Scandinavian Journal of Rheumatology

ISSN: 0300-9742 (Print) 1502-7732 (Online) Journal homepage: http://www.tandfonline.com/loi/irhe20

Cardiovascular training vs. resistance training for

improving quality of life and physical function in
patients with systemic lupus erythematosus: a
randomized controlled trial: comments on the
article by Abrhao et al

A Soriano-Maldonado, JA Vargas-Hitos & JM Sabio

To cite this article: A Soriano-Maldonado, JA Vargas-Hitos & JM Sabio (2016) Cardiovascular

training vs. resistance training for improving quality of life and physical function in patients
with systemic lupus erythematosus: a randomized controlled trial: comments on the article by
Abrhao et al, Scandinavian Journal of Rheumatology, 45:3, 253-254

To link to this article: http://dx.doi.org/10.3109/03009742.2016.1138319

Published online: 07 Apr 2016.

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 Letters
and therefore her treatment was switched to etanercept.
Her lower back-buttock pain worsened and ESR and
CRP levels remained high (49 mm/h and 29 mg/L,
respectively) after 6 months of treatment with etaner-
cept. She was started on anakinra and, after 3 months of
treatment, her back pain intensity (measured on a visual
analogue scale) had reduced from 8/10 to 1/10. In addi-
tion, her Bath Ankylosing Spondylitis Disease Activity
Index (BASDAI) scores had reduced from 6.2 (at the
time of anakinra initiation) to 1.0, while her ESR fell to
11 mm/h and CRP level to 8 mg/L.
Spondyloarthritis is a well-known chronic manifes-
tation of FMF (1, 2). Currently, treatment of
spondyloarthropathies is based on non-steroidal anti-
inammatory drugs (NSAIDs) and anti-TNF agents (3).
Anakinra is ineffective in patients with ankylosing spon-
dylitis and therefore its use is not recommended (4). Treat-
ment of FMF-associated spondylitis is the same as
Downloaded by [RMIT University Library] at 06:10 08 April 2016
the treatment algorithm of other spondyloarthropathies.
However, we suggest that anakinra could be used in FMF
patients with spondyloarthritis whenever standard
approaches are ineffective. This might be due to
possible differences in the pathogenesis of FMF-associated
Cardiovascular training vs. resistance training for improving quality of
life and physical function in patients with systemic lupus erythematosus:
a randomized controlled trial: comments on the article by Abrhao et al
We read with interest the study by Abraho et al (1) compar-
ing the effects of cardiovascular and resistance training on
quality of life and self-reported physical function in patients
with systemic lupus erythematosus (SLE). The authors
found that improvements in health-related quality of life
and aerobic capacity were larger in the cardiovascular train-
ing (CT) group compared to the resistance training (RT)
group, and highlighted that there were no signicant differ-
ences in physical function between the groups, except for
aerobic capacity. However, there are two important issues in
the study results that deserve further comment. First, the
discussion does not pay much attention to an outstanding
result of the study (i.e. the CT group improved aerobic
capacity to a signicantly greater extent than any other
group). Although it is not clear that the 12-minute walk
test is a valid and reliable measure of aerobic capacity in
patients with SLE, this nding is of potential major impor-
tance for the development of future studies and exercise
guidelines. Aerobic capacity is a strong marker of health in
the general population (2) and changes in this marker are
strongly related to long-term morbidity and mortality (3). In
addition, a low aerobic capacity is associated with physical
253
spondyloarthritis and ankylosing spondylitis. Hence, FMF
should be kept in mind in HLA-B27-negative cases
with spondylitis in endemic regions, and anakinra could
be one of the treatment options for such patients.
References
1. Kasifoglu T, Calisir C, Cansu DU, Korkmaz C. The frequency of
sacroiliitis in familial Mediterranean fever and the role of
HLA-B27 and MEFV mutations in the development of
sacroiliitis. Clin Rheumatol 2009;28:416.
2. Balaban B, Yasar E, Ozgul A, Dincer K, Kalyon TA. Sacroiliitis
in familial Mediterranean fever and seronegative spondyloarthro-
pathy: importance of differential diagnosis. Rheumatol Int
2005;25:6414.
3. Sari I, Ozturk MA, Akkoc N. Treatment of ankylosing spondylitis.
Turk J Med Sci 2015;45:41630.
4. Haibel H, Rudwaleit M, Listing J, Sieper J. Open label trial of
anakinra in active ankylosing spondylitis over 24 weeks. Ann
Rheum Dis 2005;64:2968.
Ozkan Varan, Department of Internal Medicine, Division of Rheuma-
tology, Gazi University Faculty of Medicine, 06100 Ankara, Turkey.
E-mail: ozkanvaran84@gmail.com
Accepted 30 November 2015
disability in patients with SLE (4) and could also play a
relevant role with regard to the cardiometabolic risk (5, 6)
and inammatory chronic status (7) observed in this popula-
tion. Therefore, enhancing aerobic capacity through exer-
cise-based intervention programmes is of major importance
in patients with SLE and, consequently, the results by Abra-
ho et al (1) are promising. Second, physical function in this
study was self-reported, and the conclusions with regard to
physical function are therefore limited by the outcome mea-
sures. In this sense, the authors failed to assess muscular
strength, which, in our opinion, might have been an impor-
tant secondary outcome of the study, especially considering
that there was a training group specically engaged in
resistance exercise. Patients with SLE tend to present
lower levels of muscular strength in comparison to healthy
controls (8), and a lower body muscular strength has been
shown to be an important marker of physical disability (9)
that strongly predicts declines in performance-based physi-
cal function over time, especially in those patients with the
lowest baseline tness (10).
As both aerobic capacity and muscular strength are
important outcomes in patients with SLE, we suggest
www.scandjrheumatol.dk
 254
that future exercise-based intervention studies consider
measuring these outcomes as part of a global evaluation
of disease severity and quality of life.
A Soriano-Maldonado1, JA Vargas-Hitos2, JM Sabio
1
Department of Physical Education and Sport, Faculty of
Sport Sciences, University of Granada, Granada and
2 7. Benatti FB, Pedersen BK. Exercise as an anti-inammatory therapy
Systemic Autoimmune Diseases Unit, Department of Internal Medicine,
Virgen de las Nieves University Hospital, Granada, Spain
References
1. Abraho MI, Gomiero AB, Peccin MS, Grande AJ, Trevisani V.
Cardiovascular training vs. resistance training for improving quality
of life and physical function in patients with systemic lupus erythe-
matosus: a randomized controlled trial. Scand J Rheumatol
2016;45:197204.
2. Blair SN, Kampert JB, Kohl HW, Barlow CE, Macera C, Paffen-
barger RS, et al. Inuences of cardiorespiratory tness and other
precursors on cardiovascular disease and all-cause mortality in men
Downloaded by [RMIT University Library] at 06:10 08 April 2016
and women. JAMA 1996;276:20510.
3. Lee DC, Sui X, Artero EG, Lee IM, Church TS, McAuley PA,
et al. Long-term effects of changes in cardiorespiratory tness and
body mass index on all-cause and cardiovascular disease mortality
in men: the Aerobics Center Longitudinal Study. Circulation
2011;124:248390.
4. Tench C, Bentley D, Vleck V, McCurdie I, White P, DCruz D.
Aerobic tness, fatigue, and physical disability in systemic lupus
erythematosus. J Rheumatol 2002;29:47481.
Authors reply
We read your considerations of our recent research
with great interest and would like to make a few
comments. First, we agree with your observations
and assumptions regarding cardiovascular training
(CT) groups improving aerobic capacity to a signi-
cantly greater extent than any other group, and per-
haps we did not explore this issue in sufcient
depth. Second, the choice of the 12-minute walk test
was made because of its low cost and ease of applica-
tion and the fact that there has been good correlation
compared to laboratory tests (1). In general, eld tests
are known to overestimate results and therefore a
more robust test could have shown different aerobic
capacity; however, it would need to be tested and
compared before we draw further conclusions. Third,
your comments regarding aerobic capacity being
important for the prevention of diseases and better
perception of health are well supported in the litera-
ture (2). Finally, we agree that muscular strength
could be assessed as a secondary outcome using dyna-
mometry. However, it is important to note that we
focused on general scales and on what we considered
www.scandjrheumatol.dk
Letters
5. dos Reis-Neto ET, da Silva AE, Monteiro CM, DE Camargo LM,
Sato EI. Supervised physical exercise improves endothelial func-
tion in patients with systemic lupus erythematosus. Rheumatology
(Oxford) 2013;52:218795.
6. Perandini LA, Sales-de-Oliveira D, Mello SB, Camara NO, Benatti
FB, Lima FR, et al. Exercise training can attenuate the inamma-
tory milieu in women with systemic lupus erythematosus. J Appl
Physiol (1985) 2014;117:63947.
for rheumatic diseases myokine regulation. Nat Rev Rheumatol
2015;11:8697.
8. Balsamo S, da Mota LM, de Carvalho JF, Nascimento Dda C,
Tibana RA, de Santana FS, et al. Low dynamic muscle strength
and its associations with fatigue, functional performance, and qual-
ity of life in premenopausal patients with systemic lupus erythe-
matosus and low disease activity: a case-control study. BMC
Musculoskelet Disord 2013;14:263.
9. Andrews JS, Trupin L, Schmajuk G, Barton J, Margaretten M,
Yazdany J, et al. Muscle strength, muscle mass, and physical
disability in women with systemic lupus erythematosus. Arthritis
Care Res 2015;67:1207.
10. Andrews JS, Trupin L, Schmajuk G, Barton J, Margaretten M,
Yazdany J, et al. Muscle strength and changes in physical function
in women with systemic lupus erythematosus. Arthritis Care Res
2015;67:10707.
Alberto Soriano-Maldonado, Department of Physical Education and
Sport, Faculty of Sport Sciences, University of Granada, Avda de
Alfacar s/n, 18011 Granada, Spain.
E-mail: asm@ugr.es
to be patient-centred outcomes. We thank you for your
comments and suggest that we might work together to
produce consistent research in our common area of
interest.
1 1 2 3 4,5
MI Abraho , AB Gomiero , MS Peccin , AJ Grande , VFM Trevisani
1
Federal University of So Paulo, So Paulo,
2
Federal University of So Paulo, Santos,
3
University of the Extreme South of Santa Catarina, Criciuma,
4,
Rheumatology, Santo Amaro University (UNISA), So Paulo, and
5
Department of Emergency Medicine and Evidence-Based Medicine, Fed-
eral University of So Paulo, So Paulo, Brazil
References
1. Solway S, Brooks D, Lacasse Y, Thomas S. A qualitative systematic
overview of the measurement properties of functional walk tests used
in the cardiorespiratory domain. Chest 2001;119:25670.
2. Pedersen BK, Saltin B. Exercise as medicine - evidence for pre-
scribing exercise as therapy in 26 different chronic diseases. Scand
J Med Sci Sports 2015;25(Suppl 3):172.
Antonio Jose Grande, Rua Arlindo Veiga dos Santos 50, Jd Marajoara,
CEP 04671-300 So Paulo, SP, Brazil.
E-mail: grandeto@gmail.com