Epidemiology and pathophysiology of falls in facioscapulohumeral disease

The effect of tibialis anterior weakness on foot drop and toe clearance in patients with facioscapulohumeral dystrophy

BACKGROUND

Facioscapulohumeral dystrophy is a genetic disease characterized by progressive muscle weakness leading to a complex combination of postural instability, foot drop during swing and compensatory strategies during gait that have been related to an increased risk of falling. The aim is to assess the effect of tibialis anterior muscle weakness on foot drop and minimum toe clearance of patients with facioscapulohumeral dystrophy during gait.

METHODS

Eight patients allocated to a subgroup depending on the severity of tibialis anterior muscle weakness, assessed by manual muscle testing (i.e., severe and mild weakness), and eight matched control participants underwent gait analysis at self-selected walking speeds.

FINDINGS

Walking speed, for all facioscapulohumeral dystrophy patients, and step length, for patients with severe weakness only, were significantly decreased compared to control participants. Minimum toe clearance was similar across all groups, but its variability was increased only for patients with severe weakness. A greater foot drop was systematically observed for patients with severe weakness during swing and only in late swing for patients with mild weakness. Individual strategies to compensate for foot drop remain unclear and may depend on other muscle impairment variability.

INTERPRETATION

Although all patients were able to control the average height of their foot trajectory during swing, patients with severe tibialis anterior muscle weakness exhibited increased foot drop and minimum toe clearance variability. Manual muscle testing is a simple, cheap and effective method to assess tibialis anterior muscle weakness and seems promising to identify facioscapulohumeral dystrophy patients with an increased risk of tripping.

The Impact of "Fear of Falling" on Physical Performance, Balance, and Ambulation in Duchenne Muscular Dystrophy

OBJECTIVE

The aim of this study was to investigate falls and the fear of falling (FOF) in children with Duchenne muscular dystrophy (DMD) and to determine the relationships between the FOF and physical performance, balance, and ambulation.

METHODS

Thirty-eight ambulatory children with DMD were included in the study. The functional level, falling history, FOF, physical performance, balance, and ambulation were assessed by using Brooke Lower Extremity Functional Classification, History of Falls Questionnaire, Pediatric Fear of Falling Questionnaire (Ped-FOF), timed performance tests, Timed "Up and Go" (TUG) test, and North Star Ambulatory Assessment (NSAA), respectively.

RESULTS

Of the 38 children (mean age: 9.00 ± 2.03 years) 97.4% had a history of serious fall last year and 62.2% were injured due to this fall. The Ped-FOF score was 13.79 ± 7.20. Weak to moderate relations were determined between Ped-FOF and functional level (r = 0.33), frequency of falls (r = 0.41), duration of climbing 4-steps (r = 0.38), TUG (r = 0.36), and NSAA (r = -0.32) (p < 0.05).

CONCLUSION

Ambulatory children with better performance scores had lower levels of FOF despite their history of serious falls and injuries. FOF tends to increase as the symptoms of the disease progresses. Investigating the history of falls and FOF from the earliest period will guide to take precautions and make necessary interventions on time in treatment programs.

Development of a questionnaire to assess fear of falling in children with neuromuscular diseases

Fear of falling (FOF) indicates loss of confidence in the ability to perform daily living activities without falling. Although specific questionnaires do exist to assess FOF in different patient populations, any of them targets the pediatric patients with neuromuscular diseases which falling is a frequent symptom. This study aims to present the development of a self-report FOF questionnaire for children with neuromuscular diseases, pilot application of the questionnaire, and its preliminary psychometric properties. An International Classification of Functioning, Disability and Health (ICF)-based 'Pediatric Fear of Falling Questionnaire' for neuromuscular diseases (Ped-FOF) was created by the study team following the steps of developing an instrument. The questionnaire included 34 items which were organized based on the 'Activities and Participation' component of ICF-children and youth. Thirty children with Duchenne muscular dystrophy (DMD) were recruited to obtain preliminary reliability and validity results of the questionnaire. The mean Ped-FOF score of study population was 15.30 ± 7.03. According to the preliminary results, intraclass correlation coefficient was 0.715 [confidence interval (CI) 95%], and moderate correlations between Ped-FOF and functional performance and quality of life were determined (P < 0.05). Ped-FOF promises a practical assessment of FOF in pediatrics with neuromuscular diseases with understandable items that allow self-report of children. Ped-FOF also allows clinicians and therapists to assess FOF efficiently in limited clinical time. Its preliminary reliability and validity results are also sufficient to be used in DMD that falling is a frequent condition, which indicates that the use of questionnaire is promising in many other pediatric neuromuscular disorders.

High incidence of falls in patients with myotonic dystrophy type 1 and 2: A prospective study

We aimed to examine the incidence as well as the circumstances and the consequences of falling in adult patients with myotonic dystrophy type 1 and 2 (DM1/DM2). We performed a prospective cohort study in 209 subjects, of which 102 had DM1, 42 had DM2 and 65 healthy controls. An assessment of their falls was carried out during 100 consecutive days. In addition, falls during the previous year were reported. The primary outcome measure was the number of self-reported falls per participant during these 100 days. The secondary outcome measures included self-reported causes, circumstances and consequences of the falls. Mean (SD) falls per participant in 100 days was seven- to eightfold higher in patients with DM1 (0.74 (0.14)) and DM2 (0.62 (0.20)) compared to the controls (0.09 (0.04); p < 0.001)). Sixteen percent of DM1 and 17% of DM2 patients fell at least twice. Two-thirds of the falls occurred inside. Fifty percent of falls resulted in an injury, including a head trauma in four patients. Compared to non-fallers, those patients who fell were older (DM1/DM2), had a lower DM1-Activ score (DM1), had more muscle weakness (DM1), and reported less confidence in balance (DM1). This study demonstrates a high incidence and clinical relevance of falling in patients with DM1 and DM2. Fall prevention strategies in both DM1 and DM2 should focus on adaptations of the home environment and the patient's interaction in this environment.

Mobility related physical and functional losses due to aging and disease - a motivation for lower limb exoskeletons

BACKGROUND

Physical and functional losses due to aging and diseases decrease human mobility, independence, and quality of life. This study is aimed at summarizing and quantifying these losses in order to motivate solutions to overcome them with a special focus on the possibilities by using lower limb exoskeletons.

METHODS

A narrative literature review was performed to determine a broad range of mobility-related physical and functional measures that are affected by aging and selected cardiovascular, respiratory, musculoskeletal, and neurological diseases.

RESULTS

The study identified that decreases in limb maximum muscle force and power (33% and 49%, respectively, 25-75 yrs) and in maximum oxygen consumption (40%, 20-80 yrs) occur for older adults compared to young adults. Reaction times more than double (18-90 yrs) and losses in the visual, vestibular, and somatosensory systems were reported. Additionally, we found decreases in steps per day (75%, 60-85 yrs), maximum walking speed (24% 25-75 yrs), and maximum six-minute and self-selected walking speed (38% and 21%, respectively, 20-85 yrs), while we found increases in the number of falls relative to the number of steps per day (800%), injuries due to falls (472%, 30-90 yrs) and deaths caused by fall (4000%, 65-90 yrs). Measures were identified to be worse for individuals with impaired mobility. Additional detrimental effects identified for them were the loss of upright standing and locomotion, freezing in movement, joint stress, pain, and changes in gait patterns.

DISCUSSION

This review shows that aging and chronic conditions result in wide-ranging losses in physical and sensory capabilities. While the impact of these losses are relatively modest for level walking, they become limiting during more demanding tasks such as walking on inclined ground, climbing stairs, or walking over longer periods, and especially when coupled with a debilitating disease. As the physical and functional parameters are closely related, we believe that lost functional capabilities can be indirectly improved by training of the physical capabilities. However, assistive devices can supplement the lost functional capabilities directly by compensating for losses with propulsion, weight support, and balance support.

CONCLUSIONS

Exoskeletons are a new generation of assistive devices that have the potential to provide both, training capabilities and functional compensation, to enhance human mobility.

Isokinetic assessment of trunk muscles in facioscapulohumeral muscular dystrophy type 1 patients

Facioscapulohumeral muscular dystrophy type 1 is the third most common inherited myopathy. Its severity is proportionate to the loss of microsatellite D4Z4 repetitions, which are below 10. Patients suffer from weakness in facial muscles, shoulder girdles and ankle dorsiflexors. Trunk impairment is reported in few studies. To assess correlation between D4Z4 number of repetitions in facioscapulohumeral muscular dystrophy type 1 patients and trunk extensors and flexors isokinetic peak torque, 48 patients with southern Blot confirmed facioscapulohumeral muscular dystrophy type 1 were enrolled to perform clinical evaluation (Ricci's Clinical Severity Scoring, Berg Balance Scale, Functional Reach Test, timed up-and-go test, six-minute walk test, functional independence measure) and trunk isokinetic assessment. Trunk extensors and flexors isokinetic peak torque at 60°/sec were significantly correlated with number of D4Z4 microsatellite repetitions, sex, weight and age-independent (r = 0.391 [0.121; 0.662], p < 0.006 and r = 0.334 [0.028; 0.641], p < 0.033, respectively). Ricci's Clinical Severity Scoring was significantly correlated to trunk extensors isokinetic peak torque at 60°/sec, sex and weight-independent (r = -0.743 [-0.938; -0.548], p < 0.0001). This study demonstrates moderate correlation between pathologic compression of D4Z4 microsatellite array and trunk extensors isokinetic strength among facioscapulohumeral muscular dystrophy type I patients.

High-intensity interval training in facioscapulohumeral muscular dystrophy type 1: a randomized clinical trial

Increasing evidence suggests that high-intensity training (HIT) is a time-efficient exercise strategy to improve fitness. HIT has never been explored in neuromuscular diseases, likely because it may seem counterintuitive. A single session of high-intensity exercise has been studied without signs of muscle damage in facioscapulohumeral muscular dystrophy type 1 (FSHD1). We aimed to determine whether HIT is safe and effective in FSHD1 in a randomized, controlled parallel study. Untrained adults with genetically verified FSHD1 (n = 13) able to perform cycle-ergometer exercise were randomized to 8 weeks of supervised HIT (n = 6) (3 × 10-min cycle-ergometer-HIT/week) or 8 weeks of usual care (n = 7). Following this, all participants performed 8 weeks of unsupervised HIT (3 × 10-min cycle-ergometer-HIT/week). Primary outcome was fitness, maximal oxygen uptake/min/kg body weight. Furthermore, workload, 6-min walk distance, 5-time sit-to-stand time, muscle strength, and daily activity levels were measured. Pain, fatigue, and plasma-CK were monitored. Twelve patients completed the randomized part of the study. Plasma-CK levels and pain scores were unaffected by HIT. Supervised HIT improved fitness (3.3 ml O₂/min/kg, CI 1.2-5.5, P < 0.01, n = 6, NNT = 1.4). Unsupervised HIT also improved fitness (2.0 ml O₂/min/kg, CI 0.1-3.9, P = 0.04, n = 4). There was no training effect on other outcomes. Patients preferred HIT over strength and moderate-intensity aerobic training. It may seem counterintuitive to perform HIT in muscular dystrophies, but this RCT shows that regular HIT is safe, efficacious, and well liked by moderately affected patients with FSHD1, which suggests that HIT is a feasible method for rehabilitating patients with FSHD1.

Rationale for Strengthening Muscle to Prevent Falls and Fractures: A Review of the Evidence

Falls represent a major public health problem in older people, predominantly due to the resulting injuries which lead to progressive disability, immobilization and resulting comorbidities, dependency, institutionalization, and death. Reduced muscle strength and power have been consistently identified as risk factors for falls and related injuries, and it is likely these associations result from the central role played by reduced muscle strength and power in poor balance recovery. In addition, muscle strength and power are involved with protective responses that reduce the risk of an injury if a fall occurs. Progressive resistance training (PRT) is the standard way to increase muscle strength and power, and this training forms one of the main components of fall prevention exercise interventions. However, PRT has rarely been implemented in routine practice due to multiple challenges inherent to frail older people. The ongoing development of drugs expected to increase muscle power offers a new opportunity to reduce the risk of falls and fall-related injuries. The intent here is not to replace exercise training with drugs but rather to offer a pharmacologic alternative when exercise is not possible or contraindicated. The target population would be those most likely to benefit from this mechanism of action, i.e., weak older people without major causes for falls independent of muscle weakness. Provided such a tailored strategy was followed, a muscle anabolic may address this major unmet need.

Clinical Functional Capacity Testing in Patients With Facioscapulohumeral Muscular Dystrophy: Construct Validity and Interrater Reliability of Antigravity Tests

OBJECTIVE

To evaluate the construct validity and interrater reliability of 4 simple antigravity tests in a small group of patients with facioscapulohumeral muscular dystrophy (FSHD).

DESIGN

Case-control study.

SETTING

University medical center.

PARTICIPANTS

Patients with various severity levels of FSHD (n=9) and healthy control subjects (n=10) were included (N=19).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A 4-point ordinal scale was designed to grade performance on the following 4 antigravity tests: sit to stance, stance to sit, step up, and step down. In addition, the 6-minute walk test, 10-m walking test, Berg Balance Scale, and timed Up and Go test were administered as conventional tests. Construct validity was determined by linear regression analysis using the Clinical Severity Score (CSS) as the dependent variable. Interrater agreement was tested using a κ analysis.

RESULTS

Patients with FSHD performed worse on all 4 antigravity tests compared with the controls. Stronger correlations were found within than between test categories (antigravity vs conventional). The antigravity tests revealed the highest explained variance with regard to the CSS (R(2)=.86, P=.014). Interrater agreement was generally good.

CONCLUSIONS

The results of this exploratory study support the construct validity and interrater reliability of the proposed antigravity tests for the assessment of functional capacity in patients with FSHD taking into account the use of compensatory strategies. Future research should further validate these results in a larger sample of patients with FSHD.

Dynamic stability during level walking and obstacle crossing in persons with facioscapulohumeral muscular dystrophy

Patients with FSHD suffer from progressive skeletal muscle weakness, which is associated with an elevated fall risk. To obtain insight into fall mechanisms in this patient group, we aimed to assess dynamic stability during level walking and obstacle crossing in patients at different disease stages. Ten patients with at least some lower extremity weakness were included, of whom six were classified as moderately affected and four as mildly affected. Ten healthy controls were also included. Level walking at comfortable speed was assessed, as well as crossing a 10 cm high wooden obstacle. We assessed forward and lateral dynamic stability, as well as spatiotemporal and kinematics variables. During level walking, the moderately affected group demonstrated a lower walking speed, which was accompanied by longer step times and smaller step lengths, yet dynamic stability was unaffected. When crossing the obstacle, however, the moderately affected patients demonstrated reduced forward stability margins during the trailing step, which was accompanied by an increased toe clearance and greater trunk and hip flexion. This suggests that during level walking, the patients effectively utilized compensatory strategies for maintaining dynamic stability, but that the moderately affected group lacked the capacity to fully compensate for the greater stability demands imposed by obstacle crossing, rendering them unable to maintain optimal stability levels. The present results highlight the difficulties that FSHD patients experience in performing this common activity of daily living and may help explain their propensity to fall in the forward direction.

Aerobic training and postexercise protein in facioscapulohumeral muscular dystrophy: RCT study

OBJECTIVE

To investigate the effect of regular aerobic training and postexercise protein-carbohydrate supplementation in patients with facioscapulohumeral muscular dystrophy (FSHD).

METHODS

In this randomized, double-blind, placebo-controlled parallel study, we randomized untrained men (n = 21) and women (n = 20) with FSHD (age 19-65 years) to 2 training groups-training with protein supplement (n = 18) and training with placebo supplement (n = 13)-and a nonintervention control group (n = 10). We assessed fitness, walking speed, muscle strength, questionnaires, and daily activity levels before and after 12 weeks of interventions. Training involved 36 sessions of 30-minute cycle-ergometer training. After each session, patients drank either a protein-carbohydrate or placebo beverage.

RESULTS

In the trained participants, fitness, workload, and walking speed improved (10% [confidence interval (CI) 4%-15%], 18% [CI 10%-26%], 7% [CI 4%-11%], respectively, p < 0.001, number needed to treat = 2.1). Self-assessed physical capacity and health (Short Form-36) also improved. Muscle strength and daily activity levels did not change with training. Protein-carbohydrate supplementation did not result in further improvements in any tests compared to training alone.

CONCLUSIONS

This randomized, controlled study showed that regular endurance training improves fitness, walking speed, and self-assessed health in patients with FSHD without causing muscle damage. Postexercise protein-carbohydrate supplementation does not add any further improvement to training effects alone.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that regular aerobic training with or without postexercise protein-carbohydrate supplementation improves fitness and workload in patients with FSHD.

Trunk muscle involvement is most critical for the loss of balance control in patients with facioscapulohumeral muscular dystrophy

BACKGROUND

Although it is known that muscle weakness is a major cause of postural instability and leads to an increased incidence of falls in patients with neuromuscular disease, the relative contribution of lower extremity and trunk muscle weakness to postural instability has not been studied well.

METHODS

We determined the relationship between muscle fatty infiltration and sagittal-plane balance in ten patients with facioscapulohumeral muscular dystrophy. Sagittal-plane platform translations were imposed in forward and backward directions on patients with facioscapulohumeral muscular dystrophy and healthy controls. Stepping thresholds were determined and kinematic responses and center-of-mass displacements were assessed using 3 dimensional motion analysis. In the patients, magnetic resonance imaging was used to determine the amount of fatty infiltration of trunk and lower extremity muscles.

FINDINGS

Stepping thresholds in both directions were decreased in patients compared to controls. In patients, significant correlations were found for fatty infiltration of ventral muscles with backward stepping threshold and for fatty infiltration of dorsal muscles with forward stepping threshold. Fatty infiltration of the rectus abdominis and the back extensors explained the largest part of the variance in backward and forward stepping thresholds, respectively. Center-of-mass displacements were dependent on intensity and direction of perturbation. Kinematic analysis revealed predominant ankle strategies, except in patients with lumbar hyperlordosis.

INTERPRETATION

These findings indicate that trunk muscle involvement is most critical for loss of sagittal-plane postural balance in patients with facioscapulohumeral muscular dystrophy. This insight may help to develop rehabilitation strategies to prevent these patients from falling.

Skeletal muscle imaging in facioscapulohumeral muscular dystrophy, pattern and asymmetry of individual muscle involvement

To better understand postural and movement disabilities, the pattern of total body muscle fat infiltration was analyzed in a large group of patients with facioscapulohumeral muscular dystrophy. Additionally, we studied whether residual D4Z4 repeat array length adjusted for age and gender could predict the degree of muscle involvement. Total body computed tomography scans of 70 patients were used to assess the degree of fat infiltration of 42 muscles from neck to ankle level on a semi-quantitative scale. Groups of muscles that highly correlated regarding fat infiltration were identified using factor analysis. Linear regression analysis was performed using muscle fat infiltration as the dependent variable and D4Z4 repeat length and age as independent variables. A pattern of muscle fat infiltration in facioscapulohumeral muscular dystrophy could be constructed. Trunk muscles were most frequently affected. Of these, back extensors were more frequently affected than previously reported. Asymmetry in muscle involvement was seen in 45% of the muscles that were infiltrated with fat. The right-sided upper extremity showed significantly higher scores for fat infiltration compared to the left side, which could not be explained by handedness. It was possible to explain 29% of the fat infiltration based on D4Z4 repeat length, corrected for age and gender. Based on our results we conclude that frequent involvement of fat infiltration in back extensors, in addition to the abdominal muscles, emphasizes the extent of trunk involvement, which may have a profound impact on postural control even in otherwise mildly affected patients.

Symptom burden in persons with myotonic and facioscapulohumeral muscular dystrophy

OBJECTIVE

This study examines the prevalence of pain, fatigue, imbalance, memory impairment, and vision loss in persons with myotonic and facioscapulohumeral dystrophy and their association with functioning.

DESIGN

A survey (N = 170) included measures of severity (0-10 scales) and course of these symptoms as well as measures of social integration, home competency, mental health, and productive activity. Descriptive and regression analyses examined the associations between symptoms and functioning.

RESULTS

Fatigue (91%), imbalance (82%), and pain (77%) were the most commonly reported. The most severe symptom was fatigue (mean ± SD severity, 5.14 ± 2.81), followed by imbalance (4.95 ± 3.25). Symptoms were most likely to stay the same or worsen since onset. Controlling for potential medical and demographic confounds, symptoms were associated with 17% of the mental health variance, 10% of home competency, 10% of social integration, 16% of productive activity for myotonic dystrophy type 1, and 12% of productive activity for facioscapulohumeral muscular dystrophy.

CONCLUSIONS

Pain, fatigue, and imbalance are common in persons with muscular dystrophy. Interventions may be useful to mitigate their impact on functioning. Further research should examine these relationships to guide clinical practices.

Risk of fracture in patients with muscular dystrophies

The aim of the study was to determine fracture risk in incident muscular dystrophy (MD) patients. Patients with MD are at a 1.4-fold increased risk of fracture as compared with population-based control patients. Risk further increased among elderly and female patients and among patients exposed to oral glucocorticoids.

INTRODUCTION

Muscular dystrophies (MDs) are inherited diseases causing muscle weakness and thereby increase the risk of falling and detrimental effects on bone. Both are recognised risk factors for fracture. Therefore, the aim of this study was to determine the hazard ratio of fracture in patients with MD.

METHODS

We conducted a retrospective cohort study using the UK General Practice Research Database (1987-2012). Each patient with MD was matched by year of birth, sex and practice to up to six patients without a history of MD. Outcome measure was all fractures.

RESULTS

As compared with control patients, risk of any fracture was statistically significantly increased in MD patients (adjusted hazard ratio [AHR], 1.40; 95 % confidence interval [CI], 1.14-1.71). An increased risk of fracture was observed among MD patients with female gender (AHR, 1.78; 95 % CI, 1.33-2.40) and an increasing age as compared with control patients. Stratification to Duchenne MD showed no association with fracture, whereas risk of fracture was increased twofold among patients with myotonic dystrophy (AHR, 2.34; 95 % CI, 1.56-3.51). MD patients had an almost tripled risk of fracture when they used oral glucocorticoids in the previous 6 months as compared to non-users with MD.

CONCLUSION

Patients with MD are at a 1.4-fold increased risk of fracture as compared with population-based control patients. Especially in older age groups and female gender, the fracture risk of MD versus non-MD patients is increased, whereas exposure to glucocorticoids further increased fracture risk among MD patients.

Recommendations for the management of facioscapulohumeral muscular dystrophy in 2011

Facioscapulohumeral muscular dystrophy (FSHD) is a neuromuscular disease, characterized by an autosomal dominant mode of inheritance, facial involvement, and selectivity and asymmetry of muscle involvement. In general, FSHD typically presents before age 20 years. Usually, FSHD muscle involvement starts in the face and then progresses to the shoulder girdle, the humeral muscles and the abdominal muscles, and then the anterolateral compartment of the leg. Disease severity is highly variable and progression is very slow. About 20% of FSHD patients become wheelchair-bound. Lifespan is not shortened. The diagnosis of FSHD is based on a genetic test by which a deletion of 3.3kb DNA repeats (named D4Z4 and mapping to the subtelomeric region of chromosome 4q35) is identified. The progressive pattern of FSHD requires that the severity of symptoms as well as their physical, social and psychological impact be evaluated on a regular basis. A yearly assessment is recommended. Multidisciplinary management of FSHD--consisting of a combination of genetic counselling, functional assessment, an assessment by a physical therapist, prescription of symptomatic therapies and prevention of known complications of this disease--is required. Prescription of physical therapy sessions and orthopedic appliances are to be adapted to the patient's deficiencies and contractures.

Camptocormia phenotype of FSHD: a clinical and MRI study on six patients

Recently it has been postulated that there is an atypical facioscapulohumeral muscular dystrophy (FSHD) phenotype with isolated axial myopathy. Involvement of paraspinal and limb muscles was evaluated in six patients with molecularly proven FSHD and a predominant bent spine phenotype. Consistent with the camptocormia phenotype, the most severely affected muscles in all six patients were the thoracic and lumbar spinal tract together with hamstrings. MRI disclosed severe axial muscle degeneration but mostly subclinical involvement of limb muscles. The involvement of hip extensor muscles in FSHD might considerably contribute to the clinical phenotype of camptocormia due to axial muscle involvement.

Effect of aerobic exercise training and cognitive behavioural therapy on reduction of chronic fatigue in patients with facioscapulohumeral dystrophy: protocol of the FACTS-2-FSHD trial

Background

In facioscapulohumeral dystrophy (FSHD) muscle function is impaired and declines over time. Currently there is no effective treatment available to slow down this decline. We have previously reported that loss of muscle strength contributes to chronic fatigue through a decreased level of physical activity, while fatigue and physical inactivity both determine loss of societal participation. To decrease chronic fatigue, two distinctly different therapeutic approaches can be proposed: aerobic exercise training (AET) to improve physical capacity and cognitive behavioural therapy (CBT) to stimulate an active life-style yet avoiding excessive physical strain. The primary aim of the FACTS-2-FSHD (acronym for Fitness And Cognitive behavioural TherapieS/for Fatigue and ACTivitieS in FSHD) trial is to study the effect of AET and CBT on the reduction of chronic fatigue as assessed with the Checklist Individual Strength subscale fatigue (CIS-fatigue) in patients with FSHD. Additionally, possible working mechanisms and the effects on various secondary outcome measures at all levels of the International Classification of Functioning, Disability and Health (ICF) are evaluated.

Methods/Design

A multi-centre, assessor-blinded, randomized controlled trial is conducted. A sample of 75 FSHD patients with severe chronic fatigue (CIS-fatigue ≥ 35) will be recruited and randomized to one of three groups: (1) AET + usual care, (2) CBT + usual care or (3) usual care alone, which consists of no therapy at all or occasional (conventional) physical therapy. After an intervention period of 16 weeks and a follow-up of 3 months, the third (control) group will as yet be randomized to either AET or CBT (approximately 7 months after inclusion). Outcomes will be assessed at baseline, immediately post intervention and at 3 and 6 months follow up.

Discussion

The FACTS-2-FSHD study is the first theory-based randomized clinical trial which evaluates the effect and the maintenance of effects of AET and CBT on the reduction of chronic fatigue in patients with FSHD. The interventions are based on a theoretical model of chronic fatigue in patients with FSHD. The study will provide a unique set of data with which the relationships between outcome measures at all levels of the ICF could be assessed.

Trial registration

Dutch Trial Register, NTR1447.