15 Questions with Mrs. Gina Cortese-Shipley– Exercising and Staying Fit with Lupus

This month's 15 questions is brought to you by Mrs. Cortese-Shipley, an exercise physiologist with The Cooper Institute in Texas. She has an M.S. in Exercise Physiology from Texas A & M University and a B.S. in Exercise Science and Health and Wellness from Washington State University. Click here to learn more.

A note from The Cooper Institute: Consult your physician before starting any fitness program and for further information on how exercise may affect your condition. The responses given here do not substitute for advice or information provided by your physician. Contact your physician right away if you experience any change in your symptoms.

1. What are the best exercises to do for lupus; yoga, core strength, cardio, etc.? How long and how often should we workout? North Lauderdale, FL

The best exercise is the one that you can do consistently! The different forms of exercise each have their own benefits. You have to find what works for your body while managing your lupus, what you can commit to on a regular basis, and what you enjoy. In general, low-impact, low-to-moderate intensity exercise programs are best for those with lupus. Below I have listed just a few of the benefits of the different types of exercise.

Cardiovascular exercise has been shown to prevent early death and diseases such as heart disease, stroke, some cancers, type 2 diabetes, osteoporosis, and depression. People with lupus have a significantly increased risk of premature coronary heart disease (CHD) or atherosclerosis, stroke, and other cardiovascular-related conditions, as well as, for osteoporosis making cardiovascular exercise and important component to include in your exercise plan. In addition, it helps to improve your ability to engage in activities needed for daily living, decreases fatigue, and decreases stress and anxiety.

Muscle strengthening activities help to slow the loss of muscle that often happens with lupus as a result of disuse or the use of steroid medication. This will enable you to perform activities of daily living activities with greater ease. Also, this type of activity creates stronger muscles to help protect the joints and decrease joint pain.

Flexibility exercises are important in maintaining the full range of motion of your joints. This can help reduce the pain and stiffness often associated with lupus. Other benefits include: improved circulation, reduced muscle tension, and reduced risk for injury.

Specifically, you mentioned yoga and core strength. Yoga is a nice exercise choice that includes both muscle strengthening and flexibility exercises. It has the benefit of not having large external loads (doesn’t involve lifting heavy weights) - which can be aggravating to those with lupus - and also has a calming affect so can help with the stress and anxiety that often accompanies chronic illness. Stress can often lead to flares, furthermore making managing stress an important part of your treatment plan. Core strength is an important part of maintaining a functional body, so it should be included with your muscle- strengthening activities.

In terms of how much and how often, this depends on you and the severity of your condition, and should be discussed with your physician. The public health guideline is to accumulate at least 150 minutes of moderate intensity activity per week and to engage in muscle-strengthening activity 2 times per week. You are going to have to find what works best for you. For those who are not able to reach 150 minutes per week, it is advised that they engage in as much activity as their condition allows. Start slow and gradually add more exercise to what you are currently doing. This may mean just a few minutes at a time. Listen to your body. If you are feeling fine and have no increased joint pain or fatigue, you are probably okay to continue progressing. If you notice an increase in your symptoms or experience a flare, you may need to reduce the amount of activity you are doing.

2. I am so tired when I get home from work I just want to lay down. How can I exercise when I am so tired? Palm Beach Gardens, FL

Fatigue is the most common symptom for individuals with lupus. Fatigue leads to inactivity, and inactivity leads to greater fatigue. It is a vicious cycle. And many people not living with lupus are tired at the end of the day so I can certainly see how getting motivated to exercise at that time can be a challenge. But once you start exercising you might actually see that you have a decrease in the amount of fatigue you experience, as research has shown that exercise improves the feelings of fatigue common in lupus. First, check with your doctor to be sure your fatigue isn’t related to any underlying issues that may need to be addressed. Second, my suggestion would be to try to find a time of day where you are less fatigued and more motivated to exercise. Can you fit in some exercise time before work in the morning or maybe on your lunch break? Something many people are not aware of is that exercise can be accumulated across the day which means you can break it up into smaller time segments, for example, you could go for a walk for 10 minutes in the morning before work, on your lunch break, and then when you got home and that would accumulate to 30 minutes of exercise. This definitely makes exercise more manageable when dealing with fatigue and then also our busy schedules. There are many exercises that can be done at home or in the office which can take away the extra time needed to get to a gym, a common barrier for many. Another useful strategy is to fit physical activity into the tasks that you are already doing. For example take the stairs instead of using the elevator, do your yard work at a greater intensity, walk to church, or pick up the pace when you are walking the dog. Finding what works for you may take a little time but once you do, stick with it and more than likely you will see a decrease in your fatigue as well as experience many of the other benefits exercise has to offer.

3. Prior to my diagnosis with lupus, I was a long distance runner (half marathon) and then walker. I know the mental benefit I get from prolonged aerobic exercise. Yet now I am having difficulty (pain, fatigue) increasing my walking distance and my exercise capacity. Are there key principals to slowly increase my capacity? Durango, CO

There isn’t a specific principle in terms of how to increase your capacity other than to gradually add more work to what you are currently doing. It is a trial-and-error process. You will probably have to add work at a much more gradual pace than you are used to (for example, only a few minutes at a time). Considering your exercise history, I can only imagine how frustrating that would be. This is probably easier said than done but you cannot hold yourself to your previous standard. Yes challenge yourself; however, you need to find an exercise level that you are going to be able to be consistent with so that you can derive the many benefits exercise has to offer. A rough guideline would be to increase no more than 5-10% at one time but use your body as a guide. You already mentioned that you had an increase in symptoms (pain, fatigue) with increasing your walking distance. Your body is telling you that is too much of an increase at this point in time; so next time try a little less. If you do not notice an increase in symptoms, give your body a little bit of time (i.e. at least a week) to adapt to this new level of exercise, and then try adding some more. And don’t forget, there are many ways to add a challenge to exercise. Maybe increasing your pace versus distance is something to give a try or find a slight incline (hill) in your walking route. You could also try mixing in days of lower impact activity such as swimming, water aerobics, or elliptical work. This change in activity might allow you to have the type of walk you desire, minus the increase in lupus symptoms.

4. I know it is important for joint and muscle health to exercise. However, it tends to make my pain worse. How do I know when it's ok to push on through the pain, and when I should listen to my body and stop? Saugerties, NY

A good rule of thumb to follow - if joint or muscle pain lasts for more than 2 hours after exercising, you have done too much. Other signs that you have pushed yourself too hard are unusual or persistent fatigue (greater than what you typically experience), increased weakness, decreased range of motion, and increased joint swelling. If any of the previous occur, it would be important for you to reduce the amount of activity you are doing. In terms of resistance training, this may mean decreasing the amount of weight you are lifting. In terms of cardiovascular work, you may have to decrease your pace or decrease the time of your exercise session. You may even have to stop and allow your body to rest and recover before starting up again. Also remember that your body may be able to handle more work at certain times and than others. Be sure to create a flexible exercise program that can accommodate this. And use your common sense. I think most of us know when we are pushing ourselves too hard!

5. I exercise regularly and sometimes I have pain in my joints. How can I tell if this is related to Lupus versus a possible exercise injury? Eagle, ID

Anytime you have an increase in pain, especially pain that lasts longer than 2 hours after exercise, it is signifying that something is wrong, whether it is lupus related or an exercise injury. Depending on the severity you may need to cut back on what you are doing or even take a break from exercise until you recover. Be sure to discuss this pain with your doctor. Here are some common signs and symptoms of exercise injury that may occur in addition to pain. You will notice that many are similar to what you might experience with lupus.

Swelling.
Discoloration/bruising.
Sudden intense pain while performing an exercise or other physical activity.
Loss of normal range of motion or function.
Slight pain or tenderness lasting ~ 7-10 days or more.
Moderate to severe pain.

If you experience any of the above, cold therapy may be of benefit. A bag of ice or a cold pack can be applied several times a day for up to 20-30 minutes at a time. Cold packs should be covered with a towel or cloth before application. If any of these symptoms persist, you will want to consult a physician. To prevent exercise injury as well as overuse (doing too much): wear proper clothing and shoes; stretch and warm up with range of motion exercises before you begin; perform strengthening exercises slowly and always with proper form; select lower impact cardiovascular activities; listen to your body and adjust your exercise session if necessary; and cool down following exercise.

6. I am involved in a workplace health program which includes exercise, nutrition and yoga. My legs often retain fluid, and seem to get worse after lower body weight-bearing exercise. Are there some exercises that are better than others for body strengthening? Athens, OH

There are a number of ways to strengthen our body. We have to find those that work best for us. While there are benefits to weight bearing exercise, if they are aggravating your condition then we need to find some alternatives for you. For muscle-strengthening exercises, many standing exercises have a machine that provides a seated option. For instance, instead of performing a squat you can sit and perform a leg press. You may also just have to decrease the amount of resistance you are using during the weight bearing exercise. Using the squat again as an example, instead of holding dumbbells, try just using your body weight as the resistance. Having large external loads (or high weights) does tend to aggravate those with lupus so body weight exercises or exercises with no added weights like squats, lunges, push-ups, sit-ups, and leg raises are a good alternative. Resistance tubing exercises are also an excellent choice. The nice thing about these two options is that they really can be done anywhere! If using resistance, focus on lighter resistance and a greater number of repetitions. Also muscle strengthening exercises that use the water for resistance can also provide a great challenge to your muscles with fewer adverse impacts. For cardiovascular exercises, some non-weight bearing options include bicycling and swimming. The elliptical machine is still weight bearing but because it unloads the body it is less of a load than walking. All of that said, the water is a really great place to exercise due to enhanced circulation and the unloading effect. If your workplace health program does not have a pool as an option, it might be worth it for you to check into some other facilities.

7. Taking into consideration the increased photosensitivity of those with lupus, what are some safe ways to exercise outdoors and get out of the gym? Guaynabo, Puerto Rico

The environment we exercise in can have such an impact on our exercise experience and I can see why you would want to be able to move your exercise outdoors on occasion. The challenge of course is because those with lupus have increased sensitivity to ultraviolet (UV) rays. So one of the first things you should do is use a sunscreen that blocks both ultraviolet A (UVA) and ultraviolet B (UVB) rays. It should be applied to all areas of the body exposed to the sun especially those that are often affected by lupus 15-30 minutes before going outdoors. It should be reapplied every 2 hours or after swimming or perspiring heavily. If you are going to exercise outside you should probably limit the amount of time you are out there and plan to be out early in the early morning (before 10 a.m.) or late in the afternoon (after 4 p.m.) or evening when the UV rays are not as intense. Wearing proper clothing can help too. Long sleeved shirts, long pants, and hats can keep UV exposure down. To keep cool in the warm climate you live in, choose materials that are lighter in weight and have a wicking capacity which helps to draw moisture away from the skin and aids in the cooling process. Find shaded areas where you can do your exercise to also limit UV exposure. Take some pieces of small exercise equipment out with you, like resistance tubing and light dumbbells, to perform muscle-strengthening exercises. Trees can actually be incorporated into your workout. You can use the trunk of the tree as your anchor for the resistance tubing. Take a yoga mat to sit on and do your flexibility exercises or practice some of your yoga poses. And of course there are a number of body weight exercises than can be done without equipment like push-ups, squats, lunges, and exercises for your abdominals and low back. As for cardiovascular activity, find a route that is mostly shaded. If this is too difficult there are a number of cardio movements that can be done in place such as marching in place, toe taps, hamstring curls, and leg kicks; alternate between doing a minute or so of these movements with a muscle-strengthening exercise to create a circuit. With a little creativity and careful planning, you can keep exercise fresh and exciting. But be realistic and keep track of how exercising outdoors affects you. You may have to adjust how much time you spend outdoors. If even a short period of time triggers a flare, you might have to accept that you need to keep your exercise indoors.

8. I am a diabetic on insulin and suffering with lupus since 2008. I am working in a financial institution and daily work schedule is 8-10 hours for 5 days in a week. Being a diabetic it is recommended to exercise daily but at the same point of time as I am suffering with lupus I feel tired and sometimes the condition worsens with flares of fever and joint pains. Please advice on the amount and type of exercises/walking which should be done. New Delhi, India

Exercise will not only benefit your diabetes, but also your lupus. For instance, the fatigue you experience may be somewhat decreased through consistent exercise and building the strength in your muscles may help decrease the pain in your joints. The public health guideline for Americans is to accumulate at least 150 minutes of moderate intensity activity per week and to engage in muscle-strengthening activity 2 times per week. And while there is no specific guideline for flexibility exercises, they too are important to include. That said, you have to find an amount that you feel you can handle. For those who are not able to reach 150 minutes per week, it is advised that they engage in as much activity as their condition allows. Over time you may be able to work up to this amount. During times of flares you may have to cut back on what you are doing or stop and rest for a period of time. Some great cardiovascular exercises considering both your diabetes and lupus are walking, swimming, water aerobics, elliptical training, and bicycling. When performing muscle-strengthening exercises body weight exercises, exercises in the water, or resistance tubing exercises are great options. With your work schedule you may find it best to split your exercise up. Can you perform some flexibility and strengthening exercises when you first get out of bed? Can you go for a walk on your lunch break? With our busy lives, finding the time to fit it in is hard for all of us. Sit down with an hourly calendar for your day and try to find chunks of time where you can fit activity in.

Remember to start slow and gradually add in more exercise. This may mean just a few minutes at a time. Listen to your body. If you are feeling fine and have no increased joint pain or fatigue you are probably okay to continue progressing. If you notice an increase in your symptoms or experience a flare, you may need to reduce the amount of activity you are doing. If you haven’t been exercising, sit down and set a goal for what is realistic for you to achieve and decide to what you are willing to commit. A little physical activity will go a long way to benefiting both of your conditions.

9. I have both SLE and Fibromyalgia. In exercise the common rule of thumb is if it hurts don't do it or back off. Since I have joint pain and soft tissue pain almost constantly, how do I know what level to take it to? Also it seems to me that I never progress-is that a feature of SLE and fibro-exercise intolerance and continued lack of endurance in spite of an exercise regimen? Chevy Chase, MD

It is hard to distinguish what is causing the pain, your co-existent conditions or that you are doing too much exercise. The first thing you can do is to better prepare your body for the exercise you are going to do. Applying heat to sore joints increases circulation, decreases stiffness, and allows you to move more efficiently during your activity. Warm up and stretch by performing range of motion exercises for 5-10 minutes (10 minutes is usually better) to further prepare the area for activity. Following exercise apply cold treatments to reduce inflammation. Although you mentioned you have pain constantly, try to exercise when pain and stiffness are at their lowest and when you have the most energy. These things will hopefully allow you to better determine what exercise level is appropriate for you. Also, if you have increased pain that lasts longer than 2 hours after you exercise, that is an indicator that you have done too much. In terms of progress, this depends. There is a level of exercise that your body can handle and sometimes this level is lower than where we want it to be. You should be seeing some benefit from your exercise, but at some point, you may hit an upper end in terms of what you can tolerate and may not see further increases in the benefits. If this is the case you want to maintain this level of activity in order to derive as many benefits as you can. To be sure you haven’t plateaued prematurely, be sure to change up the exercise you are doing so that you are challenging your body in a different way, for example, if you have been using light dumbbells try using resistance tubing. If you have been walking, try adding in some swimming. Our bodies have an amazing capacity for adaptation so we have to constantly change it up and challenge it in new ways. This also ensures that you are challenging multiple muscle groups. Also, if there are certain joints that cause you pain more regularly than others adapt your exercises to put less stress on those joints. This will hopefully allow you to get more out of your exercise sessions and allow you to see that progress that you want. Remember though that no matter how much exercise you are doing, it should be celebrated. You are doing more than a lot of others out there who aren’t living with lupus and gaining benefits that you wouldn’t be if you weren’t exercising (even if they are not to the level that you want them to be).

Also of note is that sleep disturbance is common with fibromyalgia and this often contributes to more pain. Some find that they experience less pain when they have good rest. Regular physical activity has been shown to help with sleep disturbances but also be sure you are engaging in other habits to create a good night’s rest.

10. Is it more important for people with lupus to focus on doing cardio exercises or lifting weights? Iowa City, IA

Both of these forms of exercise carry their own benefits. Cardiovascular exercise is important to keep up your endurance which helps you to carry out activities of daily living. It is also extremely important for the prevention of chronic disease and premature death. Lifting weights or muscle-strengthening activity is important for creating stronger muscles which helps to support and protect your joints and decrease pain and stiffness -so both are important. Flexibility exercise which helps to keep joints mobile and flexible is important as well. Even a few exercises in each of these three areas can make a tremendous difference. You have to decide what it is that you are hoping to get out of exercise, or what is your goal and then based on that decide which form of exercise is best. You also have to determine what your body can handle and what you enjoy doing. Exercise should be done for a lifetime so we need to choose activities that we enjoy doing, otherwise it is very likely that we will abandon it at some point (probably sooner rather than later).

11. What are some good exercises (48 year old) for weight loss in patients with lupus & fibromyalgia? I typically am extremely sore after exercising, but finding it difficult now that I'm menopausal to keep my BMI despite eating nutritionally. Spanish Fort, AL

Cardiovascular activity such as walking, cycling, or swimming is the way in which we burn calories. For weight loss to occur we need to be expending (burning) more calories than we are taking in (eating). And research has shown that both exercise and eating right are important for weight loss goals. Some soreness is to be expected with exercise especially if it is new to you, however excessive soreness or pain especially if prolonged could be a sign that you are doing too much or that you need to be doing a different form of exercise. Evaluate the activity that you performed and how you felt as a result of it. It could be that you just need to decrease your time or even your intensity (how hard you did the activity). Maybe you tried to take on too much at once and need to cut back and then gradually add more when your tolerance increases. Try different activities to find the one that you respond to best. Some people really enjoy walking, however for others, the pool is a better option. The water is really a nice exercise environment especially for those who have lupus. Body weight in the water ranges from about 60 to 90 percent of body weight on land depending on the depth of water. In other words, if you weigh 130 pounds on land, you may weigh only 13 pounds in the water. This leads to less stress on the joints and often allows for a greater range of motion than can be achieved on land plus higher exercise intensities. It also aids in circulation and decreases inflammation. Water walking, swimming laps, or water aerobics are all great cardiovascular options. Even water jogging is possible for some. Other low-impact cardiovascular options include using the elliptical machine or bicycling. Time is an important factor for calorie burn so gradually add as much time as you can tolerate. You may be able to tolerate more total time if you split it up into multiple sessions across the day. Aim for each session to be at least 10 minutes in length to gain the most benefits.

12. I have some weakness in my left leg, cause is unknown. It's hard for me to do exercise that requires coordination like aerobics or zumba. Can you recommend something low impact other than walking which I do often? Indianapolis, IN

It is always nice to have multiple exercise choices to keep it fresh and exciting. Have you thought about moving your exercise into the water? The water is a great medium for exercise because it decreases the stress on the joints and allows you to a have greater range of motion and exercise at higher intensities than can be achieved on land. Even if you do not know how to swim strokes, water walking and striding are nice options and you might feel more comfortable with water aerobics than traditional land aerobics. The Arthritis Foundation Aquatic Program is a great option for water exercise classes. This is a water exercise program designed for people with arthritis and related conditions such as lupus. Contact your local Arthritis Foundation office to see if there are any classes held in your area.

Outside of the water there are other options as well. If you have access to cardiovascular machines, the elliptical trainer is a nice lower-impact option. Depending on what you set the elevation of the machine to, it mimics either walking, stair climbing, or jogging without the impact. Bicycling is also another possibility. If you do not have access to equipment, you can create your own cardiovascular circuit. A circuit is when you change the exercise you are doing at a certain time interval, for instance like every minute. Some low-impact options include marching in place, heel taps, toe taps, hamstring curls, leg kicks, and side stepping. Adding movement with the arms can add intensity without the impact (and they don’t have to be coordinated). The other thing you can do, if it is okay with your doctor, is to work on strengthening that one side to help bring it in balance with the other.

13. On a weekly basis, I swim 2-3 times, then offset with gym cardio class or elliptical trainer 2-3 times during same week. Now that I am eating better using WW, I lost 13lbs in 3mths. How do i incorporate a continue weight loss goal (I have another 8-10 lbs.) if I can't make it to the gym or swim that day? (I tried a similar P90x workout program yet was too intense on my joints, so stop.) Newark, NJ

First of all, congratulations on your success! Take note of the skills you have developed that have contributed to this success and give yourself a pat on the back for a job well done. I want to commend you for seeking out alternatives that will help keep you on this path. There are a number of exercise options we can do right at home or work. Walking is a great one. How long and how intensely will depend on how your body responds to it. Stair climbing is another option again if your body can handle it. Find a stairwell at work and throw on your sneakers at lunch and walk the stairs. If you own a bicycle you can use it for your cardiovascular exercise or even use it as an active mode of transportation instead of your car! While P90X may have been too challenging, there are other exercise DVDs that are of lower intensity and might be a nice option. Turn up the music and try some of the same cardio moves that are in your cardio class right at home. Create a circuit that can be done in a small space where you alternate between muscle strengthening exercises and cardiovascular movements (such as marching, modified jumping jacks). If you have committed to physical fitness for a lifetime (as we all should), and not only for this time of weight loss, you might consider investing in a piece of cardiovascular equipment for your home like the elliptical trainer or even a treadmill or bike if it is practical for you. That way if you couldn’t get to the gym you would have an option right at home.

14. I would like some suggestions for exercises to do, when my lupus is attacking my hip joint. I have been in severe pain since Dec. I had to have cortisone injected into my hip socket. I do feel a little better, but I do suffer still with this pain. I have a stationary bike that I used to ride. I wonder if this will make my hip flare up more. Harrah, OK

Due to the nature of cycling, it is quite possible that it might aggravate your hip more. If you haven’t already, be sure that you have a discussion with your physician especially to let him or her know that you still have pain despite the cortisone injection. If you want to give cycling a try and your physician is comfortable with you doing so, there are a few things that might help. First of all, be sure that your seat is adjusted properly. Having a seat height that is too low or too high will put undue strain on your hip. Adjust the seat so that when your leg is fully extended, there is only a slight bend in your knee. You should not feel as though you are reaching for the pedal. An additional indicator of proper foot position is that when you place your heel on the downward pedal, your leg will be straight. With the ball of your foot on the upward pedal, your thigh should be at hip level or parallel to the floor. Your hips should not rock back and forth as you cycle. You can also be sure you prepare for cycling properly. Apply heat to your hip to increase circulation to the area which will help to decrease any stiffness as well. Perform range of motion exercises to warm it up. Try cycling for even just a few minutes and see how your hip does. You can apply cold afterwards to control inflammation. But considering that you have what sounds like significant pain in your hip, I would strongly suggest getting involved in water exercise. I think you will find that you will be able to exercise and see improvements that might actually help decrease the pain you are experiencing. Walking could be an option as well, but you will have to test it out to see how your hip does with this mode of exercise. If your level of pain is substantial it might be better for you to start with range of motion exercises and muscle-strengthening exercises. This will make your hip more mobile and hopefully increase the strength around the joint decreasing your pain making cardiovascular exercise more possible. If you find it difficult to move through a range of motion especially during a flare, having someone assist you through some movement will be helpful. There will probably be times when you feel like you can do more than others. This is okay. During times of flares, reduce how much activity you are doing and focus more on range of motion exercises. Also make note of any exercises that you think may have triggered a flare and either modify them or avoid them all together. I am hopeful that you will find a form of exercise that will help improve the function of your hip.

15. I really enjoy running. However, sometimes when I run my knees hurt very badly afterwards. My rheumatologist told me that she can't guarantee I'm not doing permanent damage to my joints. Is this the general belief of the experts in this field? Cincinnati, OH
Because of the high-impact nature of running, it is possible that you are damaging your knees. But I can certainly relate to the pleasure you have with running. Is this the only form of cardiovascular exercise you do? If so you might want to replace some of your running sessions with other cardiovascular alternatives. This way you could still get your running “fix” but be able to cut down on the strain and potential damage to your knees. My first suggestion is one that people often don’t think about—water running/jogging. There are special vests or waist belts that you can wear that help keep you upright in deeper water and allow you to “jog” in the water. You can get the same level of work minus the impact. Many professional runners use this form of exercise to save on the wear and tear on their body. Walking on an incline is a way for you to maintain your intensity without the impact as well. Elliptical machines are another nice option. It certainly would be hard to stop doing something you enjoy, so instead try some of these activities some of the time. That way you can save your knees and hopefully be able to continue to run well into the future if your doctor is comfortable with this. Of course, listen to your body when trying these new activities. You may have to turn to options that are of even lower-impact than these.