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Effects of resistance training on the mental health of patients with

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DOI: 10.1007/s10067-021-05738-z

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Clinical Rheumatology
https://doi.org/10.1007/s10067-021-05738-z

REVIEW ARTICLE

Effects of resistance training on the mental health of patients

with fibromyalgia: a systematic review
Guilherme Torres Vilarino 1,2 & Leonardo Vidal Andreato 1,2 & Loiane Cristina de Souza 1,2 &
Joaquim Henrique Lorenzetti Branco 1,2 & Alexandro Andrade 1,2

Received: 16 February 2021 / Revised: 12 April 2021 / Accepted: 14 April 2021

# International League of Associations for Rheumatology (ILAR) 2021

Abstract
Fibromyalgia is a chronic disease characterized by generalized skeletal muscle pain and the presence of mental disorders is
common among patients. As there is no cure, several treatment alternatives have been investigated, including the practice of
resistance training. Thus, the aim of the current study is to analyze the effects of resistance training on the mental health of patients
with fibromyalgia. This is a systematic review of the literature that followed the recommendations of the PRISMA statement. The
search for articles occurred in May 2020 in the databases PubMed, Embase, Science Direct, Web of Science, PEDro, and
CINAHL, as well as Google Scholar for gray literature. The protocol was recorded in PROSPERO and assessment of quality
was performed using the Cochrane tool. In total, 481 studies were found in the database searches, of which seven were included
in the analysis. The only variables investigated in studies related to mental health were depression and anxiety. The results
demonstrate that resistance training reduces symptoms of depression and anxiety in patients with fibromyalgia. It is concluded
that resistance training is efficient to improve the mental health of patients with fibromyalgia, reducing depression and anxiety.
The main limitation is that few variables related to mental health were analyzed.

Key Points
• Resistance training improves the mental health of patients with FM.
• The most commonly studied variables related to mental health are depression and anxiety.
• The study protocols are similar, starting with low-intensity training and gradually increasing the intensity.

Keywords Anxiety . Depression . Exercise . Fibromyalgia . Mental disorders . Rheumatic diseases

Introduction about its development, such as pathophysiological factors,

Fibromyalgia (FM) is considered a rheumatic disease, charac-
terized by chronic and generalized pain[1], and other symp-
toms such as fatigue, muscle stiffness, depression, anxiety,
and non-restorative sleep are common [2, 3]. Although the
origin of FM is still unknown, there are some hypotheses
* Guilherme Torres Vilarino
guilhermevilarino@hotmail.com
1
Health and Sports Science Center, CEFID / Santa Catarina State
University – UDESC, Florianópolis, Santa Catarina, Brazil
2
Laboratory of Sports and Exercise Psychology – LAPE,
Florianópolis, Santa Catarina, Brazil
including alteration in brain and neural function, muscle phys-
iology, hormonal factors, inflammatory markers, and genetic
influences [4, 5]. In relation to these hypotheses, inflammatory
processes are related to changes in cytokines and these can
influence patient mood (depression and anxiety). Thus, the
hypothesis related to the inflammatory process aims to com-
plement the most accepted hypothesis, which refers to central
sensitization [6, 7]; with the symptoms being caused by
changes in pain modulation pathways, with amplification of
the painful signal, due to a deficit between activation and
inhibition, which may be associated with cognitive alterations,
physical trauma, and psychological disorders[8, 9].
Although pain is the main symptom of FM, it is not always
the main complaint reported [4]. Some studies show that
symptoms such as fatigue, depression, sleep disorders,

anxiety, and difficulties in concentration are common in more
than 70% of patients [3, 10]. In addition, these symptoms can
correlate, such as pain affecting sleep quality and levels of
depression [10, 11]. To alleviate symptoms, conventional
treatments include the use of medications; however, many of
these have side effects, in addition to incurring high costs for
patients. Thus, treatment alternatives such as physical exercise
are widely used. According to the European League Against
Rheumatism (EULAR), physical exercise is the only recom-
mended intervention to receive a strong degree of recommen-
dation, with aerobic exercises and resistance training (RT)
being particularly highlighted [12].
Regarding the modalities of PE, it appears that some
have been more widely investigated than others in the
treatment of FM [13]. To date, aerobic exercise has been
the most commonly analyzed, followed by RT, and both
are highly recommended [13]. However, there are some
gaps about the effects of RT on patient symptoms [14]. In
the systematic review conducted by Andrade et al. [5],
most studies on RT had a high risk of bias or an uncertain
risk for adequate sequence generation, concealed alloca-
tion, and blinding. The presence of bias also occurred in
previous research [15], thus limiting the power to gener-
alize the results. Despite these biases, there is a consensus
that RT is a safe and effective intervention when adapted
to the individual needs of patients [16].
In addition, published studies on RT in patients with
FM generally focus on physiological issues, such as pain,
strength, fatigue, and hormonal concentrations [17–20],
while neglecting mental disorders, which are analyzed in
only a few studies and often as a secondary outcome [17,
21, 22]. This is a limitation because mental disorders are
characterized as disturbances in cognition, emotional reg-
ulation, or behavior that reflect a dysfunction of psycho-
logical processes, including depression, anxiety, and
stress[23].
In this sense, it is estimated that the prevalence of de-
pression in patients with FM ranges from 41 [24, 25] to
89% [26], while anxiety disorders range from 41 to 77%
[3, 26]. These data demonstrate the importance of studies
that verify alternative treatments for these symptoms.
Another variable related to patient mental disorders is
mood state [27–29]; however, the reviews published to
date do not analyze studies that investigated this variable,
despite some evidence showing that FM patients present
an altered mood profile [28, 29].
Thus, there is a gap in the literature on the effects of
RT on mental health in patients with FM, especially on
the intervention protocols used and their effects on the
main symptoms such as depression and anxiety.
Therefore, the aim of this study is to analyze the effects
of RT on the mental health of patients with FM through a
systematic review.
Clin Rheumatol
Materials and methods
This systematic review followed the recommendations of the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) [30] and is registered in the International
Prospective Register of Systematic Reviews (PROSPERO)
(CRD42020189737).
Search strategy
The search for studies was carried out by two researchers
(JHLB and LCS), independently, in the electronic databases:
PubMed (National Library of Medicine and National
Institutes of Health), Embase, Science Direct, Web of
Science, PEDro (Physiotherapy Evidence Database),
CINAHL (Cumulative Index to Nursing and Allied Health
Literature), SciELO (Scientific Electronic Library Online),
and Google Scholar for the gray literature. The final search
was carried out in May 2020, considering the entire time pe-
riod of the electronic databases. The following terms were
used: “fibromyalgia” AND “resistance training” OR “strength
training” OR “strength training program*” OR “training resis-
tance” OR “strengthening program.” The search strategy for
the PubMed database is available in Appendix A.
Eligibility criteria
T h i s s y s t em at i c r e v i e w i n cl ud e d r an d o m i z e d o r
nonrandomized clinical trials, published in English, with
adults (≥18 years), of both sexes, diagnosed with FM, consid-
ering the criteria of the American College of Rheumatology
prevailing on the date of publication [1, 2, 31], submitted to
RT programs (> 2 weeks), and which evaluated the effects of
RT (any intensity) on the mental health (depression, anxiety,
mood states, stress) of patients with FM.
As a comparison for mental health outcomes, a sedentary
and healthy control group or a group submitted to other types
of intervention (aerobic and flexibility exercises) were consid-
ered. In addition, the following exclusion criteria were
adopted: review articles, conference abstracts, case studies,
theses, and dissertations; RT associated with other exercise
models (e.g., aerobic training, yoga); or the use of experimen-
tal drugs.
Study selection
The selection of the articles was carried out by two re-
searchers, independently (JHLB and LCS). If there was dis-
agreement between the researchers, a third evaluator (GTV)
gave an opinion for a final decision. Initially, an analysis was
performed based on the reading of the titles, after which the
abstracts were read, and the possible articles to include in the
review were selected, which were read in full. The selection
Clin Rheumatol
was made through Rayyan CRQI [32]. References in the in-
cluded articles were reviewed to identify other potentially rel-
evant articles.
Data extraction
For synthesis and discussion of the results, data were extracted
on study design and author; number of study participants; age,
sex, and treatment group; type of exercise, intervention time,
intensity, and adherence; and conclusion of the study. The
extraction was carried out by an independent researcher who
followed a standardized spreadsheet. Afterwards, another re-
searcher checked the extracted information and any differ-
ences were resolved by consensus.
Quality assessment
To evaluate the risk of bias in the studies included in this
review, the Cochrane Collaboration Risk of Bias Tool was
used [33]. This tool includes criteria that allow the identifica-
tion of biases in the selected studies, which can be inferred in
their conclusion. The assessment of the risk of bias was per-
formed by two researchers (JHLB and LCS). To assess the
agreement index between the evaluators, the Kappa test was
used [34]. In the event of divergence between the evaluators, a
third reviewer (GTV) was consulted for a final opinion.
Results
Identification and selection of studies
In the first stage of searching in the databases, 481 studies
were identified, of which 116 duplicates were excluded, and
31 were selected for reading the full text. At the end of the
selection process, 7 studies met the inclusion criteria and were
selected for the final analysis, as shown in Fig. 1.
Characteristics of included studies
Among the seven studies included in the review, the oldest
publication was in 2001 [17] and the most recent in 2019[35]
(Table 1). The studies were conducted in the USA [36],
Sweden [20], Turkey [21], Finland [17], and Brazil, which
stand out as presenting the highest number of publications
[22, 35, 37]. All included studies were randomized controlled
clinical trials, with the exception of one study that was not
randomized [35]. The total sample of the included studies
comprised 398 women with FM, aged between 18 and 65
years, with pain being the most analyzed physical variable
(5 studies). The variables analyzed related to mental health
were depression (analyzed in seven studies) and anxiety
(analyzed in five studies). No studies were found on mood
states and stress.
Questionnaires used for mental health analysis
Anxiety symptoms were analyzed using the State-Trait
Anxiety Inventory (STAI) [22], the Hospital Anxiety and
Depression Scale (HADS-A) [20, 21], and the Beck Anxiety
inventory [35, 36]. For the analysis of depression, the re-
searchers opted for the Beck Depression Inventory (BDI)
[17, 22, 35, 36], the Hospital Anxiety and Depression Scale
(HADS-D) [20, 21], and one study used a version of the
Fibromyalgia Impact Questionnaire (FIQ) [37].
Characteristics of interventions
The duration of interventions ranged from 4 to 21 weeks, with
the frequency of training twice a week being the most com-
monly used. Only two studies included a higher training fre-
quency (3 times a week) [21, 35]. The protocol was composed
of 5 or 10 min of warm-up, with short walks or light stretches,
followed by the main part (30–50 min of RT), and then a cool
down (5 to 10 min) with stretching exercises [17, 20, 21, 35,
36]; thus, training sessions lasted a maximum of 1 h. The
intensity and volume of the exercises were similar in most
studies. The exercises were performed on machines, with
bodyweight and with free weights, beginning at 40% of 1
repetition maximum (RM) and progressing in some studies
to 85%, with one to three sets of 12 repetitions. Most studies
did not specify the time interval between sets; however, those
that did use 1 min [20, 35]. The characteristics of the studies
and the protocols used are described in Table 1.
Effects of resistance training on psychological
variables
The most commonly investigated psychological variable was
depression, which was analyzed in all included studies. The
studies analyzed showed a significant reduction in depressive
symptoms after the intervention with RT. Only the study con-
ducted by Ericsson et al. [20] did not report a significant result.
Of the five studies that evaluated anxiety, three found positive
effects of the intervention [22, 35, 36], demonstrating that the
practice of RT reduces anxiety symptoms; however, two stud-
ies found no significant differences after the intervention [20,
21]. No studies were found which assessed other psycholog-
ical variables, such as stress and mood states. Variables other
than psychological variables were evaluated in some studies,
such as pain, investigated in five studies [17, 21, 22, 35, 36]. It
was observed that the practice of RT did not negatively affect
any of the studied variables. The outcomes related to symp-
toms are presented in Table 2.

Fig. 1 PRISMA flowchart
Quality of studies and risk of bias
The Kappa agreement index was 90% for all criteria in the
seven studies. All seven studies showed a high risk of bias in
the participants’ blinding criteria and a low risk of bias in
incomplete results, selective reporting, and other sources of
bias (Fig. 2). The blinding of the participants was evaluated as
presenting a high risk of bias; however, due to the nature of the
interventions (PE), the blinding of participants is impossible,
and this fact does not affect the quality of the results.
Discussion
In total, seven studies met the inclusion criteria and the results
demonstrate that the practice of RT significantly improves the
mental health of patients with FM, reducing levels of depres-
sion and anxiety. Although RT is already considered a thera-
peutic option for the treatment of FM [12], most studies in-
vestigated the effects of RT on physical symptoms [14].
Initially, among the exercise modalities, RT was not widely
investigated due to the belief that it would increase pain. This
belief was not confirmed in subsequent studies, which dem-
onstrated that in addition to not increasing pain, RT can
Clin Rheumatol
actually reduce it [14]. However, the effects of RT on mental
health are poorly investigated.
In the current review, the only studied variables related to
mental health were depression and anxiety, which are com-
mon, with high prevalence [3, 26, 38]; however, further re-
search on other outcomes such as stress and mood states is
fundamental, since these variables are also related to mental
health and are common in patients with FM. Changes in mood
states are common in FM patients who present alterations in
the ideal profile [29]. Studies analyzing the effects of physical
exercise on mood states in these patients demonstrate positive
results [28]; however, studies which analyze the exclusive
effect of RT are lacking [27]. The study conducted by
Andrade et al. [28] analyzed the effect of a single session of
RT on the mood states of patients with FM and found signif-
icant changes through reduced tension, depression, anger, fa-
tigue, and mental confusion. Despite the promising results,
further studies are needed, as this was not a controlled and
randomized clinical trial, so the data should be interpreted
with caution. Regarding stress, data are even scarcer. Studies
indicate that FM patients present high stress levels [39]. A
pilot study conducted in Brazil verified the effect of RT on
the stress of patients with FM and showed significant im-
provements after 8 weeks of intervention [40].
 Clin Rheumatol
Table 1 Methodological characteristics and results of studies on resistance training in patients with fibromyalgia

Reference; study Sample size Age in years Intervention Results Conclusion

design (mean/sd)

Hakkinen et al. RT: 11 RT: 39±6 CG: 37±5 21 weeks; WF: 2x. Reduction of depressive symptoms in the RT RT is safe for patients with FM
(2001); RCT [17] CG: 10 HC: 37±6 Isotonic exercises: Supine, squats, extension, and group; Positive correlation with fatigue; and can be used to reduce
HC: 12 flexion of knees and trunk. No change in the CG. symptoms.
Repetitions: week 1–3: single set of 15–20 rep
with 40–60% 1-RM/week 4–7: single set of
10–12 rep with 60–70% 1-RM/week 8–14:
single set of 8–12 rep with 60–80%
1-RM/week 15–21: 1 set of 5–10 rep with
70–80% 1-RM.
Jones et al. (2002); RT: 28FG: 28 RT: 49.2±6.3 12 weeks; WF: 2x. Patients in the RT group showed a significant FM patients tolerate exercise
RCT [36] FG: 46.4±8.5 Isotonic exercises with free weight and resistance reduction in depression and anxiety. There intensity. RT showed better
bands for the muscles: gastrocnemius, tibialis was no reduction in the FG group. results than FG.
anterior, quadriceps, hamstrings, gluteus,
abdominals, erector spinae, pectorals,
latissimus dorsi and rhomboids, deltoids,
biceps, and triceps. Exercises were not
specified.
Intensity: Low (Not specified)
Repetitions: 1 set of 4 to 5 progressing to 12 rep.
Bircan et al. (2008); RT: 13 RT: 46.0±8.5 AE: 8 weeks; WF: 3x. Depression improved significantly in both RT and EA have similar effects
RCT [21] AE: 13 48.3±5.3 Isotonic exercises: Free weights and body weight groups, while in anxiety there was no on the symptoms of patients
were used for upper and lower limb muscles change. The SF-36 mental component with FM.
and trunk muscles. Exercises were not category significantly improved in the RT
specified. group.
Intensity: Not specified
Repetitions: 1 set of 4–5 progressing to 12 rep.
Gavi et al. (2014); RT: 35 RT: 44.3±7.9 16 weeks; WF: 2x. Depressive symptoms improved significantly The two interventions showed
RCT [22] FG: 31 FG: 48.65±7.6 Isotonic exercises using machines: Leg press, leg in the RT group. The FG group showed a significant results.
extension, hip flexion, pectoral fly, triceps significant reduction in trait and state
extension, shoulder flexion, leg curl, calf, anxiety, while the ST group reduced only
pulldown, shoulder abduction, biceps flexion, the trait anxiety. No group showed
and shoulder extension. improvement in the SF-36 mental compo-
Intensity: 45% of 1-RM nent.
Repetitions: 3 sets of 12 rep.
Ericsson et al. (2016); RT: 56 22–64* 15 weeks; WF: 2x. No differences were found in any group in the The RT group significantly
RCT [20] RG: 49 Isotonic exercises: leg press, knee extension, and symptoms of depression and anxiety reduced general, physical,
knee flexion using weight machine; biceps and mental fatigue and
curl and handgrip strength using free weights; improved sleep efficiency
heel raise and core stability using body weight compared to the RG; but
Intensity: 40–80% of 1-RM depression and anxiety did
Repetitions: 1–2 sets of 15–20 rep progressing to not decrease after the
5–8 rep. intervention
Assumpção et al. RT: 16 RT: 45.7±7.7 12 weeks; WF: 2x. The RT group showed a significant reduction RT was more effective in
(2018); RCT [37] FG: 14 FG: 47.9±5.3 Isotonic exercises using free weight: triceps in the depression symptom assessed by the reducing depression
CG: 14 CG: 46.9±6.5 sural, hip adductors and abductors, hip flexor, FIQ. compared to the FG group.
shoulder flexor and extensor, anterior and
 Clin Rheumatol

Legends: 1-RM, one repetition maximum; AE, aerobic exercise; CG, control group; FG, flexibility group; FIQ, fibromyalgia impact questionnaire; FM, fibromyalgia; HC, healthy control; RCT, randomized
Although there are differences in the duration of the studies

anxiety and depression in

clinical trial; rep., repetition; RG, relaxation group; RT, resistance training; SD, standard deviation; SF-36, short-form; WF, weekly frequency. *Article did not specify mean and standard deviation
RT improves symptoms of
and the protocols used, RT was shown to be effective in re-
ducing depression and anxiety. The study conducted by

patients with FM.

Andrade, Sieczkowska, and Vilarino [35] presented the
shortest intervention period (4 weeks) and still found signifi-
Conclusion

cant results in both depression and anxiety. The study of

Bircan et al. [21] also had a short duration (8 weeks) and
depression significantly reduced. Although the period ana-
lyzed was shorter than the other studies, the intervention pro-
depression and anxiety. Higher scores for

tocols used included a higher weekly training frequency (3

depression and anxiety were related to

The CG showed no significant changes.

times a week), in comparison with the other protocols that
The results demonstrated ST reduced

submitted patients to RT twice a week. These results indicate

that both depressive and anxiety symptoms can be modified in
worsening quality of life.

a short training period.

Although most studies showed positive results on depres-
sion, one study found no significant differences [20]. This
different result may be explained by the instrument used to
assess depression, the HADS-D. The majority of studies eval-
Results

uated depression using the BDI, which is an instrument com-

monly used in this population [17, 22, 35, 36]. Bircan et al.
[21] also used the HADS-D and found a significant result, but
their study included a higher frequency of training, even
dorsi, biceps and triceps brachii, quadriceps,

Repetitions: 3 sets of 12 rep with subjectively

though the program duration was shorter. Anxiety, when

including the pectoralis major, latissimus
posterior deltoids, pectoralis major, and

machines: for the main muscle groups,

hamstrings, deltoids, and triceps sural.

assessed by the HADS-A, did not change after RT [20, 21].

Isotonic exercises using free weight and

Of the three studies that analyzed anxiety and showed signif-

icant results, two used the BAI [35, 36] and one used the
IDATE [22]. As the protocols in the studies were similar,
Repetitions: 1 set of 8 rep.

starting with 40% of 1 RM and progressing to 80%, the dif-

determined intensity
Intensity: not specified

ferences found in the results may be due to the sensitivity of

4 weeks; WF: 3x.

the instruments used.

rhomboids.
Intervention

None of the selected studies evaluated only variables relat-

ed to the patients’ mental health or included these as the pri-
mary outcome. Despite this, depression and anxiety were sen-
sitive to RT and correlated with the other variables. In the
study conducted by Andrade, Sieczkowska, and Vilarino
[35], depression showed a high correlation with the quality
of life and a moderate correlation with anxiety. This result
CG: 50.6±9.6
Age in years

RT: 52.0±9.2

demonstrates the importance of a global and united therapeu-

(mean/sd)

tic evaluation and proposal, as physical and mental symptoms

are related and influence the patient’s mood state.
Of the studies analyzed, some compared the effects of RT
in relation to other modalities, such as aerobic exercise and
flexibility. Studies conducted by Jones et al. [36], Assumpção
Sample size

et al. [37], and Gavi et al. [22] compared FM patients under-

CG: 21

going RT and flexibility training for a minimum period of 12

RT: 25

weeks. Both studies found a significant reduction in depres-

sion in the group submitted to RT, demonstrating that this
Table 1 (continued)

modality is better to reduce this symptom. Anxiety, on the

Andrade et al. (2019);

other hand, showed favorable results after RT in the study of

Reference; study

non RCT [35]

Jones et al. [36] and after the flexibility training in the study of
Gavi et al. [22]. When comparing the effects of RT with aer-
design

obic exercise, it was observed that the two modalities have

similar effects [21].
Clin Rheumatol

Table 2 Variables analyzed in the selected studies and results of resistance training in patients with FM

Depression Anxiety Pain Strength Fatigue Quality of life Sleep quality

Hakkinen et al. (2001) [17] ↑ - ↑ ↑ ↑ - -

Jones et al. (2002) [36] ↑ ↑ ↑ ↑ - ↑ -
Bircan et al. (2008) [21] ↑ ↔ ↑ - ↑ - ↑
Gavi et al. (2014) [22] ↑ ↑ ↑ ↑ - ↑ -
Ericsson et al. (2016) [20] ↔ ↔ - - ↑ - ↑
Assumpção et al. (2018) [37] ↑ - - - - - -
Andrade et al. (2019) [35] ↑ ↑ ↔ - - ↑ ↔

Legends: ↑ : positive and significant effect; ↔: No effect;

Limitations and future research
We emphasize that this is the first systematic review on the
effects of RT, focusing on the mental health of patients with
FM, being innovative as it addresses important gaps in the
literature. Despite the reduced number of studies analyzed,
the results reinforce the hypothesis of the benefits of RT in
this population. However, the low number of studies analyzed
reduces the power of our results. In addition, no studies were
found analyzing stress and mood states, limiting the analysis
of mental health to only two variables, depression and anxiety.
Thus, randomized and controlled clinical trials should be con-
ducted analyzing other variables related to the mental health of
patients with FM. These studies will provide important infor-
mation for professionals who work directly with patients, im-
proving patient care and treatment.

Conclusion

After analyzing the included studies, it was concluded that RT

improves the mental health of patients with FM, significantly
reducing depression and anxiety. It was also found that RT
shows better results than flexibility training for mental health
and produces an effect similar to aerobic exercise. It is sug-
gested that further studies be carried out investigating the ef-
fects of RT on the mental health of patients with FM, espe-
cially on stress and mood states. The current evidence dem-
onstrates that RT can be used as an alternative treatment for
mental health in patients with FM.

Supplementary Information The online version contains supplementary

material available at https://doi.org/10.1007/s10067-021-05738-z.

Acknowledgements The authors thank the Foundation for Research and

Innovation Support of the State of Santa Catarina (FAPESC) for the
financial support - PAP 2018 - NO. 04/2018 - grant Nº 2019TR1154

Author contribution Guilherme Torres Vilarino: Conceptualization,

writing—original draft. Leonardo Vidal Andreato: Writing—review and
editing. Loiane Cristina de Souza: Managed the literature searches and
analyses and writing. Joaquim Henrique Lorenzetti Branco:
Conceptualization and managed the literature searches, analyses, and
writing. Alexandro Andrade: Writing—review and editing and supervi-
sion. All authors have contributed significantly to this manuscript and
agree with its content.
Fig. 2 Criteria analyzed to assess the risk of bias in each of the selected
studies

Funding Foundation for Research and Innovation Support of the State of
Santa Catarina (FAPESC) - PAP 2018 - NO. 04/2018 - grant Nº
2019TR1154.
Data availability Data sharing is not applicable to this article as no new
data were created or analyzed in this study.
Code availability Not applicable
Declarations
Disclosures None
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s10067-021-05738-z.
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