Physical exercise in Myasthenia Gravis is safe and improves neuromuscular parameters

and physical performance-based measures: a pilot study

Elisabet Westerberg, MD,1,3, Carl Johan Molin, MD, 1, Ida Lindblad, MSc,1, Margareta

Emtner, PhD, 2,4, Anna Rostedt Punga, MD; PhD1

Departments of 1. Clinical Neurophysiology and 2. Physiotherapy; Department of Neuroscience,

Uppsala University, Sweden.

3.
Department of Neurology, Ryhov County Hospital, Jönköping, Sweden.

4
Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University,

Uppsala, Sweden

Corresponding author: Anna Rostedt Punga MD, PhD, Department of Neuroscience, Uppsala

University; Box 593, BMC, SE-75124 Uppsala University, SWEDEN; Telephone: +46-18-

6113433; Fax: +46-18-504768; Email: anna.rostedt.punga@neuro.uu.se

Key words: Myasthenia Gravis; physical exercise; neuromuscular; microRNA; CMAP;

resistance training

Number of words in abstract: 150

Number of words in manuscript: 3034

Running title: Physical exercise in MG

Ethical publication statement: We confirm that we have read the Journal´s position on

issues involved in ethical publication and affirm that this report is consistent with those

guidelines.

Disclosures: None of the authors has any conflict of interest to disclose.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
‘Accepted Article’, doi: 10.1002/mus.25493

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 Muscle & Nerve Page 4 of 24

ABSTRACT

Introduction: Due to the shortage of exercise-related research in Myasthenia Gravis (MG), there

are no consensus guidelines on physical exercise for MG patients. Methods: In this prospective

pilot study, 10 MG patients with mild disease performed supervised aerobic and resistance

training twice weekly for 12 weeks. The Myasthenia Gravis Composite (MGC) score, compound

motor action potential (CMAP), repetitive nerve stimulation, muscle force, physical performance-

based measures, serum levels of interleukin-6, muscle enzymes as well as immuno-microRNAs

miR-150-5p and miR-21-5p were assessed before and after the training period. Results: Physical

exercise was well tolerated, and the MGC score was unchanged. Muscle resistance weights and

CMAP amplitudes increased for biceps brachii and rectus femoris muscles, and physical

performance-based measures improved. Muscle enzymes remained normal, whereas disease-

specific microRNAs miR-150-5p and miR-21-5p were reduced after the training period.

Conclusions: We propose that general recommendations regarding physical exercise safely can

be applied to well-regulated MG patients.

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INTRODUCTION

Although Myasthenia Gravis (MG) is a neuromuscular disease with muscle fatigue as its cardinal

symptom, there is no scientifically-based knowledge on how aerobic or muscle resistance training

affects the disease or if there are certain considerations to take into account when recommending

exercise training for MG patients. In the literature, there are a few case reports, but none have

described MG deterioration from physical activity, as well as a few studies on respiratory muscle

training 1. Nevertheless, another study indicated exercise intolerance in well-regulated MG

patients 2. The benefits of physical exercise are well known, and general recommendations

regarding physical activity are available for healthy adults 3. Major benefits of physical exercise

include reduced risk for cardiovascular disease, metabolic disease, falls, and osteoporosis-related

fractures. Further, physical exercise provides clear advantages to a number of chronic diseases

such as rheumatoid arthritis (RA), chronic obstructive pulmonary disease (COPD), and multiple

sclerosis (MS) 4-6, and is therefore recommended as part of the treatment regimen. In

inflammatory muscle diseases such as polymyositis and dermatomyositis, exercise actually

improves muscle function 7,6,8, enhances aerobic capacity, and reduces disability 9. Significant

improvements in muscle resistance, functional activities, and physiological adaptations following

exercise have also been reported in patients with hereditary chronic polyneuropathy, and reduced

chronic fatigue has been reported in patients with facioscapulohumeral muscular dystrophy type

1 10,11. Further, acute exercise is mostly pro-inflammatory in nature with marked increases in

cytokine levels, such as IL-6, whereas long-term physical activity reduces the autoimmune

response 12.

Due to the shortage of exercise-related research in MG compared to other neuromuscular

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diseases, there are no consensus guidelines on physical exercise in MG 13. We conducted this

pilot study to evaluate whether general exercise recommendations could be applied safely in MG

patients and could be recommended by treating physicians.

METHODS

Study design and ethical considerations

This was a prospective study, where each patient served as his/her own control. The primary

hypothesis was that an exercise program based on general exercise recommendations can be

conducted safely and does not worsen muscle fatigue in patients with mild MG. The secondary

hypothesis was that moderate aerobic and muscle resistance training improve neuromuscular

status in MG patients. All subjects gave written informed consent to participate in the study,

which was approved by the Regional Ethical Review Board, Linköping, Sweden (Dnr 2014/459-

31).

Inclusion criteria and patients

Individuals aged >18 years with a confirmed diagnosis of MG according to the Myasthenia

Gravis Foundation of America (MGFA)14, were recruited from the outpatient Neurology clinics

of the 3 hospitals in the region of Jönköping County in Sweden. All 70 MG patients who were

regularly followed in the clinics were invited to participate in the study, and 13 patients agreed.

In order for the patients who agreed to be eligible to participate in the training study, they had to

have well-regulated MG with ongoing treatment and/or mild fatigue (MGFA class I-II).

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Physical exercise regimen

The exercise program was based on general exercise recommendations for healthy adults 3 and

individually tailored. Each exercise session lasted 75 minutes and was supervised by a

physiotherapist. Every session consisted of aerobic, muscle resistance, and balance training in a

physiotherapy setting 2 times weekly for 12 weeks. Aerobic training was performed on stationary

bicycles, starting with a 5-minute warm-up, followed by 7 intervals of 2 minutes cycling against

high load, 1 minute cycling against minimum load, and ending with a 5-minute cool-down

period. Eight muscle resistance exercises: biceps curl, triceps pushdown, seated leg curl, cable

pull-down exercise, leg extension, cable rowing, sit-ups, and leg press were carried out, each with

2 sets of 10 repetition maximums (Supplementary material, available online). Balance was

trained by 1-leg standing for 1 minute on each leg on variable surfaces. Increasing adjustments of

bicycle resistance load and muscle resistance training weights were done throughout the 12

weeks as the participants improved.

MG status, motor nerve conduction studies, and isometric muscle resistance measurement

Motor nerve conduction studies and hand-held dynamometer (HHD) measurements were

performed before and after the entire training period. The MG Composite Scale (MGC) 15 and

Peak Expiratory Flow (PEF) were evaluated before, and on one occasion during and after the

training period. These parameters were used, since they routinely assess MG status in the

Neurology clinic.

Motor nerve stimulation and recordings of compound motor action potential (CMAP) were

achieved with Synergy EMG (Viasys Healthcare™) as previously described, since CMAP

amplitudes in proximal muscles are higher in individuals who regularly perform high resistance

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 Muscle & Nerve Page 8 of 24

muscle training than those who do not 16. A supramaximal CMAP was obtained, and the

amplitude was measured from baseline to negative peak. Repetitive nerve stimulation (RNS, 3

Hz) was subsequently performed to assess neuromuscular transmission failure, with the recording

and stimulating electrode in the same positions. Ten stimuli were delivered, and the decrement

was calculated between the first and the fourth CMAP amplitudes. CMAP amplitude as well as

neuromuscular decrement was calculated from the following muscles: abductor pollicis brevis

(APB; median nerve), biceps brachii (musculocutaneous nerve), rectus femoris (femoral nerve),

and extensor digitorum brevis (EDB; fibular nerve). Isometric muscle force was recorded with a

HHD (model 01165; Lafayette Instrument Company, Lafayette®, Ind., USA), as previously

described 16. Peak force was measured in kg during a 5-second period. Recording was obtained

from the same right-sided muscles as the CMAP amplitude and decrements were measured:

biceps brachii and rectus femoris (proximal muscles that were largely involved in the training

exercises) and APB and EDB (distal control muscles). Evaluations were made at the same time

of the day before and after the training period in order to avoid medication bias in relation to

intake of cholinesterase inhibitors. A board-certified neurologist (EW) examined the patients

clinically and neurophysiologically.

Serum analysis of muscle enzymes, microRNAs, and IL-6

Serum samples were collected from each patient before and after the training period as well as

within 1 hour before and after a single training session (after approximately 10 weeks). Analysis

of serum calcium, phosphate, myoglobin, creatine kinase, CRP, and creatinine was performed.

RNA isolation and cDNA synthesis were performed as previously described with all RT-qPCR

reactions carried out on 384-well Pick-&-Mix microRNA PCR panel plates (Exiqon) 17. The ∆CT

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value of hemolysis markers [∆CT (hemolysis) = CT (miR-23a-3p) − CT(miR-451a)], was used to

detect hemolysis. Quantification of relative miRNA expression of miR-150-5p and miR-21-5p,

that are specifically elevated in AChRab seropositive MG, was performed with the comparative

CT method using the formula 2^−∆∆CT, where ∆∆CT=[(CT gene of interest−CT reference gene)

sample A − (CT gene of interest − CT reference gene) sample B] by using miR-93-5p as the

reference gene 18. ELISA was performed for IL-6 using Human IL-6 SET (hIL-6-EIA-5,

MabTag, Germany), following the manufacturer’s instructions. All samples were assayed in

duplicate at an absorbance of 450 nm, and the detection level was 6.1 pg/ml. Intervariability

between IL-6 duplicate readings was 0.002 (median of differences).

Physical performance-based measures and physical activity self assessment

Timed Up and Go (TUG), Six Minute Walk Test (6MWT), 30-Second Chair Stand Test

(30SCST), handgrip strength test (Jamar), Romberg test, and toe-rise endurance test were

assessed before and after the training period by a licensed physiotherapist. For the Romberg test,

the time the patient was able to stand with both feet together, arms crossed over the chest and

eyes closed was measured, with 60 sec being the maximum limit and the best time out of 3 trials

noted. In the Toe-rise Endurance Test, the patient stood facing the wall and rose up onto the balls

of the feet to a maximal height minus 1 cm. This motion was performed on 1 leg at a time. The

number of fully executed up and down motions was noted.

Baseline physical activity level was measured objectively using an accelerometer (DynaPort

MoveMonitor, McRoberts, The Hague, The Netherlands) for 7 days before the training period.

The patients were also asked to rate themselves according to the Exercise Self Efficacy Scale

(ESES), consisting of 10 questions (maximum 4 points per question, total score 40 points). In

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addition, they were asked to classify how much time they devoted during a typical week to

strenuous physical activity, such as running, aerobic exercise training, or ball sports.

Anthropometrics and body composition

Height (m) and body weight (kg) were measured, and body mass index (BMI) was calculated.

Fat-free mass, muscle mass, and bone mass were assessed with the dual-energy x-ray

absorptiometry method using the Bioelectrical Impedance Analysis (Tanita Body Composition

Analyzer SC-240 MA, Tanita, Japan).

Statistical analysis

Wilcoxon signed-rank test was used to compare nonparametric data before and after training in

each patient. A P-value < 0.05 was considered significant. Parametric data from

electrophysiological and laboratory parameters were presented as mean ± SD and non-parametric

clinical scores as median ± IQR. No post-hoc analysis was performed due to the exploratory

nature of the study. The statistical analysis was performed with the GraphPad Prism software.

RESULTS

Clinical baseline status

Thirteen patients (4 women; ages 65±14 years) with mild MG according to the MGFA (class I,

ocular MG or class II, mild generalized MG) were included in the study. Three patients were

unable to complete the study due to: 1) spontaneous lumbar vertebral compression fractures; 2)

spinal stenosis; and 3) pre-scheduled thymectomy. Of the 10 remaining patients who completed

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the study, 2 patients (#2 and #4) obtained a participation rate of merely 71 %, whereas the

remaining 8 patients had a participation rate of 95 %. Eight patients were seropositive for

acetylcholine receptor antibodies (AChRab), whereas 2 were AChRab seronegative.

Demographic and clinical characteristics of the patients are listed in Table 1.

Before the training period, the number of steps per day ranged from 2961 (#9) to 16743 (#8) with

a median of 7872 steps per day. During a typical week, 5 patients devoted no time at all to

strenuous physical activity (#1,6,8,9,10), 1 patient spent <30 minutes (#4), and 4 patients spent

30-60 minutes (#2,3,5,7) on strenuous activity. ESES scores ranged from 25 (#7) to 38 (#4) with

a median score of 29.5.

The MGC score at study onset was 4.5 ± 2.8, and RNS showed initial abnormal decrement >10%

in only 1 patient (#8).

Outcome after the training period

After the 12-week training program there was no evidence of increased disease activity. The

MGC score at mid-time was 4.0 ± 3.7, and after the training period it was 3.5 ± 2.6, indicating no

change from baseline (P>0.05; Table 2). Individual slight changes in MGC did not affect

training continuation, no patient discontinued the training program due to increased muscle

fatigue, and PEF measurements remained constant (Table 2). RNS decrement remained

unchanged in all patients after the training regimen (data not shown). The CMAP amplitude

increased significantly in the biceps (P=0.0020; Figure 1B) and in the quadriceps muscle

(P=0.037; Table 2; Figure 1D) after the training period. Proximal muscle function, assessed by

increasing resistance weights within the individual muscle training set-ups, significantly

improved in both arm and leg muscles (Table 2; Figure 1A and C). Physical performance-based

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measures, including 6MWT (P=0.0020) and 30SCST (P=0.0039), improved significantly (Table

2). Nevertheless, no change was seen in muscle force measured by HHD (P>0.05; Table 2) and

handgrip strength test. Further, no changes were observed regarding maximum number of times

in the toe-rise endurance test, or maximum time in the Romberg test (P>0.05). Body weight and

BMI did not significantly change after the training period (P>0.05), although body composition

changed with increased muscle mass and reduced fat mass (all; P=0.0195; Table 2). Pulse [% of

max; (220-age)] was consistent among the patients over the course of the training period, whereas

the resistance (Watt) gradually increased over the period (Figure 2), indicating a positive aerobic

training effect. All patients also scored their ability to perform physical activity much higher with

a median ESES score of 36 (compared to median 29.5 before the training regimen; P=0.0078).

Levels of calcium, creatinine, CRP, CK, and phosphate (P≥0.05) remained unchanged, whereas

CKMB and myoglobin were increased within normal limits (both P=0.02). Before and after 1

training session, a slight mean increase within normal limits was noted for calcium (P=0.03),

myoglobin (P=0.016), and CK (P=0.016) although CKMB, creatinine, CRP, and phosphate were

unchanged (P≥0.05). The disease-specific microRNAs miR150-5p (P=0.048) and miR21-5p

(P=0.0020) were significantly reduced after the training period (Figure 1E, F). After a single

training session, miR150-5p was not significantly altered (Figure 1G), whereas miR21-5p

increased (P=0.020; Figure 1H). Baseline levels of IL-6 (1.19±2.23 pg/ml) were not significantly

changed after the training period (1.26±2.08 pg/ml; P=0.85). However, IL-6 levels were

increased after a single training session (2.24±3.44 pg/ml) compared to before the training

session (1.78±3.36 pg/ml; P=0.016).

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DISCUSSION
The cardinal symptoms of muscle fatigue in MG patients typically leave neurologists and

physiotherapists uncertain about whether or not they can safely recommend aerobic and

resistance training. Further, it is difficult to predict how physical exercise will affect MG disease

activity and muscle fatigue. Importantly, in this study, the supervised physical exercise program

was well tolerated, and none of the patients discontinued the training because of worsened MG

fatigue, based on the MGC score and neuromuscular decrement. Also, importantly, all patients

gained improved confidence regarding their ability to perform physical activity according to the

ESES. Since the patients in our cohort had long disease duration (4 to 40 years), they could be

expected to have a more stable disease compared to newly diagnosed MG patients. Nevertheless,

this study supports that MG patients with long disease duration do not worsen from a physical

exercise regimen. Based on studies of other patients with chronic diseases, for example RA, MS,

and COPD, regular exercise is a cornerstone of care in addition to pharmacological treatment 4-6.

Beneficial effects of the training regimen in our study included increased aerobic capacity and

changed body composition to less fat and more muscle mass, which is in accordance with earlier

studies on weight/body composition outcomes of physical activity 19. Additionally, high-

resistance strength training causes hypertrophy of skeletal muscles, more of arm muscles than leg

muscles, in previously untrained individuals20,21. CMAP amplitude has been proposed as an

objective neurophysiological parameter for muscle status and training effects due to its

correlations with isometric muscle strength16. CMAP amplitudes are known to be significantly

higher in the biceps and quadriceps muscles of well-trained healthy adults compared to those who

do not perform resistance training 16. In line with this, CMAP amplitudes of proximal muscles,

especially in the biceps muscles, increased in the MG patients after the training period.

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Additionally, improvement of muscle status was supported by the increased resistance weights at

the end of the training period. HHD might better indicate static muscle weakness than

neuromuscular exhaustion and responding slower to training. It is still a question in the exercise

literature as to whether raised muscle enzymes (CK, myoglobin etc.), as we noted in this study,

after exercise actually represent a degree of actual muscle damage, disruption in energy control

processes, or some other molecular reaction mechanism 22. Nevertheless, the muscle enzymes did

not reach abnormal limits.

MG patients have a disease-specific serum miRNA profile, where immuno-miRNAs miR-150-5p

and miR-21-5p have been suggested to be new biomarkers 17,18. In this study, both these miRNAs

were significantly reduced after the 12-week exercise program. In contrast, miR-21-5p was

increased after a single bout of exercise, in accordance with previous studies in healthy

individuals23, while miR-150-5p remained unaltered. This was mostly expected, since acute

exercise also increases the inflammatory cell response, while sustained exercise leads to

decreased inflammatory activity over time. In 2 patients, however, there was an increase in miR-

150-5p levels after the training period. Patient #5 received treatment with rituximab that was

planned at another clinic before the study initiation, so in this case it could have been a factor to

explain the increased miR-150-5p levels. For patient #8 we do not have a clear explanation to the

observed increased levels. In addition, the increase of IL-6 after an exercise session is known and

associated with a range of health benefits, since a transient increase in exercise-induced IL-6

seems to have an inhibitory effect on the activity of pro-inflammatory cytokines24.

A limitation to the study was the participation of a relatively small number of patients,

considering the high number of patients initially invited to participate. One possible explanation

to this could be the large time commitment required from each patient to come to the hospital and

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perform the training program of 2 times 75 minutes for 12 weeks, for practical reasons scheduled

during ordinary working hours. The invited patients live in an area of 10,475 km2, and the

training was limited to only 1 location, thereby quite far away from many of them. Thus, the

journey time could be an additional reason for not participating. This probably skewed the study

participants towards older patients who had time to participate, and resulted in fewer young

patients with a busy everyday work and family life. Another limitation was the fact that MG is a

fluctuating disease regarding muscle fatigue. In order to reduce the risk of diurnal difference,

patients were examined at the same time of day before and after the study. Thus, even if repeated

measurements would have been desirable, it was not possible practically to perform more

objective measurements than those included.

In summary, this pilot study of supervised aerobic and resistance training in MG indicates that

general recommendations regarding physical exercise can be safely applied to well-regulated MG

patients with mild disease. No worsening of MG fatigue or disease activity was noted, the

training program was well tolerated, and muscle function actually improved.

Author contributions: EW, ME and ARP designed the study. EW examined the patients

clinically and neurophysiologically. CM and IL analyzed miRNA and IL-6. ARP provided

funding and supervision. All authors performed analysis, interpreted the data and wrote the

manuscript.

Acknowledgements: The authors are grateful to the physiotherapists Maria Landén and Samuel

Ånfors at Ryhov County Hospital, who supervised the exercise regimen. The study was funded

by Futurum (FUTURUM-520281 and FUTURUM-520411) and by Palle Ferbs Memorial

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Foundation to EW. Study funding was also provided by the Swedish Society of Medicine (SLS-

499271), the Swedish Research Council (VR-523-2014-2048), Neuroförbundet (NEURO

Sweden) and Selanders memorial foundation to ARP.

Disclosures: The authors report no disclosures.

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Abbreviations:
AChRab, acetylcholine receptor antibodies;
APB, abductor pollicis brevis;
BMI, body mass index;
CMAP, compound motor action potential;
COPD, chronic obstructive pulmonary disease;
EDB, extensor digitorum brevis;
ESES, exercise self efficacy scale;
HHD, hand-held dynamometer;
MGC, Myasthenia Gravis Composite;
MG, myasthenia gravis;
MGFA, Myasthenia Gravis Foundation of America;
MS, multiple sclerosis;
PEF, Peak Expiratory Flow;
RA, rheumatoid arthritis;
RNS, Repetitive nerve stimulation;
TUG, Timed Up and Go (TUG)
6MWT, Six Minute Walk Test;
30SCST, 30-Second Chair Stand Test;

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References

1. Scheer BV, Valero-Burgos E, Costa R. Myasthenia gravis and endurance exercise. Am J

Phys Med Rehabil 2012;91(8):725-727.

2. Elsais A, Johansen B, Kerty E. Airway limitation and exercise intolerance in well-

regulated myasthenia gravis patients. Acta Neurol Scand Suppl 2010(190):12-17.

3. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC et al. Physical

activity and public health in older adults: recommendation from the American College of Sports

Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39(8):1435-1445.

4. Kierkegaard M, Lundberg IE, Olsson T, Johansson S, Ygberg S, Opava C, et al. High-

intensity resistance training in multiple sclerosis - An exploratory study of effects on immune

markers in blood and cerebrospinal fluid, and on mood, fatigue, health-related quality of life,

muscle strength, walking and cognition. J Neurol Sci 2016;362:251-257.

5. Perandini LA, de Sa-Pinto AL, Roschel H, Benatti FB, Lima FR, Bonfa E et al. Exercise

as a therapeutic tool to counteract inflammation and clinical symptoms in autoimmune rheumatic

diseases. Autoimm Rev 2012;12(2):218-224.

6. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, et al. An official

American Thoracic Society/European Respiratory Society statement: key concepts and advances

in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188(8):e13-64.

7. Giesser BS. Exercise in the management of persons with multiple sclerosis. Ther Adv

Neurol Disord 2015;8(3):123-130.

8. Stavropoulos-Kalinoglou A, Metsios GS, Veldhuijzen van Zanten JJ, Nightingale P, Kitas

GD, Koutedakis Y. Individualised aerobic and resistance exercise training improves

16
John Wiley & Sons, Inc.
This article is protected by copyright. All rights reserved.
Page 19 of 24 Muscle & Nerve

cardiorespiratory fitness and reduces cardiovascular risk in patients with rheumatoid arthritis.

Ann Rheum Dis 2013;72(11):1819-1825.

9. Lundberg IE, Vencovsky J, Alexanderson H. Therapy of myositis: biological and

physical. Curr Opin Rheumatol 2014;26(6):704-711.

10. Graham RC, Hughes RA, White CM. A prospective study of physiotherapist prescribed

community based exercise in inflammatory peripheral neuropathy. J Neurol 2007;254(2):228-

235.

11. Voet N, Bleijenberg G, Hendriks J, de Groot I, Padberg G, van Engelen B et al. Both

aerobic exercise and cognitive-behavioral therapy reduce chronic fatigue in FSHD: an RCT.

Neurology 2014;83(21):1914-1922.

12. Simpson RJ, Bosch JA. Special issue on exercise immunology: current perspectives on

aging, health and extreme performance. Brain Behav Immun 2014;39:1-7.

13. Cass S. Myasthenia gravis and sports participation. Curr Sports Med Rep 2013;12(1):18-

21.

14. Jaretzki A, 3rd, Barohn RJ, Ernstoff RM, Kaminski HJ, Keesey JC, Penn AS et al.

Myasthenia gravis: recommendations for clinical research standards. Task Force of the Medical

Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Ann Thorac Surg

2000;70(1):327-334.

15. Burns TM, Conaway M, Sanders DB. The MG Composite: A valid and reliable outcome

measure for myasthenia gravis. Neurology 2010;74(18):1434-1440.

16. Molin CJ, Punga AR. Compound Motor Action Potential: Electrophysiological Marker

For Muscle Training. J Clin Neurophysiol 2016; 33(4):340-345.

17
John Wiley & Sons, Inc.
This article is protected by copyright. All rights reserved.
 Muscle & Nerve Page 20 of 24

17. Punga AR, Andersson M, Alimohammadi M, Punga T. Disease specific signature of

circulating miR-150-5p and miR-21-5p in myasthenia gravis patients. J Neurol Sci 2015;356(1-

2):90-96.

18. Punga T, Le Panse R, Andersson M, Truffault F, Berrih-Aknin S, Punga AR. Circulating

miRNAs in myasthenia gravis: miR-150-5p as a new potential biomarker. Ann Clin Transl

Neurol 2014;1(1):49-58.

19. Millstein RA. Measuring outcomes in adult weight loss studies that include diet and

physical activity: a systematic review. J Nutr Metab 2014;2014:421423.

20. Cureton KJ, Collins MA, Hill DW, McElhannon FM, Jr. Muscle hypertrophy in men and

women. Med Sci Sports Exerc 1988;20(4):338-344.

21. Wilmore JH. Alterations in strength, body composition and anthropometric measurements

consequent to a 10-week weight training program. Med Sci Sports 1974;6(2):133-138.

22. Baird MF, Graham SM, Baker JS, Bickerstaff GF. Creatine-kinase- and exercise-related

muscle damage implications for muscle performance and recovery. J Nutr Metab

2012;2012:960363.

23. Baggish AL, Hale A, Weiner RB, Lewis GD, Systrom D, Wang F et al. Dynamic

regulation of circulating microRNA during acute exhaustive exercise and sustained aerobic

exercise training. J Physiol 2011;589(Pt 16):3983-3994.

24. Ostrowski K, Rohde T, Asp S, Schjerling P, Pedersen BK. Pro- and anti-inflammatory

cytokine balance in strenuous exercise in humans. J Physiol 1999;515 ( Pt 1):287-291.

18
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Legends to the figures

Figure 1. Improvement of neurophysiological parameters after the training period measured in

proximal arm muscles with biceps curl (A) and compound motor action potential (CMAP) of

biceps (B). Improvement of leg extension (C) and CMAP of quadriceps muscle (D). Reduced

serum levels of miR-150-5p (E) and miR-21-5p (F) after the training period. No change of miR-

150-5p after 1 training session (G), and increased levels of miR-21-5p after 1 training session

(H). Baseline levels of miR-150-5p and miR-21-5p are set to 1, before training period or training

session.

Figure 2. Aerobic training effect over the 24 individual training sessions. Pulse displayed as % of

maximum (A). Bicycle load in Watt (B).

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 Muscle & Nerve Page 22 of 24

Table 1. Patient characteristics.

No Gend Dis MG Antibody MGFA MGC score Medicati

er, Dur onset on
type
Age
(yrs) status Class before midtime after

1 M, 59 23 EOMG AChR+ II b 2 0 0 CH, PR,

IM(c),
SPT

2 W, 57 34 EOMG AChR+ II a 7 7 5 CH, PR,

IM (c,r),
SPT*

3 M, 73 4 LOMG AChR+ I 4 5 4 NT

4 M, 75 8 LOMG AChR+ I 0 0 0 IM (a)

5 W, 73 40 EOMG AChR- I 6 4 4 CH, IVIG

6 W, 66 27 EOMG AChR- II b 4 11 8 CH, PR

7 W, 86 10 LOMG AChR+ II b 1 4 3 IM (a)

8 W, 34 5 EOMG AChR+ II a 5 7 4 CH, IM

(r), SPT

9 M, 56 29 EOMG AChR+ II a 9 0 2 PR, IM

(r), SPT

10 M, 69 11 LOMG AChR+ I 5 2 0 CH, PR

M, man; W, woman; Dis dur, disease duration (years); EOMG, Early onset MG (onset < 50 years
of age), LOMG (onset ≥ 50 years of age), Late onset MG; AChR+, Acetylcholine receptor
antibody seropositive; AChR-, antibody seronegative; NT, No therapy; SPT, Status post
thymectomy; CH, Cholinesterase inhibitors; PR, corticosteroids; IM, Immunosuppression
therapy other than corticosteroids (specified as a, azathioprine; c, cyclosporine; r, rituximab);
IVIG, intravenous immunoglobulins. *Patient No 2 is also treated for Rheumatoid Arthritis.

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Page 23 of 24 Muscle & Nerve

Table 2. Evaluation of clinical, neurophysiological, physical performance-based, and biodynamic

measures before and after the training period.

Before After P-value

MG status

MGC median (IQR) 4.5 (1.75-6.25) 3.5 (0-4.25) 0.25

PEF (mean±SD) 440 ± 130 430 ± 140 0.70

Neurophysiological parameters (mean±SD)

CMAP ampl biceps (mV) 6.3 ± 3.8 8.2 ± 3.4 0.0020*

CMAP ampl APB (mV) 8.8 ± 4.1 9.4 ± 2.5 0.63

CMAP ampl rectus femoris (mV) 6.1 ± 2.1 7.7 ± 3.2 0.037*

CMAP ampl EDB (mV) 3.0 ± 2.6 3.1 ± 2.1 0.18

HHD biceps (kg) 21.3 ± 6.4 20.7 ± 5.2 0.38

HHD APB (kg) 4.3 ± 1.0 3.9 ± 1.0 0.10

HHD rectus femoris (kg) 28.9 ± 6.1 29.2 ± 5.1 0.10

HHD EDB (kg) 7.9 ± 1.5 7.6 ± 1.8 0.80

Physical performance-based measures (mean±SD)

Timed Up and Go (s) 8.5 ± 1.5 7.9 ± 1.4 0.27

Six Minute Walk Test (m) 486 ± 91 561 ± 67 0.002*

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 Muscle & Nerve Page 24 of 24

30-Second Chair Stand (numbers) 13.6 ± 5.6 18.6 ± 6.2 0.0039*

Biceps curl (kg) 3.8 ± 1.2 5.8 ± 2.3 0.016*

Triceps pushdown (kg) 10.7 ± 6.1 16.6 ± 6.9 0.0078*

Seated leg curl (kg) 21.0 ± 6.5 28.0 ± 12.5 0.031*

Cable pull-down exercise (kg) 5.1 ± 1.5 6.7 ± 2.1 0.016*

Leg extension (kg) 15.8 ± 5.4 24.3 ± 8.6 0.0039*

Cable rowing (kg) 10.2 ± 2.6 16.8 ± 4.7 0.0039*

Leg press (kg) 48.9 ± 13.2 77.3 ± 33.9 0.012*

Biodynamic measures (mean±SD)

Weight (kg) 79.0 ± 14.0 78.6 ± 13.9 0.12

BMI (kg/m2) 27.5 ± 4.5 27.3 ± 4.4 0.063

Fat Range (%) 30.9 ± 5.4 29.4 ± 5.5 0.019*

Muscle Range (%) 65.6 ± 5.2 67.1 ± 5.2 0.019*

MGC, myasthenia gravis composite score; PEF, Peak Expiratory Flow; CMAP ampl, compound
motor action potential amplitude; HHD, hand-held dynamometer; APB, abductor pollicis brevis;
EDB, extensor digitorum brevis. Results are given as mean ± SD or median with interquartile
range where applicable. * P<0.05.

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Figure 1. Improvement of neurophysiological parameters after the training period measured in proximal
arm muscles with biceps curl (A) and compound motor action potential (CMAP) of biceps (B). Improvement
of leg extension (C) and CMAP of quadriceps muscle (D). Reduced serum levels of miR-150-5p (E) and miR-
21-5p (F) after the training period. No change of miR-150-5p after 1 training session (G), and increased
levels of miR-21-5p after 1 training session (H). Baseline levels of miR-150-5p and miR-21-5p are set to 1,
before training period or training session.

132x199mm (300 x 300 DPI)

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 Muscle & Nerve Page 2 of 24

Figure 2. Aerobic training effect over the 24 individual training sessions. Pulse displayed as % of maximum
(A). Bicycle load in Watt (B).

246x126mm (300 x 300 DPI)

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