Systemic Lupus Erythematosus (SLE)

Lupus can present as joint pain and rash in one person and as kidney inflammation in another. It moves in flares and remissions, and the plan that suited last year may not suit this year. This is why an exercise programme written once and repeated is the wrong model here.

Fatigue is the symptom patients rate as most disabling, and it correlates poorly with blood markers. A patient can have quiet disease on paper and still be unable to work a full day.

Three things: aerobic deconditioning, the muscle loss caused by prolonged corticosteroid use, and joint pain without joint destruction. Graded aerobic exercise improves fatigue and physical capacity in lupus, and the evidence for it is reasonably consistent.

Resistance training is used cautiously and progressed slowly, particularly where steroids have thinned bone or where a patient has had avascular necrosis of the hip — a recognised complication of long steroid treatment that changes what the hip can tolerate.

No physical therapy modality alters the autoimmune process. Rehabilitation does not reduce antibody levels, protect the kidney or allow a medication dose to be lowered. Anyone told otherwise should ask to see the evidence.

We also do not treat a patient in an active flare with the same programme used in remission. During a flare the plan changes to joint protection, energy management and maintaining range, and it returns to loading when the flare settles.

Photosensitivity is common in lupus and outdoor sessions are planned around it. Hydrotherapy is useful because warm water reduces joint loading, but pool temperature and session length are set individually — heat intolerance is real in some patients and is not a reason to push through.

Fatigue in lupus is often more disabling than joint pain and it correlates poorly with disease activity markers. It responds to graded exercise, sleep work and pacing rather than to rest.

It is also the symptom patients most expect to be dismissed, so it is asked about directly and treated as a clinical problem.

Start below what feels possible and build up gradually. European recommendations for lupus include support for physical exercise as a complement to medication, not a substitute for it 2. European fatigue recommendations advise tailored physical activity and/or psychological approaches, adjusted to disease activity and other health problems 4.

Most of the evidence comes from people with mild or inactive disease. In them, moderate-to-high intensity aerobic exercise improves aerobic capacity, supported by moderately strong evidence, while its effect on fatigue rests on more limited evidence 5. During a flare, or with kidney, heart or lung involvement, the plan is agreed with the rheumatologist rather than taken from a standard programme.