Effects of Functional Electrical Stimulation Lower Extremity Training in Myotonic Dystrophy Type I: A Pilot Controlled Study

Should We Use the Functional Electrical Stimulation-Cycling Exercise in Clinical Practice? Physiological and Clinical Effects Systematic Review With Meta-analysis

OBJECTIVE

To examine the evidence regarding functional electrical stimulation cycling's (FES-cycling's) physiological and clinical effects.

DATA SOURCES

The study was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses protocol. PubMed, Embase, Cochrane Review, CINAHL, Scopus, Sport Discus, and Web of Science databases were used.

STUDY SELECTION

Randomized controlled trials involving FES-cycling were included. Studies that did not involve FES-cycling in the intervention group or without the control group were excluded. Two reviewers screened titles and abstracts and then conducted a blinded full-text evaluation. A third reviewer resolved the discrepancies.

DATA EXTRACTION

Meta-analysis was performed using inverse variance for continuous data, with effects measured using the mean difference and random effects analysis models. A 95% confidence interval was adopted. The significance level was set at P<.05, and trends were declared at P=.05 to ≤.10. The I2 method was used for heterogeneity analysis. The minimal clinically important difference was calculated. Methodological quality was assessed using the risk of bias tool for randomized trials. The Grading of Recommendations Assessment, Development, and Evaluation method was used for the quality of the evidence analysis.

DATA SYNTHESIS

A total of 52 studies were included. Metabolic, cardiocirculatory, ventilatory, and peripheral muscle oxygen extraction variables presented statistical (P<.05) and clinically important differences favoring FES-cycling, with moderate-to-high certainty of evidence. It also presented statistical (P<.05) and clinically important improvements in cardiorespiratory fitness, leg and total body lean mass, power, physical fitness in intensive care (moderate-to-high certainty of evidence), and torque (low certainty of evidence). It presented a trend (P=.05 to ≤.10) of improvement in muscle volume, spasticity, and mobility (low-to-moderate certainty of evidence). It showed no difference (P>.10) in 6-minute walking distance, muscle cross-sectional area, bone density, and length of intensive care unit stay (low-to-moderate certainty of evidence).

CONCLUSIONS

FES-cycling exercise is a more intense stimulus modality than other comparative therapeutic modalities and presented clinically important improvement in several clinical outcomes.

Feasibility and Safety of Applying the Functional Electrical Stimulation to Child with Facioscapulohumeral Dystrophy: A Case Report

AIMS

This study aims to investigate the feasibility and safety of short-term functional electrical stimulation (FES) training of the quadriceps femoris muscles in a child with facioscapulohumeral muscular dystrophy (FSHD).

METHODS

A 7-year-old child with FSHD received treatment due to a decrease in functional performance and difficulty climbing stairs. The child was followed up with a home-based exercise program. FES was applied twice a week during stair climbing for six weeks. Muscle activation of the quadriceps femoris was measured using superficial electromyography, muscle strength was measured with a hand-held dynamometer, and functional performance was assessed with the 6-Minute Walk and the Stair Climb Tests before and after the treatment period.

RESULTS

At the end of the treatment, there was an improvement in muscle activation. While muscle strength increased in the quadriceps femoris muscle of the non-dominant side, it remained constant on the dominant side. Functional performance test results also improved.

CONCLUSIONS

FES was a feasible and safe tool to use in our case, a child with FSHD.

Management of motor rehabilitation in individuals with muscular dystrophies. 1st Consensus Conference report from UILDM - Italian Muscular Dystrophy Association (Rome, January 25-26, 2019)

Muscular dystrophy (MD) is a group of neuromuscular diseases characterized by progressive muscle weakness due to various mutations in several genes involved in muscle structure and function. The age at onset, evolution and severity of the different forms of MD can vary and there is often impairment of motor function and activities of daily living. Although there have been important scientific advances with regard to pharmacological therapies for many forms of MD, rehabilitation management remains central to ensuring the patient's psychophysical well-being. Here we report the results of an Italian consensus conference promoted by UILDM (Unione Italiana Lotta alla Distrofia Muscolare, the Italian Muscular Dystrophy Association) in order to establish general indications and agreed protocols for motor rehabilitation of the different forms of MD.

MyomiRNAs and myostatin as physical rehabilitation biomarkers for myotonic dystrophy

MiR-1 and myostatin are markers for muscle growth and regeneration. Myostatin has a key role in the regulation of muscle mass. Myotonic dystrophy type 1(DM1) patients have a disease-specific serum miRNA profile characterized by upregulation of miR-1, miR-206, miR-133a, and miR-133b (myomiRNAs).This study aims to evaluate the possible utility of myomiRs and myostatin as biomarkers of rehabilitation efficacy in DM1, supporting clinical outcomes that are often variable and related to the patient's clinical condition.In 9 genetically proven DM1 patients, we collected biological samples before (T0) and after (T1) exercise rehabilitation training as biological measurement. We measured serum myomiRNAs by qRT-PCR and myostatin by ELISA test. The clinical outcomes measures that we utilized during a 3-6 week rehabilitation controlled aerobic exercise period were the 6-min walking test (6MWT) that increased significantly of 53.5 m (p < 0.0004) and the 10-m walk test (10MWT) that decreased of 1.38 s.We observed, after physical rehabilitation, a significant downregulation of myomiRNAs and myostatin that occurred in parallel with the improvement of clinical functional outcome measures assessed as endurance and gait speed, respectively.The modulation of biomarkers may reflect muscle regeneration and increase muscle mass after aerobic exercise. miRNAs and myostatin might be considered as circulating biomarkers of DM1 rehabilitation. The efficacy of physical rehabilitation in counteracting molecular pathways responsible for muscle atrophy and disease progression and the role of these biomarkers in DM1 and other neuromuscular diseases warrant further investigation.

Look at the cognitive deficits in patients with myotonic dystrophy type 1: an exploratory research on the effects of virtual reality

Myotonic dystrophy type 1 is a neuromuscular disease, characterized by a progressive loss of strength, muscle stiffness, and difficulty in relaxation. Myotonic dystrophy type 1 patients can present several neuropsychological deficits, as well as anxiety and mood disorders. Aim of this study is to evaluate the feasibility and the effect of virtual reality in the cognitive and behavioral recovery of myotonic dystrophy type 1 patients. Eleven patients (8 female and 3 male) underwent a specific cognitive rehabilitation program including a conventional neuropsychological treatment followed by a virtual reality neurorehabilitation training using the Virtual Reality Rehabilitation System (Khymeia, Italy). Virtual reality improved many cognitive domains, including executive function, attention, verbal and visuo-spatial abilities, as well as mood and coping strategies. Due to the high prevalence of neuropsychological symptoms in patients with myotonic dystrophy type 1, cognitive rehabilitation should enter into the framework of these patients to potentially boost cognitive and behavioral function and improve quality of life.

Strength training and aerobic exercise training for muscle disease

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Exercise in muscle disorders: what is our current state?

PURPOSE OF REVIEW

Regular exercise improves muscle and cardiovascular function, which is why exercise is used as an adjuvant treatment in myopathies. In this review, we provide an update on recent exercise studies (from 2016) performed in humans with inherited myopathy.

RECENT FINDINGS

Several studies provide new and interesting insight in the field of exercise in myopathies. A retrospective cohort study suggests that exercise may actually increase rate of disease progression in dysferlinopathy, and high intensity exercise, which is normally discouraged in muscle disorders because of the risk of muscle damage, is demonstrated to be an efficient time saving mode of exercise to train patients with facioscapulohumeral muscular dystrophy. Exoskeletons and antigravity trainers are examples of new devices, which provide an opportunity for very weak patients to train. Finally, several studies, including two randomized controlled trials, support the beneficial role of exercise as treatment of myopathy.

SUMMARY

The reviewed studies extend previous knowledge about exercise, indicating that exercise is generally safe and well tolerated, and improves functional outcomes in patients with inherited muscle disease. However, recent studies also highlight the fact that the effect of exercise differs with mode of exercise and exercise prescriptions should be disease specific.

What is known about the effects of exercise or training to reduce skeletal muscle impairments of patients with myotonic dystrophy type 1? A scoping review

BACKGROUND

Myotonic dystrophy type 1 (DM1) is a neuromuscular disease characterized by multisystemic involvements including a progressive loss of maximal muscle strength and muscle wasting. Poor lower-limb strength is an important factor explaining disrupted social participation of affected individuals. This review aims to map what is known about the effects of exercise and training programs undertaken to counteract skeletal muscle impairments in DM1 patients.

METHODS

Medline, CINAHL and EMBASE databases were searched. Regarding study eligibility, title and abstract of 704 studies followed by 45 full articles were reviewed according to the following eligibility criteria. Inclusion: (1) humans with DM1 and (2) experimental protocol relying on exercise or training. Exclusion: (1) studies that do not evaluate skeletal muscle responses or adaptations, (2) reviews covering articles already included and (3) pharmacological intervention at the same time of exercise or training program.

RESULTS

Twenty-one papers were selected for in-depth analysis. Different exercise or training protocols were found including: acute exercise, neuromuscular electric stimulation, strength training, aerobic training, balance training and multiple rehabilitation interventions. Seven studies reported clinical measurements only, five physiological parameters only and nine both types.

CONCLUSION

This scoping review offers a complete summary of the current scientific literature on the effect of exercise and training in DM1 and a framework for future studies based on the concomitant evaluation of the several outcomes in present literature. Although there were a good number of studies focusing on clinical measurements, heterogeneity between studies does not allow to identify what are the adequate training parameters to obtain exercise or training-induced positive impacts on muscle function. Scientific literature is even more scarce regarding physiological parameters, where much more research is needed to understand the underlying mechanisms of exercise response in DM1.

Cognitive behavioural therapy with optional graded exercise therapy in patients with severe fatigue with myotonic dystrophy type 1: a multicentre, single-blind, randomised trial

BACKGROUND

Myotonic dystrophy type 1 is the most common form of muscular dystrophy in adults and leads to severe fatigue, substantial physical functional impairment, and restricted social participation. In this study, we aimed to determine whether cognitive behavioural therapy optionally combined with graded exercise compared with standard care alone improved the health status of patients with myotonic dystrophy type 1.

METHODS

We did a multicentre, single-blind, randomised trial, at four neuromuscular referral centres with experience in treating patients with myotonic dystrophy type 1 located in Paris (France), Munich (Germany), Nijmegen (Netherlands), and Newcastle (UK). Eligible participants were patients aged 18 years and older with a confirmed genetic diagnosis of myotonic dystrophy type 1, who were severely fatigued (ie, a score of ≥35 on the checklist-individual strength, subscale fatigue). We randomly assigned participants (1:1) to either cognitive behavioural therapy plus standard care and optional graded exercise or standard care alone. Randomisation was done via a central web-based system, stratified by study site. Cognitive behavioural therapy focused on addressing reduced patient initiative, increasing physical activity, optimising social interaction, regulating sleep-wake patterns, coping with pain, and addressing beliefs about fatigue and myotonic dystrophy type 1. Cognitive behavioural therapy was delivered over a 10-month period in 10-14 sessions. A graded exercise module could be added to cognitive behavioural therapy in Nijmegen and Newcastle. The primary outcome was the 10-month change from baseline in scores on the DM1-Activ-c scale, a measure of capacity for activity and social participation (score range 0-100). Statistical analysis of the primary outcome included all participants for whom data were available, using mixed-effects linear regression models with baseline scores as a covariate. Safety data were presented as descriptives. This trial is registered with ClinicalTrials.gov, number NCT02118779.

FINDINGS

Between April 2, 2014, and May 29, 2015, we randomly assigned 255 patients to treatment: 128 to cognitive behavioural therapy plus standard care and 127 to standard care alone. 33 (26%) of 128 assigned to cognitive behavioural therapy also received the graded exercise module. Follow-up continued until Oct 17, 2016. The DM1-Activ-c score increased from a mean (SD) of 61·22 (17·35) points at baseline to 63·92 (17·41) at month 10 in the cognitive behavioural therapy group (adjusted mean difference 1·53, 95% CI -0·14 to 3·20), and decreased from 63·00 (17·35) to 60·79 (18·49) in the standard care group (-2·02, -4·02 to -0·01), with a mean difference between groups of 3·27 points (95% CI 0·93 to 5·62, p=0·007). 244 adverse events occurred in 65 (51%) patients in the cognitive behavioural therapy group and 155 in 63 (50%) patients in the standard care alone group, the most common of which were falls (155 events in 40 [31%] patients in the cognitive behavioural therapy group and 71 in 33 [26%] patients in the standard care alone group). 24 serious adverse events were recorded in 19 (15%) patients in the cognitive behavioural therapy group and 23 in 15 (12%) patients in the standard care alone group, the most common of which were gastrointestinal and cardiac.

INTERPRETATION

Cognitive behavioural therapy increased the capacity for activity and social participation in patients with myotonic dystrophy type 1 at 10 months. With no curative treatment and few symptomatic treatments, cognitive behavioural therapy could be considered for use in severely fatigued patients with myotonic dystrophy type 1.

FUNDING

The European Union Seventh Framework Programme.

Exciting perspectives for Translational Myology in the Abstracts of the 2018Spring PaduaMuscleDays: Giovanni Salviati Memorial - Chapter IV - Abstracts of March 17, 2018

Myologists working in Padua (Italy) were able to continue a half-century tradition of studies of skeletal muscles, that started with a research on fever, specifically if and how skeletal muscle contribute to it by burning bacterial toxin. Beside main publications in high-impact-factor journals by Padua myologists, I hope to convince readers (and myself) of the relevance of the editing Basic and Applied Myology (BAM), retitled from 2010 European Journal of Translational Myology (EJTM), of the institution of the Interdepartmental Research Center of Myology of the University of Padova (CIR-Myo), and of a long series of International Conferences organized in Euganei Hills and Padova, that is, the PaduaMuscleDays. The 2018Spring PaduaMuscleDays (2018SpPMD), were held in Euganei Hills and Padua (Italy), in March 14-17, and were dedicated to Giovanni Salviati. The main event of the “Giovanni Salviati Memorial”, was held in the Aula Guariento, Accademia Galileiana di Scienze, Lettere ed Arti of Padua to honor a beloved friend and excellent scientist 20 years after his premature passing. Using the words of Prof. Nicola Rizzuto, we all share his believe that Giovanni “will be remembered not only for his talent and originality as a biochemist, but also for his unassuming and humanistic personality, a rare quality in highly successful people like Giovanni. The best way to remember such a person is to gather pupils and colleagues, who shared with him the same scientific interests and ask them to discuss recent advances in their own fields, just as Giovanni have liked to do”. Since Giovanni’s friends sent many abstracts still influenced by their previous collaboration with him, all the Sessions of the 2018SpPMD reflect both to the research aims of Giovanni Salviati and the traditional topics of the PaduaMuscleDays, that is, basics and applications of physical, molecular and cellular strategies to maintain or recover functions of skeletal muscles. The translational researches summarized in the 2018SpPMD Abstracts are at the appropriate high level to attract endorsement of Ethical Committees, the interest of International Granting Agencies and approval for publication in top quality international journals. The abstracts of the presentations of the March 16, 2018 Padua Muscle Day and those of the remaining Posters are listed in this chapter IV. The Author Index of the 2018Spring PaduaMuscleDays follows at page 78.