactivity on various aspects of the immune system and autoimmune diseases. Physical activity leads to a significant elevation in T-regulatory cells, decreased immunoglobulin secretion and produces a shift in the Th1/Th2 balance to a decreased Th1 cell production. Moreover, physical activity has been proven to promote the release of IL-6 from muscles. IL-6 released from muscles functions as a myokine and has been shown to induce an anti-inflammatory response through IL-10 secretion and IL-1β inhibition. Physical activity has been shown to be safe in most of autoimmune diseases including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), multiple sclerosis (MS), inflammatory bowel diseases (IBD), as well as others. Additionally, the incidence of RA, MS, IBD and psoriasis has been found to be higher in patients less engaged in physical activity. As a general trend, patients with autoimmune diseases tend to be less physically active as compared to the general population. Physically active RA patients were found to have a milder disease course, better cardiovascular disease (CVD) profile, and improved joint mobility. Physical activity decreases fatigue, enhances mood, cognitive abilities and mobility in patients with MS. In SLE patients, enhanced quality of life and better CVD profile were documented in more physically active patients. Physically active patients with type 1 diabetes mellitus have a decreased risk of autonomic neuropathy and CVD. Both fibromyalgia and systemic sclerosis patients report decreased disease severity, pain, as well as better quality of life with more physical activity. Further, SSc patients improve their grip strength, finger stretching and mouth opening with increased level of exercise. The purpose of this paper is to review the clinical evidence regarding the safety, barriers to engagement, and impact of physical activity on autoimmune diseases.

The relevance of applying exercise training principles when designing therapeutic interventions for patients with inflammatory myopathies: a systematic review

Physical exercise seems to be a safe and effective intervention in patients with inflammatory myopathy (IM). However, the optimal training intervention is not clear. To achieve an optimum training effect, physical exercise training principles must be considered and to replicate research findings, FITT components (frequency, intensity, time, and type) of exercise training should be reported. This review aims to evaluate exercise interventions in studies with IM patients in relation to (1) the application of principles of exercise training, (2) the reporting of FITT components, (3) the adherence of participants to the intervention, and (4) to assess the methodological quality of the included studies. The literature was searched for exercise studies in IM patients. Data were extracted to evaluate the application of the training principles, the reporting of and the adherence to the exercise prescription. The Downs and Black checklist was used to assess methodological quality of the included studies. From the 14 included studies, four focused on resistance, two on endurance, and eight on combined training. In terms of principles of exercise training, 93 % reported specificity, 50 % progression and overload, and 79 % initial values. Reversibility and diminishing returns were never reported. Six articles reported all FITT components in the prescription of the training though no study described adherence to all of these components. Incomplete application of the exercise training principles and insufficient reporting of the exercise intervention prescribed and completed hamper the reproducibility of the intervention and the ability to determine the optimal dose of exercise.

Safety and feasibility of maximal physical testing in rheumatic diseases: a cross-sectional study with 5,910 assessments

The purpose of the study was to report on the safety and feasibility of the application of maximal physical tests in a heterogeneous cohort of rheumatic patients. This is a 5-year retrospective descriptive report on the incidence of events associated with maximal physical testing from 536 patients, totalizing 5,910 tests. Tests were classified as cardiopulmonary, muscle strength, and physical functioning tests. Any adverse events during the tests and limiting factors incurring in tests cancellation were reported. Eighteen out of 641 cardiopulmonary exercise tests had an adverse occurrence, with cardiac disturbance (1.4% of total tests) being the most prevalent. Moreover, 14 out of 641 tests were not feasible. Out of 3,478 tests comprising leg press, bench press, knee extension, and handgrip tests, 15 tests had an adverse event. The most common occurrence was joint pain (0.4% of total tests), which was also the most frequent factor precluding testing (0.5% of total tests). Forty-five out of 3,478 (1.3%) of the tests were not feasible. There was a very low incidence of events (0.2%) during the physical functioning tests. Joint pain was the only adverse event during the tests, whereas physical limitations were the most important barriers for the execution of the tests (1.1% of total tests). The incidence of limiting events in this test was 1.6% (n = 29). This report brings new data on the safety and feasibility of maximal physical testing in rheumatic patients. The physical tests described in this study may be applied for testing rheumatic patients both in research and clinical setting.