Q J Med 2000; 93: 35-40
© 2000 Association of Physicians
Low-dose ethanol consumption allows strength recovery in chronic alcoholic myopathy
From the Department of Internal Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain
Received 16 July 1999 and in revised form 21 September 1999
Dr J. Fernández-Solà, Department of Internal Medicine, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain. e-mail: nicolas{at}medicina.ub.es
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Summary |
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Chronic skeletal myopathy may affect one third of chronic alcohol misusers. It is generally accepted that abstinence allows partial recovery, and that continued high-dose ethanol consumption progressively deteriorates muscle function. However, the effect of low-dose ethanol consumption in alcoholic myopathy has not been studied. We studied 58 chronic alcoholic male patients with biopsy-proven chronic alcoholic myopathy over 5 years. We evaluated ethanol intake, biochemical and nutritional parameters, and assessed muscle strength. Eighteen patients who remained abstinent showed marked improvement in muscle strength. As expected, the 19 patients who persisted in high-dose ethanol consumption further diminished in their muscle strength. In the 11 patients who maintained low-dose (
60 g ethanol/day) `controlled' drinking, muscle strength improved (p=0.003), despite no change in nutritional and exercise status. There is a dose-dependent recovery in muscle strength according to the degree of ethanol consumption, and moderate controlled drinking of up to 60 g ethanol/day still allows improvement in muscle strength. |
Introduction |
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About one third of long-term high-dose alcohol misusers develop skeletal myopathy, which appears in a dose-dependent manner, and manifests clinically as proximal muscle weakness, pain and atrophy.1–6 Once established, alcoholic myopathy usually reverses provided complete abstinence is achieved.7–9 By contrast, continued high-dose alcohol abuse is accompanied by further deterioration in muscle strength and the appearance of histological damage to the muscle.10 In the treatment of alcoholic patients, the first goal is to achieve complete abstinence from ethanol intake. However, abstinence is not always possible, and a significant percentage of alcoholics are only able to reduce their intake to
60 g of ethanol a day (`controlled' drinking).11 Since little is known about the consequences of `controlled' drinking on the natural history of chronic skeletal myopathy,7,10 we studied a large series of chronic alcoholics with skeletal myopathy, to evaluate the effects of different doses of ethanol on muscle function. Muscle strength, measured by myometry, was taken as the paradigm of skeletal muscle function.5,6,10 |
Methods |
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Patient selection and baseline studies
Over a 2-year period, we consecutively selected male patients seen in the Alcohol Unit of the Hospital Clínic of Barcelona. This unit treats only ambulatory patients who seek assistance in terminating their dependence of alcohol, but who have no signs or symptoms of other diseases. Patients with other maladies, or overt alcohol-related disorders such as liver cirrhosis, heart failure or malnutrition, are referred to other clinics. Patients with HIV infection, neoplasm, consumption of illicit drugs or with causes of myopathy other than alcoholism were not selected for the study.
Patients who complained of muscle weakness or myalgia, or those with a significant reduction in muscle strength (<20 kg)5,6 were submitted to a deltoid muscle biopsy in the non-dominant arm. Cryostat sections of biopsy specimens were processed by standardized histological and histochemical methods, as previously described.5,8,12 Alcoholic myopathy was diagnosed according to standard histological criteria and classified as mild, moderate, or severe.5 No patient objected to inclusion in the study. The study protocol was approved by the Institutional Review Board and informed consent for the various procedures was obtained from each patient.
Of the 84 patients initially evaluated, 68 chronic alcoholics with biopsy-proven skeletal myopathy were enrolled in the study. All subjects were Caucasian men of Spanish origin who lived with their families in or around Barcelona and had histories of stable employment. No homeless people were included in the study. A detailed history, including ethanol intake, dietary habits and neuromuscular symptoms was obtained by two different interviewers (JF-S and JR) using a structured questionnaire. Alcohol dependence was diagnosed according to DSM-IV.13 A history of alcohol consumption in terms of type of alcoholic beverage, average daily consumption, yearly amount and frequency of ethanol intake was computed. Data were confirmed in consultation with family members. Basic biochemical and nutrition assessment included serum muscle enzymes, anthropometrical and protein nutritional parameters. Evaluation of muscle strength was performed at the deltoid level of the non-dominant arm with an electronic myometer (Penny & Giles), five times over a period of 20 min, measuring force against resistance using a standardized method.5,6 To assess any influence of physical activity on muscle strength along the study, the extent of daily exercise involving the shoulder girdle and upper extremities at baseline and over the follow-up period were computed. Patients and controls reported the time spent on physical activity at work and at home, as well as sports played, and were categorized in a scale score of 0–3, as previously reported.10
Follow-up studies
After baseline evaluation, an ambulatory detoxification programme was proposed to all patients. Patients were then prospectively followed over a period of 5 years. Appointments were scheduled every 6 months during the first 2 years and once a year thereafter, including clinical evaluation, nutritional status, and assessments of ethanol intake and physical activity. Functional evaluation of muscle strength was performed by myometer as described at baseline and was used as the functional marker of alcoholic myopathy. Ethanol intake was assessed by two different interviewers in consultation with the family members throughout the 5-year period, and patients were classified as: (i) abstainers, (ii) consumers of 20–60 g/day (`controlled' drinkers), (iii) consumers of 61–99 g/day, or (iv) consumers of 
100 g/day. To assess the reliability of self-reports of ethanol abstinence, the values of serum aminotransferases, gammaglutamyl transpeptidase and mean corpuscular erythrocyte volume were determined periodically and at the end of study, as was the concentration of ethanol in urine. Ten patients who changed their ethanol intake group over the follow-up period were not further evaluated and were excluded from the study.
Statistical analysis
Standard statistical methods from the SPSS Statistical Analysis System V4.0+(SPSS, Chicago) were used.14 Univariate comparisons were performed using analysis of variance and the 
2 test. Differences between baseline and follow-up values were analysed by the Student's paired t-test. All variables are expressed as means±SEM.
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Results |
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Baseline data
Fifty-eight chronic alcoholic men with biopsy-proven skeletal myopathy completed the follow-up. Their mean age was 46.1±1.3 years (range 22–64 years), and a daily ethanol intake of 206±8 g (range 100–290 g/day) was reported over a period of 22±7 years, giving a mean lifetime dose of ethanol of 25.4±1.2 kg of ethanol/kg body weight. The drinking pattern was of continuous ethanol intake as a part of everyday life, and only occasional binges were reported. These patients consumed ethanol mainly in the form of wine, beer, and brandy, and less frequently as anisette or gin. None used illicit drugs throughout the study.
Demographic, laboratory and nutritional data are shown in Table 1
. Twenty-five patients (43%) had proximal myalgia and 30 (52%) subjective muscle weakness. Baseline mean deltoid muscle strength was 19.5±0.5 kg. Based on histological criteria, alcoholic myopathy was classified as mild in 46 (80%), moderate in 10 (17%) and severe in two patients (3%).
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Follow-up studies
As a result of the detoxification program, 18 patients became abstinent and maintained sobriety over the 5 years, whereas 40 continued drinking. Of the latter, 11 patients (28%) reported a daily ethanol consumption of 20–60 g (`controlled' drinking), 10 (25%) drank 61–99 g ethanol/day, and 19 (47%) maintained an ethanol consumption of at least 100 g/day. Nevertheless, in heavy drinkers (
100 g ethanol/day), alcohol consumption fell from 227±16 g/day at baseline to 143±12 g/day in the follow-up period (Table 2). Throughout the follow-up period, patients did not exhibit changes in biochemical and nutritional parameters except for significant improvement in the tricipital skin fold, albumin, gammaglutamyl transpeptidase and aminotransferases (Table 1
), which occurred in all groups except those who maintained an ethanol intake of 100 g/day (Table 2). The degree of histological myopathy at baseline was similar in all groups (Table 2).
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Figure 1
depicts the differential evolution of muscle strength according to the degree of ethanol consumption over the 5-year follow-up period. Abstinent patients (n=18) showed a significant improvement in mean muscle strength from 18.0±1.2 to 24.4±0.7 kg (p<0.001). By contrast, heavy drinkers (n=19, 100 g/day) further reduced muscle strength over this period, from 21.8±1.1 to 18.0±1.1 kg (p=0.001). Patients consuming 61–99 g ethanol/day (n=10) did not show significant changes in muscle strength. However, it was interesting and unexpected that muscle strength improved in alcoholic patients with biopsy-proven alcoholic myopathy who continued low-dose `controlled' drinking (20–60 g/day) (n=11), rising from 18.5±1.2 to 22.3±1.4 kg (p=0.003). This improvement was non-significantly greater in the abstainers (6.4 kg vs. 3.8 kg, p=0.10). The degree of histological myopathy at baseline did not influence on the changes in muscle strength along follow-up. Physical activity over follow-up was similar to baseline in all four groups of patients. Five patients who changed their working occupation showed no significant modification in their physical activity score (Table 2).
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Discussion |
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We found that changes in muscle strength over 5 years in chronic alcoholic patients with biopsy-proven skeletal myopathy were related to the degree of persistence of ethanol consumption, supporting the idea of a dose-dependent relationship in the pathogenesis of alcohol-related muscle damage, as previously suggested.6,12,15 Notably, most of these patients were well-nourished with no evidence of overt cardiac and liver disease. As expected,7,9 all abstinent patients improved or at least maintained baseline muscle strength. Interestingly, patients with alcoholic skeletal myopathy who maintained an ethanol intake of
60 g/day did not suffer further functional muscle damage and showed improved muscle strength. By contrast, continued high-dose ethanol intake (>100 g/day) caused further deleterious consequences in muscle strength. Moreover, in the group of patients who continued drinking 61–99 g ethanol/day there was no significant change in muscle strength. We considered this group as marginal or indeterminate, since half of these patients improved and half of them deteriorated during the study. This may reflect individual biological variability, the fact that alcohol consumption reports are estimates, or the lack of a sharp distinction between excessive and controlled drinking. According to ethanol consumption guidelines,16,17 all patients with alcohol-related disorders should be advised to completely avoid ethanol intake. However, detoxification programs are only able to achieve long-term abstinence in about one third of alcoholic patients, as in the present study.11,18 Nevertheless, some of the patients who could not maintain abstinence significantly reduced their drinking. On following these patients, we observed a threshold in the amount of ethanol that allowed some recovery from chronic alcoholic myopathy. No previous studies have elaborated on the effect of low-dose ethanol consumption in the natural history of chronic alcoholic myopathy,5,6,10 and there have been no adequate experimental studies on the long-term effects of ethanol on skeletal muscle.6,8 Therefore, the biological effects of low-dose ethanol consumption still need to be studied in appropriate clinical models.
It is uncertain whether low-dose ethanol consumption is involved in alcohol-related organic damage. In this sense, some initial evidence has shown that moderate drinking allows partial left ventricular improvement in patients with alcoholic cardiomyopathy.19 Moreover, moderate drinking has been implicated in the reduction of cardiac mortality by decreasing the incidence or coronary artery disease.20,21 By contrast, low-dose ethanol intake seems to be deleterious in alcoholic liver disease22 and in alcoholic brain damage.23 Therefore, the biological effects of low-dose ethanol, as well as the threshold involved in organic damage, should be differentially evaluated for each organ.
In conclusion, there is a dose-dependent response in muscle strength according to the degree of ethanol consumption. Abstinence allows the greatest degree of improvement in muscle strength in alcoholics with skeletal myopathy. As expected, continued heavy drinking significantly further deteriorates muscle function. Controlled low-dose ethanol consumption of up to 60 g/day is sufficient to significantly improve muscle strength over a 5-year period. This effect of low-dose ethanol consumption should not be generalized to other alcohol-related organ damage.
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References |
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