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Exercise is one of the prime ingredients of successful management of various muscle disorders. Without doubt, sport is an enjoyable way of exercising, and young patients in particular are very keen. However, for some patients, care and vigilance with regard to their disease and/or concurrent medical treatments is a prerequisite when exercise is prescribed. In this letter, we describe an amateur badminton player with juvenile dermatomyositis (JDM) and briefly consider the pros and cons of exercise therapy for such patients.
A 15 year old boy presented with muscle pain in his right arm. The pain had first started 10 days previously, and occurred particularly during badminton training. It usually emerged in his right biceps and sometimes extended to the right elbow or shoulder. On detailed questioning, we discovered that he had concentrated on his “back-hand” during the preceding 10 days of training. He had had JDM for five years but was currently in remission. He was using prednisolone (7.5 mg/day), cyclosporine (100 mg/day), alendronate (10 mg/day), calcitonin, and vitamin D. Previously, he had also used various combinations of high dose steroids, methotrexate, and immunoglobulins. He had been an amateur badminton player for five years. His medical history was otherwise unremarkable.
The physical examination found tenderness on the medial side of the right biceps muscle. Elbow and shoulder motion were free and painless. The neurological examination was unremarkable except for a mild proximal weakness bilaterally. Ultrasonographic imaging was inconclusive. He was diagnosed as having a right biceps strain, caused by forceful backhand movements, and a conservative protocol was recommended including rest and intermittent cold application.
Patients with dermatomyositis may have many muscular complaints including proximal and symmetrical weakness, reduced endurance, and pain. Therefore it can have a major impact on physical function, limiting leisure and daily activities.1,2 The predominant symptom of fatigue is presumed to be secondary to muscle or cardiopulmonary involvement, and deconditioning due to reduced activity and effects of medication. The perpetuating cycle of muscle atrophy, decreased body weight, corticosteroid myopathy, skeletal muscle microvessel disease, and abnormal energy metabolism usually culminates in a sedentary lifestyle with decreased aerobic capacity.3,4 As children are known to do more walking and running than adults, muscle anaerobiosis may contribute to the limitations in endurance activities in patients with JDM.
Controlled physical exercises in patients with inflammatory myopathy have been reported to be safe. These may include stationary cycling, step aerobics, walking, and strength exercises for weak muscles, along with prompt warming, cool down, and stretching exercises.5,6 Besides considerably improving muscle strength,6,7 these regimens have been found to increase aerobic capacity and daily physical functions of patients with JDM, without any adverse effects on the disease activity, when compared with sedentary controls.5–8 However, as eccentric contractions are more closely associated with muscle damage and greater efflux of muscle enzymes into the circulation, training that consists of mainly concentric-type exercises is recommended for these patients.6
In this adolescent patient with JDM, we emphasise the positive effect of sport even though it used to be feared that exercise could aggravate muscle inflammation. Although highlighting the role of timely exercise regimens in rehabilitation programmes, we draw attention to the necessity for medical supervision. Doctors should be alert to any complications from underlying musculoskeletal pathologies such as myopathy and decreased bone mineral density in these patients.