Bethlem myopathy
Bethlem myopathy
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Bethlem myopathy

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Bethlem myopathy
Other namesMuscular dystrophy, limb-girdle, autosomal dominant 5, (LGMDD5); Muscular dystrophy, limb-girdle, autosomal recessive 22, (LGMDR22); Ehlers–Danlos syndrome, myopathic type (EDSMYP)
Bethlem myopathy has an autosomal dominant pattern of inheritance (autosomal recessive form exists as well[1]).

Bethlem myopathy is predominantly an autosomal dominant myopathy, classified as a congenital form of limb-girdle muscular dystrophy.[2] There are two types of Bethlem myopathy, based on which type of collagen is affected.[3]

Bethlem myopathy 1 (BTHLM1) is caused by a mutation in one of the three genes coding for type VI collagen.[4][3] These include COL6A1, COL6A2, and COL6A3.[5][3] It is typically autosomal dominant, though uncommonly can be autosomal recessive.[3]

Bethlem myopathy 2 (BTHLM2), formerly known as myopathic-type Ehlers–Danlos syndrome, is caused by a mutation on the COL12A1 gene coding for type XII collagen.[3] It is autosomal dominant.[3]

In 2017, an international workshop proposed a redefined criteria and naming system for limb-girdle muscular dystrophies. Bethlem myopathy 1 (collagen VI) was included into the proposed list and renamed LGMDD5 for autosomal dominant mutations and LGMDR22 for recessive mutations. Bethlem myopathy 2 (collagen XII) was not addressed.[2]

Gowers's sign, toe walking, multiple contractures of the joints (especially the fingers: 'Bethlem sign'), skin abnormalities, and muscle weakness (proximal more than distal) are typical signs and symptoms of the disease. Initially, in early childhood, there may also be joint laxity. There is no cardiac involvement in either Bethlem myopathy 1 or 2, which helps to differentiate it from Emery–Dreifuss muscular dystrophy.[6] Currently there is no cure for the disease and symptomatic treatment is used to relieve symptoms and improve quality of life.[7]

Bethlem myopathy may be diagnosed based on clinical examinations and laboratory tests may be recommended. Genetic testing for known pathological variants is preferred. In the case of a VUS, testing of dermal fibroblast culture is used for an accurate diagnosis.[6]

Bethlem myopathy 1 is a rare disease, affecting about 1 in 200,000 people.[8] Bethlem myopathy 2 is an ultra-rare disease, affecting less than 1 in 1,000,000 people.[9]

The condition was described by J. Bethlem and G. K. van Wijngaarden in 1976.[10]

Signs and symptoms

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Individual demonstrates lack of finger contractures, thus lack of Bethlem sign, by being able to make full contact of palms and fingers with elbows raised.

Bethlem myopathy is a slowly progressive muscle disease characterized predominantly by contractures, rigidity of the spine, skin abnormalities and proximal muscle weakness.[5][11] Symptoms may present as early as infancy, with typical contractures and hyperlaxity of joints; however, in some patients, symptoms may go unnoticed until adolescence or adulthood.[11] Serum creatine kinase (CK) is usually normal to mildly elevated (<5×).[11]

Much like in this painting, Bethlem sign is an inability to make full contact of palms and fingers while elbows are raised, due to finger contractures.

Early on, there may be distal laxity (hypermobility), but all of those with Bethlem myopathy eventually develop multiple joint contractures: long finger flexors, wrists, elbows, hips, knees and ankles.[5][11] There may also be club foot, scoliosis or rigid spine.[5][11] Skin abnormalities are common, including keloid formation, ‘cigarette paper scarring’ (atrophic scarring), velvety soft skin, and follicular hyperkeratosis.[11][6]

'Bethlem sign' is the typical sign in Bethlem myopathy patients demonstrating long finger flexor contractures. With palms facing each other and with elbows raised, patients try, but fail, to make full contact of one hand against the other (in what looks like the gesture of hands during prayer).[12]

Bethlem myopathy 1

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(Collagen VI genes)

See Bethlem myopathy 1 Clinical synopsis on OMIM: 158810

In Bethlem myopathy 1, in the calf, one of the first signs is often a 'rim' of fatty infiltration between the soleus and gastrocnemius muscles.[12][13][14] Although there is fatty infiltration, the calf muscles do not appear pseudohypertrophic, in fact they may appear slender.[15][12][16][17][18] In the thighs, there is also significant fatty infiltration of the vasti muscles, with a rim of fatty infiltration on the periphery of the muscles, while the center is more or less spared (characteristic "outside-in" pattern).[12][19] This "outside-in" pattern distinguishes it from other myopathies known to have contractures, such as Emery-Dreifuss muscular dystrophy.[12]

The exception is the rectus femoris muscle of the thigh, where fatty infiltration occurs in the center of the muscle, but spares the periphery. This unusual pattern is described as a "central cloud" and is also a distinguishing feature, as it is not seen in the rectus femoris of LMNA-related Emery-Dreifuss myopathy.[12]

Bethlem myopathy 1 may also include neonatal-onset torticollis (neck contracture) and hypotonia ("floppy baby"), delayed motor mile stones, with respiratory difficulties potentially occurring later in life.[20][12] Contractures presenting in infancy may resolve by age 2 years, but reoccur as the disease progresses, typically by late of the first decade or early teens.[12]

Bethlem myopathy 2

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(Collagen XII gene)

See Bethlem myopathy 2 Clinical synopsis on OMIM: 616471

In Bethlem myopathy 2, there is phenotypic variability. In one family, the only notable finding on T1-weighted MR images (used to detect fatty infiltration) was atrophy of the rectus femoris muscles of the thigh, with the degree of atrophy matching the severity of the disease, but no fatty infiltration.[14][11] In another family, only the more severely affected older patient showed significant abnormality, by having symmetrical fatty atrophy of the femoral quadriceps of the thigh, the adductor and medial gastrocnemius muscles of the calf; as well as asymmetrical fatty atrophy of the adductor longus of the thigh.[11] No muscle hypertrophy was reported and the muscles of the patients without fatty atrophy appeared normal.[11]

Bethlem myopathy 2 also differs by including the possibility of scapula winging, pectus excavatum, stooped posture, kyphosis (hunchback), micrognathia, retrognathia, and a high-arched palate.[14] Childhood muscle weakness improves in teen years, but muscle weakness returns by the third decade of life.[11]

Diagnosis

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The disease may be diagnosed based on a clinical examination, which identifies signs and symptoms generally associated with the people who have the condition. Genetic testing for known pathological variants is preferred, by testing of the COL6A1, COL6A2, COL6A3 and COL12A1 genes.[7][3] In the case of a VUS, testing of dermal fibroblast culture is used for an accurate diagnosis.[6]

Additional laboratory tests may be performed before genetic testing, such as creatine kinase (CK) blood test, MRI of the muscles, and electromyography (EMG).

Phenotypes of overlap between Ullrich congenital muscular dystrophy (UCMD) and Bethlem can be assumed. In the differential diagnosis of UCMD, even in patients without finger contractures, Bethlem myopathy could be considered.[21]

Differential diagnosis

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Ullrich congenital muscular dystrophy (UCMD) involves mutations on the same genes as Bethlem myopathy, but has a more severe presentation, with the ability to walk (ambulation) typically being lost between the ages of 5–15 years.[12] Autosomal recessive myosclerosis myopathy is allelic to the COL6A2 gene, it includes multiple contractures of the joints with slender muscles which are infiltrated by connective tissue and fibrosis, giving them a firm, "woody" feel upon palpitation.[22][23]

The symptoms of Bethlem myopathy may overlap with other conditions including Emery–Dreifuss muscular dystrophy, congenital muscular dystrophies, limb girdle muscular dystrophies, FHL1-related myopathies (X-linked myopathy with postural muscle atrophy, reducing body myopathy, and scapuloperoneal myopathy), and some forms of Ehlers–Danlos syndrome.[11] Tubular aggregate myopathy (TAM1 & TAM2) includes, among other symptoms, contractures, muscle weakness, and fatty atrophy of muscle.[24][25][26]

Typical to Bethlem myopathy 1 and 2 are the presence of multiple contractures.[11][5] A contracture can be caused by a variety of reasons, from disease to lifestyle (see Muscle contractures). If the patient lacks multiple contractures, as well as lacks other common symptoms of Bethlem myopathy, and in addition has muscular symptoms which are not known to be associated with Bethlem myopathy such as muscle hypertrophy, exercise-induced (dynamic) symptoms rather than fixed muscle weakness (static) symptoms, or cardiac involvement such as arrhythmia, then other myopathies should be considered.

Treatment

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Currently there is no cure for the disease. Symptomatic treatment, which aims to relieve symptoms and improve quality of life is the main treatment method of Bethlem myopathy. It is believed that physical therapy, stretching exercises, orthoses such as braces and splints, and mobility aids like a walker or wheelchair are beneficial to patient's condition.[7]

Surgical options could be considered in rare instances, in order to help with joint contractures or scoliosis.[7] Contractures of the legs can be alleviated with heel-cord surgery followed by bracing and regular physical therapy. Repeated surgeries to lengthen the heel cords may be needed as the child grows to adulthood.[4]

Epidemiology

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According to a Japanese study from 2007, Bethlem myopathy 1 affects about 1 in 200,000 people.[8] A 2009 study, concerning the prevalence of genetic muscle disease in Northern England, estimated the prevalence of Bethlem myopathy 1 to be at 0.77:100,000.[27] Together with Ullrich congenital muscular dystrophy 1, Bethlem myopathy 1 is believed to be underdiagnosed. Both conditions have been described in individuals from a variety of ethnic backgrounds.[28] Bethlem myopathy 2 affects less than 1 in 1,000,000 people.[9]

References

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Bethlem myopathy

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Bethlem myopathy is a rare congenital muscular dystrophy characterized by slowly progressive proximal muscle weakness and early-onset joint contractures, typically affecting the elbows, ankles, and finger flexors, with symptoms often beginning in infancy or childhood.[1] It is the mildest form of collagen VI-related myopathies, distinguished by its relatively benign progression compared to more severe variants like Ullrich congenital muscular dystrophy.[2] Caused by pathogenic variants in one of three genes—COL6A1, COL6A2, or COL6A3—that encode the α1, α2, and α3 chains of type VI collagen, these mutations disrupt the assembly and secretion of this extracellular matrix protein essential for muscle fiber stability and connective tissue integrity.[3] Most cases follow autosomal dominant inheritance, where a single mutated allele from an affected parent is sufficient, though rare autosomal recessive forms occur with biallelic variants.[4] Clinically, affected individuals often present with neonatal hypotonia, delayed motor milestones, and prominent contractures that can precede significant weakness, alongside milder distal muscle involvement and occasional skin changes such as follicular hyperkeratosis or keloid scarring.[1] Muscle weakness primarily impacts the neck flexors, trunk, and limb girdles, leading to challenges with posture, gait, and mobility; however, over two-thirds of patients remain independently ambulatory into their 50s or later, with wheelchair use typically required only in advanced stages.[4] Respiratory insufficiency may develop in adulthood due to diaphragmatic weakness, necessitating nocturnal non-invasive ventilation in some cases, while cardiac function remains largely unaffected.[3] The prevalence is estimated at less than 1 in 100,000 individuals, with diagnosis confirmed through a combination of clinical assessment, serum creatine kinase levels (mildly elevated), muscle biopsy showing dystrophic changes and reduced collagen VI expression, and targeted genetic sequencing.[2] Management is supportive and multidisciplinary, focusing on maintaining function through regular physical and occupational therapy to prevent contracture progression, orthopedic surgeries for severe deformities like scoliosis or equinovarus foot, and pulmonary monitoring with interventions such as bilevel positive airway pressure (BiPAP) for respiratory support.[4] Genetic counseling is recommended for families, offering prenatal or preimplantation testing options given the 50% recurrence risk in autosomal dominant cases.[2] Ongoing research explores potential therapies targeting collagen VI production or muscle regeneration, but no disease-modifying treatments are currently available.[3]

Introduction and Classification

Definition and characteristics

Bethlem myopathy is a rare, slowly progressive congenital muscular dystrophy primarily inherited in an autosomal dominant manner, characterized by defects in collagen VI that affect both skeletal muscles and connective tissue.[2] It manifests as a disorder of the extracellular matrix, leading to muscle weakness and joint abnormalities, with onset typically occurring from birth through early childhood.[1] Unlike many other muscular dystrophies, it features prominent early-onset contractures alongside progressive weakness, often allowing affected individuals a normal lifespan despite gradual mobility limitations.[5] Within the spectrum of collagen VI-related myopathies, Bethlem myopathy represents the mildest form, contrasting with the more severe Ullrich congenital muscular dystrophy at the opposite end.[2] This classification highlights its position as a connective tissue disorder with muscular involvement, where collagen VI dysfunction disrupts the structural integrity of muscle fibers and surrounding tissues.[6] The condition is distinguished from other muscular dystrophies by its early joint contractures and skin manifestations, such as follicular hyperkeratosis or keloid formation, which underscore the connective tissue component.[1] General characteristics include initial hypotonia in infancy, followed by proximal muscle weakness that develops gradually, often with delayed motor milestones but preservation of ambulation into adulthood for most individuals.[2] Joint contractures, particularly affecting the elbows, ankles, and fingers, emerge early and contribute to a characteristic posture, while distal joint hyperlaxity may coexist.[6] Respiratory involvement can occur later in life but is less common and severe than in related conditions, supporting a relatively benign course overall.[5]

Historical background

Bethlem myopathy was first described in 1976 by Dutch neurologists Jozef Bethlem and George K. van Wijngaarden, who reported observations in three families comprising 28 affected individuals, characterizing the condition as a benign autosomal dominant myopathy featuring early-onset muscle weakness and joint contractures. This initial report distinguished it from other congenital myopathies due to its relatively mild progression and prominent contractures, particularly in the fingers, elbows, and ankles. Throughout the 1980s, additional family studies reinforced the autosomal dominant inheritance pattern, with reports confirming the slowly progressive nature and variable expressivity, leading to broader recognition as a distinct clinical entity.[6] The terminology evolved from the original designation of "benign myopathy with autosomal dominant inheritance" to "Bethlem myopathy," honoring the lead investigator, as subsequent publications emphasized its unique combination of myopathic features and connective tissue involvement.[2] In the 1990s, genetic studies marked key milestones: linkage analysis in multiple families mapped the disease locus to chromosome 21q22.3 in 1996, coinciding with the identification of mutations in the COL6A1 and COL6A2 genes encoding collagen VI subunits.[7][8] This discovery linked Bethlem myopathy to collagen VI-related disorders, shifting understanding from a purely myopathic condition to one involving extracellular matrix defects.[9]

Genetics and Pathophysiology

Genetic causes

Bethlem myopathy is primarily inherited in an autosomal dominant manner, requiring only one mutated allele from either parent to cause the condition, though rare autosomal recessive cases have been documented, typically involving compound heterozygous mutations.[2] In autosomal recessive instances, both alleles must be affected, often leading to a similar clinical presentation but with potential variations in severity.[10] Bethlem myopathy type 1, the classic form, arises from heterozygous mutations in one of three genes encoding the alpha chains of type VI collagen: COL6A1 (chromosome 21q22.3), COL6A2 (also on chromosome 21q22.3), or COL6A3 (chromosome 2q37).[6] These genes produce the α1(VI), α2(VI), and α3(VI) chains, respectively, which assemble into a heterotrimeric collagen VI molecule essential for extracellular matrix stability. Bethlem myopathy type 2 results from mutations in the COL12A1 gene (chromosome 6q13), which encodes the α1(XII) chain of type XII collagen, a fibril-associated collagen that interacts with type I collagen fibrils.[11] This form was previously classified under myopathic Ehlers-Danlos syndrome but is now recognized as a distinct subtype of Bethlem myopathy with overlapping features.[12] The most common mutations in Bethlem myopathy type 1 are glycine substitutions within the Gly-X-Y repeats of the triple helical domain, particularly clustered in the N-terminal region, which exert dominant-negative effects by disrupting proper chain assembly and secretion of collagen VI.[13] In-frame exon skipping mutations also contribute to the dominant phenotype by producing shortened but partially functional chains. For rare recessive cases, null alleles such as nonsense, frameshift, or large deletions predominate, leading to reduced collagen VI levels without dominant interference.[2] In Bethlem myopathy type 2, reported mutations include heterozygous missense variants in COL12A1 that impair collagen XII function.[12] De novo mutations occur in a subset of autosomal dominant cases in Bethlem myopathy, particularly in sporadic presentations without family history, and are often identified through genetic testing in affected individuals. These mutations can occur in any of the implicated genes and contribute significantly to the disease's genetic heterogeneity. Recent studies continue to identify novel variants in COL6A1, COL6A2, and COL6A3, expanding the clinico-genetic scope, such as homozygous variants and associations with atypical features like calf hypertrophy (as of 2025).[14][15]

Molecular mechanisms

Collagen VI is a microfibrillar component of the extracellular matrix (ECM) in skeletal muscle, where it forms a network that provides structural support to muscle fibers by linking them to the basement membrane and stabilizing the perimysial ECM.[16] It also plays a regulatory role in cell signaling pathways, including the modulation of satellite cell self-renewal and muscle regeneration through interactions with integrins and other ECM components.[17] In Bethlem myopathy type 1, dominant mutations in the COL6A1, COL6A2, or COL6A3 genes disrupt the assembly of the collagen VI triple helix, often due to glycine substitutions or deletions in the Gly-X-Y repeat domains, leading to misfolded proteins that are retained in the endoplasmic reticulum (ER) of fibroblasts and myocytes.[18] [19] This results in reduced secretion of functional collagen VI or the deposition of structurally abnormal microfibrils in the ECM, impairing proper microfibril assembly and network formation.[20] The consequent ECM instability compromises the mechanical integrity of muscle tissue, triggering a cascade of pathological processes. Deficient collagen VI leads to mitochondrial dysfunction and defective autophagy in muscle cells, increasing susceptibility to apoptosis and contributing to progressive muscle fiber loss.[21] Additionally, the altered ECM promotes excessive deposition of fibrous connective tissue, resulting in fibrosis that further disrupts muscle architecture and impairs regeneration by hindering satellite cell function.[22] [17] Evidence from animal models supports these mechanisms; Col6a1 knockout mice exhibit early-onset myopathy characterized by ultrastructural ECM alterations, mitochondrial abnormalities, increased apoptosis, and mild fibrosis, recapitulating key features of Bethlem myopathy type 1.[23] In Bethlem myopathy type 2, caused by mutations in COL12A1, collagen XII—a fibril-associated collagen—fails to properly interact with types I and II collagens in the ECM of tendons and ligaments, leading to disorganized fibril assembly and reduced tissue integrity in connective structures.[24] This disruption affects the biomechanical properties of these tissues, contributing to myopathic features through ECM remodeling defects.[25]

Clinical Presentation

Core signs and symptoms

Bethlem myopathy typically presents with early-onset muscle hypotonia and delayed motor milestones, such as independent walking often achieved between 18 and 24 months of age, though some infants exhibit neonatal hypotonia or torticollis. Congenital contractures may occur in the hips, knees, or ankles, contributing to initial motor delays.[2] The hallmark feature is slowly progressive proximal muscle weakness, predominantly affecting the shoulder and hip girdles, which becomes more evident in childhood or early adulthood and leads to difficulties in rising from a seated position or climbing stairs. Distal muscle weakness emerges later and is generally milder, with many individuals retaining the ability to ambulate independently into their 50s or beyond, though assistive devices may be needed for outdoor mobility.[2][6][4] Joint contractures are a defining characteristic, commonly involving flexion of the elbows, plantar flexion of the ankles (Achilles tendon contractures), and the long finger flexors, often appearing by late childhood or adolescence and worsening over time. A distinctive "paradoxical" distal hyperlaxity coexists, particularly in the fingers (e.g., hyperextensibility) and ankles, despite proximal rigidity. Additional manifestations include spinal rigidity due to axial muscle involvement, mild scoliosis in some cases, and rare respiratory complications such as nocturnal hypoventilation in advanced stages.[2][6][26] Disease progression is notably slower compared to more severe collagen VI-related disorders, with variability in onset and severity, though most patients maintain a relatively preserved quality of life into adulthood.[2][4]

Disease subtypes

Bethlem myopathy exhibits a spectrum of clinical severity within the collagen VI-related disorders, ranging from mild to intermediate phenotypes, though it is distinguished as the milder end of this spectrum compared to Ullrich congenital muscular dystrophy. The classic presentation involves early-onset contractures, particularly affecting the elbows, ankles, and interphalangeal joints, alongside slowly progressive proximal muscle weakness that typically allows most individuals to remain ambulatory into adulthood.[2] Most cases are inherited in an autosomal dominant manner, though rare autosomal recessive forms have been reported. Respiratory complications, such as nocturnal hypoventilation, may develop rarely in adulthood, often requiring monitoring.[2] Genotype-phenotype correlations reveal that certain mutations, such as glycine substitutions in the triple helical domain of collagen VI, may lead to earlier onset and more pronounced early contractures compared to splice-site variants, which are associated with milder progression.[2] While cases share core symptoms such as muscle weakness and joint abnormalities, clinical distinctions primarily stem from varying genetic disruptions in extracellular matrix proteins.[2]

Diagnosis

Clinical evaluation

The clinical evaluation of suspected Bethlem myopathy begins with a thorough assessment of the patient's medical history and physical examination to identify characteristic features of this slowly progressive congenital muscular dystrophy.[2] A detailed family history is essential, as the condition typically follows an autosomal dominant inheritance pattern, with multigenerational involvement often reported, including relatives with proximal muscle weakness, joint contractures, or delayed motor milestones. Personal history should probe for early signs such as congenital hypotonia, developmental delays in gross motor skills (e.g., delayed walking), or a tendency toward W-sitting posture in infancy, which may precede overt weakness.[2] Physical examination focuses on evaluating muscle strength, joint mobility, and contracture severity to establish the extent of involvement. Muscle strength is graded using the Medical Research Council (MRC) scale, typically revealing proximal-predominant weakness in the limb-girdle muscles, with neck flexors often more affected than extensors (e.g., MRC grades 3-4 in upper and lower extremities).[27][28] Joint range of motion is assessed to detect early contractures, which are hallmark findings in the interphalangeal joints of the fingers (manifesting as the "Bethlem sign" of incomplete extension), elbows, ankles (Achilles tendons), and occasionally knees or hips; distal joint hyperlaxity may coexist, particularly in the hands and feet, creating a mixed picture of rigidity and laxity.[2] Age-specific features guide the evaluation, as manifestations vary from infantile hypotonia with feeding difficulties to childhood-onset gait abnormalities such as waddling, toe-walking, or difficulty rising from the floor (positive Gowers' sign).[2][27] In adolescence or adulthood, progressive proximal weakness and worsening contractures may become more prominent, though many individuals remain ambulatory into later decades. Red flags during evaluation include severe respiratory distress (e.g., exertional dyspnea or reduced vital capacity) or prominent skin changes such as follicular hyperkeratosis or keloid formation, which may indicate a need to consider phenotypic variability within collagen VI-related disorders.[2][27] Early involvement of a multidisciplinary team, including neurologists for neuromuscular assessment, geneticists for inheritance counseling, and orthopedists for contracture management, is recommended to optimize supportive care planning.[2]

Confirmatory testing

Confirmatory testing for Bethlem myopathy primarily involves genetic analysis to identify pathogenic variants in the collagen VI genes, supplemented by histopathological, imaging, and biochemical assessments when needed to support the diagnosis.[2] Genetic testing is the gold standard for confirmation, utilizing next-generation sequencing panels that target COL6A1, COL6A2, COL6A3, and, in select cases, COL12A1 for Bethlem myopathy type 2. These panels detect heterozygous dominant or biallelic recessive variants with high sensitivity, exceeding 95% for dominant cases through sequence analysis, though deletion/duplication testing identifies fewer than 1% of variants.[2][12] Muscle biopsy is optional but can reveal mild dystrophic changes, including fiber size variation, necrosis, regeneration, and increased connective tissue, particularly in later stages. Immunohistochemistry typically shows reduced or absent collagen VI immunoreactivity at the sarcolemma, confirming extracellular matrix involvement, though findings may be subtle in early childhood biopsies under 30 months of age.[2] Muscle magnetic resonance imaging (MRI) demonstrates characteristic fatty infiltration in proximal muscles, such as the quadriceps, with patterns like peripheral ("outside-in") involvement in the vastus lateralis and central sparing or "cloud-like" changes in the rectus femoris, aiding in guiding genetic testing. Electromyography (EMG) supports the diagnosis by revealing myopathic patterns, including small-amplitude, short-duration motor unit potentials with early recruitment.[2][29] Biochemical evaluation includes serum creatine kinase (CK) levels, which are normal or mildly elevated (typically 2-5 times the upper limit of normal, often below 1000 IU/L). For recessive COL6-related cases, skin biopsy of dermal fibroblasts may show reduced collagen VI secretion or abnormal matrix deposition via immunofluorescence, providing an adjunct to muscle biopsy. For type 2 (COL12A1-related) cases, similar biopsies may reveal abnormalities in collagen XII assembly, though less commonly used.[2][30] Prenatal diagnosis is available for at-risk families through amniocentesis or chorionic villus sampling once pathogenic variants are identified in the proband, enabling direct molecular confirmation of fetal status.[2]

Differential diagnosis

Bethlem myopathy must be differentiated from other conditions presenting with proximal muscle weakness, joint contractures, and variable onset, as accurate diagnosis relies on distinguishing clinical, histological, and genetic features.[2] Key differentials include collagen VI-related disorders such as Ullrich congenital muscular dystrophy, which is more severe with early hypotonia, prominent distal hyperlaxity, and rapid progression to respiratory failure, contrasting Bethlem's milder, slowly progressive course without marked hyperlaxity.[2] Autosomal recessive forms of collagen VI disorders, though rare, can mimic Bethlem but often exhibit earlier onset and greater severity due to biallelic mutations.[4] Emery-Dreifuss muscular dystrophy represents another important differential, characterized by early elbow and Achilles tendon contractures similar to Bethlem, but distinguished by prominent cardiac conduction defects and humeroperoneal muscle weakness, which are typically absent in Bethlem.[2] Limb-girdle muscular dystrophy type 1 (LGMD1), particularly calpainopathy (LGMDR1), may present with proximal weakness and subtle contractures, but lacks the early joint involvement and skin changes like keloid formation seen in Bethlem.[4] Congenital myotonic dystrophy differs through the presence of myotonia, facial weakness, cataracts, and multisystem involvement, with muscle biopsy showing ringed fibers rather than the mild myopathic changes in Bethlem.[31] Connective tissue disorders, such as Ehlers-Danlos syndrome with myopathy overlap (including COL12A1-related myopathy), can overlap in features like joint laxity and skin fragility, particularly in Bethlem type 2 mimics, but are differentiated by more pronounced vascular fragility and absence of progressive muscle weakness.[4] Other rare mimics include LAMA2-related dystrophy (with elevated CK and white matter changes), TTN-related myopathy (featuring a contractural phenotype and webbed neck), and FHL1-related myopathy (with early respiratory involvement).[2] The presence of early contractures and follicular hyperkeratosis favors Bethlem over pure dystrophies, while genetic testing for COL6A1, COL6A2, and COL6A3 mutations provides definitive resolution of ambiguities.[32]

Management and Treatment

Supportive therapies

Supportive therapies for Bethlem myopathy focus on symptom management, preserving mobility, and enhancing quality of life through non-curative interventions tailored to disease progression.[2] These approaches emphasize early and consistent application to mitigate complications such as contractures and respiratory decline, with a multidisciplinary team coordinating care.[33] Physical and occupational therapy form the cornerstone of management, involving regular stretching programs to prevent and alleviate joint contractures, particularly in the elbows, ankles, and spine.[2] Strengthening exercises target proximal muscles to maintain ambulation and daily function, while low-impact activities like swimming or aquatherapy improve muscle conditioning and flexibility without exacerbating weakness.[2] Annual assessments by therapists guide personalized plans, with more frequent evaluations recommended as contractures worsen.[2] Orthopedic interventions address severe contractures and skeletal deformities, including splinting or serial casting to gradually correct limitations in joint range of motion.[33] Surgical options, such as Achilles tendon releases or tendon lengthening procedures, are considered for persistent foot deformities or elbow flexion contractures that impair mobility, often followed by postoperative casting and rehabilitation.[2] Scoliosis monitoring is essential, with surgical correction pursued in severe cases as determined by an orthopedist to prevent respiratory compromise; surgery is rare.[33][2] Respiratory support is crucial in advanced cases due to diaphragmatic weakness, beginning with annual pulmonary function tests to monitor vital capacity and detect nocturnal hypoventilation.[2] Non-invasive ventilation, such as bilevel positive airway pressure (BiPAP), is initiated when forced vital capacity falls to ≤60% predicted or symptoms like fatigue emerge, typically in later adulthood for Bethlem myopathy.[2] Airway clearance techniques, including mechanical insufflation-exsufflation, may assist in secretion management during respiratory infections.[2] Pain management targets joint stiffness and muscle cramps using nonsteroidal anti-inflammatory drugs (NSAIDs) or simple analgesics as first-line options, combined with physical therapy to reduce mechanical stress on affected areas.[34] Nutritional support involves regular dietary assessments to maintain optimal body weight and prevent malnutrition, which can exacerbate weakness; high-calorie supplements or gastrostomy feeding are rarely needed in milder Bethlem cases but help sustain energy levels.[2] Multidisciplinary care ensures holistic oversight, with regular follow-up by physiatrists, neurologists, pulmonologists, and orthopedic specialists to adjust therapies based on clinical progression and prevent secondary complications like falls or infections.[33] Adherence to this coordinated approach can positively influence long-term functional outcomes.[2]

Emerging interventions

Research into gene therapy for Bethlem myopathy focuses on addressing mutations in the COL6A1, COL6A2, and COL6A3 genes, which disrupt collagen VI production and assembly. Antisense oligonucleotides (ASOs) have shown promise in preclinical models by correcting aberrant splicing in COL6 mutations, such as exon-skipping ASOs that restore functional collagen VI expression in patient-derived fibroblasts and Ullrich congenital muscular dystrophy (UCMD) models, a related collagen VI disorder. For instance, gapmer ASOs targeting dominant-negative mutations in COL6A3 have demonstrated allele-specific silencing, reducing mutant protein levels and improving extracellular matrix integrity in cellular models. Recent structural studies of collagen VI microfibrils (as of August 2025) have revealed mechanisms for molecular therapies, including the development of mini-collagens to potentially restore protein function. Additionally, advances in gene editing for collagen disorders (as of August 2025) highlight preclinical potential to enhance collagen production and tissue integrity. Adeno-associated virus (AAV)-mediated delivery systems are under investigation in mouse models of collagen VI myopathies, where AAV vectors restore COL6A2 expression in myofibers, leading to improved muscle function and collagen VI network formation. These approaches remain in preclinical stages as of 2025, with ongoing efforts to optimize delivery and efficacy for clinical translation.[35][36][37][38][20][39] Small molecule therapies aim to enhance the secretion and function of mutant collagen VI. Cyclosporin A (CsA), a calcineurin inhibitor, has been explored for its ability to correct mitochondrial dysfunction and reduce apoptosis in collagen VI-deficient cells by stabilizing the permeability transition pore. An open-label pilot trial involving five patients with collagen VI myopathies, including Bethlem myopathy, demonstrated that one month of CsA treatment improved limb muscle performance and normalized mitochondrial membrane potential in patient fibroblasts, though respiratory muscle benefits were limited. Preclinical studies in Col6a1 knockout mice further support CsA's role in rescuing myogenic responses and reducing fibrosis, but no new phase I/II trials specific to Bethlem myopathy were reported in 2024-2025, highlighting the need for larger, controlled studies to assess long-term safety and efficacy. Other chaperone molecules are being investigated to promote mutant collagen VI folding and secretion, building on these foundational findings.[40][41][42] Stem cell research targets extracellular matrix (ECM) repair in collagen VI disorders. Mesenchymal stem cells (MSCs), particularly those engineered to secrete collagen VI, have improved muscle regeneration in UCMD mouse models by supplementing ECM components and reducing fibrosis. Transplantation of human adipose-derived MSCs into these models enhanced myofiber maturation and functional recovery, suggesting potential for ECM restoration in Bethlem myopathy. Early-phase clinical trials for MSCs in broader muscular dystrophies are ongoing, but as of 2025, no dedicated trials for collagen VI-related conditions have advanced beyond preclinical evaluation, with challenges including cell survival and targeted delivery.[43][44] Recent clinical trials for Bethlem myopathy emphasize natural history and biomarker studies due to the disease's rarity. The ongoing MR in Patients With Collagen VI Related Myopathies trial (NCT03693898), initiated in 2018 and active through 2025, uses magnetic resonance imaging to assess muscle pathology and fibrosis progression in Bethlem and UCMD patients, providing data for future interventional designs. No large-scale trials targeting fibrosis reduction were completed in 2024-2025, though preclinical work on anti-fibrotic agents continues; recruitment challenges persist, with fewer than 100 global cases annually limiting trial feasibility.[45] Patient registries play a crucial role in advancing personalized medicine for Bethlem myopathy by facilitating genotype-phenotype correlations and trial recruitment. The Global Registry for COL6-related Dystrophies (NCT04020159), launched in 2019 and integrated into the TREAT-NMD Global Registry Network, collects clinical, genetic, and outcome data from over 200 participants worldwide, enabling tailored therapeutic strategies based on mutation-specific profiles. This database supports international collaboration, as seen in harmonized data sharing for rare neuromuscular diseases, accelerating the transition from preclinical research to patient-specific interventions.[46][47][48]

Prognosis and Epidemiology

Long-term outcomes

Bethlem myopathy exhibits a slow and variable progression, with muscle weakness and joint contractures typically worsening gradually over decades. In most cases, patients remain ambulatory into their 50s and beyond, though approximately two-thirds of individuals over age 50 require mobility aids such as canes, walkers, or scooters due to proximal weakness and lower limb contractures.[26] Wheelchair dependency arises in severe cases, often by the 60s, affecting about 20-30% of patients depending on genotype, while milder forms allow independent ambulation well into later adulthood.[49][50] Common long-term complications include respiratory insufficiency, occurring in 15-33% of cases, with a median onset in the 40s and progression to the need for non-invasive ventilation in about 20%.[49][50] Cardiac involvement is rare and typically absent, with no primary cardiomyopathy reported in large cohorts.[26] Skin manifestations, such as keloid scarring and follicular hyperkeratosis, are common, affecting approximately 60% of patients in some cohorts, and may be particularly notable in recessive forms, contributing to cosmetic and functional concerns over time.[49][50] Life expectancy is generally near normal, with many individuals reaching 70-80 years in the absence of significant respiratory complications; however, cases requiring mechanical ventilation may experience reduced survival, as evidenced by occasional deaths in the 30s or 40s from respiratory failure.[26][49] Quality of life is impacted by progressive contractures, which limit mobility and daily activities, often necessitating ongoing physical therapy and orthopedic interventions; psychological support is recommended to address the emotional burden of chronic disability and dependency.[26][51] Outcomes vary by genotype and inheritance pattern, with respiratory involvement reported in both autosomal dominant and recessive forms, including cases of severe progression in recessive Bethlem myopathy.[51] Supportive management can positively influence these trajectories by mitigating contracture-related limitations.[26]

Prevalence and distribution

Bethlem myopathy is a rare genetic disorder with an estimated global prevalence of less than 1 in 1,000,000 individuals.[4] A population-based study in Northern England reported a prevalence of 0.77 per 100,000 people, equivalent to approximately 1 in 129,870.[52] In the United States, fewer than 5,000 cases have been identified as of recent estimates.[53] The precise incidence remains unknown due to underdiagnosis and challenges in rare disease surveillance, though birth prevalence is thought to align closely with overall prevalence rates given the condition's slow progression and lifelong nature.[2] Recent studies, including a 2025 analysis of a Russian registry with 165 patients and a 2024 Egyptian cohort, indicate increasing recognition through improved genetic testing.[54][55] The disorder has been reported worldwide across diverse populations, with no strong evidence of ethnic or racial predisposition.[1] Cases have been documented in individuals of European, African, Middle Eastern, and other ancestries, including reports from Dutch, black Creole, Egyptian, and Saudi Arabian families.[56][57] Higher recognition and reporting appear in European regions, likely attributable to its initial description in the Netherlands in the 1970s, which facilitated earlier genetic studies there.[4] Demographically, Bethlem myopathy affects males and females equally, consistent with its primarily autosomal dominant inheritance pattern, which often results in familial clustering across generations.[2] Underreporting is a significant issue, as evidenced by limited entries in global rare disease registries and diagnostic challenges in non-specialized settings; Orphanet classifies it as having low incidence.[4]

References

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