Incorporating exercise in the treatment of lupus and other rheumatic diseases: It's time!
While there was concern in the past that exercise could trigger a pro-inflammatory state in patients with rheumatic disease, thereby increasing risk of flares, that hypothesis was long ago debunked. Physical activity is not only safe in the setting of these conditions, but of particular relevance to these patients given their increased risk of modifiable comorbidities. The comments below focus on systemic lupus erythematosus (SLE), but apply to most rheumatic diseases.
For patients with SLE, increasing physical activity is a potent and underused intervention for addressing the elevated risk of comorbidities. SLE confers a significant risk of cognitive impairment, and population studies show a protective effect of physical activity on long-term cognitive function . In SLE, the risk of death from cardiovascular disease (CVD) is approximately three times that of the general population , and physical activity is an integral part of cardiovascular risk reduction. Patients with SLE also have a higher risk of depression. Exercise has shown unequivocal benefits for mood disorders, with efficacy equal to selective serotonin reuptake inhibitors in some studies.
Furthermore, given the high pill burden and medication side effects experienced by lupus patients, many prefer lifestyle modification over additional medications for the prevention of CVD or treatment of depression.
Exercise may also have beneficial disease-specific effects. The two lupus-related symptoms and areas identified as the greatest unmet needs by patients—pain and fatigue—are diminished among patients with low-to-moderate disease activity who engage in regular exercise.
The mechanisms underlying the relationship between exercise and reduced symptom burden are not yet well established but are likely to include psychological mechanisms related to perception of pain, as well as anti-inflammatory effects. For example, a small randomized controlled trial of a 12-week moderate intensity aerobic exercise program for women with SLE showed changes in resting levels of interleukin-6, interleukin-10, and tumor necrosis factor receptor-2, toward levels of healthy controls .
Despite the benefits of exercise, the proportion of people with SLE who achieve recommended physical activity levels is low. Physical activity guidelines for US adults recommend 30 minutes per day of moderate-to-vigorous physical activity on at least 5 days per week . A Centers for Disease Control and Prevention (CDC) study found that only 48% of adults meet this target, and estimates in SLE patients are lower, at 18–26% in observational studies [5,6].
The discordance between recommended and actual activity levels among individuals with SLE begs two questions: what barriers do patients face, and what can be done to surmount them? A subset of patients with severe disease have physical disability that precludes participation in exercise, but such patients are a minority; most are in a position to safely increase activity. Other less recognized but modifiable barriers include misconceptions that exercise will exacerbate disease, comorbid depression, limited access to safe spaces to exercise, and lack of emphasis by healthcare providers.
A 2011–2012 study from the CDC reported that over half of adults who were completely sedentary had not been told by a healthcare professional to increase physical activity; patients with rheumatic diseases are even less likely to receive that message . Tackling this problem will require a multipronged, multidisciplinary approach with interventions targeting the individual (education, wearable activity monitoring), healthcare delivery (encouragement and support from clinicians, trained health coaches), and public health programs that increase access to safe walking spaces in low income communities .
In the meantime, consider simply asking your SLE patient if they exercise and recommending use of an activity tracker such as those on many smart-phones; it could change their life.
For more information on helping patients implement a safe exercise program, visit the “Exercise is Medicine” (EIM) website, a joint effort by the American College of Sports Medicine and American Medical Association.
- Zhu N, Jacobs DR, Schreiner PJ et al. Cardiorespiratory fitness and cognitive function in middle age: the CARDIA study. Neurology 2014; 82(15): 1339-1346.
- Yurkovich M, Vostretsova K, Chen W, Aviña-Zubieta JA. Overall and cause-specific mortality in patients with systemic lupus erythematosus: a meta-analysis of observational studies. Arthritis Care Res (Hoboken) 2014; 66(4): 608-616.
- Perandini LA, Sales-de-Oliviera D, Mello SB et al. Exercise training can attenuate the inflammatory milieu in women with systemic lupus erythematosus. J Appl Physiol (1985) 2014; 117(6): 639-647.
- US Department of Health and Human Services 2008 Physical Activity Guidelines for Americans. Available at http://www.health.gov/paguidelines. [Accessed 4 June 2018].
- dos Santos Fde M, Borges MC, Correia MI, Telles RW, Lanna CC. Assessment of nutritional status and physical activity in systemic lupus erythematosus patients. Rev Bras Reumatol 2010; 50(6): 631-638.
- Mancuso CA, Perna M, Sargent AB, Salmon JE. Perceptions and measurements of physical activity in patients with systemic lupus erythematosus. Lupus 2011. 20(3): 231-242.
- Loprinzi PD, Beets MW. Need for increased promotion of physical activity by health care professionals. Prev Med 2014; 69: 75-79.
- Cohen DJ, Tallia AF, Crabtree BF, Young DM. Implementing health behavior change in primary care: lessons from prescription for health. Ann Fam Med, 2005. 3 Suppl 2: S12-19.