Nonpharmacological and rehabilitative interventions for adults with myotonic dystrophy type 1: a systematic review

Myotonic dystrophy type 1 (DM1) has historically been managed cautiously with respect to physical exercise, out of concern that loading might accelerate dystrophic muscle breakdown. This systematic review synthesizes the evidence on nonpharmacological and rehabilitative interventions in adults with genetically confirmed or clinically well-defined DM1. MEDLINE/PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to 17 July 2026, without language or date restrictions; controlled and uncontrolled interventional studies were eligible. Two reviewers independently screened records, extracted data, and assessed risk of bias (Cochrane risk of bias 2 for randomized trials; ROBINS-I for nonrandomized studies). Given heterogeneity in modality, dosing, and outcomes, narrative synthesis was used without meta-analysis. Sixteen publications reporting 13 independent studies were included across five modality families: resistance/strength training (eight publications from five studies), aerobic/cycling (three studies), hand-based occupational therapy (two), electrical stimulation (two), and behavioral rehabilitation (one). Resistance training dominates the evidence, reflecting a shift away from early concerns that loaded exercise harms dystrophic muscle. Aerobic training improved cardiorespiratory fitness in single-arm studies, but the only randomized trial found no between-group differences in walking or mobility; single-sex resistance-training cohorts, absent sex-disaggregated reporting, and inconsistent outcome measures recurred across studies. Nonpharmacological rehabilitation in DM1 appears feasible and potentially efficacious, with supervised progressive resistance training currently having the most substantial evidence base. Optimal modalities, timing, and patient-selection criteria remain unclear, and larger trials using standardized outcome sets are needed before other modalities can be recommended with confidence in clinical practice.