Effects of aerobic conditioning in lupus fatigue:
A pilot study. Brit J Rheumatol.
Summary: Even in a patient whose lupus
is considered inactive, fatigue can still be debilitating. Treatment
options to deal with this problem of fatigue are extremely limited.
These authors wanted to investigate determinants of fatigue and
test whether a mild aerobic exercise-training program would favorable
impact fatigue in a group of patients with lupus.
Each of the 25 patients recruited for the study was given a variety
of questionnaires to complete. These included a depression scale,
a Profile of Mood States (this has a subscale for fatigue), and
a specific scale to evaluate fatigue. Standard lab tests were done
(i.e., complete blood counts and ESR – an indication of active
inflammation). All patients underwent a bicycle ergometer test to
assess Vo2max (a physiological indicator of aerobic fitness). The
patients were divided into a treatment and control group. The treatment
group was asked to walk, bicycle, or jog at least three times per
week, at 60-80% of their maximum heart rate, for 30 minutes at a
time. The control group was given stretching exercises to be performed
at the same duration and frequency as the aerobic exercises for
the treatment group.
At baseline, 39% of the patients met the criteria for depression
(more than a normal population). According to the Profile of Mood
States, these patients were no more fatigued than the average person.
However, fatigue scores from this questionnaire were inversely correlated
to duration of the baseline exercise test. The aerobic capacity
of these patients at baseline was severely limited (45% of normal).
After eight weeks of training, patients in the treatment group exhibited
a 19% increase in Vo2max and a 12% increase in endurance on the
post-training exercise test. In the control group, endurance times
fell by four percent after eight weeks of flexibility exercises.
Also, according to the fatigue scale, there was a significant decrease
in fatigue ratings for the treatment compared to the control group.
Commentary: In conventional medicine,
fatigue is often ignored or treated with anti-depressant medications.
This may be especially true for patients with lupus who are not
exhibiting any symptoms of an active disease state. Although these
patients have a higher than usual chance of being depressed –
and the Merck Manual suggests that
in 80% of the patients who present with fatigue, the cause is depression
– it is still worth determining (by using a questionnaire
or clinical judgment) if the patient with lupus is truly depressed
before prescribing anti-depressant medications. It is also noteworthy
that this author thoroughly disagrees with the Merck
Manual's description of the etiology of fatigue typically
being depression. There are many "subclinical" organ dysfunctions
that could account for fatigue, even with patients who have lupus.
These include hypofunction of adrenals and/or thyroid and those
organs important in helping to control blood sugar (i.e., pancreas,
It is also important to consider that significant detraining in
patients with lupus may be an important etiological factor in their
fatigue. The patients in this study had less than half the aerobic
capacity that sex- and age-matched normal individuals would be expected
to have. Since oxygen is an absolutely essential nutrient in order
to "burn" fuels to provide energy to the whole body, it
is not surprising that an individual’s ability to consume
and utilize adequate amounts of oxygen could have a major impact
on one's energy level. It appears that a moderate aerobic exercise
program (done at home) is able to significantly lessen the fatigue
in individuals with lupus. Perhaps a more moderate intensity exercise
program would achieve the same effects if done for more than eight
weeks. In fact, for individuals who are very fatigued, it makes
good clinical sense to prescribe a progressive aerobic exercise
program that can be readily accomplished on a daily basis and even
during periods of mild disease activity.
Effectiveness of minimally supervised home
aerobic training in patients with systemic rheumatic disease. Brit
J Rheumatol. 1995;34:1064.
Summary: In this study as in the previous
study, the investigators are interested in the impact of aerobic
exercise training and the symptom of fatigue. Seventy-one individuals
who had either rheumatoid arthritis (RA) or lupus agreed to participate
in this exercise study. These investigators wanted to determine
if aerobic exercise prescribed as a home-exercise program would
lead to the same decline in indices of fatigue as exercise-training
patients have done in a supervised environment.
The study was conducted in two phases. The first phase lasted three
months, and the patients were split into control and exercise groups.
Treatment group patients were given a stationary bicycle to take
home, a specific exercise prescription (standard of three days per
week, 30 min sessions, at 60-70% maximum heart rate), and were contacted
by phone on a regular basis. The second phase of the study gave
a similar exercise prescription, however, no phone contact was made,
and the stationary bicycle was taken away. Before each phase, baseline
measurements of endurance time, fatigue, depression, and helplessness
were taken. These same measures were repeated at the end of each
Although all measures in the exercising group compared to control
group demonstrated greater improvement, none were significantly
different. In general, patients with RA had greater improvements
in all scores compared to patients with lupus. For the second phase
of the study, the results were similar to the first phase, however,
the differences between treatment and control groups were even smaller.
Commentary: These authors designed
a good study to test the efficacy of an at-home exercise program
on fatigue and depression indices in patients with systemic autoimmune
diseases. Their results were somewhat disappointing when contrasted
to other studies where the patients exercised under supervision.
This suggests that compliance to the exercise program is a significant
factor or that there is a selection bias in the study population.
This means that only those patients motivated enough to engage in
exercise training at home were already more active (i.e., aerobically
trained). Whenever you start with a relatively trained group, the
differences after a specific exercise program are going to be less
significant. However, the low levels of endurance of all patients
at the beginning of this study were similar to patient populations
in supervised exercise studies.
Study subjects did report exercising 2.2 days per week; the authors
did not report exercise compliance regarding duration of exercise
sessions. This information does not rule out the confounding factor
of compliance in explaining the results from this study. Perhaps
the next step in utilizing exercise as a means of reducing fatigue
and depression in patients with systemic autoimmune diseases would
be to test an exercise program that is less intense, but of greater
frequency (i.e., five to seven days per week rather than three days
per week). Compliance may be improved if mild exercise becomes a
daily habit of enjoyment rather than a periodic undertaking.
Exercise in ankylosing spondylitis: How much
is optimum? J Rheumatol. 1998;25:2156.
Summary: Ankylosing spondylitis (AS)
is essentially rheumatoid arthritis but affects the spinal joints
rather than peripheral joints. Conventional treatment includes both
non-steroidal anti-inflammatory drugs (NSAIDS) and therapeutic exercises
to maintain normal posture and activity. Although the effectiveness
of supervised, short-term exercise prescriptions have been demonstrated
in a number of studies, it is not clear how well patients adhere
to exercise programs on a long-term, at-home basis. If patients
are continuing their exercise at home, the long-term effects of
this exercise on disease activity and function are unknown.
Four thousand patients with AS were studied in a retrospective fashion.
These patients were sent questionnaires asking about amounts and
types of exercises they engage in and to rate how effective they
thought exercise was to their improved functional capacity. Standardized
AS symptom questionnaires were also filled out. Patient groups were
established based on the number of hours per week that they exercised.
Correlations were then sought between different patient groups,
symptom scores, and functional capacity scores.
Those individuals who exercised two to four hours a week had higher
functional capacity scores and lower disease activity scores compared
to patients with AS who reported no exercise. When comparing these
same parameters in individuals who exercised ten hours or more a
week with those who did not exercise at all, the only difference
was in functional capacity. Adherence to a regular exercise program
was associated with number of visits to a rheumatologist, beliefs
in the benefits of exercise, and a higher education level.
Commentary: It does appear that moderate,
consistent activity levels can have long-term beneficial effects
on both functional capacity and disease activity in patients with
AS. Interestingly, there was not a dose-response benefit to amount
of exercise and disease activity. In fact, at ten or more hours
a week of exercise, there was no better control of disease symptomology
than those individuals who did no exercise. This suggests that there
might be an upper limit to the amount of exercise that is beneficial
to patients with AS.
Again, the issue of patient compliance or adherence is crucial in
determining success of an exercise program. Perhaps a practitioner
could consider ways to alter patients' beliefs about the benefits
of an exercise program. Education is one approach, but a specific
written exercise prescription may lend credibility to the exercise
program as a therapeutic modality and possibly influence beliefs
of the patient regarding exercise as a medication.
Reduced muscle uptake of oxygen during exercise
in patients with systemic lupus erythematosus. J
Summary: These authors wanted to investigate
whether a limited oxygen supply to the exercising muscles may contribute
to the limited aerobic capacity in patients with lupus. As a matter
of comparison, three groups of patients underwent exercise testing
to measure oxygen consumption as related to submaximal workloads.
Group 1 patients consisted of women with a variety of diseases (none
autoimmune), group 2 patients were women with chronic anemia, and
group 3 patients were those with diagnosed lupus.
Aerobic exercise capacity was significantly lower in group 3 patients
compared to the other two patient groups. Oxygen consumption indices
were also significantly lower in the lupus patients compared to
both other patient groups. A correlation was found between degree
of disease activity and aerobic capacity, i.e., the higher the disease-activity
index, the lower the aerobic capacity of the patient.
Commentary: The results of this study
suggest that patients with lupus have an impairment in either oxygen
diffusion into working skeletal muscles or are unable to adequately
utilize the oxygen when delivered. Both factors may be important
in explaining the limited aerobic capacity measured in patients
with lupus. In particular, these authors speculate that chronic
muscle inflammation may account for impairment of oxygen diffusion
into skeletal muscles of patients with lupus. They go on to suggest
that this may then account for the fatigue that is so prevalent
in patients with lupus. It would be interesting to test whether
altering an exercise prescription for the purpose of "hyperoxygenation"
would be beneficial to patients with lupus. Alternatively, there
are a number of oxygen solution products now available, and these
may be beneficial for patients with lupus and they may enhance their
Many authors have suggested that deconditioning is the cause of
the fatigue in patients with autoimmune diseases. Perhaps with aerobic
exercise conditioning, there is an improvement in not only cardiovascular
fitness, but also an improvement of oxygen uptake by the working
Sex as a determining factor in the effect
of exercise on in vivo autoimmune response adjuvant arthritis. J
Appl Physio. 1994;76(3): 1172.
Summary: A number of previous studies
have investigated the immune-modulating effects of an exercise bout.
However, no study has analyzed the effect of daily endurance exercise
on the incidence and severity of an animal model autoimmune disease.
Male and female rats were exercised daily for ten days before the
onset of autoimmune disease symptoms. This autoimmune disease in
rats is induced by the injection of a highly antigenic mixture in
a certain strain of rats and is used as a model to study human rheumatoid
arthritis. The rats were divided into four groups: male and female
control groups and male and female exercise groups. Severity of
arthritis was scored in each rat every two days. The incidence,
maximum severity of the disease, and the day of disease onset was
recorded for each of the four groups.
The incidence of disease was greater in the female compared to male
rats and higher in female trained compared to female control, but
lower in male trained compared to male controls. Disease severity
was slightly better in the trained female compared to control female
rats, while just the opposite was true in the male rats. These differences
were not statistically significant.
Commentary: There were two surprising
results from this study: 1) the clear difference in incidence of
autoimmune disease in females compared to male rats; and 2) that
the incidence of this autoimmune disease was greater in female,
exercised animals compared to untrained controls. Perhaps the explanation
for the different impact of the stress of daily exercise on males
vs. females is based on sex steroid hormone differences. Testosterone
tends to exacerbate autoimmune disease incidence in animals, whereas
estrogens tend to lessen autoimmune disease incidence. Daily exercise
would tend to decrease estrogens and allow testosterone effects
to go unopposed, while in male rats, daily exercise would tend to
suppress testosterone release.
It is important to understand that in this study the animals were
not exercised over a sufficient period of time to become trained.
It may be that the daily exercise imposed on the rats was of such
intensity as to be too much of a stressor for the female rats. In
general, with mild to moderate aerobic exercise training, exercise
itself becomes less of a stressor. Perhaps the results would have
been significantly different if the animals were exercised at a
more moderate intensity for a sufficient amount of time (before
inducing the disease) to allow for training adaptations to occur.
The results of a number of studies strongly suggest that a moderate
aerobic exercise program can be beneficial to enhancing aerobic
capacity and lessening fatigue in patients with systemic autoimmune
diseases. Attention needs to be given by practitioners to discussing
how to improve long-term adherence to an exercise program that is
prescribed on an outpatient basis. Consider what is best for that
patient, i.e., referral to supervised exercise program or ideas
they can use to enhance at-home exercising (e.g., record keeping).
Remember that the severely limited aerobic capacity often measured
in patients with lupus may be a pathological impairment of oxygen
delivery rather than "couch potato syndrome." Consider
other ways to improve oxygenation in these patients.
Finally, consider that an aerobic exercise prescription which is
more frequent, lower intensity (i.e., 40-50% of maximum vs. 70-80%
of maximum) may be a more prudent exercise prescription for patients
with autoimmune diseases. This may be especially important for female
patients who have previously been very sedentary.