Rev. Bras. Reumatol. vol.54 número5

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REVISTA

BRASILEIRA

DE

REUMATOLOGIA

www . r e u m a t o l o g i a . c o m . b r

Review

article

Assessment

of

functional

capacity

in

patients

with

rheumatoid

arthritis:

implications

for

recommending

exercise

Frederico

Santos

de

Santana

∗

_,

_Dahan

_da

_Cunha

_Nascimento,

João

Paulo

Marques

de

Freitas,

Raphaela

Franco

Miranda,

Luciana

Feitosa

Muniz,

Leopoldo

Santos

Neto,

Licia

Maria

Henrique

da

Mota,

Sandor

Balsamo

GraduateStudiesPrograminMedicalSciences,UniversidadedeBrasília,Brasília,DF,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received15February2013 Accepted12March2014 Availableonline20August2014

Keywords:

Rheumatoidarthritis Funcionality Physicalexercise

a

b

s

t

r

a

c

t

Rheumatoidarthritis(RA)isanautoimmunediseasecharacterizedbychronicsymmetric polyarthritisoflargeandsmalljointsandbymorningstiffnessthatmayleadto muscu-loskeletalimpairment,withfunctionalimpotence.Theconceptoffunctionalityrelatesto theabilityofanindividualtoperformeffectivelyandindependentlydailyactivitiesandtasks ofeverydaylife.Theaimofthisreviewistofamiliarizetherheumatologistwiththeconcept offunctionalcapacityevaluationandwiththeteststhatcanbeappliedinthispopulation, astheseareimportantstepsforaproperexerciseprescription.Fromfunctionaltestsalready usedintheelderlypopulation,thePhysicalFitnessandRheumatologyLaboratory–LAR– Brasilia,whichisaccompanyingpatientsfromBrasiliaCohortofEarlyRheumatoid Arthri-tis,describesinthisarticleaprotocolofteststoassessfunctionalcapacityforapplication inpatientswithRA,includingthedescriptionoftests:1)SitandReach;2)Agility/Dynamic Balance;3)ManualDynamometry;4)SitBackandLift;5)BicepsCurland6)Six-minuteWalk Test.

Avaliac¸ão

da

capacidade

funcional

em

pacientes

com

artrite

reumatoide:

implicac¸ões

para

a

recomendac¸ão

de

exercícios

físicos

Palavras-chave:

Artritereumatoide Funcionalidade Exercíciofísico

r

e

s

u

m

o

Aartritereumatoide(AR)éumadoenc¸aautoimunequesecaracterizaporpoliartritecrônica simétrica,degrandesepequenasarticulac¸ões,erigidezmatinalquepodelevara comprome-timentomusculoesquelético,comimpotênciafuncional.Oconceitodafuncionalidadediz respeitoàcapacidadedeoindivíduorealizaratividadesetarefasdavidadiáriaecotidiana, deformaeficazeindependente.Oobjetivodestarevisãoéfamiliarizaroreumatologistacom

DOIoforiginalarticle:http://dx.doi.org/10.1016/j.rbr.2014.03.021.

∗ _{Corresponding}_author.

E-mail:fredericosantana@hotmail.com(F.S.deSantana).

http://dx.doi.org/10.1016/j.rbre.2014.03.021

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oconceitodeavaliaçãodacapacidadefuncionaleostestesquepodemseraplicadosnessa população,poissãopassosimportantesparaumaprescriçãoadequadadeexercícios físi-cos,Apartirdetestesfuncionaisjáutilizadosempopulaçãoidosa,oLaboratóriodeAptidão FísicaeReumatologia–LAR–Brasília,queacompanhaospacientesdaCoorteBrasíliade Artrite ReumatoideInicial,descrevenesteartigoumprotocolode testesparaavaliação dacapacidadefuncionalparaaplicaçãonospacientescomdiagnósticodeAR,incluindo adescriçãodosseguintestestes:1)SentareAlcançar;2)Agilidade/EquilíbrioDinâmico;3) DinamometriaManual;4)SentareLevantar;5)RoscaBícepse6)TestedaCaminhadade SeisMinutos.

Introduction

Rheumatoidarthritis (RA) isan autoimmune disease char-acterizedprimarilybyachronicsymmetricalpolyarthritisof largeandsmalljoints,andbymorningstiffness,whichcan lead tomusculoskeletal impairment,with functional inca-pacity. These factors contribute tophysical incapacityand inefficiencyofthesepatients.Amongthestrategiesof non-pharmacologicaltreatmentofRAarephysicalexercisesthat addressthedevelopmentofrangeofmovement, functional-ity,cardiovascularcapacityandmuscularstrengthstandout.1

Generally,physicalexercisesaresafeandrecommendedfor patientswithRAandotherrheumaticdiseases.2–4

PatientswithRAareathigherriskofcardiovascular dis-ease.The possibleeffectofphysicalactivity on therisk of cardiovasculardiseaseandontheinflammatoryand immuno-logical profile is of great interest to health professionals. Studiesshowthatconstraintsofphysicalexerciseforpatients withRAaremainlyrelatedtoaworseningofthejoint symp-toms,which may contributeboth toinactivity and aerobic capacitydetrainingastoincreasedcardiovascularrisk.5

Anotherfactorthatmayinfluencethefunctionalcapacity isrheumatoidcachexia,whichoccursinapproximately66% ofRApatients,andischaracterizedbylossofcellmass, pre-dominantlyfromskeletalmuscle(sarcopenia),anditsetiology ismultifactorial,includinganincreasedproductionof proin-flammatorycytokines, hormonal changes and the physical inactivityitself.5_In_this_sense,_exercises_that_promote_strength

andmusclemassgainsare associatedwithimproved func-tionality;moreover,theyarealsoeffectiveasadjuvantsinthe controlofdiseaseactivity.6,7

Compositeindicestoclassifythe levelofactivity ofRA, forinstance,theDiseaseActivityScore28(DAS-28),the Sim-plifiedDiseaseActivityIndex(SDAI)andtheClinicalDisease ActivityIndex(CDAI),werecreated.8_However,_despite_the

sim-plicity,importanceandclinicalrelevancetorheumatologists’ use,suchinstrumentsarelimited,inordertodeterminethe characteristicsofaphysicalexerciseprograminpatientswith RA.

Duetotheimportanceofphysicalactivityforpatientswith RA,it isessentialtodevelopan exerciseprogramthatcan intentionallycontemplatefundamentalmethodological prin-ciplestoservethepurposeofpreventing,controllingand/or treating this chronic disease.However, the rheumatologist mayaskaseriesofquestionsaboutprescriptionand recom-mendation/referralforexercisepractice:Whatfitnessmust

betrained?Whatexercises?Whatweeklyfrequency?What intensity?Whatvolume?Forhowlong?

Therefore,thepurposeofthisreviewistofamiliarizethe rheumatologistwiththeconceptoffunctionalcapacity eval-uationandwiththeteststhatcanbeappliedtopatientswith RA, as theseare important stepsfor aproper prescription ofphysicalexercise. Webelievethatthose functional tests already validated in people over 50 years, with a propen-sity to physical disability and poor mobility,9,10 _could _be

usedinpatientswithRA,consideringthatsofarthereisno assessmentprotocolsforfunctionalcapacityspecificforthese patients.

Functional

tests

Theconceptoffunctionalityrelatestotheabilitytoperform, effectively and independently, dailyactivities and tasksof everydaylife.9_An_evaluation_of_{functionality,}_mainly_the

phys-icaldomain,isextremelyimportantto:a)identifypatientsat riskforfunctionaldisability;b)determineprioritiesinterms ofphysicalabilitiesandlevelsofphysicaltrainingand rehabil-itation;c)promoteajointparticipationandmotivationofthe patientintermsofadherenceandmanagementoftherapeutic methodsproposedbyhealthprofessionals.6

Thetestsoriginallyvalidatedforpeopleover50yearsare reliableandfeasible,i.e.evaluateeachofthephysicalabilities relatingtofunctionality,havegoodintra-raterandinter-rater reproducibilityandarehighlyviable,bothfromanoperational standpointandalsoinfinancialterms.11_The_cost_to_purchase

theneededequipmentislow,theproceduresforconducting thetestsaresimpleand,ingeneral,littlespaceisrequiredfor tocarryoutthephysicaltests.11

Thus,thePhysicalFitnessandRheumatologyLaboratory– LAR–Brasilia,thataccompaniespatientsfromEarly Rheuma-toidArthritisBrasiliaCohort,12–15_suggests_the_following_tests

toassessfunctionalcapacityofpatientswithRA:1)Sitand Reach;2)Agility/DynamicBalance;3)ManualDynamometry; 4)SitBackandStandUp;5)BicepsCurland6)6-MinuteWalk Test.

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Fig.1–Sitandreach.

1)SitandReach(ChairSitandReachTest)10,11

Objective–Theoriginalpurposeofthistestwastoevaluatethe rangeofmotionofthelowerlimbs’posteriormusclegroup,as showninFig.1.

Material–Onechairwithstandardseatheight(44cm)and 1rulerortape(preferably,metallic).

Unitofmeasure–Centimeter(cm). Levelofcomplexityoftestrun–Low.

Safetylevel–High.Attentiontothesubjectbalancewhen seated,especiallyifelderly.

Needtotraintheevaluator?–Lownecessity.

Theexecutionofthreeattemptsateachlimbissuggested; thehighestvalueachievedisrecorded.

Testdescription–thesubjectmust:

a) sitonthechairwiththeevaluatedkneeextended; b) takeadeepbreathand,whileexhaling,bendthe trunk,

with his/her upper limbs projected forward, elbows extended,and overlappinghands(topreventtrunk rota-tion)towardthetipofthetoes,uptothelimitofitsjoint amplitude;

c) maintainthepositionofmaximumreachforatleasttwo seconds, and should not flex the evaluated limb atno time.

2)Agility/DynamicBalance(TimedtoUpandGo)9

Objective–AsshowninFig.2,the agilityordynamicbody balancetesthasitsoriginintheanalysisofthecapacityof performingbasicmotortasksrelatedtothefunctionalityof theelderly.InRApatients,aswellasintheelderly,16_there_is

anassociationbetweenphysicalperformancewiththeriskof fallsandfractures.17

Material–Onestopwatch,1chairwithstandardseatheight (44cm),1cone.

Unitofmeasure–Second(s). Levelofcomplexityoftestrun–Low.

Safetylevel–Moderate.Attentiontothefloor,whichshould beflat,withenoughadherencetopreventanyslipping;andto markingsoffreespaceformobilizationofthesubject.Inthis specificcase,thechairusedintheevaluationmustbeplaced againstthewall,topreventitsslipping.

Needtotraintheevaluator?–Littleneed.

Theexecutionofthreeattemptsateachlimbissuggested; thehighestvalueachievedisrecorded.

Testdescription–Thesubjectstartsthetestsittingonthe chair,andisorientedto:

A) Atthe“Attention,now!”command,risefromhis/herchair, turnaroundtheconeatadistanceof3mawayasfastas possibleandwalkbacktositonthechair.Theevaluator shouldstartthestopwatchwhenthesubject’shipleavethe chair,stoppingthetimerwhenthehiptouchesthechair again.

B) Thesubjectmustbewarnedthathe/sheshouldnotrun; instead should walk with the greatest possible speed. Moreover,theevaluatorshouldwarnthesubjecttoavoid contactwiththecone,andthatatthemomentofsitting onthechair(theendofthetest),he/shemustbecareful withtheimpactsofthehiponthechairandoftheheadin thewallwherethechairisagainstto.

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3)ManualDynamometry(HandGripStrength)18

Objective – Theresults of manual dynamometry tests are usedasa parameterforassessingoverall muscle strength. InRApatients,aswellasinelderlysubjects,thedecreasein overallmuscle forceisassociatedwithdecreased function-alityofthehands19_and_with_the_negative_effects_of_chronic

inflammation.18

Material–Ahandgripdynamometer. Unitofmeasure–Kilogram(kg).

Levelofcomplexityoftestrun–Moderate. Safetylevel–High.

Needtotraintheevaluator?–Moderateneed.

Testdescription–Thesubjectbeginsthetestinthe ortho-static(standing)position.

a) Thesubjectmustholdthedynamometerinlinewiththe forearm,paralleledtothelongitudinalaxisofthebody.The proximalinterphalangealjointofthetesthandmust be setunderthebar,whichissqueezedbetweenthefingers andthethenarregion.Duringhandgripintheorthostatic position,thearmremainsmotionless,withonlyflexionof phalangealandmetacarpophalangealjoints.

b) Positionthehandsothatthethumbisaroundonesideof thehandleandtheotherfourfingersaroundtheotherside. c) An1-minuteintervalshouldbeadoptedbetween

measure-ments.

d) Atthe“Attention,now!”command,thesubjecthastopush ashardaspossible,oruntilthedynamometerhandstop climbing.

e) Theevaluatorshouldreadandrecordthevaluesobtained. Evaluatethecontralaterallimb.Repeatthisprocedurefor atotalof6times(3oneachmember).

f) Thebestofthesixmeasurementswillbeusedforthe anal-ysis.

g) Register the dominant hand (left-handed, right-handed, ambidextrous).

4)SittingandRising(30sChairStand)9,10,20

Objective–Thesittingandrisingfromachairtestwas devel-opedtoevaluatemusclestrengthconditioning,asshownin

Fig.3.

Material–Onestopwatchand1chairwithstandardseat height(44cm).

Unitofmeasure–Numberofrepetitions(reps).Inthis par-ticularcase,arepetitionisdefinedasthesumofaconcentric muscleactionandacompleteeccentricmuscleaction.

Levelofcomplexityoftestrun–Low.

Safetylevel–High.Attentiontothechairthatwillbeused inthe test,which mustbeagainstthe walltopreventany slipping.

Aprevioustrial,withaboutfivepracticetrials,shouldbe giventothesubject.

Testdescription–Thesubjectstartsthetestsittingonthe chair,withhis/hertrunkstraight(withoutsupportontheback ofthechair),feetflatonthefloorandarmsfoldedinthetrunk. Fromthispoint,thesubjectisinstructedto:

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a) Tothe“Attention,now!”command,runthelargestpossible numberofsquatsonthechairfor30seconds;

b) Theevaluatorshouldstartcountingtimeonthestopwatch afterthe“Attention,now!”command,foratimedsessionof 30seconds.Thenumberofperfectrepetitionsofsquatson thechairshouldbecountedloudandclear.Aperfect repe-titionisconsideredwhenthesubjectstands,fullyextends his/herkneeswiththetorsoupright(startingposition)and sitswithonlyminimalneedofcontactofthehipsonthe chair(finalposition).Thatis,thereisnoneedtosit com-pletelyandcomfortablyonthechair.Strongimpactonhips whenthesubjectsitsonthechairmustbeavoided.

Inthiscase,onlyonetrialattemptisperformed,andthe number of perfect and complete repetitions performed is recorded.

5)Bicepscurl(30sArmCurl)9,10

Objective–Theunilateralbicepscurltestwasdevelopedto evaluatetheconditioningofupperlimbs’muscularstrength.

Material–Onestopwatch,1dumbbell(2and4kgforwomen andmen,respectively)and1chairwithstandardseatheight (44cm).

Unitofmeasure–Numberofrepetitions(reps).Inthiscase, arepetitionisdefinedasthesumofaconcentricmuscleaction andacompleteeccentricmuscleaction.

Levelofcomplexityoftestrun–Low.

Safetylevel–High.Attentiontothechairusedinthetest, whichmustbeagainstthewalltopreventanyslipping.

Aprevioustrial,withaboutfivepracticereps, shouldbe giventothesubject.

Testdescription–Thesubjectstartsthetestsittingonthe chair,withthetorsoupright(withoutsupportonthebackof thechair,norwiththecontralateralhandontheedgeofthe chair),feetflat onthe floor.From thispoint, thesubject is instructedto:

a) Tothe“Attention,now!”command,performasmanyelbow flexionsaspossible,onthechair,during30seconds; b) Theevaluatorshouldstartcountingtimeonthestopwatch

afterthecommand“Attention,now!”foratimedsession of30seconds.Thenumberofperfectrepetitionsofelbow flexionshouldbecountedloudandclear.Aperfect repe-titionisconsideredwhenthesubjectfullyflexeshis/her elbow(wristtowardthe shoulder)and fully extendsthe elbow,keepingthetorsoupright(finalposition).The con-tralaterallimbstaysrestingonthethightoavoidgripping atthechair.Inthisparticularcase,onlyonetrialattempt isperformed,andthenumberofperfectandcomplete rep-etitionsperformedisrecorded.

6)Six-minutewalktest(6MWT)21

Objective–Theaimof6MWTistoevaluatethefunctionaland cardiovascularcapacityofthesubject.22

Material–Onestopwatch,2cones,1chair,1telephoneand 1automaticexternaldefibrillator(AED).21

Unitofmeasure–Meter(m).

Levelofcomplexityoftestrun–Moderate.

Safety level – Moderate. Attention to the floor, which should beflat,withenough adherenceto preventslipping; andtothemarkingsoffreespaceformobilizationofthe sub-ject.

Needtotraintheevaluator?–Moderateneed.

Werecommendthatashortexecutiontrial(nomorethan 1minute)should begiven,togetfamiliarwiththe walking paceofthesubject.

Absolutecontraindications: a) Unstableangina;

b) Acutemyocardialinfarction. c) Relativecontraindications:

d) Heartrateatrest>120beatsperminute(bpm); e) Systolicbloodpressure>180mmHg;

f) Diastolicbloodpressure>100mmHg; g) O2saturation≤90%

SafetyAspects

a) Thetestshallbeconductedinasuitablelocationforquick emergencycare;

b) Theprofessionalresponsiblefortheapplicationofthetest musthavecardiopulmonaryresuscitationtraining; c) Reasonstostopthetestimmediatelyinclude:chestpain,

intolerable dyspnea, leg numbness, or paleness. Health professionalsshouldbetrainedtorecognize these prob-lems.

Testdescription–Thesubjectbeginsthetestinthe ortho-staticposition(standing):

a) Thecoursecanvaryfrom20to50metres,dependingonthe sizeoftheroom;

b) Markalineacrosstheareademarcatedforthecourseatthe startofthetest;

c) Ifrepeatsofthetestareneededforcomparisonor evalua-tionoftheevolutionoftheresults,subsequenttestsshould beperformedatthesametimechosenforthe1stdayof testing;

d) Thesubjectshouldsitonachairplacednearthebeginning ofthetestduringatleast10minutes,formeasurementof bloodpressure,heartrateandO2saturation;

e) Atthe endofthetest, thesubjectwillbeaskedtowalk slowlycrosswisetothe directionofthetest, sothat the evaluatorcanmeasurethedistancetravelled.The evalua-tormustalsopresentascaleofperceivedexertionandask abouttheintensityofthetest;

f) Theevaluatorshouldexplaintothesubjectthatthe pur-poseofthetestistowalkasfaraspossibleinsixminutes, anddemonstratehowtoperformthetest;

g) Theevaluatorshouldaskiftheevaluatedsubjectisready, remindinghim/herthatthegoalistowalkasfaraspossible for6minutes,butwithoutrunningorjogging;

h) Ateveryelapsedminute,remindthesubjecthis/hertime; i) Atthe command“Attention,now!”,thesubjectstart the

test;

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Table1–Normativetablefortheperformanceoffunctionaltestsofflexibility,dynamicbalance/agility,lowerlimbs enduranceandcardiovascularcapacityintheelderly.

FunctionalTest Gender Agegroups(years)

60-64 65-69 70-74 75-79 80-84 85-89 90-94

SitandReach(cm) M −6to+10 −7.6to+7.6 −8.8to+6.3 −10.1to+5 −13.9to+3.8 −13.9to+1.2 −16.5to−1.2 W −1.2to+12.7 −1.2to+11.4 −2.5to+10.1 −3.8to+8.8 −5to+7.6 −6.3to+6.3 −11.4to−2.5 DynamicBalance(s) M 5.6to3.8 5.7to4.3 6.0to4.2 7.2to4.6 7.6to5.2 8.9to5.3 10.0to6.2

W 6.0to4.4 6.4to4.8 7.1to4.9 7.4to5.2 8.7to5.7 9.6to6.2 11.5to7.3 SitandStandUp(reps) M 14to19 12to18 12to17 11to17 10to15 8to14 7to12

W 12to17 11to16 10to15 10to15 9to14 8to13 4to11

6-MinuteWalk(m) M 555to668 509to637 495to618 427to582 404to550 345to518 277to455 M 495to600 455to577 436to559 391to532 350to491 309to464 250to400

cm,centimeters;s,seconds;reps,repetitions;m,minutes;M,men;W,women.

Norms

for

evaluating

the

results

of

functional

tests

in

clinical

practice

Aspreviouslymentioned,therearenoregulationsfor eval-uatingthe results offunctional tests described inpatients with RA. These tests have been validated for the elderly population,23_but_we_can_infer_its_application_in_patients_with

rheumaticdiseasesthatalsoexhibitadecreaseinfunctional abilityovertime.Tables1and2listtheexpectednormalvalues forhealthyindividualsolderthan50years.

Itisthereforesuggestedthat,whenapplyingthefunctional testsdescribed inpatientswithRA,and untilthereisaset ofadequaterulesforthispopulationofpatients,the assess-mentorjudgmentofthemeasuresobtainedwiththetests maybecomparedwiththenormalstandardsofthosetests(for theelderlypopulation),ortheevaluationmaybecompared againsttheindividualhimself(comparisonsoftheevolution ofresultsinserialrepetitions,overtime,forthesamesubject). Asforthesix-minutewalktest,inadditiontothevalues showninTable1,anotherpossibilityforindividualizationof resultsistheEnrightandSherrillformula,24_because_it_offers

anestimatedvalueofthecardiovascularcapacitybyagefor thistest.

Men:

DF=(7.57 cm×height[cm])−(5.02×age[years])

−(1.76×body mass[kg])−309 meters

Subtract153togetthelowerlimitofnormality

Women

DF=(2.11 cm×height[cm])−(2.29×age[years])

−(5.78×body mass[kg])−667 meters

Subtract139togetthelowerlimitofnormality

DF=Distance foreseen in the 6−minute walk test

How

to

use

the

results

of

functional

tests

in

clinical

practice

Fromthedefinitionsrelatedtotheuseoffunctional assess-ments, to the values obtained in the tests, and to the judgementofthesevalues,wecanestablish theprocessof decision makingwith respecttophysicalexercisepractice, intentionally prescribed totreat and controlthe signs and symptomsresultingfromAR.

Aspreviouslyreported,itispossible,forinstance,to com-paredataobtainedinfunctionaltestswithnormativetables available (in the elderly population) and, from this point, checkingforany physicalcapacityinworseconditionthan another.Thisinformationshallassistintherecommendation ofthetypeofphysicalactivity.Moreover,inapracticalway,it isnotpossibletomonitorthephysicalperformanceofpatients inallaspectsofphysicalfitnessthroughoutthetreatment,and ifsomeofthemcometosuffersignificantperformance degra-dation, thiscanbecircumventedintentionallywithchosen andmodulatedtypesofexercises.

Table2–Normativetableforperformanceoffunctionaltestsofmuscularstrengthandenduranceoftheupperlimbsand staticbalanceinelderly.

AgeGroups(years) 50-59 60-69 70-79

FunctionalTests p25 p50 p75 p25 p50 p75 p25 p50 p75

ManualDynamometry(kg)

Right 24 27 30 23 26 29 21 24 27

Left 23 26 29 22 25 28 20 23 26

Bicepscurl(reps) 18 22 26 18 22 25 17 20 24

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Afterthe choiceofmodality or physicalfitness, param-eters such as intensity and volume of exercise should be controlled.2 _The_exercise_intensity_is_related_to_the _level_of

effortperformedforaparticularactivityandtotheexercise volumemoretemporallyrelated totheamount ofexercise performed.2_This_is_important,_because_the_principle_of

pro-gressiveoverloadsaysthatanyphysicaltrainingproposition requiresevolutionbothofvolumeandofintensitytoescape theplateaueffect,verycommoninpeoplewhoperform phys-ical activity regularly, but without controlling the dose of exercise.25

TheConsensusfromtheBrazilianSocietyofRheumatology fortheTreatmentofRheumatoidArthritis(2012)suggeststhat the patients performphysical exercisesregularly.26,27 _Most

dynamicexerciseprogramsfollowthe recommendationsof theAmericanCollegeofSportsMedicine(ACSM).TheACSM recommendsadurationof20minutesormoreforpracticising exercise,thatitisheldatleasttwiceaweek,andableto pro-moteanincreaseof60%ofpredictedheartrateforagetobe consideredasbeingcapabletopresentpositiveclinicaleffects, notbeingdetrimentaltothedisease,i.e.withoutworseningRA activityandcausingpain.Dynamicexercise,whencompared toaconventionaljointrehabilitationprogram,promotes sig-nificantimprovementinthe qualityoflifeofpatientswith

RA.28,29

Currently,thescientificliteratureisscarcewhenitcomes todeterminewhatkind ofdose-responseexerciseis effec-tiveandsafeforRApeople.Methodologicalaspectsrelatedto dose-response(intensity,durationofsessions,typeof exer-cise, and weekly volume), lack of control of adherence in training,equipmentnotspecified,descriptionof pharmaco-logicaltreatment(doseanddurationofuse),levelofdisease activity,timeofdiagnosisandleveloffunctionalabilityinthe baselinecondition(i.e.,initiationofthestudy),arecitedas lim-itationstothegeneralizationofthefindingsintheprescription ofpatientswithRA.6

Perspectives

and

concluding

remarks

In terms of strategies for prevention, control and non-pharmacological treatment of various chronic and degen-erative diseases, in recent years the notorious recognition ofthephysicalexercisehasbeen highlighted,especiallyin rheumaticdiseases,including RA.However,thereislackof exerciseprotocolsorofadiscussionofthetypeofphysical activitythatshouldbeprescribed.

Recently,researchersinvolvedinthehealthcareareahave reflectedontheimportanceofconductinglonglasting, ran-domized,controlledclinicaltrialsthatassesstheimpactof overallimprovementoffitnessinthefunctionalcapacityand on the overall health status of physically active patients. Therefore,itisbelievedthatthescientificproductioninvolved withphysicalexerciseandARwillbeincreasinglycommon, consideringtheimportanceofunderstandingthescienceof exerciseasatherapeutictoolbytherheumatologist.

Finally,thereisanurgentneedoffurtherresearch,mainly withregard tothe specific physical regulationsfor the RA patient. Thecorrectassessment offunctional capacitycan generatesubsidiesforapreciseprescriptionofthephysical

trainingprotocol,withdefinitionofthephysicalcapabilities tobedevelopedandtheparametersofvolumecontroland ofexerciseintensity.Thus,basedontheassessmentof func-tionalcapacity,thephysicalactivityrecommendationscanbe madesafer,individualized,preciseandintentional,tryingto achieveitsmaingoalinpatientswithRA,i.e.thedevelopment ofenduranceandphysicalcapacity,aimedatimprovingthe qualityoflife.

Conflict

of

interests

Theauthorsdeclarenoconflictofinterests.

r

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f

e

r

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n

c

e

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