The Effectiveness of Exercise in Adults With Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis to Guide Evidence-Based Practice

EULAR recommendations for the non-pharmacological management of systemic lupus erythematosus and systemic sclerosis

OBJECTIVE

To develop evidence-based recommendations for the non-pharmacological management of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc).

METHODS

A task force comprising 7 rheumatologists, 15 other healthcare professionals and 3 patients was established. Following a systematic literature review performed to inform the recommendations, statements were formulated, discussed during online meetings and graded based on risk of bias assessment, level of evidence (LoE) and strength of recommendation (SoR; scale A-D, A comprising consistent LoE 1 studies, D comprising LoE 4 or inconsistent studies), following the European Alliance of Associations for Rheumatology standard operating procedure. Level of agreement (LoA; scale 0-10, 0 denoting complete disagreement, 10 denoting complete agreement) was determined for each statement through online voting.

RESULTS

Four overarching principles and 12 recommendations were developed. These concerned common and disease-specific aspects of non-pharmacological management. SoR ranged from A to D. The mean LoA with the overarching principles and recommendations ranged from 8.4 to 9.7. Briefly, non-pharmacological management of SLE and SSc should be tailored, person-centred and participatory. It is not intended to preclude but rather complement pharmacotherapy. Patients should be offered education and support for physical exercise, smoking cessation and avoidance of cold exposure. Photoprotection and psychosocial interventions are important for SLE patients, while mouth and hand exercises are important in SSc.

CONCLUSIONS

The recommendations will guide healthcare professionals and patients towards a holistic and personalised management of SLE and SSc. Research and educational agendas were developed to address needs towards a higher evidence level, enhancement of clinician-patient communication and improved outcomes.

Efficacy of lifestyle interventions in the management of systemic lupus erythematosus: a systematic review of the literature

We performed a systematic review to explore existing evidence regarding the efficacy of lifestyle interventions for the management of systemic lupus erythematosus (SLE). The search was conducted on the 22nd of June 2021 for publications between 1st of January 2000 and the date of search. Additional articles within the aforementioned timeframe and until December 2023 were added by hand searching. Databases utilized were Medline, Embase, Web of Science, and Cinahl. Lifestyle interventions were defined as any intervention encompassing one or more of the following: physical exercise, diet and nutrition, mental health, harmful exposures, sleep, and social relations. The Joanna Briggs Institute critical appraisal tools were used for risk of bias assessment. The search yielded 11,274 unique records, we assessed the full text of 199 records, and finally included 102 studies. Overall, the quality of the evidence is limited, and there were multiple sources of heterogeneity. The two domains most extensively researched were mental health (40 records) and physical exercise (39 records). Psychological interventions had a positive effect on depressive symptoms, anxiety, and health-related quality of life (HRQoL), whereas physical exercise improved fatigue, depressive symptoms, aerobic capacity, and physical functioning. Studies on diet and nutrition (15 records) support that low fat intake and Mediterranean diet may be beneficial for reducing cardiovascular risk, but large interventional studies are lacking. Studies on harmful exposures (7 records) support photoprotection and use of sunscreen. While studies imply benefits regarding disease burden and drug efficacy in non-smokers and regarding HRQoL in normal-weight patients, more survey is needed on tobacco smoking and alcohol consumption, as well as weight control strategies. Studies on social relations (1 record) and sleep (no records) were sparse or non-existent. In conclusion, psychosocial interventions are viable for managing depressive symptoms, and exercise appears essential for reducing fatigue and improving aerobic capacity and physical function. Photoprotection should be recommended to all patients. Lifestyle interventions should be considered a complement, not a substitute, to pharmacotherapy.

Effects of exercise on depression in patients with rheumatic diseases: a systematic review and meta-analysis

OBJECTIVE

To assess the effects of exercise intervention on depression in rheumatic diseases by means of a meta-analysis.

METHODS

The Cochrane Library, Embase, Medline, PubMed, and relevant records were searched. The qualities of randomized controlled trials were evaluated. Meta-analysis of the obtained related data was completed using RevMan 5.3. Heterogeneity was also evaluated with χ2 test and I2.

RESULTS

Twelve RCTs were reviewed. Compared with baseline, the meta-analysis results showed that there was significant difference in the improvement of depression assessed by HADs, BDI, CES‑D, and AIMS in patients with rheumatic diseases (post exercise vs. baseline, -0.73 [-1.05, -0.4], P < 0.0001, I2 = 0%). In subgroup analysis, although none of these trends in BDI and CES‑D subgroups were significant at P < 0.05, there were clear trends towards improvement in depression.

CONCLUSION

As an alternative or supplementary treatment, the effect of exercise on rheumatism is obvious. Rheumatologists can consider exercise as an integral part of the treatment of patients with rheumatism.

Effects of a walking exercise programme on disease activity, sleep quality, and quality of life in systemic lupus erythematosus patients

AIM

This quasi-experimental study aimed to explore effects of walking exercise on disease activity, sleep quality, and quality of life among individuals with systemic lupus erythematosus.

METHODS

After recruiting people with systemic lupus erythematosus from a hospital in Taiwan between October 2020 and June 2021, participants were free to opt to receive one walking exercise programme plus standard care for 3 months or to membership of a control group receiving routine care. Primary outcomes included Systemic Lupus Erythematosus Disease Activity Score, the Pittsburgh Sleep Quality Scale, and a quality-of-life scale for patients with systemic lupus erythematosus, namely, LupusQoL. These scales were administered first, at baseline and later, within 1 week following completion of the intervention. Between-group effects were compared using generalized estimating equations with adjustment for baseline variables.

RESULTS

The experimental and control groups each included 40 participants. Multivariate analysis indicated that adding the walking exercise programme into routine care elevated sleep quality and LupusQoL (the latter in the subscales of physical health, planning, and intimate relationships), except for disease activity.

CONCLUSION

Findings of this study supported the addition of walking exercise as part of routine care for people with systemic lupus erythematosus and may be a reference in the provision of adequate care for these patients.

Systematic literature review informing the EULAR recommendations for the non-pharmacological management of systemic lupus erythematosus and systemic sclerosis

Through this systematic literature review, we assembled evidence to inform the EULAR recommendations for the non-pharmacological management of systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). We screened articles published between January 2000 and June 2021. Studies selected for data extraction (118 for SLE and 92 for SSc) were thematically categorised by the character of their intervention. Of 208 articles included, 51 were classified as robust in critical appraisal. Physical activity was the most studied management strategy and was found to be efficacious in both diseases. Patient education and self-management also constituted widely studied topics. Many studies on SLE found psychological interventions to improve quality of life. Studies on SSc found phototherapy and laser treatment to improve cutaneous disease manifestations. In summary, non-pharmacological management of SLE and SSc encompasses a wide range of interventions, which can be combined and provided either with or without adjunct pharmacological treatment but should not aim to substitute the latter when this is deemed required. While some management strategies i.e., physical exercise and patient education, are already established in current clinical practice in several centres, others e.g., phototherapy and laser treatment, show both feasibility and efficacy, yet require testing in more rigorous trials than those hitherto conducted.

Exercise as adjunctive therapy for systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is a rare, chronic autoimmune inflammatory disease with a prevalence varying from 4.3 to 150 people in 100,000, or approximately five million people worldwide. Systemic manifestations frequently include internal organ involvement, a characteristic malar rash on the face, pain in joints and muscles, and profound fatigue. Exercise is purported to be beneficial for people with SLE. For this review, we focused on studies that examined all types of structured exercise as an adjunctive therapy in the management of SLE.

OBJECTIVES

To evaluate the benefits and harms of structured exercise as adjunctive therapy for adults with SLE compared with usual pharmacological care, usual pharmacological care plus placebo and usual pharmacological care plus non-pharmacological care.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 30 March 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of exercise as an adjunct to usual pharmacological treatment in SLE compared with placebo, usual pharmacological care alone and another non-pharmacological treatment. Major outcomes were fatigue, functional capacity, disease activity, quality of life, pain, serious adverse events, and withdrawals due to any reason, including any adverse events.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our major outcomes were 1. fatigue, 2. functional capacity, 3. disease activity, 4. quality of life, 5. pain, 6. serious adverse events, and 7. withdrawals due to any reason. Our minor outcomes were 8. responder rate, 9. aerobic fitness, 10. depression, and 11. anxiety. We used GRADE to assess certainty of evidence. The primary comparison was exercise compared with placebo.

MAIN RESULTS

We included 13 studies (540 participants) in this review. Studies compared exercise as an adjunct to usual pharmacological care (antimalarials, immunosuppressants, and oral glucocorticoids) with usual pharmacological care plus placebo (one study); usual pharmacological care (six studies); and another non-pharmacological treatment such as relaxation therapy (seven studies). Most studies had selection bias, and all studies had performance and detection bias. We downgraded the evidence for all comparisons because of a high risk of bias and imprecision. Exercise plus usual pharmacological care versus placebo plus usual pharmacological care Evidence from a single small study (17 participants) that compared whole body vibration exercise to whole body placebo vibration exercise (vibrations switched off) indicated that exercise may have little to no effect on fatigue, functional capacity, and pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). The study did not report disease activity, quality of life, and serious adverse events. The study measured fatigue using the self-reported Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-Fatigue), scale 0 to 52; lower score means less fatigue. People who did not exercise rated their fatigue at 38 points and those who did exercise rated their fatigue at 33 points (mean difference (MD) 5 points lower, 95% confidence interval (CI) 13.29 lower to 3.29 higher). The study measured functional capacity using the self-reported 36-item Short Form health questionnaire (SF-36) Physical Function domain, scale 0 to 100; higher score means better function. People who did not exercise rated their functional capacity at 70 points and those who did exercise rated their functional capacity at 67.5 points (MD 2.5 points lower, 95% CI 23.78 lower to 18.78 higher). The study measured pain using the SF-36 Pain domain, scale 0 to 100; lower scores mean less pain. People who did not exercise rated their pain at 43 points and those who did exercise rated their pain at 34 points (MD 9 points lower, 95% CI 28.88 lower to 10.88 higher). More participants from the exercise group (3/11, 27%) withdrew from the study than the placebo group (1/10, 10%) (risk ratio (RR) 2.73, 95% CI 0.34 to 22.16). Exercise plus usual pharmacological care versus usual pharmacological care alone The addition of exercise to usual pharmacological care may have little to no effect on fatigue, functional capacity, and disease activity (low-certainty evidence). We are uncertain whether the addition of exercise improves pain (very low-certainty evidence), or results in fewer or more withdrawals (very low-certainty evidence). Serious adverse events and quality of life were not reported. Exercise plus usual care versus another non-pharmacological intervention such as receiving information about the disease or relaxation therapy Compared with education or relaxation therapy, exercise may reduce fatigue slightly (low-certainty evidence), may improve functional capacity (low-certainty evidence), probably results in little to no difference in disease activity (moderate-certainty evidence), and may result in little to no difference in pain (low-certainty evidence). We are uncertain whether exercise results in fewer or more withdrawals (very low-certainty evidence). Quality of life and serious adverse events were not reported.

AUTHORS' CONCLUSIONS

Due to low- to very low-certainty evidence, we are not confident on the benefits of exercise on fatigue, functional capacity, disease activity, and pain, compared with placebo, usual care, or advice and relaxation therapy. Harms data were not well reported.

Telehealth-supervised exercise in systemic lupus erythematosus: A pilot study

OBJECTIVES

To explore the feasibility and effectiveness of telehealth-supervised exercise for adults with Systemic lupus erythematosus (SLE).

METHODS

This was a non-randomised controlled pilot trial comparing telehealth-supervised exercise (8 weeks, 2 days/week, 45 min, moderate intensity) plus usual care with usual care alone. Mixed methods were used to assess change in fatigue (FACIT-fatigue), quality of life (SF36), resting fatigue and pain (11-point scale), lower body strength (five-time sit-to-stand) and endurance (30 s sit-to-stand), upper body endurance (30 s arm curl), aerobic capacity (2 min step test), and experience (survey and interviews). Group comparison was performed statistically using a two-sample T-test or Mann-Whitney U-test. Where known, we used MCID or MCII, or assumed a change of 10%, to determine clinically meaningful change within groups over time. Interviews were analysed using reflexive thematic analysis.

RESULTS

Fifteen female adults with SLE were included (control group n = 7, exercise group n = 8). Statistically significant differences between groups, in favour of the exercise intervention, were noted for SF36 domain emotional well-being (p = 0.048) and resting fatigue (p = 0.012). There were clinically meaningful improvements over time for FACIT-fatigue (+6.3 ± 8.3, MCID >5.9), SF36 domains physical role functioning (+30%), emotional role functioning (+55%), energy/fatigue (+26%), emotional well-being (+19%), social functioning (+30%), resting pain (-32%), and upper body endurance (+23%) within the exercise group. Exercise attendance was high (98%, 110/112 sessions); participants strongly agreed (n = 5/7, 71%) or agreed (n = 2/7, 29%) they would do telehealth-supervised exercise again and were satisfied with the experience. Four themes emerged: (1) ease and efficiency of exercising from home, (2) value of live exercise instruction, (3) challenges of exercising at home, and (4) continuation of telehealth-supervised exercise sessions.

CONCLUSION

Key findings from this mixed-method investigation suggest that telehealth-supervised exercise was feasible for, and well-accepted by, adults with SLE and resulted in some modest health improvements. We recommend a follow-up RCT with more SLE participants.

Cardiorespiratory Insufficiency and Performance Fatigability in Women with Systemic Lupus Erythematosus

Purpose

Patients with systemic lupus erythematosus (SLE) experience excessive, debilitating fatigue with previously reported evidence of etiologically mediated cardiorespiratory impairments. Performance fatigability provides a precise characterization of fatigue as it can be quantified objectively as a function of time, frequency, and/or duration. Nevertheless, little consideration has been given to understanding performance fatigability and its physiological determinants in those with SLE. The purpose of this study was to characterize performance fatigability in patients with SLE, utilizing measures surrounding the anaerobic threshold, with emphasis on cardiorespiratory impairment as a potential mediating factor.

Methods

This was a case-control study design. 44 physically inactive women, 26 with SLE and 18 controls, completed a treadmill cardiopulmonary exercise test to volitional exhaustion.

Results

There were no significant differences in age (SLE 34.8(9.0) vs Control 36.9(7.3) yrs; p=0.422) between groups. BMI (SLE 27.1(5.4) vs Control 23.8(5.2) kg/m2; p=0.045) was significantly higher in the SLE vs Control group. Resting heart rate (SLE 68(16) vs Control 78(15) bpm; p=0.040) was significantly lower in the SLE compared to the Control group. The VO2 corresponding to the anaerobic threshold (AT-VO2), used to identify the onset of exercise-induced fatigue, was significantly lower in women with SLE than in controls (SLE 12.4(3.1) vs Control 16.4(2.2) ml/kg/min; p<0.001), as was AT-stage (SLE 2.5(0.90) vs Control 3.4(0.78); p=0.002). Additionally, Fatigue Severity Score (FSS) was highly and inversely correlated with AT-VO2 (rho=-0.615; p<0.001) and FSS was highly correlated with Functional Aerobic Impairment Index (FAI; rho=0.663; p<0.001).

Conclusion

This study underscores severe performance fatigability in patients with SLE and its link to cardiorespiratory insufficiency. Physiological presentation of performance fatigability was observed during very low intensities of exercise, emphasizing the negative impact it may have on physical function in this population.

Fatigue in ANCA-associated vasculitis (AAV) and systemic sclerosis (SSc): similarities with Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). A critical review of the literature

INTRODUCTION

Persistent debilitating fatigue is a frequent complaint in patients with systemic autoimmune rheumatic diseases (SARDs). Fatigue is, however, frequently overlooked in the clinic, and patients who successfully achieve remission of their disease, often still have a lowered quality of life due to its persistence. How similar is this fatigue to Myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), what is this fatigue associated with, and what tools/approaches (if any), have resulted in the improvement of fatigue in these patients is poorly defined.

AREAS COVERED

Similarities between the pathophysiology of ME/CFS, systemic sclerosis (SSc) and primary systemic vasculitides (PSV) are discussed, followed by an in-depth review of the prevalence and correlates of fatigue in these diseases. The authors reviewed literature from MEDLINE, APA PsycInfo, Embase, and CINAHL.

EXPERT OPINION

Persistent fatigue is a prominent feature in SARDs and may not be associated with components commonly associated with disease activity and/or progression. Immune and metabolic commonalities exist between ME/CFS, SSc, and PSVs - suggesting that common pathways inherent to the diseases and fatigue may be present. We suggest that patients with features of ME/CFS need to be identified by treating physicians, as they may require alternative approaches to therapy to improve their quality of life.

Perceived levels of stress, emotions and physical activity in outpatients with diffuse connective tissue diseases

BACKGROUND

Diffuse Connective Tissue Diseases (DCTD) are autoimmune diseases that can cause comorbidities, influencing physical and psychological aspects and increase stress. The latter may also be related to the practice of physical activity (PPA). Although evidence shows that it can contribute to patients' health, the level of PPA can decrease after the diagnosis.

AIMS

to evaluate the basic emotions, perceived stress (PS) and PPA levels of patients with DCTD.

METHODS

This is a field study.

METHODS AND MATERIAL

random approach of 55 participants. We used a clinical and sociodemographic profile form, for the verification of emotions, a picture with emojis of the basic emotions, the PSS-14 and the IPAQ-Brief.

STATISTICAL ANALYSIS USED

dada were analysed with Mann-Whitney U and Kruskal-Wallis tests; with 5% of significance.

RESULTS

The average age was 49.1 ± 12.9, mostly female (58.7%). High PS was reported by 54.5%; emotions such as joy (38.2%) and anxiety/fear (25.5%], as well as sadness (7.3%), were reported. About 87.3% were classified as having insufficient levels of PPA. Female patients (U=137.0; p<0.05) and insufficient PPA levels (U=86.5%; p<0.05) had higher PS scores, as well as those feeling sadness (X2 =19.0; p<0.05).

CONCLUSIONS

The results point to the need for care with the emotional domain of these patients and suggest studies that analyze the impact of implementing PPA for this population.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Physical Activity and Systemic Lupus Erythematosus Among European Populations: A Two-Sample Mendelian Randomization Study

Background: The causal relationship between physical activity (PA) and systemic lupus erythematosus (SLE) remains uncertain. We aimed to assess the causal effect of PA on SLE by two-sample Mendelian randomization (MR) study.

Methods: Summary statistics of SLE were obtained from a genome-wide association study (GWAS) meta-analysis of European descent, including 4,036 cases and 6,959 controls. Genetic instruments for PA, including MVPA, VPA, SSOE, and average acceleration, were identified from a large-scale GWAS meta-analysis among 377,234 individuals of European ancestry from United Kingdom biobank and Atherosclerosis Risk in Communities (ARIC) study, and another GWAS with 91,105 European participants was employed for sedentary behavior. The two-sample MR study was conducted to estimate causal relationship between PA and SLE, with the inverse-variance weighted (IVW) method, simple- and weighted-median method. Moreover, MR-Egger regression, MR-PRESSO and leave-one-out analysis were performed to evaluate the potential pleiotropy effect.

Results: In the end, we totally selected 37 SNPs (15 SNPs for MVPA, 5 SNPs for VPA, 9 SNPs for SSOE, 5 SNPs for average acceleration and 3 SNPs for sedentary behavior). According to the IVW results, as the primary method, we found that genetically predicted PA was not causally associated with risk of SLE (MVPA: OR 0.44, 95% CI 0.09–2.10, p = 0.305; VPA: OR 0.20, 95% CI 0.00–18.97, p = 0.490; SSOE: OR 0.96, 95% CI 0.03–29.24, p = 0.983; average acceleration: OR 0.91, 95% CI 0.79–1.05, p = 0.190; sedentary behavior: OR 1.54, 95% CI 0.35–6.81, p = 0.572). MR-Egger, MR-PRESSO, and leave-one-out analysis did not indicate horizontal pleiotropy.

Conclusions: Our MR study suggested that genetically predicted PA was not causally associated with SLE among the European populations.

New Insights Into Systemic Lupus Erythematosus Therapies: 2010-2020

ABSTRACT

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that may affect every organ. The multiple pathogenic mechanisms and heterogeneous phenotypes of SLE present unique challenges in the management of this complex disease. This article discusses new SLE therapies from the last 10 years. We will address new information in the realms of lifestyle interventions, antimalarials, nonsteroidal anti-inflammatory drugs, glucocorticoids, immunosuppressive disease modifying antirheumatic drugs, biological therapies, and other modalities as they pertain to SLE.

Effect of training on health outcome including fatigue, depression and quality of life in patients with systemic lupus erythromatosus

Background

Systemic lupus erythematosus is an inflammatory condition that causes significant tissue damage and inflammation, and is more common in women. Despite the fact that medical treatment seeks to prevent flare-ups and organ damage, up to 50% of patients believe their wellbeing is suboptimal due to unmet needs like exhaustion and pain. The aim of the new systemic lupus erythematosus treatment guidelines is to improve people's quality of life. In people with systemic lupus erythematosus, fatigue is associated with reduced health, exercise capacity, muscle strength, and impairment. The aim of the study is to compare the effects of strengthening exercise on fatigue, depression, and quality of life in patients with systemic lupus erythematosus compared to the control sedentary group. This study included 20 patients with systemic lupus erythematosus from the department of internal medicine, compared to 25 control patients. Both groups had been treated with strengthening exercises for three months. Self-rating depression scale, quality of life questioner, fatigue severity scale, 6 min’ walk test, 2 min step test and body mass index (BMI). All parameters were measured before and after 3 months of treatment.

Results

Analysis of data showed that systemic lupus erythematosus has more depression and fatigue than sedentary control. After exercises, both groups have a significant difference between pre and post treatment, but still have a difference between both groups. Both groups have a significant difference between pre and post treatment in 6-min walk test, 2-min step test, and quality of life measured by SF-36. No significant difference was found between both groups pre and post treatment in BMI, although each group has a significant difference between pre and post treatment BMI.

Conclusions

Exercises are very important in the management of systemic lupus erythematosus. They help to decrease fatigue, depression, and improve quality of life.

Effects of Exercise Intervention on Health-Related Quality of Life in Patients with Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis of Controlled Trials

Exercise and physical activity have been deemed as potentially beneficial for patients with systemic lupus erythematosus (SLE). This study aimed to evaluate the effects of exercise interventions on health-related quality of life in patients with SLE using a systematic review and meta-analysis. Randomized and non-randomized controlled trials published up to July 2021 were examined using the PubMed and Embase databases. Of the 1158 articles retrieved, nine were included for systematic review. Five of them were randomized controlled trials and these were assessed using meta-analysis. Hedges’ g effect size was 0.47; 95% (confidence interval 0.21–0.73; p < 0.001) for the physical health and function aspect of health-related quality of life. None of the other seven domains of the SF-36 showed a significant effect size. However, the latter finding was limited by the small number of available trials. In conclusion, this systematic review and meta-analysis supported that exercise intervention compared to usual care might be able to improve the physical functioning domain of health-related quality of life in patients with SLE. Future high-quality randomized controlled trials that incorporate disease-specific health-related quality of life measures are needed to elucidate the role of exercise on health-related quality of life in patients with SLE.

The landscape of systemic lupus erythematosus in Brazil: An expert panel review and recommendations

PURPOSE

The objective of this review is to address the barriers limiting access to diagnosis and treatment of systemic lupus erythematosus (SLE) and lupus nephritis (LN) in Brazil, specifically for patients in the public healthcare system, arguably those with the least access to innovation.

DESIGN

A selected panel of Brazilian experts in SLE/LN were provided with a series of relevant questions to address in a multi-day conference. During the conference, responses were discussed and edited by the entire group through numerous drafts and rounds of discussion until a consensus was achieved.

RESULTS

The authors propose specific and realistic recommendations for implementing access to innovative diagnostic tools and treatment alternatives for SLE/LN in Brazil. Moreover, in creating these recommendations, the authors strived to address barriers and impediments for technology adoption. The multidisciplinary care required for SLE/LN necessitates the collective participation of all involved stakeholders.

CONCLUSION

A great need exists to expand the adoption of innovative diagnostic tools and treatments for SLE/LN not only in Brazil but also in most countries, as access issues remain an urgent demand. The recommendations presented in this article can serve as a strategy for new technology adoption in other countries in a similar situation.

Suitability for e-health of non-pharmacological interventions in connective tissue diseases: scoping review with a descriptive analysis

Objective

Non-pharmacological interventions support patients with connective tissue diseases to better cope with and self-manage their diseases. This study aimed to map existing evidence on non-pharmacological interventions in patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and mixed connective tissue diseases regarding content, feasibility and potential suitability in an e-health setting.

Methods

A literature search was performed in eight different databases in July 2020. The intervention’s content was extracted using the ‘Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide’. A Sankey diagram and descriptive statistics were used to analyse the data and illustrate the relationships between the interventions.

Results

Of 8198 identified records, 119 papers were eligible. One hundred and four of them (87.4%) were conducted between 2000 and 2020, mainly in the USA (SLE n=24 (21.2%), SSc n=16 (14.2%)), Brazil (SLE n=8 (7.1%), SSc n=5 (4.4%)) and Italy (SLE n=0 (0%), SSc n=12 (10.6%)). Fifty-two studies (SLE n=24 (21.2%), SSc n=28 (24.8%)) used multicomponent interventions. The single interventions were physical exercises (SLE n=16 (14.2%), SSc n=17 (15.0%)), coaching/counselling (SLE n=11 (18.0%), SSc n=0 (0%)) and education (SLE n=2 (1.8%), SSc n=3 (2.7%)). Primary outcomes focused on physical function (SLE n=1 (0.9%), SSc n=15 (13.3%)), mouth opening in SSc (n=4 (5.9%)) and physical capacity (SLE n=2 (1.8%), SSc n=1 (0.9%)). No interventions for mixed connective tissue disease were found.

Conclusion

There was a great variety in the intervention’s content due to differences in body structure, activity limitations and participation restrictions in SLE and SSc. These results highlight the need for personalised, multicomponent, non-pharmacological interventions, which could be delivered as e-health interventions.

[Sports and exercise therapy in inflammatory rheumatic diseases]

Physical therapy has always been a pillar of the treatment of inflammatory rheumatic diseases in addition to targeted drug treatment; nevertheless, it is only established in the treatment guidelines for a few diseases. Within the last two decades the discovery of myokines has uncovered the physiological correlations of the anti-inflammatory effect of physical activity. For rheumatoid arthritis and spondylarthritis, several randomized controlled trials provide sufficient evidence to make well-founded recommendations. For connective tissue diseases (CTD) the data situation is clearly sparser but nevertheless shows that the positive effects of physical activity prevail. In the following article the authors present the most important clinical studies on sport and inflammatory rheumatic diseases and from these derive possible therapeutic recommendations.

DUALITY OF LIVING WITH SYSTEMIC LUPUS ERYTHEMATOSUS: FLUCTUATING BETWEEN “GOOD DAYS” AND “BAD DAYS”

ABSTRACT Objective: to learn the perception of individuals with Systemic Lupus Erythematosus about living with the disease. Method: an exploratory and descriptive research study, of a qualitative nature, carried out with 26 individuals undergoing treatment at the rheumatology outpatient clinic of a university hospital in southern Brazil. The data were collected in the period from February to July 2019, by means of semi-structured interviews that were audio-recorded and subjected to the thematic modality of content analysis. Results: a category entitled: “Fluctuating between good and bad days in living with Systemic Lupus Erythematosus”, composed of two subcategories that portray that living with Lupus is something unstable/fickle, emerged from the results. This is because, as a result of the periods of remission and exacerbation of the signs and symptoms of the disease, the patients experience a paradox of constant oscillation between ups and downs. Conclusion: it was learned that individuals with Lupus perceive that living with the disease is marked by an oscillation between good days and bad days, which are related to periods of remission and exacerbation of the manifestations of the disease, respectively.

2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that represents a prodigious challenge of diagnosis and treatment. In 2019, under the leadership of the Chinese Rheumatology Association, a multidisciplinary guideline development group was established to develop an evidence-based diagnosis and treatment guideline for patients with SLE in PR China. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the strength of recommendations. The guideline was reported following the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. In this guideline, we provided recommendations for SLE classification criteria, disease activity monitoring and assessment, medication administration and considerations for SLE patients with organs and systems involved, and management of special populations such as SLE patients in the setting of pregnancy. This guideline serves as an evidence-based tool for Chinese clinicians to diagnose and treat patients with SLE.

Effects of 12-week aerobic exercise on patient-reported outcomes in women with systemic lupus erythematosus

PURPOSE

To evaluate the effects of aerobic exercise on patient-reported outcomes (PROs) in women with systemic lupus erythematosus (SLE), and whether changes in cardiorespiratory fitness (CRF) mediate the changes in PROs.

METHODS

A total of 58 women with SLE were assigned to either an exercise group (EG; n = 26) or a control group (CG; n = 32) in this non-randomized clinical trial. The EG comprised 12 weeks of aerobic exercise (2 sessions/week) between 40%-75% of the individual's heart rate reserve. At baseline, and at week 12, CRF (Bruce test) and PROs were assessed including psychological stress (Perceived Stress Scale), sleep quality (Pittsburg Sleep Quality Index), fatigue (Multidimensional Fatigue Inventory), depressive symptoms (Beck Depression Inventory), and quality of life (36-item Short-Form Health Survey).

RESULTS

In comparison to the CG, the EG showed a significant reduction in general fatigue (mean difference (MD) -2.86 units; 95%CI -5.70 to -0.01; p = 0.049), physical fatigue (MD -4.33 units; 95%CI -7.02 to -1.65; p = 0.002) and a non-significant reduction of reduced motivation (MD - 1.29 units; 95%CI -2.60 to 0.03; p = 0.055). There were no significant between-group differences in the changes in psychological stress, sleep quality, depressive symptoms, quality of life, or other fatigue dimensions (all p > 0.05). Changes in CRF mediated the effects of the exercise intervention on general fatigue by 53.8%.

CONCLUSION

The results suggest that 12 weeks of progressive aerobic exercise might improve relevant dimensions of fatigue in women with SLE, despite the absence of effects on other PROs. Improvements in CRF seem to mediate the effect of exercise on general fatigue.Implications for rehabilitationAerobic exercise could be safely introduced in rehabilitation programs for inactive patients with SLE with mild disease activity.Including physical activity recommendations as part of rehabilitation could improve relevant aspects of fatigue in women with SLE.When rehabilitation aims at reducing fatigue, cardiorespiratory fitness improvements derived from physical activity might enhance benefits.

Effects of physical activity counselling in women with systemic lupus erythematosus: A randomized controlled trial

BACKGROUND

Low physical activity is common in systemic lupus erythematosus populations.

AIM

To evaluate the effect of physical activity counselling on physical activity and the association between physical activity changes and changes in fatigue, quality of sleep, and quality of life in women with systemic lupus erythematosus.

METHODS

A randomized, controlled, single-blind trial was conducted from March 2015 to August 2016. Seventy-six women with systemic lupus erythematosus were randomly assigned to the intervention or control groups. The intervention group received three sessions of physical activity counselling at 1, 4, and 8 weeks and three telephone follow-ups over 13 weeks. Outcome measures, which include daily steps, fatigue, quality of sleep, and the quality of life, were collected at baseline and 8 and 12 weeks.

RESULTS

The study showed that daily steps, quality of sleep, and vitality in the intervention group were significantly improved compared with those in the control group at weeks 8 and 12. Mental health was significantly improved only at week 8 in the counselling group. A positive correlation between physical activity changes and changes in vitality and mental health was observed.

CONCLUSIONS

Physical activity counselling can improve physical activity. As physical activity increases, systemic lupus erythematosus women feel more energetic and happier.

New perspectives on dry needling following a medical model: are we screening our patients sufficiently?

Myofascial trigger points are not an isolated neuromusculoskeletal phenomenon and have been implicated in systemic, visceral, and metabolic pathology, as a side effect of some medications and in the presence of psychological risk factors. This complexity can complicate adequate screening of patients prior to choosing dry needling as a treatment intervention. Regardless of whether clinicians practice in a direct access setting, they should be cognizant of medical conditions, comorbidities, and risk factors that will influence clinical decisions for dry-needling appropriateness, technique chosen, and potential adverse responses to treatment. Of primary concern are conditions that can either manifest with myalgia and/or myopathy or masquerade as a more common musculoskeletal condition. This clinical commentary reviews system-specific considerations and other common disorders that should be screened for and discusses not only whether dry needling is appropriate but comments on technique and dosage considerations when initiating dry needling.

[Effects of physical exercise in a population with systemic lupus erythematosus: A systematic review]

This systematic review was aimed at analysing the existing scientific evidence regarding the effects of physical exercise on the symptomatology, disease activity, and fitness level in a population with systemic lupus erythematosus. Following the PRISMA checklist, a search was carried out on PubMed, PEDro, and Sportdiscus databases. The PEDro and MINORS checklists were used in order to identify the methodological quality of the studies selected. A total of 14 studies were found, of which 10 were randomised controlled trials, and 4 were comparative studies. The performance of physical exercise led to significant improvements in fitness and fatigue. No adverse effects were registered. None of the studies found reported positive effects on the disease activity. The obtained results imply that the performance of physical exercise is safe for people with systemic lupus erythematosus, although its benefits are reduced mainly to improvements in their fitness and perceived level of fatigue.