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Physical Medicine and Rehabilitation for Limb-Girdle Muscular Dystrophy

  • Author: Vinod Sahgal, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Apr 19, 2016
 

Background

The earliest descriptions of limb-girdle weakness are ascribed to Leyden[1] and Möbius[2] in 1876 and 1879, respectively. They described adult patients with a pelvic and femoral distribution of weakness and atrophy with a benign course. In 1884, Erb characterized a juvenile form of proximal muscle weakness.[3] Erb's patient had only shoulder-girdle weakness and atrophy, with sparing of other muscles of the body and a benign disease course compared with that described by Duchenne in the 1860s. Duchenne, a French physician, initially described a condition of progressive lethal wasting of degenerative skeletal muscle, which was later referred to as Duchenne muscular dystrophy. At that time, the differentiation between the spinal muscular atrophies and weakness associated with central nervous system disorders and primary muscle disease had not been established.

In 1891, Erb put forward the concept of muscular dystrophies as a primary degeneration of muscle and coined the term "dystrophia muscularis progressiva."[4] Erb's description was followed by various attempts at classifying these dystrophic disorders. In 1909, Batten classified primary muscle disease into the following 7 categories, which are still used today[5] :

  • Simple atrophy [1, 2]
  • Duchenne pseudohypertrophic variety
  • Erb juvenile weakness
  • Fascioscapulohumeral dystrophy [6]
  • Distal myopathy [7, 8]
  • Myotonic dystrophy
  • Mixed form

Between 1909 and 1954, many individual case reports of primary muscle disease with a limb-girdle distribution of weakness were published. In 1954, when Walton and Nattrass reported 105 cases of limb-girdle weakness associated with many other disorders, the nosologic entity of limb-girdle dystrophy was formally established.[9] Walton and Nattrass described the disease as a progressive muscle weakness with atrophy involving predominantly proximal muscles (eg, pelvis, shoulder). They described the disease as having a variable age of onset in the late first, second, third, fourth, or fifth decade of life; a slow clinical progression; and an autosomal recessive or autosomal dominant form of inheritance. See image below.

Dystrophin-glycoprotein complex bridges the inner Dystrophin-glycoprotein complex bridges the inner cytoskeleton (F-actin) and the basal lamina. Mutations in all sarcoglycans, in dysferlin, and in caveolin-3, as well as mutations that cause abnormal glycosylation of alpha-dystroglycan, can result in limb-girdle muscular dystrophy.

The development of sophisticated diagnostic tools of histology, histochemistry, ultrastructure, electrodiagnosis, and genetic studies has since shown that the entity, as originally described, is composed of a variety of neuromuscular disorders (eg, spinal muscular atrophy, polymyositis, endocrine disorders, metabolic conditions, congenital myopathies). Since the original descriptions of the condition, reports of many sporadic cases have been published with this pattern of muscle weakness associated with many other disorders.

Thus, the concept of limb-girdle muscular dystrophy (LGMD) as a nosologic entity was challenged, and now it is fair to consider it a symptom complex that consists of at least 4 disorders with varied inheritance patterns and etiologies. Therefore, importantly, the clinical features, the inheritance pattern, and the exclusion of other entities should define the disorders of LGMD.

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Pathophysiology

Molecular genetics of limb-girdle muscular dystrophy (LGMD)

Skeletal muscle consists of 2 major components: the sarcolemma and the sarcomeres. The sarcolemma is the sheath that covers the sarcomeres; it is composed of the plasma and basement membranes and the reticular lamina, which contains collagen. The sarcomeres represent the contractile element, which is composed of actin, myosin, and Z-band proteins (see image below). These proteins, like all others, are genetically coded and have a specific structure and distribution. Advances in molecular genetics have help in the discovery of significant information on the relationship between muscle biology and clinical neuromuscular diseases. This is very well exemplified in the shift from descriptive classifications of neuromuscular diseases to molecular pathobiologic classifications of neuromuscular diseases.[10, 11]

Electron micrograph showing streaming of band Z an Electron micrograph showing streaming of band Z and splitting of the muscle fiber. A central nucleus is surrounded by a collection of small mitochondria.

This concept is best observed in regard to our understanding of the very heterogeneous LGMD syndromes. These syndromes are now classified on the basis of at least 15 identified genes—5 autosomal dominant and 10 autosomal recessive. The 5 dominant genes are associated with the components of sarcomeres. The 10 recessive genes are associated with the plasma basement membrane and the adjacent reticular lamina, which contains the fibrillary collagen.[12, 13]

See the descriptions of each type of LGMD in the History section.

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Epidemiology

Frequency

United States

Exact figures are not available. The frequency of limb-girdle muscular dystrophy in the general population cannot be estimated because of the heterogenous nature of this group of disorders (see Background).

Mortality/Morbidity

Limb-girdle muscular dystrophy is associated with low mortality and morbidity.

Race

No racial predilection is described for limb-girdle muscular dystrophy.

Sex

Limb-girdle muscular dystrophy may show an autosomal recessive or sporadic method of inheritance.

Age

Some forms of limb-girdle muscular dystrophy dramatically affect young adults, while other types progress so slowly that they are not detected until much later in life.[14]

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Contributor Information and Disclosures
Author

Vinod Sahgal, MD 

Vinod Sahgal, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Medical Association, American Spinal Injury Association

Disclosure: Nothing to disclose.

Coauthor(s)

Steven Reger, PhD 

Steven Reger, PhD is a member of the following medical societies: Association for Academic Psychiatry, New York Academy of Sciences

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Kat Kolaski, MD Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine

Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Elizabeth A Moberg-Wolff, MD Medical Director, Pediatric Rehabilitation Medicine Associates

Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference wish to thank Suneet Sahgal, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, for his previous contribution to this article.

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Hematoxylin and eosin stain. Note the variation in fiber size. Necrotic fiber is shown with many nuclei (magnification 250X).
Marked endomysial fibrosis with atrophic and hypertrophic fibers.
Hematoxylin and eosin stain. Note the splitting of the fiber.
Gomori trichrome stain. Note the variation in fiber size and subsarcolemmal vacuoles, central nuclei, and subsarcolemmal collection of trichrome-positive material.
Light type I and dark type IIA fibers.
Electron micrograph showing abnormal mitochondria, a large lysosomal body, and a central nucleus.
Electron micrograph showing mitochondria with paracrystalline inclusions and lamellar bodies
Electron micrograph showing streaming of band Z and splitting of the muscle fiber. A central nucleus is surrounded by a collection of small mitochondria.
Trichrome stain. Note variation in fiber size. Necrotic fiber giant fibers and cytoplasmic inclusions.
Dystrophin-glycoprotein complex bridges the inner cytoskeleton (F-actin) and the basal lamina. Mutations in all sarcoglycans, in dysferlin, and in caveolin-3, as well as mutations that cause abnormal glycosylation of alpha-dystroglycan, can result in limb-girdle muscular dystrophy.
 
 
 
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