Myasthenia Gravis (MG) is a chronic condition that weakens clients’ muscles and causes fatigue (Gilhus, et al., 2019; Joshua, 2022). As a Pilates instructor, it’s important to understand how this condition could impact your client’s ability to workout and the implications for instructing Pilates.

Owing to the muscle fatigue symptoms, clients with MG were previously advised not to exercise out of fear it could exhaust their already weakened muscles. However, more recent research suggests that exercise can be beneficial for improving mood, muscle strength, balance, and flexibility, which makes it easier to perform daily tasks such as showering, walking, and climbing stairs. Ultimately, improving clients’ overall quality of life (O’Connor et al., 2020). 

Regardless of how long a client has had MG, or how severe their symptoms are, a specialised exercise program can make a significant difference. While there are so many options for exercise, it is recommended that your client sees an allied health professional who has knowledge of this condition and experience in prescribing exercise for people with MG. 

WHAT IS MYASTHENIA GRAVIS?

Myasthenia Gravis (MG) is an autoimmune disease that causes muscle weakness and fatigue (Gilhus, et al., 2019; Joshua, 2022). This chronic condition occurs when the immune system attacks itself, rather than foreign objects (Gilhus, 2021). The nerves are healthy, the muscles are healthy, but the communication between them has broken down. 

Approximately 1 in every 5000 people are diagnosed with MG, making it a rare disease, but one that has important considerations for Pilates instructors (U.S. Department of Health, 2020).

SYMPTOMS

Clients with MG may experience a number of symptoms, such as –

• Drooping eyelid/s
• Double vision
• Reduced facial expressions
• Reduced speech
• Difficulty swallowing and chewing
• Trouble breathing
• Muscle weakness in neck, arms, hands, and legs
• Difficulty walking
• Difficulty holding head up
• Fatigue
• Loss of muscle control
• Myasthenic crisis – when breathing muscles are too weak to function

Symptoms such as muscle weakness and fatigue can also fluctuate over time, however they typically become worse during periods of use, and improve after rest (Joshua, 2022; U.S. Department of Health, 2020). 

CAUSES

As MG is an autoimmune condition, the symptoms are caused by the immune system attacking itself. For MG, the thymus gland is believed to trigger an antibody that attacks the neuromuscular junction, where the nerves and muscles meet (Gilhus, et al., 2019; Joshua, 2022). More specifically, the immune system is blocking or destroying the muscle’s receptor sites (Farrugia, & Goodfellow, 2020). This stops the nerves communicating with the muscles in order to stimulate muscle contraction (Gilhus, 2021). When the muscles are unable to receive signals from the nerves, they begin to weaken. It is not clear what causes an autoimmune disease, but MG is not contagious and typically not genetically inherited. While MG can impact people of all ages, it most commonly targets women under 40 years of age and men over 60 years of age (U.S. Department of Health, 2020).

TREATMENT

While there is no known cure, treatments and therapies can help manage symptoms and help people maintain a high quality of life (Gilhus, et al., 2019). Treatment may include-

• Surgery to remove the thymus gland
• Lifestyle changes
• Physical therapy
• Immunosuppressive medication
• Steroid medications
• IV immunoglobulin
• Rest

GENERAL EXERCISE GUIDELINES

Exercising with MG is generally considered safe for people with mild-to-moderate symptoms. In fact, research shows that exercise may help to improve muscle strength and volume in clients with MG (Gilhus, 2021). However, it is essential for the client to check with their health professional before beginning an exercise regime. 

Walking, jogging, swimming, and weight training are all options for exercising with MG. 

PILATES AND MYASTHENIA GRAVIS

Pilates can be particularly helpful for rehabilitation and safe for clients with MG when the program is tailored to the individual (Farrugia, & Goodfellow, 2020). The right amount of exercise can do wonders for your client with MG, but if they perform too much, then fatigue will set in. It’s important to find this balance for each client and work within the individual’s limits.

GENERAL PILATES GUIDELINES

Class Types

• Private, one-on-one, sessions are more suitable for clients with MG, as they will require a program that is tailored to their individual needs. Muscle weakness can present differently in clients with MG, which is why it is necessary to modify the program to the individual client
• Private classes will allow you to help monitor client’s muscle strength and watch for signs of fatigue
• Classes will typically be shorter initially until the client develops more strength

Change the Focus of Your Classes

• It is not uncommon for clients with MG to stop exercising altogether. If this happens, it could be helpful to check-in with your client to help keep them motivated
• Some clients with MG may feel anxious about participating in exercise, so building confidence will be important
• Keep in mind the goal, which is to improve muscle strength, balance, and flexibility, while avoiding fatigue (Westerberg, et al., 2016)
• As an instructor, be sensitive to what your client is going through. Don’t focus on the weight loss or toning benefits of exercise. Instead, exercise is about improving their quality of life and muscle strength

Create the Right Environment

• Research shows that clients with MG will fatigue more quickly in warmer temperatures (Gilhus, 2021). Keeping the workout space cool may help to prevent this
• Bright lights can increase eye strain, so keeping low lighting may help to avoid eye fatigue
• Client safety is important. Some clients may feel nervous about exercising when their muscles fatigue quickly. You will need to carefully supervise the workout in order to create a safe environment 
• If a client is experiencing impaired speech, they may not wish to talk much during their session. Alternatively, they may chat a lot at the start of the session, but become quieter as they lose muscle control. It is not uncommon for clients to experience a reduced ability to speak after muscle exertion

Session Frequency 

• Prolonged muscle use can increase muscle weakness and fatigue, so it’s important for clients to have enough time in between sessions for recovery. You may need to plan sessions further apart to allow enough time for clients muscles to recover
• As clients build muscle strength, the frequency of sessions might be able to increase, but this will depend on the individual client
• Flexibility is key. Clients with MG may experience sudden and spontaneous fatigue which prevents them from exercising. Clients might need to cancel or postpone sessions at the last minute. There might also be long periods of time in between sessions when your client’s body does not feel up to exercising. It is important to make the most of workouts when the client is feeling their best

Adjusting Workout Duration and Timing

• Clients with MG typically have the most energy and strength in the morning. For some clients, it could be helpful to schedule sessions earlier in the day, before their muscles fatigue. However, be mindful that overuse too early in the day can result in muscle fatigue, which would prevent your client from participating in their afternoon schedule
• Allow more breaks in between exercises to help avoid fatigue
• Decrease the length of exercises or hold times as needed. It will be important to build up strength and stamina in small increments. If the client exerts themselves too much, their muscles will weaken quickly
• Some clients will be able to complete repetitive movements, but others will struggle with repetitions when working against gravity
• If your client is short of breath or their symptoms become worse, it is best to stop the workout
• Rest after a workout will be essential. Please encourage your clients to recover and take it easy after a session
• Each client with MG is unique. It will be important to modify the program to the individual, as one size doesn’t fit all. It is essential to work with the client and stay within their daily activity tolerance

Programming

• Put together programs that help improve core strength, balance, flexibility, and endurance in the most energy efficient way possible
• Low-to-moderate intensity is recommended, as it is important to avoid overexertion

Balance

• Balance can be a big concern for clients with MG and a fear of falling is very normal
• Improving balance in increments will be important during workouts
• Always stand next to clients and hold their hands during balance based exercises (for safety) or get the client to hold onto a wall to assist
• Depending on the individual client’s ability, you may need to avoid exercises such as standing series initially, which require a lot of balance and instead work progressively towards more challenging exercises over time

Be Aware of Regressions

• Due to the spontaneous nature of MG, a client may regress. It will be important to adjust their springs each session depending on how the client is feeling that day

MUSCLES LIKELY TO BE TIGHT/WEAK

People with Myasthenia Gravis are likely to be – 

• Expect global weakness – clients with MG are likely to be weak in must muscles of the body (in particular, weakness in the neck muscles, legs and arms is common)
• Weakness often presents in the part of the body where the MG symptoms are occurring. For example, if a client is experiencing symptoms in their leg muscles, they are likely to be weak in this part of the body

MATWORK GUIDELINES

General

• Ideally perform Matwork exercises on an elevated surface such as on a Reformer or Cadillac (so the client does not need to get up and down off the floor)
• If you need to perform Matwork exercises on the floor, be very aware of your programming so that the client does not need to get up and down off the floor constantly – minimise position changes as much as possible
• Focus on developing core strength so the body has the core strength to support them during times of regression
• While you can get clients with MG to perform Matwork, these exercises are more likely to make the client fatigue quickly. As such, Reformer and Cadillac are often better option and are more ideal because the equipment can be more supportive and can help clients avoid exerting as much energy during the workout 
• If you choose to instruct a client MG through Matwork, it may be best to incorporate a small number of Matwork exercises into a Reformer or Cadillac workout, so that you are still doing some Matwork, but not an entire workout of Matwork exercises

Supine Abdominal Series

• Transversus Abdominus and Oblique exercises can be great options (ie. Bent Knee Fallouts, Lift and Extend, Lift Foot and Single Leg Circle). These exercises can be helpful to activate the core abdominal muscles prior to performing more challenging abdominal exercises
• These Matwork exercises can easily be performed while lying on the Reformer with the foot bar down and feet lying on standing platform (this means the client doesn’t have to get up off of the mat and you can easily move into Reformer exercises)
• The remaining abdominal exercises in the Supine Abdominal Series would be best performed on the Reformer (using the hand straps) because the client can keep their head down the whole time if needed and still get an effective abdominal workout

Supine Buttock Series

•  Perform the Reformer versions of these exercises instead of the Matwork variations

Side Lying Series

• These Matwork exercises can easily be performed while lying on the Reformer with the foot bar down (except for Inner Thigh Lift which cannot easily be performed while lying on the Reformer)

Prone Lying Series

• Recommended to avoid as these exercises require significant physical exertion

Kneeling Series

• Due to the challenging nature of these exercises, it may be necessary to choose an alternative
• Alternatively, perform the reformer version of these exercises if the client is strong enough

Plank Series

• Recommended to avoid as these exercises require significant physical exertion
• Only variation which could be performed is Plank on knees, but best to use Reformer variations as the client will not need to get up and down off the mat and will also be able to adjust spring resistance

Stretching Series

• Perform Supine Glute Stretch and Hamstring Stretch while lying in the back on the reformer (instead of on the ground) so no need to get up and down off the mat
• Neck Stretch, Roll Down Stretch, and Chest Stretch can be performed in standing
• Avoid the remaining Matwork stretches and focus on supportive Reformer stretches instead

REFORMER GUIDELINES

General

• Reformer Pilates can be helpful for clients with MG, as the Reformer can help assist in completing the full movement, when the muscle suddenly weakens
• Using a raised Reformer which is not on the ground is best for clients (so they don’t have to exert energy getting up and down off the floor)
• Depending on the severity of symptoms, only place clients in positions where they can be safe and stable without risk of falling
• Keep movements and exercises simple
• The spring resistance can be incredibly beneficial for clients in developing muscle strength
• Focus on developing core strength so the body has the core strength to support them during times of regression
• When programming the class, be aware that you will likely have fewer exercises in each series to avoid fatigue
• Keep springs light and increase gradually over time as the client develops strength

Supine Abdominal Series

• Initially avoid the higher intensity exercises such as Nutcracker 2 (Leg Extending), Hundreds Preparation, Hundreds etc.
• Start off keeping the head down and build up strength to lift the head, neck and shoulders
• Limit sustained abdominal exercises such as Bicycle Legs as these exercises are more likely to fatigue the muscles of the neck quickly (or perform them for a shorter period of time with lots of breaks in between)

Midback Series

• All exercises should be safe to perform (assuming no discomfort or pain in any exercise)
• Keep springs light to begin with

Back Rowing Series

• This series is best performed sitting on the box as opposed to sitting on the carriage
• Do not get the client to kneel in the carriage
• Assist the client to get on and off the box
• Be mindful of Biceps Half Rollback as this exercise requires quite a bit of abdominal stability
• All other exercises should be safe to perform (assuming no discomfort or pain in any exercise)

Front Rowing Series

• Perform this series sitting on the box or sitting on the carriage (kneeling may be too challenging for balance). The box also allows clients to simply focus on their arm muscles rather than adding in the balance component of kneeling
• Some clients may experience muscle weakness in their pectoral girdle and upper limb area, which means that Reformer exercises such as Salute, Overhead Triceps etc. may need to be avoided at times when this weakness is present
• If a client is performing overhead arm exercises, be aware that balance will be challenged in this position, so stand close to the client to prevent any falls

Side Arm Series

• Perform this series sitting on the box or sitting on the carriage (kneeling may be too challenging for balance). The box also allows clients to simply focus on their arm muscles rather than adding in the balance component of kneeling

Prone Arm Series

• Some clients may experience muscle weakness in their pectoral girdle and upper limb area, which means that Reformer exercises such as Overhead Press may need to be avoided at times when this weakness is present
• Clients will find Plough, Airplane and Triceps Prone the most challenging as these exercises will fatigue and work the muscles the fastest
• Be sure to place a non-slip mat over the box to avoid the client slipping

Footwork Series

• All exercises should be safe to perform (assuming no discomfort or pain in any exercise)
• With Pelvic Curl exercises, ensure that the springs are supportive – you may need to use heavier springs than normal
• With the Pelvic Curl exercises, don’t give the client Pelvic Curl 3 (Single Leg Lift) initially, but rather start with Pelvic Curl 1 and 2 to develop strength first and only progress to level 3 when the client has significant strength and good balance
• To assist clients with the Pelvic Curl exercises, you may wish to place the footbar down and perform the exercises with the feet on the standing platform – this will decrease the range of movement and provide greater stability
• If your reformer has different footbar heights, progress clients slowly from having the footbar down with the feet on the standing platform to the next level where the footbar is in a low position, to the next level where the footbar is in a medium position and finally to the footbar being in the standard high position

Feet in Straps Series

• All exercises should be safe to perform (assuming no discomfort or pain in any exercise)
• Ensure that springs are kept light
• Single leg Feet in Strap exercises require significantly more stability and pose a higher risk of clients falling off the reformer – avoid these exercises

Side Lying Series

• Foot on Bar exercises should be safe to perform (assuming no discomfort or pain in any exercise)
• Foot in Strap exercises can be more fatiguing – use these exercises with caution and perform them for a shorter period of time
• Double Leg Lift exercises – keep the head down on the head cushion. Keep the spring light and rest the feet down between repetitions if required

Kneeling Series

• Knee Stretches exercises – these are higher intensity exercises and can fatigue clients quickly – use these exercises with caution and perform them for a shorter period of time. Possibly avoid Knee Stretches 2 (Knees Off) as this exercise is likely to be too challenging
• Reverse Knee Stretches – keep the springs light and be mindful that the head is unsupported
• Hinge – this exercise is challenging for both balance and stability, use a heavier spring to provide more support, do not prescribe this exercise to a new client with myasthenia gravis, but this exercise may be able to be performed once the client has been coming for a while and has developed greater strength and balance. Be sure to stand close to the client when performing this exercise to help prevent falls

Short Box Series

• Avoid these exercises as they are challenging positions to get into and may be a fall hazard

Plank Abdominal Series

• Long Stretch 1 (On the Knees) can be a great exercise for people with myasthenia gravis as it doesn’t require clients to lift their head and you have the flexibility to adjust springs to provide the appropriate level of intensity
• Avoid all exercises in this series where the exercise is performed on the feet rather than the knees as these modifications on the feet will likely be too challenging

Standing Series

• All exercises where the client is required to stand up on the reformer pose significant fall risks for people with myasthenia gravis. If you have a reformer which is low to the ground, this risk may be less
• If the client has good balance and sufficient stability to perform these exercises safely, be sure to stand close to the client to prevent any falls

Stretching Series

• All stretches should be safe to perform (assuming no discomfort or pain in any exercise) however Kneeling Quad Stretch, Front Split Stretch and Gluteal Stretch on the Footbar may be challenging for clients to get into the correct position. These exercises also challenge balance so may need to be avoided depending on the client’s strength, balance, flexibility and ability

SUMMARY

It can take an incredible amount of energy for clients with MG to even turn up to a class when their body is working against them. Somedays a client’s body will allow them to do a full workout, whereas other days, they will need to rest after 10 minutes. Building confidence alongside muscle strength, flexibility, and balance can significantly improve your client’s quality of life. 

When teaching people with Myasthenia Gravis, the overall goal as a Pilates instructor is to provide a gentle workout that aims to increase muscle strength, without over exerting the client. 

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REFERENCES

Note: this article has been reviewed by a Studio Pilates International physiotherapist

Farrugia, M. E., & Goodfellow, J. A. (2020). A Practical Approach to Managing Patients With Myasthenia Gravis-Opinions and a Review of the Literature. Frontiers in neurology, 11, 604. https://doi.org/10.3389/fneur.2020.00604

Gilhus, N.E., Tzartos, S., Evoli, A. (2019). Myasthenia gravis. Nat Rev Dis Primers, 5 (30).  https://doi-org.ezproxy.library.uq.edu.au/10.1038/s41572-019-0079-y

Gilhus, N. E. (2021). Physical training and exercise in myasthenia gravis. Neuromuscular Disorders : NMD, 31(3), 169–173. https://doi.org/10.1016/j.nmd.2020.12.004

Joshua, A. M. (2022). Physiotherapy for adult neurological conditions. Springer.

O’Connor, L., Westerberg, E., & Punga, A. R. (2020). Myasthenia Gravis and Physical Exercise: A Novel Paradigm. Frontiers in Neurology, 11, 675–675. https://doi.org/10.3389/fneur.2020.00675

U.S. Department of Health and Human Services. (2020). Myasthenia gravis fact sheet. National Institute of Neurological Disorders and Stroke. Retrieved December 8, 2022, from https://www.ninds.nih.gov/myasthenia-gravis-fact-sheet#:~:text=Myasthenia%20gravis%20is%20a%20chronic,including%20the%20arms%20and%20legs. 

Westerberg, E., Molin, C. J., Lindblad, I., Emtner, M., & Punga, A. R. (2017). Physical exercise in myasthenia gravis is safe and improves neuromuscular parameters and physical performance‐based measures: A pilot study. Muscle & Nerve, 56(2), 207–214. https://doi.org/10.1002/mus.25493