Systemic lupus erythematosus (SLE) is an autoimmune disease that may affect men or women and may begin at any stage of life. Little research describes the aetiology and pathogenesis of SLE, and as a result of the lack of funding in this area, little is understood about the causes and underlying mechanisms of the condition. Systemic lupus erythematosus may be associated with particular infections or hormones. The susceptibility genes for SLE are also not known at the present time.
Patients with systemic lupus erythematosus tend to experience chronic and acute phases of their illness. The acute phases are of inconsistent intensity and duration and commonly lead to the patient feeling ill, such as during a high fever or virus. Patients may also experience a certain degree of associated organ damage.
Individuals suffering from lupus tend to experience “flare ups” when an acute phase of the illness places pressure on the body’s organs. In some cases, these flare ups require the administration of drug therapies to prevent further organ damage. Management techniques are centered on corticosteriods in the case of organ damage, although this has been found to inhibit bone growth.
Because organ damage predominantly occurs in SLE patients during childhood, the prescription of corticosteriods is controversial. As stated above, corticosteriods have been found to markedly inhibit bone formation, so their administration to those who are growing or even those who are suffering from osteoporosis is recommended sparingly. Central Nervous System (CNS) abnormalities are also common in patients with SLE. Symptoms of CNS dysfunction are often apparent in otherwise asymptomatic individuals with lupus.
Athletes or other individuals who take part in regular physical activity may exhibit symptoms of overtraining when lupus is the cause of the symptoms. In particular, symptoms of persistent and chronic joint pain, recurring or persistent injuries, tiredness, elevated resting heart rate and a sluggish recovery may by the result of SLE, rather than the more commonly diagnosed overtraining syndrome.
Benefits of Exercise
Little data exists pertaining to the efficacy of exercise programs as part of the treatment or management of systemic lupus erythematosus (SLE). Ward et al examined a number of psychosocial factors in female patients with SLE. They found that a greater physical disability from SLE was associated with higher depression scale scores and higher body mass index (BMI) values. This means that your patient with lupus may be overweight but more reluctant than most to be proactive in their treatment.
Ward et al also found that greater cumulative organ damage was associated with lower self esteem. Financial barriers to medical care, knowledge about activity and SLE, marital status, health behaviours including compliance with medications, smoking, alcohol use and exercise were not associated with morbidity in SLE.
A wide use of corticosteriods as a cornerstone of therapy exists for lupus patients. They are used in the case of major organ damage or times of increased susceptibility to major organ damage. This treatment elicits a growing concern for the adverse effects on growing bone - in particular, the effects on bone development in adolescents and those suffering from osteoporosis. Regardless of current state of development, the quantities of medications administered have been found to induce osteoporosis in this population. Hahn et al found that three months' treatment with high doses of glucocorticoids significantly reduces bone mass. This effect was found to be independent of age, sex or race. The bone loss was the most severe during the first 6-12 months of treatment.
In order to prevent significant bone loss, vitamin D and calcium supplementation - in conjunction with exercise training - are recommended for SLE patients using medication. I also recommend that supplementation should only be encouraged if patients cannot obtain sufficient nutrients in their diet. This is not only because nutrients from foods will be better absorbed but also to prevent any nutritional imbalances caused by overeating a particular micronutrient.
Kipen et al studied the effects of exercise training on the preservation of bone mineral density (BMD) in SLE patients using medication. The results of the study show that exercise preserved BMD in female patients using medication. The literature observed has not referred to the effects of the medication on male SLE patients, and consequently it is not appropriate to remark upon the possible benefits of exercise training to male SLE patients.
A study by Sakauchi et al refers to low aerobic exercise capacity of patients with SLE. The lower work capacity is common among all patients suffering from SLE. I support this finding and have found similar issues in my SLE patients. A consequence of this is the inability for patients to participate in normal levels of physical activity at a comfortable level. Resting heart rate as well as exercising heart rate are often elevated above normal levels. This is the result of a diminished O2 diffusion ability in the peripheral muscles, meaning that daily activities such as walking to the shops require greater effort and heart rate response than for a normal and healthy individual. Another effect of this is that the patient feels disproportionately fatigued in the days following an exercise session.
Because of the low anaerobic threshold and decreased aerobic work capacity, it is first necessary to begin increasing aerobic fitness. Use a heart-rate monitor to assess training intensity and heart rate response during the training session. Preferably use a heart rate monitor with a download facility, so that it is possible to document heart rate graphs for each workout. The benefit of this is that recovery ability can be viewed over any given period of time, and abnormal or elevated heart rate peaks can also be observed. This is particularly important with SLE patients as they will feel more fatigued from their training that you might expect.
Heart rate monitoring should not be the only means of monitoring a patient with SLE. Because heart rate is persistently elevated above values for a normal and healthy individual, the heart rate given may be misleading. In addition to the heart rate monitoring, the Rate of Perceived Exertion (Borg) scales should also be used, as well as the usual visual and verbal assessments.
Training sessions should consist of an evaluation before commencement of the workout. This is to assess the client’s state of well being and to find out if an acute stage of SLE has occurred recently or if the client has recently experienced any joint pain or above-normal feelings of lethargy. This should be taken on board and reviewed by the trainer with his/her own knowledge of that particular individual’s level of fitness and recovery from previous exercise sessions.
The workout should begin with an extended warm up of at least 10 minutes on a recumbent cycle or similarly low-intensity and easy-going piece of equipment. You would expect to begin the session with the client’s heart rate already elevated above what you would expect, and anxiety levels may be heightened due the individual’s low level of self esteem. A low level and very gradual progression in intensity would be required, and the warm up would take as long as necessary for the client to reach his working heart rate intensity before moving on.
At this stage, the client should perform mobility work before proceeding to the second piece of cardiovascular equipment. The workout should then progress as with any client but with particular care of working intensity and provision of extended recovery periods. The training could involve adjusted interval and/or Fartlek training in order to prioritize an improvement in recovery ability and to allow the client to train at an intensity level that would allow for training adaptations to take place following the workout. Ensure that the client cools down and warms up sufficiently between pieces of equipment, as it is important to avoid blood pooling during any extended rest periods. His cardiovascular system will adapt to the workout, so it is not likely to be the same sort of cool down and warm up as you would have at the beginning and end of the session, but during the first few weeks, some extra effort needs to be put in to prevent detrimental effects during the exercise session itself.
Analysis of Training Program
The structure of this training program suggests a particularly gentle approach to a new exercise behavior. Exercise is beneficial in the treatment of SLE through an improvement in aerobic capacity, and consequently an improved ability to perform activities of daily living. Aerobic training is recommended as an efficient means of increasing aerobic capacity. During exercise sessions with my SLE patients, I was able to train the individuals at a high intensity on many occasions during the workout to facilitate an increase in the lower than normal anaerobic threshold.
The average heart rate for the workout should be targeted at a moderate intensity. This is sufficient for many of the basic health benefits the client wished to obtain and is high enough to ensure that the workout allowed for some effective fat burning.
By improving cardiovascular function, the client may benefit from an improved ability to perform activities of daily living. In contrast, many sufferers of SLE who do not exercise become effectively disabled by their inability to perform small amounts of physical exertion.
Because of integration of high-intensity exercise later on in the training, the recovery ability of the client may improve quickly over time. The disadvantage of exercise programming for a client with SLE is that exercise may often trigger an acute phase of SLE. What the exercise professional must remember is that an acute phase may often be triggered when the patient walks to the shops or does some gardening. Therefore, an acute phase should almost be anticipated, and the patient should definitely be warned about this prior to commencing the exercise session. The reason you exercise is to improve aerobic capacity and prevent or limit this effect during activities of daily living. Again, I have observed this with my patients. An acute phase could be triggered by a 10- to 20-minute gentle walk and last for 3-5 days, reducing the patient to a similar state to if he had the flu. Following a gently but progression approach to a new exercise behavior, it was observed that the patient would have lower severity acute phases, and these phases would rarely be caused by activities of daily living.
Resistance training was not recommended here, despite the obvious benefits for a client who is susceptible for osteoporosis. Resistance training in the early stages of this exercise behavior would be of too high an intensity and would severely inhibit recovery ability. Some very light resistance-based exercises could be introduced after a few weeks, but initially the benefits in offsetting any orthopaedic conditions would come from the impact of weight-bearing aerobic work alone. This may obviously depend on the severity of the patient’s SLE and his prior experience of exercise.
Conclusions and Recommendations
The exercise program outlined above would be sufficient to elicit positive results in a relatively short space of time. The client should experience a greater feeling of well being and vastly improved energy levels. The client’s recovery ability should also markedly improve. Having received doctor approval and appreciating that the client is of a sufficient level of aerobic fitness, resistance training should commence as a progressive second stage of the program. The goal will be to continue improving fitness levels, reduce body fat (if appropriate), improve BMD and improve any appropriate psychosocial factors.
Research of the effects of exercise for patients with SLE is scarce. Few studies offer appropriate recommendations for the exercise programming of patients with SLE, in particular the use of aerobic training programs.
Exercise training clearly offers a number of benefits to individuals with SLE, and further research needs to evaluate appropriate training modalities, frequencies and assessment techniques for this population.
- A.C.S.M. (1997) “Exercise Management for Persons with Chronic Diseases and Disabilities”, Human Kinetics, Champaign, Ill, USA.
- Arkachaisri, T, et al, “Systemic lupus erythematosus and related disorders of childhood”, Current Opinions in Rheumatology, 1999, 11(5), 384-92.
- Hahn, B.H, et al, “Glucocorticoid-induced Osteoporosis”, Hospital Practice, 1995, 30 (8), 45-9.
- Kipen, Y, et al, “Three year follow-up of bone mineral density change in premenopausal women with systemic lupus erythematosus”, Journal of Rheumatology, 1999, 26 (2), 310-7.
- Sakauchi, M, et al, “ Reduced muscle uptake of oxygen during exercise in patients with systemic lupus erythematosus”, Journal of Rheumatology, 1995, 22 (8), 1483-7.
- Steine, H.A, et al, “Sports Injury Look-Alikes”, The physician and sports medicine, 1994, 22 (9), 60-70.
- Ward, M.M, et al, “Psychosocial correlates of morbidity in women with systemic lupus erythematosus”, Journal of Rheumatology, 1999, 26 (10), 2153-8.