# Exercise as it relates to Disease/Arm Ergometer or ROM? Which Upper Extremity Exercise works best for Duchenne Muscular Dystrophy Patients

This wiki fact sheet is an analysis of the paper "Different Types of Upper Extremity Exercise Training in Duchenne Muscular Dystrophy: Effects on Functional Performance, Strength, Endurance and Ambulation" by Alemdaroglu et.al (2015).
Note: This wiki fact sheet is an assignment for the University of Canberra (u3159550)

## What is the background to this research?

Duchenne Muscular Dystrophy (DMD) is an inherited neuromuscular degenerative condition. Patients with this disorder lack the gene, dystrophin, which causes a continuous deterioration of muscle fibres leading to a progressive loss of functional abilities and weakness in skeletal and cardiorespiratory muscles. Unfortunately, this eventually results in a severe physical disability and shortened life expectancy.
As a consequence of the gradual muscular disuse, ambulation and independence of daily activities are affected, increasing sedentary lifestyles of children with DMD. To date, no curative pharmaceutical therapy is available, hence, it is important to preserve functional abilities and lengthen the period of muscle fibre degeneration. Due to the significance of lower extremities in ambulation, lower extremity exercises have always been prioritised. Therefore, when the functional inability of the upper extremity is eventually confronted, the intervention is not as effective.
This study conducted by Alemdaroglu and companions investigates the effects of two different upper extremity exercise training programs which focus on functional performance, strength, endurance and ambulation in patients with early stages of DMD. By comparing the effects of either exercising with an arm ergometer or following a strengthening range of motion (ROM) exercise program, it can be determined which is more effective in preserving and improving the functional ability of the upper extremity.

## Where is the research from?

The study was investigated by researchers from:
* Physiotherapy and Rehabilitation Department of Bezmialem Vakif University (Turkey)
* Physiotherapy and Rehabilitation Department of Hacettepe University (Turkey)
* Pediatric Neurology Department of Hacettepe University (Turkey)
The complete study was published in the journal "Muscle and Nerve" in 2015.
Furthermore, ethical approval was obtained from the Non Invasive Clinical Research Ethics Committee of Hacettepe University.

## What kind of research was this?

This study was a randomised controlled trial that investigated two different upper extremity exercise training programs. The 'coin toss' method was used to allocate participants into either the:
* Control Group: strengthening ROM exercise program
* Study Group: arm ergometer exercise program
The National Health and Medical Research Council designated this type of research method as a 'level 2'. It is considered appropriate as it will provide strong evidence for clinical studies.

## What did the research involve?

24 children from the ages 8–12 participated in this study. It was ensured that the patients:
* functional levels were from grades 1-3 according to the Brooke Upper Extremity Functional Classification (BUEFC)
* were on steroids for over 6 months
* are still ambulant
* are able to sit independently for at least one hour
* and are able to cooperate with the evaluator's instructions
Deomographic data, muscle strength, grip strength, arm elevation, timed performance, upper extremity endurance and ambulation were recorded. The intensity of exercise is determined based on the functional level and muscle strength of each subject. The control group participants were given ROM exercises to be performed at home under family supervision for 8 weeks (40 minutes/session, 5 days/week) The study group participants were given exercise training with an arm ergometer under the supervision of a physiotherapist for 8 weeks (40 minutes/session, 3 days/week)
Through family supervision, family awareness of the situation increases, however, it would have been ideal if the ROM program was supervised by physiotherapists as well. This would have ensured the program was correctly followed to meet the same requirements.

## What were the basic results?

The researchers re-assessed each participant and the following was found:
| Assessment | Control group | Study Group |
| BUEFC Levels | no significance difference | no significance difference |
| Muscle Strength | slight increase | no significance difference |
| Grip Strength | increased | no significance difference |
| Functional Test | endurance increased only | increased |
note: functional tests include arm functions, timed performance, endurance and ambulation

## What conclusions should be taken away from this research?

The findings of this research are similar to other studies previously examined on upper extremity function in DMD patients by agreeing about the importance of maintaining functional ability. However, this study takes it a step further and concludes that upper extremity training with an arm ergometer is more adequate in preserving functional ability of early stage DMD patients compared to just following a strengthening ROM program. Compared to ROM exercises, the arm ergometer was shown to have an increase in the quality of arm movement and functions of both distal and proximal portions of the upper extremity. The arm ergometer also provided the participant with increase in both synergistic muscle activity and body support.

## Practical advice

Upper extremity training is just as vital as lower extremity training to improve functional ability and ambulation, and increase independence in daily activities. Resistance and aerobic exercises with a low to moderate intensity can improve the strength and endurance in DMD patients. In addition, it is necessary to ensure the program is enjoyable and easy to follow through. However, before commencing any rehabilitation program, screening should be done so no further harm is caused to the patient.

## Further information/resources

For more information on DMD:
Duchenne Foundation Australia: https://www.duchennefoundation.org.au/understanding-duchenne/duchenne-muscular-dystrophy/
Muscular Dystrophy Australia: http://www.mda.org.au/disorders/dystrophies/dmd-bmd.asp
Muscular Dystrophy Foundation: http://mdaustralia.org.au/
Also, help can be provided from health practitioners that specialise in this field.

## References

* 1 2 3 4 Alemdaroglu I, Karaduman A, Yilmaz OT, Topaloglu H, 2015, "Different Types Of Upper Extremity Exercise Training In Duchenne Muscular Dystrophy: Effects On Functional Performance, Strength, Endurance, And Ambulation", Muscle and Nerve 51(5): 697-705. DOI:10.1002/mus.24451
* ↑ Bartels B, Pangalila RF, Bergen MP, Cobben NAM, Stam HJ, Roebroeck ME, 2011, Upper limb function in adults with Duchenne Muscular Dystrophy, Journal of Rehabilitation Medicine, 43 (9): 770-775, DOI: 10.2340/16501977-0841
* 1 2 3 Jansen M, De Groot IJ, Van Alfen N, Geurts AC, 2010, Physical training in boys with Duchenne Muscular Dystrophy: The protocol of the no use is disuse study, BMC Pediatrics, 10(55), DOI: 10.1186/1471-2431-10-55.
* ↑ NHMRC GAR consultants, 2009, NHMRC additional levels of evidence and grades for recommendations for developers of guidelines, NHMRC, available on: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf
* ↑ Lowes LP, Alfano LN, Smigelsi J, Mendell JR, Flanigan KF, 2012, Development of a virtual upper extremity assessment tool for individuals with DMD across the lifespan, Neuromuscular Disorders, 22(9-10):878-879, DOI:10.1016/j.nmd.2007.11.004
* ↑ Mayhew A, Mazzone ES, Eagle M, Duong T, Ash M, Decostre V, et,al, 2013, Development of the performance of the upper limb module for duchenne muscular dystrophy, neuromuscular disorders, 55(11): 1038-1045, DOI: 10.1111/dmcn.12213
* ↑ Grange RW, Call JA, 2007, Recommondations to define exercise presciption for Duchenne Muscular Dystrophy, Exerc SPort Sci REv, 35(1):12-17, DOI: 10.1249/01.jes.0000240020.84630.9d