A review of the evidence for the utility of physical activity monitor use in patients with idiopathic inflammatory myopathies

Few proven therapies exist for patients with idiopathic inflammatory myopathies (IIMs), partly due to the lack of reliable and valid outcome measures for assessing treatment responses. The current core set measures developed by the International Myositis Assessment and Clinical Studies group were developed to standardize assessments of disease activity and treatment effect. None of the current measures address functional improvement in muscle weakness. Therefore, supplemental measures to more objectively assess physical activity levels and fatiguability in free-living settings are needed to assess disease activity more comprehensively. Validated physical activity monitors (PAMs) have the potential to serve as an objective functional outcome measure in clinical trials and observational studies. This review examines the current evidence for the use of body-worn PAMs in clinical settings with IIM patients. A practical overview of methods for PAM use in clinical patient populations (including measurement details and data processing) that focuses on IIM patients is also presented.

A Longitudinal, Observational, and Descriptive Study About Benefits of Craniosacral Therapy in Child Neurodevelopment

INTRODUCTION

Coordination and balance are progressive motor skills that guide physical therapists in recognizing abnormal patterns during childish neurodevelopment. We aim to compare the efficacy of craniosacral therapy (CST) together with balance and coordination therapy (BCT) vs traditional BCT during neurodevelopment.

METHODS

Longitudinal, observational, and descriptive study with 111 apparently healthy children divided into 4 groups: craniosacral-balance and coordination therapy placebo (CS-BCTp), craniosacral-balance and coordination therapy (CS-BCT), balance and coordination therapy placebo (BCTp), and balance and coordination therapy (BCT).

RESULTS

Significant changes have been observed with the CS-BCT from the fourth session. Balance and coordination therapy is less effective. There are differences in the Battelle Scale at the beginning and after the 7 therapy sessions in the CS-BCT group.

CONCLUSIONS

The study shows that CST together with balance and coordination exercises can be a more effective and faster treatment to improve these motor skills, correcting and improving alterations during child neurodevelopment.

Juvenile idiopathic inflammatory myositis: an update on pathophysiology and clinical care

The childhood-onset or juvenile idiopathic inflammatory myopathies (JIIMs) are a heterogenous group of rare and serious autoimmune diseases of children and young people that predominantly affect the muscles and skin but can also involve other organs, including the lungs, gut, joints, heart and central nervous system. Different myositis-specific autoantibodies have been identified that are associated with different muscle biopsy features, as well as with different clinical characteristics, prognoses and treatment responses. Thus, myositis-specific autoantibodies can be used to subset JIIMs into sub-phenotypes; some of these sub-phenotypes parallel disease seen in adults, whereas others are distinct from adult-onset idiopathic inflammatory myopathies. Although treatments and management have much improved over the past decade, evidence is still lacking for many of the current treatments and few validated prognostic biomarkers are available with which to predict response to treatment, comorbidities (such as calcinosis) or outcome. Emerging data on the pathogenesis of the JIIMs are leading to proposals for new trials and tools for monitoring disease.

Exercise in myositis: What is important, the prescription or the person?

Our aim for this narrative review was to undertake a search of studies into exercise for people living with Idiopathic Inflammatory myopathies (IIM). We explored the strength of existing evidence with a particular consideration for the implications for people living with IIM and what is important to them. The search strategy from the 2021 Cochrane Physical Activity review in neuromuscular disease was used, and we selected articles that included people with IIM, including Dermatomyositis (DM), Inclusion Body Myositis (IBM), Immune Mediated Necrotising Myopathy (IMNM) [also known as necrotizing autoimmune myopathy (NAM)], and Polymyositis (PM). 2967 records were screened and 16 were included in this review. Safety of exercise was demonstrated in nine articles, using a range of measures of disease activity, serum creatine kinase, indicators of inflammation, pain, or fatigue. Two studies that took muscle biopsies showed no evidence of increased inflammation. Aerobic exercise protocols were used in 8 studies across conditions and demonstrated improvements in cardiorespiratory fitness or exercise capacity. Six studies of strength training observed improvements in muscle function, with two studies reporting muscle biopsy results of amplified immune response and up regulation of genes related to recycling of damaged proteins. Nine of 13 studies that measures functional outcomes showed significant improvements, and evidence for behaviour change was observed in a study of a self-management intervention. The evidence of safety and effect of training is reassuring and welcome, and we now need to explore how we support people to incorporate exercise and physical activity longer term into active lifestyles.

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

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

Juvenile Dermatomyositis

Die juvenile Dermatomyositis (JDM) ist die häufigste chronische entzündliche Myopathie des Kindesalters. In dieser Übersicht soll der aktuelle Kenntnisstand hinsichtlich der Diagnostik, Behandlung und Überwachung der JDM dargestellt werden. So liegen häufig myositis-spezifische Antikörper vor, die mit klinischen Phänotypen und dem Verlauf der Erkrankung korrelieren. Typ I Interferone spielen eine wichtige Rolle in der Pathogenese der Erkrankung. Möglicherweise kann diese Beobachtung in der Zukunft zu gezielten Therapien führen. Da langfristig schwerwiegende Komplikationen, wie z. B. Kalzinosen oder Lipodystrophie, drohen, besonders bei auf Dauer unzureichend kontrollierter Erkrankung, ist eine möglichst rasche und effektive Behandlung anzustreben. Zu diesem Zweck sollte eine intensive Remissionsinduktionstherapie, gefolgt von einer zielgerichteten Therapie angestrebt werden. Verschiedene validierte Messinstrumente stehen zur Verfügung, um den Verlauf der Erkrankung zu beurteilen. Die Pro-KIND-Initiative der Gesellschaft für Kinder- und Jugendrheumatologie hat Praxis- und Konsens-basiert in Deutschland sowohl eine diagnostische als auch eine Treat-to-Target-Behandlungsstrategie entwickelt. Im Rahmen nationaler und internationaler Kollaborationen soll sich die Behandlung der JDM in der Zukunft weiter verbessern.

Cardiopulmonary exercise testing in neuromuscular disease: a systematic review

INTRODUCTION

Cardiopulmonary exercise testing (CPET) is increasingly used to determine aerobic fitness in health and disability conditions. Patients with neuromuscular diseases (NMDs) often present with symptoms of cardiac and/or skeletal muscle dysfunction and fatigue that might impede the ability to deliver maximal cardiopulmonary effort. Although an increasing number of studies report on NMDs' physical fitness, the applicability of CPET remains largely unknown.

AREAS COVERED

This systematic review synthesized evidence about the quality and feasibility of CPET in NMDs and patient's aerobic fitness. The review followed the PRISMA guidelines (PROSPERO number CRD42020211068). Between September and October 2020 one independent reviewer searched the PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science databases. Excluding reviews and protocol description articles without baseline data, all study designs using CPET to assess adult or pediatric patients with NMDs were included. The methodological quality was assessed according to the American Thoracic Society/American College of Chest Physicians (ATS/ACCP) recommendations.

EXPERT OPINION

CPET is feasible for ambulatory patients with NMDs when their functional level and the exercise modality are taken into account. However, there is still a vast potential for standardizing and designing disease-specific CPET protocols for patients with NMDs. Moreover, future studies are urged to follow the ATS/ACCP recommendations.

Home-based exercise program for adolescents with juvenile dermatomyositis quarantined during COVID-19 pandemic: a mixed methods study

BACKGROUND

Exercise has been suggested to prevent deterioration of health-related quality of life (HRQL) and overall health in pediatric rheumatologic diseases during the COVID-19 pandemic. Herein we describe the effects of a 12-week, home-based, exercise program on overall health and quality of life among quarantined patients with juvenile dermatomyositis (JDM).

METHOD

This prospective, quasi-experimental, mixed methods (qualitative and quantitative) study was conducted between July and December 2020, during the most restricted period of COVID-19 pandemic in Brazil. The home-based exercise program consisted of a 12-week, three-times-a-week, aerobic and strengthening (bodyweight) training program. Qualitative data were systematically evaluated. Strengths and Difficulties Questionnaire (SDQ), Pediatric Quality of Life Inventory (PedsQOL) and Pittsburgh Sleep Quality Index (PSQI) evaluate symptoms of mental health disorder, HRQL, and quality of sleep.

FINDINGS

11 patients (out of 27) met the inclusion criteria (91% female; mean ± SD age: 13.5 ± 3.2 years). Adherence to the intervention was 72.6%. Barriers to exercise involved poor internet connectivity, excessive weekly sessions, and other commitments. Even though not statistically significant, Self-report SDQ subscales Total Difficulties Score, Emotional Problems Score, and PedsQOL School Functioning Score improved after intervention (- 2.4; 95%confidence interval [CI] -5.1; 0.2, p = 0.06; - 1.0; 95%CI -2.2; 0.2, p = 0.09 and; 11.7; 95%CI -2.5; 25.8, p = 0.09, respectively). Remaining SDQ subscales were not altered. Six themes emerged from patients' and parents' comments (qualitative results). Patients engaged in exercise reported other health-related benefits including increased motivation, concentration and strength.

INTERPRETATION

A home-based exercise program was associated with qualitative perceptions of improvements in overall health and HRQL by quarantined adolescents with JDM during COVID-19 pandemic. Lessons from this trial may help developing interventions focused on tackling physical inactivity in JDM.

Physical activity in idiopathic inflammatory myopathies: two intervention proposals based on literature review

Idiopathic inflammatory myopathies (IIM) are rare diseases affecting skeletal muscles and leading to progressive muscle weakness and disability. Thanks to the better understanding of their pathogenesis, the management of IIM has been noteworthily implemented in recent years. Current therapeutic strategies include pharmacological and non-pharmacological interventions, among which physical exercise represents a useful option, able to ameliorate disease activity without worsening muscle inflammation. The aim of this narrative review is therefore to provide an updated overview of the benefits of physical exercise in patients with IIM and to suggest plausible training programs to be applied in patients with dermatomyositis, polymyositis, necrotizing myopathy, and inclusion body myositis. In this regard, a combined strategy mixing aerobic and resistance exercises could positively affect the pro-inflammatory and metabolic pathways occurring in skeletal muscles, while promoting muscle fiber regeneration and repair.

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

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

Reducing fatigue in pediatric rheumatic conditions: a systematic review

BACKGROUND

Although fatigue is a prevalent distressing symptom in children and adolescents with Pediatric Rheumatic Conditions (PRCs), intervention studies designed for reducing fatigue in PRCs are limited.

AIM

To systematically review evidence regarding the efficacy of interventions intended to reduce fatigue in patients with PRCs.

METHODS

Comprehensive electronic searches were performed in PubMed/ MEDLINE, Embase, Web of Science and Cinahl. The risk of bias was assessed using the 'Revised Cochrane risk-of-bias tool for randomized trials' and 'Quality Assessment Tool for Before-After Studies With No Control Group' for respectively studies with and without a control group.

RESULTS

Ten out of 418 studies were included with a total of 240 participants (age range 5-23 years). Interventions included land-based and aquatic-based exercise therapy, prednisolone, vitamin-D and creatine supplementation, psychological therapy and a transition program into an adult rheumatology program. Fatigue was assessed with self-reported questionnaires in all included studies. Land-based exercise therapy was effective in one pre-post intervention study, whereas not effective in two randomized controlled trials. Aquatic-based exercise therapy was found more effective than land-based exercise therapy. Two placebo-controlled studies showed a significant positive effect in reducing subjective fatigue with prednisolone and vitamin-D. Creatine was not found effective. Cognitive therapy was effective in one pre-post intervention study, while one RCT did not show an effect in reducing fatigue. A transition program based on health education showed a small reducing effect, however, it was not clear if this was a significant effect. Six studies showed a high risk of bias, three studies a moderate risk, and one study had a low risk of bias.

CONCLUSIONS

Insufficient evidence is provided to substantiate the efficacy of current interventions to reduce fatigue in PRCs. The low number of studies, non-comparable interventions, risk of bias, and inconclusive outcomes of the included studies denote future research should focus on intervention studies aimed at the treatment of fatigue in children and adolescents with PRCs. Identification of possible underlying biological and psychosocial mechanisms as possible treatment targets to reduce complaints of fatigue in children and adolescents with PRCs is warranted.

Physical activity and exercise in patients with pediatric rheumatic disease: A systematic search and review

Childhood rheumatic diseases are a group of diseases that can affect many organs and systems, resulting in pain, joint stiffness, muscle atrophy and weakness. Physical inactivity has been reported in many childhood rheumatic diseases. There are many studies in the literature comparing the effectiveness of exercise programs in children with juvenile idiopathic arthritis. Exercise and physical activity are considered major parts of the treatment of children with rheumatic disease. The aim of this review is to systematically present studies on physical activity and exercise programs in children with rheumatism from the last 5 years. An internet-based search of three databases-PubMed, PEDro and Medline- was conducted to find relevant studies. Two reviewers individually identified studies on the basis of their title, abstract or full text-as necessary-to determine their eligibility. Differences of opinion between the two examiners were resolved by discussion. Scientific studies of children with different rheumatic diagnoses have shown that physical activity and exercise have a significant effect on reducing the symptoms of the disease. However, the duration, frequency, method and evaluation of the exercises are still being discussed in the literature.

Systematic review of physical exercise for patients with idiopathic inflammatory myopathies

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

Efetividade do treinamento físico sobre o desempenho físico em pacientes com dermatomiosite e polimiosite: revisão sistemática e metanálise

RESUMO Este estudo teve por objetivo avaliar o impacto do treinamento físico sobre o desempenho físico em pacientes com dermatomiosite e polimiosite. Para tanto, uma revisão sistemática e metanálise foi conduzida de acordo com as diretrizes do PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A pesquisa bibliográfica foi realizada nas seguintes bases de dados: PubMed/MEDLINE e Web of Science, utilizando combinações das seguintes palavras-chave em inglês: dermatomyositis OR polymyositis OR myositis AND exercise OR physical exercise OR physical therapy OR aerobic exercise OR endurance exercise OR resistance exercise. Foram incluídos estudos que atenderam aos seguintes critérios: (1) os participantes apresentavam diagnóstico de dermatomiosite ou polimiosite; (2) os pacientes foram submetidos a um protocolo de treinamento físico; (3) o desempenho físico foi mensurado antes e após o protocolo de treinamento físico. Um total de 14 artigos foram selecionados para inclusão na revisão sistemática e 10 artigos foram selecionados para inclusão na metanálise. Os resultados demonstram que o treinamento físico é eficaz em aumentar o desempenho físico global nos pacientes com dermatomiosite e polimiosite (tamanho do efeito: 0,72; IC 95% 0,55; 0,89). Além disso, foi demonstrado também que tanto as variáveis de desempenho aeróbio (tamanho do efeito: 0,88; IC 95% 0,54; 1,21), quanto as variáveis de desempenho resistido (tamanho do efeito: 0,64; IC 95% 0,43; 0,85) são beneficiadas com o treinamento físico nesses pacientes. Conclui-se que o treinamento físico apresentou um efeito benéfico significativo sobre o desempenho físico global, aeróbio e resistido em pacientes com dermatomiosite e polimiosite.

Sticking to It: A Scoping Review of Adherence to Exercise Therapy Interventions in Children and Adolescents With Musculoskeletal Conditions

OBJECTIVE

To identify and categorize barriers, facilitators, and strategies to boost exercise therapy adherence in youth with musculoskeletal conditions to inform research and clinical practice.

STUDY DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, CINAHL, SPORTDiscus, Scopus, PEDro, and ProQuest from inception to October 1, 2019.

STUDY SELECTION CRITERIA

Studies written in English, with original data featuring an adherence barrier, facilitator, or boosting strategy for exercise therapy in youth (age, 19 years or younger) with musculoskeletal conditions, were included.

DATA SYNTHESIS

Arksey and O'Malley's framework and the PRISMA Extension for Scoping Reviews guided data synthesis. Study quality was assessed with the Mixed Methods Appraisal Tool. Descriptive consolidation included study and sample characteristics, exercise therapy details, and adherence measurement specifics. Inductive thematic analysis of adherence barriers, facilitators, and boosting strategies followed Braun and Clarke's 6-step guide.

RESULTS

Of 5705 potentially relevant records, 41 studies, representing 2020 participants (64% girls; age range, 2-19 years) with 12 different musculoskeletal conditions and multiple exercise therapy interventions, were included. Despite poor reporting of adherence concepts, time constraints, physical environment (eg, location), and negative exercise experiences were commonly identified barriers. Social support and positive exercise experiences were frequently identified facilitators. Reinforcement, exercise program modification, and education were recurring boosting strategies, despite being infrequent barriers or facilitators.

CONCLUSION

A diversity of barriers to and facilitators of exercise therapy for youth with musculoskeletal conditions were identified. Efforts to link adherence-boosting strategies to an individual's needs should be considered. Making exercise enjoyable, social, and convenient may be important to maximizing adherence in this population. J Orthop Sports Phys Ther 2020;50(9):503-515. Epub 1 Aug 2020. doi:10.2519/jospt.2020.9715.

Strength training and aerobic exercise training for muscle disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

A review of accelerometer-derived physical activity in the idiopathic inflammatory myopathies

Background

The idiopathic inflammatory myopathies (IIMs) are a group of rare conditions characterised by muscle inflammation (myositis). Accurate disease activity assessment is vital in both clinical and research settings, however, current available methods lack ability to quantify associated variation of physical activity, an important consequence of myositis.

This study aims to review studies that have collected accelerometer-derived physical activity data in IIM populations, and to investigate if these studies identified associations between physical and myositis disease activity.

Methods

A narrative review was conducted to identify original articles that have collected accelerometer-derived physical activity data in IIM populations. The following databases were searched from February 2000 until February 2019: Medline via PubMed, Embase via OVID and Scopus.

Results

Of the 297 publications screened, eight studies describing accelerometer use in 181 IIM cases were identified. Seven out of the eight studies investigated juvenile dermatomyositis (JDM) populations and only one reported on an adult-onset population. Population sizes, disease duration, accelerometer devices used, body placement sites, and study duration varied between each study.

Accelerometer-derived physical activity levels were reduced in IIM cohorts, compared to healthy controls, and studies reported improvement of physical activity levels following exercise programme interventions, thus demonstrating efficacy.

Higher levels of accelerometer-derived physical activity measurements were associated with shorter JDM disease duration, current glucocorticoid use and lower serum creatine kinase. However, no clear association between muscle strength and accelerometer-derived physical activity measures was identified.

Conclusions

The use of accelerometer-derived physical activity in IIM research is in its infancy. Whilst knowledge is currently limited to small studies, the opportunities are promising and future research in this area has the potential to improve disease activity assessment for clinical and research applications.

Multispecialty approach for improving outcomes in juvenile dermatomyositis

Juvenile dermatomyositis (JDM) is a pediatric rheumatic disease characterized by inflammation of the muscle and skin. Prognosis of JDM in children has improved in general owing to medical progress; however, pathogenesis and management of JDM in children and prognosis in refractory JDM remain challenging. For elucidation of JDM pathophysiology and establishment of appropriate treatment for JDM, pediatric rheumatologists need to adopt a multispecialty approach that involves experts in genetics, immunology, pathology, musculoskeletal medicine, dermatology, pulmonology, cardiology, hematology, gastroenterology, endocrinology, ophthalmology, psychology, radiology, pharmacology, physiotherapy, surgery, preventive medicine, and adult rheumatology. Such collaborations will potentially lead to improved outcomes in children with JDM.

Cardiorespiratory fitness in long-term juvenile dermatomyositis: a controlled, cross-sectional study of active/inactive disease

OBJECTIVES

To compare cardiorespiratory fitness (CRF) expressed as maximal oxygen uptake (VO2max) between patients with long-term JDM and controls and between patients with active and inactive disease, as well as to explore exercise limiting factors and associations between CRF and disease variables.

METHODS

JDM patients (n = 45) and age- and gender-matched controls (n = 45) performed a cardiopulmonary exercise test (CPET) on a treadmill until exhaustion. Physical activity was measured by accelerometers. Disease activity, damage and muscle strength/function were assessed by validated tools. Clinically inactive disease was defined according to PRINTO criteria.

RESULTS

The mean disease duration was 20.8 (s.d. 11.9) years and 29/45 (64%) patients had inactive disease. A low VO2max was found in 27% of patients vs 4% of controls (P = 0.006). The mean VO2max and maximal ventilation (VEmax) were lower in patients with active and inactive disease compared with controls. Patients with active disease also had lower maximal voluntary ventilation (MVV) compared with controls and lower VEmax and MVV compared with those with inactive disease. Patients with inactive disease had lower physical activity levels compared with controls. VO2max correlated negatively with disease damage in patients with inactive disease and positively with muscle strength/function in patients with active disease.

CONCLUSION

CRF was lower in JDM patients, both with active and inactive disease, compared with controls after a mean 20 years disease duration. Cardiopulmonary exercise test results suggested different limiting factors contributing to the reduced CRF according to disease activity, including deconditioning in inactive disease and reduced ventilatory capacity in active disease. Further research is needed to verify this.

Update on the clinical management of juvenile dermatomyositis

INTRODUCTION

Juvenile dermatomyositis (JDM) is a rare, chronic autoimmune illness with primary features of symmetric, proximal muscle weakness and involvement of the skin with a number of identifiable rashes. Evidence to support treatment decisions is limited, given the paucity of clinical trials. Consensus based methods, informed by available data, play an important role in treatment recommendations. Areas covered: This review focuses on evidence and consensus opinion regarding therapeutic options in JDM and identifies gaps where future research is needed. Expert commentary: The combination of trial evidence (as limited as it is) and consensus opinion support standard initial management for children with JDM to consist of high-dose corticosteroids, either intravenous or oral, and methotrexate. Several other agents have preliminary support, either through clinical trials or case series for their use in patients who either fail to respond adequately, have severe disease or have contraindications to standard initial therapy. One of the important goals of management in JDM will be to reduce the corticosteroid exposure experienced by patients. To meet this goal, progress in a number of key areas is needed: increased international collaboration, advances in study design and increased translational research.

Juvenile Idiopathic Inflammatory Myopathies

The juvenile idiopathic inflammatory myopathies (JIIM) are a group of rare, chronic, autoimmune illnesses that affect muscle and, to a lesser extent, skin. The presence of new-onset weakness and, in juvenile dermatomyositis, typical rahes, should lead to consideration of these diagnoses. Careful evaluation to exclude alternative diagnoses is needed. Investigations include a variety of blood tests, imaging, and possibly muscle biopsy. Validated clinical assessments are available for monitoring. Standard treatment includes corticosteroids and methotrexate and often extends beyond 1 year. Outcomes are generally good, but disease persistence remains problematic. Early involvement of providers with expertise in JIIM is essential.

Trajectories of cardiorespiratory fitness in patients with juvenile dermatomyositis

Objectives

Previous research demonstrated decreased cardiorespiratory fitness (CRF) in patients with JDM during active disease and remission. However, longitudinal data regarding trajectories of CRF are currently lacking. The objective of this study was to determine trajectories of CRF in patients with both monocyclic and chronic JDM, and to identify potential predictors of these trajectories.

Methods

Thirty-six patients with JDM [median age (interquartile range) at diagnosis: 8.3 (6.3-15.4) years] treated in our paediatric rheumatology outpatient clinic were included. All patients performed multiple cardiopulmonary exercise tests between 2003 and 2016. Relevant CRF parameters were analysed, including peak oxygen uptake, maximal workload, mechanical efficacy and oxygen uptake at ventilatory anaerobic threshold. We analysed trajectories up to 10 years after diagnosis and determined predictors of CRF outcome parameters by multilevel analyses.

Results

Trajectories demonstrated significant declines in CRF during the active phase of the disease with subsequent improvement in CRF during the initial years after diagnosis. However, hereafter no further improvements, and even a decrease, in CRF were observed over time in both monocyclic and chronic subtypes of JDM. We found that a longer disease duration, younger age of onset and higher prednisone dose negatively influence CRF.

Conclusion

Patients with both monocyclic and chronic JDM show decreases in long-term CRF trajectories. Longer disease duration, younger age of onset and higher prednisone dose negatively influence CRF. This study stresses the need for regular evaluation of CRF and implementation of (exercise) interventions to improve CRF in patients with JDM, even in monocyclic patients.