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Because the central pathology of RA occurs in the synovial membrane&#44; joint limitation is a typical manifestation of the disease&#46; This&#44; in addition to the fact that most RA patients also suffer from muscle loss&#44; contributes to decreased physical function and quality of life in these patients&#46; In this regard&#44; it has been shown that RA patients tend to exercise less than healthy controls when PA is measured by both subjective<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">3&#8211;5</span></a> and objective methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#8211;8</span></a> Moreover&#44; there remain two important unanswered questions concerning PA vis-&#224;-vis RA&#58; &#40;1&#41; Do patients who are sufficiently physically active suffer less aggressive disease&#63; and &#40;2&#41; Does disease activity influence PA in RA patients&#63; With regard to the former&#44; there is considerably more evidence favoring the prescribing PA for RA patients than there is against&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">9&#8211;11</span></a> With regard to the latter&#44; 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to identify all published literature relating to PA and&#47;or energy expenditure in people with RA&#46; The search strategy combined 2 sets of keywords&#46; For Embase&#44; EMTREE terms were used&#46; In this case the search consisted of rheumatoid arthritis AND physical activity OR motor activity OR energy expenditure OR leisure activity AND accelerometry OR questionnaire OR calorimetry&#46; For MEDLINE&#44; the MeSH terms were&#58; arthritis&#44; rheumatoid AND leisure activities OR motor activity OR energy metabolism AND accelerometry OR questionnaires&#46; The results included all publications published from 1 January 2000 to January 2015&#44; that included at least 1 search term from each of the 2 categories&#46; Only English language publications were included&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To be included in the review&#44; studies had to be&#58; &#40;1&#41; either observational studies or interventional studies with programs of exercises measuring free living PA or total&#47;activity related energy expenditure levels&#44; using either subjective or objective methods and &#40;2&#41; related to adult RA population with all subjects included in studies fulfilling the criteria set down by the American College of Rheumatology&#44; 1987&#46; Studies which were&#58; &#40;1&#41; interventional in nature with new pharmacological treatments&#59; &#40;2&#41; not in English&#59; or &#40;3&#41; published only in abstract format were excluded&#46; The article selection flowchart is described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Assessment of PA</span><p id="par0030" class="elsevierStylePara elsevierViewall">PA is defined as any bodily movement produced by skeletal muscles that result in energy expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">12</span></a> Under this broad concept&#44; activities relating to leisure-time&#44; exercise&#44; sports&#44; locomotion &#40;e&#46;g&#46;&#44; walking&#44; biking&#41;&#44; and work must be considered parts of PA&#46; Sedentarism has been defined as expenditure below 10&#37; of total daily energy expenditure performing moderate- and high-intensity activities&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">13</span></a> Since&#44; sedentarism has been associated with high incidences of obesity&#44; type-2 diabetes mellitus&#44; cardiovascular disease and other chronic illnesses&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">14</span></a> its prevention has become a priority of the public healthcare systems&#46; To avoid the consequences of sedentarism&#44; U&#46;S&#46; Department of Health and Human Services recommends that adults should do at least 150<span class="elsevierStyleHsp" style=""></span>min a week of moderate-intensity exercise &#40;e&#46;g&#46;&#44; brisk walking&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A very accurate measurement of PA can be obtained by the assessing the total daily energy expenditure&#44; albeit using expensive and cumbersome procedures such as the doubly-labeled water technique<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">16</span></a> or calorimetry&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">2</span></a> Viable alternatives&#44; involving less precise but more accessible methods&#44; are available&#44; however&#46; These include questionnaires and triaxial accelerometers&#44; approaches that are gaining acceptance for assessing PA both in healthy individuals and in patients suffering chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">17&#8211;19</span></a> Although questionnaires provide a evaluation limited by subjectivity&#44; in the last 10 years a significant number of them have been developed to assess PA in different diseases&#59; one of them&#44; the International Physical Activity Questionnaire &#40;IPAQ&#41;&#44; has been used mainly for research purpose in rheumatic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">4&#44;5&#44;20</span></a> This self-report method is the cheapest and easiest way to quickly compile PA data from a large number of people providing an assessment of PA by domains&#46; Alternatively&#44; accelerometers are easily portable devices that offer one important advantage in objectively measuring PA based on the fact that it can capture continuously&#44; for days and weeks distinctive characteristics of movement including the direction&#44; frequency&#44; intensity and duration of PA&#44; as well as resting periods&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">21</span></a> Although accelerometry has already been employed in clinical osteoarthritis trials&#44;<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">22&#8211;24</span></a> it was not until recently that this technique was used to evaluate PA patterns in inflammatory joint disorders such as RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">PA in RA patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">Regular exercise with a moderate to high level of intensity has proven to be effective in improving muscle strength and cardiovascular fitness in healthy populations and in patients with chronic illnesses&#44; including RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;26&#8211;28</span></a> RA&#44; if left uncontrolled&#44; leads to joint deformity and destruction due to the erosion of cartilage and bone&#46; Consequently&#44; it has been assumed than RA patients are less active than the general population because of such joint manifestations&#46; An additional factor that may have contributed to this inactivity tendency stems from recommendations&#44; classically given by physicians&#44; which restrict exercise due to concerns that excessive PA might aggravate both joint inflammation<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">29</span></a> and pain&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">30</span></a> and accelerate joint damage in RA patients&#46; However&#44; currently&#44; evidence suggests that exercise has no deleterious effects either on disease activity or on joint damage<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">27&#44;31</span></a> and improves muscle strength<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">32</span></a> in RA&#46; In this regard&#44; recently it has been suggested that RA patients who are physically active before clinical disease onset present with a milder disease&#44; both in terms of inflammation&#44; pain and function&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">33</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with RA have an increased risk of developing cardiovascular diseases&#44; resulting from a proatherogenic profile driven by systemic inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">34</span></a> In healthy populations there is an inverse relationship between PA and cardiovascular risk &#40;CVR&#41; factors such as BMI&#44; body composition &#40;increased whole body fat and visceral fat&#41;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">35</span></a> and blood lipid levels&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">36</span></a> Although different studies on the relationships between PA&#44; BMI&#44; fat mass and lipid levels in RA populations have yielded controversial data&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;37&#44;38</span></a> the evidence clearly suggests that PA improves the CVR profile in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;11&#44;39</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Different questionnaire-based surveys have indicated that RA patients tend to exercise less than what is currently recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">3&#44;40&#44;41</span></a> When PA is objectively assessed by doubly-labeled water or accelerometry&#44; the main disparity in PA between RA patients and healthy individuals can be seen in the time devoted to different intense activities&#46; RA patients dedicate less time than control to high-intensity PA and to moderately intensive activities<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;25</span></a> probably due to local limitations causing joint pain and disability and systemic effects like fatigue and sarcopenia&#46; A recent systematic review of the literature about this issue&#44; encompassing both objective and subjective methods for evaluating PA&#44; suggests that PA levels among RA individuals tends to be lower than in healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">42</span></a> Although&#44; this review concluded that owing to methodological limitations&#44; a definitive conclusion could not be drawn&#44; currently it is generally accepted that RA patients spend less time than controls doing moderate and vigorous PA&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Effect of PA on joints and disease activity in RA patients</span><p id="par0055" class="elsevierStylePara elsevierViewall">As in the general population&#44; regular PA in RA patients may&#44; apart from providing general health gains&#44; also yield disease-specific benefits such as reduced pain&#44; improved muscle function&#44; and delayed onset of disability&#44;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">10&#44;31&#44;43&#8211;45</span></a> without deleterious effects on joint&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">27&#44;31</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Interestingly&#44; moderate-intensity PA exerts anti-inflammatory effects both in healthy individuals and in those affected by various chronic illnesses&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">46</span></a> Indeed&#44; regular PA has been associated with a diminution in C-reactive protein &#40;CRP&#41;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;39</span></a> and erythrocyte sedimentation rate &#40;ESR&#41;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">47</span></a> levels in RA patients&#46; Although the exact mechanism by which these positive effects arise remains unknown&#44; it seems linked to reductions in blood pressure&#44; lipids&#44; and fatty mass<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">48</span></a>&#46; Taking into account that the main tissular source of IL-6 is the adipose tissue&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">49</span></a> and that several lipids have proinflammatory effects&#44; the reduction of fat accumulation in the skeletal muscle and liver is likely one of the most relevant anti-inflammatory benefits of exercise&#46; Furthermore&#44; it has been well established that PA releases IL-6 from skeletal muscle&#44; a potent inducer of IL-1 receptor antagonist &#40;IL-1ra&#41; by monocytes and macrophages&#44; which constitutes an important anti-inflammatory mechanism of exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">50</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A number of clinical trials evaluating the effects of PA on RA patients have been developed&#46; While much evidence suggests that some exercise is better than none at all&#44; specific exercise parameters &#40;intensity&#44; duration&#44; frequency&#44; and type&#41; resulting in real benefits have not been clearly defined&#46; Some short-term and several long-term clinical trials have evaluated the effects of both aerobic and resistance exercises on outcome measures in RA patients<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;27&#44;28&#44;32&#44;47&#44;51&#8211;60</span></a> &#40;see <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aerobic exercise in RA patients</span><p id="par0070" class="elsevierStylePara elsevierViewall">Although intuitively&#44; long-term regular exercise should be beneficial for RA patients because of the increased cardiovascular mobility and mortality in these patients&#44; reports about aerobic exercise interventions in RA populations are scarce&#46; A systematic review and meta-analysis of aerobic exercise&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">10</span></a> which examined 14 randomized controlled trials&#44; showed that cardiorespiratory aerobic conditioning in stable RA appears to be safe and improves quality of life&#44; functionality and pain levels&#44; but not DAS28 or joint count&#46; This meta-analysis suggests that the sooner the exercise program is initiated&#44; the better are the results obtained in terms of quality of life and functionality&#46; Other clinical trials published afterwards also found an improvement in functionality<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">57</span></a> and pain<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">57&#44;60</span></a> in RA patients who were participating in aerobic exercise programs&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Both&#44; program duration and disease duration impacted on pain&#44; with better results in cases of RA established&#44; and short-term programs&#46; However&#44; data concerning to quality of life suggested than exercise was more benefits in patients with early RA than in established RA patients&#46; When patients were followed up for a long period of time&#44;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">27</span></a> it was found that no significant decrease in aerobic fitness occurred after a relatively brief period of detraining&#59; rather&#44; long-term exercises produced a prolonged positive effect on functional ability&#46; Therefore&#44; the maintenance of a structured PA program after intervention seems to be critical for long-term benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">57&#44;61</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Of all the studies referenced in this review that focused on aerobic exercise in RA patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; three assessed disease activity changes using composite disease activity measurements&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">27&#44;32&#44;57</span></a> These studies concluded that aerobic exercise has a positive impact on disease activity&#44; reducing DAS28&#44; albeit without reaching statistical significance&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resistance exercise in RA population</span><p id="par0085" class="elsevierStylePara elsevierViewall">The value of resistance exercise for RA patients remains controversial because its effects on cardiovascular risk are not clear&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;62</span></a> and its real impact on disability seems to be very small&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">56</span></a> However&#44; despite design differences&#44; the results of previous studies suggest that high-intensity strength training is feasible and safe for many patients with RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">52&#44;56&#44;63</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A systematic review by Baillet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">9</span></a> showed that resistance exercise programs in RA patients can provide a mild&#44; but significant&#44; improvement in terms of functional capacity&#44; the number of tender and swollen joints and a decrease in ESR&#46; Resistance exercise had no impact on DAS28 or on structural damage in any of the studies analyzed&#46; The HAQ response has proven more variable in several reports&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;47&#44;53</span></a> which may reflect the fact that this outcome was designed for monitoring patients in pharmacologic trials and is not be suitable for evaluating physical interventions in patients with mild disabilities&#46; Although the short-term effects of strength training in RA patients have been described in several studies<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">64&#8211;66</span></a> the length of time that positive results achieved after cessation remains controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">32&#44;53&#44;67</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">There is no clear evidence of the superiority of supervised strengthening exercises versus home-based exercises&#44; since the results are varied&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Effects of disease activity on PA in RA patients</span><p id="par0100" class="elsevierStylePara elsevierViewall">Some studies indicate that PA levels &#40;as measured by questionnaires or by accelerometry&#41; have an inverse relationship with disease activity &#40;as assessed by DAS28 or SDAI&#41; in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7&#44;25&#44;68</span></a> One of these studies involved RA patients lacking lower-limb disease activity&#44; which suggests that it is the state of inflammation as a whole that influences patients&#8217; tendency to reduce their levels of PA&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">5</span></a> In these studies&#44; accelerometry was sufficiently sensitive to detect PA-changes related with disease activity both in RA patients&#44; who showed clinical improvements in response to treatment<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">7</span></a> and in patients who suffered a disease flare&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Several disease activity indexes &#8211; such as the DAS&#44; CDAI&#44; SDAI or ACR &#8211; are available and allow physicians to quantify changes in the disease activity of RA over time&#46; These indexes are liable to certain limitations related to both patient subjectivity and inter- and intraobserver variability&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">69</span></a> As stated above&#44; by measuring variations in PA&#44; accelerometry appears to be sufficiently sensitive to register changes in the clinical activity of RA&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7</span></a> and could be used as a complementary objective method for assessing changes in disease activity&#46; Consequently&#44; variation in accelerometry might aid physicians in optimizing the pharmacologic management of RA patients&#46; In addition&#44; accelerometry can help to determine whether or not PA level in a given patient is appropriate to reduce their cardiovascular risk&#44; main cause of premature mortality in these patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Practical applications and exercise recommendations</span><p id="par0110" class="elsevierStylePara elsevierViewall">Along the last 15 years&#44; a number of interventional clinical trials have been developed in order to obtain recommendations on aerobic &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and resistance exercises &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; in RA patients&#46; The high variability in the type&#44; intensity and duration of PA studied&#44; as well as limitations in trial quality and size&#44; suggest that the conclusions of these studies should be still considered to be tentative and further research in the field of PA and RA is warranted&#46; However&#44; a number of practical recommendations can be elaborated respect to exercise in patients with RA&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">All RA patients benefit from a balanced program of strengthening and endurance or aerobic exercise&#46; Therefore&#44; current data indicate that the benefits from performing moderate and high-intensity PA frequently &#40;both aerobic and resistance exercises 2&#8211;3 times per week for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#41; in RA patients include&#58; improved quality of life&#44; functionality&#44; reduced pain&#44; improvement in the number of swollen joints&#44; and lower levels of radiologic damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;28&#44;31</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Low-impact exercises&#44; such as walking&#44; swimming or biking are aerobic exercises recommended for arthritis patients&#46; Aerobic exercise has been shown to improve cardiovascular fitness and patient quality of life&#44; while reducing RA-associated disability and pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">10&#44;54&#44;55&#44;60</span></a> As a result of the little number of studies&#44; it has been suggested that the intensity levels in aerobic exercise should be moderate to hard &#40;i&#46;e&#46;&#44; 60&#8211;85&#37; of maximum heart rate&#41;&#44; and such exercise should be performed 3 times weekly in sessions of 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; divided in 3&#8211;4 periods of 15&#8211;20<span class="elsevierStyleHsp" style=""></span>min a day&#46; Progressive adjustment of the intensity level is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">70</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The strengthening exercises are designed to increase the joint stability&#46; Movements should be smooth&#44; performed 8&#8211;10 times twice a day and without joint pain&#46; The weight must be increased slowly and always that it does not cause pain&#46; Information derived from the reviewed studies<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">70</span></a> suggest that the load level objective for strengthening exercises should be moderate to hard &#40;i&#46;e&#46;&#44; 50&#8211;80&#37; of a maximal voluntary contraction&#41;&#44; and said exercises should be performed along 20&#8211;30<span class="elsevierStyleHsp" style=""></span>min 2&#8211;3 times per week&#46; Exercises may be static or dynamic&#44; done against body weight or with different kinds of equipment &#40;resistance training equipment&#44; pulley apparatuses&#44; dumbbells&#44; or elastic bands&#41;&#46; Progressive adjustment of the load is recommended in a supervised clinical environment or at home under professional guidance&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Adherence is difficult to maintain in long-term programs&#46; To this end&#44; physicians must be in contact with other health professionals &#40;i&#46;e&#46;&#44; occupational therapists&#44; nurses&#44; dietitians&#44; psychologists&#44; and social workers&#41; in order to support and motivate patients by helping them to cope with the disease in a positive way&#46; Health professionals must convince RA patients that becoming more physically active is the best choice they can make to take care of themselves and their joints&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Although there is a lack of studies designed to evaluate the role of PA during RA flare&#44; the most extended attitude among physicians is to recommend a reduction in the duration and intensity of exercises&#44; specifically avoiding the resistance exercise in these periods of high disease activity&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A study in 2013 involving an online survey of more than 7000 smartphone owners in the U&#46;S&#46; showed that 79&#37; of people 18&#8211;44-years-old have their smartphones with them 22<span class="elsevierStyleHsp" style=""></span>hours a day&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">71</span></a> The newest generation of smartphones now on the market features built-in accelerometer sensors&#46; This technological advance&#44; in tandem with the increased and continuous social connectedness exhibited by our society&#44; can provide a convenient and inexpensive method for accurately evaluating PA in today&#39;s population&#44; including RA patients&#46; Although these devices have not yet been validated in RA patients&#44; the implementation of such tools will enable clinicians to better gauge the actual PA undertaken by patients&#46; Since there appears to be a relationship between levels of PA&#44; disease activity<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">5</span></a> and response to treatment<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">7</span></a> in RA patients&#44; the use of smartphones to evaluate PA might help physicians&#44; not only in establishing recommendations about cardiovascular risk&#44; but also in making therapeutic decisions in these patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Concluding remarks</span><p id="par0145" class="elsevierStylePara elsevierViewall">Aerobic and resistance exercises&#44; 2&#8211;3 times per week for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min not only provide general health gains&#44; but have also been shown to confer disease-specific advantages such as reduced pain&#44; improved muscle function&#44; and delayed onset of disability in RA patients&#46; Consequently&#44; a periodic assessment of PA constitutes a useful tool for adjusting the exercise habits of RA patients in order to reduce their high cardiovascular risks and improve locomotion function and health status in general&#46; Since&#44; disease activity negatively impacts the PA capacity of RA patients&#44; the assessment of PA with objective methods &#40;e&#46;g&#46;&#44; mobile devices built-in accelerometry&#41; may be helpful to evaluate the overall response to treatment and disease activity in RA patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0165" class="elsevierStylePara elsevierViewall">This work was supported by a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Ministry of Health</span> &#40;Fondo de Investigaciones Sanitarias&#41; &#40;<span class="elsevierStyleGrantNumber" refid="gs1">FIS PI12&#47;02499</span>&#41; and cofinanced by the <span class="elsevierStyleGrantSponsor" id="gs2">European Regional Development Fund</span> to F&#46;D&#46;G and by <span class="elsevierStyleGrantSponsor" id="gs3">REUNINVES</span> &#40;Asociaci&#243;n para la Ayuda a la Investigaci&#243;n en Reumatolog&#237;a del Hospital Universitario de Canarias&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have declared no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Abstract"
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              "titulo" => "Objectives"
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          "titulo" => "Resumen"
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              "titulo" => "Objetivos"
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              "titulo" => "M&#233;todos"
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        4 => array:2 [
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          "titulo" => "Introduction"
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          "titulo" => "Strategy and results of literature searching"
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          "identificador" => "sec0015"
          "titulo" => "Assessment of PA"
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          "titulo" => "PA in RA patients"
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          "titulo" => "Effect of PA on joints and disease activity in RA patients"
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          "titulo" => "Aerobic exercise in RA patients"
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          "identificador" => "xack288224"
          "titulo" => "Acknowledgments"
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          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-12-24"
    "fechaAceptado" => "2016-04-04"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec853921"
          "palabras" => array:4 [
            0 => "Rheumatoid arthritis"
            1 => "Physical activity"
            2 => "Disease activity"
            3 => "Accelerometry"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec853922"
          "palabras" => array:4 [
            0 => "Artritis reumatoide"
            1 => "Actividad f&#237;sica"
            2 => "Actividad cl&#237;nica"
            3 => "Acelerometr&#237;a"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rheumatoid arthritis &#40;RA&#41; is a chronic inflammatory disease affecting diarthrodial joints&#44; in which patients tend to perform less physical activity &#40;PA&#41; than recommended&#46; This review focuses on the existing evidence about the relationship of PA and RA&#44; specifically how the former influences joint inflammation&#44; disability&#44; quality of life and pain in RA patients&#44; and also how disease activity potentially impacts PA in these patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A literature search of EMBASE and MEDLINE databases from January 2000 to January 2015&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The evidence indicating that PA in RA patients is safe and the benefits from regularly performing&#44; both aerobic and resistance exercises&#44; in these patients include improvement in&#58; quality of life&#44; functionality&#44; pain and number of swollen joints&#46; Interestingly&#44; recent studies suggest that changes in disease activity in RA patients inversely correlate with variations in PA&#44; as assessed by accelerometry&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The regular monitoring of PA in RA patients might facilitate a more objective evaluation of variations in disease activity&#44; helping physicians to make general and therapeutic recommendations that will improve both the health status and the joint functionality of these patients&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Methods"
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            "identificador" => "abst0015"
            "titulo" => "Results"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La artritis reumatoide &#40;AR&#41; es una enfermedad inflamatoria cr&#243;nica que afecta a las articulaciones diartrodiales&#44; en la que los pacientes tienden a realizar menos actividad f&#237;sica &#40;AF&#41; de lo que se recomienda&#46; Esta revisi&#243;n se centra en la evidencia existente sobre la relaci&#243;n entre AF y AR&#44; espec&#237;ficamente c&#243;mo la primera influye en la inflamaci&#243;n articular&#44; la discapacidad&#44; la calidad de vida y el dolor en los pacientes con AR&#44; y tambi&#233;n c&#243;mo la actividad cl&#237;nica de la AR puede afectar a la AF de estos pacientes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una b&#250;squeda bibliogr&#225;fica desde enero del 2000 hasta enero del 2015 en las bases EMBASE y MEDLINE&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La evidencia indica que la AF en pacientes con AR es segura y que los beneficios de la realizaci&#243;n peri&#243;dica de ejercicios&#44; tanto aer&#243;bicos como de resistencia&#44; en estos pacientes incluyen mejoras en&#58; calidad de vida&#44; funcionalidad&#44; dolor y n&#250;mero de articulaciones inflamadas&#46; Curiosamente&#44; estudios muy recientes muestran que los cambios en la actividad de la enfermedad en pacientes con AR se correlacionan inversamente con variaciones en su AF&#44; medida por acelerometr&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El control sistem&#225;tico de la AF en pacientes con AR podr&#237;a facilitar una evaluaci&#243;n m&#225;s objetiva de las variaciones en la actividad de la enfermedad&#44; lo que ayudar&#237;a a los m&#233;dicos a hacer recomendaciones generales y terap&#233;uticas para mejorar tanto el estado de salud como la funcionalidad articular de estos pacientes&#46;</p></span>"
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            "identificador" => "abst0025"
            "titulo" => "Objetivos"
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            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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      ]
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AIMS2-SF&#58; Arthritis Impact Measurement Scales 2 short form&#59; BMD&#58; bone mineral density&#59; BMI&#58; body mass index&#59; CRP&#58; c-reactive protein&#59; DEXA&#58; dual energy X-ray absorptiometry&#59; ESR&#58; erythrocyte sedimentation rate&#59; HADS&#58; Hospital Anxiety and Depression Scale&#59; HAQ&#58; Health Assessment Questionnaire&#59; MACTAR&#58; McMaster Toronto Arthritis patient preference disability questionnaire&#59; VAS&#58; visual analog scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Westby et al&#46;&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dynamic exercise program&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Disease activity &#40;ESR&#44; active joint count&#41;<br>- Functional ability &#40;HAQ&#41;<br>- BMD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Van den Ende et al&#46;&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Disease activity &#40;ESR&#44; DAS&#44; VAS&#41;<br>- Functional capacity &#40;muscle strength&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De Jong et al&#46;&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled multicenter trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise<br>&#40;bicycle&#44; exercise&#44; sports 75<span class="elsevierStyleHsp" style=""></span>min 2 times&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional ability &#40;MACTAR y HAQ&#41;<br>- Functional capacity&#58; aerobic fitness &#40;standardized ergometer test&#41; an muscle strength &#40;dynamometer&#41;<br>- Emotional status by HADS<br>- Radiological damage by Larsen score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Melikoglu et al&#46;&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">54</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Pain &#40;VAS&#41;<br>- Disease activity &#40;duration of morning stiffness&#44; active joint count&#44; ESR&#44; CRP&#41;<br>- Functional ability &#40;HAQ&#41;<br>- BMI &#40;DEXA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuberger et al&#46;&#44; 2007<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">55</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise<br>&#40;low impact aerobic exercise 1<span class="elsevierStyleHsp" style=""></span>hour 3 times&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Fatigue &#40;FACIT&#41;<br>- Pain &#40;McGill pain questionnaire short form&#41;<br>- Depression &#40;studies depression scale&#41;<br>- Disease activity &#40;active joint count&#44; ESR&#44; CRP&#41;<br>- Functional capacity&#58; walk time and grip strength&#44; bicycle ergometer testing&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De Jong et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiovascular exercise biweekly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional ability &#40;MACTAR y HAQ&#41;<br>- Aerobic fitness &#40;standardized ergometer test&#41;<br>- Muscle strength &#40;dynamometer&#41;<br>- Disease activity &#40;DAS4&#41;<br>- Radiological damage &#40;Larsen score&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sj&#246;quist et al&#46;&#44; 2011<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">57</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">288&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicenter randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised and Home cardiovascular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional ability&#58; HAQ<br>- Disease activity&#58; DAS28<br>- Pain&#58; VAS<br>- Health perception&#58; VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jahanbin 2014&#44;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">60</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised two 45-min sessions per week of conditioning exercises&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Pain&#58; VAS&#46;<br>- Health status&#58; AIMS2-SF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Studies of aerobic exercise programs in RA&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BMD&#58; bone mineral density&#59; DEXA&#58; dual energy X-ray absorptiometry&#59; EQ-5D&#58; EuroQol-5D&#59; ESR&#58; erythrocyte sedimentation rate&#59; HAQ&#58; Health Assessment Questionnaire&#59; MHQ&#58; Michigan Hand outcomes Questionnaire&#59; SF-12&#58; short form 12&#59; VAS&#58; visual analog scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&#228;kkinen et al&#46;&#44; 2001<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">47</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Home dynamic strength training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; muscle strength &#40;dynamometry knee extensors&#44; trunk flexors-extensors&#41;&#44; walk time&#46;<br>- Functional ability&#58; HAQ&#46;<br>- Disease activity&#58; DAS28&#44; VAS&#44; ESR&#46;<br>- Pain&#58; VAS&#46;<br>- BMD&#58; DEXA<br>- Radiological damage&#58; Larsen score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&#228;kkinen et al&#46;&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">52</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised six training sessions in a 2-week period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; maximal muscle strength &#40;dynamometry&#41;&#44; walking speed&#44; vertical squat jump<br>- Functional ability&#58; HAQ<br>- Disease activity&#58; Joint index score&#44; ESR<br>- Pain&#58; VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&#228;kkinen et al&#46;&#44; 2004<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">53</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Home dynamic strength training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Functional capacity&#58; muscle strength &#40;dynamometry knee extensors&#44; trunk flexors-extensors&#41;&#44; walk time&#46;<br>- Functional ability&#58; HAQ&#46;<br>- Disease activity&#58; DAS28&#44; VAS&#44; ESR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lemmey et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised resistance training program twice a week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; walk test&#44; arm curl test&#44; knee extensor strength&#46;<br>- Functional ability&#58; HAQ<br>- Disease activity&#58; DAS28&#44; ESR&#46;<br>- Body composition&#58; DEXA&#46;<br>- Muscle IGFs&#58; muscle biopsies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bosch et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">58</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised exercise sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; balance &#40;Berg balance test&#41;<br>- Functional ability&#58; HAQ&#46;<br>- Pain&#58; VAS<br>- Depression&#58; Beck Depression Inventory<br>- Cortisol levels<br>- Heart rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flint-Wagner et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">59</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised exercise sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; muscle strength &#40;dynamometry elbow and knee flexors-extensors&#41;&#44; walk time<br>- Functional ability&#58; HAQ<br>- Pain&#58; VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stavropoulos-Kalinoglou et al&#46;&#44; 2013<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised aerobic and resistance high intensity exercises three times per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Disease activity &#40;DAS28&#44; CRP&#41;<br>- Functional ability &#40;HAQ&#41;<br>- Cardiovascular risk&#58; BMI&#44; body fat&#44; blood pressure&#44; lipoproteins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "texto" => "<p id="par0175" class="elsevierStylePara elsevierViewall">The authors would like to thank Mercedes Guerra from the Spanish Rheumatology Society for the systematic search of the literature&#44; and the members of the Department of Rheumatology of Hospital Universitario de Canarias for their continuous support&#46; Authors also are indebted with Prof&#46; Jose Antonio L&#46; Calbet&#44; Department of Physical Education of University of Las Palmas de Gran Canaria for the critical reading of the manuscript&#46;</p>"
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Review Article
Role of physical activity in the management and assessment of rheumatoid arthritis patients
Papel de la actividad física en el manejo y evaluación de la artritis reumatoide
María Vanesa Hernández-Hernándeza, Federico Díaz-Gonzáleza,b,
Corresponding author
a Servicio de Reumatología, Hospital Universitario de Canarias, La Laguna, Spain
b Departamento de Medicina Interna, Facultad de Medicina, Universidad de La Laguna, La Laguna, Spain
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Because the central pathology of RA occurs in the synovial membrane&#44; joint limitation is a typical manifestation of the disease&#46; This&#44; in addition to the fact that most RA patients also suffer from muscle loss&#44; contributes to decreased physical function and quality of life in these patients&#46; In this regard&#44; it has been shown that RA patients tend to exercise less than healthy controls when PA is measured by both subjective<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">3&#8211;5</span></a> and objective methods&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#8211;8</span></a> Moreover&#44; there remain two important unanswered questions concerning PA vis-&#224;-vis RA&#58; &#40;1&#41; Do patients who are sufficiently physically active suffer less aggressive disease&#63; and &#40;2&#41; Does disease activity influence PA in RA patients&#63; With regard to the former&#44; there is considerably more evidence favoring the prescribing PA for RA patients than there is against&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">9&#8211;11</span></a> With regard to the latter&#44; although there is less evidence&#44; recent data suggest that disease activity influences negatively the PA in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This work reviews the current evidence about the relationship between PA and RA&#44; specifically how the former influences joint inflammation&#44; disability&#44; pain and quality of life in these individuals&#44; and also how RA disease activity potentially impacts on PA in these patients&#46; We purpose that periodic monitoring of PA using objective methods&#44; as the accelerometry would help to better handling of RA patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Strategy and results of literature searching</span><p id="par0020" class="elsevierStylePara elsevierViewall">A review was conducted by the documentation department of the Spanish Rheumatology Society &#40;SER&#41; to identify all published literature relating to PA and&#47;or energy expenditure in people with RA&#46; The search strategy combined 2 sets of keywords&#46; For Embase&#44; EMTREE terms were used&#46; In this case the search consisted of rheumatoid arthritis AND physical activity OR motor activity OR energy expenditure OR leisure activity AND accelerometry OR questionnaire OR calorimetry&#46; For MEDLINE&#44; the MeSH terms were&#58; arthritis&#44; rheumatoid AND leisure activities OR motor activity OR energy metabolism AND accelerometry OR questionnaires&#46; The results included all publications published from 1 January 2000 to January 2015&#44; that included at least 1 search term from each of the 2 categories&#46; Only English language publications were included&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To be included in the review&#44; studies had to be&#58; &#40;1&#41; either observational studies or interventional studies with programs of exercises measuring free living PA or total&#47;activity related energy expenditure levels&#44; using either subjective or objective methods and &#40;2&#41; related to adult RA population with all subjects included in studies fulfilling the criteria set down by the American College of Rheumatology&#44; 1987&#46; Studies which were&#58; &#40;1&#41; interventional in nature with new pharmacological treatments&#59; &#40;2&#41; not in English&#59; or &#40;3&#41; published only in abstract format were excluded&#46; The article selection flowchart is described in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Assessment of PA</span><p id="par0030" class="elsevierStylePara elsevierViewall">PA is defined as any bodily movement produced by skeletal muscles that result in energy expenditure&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">12</span></a> Under this broad concept&#44; activities relating to leisure-time&#44; exercise&#44; sports&#44; locomotion &#40;e&#46;g&#46;&#44; walking&#44; biking&#41;&#44; and work must be considered parts of PA&#46; Sedentarism has been defined as expenditure below 10&#37; of total daily energy expenditure performing moderate- and high-intensity activities&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">13</span></a> Since&#44; sedentarism has been associated with high incidences of obesity&#44; type-2 diabetes mellitus&#44; cardiovascular disease and other chronic illnesses&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">14</span></a> its prevention has become a priority of the public healthcare systems&#46; To avoid the consequences of sedentarism&#44; U&#46;S&#46; Department of Health and Human Services recommends that adults should do at least 150<span class="elsevierStyleHsp" style=""></span>min a week of moderate-intensity exercise &#40;e&#46;g&#46;&#44; brisk walking&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A very accurate measurement of PA can be obtained by the assessing the total daily energy expenditure&#44; albeit using expensive and cumbersome procedures such as the doubly-labeled water technique<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">16</span></a> or calorimetry&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">2</span></a> Viable alternatives&#44; involving less precise but more accessible methods&#44; are available&#44; however&#46; These include questionnaires and triaxial accelerometers&#44; approaches that are gaining acceptance for assessing PA both in healthy individuals and in patients suffering chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">17&#8211;19</span></a> Although questionnaires provide a evaluation limited by subjectivity&#44; in the last 10 years a significant number of them have been developed to assess PA in different diseases&#59; one of them&#44; the International Physical Activity Questionnaire &#40;IPAQ&#41;&#44; has been used mainly for research purpose in rheumatic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">4&#44;5&#44;20</span></a> This self-report method is the cheapest and easiest way to quickly compile PA data from a large number of people providing an assessment of PA by domains&#46; Alternatively&#44; accelerometers are easily portable devices that offer one important advantage in objectively measuring PA based on the fact that it can capture continuously&#44; for days and weeks distinctive characteristics of movement including the direction&#44; frequency&#44; intensity and duration of PA&#44; as well as resting periods&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">21</span></a> Although accelerometry has already been employed in clinical osteoarthritis trials&#44;<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">22&#8211;24</span></a> it was not until recently that this technique was used to evaluate PA patterns in inflammatory joint disorders such as RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">PA in RA patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">Regular exercise with a moderate to high level of intensity has proven to be effective in improving muscle strength and cardiovascular fitness in healthy populations and in patients with chronic illnesses&#44; including RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;26&#8211;28</span></a> RA&#44; if left uncontrolled&#44; leads to joint deformity and destruction due to the erosion of cartilage and bone&#46; Consequently&#44; it has been assumed than RA patients are less active than the general population because of such joint manifestations&#46; An additional factor that may have contributed to this inactivity tendency stems from recommendations&#44; classically given by physicians&#44; which restrict exercise due to concerns that excessive PA might aggravate both joint inflammation<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">29</span></a> and pain&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">30</span></a> and accelerate joint damage in RA patients&#46; However&#44; currently&#44; evidence suggests that exercise has no deleterious effects either on disease activity or on joint damage<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">27&#44;31</span></a> and improves muscle strength<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">32</span></a> in RA&#46; In this regard&#44; recently it has been suggested that RA patients who are physically active before clinical disease onset present with a milder disease&#44; both in terms of inflammation&#44; pain and function&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">33</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients with RA have an increased risk of developing cardiovascular diseases&#44; resulting from a proatherogenic profile driven by systemic inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">34</span></a> In healthy populations there is an inverse relationship between PA and cardiovascular risk &#40;CVR&#41; factors such as BMI&#44; body composition &#40;increased whole body fat and visceral fat&#41;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">35</span></a> and blood lipid levels&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">36</span></a> Although different studies on the relationships between PA&#44; BMI&#44; fat mass and lipid levels in RA populations have yielded controversial data&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;37&#44;38</span></a> the evidence clearly suggests that PA improves the CVR profile in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;11&#44;39</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Different questionnaire-based surveys have indicated that RA patients tend to exercise less than what is currently recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">3&#44;40&#44;41</span></a> When PA is objectively assessed by doubly-labeled water or accelerometry&#44; the main disparity in PA between RA patients and healthy individuals can be seen in the time devoted to different intense activities&#46; RA patients dedicate less time than control to high-intensity PA and to moderately intensive activities<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7&#44;8&#44;25</span></a> probably due to local limitations causing joint pain and disability and systemic effects like fatigue and sarcopenia&#46; A recent systematic review of the literature about this issue&#44; encompassing both objective and subjective methods for evaluating PA&#44; suggests that PA levels among RA individuals tends to be lower than in healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">42</span></a> Although&#44; this review concluded that owing to methodological limitations&#44; a definitive conclusion could not be drawn&#44; currently it is generally accepted that RA patients spend less time than controls doing moderate and vigorous PA&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Effect of PA on joints and disease activity in RA patients</span><p id="par0055" class="elsevierStylePara elsevierViewall">As in the general population&#44; regular PA in RA patients may&#44; apart from providing general health gains&#44; also yield disease-specific benefits such as reduced pain&#44; improved muscle function&#44; and delayed onset of disability&#44;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">10&#44;31&#44;43&#8211;45</span></a> without deleterious effects on joint&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">27&#44;31</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Interestingly&#44; moderate-intensity PA exerts anti-inflammatory effects both in healthy individuals and in those affected by various chronic illnesses&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">46</span></a> Indeed&#44; regular PA has been associated with a diminution in C-reactive protein &#40;CRP&#41;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;39</span></a> and erythrocyte sedimentation rate &#40;ESR&#41;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">47</span></a> levels in RA patients&#46; Although the exact mechanism by which these positive effects arise remains unknown&#44; it seems linked to reductions in blood pressure&#44; lipids&#44; and fatty mass<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">48</span></a>&#46; Taking into account that the main tissular source of IL-6 is the adipose tissue&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">49</span></a> and that several lipids have proinflammatory effects&#44; the reduction of fat accumulation in the skeletal muscle and liver is likely one of the most relevant anti-inflammatory benefits of exercise&#46; Furthermore&#44; it has been well established that PA releases IL-6 from skeletal muscle&#44; a potent inducer of IL-1 receptor antagonist &#40;IL-1ra&#41; by monocytes and macrophages&#44; which constitutes an important anti-inflammatory mechanism of exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">50</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A number of clinical trials evaluating the effects of PA on RA patients have been developed&#46; While much evidence suggests that some exercise is better than none at all&#44; specific exercise parameters &#40;intensity&#44; duration&#44; frequency&#44; and type&#41; resulting in real benefits have not been clearly defined&#46; Some short-term and several long-term clinical trials have evaluated the effects of both aerobic and resistance exercises on outcome measures in RA patients<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;27&#44;28&#44;32&#44;47&#44;51&#8211;60</span></a> &#40;see <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Aerobic exercise in RA patients</span><p id="par0070" class="elsevierStylePara elsevierViewall">Although intuitively&#44; long-term regular exercise should be beneficial for RA patients because of the increased cardiovascular mobility and mortality in these patients&#44; reports about aerobic exercise interventions in RA populations are scarce&#46; A systematic review and meta-analysis of aerobic exercise&#44;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">10</span></a> which examined 14 randomized controlled trials&#44; showed that cardiorespiratory aerobic conditioning in stable RA appears to be safe and improves quality of life&#44; functionality and pain levels&#44; but not DAS28 or joint count&#46; This meta-analysis suggests that the sooner the exercise program is initiated&#44; the better are the results obtained in terms of quality of life and functionality&#46; Other clinical trials published afterwards also found an improvement in functionality<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">57</span></a> and pain<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">57&#44;60</span></a> in RA patients who were participating in aerobic exercise programs&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Both&#44; program duration and disease duration impacted on pain&#44; with better results in cases of RA established&#44; and short-term programs&#46; However&#44; data concerning to quality of life suggested than exercise was more benefits in patients with early RA than in established RA patients&#46; When patients were followed up for a long period of time&#44;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">27</span></a> it was found that no significant decrease in aerobic fitness occurred after a relatively brief period of detraining&#59; rather&#44; long-term exercises produced a prolonged positive effect on functional ability&#46; Therefore&#44; the maintenance of a structured PA program after intervention seems to be critical for long-term benefits&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">57&#44;61</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Of all the studies referenced in this review that focused on aerobic exercise in RA patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; three assessed disease activity changes using composite disease activity measurements&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">27&#44;32&#44;57</span></a> These studies concluded that aerobic exercise has a positive impact on disease activity&#44; reducing DAS28&#44; albeit without reaching statistical significance&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Resistance exercise in RA population</span><p id="par0085" class="elsevierStylePara elsevierViewall">The value of resistance exercise for RA patients remains controversial because its effects on cardiovascular risk are not clear&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;62</span></a> and its real impact on disability seems to be very small&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">56</span></a> However&#44; despite design differences&#44; the results of previous studies suggest that high-intensity strength training is feasible and safe for many patients with RA&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">52&#44;56&#44;63</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">A systematic review by Baillet et al&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">9</span></a> showed that resistance exercise programs in RA patients can provide a mild&#44; but significant&#44; improvement in terms of functional capacity&#44; the number of tender and swollen joints and a decrease in ESR&#46; Resistance exercise had no impact on DAS28 or on structural damage in any of the studies analyzed&#46; The HAQ response has proven more variable in several reports&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;47&#44;53</span></a> which may reflect the fact that this outcome was designed for monitoring patients in pharmacologic trials and is not be suitable for evaluating physical interventions in patients with mild disabilities&#46; Although the short-term effects of strength training in RA patients have been described in several studies<a class="elsevierStyleCrossRefs" href="#bib0675"><span class="elsevierStyleSup">64&#8211;66</span></a> the length of time that positive results achieved after cessation remains controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">32&#44;53&#44;67</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">There is no clear evidence of the superiority of supervised strengthening exercises versus home-based exercises&#44; since the results are varied&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Effects of disease activity on PA in RA patients</span><p id="par0100" class="elsevierStylePara elsevierViewall">Some studies indicate that PA levels &#40;as measured by questionnaires or by accelerometry&#41; have an inverse relationship with disease activity &#40;as assessed by DAS28 or SDAI&#41; in RA patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7&#44;25&#44;68</span></a> One of these studies involved RA patients lacking lower-limb disease activity&#44; which suggests that it is the state of inflammation as a whole that influences patients&#8217; tendency to reduce their levels of PA&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">5</span></a> In these studies&#44; accelerometry was sufficiently sensitive to detect PA-changes related with disease activity both in RA patients&#44; who showed clinical improvements in response to treatment<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">7</span></a> and in patients who suffered a disease flare&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">5</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Several disease activity indexes &#8211; such as the DAS&#44; CDAI&#44; SDAI or ACR &#8211; are available and allow physicians to quantify changes in the disease activity of RA over time&#46; These indexes are liable to certain limitations related to both patient subjectivity and inter- and intraobserver variability&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">69</span></a> As stated above&#44; by measuring variations in PA&#44; accelerometry appears to be sufficiently sensitive to register changes in the clinical activity of RA&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">5&#44;7</span></a> and could be used as a complementary objective method for assessing changes in disease activity&#46; Consequently&#44; variation in accelerometry might aid physicians in optimizing the pharmacologic management of RA patients&#46; In addition&#44; accelerometry can help to determine whether or not PA level in a given patient is appropriate to reduce their cardiovascular risk&#44; main cause of premature mortality in these patients&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Practical applications and exercise recommendations</span><p id="par0110" class="elsevierStylePara elsevierViewall">Along the last 15 years&#44; a number of interventional clinical trials have been developed in order to obtain recommendations on aerobic &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and resistance exercises &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; in RA patients&#46; The high variability in the type&#44; intensity and duration of PA studied&#44; as well as limitations in trial quality and size&#44; suggest that the conclusions of these studies should be still considered to be tentative and further research in the field of PA and RA is warranted&#46; However&#44; a number of practical recommendations can be elaborated respect to exercise in patients with RA&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">All RA patients benefit from a balanced program of strengthening and endurance or aerobic exercise&#46; Therefore&#44; current data indicate that the benefits from performing moderate and high-intensity PA frequently &#40;both aerobic and resistance exercises 2&#8211;3 times per week for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#41; in RA patients include&#58; improved quality of life&#44; functionality&#44; reduced pain&#44; improvement in the number of swollen joints&#44; and lower levels of radiologic damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">11&#44;28&#44;31</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Low-impact exercises&#44; such as walking&#44; swimming or biking are aerobic exercises recommended for arthritis patients&#46; Aerobic exercise has been shown to improve cardiovascular fitness and patient quality of life&#44; while reducing RA-associated disability and pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">10&#44;54&#44;55&#44;60</span></a> As a result of the little number of studies&#44; it has been suggested that the intensity levels in aerobic exercise should be moderate to hard &#40;i&#46;e&#46;&#44; 60&#8211;85&#37; of maximum heart rate&#41;&#44; and such exercise should be performed 3 times weekly in sessions of 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min&#44; divided in 3&#8211;4 periods of 15&#8211;20<span class="elsevierStyleHsp" style=""></span>min a day&#46; Progressive adjustment of the intensity level is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">70</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The strengthening exercises are designed to increase the joint stability&#46; Movements should be smooth&#44; performed 8&#8211;10 times twice a day and without joint pain&#46; The weight must be increased slowly and always that it does not cause pain&#46; Information derived from the reviewed studies<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">70</span></a> suggest that the load level objective for strengthening exercises should be moderate to hard &#40;i&#46;e&#46;&#44; 50&#8211;80&#37; of a maximal voluntary contraction&#41;&#44; and said exercises should be performed along 20&#8211;30<span class="elsevierStyleHsp" style=""></span>min 2&#8211;3 times per week&#46; Exercises may be static or dynamic&#44; done against body weight or with different kinds of equipment &#40;resistance training equipment&#44; pulley apparatuses&#44; dumbbells&#44; or elastic bands&#41;&#46; Progressive adjustment of the load is recommended in a supervised clinical environment or at home under professional guidance&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Adherence is difficult to maintain in long-term programs&#46; To this end&#44; physicians must be in contact with other health professionals &#40;i&#46;e&#46;&#44; occupational therapists&#44; nurses&#44; dietitians&#44; psychologists&#44; and social workers&#41; in order to support and motivate patients by helping them to cope with the disease in a positive way&#46; Health professionals must convince RA patients that becoming more physically active is the best choice they can make to take care of themselves and their joints&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Although there is a lack of studies designed to evaluate the role of PA during RA flare&#44; the most extended attitude among physicians is to recommend a reduction in the duration and intensity of exercises&#44; specifically avoiding the resistance exercise in these periods of high disease activity&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A study in 2013 involving an online survey of more than 7000 smartphone owners in the U&#46;S&#46; showed that 79&#37; of people 18&#8211;44-years-old have their smartphones with them 22<span class="elsevierStyleHsp" style=""></span>hours a day&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">71</span></a> The newest generation of smartphones now on the market features built-in accelerometer sensors&#46; This technological advance&#44; in tandem with the increased and continuous social connectedness exhibited by our society&#44; can provide a convenient and inexpensive method for accurately evaluating PA in today&#39;s population&#44; including RA patients&#46; Although these devices have not yet been validated in RA patients&#44; the implementation of such tools will enable clinicians to better gauge the actual PA undertaken by patients&#46; Since there appears to be a relationship between levels of PA&#44; disease activity<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">5</span></a> and response to treatment<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">7</span></a> in RA patients&#44; the use of smartphones to evaluate PA might help physicians&#44; not only in establishing recommendations about cardiovascular risk&#44; but also in making therapeutic decisions in these patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Concluding remarks</span><p id="par0145" class="elsevierStylePara elsevierViewall">Aerobic and resistance exercises&#44; 2&#8211;3 times per week for 30&#8211;60<span class="elsevierStyleHsp" style=""></span>min not only provide general health gains&#44; but have also been shown to confer disease-specific advantages such as reduced pain&#44; improved muscle function&#44; and delayed onset of disability in RA patients&#46; Consequently&#44; a periodic assessment of PA constitutes a useful tool for adjusting the exercise habits of RA patients in order to reduce their high cardiovascular risks and improve locomotion function and health status in general&#46; Since&#44; disease activity negatively impacts the PA capacity of RA patients&#44; the assessment of PA with objective methods &#40;e&#46;g&#46;&#44; mobile devices built-in accelerometry&#41; may be helpful to evaluate the overall response to treatment and disease activity in RA patients&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Protection of human and animal subjects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Confidentiality of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Right to privacy and informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Funding</span><p id="par0165" class="elsevierStylePara elsevierViewall">This work was supported by a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Ministry of Health</span> &#40;Fondo de Investigaciones Sanitarias&#41; &#40;<span class="elsevierStyleGrantNumber" refid="gs1">FIS PI12&#47;02499</span>&#41; and cofinanced by the <span class="elsevierStyleGrantSponsor" id="gs2">European Regional Development Fund</span> to F&#46;D&#46;G and by <span class="elsevierStyleGrantSponsor" id="gs3">REUNINVES</span> &#40;Asociaci&#243;n para la Ayuda a la Investigaci&#243;n en Reumatolog&#237;a del Hospital Universitario de Canarias&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors have declared no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Strategy and results of literature searching"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Assessment of PA"
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          "identificador" => "sec0020"
          "titulo" => "PA in RA patients"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Effect of PA on joints and disease activity in RA patients"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Aerobic exercise in RA patients"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Resistance exercise in RA population"
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          "identificador" => "sec0040"
          "titulo" => "Effects of disease activity on PA in RA patients"
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          "titulo" => "Practical applications and exercise recommendations"
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          "titulo" => "Concluding remarks"
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          "titulo" => "Ethical disclosures"
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              "identificador" => "sec0060"
              "titulo" => "Protection of human and animal subjects"
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              "titulo" => "Confidentiality of data"
            ]
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              "identificador" => "sec0070"
              "titulo" => "Right to privacy and informed consent"
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          "titulo" => "Funding"
        ]
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          "titulo" => "Conflicts of interest"
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        17 => array:2 [
          "identificador" => "xack288224"
          "titulo" => "Acknowledgments"
        ]
        18 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-12-24"
    "fechaAceptado" => "2016-04-04"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec853921"
          "palabras" => array:4 [
            0 => "Rheumatoid arthritis"
            1 => "Physical activity"
            2 => "Disease activity"
            3 => "Accelerometry"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec853922"
          "palabras" => array:4 [
            0 => "Artritis reumatoide"
            1 => "Actividad f&#237;sica"
            2 => "Actividad cl&#237;nica"
            3 => "Acelerometr&#237;a"
          ]
        ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Rheumatoid arthritis &#40;RA&#41; is a chronic inflammatory disease affecting diarthrodial joints&#44; in which patients tend to perform less physical activity &#40;PA&#41; than recommended&#46; This review focuses on the existing evidence about the relationship of PA and RA&#44; specifically how the former influences joint inflammation&#44; disability&#44; quality of life and pain in RA patients&#44; and also how disease activity potentially impacts PA in these patients&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A literature search of EMBASE and MEDLINE databases from January 2000 to January 2015&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The evidence indicating that PA in RA patients is safe and the benefits from regularly performing&#44; both aerobic and resistance exercises&#44; in these patients include improvement in&#58; quality of life&#44; functionality&#44; pain and number of swollen joints&#46; Interestingly&#44; recent studies suggest that changes in disease activity in RA patients inversely correlate with variations in PA&#44; as assessed by accelerometry&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The regular monitoring of PA in RA patients might facilitate a more objective evaluation of variations in disease activity&#44; helping physicians to make general and therapeutic recommendations that will improve both the health status and the joint functionality of these patients&#46;</p></span>"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La artritis reumatoide &#40;AR&#41; es una enfermedad inflamatoria cr&#243;nica que afecta a las articulaciones diartrodiales&#44; en la que los pacientes tienden a realizar menos actividad f&#237;sica &#40;AF&#41; de lo que se recomienda&#46; Esta revisi&#243;n se centra en la evidencia existente sobre la relaci&#243;n entre AF y AR&#44; espec&#237;ficamente c&#243;mo la primera influye en la inflamaci&#243;n articular&#44; la discapacidad&#44; la calidad de vida y el dolor en los pacientes con AR&#44; y tambi&#233;n c&#243;mo la actividad cl&#237;nica de la AR puede afectar a la AF de estos pacientes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una b&#250;squeda bibliogr&#225;fica desde enero del 2000 hasta enero del 2015 en las bases EMBASE y MEDLINE&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La evidencia indica que la AF en pacientes con AR es segura y que los beneficios de la realizaci&#243;n peri&#243;dica de ejercicios&#44; tanto aer&#243;bicos como de resistencia&#44; en estos pacientes incluyen mejoras en&#58; calidad de vida&#44; funcionalidad&#44; dolor y n&#250;mero de articulaciones inflamadas&#46; Curiosamente&#44; estudios muy recientes muestran que los cambios en la actividad de la enfermedad en pacientes con AR se correlacionan inversamente con variaciones en su AF&#44; medida por acelerometr&#237;a&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El control sistem&#225;tico de la AF en pacientes con AR podr&#237;a facilitar una evaluaci&#243;n m&#225;s objetiva de las variaciones en la actividad de la enfermedad&#44; lo que ayudar&#237;a a los m&#233;dicos a hacer recomendaciones generales y terap&#233;uticas para mejorar tanto el estado de salud como la funcionalidad articular de estos pacientes&#46;</p></span>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AIMS2-SF&#58; Arthritis Impact Measurement Scales 2 short form&#59; BMD&#58; bone mineral density&#59; BMI&#58; body mass index&#59; CRP&#58; c-reactive protein&#59; DEXA&#58; dual energy X-ray absorptiometry&#59; ESR&#58; erythrocyte sedimentation rate&#59; HADS&#58; Hospital Anxiety and Depression Scale&#59; HAQ&#58; Health Assessment Questionnaire&#59; MACTAR&#58; McMaster Toronto Arthritis patient preference disability questionnaire&#59; VAS&#58; visual analog scale&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Westby et al&#46;&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dynamic exercise program&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Disease activity &#40;ESR&#44; active joint count&#41;<br>- Functional ability &#40;HAQ&#41;<br>- BMD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Van den Ende et al&#46;&#44; 2000<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Disease activity &#40;ESR&#44; DAS&#44; VAS&#41;<br>- Functional capacity &#40;muscle strength&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De Jong et al&#46;&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled multicenter trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise<br>&#40;bicycle&#44; exercise&#44; sports 75<span class="elsevierStyleHsp" style=""></span>min 2 times&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional ability &#40;MACTAR y HAQ&#41;<br>- Functional capacity&#58; aerobic fitness &#40;standardized ergometer test&#41; an muscle strength &#40;dynamometer&#41;<br>- Emotional status by HADS<br>- Radiological damage by Larsen score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Melikoglu et al&#46;&#44; 2006<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">54</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Pain &#40;VAS&#41;<br>- Disease activity &#40;duration of morning stiffness&#44; active joint count&#44; ESR&#44; CRP&#41;<br>- Functional ability &#40;HAQ&#41;<br>- BMI &#40;DEXA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuberger et al&#46;&#44; 2007<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">55</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">310&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised cardiovascular exercise<br>&#40;low impact aerobic exercise 1<span class="elsevierStyleHsp" style=""></span>hour 3 times&#47;week&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Fatigue &#40;FACIT&#41;<br>- Pain &#40;McGill pain questionnaire short form&#41;<br>- Depression &#40;studies depression scale&#41;<br>- Disease activity &#40;active joint count&#44; ESR&#44; CRP&#41;<br>- Functional capacity&#58; walk time and grip strength&#44; bicycle ergometer testing&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De Jong et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiovascular exercise biweekly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional ability &#40;MACTAR y HAQ&#41;<br>- Aerobic fitness &#40;standardized ergometer test&#41;<br>- Muscle strength &#40;dynamometer&#41;<br>- Disease activity &#40;DAS4&#41;<br>- Radiological damage &#40;Larsen score&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sj&#246;quist et al&#46;&#44; 2011<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">57</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">288&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicenter randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised and Home cardiovascular exercise&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional ability&#58; HAQ<br>- Disease activity&#58; DAS28<br>- Pain&#58; VAS<br>- Health perception&#58; VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jahanbin 2014&#44;<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">60</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised two 45-min sessions per week of conditioning exercises&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Pain&#58; VAS&#46;<br>- Health status&#58; AIMS2-SF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&#228;kkinen et al&#46;&#44; 2001<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">47</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Home dynamic strength training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; muscle strength &#40;dynamometry knee extensors&#44; trunk flexors-extensors&#41;&#44; walk time&#46;<br>- Functional ability&#58; HAQ&#46;<br>- Disease activity&#58; DAS28&#44; VAS&#44; ESR&#46;<br>- Pain&#58; VAS&#46;<br>- BMD&#58; DEXA<br>- Radiological damage&#58; Larsen score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&#228;kkinen et al&#46;&#44; 2003<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">52</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised six training sessions in a 2-week period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; maximal muscle strength &#40;dynamometry&#41;&#44; walking speed&#44; vertical squat jump<br>- Functional ability&#58; HAQ<br>- Disease activity&#58; Joint index score&#44; ESR<br>- Pain&#58; VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&#228;kkinen et al&#46;&#44; 2004<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">53</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Observational study&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Home dynamic strength training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-Functional capacity&#58; muscle strength &#40;dynamometry knee extensors&#44; trunk flexors-extensors&#41;&#44; walk time&#46;<br>- Functional ability&#58; HAQ&#46;<br>- Disease activity&#58; DAS28&#44; VAS&#44; ESR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lemmey et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised resistance training program twice a week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; walk test&#44; arm curl test&#44; knee extensor strength&#46;<br>- Functional ability&#58; HAQ<br>- Disease activity&#58; DAS28&#44; ESR&#46;<br>- Body composition&#58; DEXA&#46;<br>- Muscle IGFs&#58; muscle biopsies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bosch et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">58</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised exercise sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; balance &#40;Berg balance test&#41;<br>- Functional ability&#58; HAQ&#46;<br>- Pain&#58; VAS<br>- Depression&#58; Beck Depression Inventory<br>- Cortisol levels<br>- Heart rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flint-Wagner et al&#46;&#44; 2009<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">59</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised exercise sessions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Functional capacity&#58; muscle strength &#40;dynamometry elbow and knee flexors-extensors&#41;&#44; walk time<br>- Functional ability&#58; HAQ<br>- Pain&#58; VAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stavropoulos-Kalinoglou et al&#46;&#44; 2013<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Randomized controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Supervised aerobic and resistance high intensity exercises three times per week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Disease activity &#40;DAS28&#44; CRP&#41;<br>- Functional ability &#40;HAQ&#41;<br>- Cardiovascular risk&#58; BMI&#44; body fat&#44; blood pressure&#44; lipoproteins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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ISSN: 21735743
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