Myasthenia Gravis Case Study

Original Editor - Alisha Oliver Top Contributors - Alisha Oliver, Kim Jackson, Emmy Arsenault and Lydia Straznicky

Abstract

The purpose of this fictional case study is to explore the physiotherapy assessment and treatment progression of a 35 year old woman diagnosed with myasthenia gravis (MG), class IIa. The patient discussed in this case study presents with fatigable weakness affecting mainly her upper limbs as well as diplopia. Due to an increased workload, the patient developed right shoulder pain, leading her to seek physiotherapy care. The physiotherapist developed an individualized treatment plan based on the patient’s short and long term goals which involved education, self management strategies, resistance and aerobic exercises, and manual therapy. Outcome measures (QuickDASH and MG QoL 15) were completed upon initial assessment and discharge to assess her progression throughout the 6 week treatment period. By the end of the treatment period, the patient had met all her treatment goals and continued to work on self-management of her MG.

Introduction

Myasthenia Gravis (MG) is a neurological condition involving dysfunction at the neuromuscular junction . It is a rare, but chronic, auto-immune disease that is said to affect approximately 1 in 5000 Americans of varying races, ages and genders .

MG is caused when there is an interruption in the communication between the nerve impulse and the muscle at the neuromuscular junction. Antibodies can be formed by a dysregulated immune system and they block or destroy the acetylcholine receptors that would normally be responsible for muscle activation . Because of this, the disease presents mainly with generalized weakness and fatigue in any or all of the muscles of the limbs, eyes, face, respiratory system or trunk .

Due to the nature of the condition, MG (also coined “the snowflake disease” because it affects each individual differently) can pose some challenges when forming treatment plans . Sometimes, a patient's condition may decline with too much activity, but they may also lose muscle mass to disuse. It is important to work with the patient to find an optimal balance to allow them to achieve their goals and daily activities.

The purpose of this case study is to examine the physical therapy assessment and treatment intervention for a 35 year old woman diagnosed with MG experiencing mild-moderate symptoms.

Working as a librarian at a high school, in December 2017 the patient noticed her eyelids were drooping while she was taking off her makeup before bed. Over the Christmas break she began to notice double vision and arm weakness while reading which became progressively worse. She visited her Primary Care Physician in early January 2018 who referred her to a local neurologist after having concerns. During her appointment with the neurologist, he ran a blood test and found high levels of acetylcholine receptor antibodies. After her blood test results and a physical exam, he diagnosed her with Myasthenia Gravis (MG), class IIa. She was prescribed a cholinesterase inhibitor medication and took time off work to help with her symptoms. Over the summer break, the patient continued to take her medication and took time to rest and relax. She noticed improvements in her condition and was eager to return to work in late August to prepare for the upcoming school year. During the second week back to work, she began to notice pain in her right shoulder and found herself exhausted by the end of the day. Unable to keep up with her workload and increasing pain in her shoulder, she decided to go to a physiotherapist recommended to her by one of the teachers at her school. Additionally, the patient has a history of hyperthyroidism from the age of 20 and has been treating it with an anti-thyroid medication successfully.