Physical Medicine and Rehabilitation for Systemic Lupus Erythematosus

What Is Systemic Lupus Erythematosus (SLE)?

Systemic lupus erythematosus is a multi-system connective tissue disorder and affects many organs, including the skin, heart, lungs, kidneys, and blood. It occurs mainly in women accounting for about 90 percent of the patients. It is caused due to autoantibody production in SLE (systemic lupus erythematosus) patients. Usually, when an antigen (foreign molecule or substance) attacks the body, antibodies are produced as an immune response. Auto-antibodies are a malformation of antibodies by the body, without an antigen, created against the substances of their own body.

What Are the Causes of Systemic Lupus Erythematosus?

The cause of the disease is yet to be known, but it can be caused by multiple factors like genes, environment, gender, and hormones,

What Are the Symptoms of Systemic Lupus Erythematous?

• Arthritis: Arthritis occurs in about 90 percent of patients and is often associated with morning stiffness. Tenosynovitis (inflammation of tendons) is also present.

• Raynaud’s Phenomenon: It is often present along with arthritis in SLE-affected patients. Raynaud’s phenomenon is a condition causing the extremities, like fingers and toes, to become cold and numb due to restricted blood supply.

• Skin Rash: Malar rash, also known as a butterfly rash, is seen in the face, excluding the area around the mouth and nose, which is painful and itchy. Subacute cutaneous lupus erythematosus (SCLE) is a type of rash that occurs in the regions exposed to the skin. Discoid lupus is the third type of rash characterized by a coin-shaped or disc-shaped lesion, and hair loss occurs if it is in the scalp region.

• Renal Lesion: It is characterized by hematuria and proteinuria on microscopic examination. Hematuria is the presence of blood in urine, and proteinuria is the occurrence of essential proteins in the urine. This is due to proliferative glomerulonephritis, in which there is an abnormality in the blood vessels of the kidney and there is a malfunction.

• Cardiovascular Problems: Pericarditis is the most common feature and is caused due to inflammation (swelling) of the pericardium (a sac that covers the heart). Myocarditis can also occur, which is an inflammation of the muscles of the heart.

• Lung Problems: Pleurisy (inflamed chest wall) can cause chest pain and pleural effusion (accumulation of fluid in the lung wall).

• Cerebral Lupus: This causes visual hallucinations, psychosis, chorea (involuntary movements and sounds), and meningitis (inflammation of the lining of the brain).

• Hematological: Neutropenia is seen, which is characterized by a reduced count of neutrophils (type of white blood cell). Lymphopenia occurs, which is characterized by a reduced count of lymphocytes (type of white blood cell). Thrombocytopenia is also seen, which is the reduction in platelet count. Hemolytic anemia also occurs and is a condition in which the red blood cells are destroyed faster than the normal rate.

• Flare-ups: Flare-ups are caused by environmental or genetic triggers that can cause tiredness, pain, rash, headache, and dizziness. Fever, weight loss, and lymphadenopathy (swelling of lymph nodes) are also seen.

What Are the Types of Systemic Lupus Erythematosus?

1. Mild Disease: The disease is restricted to skin and joints in this type of SLE. Synovitis and pleuro-pericarditis are seen in this disease. Synovitis refers to the swelling of the lining of joints that leads to pain and swelling, and difficulty in motion. Pleural pericarditis is the abnormal accumulation of fluid (effusion) in the pleura (lining of the lung and chest) and pericardium (lining of the heart).

2. Life-Threatening Disease: Renal, cerebral and cardiac problems are seen in this type of disease, which is a threat to the individual.

How Is Systemic Lupus Erythematosus Diagnosed?

SLE can be diagnosed clinically by the individual's malar rash and photosensitivity (rash on sunlight exposure). A blood test is done to assess the levels of red and white blood cells and platelets. Urine tests are done to check for protein and blood.

How Is Systemic Lupus Erythematosus Managed?

1. Mild Disease: Management can be done by administering analgesics, NSAIDs (non-steroidal anti-inflammatory drugs), and Hydroxychloroquine. If there is any flare of disease, oral Prednisolone is given.

2. Life-Threatening Disease: Management of this disease requires high-dose corticosteroids such as Methylprednisolone in combination with Cyclophosphamide repeated at two to three weeks. Mycophenolate mofetil (MMF) is a less toxic alternative to Cyclophosphamide.

3. Maintenance Therapy: Drugs like Azathioprine, Methotrexate, and MMF (Mycophenolate mofetil) are used for maintenance. Patients with thrombosis and antiphospholipid syndrome require Warfarin to be used throughout their lifespan.

Physical Therapy:

Physical therapy is necessary for SLE patients because a majority of them are affected by arthritis. Arthritis can interfere with the daily activities of the individual. Hence it is essential to clear the patients of pain and joint stiffness. Physical therapy can also be aimed at developing the range of motion and improving mobility.

1. Aerobic Exercise: Aerobic exercise done on a moderate level daily can benefit the patients without aggravating the symptoms. Aerobic exercises also improve energy levels and relieve fatigue. Activities like walking, swimming, and cycling for 30 to 40 minutes are recommended. Patients are asked to stretch the affected joints underwater or in the pool as it is easy in water to move pain-free due to the unloading of the weight.

2. Strengthening Exercise: It is essential to strengthen the muscles weakened due to SLE. Jogging and high-impact aerobics can be done along with weight lifting.

3. Electrical Stimulation: Electrical stimulation is done by allowing an electric current to target the affected area at safe levels and instigating a response. It can reduce inflammation and improve the range of motion.

4. Cold Therapy: Cold application to the affected area can also help relieve pain.

Low-Impact Exercise for SLE:

1. Squats: Squats are performed by standing so that the feet are shoulder-width apart. Extend the shoulders straight and parallel to the floor. Now try to bend the knee keeping the hands extended, hold this position for ten seconds, and then return to the normal position.

2. Alternating Lunge: Stand straight with feet apart and bring the right leg to the front and start bending the knee along the direction of the foot and hold for five to ten seconds and come back to the resting position. Do the same for the other leg.

3. Incline Push-Up: Stand near the edge of a table with the hands apart, grasping the edges. Try to bend the elbows in a way that the whole body is reaching the table or inclined towards the table. Do a push-up and come back to the starting position, and repeat.

4. Bridge: Try to lie down and then slowly rise by bending the knee and keeping the hands over the mat by extending them away from the body. Extend the hip and hold for five seconds.

Conclusion:

Although there is not any specific cure for SLE), it can be managed symptomatically through physical medicine and rehabilitation protocols. Doing physical therapy can greatly help improve the quality of life of SLE patients. Joint stiffness and pain can be cured with painkillers and physical therapy put together. SLE affected patients tend to get tired soon, but this can be managed through routine exercise. Gentle exercises with stretching can improve mobility and provide relief from the rigidness of muscles.