The technique of therapeutic gymnastics was used for patients with mayasthenia gravis to control the consequences of hypodynamia induced by the myasthenic process. It is concluded that during myasthenia, the severity of the disease is due to the affection of the cross striated musculature. The most life threatening are the disorders in respiration and swallowing, that can be intensified by forced stay in bed and immobility. It is also concluded that the use of therapeutic gymnastics in patients which myasthenia promotes efficient presurgical preparation, and in the post surgical period; prevention of pulmonary complications and normalization of respiration. Therapeutic gymnastics with regard to the severity and localization of the myasthenic disorders must be a component part of the presurgical preparation and postsurgical management of patients with generalized myasthenia

Kapelovich, R. L.

English

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NASA TECHNICAL MEMORANDUM	 NASA TM-76312
(NASA-TM-76312)
 THERAPEU--IC GYnNASTICS IN
	 N80-32069
COMPREHENSIVE TREATMENT 01' PATIENTS WITH
GENERALIZED MYASTHENIA (National Aeronautics
and Space Administration) 9 p HC AOi/MF A01
	 Unclas
CSCL 06E G5/5l 28681
THERAPEUTIC GYMNASTICS IN COMPREHENSIVE TREATMENT OF
PATIENTS WITH GENERALIZED MYASTHENIA
R. L. Kapelovich
Translation of "Lechebnaya gimnastika v kompleksnom
lechenii bol'nykh generalizovannoy miasteniyey,"
Voprosy kurortologii, fizioterapii i lechebuoy fizi-
cheskoy kul'tury, No. 5 (Sep-Oct), 1979, pp. 41-45.
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NATIONAL AERONAUTICS AND SPACE ADMINISTRATION
WASHINGTON D.C. 20546 	 AUGUST 1980
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1.	 Tlfi• MI Subtitlel• S. Rq••f Dole
THERAPEUTIC GYMNASTICS IN COMPREHENSIVE TREAT- 0
i. P«hw•Iwe OreMi••tiM CodeMENT OF PATIENTS WITH GENERALIZED MYASTHENIA
7. Awha.t•1 itiM R•pal N•.t. /•ei•n•iwI OeeMa•
R. L. Kapelovich
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Santa Barbara, CA 93108 Translation
12. Sp•w••.iwt At•aey Nu•• •w1 Address'
National Aeronautics and Space Administration 11. Sp•w.«tq Ag.wty C•b
Washington, D.C.
	
20546
11S. Sw, IMmwf«y N•f••	 Translation of "Lechebnaya gimnastika v kompleksnom 	 •
lechenii bol'ny (Ch generalizovannoy miasteniyey", Voprosy kurortologii,
fizioterapii i •lechebnoy fizicheskoy kul'tury, No. 5 (Sep-Oct),
1979, pp. 41-45.
11.	 A► •rr•c ► 	 .
Generalized myasthenia (Myasthenia gravis) is a severe and
complicated neuroendocrine disease, in which the cross-striated musculature
suffers most often as a consequence of a disorder in transmission of
nervous excitation on the myoneural level.
We set the task of using the positive effect (controlling the
consequences of hypodynamia induced by the myasthenic process) o.f the
physical load factor that is fundamentally pathogenic for myasthenia.
Of the three conclusions, one -states therapeutic gymnastics with
regard for the severity and localization of the myasthenic di:;orders
must be a component part of the presurgical preparation and post-
surgical management of patients with generalized myasthenia.
17. K•y w«I• (selected by w.tne.ta) 1i. Distributions1•IN•Mf
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9
Unclassified Unclassified
UDC 636.851.8-009.17-085.825.1
THERAPEUTIC GYMNASTICS IN COMPREHENSIVE TREATMENT
OF PATIENTS WITH GENERALIZED MYASTHENIA
R. L. Kapelovich*
Generalized myasthenia(Myasthenia gravis) is a severe and complicated neuro- /41**
endocrine disease, in which the cross-striated musculature suffers most often as
a consequence of a disorder in transmission of nervous excitation on the myo-
neural level.
According to modern ideas, the myasthenic disorders are due to a change
in the morphological structure of synapses and density of the acetylcholine re-
ceptors, which is induced by humoral and cellular immunobiological factors.	 /42
The urgency of the problem of myasthenia is first of all due to the fact
that during this disease the motor function is damaged, without which labor and
everyday activity is impossible. The disorder in the function of swallowing and
respiration in myasthenia often becomes the cause of death. Ninety percent of
the patients are individuals in age from 11 to 40. This defines the social
nature of the problem of treating the given disease.
Studies of recent years have convincingly indicated the high effectiveness
of surgical treatment for myasthenia patients: in 60-70% of the cases stable and
positive results are obtained (M. I. Kuzin, 1965; S. A. Gadzhiyev et al., 1971,
1977; L. B. Uspenskiy, 1968; D. F. Skripchenko, 1977; Blalock, 1941; Keynes, 1949).
The substantiation for surgeical treatment of such patients was clinical, experi-
mental and dissecting data that confirm the link between myasthenia and changes
in the thymus gland (L. B. Perel'man, 1965; M. I. Kuzin, 1965; B. M. Gekht et al.
*
Department of Faculty Surgery and Physical Education of the I. M. Sechenov
First Moscow Medical Institute.
**
Numbers in margin indicate pagination in original foreign text.
1
I;.
t+.R
1965; Castleman, 1955; Osserman, 1958, and others). Surgical treatment of
myasthenia consists of removal of the thymus gland, and this entails the develop-
}	 meat of complications that are characteristic for thoracic interventions, among
which pulmonary occupy a special place.
However, in contrast to other diseases inchich pulmonary complications
usually develop in the post-surgical period, in myasthenia they often develop
even before surgery. These complications are due to the aspiration of the
oral cavity contents into the respiratory passages as a consequence of the
asthenia of muscles that guarantee swallowing, coughing and respiration.
Therefore, preparation for surgery of myasthenia patients must include both
general and special measures directed towards reducing the severity of the
myasthenic disorders that are present before the surgery. Individual selection of
the optimal doses of anticholinesterase preparations, correction of hormonal and
electrolyte shifts, and compensation for the functional disorders in the respira-
tory and cardiovascular systems are needed.
In thoracic surgery, in addition to medication, therapeutic physical culture
(TPC) is widely used in the pre- and post-surgical period (N. N. Yelanskiy, 1950;
M. I. Kuzin et al., 1967; A. N. Nechayeva, 1960; Ye. I. Yankelevich, 1968, and
others). Diametrically opposite opinions exist on the question of TPC in
myasthenia. The fact is that in-this disease, active movements can induce
intensified blockage of the nerve-muscle transmission, and promote the develop-
ment of serious disorders in such vitally important functions as respiration and
swallowing. Therefore, certain clinicians (M. I. Astvatsaturov, 1939; Ye. K.
Sepp, 1947; Oppenheim) indicate the need for observation during myasthenia of
the maximum physical rest. However, prolonged hypodynamia, governed by a dis-
order in synaptic transmission results in a disorder in the functions of the
internal organs and the regulating apparatus, and at a certain stage becomes an
additional pathogenetic factor that exacerbates the course of the main disease.
We set the task of using the positive effect (controlling the consequences
is induced by the myasthenic process) of the physical load factor
amentally pathogenic for myasthenia.
In the N. N. Burdenko Faculty Surgical Clinic of the First Moscow Medical
Institute 700 patients with myasthenia of varying severity were given surgical
treatment. The overwhelming majority of them engaged in therapeutic gymnastics
(TG). Its influence was carefully studied on 200 patients (main group). Twelve
patients did not engage in TG (control group). Forty-one percent of the patients
with generalized myasthenia were under 20 years old, 52.5X--from 21 to 40. Among
the patients there were more women, in whom the disease developed most often at
a young age. The main clinical manifestations of -+yasthenia were: rapidly
increasing fatigue when walking, fulfilling service duties and self-help, muscle
weakness, disorder in the functions of chewing and swallowing, ptosis sympa-
thetica and double vision, difficulty in breathing and talking.
The technique for conducting the TG procedure was determined to a con-
siderable degree by the reaction of the patients to reception of anticholinesterase
preparations. According to our observations, 18% of the patients did not receive
relief from the administration of these preparations, partial compensation was
noted in 30%, complete in 52%. Thus, taking of the anticholinesterase preparations
30-40 min. before the TG procedure fosters the conducting of the set of exercises 	 /43
that included muscles not only with preserved, but also with disrupted function.
A study of individual muscle groups demonstrated that most often the femoral
extensors suffer (in 741) and musculus triceps brachii (in 70%) of the cases. In
a special study on the indices of external respiration it was revealed that the
vital capacity of the lungs approached the normal only in 19% of the patients,
in 39% it was sharply reduced (up to 60% of the proper amount). The maximum
ventilation of the lungs that characterizes the performance capacity of the
respiratory muscles did not exceed 40% in 22% of the patients, and in 34%--60%
of the proper amount. A drop in the indices for the respiratory function was
directly dependent on the severity of the myasthenic disorders; in 32% of the
patients hypoventilation was observed as a consequence of the respiratory muscle
asthenia. L. V. Uspenskiy, L. M. Popova and V. F. Dubrovskaya, and others
indicate the severe disorders in respiration which often are the cause of death
of the patients.
Upon entry to the clinic, 44% of the patients complained of dyspnea, and
pains in the region of the heart. In an objective examination, in a number
3
of patients expansion in the boundaries of relative cardiac dullness to the left
and systolic noise at the apex Gordis were noted. In an electrocardiographic
study disorders were revealed in rhythm, and in half of the patients, a drop in
the ST segment (A. M. Dreyzina, 1965).
Since we did not find any similar work in the domestic and foreign literature
accessible to us by the beginning of our studies, it was decided to make a pre-
liminary special study on the effect of a single TG procedure on a number of the
patients. Here the condition of the nerve-muscle apparatus was studied with the
help of electromyographic, ergometric, dynamometric studies, a Barre test was
given that characterizes the static performance capacity; an analysis was made
of the external respiratory function by the spyrographic method, the effect on the
condition of the cardiovascular system from the change in pulse rate, arterial
pressure and EKG indices. All the studies were conducted before and directly
after the TG procedure.
A single TG procedure induced positive dynamics in the indices of hand
st rength in 52% of the patients; in 12 patients with myasthenia of average
severity, this index dropped (P<0.01). The decline in static performance capacity
was noted only in 8 out of 40 severely ill patients. It is very characteristic
that the dynamic performance capacity that was defined by the Mosso ergograph,
declined only in 2 out of 36 patients after the TG procedure. The electromyo-
graphic studies indicated an improvement in 22 of 38 patients, decline in bio-
potentials--in 12; electromyograms of 4 patients were not altered. on the EKG
in practically all the patients after the TC procedure the projection T was
altered, and in rare cases--segment ST, which we viewed as a favorable effect
of TG (M. N. Gunbina, 1950).
As the study showed, the employed tests make it possible to establish in
certain limits the functional boundaries for tolerance of the given patient for
a physical load.
Having been convinced of the favorable effect of a single TG procedure,
we included systematic TG exercises l in the set of therapeutic measures in
the preparation period for surgery and after thymectomy.
1The techniques for therapeutic gymnastics have beenpresented in the
journals Vgprasv kurortoloKii, fizioterapii i lechebngy fizkul'tu_r_y, No. 4
(1970) and No. 5 (1975); Grudnava khiru r&iya, No. 3 (1972).
4
Comparison of the indices for external respiration, strength and performance
capacity of the muscles in 34 of the patients in the main and 12 patients of the
control group makes it possible to draw a conclusion on the positive effect of TG
on the presurgical preparation and the course of the post-surgical period. Thus, /44
in the period of preparation for thymectomy, in the main group the shortening of
respiration and increase in vital capacity of the lungs occurred in 67% (P40.05),
increase in the maximum ventilation of the lungs--in 85%, increase in Shtange's
index and strength of the hand--in 94%, static performance capacity--in 91% of
the patients (P<0.01; the reliability was determined by the method of nonpara-
metrical criterion of the signs).
Of especial interest in the period of presurgical preparation is the dynamics
of performance capacity and muscle strength. In patients of the control group
these indices were increased less than in the main group. For example, in
2/3 of the patients in the main group, the strength was 'ncreased on the average
by 5 kg (P<0.01), in 1/3--by 6-20 kg, and in the majority of patients in the
control group it rose by 4-6 kg.
The index for Barre l s test in the main group rose by 15 s and more, and in
the control--the maximum by 5-10 s. Positive dynamics of vital capacity and
maximum ventilation of the lungs were observed in patients of the control group,
which was due to efficient medication treatment (anticholinesterase preparations,
antibiotics in combination with expectorants, inhalation of chemotripsin). The
absolute increase in the indices in the main group was 10-25% for the vital
capacity and 10-40% for the maximum ventilation of the lungs, while in the
control group--respectively 10 and 10-20%.
Preventive and therapeutic measures after thymectomy must be directed
first of all towards the prevention of pulmonary complications and restoration
of the respiratory function. This is attained with the help of anticholinesterase
preparations, oxygen therapy and the active use of TG. In the post-surgical
period, in the main group the number of pulmonary complications was two times
lower than in the control. In the patients of the main group, coughing improved,
and the stool and urination were normalized in earlier periods. After surgery,
in all the patients of the main group the static performance capacity of the
muscles rose. In 97% of them the indices of Shtange's test improved, the
vital capacity of the lungs, data of dynamometry (P<0.01) as well. In the
5
control group, the static performance capacity increased in 92% (P<0.01), the
indices of dynamometry, Shtange's test, the maximum ventilation of the lungs--
in 66%, and the vital capacity of the lungs--in 75% (P<0.05).
Conclusions
1. During myasthenia, the severity of the disease is mainly due to the affection
of the cross-striated musculature. The most dangerous for life are the disorders
in respiration and swallowing, that can be intensified by forced stay in bed
and immobility.
2. The use of therapeutic gymnastics in patients with myasthenia promotes
efficient presurgical preparation, and in the post-surgical period--prevention
of julmonary complications and normalization of respiration.
3. Therapeutic gymnastics with regard for the severity and localization of the
myasthenic disorders. must be a component part of the presurgical preparation and
post-surgical management of patients with generalized myasthenia.
References
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6
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COPYRTGHT: "Voprosy kurortologii, fizioterapii 1 lechebnoy fizicheskoy kul'tury;
1979•
a
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Therapeutic gymnastics in comprehensive treatment of patients with generalized myasthenia

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