Journal of Clinical and Aesthetic Dermatology - Hot Topics in Psoriasis February 2024

Regular Exercise Improved Fatigue And Musculoskeletal Pain In Young Adult Patients With Psoriasis Without Psoriatic Arthritis

Antonio J. Diaz, Miguel A. Rosety, Jose C. Armario, Manuel J. Bandez, Natalia Garcia-Gomez, Eduardo Sanchez-Sanchez, Jara Diaz, Cristina Castejon-Riber, Marco Bernardi, Manuel Rosety-Rodriguez M, Francisco J. Ordonez, Ignacio Rosety 2024-02-06 05:38:05

Dr. A. Diaz is with School of Nursing and Physiotherapy, University of Cadiz in Cadiz, Spain. Drs. M. Rosety and J. Diaz are with School of Sports Sciences, University of Cadiz in Cadiz, Spain. Dr. Armario is with Dermatology Unit, School of Medicine, University of Cadiz in Cadiz, Spain. Dr. Bandez is with Biomedicine Department, School of Medicine, University of Cadiz in Cadiz, Spain. Dr. Garcia-Gomez is with Histology and Pathology Department, School of Medicine, University of Cadiz in Cadiz, Spain. Dr. Sanchez-Sanchez is with School of Nursing, Punta de Europa Hospital in Cádiz, Spain. Dr. Castejon-Riber is with School of Education Sciences, University of Cordob in Cordoba, Spain. Dr. Bernardi is with School of Sports Medicine, University La Sapienza in Rome, Italy. Drs. Rosety-Rodriguez M and Ordonez are with School of Sports Medicine, University of Cadiz in Cadiz, Spain. Dr. I. Rosety is with Human Anatomy Department, School of Medicine, University of Cadiz in Cadiz, Spain.

Reprinted with permission. Nutrients. 2023;15(21):4563.*

ABSTRACT

Fatigue and musculoskeletal pain are also frequent in patients with psoriasis without psoriatic arthritis (PsA). The current study aimed to assess the impact of an intervention program based on aerobic training to reduce fatigue and musculoskeletal pain in patients with psoriasis without PsA. A total of 118 male patients with poriasis volunteered in the current interventional study and were randomly allocated to the experimental (n=59) or control group (n=59). The intervention consisted of a 16-week aerobic training program on a treadmill, three sessions per week, consisting of a warm-up, 35- to 50-minute treadmill exercise (increasing by 5 minutes/4 weeks) at a work intensity of 50 to 65 percent of peak heart rate (increasing by 5%/4 weeks), and cool-down. The Functional Assessment of Chronic Illness Therapy-Fatigue Scale (FACIT-Fatigue), Health Assessment Questionnaire-Disability Index (HAQ-DI), and visual analog scale (VAS) were compared pre- and postintervention. Nutritional intake, maximal aerobic power, lipid profile, serum markers of muscle damage, and body composition were also assessed. When compared to baseline, FACIT-Fatigue, HAQ-DI, and VAS scores were significantly improved without increasing markers of muscle damage. Fat mass percentage, lipid profile, and maximal oxygen consumption were also improved. In conclusion, a 16-week aerobic training program at moderate intensity was safe, well tolerated, and effective in patients with psoriasis without PsA. Long-term follow-up studies are required to examine whether these promising results may improve clinical outcomes.

KEYWORDS: Physical activity, musculoskeletal health, nutrition, psoriasis, fatigue

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors have no conflicts of interest relevant to the contents of this article.

CORRESPONDENCE: Ignacio Rosety; Email: miguelangel.rosety@uca.es

*COPYRIGHT: © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open-access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

INTRODUCTION

Psoriasis is a chronic, immune-mediated inflammatory skin disease with a high prevalence in Western societies.1 Recent studies have emphasized that psoriasis is a systemic disease with multiple comorbidities that extend beyond the skin.2–4 It has been associated with an increased risk for comorbidities, including, but not limited to, arthritic, psychological, and cardiometabolic conditions.2–5 In one study, the overall pooled prevalence of metabolic syndrome in adult patients with psoriasis was 32 percent (95% confidence interval [CI]: 0.26–0.38).6 These findings could be explained at least in part because patients with psoriasis revealed excessive ectopic fat accumulation when compared to body mass index (BMI)-matched controls without psoriasis.7 As a consequence, visceral fat should be considered a key target not only for pharmacological treatments, but also for lifestyle interventions in this population group.7

However, musculoskeletal symptoms, including pain and fatigue, are highly prevalent in patients with psoriasis, having a negative impact on their physical function and quality of life.8 These symptoms have been described not only in adults, but also in children and adolescents with psoriasis.9 Merola et al8 reported an increased prevalence of musculoskeletal symptoms in a 60-month follow-up study of newly diagnosed adult patients with psoriasis (47.1% at baseline, 48.2% after 12 months, and 82.1% after 60 months). The same authors also found that baseline musculoskeletal symptoms were correlated with an increased risk of a psoriatic arthritis (PsA) diagnosis.8 Similarly, a recent prospective cohort study demonstrated the existence of nonspecific musculoskeletal symptoms preceding the onset of PsA among patients with psoriasis.10 In fact, up to 30 percent of patients with psoriasis may develop PsA during their lifetime.11 This finding is of particular interest because PsA may interfere with daily routines, leisure/sports activities, and work/ education in a serious manner.12,13 In summary, musculoskeletal pain is frequently observed in patients with psoriasis both with and without PsA.14,15 In this respect, it should be highlighted that musculoskeletal pain may affect the quality of life of patients with psoriasis to a level similar to that of patients with PsA.2 Surprisingly, this issue has received little attention in both the medical literature and clinical settings.

For the reasons already mentioned, psoriasis may cause great physical, emotional, and social burdens that inevitably lead to considerable use of medical care and economic resources in both private and public health services.16,17 Accordingly, a comprehensive and multidisciplinary approach involving not only dermatologists, but also general practitioners, is required to achieve better health outcomes for these patients in a timely manner.16,18 In this regard, evidence-based guidelines for the treatment of PsA recommend exercise as a nonpharmacological therapy to improve functional capacity.19,20

Increasing physical activity has been inversely associated with the risk of psoriasis, as the most physically active quintile of participants during 1,195,703 person-years of follow-up (14 years, 1991–2005) had a lower multivariate relative risk (RR) of psoriasis (0.72 [95% CI: 0.59–0.89; p<0.001]).21

Additionally, high levels of physical activity have been shown to reduce the risk of PsA in patients with psoriasis in a recent population-based study in Norway.22 Also, recent metaanalyses have suggested that higher BMI increased the odds of psoriasis occurrence.23 Furthermore, obesity has been also associated with increased severity of psoriasis and lower response to modern biological treatment.23

In spite of the above-mentioned pieces of evidence, several studies have demonstrated that patients with psoriasis generally exhibited more sedentary behavior and were less physically active than matched healthy controls.24 A study of 2011 to 2014 National Health and Nutrition Examination Survey (NHANES) data from 9,174 patients demonstrated that those with psoriasis were significantly less likely to engage in moderate-to-vigorous physical activity in comparison with patients who did not suffer from psoriasis (16.1% vs. 28%; p=0.042). Similarly, other survey-based studies focused on the International Physical Activity Questionnaire (IPAQ) also found that patients with psoriasis were significantly less physically active than healthy controls.25 In any case, this fact could be of special clinical interest, provided that sedentary lifestyle may influence not only the psoriasis natural course, but also the existence of comorbidities.24

This study aimed to assess the influence of an intervention program based on aerobic training on reducing fatigue and musculoskeletal pain in adult patients with psoriasis without PsA. The secondary objective was to determine the effects of the intervention on body composition, maximal aerobic power, and serum muscle damage markers.

MATERIALS AND METHODS

Study design and participants. A total of 118 patients with psoriasis volunteered for the current interventional study, which used a pre-/ posttest design. The adequacy of sample size was tested using the statistical software Granmo v7.12 (IMIM; Barcelona, Spain) with an accepted two-sided alpha risk of 0.05 and a beta risk of 0.2. In addition, a loss-to-follow-up rate of 10 percent was estimated.

All participants met the following inclusion criteria: male sex; 18 to 45 years of age; a diagnosis of mild psoriasis on the basis of the Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) scores under 7;26 topical psoriasis treatment (excluding steroids at least in the last 3 months); and medical approval for participation in physical activity, conducted by an experienced sports medicine physician. The exclusion criteria were as follows: systemic antipsoriatic therapy; patients with plantar psoriasis; comorbidities that might have an impact on their ability to participate in an exercise program, such as PsA; regular intake of statins; regular consumption of antioxidant supplements; history of smoking or alcohol intake; participation in a training program in the six months prior to participation in the trial; and not completing at least 90 percent of the training sessions in the trial.

After reviewing the inclusion/exclusion criteria and signing the informed consent form, the participants were randomly allocated (in a 1:1 ratio) to the experimental (n=59) or control (n=59) group using a computer-generated randomization scheme.

Intervention. Participants in the intervention group participated in a 16-week aerobic training program on a conventional motorized treadmill, for three sessions per week, consisting of a warm-up (10–15 minutes), 35- to 50-minute treadmill exercise (increasing by 5 minutes every 4 weeks) at a work intensity of 50 to 65 percent of peak heart rate (increasing by 5% every 4 weeks), measured during a previous maximal treadmill test, and cool-down (5–10 minutes). In order to ensure that the training workload was appropriate during the entire session, all participants from the intervention group wore a wireless wearable heart rate monitor (Sport Tester PE3000, Polar Electro; Kempele, Finland).

Outcomes. Patient-reported outcomes. The Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-Fatigue) is a valid and reliable instrument for measuring fatigue, which has also been validated in patients with psoriasis.27 Responses to the 13 items of the FACIT-Fatigue questionnaire were each measured on a four-point Likert scale. Thus, the total score ranged from 0 to 52. A high score indicated less fatigue.

The Health Assessment Questionnaire- Disability Index (HAQ-DI) consists of 20 items ordered into eight domains to investigate the limitations in performing daily physical activities. The highest item score within each category is used as the score for that category. Finally, the scores for the categories are averaged to construct a single total score ranging from 0 (no disability) to 3 (completely disabled). This scale has been widely used in patients with PsA, both in the literature and in clinical settings.28

Pain intensity was measured using a visual analog scale (VAS). Patients were asked to rate the pain they experienced during the last week on a 100mm line anchored by two descriptors: 0, meaning “no pain,” and 100, meaning “unbearable pain.” A change of over 10mm in the VAS score has been considered a clinically important difference in previous studies that focused on patients with PsA.29

Biochemical outcomes. Blood samples were collected from the antecubital vein into tubes containing ethylenediaminetetraacetic acid (EDTA) after a 12-hour fast. The samples were centrifuged at 3000rpm for 20 minutes in a clinical centrifuge. Plasma was separated and stored at −80°C until further analysis.

The levels of plasma glucose and lipid profile (high-density lipoprotein [HDL]- cholesterol; low-density lipoprotein [LDL]- cholesterol; triglycerides) were measured by spectrophotometry (Advia 2400, Siemens HealthCare Diagnostics; Deerfield, IL, USA). Serum samples were also analyzed using one-step sandwich immunoassays for creatine kinase activity and myoglobin concentration (AU5800 Plus Biochemical Autoanalyzer, Beckman Coulter, Inc.; Brea, CA, USA) as markers of muscle damage. These outcomes were assessed in each participant at baseline (Week 0) and 24 hours after the final training session scheduled in the last week (Week 16) of the program.

Aerobic exercise power. All participants underwent a modified Bruce multistage maximal treadmill protocol,30 first at baseline (Week 0), then at one week after the end of the study. Briefly, the protocol consisted of two warm-up stages, each lasting three minutes. The first was at 1.7mph (2.74km/hour) and zero-percent gradient, and the second was at 1.7mph and five-percent gradient. The slope of the treadmill was increased by two percent at three minute intervals, and the speed was also increased in accordance with the 10-stage protocol (2.5, 3.4, 4.2, 5.0, 5.5, 6.0, 6.5, 7.0, and 7.5mph [4.02, 5,47, 6.76, 8.05, 8.85, 9.65, 10.46, 11.26, and 12.07km/hour]). The test was discontinued when the participant could not continue running due to physical exhaustion. Blood pressure and cardiac electrical activity were continuously monitored for all patients. Maximal oxygen consumption (VO2max) was measured and calculated directly using a gas analyzer (Cosmed Fitmate Med; Rome, Italy). Before each test, the gas analyzers and turbine flowmeter of the system were calibrated according to the manufacturer’s instructions.

Body composition. Body composition was assessed using a bioelectrical impedance analysis (BIA; Tanita TBF521) after an overnight fast. The participants were requested not to perform any moderate or vigorous exercise for 24 hours before testing and to abstain from eating or drinking for two hours before testing. They were also asked to urinate immediately before the collection of the samples. Measurements were obtained while the participant was standing erect and barefoot on the analyzer’s footpads and wearing either a swimsuit or undergarments. Total body water (TBW) was estimated using the equation provided by the manufacturer. The instrument was calibrated before each evaluation using known resistors. Fat mass was determined using the equation devised by Sun et al,31 which was designed for a large population and a broad range of BMI values. In this respect, free fat mass=−9.529+0.696×(height2/ resistance)+(0.168×weight)+(0.016× resistance). Fat mass was calculated as the difference between body weight and free fat mass. The intraclass correlation coefficient for fat mass was 0.98 (0.97–0.99).

Nutritional intake record. To control for the potential confounding effect of diet, participants were carefully instructed to complete a food consumption frequency questionnaire for three days (two weekdays and one weekend day). Energy and nutrient intakes were calculated using specific software (VD-FEN 2.1; Madrid, Spain) based on updated Spanish food composition tables.32

No significant difference was found between the intervention and control groups when assessing energy intake (2,361±241 vs. 2,196±212kcal; p=0.31). Furthermore, the mean daily vitamin intake showed no significant differences (vitamin E: 10.8±2.6 vs. 10.2±2.3mg/d, p=0.16; vitamin C: 87.6±24.4 vs. 82.1±22.8mg/d, p=0.36).

Ethics and statistics. The study protocol complied with the principles of the Declaration of Helsinki (2013). Written informed consent was obtained from all participants. The current protocol was approved by the Institutional Ethics Committee of Cadiz (Cadiz, Spain; protocol code 0159-N-20 02-25-2020).

The results are expressed as mean (standard deviation [SD]). The Shapiro–Wilk test was used to assess whether the data were normally distributed. To compare the mean values, one-way analysis of variance (ANOVA) with post hoc Bonferroni correction was used to account for multiple tests. For all tests, statistical significance was set at an alpha level of 0.05.

RESULTS

The baseline characteristics of patients with psoriasis in the intervention and control groups are listed in Table 1.

TABLE 1. Baseline characteristics of patients with psoriasis in the intervention and control groups

No dropouts or sport-related injuries were reported during the study period. Additionally, the overall mean adherence rate was excellent (92%).

When compared to baseline, the experimental group significantly improved their maximal aerobic power (VO2max; 22.5±5.5 vs. 25.4±4.8mLO2/kg/minute; p=0.020). On the contrary, no changes were found in the control group (21.4±5.1 vs. 21.0±5.3mLO2/kg/minute; p=0.286). Additionally, the intervention also improved fat mass percentage (35.9±4.4% vs. 33.8±4.1%; p=0.016) and BMI (31.7±3.9 vs. 30.3±3.7kg/m2; p=0.039) in the experimental group. As was expected, no significant changes were reported in the control group for both items (36.6±4.8% vs. 37.0±4.2%; p=0.156, and 32.2±4.1 vs. 32.7±4.0 kg/m2; p=0.402, respectively).

The serum lipid profile was significantly improved after the completion of the intervention program (HDL-cholesterol: 47.0±7.1 vs. 54.3±6.8mg/dL, p=0.006; triglycerides: 146.4±17.4 vs. 129.6±16.1mg/dL, p=0.021). Conversely, no significant changes were found when assessing glycemia (109.8±8.6 vs. 103.4±7.9mg/dL; p=0.208). In the control group, neither serum lipid profile nor glycemia were changed in a significant manner. These results are summarized in Table 2. Lastly, the aerobic training caused no significant changes in serum markers of muscle damage after the completion of the intervention program (creatine kinase: 307.7±41.8 vs. 326.0±39.5U/L, p=0.262; myoglobin: 45.2±6.3 vs. 48.0±5.9 ng/mL, p=0.316). None of these changes were statistically significant in the control group (Table 2).

TABLE 2. Serum lipid profile, glycemia, and markers of muscle damage at baseline (preintervention) and at the end of the study (postintervention) in male adults with psoriasis

With regard to the patient-reported outcomes, the mean FACIT-Fatigue score was significantly increased after completing the intervention program (39.2±9.4 vs. 44.5±8.6; p=0.027). Similarly, the experimental group also improved the HAQ-DI score (0.59±0.18 vs. 0.47±0.13; p=0.034). Lastly, VAS score was significantly decreased at the end of the intervention (27.8±15.2 vs. 20.6±14.8; p=0.009). Conversely, no significant changes in any of the above-mentioned outcomes (FACIT-Fatgiue, HAQ-DI, VAS) were reported in the control group (Table 3).

TABLE 3. Influence of the aerobic training program on FACIT-Fatigue, HAQ-DI, and VAS scores in patients with psoriasis at baseline and after completing the intervention program

DISCUSSION

Increasing evidence suggests that psoriasis is a high-impact chronic disease and, therefore, it is fundamental to advocate for a multidisciplinary approach to obtain better health outcomes.16 The present study was the first to evaluate the influence of aerobic training on the musculoskeletal system in patients with psoriasis who do not have PsA. As hypothesized, the intervention program significantly improved both fatigue and musculoskeletal pain. Similarly, in a recent study, Thomsen et al29 reported that patients with PsA tolerated high-intensity interval training (HIIT) without deterioration of disease activity and with a significant improvement in fatigue. This finding was of particular interest, given that the improvement of fatigue has been considered a priority by patients with psoriasis33 and with PsA.34 These promising results were also reported in a systematic review that emphasized that physical activity programs offered clear benefits on fatigue for people with chronic inflammatory conditions, such as arthritis.35

In addition, it should be emphasized that aerobic training did not significantly increase serum markers of muscle damage in the experimental group. Additionally, no dropouts or sport-related injuries were reported during the study period. These results suggest that aerobic training performed at moderate intensity is safe for this population; therefore, neither fatigue nor pain should be considered a barrier to physical activity in patients with psoriasis without PsA.36,37 In contrast, serum markers of muscle damage have been reported to have increased in patients with PsA treated with a first-line, biologic therapy etanercept38 and the Janus kinase (JAK) inhibitor upadacitinib.39

Improvement in both fatigue and pain may ultimately lead to improved function in patients with psoriasis.19,40,41 Similarly, a recent systematic review and meta-analysis concluded that exercise interventions could reduce musculoskeletal pain, which may lead to improved function in patients with other rheumatic and musculoskeletal diseases (RMDs).42 Consequently, these recommendations should guide shared decision-making between patients with RMDs and healthcare providers when developing and monitoring multidisciplinary treatment plans.43

The present study also demonstrated that the intervention improved maximal oxygen consumption in the experimental group. The latter finding could also be explained, at least in part, by the decreased fat mass percentage observed on completion of the program. Our results also demonstrated that a 16-week aerobic training program improved lipid profiles in adult patients with psoriasis. In clinical practice, similar results have been reported when using classical (statins) and new (glucagon-like peptide-1 [GLP-1] receptor agonists, e.g., pioglitazone) hypolipidemic drugs on psoriasis.44 These results could be of great interest, given the link between cholesterol metabolism and psoriatic chronic inflammation reported in recent studies.45 However, it should be highlighted that statin therapy may increase muscle pain and weakness,46 whereas the current intervention based on aerobic training may improve both pain and fatigue in patients with psoriasis.

In a previous study, Thomsen et al47 reported that a three-month intervention program based on HIIT significantly improved not only oxygen consumption (expressed as VO2max) but also truncal fat percentage in adult patients with PsA. It should be highlighted that the follow-up of these patients showed that these promising results were maintained for at least up to nine months after completing the intervention program.47 In a later study, the same research group found no evidence of inflammation in peripheral joints and entheses in patients with PsA after completing structured HIIT for 11 weeks.48 Even more pieces of evidence are available when reviewing the literature, suggesting that HIIT is safe for patients with PsA.49

The reduction in fat mass may be of great interest to these patients, as visceral fat has been shown to be strongly associated with disease activity in psoriasis.7 Similarly, weight loss induced by an intervention based on a very low-energy diet (daily intake of 640kcal) was associated with sustained improvement in disease activity after a 24-month follow-up period.50 Regarding potential confounding effects of diet in the present study, no significant differences regarding daily total energy or antioxidant vitamin intake were found between the intervention and control groups. Surprisingly, a previous study found that adult patients with psoriasis had a poor nutritional status, and were at risk of nutrient deficiencies, compared to BMI-matched controls without psoriasis.5 On reviewing the literature on this population group, it appears that future studies focusing on interventions based on the combination of a healthy anti-inflammatory personalized diet and exercise are urgently required.51

The high prevalence of overweight and obesity among patients with psoriasis may contribute to the increased cardiovascular disease risk reported in previous studies.23,52 Visceral adiposity may be a more pressing concern in psoriasis relative to PsA, because visceral fat accumulates more in patients with psoriasis alone than in patients with PsA.52 Jarret53 concluded that dermatologists and general practitioners should play an additional role in informing patients with psoriasis about their increased cardiovascular risk. For the reasons already mentioned, Blake et al7 pointed out that fat mass could be an important future target for both pharmacological and lifestyle interventions. In fact, our study demonstrated that regular exercise could be an effective and safe lifestyle intervention to achieve this goal.

The location of skin lesions should be taken into account when designing specific interventions based on physical activity for this population group. Palmoplantar psoriasis (PPP) is a disabling and challenging type of psoriasis that affects the skin of the palms and soles typically in a bilateral and symmetrical way. Although the prevalence of PPP in patients with psoriasis may be as low as 2.8 percent,54 these patients suffer from significantly higher impairment during both work and leisure time.55 In the current design, focused on treadmill running, patients with plantar psoriasis were excluded, and this fact may have contributed, at least partially, to the excellent adherence rate observed during the intervention.

Limitations and strengths. Finally, the current study has some limitations. A major limitation was the relatively short duration of the exercise intervention and the lack of follow-up to determine the optimal duration of the aerobic training for the positive effects to be maintained. Additionally, it would have been of interest to assess the effect of the intervention not only on fat mass percentage, but also on fat mass distribution, given the key role of visceral fat mass on psoriatic comorbidities. Lastly, the fact that female patients did not participate in the present study may mean that the current results have a weaker applicability in clinical practice. The current intervention focused just on male patients was based on the fact that pain and fatigue are more severe and frequent among female patients with psoriasis, so more withdrawals and injuries could be expected.56 In addition, previous studies have also reported a higher incidence and prevalence of PsA in male patients.57 Consequently, future studies ensuring the appropriate enrollment of female patients are still required to confirm the current promising results in male patients with psoriasis.

On the other hand, the strengths of the current study include the excellent adherence rate and safety of aerobic training for adults with psoriasis. In addition, a larger (n=118 vs. n=67) and more homogeneous (118 men vs. 43 women plus 27 men) study population was enrolled than that in a previous study on this topic.29 It should also be noted that the threshold for disease activity (PASI 1) was among the inclusion criteria for the study. This intervention can easily be reproduced using a conventional motorized treadmill at home. In fact, in a recent study that focused on barriers to physical activity, it was found that patients with psoriasis may fear the negative reaction of other people to their visible skin lesions and, consequently, they were less likely to exercise in fitness centers and swimming pools.36 Similarly, children and adolescents with this condition have been reported to be stigmatized by peers, so their recreational activity could also be severely affected.58 Lastly, given that psoriatic skin lesions also interfere with sweating,59 the control of temperature and humidity during exposure to exercise may play a key role in guaranteeing participants’ comfort and reducing the risk of heat intolerance. Accordingly, treadmill running in climate-controlled environments was an adequate intervention design that may explain, at least in part, the excellent adherence rate in the current study.

CONCLUSION

A 16-week moderate-intensity aerobic training program reduced fatigue and muscle pain in patients with psoriasis without PsA. In addition, it improved aerobic power and body composition. More long-term follow-up studies are required to determine whether the effects induced by aerobic training may improve clinical outcomes in patients with psoriasis without PsA.

AUTHOR CONTRIBUTIONS

Conceptualization: AJD, JCA, IR, and MB; methodology: MAR, JD, FJO, CC-R, and MR-RM; software: MJB, NG-G, ES-S, and CC-R; validation: AJD, JCA, and IR; formal analysis: MJB, NG-G, and ES-S; resources: AJD, JCA, IR, and JD; data curation: MJB, NG-G, MB, JD, and CC-R; writing— original draft preparation, AJD, ES-S, MAR, IR, and JD; writing—review and editing: MR-RM, FJO, MB, and JCA; visualization: AJD, IR, FJ,. and MR-RM; supervision: AJD, IR, FJO, and MR-RM. All authors have read and agreed to the published version of the manuscript.

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Regular Exercise Improved Fatigue And Musculoskeletal Pain In Young Adult Patients With Psoriasis Without Psoriatic Arthritis
https://jcad.mydigitalpublication.com/articles/regular-exercise-improved-fatigue-and-musculoskeletal-pain-in-young-adult-patients-with-psoriasis-without-psoriatic-arthritis

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