Rehabilitation Program
Physical Therapy
Some literature suggests that aerobic exercises and resistance training may help to prevent weakness or reduce its severity. Although there are no definitive recommendations regarding therapy for steroid myopathy, it would seem reasonable to direct therapy to address the weakness and resulting impaired mobility. Range-of-motion exercises (either passive, active-assisted, or active, depending on the degree of weakness) and stretching exercises should be performed to prevent joint contractures. As a general rule, resistance exercises should be limited to muscles with greater than antigravity strength. Bed mobility, balance activities, transfer training, and gait training should be included to address decreased mobility. However, high-intensity exercise should be avoided because, according to some preliminary animal research models, it may be harmful. [7]
Occupational Therapy
Occupational therapy may focus on maximizing the patient's ability to independently perform activities of daily living. Training may include the use of assistive devices to enhance the patient's performance of self-care tasks, such as a balanced forearm orthosis to allow positioning of the upper arm in a manner that permits more independent feeding. Other adaptive equipment may include a raised toilet seat and similar devices that allow the patient to rise from a sitting position, and/or a motorized lift for ascending stairs.
Consultations
Any adjustment of a patient's corticosteroid medications should be coordinated with the physician who has been prescribing those agents. Given reports of respiratory muscle weakness causing respiratory impairments, [4, 8] consider consultation with a pulmonologist. Consultation with a neurologist can be considered for assistance with diagnosis and for the exclusion of other potential causes of weakness. A physiatrist can also be consulted for assistance with diagnosis and with the management of a therapy program.
Other Treatment
In cases of myopathy caused by long-term corticosteroid use, decreasing the corticosteroid dose to below a 30 mg/d threshold may result in resolution of muscle weakness. In patients in whom myopathy has resulted from a short course of high-dose corticosteroid use, partial or complete recovery has been reported following the discontinuation of steroid administration. [8] Eddelien et al, for example, reported on a patient who, following 10 days of treatment in the intensive care unit (ICU) with methylprednisolone 240 mg/d for severe respiratory failure due to bronchospasm, awoke from sedation with quadriplegia. With glucocorticoid-induced myopathy suspected, glucocorticoid treatment was tapered; within a few months, complete recovery from quadriplegia had been attained. [24]
A study by Meduri et al indicated that the advantages of low to moderate glucocorticoid doses in the treatment of ICU patients with sepsis and acute respiratory distress syndrome (ARDS) outweigh concerns about glucocorticoid-associated ICU-acquired weakness (ICUAW). The report states that prolonged use of low to moderate doses of glucocorticoid in these patients decreases nuclear factor (NF)-ĸB DNA binding, reduces inflammatory cytokine transcription, helps to resolve systemic and pulmonary inflammation, and reduces mortality. The investigators also reported that meta-analyses of randomized, controlled trials involving cases of severe sepsis and ARDS indicated that low to moderate glucocorticoid doses do not increase the risk of ICUAW. [25]
Preliminary studies on rats suggest that creatine plays a part in the prophylaxis of steroid-induced myopathy. Further studies are needed to explore this possible treatment/prevention option. [26]
Other experimental treatments include IGF-I, branched-chain amino acids, glutamine, and androgens such as testosterone and DHEA. Further studies are needed to correlate the benefits of such treatment. [27] One study demonstrated that the concomitant injection of branched-chain amino acids with dexamethasone seemed to reverse the reduction of total protein concentration induced by the steroid in rat muscles. [28]
Banerjee et al described the successful use of the glucocorticoid-receptor antagonist mifepristone in a pediatric patient with Cushing syndrome, with effects including a significant improvement in myopathy. [29]
