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

Physical inactivity exacerbates pathologic inflammatory signalling at the single cell level in patients with systemic lupus

BACKGROUND

Physical activity is an adjunctive therapy that improves symptoms in people living with systemic lupus erythematosus (SLE), yet the mechanisms underlying this benefit remain unclear.

METHODS

We carried out a cohort study of 123 patients with SLE enrolled in the California Lupus Epidemiology Study (CLUES). The primary predictor variable was self-reported physical activity, which was measured using a previously validated instrument. We analyzed peripheral blood mononuclear cell (PBMC) single-cell RNA sequencing (scRNA-seq) data available from the cohort. From the scRNA-seq data, we compared immune cell frequencies, cell-specific gene expression, biological signalling pathways, and upstream cytokine activation states between physically active and inactive patients, adjusting for age, sex and race.

FINDINGS

We found that physical activity influenced immune cell frequencies, with sedentary patients most notably demonstrating greater CD4+ T cell lymphopenia (Padj = 0.028). Differential gene expression analysis identified a transcriptional signature of physical inactivity across five cell types. In CD4+ and CD8+ T cells, this signature was characterized by 686 and 445 differentially expressed genes (Padj < 0.1). Gene set enrichment analysis demonstrated enrichment of proinflammatory genes in the TNF-α signalling through NF-kB, interferon-γ (IFN-γ), IL2/STAT5, and IL6/JAK/STAT3 signalling pathways. Computational prediction of upstream cytokine activation states suggested CD4+ T cells from physically inactive patients exhibited increased activation of TNF-α, IFN-γ, IL1Β, and other proinflammatory cytokines. Network analysis demonstrated interconnectivity of genes driving the proinflammatory state of sedentary patients. Findings were consistent in sensitivity analyses adjusting for corticosteroid treatment and physical function.

INTERPRETATION

Taken together, our findings suggest a mechanistic explanation for the observed benefits of physical activity in patients with SLE. Specifically, we find that physical inactivity is associated with altered frequencies and transcriptional profiles of immune cell populations and may exacerbate pathologic inflammatory signalling via CD4+ and CD8+ T cells.

FUNDING

This work was supported by the US National Institutes of Health (NIH) (R01 AR069616, K23HL138461-01A1, K23AT011768) the US CDC (U01DP0670), and the CZ Biohub.

The effects of lifestyle interventions on disease activity and quality of life in patients with systemic lupus erythematosus: A systematic review

INTRODUCTION

Systemic Lupus Erythematosus (SLE) is an autoimmune disease affecting multiple organs, characterized by flares and remission. Treatment aims to reduce flare severity and prevent long-term damage, but remission is often elusive, and patients may still experience flares and a reduced quality of life (QoL). This had led to a growing interest in non-pharmacological therapies to improve patient wellbeing.

OBJECTIVE

We aimed to assess and summarize the efficacy of lifestyle interventions in SLE patients on disease activity and QoL.

METHODS

A systematic search on lifestyle interventions, SLE, disease activity, and QoL was conducted in PubMed/Medline, Embase and Clinicaltrials.gov in August 2024. Included studies were randomized controlled trials on lifestyle interventions in adult SLE patients. Each trial was appraised using Scottish Intercollegiate Guidelines Network (SIGN) criteria, with participant numbers, study duration, intervention type and outcome measures detailed in separate tables.

RESULTS

A total of 3564 articles were screened, resulting in the inclusion of 25 randomized controlled trials with 1521 patients. Study quality varied from high (11 studies) to low (6 studies) with considerable intervention heterogeneity. The interventions fell into five categories: physical activity, psychotherapy, lifestyle coaching, supplements and dietary interventions. Physical activity (2 studies, 116 patients), psychotherapy (5 studies, 507 patients) and coaching (1 study with 30 patients) had no significant effect on disease activity, while fish oil supplementation showed a slight benefit in two studies with a total of 102 patients. Quality of life generally improved with physical activity (4 studies with in total 253 patients) and psychotherapy (9 studies with in total 623 patients), with significant mental health benefits, but coaching (3 studies with in total 186 patients) showed no effect.

CONCLUSION

Various lifestyle interventions influence quality of life in SLE patients. Consistent with recent guidelines, both exercise and psychotherapy may positively impact the health-related quality of life in these patients. However, some studies were biased due to self-reported outcomes and the Hawthorne effect, where participants' behavior changed from receiving extra attention. Further research with larger patient cohorts is necessary to reduce the influence of heterogeneity across different studies and to better understand the potential of these promising therapies.

Sleep Disorders in Connective Tissue Diseases-Coexisting Diseases or Disease Components?

This comprehensive review examines the complex relationship between sleep disorders and rheumatic diseases, supported by findings from the latest research articles. It encompasses various rheumatic conditions, including rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis. The review reveals the bidirectional relationship between sleep disorders and these diseases, emphasizing their impact on disease progression and quality of life. Conventional and alternative therapeutic interventions for connective tissue diseases are presented, focusing on improving sleep quality and alleviating rheumatic symptoms. The role of pro-inflammatory cytokines and their potential modulation through pharmacological agents is also discussed. In the treatment of sleep disorders, various options are proposed, such as cognitive behavioral therapy for insomnia, physical activity, dietary modifications, and alternative approaches like reflexology and acupuncture. Thus, this review offers a nuanced understanding of the connection between sleep disorders and rheumatic diseases, supported by evidence from diverse studies. Such an approach is particularly important because it enhances sleep quality for overall patient well-being in the holistic management of rheumatic conditions.

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 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.

Efficacy of non-pharmacological interventions: a systematic review informing the 2023 EULAR recommendations for the management of fatigue in people with inflammatory rheumatic and musculoskeletal diseases

OBJECTIVE

To identify the best evidence on the efficacy of non-pharmacological interventions in reducing fatigue in people with inflammatory rheumatic and musculoskeletal diseases (I-RMDs) and to summarise their safety in the identified studies to inform European Alliance of Associations for Rheumatology recommendations for the management of fatigue in people with I-RMDs.

METHODS

Systematic review of randomised controlled trials (RCTs) including adults with I-RMDs conducted according to the Cochrane Handbook. Search strategy ran in Medline, Embase, Cochrane Library, CINAHL Complete, PEDro, OTseeker and PsycINFO. Assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. Data were pooled in meta-analyses.

RESULTS

From a total of 4150 records, 454 were selected for full-text review, 82 fulfilled the inclusion criteria and 55 RCTs were included in meta-analyses. Physical activity or exercise was efficacious in reducing fatigue in rheumatoid arthritis (RA) (standardised mean differences (SMD)=-0.23, 95% CI=-0.37 to -0.1), systemic lupus erythematosus (SLE) (SMD=-0.54, 95% CI=-1.07 to -0.01) and spondyloarthritis (SMD=-0.94, 95% CI=-1.23 to -0.66); reduction of fatigue was not significant in Sjögren's syndrome (SMD=-0.83, 95% CI=-2.13 to 0.47) and systemic sclerosis (SMD=-0.66, 95% CI=-1.33 to 0.02). Psychoeducational interventions were efficacious in reducing fatigue in RA (SMD=-0.32, 95% CI=-0.48 to -0.16), but not in SLE (SMD=-0.19, 95% CI=-0.46 to 0.09). Follow-up models in consultations (SMD=-0.05, 95% CI=-0.29 to 0.20) and multicomponent interventions (SMD=-0.20, 95% CI=-0.53 to 0.14) did not show significant reductions of fatigue in RA. The results of RCTs not included in the meta-analysis suggest that several other non-pharmacological interventions may provide a reduction of fatigue, with reassuring safety results.

CONCLUSIONS

Physica activity or exercise and psychoeducational interventions are efficacious and safe for managing fatigue in people with I-RMDs.

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.

Nurse-led interventions in systemic autoimmune rheumatic diseases: a systematic review

BACKGROUND

Nurses play an important role in the management of patients with systemic autoimmune rheumatic diseases. Little is known about the effectiveness of nurse-led interventions on patient-reported outcomes in this population. The aim of this systematic review was to examine the evidence of nurse-led interventions in systemic autoimmune rheumatic diseases.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a comprehensive literature search was conducted in PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Embase for studies published from database inception to September 2022. Studies were included if they were published in a peer-reviewed journal in English and evaluated the effectiveness of a nurse-led intervention using a randomized controlled trial design in adults with a systemic autoimmune rheumatic disease. Screening, full-text review, and quality appraisal were conducted by two independent reviewers.

RESULTS

A total of 162 articles were identified for possible inclusion, of which five studies were included. Four of five studies (80%) were conducted in systemic lupus erythematosus. There was significant variability in the types of nurse-led interventions; the majority included educational sessions and follow up counseling by a nurse (n = 4). The most common patient-reported outcomes were health-related quality of life (n = 3), fatigue (n = 3), mental health (including anxiety and depression) (n = 2), and self-efficacy (n = 2). The duration of the interventions varied from 12 weeks to 6 months. All studies included a nurse with specialized training and education and showed significant improvements in their primary outcomes. The majority of the studies (60%) were considered high methodological quality.

CONCLUSION

This systematic review provides emerging evidence for the use of nurse-led interventions in systemic autoimmune rheumatic diseases. Our findings emphasize the important role of nurses in providing nonpharmacological strategies to help patients better manage their disease and improve health outcomes.

Benefits & risks of physical activity in patients with Systemic Lupus Erythematosus: a systematic review of the literature

INTRODUCTION

Most patients with Systemic Lupus Erythematosus (SLE) have limited levels of physical activity (PA). The aim of this systematic review was to examine the evidence regarding the benefits and potential risks of PA in SLE.

METHODS

We searched the medical literature on MEDLINE (via PubMed) from inception to March 2022 using the Medical Subject Headings (MeSH) terms "Exercise" and "Lupus Erythematosus, Systemic" as well as free text combinations such as "physical activity". We also searched the reference lists of retrieved studies. Two authors independently assessed all studies identified by the search for inclusion in the review and independently extracted data.

RESULTS

A total of 40 articles (2291 SLE patients) published between 1989 and 2022 were included in this systematic review. Compared to the general population, SLE patients had low levels of PA, with 11% to 29.8% objectively meeting World Health Organization (WHO) recommendations. SLE patients also had impaired aerobic capacities (VO2_max ranging from 18.8 to 25.78 ml/kg/min). Aerobic programs had significant benefits on global aerobic capacity and estimated cardiovascular risk while resistance training programs improved strength and function in SLE. Fatigue, depression and Health-Related Quality of life improved significantly following PA training. No severe adverse event was reported across included studies.

CONCLUSION

Aerobic and resistance training programs had clear benefits and were well tolerated in SLE patients with stable disease. There is currently no universal recommendations about PA in SLE. Dedicated recommendations informed by this systematic review are needed to promote physical activity and its benefits in SLE patients.

A glimpse into the future of systemic lupus erythematosus

This viewpoint article on a forecast of clinically meaningful changes in the management of systemic lupus erythematosus (SLE) in the next 10 years is based on a review of the current state of the art. The groundwork has been laid by a robust series of classification criteria and treatment recommendations that have all been published since 2019. Building on this strong foundation, SLE management predictably will take significant steps forward. Assessment for lupus arthritis will presumably include musculoskeletal sonography. Large-scale polyomics studies are likely to unravel more of the central immune mechanisms of the disease. Biomarkers predictive of therapeutic success may enter the field; the type I interferon signature, as a companion for use of anifrolumab, an antibody against the common type I interferon receptor, is one serious candidate. Besides anifrolumab for nonrenal SLE and the new calcineurin inhibitor voclosporin in lupus nephritis, both of which are already approved in the United States and likely to become available in the European Union in 2022, several other approaches are in advanced clinical trials. These include advanced B cell depletion, inhibition of costimulation via CD40 and CD40 ligand (CD40L), and Janus kinase 1 (Jak1) and Tyrosine kinase 2 (Tyk2) inhibition. At the same time, essentially all of our conventional therapeutic armamentarium will continue to be used. The ability of patients to have successful SLE pregnancies, which has become much better in the last decades, should further improve, with approaches including tumor necrosis factor blockade and self-monitoring of fetal heart rates. While we hope that the COVID-19 pandemic will soon be controlled, it has highlighted the risk of severe viral infections in SLE, with increased risk tied to certain therapies. Although there are some data that a cure might be achievable, this likely will remain a challenge beyond 10 years from now.

Quality of life measures in Systemic Lupus Erythematosus: A systematic review

In this study we systematically investigated the health-related quality of life (HRQoL) tools, which have been most often used over the last five years to evaluate the QoL in patients with systemic lupus erythematosus (SLE), focusing on their items and applications. A detailed literature search was conducted: the inclusion criteria were as follows: 1) studies including at least 50 patients; 2) studies including at least 25 patients with SLE; 3) quality of life testing with validated measures. The systematic review was based on 119 studies for a total of 32,449 SLE patients and 3092 controls. A total of 35 different patients-reported quality of life measures, applied in cohorts of patients with SLE, were retrieved with the 36-item Medical Outcome Short Form (SF-36) (63 studies of 119 =52.95%), Lupus Quality of Life (LupusQoL) (17 studies =14.3%) and Lupus Patient-Reported Outcome (LupusPRO) (12 studies =10%) being the most commonly used tools. Overall, this systematic review of the literature indicated that quality of life in patients with SLE appears to be poor and generally lower compared to both the general population and patients with other chronic conditions, as was shown by a few studies that used SF-36 and LupusPRO. The use of HRQoL scoring in SLE is gaining increasing interest and is used both in randomized controlled trials and in real-life. Future efforts are needed to improve the understanding of the impact of the disease burden on quality of life from the patient’s perspective.

A prescription for exercise in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) have increased cardiovascular risk, and fatigue is a major subjective complaint. Sedentary lifestyle has been shown to have negative health impacts in cardiovascular and rheumatic disease, though exercise has not traditionally been incorporated into routine therapy recommendations. Regular exercise in SLE may improve difficult to treat Type 2 symptoms, such as fatigue, depression, stress, and quality of life. Insufficient counseling on exercise by physicians is a notable barrier for SLE patients to engage in physical activity. Aerobic exercise regimens are more commonly studied, and have been shown to improve cardiovascular health in SLE. Exercise may improve some inflammatory markers, though does not definitively affect SLE clinical disease activity. Physical activity should be recommended to improve quality of life and cardiovascular health in patients with SLE. Developing clearer guidelines for exercise regimens in a patient-centered manner is warranted, especially given diverse phenotypes of SLE patients and varying degrees of physical limitations.

Systematic review of digital and non-digital non-pharmacological interventions that target quality of life and psychological outcomes in adults with systemic lupus erythematosus

BACKGROUND

Patients with systemic lupus erythematous (SLE) experience psychological comorbidities and impaired quality of life (QOL). We conducted a systematic review to examine the efficacy of non-pharmacological interventions for improving psychological outcomes and/or QOL in patients with SLE. To expand on a previous systematic review in this area and enhance our understanding of efficacious interventions for this population, our search included quasi-experimental and experimental studies of interventions delivered or supported by remote methods (including digitally) or in person.

METHODS

A comprehensive literature search was conducted with a research librarian using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered before data extraction on the international prospective register of systematic reviews PROSPERO Web site (CRD42020154962). The search included controlled-vocabulary and title/abstract terms related to non-pharmacological interventions for SLE published through October 2019 in MEDLINE (Ovid), Cochrane Library databases (Wiley), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (EBSCO), Web of Science (Clarivate), ACM Digital (Association of Computer Machinery), and IEEE Xplore. Studies were synthesized using a systematic narrative synthesis framework. Risk of bias was assessed.

RESULTS

Twenty-three studies were included: 21 randomized controlled trials and two quasi-experimental studies. Non-pharmacological diet, physical activity, psychological, and course-based interventions improved QOL and psychological outcomes, and were delivered in traditional settings (e.g., hospital) or remotely. No studies assessing digital non-pharmacological interventions were identified in our search. Quality assessments showed serious risk of bias for the two quasi-experimental studies, and high risk of bias in a subset of experimental studies.

CONCLUSIONS

Non-pharmacological interventions benefit patients with SLE. Future research should include more representative samples in rigorous evaluations and consider ways to incorporate digital technologies to increase accessibility.

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.