Myasthenia Gravis
Myasthenia gravis (MG), an primary areas of muscular involvement.
uncommon condition, develops when,
for unknown reasons, antibodies
produced by the immune system block
receptors in muscles that receive
signals of acetylcholine (a chemical
messenger generated by nerve
impulses), thus impairing muscle
function.
MG may begin at any time in life,
including in the newborn infant, but
there are two major peaks of onset. In
early-onset MG, at age 20 to 30 years,
women are more often affected than
men. In lateonset MG, after age 50
years, men are more often affected.
CLINICAL SIGNS AND SYMPTOMS
Clinically, the disease is
characterized by muscle weakness and
fatigability, most commonly in muscles
controlling eye movement, chewing,
swallowing, and facial expressions.
Symptoms show fluctuations in intensity
and are more severe late in the day or
after prolonged activity. Speech may
become unintelligible after prolonged
periods of talking. Fluctuations also
occur with superimposed illness,
menses, and air temperature (worse
with warming; improved with cold).
Fatigable and rapidly fluctuating
asymmetric ptosis is a hallmark of the
problem, since ocular muscle
dysfunction is usually one of the first
symptoms. The ice pack test, rest test,
sleep tests, and peek sign are all useful
in confirming the presence of MG (Box
12-4).6 5
Proximal muscles are affected more
than distal muscles, and difficulty in
climbing stairs, rising from chairs,
combing the hair, or even holding up the
head occurs. Cranial muscles, neck
muscles, respiratory muscles, and
muscles of the proximal limbs are the
Neurologic findings are normal except
for muscle weakness. There is no
muscular atrophy or loss of sensation.
Muscular weakness ranges from mild to
life threatening (when involving
respiratory muscles).
BOX 12-4 Eliciting Signs and
Symptoms of Myasthenia Gravis
The characteristic finding in myasthenia
gravis (MG) is decreased muscle
strength that gets worse with repetition
and improves with rest.
Asymmetric drooping of the eyelids
(ptosis) is one of the first signs and can
be identified using the following tests.
The client sits and fixes his or her gaze
on a distant object without blinking. The
frontalis muscle should be relaxed
although this may be difficult. The eye
with the most noticeable ptosis is tested.
The Ice Pack Test
Place a latex-free glove filled with
crushed ice over the eyelid for 2
minutes.
The Rest Test
Place a cotton-filled latex-free glove
(rest) over the eyelid while holding the
eyes closed for 2 minutes.
The Sleep Test
Client is placed in a dark room with eyes
closed for 30 minutes.
Key: Evaluate response to these tests
immediately following timed period. A
positive response is complete or almost
complete resolution of the ptosis.
Improvement may be greater with the
ice test compared to the rest test.6 6
Medical referral is required.
Data from Scherer K, Bedlack RS, Simel Ptosis (extraocular muscle
L: Does this patient have myasthenia weakness resulting in drooping of
gravis? JAMA 293(15):1906-1914, the upper eyelid)
2005. Diplopia (double vision)
Dysarthria (slurred speech)
Clinical Signs and Symptoms of Bulbar involvement
MyastheniaGravis Alteration in voice quality
Muscle fatigability and proximal Dysphagia (difficulty swallowing)
muscle weakness aggravated by Nasal regurgitation
exertion Choking, difficulty in chewing
Respiratory failure from
progressive involvement of
respiratory muscles

Goodman, C.C., & Snyder, T.E.K. (2007). Differential Diagnosis for the physical
therapist: screening for referral. St. Louis, MI: Elsevier