Overview of paediatric neuromuscular disorders and related pulmonary issues: diagnostic and therapeutic considerations

Neuromuscular diseases and social distance resulting from the COVID-19 pandemic

BACKGROUND

Coronavirus 2 severe acute respiratory syndrome (SARS-CoV-2), generically called COVID-2019, classified as a pandemic by the World Health Organization, has made health practices around the world face unique challenges. Since then, physical distancing and measures such as confinement have been adopted by different governments to control human-to-human transmission. This distance affected the treatment of individuals with progressive diseases such as neuromuscular diseases (NMDs).

OBJECTIVE

To identify how patients with NMDs performed the therapeutic routine during social distancing and confinement resulting from the COVID-19 pandemic.

METHODS

Application of a questionnaire prepared in the Google forms application, whose link for access and participation was sent by email or WhatssApp for family members and/or individuals with DNMs to respond. The questionnaire consisted of multiple-choice questions, divided into the following sections: personal data, treatments performed before and during the pandemic, activities performed during confinement, and characterization of motor function in activities of daily living comprising the period between September and October 2020.

RESULTS

We observed a significant reduction in medical appointments for patients with NMDs. On the other hand, the results showed that most patients underwent motor and/or respiratory physiotherapy in person or by telemonitoring. The study participants reported spending more time playing indoors, and all pointed out motor changes during social distancing.

CONCLUSION

There were changes in the therapeutic routine of patients with NMDs during the period of social distancing due to COVID-19.

Methods and Applications in Respiratory Physiology: Respiratory Mechanics, Drive and Muscle Function in Neuromuscular and Chest Wall Disorders

Individuals with neuromuscular and chest wall disorders experience respiratory muscle weakness, reduced lung volume and increases in respiratory elastance and resistance which lead to increase in work of breathing, impaired gas exchange and respiratory pump failure. Recently developed methods to assess respiratory muscle weakness, mechanics and movement supplement traditionally employed spirometry and methods to evaluate gas exchange. These include recording postural change in vital capacity, respiratory pressures (mouth and sniff), electromyography and ultrasound evaluation of diaphragmatic thickness and excursions. In this review, we highlight key aspects of the pathophysiology of these conditions as they impact the patient and describe measures to evaluate respiratory dysfunction. We discuss potential areas of physiologic investigation in the evaluation of respiratory aspects of these disorders.

The role of physiotherapy in the respiratory management of children with neuromuscular diseases: A South African perspective

Background

Respiratory morbidity is common in children with neuromuscular diseases (NMD) owing to chronic hypoventilation and impaired cough. Optimal, cost-effective respiratory management requires implementation of clinical practice guidelines and a coordinated multidisciplinary team approach.

Objectives

To explore South African physiotherapists’ knowledge, perception and implementation of respiratory clinical practice guidelines for non-ventilated children with NMD.

Methods

An online survey was conducted amongst members of the South African Society of Physiotherapy’s Cardiopulmonary Rehabilitation (CPRG) and Paediatric special interest groups and purposive sampling of non-member South African physiotherapists with respiratory paediatrics expertise (N= 481).

Results

Most respondents worked in private healthcare, with 1–10 years’ experience treating patients with NMD. For acute and chronic management, most participants recommended nebulisation and 24-h postural management for general respiratory care. Percussions, vibrations, positioning, adapted postural drainage, breathing exercises and manually assisted cough were favoured as airway clearance techniques. In addition, participants supported non-invasive ventilation, oscillatory devices and respiratory muscle training for chronic management.

Conclusion

Respondents seemed aware of internationally-endorsed NMD clinical practice guidelines and recommendations, but traditional manual airway clearance techniques were favoured. This survey provided novel insight into the knowledge, perspectives and implementation of NMD clinical practice guidelines amongst South African physiotherapists.

Clinical implications

There is an urgent need to increase the abilities of South African physiotherapists who manage children with NMD, as well as the establishment of specialised centres with the relevant equipment, ventilatory support and expertise in order to provide safe, cost-effective and individualised patient care.

Functional outcome measures for infantile Charcot-Marie-Tooth disease: a systematic review

A functional outcome measure for infants (aged 0-3 years) with Charcot-Marie-Tooth (CMT) disease is needed for upcoming disease-modifying trials. A systematic review of outcome measures for infants with neuromuscular disorders was completed to determine if validated measures were available for the CMT infant population. We assessed 20,375 papers and identified seven functional outcome measures for infants with neuromuscular disorders. Six were developed and validated for spinal muscular atrophy (SMA). There were no CMT-specific outcome measures identified; however, one (motor function measure) assessed a range of neuromuscular disorders including 13 infants and children with CMT. The included studies exhibited "good" face, discriminant, convergent and concurrent validity, and reported excellent intra- and inter-rater reliability. No outcome measure was subjected to item response theory. Studies reported outcome measures comprising of 51 different items assessing six domains of function: reflexive movement, axial movement, limb movement, positioning, gross motor, and fine-motor skills. Scoring of items ranged from 2- to 7-point rating scales; and none were scaled to normative reference values to account for changes in growth and development. The SMA focus of most items is likely to produce ceiling effects and lack sensitivity and responsiveness for within and between types of CMT in infants. Nevertheless, several items across scales assessing distal strength, gross- and fine-motor function, could be included in the development of a composite functional outcome measure for infants with CMT to assess disease-modifying interventions.

Neuromuscular disorders and chronic ventilation

Morbidity and mortality have decreased in patients with neuromuscular disease due to implementation of therapies to augment cough and improve ventilation. Infants with progressive neuromuscular disease will eventually develop respiratory complications as a result of muscle weakness and their inability to compensate during periods of increased respiratory loads. The finding of nocturnal hypercapnia is often the trigger for initiating non-invasive ventilation and studies have shown that its use not only may improve sleep-disordered breathing, but also that it may have an effect on daytime function, symptoms related to hypercapnia, and partial pressure of CO₂. It is important to understand the respiratory physiology of this population and to understand the benefits and limitations of assisted ventilation.

Inspiratory muscle training for children and adolescents with neuromuscular diseases: A systematic review

Patients with neuromuscular diseases are at risk of morbidity and mortality due to respiratory compromise caused by respiratory muscle weakness. A systematic review was performed using pre-specified search strategies to determine the safety of inspiratory muscle training (IMT) and whether it has an impact on inspiratory muscle strength and endurance, exercise capacity, pulmonary function, dyspnoea and health-related quality of life. Randomised, quasi-randomised, cross-over and clinical controlled trials were included if they assessed the use of an external IMT device compared to no, sham/placebo, or alternative IMT treatment in children aged 5-18 years with neuromuscular diseases. Seven full-text articles and two on-going trials (n = 168) were included. Most studies used threshold IMT devices over a medium to long-term period, and none reported any adverse events. Studies differed regarding intensity, repetitions, frequency, rest intervals and duration of IMT. Six studies reported no significant improvement in pulmonary function tests following IMT. Two comparable studies reported significant improvement in inspiratory muscle endurance and four studies reported significantly greater improvement in inspiratory muscle strength in experimental groups. The latter was confirmed in a meta-analysis of two comparable studies (overall effect p < 0.00001). Other outcome measures could not be pooled. There is currently insufficient evidence to guide clinical IMT practice, owing to the limited number of included studies; small sample sizes; data heterogeneity; and risk of bias amongst included studies. Large sample randomised controlled trials are needed to determine safety and efficacy of IMT in paediatric and adolescent patients with neuromuscular diseases.

Treatment of muscle weakness in neuromuscular disorders

INTRODUCTION

Weakness is one of the predominant clinical manifestations of neuromuscular disorders (NMDs), which strongly influences daily life, prognosis, and outcome of affected patients. One of the major therapeutic goals in NMD-patients is to completely resolve muscle weakness. Various treatment options are available and include physical therapy, electrotherapy, diet, drugs, avoidance or withdrawal of muscle-toxic and weakness-inducing agents, detoxification, stem-cell-therapy, plasma-exchange, respiratory therapy, or surgery. Most accessible to treatment is weakness from immune-mediated neuropathies, immune-mediated transmission-disorders, and idiopathic immune myopathies. Areas covered: This manuscript aims to summarize and discuss recent findings and future perspectives concerning the treatment of muscle weakness in NMDs. Data were obtained by a literature search in databases such as PubMed and Current-Contents. Expert commentary: Weakness is most easily treatable in acquired NMDs and in hereditary myopathies and neuropathies beneficial treatment options are also available. Research needs to be encouraged and intensified to further expand the spectrum of treatment options for weakness.

Feeding and Swallowing Disorders in Pediatric Neuromuscular Diseases: An Overview

Feeding and swallowing problems in infants and children have a great impact on health and wellbeing. The aim of this study was to provide an overview of recognized feeding and swallowing problems in different groups of children with neuromuscular diseases, based on relevant literature and expert opinion, and to propose recommendations for the assessment and treatment of these problems. Almost all pediatric neuromuscular diseases are accompanied by feeding and swallowing problems during the different phases of deglutition, problems that give rise to a wide variety of signs and symptoms, which emphasizes the importance of a comprehensive feeding and swallowing assessment by a speech and language therapist.