Application of functional exercise in patients with systemic lupus erythematosus with pulmonary hypertension

The article is from ~ China Clinical Nursing, No. 6, 2021

Author: Chen Peiling Xie Lunfang

【Abstract】 This paper reviews the research results of functional exercise in patients with pulmonary hypertension in recent years, including the research status of functional exercise in patients with pulmonary hypertension, the safety of functional exercise, the choice of exercise location, and the form of functional exercise, etc., aiming to provide relevant reference for functional exercise in patients with systemic lupus erythematosus and pulmonary hypertension.

【Keywords】 Pulmonary hypertension; functional exercise; lupus erythematosus systemic; review

Systemic lupus erythematosus (SLE) is a complex autoimmune system disease that invades various organs of the body, often with severe lung and cardiac complications, and severely affects the quality of life of patients [1-3]. Pulmonary arterial hypertension (PAH) is a clinical syndrome characterized by progressive increased pulmonary vascular resistance, which can lead to progressive overburden of the right heart, myocardial hypertrophy, and dilation, which in turn leads to right heart failure, and ultimately death [4]. Currently, the prevalence of systemic lupus erythematosus with pulmonary hypertension (SLE-PAH) is 3.8 percent in China [5]. The etiology of SLE-PAH is unclear, and the use of targeted drugs can improve patients' pulmonary hemodynamics and alleviate their clinical symptoms, but it does not cure the disease fundamentally [6]. SLE-PAH worsens with prolonged course of illness and has a worse prognosis than in patients with SLE alone [7-8]. For a long time, patients with PAH have been considered unsuitable for exercise therapy [9], resulting in the clinical lack of clinical access to functional exercise in patients with PAH. In recent years, with the further study of the pathology and physiology of PAH patients, experts at home and abroad have analyzed the advantages and disadvantages of functional exercise in PAH patients, and found that although there is a potential danger in PAH patients to carry out functional exercise, exercise can well promote the recovery of patients' physical and respiratory muscle function, which has important clinical significance for PAH patients [6]. Studies [10-11] have demonstrated that exercise therapy can be used as an adjunctive treatment for the treatment of patients with SLE, improving exercise endurance in patients with SLE, improving depression and fatigue in patients, improving the quality of life of patients, and not increasing disease activity, and is equally effective in patients with SLE-PAH [12-13]. This paper reviews the research results of functional exercise in various types of PAH patients in recent years, and aims to provide relevant reference for functional exercise in patients with SLE-PAH.

1 Research status of functional exercise in patients with PAH

In 2006, Mereles et al. [14] conducted a randomized controlled trial of functional exercise for pulmonary hypertension, which demonstrated for the first time that functional exercise can improve exercise endurance and quality of life in patients with PAH, and can be used as a promising additional intervention for patients. In 2009, the European Society of Cardiology (ESC) and the European Respiratory Society (ERS) first proposed functional exercise as a routine measure for the treatment of patients with PAH, suggesting that within the limits of the patient's symptoms and on the basis of controlling the primary disease, exercise training can be carried out under supervision, but not excessive physical activity. Grünig et al. [15] conducted a prospective study of 21 patients with connective tissue disease with severe PAH, including 7 patients with SLE-PAH, and the results showed the effectiveness of aerobic exercise in this group of patients, which can reduce the fatigue level of patients, improve their quality of life, and improve disease prognosis. This result also proves that functional exercise is suitable for patients with SLE-PAH. However, existing trials have been conducted primarily in a single setting, with most without parallel controls and without authoritative recommendations for the type, modalities, frequency, duration, and intensity of exercise therapy [13]. Therefore, the optimal exercise patterns for patients with pulmonary hypertension are still unclear, including the frequency, duration, and intensity of exercise [14].

2 Safety of functional workouts

2.1 Complications of functional exercise

Studies [9] showed that 100% and 95% of PAH patients who participated in functional exercise had 100% and 95% 2-year survival rates, respectively. The survey by Grünig et al. [15] found that most patients with PAH had a good exercise tolerance, 14% of the participants had adverse events, about 7.6% of the patients temporarily stopped exercising due to respiratory infections, 2 cases of syncope, 6 cases of pre-syncope, all occurred within a few hours after exercise, and 2 patients developed self-limited supraventricular tachycardia during exercise. The proportion of serious adverse reactions of syncope, presynophoidosis, and supraventricular tachycardia was only 4.4%, and overall, the safety of patients with PAH to participate in functional exercise was higher. In addition to the adverse effects mentioned above, complications include occasional ventricular tachycardia, hypoxia symptoms, and bradycardia [16]. Therefore, when patients with PAH perform functional exercises, they require experienced medical staff to supervise and pay close attention to them.

2.2 Prevention of complications

Although the criteria for clinical statutory inclusion are inconclusive during functional exercise in patients, the criteria for inclusion and exclusion of clinical trial participants must consider the safety of clinical practice [9]. (1) Functional exercise should be carried out when the patient's condition is stable and the underlying disease is effectively controlled by the drug. Patients with a previous history of syncope and symptoms of right-sided heart failure are contraindicated from exercise training [9]. Patients with PAH with concomitant respiratory tract infections should also not exercise [17]. (2) Pay attention to the patient's cardiac function. Although the current literature volume and sample size are limited, it is generally believed that patients with cardiac function level I are the most suitable group for exercise, and patients with cardiac function level II or III are the most studied groups. Functional exercise is also appropriate for patients with cardiac function iv, but there are too many uncertainties. Patients should have functional exercises under the guidance of a professional [10]. (3) Exercise endurance test and equipped with oxygen therapy facilities. Although there are not many patients who develop syncope during exercise, the harm is greater. The best way to avoid syncope is to take precautions in advance and test your patients for exercise endurance before exercise training begins so that they are aware of their athletic limits. Exercise endurance test is the premise and guarantee of safe functional exercise, the patient must undergo a comprehensive assessment before exercise, accurate assessment of exercise endurance, set personalized exercise goals for patients, suitable environment and appropriate amount of activity, can ensure the patient's sports safety [12]. For patients requiring daily home oxygen therapy, exercise training should only be performed in an oxygen-configured, supervised setting [18].

3 Functional workout location selection

Training models vary from country to country. Athletic training can be started in the hospital and then done at home, or it can be implemented as a complete outpatient program [17]. Although exercise in the hospital can ensure patient safety, accurately record the patient's exercise volume, frequency, intensity and duration, and observe the effect of exercise, in view of the current shortage of medical staff, patients and their families spend too much travel time, limited medical resources, etc., resulting in the hospital functional exercise method is difficult to popularize. For most patients with PAH, out-of-hospital exercise training is a more realistic and practical model of care, and the home-based training model is suitable for groups without public health support, however, all patients with PAH are required to maintain close contact with the doctor who specifies the training program [9]. Heart and lung rehabilitation programmes in Australia are often provided by public hospital outpatient services or community agencies, and the study[9] concluded that patients with the first 3 weeks of illness can exercise in hospitals, with 12 weeks after discharge being family-based or community rehabilitation-based, but simplified family maintenance programs or community rehabilitation must be institutionally supervised.

4 Functional workout forms

At present, the functional exercise methods of PAH patients at home and abroad include aerobic exercise, resistance training, respiratory muscle function exercise, and include frequency, intensity, time, type, progress, personalization, starting level, etc., and the formulation of appropriate exercise training programs is essential for patients with pulmonary hypertension [18].

4.1 Aerobic exercise

Aerobic exercise usually refers to physical exercise performed by the human body in a sufficient supply of oxygen and is the core of functional exercise. Patient preference and accessibility to equipment determine the mode of aerobic exercise, including walking, brisk walking, jogging, and stair climbing, and treadmills are the dominant exercise methods in all studies aimed at evaluating the effectiveness of exercise training [19]. When patients with PAH exercise, the safety parameters of heart rate are not more than 60% to 80% of the patient's maximum heart rate. Patients can walk outdoors for 60 minutes a day. If it cannot be completed at one time, it can be done in stages and gradually, and patients with SLE-PAH can also refer to [20]. Adjust the amount of exercise and whether to give oxygen according to pre-set heart rate safety parameters.

4.2 Resistance training

Limitation of motor capacity in patients with PAH can be explained not only by changes in pulmonary hemodynamics, but also by weakness in surrounding muscles [21]. Most of the current studies involve low-level resistance training, mainly low-weight training for large muscle groups [16]. Training formats can be aerobics gymnastics, elastic bands, dumbbells, barbells, weight-bearing equipment, wall pulleys, etc., and the recommended exercise intensity is gradually from low intensity to medium intensity [22]. You can use 0.5 to 1 kg of dumbbell training, or lift 1 to 2 kg of objects, or you can use a chair to support the body to exercise skeletal muscles. Studies [23] have shown that dumbbell training can be safely used for low-waist monomuscular training, and after a resistance exercise program of 5 days a week, 30 minutes a day, lasting 12 weeks, patients have increased capillaries of muscle fibers and increased oxidase activity, which are associated with increased endurance in quadriceps.

4.3 Respiratory muscle training

Respiratory muscle weakness is a special feature of patients with PAH [19], and respiratory muscle training improves the strength and function of the respiratory muscles, reduces fatigue in patients with PAH, and reduces the incidence of dyspnea. Respiratory muscle training is a common clinical training method [24]. Studies [25] have demonstrated that patients with severe PAH undergo respiratory function training for 5 days a week for 30 min each time, with no adverse reactions occurring, and satisfactory respiratory muscle training results can be achieved. Respiratory function training exercise load is small, has a positive effect on lung function, hemodynamics and motor capacity, SLE-PAH patients can refer to this frequency of respiratory muscle training. Jia Ruoya et al. [26] On the basis of lip-constricted breathing-abdominal breathing, combined with the methods of full-body exercises such as lifting, moving up, sliding, punching, alternating lower limbs lifting of both upper limbs, etc., the patient's ventilation status and motor endurance were improved, and the symptoms of breathing difficulties and hypoxia were effectively improved.

4.4 Daily home exercise therapy

Although exercise is safer for patients with PAH, exercise may be very uncomfortable, reinforcing negative perceptions of exercise and fear of harm [18]. In view of the fact that the standardized exercise mode is not easy to widely promote to conventional clinical practice, clinical medical staff can encourage patients to walk, ride bicycles, climb stairs, etc., exercise anytime and anywhere, integrate exercise into patients' daily lives, and improve patients' exercise compliance. At the same time, patients are taught to recognize their physical abilities and exercise limits, and how to respond to emergencies.[16]

4.5 Combined Motility

Studies [27] have demonstrated that the combination of aerobic exercise, resistance exercise, and respiratory muscle exercise can improve pulmonary hemodynamics and enhance exercise endurance in patients with PAH. Mereles et al. [14] exercise training on different types of pulmonary hypertension are all patients with severe pulmonary hypertension, and the following combination methods are adopted. (1) Do cycling training; (2) take 60 min outdoor walks every day; (3) dumbbell training for 30 min per day; (4) 5 days per week for 30 min breathing function training. The patient did not see any adverse reactions after exercise, and at the same time achieved satisfactory results, which proved that the above 4 combined exercise methods were safe and effective. The Saiz et al. [21] study confirmed that an 8-week exercise intervention, including aerobic exercise, resistance exercise, and specific respiratory muscle function exercises, was safe for patients with PAH and significantly improved muscle strength. Although hydrotherapy is often used in rehabilitation regimens, hydrotherapy is not suitable for patients with PAH due to the risk of increased intrathoracic pressure in patients due to the risk of hydrotherapy. Zhao Shimei et al. [28] found that comprehensive rehabilitation treatment with fast walking as the main exercise method is more suitable for Chinese PAH patients, and its efficacy is better. Studies [29] have shown that short-term functional exercise has no significant effect on patients with PAH, and it is recommended to develop a long-term rehabilitation plan in which patients can gradually increase the amount of exercise and gradually extend the duration of exercise to increase the effectiveness of exercise. However, the patient's heart rate should not exceed 120 beats per minute when exercising, and the blood oxygen saturation should not be less than 85% [8].

Exercise therapy is gaining more and more attention worldwide, but the study's use in patients with SLE-PAH is still in the exploratory stage. Large-scale, multicenter, randomized controlled clinical studies are necessary to further determine the clinical efficacy, cost-effectiveness, and safety of functional exercise. The manner, intensity, and duration of exercise in patients with SLE-PAH need to be individualized and require the joint efforts of medical staff to ensure that the exercise program is optimized. Because SLE-PAH patients are critically ill, in addition to rheumatologists, clinical nurses, physicians, physiotherapists, occupational therapists, and social workers are needed to establish interdisciplinary medical teams to ensure patient safety.

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doi:10.3969/j.issn.1674-3768.2021.06.015

Fund Project: 2016 National Natural Science Foundation of China Youth Science Foundation Training Program (No. 2016KJ18)

Author Affilications:230022 Hefei,The First Affiliated Hospital of Anhui Medical University Rheumatology and Immunology Ward I(Chen Peiling),School of Nursing,Anhui Medical University(Xie Lunfang)

(Received:2020-05-14)