Addition of the combination of sims technique and semi-fowler positioning to cardiorespiratory exercises in patients with myasthenia gravis: case report

Putu Ayu Meka Raini, Luh Putu Ratna Sundari, Ni Kadek Yuni Fridayani


Myasthenia gravis (MG) is an autoimmune disorder characterized by fluctuating muscle fatigue, worsening with increased activity, and improving at rest. Physiotherapy plays a role in reducing symptoms such as shortness of breath, respiratory muscle weakness, and airway obstruction due to decrease the sputum in the lung lobes and prevent of the exacerbation. Respiratory training and postural drainage techniques are part of intervention that given by physiotherapy for patients diagnosed with MG and had symptoms hospital acquired pneumonia (HAP). A male, 28 years old patient diagnosed with HAP and had history of MG hospitalized a month with dyspnoea and disable to do activity daily living. Physiotherapy treatment that given to the patient from 18th July 2018 till 28th July 2018 are respiratory training included breathing exercise, cough exercise, shoulder expansion, Active Range of motion (ROM) exercise, stretching of respiratory muscle and home program exercise that helped by nurse and caregiver. Patient had medical treatment from all medical team by pulmonologist, neurologist and nurse too. Combined this new technique postural drainage and all physiotherapy programs showed significant in patient such as dyspnoea decreased. 


MG, Sims, Semi-fowler position, Cardiorespiratory exercise

Full Text:



Akaishi T, Yamaguchi T, Suzuki Y, Nagane Y, Suzuki S, Murai H et al. Insights into the Classification of Myasthenia Gravis. Plus One. 2014;9(9):1-5.

Kurniawan SN. Myasthenia Gravis: an Update dalam Continuing Neurological Education, Malang. UB Media, Universitas Brawijaya, Malang. 2014;59-80.

Berkel MAV, Twilla JD, England BS. Emergency Department Management of a Myasthenia Gravis Patient with Community-Acquired Pneumonia: Does Initial Antibiotic Choice Lead to Cure or Crisis? J Emergency Med. 2015;50(2):1-5.

Kwiatkowska K, Lamtych M, Kubiak K, Badiuk N. Physiotherapy in myasthenia gravis. J Education, Health Sport. 2018;8(12):1027-38.

Abraham A, Kassardjian CD, Katzberg HD, Bril V, Breiner A. Selective or predominant triceps muscle weakness in African-American patients with myasthenia gravis. Neuromuscul Disord. 2017;27(7):646-9.

Kumar R. Myasthenia gravis and thymic neoplasms: A brief review. World J Clin Cases. 2015;3(12):980-3.

Zouvelou V, Karavasilis E, Velonakis G. Benign thymic enlargement in myasthenia gravis. Neuromuscul. Disord. 2018;28(5):454-5.

Naumes J, Hafer-Macko C, Foidel S. Exercise and Myasthenia Gravis: A Review of the Literature to Promote Safety, Engagement, and Functioning. Int J Neurorehabilitation Eng. 2016;3(3):1-3.

Grohar-Murray ME, Becker A, Reilly S, Ricci M. Self-care actions to manage fatigue among myasthenia gravis patients. J Neurosci Nursing. 1998;30(3):191-9.

Fregonezi GA, Resqueti VR, Güell R, Pradas J, Casan P. Effects of 8-week, interval-based inspiratory muscle training and breathing retraining in patients with generalized myasthenia gravis. Chest. 2005;128(3):1524-30.

Weiner P, Gross D, Meiner Z, Ganem R, Weiner M, Zamir D, Rabner M. Respiratory muscle training in patients with moderate to severe myasthenia gravis. Can J Neurol Sci. 1998;25(3):236-41.

Rassler B, Hallebach G, Kalischewski P, Baumann I, Schauer J, Spengler CM. The effect of respiratory muscle endurance training in patients with myasthenia gravis. Neuromuscular Disord. 2007;17(5):385-91.

Reid WD, Frank C. Clinical Management Notes and Case Histories in- Cardiopulmonary Physical Therapy. USA: SLACK. 2004.

Smeltzer SC, Bare BG, Hincle JI, Cheever KH. Textbook of Medical Nursing; Brunner and Suddart. 2nd. EGC: Jakarta. 2008.

Bello AI, Gifty GN, Mary WA, Stella EL, Hosea B. Physiotherapy Management For COVID-19 In the Primary, Community and Acute (Hospital) Settings A Preliminary Guideline: Submited by Guideline Development Committee For COVID -19 To Ghana Physiotherapy Association. 2020.

Ishikawa A. Current Situation of Pulmonary Care and Rehabilitation. International Symposium Udayana University-Kobe University. 2018.

Carrolyn K, Colby LA. Therapeutic Exercise Foundations and Techniques. USA: Philadelphia. 2012.

Lohi EL, Lindberg C, Andersen O. Physical Training Effects in Myasthenia gravis. Arch Phys Med Rehabil. 1993;74:1178-80.

Gross WP, Meiner D, Ganem Z, Weiner R, Zamir M, Rabner DM. Respiratory Muscle Training in Patients with Moderate to Severe Myasthenia Gravis. Can J Neurol Sci. 1998;25(3):236-41.

Fregonezi GA, Resqueti VR, Güell R, Pradas J, Casan P. Effects of 8-week, Interval-based Inspiratory Muscle Training and Breathing Retraining in Patients with Generalized Myasthenia Gravis. Chest. 2005;128(3):1524-30.

Keenan SP, Alexander D, Road JD, Ryan CF, Oger J, Wilcox PG. Ventilatory Muscle Strength and Endurance in Myasthenia Gravis. Eur Respir J. 1995;1130-35.

Aslan GK, Gurses HN, Issever H, Kiyan E. Effects of Respiratory Muscle Training on Pulmonary Functions in Patients with Slowly Progressive Neuromuscular Disease: A randomized Controlled Trial. Clin Rehabil. 2014;28(6):573-81.

Freitag S, Hallebach S, Baumann I, Kalischewski P, Rassler B. Effects of Long-term Respiratory Muscle Endurance Training on Respiratory and Functional Outcomes in Patients with Myasthenia Gravis. Respir Med. 2018;144:7-15.

Shakil ur-Rehman S, Danish KF, Manzoor F, Sibtain F, Asghar K, Siddiqi FA. Effects of Postural Drainage Physical Therapy Techniques on Management of Pneumonia. Rawal Med J. 2012;37(3):250-52.

Shah DS, Anjan RD, Gohil N. A comparison of effect of semi fowler’s vs side lying position on tidal volume and pulse oximetry in ICU patients. Innovative J Med Health Sci. 2012;2(5):81-5.