Muscle Strength and Changes in Physical Function in Women With Systemic Lupus Erythematosus

Physical Performance in a Diverse, Population-Based Cohort of Individuals With Systemic Lupus Erythematosus

OBJECTIVE

To report the burden and correlates of poor physical performance in a diverse cohort of individuals with systemic lupus erythematosus (SLE).

METHODS

In this single-visit study of 446 individuals with SLE from a population-based metropolitan Atlanta cohort, we measured physical performance via the Short Physical Performance Battery (score range 0-12; intermediate-low [<10] vs high [≥10]). We also collected demographic, clinical, and psychosocial variables and examined the associations (adjusted odds ratios [aORs]) of intermediate-low versus high physical performance with these characteristics via multivariable logistic regression.

RESULTS

We found that more than half (59.6%) of our participants had poorer (intermediate-low) overall physical performance. Only 7% of the cohort received the maximum score on the lower body strength task versus 90% and 76% receiving the maximum scores on balance and gait speed tasks. Current employment status (aOR 0.69, 95% confidence interval [CI] 0.45-1.05) and higher cognitive functioning (aOR 0.57, 95% CI 0.42-0.77) were strongly associated with lower odds of intermediate-low physical performance. Higher body mass index (aOR 1.25, 95% CI 1.01-1.56), disease activity (aOR 1.59, 95% CI 1.27-1.98), and disease burden (aOR 1.38, 95% CI 1.08-1.77) were associated with poorer performance, as were higher depressive symptoms, perceived stress scores, and lower educational attainment (not statistically significant).

CONCLUSION

In our population-based, primarily Black cohort, we found that individuals with SLE commonly had poor physical performance. We identified both SLE- and non-SLE-specific factors that could help clinicians identify those most at risk for poor physical performance and intervene to improve, maintain, and support physical performance among those with SLE.

Muscle strength, not muscle mass, determines the health-related quality of life in Indonesian women with systemic lupus erythematosus

OBJECTIVE

No study evaluated the impact of low muscle strength and mass on the Sarcopenia-related Quality of Life (SarQoL) in women with SLE.

METHODS

This cross-sectional study recruited 145 women with SLE consecutively; muscle strength was measured with a calibrated Jamar handheld dynamometer, muscle mass was measured with appendicular muscle mass index (Tanita MC-780 MAP body impedance analyser) and health-related quality of life with SarQoL Questionnaire. The cut-off points for low muscle strength, low muscle mass and sarcopenia were derived from the Asian Working Group on Sarcopenia 2019. Statistical analysis was conducted with a t-test for mean difference, and logistic regression was used to evaluate for low muscle strength contributing factors.

RESULTS

There was a significant difference in the mean total score of SarQoL in individuals with normal compared with low muscle strength (74.36 vs 64.85; mean difference 9.50; 95% CI 2.10 to 5.33; p<0.001). On the other hand, there was no difference in individuals with normal compared with low muscle mass (71.07 vs 70.79; mean difference 0.28; -5.18 to 5.74; p=0.91). After minimally adjusted with age, we found moderate-severe joint pain (B -9.280; p<0.001) and low muscle strength (B -6.979; p=0.001) to be independently associated with low mean SarQoL total score.

CONCLUSION

There was a lower total SarQoL score in individuals with low muscle strength but not with low muscle mass.

Systemic lupus erythematosus: a systematic review with meta-analysis on muscle strength, muscle mass, and physical function

To perform a systematic review with meta-analysis to verify muscle strength, muscle mass, and physical function of patients with systemic lupus erythematosus (SLE) and compare then with healthy individuals and patients with rheumatoid arthritis (RA). A systematic review with meta-analysis of observational studies published in English up to 2022 was performed using MEDLINE (via PubMed) and other relevant sources. Search strategies were based on pre-defined keywords and medical subject headings. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale. Mean difference (MD) or standardized mean difference (SMD) and 95% confidence intervals (CI) were combined using a random-effects model. Sensitivity analyses were performed when necessary. The significance level was set at p < 0.05. The systematic review included 19 studies and the meta-analysis included 11 studies. SLE patients appear to have less muscle strength assessed by handgrip than healthy controls (SLE = 21.74 kg; healthy controls = 29.34 kg; p < 0.05). SLE patients seem to have greater strength than patients with RA, but this difference was not statistically significant (RA = 17.24 kg; p = 0.210). However, in the sensitivity analysis, SLE group without deforming arthropathy showed higher muscle strength than the RA (p = 0.0001). SLE patients with deforming arthropathy have lower muscle strength compared to SLE patients without deforming arthropathy (p < 0.01). Muscle mass was similar in SLE patients compared to the RA group and healthy controls (p > 0.05). However, RA patients have a higher BMI than the two groups (p < 0.05). Patients with SLE have regular physical function. Muscle strength is affected in SLE patients. SLE patients with deforming arthropathy have less muscle strength than patients without deforming arthropathies.

Vitamin D supplementation modulates autophagy in the pristane-induced lupus model

Introduction/objectives

Clinical evidence of skeletal muscle involvement is not uncommon in systemic lupus erythematosus (SLE). Because of the poor understanding of signaling pathways involved in SLE muscle wasting, the  aim of this study was to evaluate the effects of vitamin D supplementation on skeletal muscle in mice with pristane-induced lupus.

Methods

Balb/c mice with lupus-like disease induced by pristane injection were randomized into three groups: pristane-induced lupus (PIL; n = 10), pristane-induced lupus + vitamin D supplementation (PIL + VD; n = 10) and healthy controls (CO; n = 8). Physical function was evaluated on days 0, 60, 120 and 180. The tibialis anterior and gastrocnemius muscles were collected to evaluate myofiber cross-sectional area (CSA) and protein expression.

Results

The PIL + VD group showed lower muscle strength compared to the CO and PIL groups at different time points. PIL mice showed similar myofiber CSA compared to CO and PIL + VD groups. LC3-II expression was higher in PIL compared to CO and PIL + VD groups. MyoD expression was higher in PIL mice compared to PIL + VD, while myostatin expression was higher in PIL + VD than PIL group. Myogenin expression levels were decreased in the PIL + VD group compared with the CO group. The Akt, p62 and MuRF expressions and mobility assessment showed no significance.

Conclusions

Changes in skeletal muscle in PIL model happen before CSA reduction, possibly due to autophagy degradation, and treatment with Vitamin D has a impact on physical function by decreasing muscle strength and time of fatigue.. Vitamin D supplementation has a potential role modulating physical parameters and signaling pathways in muscle during pristane-induced lupus model.

The impact of low muscle function on health-related quality of life in Indonesian women with systemic lupus erythematosus

OBJECTIVE

There was no study aimed at evaluating the effect of muscle function on SLE patients' quality of life using the Sarcopenia Quality of Life (SarQoL) questionnaire.

METHODS

This cross-sectional study recruited 61 women with SLE consecutively, muscle function was measured with Jamar handheld-dynamometer and 6-meter walk test, HRQoL was measured with Sarcopenia Quality of Life (SarQoL) questionnaire. The cut-off point for low muscle strength (<18 kg) and low gait speed (<1.0 m/s) was according to the Asian Working Group on Sarcopenia 2019 criteria. Statistical analysis was conducted with a t-test for mean difference, and linear regression was used to adjust confounders (age, protein intake, physical exercise, and disease activity).

RESULTS

The subjects' mean muscle strength was 19.54 kg (6.94), and 44.3% (n = 27) was found to have low muscle strength. The subjects' mean gait speed was 0.77 m/s (0.20), and 90.3% (n = 55) was found to have low gait speed. The difference of total SarQoL score in subjects with normal and low muscle strength was found to be significant; 74.86 (9.48) vs. 65.49 (15.51) (p = 0.009), and still statistically significant after adjustments with age, protein intake, physical exercise level, and disease activity [B 0.56; 95% CI 0.08-1.03; p = 0.022]. The difference of total SarQoL score in subjects with normal and low physical performance was found to be not significant, 70.67 (11.08) vs. 70.72 (13.56) (p = 0.993).

CONCLUSION

There was a significant difference in SarQoL's total score in normal compared with low muscle strength groups of Indonesian women with SLE.

Effectiveness of Occupational Therapy Interventions for Adults With Systemic Lupus Erythematosus: A Systematic Review

OBJECTIVE. Our objective was to assess the efficacy of occupational therapy–related interventions for adults with systemic lupus erythematosus (SLE).

METHOD. We reviewed intervention studies published from 2000 to 2017. The method used for conducting the review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PEDro scale was used to evaluate methodological quality. Risk of bias was appraised with methods described by the Cochrane Methods Group.

RESULTS. The final analysis included 20 studies (10 physical activity and 10 psychoeducational). Moderate evidence supports physical activity to improve depression, fatigue, exercise tolerance, and function without exacerbation of disease symptoms. Strong evidence supports psychoeducational interventions using cognitive–behavioral approaches to improve pain, depression, anxiety, perceived stress, quality of life, and function. Moderate evidence supports patient education and self-management interventions for pain, depression, anxiety, perceived stress, quality of life, and function.

CONCLUSION. Further research on occupation-based interventions for people with SLE is needed.

Physical Fitness and Body Composition in Women with Systemic Lupus Erythematosus

Background and objectives: Higher physical fitness is associated with a more favorable weight and body composition in the general population, although this association has not been studied in patients with systemic lupus erythematosus (SLE). The aim of the present study was to examine the association of different components of physical fitness with body composition in women with SLE with mild disease activity. Materials and Methods: This cross-sectional study included 77 women with SLE (43.2 ± 13.8 years old) and clinical stability during the previous 6 months. Body composition (including body mass index (BMI), fat mass index (FMI), waist circumference, waist-to-height ratio and waist-to-hip ratio) was assessed using a stadiometer, an anthropometric tape, and a bioimpedance device. Physical fitness included cardiorespiratory fitness (Siconolfi step test and 6 min walk test), muscular strength (handgrip strength test as upper body measure and 30 s chair stand as lower body measure), and flexibility (back-scratch test). Participants with a fitness level equal or above the median of the study sample were categorized as "fit" and those below the median were categorized as "unfit". Linear regression assessed the association of physical fitness with body composition parameters. Results: Cardiorespiratory fitness and upper body muscular strength were negatively associated with BMI, FMI, waist circumference, and waist-to-height ratio (all, p < 0.05). Lower body muscular strength and flexibility were negatively related to FMI, waist circumference, waist-to-height ratio, and waist-to-hip ratio (all, p < 0.05). These relationships were still significant after controlling for age, disease duration, accrual damage, and SLE activity. Overall, fit patients presented significantly lower values in all body composition parameters compared to unfit patients (all, p < 0.05). Conclusions: The main findings of the present study suggest that physical fitness is inversely associated with body composition in women with SLE. Given the cross-sectional nature of this study, future clinical trials should study the causal pathways underlying these relationships.

Association of physical fitness components and health-related quality of life in women with systemic lupus erythematosus with mild disease activity

OBJECTIVES

To study the association of different components of physical fitness [flexibility, muscle strength and cardiorespiratory fitness (CRF)] and a clustered fitness score with health-related quality of life (HRQoL) in women with systemic lupus erythematosus (SLE) and to analyze whether participants with high fitness level have better HRQoL.

METHODS

This cross-sectional study included 70 women with SLE (aged 42.5; SD 13.9 years). The back-scratch test assessed flexibility, the 30-sec chair stand and handgrip strength tests assessed muscle strength, and the 6-min walk test (n = 49) assessed CRF. HRQoL was assessed through the 36-item Short-Form Health Survey (SF-36).

RESULTS

Flexibility was positively associated with the physical function dimension and the physical component summary (PCS) (rpartial between 0.26 and 0.31; p<0.05), and negatively related with social functioning dimension (rpartial = -0.26; p<0.05). Muscle strength was positively associated with the physical function, physical role, bodily pain dimensions and the PCS (rpartial between 0.27 and 0.49; all p<0.05). CRF was positively associated with the physical function and bodily pain dimensions, and PCS (rpartial between 0.39 and 0.65; all p<0.05). The clustered fitness score was associated with the physical function (B = 17.16) and bodily pain (B = 14.35) dimensions, and the PCS (B = 6.02), all p<0.005. Patients with high fitness level had greater scores in the physical function, physical role, and bodily pain dimensions and the PCS, all p≤0.05.

CONCLUSIONS

Our study suggests that muscle strength and CRF are positively associated with HRQoL, while flexibility showed contradictory results. These findings highlight the importance of maintaining adequate fitness levels in women with SLE.

Effects of whole-body electromyostimulation combined with individualized nutritional support on body composition in patients with advanced cancer: a controlled pilot trial

BACKGROUND

Physical exercise and nutritional treatment are promising measures to prevent muscle wasting that is frequently observed in advanced-stage cancer patients. However, conventional exercise is not always suitable for these patients due to physical weakness and therapeutic side effects. In this pilot study, we examined the effect of a combined approach of the novel training method whole-body electromyostimulation (WB-EMS) and individualized nutritional support on body composition with primary focus on skeletal muscle mass in advanced cancer patients under oncological treatment.

METHODS

In a non-randomized controlled trial design patients (56.5% male; 59.9 ± 12.7 years) with advanced solid tumors (UICC III/IV, N = 131) undergoing anti-cancer therapy were allocated to a usual care control group (n = 35) receiving individualized nutritional support or to an intervention group (n = 96) that additionally performed a supervised physical exercise program in form of 20 min WB-EMS sessions (bipolar, 85 Hz) 2×/week for 12 weeks. The primary outcome of skeletal muscle mass and secondary outcomes of body composition, body weight and hand grip strength were measured at baseline, in weeks 4, 8 and 12 by bioelectrical impedance analysis and hand dynamometer. Effects of WB-EMS were estimated by linear mixed models. Secondary outcomes of physical function, hematological and blood chemistry parameters, quality of life and fatigue were assessed at baseline and week 12. Changes were analyzed by t-tests, Wilcoxon signed-rank or Mann-Whitney-U-tests.

RESULTS

Twenty-four patients of the control and 58 of the WB-EMS group completed the 12-week trial. Patients of the WB-EMS group had a significantly higher skeletal muscle mass (0.53 kg [0.08, 0.98]; p = 0.022) and body weight (1.02 kg [0.05, 1.98]; p = 0.039) compared to controls at the end of intervention. WB-EMS also significantly improved physical function and performance status (p < 0.05). No significant differences of changes in quality of life, fatigue and blood parameters were detected between the study groups after 12 weeks.

CONCLUSIONS

Supervised WB-EMS training is a safe strength training method and combined with nutritional support it shows promising effects against muscle wasting and on physical function in advanced-stage cancer patients undergoing treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02293239 (Date: November 18, 2014).

Bone Disease in Connective Tissue Disease/Systemic Lupus Erythematosus

This article reviews recent advances in the research of the mechanisms of bone loss, as well as clinical features, economic impact and therapeutic implications of osteoporosis and fractures in patients with systemic lupus erythematosus (SLE) as an illustration of bone disease in a complex systemic autoimmune connective tissue disease. Recent studies demonstrated an increased incidence of osteoporosis and peripheral and vertebral fractures in patients with SLE. The aetiology of bone loss in SLE is multifactorial, including clinical osteoporosis risk factors, systemic inflammation, serological factors, metabolic factors, hormonal factors, possibly genetic factors and medication-induced adverse effects. The incidence of symptomatic fractures in patients with SLE is increased 1.2-4.7-fold and age, disease duration, glucocorticoid use, previous cyclophosphamide use, seizures and a prior cerebrovascular event have been identified as important risk factors. Moreover, a high prevalence of morphometric vertebral fractures was demonstrated, while one in three of these patients has normal bone density, which finding points to the multifactorial aetiology of fractures in SLE. The clinical consequences and economic burden of osteoporosis and fractures as glucocorticoid treatment-related adverse events and the high frequency of glucocorticoid therapy underline the importance of reducing glucocorticoid treatment and prescribing steroid-sparing agents. No data on fall risk and its determinants and the relationship with the occurrence of fractures in patients with SLE are currently available. Fall risk might be increased in lupus patients for several reasons. In addition, the recently reported high prevalence (20%) of frailty in SLE patients may contribute to the increased fracture incidence. Therefore, the relationships between fall risk, frailty and fracture occurrence in SLE might be interesting subjects for future studies.

Is frailty a relevant concept in SLE?

Objective

In geriatric populations, frailty is associated with poor health outcomes, including mortality. Frailty has not been examined in lupus, although components of the phenotype seem relevant.

Methods

Women with lupus (n=152) participated in research visits in 2008–2009. Frailty was assessed by Fried's frailty phenotype criteria: low weight/unintentional weight loss, slow gait (4-m walk using sex and height criteria), weakness (grip strength using gender and body mass index criteria), exhaustion (2 specific questions) and inactivity (from physical activity questionnaire). Women accumulating 3+ components were classified as ‘frail’, one or two components as ‘prefrail’, and none as ‘robust’. Physical function (36-item Short Form (SF-36) Physical Functioning subscale and Valued Life Activities disability scale), cognitive function (from a 12-test battery) and mortality were examined as outcomes. Mortality was determined as of December 2015. Multiple regression analyses examined concurrent and 2-year function controlling for age, lupus duration, race/ethnicity, glucocorticoid use, obesity, self-reported disease activity and damage and, for longitudinal analyses, baseline function. Mortality analyses controlled for age, lupus duration and baseline disease damage scores.

Results

Mean age was 48 (±12) years, mean lupus duration was 16 (±9) years. 20% of the sample was classified as frail and 50% as prefrail. Frail women had significantly worse physical functioning than both robust and prefrail women and were more likely to have cognitive impairment. Frail women were also more likely to experience declines in functioning and onset of cognitive impairment. Mortality rates were significantly higher in the frail group (frail 19.4%; prefrail 3.9%; robust 2.3%). Odds (95% CI) of death for frail women were elevated, even after adjusting for age, lupus duration and baseline disease damage (5.9 (0.6 to 57.1)).

Conclusions

Prevalence of frailty in this sample of women with lupus was higher than in samples of older adults. Frailty was associated with poor physical and cognitive function, functional declines and mortality.

Frailty and reduced physical function go hand in hand in adults with rheumatoid arthritis: a US observational cohort study

Reduced physical function and health-related quality of life are common in rheumatoid arthritis (RA), and further studies are needed that examine novel determinates of reduced physical function in RA. This study examines whether frailty, a state of increased vulnerability to stressors, is associated with differences in self-reported physical function among adults with RA. Adults from a longitudinal RA cohort (n = 124) participated in the study. Using an established definition of frailty, individuals with three or more of the following physical deficits were classified as frail: (1) body mass index ≤18.5, (2) low grip strength (adjusted for sex and body mass index (BMI), measured by handheld dynamometer), (3) severe fatigue (measured by the Multidimensional Assessment of Fatigue), (4) slow 4-m walking speed (adjusted for sex and height), and (5) low physical activity (measured by the International Physical Activity Questionnaire). Individuals with one or two deficits were classified as "pre-frail" and those with no deficits as "robust." Self-reported physical function was assessed by the Health Assessment Questionnaire (HAQ) and the Valued Life Activities Difficulty scale. Regression analyses modeled associations of frailty category with HAQ and Valued Life Activities (VLA) Difficulty scores with and without controlling for age, sex, disease duration, C-reactive protein, use of oral steroids, and pain. Among adults with RA, being frail compared to being robust was associated with a 0.44 worse VLA score (p < 0.01) when the effects of covariates are held constant. Being frail, compared to being robust, is associated with clinically meaningful differences in self-reported physical function among adults with RA.

Serum biomarkers of inflammation and muscle strength among women with systemic lupus erythematosus

OBJECTIVES

Muscle strength is an important determinant of physical function in women with systemic lupus erythematosus (SLE). Serum biomarkers of inflammation, including interleukin-6 (IL-6) and C-Reactive Protein (CRP), are associated with differences in muscle strength among individuals without rheumatologic disease. We examined whether serum levels of IL-6 and CRP are associated with upper and lower extremity muscle strength among adult women with SLE.

METHODS

One hundred thirty-six women with SLE participated in this cross-sectional study. High-sensitivity CRP was analyzed by nephelometry. IL-6 serum levels were analyzed by high sensitivity enzyme-linked immunosorbent assay. Upper and lower extremity muscle strength were assessed by grip strength and peak torque of knee extension and flexion, respectively. Regression analyses modeled associations of CRP and IL-6 with upper and lower extremity muscle strength controlling for age, SLE duration, physical activity, prednisone use, BMI, plaquenil use, and pain.

RESULTS

Higher serum levels of IL-6 and CRP were associated with significantly weaker upper and lower extremity muscle strength even when controlling for covariates.

CONCLUSIONS

Increased serum IL-6 and CRP are associated with clinically significant differences in upper and lower extremity muscle strength and may be useful in identifying those at risk for weakness and decreased physical function.

The effects of bolus supplementation of branched-chain amino acids on skeletal muscle mass, strength, and function in patients with rheumatic disorders during glucocorticoid treatment

OBJECTIVES

To test the effects of bolus supplementation of branched-chain amino acids (BCAA) on skeletal muscle mass, strength, and function in patients with rheumatic disorders taking glucocorticoid (GC).

METHODS

Patients with rheumatic disorders treated with prednisolone (≥10 mg/day) were randomized to ingest additional daily 12 g of BCAA (n = 9) or not (n = 9) for 12 weeks. At baseline, and 4, 8, and 12 weeks, they underwent bioelectrical impedance analysis, muscle strength and functional tests, and computed tomography analysis for cross-sectional area of mid-thigh muscle.

RESULTS

Disease activities of the patients were well controlled and daily GC dose was similarly reduced in both groups. Limb muscle mass was recovered in both groups. Whole-body muscle mass and muscle strength and functional mobility were increased only in BCAA (+) group. The effects of BCAA supplementation on recovering skeletal muscle mass were prominent in particular muscles including biceps femoris muscle.

CONCLUSIONS

This trial is the first-in-man clinical trial to demonstrate that BCAA supplementation might be safe and, at least in part, improve skeletal muscle mass, strength, and function in patients with rheumatic disorders treated with GC.

Abnormal body composition, cardiovascular endurance, and muscle strength in pediatric SLE

BACKGROUND

Children with SLE are known to have higher fat mass compared to their peers but there are no published data regarding exercise capacity as measured by cardiovascular endurance and muscle strength. In our pilot study of ten children with SLE, we sought to examine body composition, cardiovascular endurance, and isometric muscle strength.

FINDINGS

Ten pediatric SLE patients were studied with a mean age of 15.5 years and 90 % female. Percent body fat above 30 %, the recommended normal level in adolescent females, were found in 89 % of female subjects and 40 % of all participants had lower than the recommended norms of muscle mass for their age/gender. Subjects with renal disease were more likely to have low muscle mass compared to those without renal disease (p = 0.03). Cardiovascular endurance was reported as estimated maximal oxygen consumption (VO2max) during cycle ergometry. All participants scored in less than fifth percentile for VO2max measurements compared to data from age and gender matched published norms. Isokinetic muscle strength testing was performed on upper and lower extremities. Only one participant (male subject) reached goal percentiles for age and gender.

CONCLUSIONS

We found significant deficit in body composition, muscle strength and cardiovascular endurance in the pediatric SLE population compared to reported published norms. Clinicians should consider these data and focus on exercise programs that can increase aerobic capacity and muscle strength in this high-risk population.