Therapy of Myositis: Biological and Physical
Therapy of Myositis: Biological and Physical
Earlier, only a few studies had demonstrated beneficial effects of physical therapy in the form of aerobic exercise alone or in combination with resistance training in patients with established myositis.
The mechanisms explaining the beneficial effects may be several. An acquired metabolic disturbance that exercise may reverse has been postulated. Bertolucci et al reported abnormal blood lactate levels in 20 patients with established polymyositis/dermatomyositis compared with 15 healthy controls at rest and after an incremental submaximal treadmill-walking exercise bout. Four patients were included in an aerobic treadmill-walking program performed 3 days a week for 6 weeks. Reduced lactate levels were seen in all, and two patients improved by more than 20% in physical capacity and three in autonomy in life.
An RCT was undertaken with a 12-week endurance exercise program of ergometer biking, along with resistance training of the quadriceps. The exercise group exercised for 1 h for 3 days a week and was compared with a nonexercising control group. The exercise group improved in VO2 max, muscle strength, daily activities and quality of life compared with the nonexercising control group. Intramuscular lactate levels after an all-out cycling session investigated by microdialysis were lower, and the cycling time to exhaustion was doubled in the exercise group but was unchanged in the control group. These observations together with increased mitochondria enzyme activities in muscle tissue indicate that exercise can improve the within-muscle aerobic capacity. A 1-year open extension revealed that only quadriceps strength improvement was sustained whereas all other variables returned to the baseline values, indicating that continuing exercise is necessary to maintain and improve function and health.
Eight patients with JDM in remission but with muscle impairment, ages 16–42 years, completed a home-based 12-week aerobic exercise program. The program was well tolerated and resulted in improved VO2 max, reduced exercise heart rate and improved 6-min walking distance without increased serum Creatine kinase (CK) levels. Ten children between 7 and 17 years with chronic and mild JDM improved in VO2 max, muscle strength and quality of life without increased release of muscle enzymes after a twice a week 12-week aerobic and resistance training program.
Reports on effects of exercise in inflammatory, active, recent-onset polymyositis/dermatomyositis are fewer, but some new studies suggest their safety. An RCT confirmed safety of resistance training combined with brisk walking performed 5 days a week, introduced about 4 weeks after start of pharmacological therapy. The control group performed a range of motion program 5 days a week. After 24 weeks both groups had improved muscle function and aerobic capacity, indicating that the exercise program did not have short-term additional value in this phase of disease. There were no signs of increased inflammation by analysis of muscle biopsies or CPK levels. In an open 2-year follow-up, the exercise group was still significantly improved in muscle function and aerobic capacity and seemingly more physically active compared with the control group, indicating that exercise employed early with regular support might enhance physical activity levels in the long term.
Three patients with active polymyositis with persistent muscle weakness and elevated muscle enzymes despite treatment were introduced to strengthening exercise in combination with aerobic treadmill walking. Above 20% improvement was achieved in grip strength and aerobic capacity in one patient, and two improved in daily activities and quality of life. A case report described safety of a 4-week hospital-based rehabilitation program in a young woman with active polymyositis.
Safety and efficacy of resistance training have been established by several studies. Exercise with resistance putty to improve grip strength was feasible and well tolerated in a pilot study of patients with established polymyositis/dermatomyositis, but more studies are needed to optimize the training program. Available studies support safety of resistance training in IBM, but results regarding efficacy to improve function are inconclusive and more studies are needed. All exercise studies published within the annual period of review are presented in Table 1.
Patients with recent-onset polymyositis/dermatomyositis could be introduced to resistance training in combination with aerobic exercise about 4 weeks after starting medical treatment or as soon as they can cope with exercise. The exercise intensity needs to be adapted to individual levels of muscle impairment, fatigue and disease activity. Muscle strength and disease activity should be monitored regularly and exercise load and intensity should be adapted according to the clinical improvement. In patients with low disease activity, exercise could be performed on 65–70% of maximal oxygen uptake or maximal heart rate, 2–3 days a week. To improve muscle strength, strength training should be performed on loads of 10 Voluntary repetition maximum (VRM) (ca 70% of 1 VRM), 2–3 days a week. On the basis of the small number of studies evaluating exercise effects in JDM and IBM, it is too early to make recommendations for these patients.
Physical Therapy
Earlier, only a few studies had demonstrated beneficial effects of physical therapy in the form of aerobic exercise alone or in combination with resistance training in patients with established myositis.
Aerobic Exercise and Resistance Training
The mechanisms explaining the beneficial effects may be several. An acquired metabolic disturbance that exercise may reverse has been postulated. Bertolucci et al reported abnormal blood lactate levels in 20 patients with established polymyositis/dermatomyositis compared with 15 healthy controls at rest and after an incremental submaximal treadmill-walking exercise bout. Four patients were included in an aerobic treadmill-walking program performed 3 days a week for 6 weeks. Reduced lactate levels were seen in all, and two patients improved by more than 20% in physical capacity and three in autonomy in life.
An RCT was undertaken with a 12-week endurance exercise program of ergometer biking, along with resistance training of the quadriceps. The exercise group exercised for 1 h for 3 days a week and was compared with a nonexercising control group. The exercise group improved in VO2 max, muscle strength, daily activities and quality of life compared with the nonexercising control group. Intramuscular lactate levels after an all-out cycling session investigated by microdialysis were lower, and the cycling time to exhaustion was doubled in the exercise group but was unchanged in the control group. These observations together with increased mitochondria enzyme activities in muscle tissue indicate that exercise can improve the within-muscle aerobic capacity. A 1-year open extension revealed that only quadriceps strength improvement was sustained whereas all other variables returned to the baseline values, indicating that continuing exercise is necessary to maintain and improve function and health.
Eight patients with JDM in remission but with muscle impairment, ages 16–42 years, completed a home-based 12-week aerobic exercise program. The program was well tolerated and resulted in improved VO2 max, reduced exercise heart rate and improved 6-min walking distance without increased serum Creatine kinase (CK) levels. Ten children between 7 and 17 years with chronic and mild JDM improved in VO2 max, muscle strength and quality of life without increased release of muscle enzymes after a twice a week 12-week aerobic and resistance training program.
Reports on effects of exercise in inflammatory, active, recent-onset polymyositis/dermatomyositis are fewer, but some new studies suggest their safety. An RCT confirmed safety of resistance training combined with brisk walking performed 5 days a week, introduced about 4 weeks after start of pharmacological therapy. The control group performed a range of motion program 5 days a week. After 24 weeks both groups had improved muscle function and aerobic capacity, indicating that the exercise program did not have short-term additional value in this phase of disease. There were no signs of increased inflammation by analysis of muscle biopsies or CPK levels. In an open 2-year follow-up, the exercise group was still significantly improved in muscle function and aerobic capacity and seemingly more physically active compared with the control group, indicating that exercise employed early with regular support might enhance physical activity levels in the long term.
Three patients with active polymyositis with persistent muscle weakness and elevated muscle enzymes despite treatment were introduced to strengthening exercise in combination with aerobic treadmill walking. Above 20% improvement was achieved in grip strength and aerobic capacity in one patient, and two improved in daily activities and quality of life. A case report described safety of a 4-week hospital-based rehabilitation program in a young woman with active polymyositis.
Resistance Training
Safety and efficacy of resistance training have been established by several studies. Exercise with resistance putty to improve grip strength was feasible and well tolerated in a pilot study of patients with established polymyositis/dermatomyositis, but more studies are needed to optimize the training program. Available studies support safety of resistance training in IBM, but results regarding efficacy to improve function are inconclusive and more studies are needed. All exercise studies published within the annual period of review are presented in Table 1.
Recommendations for Exercise
Patients with recent-onset polymyositis/dermatomyositis could be introduced to resistance training in combination with aerobic exercise about 4 weeks after starting medical treatment or as soon as they can cope with exercise. The exercise intensity needs to be adapted to individual levels of muscle impairment, fatigue and disease activity. Muscle strength and disease activity should be monitored regularly and exercise load and intensity should be adapted according to the clinical improvement. In patients with low disease activity, exercise could be performed on 65–70% of maximal oxygen uptake or maximal heart rate, 2–3 days a week. To improve muscle strength, strength training should be performed on loads of 10 Voluntary repetition maximum (VRM) (ca 70% of 1 VRM), 2–3 days a week. On the basis of the small number of studies evaluating exercise effects in JDM and IBM, it is too early to make recommendations for these patients.