The Effectiveness of an ETP Programme in Myasthenia Gravis: a Proof-of-concept Study. (MY-EDUC)

Efficacité d'un Programme d'ETP Dans la myasthénie : étude de Preuve de Principe (MY-EDUC).

CONTEXTE. Myasthenia gravis is a rare neuromuscular junction disorder affecting one in five thousand people (ORPHA 589). It is a chronic condition that progresses in episodes. Its severity varies, ranging from the invisible disability of fatigue to respiratory distress requiring intensive care. Currently, 270 patients with myasthenia gravis are being treated at Grenoble University Hospital in the Reference Centre for Rare Neuromuscular Diseases.

The impact of this disease on quality of life is significant, and medication alone is not sufficient. However, to date, there are virtually no psychosocial interventions for patients with myasthenia gravis and no studies evaluating their effectiveness.

In this context, the Cognitive Behavioural Stress Management (CBSM) programme is one of the stress management programmes applied to chronic health conditions whose effectiveness has already been demonstrated, particularly in terms of treatment adherence, quality of life, patients' coping strategies in the face of a chronic illness, and the outcomes of medical treatments (Antoni, 2003; Antoni et al., 2002, 2006).

PRIMARY OBJECTIVE. Evaluation of the adaptation of an existing patient education programme, 'Living Better with Myasthenia', following the inclusion of an eight-session CBSM-based stress management module for adult patients living with myasthenia.

METHODOLOGY (brief). Adaptation of the CBSM programme to the specific characteristics of myasthenia gravis:

1. Focus groups: exploration of beliefs associated with stress in myasthenia gravis.
2. DELPHI group: validation of the adaptation of the ETP programme 'Living better with myasthenia gravis' implemented at CHUGA following the inclusion of a stress management module (CBSM).

Assessment of the feasibility of the MY-EDUC programme among groups of patients with myasthenia gravis.

PRIMARY OUTCOME MEASURE. Comparison of levels of anxiety, depression (HADS), perceived stress (PSS) and quality of life (SF-36) as self-reported by patients enrolled in the programme before and after the MY-EDUC intervention.

RESEARCH PROCEDURE. 1.1. FOCUS GROUPS. Expert patients and partner patients. They will be contacted via the list maintained by the rare disease healthcare network.

'General public' patients. A call for participants will be displayed in the CHUGA waiting room and circulated by partner organisations to their members.

The study will be presented to expert and partner patients, as well as to "walk-in" patients in the focus groups, using the contact details on the "rare disease healthcare network" lists and via posters. An information leaflet outlining the study and its objectives will be provided to them.

1.2. FEASIBILITY AND ACCEPTABILITY STUDY OF THE MY-EDUC PROGRAMME. 1.2.1. Participant inclusion. Patient eligibility. The assessment of patient eligibility will be carried out by a specialist doctor from the CHUGA Rare Disease Centre of Excellence during a routine consultation with the patient (routine care).

Participant inclusion. Once patient eligibility has been verified, the investigator from the CHUGA Rare Disease Centre, or a person to whom they have delegated this task, will contact the patient to invite them to participate in the MY-EDUC study. They will provide a verbal explanation of the study and hand over an information sheet during a follow-up consultation with the patient as part of routine care. If the patient volunteers to participate, they will give their consent to participate.

The patient's consent will be recorded in the medical record. 1.2.2. Baseline assessment (T0). In the week leading up to the first session of the MY-EDUC programme, participants will complete the baseline assessment online (using the LimeSurvey platform - secure servers at the University of Grenoble Alpes) with questionnaires presented in a randomised order.

1.2.3. Assessment during the intervention (T1). Based on repeated ecological measurements (Shiffman et al., 2008) via the study participants' mobile phones (two measurement points, before and after each session, randomly scheduled at least 36 hours apart, i.e. 16 measurements) using the free PielsSurvey software.

1.2.4. Final assessments (T2 and T3). Within one week of the final session of the MY-EDUC programme (T2: week 10 after T0), participants will complete a set of questionnaires electronically (using the LimeSurvey platform - secure servers at the University of Grenoble Alpes), with the validated questionnaires presented in a randomised order.

Study Overview

• Status: Not yet recruiting
• Conditions: Myasthenia Gravis (MG)
• Intervention / Treatment: Behavioral: CBSM

Detailed Description

1. Background and Rationale Myasthenia Gravis (MG) is a rare autoimmune disorder of the neuromuscular junction (ORPHA 589), characterised by its chronic nature and the occurrence of fluctuating symptoms or flare-ups. Beyond the physical manifestations, the condition has a major impact on patients' quality of life. Recent data suggest that approximately 46.3% of patients suffer from anxiety disorders. While a Therapeutic Patient Education (TPE) programme entitled "Living better with myasthenia" is already established at Grenoble University Hospital, patients have expressed a clear requirement for specific modules addressing stress and anxiety management.

   The MY-EDUC programme aims to adapt the current TPE framework by integrating a stress management module based on Cognitive Behavioural Stress Management (CBSM). CBSM has proven effectiveness in various chronic pathologies for improving treatment adherence, quality of life, and coping strategies.

2. Objectives Primary Objective: To evaluate the adaptation of the existing TPE programme after incorporating a CBSM-based stress management module (8 sessions) for adult patients with myasthenia gravis.

   Secondary Objectives: To assess the feasibility and acceptability of the MY-EDUC programme.

3. Study Design and Methodology

   This is an observational, prospective, descriptive, and monocentric study (classified as RIPH3 under French regulations). The research is conducted in three phases:

   Phase 1 (Focus Groups): Exploration of stress-related beliefs with both expert patients and regular patients to adapt the session content.

   Phase 2 (Feasibility Study): Implementation of the programme with 40 patients (organised into 5 groups of 8 participants maximum).

4. Description of the Intervention (MY-EDUC) The programme consists of 8 weekly sessions. It combines transversal stress management modules with modules specifically tailored to myasthenia. The approach is modular and transdiagnostic, designed to facilitate future national rollout within the FILNEMUS network.

5. Outcome Measures and Assessments Assessments are performed electronically (via LimeSurvey) at several intervals: T0 (baseline), T1 (during the intervention via repeated ecological momentary assessments on smartphones), T2 (post-intervention), and T3 (1-month follow-up).

   Psychological Measures: Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS), and Brief COPE.

   Quality of Life: 36-Item Short Form Survey (SF-36).

   Ecological Assessments: Evaluation of stress and anxiety levels before and after each session (16 measurement points via PielsSurvey).

6. Statistical Analysis Plan

   Data analysis will include:

   Descriptive statistics of the population's demographic and medical characteristics.

   Analysis of Covariance (ANCOVA) to compare means between groups at different time points.

   Repeated measures Analysis of Variance (ANOVA) to evaluate the sustainability of the effects.

   Multivariate linear regressions and network analyses to explore interactions between variables and identify subgroups of responders to the intervention.

7. Expected Results The study intends to demonstrate that a TPE programme enhanced by a cognitive-behavioural approach reduces anxiety and depression while improving pain management and overall quality of life. Ultimately, this modular model could be transposed to other rare diseases, such as Amyotrophic Lateral Sclerosis (ALS).

• Study Type: Observational
• Enrollment (Estimated): 62

Contacts and Locations

• Study Contact: Name: Damien OUDIN DOGLIONI, PhD; Phone Number: 0033 0615871407; Email: damien.oudin-doglioni@univ-grenoble-alpes.fr

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

Adults living with myasthenia gravis followed at University Hospital Grenoble Alpes.

Description

Inclusion Criteria:

• Participant is aged 18 years or over (legal age of majority under French law).
• Participant has freely provided their non-opposition to participate in the study.
• Participant has a confirmed diagnosis of Myasthenia Gravis.
• Participant has sufficient proficiency in both spoken and written French to complete assessments and questionnaires, attend the programme sessions, and carry out home-based exercises.

Exclusion Criteria:

• Participant presenting with one or more severe and established psychiatric disorders (e.g. severe depression, psychosis) that could interfere with the study's conduct, particularly the assessment of the primary and secondary endpoints.
• Participant presenting with another chronic condition that induces fatigue. Protected persons (as defined by Articles L1121-5 to L1121-8 of the French Public Health Code [CSP]).

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

MY-EDUC; Adults living with myasthenia gravis

Behavioral: CBSM; Cognitive Behavioural Stress Management (CBSM) is a structured, multimodal psychological intervention based on the transactional model of stress. It addresses the distress arising from the perceived imbalance between disease-related threats and available coping resources. CBSM aims to disrupt the cycle of physical symptoms and psychological strain. The intervention integrates several core evidence-based techniques: Cognitive Restructuring: Identifying and challenging dysfunctional thoughts related to MG to foster adaptive appraisals. Physiological Regulation: Training in relaxation techniques (e.g. progressive muscle relaxation) to reduce autonomic arousal. Coping Skills: Enhancing problem-solving, assertiveness, and time management to mitigate the impact of fatigue. Delivered over eight weekly sessions, this transdiagnostic approach increases self-efficacy and improves quality of life by providing patients with practical tools to manage their condition effectively.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Perceived stress	The Perceived Stress Scale (PSS), developed by Cohen et al. (1983), is a widely established psychological instrument designed to measure the degree to which situations in an individual's life are appraised as stressful. Rather than focusing on objective life events, it assesses the extent to which respondents find their lives unpredictable, uncontrollable, and overloaded. This study utilises the PSS-10, a 10-item version refined for its robust psychometric properties. Participants rate items on a five-point Likert scale (0 = Never to 4 = Very Often) based on their feelings and thoughts during the last month. Total scores range from 0 to 40, with higher values indicating greater perceived stress. The PSS is favoured in clinical trials for its brevity, high internal consistency, and sensitivity to change, providing a reliable measure of psychological distress and the effectiveness of behavioural stress management interventions.	T0: Initial assessment at least 7 days before intervention. T2: After intervention assessment (maximum 7 days after intervention). 73: Maintenance effect (4 weeks after the end of the intervention).
Anxiety	The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith (1983), is a validated 14-item self-report tool used to screen for anxiety and depression in clinical populations. It consists of two 7-item subscales: HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D). A significant advantage of the HADS is its exclusion of somatic symptoms, such as fatigue or sleep disturbance, which may be symptoms of physical conditions like Myasthenia Gravis rather than psychological distress. This prevents the overestimation of emotional disorders in medically ill patients. Items are rated on a 4-point Likert scale (0-3), with subscale scores ranging from 0 to 21. Typically, scores of 0-7 are considered normal, 8-10 indicate borderline cases, and 11-21 suggest a probable clinical disorder. Its high internal consistency and sensitivity to therapeutic change make it a robust metric for evaluating the psychological impact of the MY-EDUC intervention.	T0: Initial assessment at least 7 days before intervention. T2: After intervention assessment (maximum 7 days after intervention). 73: Maintenance effect (4 weeks after the end of the intervention).
Depression	The Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith (1983), is a validated 14-item self-report tool used to screen for anxiety and depression in clinical populations. It consists of two 7-item subscales: HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D). A significant advantage of the HADS is its exclusion of somatic symptoms, such as fatigue or sleep disturbance, which may be symptoms of physical conditions like Myasthenia Gravis rather than psychological distress. This prevents the overestimation of emotional disorders in medically ill patients. Items are rated on a 4-point Likert scale (0-3), with subscale scores ranging from 0 to 21. Typically, scores of 0-7 are considered normal, 8-10 indicate borderline cases, and 11-21 suggest a probable clinical disorder. Its high internal consistency and sensitivity to therapeutic change make it a robust metric for evaluating the psychological impact of the MY-EDUC intervention.	T0: Initial assessment at least 7 days before intervention. T2: After intervention assessment (maximum 7 days after intervention). 73: Maintenance effect (4 weeks after the end of the intervention).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Health-related Quality of Life	The 36-Item Short Form Health Survey (SF-36) is a globally recognised, self-reported instrument designed to assess health-related quality of life (HRQoL). It comprises 36 items covering eight health domains: physical functioning, role limitations due to physical health, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health. These scales are further aggregated into two primary summary measures: the Physical Component Summary (PCS) and the Mental Component Summary (MCS). Each domain is scored from 0 to 100, with higher scores indicating superior health status or functional ability. The SF-36 is highly valued in clinical research for its strong psychometric properties, including high internal consistency and sensitivity to therapeutic changes. In this study, it serves as a key outcome measure to evaluate the holistic impact of the intervention on patients' daily functioning and well-being.	T0: Initial assessment at least 7 days before intervention. T2: After intervention assessment (maximum 7 days after intervention). 73: Maintenance effect (4 weeks after the end of the intervention).

Collaborators and Investigators

• Sponsor: University Hospital, Grenoble
• Collaborators: Laboratoire interuniversitaire de psychologie : personnalité, cognition et changement social - LIP-PC2S

Publications and helpful links

General Publications

• Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological momentary assessment. Annual Review of Clinical Psychology, 4, 1-32. https://doi.org/10.1146/annurev.clinpsy.3.022806 .091415
• Roy-Byrne, P. P., Davidson, K. W., Kessler, R. C., Asmundson, G. J. G., Goodwin, R. D., Kubzansky, L., Lydiard, R. B., Massie, M. J., Katon, W., Laden, S. K., & Stein, M. B. (2008). Anxiety disorders and comorbid medical illness. General Hospital Psychiatry, 30(3), 208-225. https://doi.org/10.1016/j.genhosppsych.2007.12. 006
• Philippot, P., Bouvard, M., Baeyens, C., & Dethier, V. (2015). Vers un protocole de traitement processuel et modulaire des troubles anxio- dépressifs. Journal de Thérapie Comportementale et Cognitive, 25(3), 106-116. https://doi.org/10.1016/j.jtcc.2015.07.001
• Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J., Carl, J. R., Gallagher, M. W., & Barlow, D. H. (2012). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders : A Randomized Controlled Trial. Behavior Therapy, 43(3), 666-678. https://doi.org/10.1016/j.beth.2012.01.001
• Chorpita, B. F., Weisz, J. R., Daleiden, E. L., Schoenwald, S. K., Palinkas, L. A., Miranda, J., Higa-McMillan, C. K., Nakamura, B. J., Austin, A. A., Borntrager, C. F., Ward, A., Wells, K. C., Gibbons, R. D., & Research Network on Youth Mental Health. (2013). Long-term outcomes for the Child STEPs randomized effectiveness trial : A comparison of modular and standard treatment designs with usual care. Journal of Consulting and Clinical Psychology, 81(6), 999-1009. https://doi.org/10.1037/a0034200
• Chen, S., Forster, S., Yang, J., Yu, F., Jiao, L., Gates, J., Wang, Z., Liu, H., Chen, Q., Geldsetzer, P., Wu, P., Wang, C., McMahon, S., Bärnighausen, T., & Adam, M. (2022). Animated, video entertainment-education to improve vaccine confidence globally during the COVID-19 pandemic : An online randomized controlled experiment with 24,000 participants. Trials, 23(1), 161. https://doi.org/10.1186/s13063-022-06067-5
• Carver, C. S. (1997). You want to measure coping but your protocol' too long : Consider the brief cope. International Journal of Behavioural Medicine, 4(1), 92-100. https://doi.org/10.1207/s15327558ijbm0401_6
• Antoni, M. H., Wimberly, S. R., Lechner, S. C., Kazi, A., Sifre, T., Urcuyo, K. R., Phillips, K., Smith, R. G., Petronis, V. M., Guellati, S., Wells, K. A., Blomberg, B., & Carver, C. S. (2006). Reduction of Cancer-Specific Thought Intrusions and Anxiety Symptoms With a Stress Management Intervention Among Women Undergoing Treatment for Breast Cancer. American Journal of Psychiatry, 163(10), 1791-1797. https://doi.org/10.1176/ajp.2006.163.10.1791
• Antoni, M. H., Cruess, D. G., Klimas, N., Maher, K., Cruess, S., Kumar, M., Lutgendorf, S., Ironson, G., Schneiderman, N., & Fletcher, M. A. (2002). Stress management and immune system reconstitution in symptomatic HIV-infected gay men over time : Effects on transitional naive T cells (CD4(+)CD45RA(+)CD29(+)). The American Journal of Psychiatry, 159(1), 143-145. https://doi.org/10.1176/appi.ajp.159.1.143
• Antoni, M. H. (2003). Stress management intervention for women with breast cancer (p. xvi, 215). American Psychological Association. https://doi.org/10.1037/10488-000
• Law, C., Flaherty, C. V., & Bandyopadhyay, S. (2020). A Review of Psychiatric Comorbidity in Myasthenia Gravis. Cureus. https://doi.org/10.7759/cureus.9184

Study record dates

Study Major Dates

• Study Start (Estimated): April 1, 2026
• Primary Completion (Estimated): November 1, 2026
• Study Completion (Estimated): June 1, 2027

Study Registration Dates

• First Submitted: March 30, 2026
• First Submitted That Met QC Criteria: March 30, 2026
• First Posted (Actual): April 6, 2026

Study Record Updates

• Last Update Posted (Actual): April 6, 2026
• Last Update Submitted That Met QC Criteria: March 30, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Nervous System Diseases; Neoplasms by Site; Neoplasms; Neuromuscular Diseases; Autoimmune Diseases; Immune System Diseases; Autoimmune Diseases of the Nervous System; Neurodegenerative Diseases; Paraneoplastic Syndromes, Nervous System; Nervous System Neoplasms; Paraneoplastic Syndromes; Neuromuscular Junction Diseases; Myasthenia Gravis
• Other Study ID Numbers: 38RC25.0025

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Sharing Access Criteria: Study protocol on OSF SAP with publication.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No