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Exercise for the Treatment of Lupus

By Andrew Williams and Adam Knapek
Introduction
Systemic Lupus Erythematosus (SLE) is an autoimmune disease which can affect almost every organ system within the body. SLE develops when there is a malfunction in the production of antibodies, which lack the ability to recognise ‘self’. As a result the antibodies begin to attack healthy cells within the body, resulting in inflammation, tissue damage and loss of function (Miah, Hague et al. 2008). SLE affects 1 in 700 people, with a higher prevalence of the condition among women than men (Jimenez, Cervera et al. 2003).

Common symptoms include musculoskeletal issues, heart disease, pulmonary disease and depression (Strombeck and Jacobsson 2007). One of the most prominent and debilitating symptoms reported by patients with SLE is severe fatigue (Madhok and Wu 2009). These symptoms can reduce the physical capabilities of the individual, including functional capacity (Hochberg and Sutton 1988), aerobic capacity (Tench, Bentley et al. 2002) and quality of life (Fortin, Abrahamowicz et al. 1998). A vicious cycle can arise as these symptoms often cause individuals to stop exercising and can lead to them avoiding activity altogether (Ayan and Martin 2007). This sedentary state results in further de-conditioning of the individual, resulting in greater disability and fatigue and increasing the risk of the development or progression of associated cardiovascular and metabolic conditions. Patients with SLE exercise less frequently and have lower exercise capacity compared to healthy counterparts (Eriksson, Svenungsson et al. 2012) and individuals’ with more severe forms of SLE exercise even less than those with less severe SLE.

Individuals with SLE typically experience ‘flares’ when symptoms are exacerbated as well as stages of remission (Gurevitz, Snyder et al. 2013). There is currently no cure for SLE however there are treatment options available. The treatment of SLE is individualised for each patient as it depends on the clinical manifestations present, organ systems involved and severity of the condition (Gurevitz, Snyder et al. 2013). Treatment is currently dominated by pharmacological options, primarily to reduce inflammation as well as treat specific symptoms such as depression and pain.

Implications/Progression of Disease
Currently pharmacological therapy is the main treatment modality for the treatment of autoimmune diseases with medications targeting inflammation and symptoms such as pain. There is no doubt that these medications can lead to reductions in inflammation and chronic pain thereby reducing a number of health and clinical impairments that occur as a result of chronic inflammation. However these powerful medications often have side effects which can contribute to wasting of muscle and bone, and changes in the structure of muscles leading to them becoming more fatigable, and increasing the risks of suffering accidental falls and bone fractures. Other effects of these medications can also make the patient more susceptive to external pathogens, cause metabolic disease, fatty liver disease or type 2 diabetes, and contribute to progression towards cardiovascular disease (Perandini, de Sa-pinto et al. 2012).
Regular exercise in its many forms can directly lead to reductions in inflammation in chronic diseases that are characterised by a low-grade systemic inflammation, for example type 2 diabetes or chronic heart failure.

Given that SLE is characterised by chronic inflammation, it seems reasonable to suggest that exercise may directly combat inflammation at the heart of the disease process. In addition to this proposed mechanism however, exercise has been shown to result in improvements in immune function, to manage and even reverse metabolic conditions such as type II diabetes and to assist in maintaining and building bone density and muscle mass thereby improving functional capacity and reducing the risk of falls and fractures particularly in older individuals. Consequently there is a strong argument that exercise should be considered as a complementary therapy in the treatment of SLE and other autoimmune diseases. To date however there have been few studies that have investigated the benefits of exercise training in patients with SLE. The studies that have been conducted have not always reported similar results which may be due to differences in the length of exercise training programs trialled and the types and intensities of the training stimulus that has been used. What can be stated with certainty however, is that exercise training can lead to a number of benefits without leading to any worsening of the disease or increases in inflammation (Perandini, de Sa-Pinto et al. 2012) and that exercise can delay or reverse many of the side effects associated with the common pharmacological treatments through its positive effects on bone development, and its ability to reduce cholesterol levels in the blood and prevent the progression towards type II diabetes.

Figure 1 

exercise-figure-1 

Recommendations
In most chronic conditions and exercise program containing endurance, resistance and flexibility exercises will provide the best outcomes. Although the benefits of exercise have not been as well established in SLE as for other chronic conditions, it is recommended that exercise should contain a combination of aerobic, resistance and flexibility exercises due to the combined benefit that these different exercise modalities provide in other conditions.

Aerobic is important as it increases exercise tolerance and improves the health of the blood vessels (dos Reis-Neto, da Silva et al. 2013) thereby reducing the risk of cardiovascular complications, and improving the ability to perform normal activities of daily living as well as reducing depression, anxiety, pain and fatigue in SLE patients (Perandini, de Sa-Pinto et al. 2012).

Resistance exercise has been shown to increase muscle strength which assists in taking pressure off sore joints affected by the disease and also assists in maintenance of balance and consequently reduced falls risk (Perandini, de SA-Pinto et al. 2012). Another benefit of resistance training is the maintenance of bone mass reducing the risk of fractures.

Where possible flexibility exercise (stretching) should be combined with the other forms of training you maintain flexibility and assist in ongoing maintenance of function.

General recommendations for each type of exercise for patients with SLE are included in Table 1

Table 1 Exercise Recommendations for Non-Complex patients with SLE

  Aerobic (Endurance) Resistance (Strength) Flexibilility
Mode Large Muscle Groups

All major muscle groups (6-10 exercises)

Major Muscle Groups
Frequency 3-4 Days per Week 2-3 Days per Week 5-7 Days per Week
Intensity

60-80% max Heart Rate
(A level at which there is a noticeable increase in rate
and depth of breathing but at which you can
still maintain conversation)

3-4 sets of 8-12 Repetitions

 
Duration

20-60 minutes per session

20-60 minutes per session

~10 minutes per session

 

Length and intensity of training are also important with studies that have exercised participants at higher intensities or had longer intervention periods (≥ 12 weeks) generally reporting better outcomes than those that have had shorter invention periods or lower intensity often unsupervised exercise or physical activity.

This is important  - Aerobic (Endurance) Resistance (Strength) Flexibilility (Stretching) Mode Frequency Intensity Duration Large Muscle groups 3-4 days per week 60-80% max Heart Rate (A level at which there is a noticeable increase in rate and depth of breathing but at which you can still maintain conversation) 20-60 minutes per session All major muscle groups (6-10 exercises) 2-3 days per week 3-4 sets of 8-12 Repetitions 20-60 minutes per session Major muscle groups 5-7 days per week ~10 minutes per session they start noticing improvements in their condition. This must be kept in mind as it can be easy during the early weeks to give up as the exercise does not appear to be providing the expected benefits.

While exercise of the types and intensity included in table 1 is encouraged it needs to be prescribed and commenced with care due to the many contraindications for specific types of exercise that may exist in patients with SLE due to coexisting medical conditions. The effects of any additional conditions on overall health and subsequent risks should be considered when prescribing exercise for these patients and if in any doubt how to commence exercise, individuals should seek advice from an appropriate health professional. For many individuals with SLE this may involve discussing their wish to become more active with their GP. The GP may be able to provide suitable advice or may choose to refer to an Exercise Physiologist for prescription and supervision of an appropriate exercise program. If sufferer qualifies for a chronic disease management plan, this may allow any allocated visits to an Exercise Physiologist to be at least partially covered by Medicare.

In summary, exercise is likely to provide multiple benefits to the SLE sufferer, reducing the disease burden, and improving physical function and quality of life. However to really be of benefit it must be performed regularly and at an appropriate intensity. Those seeking help with getting started should consult an appropriate health professional.

References
Ayan, C. and V. Martin (2007). “Systemic lupus erythematosus and exercise.” Lupus 16 (1): 5-9.

Dos Reis-Neto, E. T.,A. E. da Silva, et al. (2013). “Supervised physical exer cise I improves endothelial function in patients with systemic lupus ery thematosus and matched controls.” Rheumatology (Oxford) 52 (12): 2187-2195.

Eriksson, K., E. Svenungsson, et al. (2012). “Physical activity in patients with sys temic lupus erythematosus and matched controls.” Scand J Rheumatol 41 ( (4):290-297.

Fortin, P.R., M.Abrahamowicz, et al. (1998). “Impact of disease activity and cumulative damage on the health of lupus patients”. Lupus 7( 2): 101-107.

Gurevitz, S. L., J. A. Snyder, et al. (2013). “Systemic lupus erythmatosus: a review of the disease and treatment options.” Consult Pharm 28(2): 110– 121.

Hochberg, M.C. and J.D. Sutton (1998). “Physical disability and psychosocial dys function in systemic lupus erythematosus. “ J Rheumatol 15(6): 959-964.

Jimenez, S., R. Cervera, et al. (2003). “The epidemiology of systemic lupus erythe matosus.” Clin Rev Allergy Immunol 25(1): 3-12.

Madhok, R. and O. Wu (2009). “Systemic lupus erythematosus.” Clin Evid (online) 2009. Miah, T., M.A. Haque, et al. (2008). “Clinical profile, management and outcome of l lupus.” Mymensingh Med 17(2 suppl): S6-11.

Perandini, L.A., A.L. de Sa-pinto, et al. (2012). “Exercise as a therapeutic tool to counteract inflammation and clinical symptoms in autoimmune rheumatic dis eases.” Autoimmune Rev.

Strombeck, B. and L.T.Jacobsson (2007). “The role of exercise in the rehabilitation of patients with systemic lupus erythematosus and primary Sjogren’s syndrome.” Curr Opin Rheumatol 19(2): 197-203.

Tench, C., D. Bentley, et al. (2002). “Aerobic fitness, fatigue, and physical disability in systemic lupus erythematosus.” J Rheumatol 29(3): 474-481.

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