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

EXamining the feasibility of exerCisE to manage symptoms of Lupus (EXCEL): a protocol for a randomised controlled pilot study

INTRODUCTION

SLE is a chronic autoimmune disease that results in sustained hyperactivation of innate and adaptive immune cells and widespread inflammatory damage. Regular exercise reduces SLE symptoms including fatigue and joint pain and improves patient quality of life. However, most individuals with SLE are not sufficiently active to achieve these benefits, and guidance on the optimal approach to exercise is limited. EXCEL will examine the feasibility of conducting a large-scale randomised controlled trial comparing the effects of a remotely monitored, home-based, exercise programme with standard of care for individuals with SLE.

METHODS AND ANALYSIS

30 females with SLE will be recruited, and those randomised into Exercise (SLE-Ex) will codesign a progressive training plan with support from the research team. The aim of each 12-week plan will be to complete 150 min of moderate (60-70% heart rate max, HRmax) or 90 min of vigorous exercise (>70% HRmax) per week. SLE-Ex will be encouraged to exercise independently (without support) from weeks 13-18. Participants with SLE that are randomised into Control (SLE-Con) will maintain habitual activity without support for 18 weeks. Measures of feasibility and acceptability will be reported, and peripheral blood will be collected at weeks 0, 12 and 18 to explore whether the frequency, phenotype and metabolic profile of lymphocyte subsets has changed. Biomarkers of SLE activity, and self-reported measures of fatigue, sleep quality and health-related quality of life will also be monitored at these timepoints. Blood and self-reported measures will be compared with a healthy control (HC) group (n=15, age and body mass index matched) at baseline only.

ETHICS AND DISSEMINATION

A favourable ethical opinion was given by South East Scotland Research Ethics Committee (22/SS/0082). Findings will be disseminated at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN72757645.

Effect of Benson relaxation response technique on the quality of life among patients with systemic lupus erythematous: quasi-experimental study

OBJECTIVES

To investigate the effect of Benson relaxation response technique (BRRT) on the quality of life (QOL) among patients with systemic lupus erythematous (SLE).

METHODOLOGY

A quasi-experimental design was used to conveniently recruit 170 patients with SLE. Participants were divided into two groups, the control and the intervention group for which the BRRT intervention was administered. Utilising an online questionnaire, the QOL was assessed among the two groups, before and 2 months after the intervention, using the Arabic version of the short form 36-item health survey.

RESULTS

After 2 months of the intervention, the intervention group exhibited significantly higher levels in both components of QOL; physical (t(143.31)=15.35, p<0.001); and mental component (t(143.58)=12.35, p<0.001). Additionally, for the intervention group, the results revealed a statistically significant increase in the levels of both components from baseline measurement; physical (t(84)=-16.24, p<0.001) and mental component (t(84)=-12.93, p<0.001).

CONCLUSION

The findings demonstrate a notable positive impact of BRRT on QOL among patients with SLE. Healthcare professionals can potentially improve the overall well-being of patients with SLE and complement traditional treatment by implementing BRRT into their care.

Effects of an intervention with EVOO and physical exercise in systemic lupus erythematosus patients: Efinutriles trial protocol

BACKGROUND

Health-related lifestyle management could improve related symptoms and adverse events in patients with systemic lupus erythematosus (SLE). The phenolic compounds in extra virgin olive oil (EVOO) and physical exercise (PE) have both shown benefits for autoimmune conditions, but no intervention has synergised the two approaches.

AIM

To analyse the effects of an intervention combining EVOO and a multicomponent health promotion and PE programme on disease activity, clinical characteristics, cardiovascular risk, physical fitness, and the molecular level in SLE sufferers.

METHODS

Three-arm prospective randomised controlled 24-week clinical trial. 90 participants will be randomised into one of three groups: control; EVOO supplements; or EVOO and multicomponent health promotion and PE programme.

RESULTS

Pre-, mid- and post-intervention assessments will record disease activity, clinical characteristics, nutritional evaluation, cardiovascular risk assessment, physical condition and functioning, and molecular markers.

CONCLUSIONS

The proposed trial will help clarify whether a combined intervention adding an EVOO supplement to a Mediterranean Diet intake pattern and adherence to an active-healthy lifestyle are beneficial for SLE patients, as well as the need for health and pharmacological care, increasing knowledge of the organic mechanisms mediated by EVOO and PE adherence, allowing new useful biomarkers to be characterised at the diagnostic/prognostic level.

Progressive resisted exercise program combined with aerobic exercise on osteoporotic systemic lupus erythematous patients: a prospective randomized controlled trial

PURPOSE

To investigate the effect of progressive resisted exercise (PRE) and aerobic exercise (AE) on bone mineral density (BMD), muscular strength, exercise capacity, and health related quality of life (HRQoL) in patients with osteoporotic systemic lupus erythematous (SLE).

METHODS

This study was a single blinded randomized controlled trail. Eighty SLE participants, 30-50 years old, were randomly allocated into four equal groups. Group A received PRE and AE, group B received AE, group C received PRE, and group D received traditional medical treatment only. The intervention was implemented three days/week for six months. BMD was measured by Dual Energy X-ray Absorptiometry, muscle strength was measured by an isokinetic device, exercise capacity was measured by 6-min walk test, and HRQoL was measured by short form 36(SF-36). Every outcome was assessed at baseline, six months, and nine months.

RESULTS

There were statistically significant differences among the groups in knee muscle strength, exercise capacity, and HRQol after 6 months (p < 0.05) in favor of the combined group. BMD increased significantly in the combined and PRE groups compared to the AE and control groups (p < 0.05).

CONCLUSION

PRE combined with AE were more beneficial than either exercise alone in improving knee muscle strength, exercise capacity, and HRQoL.

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.

Exercise-induced modulation of Interferon-signature: a therapeutic route toward management of Systemic Lupus Erythematosus

Systemic Lupus Erythematosus (SLE) is a multisystemic autoimmune disorder characterized by flares-ups/remissions with a complex clinical picture related to disease severity and organ/tissue injury, which, if left untreated, may result in permanent damage. Enhanced fatigue and pain perception, worsened quality of life (QoL) and outcome are constant, albeit symptoms may differ. An aberrant SLE immunoprofiling, note as "interferon (IFN)α-signature", is acknowledged to break immunotolerance. Recently, a deregulated "IFNγ-signature" is suggested to silently precede/trigger IFNα profile before clinical manifestations. IFNα- and IFNγ-over-signaling merge in cytokine/chemokine overexpression exacerbating autoimmunity. Remission achievement and QoL improvement are the main goals. The current therapy (i.e., corticosteroids, immunosuppressants) aims to downregulate immune over-response. Exercise could be a safe treatment due to its ever-emerging ability to shape and re-balance immune system without harmful side-effects; in addition, it improves cardiorespiratory capacity and musculoskeletal strength/power, usually impaired in SLE. Nevertheless, exercise is not yet included in SLE care plans. Furthermore, due to the fear to worsening pain/fatigue, SLE subjects experience kinesiophobia and sedentary lifestyle, worsening physical health. Training SLE patients to exercise is mandatory to fight inactive behavior and ameliorate health. This review aims to focus the attention on the role of exercise as a non-pharmacological therapy in SLE, considering its ability to mitigate IFN-signature and rebalance (auto)immune response. To this purpose, the significance of IFNα- and IFNγ-signaling in SLE etiopathogenesis will be addressed first and discussed thereafter as biotarget of exercise. Comments are addressed on the need to make aware all SLE care professional figures to promote exercise for health patients.

WHODAS Assessment Feasibility and Mental Health Impact on Functional Disability in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE), besides rheumatological dysfunction, manifests in neuropsychiatric disorders like depression and anxiety. Mental health illnesses in SLE patients have a high prevalence and a profound impact on quality of life, generating an increased disability and premature mortality. This study aimed to establish the degree of disability in patients with SLE and the impact of depression and anxiety on patients’ functioning. Additionally, the study aimed to verify whether World Health Organization-Disability Assessment Schedule (WHODAS) 2.0 is suitable for the evaluation of patients with SLE associating depression and/or anxiety symptoms. Cross-sectional research was performed, including adult patients, diagnosed with SLE. To evaluate depression, anxiety, and functioning, approved questionnaires Hamilton Anxiety Rating Scale, Hamilton Depression Rating Scale, and, World Health Organization-Disability Assessment Schedule (WHODAS) were applied. Confirmatory factor analysis was performed on WHODAS subscales. Sixty-two patients were included in the research, with a mean of SLE diagnosis of 12.48 years; 53 patients (85%) had depression (p < 0.001). Anxiety was found in 38 patients (61.29%, p < 0.05). WHODAS assessment results depicted that 39 patients (62.90%, p < 0.05) manifested disability, from which 26 (66.66%, p < 0.05) presented moderate and severe disability. A strong correlation between the severity of anxiety and the degree of disability (r > 0.6, p < 0.001) was found. The WHODAS scale assessment proved to be a valuable tool for SLE patient’s functioning assessment. This study suggests that depression and anxiety negatively impact WHODAS disability scores, decreasing the quality of life in SLE patients.