Physical training and exercise in myasthenia gravis

Current state of research on exercise for the treatment of myasthenia gravis: A scoping review

OBJECTIVE

To provide a comprehensive overview of existing evidence, research gaps, and future research priorities concerning the treatment of myasthenia gravis (MG) using exercise therapies.

METHOD

Clinical studies on exercise treatment for MG were searched in nine databases to conduct a scoping review. Two independent researchers screened the literature and comprehensively analyzed the characteristics and limitations of the included articles.

RESULTS

A total of 5725 studies were retrieved, of which 24 were included. The included studies were conducted in 16 different countries/regions and 456 patients were enrolled. Study designs included both interventional and observational studies. Exercise interventions included aerobic exercise, resistance exercise, balance training, and stretch training, and are typically administered in conjunction with medication, usual care, or some other interventions. The intensity, frequency, and duration of exercise interventions varied hugely among studies. Six-minute walk test, adverse events, muscle strength, MG quality of life-15 scale, forced vital capacity, quantitative MG scale, and MG activities of daily living scale were the most frequently used outcomes. All studies reported results in favor of the efficacy and safety of exercise in MG, and exercise-related adverse events were reported in two studies.

CONCLUSION

This scoping review provides an overview of the evidence concerning exercise treatment for MG. Key gaps in evidence include a limited number of participants, complex interventions, variability in outcome selection, and insufficient reporting in publications. The promotion of exercise treatment for MG still encounters several obstacles. A larger population, rigorous study design and conduction, standardized interventions and outcomes, and standardized reporting are essential.

Perspectives of people with myasthenia gravis on physical activity and experience of physical activity advice from health professionals in the Australian context: a qualitative study

PURPOSE

Physical activity is an important modifiable determinant of health. There has been a historical aversion to movement in people with myasthenia gravis (MG) due to the pathophysiology of the disease, however, research suggests engagement in physical activity is safe and does not exacerbate symptoms. There are currently no studies investigating the qualitative perspectives of people with MG on physical activity. The aim of this study was to explore perceptions of physical activity, barriers, enablers, and participants' experiences of physical activity advice from health professionals.

MATERIALS AND METHODS

Semi-structured interviews were used, with verbatim transcripts analysed using content analysis.

RESULTS

Ten adults (median age 64.5 years) living in Australia with generalised MG were interviewed. Key findings were identified: (1) Physical activity is perceived to be important for general health and for MG; (2) Medical management and social support are key enablers; (3) Fatigue and pain are potential barriers; and (4) Experiences with healthcare professionals were considered insufficient and failed to provide disease specific advice regarding MG and physical activity.

CONCLUSION

People with MG have unique barriers and enablers to physical activity engagement that clinicians should consider when providing physical activity behaviour change support to this population.

Genetically predicted effects of physical activity and sedentary behavior on myasthenia gravis: evidence from mendelian randomization study

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction. Despite the potential benefits of higher physical activity and lower sedentary behavior in MG patients, evidence from observational studies for the effect of physical activity on the risk of MG is limited and inconclusive.

METHODS

We employed linkage disequilibrium score (LDSC) regression, two-sample Mendelian randomization (MR), and its multivariable extension analyses (MVMR) to assess the relationship between leisure screen time (LST), moderate-to-vigorous intensity physical activity during leisure time (MVPA) and the risk of MG using genome-wide association studies (GWAS) summary datasets. MR analyses were performed using the inverse-variance-weighted (IVW), weighted-median, and MR-Egger regression. Sensitivity analyses were further performed using alternative instruments to test the robustness of our findings.

RESULTS

We found evidence of genetic overlap between LST (rg = 0.113, P = 0.023) and MG, as well as between MVPA (rg=-0.220, P = 0.0001) and MG, using LDSC method. The results of the MR suggested an association between genetic liability to LST and increased risk of MG (IVW OR = 1.609, 95% CI = 1.153 to 2.244; P = 0.005). This association was particularly notable for late-onset MG (IVW OR = 1.698, 95% CI = 1.145 to 2.518; P = 0.008), but not for early-onset MG. Consistent findings were obtained in the MVMR analysis using BMI as covariate (IVW OR = 1.593, 95% CI 1.167 to 2.173, P = 0.003). However, the MR analysis does not support a substantial causal effect of MVPA on the risk of MG.

CONCLUSION

Our findings support a causal effect of sedentary behavior as measured by LST on MG, indicating that lack of exercise may play a role in the development of MG. Longitudinal and interventional studies of this association are warranted.

Myasthenia Gravis: Novel Findings and Perspectives on Traditional to Regenerative Therapeutic Interventions

The prevalence of myasthenia gravis (MG), an autoimmune disorder, is increasing among all subsets of the population leading to an elevated economic and social burden. The pathogenesis of MG is characterized by the synthesis of autoantibodies against the acetylcholine receptor (AChR), low-density lipoprotein receptor-related protein 4 (LRP4), or muscle-specific kinase at the neuromuscular junction, thereby leading to muscular weakness and fatigue. Based on clinical and laboratory examinations, the research is focused on distinguishing MG from other autoimmune, genetic diseases of neuromuscular transmission. Technological advancements in machine learning, a subset of artificial intelligence (AI) have been assistive in accurate diagnosis and management. Besides, addressing the clinical needs of MG patients is critical to improving quality of life (QoL) and satisfaction. Lifestyle changes including physical exercise and traditional Chinese medicine/herbs have also been shown to exert an ameliorative impact on MG progression. To achieve enhanced therapeutic efficacy, cholinesterase inhibitors, immunosuppressive drugs, and steroids in addition to plasma exchange therapy are widely recommended. Under surgical intervention, thymectomy is the only feasible alternative to removing thymoma to overcome thymoma-associated MG. Although these conventional and current therapeutic approaches are effective, the associated adverse events and surgical complexity limit their wide application. Moreover, Restivo et al. also, to increase survival and QoL, further recent developments revealed that antibody, gene, and regenerative therapies (such as stem cells and exosomes) are currently being investigated as a safer and more efficacious alternative. Considering these above-mentioned points, we have comprehensively reviewed the recent advances in pathological etiologies of MG including COVID-19, and its therapeutic management.

Exploring impairments and allied health professional utilisation in people with myasthenia gravis: A cross-sectional study

This study aimed to explore how people with myasthenia gravis experience impairments in vision, dizziness, hearing, and fatigue, and how these relate to balance confidence, community participation, and health-related quality of life. Additionally, this study investigated the utilisation and perception of the allied health role in managing these impairments in the Australian context. Visual and hearing impairments, along with fatigue, were found to be correlated with health-related quality of life and community participation to varying degrees, while visual impairment and dizziness were correlated with balance confidence. Perception and utilisation of allied health professionals was variable; common barriers to better utilisation included participant perception of clinicians having poor knowledge around myasthenia gravis, previous poor experiences with clinicians, uncertainty about the clinicians' role, and lack of awareness that symptoms were associated with myasthenia gravis. Further research exploring clinicians' knowledge of myasthenia gravis is recommended, along with education for people with the disease about symptoms associated and how to appropriately access care.

Myasthenia gravis, respiratory function, and respiratory tract disease

Myasthenia gravis (MG) is characterized by muscle weakness caused by autoantibodies that bind to the postsynaptic membrane at the neuromuscular junction and impair acetylcholine receptor function. Weakness of respiratory muscles represents the most severe MG manifestation, and 10-15% of all patients experience an MG crisis with the need of mechanical ventilatory support at least once in their life. MG patients with respiratory muscle weakness need active immunosuppressive drug treatment long term, and they need regular specialist follow-up. Comorbidities affecting respiratory function need attention and optimal treatment. Respiratory tract infections can lead to MG exacerbations and precipitate an MG crisis. Intravenous immunoglobulin and plasma exchange are the core treatments for severe MG exacerbations. High-dose corticosteroids, complement inhibitors, and FcRn blockers represent fast-acting treatments that are effective in most MG patients. Neonatal myasthenia is a transient condition with muscle weakness in the newborn caused by mother's muscle antibodies. In rare cases, treatment of respiratory muscle weakness in the baby is required.

Preoperative respiratory muscle training combined with aerobic exercise improves respiratory vital capacity and daily life activity following surgical treatment for myasthenia gravis

OBJECTIVE

The effects of preoperative respiratory muscle training (RMT) on postoperative complications in patients surgically treated for myasthenia gravis (MG) remain unclear. The present study therefore evaluated the effects of preoperative moderate-to-intense RMT and aerobic exercise, when added to respiratory physiotherapy, on respiratory vital capacity, exercise capacity, and duration of hospital stay in patients with MG.

METHODS

Eighty patients with MG scheduled for extended thymectomy were randomly divided into two groups. The 40 subjects in the study group (SG) received preoperative moderate-to-intense RMT and aerobic exercise in addition to respiratory physiotherapy, whereas the 40 subjects in the control group (CG) received only chest physiotherapy. Respiratory vital capacity (as determined by VC, FVC, FEV1, FEV1/FVC, and PEF) and exercise capacity (as determined by the 6-min walk test [6 MWT]) were measured pre- and postoperatively and before discharge. The duration of hospital stay and activity of daily living (ADL) were also determined.

RESULTS

Demographic and surgical characteristics, along with preoperative vital capacity and exercise capacity, were similar in the two groups. In the CG, VC (p = 0.001), FVC (p = 0.001), FEV1 (p = 0.002), PEF (p = 0.004), and 6MWT (p = 0.041) were significantly lower postoperatively than preoperatively, whereas the FEV1/FVC ratio did not differ significantly. Postoperative VC (p = 0.012), FVC (p = 0.030), FEV1 (p = 0.014), and PEF (p = 0.035) were significantly higher in the SG than in the CG, although 6MWT results did not differ. ADL on postoperative day 5 was significantly higher in the SG than in the CG (p = 0.001).

CONCLUSION

RMT and aerobic exercise can have positive effects on postoperative respiratory vital capacity and daily life activity, and would enhance recovery after surgery in MG patients.

Multi-user upper limb rehabilitation training system integrating social interaction

COVID-19 causes persistent symptoms such as weakness and myasthenia in most patients. Due to the cross-infection of COVID-19, the traditional face-to-face rehabilitation services are risky for the elderly. To ensure that the elderly in urgent need of rehabilitation services receive training while minimizing the disturbance of the COVID-19 pandemic on their social activities. We have improved the existing virtual upper limb training system, and added a social factor to the system. Seniors with upper limb rehabilitation needs can use the system to compete or collaborate with others for training. In addition, a set of natural and scientific exclusive gestures have been designed under the direction of following the doctor's advice. The experiment is conducted jointly with the chief physicians of the geriatrics department in the authoritative class-A hospitals of Class III. Our experiment, which lasted for two months, showed that the virtual training system with social factors added had the best rehabilitation effect and enhanced the initiative of patients. The system has value for popularization during the COVID-19 epidemic.

Prevention of Adverse Outcomes and Treatment Side Effects in Patients with Neuromuscular Disorders

In this article, we review prevention of serious adverse clinical outcomes and treatment side effects in patients with neuromuscular disorders including myopathies and myasthenia gravis. While neither of these entities is preventable, their course can often be modified, and severe sequelae may be prevented, with the identification of risk factors and proactive attention toward treatment planning.