Neuromuscular diseases and Covid-19: Advices from scientific societies and early observations in Italy

The European reference network for metabolic diseases (MetabERN) clinical pathway recommendations for Pompe disease (acid maltase deficiency, glycogen storage disease type II)

Clinical pathway recommendations (CPR) are based on existing guidelines and deliver a short overview on how to deal with a specific diagnosis, resulting therapy and follow-up. In this paper we propose a methodology for developing CPRs for Pompe disease, a metabolic myopathy caused by deficiency of lysosomal acid alpha-glucosidase. The CPR document was developed within the activities of the MetabERN, a non-profit European Reference Network for Metabolic Diseases established by the European Union. A working group was selected among members of the MetabERN lysosomal storage disease subnetwork, with specific expertise in the care of Pompe disease, and patient support group representatives. The working strategy was based on a systematic literature search to develop a database, followed by quality assessment of the studies selected from the literature, and by the development of the CPR document according to a matrix provided by MetabERN. Quality assessment of the literature and collection of citations was conducted according to the AGREE II criteria and Grading of Recommendations, Assessment, Development and Evaluation methodology. General aspects were addressed in the document, including pathophysiology, genetics, frequency, classification, manifestations and clinical approach, laboratory diagnosis and multidisciplinary evaluation, therapy and supportive measures, follow-up, monitoring, and pregnancy. The CPR document that was developed was intended to be a concise and easy-to-use tool for standardization of care for patients among the healthcare providers that are members of the network or are involved in the care for Pompe disease patients.

[Neurophysiological substantiation and validity assessment of manual muscle testing in clinical practice. (A literature review)]

The relevance of the study of neuromuscular dysfunction's causes and mechanisms is undeniable, considering the large number of nosologies accompanied by malfunction of muscles. Adequate diagnosis and correction of these disorders is impossible without understanding of their pathogenetic mechanisms. Currently, manual muscle testing (MMT) is a widespread technique. MMT is an agile diagnostic tool used by physiatrists, doctors in sports medicine, osteopaths and rehabilitation physicians to assess the functional status of muscles. Unconditionally, this method attracts with its low cost, which will optimize the financial costs of hospital and the healthcare system as a whole. In addition, there is no clear substantiation of the objectivity and validity of the MMT to date. The article considers the issues of neurophysiological principles, classification of methods and approaches, assessment criteria of repeatability and accuracy of MMT. Understanding of the pathophysiological mechanisms of MMT effectiveness will allow to timely correct the therapy and improve the results of treatment and rehabilitation of patients with neuromuscular dysfunction.

Optimized progression of Full-Body In-Bed Gym workout: an educational case report

People suffering from fatigue syndromes spend less time exercising each day, thus aggravating their motor difficulties. Indeed, muscles and mobility deteriorate with age, while exercising muscles is the only sure countermeasure. It is useful to offer a safe and toll-free rehabilitation training: Full-Body In-Bed Gym, easy to learn and performe at home. We suggest a 10-20 min daily routine of easy and safe physical exercises that may improve the main 200 skeletal muscles used for every-day activities. Many of the exercises can be performed in bed (Full-Body In-Bed Gym), so hospital patients can learn this light workout before leaving the hospital. The routine consists of series of repetitions of 15 bodyweight exercises to be performed one after the other without time breaks in between. Alternating sequences of arm and leg exercises are followed by moving body parts in lying and sitting positions in bed. These are followed by series of tiptoeing off the bed. Progressive improvements can be tested by a series of push-ups on the floor. Starting from 3-5, number of repetitions are increased by adding 3 more every week. To maintain or even shorten total daily time of workout each movement is weekly speeded up. The devoted time every morning (or at least five days a week) to train all the major muscles of the body can remain under 10 minutes. Because there are no breaks during and between sets, the final push-ups become very challenging: at the end of the daily workout heart rate, depth and number of ventilations and frontal perspiration increase for a few minutes. We here provide an example of how to implement the progression of the Full-Body In-Bed Gym presenting an educational Case Report of a trained 80-year old person in stable pharmacological managements. In addition to strengthening the main muscles, including the ventilatory muscles, Although performed in bed, Full-Body In-Bed Gym is a resistance training equivalent to a short jog.. Started in early winter and continued regularly throughout spring and summer, Full-Body In-Bed Gym can help maintain independence of frail people, including those younger persons suffering with the fatigue syndrome related to the viral infection of the recent COVID-19 pandemic.

Health-related quality of life (HRQoL) and psychological impact of the COVID-19 pandemic on patients with myasthenia gravis

The aim of this study was to compare the effects of the pandemic on health-related quality of life (HRQoL), anxious-depressive symptoms, feelings of loneliness, and fear of COVID-19 between people with myasthenia gravis (MG) and healthy controls. We also wanted to know in which group the variable fear of COVID-19 interfered the most with the results. This cross-sectional study involved 60 people with MG and 60 healthy controls. Participants using an online platform completed a sociodemographic questionnaire, the Short Form-36 Health Survey (SF-36), the Hospital Anxiety and Depression Scale (HADS), the revised UCLA Loneliness Scale and the Fear of COVID19 Scale (FCV- 19S). The MG group reported worse levels in HRQoL indicators (p = 0.043- <.001), more severe anxiety-depressive symptoms (p = 0.002), and greater fear of COVID-19 (p < 0.001), but there were no differences in feelings of loneliness (p = 0.002). Furthermore, after controlling for the effect of the fear of COVID-19 variable, the differences remained for physical health indicators, but not for the most of psychosocial indicators (Social Functioning p = 0.102, η²_p = 0.023; Role Emotional p = 0.250, η²_p = 0.011; and HADS Total p = 0.161, η²_p = 0.017). The harmful effect of the COVID-19 pandemic was greater in the MG group, and the perceived fear of COVID-19 had also a greater impact among this group, which has increased its negative effect on their psychosocial health.

Telemedicine in Neuromuscular Diseases During Covid-19 Pandemic: ERN-NMD European Survey

BACKGROUND

Telemedicine (TM) contributes to bridge the gap between healthcare facilities and patients' homes with neuromuscular disease (NMD) because of mobility issues. However, its deployment is limited due to difficulties evaluating subtle neurological signs such as mild weakness or sensory deficits. The COVID-19 pandemic has disrupted healthcare delivery worldwide, necessitating rapid measures implementation by health care providers (HCPs) to protect patients from acquiring SARS-CoV-2 while maintaining the best care and treatment.

OBJECTIVES

Given the challenges faced by remote healthcare assistance of NMD patients, we aim to evaluate the use of TM in NMD during the COVID-19 pandemic.

METHODS

Based on the Model for Assessment-of-Telemedicine-Applications (MAST), we conducted a survey amongst clinicians of the ERN EURO NMD (European-Reference-Network-for-Rare-Neuromuscular-Diseases).

RESULTS

Based on 42 responses over 76 expected ones, our results show that the COVID-19 pandemic significantly increased the number of HCPs using TM (from 60% to 100%). The TM types most used during the COVID-19 period are teleconsultation and consultation by phone, particularly in the context of symptoms worsening in NMD patients with COVID-19 infection. Most European HCPs were satisfied when using TM but as a complementary option to physical consultations. Many responses addressed the issue of technical aspects needing improvement, particularly for elderly patients who need caregivers' assistance for accessing the TM platform.

CONCLUSIONS

TM has been essential during COVID-19, but its use still presents some limitations for NMD patients with cognitive deficits or for first-time diagnosis. Thus, TM should be used as complement to, rather than substitute, for face-to-face consultations.

COVID-19 management in Iran and international sanctions

Iran has one of the highest death rates from COVID-19 among Middle Eastern countries. In addition to having a better disease registration system compared to neighboring countries, many factors including economic conditions, have played an important role in increasing the number of mortality rate. This is while that during the Corona pandemic, Iran has been undergo severe sanctions by the United States, that has faced this country with a severe economic crisis. Considering the role of sanction on the country's health management in our study, we examined Iran's management plans against the Corona pandemic and the effect of sanctions on it. Quarantine and corona restrictions, on the one hand, and international sanctions, on the other hand, have put double pressure on the Iranian government. Although drugs and basic medical equipment are exempted from economic sanctions, direct and indirect effects of the sanctions have limited Iran's banking system and created widespread restrictions in the fields of trade, production, and investment. Fortunately, despite the sanctions, many hospitals had an appropriate performance in line with the health promotion program. It is obvious that economic sanctions have severe and harmful effects on public health and have led to poor health consequences in Iran, but attention to planning, standards and improving the quality of the hospital is an important issue in Corona management. Despite multiple mutations, this virus is likely to face with a more dangerous virus in the world future. Now, it is time to take appropriate management measures to remove these sanctions by relying on international solutions and interactions.

Intensive care unit-acquired weakness: From molecular mechanisms to its impact in COVID-2019

Intensive Care Unit-Acquired Weakness (ICU-AW) is a generalized and symmetric neuromuscular dysfunction associated with critical illness and its treatments. Its incidence is approximately 80% in intensive care unit patients, and it manifests as critical illness polyneuropathy, critical illness myopathy, and muscle atrophy. Intensive care unit patients can lose an elevated percentage of their muscle mass in the first days after admission, producing short- and long-term sequelae that affect patients’ quality of life, physical health, and mental health. In 2019, the world was faced with coronavirus disease 2019 (COVID-19), caused by the acute respiratory syndrome coronavirus 2. COVID-19 produces severe respiratory disorders, such as acute respiratory distress syndrome, which increases the risk of developing ICU-AW. COVID-19 patients treated in intensive care units have shown early diffuse and symmetrical muscle weakness, polyneuropathy, and myalgia, coinciding with the clinical presentation of ICU-AW. Besides, these patients require prolonged intensive care unit stays, invasive mechanical ventilation, and intensive care unit pharmacological therapy, which are risk factors for ICU-AW. Thus, the purposes of this review are to discuss the features of ICU-AW and its effects on skeletal muscle. Further, we will describe the mechanisms involved in the probable development of ICU-AW in severe COVID-19 patients.

COVID-19 patients at referral to hospital during the first peak of disease: Common clinical findings including myalgia and fatigue

The wide range of manifestations and clinical symptoms of COVID-19 has made it a unique disease. Investigating the epidemiology of different clinical manifestations of this disease in patients referred to medical centers is one of the most effective steps in adopting a suitable diagnostic and treatment approach. These findings also provide a basis for comparing the evolution of the virus and its clinical manifestations over time and at different peaks of the disease. Therefore, the present study was aimed at investigating common clinical findings at the time of referral in patients with COVID-19 in Afzalipour Hospital, Kerman, during the first peak of the disease. This descriptive-analytical cross-sectional study was performed on hospitalized patients diagnosed with COVID-19, between March 2020 and June 2020. The patients were included in the study by census method, and the research variables related to demographic indicators, disease course and clinical symptoms were extracted from the patients' medical records, and then subjected to statistical analysis. In this study, a total of 210 patients were examined, consisted mainly of male patients (59.5%). The mean age was found to be 53.95 ± 19.55 years. Also, 20.3% of patients needed admission in the intensive care unit. In addition, 1% of patients were infected in February 2020, 24% in March 2020, 47.4% in April 2020 and 27.4% in May 2020. The mean onset of symptoms until hospitalization was also found as 6.51 days. The most common clinical symptoms included shortness of breath (75.7%), dry cough (52.9%), fever (50.5%), myalgia (45.7%) and fatigue (41.9%). Fever at admission time was significantly more common in ages less than 50 years (p=0.034). Our study showed that the most common clinical symptoms were shortness of breath, dry cough, fever, myalgia and fatigue. No statistically significant difference was found in common symptoms between men and women. Among the common clinical symptoms, only fever at admission time was observed to be significantly higher in those under 50 years of age.

Adaptive Force and emotionally related imaginations - preliminary results suggest a reduction of the maximal holding capacity as reaction to disgusting food imagination

The link between emotions and motor control has been discussed for years. The measurement of the Adaptive Force (AF) provides the possibility to get insights into the adaptive control of the neuromuscular system in reaction to external forces. It was hypothesized that the holding isometric AF is especially vulnerable to disturbing inputs. Here, the behavior of the AF under the influence of positive (tasty) vs. negative (disgusting) food imaginations was investigated. The AF was examined in n = 12 cases using an objectified manual muscle test of the hip flexors, elbow flexors or pectoralis major muscle, performed by one of two experienced testers while the participants imagined their most tasty or most disgusting food. The reaction force and the limb position were measured by a handheld device. While the slope of force rises and the maximal AF did not differ significantly between tasty and disgusting imaginations (p > 0.05), the maximal isometric AF was significantly lower and the AF at the onset of oscillations was significantly higher under disgusting vs. tasty imaginations (both p = 0.001). A proper length tension control of muscles seems to be a crucial functional parameter of the neuromuscular system which can be impaired instantaneously by emotionally related negative imaginations. This might be a potential approach to evaluate somatic reactions to emotions.

Neuromuscular monitoring devices - where to go next?

PURPOSE OF REVIEW

This paper reviews the clinical applications, technology, and evidence supporting the use of telemedicine devices and telehealth in neuromuscular disease.

RECENT FINDINGS

The COVID-19 pandemic interrupted standard multidisciplinary care of patients with neuromuscular disease and created a need to adapt to remote care. Telemedicine applications were rapidly introduced and have rapidly proved an important tool in maintaining specialist care. This review presents the current data being gathered identifying the patients who benefit from telehealth applications, the appropriate type of telemedicine approach to specific conditions, the conditions needed to optimise telehealth approaches, and potential pitfalls and limitations in their use.

SUMMARY

Telemedicine is an important tool in providing robust remote care for patients with neuromuscular disorders, but further investigation is needed to optimise applications.

Impact of the COVID-19 pandemic on biopsychosocial health and quality of life among Danish children and adults with neuromuscular diseases (NMD)-Patient reported outcomes from a national survey

The purpose was to investigate the impact of the COVID-19 pandemic on biopsychosocial health, daily activities, and quality of life among children and adults with neuromuscular diseases, and to assess the prevalence of COVID-19 infection and the impact of this in patients with neuromuscular diseases. The study was a national questionnaire survey. Responses were obtained from 811 adults (29%) and 67 parents of children (27%) with neuromuscular diseases. Many patients reported decreased health or physical functioning, and changes in access to physiotherapy or healthcare due to the pandemic. Participants generally perceived themselves or their child to be at high risk of severe illness from COVID-19, but only 15 patients had suffered from COVID-19 and experienced mild flu-like symptoms. 25.3% of adults and 46.6% of parents experienced anxiety. 20.4% of adults and 27.6% of parents experienced symptoms of depression. In general, the pandemic contributed to anxiety, a depressed mood as well as to fewer leisure activities, less social contact, isolation from work/school and a reduced quality of life, in particular for patients who perceived themselves to be at high risk of severe illness. The results demonstrate that the pandemic has had a negative impact on biopsychosocial health and quality of life of patients with neuromuscular diseases.

Assessment of the Adaptive Force of Elbow Extensors in Healthy Subjects Quantified by a Novel Pneumatically Driven Measurement System with Considerations of Its Quality Criteria

Adaptive Force (AF) reflects the capability of the neuromuscular system to adapt adequately to external forces with the intention of maintaining a position or motion. One specific approach to assessing AF is to measure force and limb position during a pneumatically applied increasing external force. Through this method, the highest (AF_max), the maximal isometric (AFiso_max) and the maximal eccentric Adaptive Force (AFecc_max) can be determined. The main question of the study was whether the AFiso_max is a specific and independent parameter of muscle function compared to other maximal forces. In 13 healthy subjects (9 male and 4 female), the maximal voluntary isometric contraction (pre- and post-MVIC), the three AF parameters and the MVIC with a prior concentric contraction (MVICpri-con) of the elbow extensors were measured 4 times on two days. Arithmetic mean (M) and maximal (Max) torques of all force types were analyzed. Regarding the reliability of the AF parameters between days, the mean changes were 0.31–1.98 Nm (0.61%–5.47%, p = 0.175–0.552), the standard errors of measurements (SEM) were 1.29–5.68 Nm (2.53%–15.70%) and the ICCs(3,1) = 0.896–0.996. M and Max of AFiso_max, AF_max and pre-MVIC correlated highly (r = 0.85–0.98). The M and Max of AFiso_max were significantly lower (6.12–14.93 Nm; p ≤ 0.001–0.009) and more variable between trials (coefficient of variation (CVs) ≥ 21.95%) compared to those of pre-MVIC and AF_max (CVs ≤ 5.4%). The results suggest the novel measuring procedure is suitable to reliably quantify the AF, whereby the presented measurement errors should be taken into consideration. The AFiso_max seems to reflect its own strength capacity and should be detected separately. It is suggested its normalization to the MVIC or AF_max could serve as an indicator of a neuromuscular function.

To contrast and reverse skeletal muscle weakness by Full-Body In-Bed Gym in chronic COVID-19 pandemic syndrome

Mobility-impaired persons, either very old or younger but suffering with systemic neuromuscular disorders or chronic organ failures, spend small amounts of time for daily physical activity, contributing to aggravate their poor mobility by resting muscle atrophy. Sooner or later the limitations to their mobility enforce them to bed and to more frequent hospitalizations. We include among these patients at risk those who are negative for the SARS-COV-2 infection, but suffering with COVID-19 pandemic syndrome. Beside managements of psychological symptoms, it is mandatory to offer to the last group physical rehabilitation approaches easy to learn and self-managed at home. Inspired by the proven capability to recover skeletal muscle contractility and strength by home-based volitional exercises and functional electrical stimulation, we suggest also for chronic COVID-19 pandemic syndrome a 10-20 min long daily routine of easy and safe physical exercises that can activate, and recover from weakness, the main 400 skeletal muscles used for every-day mobility activities. Persons can do many of them in bed (Full-Body in-Bed Gym), and hospitalized patients can learn this light training before leaving the hospital. It is, indeed, an extension of well-established cardiovascular-respiratory rehabilitation training performed after heavy surgical interventions. Blood pressure readings, monitored before and after daily routine, demonstrate a transient decrease in peripheral resistance due to increased blood flow of many muscles. Continued regularly, Full-Body in-Bed Gym may help maintaining independence of frail people, including those suffering with the COVID-19 pandemic syndrome.

To contrast and reverse skeletal muscle weakness by Full-Body In-Bed Gym in chronic COVID-19 pandemic syndrome

Mobility-impaired persons, either very old or younger but suffering with systemic neuromuscular disorders or chronic organ failures, spend small amounts of time for daily physical activity, contributing to aggravate their poor mobility by resting muscle atrophy. Sooner or later the limitations to their mobility enforce them to bed and to more frequent hospitalizations. We include among these patients at risk those who are negative for the SARS-COV-2 infection, but suffering with COVID-19 pandemic syndrome. Beside managements of psychological symptoms, it is mandatory to offer to the last group physical rehabilitation approaches easy to learn and self-managed at home. Inspired by the proven capability to recover skeletal muscle contractility and strength by home-based volitional exercises and functional electrical stimulation, we suggest also for chronic COVID-19 pandemic syndrome a 10–20 min long daily routine of easy and safe physical exercises that can activate, and recover from weakness, the main 400 skeletal muscles used for every-day mobility activities. Persons can do many of them in bed (Full-Body in-Bed Gym), and hospitalized patients can learn this light training before leaving the hospital. It is, indeed, an extension of well-established cardiovascular-respiratory rehabilitation training performed after heavy surgical interventions. Blood pressure readings, monitored before and after daily routine, demonstrate a transient decrease in peripheral resistance due to increased blood flow of many muscles. Continued regularly, Full-Body in-Bed Gym may help maintaining independence of frail people, including those suffering with the COVID-19 pandemic syndrome.

Manual Muscle Testing-Force Profiles and Their Reproducibility

The manual muscle test (MMT) is a flexible diagnostic tool, which is used in many disciplines, applied in several ways. The main problem is the subjectivity of the test. The MMT in the version of a "break test" depends on the tester's force rise and the patient's ability to resist the applied force. As a first step, the investigation of the reproducibility of the testers' force profile is required for valid application. The study examined the force profiles of n = 29 testers (n = 9 experiences (Exp), n = 8 little experienced (LitExp), n = 12 beginners (Beg)). The testers performed 10 MMTs according to the test of hip flexors, but against a fixed leg to exclude the patient's reaction. A handheld device recorded the temporal course of the applied force. The results show significant differences between Exp and Beg concerning the starting force (padj = 0.029), the ratio of starting to maximum force (padj = 0.005) and the normalized mean Euclidean distances between the 10 trials (padj = 0.015). The slope is significantly higher in Exp vs. LitExp (p = 0.006) and Beg (p = 0.005). The results also indicate that experienced testers show inter-tester differences and partly even a low intra-tester reproducibility. This highlights the necessity of an objective MMT-assessment. Furthermore, an agreement on a standardized force profile is required. A suggestion for this is given.

Neurogenic vs. Myogenic Origin of Acquired Muscle Paralysis in Intensive Care Unit (ICU) Patients: Evaluation of Different Diagnostic Methods

Introduction. The acquired muscle paralysis associated with modern critical care can be of neurogenic or myogenic origin, yet the distinction between these origins is hampered by the precision of current diagnostic methods. This has resulted in the pooling of all acquired muscle paralyses, independent of their origin, into the term Intensive Care Unit Acquired Muscle Weakness (ICUAW). This is unfortunate since the acquired neuropathy (critical illness polyneuropathy, CIP) has a slower recovery than the myopathy (critical illness myopathy, CIM); therapies need to target underlying mechanisms and every patient deserves as accurate a diagnosis as possible. This study aims at evaluating different diagnostic methods in the diagnosis of CIP and CIM in critically ill, immobilized and mechanically ventilated intensive care unit (ICU) patients. Methods. ICU patients with acquired quadriplegia in response to critical care were included in the study. A total of 142 patients were examined with routine electrophysiological methods, together with biochemical analyses of myosin:actin (M:A) ratios of muscle biopsies. In addition, comparisons of evoked electromyographic (EMG) responses in direct vs. indirect muscle stimulation and histopathological analyses of muscle biopsies were performed in a subset of the patients. Results. ICU patients with quadriplegia were stratified into five groups based on the hallmark of CIM, i.e., preferential myosin loss (myosin:actin ratio, M:A) and classified as severe (M:A < 0.5; n = 12), moderate (0.5 ≤ M:A < 1; n = 40), mildly moderate (1 ≤ M:A < 1.5; n = 49), mild (1.5 ≤ M:A < 1.7; n = 24) and normal (1.7 ≤ M:A; n = 19). Identical M:A ratios were obtained in the small (4–15 mg) muscle samples, using a disposable semiautomatic microbiopsy needle instrument, and the larger (>80 mg) samples, obtained with a conchotome instrument. Compound muscle action potential (CMAP) duration was increased and amplitude decreased in patients with preferential myosin loss, but deviations from this relationship were observed in numerous patients, resulting in only weak correlations between CMAP properties and M:A. Advanced electrophysiological methods measuring refractoriness and comparing CMAP amplitude after indirect nerve vs. direct muscle stimulation are time consuming and did not increase precision compared with conventional electrophysiological measurements in the diagnosis of CIM. Low CMAP amplitude upon indirect vs. direct stimulation strongly suggest a neurogenic lesion, i.e., CIP, but this was rarely observed among the patients in this study. Histopathological diagnosis of CIM/CIP based on enzyme histochemical mATPase stainings were hampered by poor quantitative precision of myosin loss and the impact of pathological findings unrelated to acute quadriplegia. Conclusion. Conventional electrophysiological methods are valuable in identifying the peripheral origin of quadriplegia in ICU patients, but do not reliably separate between neurogenic vs. myogenic origins of paralysis. The hallmark of CIM, preferential myosin loss, can be reliably evaluated in the small samples obtained with the microbiopsy instrument. The major advantage of this method is that it is less invasive than conventional muscle biopsies, reducing the risk of bleeding in ICU patients, who are frequently receiving anticoagulant treatment, and it can be repeated multiple times during follow up for monitoring purposes.