SS Radio #230: Another Mistaken Attempt to Involve the Audience. We Never Learn.

[Mark Rippetoe]

Q&A Episode - Neuromuscular Disease, Training Kids in Season, and Elbow Replacement | Starting Strength Radio #230

[Maybach]

A thought about John, the final caller who called in with a question about myasthenia gravis: it seems that the disease represents a straightforward impairment of neuromuscular efficiency. It is literally a disease which affects the signaling of muscle contraction, which means that sufferers cannot as efficiently call their muscles into contraction. With that in mind, the standard proscription for populations with limited NME (females and the elderly), that is, triples, would seem to be the ticket. If John or anyone else who suffers from a similar condition is reading this, it'd be interesting to see how that works. The recommendation against sets across might still hold, since there is also an probably effect on recovery through diminished parasympathetic activation (probably the source of the squeamishness on the part of the doctors about TRT. You get similar ill conceived caution occurring about disorders like Cushing's and Addison's).

[dfclark68]

A thought about John, the final caller who called in with a question about myasthenia gravis: it seems that the disease represents a straightforward impairment of neuromuscular efficiency. It is literally a disease which affects the signaling of muscle contraction, which means that sufferers cannot as efficiently call their muscles into contraction. With that in mind, the standard proscription for populations with limited NME (females and the elderly), that is, triples, would seem to be the ticket. If John or anyone else who suffers from a similar condition is reading this, it'd be interesting to see how that works. The recommendation against sets across might still hold, since there is also an probably effect on recovery through diminished parasympathetic activation (probably the source of the squeamishness on the part of the doctors about TRT. You get similar ill conceived caution occurring about disorders like Cushing's and Addison's).

I'm a neurologist who treats a lot of patients with neuromuscular disorders and this caller's question really got me thinking about what the best programming approach. In generalized myasthenia gravis the pathology is immune complexes forming on the acetylcholine receptors, which are concentrated on the muscle cell membranes at the neuromuscular junction. The enemy and limiting factor in expressing physical strength is fatigue, but it's a very different kind fatigue than in the normal state. Depending on the severity, one may only be able to operate at 10-20% of 1RM for sets of five. MG fatigue is very fast onset but short-lived, however, typically lasting minutes to hours. It is worsened by heat. I would think the main challenge would be creating the enough stress to the muscle fibers to produce much adaptation since the neuromuscular junction blockade is the limiting factor. Mind you, all this is in the untreated or under-treated MG state. Modern treatments have actually gotten pretty good, so he should make sure he's working with his neurologist on that or find another one who knows what he or she is doing.
I'm not his doctor or his coach, but this is the way I would think about it (only education and entertainment, of course):
1) Don't be afraid to push both the intensity or volume as hard needed to find where the sweet spots are. I honestly have know idea where those sweet spots would be and they may be quite dynamic over the course of a day or week. He might get as fatigued as all get out, but most likely will not be able to do enough work to produce soreness and he'll be just as fresh the next day. MG may make one virtually immune to "normal" overtraining.
2) Extra long resting periods will probably be productive.
3) Given the MG fatigue limitations, daily work outs may be productive.
4) Keep as cool as possible during work outs.
5) An extra pyridostigmine dose 30 minutes before work outs will probably help.
6) Make sure you're on a disease-modifying agent that is working well. Corticosteroids have been used traditionally, but that should only be temporary. Work with a neuromuscular neurologist on this if you can find one.

By the way, testosterone replacement probably has no direct effect on the myasthenia pathophysiology, but there's certainly no contraindication if there is a reason to do it.

[Mark Rippetoe]

Thank you, Dr. Clark.