# Exercise as it relates to Disease/Effects of exercise on patients with Lupus

This is a critique of the research article: Ramsey‐Goldman R, Schilling EM, Dunlop D, Langman C, Greenland P, Thomas RJ, et al. A pilot study on the effects of exercise in patients with systemic lupus erythematosus. Arthritis Care & Research. 2000;13(5):262-9.
The critique was written as an assignment in the unit; Health, Disease and Exercise at University of Canberra, August–September 2020.

## What is the background to this research?

Patients who suffer from systemic lupus erythematosus, a chronic inflammatory autoimmune disease, are risk to co-morbidities such as hyper-tension, obesity and disability. These risk factors are mostly a product of the fatigue and reduced functional status the disease causes. Fatigue is a major contributor of health problems with 50-83% of SLE patients reporting it as a primary symptom.
Previous articles have investigated the effects of aerobic exercise and the improvements on fatigue, psychological and physical well-being on disease states. Aware of the primary symptom and the cause of many of the comorbidities, as well as the benefits of exercise on disease states and fatigue itself, the paper had a clear research objective.
This study aimed to assess the effects, and safety, of exercise therapies on SLE patients on self-reported fatigue and functional status - as well the effect on the disease itself. The two methods of exercise therapies; aerobic exercise and range of motion/strengthening, were delivered to two groups of 10 patients.

## Where is the research from?

This researched was published by the ‘American College of Rheumatology’ in June 2001 after revision of the publication in April of that year. The ACR publishes peer-reviewed articles that focus on all aspects, and improvement in care of patients with rhematic diseases, understanding that patients who suffer from arthritis battle chronic fatigue; sharing similarities with SLE patients.
The research was conducted in a women’s hospital in the North-western University in Chicago, Illinoi in a ward 3-315. All the patients who volunteered for the study were female. The study was backed by grants from the University, the Multipurpose Arthritis and Musculoskeletal Disease Center and the Lupus Foundation of America. These organisations have clear motives and goals to support research that promotes care and treatment of persons afflicted with these diseases.
The leading author of the study, Rosalind Ramsey-Goldman had published 17 articles relating to SLE prior to this article in critique. Ramsey-Goldman has a huge reputation in the field of SLE as this comprises of a large majority of her research.

## What kind of research was this?

This study was a randomised control pilot trial that involved two groups of patients. Each member who volunteered underwent physical testing to assess exercise capacity, measured in metabolic equivalents. Subjects with similar MET values were paired with a similar ranking participant and then randomly assigned to either the aerobic exercise group or the range of motion group. The range of motion group were used as the control as there was no cardiovascular influence.

## What did the research involve?

The research involved 10 female SLE patients that were split evenly into group 1: the aerobic exercise group or group 2: the ROM group. Both groups engaged in two phases of the program, phase I and phase II lasting 2 and then 6 months, respectively. Phase I was delivered and monitored by health professionals who managed the intensity and duration of the aerobic exercise session. Also ensuring ample rest periods for the ROM group to dismiss cardiovascular influence. Phase II began when patients were asked to continue these programs at home unsupervised but were monitored by telephone and exercise logs.
Aerobic Exercise Group Session :
| Warm-up | Exercise | Intensity | Cool-down | Duration | Frequency |
| 5–10 minutes | Aerobic Activities | 70-80% of HR Max | 5–10 minutes | 20–30 minutes | 3x per week |
Range of Motion Group: This group practiced movement patterns and isolated upper and lower body extremity range of motion for 50 minutes, 3 times a week in Phase I. In Phase II, a muscle strengthening was added to test safety of common exercises and the effect on their fatigue.
The obvious limitations of the methodology came from the unsupervised exercise at home. Not only because of the self-reported data, as is often over-estimated, but the adherence to the specific types of exercise or intensity as well. The exercise may potentially be governed by the participants own motivation, which may differ from the parameters that health professionals made sure were met.

## What were the basic results?

The study looked at several outcome measures and those of importance were:
* Fatigue: By a questionnaire called the ‘Fatigue Severity Scale (FSS)’. It consisted of 9 statements that were scaled from 1 (strong disagreement) to 7 (strong agreement).
* Functional Status: By a self-administered survey called ‘The Medical Outcomes Study Short Form (SF-36). Physical function subscales were measured to maximum value of 100.
* Lupus Disease and Activity: By a measurement index called ‘Systemic Lupus Activity Measure’ (SLAM) that looked at the severity and activity for individual organ systems as well as combined.
Baseline results :
| | Aerobic Group | Range of Motion Group |
| FSS | 4.45 | 4.73 |
| SF36 | 80.0 | 73.0 |
| SLAM | 4.40 | 5.60 |
Phase I results - Baseline results :
| | Aerobic Group | Range of Motion Group |
| FSS | -0.70 | -0.47 |
| SF36 | 10.00 | 6.00 |
| SLAM | -0.80 | -0.10 |
Phase II results - Baseline results :
| | Aerobic Group | Range of Motion Group |
| FSS | -0.71 | -0.68 |
| SF36 | 7.00 | 2.5 |
| SLAM | 2.80 | 0.40 |
There were no significant increases in the SLAM scores meaning that disease activity did not increase. Patients showed some improvement in fatigue with a decrease of 0.70 and 0.68 in FSS scores as well as improved functional status with scores going from 80 and 73 to 87 and 75.5.
Although there were some improvements, the results do not represent a significant difference between the two very different exercise therapies. The two therapies yielded similar results in fatigue and functional status even at the end of Phase I, where exercise was professionally supervised, and Phase II was not. This may suggest that the two exercise therapies had little effect in general.

## What conclusions can we take from this research?

The finding of this study indicates that these exercise therapies offer a safe intervention for patients with SLE as their fatigue and disease activity did not increase. While the results were not statistically great, as this was a small pilot study, the benefits of exercise are still evident. Additional larger studies have yielded better results in demonstrating a significant improvement in fatigue and physical well-being in SLE patients through intervention of aerobic exercise.

## Practical advice

The risk factors associated with the fatigue SLE patients suffer from are still modifiable through exercise. Along with improvement of health conditions, there is evidence to support the improvements in mood, fatigue and functional status through aerobic exercise. Studies suggest an exercise intensity at 60-80% of heart rate maximum 3 times a week while performing activities such as:
* walking
* cycling
* jogging
* swimming
Noncompliance to exercise routines in vulnerable populations is quite common, as is with the rest of the population. This study ends with the advice to make exercise a routine part of check-ups, and to educate SLE patients to change their view on exercise. A change in perception may provide motivation and increased adherence to physical activity guidelines.

## Further information/resources

* Lupus Foundation of America
* Australiasian Lupus Foundation
* Rosalind Ramsey-Goldman - Scholar Profile
* Effectiveness of non‐pharmacological interventions for systemic lupus erythematosus

## References

* 1 2 Ramsey‐Goldman R, Schilling EM, Dunlop D, Langman C, Greenland P, Thomas RJ, et al. A pilot study on the effects of exercise in patients with systemic lupus erythematosus. Arthritis Care & Research. 2000;13(5):262-9.
* ↑ Ahn GE, Ramsey-Goldman R. Fatigue in systemic lupus erythematosus. International journal of clinical rheumatology. 2012;7(2):217.
* ↑ Lindsey AM, West CM, Carrieri-Kohlman V. Pathophysiological phenomena in nursing: Human responses to illness: Saunders; 1993.
* ↑ Neuberger GB, Press AN, Lindsley HB, Hinton R, Cagle PE, Carlson K, et al. Effects of exercise on fatigue, aerobic fitness, and disease activity measures in persons with rheumatoid arthritis. Research in nursing & health. 1997;20(3):195-204.
* ↑ Bravo G, Gauthier P, Roy PM, Payette H, Gaulin P, Harvey M, et al. Impact of a 12‐month exercise program on the physical and psychological health of osteopenic women. Journal of the American Geriatrics Society. 1996;44(7):756-62.
* ↑ Our Mission American College of Rheumatology; 2020 [Available from: https://www.rheumatology.org/.
* ↑ Our Mission Nation Institues of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases 2020 [Available from: https://www.niams.nih.gov/.
* ↑ Advancing Research. Improving Lives. : Lupus Foundation of America 2020 [Available from: https://www.lupus.org/.
* ↑ Rosalind Ramsey-Goldman Northwestern Scholars Elsevier B.V; [Available from: https://www.scholars.northwestern.edu/en/persons/rosalind-ramsey-goldman/publications/?type=%2Fdk%2Fatira%2Fpure%2Fresearchoutput%2Fresearchoutputtypes%2Fcontributiontojournal%2Farticle&ordering=publicationYearThenTitle&descending=false.
* 1 2 Tench C, McCarthy J, McCurdie I, White P, D'Cruz D. Fatigue in systemic lupus erythematosus: a randomized controlled trial of exercise. Rheumatology. 2003;42(9):1050-4.
* 1 2 Neill J, Belan I, Ried K. Effectiveness of non‐pharmacological interventions for fatigue in adults with multiple sclerosis, rheumatoid arthritis, or systemic lupus erythematosus: a systematic review. Journal of advanced nursing. 2006;56(6):617-35.