## 4 Discussion  
This systematic review aimed to provide scientific evidence on the effectiveness of exercise as a therapeutic approach for patients with pSS. The results may be valuable to professionals looking for rehabilitation strategies to reduce the impact of this condition on patients' overall health. After conducting an extensive and thorough search, only a small number of studies met the criteria for inclusion in this review. However, the majority of the studies analyzed were RCTs of good methodological quality. Considering the existing gap in the literature regarding the prescription of exercise for individuals with pSS, the findings of this review offer valuable and thought-provoking data that merit further discussion. For instance, it is noteworthy that all the studies included reported on the effects of exercise on quality of life. This is an important topic to address, as treatment goals for patients with pSS should focus not only on extragalandular symptoms but also on improving quality of life outcomes [50]. Fatigue levels have also been considered as a predictor of quality of life in this population, given their detrimental impact on both physical and mental health [51]. Previous systematic reviews have demonstrated that exercise modalities, such as yoga and resistance training, result in significant improvements in the quality of life for patients with rheumatic diseases [52, 53]. Interestingly, while intra-group analyses typically showed significant positive effects of exercise on this outcome, inter-group comparisons largely indicated that these effects were not superior to those achieved with standard treatment. This lack of effect of exercise on the usual treatment may be attributed to the limited impact that exercising has on several disease hallmarks that significantly influence the quality of life in this population, including dryness, autonomic responses, pruritus, and both oral and ocular disorders [54]. Additionally, it is important to note that exercise was not found to be superior to standard treatment in alleviating anxiety and depression, both of which are strongly linked to quality of life [55]. Similarly, other systematic reviews have noted that exercise could have a similar but not superior effect to standard treatment for depression [56] or anxiety [57]. Thus, it appears that the impact of exercise on the mental health of patients with pSS is limited. \begin{table}
\begin{tabular}{c c c c c} \hline \hline \multirow{2}{*}{**Randomized Controlled Trials (PEDro Scale)**} & \multicolumn{5}{c}{**First Author, Year**} \\ \cline{2-5}  & **[PERSON] et al.** & **[PERSON] et al.** & **[PERSON] et al.** & **[PERSON] et al.** \\  & **(2022)**[40]** & **(2021)**[41]** & **(2019)**[43]** & **(2019)**[42]** \\ \hline
7. Adequate follow-up & + & + & + & + \\
8. Intention-to-treat analysis & – & + & + & + \\
9. Between-group comparisons & + & + & + & + \\
10. Point estimates and variability & + & + & + & + \\ \hline Total score & 7/10 & 8/10 & 8/10 & 8/10 \\ \hline Comparative study (MINORS scale) & & [PERSON] et al. (2007) [44] & & \\ \hline
1. Clearly stated aim & & 2 & & \\
2. Inclusion of consecutive patients & & 1 & & \\
3. Prospective collection of data & & 2 & & \\
4. Endpoints appropriate to the aim of the study & & 2 & \\
5. Unbiased assessment of the study endpoint & & 0 & \\
6. Follow-up period appropriate to the aim of the study & & 2 & \\
7. Loss to follow up less than 5\% & & 0 & \\
8. Prospective calculation of the study size & & 0 & \\
9. Adequate control group & & 2 & \\
10. Contemporary groups & & 2 & \\
11. Baseline equivalence of groups & & 2 & \\
12. Adequate statistical analyses & & 2 & \\ \hline Total score & & 17/24 & \\ \hline \hline \end{tabular}
\end{table} 
Table 3: _Cont._In this context, most of the analyzed studies indicated that disease severity was not influenced by participation in exercise training programs. The lack of efficacy of exercise in modifying disease activity has also been observed in patients with lupus [58].