Physical Medicine and Rehabilitation for Systemic Lupus Erythematosus
- Author: Bertram Greenspun, DO; more...
Overview
Background
Systemic lupus erythematosus (SLE) is an inflammatory connective tissue disease with variable manifestations (eg, rash; see the images below).[1, 2, 3] SLE may affect many organ systems with immune complexes and a large array of autoantibodies, particularly antinuclear antibodies (ANAs).
The classic malar rash, also known as a butterfly rash, of systemic lupus erythematosus, with distribution over the cheeks and nasal bridge. Note that the fixed erythema, sometimes with mild induration as seen here, characteristically spares the nasolabial folds. 
Photosensitive systemic lupus erythematosus rashes typically occur on the face or extremities, which are sun-exposed regions. Photo courtesy of Dr. Erik Stratman, Marshfield Clinic. Physical medicine and rehabilitation for SLE may involve physical therapy, occupational therapy, speech therapy, recreational therapy, or combinations thereof. Follow-up medical care of patients with SLE must be ongoing. One physician should coordinate the patient’s care. The physician and the patient must be alert to subtle changes in symptoms that may indicate a flare-up in the disease process.
Treatment & Management
Physical therapy
Physical therapy (PT) is often beneficial for patients with systemic lupus erythematosus (SLE). The role of the physical therapist is to assess each patient and to determine an effective plan of care to help reduce pain, stiffness, and inflammation, as well as to improve joint range of motion (ROM) and functional mobility. Key points to keep in mind when developing a PT program for a patient with SLE include the following.
Exercises should be individualized. For patients with predominant arthralgias or arthritis, techniques used in rheumatoid arthritis may be helpful.
Aerobic exercise might improve aerobic capacity in patients with mild SLE.[4] Incorporate isometric exercises for patients with joint inflammation, especially for the hip and knee (to help maintain biomechanical stability).[5] Isotonic exercises can be used when joint inflammation is reduced or absent. Transfers and ambulation activities are important for maintaining mobility.
Strengthening exercises are initiated when appropriate. Fatigue may hinder progress in some patients. ROM exercises in the presence of inflammation may induce more pain. Isometric exercises may be better tolerated.[5] Hydrocollator packs can be helpful prior to completing ROM to help reduce pain and stiffness.
If pain lasts for more than 1-1.5 hours following activity, the exercise regimen should be reduced in intensity and/or duration.
Proper positioning may prevent joint contractures in patients with SLE. Do not use a pillow under a painful knee.
Ultrasonography (US) is a modality commonly used to provide deep heat to the affected joint, but it should not be used in the presence of inflammation; ice is the preferred modality for inflamed joints. When US is used to improve ROM, movement of the joint and the application of US should be simultaneous.
A pool, when available, is an excellent setting for exercising inflamed joints because of the buoyancy of the water (providing unloading of the joint) and the soothing quality of warm water.
Pacing strategies and breathing exercises are useful when severe cardiac and pulmonary problems are apparent. Assistive devices, such as canes and walkers, are often helpful.
Occupational therapy
The role of the occupational therapist (OT) is to help the patient regain as much of his or her functional independence as possible despite of the problems caused by the disease. Principles of occupational therapy for patients with SLE include the following.
Activities of daily living (ADLs) are encouraged and may require training with special equipment, techniques, and procedures. ADLs include feeding, dressing, bathing, toileting, grooming, and homemaking.
Adaptive equipment may be necessary for patients to complete ADL tasks; some of the more common adaptive equipment includes a raised toilet seat, splints, and reachers. Elastic (no-tie) shoelaces and wide-handled tools may increase the degree of independence.
Educating the patient in joint conservation techniques to protect the joints from damage is important. Paraffin baths are comforting for patients with hand involvement and may improve use.
Fatigue is one of the most frequent symptoms that must be dealt with in patients with SLE. The OT can be helpful in teaching the patient energy conservation techniques, frequently using adaptive equipment.
A home safety evaluation may be indicated. The OT can provide recommendations for equipment (eg, bathtub bench, raised toilet seat, grab bar) to increase the patient’s independence and safety with mobility at home.
Gentleness is important in all settings.
Speech therapy
The speech pathologist can be helpful when a patient with SLE has slurred speech, difficulty understanding speech, or difficulty speaking appropriately. SLE patients with swallowing problems can also be evaluated and treated by the speech pathologist.
Recreational therapy
The role of the recreational therapist (RT) is to involve the SLE patient in enjoyable activities that have therapeutic value. For example, a patient who has painful or weak hands, may benefit from putting a jigsaw puzzle together, which is a light activity that enhances the patient’s eye-hand coordination and his/her ability to match pieces by color. Patients can do this while standing or sitting (whichever is most appropriate) and at the same time can be socializing with other patients.
Wallace DJ, Hahn BH, eds. Dubois' Lupus Erythematosus. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
Mackillop LH, Germain SJ, Nelson-Piercy C. Systemic lupus erythematosus. BMJ. Nov 3 2007;335(7626):933-6. [Medline].
Rahman A, Isenberg DA. Systemic lupus erythematosus. N Engl J Med. Feb 28 2008;358(9):929-39. [Medline].
Clarke-Jenssen AC, Fredriksen PM, Lilleby V, et al. Effects of supervised aerobic exercise in patients with systemic lupus erythematosus: a pilot study. Arthritis Rheum. Apr 15 2005;53(2):308-12. [Medline]. [Full Text].
Hicks JE, Miller F, Plotz P, et al. Isometric exercise increases strength and does not produce sustained creatinine phosphokinase increases in a patient with polymyositis. J Rheumatol. Aug 1993;20(8):1399-401. [Medline].
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