1
|
Jensen KY, Aagaard P, Suetta C, Nielsen JL, Bech RD, Schrøder HD, Christensen J, Simonsen C, Diederichsen LP. High-intensity resistance training improves quality of life, muscle endurance and strength in patients with myositis: a randomised controlled trial. Rheumatol Int 2024; 44:1909-1921. [PMID: 39192022 PMCID: PMC11392978 DOI: 10.1007/s00296-024-05698-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/09/2024] [Indexed: 08/29/2024]
Abstract
Myositis is associated with reduced quality of life, which is accompanied by significant impairments in muscle endurance and strength, altogether representing cardinal traits in patients with myositis. This randomised controlled trial aimed to investigate the effect of high-intensity resistance training on quality of life in patients with myositis. Thirty-two patients with established, stable myositis were randomised to 16 weeks of high-intensity resistance training (intervention group) or 16 weeks of usual care (control group). Primary outcome was quality of life assessed as the change in the physical component summary score (PCS) of the Short Form-36 health questionnaire from baseline to post-intervention. Secondary outcomes included functional capacity measures, such as functional index 3, and International Myositis Assessment and Clinical Studies Group (IMACS) disease activity and damage core set measures, including manual muscle testing 8 (MMT8). The primary outcome PCS showed an improvement in favour of high-intensity resistance training with a between-group difference of 5.33 (95% CI 0.61; 10.05) (p = 0.03). Additionally, functional index 3 showed a between-group difference indicating greater gains with high-intensity resistance training 11.49 (95% CI 3.37; 19.60) (p = 0.04), along with a between-group improvement in MMT8 1.30 (95% CI 0.09; 2.51) (p = 0.04). High-intensity resistance training for 16 weeks effectively improved quality of life in patients with myositis. Clinical measures of muscle endurance and muscle strength were also found to improve with high-intensity resistance training, while patients stayed in disease remission. Consequently, progressively adjusted high-intensity resistance training is feasible and causes no aggravation of the disease, while benefitting patients with myositis.Clinical trial registration: Clinicaltrials.gov ID: NCT04486261- https://clinicaltrials.gov/study/NCT04486261 .
Collapse
Affiliation(s)
- Kasper Yde Jensen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark.
| | - Per Aagaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Charlotte Suetta
- Geriatric Research Unit, Department of Geriatric and Palliative Medicine, Copenhagen University Hospital, Bispebjerg, Frederiksberg, Denmark
- Department of Clinical Medicine, Faculty of Health and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Lindberg Nielsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Rune Dueholm Bech
- Department of Orthopaedics and Traumatology, Zealand University Hospital, Koege, Denmark
| | | | - Jan Christensen
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Casper Simonsen
- Centre for Physical Activity Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Louise Pyndt Diederichsen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
2
|
Saygin D, Alexanderson H, DiRenzo D, Raaphorst J, de Visser M, Ren D, Regardt M, de Groot I, Sarver C, Kim JY, Lodin K, Beer K, Needham M, Park JK, Christopher-Stine L, Mecoli CA. The impact of pain on daily activities in patients with idiopathic inflammatory myopathies: Report from the OMERACT myositis working group. Semin Arthritis Rheum 2024; 67:152476. [PMID: 38851171 DOI: 10.1016/j.semarthrit.2024.152476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/20/2024] [Accepted: 04/05/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND International focus groups with patients with idiopathic inflammatory myopathies (IIM) conducted by the OMERACT Myositis Working Group over the years demonstrated the pain as an important symptom experienced by these patients. In this study, we aimed to examine the frequency and degree of pain interference, the aspects of daily life impacted by pain, and the factors associated with pain interference in adults with IIM. METHODS This was a prospective observational study with two visits. The patients who fulfilled the probable/definite IIM (ACR/EULAR Myositis Classification Criteria) were enrolled. Pain interference was assessed with PROMIS pain interference form (6a). Myositis core set measures and PROMIS fatigue (7a) and physical function (8b) were obtained at both visits. Logistic regression and linear mixed models were performed to assess the association between pain interference and other parameters. RESULTS A total of 129 patients with IIM (60 % females) were recruited from U.S., South Korea, Netherlands, Sweden, and Australia. Approximately 71 % reported pain interference. The patients in the greater pain interference group were more likely to be female, had significantly worse patient/physician global disease activity, fatigue, and physical function than those in the lower pain interference group. The most commonly impacted life aspect was household chores. Manual muscle testing, patient/physician global disease activity, fatigue, and physical function were all significantly associated with pain interference score >60. CONCLUSION The majority of the patients with IIM experience the impact of pain on their daily activities, particularly household chores. Myositis disease activity, duration, and subtype could be associated with greater pain interference.
Collapse
Affiliation(s)
- Didem Saygin
- Division of Rheumatology, Department of Medicine, University of Pittsburgh, USA.
| | - Helene Alexanderson
- Medical Unit Occupational Therapy and Physical Therapy, Karolinska University Hospital and Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Dana DiRenzo
- Division of Rheumatology, Department of Medicine, University of Pennsylvania
| | - Joost Raaphorst
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Marianne de Visser
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Dianxu Ren
- Health and Community Systems, University of Pittsburgh, Pittsburgh, PA, USA
| | - Malin Regardt
- Department of Neurobiology, Care Sciences and Society, Division of Occupational Therapy, Karolinska Institutet and Medical Unit Occupational Therapy and Physical Therapy, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Ju Yeon Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | - Karin Lodin
- Department of Medicine, Division of Rheumatology, Karolinska Institutet, Solna, Stockholm, Sweden; Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Kelly Beer
- Department of Neurology, Fiona Stanley Hospital, IIID Murdoch University and University of Notre Dame, Perth, Australia
| | - Merrilee Needham
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, USA
| | - Jin Kyun Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | | | | |
Collapse
|
3
|
Driskill E, Zhang Z, Chi J, Cui Q. Increased Rate of Complications Following Total Knee Arthroplasty in Patients Who Have Polymyositis. J Arthroplasty 2024; 39:1731-1735. [PMID: 38211729 DOI: 10.1016/j.arth.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/14/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Polymyositis (PM) is a systemic connective tissue disorder that can lead to early onset degenerative joint disease and a need for total knee arthroplasty (TKA). Outcomes of TKA in patients who have PM are not well documented in the literature. The purpose of this study was to evaluate PM as a risk factor for complications after TKA. METHODS Using a national private payer insurance database from 2010 to 2022, PM patients undergoing primary TKA were compared to 10:1 matched controls based on age, sex, and comorbidities. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. 90-day emergency department visits and inpatient readmissions were also documented. A total of 25,039 patients undergoing primary TKA were queried, of which 2,290 had PM. RESULTS Compared to the matched controls, patients who had PM demonstrated higher rates of medical and surgical complications, including pulmonary embolism (1.0% versus 0.5%, P = .001), cerebrovascular accident (1.3% versus 0.7%, P = .002), wound complications (3.4% versus 2.1%, P < .001), and periprosthetic joint infection at 1 year (1.7% versus 1.3%, P = .042) and 2 years (2.6% versus 1.9%, P = .006). Patients who had PM displayed elevated 90-day emergency department (14.9% versus 13.3%, P = .032) and hospital readmission rate (7.1% versus 4.8%, P < .001). CONCLUSIONS Patients who have PM are at higher risks of postoperative medical and surgical complications, including pulmonary embolism, cerebrovascular accident, wound complication, and periprosthetic joint infection. Given these results, it is helpful for orthopedic surgeons and patients to consider these risks when considering TKA for patients who have PM.
Collapse
Affiliation(s)
- Elizabeth Driskill
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Zhichang Zhang
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; Department of Orthopaedic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, China
| | - Jialun Chi
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| |
Collapse
|
4
|
Jensen KY, Aagaard P, Suetta C, Nielsen JL, Schrøder HD, Grønset C, Simonsen C, Diederichsen LP. Quality of life in patients with myositis is associated with functional capacity, body composition, and disease activity-Baseline data from a randomized controlled trial. Int J Rheum Dis 2024; 27:e15132. [PMID: 38509721 DOI: 10.1111/1756-185x.15132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/22/2024] [Accepted: 03/09/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE To investigate the potential associations between functional capacity, muscle strength, body composition, and disease-related measures and quality of life in patients with myositis. METHODS Baseline measures of functional capacity (functional index 3 (FI3), 2-minute walk test (2MWT), timed up and go (TUG) and 30-s sit-to-stand (30-STS)), muscle strength (incl. leg and handgrip strength), maximal leg extensor power, body composition (appendicular lean mass, fat percentage/mass) and disease-related measures (disease activity & damage core sets) were examined for their associations with quality of life (physical- and mental component summary scores, Short Form 36 questionnaire (SF-36)) by means of Spearman's correlation analysis. RESULTS A total of 32 patients with myositis were included. Positive correlations between SF-36 physical component summary score (PCS) and FI3, 30-STS, TUG, 2MWT, leg extensor power, leg strength, bench press strength, and handgrip strength were observed. In contrast, fat percentage and fat mass correlated negatively with PCS. In disease-related measures, Extramuscular global assessment, health assessment questionnaire, physician global damage, and patient global damage scores were negatively associated with SF-36 PCS. No correlations to the mental component summary score of SF-36 were observed. CONCLUSION All measures of functional capacity were positively related to the SF-36 physical component summary score, indicating higher functional capacity positively affects quality of life in patients with myositis. Health assessment questionnaire and patient global damage scores demonstrated the strongest correlations with SF-36 physical component summary scores, further supporting these patient-reported outcomes as viable monitoring tools in patients with myositis.
Collapse
Affiliation(s)
- Kasper Yde Jensen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Aagaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Charlotte Suetta
- Geriatric Research Unit, Department of Geriatric and Palliative Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jakob L Nielsen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Henrik D Schrøder
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Charlotte Grønset
- Department of Occupational Therapy and Physiotherapy, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Casper Simonsen
- Centre for Physical Activity Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Louise P Diederichsen
- Copenhagen Research Center for Autoimmune Connective Tissue Diseases (COPEACT), Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
5
|
Roy D. Editorial on "Pain in individuals with idiopathic inflammatory myopathies, other systemic autoimmune rheumatic diseases, and without rheumatic diseases: A report from the COVAD study". Int J Rheum Dis 2023; 26:1904-1907. [PMID: 37807616 DOI: 10.1111/1756-185x.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Debaditya Roy
- Department of Clinical Immunology and Rheumatology, Institute of Postgraduate Medical Education & Research (IPGMER), Kolkata, India
| |
Collapse
|
6
|
Armadans-Tremolosa I, Selva-O'Callaghan A. Inflammatory myopathy in adults, health-related quality of life, and wellbeing: a round trip between immune disease and wellness. Expert Rev Clin Immunol 2023; 19:1239-1246. [PMID: 37452824 DOI: 10.1080/1744666x.2023.2238128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/07/2023] [Accepted: 07/14/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Health-related quality of life (HRQoL) and wellbeing are poorer in patients with chronic conditions than in the general population, and this is the case of individuals with myositis. Research has shown a negative relationship between this disease and wellbeing, but there is little data on the effect that enhanced wellbeing has on the disease course. AREAS COVERED HRQoL, wellbeing, and other related concepts are examined here with special emphasis on the benefits of positive status in the physical, environmental, psychological, and social function areas for reducing the severity of the clinical course and organ damage in a chronic condition such as myositis. The factors affecting HRQoL, and wellbeing are analyzed to delineate specific strategies that will lead to improvements in the life of adult patients with myositis. The mechanisms implicated in these changes are also discussed. EXPERT OPINION Myositis refers to a heterogeneous group of chronic systemic autoimmune diseases. HRQoL and wellbeing are poor in these patients, and evidence suggests that improvements in this line can have positive repercussions on the course and outcome of the disease. Strategies to improve HRQoL and wellbeing should be designed for adults with myositis.
Collapse
Affiliation(s)
- Immaculada Armadans-Tremolosa
- Department of Social Psychology and Quantitative Psychology, PsicoSAO-Research Group in Social, Environmental, and Organizational Psychology, Universitat de Barcelona, Barcelona, Spain
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Diseases Unit, Department of Medicine, Vall d'Hebron General Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
| |
Collapse
|
7
|
Leclair V, Tsui H, Hudson M. Pain in autoimmune inflammatory myopathies: a scoping review. RMD Open 2023; 9:rmdopen-2022-002591. [PMID: 36635001 PMCID: PMC9843184 DOI: 10.1136/rmdopen-2022-002591] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/26/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pain is considered a priority for research by adult patients with autoimmune inflammatory myopathy (AIM) and their families. Our aim was to review the literature for studies reporting on pain in adult AIM and to summarise their findings. METHODS A scoping review was conducted searching for studies in PubMed and MEDLINE including more than five adult patients with AIM and assessing pain using a patient-reported outcome measure. Study population characteristics, pain measurement and clinical correlates of pain were extracted using a standardised protocol. RESULTS The search strategy identified 2831 studies with 33 meeting inclusion criteria. Most studies used visual analogue scales (n=14) and/or the Medical Outcomes Study 36-Item Short Form Bodily Pain Scale (n=17). Frequency of pain and/or myalgias ranged from 64% to 100%. Subjects with AIM had significantly more pain than the general population and comparable pain to other chronic rheumatic diseases. Insufficient results were available to identify significant clinical correlates of pain in AIM. CONCLUSION This review suggests that the burden of pain in AIM is considerable. Still, due to the heterogeneity and low quality of the evidence, significant knowledge gaps persist. Studies are needed to characterise pain trajectories of patients with AIM.
Collapse
Affiliation(s)
- Valérie Leclair
- Division of Rheumatology, Jewish General Hospital and Lady Davis Institute, McGill University, Montreal, Quebec, Canada
| | - Harmony Tsui
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Marie Hudson
- Division of Rheumatology, Jewish General Hospital and Lady Davis Institute, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
8
|
Assessment of Physical Activity and Muscle Function in Adult Inflammatory Myopathies. Curr Rheumatol Rep 2022; 24:54-63. [PMID: 35244882 DOI: 10.1007/s11926-022-01059-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The aim is to summarize the outcome measures used in the assessment and monitoring of muscle function and physical activity in the management idiopathic inflammatory myopathy. RECENT FINDINGS Assessment techniques have progressed and matured over the past decade, and new options are now available to clinicians working in this field. Newer outcome measures, including the Functional Index-3 and wearable motion sensors are reviewed, as well as the current application of more established measures. The available outcome measures for use in clinical practice in idiopathic inflammatory myopathies with regard to muscle function and physical activity have expanded over the past 15 years. There are valid and reliable options for several domains and methods for assessing these factors. In a busy clinical setting, efficiency is important, but there also needs to be considered the choosing of tools that work together to give the fullest picture of the status of the patient.
Collapse
|
9
|
Kimura N, Kawahara T, Uemura Y, Atsumi T, Sumida T, Mimura T, Kawaguchi Y, Amano H, Iwasaki Y, Kaneko Y, Matsui T, Muro Y, Imura Y, Kanda T, Tanaka Y, Kawakami A, Jinnin M, Ishii T, Hiromura K, Miwa Y, Nakajima H, Kuwana M, Nishioka Y, Morinobu A, Kameda H, Kohsaka H. Branched chain amino acids in the treatment of polymyositis and dermatomyositis: a phase II/III, multi-center, randomized controlled trial. Rheumatology (Oxford) 2022; 61:4445-4454. [PMID: 35179548 DOI: 10.1093/rheumatology/keac101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/23/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To assess the efficacy and safety of branched chain amino acids (BCAAs) in the treatment of PM/DM prior to official approval of their use in Japan. METHODS Treatment naïve adults with PM/DM were enrolled in a randomized, double-blind trial to receive either TK-98 (drug name of BCAAs) or placebo in addition to conventional treatment. After 12 weeks, patients with an average manual muscle test (MMT) score <9.5 were enrolled in an open label extension study for a further 12 weeks. The primary end point was the change of the MMT score at 12 weeks. The secondary end points were the clinical response and the change of functional index (FI). RESULTS Forty-seven patients were randomized either to the TK-98 (n = 24) or placebo (n = 23) groups. The changes of MMT scores at 12 weeks were 0.70±0.19 (mean±SEM) and 0.69±0.18, respectively (P = 0.98). Thirteen patients from the TK-98 group and 12 from the placebo group were enrolled in the extension study. The MMT scores in both groups improved similarly. The increase of the FI scores of the shoulder flexion at 12 weeks was significantly greater in the TK-98 group (27.9±5.67 vs. 12.8±5.67 for the right shoulder flexion, and 27.0±5.44 vs. 13.4±5.95 for the left shoulder [P < 0.05]). Frequencies of adverse events upto 12 weeks were similar. CONCLUSION BCAAs showed no effect on the improvement of the muscle strength evaluated by MMT and the clinical response. However, they were partly effective for improving dynamic repetitive muscle functions. TRIAL REGISTRATION UMIN-CTR Clinical Trial, https://center6.umin.ac.jp/, UMIN000016233.
Collapse
Affiliation(s)
- Naoki Kimura
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takuya Kawahara
- Clinical Research Promotion Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Yukari Uemura
- Clinical Research Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Hokkaido, Japan
| | - Takayuki Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Toshihide Mimura
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yasushi Kawaguchi
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Hirofumi Amano
- Department of Rheumatology and Internal Medicine, Juntendo University School of Medicine,Tokyo, Japan
| | - Yukiko Iwasaki
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Japan.,Department of Palliative Medicine, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiro Matsui
- Department of Rheumatology, Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Yoshinao Muro
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshitaka Imura
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Department of Clinical Immunology and Rheumatology, Tazuke-Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences,Nagasaki, Japan
| | - Masatoshi Jinnin
- Department of Dermatology, Wakayama Medical University Graduate School of Medicine, Wakayama, Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine,Maebashi, Japan
| | - Yusuke Miwa
- Department of Medicine, Division of Rheumatology, Showa University School of Medicine, Tokyo, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Yasuhiko Nishioka
- Department of Respiratory Medicine and Rheumatology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Akio Morinobu
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Section of Rheumatology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideto Kameda
- Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Hitoshi Kohsaka
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Rheumatology Center, Chiba-Nishi General Hospital, Matsudo, Japan
| |
Collapse
|
10
|
Jensen KY, Aagaard P, Schrøder HD, Suetta C, Nielsen JL, Boyle E, Diederichsen LP. High-intensity strength training in patients with idiopathic inflammatory myopathies: a randomised controlled trial protocol. BMJ Open 2021; 11:e043793. [PMID: 34172544 PMCID: PMC8237738 DOI: 10.1136/bmjopen-2020-043793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Idiopathic inflammatory myopathies (IIMs) are rare diseases characterised by non-suppurative inflammation of skeletal muscles and muscle weakness. Additionally, IIM is associated with a reduced quality of life. Strength training is known to promote muscle hypertrophy and increase muscle strength and physical performance in healthy young and old adults. In contrast, only a few studies have examined the effects of high intensity strength training in patients with IIM and none using a randomised controlled trial (RCT) set-up. Thus, the purpose of this study is to investigate the effects of high-intensity strength training in patients affected by the IIM subsets polymyositis (PM), dermatomyositis (DM) and immune-mediated necrotising myopathy (IMNM) using an RCT study design. METHODS AND ANALYSIS 60 patients with PM, DM or IMNM will be included and randomised into (1) high-intensity strength training or (2) Care-as-Usual. The intervention period is 16 weeks comprising two whole-body strength exercise sessions per week. The primary outcome parameter will be the changes from pre training to post training in the Physical Component Summary measure in the Short Form-36 health questionnaire. Secondary outcome measures will include maximal lower limb muscle strength, skeletal muscle mass, functional capacity, disease status (International Myositis Assessment and Clinical Studies Group core set measures) and questionnaires assessing physical activity levels and cardiovascular comorbidities. Furthermore, blood samples and muscle biopsies will be collected for subsequent analyses. ETHICS AND DISSEMINATION The study complies with the Helsinki Declaration II and is approved by The Danish Data Protection Agency (P-2020-553). The study is approved by The Danish National Committee on Health Research Ethics (H-20030409). The findings of this trial will be submitted to relevant peer-reviewed journals. Abstracts will be submitted to international conferences. TRIAL REGISTRATION NUMBER NCT04486261.
Collapse
Affiliation(s)
- Kasper Yde Jensen
- Rigshospitalet, Copenhagen University Hospital Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
| | - Per Aagaard
- Research Unit for Muscle Physiology and Biomechanics, University of Southern Denmark Department of Sports Science and Clinical Biomechanics, Odense, Denmark
| | - Henrik Daa Schrøder
- Department of Pathology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Charlotte Suetta
- Geriatric Research Unit, Department of Geriatric and Palliative Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Geriatric Research Unit, Department of Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jakob Lindberg Nielsen
- Research Unit for Muscle Physiology and Biomechanics, University of Southern Denmark Department of Sports Science and Clinical Biomechanics, Odense, Denmark
| | - Eleanor Boyle
- Research Unit of Clinical Biomechanics, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Louise Pyndt Diederichsen
- Rigshospitalet, Copenhagen University Hospital Center for Rheumatology and Spine Diseases, Copenhagen, Denmark
- Department of Rheumatology, Odense University Hospital, Odense, Denmark
| |
Collapse
|
11
|
Xu A, Sun C, Metcalf R, Limaye V. Health-related quality of life and work impairment in idiopathic inflammatory myopathies in South Australia. Int J Rheum Dis 2021; 24:809-814. [PMID: 33881230 DOI: 10.1111/1756-185x.14120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
AIM The idiopathic inflammatory myopathies (IIM) are rare autoimmune diseases that are usually chronic and often present with skeletal muscle inflammation and weakness. We sought to examine the impact of IIM in a cohort of 50 South Australian patients on health-related quality of life (HRQOL) and work productivity (WP). We uniquely categorized patients across gender, IIM subtypes, employment status, and also whether there was extramuscular involvement from IIM. METHODS Multiple modalities were used, as recommended by the International Myositis Assessment and Clinical Studies Group (IMACS), to assess the impact of IIM, including manual muscle strength testing (MMT-8), the Physician and Patient Global Activity Assessments (PHGAA, PTGAA), Myositis Disease Activity Assessment Tool (MDAAT), and serum creatinine kinase (CK) levels. The impacts of IIM on HRQOL and WP were analyzed using the Medical Outcomes Study 36-items Short Form (SF-36) and Work Productivity and Activity Impairment (WPAI) questionnaires, respectively. RESULTS We found significantly lower HRQOL outcome scores in most of the SF-36 domains when compared to the most recent population norms (P ≤ .01). Physical health was predominantly affected with relative preservation of emotional health. There were also significant associations between MMT-8, PHGAA and PTGAA scores and HRQOL and WP. CONCLUSIONS Our findings highlight the significant impact of IIM on HRQOL and WP in a well-characterized cohort of patients with IIM within Australia, and therefore the importance of a holistic approach to the management of these patients.
Collapse
Affiliation(s)
- Alan Xu
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Caitlyn Sun
- Department of Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Robert Metcalf
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Vidya Limaye
- Department of Rheumatology, Royal Adelaide Hospital, Adelaide, SA, Australia
| |
Collapse
|
12
|
Zhang H, Liu Y, Ma J, Li Z. Systematic review of physical exercise for patients with idiopathic inflammatory myopathies. Nurs Health Sci 2021; 23:312-324. [PMID: 33511721 DOI: 10.1111/nhs.12817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 01/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- Huan Zhang
- School of Nursing, Peking Union Medical College, Beijing, China
| | - Yuanfei Liu
- School of Nursing, Peking Union Medical College, Beijing, China
| | - Jingya Ma
- School of Nursing, Peking Union Medical College, Beijing, China
| | - Zheng Li
- School of Nursing, Peking Union Medical College, Beijing, China
| |
Collapse
|
13
|
Helm MF, Bazewicz CG, Butt M, Washington A, Shumaker K, Foulke GT. Concern about malignancy contributes to the psychosocial toll of dermatomyositis. Scand J Rheumatol 2021; 50:227-230. [PMID: 33432833 DOI: 10.1080/03009742.2020.1843706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: Dermatomyositis (DM) is associated with increased morbidity and mortality, decreased quality of life, and an increased incidence of psychiatric illness. We performed a pilot study to investigate whether concern about malignancy contributes to the psychosocial toll of DM.Method: Patients with a recent DM diagnosis at our institution between 2013 and 2018 and no history of DM-associated malignancy completed standardized questionnaires and a novel survey generated by our group, and participated in focus groups.Results: Seventeen patients (14 females and three males) completed the surveys. The mean Dermatology Life Quality Index (DLQI) score was 2.75. The mean score on the Patient Health Questionnaire-9 (PHQ-9) was 5.35, with a range of 0-20. Our independent DM-specific questionnaire revealed a mean of 17.41 (range 2-40).Conclusion: Concern about the increased risk of malignancy contributes to the psychosocial toll of DM. Individual impacts are highly variable and patient specific. Clinicians should assess for depression and anxiety in patients with DM, understanding that concern for malignancy adds to the total psychosocial burden in some patients.
Collapse
Affiliation(s)
- M F Helm
- Department of Dermatology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - C G Bazewicz
- Department of Dermatology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - M Butt
- Department of Dermatology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - A Washington
- Department of Dermatology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - K Shumaker
- Department of Dermatology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - G T Foulke
- Department of Dermatology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
14
|
Christopher-Stine L, Wan GJ, Kelly W, McGowan M, Bostic R, Reed ML. Patient-reported dermatomyositis and polymyositis flare symptoms are associated with disability, productivity loss, and health care resource use. J Manag Care Spec Pharm 2020; 26:1424-1433. [PMID: 33119444 PMCID: PMC10391285 DOI: 10.18553/jmcp.2020.26.11.1424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Flare activity or worsening symptoms are not well defined for myositis. OBJECTIVES: To (a) characterize dermatomyositis (DM) and polymyositis (PM) flares from the patient perspective and (b) report the corresponding disability and rate of unplanned medical encounters. METHODS: Online survey data were collected from volunteer patients from The Myositis Association and Johns Hopkins Myositis Center. Flare frequency; Health Assessment Questionnaire Disability Index (HAQ-DI), HAQ-Pain Index, Work Productivity and Activity Impairment (WPAI) scales; emergency department/urgent care (ED/UC) visits; and hospital admissions during the past year were examined. RESULTS: 564 individuals with selfreported diagnoses of DM/PM were surveyed between December 2017 and May 2018. Recall of symptom flares was reported by 524 respondents (78.1% were female, mean age of 55 years). Among the respondents, 378 (72.1%) reported ≥ 1 flare in the past year. The pattern of flare frequency was similar for DM and PM respondents. The most common symptoms were muscle weakness (83%), extreme fatigue (78%), and muscle pain/discomfort (64%). Increasing flare frequency was associated with significantly (P < 0.01) greater mean HAQ-DI and HAQ-Pain scores, myositis-related ED/UC visits, hospital admissions, WPAI work productivity loss (among those employed), and WPAI nonwork activity impairment. CONCLUSIONS: DM/PM-related flares are common with exacerbations of muscle weakness and fatigue being the most common flare symptoms. Flare frequency was associated with greater disability, pain, work productivity loss, nonwork activity impairment, and increased ED/UC utilization. Higher frequency of patient-reported flares may serve as a marker of worsening physical functioning and intensifying health care needs and, therefore, suggests their importance in the clinical assessment of patients with DM/PM. DISCLOSURES: This study was supported by Mallinckrodt Pharmaceuticals (Bedminster, NJ) via grants to Vedanta Research and The Myositis Association. Christopher-Stine has received compensation from previous Mallinckrodt Advisory Board meetings, unrelated to this subject matter. Wan is an employee of Mallinckrodt Pharmaceuticals and is a stockholder of the company. Reed and Bostic received grant support from Mallinckrodt Pharmaceuticals for data collection and analysis. McGowan is an employee of The Myositis Foundation, which received grant funding to support study data collection. Kelly has no conflicts to disclose. This study was presented, in part or full, at the 2019 Annual American College of Rheumatology and Association of Rheumatology Professional Meeting (November 8-13, 2018; Atlanta, GA) and at the Third Global Conference on Myositis (March 27, 2019; Berlin, Germany).
Collapse
|
15
|
Tory H, Zurakowski D, Kim S. Patient and physician discordance of global disease assessment in juvenile dermatomyositis: findings from the Childhood Arthritis & Rheumatology Research Alliance Legacy Registry. Pediatr Rheumatol Online J 2020; 18:5. [PMID: 31941511 PMCID: PMC6964044 DOI: 10.1186/s12969-020-0402-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/06/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Global disease activity scores (gVAS) capture patient or family (PF) and physician (MD) assessments of disease. This study sought to measure discordance between PF and MD global activity scores in juvenile dermatomyositis (JDM), and determine factors associated with discordance. METHODS Patients with JDM were included from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry (N = 563). PF and MD gVAS were assessed for discordance, defined as a ≥ 2-point difference. Factors associated with discordant gVAS were compared in univariate analysis. Multivariable regression analysis was used to identify predictors of discordance. RESULTS Almost 40% (N = 219) of PF and MD gVAS were discordant. Among discordant scores, 68% of PF rated gVAS ≥2-points above MD, which was associated with calcinosis and lower quality of life and functional scores (p < 0.01). MD gVAS rated ≥2-points above PF in 32%, which was associated with abnormal laboratory results, weakness, arthritis, rash and other skin changes, and current intravenous steroid treatment (p < 0.01). In multivariate analysis, predictors for higher PF rating included calcinosis, lower quality of life and functional scores, while predictors for higher MD rating included rash, calcinosis, nailfold capillaroscopy changes, and current intravenous steroid treatment. CONCLUSIONS Discordance between PF and MD gVAS was common in this JDM cohort. Overall, higher PF rating was associated with poorer patient reported outcome (PRO) scores, while higher MD rating was associated with poorer objective measures. This suggests PF and MD assessments of gVAS may be measuring different aspects of disease, highlighting the importance of integrating PROs into clinical practice and research.
Collapse
Affiliation(s)
- Heather Tory
- Division of Pediatric Rheumatology, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT, 06106, USA. .,Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - David Zurakowski
- Departments of Anesthesiology and Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Susan Kim
- Pediatric Rheumatology, Benioff Children’s Hospital and University of San Francisco Medical Center, San Francisco, CA USA
| | | |
Collapse
|
16
|
Abstract
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.
Collapse
Affiliation(s)
- Helene Alexanderson
- Department of NVS, Huddinge, Karolinska Institutet and Department of Medicine, Karolinska Institutet, Solna and Function Area Occupational Therapy and Physical Therapy, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| |
Collapse
|
17
|
Sigmund EE, Baete SH, Luo T, Patel K, Wang D, Rossi I, Duarte A, Bruno M, Mossa D, Femia A, Ramachandran S, Stoffel D, Babb JS, Franks AG, Bencardino J. MRI assessment of the thigh musculature in dermatomyositis and healthy subjects using diffusion tensor imaging, intravoxel incoherent motion and dynamic DTI. Eur Radiol 2018; 28:5304-5315. [DOI: 10.1007/s00330-018-5458-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/23/2018] [Accepted: 04/03/2018] [Indexed: 12/20/2022]
|
18
|
Rider LG, Aggarwal R, Machado PM, Hogrel JY, Reed AM, Christopher-Stine L, Ruperto N. Update on outcome assessment in myositis. Nat Rev Rheumatol 2018; 14:303-318. [PMID: 29651119 PMCID: PMC6702032 DOI: 10.1038/nrrheum.2018.33] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The adult and juvenile myositis syndromes, commonly referred to collectively as idiopathic inflammatory myopathies (IIMs), are systemic autoimmune diseases with the hallmarks of muscle weakness and inflammation. Validated, well-standardized measures to assess disease activity, known as core set measures, were developed by international networks of myositis researchers for use in clinical trials. Composite response criteria using weighted changes in the core set measures of disease activity were developed and validated for adult and juvenile patients with dermatomyositis and adult patients with polymyositis, with different thresholds for minimal, moderate and major improvement in adults and juveniles. Additional measures of muscle strength and function are being validated to improve content validity and sensitivity to change. A health-related quality of life measure, which incorporates patient input, is being developed for adult patients with IIM. Disease state criteria, including criteria for inactive disease and remission, are being used as secondary end points in clinical trials. MRI of muscle and immunological biomarkers are promising approaches to discriminate between disease activity and damage and might provide much-needed objective outcome measures. These advances in the assessment of outcomes for myositis treatment, along with collaborations between international networks, should facilitate further development of new therapies for patients with IIM.
Collapse
Affiliation(s)
- Lisa G. Rider
- Environmental Autoimmunity Group, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD
| | - Rohit Aggarwal
- Department of Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA
| | - Pedro M. Machado
- Centre for Rheumatology & MRC Centre for Neuromuscular Diseases, University College London, London, UK
| | | | - Ann M. Reed
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Lisa Christopher-Stine
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nicolino Ruperto
- Istituto Giannina Gaslini, Clinica Pediatria e Reumatologia, PRINTO, Genoa, Italy
| |
Collapse
|