Aquatic therapy for boys with Duchenne muscular dystrophy (DMD): an external pilot randomised controlled trial

Feasibility of Using the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) as a Framework for Aquatic Activities: A Scoping Review

(1) Background: In recent years, reviewing studies of aquatic activities for children with developmental delays has been a complex task due to the multitude of indices and professional languages. (2) Aim: To determine if the ICF-CY framework can be used as the unifying language in AA studies of children with DD. (3) Methods: Part One-A systematic review of selected studies focusing on goals that were found to be positive. These goals were linked to the ICF-CY categories. Part Two-Review of all studies using the ICF-CY's functioning components. (4) Results: Most of the positive goals were properly linked to ICF-CY and made it possible to review the 71 articles in a uniform language. (5) Conclusions: It is feasible to use the ICF framework as a universal structure and language.

Efficacy and safety of hydrokinesitherapy in patients with dystrophinopathy

Duchenne muscular dystrophy (DMD) is one of the most common forms of hereditary muscular dystrophies in childhood and is characterized by steady progression and early disability. It is known that physical therapy can slow down the rate of progression of the disease. According to global recommendations, pool exercises, along with stretching, are preferable for children with DMD, as these types of activities have a balanced effect on skeletal muscles and allow simultaneous breathing exercises. The present study aimed to evaluate the effectiveness of regular pool exercises in patients with Duchenne muscular dystrophy who are capable of independent movement during 4 months of training. 28 patients with genetically confirmed Duchenne muscular dystrophy, who were aged 6.9 ± 0.2 years, were examined. A 6-min distance walking test and timed tests, namely, rising from the floor, 10-meter running, and stair climbing and descending, muscle strength of the upper and lower extremities were assessed on the baseline and during dynamic observation at 2 and 4 months. Hydrorehabilitation course lasted 4 months and was divided into two stages: preparatory and training (depend on individual functional heart reserve (IFHR)). Set of exercises included pool dynamic aerobic exercises. Quantitative muscle MRI of the pelvic girdle and thigh was performed six times: before training (further BT) and after training (further AT) during all course. According to the results of the study, a statistically significant improvement was identified in a 6-min walking test, with 462.7 ± 6.2 m on the baseline and 492.0 ± 6.4 m after 4 months (p < 0.001). The results from the timed functional tests were as follows: rising from the floor test, 4.5 ± 0.3 s on the baseline and 3.8 ± 0.2 s after 4 months (p < 0.001); 10 meter distance running test, 4.9 ± 0.1 s on the baseline and 4.3 ± 0.1 s after 4 months (p < 0.001); 4-stair climbing test, 3.7 ± 0.2 s on the baseline and 3.2 ± 0.2 s after 4 months (p < 0.001); and 4-stair descent test, 3.9 ± 0.1 s on the baseline and 3.2 ± 0.1 s after 4 months (p < 0.001). Skeletal muscle quantitative MRI was performed in the pelvis and the thighs in order to assess the impact of the procedures on the muscle structure. Muscle water T2, a biomarker of disease activity, did not show any change during the training period, suggesting the absence of deleterious effects and negative impact on disease activity. Thus, a set of dynamic aerobic exercises in water can be regarded as effective and safe for patients with DMD.

Aquatic Therapy for Persons with Neuromuscular Diseases - A Scoping Review

Background:

Aquatic exercise is among the most common physical activity modalities performed by people with disabilities.

Objective:

The present paper reviews currently-available research on aquatic therapy (AT) for persons with neuromuscular diseases (NMD).

Methods:

A scoping review of the existing literature was conducted on PubMed, Embase, Medline, Scopus, Web of Science, SPORTdiscus, CINAHL and Lilacs from the earliest date available until October 2020. It follows the methodological framework for conducting a scoping review proposed by the Joanna Briggs Institute.

Results:

A total of 28 articles were analyzed and the study parameters grouped by the topography of NMD; most of the studies (n = 16) addressed myopathies. A considerable increase in the number of studies was found over time, and heterogeneity was identified across and within AT interventions for persons with NMD; hence, to allow more effective interpretation of study results, there is a need to standardize the fundamental parameters and procedures for AT.

Conclusions:

This scoping review provides a comprehensive outline of available literature; the findings could serve as a starting point for clinical studies on the effects of AT on persons with NMD, and encourage a more coherent approach to their design.

Safety, feasibility, and efficacy of strengthening exercise in Duchenne muscular dystrophy

BACKGROUND

This two-part study explored the safety, feasibility, and efficacy of a mild-moderate resistance isometric leg exercise program in ambulatory boys with Duchenne muscular dystrophy (DMD).

METHODS

First, we used a dose escalation paradigm with varying intensity and frequency of leg isometric exercise to determine the dose response and safety in 10 boys. Second, we examined safety and feasibility of a 12-wk in-home, remotely supervised, mild-moderate intensity strengthening program in eight boys. Safety measures included T₂ MRI, creatine kinase levels, and pain. Peak strength and function (time to ascend/descend four stairs) were also measured.

RESULTS

Dose-escalation revealed no signs of muscle damage. Seven of the eight boys completed the 12-wk in-home program with a compliance of 84.9%, no signs of muscle damage, and improvements in strength (knee extensors P < .01; knee flexors P < .05) and function (descending steps P < .05).

CONCLUSIONS

An in-home, mild-moderate intensity leg exercise program is safe with potential to positively impact both strength and function in ambulatory boys with DMD.

Aquatic high intensity interval training to improve aerobic capacity is feasible in adolescents with cerebral palsy: pilot randomised controlled trial

OBJECTIVE

To investigate feasibility of aquatic high intensity interval training for adolescents with cerebral palsy, who can ambulate independently but may choose a mobility aid in some circumstances.

DESIGN

Pilot randomised controlled trial.

METHOD

Following baseline assessments, participants were randomised to usual care or ten weeks of twice weekly aquatic high intensity interval training. Each class comprised 10 one-minute exercise intervals separated by one-minute rest. High intensity exercise was defined as the attainment of ⩾80% of peak heart rate measured by telemetry.

SETTING

Tertiary paediatric hospital.

MAIN MEASURES

Primary outcomes related to the feasibility of the protocol to progress to a definitive trial. Consumer feedback was obtained.

RESULTS

Of 119 potential participants, 46 appeared eligible and 17 consented, resulting in a recruitment fraction of 37% (95% CI 23-52). Twelve completed baseline assessments and were randomised (5 males; 14 years 7 months SD 2 years 0 months). In the intervention group, of the 1190 exercise stations (across all participants and sessions), heart rate data were available for 1180 stations and high intensity exercise was achieved during 1111 stations (93%, 95% CI 92-95). All randomised participants completed the study and reported that the intervention was fun and provided friendship opportunities. There were no major adverse events or exacerbation of pain.

CONCLUSIONS

Aquatic high intensity interval training in ambulant adolescents with cerebral palsy is feasible, while maintaining adherence and fidelity. Uncertainty remains on the efficacy of the intervention, highlighting the need for a large definitive trial.

Impact of Aquatic Exercise on Respiratory Outcomes and Functional Activities in Children with Neuromuscular Disorders: Findings from an Open-Label and Prospective Preliminary Pilot Study

Neuromuscular disorders (NMD) lead to the progressive loss of motor and respiratory functions and a decline in daily activities and participation. We aimed to evaluate respiratory changes and functional outcomes in children attending an aquatic therapy program. Eleven patients diagnosed with NMD (4-18 years, Vignos scale 1-9) were involved in a 10-week aquatic exercise program. The ventilation variables were: peak cough flow, volumes (forced expiratory volume in one second-FEV₁ and inspiratory volume) and respiratory pressures to evaluate strength and oxygen saturation (O₂ sat). Functional skills were measured in the aquatic environment (Water Orientation Test Alyn 1) and on dry land, (Pediatric Evaluation of Disability Inventory), together with quality of life (Pediatric Quality of Life Inventory). Our evaluation included several 2 × 6 mixed-model repeated measures analysis of covariance (ANCOVA) with time (baseline, post 1 session, pre-post at five weeks and pre-post at 10 weeks). Important improvements in functional skills were observed in and out of the water and children under the age of 11 displayed a significant difference for inspirational volume (p = 0.002) and O₂ sat (p = 0.029). Clinical, statistically insignificant changes were found for peak cough flow and expiratory pressures values after aquatic exercise. These results may support a relationship between aquatic exercise in NMD, respiratory outcomes and functional activities in water and on land.

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.

Are pilot trials useful for predicting randomisation and attrition rates in definitive studies: A review of publicly funded trials

BACKGROUND/AIMS

External pilot trials are recommended for testing the feasibility of main or confirmatory trials. However, there is little evidence that progress in external pilot trials actually predicts randomisation and attrition rates in the main trial. To assess the use of external pilot trials in trial design, we compared randomisation and attrition rates in publicly funded randomised controlled trials with rates in their pilots.

METHODS

Randomised controlled trials for which there was an external pilot trial were identified from reports published between 2004 and 2013 in the Health Technology Assessment Journal. Data were extracted from published papers, protocols and reports. Bland-Altman plots and descriptive statistics were used to investigate the agreement of randomisation and attrition rates between the full and external pilot trials.

RESULTS

Of 561 reports, 41 were randomised controlled trials with pilot trials and 16 met criteria for a pilot trial with sufficient data. Mean attrition and randomisation rates were 21.1% and 50.4%, respectively, in the pilot trials and 16.8% and 65.2% in the main. There was minimal bias in the pilot trial when predicting the main trial attrition and randomisation rate. However, the variation was large: the mean difference in the attrition rate between the pilot and main trial was -4.4% with limits of agreement of -37.1% to 28.2%. Limits of agreement for randomisation rates were -47.8% to 77.5%.

CONCLUSION

Results from external pilot trials to estimate randomisation and attrition rates should be used with caution as comparison of the difference in the rates between pilots and their associated full trial demonstrates high variability. We suggest using internal pilot trials wherever appropriate.

Aquatic therapy for children with Duchenne muscular dystrophy: a pilot feasibility randomised controlled trial and mixed-methods process evaluation

BACKGROUND

Duchenne muscular dystrophy (DMD) is a rare disease that causes the progressive loss of motor abilities such as walking. Standard treatment includes physiotherapy. No trial has evaluated whether or not adding aquatic therapy (AT) to land-based therapy (LBT) exercises helps to keep muscles strong and children independent.

OBJECTIVES

To assess the feasibility of recruiting boys with DMD to a randomised trial evaluating AT (primary objective) and to collect data from them; to assess how, and how well, the intervention and trial procedures work.

DESIGN

Parallel-group, single-blind, randomised pilot trial with nested qualitative research.

SETTING

Six paediatric neuromuscular units.

PARTICIPANTS

Children with DMD aged 7-16 years, established on corticosteroids, with a North Star Ambulatory Assessment (NSAA) score of 8-34 and able to complete a 10-m walk without aids/assistance. Exclusions: > 20% variation between baseline screens 4 weeks apart and contraindications.

INTERVENTIONS

Participants were allocated on a 1 : 1 ratio to (1) optimised, manualised LBT (prescribed by specialist neuromuscular physiotherapists) or (2) the same plus manualised AT (30 minutes, twice weekly for 6 months: active assisted and/or passive stretching regime; simulated or real functional activities; submaximal exercise). Semistructured interviews with participants, parents (n = 8) and professionals (n = 8) were analysed using Framework analysis. An independent rater reviewed patient records to determine the extent to which treatment was optimised. A cost-impact analysis was performed. Quantitative and qualitative data were mixed using a triangulation exercise.

MAIN OUTCOME MEASURES

Feasibility of recruiting 40 participants in 6 months, participant and therapist views on the acceptability of the intervention and research protocols, clinical outcomes including NSAA, independent assessment of treatment optimisation and intervention costs.

RESULTS

Over 6 months, 348 children were screened - most lived too far from centres or were enrolled in other trials. Twelve (30% of target) were randomised to AT (n = 8) or control (n = 4). People in the AT (n = 8) and control (n = 2: attrition because of parental report) arms contributed outcome data. The mean change in NSAA score at 6 months was -5.5 [standard deviation (SD) 7.8] for LBT and -2.8 (SD 4.1) in the AT arm. One boy suffered pain and fatigue after AT, which resolved the same day. Physiotherapists and parents valued AT and believed that it should be delivered in community settings. The independent rater considered AT optimised for three out of eight children, with other children given programmes that were too extensive and insufficiently focused. The estimated NHS costs of 6-month service were between £1970 and £2734 per patient.

LIMITATIONS

The focus on delivery in hospitals limits generalisability.

CONCLUSIONS

Neither a full-scale frequentist randomised controlled trial (RCT) recruiting in the UK alone nor a twice-weekly open-ended AT course delivered at tertiary centres is feasible. Further intervention development research is needed to identify how community-based pools can be accessed, and how families can link with each other and community physiotherapists to access tailored AT programmes guided by highly specialised physiotherapists. Bayesian RCTs may be feasible; otherwise, time series designs are recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41002956.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 27. See the NIHR Journals Library website for further project information.