Physiotherapy in Myasthenia Gravis.pdf

Myasthenia Gravis is an autoimmune disorder affecting the neuromuscular junction. Physiotherapy can help patient not only in teaching the patients learn muscle energy conservation technique but also improve the overall functional status of the patient.

1. Physiotherapy in Myasthenia Gravis
-Dr. Husne Ara Tarannum Laskar (PT)
Asst Professor
Department of Physiotherapy
Science College Kokrajhar

2. INTRODUCTION
•Myasthenia Gravis is a chronic autoimmmune
neuromuscular disease.
•Originated from Greek & Latin means 'Grave muscle
weakness'
•No cure but available treatment makes symptom
manageable

3. EPIDEMIOLOGY
•1:7500
•20-40 Years
•Female>Male

4. DEFINITION
•Myasthenia gravis (MG) is an autoimmune disease of the
neuromuscular junction (NMJ) caused by antibodies that
attack components of the postsynaptic membrane, impair
neuromuscular transmission, and lead to weakness and
fatigue of skeletal muscle.

5. PATHOLOGY
•MG is caused by impaired nerve transmission to muscle
Acetylcholine receptor (AchR) antibodies block/alter/destroy
nicotinic Post-Synaptic receptors for acetylcholine
↓
Acetylcholine amount release ↓ per impulse on repeated
activity (pre-synaptic rundown)
↓
muscle contraction is prevented

8. Role of Thymus
•Thymic abnormalities in 80 % patients
•Main function of thymus: affects T-Lymphocyte production
which participates in immune responses

9. MYASTHENIA GRAVIS FOUNDATION OF AMERICA CLINICAL CLASSIFICATION
Class I: Any ocular muscle weakness; may have weakness of eye closure. All other muscle strength is normal
Class II: Mild weakness affecting muscles other than ocular muscles;may also have ocular muscle weakness of any
severity
A. IIa. Predominantly affecting limb, axial muscles, or both. May also have involvement of oropharyngeal
muscles.
B. IIb.Predominantly affecting oropharyngeal,respiratory muscles, or both. May also have lesser or equal
involvement of limb, axial muscles, or both.
Class III: Moderate weakness affecting muscles other than ocular muscles; may also have ocular muscle weakness
of any severity.
A. IIIa. Predominantly affecting limb, axial muscles, or both. May also have involvement of oropharyngeal
muscles.
B. IIIb.Predominantly affecting oropharyngeal,respiratory muscles, or both. May also have lesser or equal
involvement of limb, axial muscles, or both.
Class IV: Severe weakness affecting muscles other than ocular muscles; may also have ocular muscle weakness of
any severity.
A. IVa. Predominantly affecting limb, axial muscles, or both. May also have involvement of oropharyngeal
muscles.
B. IVb.Predominantly affecting oropharyngeal,respiratory muscles, or both. May also have lesser or equal
involvement of limb, axial muscles, or both.
Class V: Defined as intubation, with or without mechanical ventilation, except when employed during routine
postoperative management. The use of a feeding tube without intubation places the patient in class IVb.

10. CLINICAL FEATURE
•Dysarthria
•Dysphagia
•Ptosis
•Nasal sound speech
•Fatigability
•Progressive weakness(arms,trunk, limbs)
•progressive muscle weakness after activity, recovers aftre
rest
•Respiratory muscles also might get affected
•Unstable or Waddling Gait
•Expressionless face

11. EXAMINATION OF CASE
•muscle fatigability can be tested by:
–Looking Up & Sidewards 30 sec
(Diplobia, Ptosis)
–Looking at Feet while lying on the back
60 sec
–Keeping arms outstretched 60 sec
–10 deep knee bends
–toe walking, heel walking 30 steps
–5 sit ups
–lying down and sitting up completely
–peek sign


Image credit: Bing.com

12. COMPLICATION
•Myasthenia crisis: medical emergency, involves
respiratory muscle paralysis
•Other complications may include choking, pneumonia,
food aspiration

13. Myasthenia Crisis
•It is a complication of MG characterized by worsening of
muscle weakness,resulting in respiratory failure that
requires intubation and mechanical ventilation.
•Due to advances in critical care, the mortality rate
associated with myasthenia crisis has greatly reduced.

14. INVESTIGATION
•Blood tests: Serum antibodies sensitivity to acetylcholine
•EMG studies
•Chest X-Ray
•Pulmonary Function Tests

15. MANAGEMENT
•Medical
•Physiotherapy

16. Medical Management
•Administration of Cholinesterase inhibitors e.g
Neostigmine
•Immunosupressive drugs e.g Prednisolone
•Thymectomy

17. PHYSIOTHERAPY MANAGEMENT
AIMS:
•Provide Psychological support
•Prevent Respiratory Complications
•Improve Vital Capacity
•Avoid Undue Fatigue
•Train Oromotor Control
•Advise assistive devices
•Main normal muscle properties
•Improve functional capacity

18. PLAN:
•Psychological counselling
•Encourage active limb movements. If needed PROM may
be given
•Passive stretching.Use corrective Splints
•Chest PT: DBT, VMT,Pranayama
•Postural drainage, couhing, huffing
•Pressure sore prevention precautionary measures

19. •If pressure sore has already occured , regular dressing of
wound
–Cryotherapy
–IR radiation
–UVR Therapy
–LASER
–US with Couplant sheet
–Bladder care

20. •Muscle Energy Conservation Technique
•Maintain functional independence
–MAT Exercise
–Strengthening Exercise
–Weight Bearing
–Gait Training
–Transfer Techniques

21. General Advice
•Aim to strengthen large muscle groups, particularly proximal muscles of
shoulders and hips
•Advise patient to do the exercises at their "best time of day" ie. when not
feeling tired - for the majority of MG patients this will be morning
•If a patient is taking pyridostigmine, exercise at peak dose ie. 1.5 to 2 hours
after taking a dose
•Moderate intensity of exercise only: the patient should not experience
worsening of MG symptoms (eg. ptosis or diplopia) during exercise
•General aerobic exercise is also valuable, helping with respiratory function as
well stamina

22. RECENT EVIDENCE
•In a review done in 2020, it was concluded that MG
patients and their care givers should be encouraged to
commence tailored exercise programme in stable well
controlled MG (O'Connor L, Westerberg E, Punga AR. Myasthenia Gravis and Physical Exercise: A
Novel Paradigm. Front Neurol. 2020;11:675. Published 2020 Jul 29. doi:10.3389/fneur.2020.00675)

•In a study done by Westerberg E et al 2017, it was found
that physical exercise was well tolerated by patients with
MG and safe to be carried out by them (Westerberg E, Molin CJ, Lindblad I,
Emtner M, Punga AR. Physical exercise in myasthenia gravis is safe and improves neuromuscular parameters and
physical performance-based measures: A pilot study. Muscle Nerve. 2017 Aug;56(2):207-214. doi:
10.1002/mus.25493. Epub 2017 Apr 2. PMID: 27935072.)

23. •In a study done in 2015, it was found that Balance
Strategy Training was effective in improving balance in
MG Patients (EFFECTS OF BALANCE STRATEGYTRAINING IN MYASTHENIA GRAVIS: A CASE STUDY SERIES S.H. Wong, J.
Nitz, K. Williams, S. Brauer)

24. REFERENCES
•Neurology & Neurosurgery Illustrated, 5th edition; Lindsay KW, Bone I & Fuller G
•Physiotherapy in Neurological Conditions wih assessment and treatment Protocol; Potturi G
•Myasthenia Gravis Fact Sheet
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Myasthenia-Gravis-Fact-
Sheet
•Figure 1 sourced from https://www.myasthenia.asia/news.aspx?category=1
•Pathogenesis of myasthenia gravis: update on disease types,models, and mechanisms [version 1;
referees: 2 approved] retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926737/#:~:text=Myasthenia%20gravis%20is%20an%
20autoimmune,and%20fatigue%20of%20skeletal%20muscle.
•Wendell L C, Levine J M. Myasthenic Crisis.Neurohospitalist. 2011 Jan 1(1): 16-22. doi:
10.1177/1941875210382918. PMCID:PMC3726100. PMID: 23983833
•Westerberg E, Molin CJ, Lindblad I, Emtner M, Punga AR. Physical exercise in myasthenia gravis is
safe and improves neuromuscular parameters and physical performance-based measures: A pilot
study. Muscle Nerve. 2017 Aug;56(2):207-214. doi: 10.1002/mus.25493. Epub 2017 Apr 2. PMID:
27935072.

25. •O'Connor L, Westerberg E, Punga AR. Myasthenia Gravis and Physical Exercise: A Novel
Paradigm. Front Neurol. 2020;11:675. Published 2020 Jul 29. doi:10.3389/fneur.2020.00675
•Effects of balance strategy training in myasthenia gravis: a case study series S.H. Wong J.
Nitz K. Williams S. Brauer DOI:https://doi.org/10.1016/j.physio.2015.03.053

Web Sources:
www.physio-pedia.com
www.myasthenia.org

26. *Thank You*