Myasthenia gravis affects approximately 20 in every 100,000 people worldwide. It is more commonly seen in women under 40 and men over 60, but it can occur at any age.
Myasthenia gravis is a condition where the body's immune cells produce antibodies that interfere with nerve signals to muscles. This can lead to muscle weakness and fatigue. Typically, these symptoms may worsen with muscle use and improve with rest. A functional medicine approach to Myasthenia gravis aims to explore and address factors that may contribute to the condition, focusing on the communication between nerves and muscles.
What is Myasthenia Gravis?
Myasthenia gravis is a chronic autoimmune condition where nerves and muscles do not communicate effectively. This neuromuscular condition occurs when the immune system produces antibodies that interfere with the transmission of nerve signals to the muscles that help you breathe and move parts of your body, like the arms and the legs (known as skeletal or voluntary muscles). These antibodies disrupt the connections and communication between the nerves and the muscles. As a result, the affected muscles may not contract normally, which can cause muscle weakness and rapid fatigue that worsens during activity and improves with rest.
Myasthenia Gravis Signs & Symptoms
The most common symptoms of Myasthenia gravis include muscle weakness and fatigue due to interference with the communication between nerves and muscles. These symptoms may vary, often improving with rest. In many people, the symptoms may progress over time, peaking within a few years after the onset of the condition. The specific symptoms of myasthenia depend on which muscles are most affected. The condition can impact any of the muscles you control voluntarily, but certain muscle groups are more commonly affected than others.
Eye Muscles
The muscles of the eyes are commonly affected, leading to the following:
- Drooping of one or both eyelids (ptosis)
- Double vision (diplopia) that improves when one eye is closed
Neck and Limb Muscles
Weakness in the voluntary muscles of the neck and limbs can impact
- The ability to walk
- The function of the arms and hands
- The ability to hold up the head
Face and Throat Muscles
The muscles of the face and throat are also commonly affected, causing:
- Difficulty speaking with nasal or soft speech
- Difficulty swallowing leading to easy choking and problems eating and drinking fluids
- The muscles used for chewing can become tired while eating
- Changes in facial expressions, such as maintaining a normal smile
Myasthenic Crisis
A potential complication known as a myasthenic crisis can occur when the muscles that control breathing become too weak to function properly. This requires emergency treatment and mechanical assistance with breathing while addressing the antibodies that affect muscle function.
What Causes Myasthenia Gravis?
During normal voluntary movement, a signal travels from the brain down a peripheral motor nerve and triggers nerve endings to release a chemical or neurotransmitter called acetylcholine. Acetylcholine travels through the neuromuscular junction (NMJ), where nerve cells connect with the muscles they control. It binds to acetylcholine receptors at particular sites within the muscle tissue membrane called motor end plates. This triggers an electrical impulse to propagate through the muscle and generate a muscle contraction.
Antibodies
In myasthenia gravis, antibodies are produced against the body's tissues. These antibodies block, alter or destroy components found at the NMJ. These antibodies can target:
- Acetylcholine receptors
- Muscle-specific receptor tyrosine kinase (MuSK), a protein involved in forming the NMJ
- Lipoprotein-related protein 4 (LRP4)
This alters the communication between the central nervous system (CNS), including the brain and motor nerves, which can affect normal muscle contractions.
Lymphoid Hyperplasia of the Thymus and Autoimmunity
Research suggests that many individuals with myasthenia gravis have abnormally large thymus glands, which show lymphoid hyperplasia or an increase in the number of the same types of cells contained in the lymph nodes. The thymus gland is a part of the immune system found in the upper chest behind the sternum. It is involved in the development of the immune system and usually shrinks in size into adulthood. It is still under study, but it is suspected that the thymus plays a role in triggering the developing immune cells to produce antibodies that affect skeletal muscle NMJs.
Triggers of Attacks
Certain factors can bring on or worsen myasthenia gravis flares.
- Fatigue
- Illness or infection
- Surgery
- Smoking
- Stress
- Medications such as beta-blockers, quinidine gluconate, quinidine sulfate, quinine (Qualaquin), phenytoin, certain anesthetics, and some antibiotics
- Pregnancy
- Menstrual periods
- Certain Vaccines
In general, various factors may contribute to the development of autoimmunity that is associated with myasthenia gravis. When someone with a genetic predisposition to autoimmunity is exposed to environmental or other factors, the immune system can become dysregulated. These factors include:
- Imbalances in gut health
- Nutrition
- Infections
- Environmental exposures
- Genetics
Gut Health & Myasthenia Gravis
The digestive tract is the main barrier to the outside world and a critical immune system mediator. The gut microbiome or microbes that populate the digestive system play critical roles in regulating hormones, immunity, detoxification, and overall health.
Ongoing stressors can lead to dysbiosis, where the gut bacteria become imbalanced and damage the gut lining contributing to inflammation. When the microbiome becomes imbalanced, or the gut lining becomes damaged and leaky from chronic exposures to toxicants, inflammatory foods such as gluten or lectins, and chronic stress, the barrier becomes less effective. Once the gut is "leaky," substances can enter the circulation and may trigger inflammation and immune responses throughout the body.
Infections
Viral or bacterial infections, including human immunodeficiency virus (HIV), herpes simplex, and hepatitis B and C viruses, can contribute to inflammation and molecular mimicry, where the immune system mistakenly identifies its tissues as foreign invaders and mounts an immune response.
Environmental Exposures
Past or ongoing exposures to heavy metals, mercury, arsenic, cadmium, solvents, plastics, and pesticides may contribute to dysbiosis, inflammation, and immune responses by affecting the body's detoxification, nervous, and endocrine systems.
Genetics
There is not one genetic cause identified, but several genetic risk factors for myasthenia gravis have been identified, including variation in HLA genes of the immune system and CHRNA1 (a gene encoding part of the Acetylcholine receptor), among others. Genetics can predispose an individual to develop autoimmune issues like myasthenia when combined with environmental and nutritional factors.
Other Autoimmune Disorders
Those with other autoimmune disorders such as lupus, rheumatoid arthritis, thyroid disease, and diabetes may have a higher likelihood of developing myasthenia gravis.
Diagnosing Myasthenia Gravis
Myasthenia Gravis is generally diagnosed based on a neurological physical examination and some specialized testing to investigate the nature of the muscle weakness.
Neurological examination
A thorough neurological examination investigates nerve and muscle function and the ways they communicate together. This includes checking the following:
- Reflexes
- Muscle strength
- Muscle tone
- Senses of touch and sight
- Coordination
- Balance
Ice Pack Test
In this test, an ice pack is placed on the eyelids for a few minutes and then removed. In people with myasthenia, there is a temporary improvement in eyelid drooping due to the cold decreasing the acetylcholinesterase breaking down acetylcholine at the neuromuscular junction.
Nerve Conduction Studies
Repetitive nerve stimulation involves attaching electrodes to the skin over the muscles and sending small pulses of electricity through the electrodes to measure the nerve's ability to send a signal to the muscle. In myasthenia gravis, repeatedly testing the nerve will show a decreased ability to send signals to the muscle.
Single-Fiber Electromyography (EMG)
This test involves inserting a fine wire electrode through the skin and into a muscle to test a single muscle fiber. It measures the electrical activity traveling between the brain, nerves, and into muscles.
Imaging
Imaging tests like a CT scan or an MRI can look for any visual abnormalities of the thymus.
Pulmonary Function Tests
Pulmonary function tests (PFTs) can assess if myasthenia impacts the breathing muscles.
Functional Medicine Testing
Antibodies
A blood test (anti-acetylcholine receptor (AChR) antibody test) can reveal the presence of antibodies that may disrupt the receptor sites where nerve impulses signal muscles to move.
A blood test for muscle-specific tyrosine kinase (MuSK) antibodies is also available.
Gut Health
Since dysbiosis and leaky gut are considered factors in the development of the autoimmunity that occurs in myasthenia gravis, assessing gut health can help provide targeted interventions to help regain balance. A Comprehensive Stool Test measures amounts of healthy and unbalanced gut bacteria (dysbiosis), inflammatory markers, leaky gut, parasites, and yeast to assess the state of the gut and guide approaches aimed at restoring balance.
For example, the ratio of certain types of bacteria (Firmicutes/Bacteroidetes) in patients with myasthenia gravis is significantly lower than in unaffected populations.
Food sensitivities can contribute to increased intestinal permeability, inflammation, and immune responses. Foods to which an individual is sensitive can be identified with ELISA testing.
Inflammation
Inflammation markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) assess inflammation levels throughout the body. The results of these tests can help practitioners narrow down other tests necessary to find the root causes of inflammation.
Environmental Exposures
Since toxins can contribute to immune responses, your practitioner may want to evaluate you for past or current heavy metal or toxin exposures to narrow down the exact factors involved. The Total Tox-Burden panel looks at a combination of common environmental toxins, mycotoxins, and heavy metals in one easy-to-do at-home urinalysis test.
Conventional Treatment for Myasthenia Gravis
Conventional medications may be used to address the muscle weakness in Myasthenia Gravis by supporting the levels of acetylcholine at the NMJ or modulating the immune system to reduce antibody production.
Anticholinesterase Medications
Anticholinesterase medications like pyridostigmine (Mestinon) may help improve neuromuscular transmission to support muscle contraction and strength.
Immunosuppressive Medications
Medications, including corticosteroids like prednisone and agents like cyclosporine (Sandimmune) and azathioprine (Imuran), are used to modulate the production of antibodies. These can help support muscle function but may produce side effects such as bone thinning, weight gain, diabetes, an increase and redistribution of body fat, infertility, and decreased white blood cell counts, which can increase the risk of infection.
Plasmapheresis
Plasmapheresis involves removing antibodies from the blood using a filtering process similar to dialysis. The beneficial effects of this treatment usually last only a few weeks and must be repeated regularly.
High-dose Intravenous Immune Globulin (IVIg)
IVIg involves giving pooled collections of immunoglobulins, temporarily modifying the immune system by providing normal antibodies from donated blood.
Monoclonal Antibodies
Rituximab (Rituxan) and eculizumab (Soliris) are intravenous medications that may be used for myasthenia when other treatments are not effective.
Thymectomy
The surgical removal of the thymus gland (thymectomy) is sometimes used to help reduce symptoms in those individuals with or without an enlarged thymus.
Functional Medicine Treatment for Myasthenia Gravis
Balancing Gut Health
Since the gut microbiome significantly impacts the immune system and may influence autoimmunity, maintaining diverse and balanced bacteria can be beneficial for individuals with myasthenia gravis.
Restoring equilibrium in the gut microbiota by eating a variety of whole foods and incorporating probiotic-rich foods like kimchi and sauerkraut that contain naturally-occurring probiotics and prebiotic-rich foods like artichokes, garlic, and beans that nourish healthy bacteria is important for supporting the mucosal barrier and overall immune health.
An Individualized Anti-Inflammatory Diet
Inflammation may increase the risk of immune reactions, so a nutrient-rich, anti-inflammatory diet tailored to an individual's sensitivities and needs can help support balanced inflammation and immune health. Identifying and reducing individual trigger foods, such as gluten and other grains, dairy, processed sugars, and other foods that an individual is sensitive to, and balancing the intake of micronutrients can help to support overall well-being.
Meal Timing
Some individuals find it helpful to space out meals and eat several smaller meals during the day to maintain the strength to chew well and eat slowly.
Stress Management
High levels of chronic stress may contribute to inflammation and have been associated with immune responses. Finding balance via lifestyle practices like adequate sleep, stress management, and balanced movement can support overall health and help manage myasthenia.
Restorative exercises such as yoga, walking, and Qi gong are generally more supportive for balancing inflammation than overly intense exercise, especially with myasthenia. Spending quiet time in nature can also support well-being by providing exposure to natural sunlight to optimize vitamin D and direct contact with the earth.
Addressing Environmental Factors
Chemicals in plastics, pesticides, heavy metals, and other pollutants may increase the risk of immune responses. You can consider reducing exposure to these chemicals by using high-quality water and air filters, choosing organic produce, and assessing other exposures, such as metal dental amalgams. Many practitioners may suggest a metabolic detox nutrition plan alongside herbs and supplements that may help support the body's natural detoxification processes.
Acupuncture
Acupuncture and traditional Chinese medicine have been studied for their potential to support symptoms of myasthenia gravis, such as eye weakness and fatigue. For these types of treatments, it's important to work with a licensed acupuncturist for proper assessment and treatment protocol.
Summary
Myasthenia gravis is an autoimmune condition associated with the production of antibodies against proteins at the neuromuscular junction, where nerves influence voluntary muscle movements. This can result in fatigue, weakness of arm or leg muscles, double vision, drooping eyelids, and difficulties with speech, chewing, swallowing, and breathing. Muscle weakness generally worsens with activity and improves after rest.
A functional medicine approach to myasthenia gravis utilizes blood and stool testing to explore potential factors that may contribute to inflammation and immune responses that can trigger myasthenia flares. These include testing for antibodies associated with myasthenia gravis, examining the diversity of the gut microbiome, and testing for food sensitivities. Addressing identified contributing factors may help support the immune system and overall health.