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REVIEW ARTICLE
Ahead of print publication  

Exercise training in myositis recovery: Practical issues and challenges


 Department of Medicine, Karolinska Institutet, Karolinska University Hospital; Medical Unit Occupational and Physical Therapy, Karolinska University Hospital, Gaevlegatan, Stockholm, Sweden

Date of Submission01-Jul-2022
Date of Acceptance01-Aug-2022
Date of Web Publication20-Sep-2022

Correspondence Address:
Kristofer Magnus Andreasson,
Karolinska University Hospital, Gaevlegatan 55, Occupational & Physical Therapy, NB00:02, 17164, Solna, Stockholm
Sweden
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_132_22

  Abstract 


Idiopathic inflammatory myopathies (IIMs), or myositis, are a heterogeneous group of autoimmune disorders characterized by chronic inflammation of the muscle with a variety in clinical manifestations. Muscle impairment, myalgia, fatigue, and extramuscular involvement are common, such as lung and cardiac involvement. Exercise is an important part of the treatment in IIM; however, knowledge on how to individually adjust and optimize exercise considering specific aspects of the disease and extramuscular involvement is scarce. In many studies, patients with extramuscular involvement are excluded which makes the safety and efficacy of exercise for these patients unclear. This study aims to review the practical issues and challenges of exercise regarding different aspects of the disease and extramuscular involvement, as well as to give a clinical perspective on how to initiate and progress exercise for these patients.

Keywords: Idiopathic inflammatory myopathies, physical therapy, rehabilitation, review, treatment



How to cite this URL:
Andreasson KM. Exercise training in myositis recovery: Practical issues and challenges. Indian J Rheumatol [Epub ahead of print] [cited 2022 Oct 3]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=356476




  Introduction Top


Idiopathic inflammatory myopathies (IIMs), or myositis, are a heterogeneous group of autoimmune disorders characterized by chronic inflammation of the muscle with a variety of clinical manifestations.[1] Muscle impairment in various degrees is common with muscle weakness and primarily reduced muscle endurance.[2] Myalgia and fatigue are also frequent symptoms.[1],[3] The extramuscular symptoms, such as skin rash, interstitial lung disease (ILD), heart involvement, and arthritis, are common and emphasize the systemic nature of these disorders. In some patients, the extramuscular symptoms are dominant and muscle weakness is absent or near absent in the clinical picture, which makes the diagnosis challenging.[1] Due to the heterogeneity and rarity, medical treatment is challenging. The first-line treatment is oral glucocorticoids; pulse glucocorticoid treatment can be given in acute onset or in case of severe muscle or vital organ involvement. To limit the duration of high-dose glucocorticoid treatment, immunosuppressants are used, usually methotrexate or azathioprine.[1]

Exercise is an important part of the treatment for patients with IIM.[2],[4] A systematic review based on only randomized controlled trials (RCTs) published in 2020 reported limited evidence (++) to support the efficacy of a combination of moderate-to-high intensity aerobic and resistance exercise to reduce inflammation and improve aerobic capacity, muscle strength and quality of life in patients with low disease activity.[2] There is insufficient evidence (+) supporting that low-to-moderate-intensity aerobic and resistance exercise is safe and can improve aerobic capacity and muscle endurance in patients with recent onset, active IIM.[2] Other studies have been published with similar results, also stating that for patients with recent onset or refractory active IIM, exercise seems to be safe and effective; however, evidence is limited yet.[2],[4],[5],[6],[7]

This study aims to review exercise in relation to extramuscular involvement and the rarity and heterogeneity of IIM, as well as give a clinical perspective on how to prescribe exercise for these patients.


  Overall Issue of Exercise Prescription Top


Rarity, heterogeneity and possible severe vital organ involvement of the IIMs constitute a challenge when prescribing a specific exercise program. Since patients with severe vital-organ involvement have been excluded from exercise studies, exercise treatment for these patients is mainly based on research in other diseases or clinical experience. A holistic view including all aspects of disease and disease impact is important. Baseline screening is of importance for the presence of extramuscular involvement such as lungs, heart, skeletal (joints, bone density), and gastrointestinal (dysphagia). It is also important with regular follow-ups to assess changes in physical capacity where the Functional Index 2 and/or 3 are validated and disease specific.[8],[9]


  Newly Diagnosed Patients Top


Less is known about the safety and efficacy of exercise in newly diagnosed patients. One study reported the safety of an easy-moderate intensity home exercise program employed about 4 weeks after diagnosis.[10] The exercise program was performed 5 days a week combined with 20-min walks. There were no signs of increased inflammation after 12 weeks of exercise. However, the exercise group did not improve significantly compared to those on medical treatment alone, likely due to the low intensity of the exercise. Since then, one additional study have been conducted on patients with established but active disease. Although small and open design it still shows thesame - exercise is safe and does not increase creatine kinase (CK) levels.[11]


  Extramuscular Manifestations Top


Lung involvement

ILD is present to some degree in about 64% of patients.[12] Although rare, rapidly progressive ILD is a major cause of mortality early in the disease. Milder forms of ILD are more common with a less severe prognosis, it can also be asymptomatic. Common symptoms of ILD are dyspnea, cough, and reduced exercise tolerance, and can precede muscular symptoms. Total lung capacity and diffusing capacity will likely be reduced. Respiratory muscle weakness and pulmonary arterial hypertension (PAH) can be present in IIM, often developed over time. It is important to evaluate the lung involvement with lung function testing (spirometry) to be able to adapt the exercise intervention and apply an adequate level of supervision during exercise.[13],[14]

As patients with symptomatic ILD were excluded from most exercise studies, it is unclear how to take ILD into consideration when prescribing an exercise program for an IIM patient. On one hand, the pathophysiology of ILD can induce exercise intolerance and abnormal exertion dyspnea.[15] On the other hand, patients with ILD (idiopathic, COVID-and SARS-related) tolerate exercise with positive effects on forced vital capacity, walking distance in the 6-min walking test[16] and in health-related quality of life.[17] However, a lower exercise response might be expected in IIM-ILD (as reported in connective-tissue disease-related ILD), that aerobic exercise is insufficient, and aquatic and strength training could improve response.[18] Very little is known about the safety and effects of exercise in patients with PAH. Although uncommon in IIM, when present exercise needs to be adapted. One very recent study showed that a continuous aerobic exercise with an intensity of 5–6 out of 10 (Borg CR10-scale) and a sustained SpO2% was safe. Further, low-intensity strength training and inspiratory muscle training were performed and safe as well. It is however important to measure the pressure by heart catheterization before initiating exercise.[19]

Cardiac involvement

Myocarditis, inflammatory infiltration in the cardiac conduction system and replacement fibrosis, and subclinical electrocardiogram abnormalities can all be part of the cardiac involvement in IIM. Patients with IIM also have a higher risk of developing cardiovascular disease.[20] Around 10%–15% of the patients have clinically relevant cardiac involvement and around 70% have sub-clinical cardiac involvement. These changes can lead to arrhythmias, heart failure, and ventricular dysfunction, the two latter might lead to dyspnea, as can myocarditis. To identify subclinical cardiac inflammation or irreparable changes early cardiac magnetic resonance imaging might be necessary.[1],[13],[20] To be able to correctly adapt, supervise and safely conduct the exercise, a thorough pre-exercise examination of the cardiovascular system is relevant and important.

Exercise is widely used in cardiac rehabilitation and there is growing evidence supporting the efficacy of high-intensity interval training for patients with heart failure;[21] however, only in the absence of other risk factors such as uncontrolled or untreated acute myo- or pericarditis, symptomatic heart failure or arrhythmias, unstable coronary artery disease which are absolute contraindications for such intensive exercise. However, stabilized with medical treatment, exercise is possible,[22] however in a clinical setting with experienced staff using adequate monitoring, cardiac high-risk patients can safely manage the high-intensity exercise.[23] For safety reasons, aerobic exercise can be reduced to moderate intensity.

Skeletal involvement

Arthritis is present in 20%–50% of patients with IIM, especially in patients with the antisynthetase syndrome (ASyS) who more often present with erosive arthritis. Generally, arthritis is nonerosive and symmetric involving the small joints of the hand although not exclusively. Often the arthritis is nonerosive, nor the main symptom, but it can still be mistaken for rheumatoid arthritis (RA). Sometimes there is an IIM-RA overlap where arthritis more often is erosive.[1],[24] Both intensive aerobic exercise and resistance training is safe in patients with well-controlled RA.[25],[26] Based on this, we hypothesize that exercise is also safe in patients with IIM and arthritis if the exercise is adapted to pain levels with lower weights/higher repetitions.[27] Pain might increase during the start of an exercise program, even though the pain is in the joints, it can be regarded as nonnegative exercise-related pain. However, sustained increased pain for more than 24 h indicates the need to reduce the intensity.

There is also a risk of osteopenia or osteoporosis. A reduced bone mineral density has been reported among IIM patients as early as 6 months from diagnosis, although more present with longer disease duration.[28] Medical treatment is used to combat or minimize the loss of bone minerals with the use of glucocorticoids.[29] In addition, exercise can increase bone mineral density.[4] To minimize the risk of fractures, exercise should be done with the higher number of repetitions and lower weights, and without jumps and spinal flexion (e.g., sit-ups). Exercise adaptations are especially important with high doses of oral glucocorticoids and for women after menopause. With a high corticosteroid dose start with a low–moderate exercise intensity, then increasing exercise intensity along with a tapered glucocorticoid dose, [Figure 1].
Figure 1: The relation between glucocorticoid dose and exercise intensity

Click here to view


Pain and fatigue

Pain and fatigue were by patients, health-care providers and caregivers considered the most important symptoms to assess in clinical trials and clinical practice.[30] Patients with IIM seem to suffer from pain and fatigue to a further extent than normative populations,[31],[32],[33] although prevalence, type of pain, localization, intensity, and progression over time are unclear. The cause of fatigue in IIM is also not quite clear and is probably multi-factorial as in other rheumatic inflammatory conditions, such as RA.[34] Central fatigue due to inflammation itself, medication, pain, and poor sleep are a few factors that can contribute to central fatigue. Peripheral fatigue, functional or structural impairment of the muscle, could be due to multiple causes such as myofiber alterations, interstitial connective disarrangement, or altered muscle vascularization. These changes can be both structural and metabolic.[35] Fatigue might emerge as a possible surrogate measure for disease activity as self-reported symptomatic flares are fatigue-based.[36]

Exercise has been described to both worsen and mitigate pain in IIM.[4] A systematic review by Misse et al.[37] found that exercise might have a positive effect on pain and perceived fatigue. However, more research is needed to fully understand the characteristics and behavior of both pain and fatigue in IIM, and the effect of exercise. Until then, exercise, both aerobic and strength, should be used to try to combat pain and fatigue based on evidence indicating that exercise can reduce pain and fatigue in other inflammatory diseases such as systemic lupus erythematosus, RA, and psoriatic arthritis.[25],[38],[39],[40],[41] In the presence of pain, the patient should start with low weight/intensity and a higher number of repetitions with frequent follow-up to not intensify the pain. As the exercise continues without intensification of the pain, the weight/intensity can increase, and the number of repetitions decreases.

Exercise prescription in relation to the disease and extramuscular manifestations

An inter-professional team approach is essential to optimize treatment for patients with IIM. As additional precautions, baseline measuring of the heart rate, blood pressure, and peripheral oxygen saturation can be done regularly, as well as asking the patient to rate the exertion and breathlessness or dizziness, chest pain, or general discomfort. To avoid muscle fatigue during exercise, change which muscle is targeted after each set in a circuit training fashion.

Exercise goal – the optimal amount of exercise

It is unclear what level of physical activity that is optimal for patients with IIM, however, in [Table 1] the best available recommendations are presented for patients with established, low-active IIM (inclusion body myositis [IBM] excluded). People with inflammatory systemic rheumatic conditions have a higher risk of developing cardiovascular disease. A high aerobic capacity is strongly associated with the absence of cardiovascular disease,[46] thus aerobic exercise should be an important part of the exercise treatment.
Table 1: Recommendations of exercise dose to improve muscle function and aerobic capacity for general population and for people with idiopathic inflammatory myopathy according to frequency, intensity, type, and time

Click here to view


To reach health-enhancing levels of physical activity, support from health care is needed for most patients with IIM, such as a physical therapist for assessments and specific advice on exercise and physical activity. Long-term follow-up is important for compliance. Examples of aerobic exercise are walking (or Nordic walking), swimming, aquatic training, stationary biking, jogging/running, or aerobics class. Strength training can be done at home, outdoors, or at a gym, with or without external loads. Daily activities can also be the exercise for patients with low fitness. There are a few considerations before, during, and after exercise [Table 2].
Table 2: Extramuscular involvement, related auto-antibodies, manifestations, and symptoms with exercise considerations

Click here to view


What results can be expected?

Dysphagia, shorter time from symptom onset to treatment start and more intensive initial glucocorticoid treatment are associated with a higher rate of clinical improvement after 1 year of medical treatment.[49] Since exercise is an important part of the treatment, it is likely that a shorter time to exercise start and higher initial exercise intensity than previously studied might be beneficial to avoid deterioration and irreversible damage as can be expected with a prolonged time from symptom onset to treatment. Further, clinical experience suggests that the degree of muscle atrophy or fat replacement in muscle and fibrosis in the lungs can influence the exercise response. In addition, medication tolerance and flares can also affect exercise response. It is not possible to in detail predict recovery by exercise, thus a longitudinal follow-up is essential to evaluate the outcome and adapt exercise according to possible improvement or worsening in disease.

Even without significant improvement in physical capacity, it is still important to continue with an exercise and physical capacity. Physical inactivity leads to a more rapid decrease in muscle function. Regular exercise will if not improve function, help to maintain, slow down the deterioration,[4] and reduce the risk of cardiovascular disease, type 2 diabetes, and cancer. In case of reaching a plateau in exercise response, a visit with a physical therapist with experience of IIM is important. The exercise intensity, duration, or frequency might need adaption. Further, creatine supplementation can boost exercise response. Exercise in combination with daily creatine supplementation is more effective to improve muscle function than exercise and placebo in established PM and DM.[50] It is important to screen for kidney health and that the patient already is exercising regularly on an adequate level at least twice a week.

Inclusion body myositis

IBM differs from the other forms of IIM mentioned in this article. IBM is autoimmune, with degenerative components. Mechanisms leading to impaired muscle functions are unclear but protein aggregation, muscle fiber, and mitochondrial dysfunction are suggested,[51],[52],[53] although not the only mechanisms suggested. Distal muscle weakness is common to a further extent compared to other IIMs, often asymmetric as well. IBM has a slow progression over time and is usually unresponsive to medical treatment. There is in general no extra-skeletal muscular involvement in IBM, other than esophageal muscle weakness, leading to dysphagia.[1] There are only a few studies evaluating the safety and efficacy of exercise in IBM, however, all support safety with unchanged levels of CK and inflammatory infiltrates in muscle tissue. However, evidence on efficacy to improve muscle function is less unified. One RCT indicates that blood-flow restricted submaximal resistance training can sustain quadriceps muscle strength compared to a nonexercising control group worsening almost 10% during the 12-week study period without signs of increased inflammation in muscle.[54],[55] A small, open study showed improvement in muscle strength even in the most affected muscle groups in IBM by a 16-week, twice-a-day home exercise program.[56] Patients with IBM do not respond to exercise as well as patients with other IIM subtypes, and a sustained muscle function should be considered as a positive effect versus a decline that is part of the natural disease course.[54] Careful goal setting and motivational conversations are two important parts of the exercise prescription and follow-up. Further, supervised exercise is of high importance later in the disease course when poor balance and muscle strength might hinder exercise in a regular gym. Aquatic training can be a safe and effective exercise mode.

Limitations with available research

Today, IIMs are classified by autoantibody status associated with various clinical profiles.[1] Most exercise research has been done before the classification systems only including patients diagnosed according to Bohan and Peter criteria.[57],[58] Most likely, patients classified today as ASyS or immune-mediated necrotizing myopathy have participated in exercise studies but as polymyositis (PM) or dermatomyositis (DM) patients. This causes some difficulties as to how and if exercise research can be applied to all IIM patients or if it should be adjusted with regard to autoantibody, or to clinical or serological data.

The rarity of IIM makes larger studies difficult with a result that most exercise studies are small clinical studies and not RCTs with statistical power. However, all publications point in the same direction regarding exercise – it is safe and effective in combating the disease, disease-related manifestations as well as secondary co-morbidities.[59],[60],[61] However, it is still unclear how to prescribe the optimal exercise program, and if the exercise must differ for newly diagnosed, active disease and inactive diseases. As we are moving from only PM/DM/IBM to a spectrum of IIMs with different disease severity and manifestations, it is likely that individualized exercise programs are needed. By combining evidence on exercise in IIM and other similar diseases (ILD, heart failure, myocarditis, and arthritis) and basic exercise physiology, we can prescribe exercise that would most likely be safe and effective to each individual patient.


  Summary Top


Exercise is a safe and effective adjuvant therapy in established IIM with low extramuscular involvement to increase muscle strength, function and endurance, aerobic capacity and reduce inflammation and disease activity. It is still unclear how to optimize exercise for patients with recent onset disease or patients with much extramuscular involvement. However, exercise is safe even for patients with recent onset or active disease or extramuscular involvement – if it is supervised and individualized. As patients with severe vital-organ involvement are usually excluded from exercise studies, it should be prioritized to include patients with severe lung and heart involvement in future studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lundberg IE, Fujimoto M, Vencovsky J, Aggarwal R, Holmqvist M, Christopher-Stine L, et al. Idiopathic inflammatory myopathies. Nat Rev Dis Primers 2021;7:86.  Back to cited text no. 1
    
2.
Alexanderson H, Boström C. Exercise therapy in patients with idiopathic inflammatory myopathies and systemic lupus erythematosus-A systematic literature review. Best Pract Res Clin Rheumatol 2020;34:101547.  Back to cited text no. 2
    
3.
Regardt M, Mecoli CA, Park JK, de Groot I, Sarver C, Needham M, et al. OMERACT 2018 Modified Patient-reported Outcome Domain Core Set in the Life Impact Area for Adult Idiopathic Inflammatory Myopathies. J Rheumatol 2019;46:1351-4.  Back to cited text no. 3
    
4.
Zhang H, Liu Y, Ma J, Li Z. Systematic review of physical exercise for patients with idiopathic inflammatory myopathies. Nurs Health Sci 2021;23:312-24.  Back to cited text no. 4
    
5.
Alemo Munters L, Dastmalchi M, Katz A, Esbjörnsson M, Loell I, Hanna B, et al. Improved exercise performance and increased aerobic capacity after endurance training of patients with stable polymyositis and dermatomyositis. Arthritis Res Ther 2013;15:R83.  Back to cited text no. 5
    
6.
Coskun Benlidayi I, Gupta L. The pathophysiological effects of exercise in the management of idiopathic inflammatory myopathies: A scoping review. Int J Rheum Dis 2021;24:896-903.  Back to cited text no. 6
    
7.
de Souza JM, de Oliveira DS, Perin LA, Misse RG, Dos Santos AM, Gualano B, et al. Feasibility, safety and efficacy of exercise training in immune-mediated necrotising myopathies: A quasi-experimental prospective study. Clin Exp Rheumatol 2019;37:235-41.  Back to cited text no. 7
    
8.
Ernste FC, Chong C, Crowson CS, Kermani TA, Mhuircheartaigh ON, Alexanderson H. Functional index-3: A valid and reliable functional outcome assessment measure in patients with dermatomyositis and polymyositis. J Rheumatol 2021;48:94-100.  Back to cited text no. 8
    
9.
Alexanderson H, Broman L, Tollbäck A, Josefson A, Lundberg IE, Stenström CH. Functional index-2: Validity and reliability of a disease-specific measure of impairment in patients with polymyositis and dermatomyositis. Arthritis Rheum 2006;55:114-22.  Back to cited text no. 9
    
10.
Alexanderson H, Stenström C, Jenner G, Lundberg I. The safety of a resistive home exercise program in patients with recent onset active polymyositis or dermatomyositis. Scand J Rheumatol 2000;29:295-301.  Back to cited text no. 10
    
11.
Tiffreau V, Rannou F, Kopciuch F, Hachulla E, Mouthon L, Thoumie P, et al. Postrehabilitation functional improvements in patients with inflammatory myopathies: The results of a randomized controlled trial. Arch Phys Med Rehabil 2017;98:227-34.  Back to cited text no. 11
    
12.
Fathi M, Vikgren J, Boijsen M, Tylen U, Jorfeldt L, Tornling G, et al. Interstitial lung disease in polymyositis and dermatomyositis: Longitudinal evaluation by pulmonary function and radiology. Arthritis Rheum 2008;59:677-85.  Back to cited text no. 12
    
13.
Lega JC, Reynaud Q, Belot A, Fabien N, Durieu I, Cottin V. Idiopathic inflammatory myopathies and the lung. Eur Respir Rev 2015;24:216-38.  Back to cited text no. 13
    
14.
Barba T, Fort R, Cottin V, Provencher S, Durieu I, Jardel S, et al. Treatment of idiopathic inflammatory myositis associated interstitial lung disease: A systematic review and meta-analysis. Autoimmun Rev 2019;18:113-22.  Back to cited text no. 14
    
15.
Molgat-Seon Y, Schaeffer MR, Ryerson CJ, Guenette JA. Exercise pathophysiology in interstitial lung disease. Clin Chest Med 2019;40:405-20.  Back to cited text no. 15
    
16.
Agarwala P, Salzman SH. Six-minute walk test: Clinical role, technique, coding, and reimbursement. Chest 2020;157:603-11.  Back to cited text no. 16
    
17.
Reina-Gutiérrez S, Torres-Costoso A, Martínez-Vizcaíno V, Núñez de Arenas-Arroyo S, Fernández-Rodríguez R, Pozuelo-Carrascosa DP. Effectiveness of pulmonary rehabilitation in interstitial lung disease, including coronavirus diseases: A systematic review and meta-analysis. Arch Phys Med Rehabil 2021;102:1989-97.e3.  Back to cited text no. 17
    
18.
Dowman LM, McDonald CF, Hill CJ, Lee AL, Barker K, Boote C, et al. The evidence of benefits of exercise training in interstitial lung disease: A randomised controlled trial. Thorax 2017;72:610-9.  Back to cited text no. 18
    
19.
Butāne L, Spilva-Ekerte L, Skride A, Šmite D. Individually tailored remote physiotherapy program improves participation and autonomy in activities of everyday life along with exercise capacity, self-efficacy, and low-moderate physical activity in patients with pulmonary arterial hypertension: A randomized controlled study. Medicina (Kaunas) 2022;58:662.  Back to cited text no. 19
    
20.
Schwartz T, Diederichsen LP, Lundberg IE, Sjaastad I, Sanner H. Cardiac involvement in adult and juvenile idiopathic inflammatory myopathies. RMD Open 2016;2:e000291.  Back to cited text no. 20
    
21.
Yu AK, Kilic F, Dhawan R, Sidhu R, Elazrag SE, Bijoora M, et al. High-intensity interval training among heart failure patients and heart transplant recipients: A systematic review. Cureus 2022;14:e21333.  Back to cited text no. 21
    
22.
Arraiz GA, Wigle DT, Mao Y. Risk assessment of physical activity and physical fitness in the Canada Health Survey mortality follow-up study. J Clin Epidemiol 1992;45:419-28.  Back to cited text no. 22
    
23.
Pineda-García AD, Lara-Vargas JA, Ku-González A, Lastra-Silva VJ, Arteaga R, Pineda-Juárez JA. Safety and improvement in exercise tolerance with interval training vs. moderate-intensity continuous training in heart disease patient of very high cardiovascular risk. Arch Cardiol Mex 2021;91:178-85.  Back to cited text no. 23
    
24.
Klein M, Mann H, Vencovský J. Arthritis in idiopathic inflammatory myopathies. Curr Rheumatol Rep 2019;21:70.  Back to cited text no. 24
    
25.
Hu H, Xu A, Gao C, Wang Z, Wu X. The effect of physical exercise on rheumatoid arthritis: An overview of systematic reviews and meta-analysis. J Adv Nurs 2021;77:506-22.  Back to cited text no. 25
    
26.
Bartlett DB, Willis LH, Slentz CA, Hoselton A, Kelly L, Huebner JL, et al. Ten weeks of high-intensity interval walk training is associated with reduced disease activity and improved innate immune function in older adults with rheumatoid arthritis: A pilot study. Arthritis Res Ther 2018;20:127.  Back to cited text no. 26
    
27.
Alexanderson H, Dastmalchi M, Esbjörnsson-Liljedahl M, Opava CH, Lundberg IE. Benefits of intensive resistance training in patients with chronic polymyositis or dermatomyositis. Arthritis Rheum 2007;57:768-77.  Back to cited text no. 27
    
28.
Hanna B, Sakiniene E, Gjertsson I, Pullerits R, Jin T. Osteopenia/osteoporosis develops in the early phase of disease in patients with idiopathic inflammatory myopathies. Scand J Rheumatol 2021;50:398-401.  Back to cited text no. 28
    
29.
Klein GL. The effect of glucocorticoids on bone and muscle. Osteoporos Sarcopenia 2015;1:39-45.  Back to cited text no. 29
    
30.
Mecoli CA, Park JK, Alexanderson H, Regardt M, Needham M, de Groot I, et al. Perceptions of patients, caregivers, and healthcare providers of idiopathic inflammatory myopathies: An international OMERACT study. J Rheumatol 2019;46:106-11.  Back to cited text no. 30
    
31.
Alexanderson H, Regardt M, Ottosson C, Alemo Munters L, Dastmalchi M, Dani L, et al. Muscle strength and muscle endurance during the first year of treatment of polymyositis and dermatomyositis: A prospective study. J Rheumatol 2018;45:538-46.  Back to cited text no. 31
    
32.
Regardt M, Welin Henriksson E, Alexanderson H, Lundberg IE. Patients with polymyositis or dermatomyositis have reduced grip force and health-related quality of life in comparison with reference values: An observational study. Rheumatology (Oxford) 2011;50:578-85.  Back to cited text no. 32
    
33.
Sultan SM, Ioannou Y, Moss K, Isenberg DA. Outcome in patients with idiopathic inflammatory myositis: Morbidity and mortality. Rheumatology (Oxford) 2002;41:22-6.  Back to cited text no. 33
    
34.
Hewlett S, Chalder T, Choy E, Cramp F, Davis B, Dures E, et al. Fatigue in rheumatoid arthritis: Time for a conceptual model. Rheumatology (Oxford) 2011;50:1004-6.  Back to cited text no. 34
    
35.
Ricci G, Fontanelli L, Torri F, Schirinzi E, Siciliano G. Fatigue as a common signature of inflammatory myopathies: Clinical aspects and care. Clin Exp Rheumatol 2022;40:425-32.  Back to cited text no. 35
    
36.
Oldroyd AG, Krogh NS, Dixon WG, Chinoy H. Investigating characteristics of idiopathic inflammatory myopathy flares using daily symptom data collected via a smartphone app. Rheumatology (Oxford) 2022:keac161.  Back to cited text no. 36
    
37.
Misse RG, Borges IB, Dos Santos AM, Gupta L, Shinjo SK. Effect of exercise training on fatigue and pain in patients with systemic autoimmune myopathies: A systematic review. Autoimmun Rev 2021;20:102897.  Back to cited text no. 37
    
38.
Kessler J, Chouk M, Ruban T, Prati C, Wendling D, Verhoeven F. Psoriatic arthritis and physical activity: A systematic review. Clin Rheumatol 2021;40:4379-89.  Back to cited text no. 38
    
39.
Sharif K, Watad A, Bragazzi NL, Lichtbroun M, Amital H, Shoenfeld Y. Physical activity and autoimmune diseases: Get moving and manage the disease. Autoimmun Rev 2018;17:53-72.  Back to cited text no. 39
    
40.
Cramp F, Hewlett S, Almeida C, Kirwan JR, Choy EH, Chalder T, et al. Non-pharmacological interventions for fatigue in rheumatoid arthritis. Cochrane Database Syst Rev 2013; 8:CD008322.  Back to cited text no. 40
    
41.
Yuen HK, Cunningham MA. Optimal management of fatigue in patients with systemic lupus erythematosus: A systematic review. Ther Clin Risk Manag 2014;10:775-86.  Back to cited text no. 41
    
42.
Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc 2011;43:1334-59.  Back to cited text no. 42
    
43.
Alemo Munters L, Dastmalchi M, Andgren V, Emilson C, Bergegård J, Regardt M, et al. Improvement in health and possible reduction in disease activity using endurance exercise in patients with established polymyositis and dermatomyositis: A multicenter randomized controlled trial with a 1-year open extension followup. Arthritis Care Res (Hoboken) 2013;65:1959-68.  Back to cited text no. 43
    
44.
Alexanderson H, Alemo Munters L, Dastmalchi M, Loell I, Heimburger M, Opava C, et al. Resistive home exercise in patients with recent-onset polymyositis and dermatomyositis-A randomised controlled single-blinded study with a 2-year followup. J Rheumatol 2014;41:1124-32.  Back to cited text no. 44
    
45.
Wiesinger GF, Quittan M, Aringer M, Seeber A, Volc-Platzer B, Smolen J, et al. Improvement of physical fitness and muscle strength in polymyositis/dermatomyositis patients by a training programme. Br J Rheumatol 1998;37:196-200.  Back to cited text no. 45
    
46.
Carnethon MR. Physical activity and cardiovascular disease: How much is enough? Am J Lifestyle Med 2009;3 Suppl 1:44S-9S.  Back to cited text no. 46
    
47.
Galindo-Feria AS, Horuluoglu B, Day J, Fernandes-Cerqueira C, Wigren E, Gräslund S, et al. Autoantibodies against four-and-a-half-LIM domain 1 (FHL1) in inflammatory myopathies: Results from an Australian single-centre cohort. Rheumatology 2022:keac003.  Back to cited text no. 47
    
48.
Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-81.  Back to cited text no. 48
    
49.
Espinosa-Ortega F, Holmqvist M, Dastmalchi M, Lundberg IE, Alexanderson H. Factors associated with treatment response in patients with idiopathic inflammatory myopathies: A registry-based study. Arthritis Care Res (Hoboken) 2022;74:468-77.  Back to cited text no. 49
    
50.
Chung YL, Alexanderson H, Pipitone N, Morrison C, Dastmalchi M, Ståhl-Hallengren C, et al. Creatine supplements in patients with idiopathic inflammatory myopathies who are clinically weak after conventional pharmacologic treatment: Six-month, double-blind, randomized, placebo-controlled trial. Arthritis Rheum 2007;57:694-702.  Back to cited text no. 50
    
51.
Lassche S, Rietveld A, Heerschap A, van Hees HW, Hopman MT, Voermans NC, et al. Muscle fiber dysfunction contributes to weakness in inclusion body myositis. Neuromuscul Disord 2019;29:468-76.  Back to cited text no. 51
    
52.
Catalán-García M, García-García FJ, Moreno-Lozano PJ, Alcarraz-Vizán G, Tort-Merino A, Milisenda JC, et al. Mitochondrial dysfunction: A common hallmark underlying comorbidity between sIBM and other degenerative and age-related diseases. J Clin Med 2020;9:E1446.  Back to cited text no. 52
    
53.
Snedden AM, Kellett KA, Lilleker JB, Hooper NM, Chinoy H. The role of protein aggregation in the pathogenesis of inclusion body myositis. Clin Exp Rheumatol 2022;40:414-24.  Back to cited text no. 53
    
54.
Jørgensen AN, Aagaard P, Frandsen U, Boyle E, Diederichsen LP. Blood-flow restricted resistance training in patients with sporadic inclusion body myositis: A randomized controlled trial. Scand J Rheumatol 2018;47:400-9.  Back to cited text no. 54
    
55.
Jensen KY, Jacobsen M, Schrøder HD, Aagaard P, Nielsen JL, Jørgensen AN, et al. The immune system in sporadic inclusion body myositis patients is not compromised by blood-flow restricted exercise training. Arthritis Res Ther 2019;21:293.  Back to cited text no. 55
    
56.
Johnson LG, Edwards DJ, Walters S, Thickbroom GW, Mastaglia FL. The effectiveness of an individualized, home-based functional exercise program for patients with sporadic inclusion body myositis. J Clin Neuromusc Dis 2007;8:187-94.  Back to cited text no. 56
    
57.
Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med 1975;292:403-7.  Back to cited text no. 57
    
58.
Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med 1975;292:344-7.  Back to cited text no. 58
    
59.
Munters LA, Loell I, Ossipova E, Raouf J, Dastmalchi M, Lindroos E, et al. Endurance exercise improves molecular pathways of aerobic metabolism in patients with myositis. Arthritis Rheumatol 2016;68:1738-50.  Back to cited text no. 59
    
60.
Alemo Munters L, Alexanderson H, Crofford LJ, Lundberg IE. New insights into the benefits of exercise for muscle health in patients with idiopathic inflammatory myositis. Curr Rheumatol Rep 2014;16:429.  Back to cited text no. 60
    
61.
Alexanderson H. Physical exercise as a treatment for adult and juvenile myositis. J Intern Med 2016;280:75-96.  Back to cited text no. 61
    


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