668 - Is a patient with HMG-CoA myositis appropriate for Inpatient Rehab?

The patient’s symptoms started upon initiation of atorvastatin for hyperlipidemia. Workup for inflammatory myopathy etiology revealed diffuse myotonic discharges on electromyography, CPK elevated to the 1900s, and lastly a myositis panel positive for HMG-CoA myositis.   

Prior to admission, she received IVIG infusions and IV solumedrol with notable improvement, allowing her to ambulate with a walker. Nonetheless, 5 months later she experienced another decline in strength and mobility.   

Upon admission to rehabilitation, she demonstrated proximal lower extremity weakness, notable in the hip flexors. Neurology initiated PLEX treatment as recent literature has shown a significant decrease in CK level by the removal of pathogenic antibodies. However, despite receiving two PLEX treatments, she exhibited decrease in therapy tolerance, particularly with ambulation, but maintained a stable strength exam. We decreased therapy frequency and intensity due to poor tolerance. After resting 48 hours, her ability to participate in therapies once again returned to baseline.   


Discussions: HMG-CoA myositis is associated with necrotizing autoimmune myopathy and more broadly idiopathic inflammatory myopathy (IMM). The efficacy and safety of physical therapy (PT) has widely been debated. In a recent systematic review, PT treatments focused on endurance and resistance training did not have a negative effect but could improve functional outcome. In this case, a patient focused approach was imperative when considering volume and intensity of therapy.   

Conclusions: Due to the recent perspective change regarding PT intervention in IMM patients, this case, while it does not successfully provide insight for appropriate exercises and volume, does emphasize the importance of having detailed instructions on approaching a patient with IMM pathologies. Consider an individualized therapy plan incorporating VO2 max or perceived exertion to customize therapy intensity and frequency for patients with HMG-CoA myositis.