Exercise program effects on one woman with dermatomyositis

Pain in individuals with idiopathic inflammatory myopathies, other systemic autoimmune rheumatic diseases, and without rheumatic diseases: A report from the COVAD study

OBJECTIVES

To compare pain intensity among individuals with idiopathic inflammatory myopathies (IIMs), other systemic autoimmune rheumatic diseases (AIRDs), and without rheumatic disease (wAIDs).

METHODS

Data were collected from the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study, an international cross-sectional online survey, from December 2020 to August 2021. Pain experienced in the preceding week was assessed using numeral rating scale (NRS). We performed a negative binomial regression analysis to assess pain in IIMs subtypes and whether demographics, disease activity, general health status, and physical function had an impact on pain scores.

RESULTS

Of 6988 participants included, 15.1% had IIMs, 27.9% had other AIRDs, and 57.0% were wAIDs. The median pain NRS in patients with IIMs, other AIRDs, and wAIDs were 2.0 (interquartile range [IQR] = 1.0-5.0), 3.0 (IQR = 1.0-6.0), and 1.0 (IQR = 0-2.0), respectively (P < 0.001). Regression analysis adjusted for gender, age, and ethnicity revealed that overlap myositis and antisynthetase syndrome had the highest pain (NRS = 4.0, 95% CI = 3.5-4.5, and NRS = 3.6, 95% CI = 3.1-4.1, respectively). An additional association between pain and poor functional status was observed in all groups. Female gender was associated with higher pain scores in almost all scenarios. Increasing age was associated with higher pain NRS scores in some scenarios of disease activity, and Asian and Hispanic ethnicities had reduced pain scores in some functional status scenarios.

CONCLUSION

Patients with IIMs reported higher pain levels than wAIDs, but less than patients with other AIRDs. Pain is a disabling manifestation of IIMs and is associated with a poor functional status.

Effect of exercise training on fatigue and pain in patients with systemic autoimmune myopathies: A systematic review

Systemic autoimmune myopathies (or idiopathic inflammatory myopathies) are a wide group of rare rheumatic diseases characterized by muscle weakness due to muscle inflammation. Recent evidence has continually reinforced the relevance of the perception of pain and fatigue as parameters of notable contribution to reducing the quality of life of these patients. However, due to the multidimensional characteristic of these variables, few studies address the effects of pharmacological and non-pharmacological therapies, such as exercise training on these variables. With regard to patients with systemic autoimmune myopathies, the outcomes related to the effects of exercise training are focused on muscle strength and endurance, few explore the effects on the perception of pain and fatigue. Given this, studies that review systematically the available evidence of the effects of exercise training on these perceptions can contribute to management of this parameter in clinical practice. Given this context, the present study aims to review systematically the effectiveness of exercise training specifically on the perception of pain and fatigue.

Exercise in Myositis

Purpose of the review

A growing body of evidence supports exercise as a very important part of the treatment for adult patients with idiopathic inflammatory myopathies (IIM). This review mainly focuses on exercise studies published during the last 2 years in adult myositis.

Recent findings

During the last couple of years, new publications present further evidence for intensive endurance exercise as an anti-inflammatory treatment inducing muscle growth and improving mitochondrial function compared a non-exercising control group. Further, blood-flow restricted resistance training was effective to maintain muscle strength compared to a non-exercising control group which lost a mean of 9.2% in quadriceps strength over 3 months in inclusion body myositis. Another study evaluates the effects of intra-muscular injections of an isoform of follistatin (FS344) by AAV1 in combination with exercise in a small group of patients with inclusion body myositis. An improvement in physical capacity was associated to higher exercise levels. Less is known about exercise effects in patients with recent onset, active polymyositis, and dermatomyositis.

Summary

All studies report safety of exercise in all types and stages of myositis and exercise could now be considered as medicine. It is recommended to initiate exercise on a low intensity under supervision of a physical therapist with regular follow-up and progression of intensity over time.

[Usefulness of rehabilitation in inflammatory myopathies]

Rehabilitation, for a long time not recommended, seems today to hold a prominent place within the therapeutic arsenal of inflammatory myopathies. The difficulty of its evaluation, apart from the low prevalence of these diseases, lies in a triple heterogeneity: first that distinguishing the different forms of inflammatory myopathies and the phase where they are active; second, that concerning the endpoint considered to assess the efficiency of the intervention; lastly, the diversity of the rehabilitation programs that can be undertaken. Between 1993 and 2016, about 30 studies estimating the rehabilitation of inflammatory myopathies have been published, among which five randomized controlled trials, four controlled trials, 15 open studies, and seven case reports. All these studies evidence the safety of rehabilitation and some show a significant improvement of the criteria estimating the activity of the disease, its functional impact or the impairment of quality of life and the limitation in daily life activities triggered by the disease. The rehabilitation, whether aerobic, anaerobic or mixed, must today systematically be associated with the pharmaceutic treatment proposed to patients affected by inflammatory myopathies. Other studies are necessary to optimize the rehabilitation methods, to understand their effects and action, and to quantify their impact and provide more trustworthy evidence.

Physical exercise as a treatment for adult and juvenile myositis

There is growing evidence to support the safety and efficacy of exercise in patients with adult and juvenile idiopathic inflammatory myopathies. Five randomized controlled trials including adult patients with polymyositis and dermatomyositis (DM) and additional open studies have demonstrated reduced impairment and activity limitation as well as improved quality of life. In addition, recent studies have shown reduced disease activity assessed by consensus disease activity measures and reduced expression of genes regulating inflammation and fibrosis. Furthermore, exercise could improve muscle aerobic capacity as shown by increased mitochondrial enzyme activity. These data suggest that intensive aerobic exercise and resistance training could reduce disease activity and inflammation and improve muscle metabolism. Encouraging results have been reported from available open studies including patients with inclusion body myositis (IBM) and juvenile DM, indicating reduced impairment, activity limitation and improved quality of life also in these patients. Larger studies are needed to increase understanding of the effects of exercise in patients with active, recent-onset polymyositis and DM as well as in patients with IBM and juvenile DM.