The best clinicians see medicine as an ever-evolving discipline that is unafraid to admit mistakes and learn from them. They also embrace a level of curiosity that causes them to question everything, understanding that no set of guidelines is perfect and they are subject to change once new evidence emerges.
It is when medicine becomes complacent and unthinking that the risk of errors is at its highest. A very practical example is checking the patient’s allergic status prior to hospital admission. On rare occasions, healthcare staff neglect this step, with the result being the patient experiencing severe anaphylaxis in response to a drug or a type of food consumed. This may even lead to death.
When it comes to diseases in which patients are fighting tooth and nail to enjoy a better quality of life, we as healthcare professionals must support them to the best of our ability. And that means questioning whether what we do are indeed best practices according to the latest evidence. Medicine is all about agility; we must be agile enough to change strategies when the moment calls for it.
The Value of Strengthening Exercises in DMD
In Duchenne muscular dystrophy (DMD), an aspect of treatment recommended again and again by clinical trials is conducting strengthening exercises to improve muscular strength and delay deterioration. However, can we be sure that the quality of movements patients are asked to perform is uniform among all physiotherapists?
Also, to what extent are physiotherapists pushing their patients to go the distance in the hopes of ultimately leading to better clinical outcomes? Evidence suggests that an optimistic, purpose-filled outlook on life can do wonders.
In other words, the mere prescription of “muscle-strengthening exercises” can lead to vastly different outcomes, even though the general set-up remains similar.
Let’s first establish the importance of strengthening exercise in patients with DMD.
“Exercise is known to improve muscle health and strength in healthy individuals as well as positively affect other systems,” Spaulding and Selsby wrote in Medicine & Science in Sports & Exercise. “Because of this, exercise has been investigated as a potential therapeutic approach for DMD.”
Read more about DMD etiology
In Exercise Training and Supplements for Improving Function in Muscular Dystrophy, Kostek wrote, “Physical activity is likely to synergistically improve [precision therapies] and can be used to enhance muscle health and quality of life after these therapies are delivered using the tools of precision medicine.”
Safety and Feasibility
We have heard voices from different researchers about the value of physical exercise in the management of Duchenne muscular dystrophy. Let us now turn our attention toward a study conducted by Lott et al on the safety and feasibility of a 12-week in-home strengthening program among 8 boys conducted via remote supervision. (The COVID-19 pandemic has made remote supervision more palatable to patients and carers alike).
To conduct this study, the research team recruited ambulatory boys with DMD. This study was 2-part: the first was on determining the dose-response and safety of isometric leg strengthening exercises in pediatric patients in DMD; the second investigated the safety and feasibility of an in-home, mild to moderate intensity strengthening exercise program.
“Our results from Study 1 provide promising data that one to three bouts of mild- to moderate-intensity isometric exercise do not cause acute muscle damage in boys with DMD,” Lott and colleagues wrote. “Furthermore, results from Study 2 suggest a moderate-intensity isometric strengthening exercise program is not only safe but also promotes improvements in strength and function in ambulatory boys with DMD.”
In other words, both these approaches to DMD care are found to be safe. As alluded to earlier, the COVID-19 pandemic has caused the sharp rise of telemedicine, which in some cases means that physicians can observe patients performing exercise through a secure internet video line. The benefits of this are that there is no travel time, and that remote observation can be just as effective as in-person observation, minus the red tape.
Read more about DMD treatment
The authors of this study concluded, “The results of this work suggest an in-home, mild- to moderate-intensity isometric exercise program done [3 times per week] is safe and potentially has a positive effect on strength and function in ambulatory boys with DMD.”
The Efficacy of Remote Assessment
The importance of this study is that an effort was made to investigate the efficacy of this new form of exercise monitoring instead of just assuming that both patient and physician will readily adjust and that there are no downsides to the increasing use of technology in the way we communicate with our patients and monitor their progress.
In truth, many of us are excited about how telemedicine and telemonitoring can simplify medicine, make patients’ lives easier, and still yield impressive results. Every patient deserves the best shot at a normal life. Whether this is accomplished through in-person consultations, remote observation, or a hybrid of both, the goal remains the same: to prolong quality of life with the hopes that a cure can be found in the meantime.
On one hand, physicians are expected to adapt to the latest technology to better serve our patients. On the other hand, it is entirely the right thing to do for physicians to investigate whether new approaches achieve the same desired results. This is clearly demonstrated by the study conducted by Lott et al.
As doctors, we must be clear-eyed about opportunities, threats, innovations, and false hopes. At the end of the day, we stand squarely on the side of our patients. In the years ahead, may genuine innovations and discoveries far outnumber false starts.
Spaulding HR, Selsby JT. Is exercise the right medicine for dystrophic muscle? Med Sci Sports Exerc. 2018;50(9):1723-1732. doi:10.1249/MSS.0000000000001639
Kostek M. Precision medicine and exercise therapy in Duchenne muscular dystrophy. Sports (Basel). 2019;7(3):64. doi:10.3390/sports7030064
Lott DJ, Taivassalo T, Cooke KD, et al. Safety, feasibility, and efficacy of strengthening exercise in Duchenne muscular dystrophy. Muscle Nerve. 2021;63(3):320-326. doi:10.1002/mus.27137