Progressive resisted exercise program combined with aerobic exercise on osteoporotic systemic lupus erythematous patients: a prospective randomized controlled trial

PURPOSE

To investigate the effect of progressive resisted exercise (PRE) and aerobic exercise (AE) on bone mineral density (BMD), muscular strength, exercise capacity, and health related quality of life (HRQoL) in patients with osteoporotic systemic lupus erythematous (SLE).

METHODS

This study was a single blinded randomized controlled trail. Eighty SLE participants, 30-50 years old, were randomly allocated into four equal groups. Group A received PRE and AE, group B received AE, group C received PRE, and group D received traditional medical treatment only. The intervention was implemented three days/week for six months. BMD was measured by Dual Energy X-ray Absorptiometry, muscle strength was measured by an isokinetic device, exercise capacity was measured by 6-min walk test, and HRQoL was measured by short form 36(SF-36). Every outcome was assessed at baseline, six months, and nine months.

RESULTS

There were statistically significant differences among the groups in knee muscle strength, exercise capacity, and HRQol after 6 months (p < 0.05) in favor of the combined group. BMD increased significantly in the combined and PRE groups compared to the AE and control groups (p < 0.05).

CONCLUSION

PRE combined with AE were more beneficial than either exercise alone in improving knee muscle strength, exercise capacity, and HRQoL.

Impaired hand function and performance in activities of daily living in systemic lupus erythematosus, even in patients achieving lupus low disease activity state (LLDAS)

Objective

The aim was to examine hand function and performance in activities of daily living (ADL) in patients with SLE vs healthy controls, and any associations with demographic and disease-related characteristics.

Methods

Hand function (grip strength, pinch strength and dexterity) and ADL performance were evaluated in 240 patients with SLE and 122 age- and biological sex-matched healthy controls. Grip strength, pinch strength and dexterity were measured by Jamar dynamometer, pinch gauge and Purdue pegboard test, respectively. Self-reported ADL performance was assessed by disabilities of the arm, shoulder and hand (DASH) and HAQ. Regression analysis was performed to assess the determinants of hand dysfunction.

Results

All hand function and ADL performance variables were significantly impaired in the entire SLE cohort and the subgroup of patients achieving lupus low disease activity state (LLDAS; n = 157) compared with healthy subjects (P < 0.05). Joint pain, often underestimated in SLE, was the major determinant of hand function and ADL performance in multiple regression models. In addition, age was correlated with grip strength and Purdue scores, gender with grip strength, arthritis with DASH and HAQ, and use of immunosuppressives with DASH, HAQ and grip strength. Likewise, in patients in LLDAS, painful joints were correlated with DASH and HAQ, age with grip strength and Purdue (P < 0.001), gender with grip strength, and immunosuppressives with HAQ and grip strength.

Conclusion

Hand function and performance of daily activities are significantly impaired in SLE, even in patients who achieve LLDAS, suggesting the need for their evaluation and management in clinical practice.

Hand-held dynamometry for assessment of muscle strength in patients with inflammatory myopathies

OBJECTIVES

Muscle weakness in idiopathic inflammatory myopathies (IIMs) is conventionally assessed using manual muscle testing (MMT). However, more objective tools must be developed to accurately and reliably quantify muscle strength in myositis patients. Hand-held dynamometry (HHD) is a quantitative, portable device with reported reliability in neuromuscular disorders. Our aim was to assess the reliability, validity and responsiveness of HHD in myositis.

METHODS

Myositis patients [DM, necrotizing myopathy (NM), PM and anti-synthetase syndrome] evaluated at the University of Pittsburgh myositis centre were prospectively enrolled. Each patient was assessed at 0, 3 and 6 months for validated outcome measures of myositis disease activity and physical function. At each visit, muscle strength was assessed using both MMT and HHD (Micro FET2, Hoggan Health Industries, Draper, UT, USA). The reliability, validity and responsiveness of the HHD was assessed using standard statistical methods.

RESULTS

Fifty IIM patients (60% female; mean age 51.6 years; 6 PM, 9 NM, 24 DM and 11 anti-synthetase syndrome) were enrolled. HHD showed strong test-retest intrarater reliability (r = 0.96) and interrater reliability (r = 0.98). HHD correlated significantly with the MMT score (r = 0.48, P = 0.0006) and myositis disease activity and functional measures. Longitudinal analysis showed a significant and strong association between the HHD and MMT as well as 2016 ACR/EULAR myositis response criteria (r = 0.8, P < 0.0001) demonstrating responsiveness. The mean effect size and standardized response mean of HHD was large: 0.95 and 1.03, respectively. MMT had a high ceiling effect compared with HHD.

CONCLUSION

HHD demonstrated strong reliability, construct validity and responsiveness in myositis patients. External validation studies are required to confirm these findings.

Involvement of the wrist and hand joints and tendons in an Egyptian systemic lupus erythematosus cohort

Background

Systemic lupus erythematosus (SLE) patients often suffer hand function limitations even in the absence of symptoms related to joint or tendon disorders. Recent researches reported the presence of ultrasonographic (US) subclinical synovitis and tendon involvement in asymptomatic patients. We aimed to assess US patterns in SLE patients and determine their relationship with clinical assessment, disease activity and hand functional status using handheld dynamometry.

Results

We assessed 30 SLE patients (60 hands) using US; 21 (70%) patient had synovial hypertrophy, 8 (26%) showed a power Doppler (PD) activity, 6 (20%) had erosions and 11 (36.6%) had tendon US abnormality. Both patients with hand arthralgia/arthritis (symptomatic) and patients without arthralgia/arthritis (asymptomatic) had a statistically insignificant difference regarding the global synovitis score (p= 0.2) and disease activity (p= 0.3). However, the symptomatic group had a significantly increased number of joints with effusion (p= 0.04) and tendons involved (p= 0.04). The mean grip strength had a significant negative correlation with SLEDAI-2 K score (rs = − 0.4,p= 0.02) in the total patient group. In the asymptomatic group, a negative correlation was found between both mean grip (rs = − 0.5,p= 0.04) and pinch strength (rs = − 0.6,p= 0.01) with PD index, and mean pinch strength with the Jaccoud’s arthropathy index (rs = − 0.49,p= 0.05).

Conclusions

SLE patients may have higher subclinical synovitis, erosions and tendon involvement than expected, which may in turn reduce hand grip and pinch strength. Disease activity may also have a negative impact on the hand grip functional strength.

Test-retest reliability and measurement errors of grip strength test in patients with traumatic injuries in the upper extremity: a cross-sectional study

BACKGROUND

Grip strength (GS) test is an essential aspect of clinical practice with patients with upper extremity injuries. The random error of GS test was hypothesized to be proportional to the level of GS. The purpose of the current study was to estimate a precise range for the measurement error of GS in patients following traumatic injuries in the upper extremity.

METHODS

Following traumatic injuries in the upper extremity, 109 participants completed GS tests twice one weekend apart. The Bland-Altman plot analysis was adopted to estimate the precise limits of agreement with 95% confidence interval (CI).

RESULTS

The mean of three consecutive trials had a higher intraclass correlation coefficient of 0.974 (95% CI = 0.963, 0.982) than those of one trial and the mean of the first two trials in injured upper extremities. When GS was ≤20 kg, the upper limit of agreement with 95% CI was estimated as (0.41 × average GS + 1.24), while the lower limit was estimated as (- 0.41 × average GS - 0.39). A table of one-to-one matches between averaged GS ≤ 20 kg and transformed ranges of random errors with 95% certainty was created; the standard error of measurement and minimal detectable change with 95% certainty of GS test were 1.8 and 4.9 kg, respectively. When GS was > 20 kg, the width of agreement with 95% CI ranged from - 4.9 to 5.3 kg, and the standard error of measurement and minimal detectable change with 95% certainty were 1.8 and 5.1 kg, respectively.

CONCLUSION

The one-to-one match table can be considered as a practical tool to judge a change in GS score is real or due to random errors when it is ≤20 kg.

Reliability of the hand held dynamometer in measuring muscle strength in people with interstitial lung disease

OBJECTIVE

To evaluate the inter-rater and intra-rater reliability of the hand held dynamometer in measuring muscle strength in people with interstitial lung disease (ILD).

DESIGN

Test retest reliability of hand-held dynamometry for elbow flexor and knee extensor strength between two independent raters and two testing sessions.

SETTING

Physiotherapy department within a tertiary hospital.

PARTICIPANTS

Thirty participants with ILD of varying aetiology were included. Twenty participants completed the inter-rater reliability protocol (10 idiopathic pulmonary fibrosis, mean (SD) age 73 (10) years, 11 male) and 21 participants completed the intra-rater reliability protocol (10 idiopathic pulmonary fibrosis, mean age 71 (10) years, 11 male).

MAIN OUTCOME MEASURES

Mean muscle strength (kg). Agreement between the two raters and testing sessions was analyzed using Bland-Altman plots and reliability was estimated using intraclass correlation coefficients (ICC).

RESULTS

For elbow flexor strength there was a mean difference between raters of -0.6kg (limits of agreement (LOA) -5.6 to 4.4kg) and within raters of -0.3kg (LOA -2.8 to 2.3kg). The ICCs were 0.95 and 0.98, respectively. For knee extensor strength there was a mean difference between raters of -1.5kg (LOA -6.9 to 3.9kg) and within raters of -0.7kg (LOA -3.9 to 2.4kg). The ICCs were 0.95 and 0.97, respectively.

CONCLUSIONS

Hand-held dynamometry is reliable in measuring elbow flexor and knee extensor strength in people with ILD.

Muscle Strength and Changes in Physical Function in Women With Systemic Lupus Erythematosus

OBJECTIVE

Cross-sectional studies have observed that muscle weakness is associated with worse physical function among women with systemic lupus erythematosus (SLE). The present study examines whether reduced upper and lower extremity muscle strength predict declines in function over time among adult women with SLE.

METHODS

One hundred forty-six women from a longitudinal SLE cohort participated in the study. All measures were collected during in-person research visits approximately 2 years apart. Upper extremity muscle strength was assessed by grip strength. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion. Physical function was assessed using the Short Physical Performance Battery (SPPB). Regression analyses modeled associations of baseline upper and lower extremity muscle strength with followup SPPB scores controlling for baseline SPPB, age, SLE duration, SLE disease activity (Systemic Lupus Activity Questionnaire), physical activity level, prednisone use, body composition, and depression. Secondary analyses tested whether associations of baseline muscle strength with followup in SPPB scores differed between intervals of varying baseline muscle strength.

RESULTS

Lower extremity muscle strength strongly predicted changes over 2 years in physical function even when controlling for covariates. The association of reduced lower extremity muscle strength with reduced physical function in the future was greatest among the weakest women.

CONCLUSION

Reduced lower extremity muscle strength predicted clinically significant declines in physical function, especially among the weakest women. Future studies should test whether therapies that promote preservation of lower extremity muscle strength may prevent declines in function among women with SLE.

Persistent Pain Among Older Adults Discharged Home From the Emergency Department After Motor Vehicle Crash: A Prospective Cohort Study

STUDY OBJECTIVE

Motor vehicle crashes are the second most common form of trauma among older adults. We seek to describe the incidence, risk factors, and consequences of persistent pain among older adults evaluated in the emergency department (ED) after a motor vehicle crash.

METHODS

We conducted a prospective longitudinal study of patients aged 65 years or older who presented to one of 8 EDs after motor vehicle crash between June 2011 and June 2014 and were discharged home after evaluation. ED evaluation was done through in-person interview; follow-up data were obtained through mail-in survey or telephone call. Pain severity (0 to 10 scale) overall and for 15 parts of the body were assessed at each follow-up point. Principal component analysis was used to assess the dimensionality of the locations of pain data. Participants reporting pain severity greater than or equal to 4 attributed to the motor vehicle crash at 6 months were defined as having persistent pain.

RESULTS

Of the 161 participants, 72% reported moderate to severe pain at the ED evaluation. At 6 months, 26% of participants reported moderate to severe motor vehicle crash-related pain. ED characteristics associated with persistent pain included acute pain severity; pain located in the head, neck, and jaw or lower back and legs; poor self-rated health; less formal education; pre-motor vehicle crash depressive symptoms; and patient's expected time to physical recovery more than 30 days. Compared with individuals without persistent pain, those with persistent pain were substantially more likely at 6-month follow-up to have also experienced a decline in their capacity for physical function (73% versus 36%; difference=37%; 95% confidence interval [CI] 19% to 52%), a new difficulty with activities of daily living (42% versus 17%; difference=26%; 95% CI 10% to 43%), a 1-point or more reduction in overall self-rated health on a 5-point scale (54% versus 30%; difference=24%; 95% CI 6% to 41%), and a change in their living situation to obtain additional help (23% versus 8%; difference=15%; 95% CI 2% to 31%).

CONCLUSION

Among older adults discharged home from the ED post-evaluation after a motor vehicle crash, persistent pain is common and frequently associated with functional decline and disability.

Muscle strength, muscle mass, and physical disability in women with systemic lupus erythematosus

OBJECTIVE

Data describing relationships between muscle strength, muscle mass, and physical disability among individuals with systemic lupus erythematosus (SLE) are limited. The present study examines the relationship of muscle strength and muscle mass with physical disability among adult women with SLE.

METHODS

A total of 146 women from a longitudinal SLE cohort participated in the study. All measures were collected during an in-person research visit. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion and by chair-stand time. Total lean body mass, appendicular lean mass, and fat mass (kg/m(2) ) were measured by whole-body dual x-ray absorptiometry. Self-reported physical disability was assessed using the Short Form 36 health survey (SF-36) physical functioning subscale, and the Valued Life Activities (VLA) disability scale. Spearman's rank correlation coefficients tested the correlations between muscle strength, muscle mass, and disability scores. Regression analyses modeled the effect of lower extremity muscle strength and mass on SF-36 and VLA disability scores controlling for age, SLE duration, SLE disease activity measured with the Systemic Lupus Activity Questionnaire, physical activity level, prednisone use, body composition, and depression.

RESULTS

On all measures, reduced lower extremity muscle strength was associated with poorer SF-36 and VLA disability scores. Trends persisted after adjustment for covariates. Muscle mass was moderately correlated with muscle strength, but did not contribute significantly to adjusted regression models.

CONCLUSION

Lower extremity muscle strength, but not muscle mass, was strongly associated with physical disability scores. While further studies are needed, these findings suggest that improving muscle strength may reduce physical disability among women with SLE.

Intraexaminer reliability of hand-held dynamometry in the upper extremity: a systematic review

OBJECTIVE

To summarize and appraise the literature on the intraexaminer reliability of hand-held dynamometry (HHD) in the upper extremity.

DATA SOURCES

MEDLINE, CINAHL, and EMBASE were searched for relevant studies published up to December 2011. In addition, experts were contacted, and journals and reference lists were hand searched.

STUDY SELECTION

To be included in the review, articles needed to (1) use a repeated-measures, within-examiner(s) design; (2) include symptomatic or asymptomatic individuals, or both; (3) use HHD to measure muscle strength in any of the joints of the shoulder, elbow, or wrist with the "make" or the "break" technique; (4) report measurements in kilogram, pound, or torque; (5) use a device that is placed between the examiner's hand and the subject's body; and (6) present estimates of intraexaminer reliability.

DATA EXTRACTION

Quality assessment and data extraction were performed by 2 reviewers independently.

DATA SYNTHESIS

Fifty-four studies were included, of which 26 (48%) demonstrated acceptable intraexaminer reliability. Seven high-quality studies showed acceptable reliability for flexion and extension of the elbow in healthy subjects. Conflicting results were found for shoulder external rotation and abduction. Reliability for all other movements was unacceptable. Higher estimates were reached for within-sessions reliability and if means of trials were used.

CONCLUSIONS

Intraexaminer reliability of HHD in upper extremity muscle strength was acceptable only for elbow measurements in healthy subjects. We provide specific recommendations for future research. Physical therapists should not rely on HHD measurements for evaluation of treatment effects in patients with upper extremity disorders.

Low dynamic muscle strength and its associations with fatigue, functional performance, and quality of life in premenopausal patients with systemic lupus erythematosus and low disease activity: a case-control study

BACKGROUND

The purpose of the present study was to compare dynamic muscle strength, functional performance, fatigue, and quality of life in premenopausal systemic lupus erythematosus (SLE) patients with low disease activity versus matched-healthy controls and to determine the association of dynamic muscle strength with fatigue, functional performance, and quality of life in SLE patients.

METHODS

We evaluated premenopausal (18-45 years) SLE patients with low disease activity (Systemic lupus erythematosus disease activity index [SLEDAI]: mean 1.5 ± 1.2). The control (n = 25) and patient (n = 25) groups were matched by age, physical characteristics, and the level of physical activities in daily life (International Physical Activity Questionnaire IPAQ). Both groups had not participated in regular exercise programs for at least six months prior to the study. Dynamic muscle strength was assessed by one-repetition maximum (1-RM) tests. Functional performance was assessed by the Timed Up and Go (TUG), in 30-s test a chair stand and arm curl using a 2-kg dumbbell and balance test, handgrip strength and a sit-and-reach flexibility test. Quality of life (SF-36) and fatigue were also measured.

RESULTS

The SLE patients showed significantly lower dynamic muscle strength in all exercises (leg press 25.63%, leg extension 11.19%, leg curl 15.71%, chest press 18.33%, lat pulldown 13.56%, 1-RM total load 18.12%, P < 0.001-0.02) compared to the controls. The SLE patients also had lower functional performance, greater fatigue and poorer quality of life. In addition, fatigue, SF-36 and functional performance accounted for 52% of the variance in dynamic muscle strength in the SLE patients.

CONCLUSIONS

Premenopausal SLE patients with low disease activity showed lower dynamic muscle strength, along with increased fatigue, reduced functional performance, and poorer quality of life when compared to matched controls.

Strength and jump biomechanics of elite and recreational female youth soccer players

CONTEXT

Most researchers investigating soccer injuries have studied elite athletes because they have greater athletic-exposure hours than other athletes, but most youth participate at the recreational level. If risk factors for injury vary by soccer level, then recommendations generated using research with elite youth soccer players might not generalize to recreational players.

OBJECTIVE

To examine injury risk factors of strength and jump biomechanics by soccer level in female youth athletes and to determine whether research recommendations based on elite youth athletes could be generalized to recreational players.

DESIGN

Cross-sectional study.

SETTING

Seattle Youth Soccer Association.

PATIENTS OR OTHER PARTICIPANTS

Female soccer players (N = 92) aged 11 to 14 years were recruited from 4 randomly selected elite (n = 50; age = 12.5 years, 95% confidence interval [95% CI]) = 12.3, 12.8 years; height = 157.8 cm, 95% CI = 155.2, 160.3 cm; mass = 49.9 kg, 95% CI = 47.3, 52.6 kg) and 4 randomly selected recreational (n = 42; age = 13.2 years, 95% CI = 13.0, 13.5 years; height = 161.1 cm, 95% CI = 159.2, 163.1 cm; mass = 50.6 kg, 95% CI = 48.3, 53.0 kg) soccer teams.

MAIN OUTCOME MEASURE(S)

Players completed a questionnaire about demographics, history of previous injury, and soccer experience. Physical therapists used dynamometry to measure hip strength (abduction, adduction, extension, flexion) and knee strength (flexion, extension) and Sportsmetrics to measure vertical jump height and jump biomechanics. We compared all measurements by soccer level using linear regression to adjust for age and mass.

RESULTS

Elite players were similar to recreational players in all measures of hip and knee strength, vertical jump height, and normalized knee separation (a valgus estimate generated using Sportsmetrics).

CONCLUSIONS

Female elite youth players and recreational players had similar lower extremity strength and jump biomechanics. This suggests that recommendations generated from research with elite youth soccer players could be generalized to recreational players.

Effect of treadmill training on specific gait parameters in older adults with frailty: case series

BACKGROUND AND PURPOSE

Treadmill-walking training (TWT) as an intervention to improve the gait of frail older adults has not been well studied. In this pilot study, we describe the feasibility, tolerance, and effect of TWT on specific gait parameters during overground walking in 4 frail older adults as a prelude to developing larger-scale exercise intervention trials in this high-risk population.

CASE DESCRIPTION

Four community-residing frail older individuals (age > 70 years) with Mini-Mental State Examination score of 26 or higher and no activity limitations. Frailty was defined as the presence of at least 3 of the following 5 attributes: slow gait (<1 m/s); unintentional weight loss (>10 lb in prior year); self-report of poor grip strength; exhaustion; and low level of physical activity.

INTERVENTION

The TWT consisted of 24 sessions (3 times per week for 8 weeks). Five quantitative gait parameters (velocity, stride length, swing time, percentage of double support phase, and coefficient of variation [COV] of stride length) during overground walking were measured at baseline, weekly during training, and immediately post-TWT.

OUTCOME

All participants tolerated TWT without significant complications. Following TWT, gait velocity increased in all participants by 6.4 to 26.8 cm/s, which was larger than the reported value for meaningful change in gait velocity (4 cm/s). Stride length and double support phase also showed improvement in all participants (mean percentage increase of 10.8% for stride length and 17.1% reduction for double support phase posttraining compared with baseline). Swing time improved in 3 participants (mean reduction of 4.5%). The COV of stride length did not show consistent improvement.

DISCUSSION

This case series shows that TWT is feasible and well tolerated by frail older adults and may improve most gait parameters in this high-risk population.

Muscle strength assessment in critically ill patients with handheld dynamometry: an investigation of reliability, minimal detectable change, and time to peak force generation

PURPOSE

Dynamometry is an objective tool for volitional strength evaluation that may overcome the limited sensitivity of the Medical Research Council scale for manual muscle tests, particularly at grades 4 and 5. The primary aims of this study were to investigate the reliability, minimal detectable change, and time to peak muscle force, measured with portable dynamometry, in critically ill patients.

MATERIALS AND METHODS

Isometric hand grip, elbow flexion, and knee extension were measured with portable dynamometry.

RESULTS

Interrater consistency (intraclass correlation coefficient [95% confidence interval]) (0.782 [0.321-0.930] to 0.946 [0.840-0.982]) and test-retest agreement (0.819 [0.390-0.943] to 0.918 [0.779-0.970]) were acceptable for all dynamometry forces, with the exception of left elbow flexion. Despite generally good reliability, a mean change (upper 95% confidence interval) of 2.8 (7.8) kg, 1.9 (5.2) kg, and 2.6 (7.1) kg may be required from a patient's baseline force measurement of right grip, elbow flexion, and knee extension to reflect real force changes. There was also a delay in the time for critically ill patients to generate peak muscle forces, compared with healthy controls (P ≤ .001).

CONCLUSIONS

Dynamometry can provide reliable measurements in alert critically ill patients, but moderate changes in strength may be required to overcome measurement error, during the acute recovery period. Deficits in force timing may reflect impaired neuromuscular control.

Fatigue, muscle strength and vitamin D status in women with systemic lupus erythematosus compared with healthy controls

Recent studies have demonstrated an inverse relationship between vitamin D levels and fatigue in systemic lupus erythematosus (SLE). The aims of this study were to evaluate proximal muscle strength, fatigue and vitamin D levels in women with SLE compared with healthy controls and to investigate relationships between these factors in a cohort of women with SLE. Forty-five women (24 SLE, 21 healthy controls) participated. Primary outcome measures were the fatigue severity scale (FSS), isometric muscle strength of dominant limbs using hand held dynamometry, two functional tests – the 30-second chair stand test and the 1-kg arm lift test, with vitamin D status measured using 25(OH)D. Overall 25(OH)D levels were 68.4 (22.4) nmol/L with no difference between SLE and control groups. There was a statistically and clinically significant difference in fatigue, 1-kg arm lift, 30-second sit to stand, knee extension, hip flexion, hip abduction, shoulder flexion and grip strength in the SLE group compared with the control group ( p < 0.05). In the SLE group FSS was moderately correlated with both functional measures (1-kg arm lift r = −0.42, 30-second chair stand r = −0.44, p < 0.05). However, no statistically significant correlation between dynamometry measures and fatigue was evident. There was no association between fatigue and 25(OH)D level ( r = −0.12). In summary, women with SLE were weaker and demonstrated reduced physical function and higher fatigue levels than healthy controls. Fatigue was related to physical function but not vitamin D status or maximal isometric strength in vitamin D replete individuals with SLE.