Joshua Burns1, Amy D Sman2, Kayla M D Cornett3, Elizabeth Wojciechowski4, Terri Walker5, Manoj P Menezes6, Melissa R Mandarakas3, Kristy J Rose3, Paula Bray7, Hugo Sampaio8, Michelle Farrar9, Kathryn M Refshauge3, Jacqueline Raymond3. 1. Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia; Paediatric Gait Analysis Service of New South Wales, Sydney, New South Wales, Australia. Electronic address: joshua.burns@sydney.edu.au. 2. Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia; Fysiotherapie Centraal, Radboudumc, Nijmegen, Netherlands. 3. Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia. 4. Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia; Paediatric Gait Analysis Service of New South Wales, Sydney, New South Wales, Australia. 5. Department of Medical Imaging, Sydney Children's Hospitals Network (Randwick and Westmead), Sydney, New South Wales, Australia. 6. Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; T Y Nelson Department of Neurology and Neurosurgery, Sydney Children's Hospitals Network (Randwick and Westmead), Sydney, New South Wales, Australia. 7. Paediatric Gait Analysis Service of New South Wales, Sydney, New South Wales, Australia. 8. Department of Paediatric Neurology, Sydney Children's Hospitals Network (Randwick and Westmead), Sydney, New South Wales, Australia. 9. Department of Paediatric Neurology, Sydney Children's Hospitals Network (Randwick and Westmead), Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
Abstract
BACKGROUND:Exercise is potentially therapeutic for neuromuscular disorders, but a risk of harm exists due to overwork weakness. We aimed to assess the safety and efficacy of progressive resistance exercise for foot dorsiflexion weakness in children with Charcot-Marie-Tooth disease. METHODS: We did this randomised, double-blind, sham-controlled trial across the Sydney Children's Hospitals Network (NSW, Australia). Children aged 6-17 years with Charcot-Marie-Tooth disease were eligible if they had foot dorsiflexion weakness (negative Z score based on age-matched and sex-matched normative reference values). We randomly allocated (1:1) children, with random block sizes of 4, 6, and 8 and stratification by age, to receive 6 months (three times per week on non-consecutive days; 72 sessions in total) of progressive resistance training (from 50% to 70% of the most recent one repetition maximum) or sham training (negligible non-progressed intensity), using an adjustable exercise cuff to exercise the dorsiflexors of each foot. The primary efficacy outcome was the between-group difference in dorsiflexion strength assessed by hand-held dynamometry (expressed as a Z score) from baseline to months 6, 12, and 24. The primary safety outcome was the between-group difference in muscle and intramuscular fat volume of the anterior compartment of the lower leg assessed by MRI (expressed as a scaled volume) from baseline to 6 months and 24 months. Participants, parents, outcome evaluators, and investigators other than the treatment team were masked to treatment assignment. Analysis was by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613000552785. FINDINGS: From Sept 2, 2013, to Dec 11, 2014, we randomly assigned 60 children to receive progressive resistance exercise (n=30) or sham training (n=30), and 55 (92%) children completed the trial. ANCOVA-adjusted Z score differences in dorsiflexion strength between groups were 0 (95% CI -0·37 to 0·42; p=0·91) at 6 months, 0·3 (-0·23 to 0·81; p=0·27) at 12 months, and 0·6 (95% CI 0·03 to 1·12; p=0·041) at 24 months. Scaled muscle and fat volume was comparable between groups at 6 months (ANCOVA-adjusted muscle volume difference 0, 95% CI -0·03 to 0·10, p=0·24; and fat volume difference 0, 95% CI -0·01 to 0·05, p=0·25) and 24 months (0, -0·08 to 0·12, p=0·67; and 0, -0·05 to 0·03, p=0·58). No serious adverse events were reported. INTERPRETATION: 6 months of targeted progressive resistance exercise attenuated long-term progression of dorsiflexion weakness without detrimental effect on muscle morphology or other signs of overwork weakness in paediatric patients with Charcot-Marie-Tooth disease. FUNDING: Muscular Dystrophy Association and Australian National Health and Medical Research Council.
RCT Entities:
BACKGROUND: Exercise is potentially therapeutic for neuromuscular disorders, but a risk of harm exists due to overwork weakness. We aimed to assess the safety and efficacy of progressive resistance exercise for foot dorsiflexion weakness in children with Charcot-Marie-Tooth disease. METHODS: We did this randomised, double-blind, sham-controlled trial across the Sydney Children's Hospitals Network (NSW, Australia). Children aged 6-17 years with Charcot-Marie-Tooth disease were eligible if they had foot dorsiflexion weakness (negative Z score based on age-matched and sex-matched normative reference values). We randomly allocated (1:1) children, with random block sizes of 4, 6, and 8 and stratification by age, to receive 6 months (three times per week on non-consecutive days; 72 sessions in total) of progressive resistance training (from 50% to 70% of the most recent one repetition maximum) or sham training (negligible non-progressed intensity), using an adjustable exercise cuff to exercise the dorsiflexors of each foot. The primary efficacy outcome was the between-group difference in dorsiflexion strength assessed by hand-held dynamometry (expressed as a Z score) from baseline to months 6, 12, and 24. The primary safety outcome was the between-group difference in muscle and intramuscular fat volume of the anterior compartment of the lower leg assessed by MRI (expressed as a scaled volume) from baseline to 6 months and 24 months. Participants, parents, outcome evaluators, and investigators other than the treatment team were masked to treatment assignment. Analysis was by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12613000552785. FINDINGS: From Sept 2, 2013, to Dec 11, 2014, we randomly assigned 60 children to receive progressive resistance exercise (n=30) or sham training (n=30), and 55 (92%) children completed the trial. ANCOVA-adjusted Z score differences in dorsiflexion strength between groups were 0 (95% CI -0·37 to 0·42; p=0·91) at 6 months, 0·3 (-0·23 to 0·81; p=0·27) at 12 months, and 0·6 (95% CI 0·03 to 1·12; p=0·041) at 24 months. Scaled muscle and fat volume was comparable between groups at 6 months (ANCOVA-adjusted muscle volume difference 0, 95% CI -0·03 to 0·10, p=0·24; and fat volume difference 0, 95% CI -0·01 to 0·05, p=0·25) and 24 months (0, -0·08 to 0·12, p=0·67; and 0, -0·05 to 0·03, p=0·58). No serious adverse events were reported. INTERPRETATION: 6 months of targeted progressive resistance exercise attenuated long-term progression of dorsiflexion weakness without detrimental effect on muscle morphology or other signs of overwork weakness in paediatric patients with Charcot-Marie-Tooth disease. FUNDING: Muscular Dystrophy Association and Australian National Health and Medical Research Council.
Authors: Tejaswi Kandula; Michelle Anne Farrar; Richard J Cohn; David Mizrahi; Kate Carey; Karen Johnston; Matthew C Kiernan; Arun V Krishnan; Susanna B Park Journal: JAMA Neurol Date: 2018-08-01 Impact factor: 18.302
Authors: Melissa R Mandarakas; Manoj P Menezes; Kristy J Rose; Rosemary Shy; Kate Eichinger; Maria Foscan; Timothy Estilow; Rachel Kennedy; Karen Herbert; Paula Bray; Kathryn Refshauge; Monique M Ryan; Eppie M Yiu; Michelle Farrar; Hugo Sampaio; Isabella Moroni; Emanuela Pagliano; Davide Pareyson; Sabrina W Yum; David N Herrmann; Gyula Acsadi; Michael E Shy; Joshua Burns; Oranee Sanmaneechai Journal: Brain Date: 2018-12-01 Impact factor: 13.501
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