What is a recommended workout plan for individuals with systemic sclerosis?

Workout Recommendations for Systemic Sclerosis

Individuals with systemic sclerosis should engage in at least 150 minutes per week of moderate-intensity aerobic exercise combined with resistance training 2-3 days per week, as exercise functions as a disease-modifying intervention that directly targets the inflammatory and fibrotic pathways driving SSc pathology. 1

Aerobic Exercise Protocol

• Perform 150-300 minutes per week of moderate-intensity aerobic activity, which can be divided into sessions of at least 10 minutes duration 2
• Walking is the most commonly performed and well-tolerated exercise in SSc patients (reported by 76% of exercising patients), making it an ideal starting point 3
• For those without pulmonary involvement, moderate-intensity aerobic exercise improves exercise tolerance, aerobic capacity, walking distance, and health-related quality of life 4
• Patients with mild pulmonary involvement can also participate in moderate-intensity aerobic exercise safely, though closer monitoring is warranted 4
• Alternative low-impact options include swimming, stationary cycling, and elliptical training for those with joint involvement or higher disability 5

Resistance Training Protocol

• Perform resistance exercises 2-3 days per week on non-consecutive days, allowing at least 48 hours rest between sessions for any single muscle group 6, 5
• Start with low resistance (40-60% of one-repetition maximum) and higher repetitions (10-20 repetitions), progressing gradually as tolerated 6, 5
• Focus on 8-10 different exercises targeting major muscle groups per session 6
• Execute movements in a rhythmical manner at moderate to slow controlled speed through full range of motion 6
• Resistance training combined with aerobic exercise improves muscle strength, muscle function, and physical capacity in SSc 4

Flexibility and Range of Motion

• Perform stretching exercises daily, holding each stretch for 10-30 seconds and repeating 2-4 times per muscle group 2
• Stretching is particularly important in SSc to counteract skin tightening and joint contractures that characterize the disease 1
• Gentle, full range of motion exercises help maintain joint mobility and prevent painful contractures 2

Critical Disease-Specific Considerations

Exercise directly targets SSc pathogenic mechanisms by downregulating inflammatory and fibrotic pathways in serum and tissue while increasing circulation and vascular repair 1. This makes exercise not merely symptomatic treatment but a true disease-modifying intervention.

Safety Monitoring and Progression

• Use pain or symptom provocation as the primary indicator to guide progression, advancing at an individualized rate based on baseline fitness and disease severity 7
• Monitor for unusual fatigue, increased weakness, or decreased range of motion during and after exercise 5
• Discontinue exercise if joint swelling or pain persists more than 1 hour post-exercise 5
• Progress gradually toward exercise targets based on individual abilities, preferences, and safety 8

Disease Subtype Adaptations

• Limited/sine SSc patients typically tolerate exercise better than those with diffuse disease and extensive skin thickening 3
• Patients with pulmonary involvement require more conservative intensity progression but can still benefit from structured exercise programs 4
• Those with higher disability levels (EDSS >6.0) should work with physical therapists or exercise specialists experienced in autoimmune conditions to ensure safe prescription 8

Barriers to Address

Approximately only 51.7% of SSc patients currently exercise, with lower exercise participation associated with higher body mass index, smoking, greater disability, higher anxiety and depression symptoms, more fatigue, and greater pain 3. These barriers must be actively addressed through:

• Early referral to physical or occupational therapists experienced in SSc for individualized exercise planning 8
• Education about exercise safety—patients often avoid activity due to fear of worsening symptoms, but evidence shows exercise does not trigger disease exacerbations 9, 1
• Addressing modifiable factors like smoking cessation and weight management that independently reduce exercise participation 3

Common Pitfalls to Avoid

• Do not prescribe generic exercise programs—SSc manifestations are highly diverse, requiring individually designed programs that account for specific organ involvement, disability level, and symptom fluctuations 3, 1
• Do not delay exercise initiation—early establishment of exercise habits is crucial, as improvements may only be partially retained at follow-up, necessitating ongoing participation 4
• Do not ignore sedentary behavior—patients should break up prolonged sitting every 30 minutes with light activity, as sedentary time independently contributes to deconditioning 2
• Do not overlook concurrent medical optimization—exercise should complement, not replace, disease-modifying medications and management of specific organ complications 6

Practical Implementation Algorithm

1. Obtain baseline assessment of pulmonary function, skin involvement, joint mobility, and current disability level to stratify exercise prescription 1, 4
2. Refer to physical therapist or exercise specialist experienced in SSc for initial evaluation and exercise plan development 8
3. Start conservatively with walking 10-15 minutes daily and light resistance exercises 2 days per week 5, 4
4. Progress gradually toward 150-300 minutes weekly aerobic exercise and 2-3 days resistance training over 8-12 weeks 2, 4
5. Monitor response at 4-6 week intervals, adjusting intensity based on symptom response and functional improvements 7, 8
6. Maintain long-term adherence through ongoing specialist support, as benefits diminish with exercise cessation 4