Submit a Manuscript: http://www.wjgnet.

com/esps/ World J Orthop 2015 November 18; 6(10): 762-769

Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx ISSN 2218-5836 (online)
DOI: 10.5312/wjo.v6.i10.762 © 2015 Baishideng Publishing Group Inc. All rights reserved.

EDITORIAL

Effects of exercise on physical limitations and fatigue in

rheumatic diseases

Giuseppe Musumeci

Giuseppe Musumeci, Department of Biomedical and Bio­ and playing. Regular exercise has a great importance
technological Sciences, Human Anatomy and Histology Section, in maintaining good health, indeed inactivity is a risk
School of Medicine, University of Catania, 95123 Catania, Italy factor for different chronic diseases. Physical exercise
can play a crucial role in the treatment of rheumatic
Author contributions: Musumeci G solely contributed to this diseases, optimizing both physical and mental health,
paper.
enhancing energy, decreasing fatigue and improving
Supported by A grant-in-aid from FIR 2014-2016 (COD: sleep. An exercise program for patients with rheumatic
314509), University of Catania. diseases aims to preserve or restore a range of motion
of the affected joints, to increase muscle strength
Conflict-of-interest statement: No conflict of interest is declared and endurance, and to improve mood and decrease
by any of the authors. health risks associated with a sedentary lifestyle. In
this editorial I describe the benefits of the exercise on
Open-Access: This article is an open-access article which was physical limitations and fatigue in rheumatic diseases
selected by an in-house editor and fully peer-reviewed by external that seem to have a short and long-term effectiveness.
reviewers. It is distributed in accordance with the Creative A literature review was conducted on PubMed, Scopus
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
and Google Scholar using appropriate keywords based
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on on the present editorial.
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/ Key words: Physical activity; Physiatric rehabilitation
licenses/by-nc/4.0/ therapy; Rheumatic diseases; Flexibility training; Home
exercise program; Knee osteoarthtritis
Correspondence to: Giuseppe Musumeci, PhD, Master
of Science, Department of Biomedical and Biotechnological © The Author(s) 2015. Published by Baishideng Publishing
Sciences, Human Anatomy and Histology Section, School of Group Inc. All rights reserved.
Medicine, University of Catania, 95123 Catania,
Italy. [email protected] Core tip: In this interesting editorial, I illustrated the
Telephone: +39-095-3782043
beneficial effects of the physical activity in our life and
Fax: +39-095-3782044
in rheumatic diseases, including home and gym exercise
Received: May 12, 2015 programs, flexibility training and physiatric rehabilitation
Peer-review started: May 12, 2015 therapy. Physical exercise is able to improve balance,
First decision: July 28, 2015 reduce pain, activate muscle and increase functional
Revised: August 8, 2015 joint stability in patients with rheumatic diseases and
Accepted: August 30, 2015 osteoarthritis. The benefits of the exercise on physical
Article in press: August 31, 2015 limitations and fatigue in rheumatic diseases that seem
Published online: November 18, 2015 to have a short and long-term effectiveness.

Musumeci G. Effects of exercise on physical limitations and

Abstract fatigue in rheumatic diseases. World J Orthop 2015; 6(10): 762-769
Available from: URL: http://www.wjgnet.com/2218-5836/full/v6/
Physical activity covers not just sports but also simple
i10/762.htm DOI: http://dx.doi.org/10.5312/wjo.v6.i10.762
everyday movements such as housework, walking

WJO|www.wjgnet.com 762 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

activity. For example, in patients with rheumatoid

INTRODUCTION arthritis (RA) and fibromyalgia (FM), reduced levels of
Physical activity covers not just sports but also simple fatigue were reported in association with a higher daily
everyday movements, no training exercise, such as [3,6]
physical activity . In patients with RA, fatigue can
housework, walking, biking and playing (Figure 1). be associated not only with the inflammation per se,
Indeed, according to the World Health Organization, but especially with pain, disability, anxiety, depressive
“any effort exerted by the muscle-skeletal system thoughts, reduced self-efficacy, feelings of helplessness,
which results in a higher power consumption than that sleep disturbances, and limitations in social functioning.
[1]
in the rest position” is classified as physical activity . Based on these findings, psychosocial factors may
Regular exercise has a great importance in maintaining have an important role in the onset and persistence
good health. Inactivity is a risk factor for chronic dis­ [7-9]
of fatigue . Both cognitive-behavioral therapy and
eases and the benefits of a regular and moderate physical exercise are reported to be effective for treating
exercise include reduced risks of coronary artery dis­ [10]
fatigue in patients with RA . Furthermore, exercise
ease, hypertension, diabetes, obesity, serum lipid can enhance weight loss and promote long-term weight
[2]
abnormalities, osteoporosis and cancer . Moreover, management in those rheumatic diseases patients who
physical activity is a good way to socialize and an are overweight. Water is an excellent environment for
excellent anti-stress, decreasing the urge to smoke. the exercises and the water temperature (between 28
Physical exercise can play a crucial role in the treatment ℃ and 32 ℃) can give pain relief. It allows the patient
of rheumatic diseases in optimizing both physical to be in a situation of reduced weight, thus allowing
and mental health, enhancing energy, decreasing some patients to perform exercises that they would
fatigue and improving sleep. In this way, the muscles otherwise not be able to perform. FM is a chronic pain
around the affected joints become strong, the bone loss disorder, commonly associated with a reduced quality of
decreases and the control of joint swelling, stiffness life, since it is accompanied by other symptoms such as
and pain improves thanks to a better lubrication of the fatigue, psychological distress, cognitive disorders, no
[3]
joint cartilage . Moreover, immediately after exercising, restorative sleep, poor balance, and impaired physical
anxiety decreases and the mood improves. An exercise function
[11-13]
. The current treatment for FM envisages a
program for patients with rheumatic diseases aims to comprehensive assessment including pharmacological
preserve or restore a range of motion of the affected and non-pharmacological therapies. The latter provide
joints, to increase muscle strength and endurance, and for a multimodal approach including physical activity,
to improve mood and decrease health risks associated sleep hygiene, behavioural therapy, regular education
[3] [14,15]
with a sedentary lifestyle . The management of these and monitoring of treatment response . It has
patients is multidisciplinary involving rheumatologists, been shown that regular exercise, in particular aerobic,
radiologists, human movement scientists, rehabilitation improves pain, fatigue and sleep disturbance in patients
physicians, physical therapists, sports instructors and with FM. Physical exercise is one of the most widely
research assistants. recognized and beneficial forms of non-pharmacological
[16]
The aim of this editorial is to illustrate the beneficial therapy , effective in reducing pain and depression
effects of the physical activity in our life and in rheu­ and producing positive effects on physical function,
[17]
matic diseases, including home and gym exercise fitness, and global health , particularly in patients
[18]
programs, flexibility training and physiatric rehabilitation affected by rheumatic disease . No one particular form
therapy. Physical exercise is able to improve balance, of exercise is preferred and all types may be considered.
reduce pain, activate muscle and increase functional The most consistent results have been demonstrated
joint stability, in patients with rheumatic diseases and for aerobic and strengthening exercise that, when
osteoarthritis (OA). combined with stretching, had equivalent effects on
[19]
limiting pain severity among patients with FM .
Patients who express concerns regarding the possible
THE EFFECTS OF PHYSICAL ACTIVITY IN worsening of pain and fatigue need to be reassured.
The initiation of any exercise program, indeed, must
RHEUMATIC DISEASES [20]
be slow and gradual . A good way to start could
Rheumatic diseases are disorders affecting the musculo­ be an exercise regimen with hydrotherapy pool, as
[4]
skeletal system and in general the connective tissues . the warmth of the water and relative weightlessness
Such diseases are very different from each other, also relieves symptoms while the resistance provides a
for their severity. Some of them can affect not only [19]
gentle workout . Moreover, it has been shown that
joints, bones, tendons, but also other tissues and organs the combination of aerobic exercise, strengthening,
[5]
having thus a systemic expression . Rheumatic diseases and flexibility improves psychological health status
lead to pain, disability, loss of functional autonomy, [21]
and quality of life, preventing depression . There is
reducing the quality of life, both for the side effects of evidence to support the use of yoga, qi gong and tai chi
drugs, and for the involvement of vital structures of the (disciplines including stretching exercises) in patients
organism. Fatigue is common in patients affected by [22]
with fibromyalgia . Studies in which the use of these
various chronic medical conditions with a low physical therapies resulted in improvement in fibromyalgia

WJO|www.wjgnet.com 763 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

Rarely

Watching TV, playing

video games, be sitting
for more than 30 min

Recreational Muscle exercises:

2-3 times a week Stretching
activities
Golf Yoga
Bowling Flexions
Archery Squat

Aerobic exercise (at Recreational activities

least 20') (at least 30')
Swimming Football
3-5 times a week
Running Tennis
Biking Basketball
Skiing Dancing
Climbing

Walking the dog Every day Gardening

Stair climbing instead of using elevator Parking car away from home
Choosing the longest streets Walking to supermarket

Figure 1 Graphic design of physical activity guidelines during our normal life in one week, suggested by the World Health Organization recommendations,
to prevent the onset of some diseases related to sedentary lifestyle. This graphic represents the pyramid of the physical activity recommendation. At the base the
suggestions for every day’s activities and at the top the activities to perform rarely are shown.

symptoms and physical functioning were generally The most frequent degenerative rheumatic disorder
[26]
small and unblended, however, given the lack of serious in the population is OA . Unfortunately, in contrast
adverse effects and the promotion of self-efficacy, these to systemic inflammatory rheumatic diseases, such as
[27]
management modalities are generally useful options. RA, the therapeutic options in OA are still limited .
Graded exercise training and cognitive-behavioural OA is a chronic disease characterized by degenerative
[28]
therapy are the two interventions considered to be and productive changes of the joints (Figure 2) . It is
[23]
effective in chronic fatigue syndrome (CFS) . Myalgic essentially linked to an imbalance between excessive
encephalomyelitis, commonly known as chronic fatigue cartilage damage and the ability of cartilage to “heal”,
syndrome, is a debilitating and complex disorder chara­ but involves and compromises the whole joint, in all its
cterized by profound medically unexplained fatigue aspects, both macroscopic and microscopic changes
[29-31] [32,33]
that is not improved by bed rest and that may be (Figure 2) . Risk factors include age , mechanical
[33] [34] [35,36]
worsened by physical or mental activity. Symptoms factors , obesity , and inflammation . The
affect several body systems and may include weakness, key intervention in the management of OA is exercise
[37,38]
musculoskeletal pain, sleep disturbance, impaired therapy . It is well known that exercise training
memory and/or mental concentration, which can result affects the articular cartilage metabolism and modifies
in reduced participation in daily activities. Compared the cartilaginous structure by a mechanotransduction
[37-39]
to healthy controls equal in age, patients with CFS are response . Biomechanical stimulus generated by
[24]
significantly less physically active . After exercise dynamic compression, during a moderate exercise, can
therapy, patients with CFS may generally feel less reduce the synthesis of proteolytic enzymes, regulating
fatigued, and no evidence suggests that exercise the metabolic balance and preventing the progression
[40,41]
therapy may worsen outcomes. Moreover, a positive of the disease . Moreover, reduction in inflammation
effect with respect to sleep, physical function and self- seems to be a crucial mechanism, since exercise is a
[25]
perceived general health has also been observed . potential anti-inflammatory treatment for patients with

WJO|www.wjgnet.com 764 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

A Flexibility training

Resistance

Aerobic

Figure 2 Macroscopic and microscopic signs of osteoarthritis knee hyaline Figure 3 Graphic design of the three basic categories of physical activity.
cartilage. A: The microscopic observations of osteoarthritis knee hyaline cartilage Aerobic (aerobic physical exercise such as walking or jogging), resistance
showed structural alterations, reduction of cartilage thickness of the cartilage (anaerobic endurance exercise such as marathon or cross country skiing), and
zones and subchondral bone fibrillations; B: The microscopic observations of flexibility training (stretching exercises to increase functional range of motion and
healthy knee hyaline cartilage showed a preserved morphological structure with to reduce the risk of injury).
no sign of cartilage degradation.
[49,50]
[41,42]
flexibility through stretching exercises (Figure 4) .
rheumatic diseases and OA . The exercise regime The 2009 American College of Sports Medicine position
could range from mild to moderate in OA patients, and statement “exercise and physical activity for older
also, more importantly, must be “adapted” or “tailor- adults” highlighted the lack of studies on the effects of
made”, since the level of exercises will be dependent a range of motion exercises on flexibility outcomes in
on the tolerability of the patients, as recommended by older populations and also the absence of consensus
the American College of Rheumatology, the EULAR and [51]
about the prescription of stretching exercises . Despite
[41-43]
OARSI guidelines . Authors recently showed that the lack of scientific support for the recommendation of
a higher increase in muscle strength is associated to a flexibility component in older adult exercise programs,
[44]
a higher increase in physical functioning , tolerability many activity programs place a considerable emphasis
was assessed at every training session, for the patients on flexibility. When injuries or diseases result in a
who were not able to tolerate high intensity training, restricted range of motion of the joints, stretching
[3-5]
training intensity was adapted to a lower level . exercises are used in the rehabilitation context in
Moreover, in order to preserve the articular cartilage, order to regain “normal” range of motion in the major
physicians should promote a healthy lifestyle. Physical muscle tendon groups in accordance with individualized
activity (mild exercise) must be associated to a balanced [52]
goals . For the majority of the aging population, the
diet, such as Mediterranean Diet (olive oil and red goals are not related to athletic performance, but rather
orange), in order to prevent and reduce the progression to daily living activities. Despite the lack of research
[35,44-47]
of rheumatic and OA disease . [53]
confirming the health benefits , it is common to
find in the literature flexibility training as a presumed
Exercise programs “component of fitness” and a beneficial adjunct to
Exercise and physical activity are usually classified other forms of exercise. Other physical therapies can
in three basic categories (Figure 3): (1) aerobic, such be helpful in the management of rheumatic diseases,
as walking and jogging, which are repetitive, rigorous, particularly those that can be self-administered.
rhythmic, and involve the large muscles; (2) resistance,
which utilizes resistance to muscular contraction to Physiatric rehabilitation therapy
build the strength, anaerobic endurance and size of Patients with rheumatic diseases have a high risk of
skeletal muscles; and (3) flexibility training, which progressive deterioration of articular function over
keeps the body flexible, relaxes muscles and protects the years. The main limitations are due to the pain,
[48]
from physical injury . Sometimes initially patients a reduced range of motion, the muscle wasting and
complain of the increase of pain and fatigue usually the reduction in strength. Psychological motivations of
decrease with the continuation of the physical activity anxiety and depression are often associated and could
and can be avoided by introducing breaks in the further compromise the ability to address common
exercise sessions. daily activities. Physiotherapy and kinesiology is an
essential component in the overall treatment of the
Flexibility training disease. It provides for interventions predominantly
Flexibility programs can increase functional range of educational and preventive but also with specific
motion and reduce the risk of injury. Joint flexibility measures targeted to the condition of each patient.
may decrease with age, affecting normal daily function, The levels of intervention include: Training on the
older adults could maintain the ability improving prevention of damage (joint protection), training in

WJO|www.wjgnet.com 765 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

Head, neck and upper limb stretching exercises

Spine and upper limb stretching exercises

Spine and lower limb stretching exercises

Lower limb stretching exercises

Figure 4 Graphic design of different stretching exercises (head, neck, spine, upper and lower limb stretching exercises). This graphic includes the stretching
movement for all joints and muscles of the body such as flexion, extension, adduction, abduction, pronation, supination, intra and extra rotation, circumduction.

autonomy (use of aids), and specific rehabilitation Home exercise program

[54]
treatment in relation to surgery . The first step is to After the completion of the rehabilitation programme
inform and educate the patient about the nature and in hospital, the patient is then discharged with a home
[57]
consequences of the disease. The conviction of the exercise program and followed up at regular intervals .
importance of taking care of their joints is an important Home exercise program (Figure 5) should be adapted
element in the treatment. The articular overexertion to the patient’s capacity. It is a crucial aspect of
during repetitive daily activities, contributes to the the rehabilitation program, allowing the patients to
deterioration of appearance and aggravation of the return home. The training program should be made
[55]
deformations . The joint protection is based on in the patient’s home environment in order to ensure
gesture education, avoidance of incorrect movements the patient’s independence. Patients improvements
and use of the most appropriate ones. This technique and general condition should be evaluated at regular
[58]
reduces the risk of joint deterioration, minimizing intervals . Moreover, the training should be gradually
the efforts that exert on the joint structures in order changed, according to the improvement of the patients
to facilitate the movements and make them more to facilitate the more complex activities of daily living,
[56]
comfortable when they are painful and tiring . The and also in the late stages when the patients return
[58]
program is carried out by qualified personnel in phy­ to work . In addition to the exercises performed
siatric facilities. It consists of passive motion exercises, during the subacute and chronic stages, shoulder,
assisted active and stretching exercises to increase wrist, hand, hip and knee joint exercises (flexion
the extensibility. Mobilization exercises are usually and extension), full abduction, extension and flexion
associated with those of muscle strengthening. It exercises for abdominal, sacrospinal, iliopsoas,
is shown that a static or dynamic exercise program gluteus maximus, gluteus minimus, hamstring, and
can improve strength, aerobic capacity and physical quadriceps muscles, and resistive exercises for oblique
performance without increasing disease activity or abdominal muscles are recommended to be performed
[48] [59]
aggravating joint damage . In cases where surgical at home . Exercises to increase respiratory capacity
orthopedic treatment is indicated, physiatric preparation are continued. Cardiovascular moderate exercises
and follow up to the intervention is necessary - rehab­ (spinning, running) are also advised/prescribed. At the
ilitation adapted to the type of operation, the situation end of the rehabilitation program patients experienced
[49]
of the patient . less pain, improve their range of motion and were able

WJO|www.wjgnet.com 766 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

Figure 5 Graphic design of some home exercise. This graphic includes different types of exercises that can be performed safely at home, using the common home
furniture.

to perform their daily work with fewer complications. stability; also it is able to reduce the tender points,
Help in home exercise can come from listening to music enhance energy, decrease fatigue and it is an excellent
during activity, helping in maintaining a good rhythm, anti-stress strategy. Moreover, physical activity is a
body coordination, and motivation in the rehabilitation good way to socialize, an excellent anti-stress agent
program and distracting the mind from the pain
[60-62]
. and the best aesthetic method for our body “mens sana
in corpore sano”. We all should follow the example of
some north European countries such as Germany, the
CONCLUSION Netherlands, Switzerland, Finland and others, more
Exercise can be beneficial both physically and psy­ sensitive to disease prevention through the use of
chologically. It works by improving muscle trophism physical activity, where moderate exercise is a lifestyle. I
and capillarisation, and reducing muscle hypoxia. hope with this editorial to help readers and the scientific
It also promotes the secretion of endorphins and community to better understand the importance of
growth hormone; increases the production of serotonin physical activity in our lifestyle.
in the brain and activates adrenergic mechanisms of It’s never too late to begin to move, there is no
pain inhibition. Inactivity in patients with rheumatic minimum level to have benefits: A bit of activity is
diseases is very harmful both physically (reduced better than none. The benefits begin as soon as you
muscle strength, deconditioning, greater rigidity), and start to be more active.
psychologically (fear of movement, depression, loss
of self-confidence). The exercise suggested is aerobic
ACKNOWLEDGEMENTS
with moderate intensity, adapted to the patient and
then slowly increased according to the improvement of The authors would like to thank professor Iain Halliday
the conditions. for commenting and making corrections to the paper.
In conclusion I can assert that regular moderate The decision to submit this paper for publication was
not influenced by any the funding bodies. Furthermore,
physical activity (housework, slow running, walking,
the funders had no role in the design of the study,
biking and swimming) combined with a useful stretching
the collection and analysis of the data, the decision to
has a great importance in maintaining good health.
publish, or the preparation of the manuscript.
Moreover, physical activity can play a crucial role in
the treatment of rheumatic diseases in optimizing
both physical and mental health. In fact, in patients REFERENCES
with rheumatic diseases, physical activity is a great 1 Romano Spica V, Giampaoli S, Di Onofrio V, Liguori G. Safety of
method to improve: pain, sleep, a range of motion, sports facilities and training of graduates in physical education. Ann
body coordination, balance, motivation, functional joint Ig 2015; 27: 3-10 [PMID: 25748500 DOI: 10.7416/ai.2015.2017]

WJO|www.wjgnet.com 767 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

2 Trovato GM, Catalano D, Martines GF, Pirri C, Trovato FM. 343-380 [DOI: 10.2217/ijr.09.23]
Western dietary pattern and sedentary life: independent effects of diet 20 Hooten WM, Qu W, Townsend CO, Judd JW. Effects of strength
and physical exercise intensity on NAFLD. Am J Gastroenterol 2013; vs aerobic exercise on pain severity in adults with fibromyalgia:
108: 1932-1933 [PMID: 24300872 DOI: 10.1038/ajg.2013.356] a randomized equivalence trial. Pain 2012; 153: 915-923 [PMID:
3 Rongen-van Dartel SA, Repping-Wuts H, van Hoogmoed D, 22341565 DOI: 10.1016/j.pain.2012.01.020]
Knoop H, Bleijenberg G, van Riel PL, Fransen J. Relationship 21 Häuser W, Thieme K, Turk DC. Guidelines on the management of
between objectively assessed physical activity and fatigue in fibromyalgia syndrome - a systematic review. Eur J Pain 2010; 14:
patients with rheumatoid arthritis: inverse correlation of activity and 5-10 [PMID: 19264521 DOI: 10.1016/j.ejpain.2009.01.006]
fatigue. Arthritis Care Res (Hoboken) 2014; 66: 852-860 [PMID: 22 Mist SD, Firestone KA, Jones KD. Complementary and alternative
24339437 DOI: 10.1002/acr.22251] exercise for fibromyalgia: a meta-analysis. J Pain Res 2013; 6:
4 Kim KJ, Lee S, Kim WU. Applications of systems approaches in 247-260 [PMID: 23569397 DOI: 10.2147/JPR.S32297]
the study of rheumatic diseases. Korean J Intern Med 2015; 30: 23 Schreurs KM, Veehof MM, Passade L, Vollenbroek-Hutten MM.
148-160 [PMID: 25750554 DOI: 10.3904/kjim.2015.30.2.148] Cognitive behavioural treatment for chronic fatigue syndrome in
5 Landolt-Marticorena C. The need for preclinical biomarkers in a rehabilitation setting: effectiveness and predictors of outcome.
systemic autoimmune rheumatic diseases. J Rheumatol 2015; 42: Behav Res Ther 2011; 49: 908-913 [PMID: 21982345 DOI:
152-154 [PMID: 25641964 DOI: 10.3899/jrheum.141366] 10.1016/j.brat.2011.09.004]
6 Escalante A, Del Rincón I. The disablement process in rheumatoid 24 Vercoulen JH, Bazelmans E, Swanink CM, Fennis JF, Galama JM,
arthritis. Arthritis Rheum 2002; 47: 333-342 [PMID: 12115165 Jongen PJ, Hommes O, Van der Meer JW, Bleijenberg G. Physical
DOI: 10.1002/art.10418] activity in chronic fatigue syndrome: assessment and its role in
7 Abad VC, Sarinas PS, Guilleminault C. Sleep and rheumatologic fatigue. J Psychiatr Res 1997; 31: 661-673 [PMID: 9447571 DOI:
disorders. Sleep Med Rev 2008; 12: 211-228 [PMID: 18486034 10.1016/S0022-3956(97)00039-3]
DOI: 10.1016/j.smrv.2007.09.001] 25 Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy
8 Luyster FS, Chasens ER, Wasko MC, Dunbar-Jacob J. Sleep for chronic fatigue syndrome. Cochrane Database Syst Rev 2015; 2:
quality and functional disability in patients with rheumatoid CD003200 [PMID: 25674924 DOI: 10.1002/14651858.CD003200.
arthritis. J Clin Sleep Med 2011; 7: 49-55 [PMID: 21344040] pub3]
9 Trovato GM, Pace P, Salerno S, Trovato FM, Catalano D. Pain 26 Mobasheri A, Matta C, Zákány R, Musumeci G. Chond­
assessment in fibromyalgia and rheumatoid arthritis: influence rosenescence: definition, hallmarks and potential role in the
of physical activity and illness perception. Clin Ter 2010; 161: pathogenesis of osteoarthritis. Maturitas 2015; 80: 237-244 [PMID:
335-339 [PMID: 20931156] 25637957 DOI: 10.1016/j.maturitas.2014.12.003]
10 Nikolaus S, Bode C, Taal E, van de Laar MA. Fatigue and factors 27 Mobasheri A, Kalamegam G, Musumeci G, Batt ME. Chondrocyte
related to fatigue in rheumatoid arthritis: a systematic review. Arthritis and mesenchymal stem cell-based therapies for cartilage repair in
Care Res (Hoboken) 2013; 65: 1128-1146 [PMID: 23335492 DOI: osteoarthritis and related orthopaedic conditions. Maturitas 2014; 78:
10.1002/acr.21949] 188-198 [PMID: 24855933 DOI: 10.1016/j.maturitas.2014.04.017]
11 Miyakoshi N. [Therapeutic exercise]. Clin Calcium 2008; 18: 28 Giunta S, Castorina A, Marzagalli R, Szychlinska MA, Pichler K,
1611-1615 [PMID: 18974450] Mobasheri A, Musumeci G. Ameliorative effects of PACAP against
12 Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, cartilage degeneration. Morphological, immunohistochemical
Mease P, Russell AS, Russell IJ, Winfield JB, Yunus MB. The and biochemical Evidence from in vivo and in vitro models of rat
American College of Rheumatology preliminary diagnostic criteria osteoarthritis. Int J Mol Sci 2015; 16: 5922-5944 [PMID: 25782157
for fibromyalgia and measurement of symptom severity. Arthritis DOI: 10.3390/ijms16035922]
Care Res (Hoboken) 2010; 62: 600-610 [PMID: 20461783 DOI: 29 Musumeci G, Castrogiovanni P, Mazzone V, Szychlinska MA,
10.1002/acr.20140] Castorina S, Loreto C. Histochemistry as a unique approach for
13 Mease PJ, Arnold LM, Crofford LJ, Williams DA, Russell IJ, investigating normal and osteoarthritic cartilage. Eur J Histochem
Humphrey L, Abetz L, Martin SA. Identifying the clinical domains 2014; 58: 2371 [PMID: 24998926 DOI: 10.4081/ejh.2014.2371]
of fibromyalgia: contributions from clinician and patient Delphi 30 Musumeci G, Trovato FM, Loreto C, Leonardi R, Szychlinska
exercises. Arthritis Rheum 2008; 59: 952-960 [PMID: 18576290 MA, Castorina S, Mobasheri A. Lubricin expression in human
DOI: 10.1002/art.23826] osteoarthritic knee meniscus and synovial fluid: a morphological,
14 Häuser W, Bernardy K, Arnold B, Offenbächer M, Schiltenwolf M. immunohistochemical and biochemical study. Acta Histochem 2014;
Efficacy of multicomponent treatment in fibromyalgia syndrome: 116: 965-972 [PMID: 24932985 DOI: 10.1016/j.acthis.2014.03.011]
a meta-analysis of randomized controlled clinical trials. Arthritis 31 Musumeci G, Castrogiovanni P, Loreto C, Castorina S, Pichler K,
Rheum 2009; 61: 216-224 [PMID: 19177530 DOI: 10.1002/ Weinberg AM. Post-traumatic caspase-3 expression in the adjacent
art.24276] areas of growth plate injury site: a morphological study. Int J Mol
15 Arnold LM, Clauw DJ, Dunegan LJ, Turk DC. A framework Sci 2013; 14: 15767-15784 [PMID: 23899790 DOI: 10.3390/
for fibromyalgia management for primary care providers. Mayo ijms140815767]
Clin Proc 2012; 87: 488-496 [PMID: 22560527 DOI: 10.1016/ 32 Musumeci G, Szychlinska MA, Mobasheri A. Age-related dege­
j.mayocp.2012.02.010] neration of articular cartilage in the pathogenesis of osteoarthritis:
16 Cazzola M, Atzeni F, Salaffi F, Stisi S, Cassisi G, Sarzi-Puttini molecular markers of senescent chondrocytes. Histol Histopathol
P. Which kind of exercise is best in fibromyalgia therapeutic 2015; 30: 1-12 [PMID: 25010513]
programmes? A practical review. Clin Exp Rheumatol 2010; 28: 33 Musumeci G, Castrogiovanni P, Trovato FM, Imbesi R, Giunta
S117-S124 [PMID: 21176431] S, Szychlinska MA, Loreto C, Castorina S, Mobasheri A. physical
17 Busch AJ, Webber SC, Brachaniec M, Bidonde J, Bello-Haas VD, activity ameliorates cartilage degeneration in a rat model of aging:
Danyliw AD, Overend TJ, Richards RS, Sawant A, Schachter CL. a study on lubricin expression. Scand J Med Sci Sports 2015; 25:
Exercise therapy for fibromyalgia. Curr Pain Headache Rep 2011; e222-e230 [PMID: 25039883 DOI: 10.1111/sms.12290]
15: 358-367 [PMID: 21725900 DOI: 10.1007/s11916-011-0214-2] 34 Musumeci G, Aiello FC, Szychlinska MA, Di Rosa M,
18 Masiero S, Boniolo A, Wassermann L, Machiedo H, Volante D, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst century:
Punzi L. Effects of an educational-behavioral joint protection risk factors and behaviours that influence disease onset and
program on people with moderate to severe rheumatoid arthritis: a progression. Int J Mol Sci 2015; 16: 6093-6112 [PMID: 25785564
randomized controlled trial. Clin Rheumatol 2007; 26: 2043-2050 DOI: 10.3390/ijms16036093]
[PMID: 17404783] 35 Musumeci G, Trovato FM, Pichler K, Weinberg AM, Loreto C,
19 Busch AJ, Overend TJ, Schachter CL. Fibromyalgia treatment: the Castrogiovanni P. Extra-virgin olive oil diet and mild physical activity
role of exercise and physical activity. Int J Clin Rheumtol 2009; 4: prevent cartilage degeneration in an osteoarthritis model. An “in vivo”

WJO|www.wjgnet.com 768 November 18, 2015|Volume 6|Issue 10|

 Musumeci G. Effects of exercise in rheumatic diseases

and “in vitro” study on lubricin expression. J Nutr Biochem 2013; 24: 4408-4409. [PMID: 23714600 DOI: 10.1016/j.ijcard.2013.05.034]
2064-2075 [PMID: 24369033 DOI: 10.1016/j.jnutbio.2013.07.007] 48 Musumeci G, Loreto C, Imbesi R, Trovato FM, Di Giunta A,
36 Di Rosa M, Szychlinska MA, Tibullo D, Malaguarnera L, Lombardo C, Castorina S, Castrogiovanni P. Advantages of exercise
Musumeci G. Expression of CHI3L1 and CHIT1 in osteoarthritic in rehabilitation, treatment and prevention of altered morphological
rat cartilage model. A morphological study. Eur J Histochem 2014; features in knee osteoarthritis. A narrative review. Histol Histopathol
58: 2423 [PMID: 25308850 DOI: 10.4081/ejh.2014.2423] 2014; 29: 707-719 [PMID: 24452819]
37 Pichler K, Loreto C, Leonardi R, Reuber T, Weinberg AM, 49 Burguera M, López-Merino V, García-Civera R, Chorro J, Ruiz-
Musumeci G. RANKL is downregulated in bone cells by physical Granell R, Sanchís J. [Heart rate-ventricular extrasystole relations
activity (treadmill and vibration stimulation training) in rat with and their dependence on circadian rhythms]. Rev Esp Cardiol 1989;
glucocorticoid-induced osteoporosis. Histol Histopathol 2013; 28: 42: 658-665 [PMID: 2482986 DOI: 10.5312/wjo.v5.i2.80]
1185-1196 [PMID: 23553492] 50 Paterson DH, Warburton DE. Physical activity and functional
38 Musumeci G, Loreto C, Leonardi R, Castorina S, Giunta S, limitations in older adults: a systematic review related to Canada’s
Carnazza ML, Trovato FM, Pichler K, Weinberg AM. The effects Physical Activity Guidelines. Int J Behav Nutr Phys Act 2010; 7: 38
of physical activity on apoptosis and lubricin expression in articular [PMID: 20459782 DOI: 10.1186/1479-5868-7-38]
cartilage in rats with glucocorticoid-induced osteoporosis. J Bone 51 Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson
Miner Metab 2013; 31: 274-284 [PMID: 23263781 DOI: 10.1007/ CT, Nigg CR, Salem GJ, Skinner JS. American College of Sports
s00774-012-0414-9] Medicine position stand. Exercise and physical activity for older
39 Knobloch TJ, Madhavan S, Nam J, Agarwal S, Agarwal S. adults. Med Sci Sports Exerc 2009; 41: 1510-1530 [PMID:
Regulation of chondrocytic gene expression by biomechanical 19516148 DOI: 10.1249/MSS.0b013e3181a0c95c]
signals. Crit Rev Eukaryot Gene Expr 2008; 18: 139-150 [PMID: 52 Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte
18304028 DOI: 10.1615/CritRevEukarGeneExpr.v18.i2.30] MJ, Lee IM, Nieman DC, Swain DP. American College of Sports
40 Leeuwenburgh C, Heinecke JW. Oxidative stress and antioxidants Medicine position stand. Quantity and quality of exercise for
in exercise. Curr Med Chem 2001; 8: 829-838 [PMID: 11375753 developing and maintaining cardiorespiratory, musculoskeletal,
DOI: 10.2174/0929867013372896] and neuromotor fitness in apparently healthy adults: guidance for
41 Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen prescribing exercise. Med Sci Sports Exerc 2011; 43: 1334-1359
P, Conaghan PG, Doherty M, Geenen R, Hammond A, Kjeken I, [PMID: 21694556 DOI: 10.1249/MSS.0b013e318213fefb]
Lohmander LS, Lund H, Mallen CD, Nava T, Oliver S, Pavelka 53 Houston MN, Hodson VE, Adams K KE, Hoch JM. The
K, Pitsillidou I, da Silva JA, de la Torre J, Zanoli G, Vliet Vlieland effectiveness of whole-body-vibration training in improving
TP; European League Against Rheumatism (EULAR). EULAR hamstring flexibility in physically active adults. J Sport Rehabil
recommendations for the non-pharmacological core management 2015; 24: 77-82 [PMID: 25606860 DOI: 10.1123/JSR.2013-0059]
of hip and knee osteoarthritis. Ann Rheum Dis 2013; 72: 1125-1135 54 Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI.
[PMID: 23595142 DOI: 10.1136/annrheumdis-2012-202745] Critical review of prolotherapy for osteoarthritis, low back pain,
42 Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, and other musculoskeletal conditions: a physiatric perspective. Am
Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, J Phys Med Rehabil 2004; 83: 379-389 [PMID: 15100629]
Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, 55 Gibbs RL, Rosen BS, Lacerte M. Published research and physiatric
Tugwell P. OARSI recommendations for the management of hip opinion in life care planning. Phys Med Rehabil Clin N Am 2013;
and knee osteoarthritis: part III: Changes in evidence following 24: 553-566 [PMID: 23910491 DOI: 10.1016/j.pmr.2013.03.002]
systematic cumulative update of research published through 56 Moreira V, Antunes F. [Ankle sprains: from diagnosis to management.
January 2009. Osteoarthritis Cartilage 2010; 18: 476-499 [PMID: the physiatric view]. Acta Med Port 2008; 21: 285-292 [PMID:
20170770 DOI: 10.1016/j.joca.2010.01.013] 18674420]
43 Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, 57 Matassi F, Duerinckx J, Vandenneucker H, Bellemans J. Range of
McGowan J, Towheed T, Welch V, Wells G, Tugwell P. American motion after total knee arthroplasty: the effect of a preoperative home
College of Rheumatology 2012 recommendations for the use of exercise program. Knee Surg Sports Traumatol Arthrosc 2014; 22:
nonpharmacologic and pharmacologic therapies in osteoarthritis of 703-709 [PMID: 23271039 DOI:10.1007/s00167-012-2349-z]
the hand, hip, and knee. Arthritis Care Res (Hoboken) 2012; 64: 58 Chen H, Onishi K. Effect of home exercise program performance
465-474 [PMID: 22563589] in patients with osteoarthritis of the knee or the spine on the
44 Musumeci G, Castrogiovanni P, Coleman R, Szychlinska MA, visual analog scale after discharge from physical therapy. Int J
Salvatorelli L, Parenti R, Magro G, Imbesi R. Somitogenesis: From Rehabil Res 2012; 35: 275-277 [PMID: 22872301 DOI: 10.1097/
somite to skeletal muscle. Acta Histochem 2015; 117: 313-328 MRR.0b013e328355a1bd]
[PMID: 25850375 DOI: 10.1016/j.acthis.2015.02.011] 59 Han AS, Nairn L, Harmer AR, Crosbie J, March L, Parker D,
45 Frasca G, Panico AM, Bonina F, Messina R, Rizza L, Musumeci Crawford R, Fransen M. Early rehabilitation after total knee
G, Rapisarda P, Cardile V. Involvement of inducible nitric oxide replacement surgery: a multicenter, noninferiority, randomized
synthase and cyclooxygenase-2 in the anti-inflammatory effects of a clinical trial comparing a home exercise program with usual
red orange extract in human chondrocytes. Nat Prod Res 2010; 24: outpatient care. Arthritis Care Res (Hoboken) 2015; 67: 196-202
1469-1480 [PMID: 20812134 DOI: 10.1080/14786410903169987] [PMID: 25220488 DOI: 10.1002/acr.22457]
46 Musumeci G, Trovato FM, Imbesi R, Castrogiovanni P. Effects 60 McCutchen A. Music therapy in the management of chronic
of dietary extra-virgin olive oil on oxidative stress resulting from osteoarthritis pain. Ky Nurse 2007; 55: 10 [PMID: 17707973]
exhaustive exercise in rat skeletal muscle: a morphological study. 61 Skingley A, Vella-Burrows T. Therapeutic effects of music and
Acta Histochem 2014; 116: 61-69 [PMID: 23810034 DOI: 10.1016/ singing for older people. Nurs Stand 2010; 24: 35-41 [PMID:
j.acthis.2013.05.006] 20175359]
47 Catalano D, Trovato GM, Pace P, Martines GF, Trovato FM. 62 Musumeci G. Welcome to the New Open Access Journal of
Mediterranean diet and physical activity: an intervention study. Does Functional Morphology and Kinesiology. J Functional Morphology
olive oil exercise the body through the mind? Int J Cardiol 2013; 168: Kinesiology 2016; 1: 1-5 [DOI: 10.3390/jfmk1010001]

P- Reviewer: Maurizio T, Song J S- Editor: Qiu S L- Editor: A

E- Editor: Lu YJ

WJO|www.wjgnet.com 769 November 18, 2015|Volume 6|Issue 10|

 Published by Baishideng Publishing Group Inc
8226 Regency Drive, Pleasanton, CA 94588, USA
Telephone: +1-925-223-8242
Fax: +1-925-223-8243
E-mail: [email protected]
Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx
http://www.wjgnet.com

© 2015 Baishideng Publishing Group Inc. All rights reserved.