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Thursday, August 25, 2016

Physiotherapy and Systemic lupus Erythematosus (SLE)

Systemic Lupus Erythematosus  (SLE)


Bismillahirahmanirahim, for today there is some sharing i want to give all of reader to read and know a one of the autoimmune disease that can be threatening in your life , its called SLE.

What is SLE?
·        Autoimmune disease
·        Characterised by inflammation of various tissues and organs in the body

Breaking it Down
·        Lupus: means wolf, refer to lesions of the skin that looks like its been attacked by a wolf
·        Erythematosus: redness of the skin caused by inflammation
·        Systemic: can affect tissues and organs right throughout the body
·        Systemic Lupus Erythematosus

What happens in the body?
·        Body’s immune system produces antibodies against itself
·        Abnormalities in apoptosis (programmed cell death)
·        T and B cells become overactive and attack self-antigens
·        Inflammatory and autoimmune response activated.

Signs and Symptoms
·        Common symptoms:
Ø Non-specific fatigue
Ø Rashes
Ø Fever
Ø Joint pain
Ø Weight changes


Dermatological Changes
·        65% of SLE patients develop skin rashes
·        Commonly on the face, neck, upper chest and elbows
·        Butterfly-like patchy redness appearance (Malar butterfly rash)
·        Can be made worse with exposure to the sun

Malar Rash ( Butterfly Rash)


Musculoskeletal Problems
·        90% of SLE patients have joint pain
·        May develop joint deformity (~10%)
·        Most commonly affects:
Ø Fingers
Ø Hands
Ø Wrists
Ø Knee

Lymph Node and Spleen Problems
·        Inflammation or enlargement of lymph nodes are quite common
·        Splenomegaly occurs in 10% of SLE patients
·        Symptoms:
Ø Nausea
Ø Diarrhoea
Ø Vague abdominal discomfort

Nervous System Problems
·        Signs and Symptoms:
Ø Headaches
Ø Personality changes
Ø Confusion
Ø Stroke
Ø Epilepsy
Ø Psychoses
Ø Dementia
Ø Peripheral neurological symptoms – e.g. Weakness and change in sensation

Gastrointestinal Tract Problems
·        Liver, pancreas or GIT can be involved.
·        Signs and Symptoms:
Ø Abdominal pain
Ø Nausea
Ø Indigestion

Renal Problems
·        Kidney is the most commonly affected viseceral organ
·        50% of SLE patients develop renal disease
·        Symptoms related to fluid overload
·        Kidney transplant may be required

Haematological Problems
·        Anaemia in up to 50% of cases
·        RBC, WBC and platelets may decrease
·        Difficulty in blood clotting
Ø Bleeding/harmorrhages may occur

Respiratory problems
·        Pleurisy is very common
·        Occasionally a pleural effusion is present
·        Other lung conditions:
Ø PE (Pulmonary Edema)
Ø Chronic interstitial lung disease
Ø Chest infections
Ø Alveolar haemorrahge
Ø Symptoms:
Ø Pleuritic chest pain
Ø Dyspneoa
Ø Haemoptysis

Jonsson et al 1989
·        Studied the lung function in patients with SLE and persistent chest symptoms
·        Dyspnoea and Thoracic chest pain
·        They found that lung function was preserved despite the chronic chest symptoms

Cardiovascular Problems
·        Pericarditis is the most common cardiac manifestation of SLE
·        Other conditions:
Ø Coronary artery vasculities
Ø Myocarditis
·        Symptoms:
Ø Chest pain
Ø Angina
Ø Fatigue

Diagnosis
·        Based on individual’s symptoms and findings
·        Blood tests and urine tests may be performed
·        Anti-nuclear antibody (ANA) test
·        Anti-DNA test
·        Antiphospholipid antibody test
·        Other blood tests: to check levels of complement proteins in blood, RBC and WBC count, platelet counts etc.

Characteristics of Lupus
American Rheumatism Association established 11 criterias and 4 have to be met for SLE:
·        Butterfly-shaped like rash on face
·        Typical rash on other parts of body
·        Increased sensitivity to sunlight
·        Mucous membrane ulcers
·        Joint inflammaation
·        Serositis
·        Kidney dysfunction
·        Low WBC count, low RBC count or low platelet count
·        Nerve or brain dysfunction
·        Immunologic disorder
·        Antinuclear antibodies in the blood


Aetiology
·        Unknown
·        Popular hypothesis: Viral infection
·        Other causes:
Ø Genetics
Ø Hormonal factors
Ø Ultraviolet light
Ø Medications
Ø Pregnancy
Ø Environmental factors

Incidence and Prevalence
·        90% of lupus patients are women
·        Prevalence highest among women aged 14-64 years
·        In the United States:
Ø 1.4 million people affected
Ø 1/2000 in US has SLE
Ø 1 in 250 young, African-American women
·        In Australia
Ø 1 in 700 Australians affected
Ø Over 17000 people has SLE

Prognosis
·        No cure
·        Flare ups and remissions
·        97% of patients live >5years after diagnosis
·        90% of patients live >10 years after diagnosis
·        Patients with mild SLE can live a relatively normal life span
·        Life expectancy varies for severe SLE patients
·        Common cause of death:
Ø Kidney failure
Ø Central nervous system dysfunction
Ø Infections
Ø Cardiovascular disease

Treatment
·        Aimed at reducing inflammation and controlling abnormalities in the immune system
·        Address sleep quality, lack of exercise and self-care strategies
·        Avoid excessive sun exposure
·        Medications:
Ø NSAIDS
Ø Anti-malarial drugs
Ø Corticosteroids
Ø Immunosuppressants

NSAIDS
·        Used for pain relief
·        Suppress inflammation
·        Relieves fevers, headaches, muscle aches, malaise and arthritis
·        Side-effect:
·        High GIT toxicity
·        Stomach irritation
·        Stomach ulcers
·        Alternative/newer medication: COX-2 inhibitors

Anti-malarial drugs
·        Hydroxychloroquine and Chloroquine
·        Helps with skin rashes, fatigue, mouth ulcers and hair loss
·        May also decrease joint swelling and aching
·        Side-effect:
Ø Nausea

Corticosteroids
·        Example: Prednisone
·        Used to reduce inflammation and controlling disease activity of lupus
·        Used for moderate to severe lupus
·        Side effects:
Ø Osteoporosis
Ø Heart palpitations
Ø Tachycardia
Ø Hypertension
Ø Weight gain
Ø Diabetes
Ø Sleeplessness

Immunosuppressants
·        Example: Methotrexate, Cyclophosphamide and azathioprine
·        Used to suppress the body’s over-active immune system
·        For more severe manifestations of SLE
·        Side effects:
Ø Depress blood-cell counts
Ø Cause anaemia
Ø Increase rick of infections
Ø Increase risk of bleeding

Advice for patients living with Lupus
·        Encourage the patient to exercise
·        Advise the patient to get plenty of rest and to take a rest if they feel fatigued
·        Advise patient to avoid excessive exposure to the sun.
·        Avoid contact with people who have an infection

Systematic Review by Neill et al 2006
·        Effectiveness of non-pharmacological interventions for fatigue in adults with multiple sclerosis, rheumatoid arthritis, or systemic lupus erythematosus.
·        The review suggest that aerobic exercise whether home-based or supervised classes, is an effective non-pharmacological means of managing fatigue for people with SLE.
·        Low-impact aerobics, walking, cycling and jogging were effective interventions.

Relevance to physiotherapy
1.     Knowing what SLE is
2.     How it would affect your treatment
3.     Encourage patient to exercise to improve aerobic capacity (Celeste Robb-Nicholson et al 1989)
4.     Understand the effects of longstanding medications SLE patients have been on
Wallahuaklam..




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