Overview

Background
Systemic lupus erythematosus (SLE) is an inflammatory connective tissue
disease with variable manifestations (eg, rash; see the images
below). [1, 2, 3] SLE may affect many organ systems with immune complexes
and a large array of autoantibodies, particularly antinuclear antibodies (ANAs).
It is a disease characterized by relapses, flares, and remissions. Common
manifestations, in addition to the malar rash, include cutaneous
photosensitivity, nephropathy, serositis, and polyarthritis. The overall outcome
of the disease is highly variable with extremes ranging from permanent
remission to death. [4]

The classic malar rash, also

known as a butterfly rash, of systemic lupus erythematosus, with distribution
over the cheeks and nasal bridge. Note that the fixed erythema, sometimes
with mild induration as seen here, characteristically spares the nasolabial
folds.
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 Photosensitive systemic lupus
erythematosus rashes typically occur on the face or extremities, which are
sun-exposed regions. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic.
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As with many chronic conditions, SLE adversely affects quality of life due to
factors such as depression, pain, cognitive dysfunction, and sleep
disturbances. [5]
Despite having a poorly understood etiology, fatigue is associated with SLE in
approximately 80% of cases, which leads to a decreased level of physical
fitness and, subsequently, decreased ability to perform activities of daily
living. [6] Surveys of European SLE patients furthermore associate fatigue and
burden to others as primary causes of decreased quality of life, impaired
productivity, and hindered career choices. [5]
In addition to decreased isometric strength, premenopausal SLE patients
have also been found to have less upper and lower body dynamic muscle
strength, which is further associated with low functional performance,
decreased quality of life, and fatigue. [6]
Physical medicine and rehabilitation for SLE may involve physical therapy,
occupational therapy, speech therapy, recreational therapy, or combinations
thereof. Follow-up medical care of patients with SLE must be ongoing. One
physician should coordinate the patient’s care. The physician and the patient
must be alert to subtle changes in symptoms that may indicate a flare-up in
the disease process.
A study by Perandini et al reviewing postexercise levels of interleukin and
soluble tumor necrosis factor receptor levels in women with SLE indicated,
after comparison with healthy controls, that exercise has a homeostatic
immunomodulatory effect in SLE. [7]

Treatment & Management

Physical therapy
Physical therapy (PT) is often beneficial for patients with systemic lupus
erythematosus (SLE). The role of the physical therapist is to assess each
patient and to determine an effective plan of care to help reduce pain,
stiffness, and inflammation, as well as to improve joint range of motion (ROM)
and functional mobility. [8] Key points to keep in mind when developing a PT
program for a patient with SLE include the following.
SLE is a disease with high individual clinical variability in presentation. Thus,
exercises should be individualized. [9]
Individuals with SLE also have reported less overall exercise and lower
exercise capacity when compared with controls. [10] Aerobic exercise might
improve aerobic capacity in patients with mild SLE [11] and may also decrease
overall fatigue. [12]
Arthritis is a common occurrence of SLE, with an incidence of 69-95%;
however, it is usually less inflammatory than rheumatoid arthritis, although
joint deformities may still occur. Arthritis in SLE occurs predominately in the
hand and knee, yet most joints may be affected. [13] For patients with
predominant arthralgias or arthritis, techniques used in rheumatoid arthritis
may be helpful. Incorporate isometric exercises for patients with joint
inflammation, especially for the hip and knee (to help maintain biomechanical
stability). [14] Isotonic exercises can be used when joint inflammation is
reduced or absent. Transfers and ambulation activities are important for
maintaining mobility.
Aerobic exercise has not been shown to aggravate disease activity in patients
with low-to-moderate disease activity in SLE; however, this has not been well
documented in patients with high disease activity. [11] A literature review by
Del Pino-Sedeño et al indicated that aerobic exercise can reduce fatigue in
adults with SLE. The investigators found, however, that the results of this
intervention were not completely consistent across the instruments used in
the report's studies. [15]
Strengthening exercises are initiated when appropriate. Fatigue may hinder
progress in some patients. ROM exercises in the presence of inflammation
may induce more pain. Isometric exercises may be better
tolerated. [14] Hydrocollator packs can be helpful prior to completing ROM to
help reduce pain and stiffness.
If pain lasts for more than 1-1.5 hours following activity, the exercise regimen
should be reduced in intensity and/or duration.
Proper positioning may prevent joint contractures in patients with SLE. Do not
use a pillow under a painful knee.
Ultrasonography (US) is a modality commonly used to provide deep heat to
the affected joint, but it should not be used in the presence of inflammation;
ice is the preferred modality for inflamed joints. When US is used to improve
ROM, movement of the joint and the application of US should be
simultaneous.
A pool, when available, is an excellent setting for exercising inflamed joints
because of the buoyancy of the water (providing unloading of the joint) and
the soothing quality of warm water.
The cardiovascular and pulmonary systems may also be affected in SLE.
Pacing strategies are useful when severe cardiac and pulmonary problems
are apparent. In addition to improving aerobic capacity, physical exercise may
also improve endothelial function. [16] Abnormal breathing patterns during
exercise may contribute to exercise intolerance, and respiratory exercises
could be beneficial. [17]
Assistive devices, such as canes and walkers, are often helpful based on the
patient’s individual needs.
Occupational therapy
The role of the occupational therapist (OT) is to help the patient regain as
much of his or her functional independence as possible despite the problems
caused by the disease. Principles of occupational therapy for patients with
SLE include the following.
Activities of daily living (ADLs) are encouraged and may require training with
special equipment, techniques, and procedures. ADLs include feeding,
dressing, bathing, toileting, grooming, and homemaking. [18]
Adaptive equipment may be necessary for patients to complete ADL tasks;
some of the more common adaptive equipment includes a raised toilet seat,
splints, and reachers. Elastic (no-tie) shoelaces and wide-handled tools may
increase the degree of independence.
Educating the patient in joint conservation techniques to protect the joints from
damage is important. Paraffin baths are comforting for patients with hand
involvement and may improve use.
As stated previously, fatigue is one of the most frequent and debilitating
symptoms that must be dealt with in patients with SLE. The OT can be helpful
in teaching the patient energy conservation techniques, frequently using
adaptive equipment.
A home safety evaluation may be indicated. The OT can provide
recommendations for equipment (eg, bathtub bench, raised toilet seat, grab
bar) to increase the patient’s independence and safety with mobility at home.
Gentleness is important in all settings.
Speech therapy
Patients with neuropsychiatric SLE may also present with cognitive
dysfunction, with deficits of executive skills, attention, language, memory,
psychomotor speed, and visual-spatial processing. [19, 20]
The speech pathologist can be helpful when a patient with SLE has slurred
speech, difficulty understanding speech, or difficulty speaking appropriately.
Evaluation by a speech pathologist may also be beneficial for patients with
memory impairment, attention deficits, and visual-spatial rehabilitation. [13]
SLE patients with swallowing problems can also be evaluated and treated by
the speech pathologist.
Recreational therapy
The role of the recreational therapist (RT) is to involve the SLE patient in
enjoyable activities that have therapeutic value. For example, a patient who
has painful or weak hands, may benefit from putting a jigsaw puzzle together,
which is a light activity that enhances the patient’s eye-hand coordination and
his/her ability to match pieces by color. Patients can do this while standing or
sitting (whichever is most appropriate) and at the same time can be socializing
with other patients.
Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered for
symptomatic management of arthralgia, myalgia, and serositis; however, they
should be used for short durations and caution should be used in patients with
renal insufficiency, cardiac comorbidities, and risks for GI complications. [21]
Hydroxychloroquine is anti-inflammatory and immunomodulatory. It is useful
for managing musculoskeletal and mucocutaneous issues and symptoms
such as fatigue and fever. It may also be cardioprotective and reduce low-
grade flares, thereby slowing disease progression. [21]
Corticosteroids have often been used in the treatment of SLE owing to their
immunosuppressive and anti-inflammatory properties. In addition to topical
applications for discoid lupus and certain rashes and oral/IV uses for mild-to-
severe disease manifestations, intra-articular steroid injections may also be
considered for joint involvement. Caution should be used when giving
corticosteroids with NSAIDs owing to increased risk of GI ulceration. [21]
Immunosuppressive agents such as azathioprine and cyclophosphamide may
be used in moderate-to-severe disease to further reduce organ damage and
inflammation. These medications may also serve to decrease steroid use.
Other agents are used in SLE work to deplete B cells or target T- and B-cell
interaction to interfere with the immune cascade. [21]

https://emedicine.medscape.com/article/305578-overview#showall
 Cardiovascular and Pulmonary Physical Therapy - E-Book: Evidence to Practice
Oleh Donna Frownfelter,Elizabeth Dean
Recommended Baseline Testing of Fitness Levels

 Use a walking test to assess aerobic capacity tests.

 Measure fatigue by using the Fatigue Severity Score or a visual analog scale.2

Exercise Prescription

Type: Walking, treadmill walking, stationary cycling, and swimming1,3

Intensity: Start at low intensities

Duration: 20–30 minutes

Frequency: Three times per week

Getting Started

Aerobic exercises can be progressed by increasing the duration of the treatment

sessions as this will help improve the client's tolerance to exercise activities and can
result in improved tolerance to more daily activities.1 Clients with severe manifestations
or flare-ups of SLE will need to pace activities to conserve energy and may be unable to
maintain a consistent exercise program. Clients with SLE may have photosensitivities
that may limit or preclude exercise programs outdoors. Clients with neuropsychiatric
manifestations should be monitored for cognitive dysfunctions and may need
precautions for seizures. Aerobic activities at 70% to 80% of maximum heart rate for 30
to 40 minutes three times a week have been shown to result in a significant
improvement in aerobic capacity, exercise tolerance, and quality-of-life
measurements.4 A heart rate monitor is recommended to ensure the client is
maintaining an adequate intensity of exercise. Swimming or water exercises require
periodic checks of heart rate levels to ensure an adequate intensity of exercise.
Resistance exercises can be performed with low weights with two to three sets of 12
repetitions using muscle groups whose weakness is limiting daily activities.

References

1.
Ayan C, Martin V. Systemic lupus erythematosus and exercise. Lupus 16:5–9,
2007. [PubMed: 17283578]
2.
Tench CM, McCarthy J, McCurdie I, et al. Fatigue in systemic lupus erythematosus:
A randomized controlled trial of exercise. Rheumatology (Oxford) ..