Safety and Tolerability of Strength Training in Spinal and Bulbar Muscular Atrophy: A Case Report

Objective: Spinal and bulbar muscular atrophy is characterized by slow-progressive muscle weakness, decreased functional performance and falls. Research into the use of exercise in spinal and bulbar muscular atrophy has shown equivocal to negative results, although authors suggest that patients with spinal and bulbar muscular atrophy may benefit from both increased exercise intensity and shorter bout duration. The aim of this case report is to explore the safety of a moderate-intensity strength training programme coupled with dynamic balance and function-specific training in a patient with spinal and bulbar muscular atrophy.Case report: A 56-year-old man with spinal and bulbar muscular atrophy presented with multiple falls and declining performance in physical, vocational, and recreational activities. Examination revealed several musculoskeletal impairments that were sub-clinical to mild compared with an SBMA natural history cohort.Intervention and outcome: A 15-week moderate-intensity exercise programme combining weightlifting and functional exercises was performed under clinical supervision. Exercise volume, frequency and intensity were adjusted based on patient-reported outcomes and muscle damage blood markers. Performance-based and selfreported functional improvements occurred that exceeded the minimal clinically important difference. The intervention was well tolerated and the patient nearly doubled his baseline 10-repetition maximums for weight-lifting exercises. Conclusion: Exercise therapy combining weightlifting and upright functional training led to meaningful performance improvements in this case of a patient with spinal and bulbar muscular atrophy and relatively low disease burden. LAY ABSTRACTSpinal and bulbar muscular atrophy (SBMA) is a rare neuromuscular disease characterized by slow-progressive muscle weakness, decreased functional performance, and falling. With limited research for guidance, medical practitioners often advise patients with SBMA to avoid weight lifting or intensive exercise. The patient was a high-functioning 56-year-old man with SBMA who struggled with performing daily activities and intensive physical work demands. He participated in a closely monitored 15-week exercise program that combined weight lifting and functional exercises. The patient safely tolerated the program, self-reported physical improvements, and nearly doubled the weight for lifting exercises. This case report highlights one individual with SBMA who benefitted from moderate-intensity exercise, including weight lifting, under careful clinical supervision. More research is needed before this intervention can be recommended for people with SBMA.

Preliminary Validation of Muscle Ultrasound in Juvenile Dermatomyositis (JDM)

OBJECTIVE

To compare muscle ultrasound (MUS) parameters in patients with juvenile dermatomyositis (JDM) and healthy controls, and examine their association with JDM disease activity measures and magnetic resonance imaging (MRI).

METHODS

MUS of the right mid-rectus femoris was performed in 21 patients with JDM meeting probable or definite Bohan and Peter criteria and 28 demographically-matched healthy control subjects. MUS parameters were quantitated by digital image processing, and correlated with JDM disease activity measures and semi-quantitative thigh MRI short tau inversion recovery (STIR) and T1 scores.

RESULTS

Rectus femoris MUS echogenicity was increased (median 47.8 vs 38.5, p= 0.002) in patients with JDM compared with controls. Rectus femoris MUS echogenicity correlated with Physician Global Activity (PGA), Manual Muscle Testing (MMT), and Childhood Myositis Assessment Scale (CMAS) (rs 0.4-0.54). Some MUS parameters correlated with functional quantitative measures of muscle strength: resting RF area on MUS strongly correlated with knee extension quantitative muscle testing (QMT) (rs 0.76), and contracted area correlated with proximal MMT, knee extension QMT, and CMAS (rs 0.71-0.80). MUS echogenicity correlated with both STIR and T1 MRI (rs 0.43), and T1 MRI correlated inversely with RF contracted area (rs -0.49) on MUS. There were differences in pre- and post-exercise vascular power and colour Doppler on MUS in patients with JDM vs controls, with the percentage change of post-exercise vascular power Doppler lower in JDM compared with controls (7.1% vs 100.0%).

CONCLUSIONS

These data suggest MUS may be a valuable imaging modality to assess JDM disease activity and damage.

Skeletal Muscle Magnetic Resonance Biomarkers in GNE Myopathy

OBJECTIVE

To characterize muscle involvement and evaluate disease severity in patients with GNE myopathy using skeletal muscle MRI and proton magnetic resonance spectroscopy (¹H-MRS).

METHODS

Skeletal muscle imaging of the lower extremities was performed in 31 patients with genetically confirmed GNE myopathy, including T1-weighted and short tau inversion recovery (STIR) images, T1 and T2 mapping, and ¹H-MRS. Measures evaluated included longitudinal relaxation time (T1), transverse relaxation time (T2), and ¹H-MRS fat fraction (FF). Thigh muscle volume was correlated with relevant measures of strength, function, and patient-reported outcomes.

RESULTS

The cohort was representative of a wide range of disease progression. Contractile thigh muscle volume ranged from 5.51% to 62.95% and correlated with thigh strength (r = 0.91), the 6-minute walk test (r = 0.82), the adult myopathy assessment tool (r = 0.83), the activities-specific balance confidence scale (r = 0.65), and the inclusion body myositis functional rating scale (r = 0.62). Four stages of muscle involvement were distinguished by qualitative (T1W and STIR images) and quantitative methods: stage I: unaffected muscle (T1 = 1,033 ± 74.2 ms, T2 = 40.0 ± 1.9 ms, FF = 7.4 ± 3.5%); stage II: STIR hyperintense muscle with minimal or no fat infiltration (T1 = 1,305 ± 147 ms, T2 = 50.2 ± 3.5 ms, FF = 27.6 ± 12.7%); stage III: fat infiltration and STIR hyperintensity (T1 = 1,209 ± 348 ms, T2 = 73.3 ± 12.6 ms, FF = 57.5 ± 10.6%); and stage IV: complete fat replacement (T1 = 318 ± 39.9 ms, T2 = 114 ± 21.2 ms, FF = 85.6 ± 4.2%). ¹H-MRS showed a significant decrease in intramyocellular lipid and trimethylamines between stage I and II, suggesting altered muscle metabolism at early stages.

CONCLUSION

MRI biomarkers can monitor muscle involvement and determine disease severity noninvasively in patients with GNE myopathy.

CLINICALTRIALSGOV IDENTIFIER

NCT01417533.

Exercise Intervention Leads to Functional Improvement in a Patient with Spinal and Bulbar Muscular Atrophy

Introduction

Spinal and bulbar muscular atrophy is a progressive neuromuscular disease that leads to muscle weakness and reduced physical function. Benefits of physical therapy for people with spinal and bulbar muscular atrophy have not been reported in the literature.

Case report

A 62-year-old male patient with spinal and bulbar muscular atrophy reported falling, difficulty walking and completing upright tasks, and showed clinical signs of low baseline function on examination. Transportation challenges made it difficult for this patient to attend frequent one-on-one physical therapy sessions.

Interventions and outcomes

A minimally supervised home-based exercise intervention was chosen with the goal of safely improving his functional capacity. The 5-visit clinical intervention, spread over 10 months, provided 3 exercise modules: seated-to-standing postural alignment and core muscle activation; upright functional and endurance training; and balance training and rhythmic walking. Post-intervention the patient had increased lower extremity muscle strength, improved balance, and reduced self-reported fatigue.

Conclusion

Home-based exercises were well tolerated with no increase in creatine kinase. Multiple clinical measures of strength and function improved, possibly related to the patients’ excellent motivation and compliance with the programme. Promising utilization of a minimally supervised home-based programme is described here.

Cognitive and motor aspects of cancer-related fatigue

BACKGROUND

Cancer-related fatigue (CRF) is a debilitating symptom frequently reported by patients during and after treatment for cancer. CRF is a multidimensional experience and is often solely assessed by self-report measures. The goal of the study is to examine the physical and cognitive aspects of self-reported CRF using a cognitive function test and a physical fatigue index in order to provide objective measures that can characterize the CRF phenotype.

METHODS

A total of 59 subjects with nonmetastatic prostate cancer receiving external beam radiation therapy were included in the study. Fatigue was measured using the Functional Assessment of Cancer Therapy-Fatigue (FACT-F) questionnaire. Cognitive characteristics of CRF was measured using the Stroop Color-Word Interference computerized test and the motor aspect of fatigue was measured using the static fatigue test using a handgrip dynamometer.

FINDINGS

Functional Assessment of Cancer Therapy-Fatigue scores significantly correlated with the Stroop Interference score, but not performance accuracy in all test conditions. Fatigued subjects exhibited a more rapid decline to 50% of maximal strength and increased static fatigue index in the handgrip test, whereas maximal grip strength was not affected.

CONCLUSIONS

The results suggest that CRF exhibits both cognitive and physical characteristics. Subjective fatigue was associated with increased time required to overcome cognitive interference, but not cognitive performance accuracy. Fatigued patients exhibited decreased physical endurance and the ability to sustain maximal strength over time. These objective measures may serve as valuable tools for clinicians to detect cognitive and physical impairment associated with CRF.

Identification of an Alu element-mediated deletion in the promoter region of GNE in siblings with GNE myopathy

Background

GNE myopathy is a rare genetic disease characterized by progressive muscle atrophy and weakness. It is caused by biallelic mutations in the GNE gene that encodes for the bifunctional enzyme, uridine diphosphate (UDP)‐N‐acetylglucosamine (GlcNAc) 2‐epimerase/N‐acetylmannosamine (ManNAc) kinase. Typical characteristics of GNE myopathy include progressive myopathy, first involving anterior tibialis muscle and sparing the quadriceps, and rimmed vacuoles on muscle biopsy. Identifying biallelic mutations by sequencing of the GNE gene confirms the diagnosis of GNE myopathy. In a subset of patients, diagnostic confirmation is challenged by the identification of mutations in only one allele, suggesting mutations in deep intronic regions or regulatory regions.

Methods

We performed targeted sequencing and copy number variant (CNV) analysis of GNE in two siblings who clinically presented with GNE myopathy. Further molecular and biochemical studies were done to characterize the effect of a previously uncharacterized GNE mutation.

Results

We report two siblings of Indian descent with characteristic features of GNE myopathy, including progressive skeletal muscle weakness initially involving the anterior tibialis, and rimmed vacuoles on muscle biopsy, in which a heterozygous mutation, p.Val727Met, was identified in both affected siblings, but no other deleterious variants in either coding region or exon–intron boundaries of the gene. Subsequent insertion/deletion analysis identified a novel 11.3‐kb deletion (Chr9 [GRCh37]: g.36257583_36268910del) encompassing the GNE promoter region, with breakpoints residing in Alu repeats. Gene expression analysis revealed reduced GNEmRNA and protein levels, confirming decreased expression of the deleted allele harboring the deletion.

Conclusions

We have identified GNE as one of the genes susceptible to Alu‐mediated recombination. Our findings suggest that the deletion may encompass the promoter or another region necessary for GNE expression. In patients with typical manifestations of GNE myopathy and a single GNE variant identified, copy number variant (CNV) analysis may be useful in arriving at the diagnosis.

Sexual Reassignment Fails to Prevent Kennedy's Disease

Spinal and bulbar muscular atrophy is caused by polyglutamine expansion in the androgen receptor. As an X-linked disease dependent on androgens, symptoms and findings are only fully manifest in males. Here we describe a 40-year-old male-to-female transgender SBMA patient who developed full disease manifestations despite undetectable levels of androgens. We used cell culture and animal models to show that spironolactone, the anti-androgen she had taken for 15 years, promotes nuclear localization and toxicity of the mutant protein, which may explain the disease manifestations in this patient.

Magnetic resonance measurement of muscle T2, fat-corrected T2 and fat fraction in the assessment of idiopathic inflammatory myopathies

OBJECTIVE

This study examines the utility of MRI, including T2 maps and T2 maps corrected for muscle fat content, in evaluating patients with idiopathic inflammatory myopathy.

METHODS

A total of 44 patients with idiopathic inflammatory myopathy, 18 of whom were evaluated after treatment with rituximab, underwent MRI of the thighs and detailed clinical assessment. T2, fat fraction (FF) and fat corrected T2 (fc-T2) maps were generated from standardized MRI scans, and compared with semi-quantitative scoring of short tau inversion recovery (STIR) and T1-weighted sequences, as well as various myositis disease metrics, including the Physician Global Activity, the modified Childhood Myositis Assessment Scale and the muscle domain of the Myositis Disease Activity Assessment Tool-muscle (MDAAT-muscle).

RESULTS

Mean T2 and mean fc-T2 correlated similarly with STIR scores (Spearman rs = 0.64 and 0.64, P < 0.01), while mean FF correlated with T1 damage scores (rs = 0.69, P < 0.001). Baseline T2, fc-T2 and STIR scores correlated significantly with the Physician Global Activity, modified Childhood Myositis Assessment Scale and MDAAT-muscle (rs range = 0.41-0.74, P < 0.01). The response of MRI measures to rituximab was variable, and did not significantly agree with a standardized clinical definition of improvement. Standardized response means for the MRI measures were similar.

CONCLUSION

Muscle T2, fc-T2 and FF measurements exhibit content validity with reference to semi-quantitative scoring of STIR and T1 MRI, and also exhibit construct validity with reference to several myositis activity and damage measures. T2 was as responsive as fc-T2 and STIR scoring, although progression of muscle damage was negligible during the study.

Reliability of the adult myopathy assessment tool in individuals with myositis

OBJECTIVE

The Adult Myopathy Assessment Tool (AMAT) is a 13-item performance-based battery developed to assess functional status and muscle endurance. The purpose of this study was to determine the intrarater and interrater reliability of the AMAT in adults with myositis.

METHODS

Nineteen raters (13 physical therapists and 6 physicians) scored videotaped recordings of patients with myositis performing the AMAT for a total of 114 tests and 1,482 item observations per session. Raters rescored the AMAT test and item observations during a followup session (mean ± SD 19 ± 6 days between scoring sessions). All raters completed a single, self-directed, electronic training module prior to the initial scoring session.

RESULTS

Intrarater and interrater reliability correlation coefficients were ≥0.94 for the AMAT functional subscale, endurance subscale, and total score (all P < 0.02 for Ho , ρ ≤0.75). All AMAT items had satisfactory intrarater agreement (kappa statistics with Fleiss-Cohen weights, with values κw = 0.57-1.00). Interrater agreement was acceptable for each AMAT item (κ = 0.56-0.89) except the sit up (κ = 0.16). The standard error of measurement and 95% confidence interval range for the AMAT total scores did not exceed 2 points across all observations (AMAT total score range 0-45).

CONCLUSION

The AMAT is a reliable, domain-specific assessment of functional status and muscle endurance for adult subjects with myositis. Results of this study suggest that physicians and physical therapists may reliably score the AMAT following a single training session. The AMAT functional subscale, endurance subscale, and total score exhibit interrater and intrarater reliability suitable for clinical and research use.

A randomized controlled trial of exercise in spinal and bulbar muscular atrophy

Objective

To determine the safety and efficacy of a home-based functional exercise program in spinal and bulbar muscular atrophy (SBMA).

Methods

Subjects were randomly assigned to participate in 12 weeks of either functional exercises (intervention) or a stretching program (control) at the National Institutes of Health in Bethesda, MD. A total of 54 subjects enrolled, and 50 completed the study with 24 in the functional exercise group and 26 in the stretching control group. The primary outcome measure was the Adult Myopathy Assessment Tool (AMAT) total score, and secondary measures included total activity by accelerometry, muscle strength, balance, timed up and go, sit-to-stand test, health-related quality of life, creatine kinase, and insulin-like growth factor-1.

Results

Functional exercise was well tolerated but did not lead to significant group differences in the primary outcome measure or any of the secondary measures. The functional exercise did not produce significantly more adverse events than stretching, and was not perceived to be difficult. To determine whether a subset of the subjects may have benefited, we divided them into high and low functioning based on baseline AMAT scores and performed a post hoc subgroup analysis. Low-functioning individuals receiving the intervention increased AMAT functional subscale scores compared to the control group.

Interpretation

Although these trial results indicate that functional exercise had no significant effect on total AMAT scores or on mobility, strength, balance, and quality of life, post hoc findings indicate that low-functioning men with SBMA may respond better to functional exercises, and this warrants further investigation with appropriate exercise intensity.

Lower extremity peak force and gait kinematics in individuals with inclusion body myositis

OBJECTIVE

To determine the relationship between peak isometric muscle force and temporal characteristics of gait in individuals with sporadic inclusion body myositis (s-IBM).

METHODS

An observational study of 42 individuals with s-IBM (12 women; mean ± SD age 61.8 ± 7.3 years and mean ± SD disease duration 8.9 ± 4.3 years) was conducted at a federal hospital. Peak isometric force measurements for lower extremity (LE) muscle groups were obtained using quantitative muscle testing. Temporal characteristics of gait during habitual and fast walking conditions were measured using a portable gait analysis system.

RESULTS

All observed muscle force values were significantly lower than predicted values (P ≤ 0.001). During habitual walking, the subjects' gait speed and cadence were ≤83% of normative literature values. During fast walking, total gait cycle time was 133% of normal, while gait speed and cadence were 58% and 78% of normative literature values, respectively. Scaled LE peak muscle forces showed significant moderate correlations with temporal gait variables. Weaker subjects had greater limitations in gait speed and cadence compared with stronger subjects (P < 0.05). Peak isometric force of the knee flexors and ankle plantar flexors was significantly correlated with most temporal features of habitual gait.

CONCLUSION

Muscle weakness associated with s-IBM disease activity may contribute to diminished gait kinematics. Temporal features of gait were not substantially influenced by knee extensor weakness alone, considering the knee flexors and ankle plantar flexors played a compensatory role in maintaining the walking ability of individuals with s-IBM.

Novel assessment tools to evaluate clinical and laboratory responses in a subset of patients enrolled in the Rituximab in Myositis trial

OBJECTIVES

We aimed to assess changes in myositis core set measures and ancillary clinical and laboratory data from the National Institutes of Health's subset of patients enrolled in the Rituximab in Myositis trial.

METHODS

Eighteen patients (5 dermatomyositis, 8 polymyositis, 5 juvenile dermatomyositis) completed more in-depth testing of muscle strength and cutaneous assessments, patient-reported outcomes, and laboratory tests before and after administration of rituximab. Percentage change in individual measures and in the definitions of improvement (DOIs) and standardized response means were examined over 44 weeks.

RESULTS

Core set activity measures improved by 18-70% from weeks 0-44 and were sensitive to change. Fifteen patients met the DOI at week 44, 9 patients met a DOI 50% response, and 4 met a DOI 70% response. Muscle strength and function measures were more sensitive to change than cutaneous assessments. Constitutional, gastrointestinal, and pulmonary systems improved 44-70%. Patient-reported outcomes improved up to 28%. CD20+ B cells were depleted in the periphery, but B cell depletion was not associated with clinical improvement at week 16.

CONCLUSIONS

This subset of patients had high rates of clinical response to rituximab, similar to patients in the overall trial. Most measures were responsive, and muscle strength had a greater degree of change than cutaneous assessments. Several novel assessment tools, including measures of strength and function, extra-muscular organ activity, fatigue, and health-related quality of life, are promising for use in future myositis trials. Further study of B cell-depleting therapies in myositis, particularly in treatment-naïve patients, is warranted.

Atypical presentation of GNE myopathy with asymmetric hand weakness

GNE myopathy is a rare autosomal recessive muscle disease caused by mutations in GNE, the gene encoding the rate-limiting enzyme in sialic acid biosynthesis. GNE myopathy usually manifests in early adulthood with distal myopathy that progresses slowly and symmetrically, first involving distal muscles of the lower extremities, followed by proximal muscles with relative sparing of the quadriceps. Upper extremities are typically affected later in the disease. We report a patient with GNE myopathy who presented with asymmetric hand weakness. He had considerably decreased left grip strength, atrophy of the left anterior forearm and fibro-fatty tissue replacement of left forearm flexor muscles on T1-weighted magnetic resonance imaging. The patient was an endoscopist and thus the asymmetric hand involvement may be associated with left hand overuse in daily repetitive pinching and gripping movements, highlighting the possible impact of environmental factors on the progression of genetic muscle conditions.

Early onset and novel features in a spinal and bulbar muscular atrophy patient with a 68 CAG repeat

Spinal and bulbar muscular atrophy (SBMA) is an X-linked neuromuscular disease caused by a trinucleotide (CAG) repeat expansion in the androgen receptor gene. Patients with SBMA have weakness, atrophy, and fasciculations in the bulbar and extremity muscles. Individuals with CAG repeat lengths greater than 62 have not previously been reported. We evaluated a 29year old SBMA patient with 68 CAGs who had unusually early onset and findings not seen in others with the disease. Analysis of the androgen receptor gene confirmed the repeat length of 68 CAGs in both peripheral blood and fibroblasts. Evaluation of muscle and sensory function showed deficits typical of SBMA, and in addition the patient had manifestations of autonomic dysfunction and abnormal sexual development. These findings extend the known phenotype associated with SBMA and shed new insight into the effects of the mutated androgen receptor.

Validity of the single limb heel raise test to predict lower extremity disablement in patients with sporadic inclusion body myositis

PURPOSE

To determine the validity of the single limb heel raise (SLHR) test as a potential screening tool to detect lower extremity disability in patients with sporadic inclusion body myositis (sIBM).

METHODS

We compared gait speed and fall history between subjects with sIBM who either could complete one SLHR (SLHR group) or could not complete one SLHR. Discriminative validity was established by comparing between group differences in functional measures based on group assignment. Receiver operating characteristics curve analysis was used to determine the predictive validity of completing one repetition on the SLHR test. Spearman correlations were used to determine the association between gait kinematics and number of repetitions achieved on the SLHR test.

RESULTS

Forty-three subjects (13 females) were studied. The SLHR group (n = 21) showed significantly greater gait speed (p < 0.001) and decreased gait aid use (p < 0.05) compared to the no SLHR group (n = 22). SLHR cut scores of 1, 20, and 22 repetitions maximized positive likelihood ratios (+LR) for the ability to walk at 54.9 (+LR. 2.2), 63.2 (+LR. 9.5), and 73.1 m/min (+LR. 5.0), respectively.

CONCLUSION

The SLHR test demonstrates adequate discriminative and predictive validity as a screening tool for lower extremity disablement in patients with sIBM. Implications for Rehabilitation The SLHR test has adequate reliability and validity to screen for the presence of lower extremity disablement in patients with sIBM. Results of this rapid field test may be used to guide the need for rehabilitation services to mitigate the effects of slow gait speeds in patients with sIBM.

Synthetic human parathyroid hormone 1-34 replacement therapy: a randomized crossover trial comparing pump versus injections in the treatment of chronic hypoparathyroidism

CONTEXT

Vitamin D therapy for hypoparathyroidism does not restore PTH-dependent renal calcium reabsorption, which can lead to renal damage. An alternative approach, PTH 1-34 administered twice daily, provides acceptable long-term treatment but is associated with nonphysiological serum calcium fluctuation.

OBJECTIVE

Our objective was to compare continuous PTH 1-34 delivery, by insulin pump, with twice-daily delivery.

RESEARCH DESIGN AND METHODS

In a 6-month, open-label, randomized, crossover trial, PTH 1-34 was delivered by pump or twice-daily sc injection. After each 3-month study period, serum and 24-h urine mineral levels and bone turnover markers were measured daily for 3 d, and 24-h biochemical profiles were determined for serum minerals and 1,25-dihydroxyvitamin D(3) and for urine minerals and cAMP. STUDY PARTICIPANTS AND SETTING: Eight patients with postsurgical hypoparathyroidism (mean ± sd age 46 ± 5.6 yr) participated at a tertiary care referral center.

RESULTS

Pump vs. twice-daily delivery of PTH 1-34 produced less fluctuation in serum calcium, a more than 50% reduction in urine calcium (P = 0.002), and a 65% reduction in the PTH dose to maintain eucalcemia (P < 0.001). Pump delivery also produced higher serum magnesium level (P = 0.02), normal urine magnesium, and reduced need for magnesium supplements. Finally, pump delivery normalized bone turnover markers and significantly lowered urinary cross-linked N-telopeptide of type 1 collagen and pyridinium crosslinks compared with twice-daily injections (P < 0.05).

CONCLUSION

Pump delivery of PTH 1-34 provides the closest approach to date to physiological replacement therapy for hypoparathyroidism.

Posttransplant distal limb syndrome

The patient was a 45-year-old woman who was referred to a physical therapist and a physiatrist in a rehabilitation medicine department for evaluation and treatment of severe bilateral lower leg, ankle, and foot pain. The patient's past medical history was significant for sickle cell disease and she had undergone an allogeneic stem cell transplant 4 months prior with Sirolimus prescribed to prevent rejection. Magnetic resonance imaging of both lower legs revealed extensive bone marrow edema, as well as soft tissue swelling about the lower legs and ankles. These findings, along with the patient's presentation (constant bilateral pain and erythema of the lower legs within 6 months of transplantation) were found to be consistent with an atypical condition called posttransplant distal limb syndrome.

Clinical features of spinal and bulbar muscular atrophy

Spinal and bulbar muscular atrophy is an X-linked motor neuron disease caused by a CAG repeat expansion in the androgen receptor gene. To characterize the natural history and define outcome measures for clinical trials, we assessed the clinical history, laboratory findings and muscle strength and function in 57 patients with genetically confirmed disease. We also administered self-assessment questionnaires for activities of daily living, quality of life and erectile function. We found an average delay of over 5 years from onset of weakness to diagnosis. Muscle strength and function correlated directly with serum testosterone levels and inversely with CAG repeat length, age and duration of weakness. Motor unit number estimation was decreased by about half compared to healthy controls. Sensory nerve action potentials were reduced in nearly all subjects. Quantitative muscle assessment and timed 2 min walk may be useful as meaningful indicators of disease status. The direct correlation of testosterone levels with muscle strength indicates that androgens may have a positive effect on muscle function in spinal and bulbar muscular atrophy patients, in addition to the toxic effects described in animal models.

Patellofemoral knee pain in an adult with radiographic osteoarthritis and human immunodeficiency virus infection

STUDY DESIGN

Resident's case problem.

BACKGROUND

Kaposi's sarcoma (KS) is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although KS is often initially asymptomatic, this neoplasm may progress to affect multiple organ systems, including structures of the musculoskeletal system, which can produce symptoms similar to those associated with common orthopaedic conditions. This resident's case problem describes the evaluation and differential diagnosis of a 45-year-old male with HIV and KS, referred to physical therapy with an initial diagnosis of radiographic osteoarthritis (OA) and patellofemoral pain syndrome (PFPS) of the left knee. His primary complaint was knee pain during end range knee flexion.

DIAGNOSIS

The history, systems review, and examination suggested a source of pain of a nonorthopaedic origin. Differential examination ruled out clinical OA, PFPS, ligament/cartilage derangement, and tendonitis. Avascular necrosis of the medial femoral condyle was also considered as a possible source of pain. Recent blood tests indicated a high viral load and low CD4 count, which might have increased susceptibility to opportunistic infections or KS tumor progression. The patient was referred back to his physician for additional follow-up. Magnetic resonance imaging (MRI) of the knees were consistent with a systemic inflammatory process such as KS. A true-cut biopsy was subsequently scheduled, which confirmed KS lesions at the left knee.

DISCUSSION

Physical therapists who manage orthopaedic conditions should be aware of the disablement that may result from acquired immunodeficiency syndrome-related KS. A thorough joint-specific examination, with a broad differential diagnosis, should be employed for patients having known systemic diseases.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.

Effect of Alemtuzumab (CAMPATH 1-H) in patients with inclusion-body myositis

Sporadic inclusion-body myositis (sIBM) is the most common disabling, adult-onset, inflammatory myopathy histologically characterized by intense inflammation and vacuolar degeneration. In spite of T cell-mediated cytotoxicity and persistent, clonally expanded and antigen-driven endomysial T cells, the disease is resistant to immunotherapies. Alemtuzumab is a humanized monoclonal antibody that causes an immediate depletion or severe reduction of peripheral blood lymphocytes, lasting at least 6 months. We designed a proof-of-principle study to examine if one series of Alemtuzumab infusions in sIBM patients depletes not only peripheral blood lymphocytes but also endomysial T cells and alters the natural course of the disease. Thirteen sIBM patients with established 12-month natural history data received 0.3 mg/kg/day Alemtuzumab for 4 days. The study was powered to capture > or =10% increase strength 6 months after treatment. The primary end-point was disease stabilization compared to natural history, assessed by bi-monthly Quantitative Muscle Strength Testing and Medical Research Council strength measurements. Lymphocytes and T cell subsets were monitored concurrently in the blood and the repeated muscle biopsies. Alterations in the mRNA expression of inflammatory, stressor and degeneration-associated molecules were examined in the repeated biopsies. During a 12-month observation period, the patients' total strength had declined by a mean of 14.9% based on Quantitative Muscle Strength Testing. Six months after therapy, the overall decline was only 1.9% (P < 0.002), corresponding to a 13% differential gain. Among those patients, four improved by a mean of 10% and six reported improved performance of daily activities. The benefit was more evident by the Medical Research Council scales, which demonstrated a decline in the total scores by 13.8% during the observation period but an improvement by 11.4% (P < 0.001) after 6 months, reaching the level of strength recorded 12 months earlier. Depletion of peripheral blood lymphocytes, including the naive and memory CD8+ cells, was noted 2 weeks after treatment and persisted up to 6 months. The effector CD45RA(+)CD62L(-) cells, however, started to increase 2 months after therapy and peaked by the 4th month. Repeated muscle biopsies showed reduction of CD3 lymphocytes by a mean of 50% (P < 0.008), most prominent in the improved patients, and reduced mRNA expression of stressor molecules Fas, Mip-1a and alphaB-crystallin; the mRNA of desmin, a regeneration-associated molecule, increased. This proof-of-principle study provides insights into the pathogenesis of inclusion-body myositis and concludes that in sIBM one series of Alemtuzumab infusions can slow down disease progression up to 6 months, improve the strength of some patients, and reduce endomysial inflammation and stressor molecules. These encouraging results, the first in sIBM, warrant a future study with repeated infusions

Distribution and severity of weakness among patients with polymyositis, dermatomyositis and juvenile dermatomyositis

OBJECTIVE

To describe the distribution and severity of muscle weakness using manual muscle testing (MMT) in 172 patients with PM, DM and juvenile DM (JDM). The secondary objectives included characterizing individual muscle group weakness and determining associations of weakness with functional status and myositis characteristics in this large cohort of patients with myositis.

METHODS

Strength was assessed for 13 muscle groups using the 10-point MMT and expressed as a total score, subscores based on functional and anatomical regions, and grades for individual muscle groups. Patient characteristics and secondary outcomes, such as clinical course, muscle enzymes, corticosteroid dosage and functional status were evaluated for association with strength using univariate and multivariate analyses.

RESULTS

A gradient of proximal weakness was seen, with PM weakest, DM intermediate and JDM strongest among the three myositis clinical groups (P < or = 0.05). Hip flexors, hip extensors, hip abductors, neck flexors and shoulder abductors were the muscle groups with the greatest weakness among all three clinical groups. Muscle groups were affected symmetrically.

CONCLUSIONS

Axial and proximal muscle impairment was reflected in the five weakest muscles shared by our cohort of myositis patients. However, differences in the pattern of weakness were observed among all three clinical groups. Our findings suggest a greater severity of proximal weakness in PM in comparison with DM.

Navicular drop measurement in people with rheumatoid arthritis: interrater and intrarater reliability

BACKGROUND AND PURPOSE

Navicular drop (ND) measurement may be a valuable examination technique for patients with rheumatoid arthritis (RA). However, no data exist on reliability for this technique in patients with RA. The purposes of this study were: (1) to determine interrater and intrarater reliability of ND measurements in people with RA, (2) to compare ND values of people with RA with published normative data, and (3) to investigate ND measurement error associated with the use of skin markings.

SUBJECTS

Ten women (20 feet) with RA consented to participate.

METHODS

Patients completed demographic and function questionnaires. Navicular height (NH) measurements were taken by 2 physical therapists and 1 physical therapist student, following four 1-hour training sessions, using standardized methods and a digital height gauge. Four different NH measurements were taken 3 times on each foot by each of the 3 examiners during a morning session and then repeated during an afternoon session on the same day. Navicular drop values were calculated, including ND1 (as reported in the literature), ND2 (compensating for skin error), and ND3 (single-limb stance). Intraclass correlation coefficients (ICCs) and standard errors of measurement (SEMs) were used to establish reliability.

RESULTS

Means (+/-SD) for each ND measure for sessions 1 and 2, respectively, were as follows: ND1=8.36+/-5.29 mm and 8.29+/-5.24 mm, ND2=9.95+/-5.44 mm and 9.57+/-5.37 mm. The ICCs (2,1 and 2,k, respectively) for all interrater measurements ranged from .67 to .92 (SEM=2.0-3.3 mm) and from .85 to .97 (SEM=1.1-2.0 mm). The ICCs (2,1 and 2,k, respectively) for intrarater measurements ranged from .73 to .95 (SEM=1.3-2.8 mm) and from .90 to .98 (SEM=0.7-1.6 mm). Paired t tests showed the means of ND1 and ND2 for each examiner and for both sessions were significantly different.

DISCUSSION AND CONCLUSION

The results suggest that ND measurements for people with RA can be taken reliably by clinicians with varied experience. The ND values for our subjects were slightly greater than reported normal values of 6 to 8 mm. Error associated with skin markings was statistically significant for all sessions and examiners.

Physiotherapy management of patients with HIV-associated Kaposi's sarcoma

BACKGROUND

Kaposi's sarcoma is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although Kaposi sarcoma lesions may contribute to significant physical impairments, there is a lack of scientific literature detailing the role of physiotherapy in the treatment of HIV-associated Kaposi's sarcoma. The present Case Report includes two males, aged 36 and 39 years, seropositive for HIV with invasive Kaposi's sarcoma.

METHOD AND RESULTS

Patient A was evaluated for bilateral foot pain caused by plantar surface Kaposi s sarcoma lesions that rendered him unable to walk. He progressed to walking 400feet after a treatment regimen of gait training with the use of custom plastazote sandals. Patient B was evaluated for right lower extremity lymphoedema secondary to invasive Kaposi's sarcoma. He experienced an 18% reduction in limb volume, a 38% reduction in pain and a 20 degrees increase in terminal knee flexion after therapeutic exercise and the use of compressive bandaging and garments.

CONCLUSIONS

This Case Report suggests that physiotherapy interventions may be valuable in the conservative management of patients with HIV-associated Kaposi s sarcoma.

Nonoperative management of functional hallux limitus in a patient with rheumatoid arthritis

BACKGROUND AND PURPOSE

Functional hallux limitus (FHL) is a condition that affects motion at the first metatarsophalangeal joint and may lead to abnormal forefoot plantar pressures, pain, and difficulty with ambulation. The purpose of this case report is to describe a patient with rheumatoid arthritis (RA) and FHL who was managed with foot orthoses, footwear, shoe modifications, and patient education.

CASE DESCRIPTION

The patient was a 55-year-old woman diagnosed with seropositive RA 10 years previously. Her chief complaint was bilateral foot pain, particularly under the left great toe. Her foot pain had been present for several years, but during the past 5 months it had intensified and interfered with her work performance, activities of daily living, and social life.

OUTCOMES

Following 4 sessions of physical therapy over a 6-week time period, the patient reported complete relief of forefoot pain despite no change in medication use or RA disease pathophysiology. She was able to continuously walk for up to 4 hours. Left hallux peak plantar pressures were reduced from 43 N/cm2 to 18 N/cm2 with the foot orthoses.

DISCUSSION

Patients with RA who develop FHL may benefit from physical therapist management using semirigid foot orthoses, footwear, shoe modifications, and patient education.

Nonsurgical management of the foot and ankle affected by rheumatoid arthritis

Rheumatoid arthritis frequently affects foot and ankle function, leading to pain, difficulty with ambulation, and disability. The purpose of this article is to describe common foot and ankle deformities associated with rheumatoid arthritis and present state-of-the-art nonsurgical management strategies. Physical impairments thought to be commonly associated with limitations of function and practical interventions for alleviating those impairments or reducing the impact of the impairment on ambulation are identified. Examples of rehabilitation interventions discussed include prescription footwear, custom and premolded foot orthoses, hindfoot orthoses, ankle-foot orthoses, shoe modifications, therapeutic exercises, and patient education. Early and aggressive attempts at prevention, delay, or correction of foot and ankle pathomechanics related to rheumatoid arthritis may play a key role in helping patients maintain an active ambulatory lifestyle.

Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions

PURPOSE

The purpose of this study was to determine whether the pain response after phonophoresis (PH) differs from the pain response after ultrasound (US) alone.

METHODS

Forty-nine subjects with soft tissue injuries including epicondylitis, tendinitis, and tenosynovitis were randomly assigned (double blinded technique) to PH or US treatment groups. Both groups received 8 min of continuous US at 1.5 w x cm(-2), three times per week for 3 wk. For the PH group a gel containing 0.05% fluocinonide was used as a coupling agent. An identical gel absent the steroid was used for the US group. Subjects indicated their pain level by marking on a visual analog scale (VAS) at the start of treatment and at the end of weeks 1, 2, and 3. Pressure algometry was used to note tolerance to direct pressure over the target tissue. ANOVA for repeated measures was used to analyze data.

RESULTS

At the end of 3 wk of treatment, both groups combined showed a significant decrease in pain level and an increase in pressure tolerance (P < 0.05), but there were no differences between groups from the onset of treatment to the end of week 3 (VAS: US 5.5-1.9, PH 5.0-2.0; algometry (involved limb): US 4.7 lb-7.1 lb, PH 5.1 lb-6.6 lb).

CONCLUSIONS

We conclude that US results in decreased pain and increased pressure tolerance in these selected soft tissue injuries. The addition of PH with fluocinonide does not augment the benefits of US used alone.

Postsurgical hindfoot deformity of a patient with rheumatoid arthritis treated with custom-made foot orthoses and shoe modifications

This case report describes the treatment of a 73-year-old woman with long-standing, severe rheumatoid arthritis, using custom-made foot orthoses and shoe modifications. The patient was referred for physical therapy 4 weeks after triple arthrodesis of her right foot. Her primary complaint was periodic unsteadiness during gait, which necessitated the use of a cane at all times. Other problems included a lower-extremity length discrepancy and right foot pain. Physical therapy included fabrication of bilateral semirigid foot orthoses, shoe modifications, gait training, and instruction in strengthening exercises. After treatment, the patient reported feeling steady during walking without a cane, and she was able to resume community activities without right foot pain. Computerized movement analysis of gait revealed that the use of orthoses and modified footwear reduced weight bearing and movement-pattern abnormalities, as compared with barefoot walking. The findings in this case show that physical therapy including foot orthoses, shoe modifications, gait training, and strengthening exercises can be instrumental in the postsurgical rehabilitation of a patient with severe rheumatoid arthritis.