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Improvement of physical fitness and muscle strength in

polymyositis/dermatomyositis patients by a training programme

Article  in  British journal of rheumatology · February 1998

DOI: 10.1093/rheumatology/37.2.196 · Source: PubMed

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British Journal of Rheumatology 1998;37:196–200

IMPROVEMENT OF PHYSICAL FITNESS AND MUSCLE STRENGTH IN

POLYMYOSITIS/DERMATOMYOSITIS PATIENTS BY A TRAINING PROGRAMME
G. F. WIESINGER, M. QUITTAN, M. ARINGER,* A. SEEBER,‡ B. VOLC-PLATZER,† J. SMOLEN*
and W. GRANINGER*
Department of Physical Medicine and Rehabilitation, *Department of Internal Medicine, Division of Rheumatology,
†Department of Dermatology, Division of Immunology, Allergy and Infectious Disease and ‡Division of General Dermatology,
University of Vienna, Austria

SUMMARY
In the present investigation, the benefit of physical training in patients with inflammatory myopathy was studied. In this
prospective, randomized, controlled study, 14 patients with polymyositis (PM ) or dermatomyositis (DM ) were investigated.
The training, consisting of bicycle exercise and step aerobics, took place over a 6 week period. Baseline and endpoint
measurements included an ‘activities of daily living’ (ADL) score, peak isometric torque (PIT ) generated by muscle groups in
the lower extremities, peak oxygen consumption ( VO max), and creatine phosphokinase (CPK ) levels. There was no significant
2
rise in disease activity in the training group in comparison to the controls. The ADL score for the treatment group, in
comparison to the control group, improved (P < 0.02), PIT rose (P < 0.05) and there was a statistically significant increase in
oxygen uptake relative to body weight (P < 0.05). No rise in inflammatory activity, but significant improvement in muscle
strength, oxygen uptake and well-being, were found in patients with inflammatory myopathy as a result of physical training.
Besides medication, a physical training programme consisting mainly of concentric muscle contractions should therefore be an
integral part of therapy, particularly in view of the cardiopulmonary risk of these patients.
K : Polymyositis, Dermatomyositis, Physical training, Rehabilitation, Rheumatology, Dermatology.

P and dermatomyositis (PM/DM ) are MATERIALS AND METHODS

inflammatory myopathies of unknown aetiology. Study design
Muscle weakness, myalgias and sometimes generalized Patients. Patients were entered into this prospective,
fatigue lead to malaise and to decreased use of striated randomized and controlled study if they met the follow-
muscles [1]. In addition, cardiac abnormalities and ing criteria.
pulmonary involvement may restrain cardiovascular
fitness [2–7]. Decreased muscle activity leads to further (1) Established DM or PM with a disease duration of
atrophy of muscle fibres and a decrease in cardiorespir- >6 months.
atory training status. Despite these facts, many physi- (2) Clinical activity defined as the presence of proximal
cians recommend a reduction in physical activity since muscle weakness, characterized clinically by a
it is feared that the use of inflamed tissue would further reduced ability to climb stairs, to cross one leg
worsen the inflammatory process [1, 8–10]. over the other, to rise from a squatting position,
In many chronic diseases, a controlled muscle train- to rise from a seated position, to comb the hair;
ing and exercise programme has been shown to result and/or by the elevation of serum muscle enzyme
in an improvement in the clinical symptoms [11–15]. values [creatine phosphokinase (CPK ) levels above
Therefore, we hypothesized that also in myositis, at the upper limit of normal (70 IU/l ) on three or
least during stable phases of chronic muscle inflamma- more consecutive observations during the preced-
tion, controlled muscle training might be of benefit to ing 3 month period ].
the well-being and cardiorespiratory fitness of the (3) The drug therapy had to be stable for at least 3
patients. months before the start of the training programme.
In this prospective, controlled study of a physical Exclusion criteria were clinically manifest pulmonary
exercise programme in chronic myositis patients, we or cardiac disorders, inclusion body myositis, fever,
evaluated its effects on (a) disease activity, (b) well- neoplasms, physical inability of patients to exercise, or
being, (c) muscle strength and (d ) cardiorespiratory increase in muscle destruction during the past 3 months
fitness. We show that the training programme does not before the start of the training programme, as indicated
have negative effects on disease activity, but led to by at least a 50% increase in CPK levels over the
significant improvement of the variables investigated baseline value.
and thus to overall benefit to the patients. Fourteen consecutive patients (nine women and five
men) between 24 and 70 yr of age (median 51), who
met these criteria, were entered into the study. All
Submitted 24 February 1997; revised version accepted 25 June
1997.
patients had a diagnosis of primary inflammatory
Correspondence to: W. Graninger, Division of Rheumatology, muscle disease as defined by the established criteria of
Department of Internal Medicine III, University of Vienna, Vienna Bohan and Peter [16 ]. In all patients, muscle biopsies,
General Hospital, Waehringer Guertel 18–20, A-1090, Vienna, electromyograms and laboratory studies had been per-
Austria. formed to establish the diagnosis. Nine out of the

© 1998 British Society for Rheumatology

196
 WIESINGER ET AL.: AEROBIC CONDITIONING IN POLYMYOSITIS 197

14 suffered from DM and five had PM. In all patients, Assessment of efficacy and unwanted effects
medication was kept constant for the study period. Laboratory assessment. Elevated serum levels of
Nine patients were treated with prednisolone (up to enzymes, such as CPK and aldolase, which leak from
25 mg/day); four patients received high-dose i.v. injured skeletal muscle are valuable aids in detecting
immunoglobulins; two patients had azathioprine, active muscle inflammation [17]. In order to determine
100 mg/day, and two other patients received cyclospo- the effects of training on the degree of muscle destruc-
rin A; one patient was treated with a non-steroidal tion, these two enzymes were measured weekly on
anti-inflammatory drug only. The characteristics of Monday after a weekend recovery phase without
patients with DM and PM were similar ( Table I ). exercise.
None of the patients had participated in regular phys- Functional assessment. For describing individual abil-
ical exercise for 2 yr before inclusion in our study. ities and limitations, we used a modified Functional
Randomization. The study was conducted at the Assessment Screening Questionnaire. This question-
University Hospital of Vienna following approval by naire has been well described [18] and used for evaluat-
the local ethical committee. Informed consent was ing disability [19]. The questionnaire was used in a
obtained from all patients before they were randomly German translation. Questionnaires for functional
assigned either to the training group ( TG) or to the assessment have been validated in many languages,
control group (CG). Distinct randomization lists were including German [20, 21], and have proved useful
used. According to the decision of the ethical commit- across many language and cultural barriers [22–24].
tee, the patients in the control group were also to be The patients had to fill in the questionnaires at the
guaranteed participation in the training programme at beginning and at the end of the 6 weeks observation
the end of the study, if it should prove beneficial. period. Since the use of visual analogue scale ( VAS)
anchors that clearly indicate extremes appears to have
Description of exercise regime the greatest sensitivity and is the least susceptible to
Patients in the training group took part in a 6 week bias or distortions in rating [25, 26 ], a 10-cm-long
training programme which included a mixed pro- VAS was used for each question.
gramme of stationary cycling and step aerobics. Each Measurement of muscle strength. Muscle strength
exercise session lasted for 1 h. Cycling was slowly was determined in the TG and the CG before and at
increased on an individual basis. Following a 3–5 min the end of the 6 weeks observation period. The muscle
warm-up phase, resistance was increased until a heart strength of the hip flexors and the knee extensors
rate of 60% of the previously established maximum on the right and on the left side was analysed by
heart rate was reached. If the patient reported increased a computerized isokinetic system (CYBEX 6000
muscle tenderness from the preceding exercise, the Isokinetic dynamometer, Lumex Inc., New York),
resistance was decreased to a previously tolerated which measures the peak isometric torque (PIT ).
amount. Every training session also included one half- CYBEX assessment was carried out by the same
hour of step aerobics. The last 5 min were used for person who was unaware of the group to which
cool-down and stretching exercises. Because of the individual patients belonged. Bilaterally, the extensors
different rate levels, the training load of this exercise of the knee in the seated position, and the flexors of
could be adjusted and changed. During the first 2 the hip in the supine position, were tested. The patients
weeks, training was carried out twice weekly and three had to perform maximal isometric contractions and,
times weekly during the remaining 4 weeks. The train- during these measurements, the best of three attempts
ing was guided by a physiotherapist and supervised by by the individual patient was recorded. The results of
the authors regularly. The patients were allowed to the PIT are expressed as the sum of values obtained
carry out an additional training programme, such as for the four muscle groups (hip flexors and knee
stationary cycling at home, if they so wished. Patients extensors on both legs) [27].
in the control group did not undergo any training and The CYBEX system has been used extensively to
continued their previous way of life. assess muscle strength in normal and in some diseased

TABLE I
Clinical characteristics of study patients

Characteristics Training group (n = 7) Control group (n = 7)

Age (yr) (median, range) 56 (44–68) 40 (24–70)*

Sex (f/m) 4/3 5/2
PM/DM 2/5 2/5
CPK level elevated above 7/0 4/3
upper limit of normal (y/n)
ADL score (mean ± ...) 156.6 (±9.7) 142.6 (±19.8)*
PIT (Nm) (mean ± ...) 633.1 (±100) 435 (±82)*
VO max (ml/min/kg) (mean ± ...) 17.4 (±1) 16.9 (±1.8)*
2
*No statistically significant differences between the training and control group.
198 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 37 NO. 2

populations, and has been reported to give valid and Statistical analysis
reliable results [28]. The detailed method has been Descriptive statistics (means, ..., median, range)
outlined previously and its utility in the assessment of were performed for all dependent variables. In order
strength in patients with inflammatory muscle disease to determine changes in each patient, the differences
has been described [29]. in the variable values between baseline and endpoint
Exercise testing. Exercise studies were performed were determined. Owing to the small sample sizes and
using a symptom-limited, incremental cycle ergometer non-normality of the data of this prospective, random-
protocol. Pedalling at 50–60 r.p.m., the work rate was ized, controlled trial, exact non-parametric tests were
increased every 2 min by 25 W from an initial load of used. The exact Wilcoxon signed rank test was used
25 W. Ventilatory parameters were collected breath by to test for significant changes in the variable values
breath using a computer-based device (Sensor Medics before and after the training programme within the
2900 System, Sensormedics, Yorba Linda, LA, CA, groups. The exact Mann–Whitney U-test was used to
USA) and 20 s averages for each parameter were compare these changes between the two groups. Both
registered. Patients breathed through a mouthpiece were performed using the software system StatXact-
connected to a mass flowmeter (Sensor Medics, CA, Turbo (CYTEL Software Corporation, 1992,
USA), measuring minute ventilation by the thermal Cambridge, MA, USA). A P value of <0.05 was
conductivity technique. Oxygen uptake ( VO ) was considered statistically significant.
2
measured with a fast-response zirconium oxide
analyser (Servomex-Taylor, Fussex). The anaerobic RESULTS
threshold was determined by using the V slope tech- The clinical characteristics of the training group
nique [30]. Samples of whole blood were taken from (n = 7) and the control group (n = 7) at baseline are
the hyperaemized earlobe at rest, within the last 20 s indicated in Table I. The two groups were well balanced
of each work rate, and at maximal exercise with a with respect to most baseline characteristics. No statist-
20 ml capillary to assess lactate concentration ( ESAT ically significant differences were observed between the
6661, Eppendorf, Hamburg, Germany). The heart rate two groups. Medication remained unchanged during
and rhythm were recorded continuously at rest and the 3 months before and during the study in all subjects
throughout exercise with a 12-lead electrocardiogram participating in the trial. Questioning at the end of the
(Siemens, Germany). Maximal oxygen uptake study revealed that none of the control patients had
( VO max) was defined as the highest O consumption changed the extent of their daily physical activities.
2 2
obtained during the symptom-limited exercise test [31]. Overall, the training programme was well tolerated.
In order to examine the effects of the training, values The changes in endpoint results as a percentage of
for VO max (ml/min/kg) at initiation and at the end baseline for patients in the training and control groups
2
of the study were compared. are shown in Fig. 1. There was no statistically signific-

F. 1.—Endpoint results of creatine phosphokinase (CPK ), peak isometric torque (PIT ), peak oxygen consumption ( VO max) and ‘activities
2
of daily living’ (ADL) score are depicted as a percentage of the baseline for both the training (A) and the control group (B). The P values
(endpoint vs baseline; Wilcoxon signed rank test) indicate significant improvement of PIT (P < 0.05), VO max (P < 0.05) and ADL score
2
(P < 0.02) for the training group. For PIT, VO max and ADL score in the control group, and for CPK in both groups, changes did not reach
2
statistical significance.
 WIESINGER ET AL.: AEROBIC CONDITIONING IN POLYMYOSITIS 199

ant change in CPK and aldolase (data not shown) intensity was adjusted to fit the individual needs of the
during the observation periods either in the CG (mean patients.
−13.9%; ... 14) or in the TG (mean −6%; ... A sedentary lifestyle is an important health risk
8.5) (in spite of the training programme). factor that has been well documented in the physically
However, after the 6 weeks of training, there was a abled population. It is particularly associated with an
significant (P < 0.02) improvement in ADL rating in increased risk of cardiovascular and coronary heart
the patients who participated in the training (mean disease [37–39]. A physically active lifestyle, in con-
20.5%; ... 4.1), but not in the control group (mean trast, has been shown to be effective in lowering all-
2.9%; ... 11.1). There was also a significant group cause mortality in the able-bodied population [40].
difference for the ADL score (P < 0.02) after (but not The present study leads us to conclude that a physical
before) the observation period. training programme should be recommended for
Moreover, muscle strength when measured with PIT patients with chronic DM/PM as an adjunct to drug
improved significantly (P = 0.03) in the training group therapy. Training, however, must be carried out under
(mean 29.4%; ... 6.9), in contrast to the control medical supervision and must be adjusted to fit the
group (mean 11.1%; ... 11.6). Again, after the 6 needs of the patients.
weeks training programme, the group difference was
significant (P < 0.05). A
Finally, after the training, the maximal VO The authors wish to thank Mrs M. Knötig for
2 technical assistance.
(ml/min/kg) uptake had increased in the training group
(mean 12%; ... 4.7; P < 0.05), but not in the control
group (mean −2.6%; ... 6.4), and a significant R
group difference in maximal VO (ml/min/kg) uptake 1. Cronin ME. Treatment. In: Plotz PH, moderater.
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