Project: Ghana Emergency Medicine Collaborative
Document Title: Myasthenia Gravis (Case of the Week)
Author(s): Chris Oppo...
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CASE OF THE WEEK
BY CHRIS K. OPPONG,
BSc HUMAN BIOLOGY, MBChB
EMERGENCY MEDICINE RESIDENT-KATH

3
CASE OF THE WEEK
A 17 year old female presented to KATH ED
with a 3 day history of difficulty in
swallowing , drooling ,dy...
PmHx: mother claims she has been treated
for chronic tonsillitis recently and has been
having non-specific recurrent illne...
O/E
Lethargic
l  Weak respiratory effort
l  Drooling
l  Afebrile
l 

l 

Vital signs:Bp-130/95, pulse-105bpmRGV,
RR-3...
Admission Day 1
UPPER AIRWAY OBSTRUCTION ?cause
ABC’s
l  Normal throat examination :tonsils , soft
palate
l  Consult to ...
Lab results
Wbc-15, Hb-10.1, ESR-18
l  ABG- pH-7.1, pCo2-42.9, HCO3- 15.8,
pO2-29, Na-149.4, Cl-111.4
l  AST 275, ALT-29...
DAY 2
ENT consult : acute laryngitis
l  Patient transferred to ENT ward
l 

9
DAY 3
Improvement in patients condition on the
ward.
l  Feeding again
l  Mother expressed concern to doctors that her
co...
Day 4
Better in the morning
l  c/o diffiulty in swallowing
l  Ward cover doctor called in the evening to
see patient who...
Day 5
15:35 GMT , doctor called to see patient who
had become unresponsive with a GCS of
8/15
l  Physician consult; epigl...
CPR
l  Patient revived after 3 cycles and intubated
l  ICU ventilators were malfunctioning so
patient was kept at RED on...
Day 6
Patient transferred to ICU
l  Physician consult; atypical
pneumonia(mycoplasma pneumonia)
l  Rapid HIV test ?posit...
Day 7
Massive subcutaneous emphysema ??
barotrauma
l  RT pneumothorax
l 

15
Source Undetermined

16
Day 10

Source Undetermined

17
Hypopyon
l  Ophthalmology consult
l  Ophthalmologist recognizes patient and
discloses he had treated her for ocular
myas...
Day 18 post admission
Patient is still on a ventilator on CPAP
l  Being treated with pyridostigmine,
azathioprine and iv ...
Myasthenia Gravis

20
MYASTHENIC CRISIS

21
Outline
l 
l 
l 
l 
l 
l 
l 
l 

Background
Anatomy
Pathophysiology
Epidemiology
Clinical Presentation
Work-up
Tre...
Background
Acquired autoimmune disorder
l  Clinically characterized by:
l 

l 
l 

l 

Weakness of skeletal muscles
F...
Anatomy
l 

Neuromuscular Junction (NMJ)
l 

Components:
l 
l 
l 

l 

l 

Presynaptic membrane
Postsynaptic membra...
Nrets, Wikimedia Commons

25
Anatomy
l 

Neuromuscular Junction (NMJ)
l 

The Acetylcholine receptor (AChR) is a sodium
channel that opens when bound...
Pathophysiology
In MG, antibodies are directed toward the
acetylcholine receptor at the neuromuscular
junction of skeletal...
Pathophysiology
l 

Anti-AChR antibody is found in
80-90% of patients with MG

l 

MG may be considered a B cellmediated...
Pathophysiology
l 

T-cell mediated immunity has some influence
l  Thymic hyperplasia and thymomas are
recognized in mya...
Epidemiology
l 

l 

Frequency
l  Annual incidence in US- 2/1,000,000
l  Worldwide prevalence 1/10,000
Mortality/morbi...
Clinical Presentation
l 

Fluctuating weakness increased by exertion
l 

l 

Extraocular muscle weakness
l 

l 

Weak...
Clinical presentation
l 

Progression of disease
l 

l 

Mild to more severe over weeks to months
l  Usually spreads f...
Clinical presentation
l 

Basic physical exam findings
l 
l 

l 

Muscle strength testing
Recognize patients who may d...
Clinical presentation
l 

Muscle strength
l 
l 
l 
l 
l 

Facial muscle weakness
Bulbar muscle weakness
Limb muscle ...
Clinical presentation
l 

Facial muscle weakness is almost
always present
l 

l 

Ptosis and bilateral facial muscle
we...
Clinical presentation
l 

Bulbar muscle weakness
l 

l 

Palatal muscles
l  “Nasal voice”, nasal regurgitation
l  Che...
Clinical presentation
l 

Limb muscle weakness
l 

Upper limbs more common than lower limbs

Upper Extremities
Deltoids
...
Clinical presentation
l 

Respiratory muscle weakness
l 

l 

Weakness of the intercostal muscles and the diaghram
may ...
Clinical presentation
l 

Occular muscle weakness
l 

Asymmetric
l 

l 

Usually affects more than one extraocular mus...
Clinical presentation
l 

Co-existing autoimmune diseases
l 

Hyperthyroidism
l 

Occurs in 10-15% MG patients
§ 
§ 
...
Clinical presentation
l 

Causes
l 
l 

Idiopathic
Penicillamine
l 

l 

AChR antibodies are found in 90% of patients...
Clinical presentation
l 

Causes
l 

Drugs
l  Antibiotics
(Aminoglycosides,
ciprofloxacin, ampicillin,
erythromycin)
l...
Differentials
l 
l 
l 
l 
l 
l 

Amyotropic Lateral
Sclerosis
Basilar Artery
Thrombosis
Brainstem gliomas
Cavernous ...
Work-up
l 

Lab studies
l 

Anti-acetylcholine receptor antibody
l 
l 
l 

l 

Positive in 74%
80% in generalized my...
Work-up
l 

Lab studies
l 

Interleukin-2 receptors
l 
l 

Increased in generalized and bulbar forms of MG
Increase se...
Work-up
l 

Imaging studies
l 

Chest x-ray
l 

l 
l 

Plain anteroposterior and lateral views may identify a
thymoma...
Work-up
l 

Electrodiagnostic studies
l 

Repetitive nerve stimulation
Single fiber electromyography (SFEMG)

l 

SFEMG...
Electrodiagnostic studies:
Single-fiber electromyography
l 

Generalized MG
l 
l 

l 

Abnormal extensor digiti minimi...
Workup
Pharmacological testing
l 

Edrophonium (Tensilon test)
l 
l 
l 

l 

Patients with MG have low numbers of ACh...
Workup
Pharmacological testing
Before

After

Source Undetermined

50
Workup
Pharmacological testing
l 

Edrophonium (Tensilon test)
l 

Steps
l 

l 

l 

0.1ml of a 10 mg/ml edrophonium ...
Treatment
AChE inhibitors
l  Immunomodulating therapies
l  Plasmapheresis
l  Thymectomy
l 

l 

Important in treatmen...
Treatment
l 

AChE inhibitor
l 

Pyridostigmine bromide (Mestinon)
l 
l 
l 

Starts working in 30-60 minutes and last...
Treatment
l 

Immunomodulating therapies
l 

Prednisone
l 
l 
l 

Most commonly used corticosteroid in US
Significant...
Treatment
Behavioral modifications
l 

Diet
l 

Patients may experience difficulty chewing and
swallowing due to orophar...
Complications of MG
Respiratory failure
l  Dysphagia
l  Complications secondary to drug treatment
l 

l 

Long term st...
Prognosis
Untreated MG carries a mortality rate of
25-31%
l  Treated MG has a 4% mortalitiy rate
l  40% have ONLY occula...
Rehabilitation
l 

Strategies emphasize
l 
l 
l 
l 
l 

Patient education
Timing activity
Providing adaptive equipme...
References
1. Delisa, S. A., Goans, B., Rehabilitatoin Medicine Principles and
Practice, 1998, Lippencott-Raven
2. Kimura,...
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GEMC: Myasthenia Gravis (Case of the Week): Resident Training

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This is a lecture by Dr. Chris Oppong from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC: Myasthenia Gravis (Case of the Week): Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Myasthenia Gravis (Case of the Week) Author(s): Chris Oppong, BSc, MBChB License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that 2 your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. CASE OF THE WEEK BY CHRIS K. OPPONG, BSc HUMAN BIOLOGY, MBChB EMERGENCY MEDICINE RESIDENT-KATH 3
  4. 4. CASE OF THE WEEK A 17 year old female presented to KATH ED with a 3 day history of difficulty in swallowing , drooling ,dysphasia and shortness of breath. l  Differential diagnosis?? l  4
  5. 5. PmHx: mother claims she has been treated for chronic tonsillitis recently and has been having non-specific recurrent illnesses which has been managed on OPD basis l  Drug hx: iv ceftriazone 2g, iv amoksiklav 1.2g l  Social hx: SHS 3 , boarding house l  5
  6. 6. O/E Lethargic l  Weak respiratory effort l  Drooling l  Afebrile l  l  Vital signs:Bp-130/95, pulse-105bpmRGV, RR-30cpm, temp.-36.8oC, Spo2-62% room air. GCS m-6, v-5, e-3. any concerns?? 6
  7. 7. Admission Day 1 UPPER AIRWAY OBSTRUCTION ?cause ABC’s l  Normal throat examination :tonsils , soft palate l  Consult to ENT l  CBC, ABG’s, LFT ,RFT, pregnancy test l  Chest x-ray, lateral neck x-ray, ECG 7
  8. 8. Lab results Wbc-15, Hb-10.1, ESR-18 l  ABG- pH-7.1, pCo2-42.9, HCO3- 15.8, pO2-29, Na-149.4, Cl-111.4 l  AST 275, ALT-294 l  UREA-6.02,CRT-67, BUN /CRT-42 l  8
  9. 9. DAY 2 ENT consult : acute laryngitis l  Patient transferred to ENT ward l  9
  10. 10. DAY 3 Improvement in patients condition on the ward. l  Feeding again l  Mother expressed concern to doctors that her condition keeps fluctuating, worse in the evening???hysteria l  Ward cover doctor called to see patient who had become restless. l  10
  11. 11. Day 4 Better in the morning l  c/o diffiulty in swallowing l  Ward cover doctor called in the evening to see patient who had become restless again l  11
  12. 12. Day 5 15:35 GMT , doctor called to see patient who had become unresponsive with a GCS of 8/15 l  Physician consult; epiglotitis with sepsis+ adrenal insufficiency, requested head CTscan l  21:30 GMT, patient rushed to RED by ENT ward nurses with no cardio respiratory activity and brownish secretions from mouth and nostrils l  12
  13. 13. CPR l  Patient revived after 3 cycles and intubated l  ICU ventilators were malfunctioning so patient was kept at RED on the transport ventilator l  CXR- aspiration l  13
  14. 14. Day 6 Patient transferred to ICU l  Physician consult; atypical pneumonia(mycoplasma pneumonia) l  Rapid HIV test ?positive l  ELISA-negative l  14
  15. 15. Day 7 Massive subcutaneous emphysema ?? barotrauma l  RT pneumothorax l  15
  16. 16. Source Undetermined 16
  17. 17. Day 10 Source Undetermined 17
  18. 18. Hypopyon l  Ophthalmology consult l  Ophthalmologist recognizes patient and discloses he had treated her for ocular myasthenia gravis l  MYASTHENIC CRISIS now the working diagnosis l  18
  19. 19. Day 18 post admission Patient is still on a ventilator on CPAP l  Being treated with pyridostigmine, azathioprine and iv immunoglobulin l  Significant improvement, , GCS m-5, e-2 v-Intubated l  19
  20. 20. Myasthenia Gravis 20
  21. 21. MYASTHENIC CRISIS 21
  22. 22. Outline l  l  l  l  l  l  l  l  Background Anatomy Pathophysiology Epidemiology Clinical Presentation Work-up Treatment Rehabilitation Posey & Spiller, Wikimedia Commons 22
  23. 23. Background Acquired autoimmune disorder l  Clinically characterized by: l  l  l  l  Weakness of skeletal muscles Fatigability on exertion. First clinical description in 1672 by Thomas Willis 23
  24. 24. Anatomy l  Neuromuscular Junction (NMJ) l  Components: l  l  l  l  l  Presynaptic membrane Postsynaptic membrane Synaptic cleft Presynaptic membrane contains vesicles with Acetylcholine (ACh) which are released into synaptic cleft in a calcium dependent manner ACh attaches to ACh receptors (AChR) on postsynaptic membrane 24
  25. 25. Nrets, Wikimedia Commons 25
  26. 26. Anatomy l  Neuromuscular Junction (NMJ) l  The Acetylcholine receptor (AChR) is a sodium channel that opens when bound by ACh l  l  There is a partial depolarization of the postsynaptic membrane and this causes an excitatory postsynaptic potential (EPSP) If enough sodium channels open and a threshold potential is reached, a muscle action potential is generated in the postsynaptic membrane 26
  27. 27. Pathophysiology In MG, antibodies are directed toward the acetylcholine receptor at the neuromuscular junction of skeletal muscles l  Results in: l  l  l  l  Decreased number of nicotinic acetylcholine receptors at the motor end-plate Reduced postsynaptic membrane folds Widened synaptic cleft 27
  28. 28. Pathophysiology l  Anti-AChR antibody is found in 80-90% of patients with MG l  MG may be considered a B cellmediated disease l  Antibodies 28
  29. 29. Pathophysiology l  T-cell mediated immunity has some influence l  Thymic hyperplasia and thymomas are recognized in myasthenic patients* Source Undetermined Source Undetermined 29
  30. 30. Epidemiology l  l  Frequency l  Annual incidence in US- 2/1,000,000 l  Worldwide prevalence 1/10,000 Mortality/morbidity l  Recent decrease in mortality rate due to advances in treatment l  l  Risk factors l  l  l  3-4% (as high as 30-40%) Age > 40 Thymoma Sex l  F-M (6:4) l  Mean age of onset (M-42, F-28) l  Incidence peaks- M- 6-7th decade F- 3rd decade 30
  31. 31. Clinical Presentation l  Fluctuating weakness increased by exertion l  l  Extraocular muscle weakness l  l  Weakness increases during the day and improves with rest Ptosis is present initially in 50% of patients and during the course of disease in 90% of patients Head extension and flexion weakness l  Weakness may be worse in proximal muscles 31
  32. 32. Clinical presentation l  Progression of disease l  l  Mild to more severe over weeks to months l  Usually spreads from ocular to facial to bulbar to truncal and limb muscles l  Often, symptoms may remain limited to EOM and eyelid muscles for years l  The disease remains ocular in 16% of patients Remissions l  l  Spontaneous remissions rare Most remissions with treatment occur within the first three years 32
  33. 33. Clinical presentation l  Basic physical exam findings l  l  l  Muscle strength testing Recognize patients who may develop respiratory failure (i.e. difficult breathing) Sensory examination and DTR’s are normal 33
  34. 34. Clinical presentation l  Muscle strength l  l  l  l  l  Facial muscle weakness Bulbar muscle weakness Limb muscle weakness Respiratory weakness Ocular muscle weakness 34
  35. 35. Clinical presentation l  Facial muscle weakness is almost always present l  l  Ptosis and bilateral facial muscle weakness Sclera below limbus may be exposed due to weak lower lids Cumulus, Wikimedia Commons 35
  36. 36. Clinical presentation l  Bulbar muscle weakness l  l  Palatal muscles l  “Nasal voice”, nasal regurgitation l  Chewing may become difficult l  Severe jaw weakness may cause jaw to hang open l  Swallowing may be difficult and aspiration may occur with fluids—coughing and choking while drinking Neck muscles l  Neck flexors affected more than extensors 36
  37. 37. Clinical presentation l  Limb muscle weakness l  Upper limbs more common than lower limbs Upper Extremities Deltoids Wrist extensors Finger extensors Triceps > Biceps Lower Extremities Hip flexors (most common) Quadriceps Hamstrings Foot dorsiflexors Plantar flexors 37
  38. 38. Clinical presentation l  Respiratory muscle weakness l  l  Weakness of the intercostal muscles and the diaghram may result in CO2 retention due to hypoventilation l  May cause a neuromuscular emergency(myasthenic crisis) Weakness of pharyngeal muscles may collapse the upper airway l  Monitor negative inspiratory force, vital capacity and tidal volume l  Do NOT rely on pulse oximetry §  Arterial blood oxygenation may be normal while CO2 is retained 38
  39. 39. Clinical presentation l  Occular muscle weakness l  Asymmetric l  l  Usually affects more than one extraocular muscle and is not limited to muscles innervated by one cranial nerve Weakness of lateral and medial recti may produce a pseudointernuclear opthalmoplegia §  l  l  Limited adduction of one eye with nystagmus of the abducting eye on attempted lateral gaze Ptosis caused by eyelid weakness Diplopia is very common 39
  40. 40. Clinical presentation l  Co-existing autoimmune diseases l  Hyperthyroidism l  Occurs in 10-15% MG patients §  §  l  l  l  Exopthalamos and tachycardia point to hyperthyroidism Weakness may not improve with treatment of MG alone in patients with co-existing hyperthyroidism Rheumatoid arthritis Scleroderma Lupus 40
  41. 41. Clinical presentation l  Causes l  l  Idiopathic Penicillamine l  l  AChR antibodies are found in 90% of patients developing MG secondary to penicillamine exposure Drugs 41
  42. 42. Clinical presentation l  Causes l  Drugs l  Antibiotics (Aminoglycosides, ciprofloxacin, ampicillin, erythromycin) l  B-blocker (propranolol) l  Lithium l  Magnesium l  l  l  l  l  l  l  Procainamide Verapamil Quinidine Chloroquine Prednisone Timolol Anticholinergics 42
  43. 43. Differentials l  l  l  l  l  l  Amyotropic Lateral Sclerosis Basilar Artery Thrombosis Brainstem gliomas Cavernous sinus syndromes Dermatomyositis Lambert-Eaton Myasthenic Syndrome l  l  l  l  l  l  Multiple Sclerosis Sarcoidosis and Neuropathy Thyroid disease Botulism Oculopharyngeal muscular dystrophy Brainstem syndromes 43
  44. 44. Work-up l  Lab studies l  Anti-acetylcholine receptor antibody l  l  l  l  Positive in 74% 80% in generalized myasthenia 50% of patients with pure ocular myasthenia Anti-striated muscle l  Present in 84% of patients with thymoma who are younger than 40 years 44
  45. 45. Work-up l  Lab studies l  Interleukin-2 receptors l  l  Increased in generalized and bulbar forms of MG Increase seems to correlate to progression of disease 45
  46. 46. Work-up l  Imaging studies l  Chest x-ray l  l  l  Plain anteroposterior and lateral views may identify a thymoma as an anterior mediastinal mass Chest CT scan is mandatory to identify thymoma MRI of the brain and orbits may help to rule out other causes of cranial nerve deficits but should not be used routinely 46
  47. 47. Work-up l  Electrodiagnostic studies l  Repetitive nerve stimulation Single fiber electromyography (SFEMG) l  SFEMG is more sensitive than RNS in MG l  47
  48. 48. Electrodiagnostic studies: Single-fiber electromyography l  Generalized MG l  l  l  Abnormal extensor digiti minimi found in 87% Examination of a second abnormal muscle will increase sensitivity to 99% Occular MG l  l  Frontalis muscle is abnormal in almost 100% More sensitive than EDC (60%) 48
  49. 49. Workup Pharmacological testing l  Edrophonium (Tensilon test) l  l  l  l  Patients with MG have low numbers of AChR at the NMJ Ach released from the motor nerve terminal is metabolized by Acetylcholine esterase Edrophonium is a short acting Acetylcholine Esterase Inhibitor that improves muscle weakness Evaluate weakness (i.e. ptosis and opthalmoplegia) before and after administration 49
  50. 50. Workup Pharmacological testing Before After Source Undetermined 50
  51. 51. Workup Pharmacological testing l  Edrophonium (Tensilon test) l  Steps l  l  l  0.1ml of a 10 mg/ml edrophonium solution is administered as a test If no unwanted effects are noted (i.e. sinus bradychardia), the remainder of the drug is injected Consider that Edrophonium can improve weakness in diseases other than MG such as ALS, poliomyelitis, and some peripheral neuropathies 51
  52. 52. Treatment AChE inhibitors l  Immunomodulating therapies l  Plasmapheresis l  Thymectomy l  l  Important in treatment, especially if thymoma is present 52
  53. 53. Treatment l  AChE inhibitor l  Pyridostigmine bromide (Mestinon) l  l  l  Starts working in 30-60 minutes and lasts 3-6 hours Individualize dose Adult dose: §  §  l  Caution §  l  60-960mg/d PO 2mg IV/IM q2-3h Check for cholinergic crisis Others: Neostigmine Bromide 53
  54. 54. Treatment l  Immunomodulating therapies l  Prednisone l  l  l  Most commonly used corticosteroid in US Significant improvement is often seen after a decreased antibody titer which is usually 1-4 months No single dose regimen is accepted §  §  l  l  Some start low and go high Others start high dose to achieve a quicker response Clearance may be decreased by estrogens or digoxin Patients taking concurrent diuretics should be monitored for hypokalemia 54
  55. 55. Treatment Behavioral modifications l  Diet l  Patients may experience difficulty chewing and swallowing due to oropharyngeal weakness l  If dysphagia develops, liquids should be thickened §  l  Thickened liquids decrease risk for aspiration Activity l  l  Patients should be advised to be as active as possible but should rest frequently and avoid sustained activity Educate patients about fluctuating nature of weakness and exercise induced fatigability 55
  56. 56. Complications of MG Respiratory failure l  Dysphagia l  Complications secondary to drug treatment l  l  Long term steroid use l  l  l  Osteoporosis, cataracts, hyperglycemia, HTN Gastritis, peptic ulcer disease Pneumocystis carinii 56
  57. 57. Prognosis Untreated MG carries a mortality rate of 25-31% l  Treated MG has a 4% mortalitiy rate l  40% have ONLY occular symptoms l  l  Only 16% of those with occular symptoms at onset remain exclusively occular at the end of 2 years 57
  58. 58. Rehabilitation l  Strategies emphasize l  l  l  l  l  Patient education Timing activity Providing adaptive equipment Providing assistive devices Exercise is not useful 58
  59. 59. References 1. Delisa, S. A., Goans, B., Rehabilitatoin Medicine Principles and Practice, 1998, Lippencott-Raven 2. Kimura, J., Electrodiagnosis in Diseases of Nerve and Muscle, F.A.Davis Company, Philadelphia 3. Rosenberg, R. N., Comprehensive Neurology, 1991, Raven Press Ltd 4. O’sullivan, Schmidtz, Physical Medicine and Rehabilitation Assessment and Treatment, pg. 151-152 5. Grabois, Garrison, Hart, Lehmke, Neuromuscular Diseases, pgs. 1653-1655 6. Shah, A. K., www.emedicine.com, Myasthenia Gravis, 2002, Wayne State University 7. Tensilon test pictures http://www.neuro.wustl.edu/neuromuscular/ mtime/mgdx.html 59
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