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Exercise as it relates to Disease/The benefits of exercise on patients with Lupus Erythematosus

Lupus Erythematosus or Systemic Lupus Erythematosus (SLE) is an autoimmune disease [1] that causes chronic inflammation and damage to body tissues including the renal, cardiovascular, neural, musculoskeletal, and cutaneous tissues.[2] It is associated with periods of active disease involvement and remission.[3] The severity and symptoms of the disease varies among patients however research has indicated that if the onset of the disease occurs during childhood or adolescents then the disease is more likely to be severe going into adulthood.[1] The cause of SLE is suggested to result from environmental and genetic factors that lead to a break down in the tolerance of the immune system.[4] A common abnormality in this population is irregularities in their T and B lymphocytes.[2][5] In addition, an increase in IL-10 production in peripheral blood b cells and monocytes,[5] and elevated levels of IFN- α are indicative of the presence SLE disease activity.[6]

PrevalenceEdit

Research has indicated that the prevalence of SLE is greater in the female population of a child bearing age with a prevalence rate of 90%,[7][8] although the disease can occur at any stage of life.[3] The characteristics of the disease are strongly influenced by environmental factors and this differs between racial and ethnic groups.[9] It has been indicated that children with SLE have a more active disease activity and a higher prevalence rate of renal damage and which occurs at a more rapid rate compared to adult onset SLE(A-SLE).[9]

Childhood onset SLE (C-SLE) is generally characterised by onset of symptoms before the age of 18.[4] The onset of the disease has an around 15-20% prevalence in child populations[3] with 60% of those developing the disease after 10 years of age.[4] There is research to suggest that there is less gender bias towards females with C-SLE compared to adult onset.[4] However, C-SLE is thought to be more prevalent and severe in those of African, Asian, Hispanic and Native American descent.[4] It should be noted that not all studies support this finding.

Main Signs and Symptoms Associated with C-SLE and A-SLEEdit

  • Fatigue[4]
  • Joint Pain and Swelling[8]
  • Weight loss[8]
  • Fever[4][8]
  • Generalised lymphadenopathy[4]
  • Raynaud’s Syndrome[3]

  • Erythematous rash seen on both cheeks and bridge of nose[4]
  • Photosensitive rash[3][4]
  • Oral ulcers[4]
  • Serositis in the form of pleuritis[4]
  • Pericarditis[3][4]
  • Cardiac Arrhythmias and Murmurs[3]

This is not exhaustive list of signs and symptoms as they will vary between patients.

Current Treatments AvailableEdit

PharmaceuticalEdit

Pharmaceutical treatment for this disease varies with the individual, their symptoms and severity. Nonspecific drug treatments are the most common way to treat this disease [10] as currently there is no cure. The current drug treatments used carry a significant risk of toxicity, cytopenia, infection and malignancy.[10] The drugs used include:[10]

  • NSAIDS
  • Anti – malarial drugs (Hydroxychloroquine and chloroquine)
  • Corticosteroids
  • Immune Suppressant drugs (methotrexate)
  • Cytotoxic drugs (cyclophosphamide)

Hematopoietic stem cell and Mesenchymal stem cells transplantations are used in the most severe cases in an attempt to restart the immune system[10] however it is not a cure but can improve the immune system activity.[10]

ExerciseEdit

In SLE patients exercise has been found to be an important non pharmaceutical treatment.[11] Although undertaking exercise in this population can be difficult due to individuals suffering from chronic fatigue and pain and other comorbidities including premature atherosclerosis, dyslipidaemia [12][13] and insulin resistance.[13] This is due to the increased levels of IFN-γ, IL-6, TNF-α, IL-10, and sTNFRs that also increase the risk of cardiovascular disease.[13] Multiple other cardiac abnormalities can be found in SLE patients, including autonomic dysfunction, coronary heart disease and ischemic heart disease.[14] Therefore exercise has been found to decrease the inflammatory response in SLE, as patients display decreased levels of IL-6, IL-10 and TNF α at rest post chronic exercise training.[13]

Cardiac abnormalities in SLE can also be reduced through exercise by:

  • Improved aerobic capacity[14]
  • Improved cardiovascular functioning[11]
  • Reduced chronotropic incompetence[11]
  • Reduced delayed heart rate recovery[11]

Furthermore, exercise has been found to be an effective management tool in treating dyslipidaemia as it improves lipid profiles in the TC/HDL-c ratio, VLDLc and LDL-c particle size.[12] This is important as it is suggested that TNF- α, oxidation of LDL and abnormal chylomicron metabolism is involved in the deregulation lipoprotein lipase activity in SLE.[12]

Exercise RecommendationsEdit

Performing exercise in this population has been found to not cause flare ups in the disease activity or cause any other adverse effects.[11][13][15] Although this was stated from research in patients with inactive SLE.[11][15] Establishing an exercise program for this population is difficult due to the variety of symptoms and severity. Research has suggested that weight bearing exercise can improve bone mineral density in SLE as the disease causes an imbalance of IL-6 which is involved in accelerating bone remodelling.[14] However, aerobic exercise has been found to be the most beneficial due to the increased risk of cardiovascular disease in SLE[11] but any form of physical activity would provide a physical and psychological improvement.[14]

General exercise programs considerations for SLE patients should involve:[16] Exercise Program Recommendations:[14]
Starting the exercise early in the disease course or following a disease flare Walking, 3 times a week at an intensity of 70% of maximum heart rate and progressively increase the duration
Beginning with low intensity activities to avoid flare ups Swimming or stationary cycling, 3 times a week at an intensity of 70–80% of maximum heart rate
Progressively increase exercise intensity and frequency Resistance training, three times a week of 2-3 sets of 10 reps isotonic contractions per muscle group with progression
The medication the patient is on, may affect the response to exercise training

Further readingEdit

Australasian Society of Clinical Immunology and Allergy - SLE

Arthritis Victoria -Lupus

ReferencesEdit

  1. a b Prado, D. M., Benatti, F. B., de Sá-Pinto, A. L., Hayashi, A. P., Gualano, B., Pereira, R. M., Roschel, H. (2013). Exercise training in childhood-onset systemic lupus erythematosus: a controlled randomized trial. Arthritis Research & Therapy, 15(2), R46.
  2. a b Sun, L., Akiyama, K., Zhang, H., Yamaza, T., Hou, Y., Zhao, S., Shi, S. (2009). Mesenchymal stem cell transplantation reverses multiorgan dysfunction in systemic lupus erythematosus mice and humans. Stem Cells (Dayton, Ohio), 27(6), 1421-1432. doi: 10.1002/stem.68
  3. a b c d e f g Livingston, B., Bonner, A., & Pope, J. (2011). Differences in clinical manifestations between childhood-onset lupus and adult-onset lupus: a meta-analysis. Lupus, 20(13), 1345-1355. doi: 10.1177/0961203311416694
  4. a b c d e f g h i j k l m Aggarwal, A., & Srivastava, P. (2014). Childhood onset systemic lupus erythematosus: how is it different from adult SLE? International Journal of Rheumatic Diseases
  5. a b Deng, Y., & Tsao, B. P. (2010). Genetic susceptibility to systemic lupus erythematosus in the genomic era. Nature Reviews Rheumatology, 6(12), 683-692.
  6. Crow, M. K. (2010). Interferon-alpha: a therapeutic target in systemic lupus erythematosus. Rheumatic Diseases Clinics of North America, 36(1), 173. doi: 10.1016/j.rdc.2009.12.008
  7. Weckerle, C. E., & Niewold, T. B. (2011). The unexplained female predominance of systemic lupus erythematosus: clues from genetic and cytokine studies. Clinical Reviews in Allergy & Immunology, 40(1), 42-49.
  8. a b c d Gordon, C., Li, C. K., & Isenberg, D. A. (2010). Systemic lupus erythematosus. Medicine, 38(2), 73-80. doi: 10.1016/j.mpmed.2009.10.006
  9. a b Brunner, H. I., Gladman, D. D., Ibañez, D., Urowitz, M. D., & Silverman, E. D. (2008). Difference in disease features between childhood-onset and adult-onset systemic lupus erythematosus. Arthritis & Rheumatism, 58(2), 556-562. doi: 10.1002/art.23204
  10. a b c d e Yu, Y., & La Cava, A. (2011). Current drugs in systemic lupus erythematosus. Drug Development Research, 72(7), 561-572. doi: 10.1002/ddr.20466
  11. a b c d e f g Miossi, R., Benatti, F. B., Lúcia de Sá Pinto, A., Lima, F. R., Borba, E. F., Prado, D. M. L., Roschel, H. (2012). Using exercise training to counterbalance chronotropic incompetence and delayed heart rate recovery in systemic lupus erythematosus: A randomized trial. Arthritis Care & Research, 64(8), 1159-1166. doi: 10.1002/acr.21678
  12. a b c Ardoin, S. P., Sandborg, C., & Schanberg, L. E. (2007). Management of dyslipidemia in children and adolescents with systemic lupus erythematosus. Lupus, 16(8), 618-626.
  13. a b c d e Perandini, L. A., Sales-de-Oliveira, D., Mello, S. B., Camara, N. O., Benatti, F. B., Lima, F. R., Gualano, B. (2014). Exercise training can attenuate the inflammatory milieu in women with systemic lupus erythematosus. Journal of Applied Physiology (Bethesda, Md.: 1985), 117(6), 639-647. doi: 10.1152/japplphysiol.00486.2014 [doi]
  14. a b c d e Ayán, C., & Martín, V. (2007). Systemic lupus erythematosus and exercise. In (pp. 5-9). England: Sage Publications. doi: 10.1177/0961203306074795.
  15. a b Tench, C. M., McCarthy, J., McCurdie, I., White, P. D., & D'Cruz, D. P. (2003). Fatigue in systemic lupus erythematosus: a randomized controlled trial of exercise. Rheumatology (Oxford, England), 42(9), 1050-1054. doi: 10.1093/rheumatology/keg289 [doi]
  16. Neill, J., Belan, I., & Ried, K. (2006). Effectiveness of non-pharmacological interventions for fatigue in adults with multiple sclerosis, rheumatoid arthritis, or systemic lupus erythematosus: a systematic review. Journal of Advanced Nursing, 56(6), 617-635.