Rehabilitation in Lupus

Rehabilitation in Lupus
Bertram Greenspun, DO

Rehabilitation medicine is the field of medicine that concerns itself not only with how the disease process has affected the individual but also with how the disease has changed the person's ability to maintain the lifestyle and roles in life which they had before the disease started.

The rehabilitation team concentrates on how to improve the person's functioning and independence to the highest possible level. Systemic Lupus Erythematosus (SLE) at times presents problems that can be helped by an individualized rehabilitation program. Among the body systems that can be affected by lupus (and may be helped by rehabilitation) are the central nervous system (CNS), the musculoskeletal system (muscles, bones and joints), and the vascular system (blood vessels).

The CNS can be involved in a variety of ways. Patients who develop stroke-like syndromes or problems of the spinal cord usually require an in-patient program in a comprehensive rehabilitation center. These problems often result in weakness of one or both arms or legs. Weakness can be so profound that it may result in paralysis. Under such circumstances, passive range of motion (ROM) exercises should be started by the physical therapist (PT). Family and friends may also be instructed by the physical therapist to perform ROM exercises for the patient. These exercises are done without the patient having to do any of the work. Since some degree of strength almost always returns when the stroke or the spinal cord damage resolves, it is vital not to allow contractures to develop.

Contractures happen when the joints are allowed to stiffen to the point where they will be unable to bend. Should this occur, even if muscle power returns it will do no good unless the stiffness is reduced or eliminated. This can take a very long time and even require surgery. It is much wiser and easier to prevent contractures in the first place than it is to correct them after the fact. As the patient improves, he/she can move the joint along with the physical therapist. Then the exercise is known as active-assistive ROM. When the patient can move the joint through the entire ROM, he/she no longer needs the assistance of another person and is instructed on how to do regular, active ROM exercises independently.

In addition to ROM exercises, strengthening exercises can be started under proper supervision as soon as is medically possible. The strengthening program should begin at a low intensity that is well within the capability of the patient. It is increased only gradually and slowly. The patient must learn to "listen" to his/her body. This means that if muscle pain or fatigue lasts for more than an hour to an hour and a half after a session, the level of exercise intensity should be temporarily reduced. if the discomfort or fatigue continues after each session the physician who prescribed the program should be notified.

Too much exercise, done too quickly, can easily make the situation worse. If the weakness is associated with acute inflammatory joint pain, isometric exercises can be helpful. Isometric exercises involve contracting the muscles without moving the involved joint. In this way strength can be maintained without triggering the intense pain associated with moving an acutely inflamed joint. Since isometric exercises can cause the blood pressure to rise they should be performed cautiously and without holding the breath, especially in the individual with hypertension. Almost all patients with lupus will, at some point in the disease process, have joint pain. There is often associated morning stiffness and joint swelling. Tenderness and painful movement are common. Deformities may result. Most of these problems can be dealt with on an out-patient basis.

An early morning shower will frequently shorten the duration of morning stiffness. Moist heat is quite helpful for most joint problems and is used prior to ROM exercises. This can be provided by using an inexpensive hydrocollator pack (a wan-n, moistened, sand-filled canvas bag). The moist heat helps to prevent or reduce joint pain caused by motion. For chronic pain, deep heat, such as is provided by ultrasound, can be applied by a PT.

For acute, severe joint pain, ice is most helpful. Bed rest is occasionally prescribed for widespread severe pain. In such cases, it is especially important to properly position the patient in bed to avoid the development of contractures of the joints. One of the most common mistakes is to put pillows under the knees. This forces the knees into a bent position and, along with them, the hips. To imagine the difficulties this can cause, try walking with your hips and knees bent. Both musculoskeletal and CNS manifestations can lead to problems in performing the activities of daily living (ADL) such as dressing, bathing, toileting, etc. An occupational therapist (OT) can be most helpful in suggesting ways to solve these problems.

The OT can provide tools such as button hooks and long-handled sponges to make these activities easier, and can fit splints to allow painful hands and arms to rest while keeping them positioned properly. The OT can educate the patient in joint conservation techniques (ways to protect the joints yet still get the task done). The OT can also aid in the selection of devices to make living at home less difficult (tub benches, raised toilet seats, stair glides, etc.) and can help evaluate the home environment from the point of view of the patient's safety. If mobility has become a problem as a result of joint or CNS involvement, the PT teaches transfer techniques (bed to chair, sit to stand,etc.) and ambulation training, including going up and down stairs. The physical therapist also teaches patients to make proper use of assistive devices such as canes and crutches and helps the patient to adapt to leg braces and splints.

As a result of lupus vasculitis (inflammation of the blood vessels), patients may develop ulcerations of the skin. Special exercises can then be used to help improve circulation and whirlpool treatments can be given to clean the ulcers by removing dead tissue. Rarely, as a result of ulcerations of the feet or ankles, or as a result of blood clots in the major leg arteries, amputation of part of a leg may become necessary.

There has been dramatic improvement in prosthetic (artificial) feet in the last three to four years, allowing many more normal activities such as running and jumping, and materials are now available that result in a much lighter limb. In each state, there is a government office concerned with helping individuals with disabilities obtain training or education so that they can return to gainful employment if their disability prevents them from resuming their previous vocation. This office is usually known as the Office of Vocational Rehabilitation. Social workers can be most helpful in directing people with lupus-related disabilities to the appropriate office or case worker.

The social worker is familiar with the many resources that can help the person with lupus obtain a wide variety of services. Social workers are available in medical clinics, hospitals and social agencies and are members of all rehabilitation teams. If lupus patients have to be hospitalized in a rehabilitation center they will encounter physicians responsible for directing their rehabilitative care. Such physicians are specialists in Physical Medicine and Rehabilitation and are called "physiatrists". In addition to the PT, the OT and the social worker, the rehabilitation team usually includes a number of other professionals. These are a rehabilitation nurse (who has had special training in working with patients disabled by different diseases) a psychiatrist and/or psychologist (to help with the emotional problems that may be present), a recreational therapist (to get patients involved in activities that they may have enjoyed previously or to introduce new interesting activities that make them aware that life can still be enjoyed) and a speech therapist (to help in problems with language or with swallowing difficulties). As well as working with the patient, all members of the rehabilitation team work with the patient's family and friends so that they know what to do and what not to do, when the patient goes home. In summary, the primary purpose of any rehabilitation program is to improve the functional independence of the individual.

Most of the patients requiring a rehabilitation program can be treated in an out-patient setting or at home. Only a small minority will require an intensive in-patient program. While no patients are cured, almost all can be helped.

=========================================================== This information is for"informational purposes" and is not meant to be used for medical diagnosis. Alwaysconsult your physician on matters such as this.