Sjögren's syndrome

Considerable knowledge has accumulated in recent decades concerning the significance of physical activity in the treatment of a number of diseases, including diseases that do not primarily manifest as disorders of the locomotive apparatus. In this review we present the evidence for prescribing exercise therapy in the treatment of metabolic syndrome-related disorders (insulin resistance, type 2 diabetes, dyslipidemia, hypertension, obesity), heart and pulmonary diseases (chronic obstructive pulmonary disease, coronary heart disease, chronic heart failure, intermittent claudication), muscle, bone and joint diseases (osteoarthritis, rheumatoid arthritis, osteoporosis, fibromyalgia, chronic fatigue syndrome) and cancer, depression, asthma and type 1 diabetes. For each disease, we review the effect of exercise therapy on disease pathogenesis, on symptoms specific to the diagnosis, on physical fitness or strength and on quality of life. The possible mechanisms of action are briefly examined and the principles for prescribing exercise therapy are discussed, focusing on the type and amount of exercise and possible contraindications.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0838.2006.00520.x

Evidence for prescribing exercise as therapy in chronic disease.

Sjogren syndrome (SS) is a common autoimmune disease evidenced by broad organ-specific and systemic manifestations, the most prevalent being diminished lacrimal and salivary gland function, xerostomia, keratoconjunctivitis sicca, and parotid gland enlargement. Primary SS presents alone, and secondary SS occurs in connection with autoimmune rheumatic diseases. In addition, symptoms do not always present concurrently. This diversity of symptomatic expression adds to the difficulty in initial diagnosis. Armed with the recently refined criteria for diagnosis, specialists, such as rheumatologists, primary care physicians, ophthalmologists, and dentists, who would otherwise focus only on those symptoms that encompass their areas of expertise, can get a comprehensive image of the presenting patient, leading to earlier identification and treatment of SS.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/217138/ira30008.pdf

Clinical Manifestations and Early Diagnosis of Sjogren Syndrome

Background
Fibromyalgia (FM) is a syndrome expressed by chronic widespread body pain which leads to reduced physical function and frequent use of health care services. Exercise training is commonly recommended as a treatment. This is an update of a review published in Issue 2, 2002.

Objectives
The primary objective of this systematic review was to evaluate the effects of exercise training including cardiorespiratory (aerobic), muscle strengthening, and/or flexibility exercise on global well-being, selected signs and symptoms, and physical function in individuals with FM.

Search methods
We searched MEDLINE, EMBASE, CINAHL, SportDiscus, PubMed, PEDro, and the Cochrane Central Register for Controlled Trials (CENTRAL, Issue 3, 2005) up to and including July 2005. We also reviewed reference lists from reviews and meta-analyses of treatment studies.

Selection criteria
Randomized trials that were selected focused on cardiorespiratory endurance, muscle strength and/or flexibility as treatment for FM.

Data collection and analysis
Two of four reviewers independently extracted data for each study. All discrepancies were rechecked and consensus was achieved by discussion. Methodological quality was assessed by two instruments: the van Tulder and the Jadad methodological quality criteria. We used the American College of Sport Medicine (ACSM) guidelines to evaluate whether interventions had provided a training stimulus that would effect changes in physical fitness. Due to significant clinical heterogeneity among the studies we were only able to meta-analyze six aerobic-only studies and two strength-only studies.

Main results
There were a total of 2276 subjects across the 34 included studies; 1264 subjects were assigned to exercise interventions. The 34 studies comprised 47 interventions that included exercise. Effects of several disparate interventions on global well-being, selected FM signs and symptoms, and physical function in individuals with FM were summarized using standardized mean differences (SMD). There is moderate quality evidence that aerobic-only exercise training at recommended intensity levels has positive effects global well-being (SMD 0.49, 95% CI: 0.23 to 0.75) and physical function (SMD 0.66, 95% CI: 0.41 to 0.92) and possibly on pain (SMD 0.65, 95% CI: -0.09 to 1.39) and tender points (SMD 0.23, 95% CI: -0.18 to 0.65). Strength and flexibility remain under-evaluated.

Authors' conclusions
There is 'gold' level evidence (www.cochranemsk.org) that supervised aerobic exercise training has beneficial effects on physical capacity and FM symptoms. Strength training may also have benefits on some FM symptoms. Further studies on muscle strengthening and flexibility are needed. Research on the long-term benefit of exercise for FM is needed.

Exercise for treating fibromyalgia syndrome.

Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population in the USA and other regions in the world where FM is studied. Prevalence rates in some regions have not been ascertained and may be influenced by differences in cultural norms regarding the definition and attribution of chronic pain states. Chronic, widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headache, and mood disorders. Although the etiology of FM is not completely understood, the syndrome is thought to arise from influencing factors such as stress, medical illness, and a variety of pain conditions in some, but not all patients, in conjunction with a variety of neurotransmitter and neuroendocrine disturbances. These include reduced levels of biogenic amines, increased concentrations of excitatory neurotransmitters, including substance P, and dysregulation of the hypothalamic-pituitary-adrenal axis. A unifying hypothesis is that FM results from sensitization of the central nervous system. Establishing diagnosis and evaluating effects of therapy in patients with FM may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. Diagnostic criteria, originally developed for research purposes, have aided our understanding of this patient population in both research and clinical settings, but need further refinement as our knowledge about chronic widespread pain evolves. Outcome measures, borrowed from clinical research in pain, rheumatology, neurology, and psychiatry, are able to distinguish treatment response in specific symptom domains. Further work is necessary to validate these measures in FM. In addition, work is under way to develop composite response criteria, intended to address the multidimensional nature of this syndrome. A range of medical treatments, including antidepressants, opioids, nonsteroidal antiinflammatory drugs, sedatives, muscle relaxants, and antiepileptics, have been used to treat FM. Nonpharmaceutical treatment modalities, including exercise, physical therapy, massage, acupuncture, and cognitive behavioral therapy, can be helpful. Few of these approaches have been demonstrated to have clear-cut benefits in randomized controlled trials. However, there is now increased interest as more effective treatments are developed and our ability to accurately measure effect of treatment has improved. The multifaceted nature of FM suggests that multimodal individualized treatment programs may be necessary to achieve optimal outcomes in patients with this syndrome.

https://www.jrheum.org/content/jrheumsupp/75/6.full.pdf

Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment.

Aerobic fitness was evaluated in 25 women with fibrositis, by having them exercise to volitional exhaustion on an electronically braked cycle ergometer. Compared with published standards, greater than 80% of the fibrositis patients were not physically fit, as assessed by maximal oxygen uptake. Compared with matched sedentary controls, fibrositis patients accurately perceived their level of exertion in relation to oxygen consumption and attained a similar level of lactic acidosis, as assessed by their respiratory quotient and ventilatory threshold. Exercising muscle blood flow was estimated by 133xenon clearance in a subgroup of 16 fibrositis patients and compared with that in 16 matched sedentary controls; the fibrositis patients exhibited reduced 133xenon clearance. These results indicate a need to include aerobic fitness as a matched variable in future controlled studies of fibrositis and suggest that the "detraining phenomenon" may be of relevance to the etiopathogenesis of the disease.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/anr.1780320415

Aerobic fitness in patients with fibrositis. A controlled study of respiratory gas exchange and 133xenon clearance from exercising muscle

Objective. Fibromyalgia patients often describe the presence of dry eyes and dry mouth. Conversely there is an increasing recognition that many patients with Sjogren's syndrome (SS) have fibromyalgia (FM). We decided to investigate this association. Methods. Seventy-two patients with FM were screened with a Schirmer's test. All patients with an abnormal test had a minor salivary gland biopsy. Results. Thirty-eight percent (n=28) had a Schimer's test of <15 mm wetting at 5 minutes, however sicca symptoms were noted in only 19% of patients. Salivary gland biopsy in these 28 patients showed a focus score of ≥1 in 5; a positive antinuclear antibody test (ANA) was found in 4, a positive rheumatoid factor in 3 and anti-SSA SSB antibodies in 2. Another 8 patients had abnormal salivary gland lymphocytic foci, but there were <50 CELLS OR THE DENSITY WAS <1 FOCUS/4 MM 2 ; all 8 of these patients had a positive ANA. None of these patients have developed systemic features of SS over a 6 year period of follow-up. Conclusion. There is a subgroup of patients presenting with FM who, on further testing, have findings consistent with primary SS. The prevalence of this association was 6.9% for probable SS and 11% for possible SS. These figures are probably an overestimation due to tertiary center referral bias. The etiologic and management implications of these observations are unclear

An association of fibromyalgia with primary Sjögren's syndrome: a prospective study of 72 patients.

The cause of shoulder pain can usually be diagnosed after a pertinent history has been obtained and a relevant physical examination performed. To carry out such an evaluation, the examiner must understand the salient anatomic relationships of the shoulder. Causes of shoulder pain include supraspinatus tendinitis (the most common), bicipital tendinitis, impingement syndromes, supraspinatus rupture, subacromial bursitis, arthritis, frozen shoulder, and various conditions that refer pain to the shoulder. Treatment in most cases consists of rest and administration of a nonsteroidal antiinflammatory drug or injection of a corticosteroid preparation, or both.

R P Bonafede

Papers

Aerobic fitness in patients with fibrositis. A controlled study of respiratory gas exchange and 133xenon clearance from exercising muscle

An association of fibromyalgia with primary Sjögren's syndrome: a prospective study of 72 patients.

Shoulder pain. Guidelines to diagnosis and management.