Hand exercise intervention in patients with polymyositis and dermatomyositis: a pilot study

Physical exercise for dermatomyositis and polymyositis: a systematic review and meta-analysis

Trials regarding physical exercise in dermatomyositis (DM) and polymyositis (PM) are heterogeneous. We aimed to summarize and critically analyze the available evidence to support the hypothesis that exercise is safe and improves strength and aerobic capacity. We performed a systematic review of clinical trials regarding physical exercise in dermatomyositis and polymyositis, without time restriction. We included studies from MEDLINE, EMBASE, SciELO, and Web of Science, published in English, Portuguese, or Spanish, and reporting outcomes related to safety, muscle performance, or aerobic capacity. The certainty of evidence was evaluated in accordance with the GRADE methodology. Meta-analysis was carried using pooled standardized mean differences (SMD) with 95% confidence interval as effect measure. We included 19 studies and 298 patients. The certainty of evidence was downgraded due to unbalanced confounding variables. The meta-analysis demonstrated improvements in strength (SMD [95% CI] = 0.61 [0.37-0.85], P < .00001) and aerobic capacity (SMD [95% CI] = 0.82 [0.29-1.34], P = .002), with no difference in creatine phosphokinase levels (SMD [95% CI] =  - 0.23 [- 0.5-0.03], P = .08) after the interventions. No exacerbation was reported, and results were favorable in all stages of disease and ages, but might be different in the future with new classification criteria for PM and the inclusion of other idiopathic inflammatory myopathies. Novel approaches such as blood flow restriction training and aquatic plyometric exercises were promising. Physical exercise in DM/PM patients of all ages is probably safe and moderately improves muscle strength and aerobic capacity.

Beyond the hand and upper extremity: The role of hand therapists in care of people with rheumatic diseases

STUDY DESIGN

Invited Clinical Commentary BACKGROUND: Arthritis is one of the most frequently reported causes of disability in the United States and the prevalence is expected to increase in the coming decades. While many rheumatic diseases involve hand impairments, most are systemic and involve more than the musculoskeletal system. Functional and work disability are high and people would benefit from the services of occupational and physical therapists.

PURPOSE OF STUDY

This paper reviews concepts of self-management, and symptoms that contribute to limitations and restrictions to participation in daily life in people with rheumatic diseases and suggests roles for hand therapists beyond the immediate hand impairments.

METHODS

The impact of selected rheumatic diseases on functional and work disability are reviewed along with strategies for symptom management and self-management. Upper extremity impairments of selected rheumatic diseases are also discussed.

RESULTS

The role for hand therapists in evaluating and addressing the complex needs of persons with rheumatic diseases, including less common diseases, is discussed. Outcome measures for fatigue, muscle involvement, ergonomics and computer use, and work disability are introduced. Finally, strategies for self-management and prevention of work and functional disability, along with symptom management for fatigue and pain are presented.

CONCLUSION

Hand therapists can play a vital role in chronic rheumatic disease management to improve self-management and increase participation in meaningful activities. Patients, primary care and rheumatology providers need to be educated about the scope of services occupational and physical therapists provide beyond the hand impairments.

Systematic review of physical exercise for patients with idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies (IIM) are systemic autoimmune connective tissue diseases. The safety and effectiveness of exercise for patients with idiopathic inflammatory myopathies remains unclear. This study aimed to systematically review the evidence for physical exercise among patients with idiopathic inflammatory myopathies. Relevant experimental studies were identified through searching the PubMed, Cochrane, Embase, Scopus, and CINAHL databases, and studies involving any type of physical exercise for ≥1 month were considered. The primary outcome was muscle strength, and the secondary outcomes included aerobic fitness, functional performance, health status, quality of life, activities of daily living, pain, and fatigue. Eight randomized controlled trials and thirteen nonrandomized uncontrolled trials were reviewed. Physical exercise appeared safe, with several positive effects. However, selection or allocation biases and small sample sizes affected the certainty of the evidence. While physical exercise appeared safe for patients with idiopathic inflammatory myopathies with several positive effects, studies of a higher methodological quality and involving patients with active disease are needed. Furthermore, to design optimal exercise programs, consistent and sensitive outcome measures are needed to facilitate comparisons of results from different studies.

Boccia as a Rehabilitation Intervention for Adults With Severe Mobility Limitations Due to Neuromuscular and Other Neurological Disorders: Feasibility and Effects on Upper Limb Impairments

Purpose

Scant research exists regarding the effects of playing Boccia as a rehabilitation strategy for people with severe mobility limitations due to neuromuscular and other neurological disorders. This study is aimed at identifying the feasibility and effects of playing Boccia on the upper limb impairments of people with severe mobility limitations due to neuromuscular and other neurological disorders.

Materials and Methods

Seven people played Boccia three times per week for 20 weeks as part of the rehabilitation process, while other seven kept up with their usual rehabilitation schedule. Attrition, adherence, adverse effects, participation and completion rate were registered to assess feasibility. The effects of the program on grip, pinch strength and upper-limb active range of motion were assessed by means of a dynamometer and a goniometer.

Results and Conclusions

The program was feasible, although no effects were observed after its completion on variables assessed, except for hand flexion and ulnar deviation active range of motion. In a group of people with severe disability due to neuromuscular and other neurological disorders, playing Boccia as part of a multidisciplinary rehabilitation program was shown to be a feasible therapy. However, practicing this game did not lead to significant improvements in upper limb impairments, except for wrist flexion and ulnar deviation active range of motion.

Strength training and aerobic exercise training for muscle disease

BACKGROUND

Strength training or aerobic exercise programmes, or both, might optimise muscle and cardiorespiratory function and prevent additional disuse atrophy and deconditioning in people with a muscle disease. This is an update of a review first published in 2004 and last updated in 2013. We undertook an update to incorporate new evidence in this active area of research.

OBJECTIVES

To assess the effects (benefits and harms) of strength training and aerobic exercise training in people with a muscle disease.

SEARCH METHODS

We searched Cochrane Neuromuscular's Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL in November 2018 and clinical trials registries in December 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-RCTs or cross-over RCTs comparing strength or aerobic exercise training, or both lasting at least six weeks, to no training in people with a well-described muscle disease diagnosis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 14 trials of aerobic exercise, strength training, or both, with an exercise duration of eight to 52 weeks, which included 428 participants with facioscapulohumeral muscular dystrophy (FSHD), dermatomyositis, polymyositis, mitochondrial myopathy, Duchenne muscular dystrophy (DMD), or myotonic dystrophy. Risk of bias was variable, as blinding of participants was not possible, some trials did not blind outcome assessors, and some did not use an intention-to-treat analysis. Strength training compared to no training (3 trials) For participants with FSHD (35 participants), there was low-certainty evidence of little or no effect on dynamic strength of elbow flexors (MD 1.2 kgF, 95% CI -0.2 to 2.6), on isometric strength of elbow flexors (MD 0.5 kgF, 95% CI -0.7 to 1.8), and ankle dorsiflexors (MD 0.4 kgF, 95% CI -2.4 to 3.2), and on dynamic strength of ankle dorsiflexors (MD -0.4 kgF, 95% CI -2.3 to 1.4). For participants with myotonic dystrophy type 1 (35 participants), there was very low-certainty evidence of a slight improvement in isometric wrist extensor strength (MD 8.0 N, 95% CI 0.7 to 15.3) and of little or no effect on hand grip force (MD 6.0 N, 95% CI -6.7 to 18.7), pinch grip force (MD 1.0 N, 95% CI -3.3 to 5.3) and isometric wrist flexor force (MD 7.0 N, 95% CI -3.4 to 17.4). Aerobic exercise training compared to no training (5 trials) For participants with DMD there was very low-certainty evidence regarding the number of leg revolutions (MD 14.0, 95% CI -89.0 to 117.0; 23 participants) or arm revolutions (MD 34.8, 95% CI -68.2 to 137.8; 23 participants), during an assisted six-minute cycle test, and very low-certainty evidence regarding muscle strength (MD 1.7, 95% CI -1.9 to 5.3; 15 participants). For participants with FSHD, there was low-certainty evidence of improvement in aerobic capacity (MD 1.1 L/min, 95% CI 0.4 to 1.8, 38 participants) and of little or no effect on knee extension strength (MD 0.1 kg, 95% CI -0.7 to 0.9, 52 participants). For participants with dermatomyositis and polymyositis (14 participants), there was very low-certainty evidence regarding aerobic capacity (MD 14.6, 95% CI -1.0 to 30.2). Combined aerobic exercise and strength training compared to no training (6 trials) For participants with juvenile dermatomyositis (26 participants) there was low-certainty evidence of an improvement in knee extensor strength on the right (MD 36.0 N, 95% CI 25.0 to 47.1) and left (MD 17 N 95% CI 0.5 to 33.5), but low-certainty evidence of little or no effect on maximum force of hip flexors on the right (MD -9.0 N, 95% CI -22.4 to 4.4) or left (MD 6.0 N, 95% CI -6.6 to 18.6). This trial also provided low-certainty evidence of a slight decrease of aerobic capacity (MD -1.2 min, 95% CI -1.6 to 0.9). For participants with dermatomyositis and polymyositis (21 participants), we found very low-certainty evidence for slight increases in muscle strength as measured by dynamic strength of knee extensors on the right (MD 2.5 kg, 95% CI 1.8 to 3.3) and on the left (MD 2.7 kg, 95% CI 2.0 to 3.4) and no clear effect in isometric muscle strength of eight different muscles (MD 1.0, 95% CI -1.1 to 3.1). There was very low-certainty evidence that there may be an increase in aerobic capacity, as measured with time to exhaustion in an incremental cycle test (17.5 min, 95% CI 8.0 to 27.0) and power performed at VO₂ max (maximal oxygen uptake) (18 W, 95% CI 15.0 to 21.0). For participants with mitochondrial myopathy (18 participants), we found very low-certainty evidence regarding shoulder muscle (MD -5.0 kg, 95% CI -14.7 to 4.7), pectoralis major muscle (MD 6.4 kg, 95% CI -2.9 to 15.7), and anterior arm muscle strength (MD 7.3 kg, 95% CI -2.9 to 17.5). We found very low-certainty evidence regarding aerobic capacity, as measured with mean time cycled (MD 23.7 min, 95% CI 2.6 to 44.8) and mean distance cycled until exhaustion (MD 9.7 km, 95% CI 1.5 to 17.9). One trial in myotonic dystrophy type 1 (35 participants) did not provide data on muscle strength or aerobic capacity following combined training. In this trial, muscle strength deteriorated in one person and one person had worse daytime sleepiness (very low-certainty evidence). For participants with FSHD (16 participants), we found very low-certainty evidence regarding muscle strength, aerobic capacity and VO₂ peak; the results were very imprecise. Most trials reported no adverse events other than muscle soreness or joint complaints (low- to very low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence regarding strength training and aerobic exercise interventions remains uncertain. Evidence suggests that strength training alone may have little or no effect, and that aerobic exercise training alone may lead to a possible improvement in aerobic capacity, but only for participants with FSHD. For combined aerobic exercise and strength training, there may be slight increases in muscle strength and aerobic capacity for people with dermatomyositis and polymyositis, and a slight decrease in aerobic capacity and increase in muscle strength for people with juvenile dermatomyositis. More research with robust methodology and greater numbers of participants is still required.

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.

Novel insights of disability assessment in adult myositis

PURPOSE OF REVIEW

To review the novel development of standardized clinical outcome measures used in adult patients with idiopathic inflammatory myopathies (IIMs). A further aim was to determine what aspects of IIM are covered by these outcome measures according to the International Classification of Functioning, Disability and Health (ICF).

RECENT FINDINGS

The sporadic inclusion body myositis functional assessment (sIFA) is the first diagnosis-specific patient-driven patient-reported outcome measure. The adult myositis assessment tool (AMAT) is a new outcome measure assessing physical performance. Also, new criteria to assess response to treatment have been presented for both adults and children with IIM. The ICF provides a standardized frame and structure to report outcome, including functional disability. Using this framework, it is evident that there is a lack of validated patient-reported outcome measures to assess disease aspects important to patient, and that no studies have evaluated life-style factors such as physical activity in these patients.

SUMMARY

The sIFA will ensure patient-relevant patient-reported assessment of activity limitations in patients with inclusion body myositis. The AMAT is a partly validated tool that needs to be used in clinical trials for further validation. The response criteria will enhance assessment of individual response to different treatments.

[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.