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PMC10001724 | Increased Prolonged Sitting in Patients with Rheumatoid Arthritis during the COVID-19 Pandemic: A Within-Subjects, Accelerometer-Based Study | [
"Bruno Gualano",
"Hamilton Roschel",
"David W. Dunstan",
"Neville Owen",
"Eloisa Bonfá",
"Ana Cristina de Medeiros Ribeiro",
"Karina Bonfiglioli",
"Kamila Meireles",
"Sofia Mendes Sieczkowska",
"Diego Rezende",
"Ana Jessica Pinto"
] | Background: Social distancing measures designed to contain the COVID-19 pandemic can restrict physical activity, a particular concern for high-risk patient groups. We assessed rheumatoid arthritis patients’ physical activity and sedentary behavior level, pain, fatigue, and health-related quality of life prior to and during the social distancing measures implemented in Sao Paulo, Brazil. Methods: Post-menopausal females diagnosed with rheumatoid arthritis were assessed before (from March 2018 to March 2020) and during (from 24 May to 7 July 2020) social distancing measures to contain COVID-19 pandemic, using a within-subjects, repeated-measure design. Physical activity and sedentary behavior were assessed using accelerometry (ActivPAL micro). Pain, fatigue, and health-related quality of life were assessed by questionnaires. Results: Mean age was 60.9 years and BMI was 29.5 Kg/m2. Disease activity ranged from remission to moderate activity. During social distancing, there were reductions in light-intensity activity (13.0% [−0.2 h/day, 95% CI: −0.4 to −0.04; p = 0.016]) and moderate-to-vigorous physical activity (38.8% [−4.5 min/day, 95% CI: −8.1 to −0.9; p = 0.015]), but not in standing time and sedentary time. However, time spent in prolonged bouts of sitting ≥30 min increased by 34% (1.0 h/day, 95% CI: 0.3 to 1.7; p = 0.006) and ≥60 min increased by 85% (1.0 h/day, 95% CI: 0.5 to 1.6). There were no changes in pain, fatigue, and health-related quality of life (all p > 0.050). Conclusions: Imposed social distancing measures to contain the COVID-19 outbreak were associated with decreased physical activity and increased prolonged sedentary behavior, but did not change clinical symptoms sitting among patients with rheumatoid arthritis. | 10.3390/ijerph20053944 | [
"health-related quality of life",
"fatigue",
"pain",
"inflammatory arthritis",
"physical activity level",
"sedentary behavior"
] | [{"citation_id": "B1-ijerph-20-03944", "related_text": ["A preliminary, multinational survey reporting step counts provided by smartphones showed that social distancing measures to contain the spread of SARS-CoV-2 have induced physical inactivity (i.e., not meeting the physical activity guidelines) [1]. The onset of the coronavirus disease 2019 (COVID-19) pandemic has placed further spotlight on participation in sedentary behavior (i.e., time spent in a sitting or reclining posture with a low energy expenditure [≤1.5 METs]), with reported increases in daily sitting time from pre-pandemic levels ranging from 30 min up to 3 h in different populations [2,3]."], "reference_info": "TisonG.H. AvramR. KuharP. AbreauS. MarcusG.M. PletcherM.J. OlginJ.E. Worldwide Effect of COVID-19 on Physical Activity: A Descriptive StudyAnn. Intern. Med.202017376777010.7326/M20-266532598162", "reference_doi": "10.7326/M20-2665"}, {"citation_id": "B2-ijerph-20-03944", "related_text": ["A preliminary, multinational survey reporting step counts provided by smartphones showed that social distancing measures to contain the spread of SARS-CoV-2 have induced physical inactivity (i.e., not meeting the physical activity guidelines) [1]. The onset of the coronavirus disease 2019 (COVID-19) pandemic has placed further spotlight on participation in sedentary behavior (i.e., time spent in a sitting or reclining posture with a low energy expenditure [≤1.5 METs]), with reported increases in daily sitting time from pre-pandemic levels ranging from 30 min up to 3 h in different populations [2,3]."], "reference_info": "HallG. LadduD.R. PhillipsS.A. LavieC.J. ArenaR. A tale of two pandemics: How will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another?Prog. Cardiovasc. Dis.20216410811010.1016/j.pcad.2020.04.00532277997", "reference_doi": "10.1016/j.pcad.2020.04.005"}, {"citation_id": "B3-ijerph-20-03944", "related_text": ["A preliminary, multinational survey reporting step counts provided by smartphones showed that social distancing measures to contain the spread of SARS-CoV-2 have induced physical inactivity (i.e., not meeting the physical activity guidelines) [1]. The onset of the coronavirus disease 2019 (COVID-19) pandemic has placed further spotlight on participation in sedentary behavior (i.e., time spent in a sitting or reclining posture with a low energy expenditure [≤1.5 METs]), with reported increases in daily sitting time from pre-pandemic levels ranging from 30 min up to 3 h in different populations [2,3]."], "reference_info": "AmmarA. BrachM. TrabelsiK. ChtourouH. BoukhrisO. MasmoudiL. BouazizB. BentlageE. HowD. AhmedM. Effects of COVID-19 Home Confinement on Eating Behaviour and Physical Activity: Results of the ECLB-COVID19 International Online SurveyNutrients202012158310.3390/nu1206158332481594", "reference_doi": "10.3390/nu12061583"}, {"citation_id": "B4-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "LeeI.M. ShiromaE.J. LobeloF. PuskaP. BlairS.N. KatzmarzykP.T. Lancet Physical Activity Series WorkingG. Effect of physical inactivity on major non-communicable diseases worldwide: An analysis of burden of disease and life expectancyLancet201238021922910.1016/S0140-6736(12)61031-922818936", "reference_doi": "10.1016/S0140-6736(12)61031-9"}, {"citation_id": "B5-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "ChastinS. McGregorD. Palarea-AlbaladejoJ. DiazK.M. HagstromerM. HallalP.C. van HeesV.T. HookerS. HowardV.J. LeeI.M. Joint association between accelerometry-measured daily combination of time spent in physical activity, sedentary behaviour and sleep and all-cause mortality: A pooled analysis of six prospective cohorts using compositional analysisBr. J. Sports Med.2021551277128510.1136/bjsports-2020-10234534006506", "reference_doi": "10.1136/bjsports-2020-102345"}, {"citation_id": "B6-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "EkelundU. TarpJ. FagerlandM.W. JohannessenJ.S. HansenB.H. JefferisB.J. WhincupP.H. DiazK.M. HookerS. HowardV.J. Joint associations of accelero-meter measured physical activity and sedentary time with all-cause mortality: A harmonised meta-analysis in more than 44 000 middle-aged and older individualsBr. J. Sports Med.2020541499150610.1136/bjsports-2020-10327033239356", "reference_doi": "10.1136/bjsports-2020-103270"}, {"citation_id": "B7-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "EkelundU. TarpJ. Steene-JohannessenJ. HansenB.H. JefferisB. FagerlandM.W. WhincupP. DiazK.M. HookerS.P. ChernofskyA. Dose-response associations between accelerometry measured physical activity and sedentary time and all cause mortality: Systematic review and harmonised meta-analysisBMJ2019366l457010.1136/bmj.l457031434697", "reference_doi": "10.1136/bmj.l4570"}, {"citation_id": "B8-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures."], "reference_info": "DiazK.M. HowardV.J. HuttoB. ColabianchiN. VenaJ.E. SaffordM.M. BlairS.N. HookerS.P. Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults: A National Cohort StudyAnn. Intern. Med.201716746547510.7326/M17-021228892811", "reference_doi": "10.7326/M17-0212"}, {"citation_id": "B9-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "NicholasJ.A. Lo SiouG. LynchB.M. RobsonP.J. FriedenreichC.M. CsizmadiI. Leisure-Time Physical Activity Does not Attenuate the Association Between Occupational Sedentary Behavior and Obesity: Results From Alberta’s Tomorrow ProjectJ. Phys. Act. Health2015121589160010.1123/jpah.2014-037025830327", "reference_doi": "10.1123/jpah.2014-0370"}, {"citation_id": "B10-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "van der BergJ.D. StehouwerC.D. BosmaH. van der VeldeJ.H. WillemsP.J. SavelbergH.H. SchramM.T. SepS.J. van der KallenC.J. HenryR.M. Associations of total amount and patterns of sedentary behaviour with type 2 diabetes and the metabolic syndrome: The Maastricht StudyDiabetologia20165970971810.1007/s00125-015-3861-826831300", "reference_doi": "10.1007/s00125-015-3861-8"}, {"citation_id": "B11-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "WilmotE.G. EdwardsonC.L. AchanaF.A. DaviesM.J. GorelyT. GrayL.J. KhuntiK. YatesT. BiddleS.J. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: Systematic review and meta-analysisDiabetologia2012552895290510.1007/s00125-012-2677-z22890825", "reference_doi": "10.1007/s00125-012-2677-z"}, {"citation_id": "B12-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "PattersonR. McNamaraE. TainioM. de SaT.H. SmithA.D. SharpS.J. EdwardsP. WoodcockJ. BrageS. WijndaeleK. Sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: A systematic review and dose response meta-analysisEur. J. Epidemiol.20183381182910.1007/s10654-018-0380-129589226", "reference_doi": "10.1007/s10654-018-0380-1"}, {"citation_id": "B13-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "EngelenL. GaleJ. ChauJ.Y. HardyL.L. MackeyM. JohnsonN. ShirleyD. BaumanA. Who is at risk of chronic disease? Associations between risk profiles of physical activity, sitting and cardio-metabolic disease in Australian adultsAust. N. Z. J. Public Health20174117818310.1111/1753-6405.1262727960249", "reference_doi": "10.1111/1753-6405.12627"}, {"citation_id": "B14-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "LynchB.M. Sedentary behavior and cancer: A systematic review of the literature and proposed biological mechanismsCancer Epidemiol. Biomark. Prev.2010192691270910.1158/1055-9965.EPI-10-081520833969", "reference_doi": "10.1158/1055-9965.EPI-10-0815"}, {"citation_id": "B15-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "MatthewsC.E. GeorgeS.M. MooreS.C. BowlesH.R. BlairA. ParkY. TroianoR.P. HollenbeckA. SchatzkinA. Amount of time spent in sedentary behaviors and cause-specific mortality in US adultsAm. J. Clin. Nutr.20129543744510.3945/ajcn.111.01962022218159", "reference_doi": "10.3945/ajcn.111.019620"}, {"citation_id": "B16-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "FalckR.S. DavisJ.C. Liu-AmbroseT. What is the association between sedentary behaviour and cognitive function? A systematic reviewBr. J. Sports Med.20165180081110.1136/bjsports-2015-09555127153869", "reference_doi": "10.1136/bjsports-2015-095551"}, {"citation_id": "B17-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "DempseyP.C. StrainT. WinklerE.A.H. WestgateK. RennieK.L. WarehamN.J. BrageS. WijndaeleK. Association of Accelerometer-Measured Sedentary Accumulation Patterns With Incident Cardiovascular Disease, Cancer, and All-Cause MortalityJ. Am. Heart Assoc.202211e02384510.1161/JAHA.121.02384535470706", "reference_doi": "10.1161/JAHA.121.023845"}, {"citation_id": "B18-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "BiswasA. OhP.I. FaulknerG.E. BajajR.R. SilverM.A. MitchellM.S. AlterD.A. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysisAnn. Intern. Med.201516212313210.7326/M14-165125599350", "reference_doi": "10.7326/M14-1651"}, {"citation_id": "B19-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]."], "reference_info": "KatzmarzykP.T. PowellK.E. JakicicJ.M. TroianoR.P. PiercyK. TennantB. Physical Activity Guidelines AdvisoryC. Sedentary Behavior and Health: Update from the 2018 Physical Activity Guidelines Advisory CommitteeMed. Sci. Sports Exerc.2019511227124110.1249/MSS.000000000000193531095080", "reference_doi": "10.1249/MSS.0000000000001935"}, {"citation_id": "B20-ijerph-20-03944", "related_text": ["Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "EkelundU. Steene-JohannessenJ. BrownW.J. FagerlandM.W. OwenN. PowellK.E. BaumanA. LeeI.M. Lancet Physical Activity Series 2 ExecutiveC. Lancet Sedentary Behaviour WorkingG. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and womenLancet20163881302131010.1016/S0140-6736(16)30370-127475271", "reference_doi": "10.1016/S0140-6736(16)30370-1"}, {"citation_id": "B21-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]."], "reference_info": "ScottD.L. WolfeF. HuizingaT.W. Rheumatoid arthritisLancet20103761094110810.1016/S0140-6736(10)60826-420870100", "reference_doi": "10.1016/S0140-6736(10)60826-4"}, {"citation_id": "B22-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]."], "reference_info": "LeeD.M. WeinblattM.E. Rheumatoid arthritisLancet200135890391110.1016/S0140-6736(01)06075-511567728", "reference_doi": "10.1016/S0140-6736(01)06075-5"}, {"citation_id": "B23-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]."], "reference_info": "PincusT. Long-term outcomes in rheumatoid arthritisBr. J. Rheumatol.199534(Suppl. S2)597310.1093/rheumatology/XXXIV.suppl_2.598535651", "reference_doi": "10.1093/rheumatology/XXXIV.suppl_2.59"}, {"citation_id": "B24-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]."], "reference_info": "GabrielS.E. Cardiovascular morbidity and mortality in rheumatoid arthritisAm. J. Med.200812191410.1016/j.amjmed.2008.06.01118926169", "reference_doi": "10.1016/j.amjmed.2008.06.011"}, {"citation_id": "B25-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]."], "reference_info": "Sarzi-PuttiniP. AtzeniF. GerliR. BartoloniE. DoriaA. BarskovaT. Matucci-CerinicM. SitiaS. TomasoniL. TurielM. Cardiac involvement in systemic rheumatic diseases: An updateAutoimmun. Rev.2010984985210.1016/j.autrev.2010.08.00220692379", "reference_doi": "10.1016/j.autrev.2010.08.002"}, {"citation_id": "B26-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28].", "Patients with rheumatoid arthritis have been shown to be more susceptible to COVID-19 infection [33] and, therefore, may be subjected to more restrictive measures of social distancing, potentially with significant impacts on their activity options, and, hence, on their burden of cardiovascular disease risk, the main cause of mortality in this population [26].", "As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28]."], "reference_info": "HollanI. MeroniP.L. AhearnJ.M. Cohen TervaertJ.W. CurranS. GoodyearC.S. HestadK.A. KahalehB. RiggioM. ShieldsK. Cardiovascular disease in autoimmune rheumatic diseasesAutoimmun. Rev.2013121004101510.1016/j.autrev.2013.03.01323541482", "reference_doi": "10.1016/j.autrev.2013.03.013"}, {"citation_id": "B27-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]."], "reference_info": "Rausch OsthoffA.K. NiedermannK. BraunJ. AdamsJ. BrodinN. DagfinrudH. DuruozT. EsbensenB.A. GuntherK.P. HurkmansE. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritisAnn. Rheum. Dis.2018771251126010.1136/annrheumdis-2018-21358529997112", "reference_doi": "10.1136/annrheumdis-2018-213585"}, {"citation_id": "B28-ijerph-20-03944", "related_text": ["Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28].", "Physical inactivity and sedentary behavior are modifiable risk factors considered to be potential targets to prevent morbimortality in autoimmune rheumatic diseases [28,29]. Among patients with rheumatoid arthritis, sedentary behavior is associated with higher disease scores, increased pain, fatigue [30] and number of comorbidities, reduced aerobic capacity [31] and physical function [30], and poor self-efficacy [32]. Furthermore, physically inactive patients with rheumatoid arthritis exhibit higher cardiovascular risk factors (e.g., higher systolic blood pressure and homeostasis model assessment (HOMA) index, abnormal lipid profile) when compared to their physically active counterparts.", "As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28].", "Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares.", "Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures."], "reference_info": "PintoA.J. RoschelH. de Sa PintoA.L. LimaF.R. PereiraR.M.R. SilvaC.A. BonfaE. GualanoB. Physical inactivity and sedentary behavior: Overlooked risk factors in autoimmune rheumatic diseases?Autoimmun. Rev.20171666767410.1016/j.autrev.2017.05.00128479487", "reference_doi": "10.1016/j.autrev.2017.05.001"}, {"citation_id": "B29-ijerph-20-03944", "related_text": ["Physical inactivity and sedentary behavior are modifiable risk factors considered to be potential targets to prevent morbimortality in autoimmune rheumatic diseases [28,29]. Among patients with rheumatoid arthritis, sedentary behavior is associated with higher disease scores, increased pain, fatigue [30] and number of comorbidities, reduced aerobic capacity [31] and physical function [30], and poor self-efficacy [32]. Furthermore, physically inactive patients with rheumatoid arthritis exhibit higher cardiovascular risk factors (e.g., higher systolic blood pressure and homeostasis model assessment (HOMA) index, abnormal lipid profile) when compared to their physically active counterparts.", "As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28]."], "reference_info": "PintoA.J. DunstanD.W. OwenN. BonfaE. GualanoB. Combating physical inactivity during the COVID-19 pandemicNat. Rev. Rheumatol.20201634734810.1038/s41584-020-0427-z32355296", "reference_doi": "10.1038/s41584-020-0427-z"}, {"citation_id": "B30-ijerph-20-03944", "related_text": ["Physical inactivity and sedentary behavior are modifiable risk factors considered to be potential targets to prevent morbimortality in autoimmune rheumatic diseases [28,29]. Among patients with rheumatoid arthritis, sedentary behavior is associated with higher disease scores, increased pain, fatigue [30] and number of comorbidities, reduced aerobic capacity [31] and physical function [30], and poor self-efficacy [32]. Furthermore, physically inactive patients with rheumatoid arthritis exhibit higher cardiovascular risk factors (e.g., higher systolic blood pressure and homeostasis model assessment (HOMA) index, abnormal lipid profile) when compared to their physically active counterparts."], "reference_info": "HenchozY. BastardotF. GuessousI. ThelerJ.M. DudlerJ. VollenweiderP. SoA. Physical activity and energy expenditure in rheumatoid arthritis patients and matched controlsRheumatology2012511500150710.1093/rheumatology/kes06722539478", "reference_doi": "10.1093/rheumatology/kes067"}, {"citation_id": "B31-ijerph-20-03944", "related_text": ["Physical inactivity and sedentary behavior are modifiable risk factors considered to be potential targets to prevent morbimortality in autoimmune rheumatic diseases [28,29]. Among patients with rheumatoid arthritis, sedentary behavior is associated with higher disease scores, increased pain, fatigue [30] and number of comorbidities, reduced aerobic capacity [31] and physical function [30], and poor self-efficacy [32]. Furthermore, physically inactive patients with rheumatoid arthritis exhibit higher cardiovascular risk factors (e.g., higher systolic blood pressure and homeostasis model assessment (HOMA) index, abnormal lipid profile) when compared to their physically active counterparts."], "reference_info": "YuC.A. RouseP.C. Veldhuijzen Van ZantenJ.J. NtoumanisN. KitasG.D. DudaJ.L. MetsiosG.S. Subjective and objective levels of physical activity and their association with cardiorespiratory fitness in rheumatoid arthritis patientsArthritis Res. Ther.2015175910.1186/s13075-015-0584-725885649", "reference_doi": "10.1186/s13075-015-0584-7"}, {"citation_id": "B32-ijerph-20-03944", "related_text": ["Physical inactivity and sedentary behavior are modifiable risk factors considered to be potential targets to prevent morbimortality in autoimmune rheumatic diseases [28,29]. Among patients with rheumatoid arthritis, sedentary behavior is associated with higher disease scores, increased pain, fatigue [30] and number of comorbidities, reduced aerobic capacity [31] and physical function [30], and poor self-efficacy [32]. Furthermore, physically inactive patients with rheumatoid arthritis exhibit higher cardiovascular risk factors (e.g., higher systolic blood pressure and homeostasis model assessment (HOMA) index, abnormal lipid profile) when compared to their physically active counterparts."], "reference_info": "HuffmanK.M. PieperC.F. HallK.S. St ClairE.W. KrausW.E. Self-efficacy for exercise, more than disease-related factors, is associated with objectively assessed exercise time and sedentary behaviour in rheumatoid arthritisScand. J. Rheumatol.20154410611010.3109/03009742.2014.93145625222824", "reference_doi": "10.3109/03009742.2014.931456"}, {"citation_id": "B33-ijerph-20-03944", "related_text": ["Patients with rheumatoid arthritis have been shown to be more susceptible to COVID-19 infection [33] and, therefore, may be subjected to more restrictive measures of social distancing, potentially with significant impacts on their activity options, and, hence, on their burden of cardiovascular disease risk, the main cause of mortality in this population [26].", "Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures."], "reference_info": "ZhongJ. ShenG. YangH. HuangA. ChenX. DongL. WuB. ZhangA. SuL. HouX. COVID-19 in patients with rheumatic disease in Hubei province, China: A multicentre retrospective observational studyLancet Rheumatol.20202e557e56410.1016/S2665-9913(20)30227-732838309", "reference_doi": "10.1016/S2665-9913(20)30227-7"}, {"citation_id": "B34-ijerph-20-03944", "related_text": ["Post-menopausal female patients diagnosed with rheumatoid arthritis, according to American College of Rheumatology European League against rheumatism collaborative initiative revised criteria [34], were recruited directly from the Rheumatoid Arthritis Outpatient Clinic of the Rheumatology Division. The exclusion criteria included: (1) participation in structured exercise training programs within the last 12 months; (2) unstable drug therapy in the last 3 months prior to and during the study; (3) Health Assessment Questionnaire score >2.0 (i.e., severe to very severe physical impairment)."], "reference_info": "AletahaD. NeogiT. SilmanA.J. FunovitsJ. FelsonD.T. BinghamC.O.3rd BirnbaumN.S. BurmesterG.R. BykerkV.P. CohenM.D. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiativeArthritis Rheum.2010622569258110.1002/art.2758420872595", "reference_doi": "10.1002/art.27584"}, {"citation_id": "B35-ijerph-20-03944", "related_text": ["Physical activity level was measured using activPAL micro™ (PAL Technology, Glasgow, UK) activity-based accelerometers before and during social distancing. Patients wore the accelerometer for 7 consecutive days (24 h/day), which was fitted using tape (3M, Tegaderm®, adhesive tape) on the right medial front thigh, orientated with the x-axis pointing downward, y-axis horizontally to the left and z-axis horizontally forward. Data were exported and analyzed using ActivPAL3™ software, version 8.10.9.46 (PAL Technology, UK). Data was checked by an experienced researcher and also crosschecked with a sleep diary. All data were standardized to a 16-h day in order to avoid bias from differences in patients’ wear time, by the formula: (data × 16)/wear time. Data were reported as follows: time spent sitting and lying (h/day), in prolonged sitting (h/day), standing (h/day), stepping (h/day), time spent in light-intensity physical activity (step cadency <100 steps/min [35]), time spent in moderate-to-vigorous intensity physical activity (step cadence of ≥100 steps/min [35]), and number of sit to stand (i.e., breaks) in time spent in sedentary behavior."], "reference_info": "Tudor-LockeC. SissonS.B. CollovaT. LeeS.M. SwanP.D. Pedometer-determined step count guidelines for classifying walking intensity in a young ostensibly healthy populationCan. J. Appl. Physiol.20053066667610.1139/h05-14716485518", "reference_doi": "10.1139/h05-147"}, {"citation_id": "B36-ijerph-20-03944", "related_text": ["Clinical characteristics were assessed at baseline, before the set of social distancing, Disease activity was assessed by the Disease Activity Score in 28 joints (DAS28 PCR) [36] and Clinical Disease Activity Index (CDAI) [37], in which higher scores represent more severe disease activity. The Health Assessment Questionnaire (HAQ) [38], which evaluates physical functioning in eight domains of daily life, was also used; higher scores represent greater physical disability. Disease duration, presence of comorbidities (e.g., hypertension, dyslipidemia, type 2 diabetes, depression, and other rheumatic diseases), current dose of prednisone, current use of biological agents (e.g., anti-TNF, anti-IL6, anti-IL1, B-cell depleting agents, and T-cell activation inhibiters), non-biological disease-modifying anti-rheumatic drugs (e.g., methotrexate and leflunomide), and other medications (i.e., anti-inflammatory drugs, pain killers, antihypertensive drugs, antihyperlipidemic drugs, antidiabetic drugs, and anti-depressants) were obtained by reviewing medical records and interviewing patients with rheumatoid arthritis. Blood samples (~10 mL) were collected after a 12-h overnight fast for measuring the following parameters: C-reactive protein and erythrocyte sedimentation rate. Samples were collected in vacutainer tubes and subsequently analyzed at the Clinical Hospital Central Laboratory (School of Medicine, University of Sao Paulo). C-reactive protein was determined by immunoturbidimetry. Erythrocyte sedimentation rate was assessed using an automated analyzer."], "reference_info": "PrevooM.L. van′t HofM.A. KuperH.H. van LeeuwenM.A. van de PutteL.B. van RielP.L. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritisArthritis Rheum.199538444810.1002/art.17803801077818570", "reference_doi": "10.1002/art.1780380107"}, {"citation_id": "B37-ijerph-20-03944", "related_text": ["Clinical characteristics were assessed at baseline, before the set of social distancing, Disease activity was assessed by the Disease Activity Score in 28 joints (DAS28 PCR) [36] and Clinical Disease Activity Index (CDAI) [37], in which higher scores represent more severe disease activity. The Health Assessment Questionnaire (HAQ) [38], which evaluates physical functioning in eight domains of daily life, was also used; higher scores represent greater physical disability. Disease duration, presence of comorbidities (e.g., hypertension, dyslipidemia, type 2 diabetes, depression, and other rheumatic diseases), current dose of prednisone, current use of biological agents (e.g., anti-TNF, anti-IL6, anti-IL1, B-cell depleting agents, and T-cell activation inhibiters), non-biological disease-modifying anti-rheumatic drugs (e.g., methotrexate and leflunomide), and other medications (i.e., anti-inflammatory drugs, pain killers, antihypertensive drugs, antihyperlipidemic drugs, antidiabetic drugs, and anti-depressants) were obtained by reviewing medical records and interviewing patients with rheumatoid arthritis. Blood samples (~10 mL) were collected after a 12-h overnight fast for measuring the following parameters: C-reactive protein and erythrocyte sedimentation rate. Samples were collected in vacutainer tubes and subsequently analyzed at the Clinical Hospital Central Laboratory (School of Medicine, University of Sao Paulo). C-reactive protein was determined by immunoturbidimetry. Erythrocyte sedimentation rate was assessed using an automated analyzer."], "reference_info": "AletahaD. SmolenJ. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): A review of their usefulness and validity in rheumatoid arthritisClin. Exp. Rheumatol.200523S100S10816273793", "reference_doi": null}, {"citation_id": "B38-ijerph-20-03944", "related_text": ["Clinical characteristics were assessed at baseline, before the set of social distancing, Disease activity was assessed by the Disease Activity Score in 28 joints (DAS28 PCR) [36] and Clinical Disease Activity Index (CDAI) [37], in which higher scores represent more severe disease activity. The Health Assessment Questionnaire (HAQ) [38], which evaluates physical functioning in eight domains of daily life, was also used; higher scores represent greater physical disability. Disease duration, presence of comorbidities (e.g., hypertension, dyslipidemia, type 2 diabetes, depression, and other rheumatic diseases), current dose of prednisone, current use of biological agents (e.g., anti-TNF, anti-IL6, anti-IL1, B-cell depleting agents, and T-cell activation inhibiters), non-biological disease-modifying anti-rheumatic drugs (e.g., methotrexate and leflunomide), and other medications (i.e., anti-inflammatory drugs, pain killers, antihypertensive drugs, antihyperlipidemic drugs, antidiabetic drugs, and anti-depressants) were obtained by reviewing medical records and interviewing patients with rheumatoid arthritis. Blood samples (~10 mL) were collected after a 12-h overnight fast for measuring the following parameters: C-reactive protein and erythrocyte sedimentation rate. Samples were collected in vacutainer tubes and subsequently analyzed at the Clinical Hospital Central Laboratory (School of Medicine, University of Sao Paulo). C-reactive protein was determined by immunoturbidimetry. Erythrocyte sedimentation rate was assessed using an automated analyzer."], "reference_info": "FerrazM.B. OliveiraL.M. AraujoP.M. AtraE. TugwellP. Crosscultural reliability of the physical ability dimension of the health assessment questionnaireJ. Rheumatol.1990178138172388204", "reference_doi": null}, {"citation_id": "B39-ijerph-20-03944", "related_text": ["Pain, fatigue, and health-related quality of life were assessed before and during social distancing. Pain was assessed by the Visual Analogic Scale [39], in which patients graded their pain using a 10-point scale; zero means no pain and 10 means severe or unbearable pain. Fatigue was assessed by the Fatigue Severity Scale [40], in which scores range from 9 to 63; lower scores indicate lower fatigue. Physical and mental health-related quality of life were assessed by the 36-Item Short Form Survey (SF-36) questionnaire [41], in which scales (physical health: physical function, role-physical, bodily pain, and general health; mental health: vitality, social function, and role-emotional) range from 0 to 100; higher scores indicate better quality of life."], "reference_info": "PriceD.D. BushF.M. LongS. HarkinsS.W. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scalesPain19945621722610.1016/0304-3959(94)90097-38008411", "reference_doi": "10.1016/0304-3959(94)90097-3"}, {"citation_id": "B40-ijerph-20-03944", "related_text": ["Pain, fatigue, and health-related quality of life were assessed before and during social distancing. Pain was assessed by the Visual Analogic Scale [39], in which patients graded their pain using a 10-point scale; zero means no pain and 10 means severe or unbearable pain. Fatigue was assessed by the Fatigue Severity Scale [40], in which scores range from 9 to 63; lower scores indicate lower fatigue. Physical and mental health-related quality of life were assessed by the 36-Item Short Form Survey (SF-36) questionnaire [41], in which scales (physical health: physical function, role-physical, bodily pain, and general health; mental health: vitality, social function, and role-emotional) range from 0 to 100; higher scores indicate better quality of life."], "reference_info": "PouchotJ. KheraniR.B. BrantR. LacailleD. LehmanA.J. EnsworthS. KopecJ. EsdaileJ.M. LiangM.H. Determination of the minimal clinically important difference for seven fatigue measures in rheumatoid arthritisJ. Clin. Epidemiol.20086170571310.1016/j.jclinepi.2007.08.01618359189", "reference_doi": "10.1016/j.jclinepi.2007.08.016"}, {"citation_id": "B41-ijerph-20-03944", "related_text": ["Pain, fatigue, and health-related quality of life were assessed before and during social distancing. Pain was assessed by the Visual Analogic Scale [39], in which patients graded their pain using a 10-point scale; zero means no pain and 10 means severe or unbearable pain. Fatigue was assessed by the Fatigue Severity Scale [40], in which scores range from 9 to 63; lower scores indicate lower fatigue. Physical and mental health-related quality of life were assessed by the 36-Item Short Form Survey (SF-36) questionnaire [41], in which scales (physical health: physical function, role-physical, bodily pain, and general health; mental health: vitality, social function, and role-emotional) range from 0 to 100; higher scores indicate better quality of life."], "reference_info": "CiconelliR.M. FerrazM.B. SantosW. MeinãoI. QuaresmaM.R. Brazilian-Portuguese version of the SF-36. A reliable and valid quality of life outcome measureRev. Bras. Rheumatol.1999398", "reference_doi": null}, {"citation_id": "B42-ijerph-20-03944", "related_text": ["As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28]."], "reference_info": "FreibergA. SchubertM. Romero StarkeK. HegewaldJ. SeidlerA. A Rapid Review on the Influence of COVID-19 Lockdown and Quarantine Measures on Modifiable Cardiovascular Risk Factors in the General PopulationInt. J. Environ. Res. Public Health202118856710.3390/ijerph1816856734444316", "reference_doi": "10.3390/ijerph18168567"}, {"citation_id": "B43-ijerph-20-03944", "related_text": ["As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28]."], "reference_info": "SilvaD.R. WerneckA.O. MaltaD.C. Souza-JuniorP.R.B. AzevedoL.O. BarrosM.B.A. SzwarcwaldC.L. Incidence of physical inactivity and excessive screen time during the first wave of the COVID-19 pandemic in Brazil: What are the most affected population groups?Ann. Epidemiol.202162303510.1016/j.annepidem.2021.05.00134029704", "reference_doi": "10.1016/j.annepidem.2021.05.001"}, {"citation_id": "B44-ijerph-20-03944", "related_text": ["As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28]."], "reference_info": "SilvaD. WerneckA.O. MaltaD.C. Souza JuniorP.R.B. AzevedoL.O. BarrosM.B.A. SzwarcwaldC.L. Changes in the prevalence of physical inactivity and sedentary behavior during COVID-19 pandemic: A survey with 39,693 Brazilian adultsCad. Saude Publica202137e0022192010.1590/0102-311x0022192033950077", "reference_doi": "10.1590/0102-311x00221920"}, {"citation_id": "B45-ijerph-20-03944", "related_text": ["Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "BoothF.W. RobertsC.K. ThyfaultJ.P. RuegseggerG.N. ToedebuschR.G. Role of Inactivity in Chronic Diseases: Evolutionary Insight and Pathophysiological MechanismsPhysiol. Rev.2017971351140210.1152/physrev.00019.201628814614", "reference_doi": "10.1152/physrev.00019.2016"}, {"citation_id": "B46-ijerph-20-03944", "related_text": ["Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "BellettiereJ. WinklerE.A.H. ChastinS.F.M. KerrJ. OwenN. DunstanD.W. HealyG.N. Associations of sitting accumulation patterns with cardio-metabolic risk biomarkers in Australian adultsPLoS ONE201712e018011910.1371/journal.pone.018011928662164", "reference_doi": "10.1371/journal.pone.0180119"}, {"citation_id": "B47-ijerph-20-03944", "related_text": ["Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "van DijkS.B. TakkenT. PrinsenE.C. WittinkH. Different anthropometric adiposity measures and their association with cardiovascular disease risk factors: A meta-analysisNeth Heart J20122020821810.1007/s12471-011-0237-722231153", "reference_doi": "10.1007/s12471-011-0237-7"}, {"citation_id": "B48-ijerph-20-03944", "related_text": ["Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "PedersenB.K. SaltinB. Exercise as medicine—Evidence for prescribing exercise as therapy in 26 different chronic diseasesScand. J. Med. Sci. Sports201525(Suppl. S3)17210.1111/sms.1258126606383", "reference_doi": "10.1111/sms.12581"}, {"citation_id": "B49-ijerph-20-03944", "related_text": ["Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares."], "reference_info": "BenattiF.B. PedersenB.K. Exercise as an anti-inflammatory therapy for rheumatic diseases-myokine regulationNat. Rev. Rheumatol.201511869710.1038/nrrheum.2014.19325422002", "reference_doi": "10.1038/nrrheum.2014.193"}, {"citation_id": "B50-ijerph-20-03944", "related_text": ["Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures."], "reference_info": "SaundersT.J. AtkinsonH.F. BurrJ. MacEwenB. SkeaffC.M. PeddieM.C. The Acute Metabolic and Vascular Impact of Interrupting Prolonged Sitting: A Systematic Review and Meta-AnalysisSports Med.2018482347236610.1007/s40279-018-0963-830078066", "reference_doi": "10.1007/s40279-018-0963-8"}, {"citation_id": "B51-ijerph-20-03944", "related_text": ["Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures."], "reference_info": "FentonS.A.M. Veldhuijzen van ZantenJ. KitasG.D. DudaJ.L. RouseP.C. YuC.A. MetsiosG.S. Sedentary behaviour is associated with increased long-term cardiovascular risk in patients with rheumatoid arthritis independently of moderate-to-vigorous physical activityBMC Musculoskelet. Disord.20171813110.1186/s12891-017-1473-928356089", "reference_doi": "10.1186/s12891-017-1473-9"}, {"citation_id": "B52-ijerph-20-03944", "related_text": ["Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures."], "reference_info": "PintoA.J. MeirelesK. PecanhaT. MazzolaniB.C. SmairaF.I. RezendeD. BenattiF.B. RibeiroA.C.M. PintoA.L.S. LimaF.R. Acute cardiometabolic effects of brief active breaks in sitting for patients with rheumatoid arthritisAm. J. Physiol. Endocrinol. Metab.2021321E782E79410.1152/ajpendo.00259.202134693756", "reference_doi": "10.1152/ajpendo.00259.2021"}, {"citation_id": "B53-ijerph-20-03944", "related_text": ["Our findings suggested social distancing did not affect pain, fatigue, and physical and mental health-related quality of life. Qualitative evidence in patients with rheumatoid arthritis demonstrate that patients reported no changes in physical health outcomes. Conversely, they noted social distancing resulted in worsened mental health-related symptoms [53]. Additionally, changes in these variables did not associate with changes in physical activity and sedentary behavior. Because this study was performed 2 to 4 months after the set of social distancing measures, we cannot rule out that such a short period of exposure did not allow detecting impairments in these outcomes. Alternatively, it is possible that patients with rheumatoid arthritis may be more resilient than general population to the detrimental impacts of the pandemic on overall health."], "reference_info": "RyanS. CampbellP. PaskinsZ. HiderS. ManningF. RuleK. BrooksM. HassellA. Exploring the physical, psychological and social well-being of people with rheumatoid arthritis during the coronavirus pandemic: A single-centre, longitudinal, qualitative interview study in the UKBMJ Open202212e05655510.1136/bmjopen-2021-05655535882463", "reference_doi": "10.1136/bmjopen-2021-056555"}] | {"introduction": "A preliminary, multinational survey reporting step counts provided by smartphones showed that social distancing measures to contain the spread of SARS-CoV-2 have induced physical inactivity (i.e., not meeting the physical activity guidelines) [1]. The onset of the coronavirus disease 2019 (COVID-19) pandemic has placed further spotlight on participation in sedentary behavior (i.e., time spent in a sitting or reclining posture with a low energy expenditure [≤1.5 METs]), with reported increases in daily sitting time from pre-pandemic levels ranging from 30 min up to 3 h in different populations [2,3]. Extensive epidemiological evidence has indicated that physical inactivity is a major risk factor for early mortality and chronic diseases, including obesity, type 2 diabetes, cardiovascular diseases, metabolic syndrome, certain type of cancers, and others [4]. Even though time spent in moderate-to-vigorous intensity physical activity has the strongest detrimental associations with health outcomes [5,6,7], similar (albeit, detrimental) relationships have been broadly observed for excessive time in sedentary behaviors [7,8,9,10,11,12,13,14,15,16]. Importantly, both total sitting time and prolonged, uninterrupted sitting time are associated with increased risk of all-cause mortality even after consideration of the influence of participation in moderate-to-vigorous intensity physical activity [7,8,17]. Moreover, the deleterious associations of sedentary behavior with cardiometabolic risk and all-cause mortality are most pronounced in those who are physically inactive [6,11,18,19,20]. Rheumatoid arthritis is a rheumatic autoimmune disease characterized by chronic inflammation, pain, and physical disability [21]. Clinical disease symptoms can include joint pain, swelling, stiffness, and deformity, fatigue, muscle weakness, and reduced physical functioning [22,23]. Patients with rheumatoid arthritis have a higher risk of morbidity and mortality from cardiovascular diseases [24]. This increased risk can be at least partially explained by the complex interplay between chronic inflammation, adverse effects of drugs, associated comorbidities (e.g., dyslipidemias, insulin resistance, hypertension), and lifestyle [25,26]. Despite physical activity being advocated as an integral part of disease standard care [27], physical inactivity and sedentary behavior are highly prevalent among patients with rheumatoid arthritis [28]. Physical inactivity and sedentary behavior are modifiable risk factors considered to be potential targets to prevent morbimortality in autoimmune rheumatic diseases [28,29]. Among patients with rheumatoid arthritis, sedentary behavior is associated with higher disease scores, increased pain, fatigue [30] and number of comorbidities, reduced aerobic capacity [31] and physical function [30], and poor self-efficacy [32]. Furthermore, physically inactive patients with rheumatoid arthritis exhibit higher cardiovascular risk factors (e.g., higher systolic blood pressure and homeostasis model assessment (HOMA) index, abnormal lipid profile) when compared to their physically active counterparts. Patients with rheumatoid arthritis have been shown to be more susceptible to COVID-19 infection [33] and, therefore, may be subjected to more restrictive measures of social distancing, potentially with significant impacts on their activity options, and, hence, on their burden of cardiovascular disease risk, the main cause of mortality in this population [26]. In this prospective study using a within-subjects design, we assessed physical activity and sedentary behavior levels using accelerometers in patients with rheumatoid arthritis prior to and during the imposed measures of social distancing to combat COVID-19 in Sao Paulo, Brazil. Additionally, we have assessed whether potential changes in physical activity and sedentary behavior levels would be associated with changes in pain, fatigue, and health-related quality of life.", "participants": "Sixty-four patients diagnosed with rheumatoid arthritis were recruited from the Outpatient Rheumatoid Arthritis Clinic of the Clinical Hospital (School of Medicine, University of Sao Paulo) between March 2018 and March 2020 to participate in a randomized controlled trial (clinicaltrials.gov: NCT03186924). Thirty-five out of 64 patients with rheumatoid arthritis accepted to participate in this ancillary study. Post-menopausal female patients diagnosed with rheumatoid arthritis, according to American College of Rheumatology European League against rheumatism collaborative initiative revised criteria [34], were recruited directly from the Rheumatoid Arthritis Outpatient Clinic of the Rheumatology Division. The exclusion criteria included: (1) participation in structured exercise training programs within the last 12 months; (2) unstable drug therapy in the last 3 months prior to and during the study; (3) Health Assessment Questionnaire score >2.0 (i.e., severe to very severe physical impairment). This trial was approved by the local ethical committee (Commission for Analysis of Research Projects, CAPPesq; protocol code: 58340316.0.0000.0068; approval number: 1.735.096). Patients signed an informed consent form before participation in the study.", "2. experimental design": "All patients with rheumatoid arthritis had been through a clinical and physical activity assessment before the official set of social distancing measures to contain the COVID-19 outbreak, adopted on the 24 of March 2020. This facilitated the unique opportunity to track physical activity levels during the pandemic in a within-subjects, repeated measure design. We then obtained a new approval from the ethics committee for collecting data during the social distancing. Three members of our staff (DR, SMS, KM) delivered the accelerometers (ActivPAL micro™, PAL Technology, Glasgow, UK) and questionnaires to the patients at home from the 24 May to 7 July. The time elapsed for data collection between baseline and during social distancing was 12.5 months (9.9, 15.2). Patients were asked if they had adhered to the social distancing measures. All but two responded affirmatively. Data were assessed with and without the two non-compliers, and results remained the same. Thus, we reported the full data in this manuscript.", "3. physical activity level": "Physical activity level was measured using activPAL micro™ (PAL Technology, Glasgow, UK) activity-based accelerometers before and during social distancing. Patients wore the accelerometer for 7 consecutive days (24 h/day), which was fitted using tape (3M, Tegaderm®, adhesive tape) on the right medial front thigh, orientated with the x-axis pointing downward, y-axis horizontally to the left and z-axis horizontally forward. Data were exported and analyzed using ActivPAL3™ software, version 8.10.9.46 (PAL Technology, UK). Data was checked by an experienced researcher and also crosschecked with a sleep diary. All data were standardized to a 16-h day in order to avoid bias from differences in patients’ wear time, by the formula: (data × 16)/wear time. Data were reported as follows: time spent sitting and lying (h/day), in prolonged sitting (h/day), standing (h/day), stepping (h/day), time spent in light-intensity physical activity (step cadency <100 steps/min [35]), time spent in moderate-to-vigorous intensity physical activity (step cadence of ≥100 steps/min [35]), and number of sit to stand (i.e., breaks) in time spent in sedentary behavior.", "4. clinical assessment": "Clinical characteristics were assessed at baseline, before the set of social distancing, Disease activity was assessed by the Disease Activity Score in 28 joints (DAS28 PCR) [36] and Clinical Disease Activity Index (CDAI) [37], in which higher scores represent more severe disease activity. The Health Assessment Questionnaire (HAQ) [38], which evaluates physical functioning in eight domains of daily life, was also used; higher scores represent greater physical disability. Disease duration, presence of comorbidities (e.g., hypertension, dyslipidemia, type 2 diabetes, depression, and other rheumatic diseases), current dose of prednisone, current use of biological agents (e.g., anti-TNF, anti-IL6, anti-IL1, B-cell depleting agents, and T-cell activation inhibiters), non-biological disease-modifying anti-rheumatic drugs (e.g., methotrexate and leflunomide), and other medications (i.e., anti-inflammatory drugs, pain killers, antihypertensive drugs, antihyperlipidemic drugs, antidiabetic drugs, and anti-depressants) were obtained by reviewing medical records and interviewing patients with rheumatoid arthritis. Blood samples (~10 mL) were collected after a 12-h overnight fast for measuring the following parameters: C-reactive protein and erythrocyte sedimentation rate. Samples were collected in vacutainer tubes and subsequently analyzed at the Clinical Hospital Central Laboratory (School of Medicine, University of Sao Paulo). C-reactive protein was determined by immunoturbidimetry. Erythrocyte sedimentation rate was assessed using an automated analyzer. Pain, fatigue, and health-related quality of life were assessed before and during social distancing. Pain was assessed by the Visual Analogic Scale [39], in which patients graded their pain using a 10-point scale; zero means no pain and 10 means severe or unbearable pain. Fatigue was assessed by the Fatigue Severity Scale [40], in which scores range from 9 to 63; lower scores indicate lower fatigue. Physical and mental health-related quality of life were assessed by the 36-Item Short Form Survey (SF-36) questionnaire [41], in which scales (physical health: physical function, role-physical, bodily pain, and general health; mental health: vitality, social function, and role-emotional) range from 0 to 100; higher scores indicate better quality of life.", "statistical analysis": "Dependent variables were tested using repeated measures mixed models, with time (Before social distancing versus During social distancing) as fixed factor and participants as random factor, with a compound symmetry covariance matrix. Delta changes in all dependent variables were calculated with the following formula: delta change = data during social distancing—data before social distancing. Associations between changes in physical activity and sedentary behavior level and changes in pain, fatigue, and health-related quality of life were tested using Pearson correlation tests. Statistical analysis was performed in SAS 9.3 (SAS Institute Inc., Cary, NC, USA). Data are presented as mean, estimated mean difference from the repeated measures mixed models, and 95% confidence intervals (95% CI). The significance level was set at p ≤ 0.05.", "results/conclusion": "Patients’ clinical characteristics are presented in Table 1. In summary, mean age was 60.9 years (95% CI: 58.0 to 63.7) and BMI was 29.5 Kg/m2 (95% CI: 27.2 to 31.9). Disease activity ranged from remission to moderate activity, as assessed by DAS28 PCR and CDAI. Disability assessed by HAQ ranged from mild to severe. Mean disease duration was 18.5 years (95% CI: 14.7, 22.3). Mean C-reactive protein was 10.8 mg/dL (95% CI: 5.5 to 16.2) and erythrocyte sedimentation rate was 28.4 mm/H (95% CI: 15.7 to 41.1). Most of the patients were using disease-modifying anti-rheumatic drugs and prednisone (85.7% and 74.3%, respectively). Hypertension, dyslipidemia and type 2 diabetes were the most frequent comorbidities (51.4%, 48.6% and 34.3%, respectively). Before social distancing, mean pain was 5.0 (95% CI: 4.1 to 6.0), fatigue was 39.3 (95% CI: 33.8 to 44.8), and physical and mental health-related quality of life were 39.8 (95% CI: 33.1 to 46.5) and 62.0 (95%CI: 52.3 to 71.7), respectively. During social distancing, there were reductions in total stepping time (15.7% [−0.3 h/day, 95% CI: −0.4 to −0.1; p = 0.004]), in light-intensity physical activity (13.0% [−0.2 h/day, 95% CI: −0.4 to −0.04; p = 0.016]) and in moderate-to-vigorous physical activity (38.8% [−4.5 min/day, 95% CI: −8.1 to −0.9; p = 0.015]), but no changes in total standing time (−0.1 h/day, 95% CI: −0.7 to 0.5; p = 0.767) or total sedentary time (0.3 h/day, 95% CI: −0.4 to 1.0; p = 0.335) in patients with rheumatoid arthritis. However, time spent in prolonged bouts of sitting ≥ 30 min increased by 34% (1.0 h/day, 95% CI: 0.3 to 1.7; p = 0.006; Figure 1A) and sitting bouts ≥60 min increased by 85% (1.0 h/day, 95% CI: 0.5 to 1.6; p < 0.001; Figure 1B). Sit-stand transitions were reduced by 10% (−5.1/day, 95% CI: −10.3 to 0.0; p = 0.051). Figure 1C and Figure 1D illustrate the accelerometer data from a patient who experienced decreased activity and increased prolonged sitting after social distancing. During social distancing, there were no changes in pain (0.31 [95% CI: −1.04 to 1.67; p = 0.652), fatigue (−2.3 [95% CI: −10.0 to 5.4]; p = 0.550), and physical and mental health-related quality of life (1.2 [95% CI: −8.2 to 10.7]; p = 0.796 and −9.3 [95% CI: −23.0 to 4.5], p = 0.183, respectively) in patients with rheumatoid arthritis. Changes in physical activity and sedentary behavior levels were not associated with changes in pain, fatigue, and physical and mental health-related quality of life during social distancing (all p > 0.050). Imposed social distancing measures to contain the COVID-19 outbreak were associated with decreased physical activity and increased prolonged sitting time, but no changes in clinical symptoms (pain, fatigue, and health-related quality of life) among patients with rheumatoid arthritis. Since this has the potential to increase the burden of cardiovascular diseases in such high-risk group of patients, attention to maintaining their activity levels is an urgent consideration during the pandemic, and possibly thereafter since inactivity and sedentariness may carry over as consequences of the outbreak.", "discussion": "To our knowledge, this is the first study to track physical activity and sedentary behavior patterns before and during the COVID-19 pandemic using validated accelerometry and a within-subjects design. Our main findings suggest that social distancing (including stay-at-home order) can lead to reduced ambulatory activities and increased physical inactivity as well as increased prolonged sitting among patients with rheumatoid arthritis. In contrast, social distancing was not associated with worsened pain, fatigue, and physical and mental health-related quality of life. Physical inactivity along with too much sitting emerge as a risk factor that could be detrimental to cardiometabolic health in such a high-risk group of patients during and possibly after the COVID-19 pandemic. As those confined at home are less prone to perform physical activity, it has been speculated that inactivity and sedentary behavior could peak during the COVID-19 pandemic [29]. In fact, a rapid review has shown a substantial decrease in physical activity with a concomitant increase in sedentary behavior across all age groups during COVID-19 lockdown [42]. As for the Brazilian population, a national retrospective survey comprising 39,693 adults and older adults has shown a significant increase on self-reported physical inactivity and screen-based sedentary behaviors during the COVID-19 pandemic [43,44], which corroborates the objectively measured data presented herein. Such an increase in inactivity and sedentary behavior is of particular concern for those who are usually hypoactive and show higher risk of cardiovascular diseases, this being the case of patients with rheumatoid arthritis (see the patients’ comorbidities in Table 1) [26,28]. Observational and experimental evidence demonstrates that inactivity can predispose to pathological states and poor outcomes [45]. Sedentary behavior can add to the adverse impacts of physical inactivity in impairing cardiovascular health [46]. Consequently, individuals who are both physically inactive and highly sedentary are at the highest risk for poor outcomes [6,20], which might be the case for patients with autoimmune rheumatic diseases, as they commonly spent most of their daily hours engaged in sedentary behavior and did not achieve minimum levels of moderate-to-vigorous physical activity [28]. Namely in rheumatoid arthritis, the estimates of physical inactivity and sedentary behavior are comparable to those of other chronic diseases (e.g., type 2 diabetes and cardiovascular diseases), groups in which both physical inactivity and sedentary behaviors are associated with poor disease prognosis and mortality [9,10,11,13,47], as well as poor health-related outcomes (i.e., higher disease activity score, disease symptoms and number of comorbidities, and lower physical capacity and functioning) [28]. In rheumatoid arthritis, regular participation in exercise improves disease symptoms, inflammatory markers, cardiometabolic risk factors, and physical capacity [48,49]. However, regular participation in moderate-to-vigorous physical activity may not be feasible for some patients, especially those with poor mobility or during disease flares. Interestingly, we observed that even in the absence of changes in total sedentary time, prolonged sitting time rose considerably. Prolonged, uninterrupted bouts of sedentary behavior are associated with all-cause mortality [8], whereas well-controlled studies show that very-light to light-intensity active interruptions in prolonged sedentary time (e.g., 2 min of walking for every 30 min of sitting) can elicit immediate improvements in cardiometabolic risk factors [50]. Recent evidence has shown that light-intensity physical activity is associated with lower disability, disease activity and cardiovascular risk in rheumatoid arthritis, in contrast to excessive sitting [28,51]. Additionally, a crossover randomized trial demonstrated that performing 3-min bouts of light-intensity walking every 30 min of sitting (total: 42 min) resulted in improved glycemic (i.e., glucose, insulin, and c-peptide) and inflammatory (i.e., IL-1β, IL-1ra, IL-10, and TNF-α) markers when compared to 8 h of prolonged, uninterrupted sitting in postmenopausal females with rheumatoid arthritis [52]. This raises the need for widespread recommendation of breaking-up prolonged sitting whenever possible (e.g., 3 min breaks of light-intensity walking every 30 min of sitting) to avoid poor health outcomes during the pandemic, which tend to be more restrictive for high-risk groups for COVID-19, such as those with autoimmune rheumatic diseases [33], a condition associated with lower vaccine responses, which may enforce more vulnerable patients to maintain some degree of physical distance and home isolation for as long as the pandemic endures. Our findings suggested social distancing did not affect pain, fatigue, and physical and mental health-related quality of life. Qualitative evidence in patients with rheumatoid arthritis demonstrate that patients reported no changes in physical health outcomes. Conversely, they noted social distancing resulted in worsened mental health-related symptoms [53]. Additionally, changes in these variables did not associate with changes in physical activity and sedentary behavior. Because this study was performed 2 to 4 months after the set of social distancing measures, we cannot rule out that such a short period of exposure did not allow detecting impairments in these outcomes. Alternatively, it is possible that patients with rheumatoid arthritis may be more resilient than general population to the detrimental impacts of the pandemic on overall health. The main strengths of this study are its within-subjects design and the use of posture-based accelerometers, which enables an objective and a comprehensive assessment of sedentary behavior patterns. The limitations include the relatively low sample size; lack of measurement of mood and use of medication and supplements during social distancing, which may also alter habitual physical activity; and the inability to stablish a cause-and-effect relationship between changes in behavior with social distancing measures, although elements of temporality and plausibility do support our assumptions."} | [] | [] |
PMC10003738 | "Impact of Age and Severe Acute Respiratory Syndrome Coronavirus 2 Breakthrough Infection on Humoral(...TRUNCATED) | ["Mark A Brockman","Zabrina L Brumme","Marc G Romney","Masahiro Niikura","Janet Simons","Daniel T Ho(...TRUNCATED) | "Longer-term immune response data after 3 doses of coronavirus disease 2019 (COVID-19) mRNA vaccine (...TRUNCATED) | 10.1093/ofid/ofad073 | [
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PMC10004034 | "2-Year Change in Revised Hammersmith Scale Scores in a Large Cohort of Untreated Paediatric Type 2 (...TRUNCATED) | ["Francesco Muntoni","Eugenio Mercuri","Richard S. Finkel","Darryl C. De Vivo","Basil T. Darras","Jo(...TRUNCATED) | "The Revised Hammersmith Scale (RHS) is a 36-item ordinal scale developed using clinical expertise a(...TRUNCATED) | 10.3390/jcm12051920 | [
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PMC10004519 | "Association between intraoperative end-tidal carbon dioxide and postoperative organ dysfunction in (...TRUNCATED) | ["Toshiyuki Mizota","Yosuke Yamamoto","Akiko Hirotsu","Miho Hamada","Tsukasa Kamitani","Chikashi Tak(...TRUNCATED) | "Data on the effects of intraoperative end-tidal carbon dioxide (EtCO2) levels on postoperative orga(...TRUNCATED) | 10.1371/journal.pone.0268362 | [] | "[{\"citation_id\": \"pone.0268362.ref001\", \"related_text\": [\"Although high-risk surgeries accou(...TRUNCATED) | "{\"introduction\": \"Although high-risk surgeries account for only 12.5% of all surgical procedures(...TRUNCATED) | "[{\"id\": \"\", \"caption\": \"We included consecutive patients aged 18 years or older who underwen(...TRUNCATED) | "[{\"caption\": \"\", \"content\": \"<table frame=\\\"hsides\\\" rules=\\\"groups\\\"><colgroup span(...TRUNCATED) |
PMC10004542 | Real-time emotion detection by quantitative facial motion analysis | ["Sima Mofakham","Pawel Polak","Charles B. Mikell","Miriam Rafailovich","Michael Sepe","Theresa Gamm(...TRUNCATED) | "Research into mood and emotion has often depended on slow and subjective self-report, highlighting (...TRUNCATED) | 10.1371/journal.pone.0282730 | [] | "[{\"citation_id\": \"pone.0282730.ref001\", \"related_text\": [\"The ability to accurately assess t(...TRUNCATED) | "{\"introduction\": \"The ability to accurately assess the internal states of the human mind remains(...TRUNCATED) | "[{\"id\": \"\", \"caption\": \"(A)–(C): Different classifiers using the DISC method. (D): Amazon (...TRUNCATED) | [] |
PMC10004567 | "Prevalence of lung cancer in Colombia and a new diagnostic algorithm using health administrative da(...TRUNCATED) | [
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PMC10005169 | "Spectral imaging enables contrast agent–free real-time ischemia monitoring in laparoscopic surger(...TRUNCATED) | ["Lena Maier-Hein","Dogu Teber","Annette Kopp-Schneider","Brittaney Everitt","Sebastian Pirmann","Mi(...TRUNCATED) | "Laparoscopic surgery has evolved as a key technique for cancer diagnosis and therapy. While charact(...TRUNCATED) | 10.1126/sciadv.add6778 | [] | "[{\"citation_id\": \"R1\", \"related_text\": [\"A common necessity of laparoscopic surgeries, for e(...TRUNCATED) | "{\"introduction\": \"Replacing traditional open surgery with minimally invasive techniques for comp(...TRUNCATED) | "[{\"id\": \"\", \"caption\": \"We recorded two MSI sequences [perfused1 (for training) and perfused(...TRUNCATED) | "[{\"caption\": \"ccRCC, clear cell renal cell carcinoma; PRCC, papillary renal cell carcinoma; ChRC(...TRUNCATED) |
PMC10005935 | "Brain ageing in schizophrenia: evidence from 26 international cohorts via the ENIGMA Schizophrenia (...TRUNCATED) | ["Esther Walton","Danai Dima","Rosa Ayesa-Arriola","James H. Cole","Jessica Turner","Theo G. M. van (...TRUNCATED) | "Schizophrenia (SZ) is associated with an increased risk of life-long cognitive impairments, age-rel(...TRUNCATED) | 10.1038/s41380-022-01897-w | [
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PMC10005942 | Inflammation and cognition in severe mental illness: patterns of covariation and subgroups | ["Torill Ueland","Ole Andreas Andreassen","Ingrid Melle","Nils Eiel Steen","Trine Vik Lagerberg","Mo(...TRUNCATED) | "A potential relationship between dysregulation of immune/inflammatory pathways and cognitive impair(...TRUNCATED) | 10.1038/s41380-022-01924-w | [
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