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Myasthenia Gravis

Myasthenia gravis is a rare autoimmune disorder of the neuromuscular junction characterized by varying degrees of weakness of the voluntary muscles.


Presentation

Myasthenia gravis affects children and neonates as well as adults. There will be weakness noticed in children too. There might be a weak cry and difficult movement of muscles or delayed milestones.

In adults, extraocular muscle weakness is the most common affection seen in maximum patients [4]. The hallmark of the myasthenia gravis is fatiguability or tiredness of the voluntary muscles [5]. Many patients present with bulbar muscle weakness and limb weakness which is often seen first in the proximal limbs and then in distal limbs. Since it is a chronic disorder, signs and symptoms are visible only after there is 30% reduction or destruction of the receptor sites and till then there is no evident sign.

Typically, extraocular muscle weakness is asymmetric and can be noticed easily. Drooping eyelids or ptosis occurs after straining the eyes for a long time as muscles give up after continuously using them due to a deficiency of acetylcholine at the neuromuscular junction.

Other common symptoms occurring out of fatiguability are slurred speech, diplopia or blurred vision, difficulty in chewing and dysphagia, weakness in arms and legs, chronic muscle fatigue, dyspnea, unstable gait, dysarthria i.e. difficulty in speaking or talking and impaired speech.

Weakness of muscles is typically least in the morning and progresses as the day progresses. Weakness increases as there is increased exertion and gets better with rest. Proximal muscle weakness is more often seen than distal muscle weakness.

Fatigue
  • […] residual problematic fatigue.[ncbi.nlm.nih.gov]
  • Abnormal amplitude decrement was found in 54% of patients with ocular MG, 77% of patients with predominantly bulbar fatigue, and in 83% of patients with predominantly limb fatigue.[ncbi.nlm.nih.gov]
  • Other common symptoms occurring out of fatiguability are slurred speech, diplopia or blurred vision, difficulty in chewing and dysphagia, weakness in arms and legs, chronic muscle fatigue, dyspnea, unstable gait, dysarthria i.e. difficulty in speaking[symptoma.com]
  • Central/bulbar involvement Test the power of head/neck flexion and extension (fatigue this movement as above) Ask the patient to take a deep breath and count out loud as many numbers as they can.[oxfordmedicaleducation.com]
  • Myasthenia gravis is a disorder of neuromuscular transmission that leads to fatigue of skeletal muscles and fluctuating weakness.[ncbi.nlm.nih.gov]
Chronic Fatigue Syndrome
  • Myalgic encephalomyelitis (ME) - 'chronic fatigue syndrome' - will have vague feelings of exhaustion made worse by any effort and no neurological signs to accompany it unless from disuse. The specific tests for MG will be negative.[patient.info]
Hoarseness
  • KEYWORDS: Hoarseness; diagnosis; edrophonium test; myasthenia gravis; sound spectrography[ncbi.nlm.nih.gov]
  • Chewing or swallowing difficulty, causing frequent gagging, choking, or drooling Difficulty climbing stairs, lifting objects, or rising from a seated position Difficulty talking Drooping head Facial paralysis or weakness of the facial muscles Fatigue Hoarseness[web.archive.org]
  • […] swallowing difficulty, causing frequent gagging, choking, or drooling Difficulty climbing stairs, lifting objects, or rising from a seated position Difficulty talking Drooping head and eyelids Facial paralysis or weakness of the facial muscles Fatigue Hoarseness[nlm.nih.gov]
  • Double vision Difficulty maintaining a steady gaze Eyelid drooping Other symptoms include: A drooping head Difficulty breathing Difficulty chewing and swallowing Difficulty climbing stairs Difficulty talking Facial paralysis Difficulty lifting objects Hoarseness[bmc.org]
Dysphagia
  • The subjects were classified into three groups; patients without dysphagia (group 1), patients with dysphagia (group 2), and healthy participants (group 3).[ncbi.nlm.nih.gov]
  • Dysphagia as a Presenting Symptom of Myasthenia Gravis—Case Report ABSTRACT Dysphagia is a common symptom in otolaryngology, but neuromuscular causes are rarely diagnostic hypotheses to be consider ed.[dx.doi.org]
  • Although the presentation is typically observed with complaints of vision and bulbar symptoms such as diplopia, dystonia, and dysphagia, this article presents a case study of an elderly man with a history of increasing upper extremity weakness with complaints[ncbi.nlm.nih.gov]
  • Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia.[ncbi.nlm.nih.gov]
  • After 3 months, the patient complained of increasing physical exhaustion, reduction of his walking distance, worsening of the residual dysphagia, and dysarthria with an inability to swallow.[ncbi.nlm.nih.gov]
Choking
  • Affected individuals may have unusual facial expressions, difficulty holding up the head, speech impairment (dysarthria), and chewing and swallowing problems (dysphagia) that may lead to choking, gagging, or drooling.Other muscles in the body are also[ncbi.nlm.nih.gov]
  • Severe attacks can be life‐threatening because of weakness of muscles involved in swallowing causing choking, and chest muscles causing difficulty with breathing. In MG, immunosuppressant drugs act mainly by reducing the production of antibodies.[web.archive.org]
  • Swallowing, speaking and breathing If the weakness affects the muscles in the mouth, throat and chest, it can cause: difficulty chewing slurred speech a husky, quiet or nasal-sounding voice difficulty swallowing choking and accidentally inhaling bits[nhs.uk]
  • The muscle weakness can lead to a variety of symptoms, including: Breathing difficulty because of weakness of the chest wall muscles Chewing or swallowing difficulty, causing frequent gagging, choking, or drooling Difficulty climbing stairs, lifting objects[web.archive.org]
  • Myasthenia gravis symptoms can include: Breathing difficulties Fatigue Problems chewing and swallowing (choking) Facial muscle weakness or paralysis such as eyelid drooping Difficulty talking Difficulty climbing stairs A drooping head A common trait of[wakehealth.edu]
Hypersalivation
  • Features suggestive of a cholinergic crisis (too much medication) include muscle fasciculation, pallor, sweating, hypersalivation and small pupils. If in doubt, perform an edrophonium test.[patient.info]
Ptosis
  • Abstract INTRODUCTION: Medical management can have limitations in improving ptosis in patients with myasthenia gravis (MG). We present our experience of ptosis surgery in MG.[ncbi.nlm.nih.gov]
  • KEYWORDS: Myasthenia gravis; adjustable ptosis; developing countries; open innovation; ptosis crutch[ncbi.nlm.nih.gov]
  • Except for unilateral moderate ptosis and restriction of extraocular movements, ocular and systemic examination was normal. Both ice pack and tensilon tests revealed improvement in ptosis.[ncbi.nlm.nih.gov]
  • The resulting sequence of daily selfies captured striking fluctuations in her ocular alignment and ptosis. Daily selfies may be a useful strategy for confirming the clinical diagnosis of ocular myasthenia gravis.[ncbi.nlm.nih.gov]
  • Patients with ocular myasthenia gravis can have disabling diplopia or functional blindness from ptosis and in most cases treatment is required.[ncbi.nlm.nih.gov]
Diplopia
  • Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia.[ncbi.nlm.nih.gov]
  • He experienced resolution of his diplopia and ptosis after one cycle of chemotherapy and achieved complete remission of the orbital masses and myasthenia symptoms after 6 cycles.[ncbi.nlm.nih.gov]
  • Risks of diplopia and exposure keratopathy should be discussed with the patient pre-operatively. KEYWORDS: External levator advancement; eyelid surgery; myasthenia gravis; ocular myasthenia; ptosis[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 65-year-old man with advanced squamous cell lung carcinoma developed ptosis, diplopia, drop head, and general weakness 5 days after a third Nivo infusion.[ncbi.nlm.nih.gov]
  • There was no diplopia and the rest of her neurological and systemic examination was unremarkable. An ice pack test was performed to aid the diagnosis of MG which was strongly positive.[doi.org]
Strabismus
  • [J Pediatr Ophthalmol Strabismus. 2018;55(5):339-342.]. Copyright 2018, SLACK Incorporated.[ncbi.nlm.nih.gov]
  • Children with myasthenia gravis require monitoring by a pediatric ophthalmologist for the development of amblyopia from ptosis or strabismus. Copyright 2017 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • By contrast, control EOM from a patient undergoing strabismus surgery for a sensory exotropia in a nonseeing eye and a similar duration of deviation, showed normal muscle histology.[ncbi.nlm.nih.gov]
  • Strabismus surgery in patients with myasthenia. J Pediatr Ophthalmol Strabismus. 1993 Sep-Oct. 30(5):292-5. [Medline]. Peragallo JH, Velez FG, Demer JL, Pineles SL.[emedicine.com]
  • The ptosis and strabismus related to myasthenia can at times be helped with surgery; Surgical intervention is sometimes advised if the ptosis and/or strabismus deviation has been stable for at least one year.[aapos.org]
Blepharoptosis
  • Blepharoptosis surgery: In some cases, medication or other therapies may not be effective for treating ptosis.[eyehealthweb.com]
  • Surgical correction of blepharoptosis in patients with myasthenia gravis. Ophthal Plast Reconstr Surg. 2001 Mar. 17(2):103-10. [Medline]. Bernardini FP, de Conciliis C, Devoto MH.[emedicine.com]
  • Effect of local heat versus ice on blepharoptosis resulting from ocular myasthenia. Ophathalmology 2000 ; 107: 2209 – 14. Google Scholar 9. Engstrom, JW. Myasthenia gravis: diagnostic mimics. Semin Neurol 2004 ; 24: 141 – 7. Google Scholar[doi.org]
Blurred Vision
  • Case report A 63-year-old male presented with right eyelid drooping, puffiness, blurred vision, and shortness of breath two weeks after an initial infusion of pembrolizumab.[ncbi.nlm.nih.gov]
  • Other common symptoms occurring out of fatiguability are slurred speech, diplopia or blurred vision, difficulty in chewing and dysphagia, weakness in arms and legs, chronic muscle fatigue, dyspnea, unstable gait, dysarthria i.e. difficulty in speaking[symptoma.com]
  • The disorder can affect any voluntary muscles, but specific muscle groups are frequently involved, including: Eye muscles - Effects include the drooping if one or both eyelids and double or blurred vision.[virginiamason.org]
Muscle Weakness
  • Muscle weakness can involve any voluntary muscle.[ncbi.nlm.nih.gov]
  • Typically, extraocular muscle weakness is asymmetric and can be noticed easily.[symptoma.com]
  • Factors that influenced the HRQOL in MG were skeletal muscle weakness and anxiety and depressive symptoms (p CONCLUSION: Anxiety and depressive symptoms, besides motor symptoms, influence HRQOL in MG.[ncbi.nlm.nih.gov]
  • Some patients develop generalized muscle weakness, which may become serious with respiratory muscle weakness.[orpha.net]
  • OUTCOMES: Dyspnea and muscle weakness improved gradually. Ipilimumab and nivolumab were permanently discontinued.[ncbi.nlm.nih.gov]
Myopathy
  • METHODS: We described four patients with both MG and inflammatory myopathy. RESULTS: These cases correspond to 2.3% of our MG cohort.[ncbi.nlm.nih.gov]
  • RESULTS: We describe a girl with MuSK-antibody positive myasthenia gravis who developed a myopathy with severe generalized muscular weakness, muscle atrophy, and myopathic changes on electromyography.[ncbi.nlm.nih.gov]
  • Hohlfeld R, Goebels N, Engel AG (1993) Cellular mechanisms in inflammatory myopathies. Baillieres Clin Neurol 2:617–635 PubMed 23. Jaretzki A, Steinglass KM, Sonett JR (2004) Thymectomy in the management of myasthenia gravis.[springermedizin.at]
  • Other myopathies - may show fasciculation and elevated creatine kinase (CK). Toxins and drugs - eg, botulinum, organophosphate poisoning. Acute Guillain-Barré syndrome - the motor type will have LMN features.[patient.info]
  • […] polyneuropathies have been reported in patients with concurrent MG. [35, 36] Various autoimmune channelopathies, autonomic neuropathy with and without encephalopathy concomitant with the MG and thymoma has also been reported. [37] MG and inflammatory myopathy[emedicine.medscape.com]
Proximal Muscle Weakness
  • CASE PRESENTATION: This report presents a case-vignette of a 72-year-old woman with progressive proximal muscle weakness and myalgias, diagnosed with thymoma-associated myasthenia and bioptically verified granulomatous myositis, with positive autoantibody[ncbi.nlm.nih.gov]
  • A 54-year-old gentleman presented with fluctuating ophthalmoplegia and proximal muscles weakness of 7 years duration that remitted with pyridostigmine and prednisolone.[ncbi.nlm.nih.gov]
  • Proximal muscle weakness is more often seen than distal muscle weakness. The anti-acetylcholine receptor antibody test is a very specific test which is done to diagnose myasthenia gravis.[symptoma.com]
  • The clinical features in LEMS include proximal muscle weakness and hyporeflexia with improvement of symptoms with repeated muscle stimulation. LEMS is caused by antibodies directed against presynaptic calcium channels.[eyewiki.aao.org]
  • Systemic myasthenia can manifest as dysphagia, dyspnea, dysphonia, and proximal muscle weakness (eg, difficulty climbing stairs or getting out of chairs).[emedicine.com]
Neck Weakness
  • weakness, a generally worse disease severity and a tendency to develop muscle atrophy.[ncbi.nlm.nih.gov]
Dysarthria
  • Patients of MG usually present with bilateral ptosis, diplopia and fatigability, which may or may not coexist with generalised weakness, dysphagia and dysarthria. A46-year male presented with unilateral ptosis and diplopia.[ncbi.nlm.nih.gov]
  • After 3 months, the patient complained of increasing physical exhaustion, reduction of his walking distance, worsening of the residual dysphagia, and dysarthria with an inability to swallow.[ncbi.nlm.nih.gov]
  • She denied shortness of breath, dysarthria, and fatigue. DIAGNOSES: She had been diagnosed with MG 6 years previously at the Neurology Department of our hospital.[ncbi.nlm.nih.gov]
  • Six years later, he had a mild relapse of his PRCA and subsequently developed severe dysphagia and dysarthria which were fatigable. Positive antiacetylcholine receptor antibodies confirmed the diagnosis of myasthenia gravis.[ncbi.nlm.nih.gov]
  • We report the case of a 22-year-old man who presented with diplopia on lateral gaze to both sides, facial diplegia, nasal dysarthria and dysphagia.[ncbi.nlm.nih.gov]
Chronic Progressive External Ophthalmoplegia
  • This includes: an intracranial lesion, tumor, pituitary adenoma, aneurysm, fascicular lesion of CN 3, evolving CN 3 palsy, post-viral neuropathy, thyroid disorders *, migraines, meningitis, Horner's syndrome, levator aponeurosis, chronic progressive external[eyewiki.aao.org]
  • Chronic progressive external ophthalmoplegia (CPEO) may manifest as ptosis and decreased eye movements.[emedicine.com]

Workup

The anti-acetylcholine receptor antibody test is a very specific test which is done to diagnose myasthenia gravis [7]. This is a very reliable test and is positive in almost 90% of the patients. Antistriated muscle antibody is another sensitive test to be diagnose myasthenia gravis. Muscle weakness should be tested for different parts of the body:

  • Looking upward and sideways for 30 seconds.
  • Walking 30 steps on both the toes or heels.
  • Keeping arms stretched for 60 seconds.

If any of the above tests is positive, i.e. there is fatigue at the end of the set time, it reveals that the patient is suffering from myasthenia gravis.

Single fiber electromyography might be performed [6] [8]. Repeated electrical impulses are given to the muscle fibers of the patient and electrodes are placed in to the muscle fiber to check for action potentials changes of the muscle fiber. This is a very specific test for myasthenia gravis and helps confirm the diagnosis.

Ice test: Application of ice will characteristically improve the weakness in the patients muscle and this is a very important non-invasive test to be performed. The basis of performing this test is that at lower temperatures acetylcholinesterase is inhibited, leaving more acetylcholine available at the junctions. Thus the patient can perform better as weakness is less [9].

Edrophonium test: Intravenous edrophonium bromide or tensilon will cause inhibition of breakdown of acetylcholine and thus improve weakness temporarily [10]. This test is usually performed only after all the other tests have failed to give an accurate result.

Radiography and CT scan or MRI will help confirm the diagnosis and show if a thymoma or any other tumor is leading to myasthenia gravis.

Anterior Mediastinal Mass
  • BACKGROUND: Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma.[ncbi.nlm.nih.gov]
Hypercapnia
  • Preliminary studies suggest that bilevel positive airway pressure (BiPAP) can prevent intubation in patients with myasthenic crisis without overt hypercapnia and should be considered in the patient who can be closely monitored. [9, 14] Hypercapnia present[emedicine.medscape.com]
Thymus Hyperplasia
  • Jing Yang, Chanchan Liu, Tao Li and Chengyan Li, Prognosis of thymectomy in myasthenia gravis patients with thymus hyperplasia, International Journal of Neuroscience, 127, 9, (785), (2017).[doi.org]
HLA-DR3
  • The early peak shows a female predominance, approximately 3:1, and an association with HLA-B8, HLA-DR3, and HLA-DR1, the latter being more specific for ocular MG.[eyewiki.aao.org]
  • Ocular myasthenia gravis induced by human acetylcholine receptor ϵ subunit immunization in HLA DR3 transgenic mice. Immunol Lett. 2015 Oct 19. [Medline]. Pevzner A, Schoser B, Peters K, Cosma NC, Karakatsani A, Schalke B, et al.[emedicine.com]
  • […] associated with the likelihood of encouraging other women with myasthenia gravis to abstain from having children. [5] Etiology Genetic studies have revealed a correlation between early-onset myasthenia gravis, which affects women of childbearing age, and the HLA-DR3[emedicine.com]
HLA-B8
  • This suggests an association of MG with HLA B8 and DR3. In terms of underlying genetic abnormalities, work is ongoing [ 8 ]. Presentation Almost all MG patients will have ocular manifestations at some point during the course of their disease.[patient.info]
  • The early peak shows a female predominance, approximately 3:1, and an association with HLA-B8, HLA-DR3, and HLA-DR1, the latter being more specific for ocular MG.[eyewiki.aao.org]

Treatment

Pharmacology includes medication and immunosuppressive agents like corticosteroids, cyclosporine, plasmapheresis and intravenous immunoglobulin. Thymectomy is another option for people who have thymoma.

Acetylcholineesterase inhibitors and immunomodulations are the most important modalities of treating patients with myasthenia gravis. They mostly prevent the acetylcholine from degrading and the weakness of the muscles thus reduces. This remains the initial line of treatment followed by corticosteroids as per need. Long term corticosteroids should be avoided as they may lead to further complications like osteoporosis, weight gain, diabetes etc.

Plasmapheresis is a procedure where the plasma is exchanged with fresh plasma which helps in removing out the circulating antibodies from the body. The new plasma contains lesser acetylcholine antibodies, reducing muscle weakness and fatiguability. This is short term relief for the patient especially if they undergo surgery. Exercise helps in a better prognosis.

Prognosis

The prognosis is good today as science has advanced a lot. Patients earlier had 3 to 4 % morbidity but now it has reduced further. Long term use of medications will give these patients a near normal life with very minimal complications. The only threat for these patients is the weakness affecting their respiratory muscles. This might lead to a need for supportive respiration i.e. ventilator support.

Etiology

Myasthenia gravis is an autoimmune disorder. It is the result of antibodies against the acetylcholinesterase receptors present at neuromuscular junctions which are responsible for muscular movements. These circulating antibodies cause weakness of the body by blocking acetylcholine receptors at the neuromuscular junctions.

Thymus gland abnormality is seen in 75% of the patients with myasthenia gavis. Very few patients may have a thymus tumor called as thymoma.

Certain drugs may induce myasthenia gravis e.g. Penicillamine, Antibiotics, lithium, Beta-adrenergic receptor blocking agents.

Epidemiology

Myasthenia gravis affects people of both the sexes but is more commonly seen in women of the age group 20 to 40 years. It also affects people who have thymus gland abnormalities. More commonly, it is seen in people who have other autoimmune disorders. The female to male ratio is 3:2 whereas in children the ratio is typically 5:1.

Sex distribution
Age distribution

Pathophysiology

Voluntary muscles of the body move by the excitatory impulses sent by nerves to the muscle through the neuromuscular junctions. In myasthenia gravis, the circulating antibodies block the receptors for acetylcholine at the neuromuscular junction leading to failure of transmission of efferent impulses to the muscle.

The acetylcholine receptor present in the motor end plate is called nicotinic acetylcholine receptor. Myasthenia gravis usually causes blocking or destruction of this receptor sites placed all over the body leading to weakness of varying degrees in voluntary muscles [2]. In a healthy person, the nerve carries impulses from the brain and passes on to the muscles through the neuromuscular junction where the neurotransmitter acetylcholine is released. This neurotransmitter then causes excitation of the receptor sites present on the muscular end of the junction.

In a myasthenia gravis patient, the nicotinic receptor sites are destroyed much faster than the body can repair and there is around 80% reduction in the receptor sites [3]. Even though acetylcholine is present, there aren’t enough receptor sites to bring about purposeful muscle movements.

Prevention

Myasthenia gravis might be prevented by avoiding ingestion of certain drugs which may cause this disease. However, it is essentially an autoimmune disorder and there is no exact way of preventing it.

Summary

Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junctions between nerves and muscles affecting voluntary movements. It causes muscle weakness in varying proportions depending on the degree of affection.

It is also known as Goldflam disease and affects the voluntary group of muscles [1]. The term “Myasthenia gravis” literally originates from the Greek and Latin words which mean “grave muscular weakness.”

Patient Information

Myasthenia gravis is an autoimmune disorder which affects the neuromuscular junction (the junction where the nerve synapses meet the muscle fiber and transmits the impulse carried from the brain to the muscle). There are circulating antibodies that block the receptors for the neurotransmitter acetylcholine which are present at the junction and thereby do not allow the voluntary muscle to contract and produce movement.

This is a chronic disorder and gradually many of the receptor sites are destroyed leading to fatigability. There is drooping of eyelids on repeated eye strain, difficulty in swallowing or chewing, slurred or impaired speech, weakness of hands, fingers, legs. There may be weakness of head and difficulty in holding the head up straight. The weakness is least in the morning and keeps on increasing as the day progresses and the most important aspect of this weakness is that there is amelioration of weakness on rest.

This disease also affects children and neonates if the mother has the disease at the time of conception. Ice test, tensilon test and electromyography are the basic tests done for investigating this disease. Prognosis is good and patients are kept on long term acetylcholinesterase inhibitors, intravenous immunoglobulin and plasmapheresis.

References

Article

  1. ContiFine B, Milani M, Kaminski H et al. Myasthenia Gravis: past, present and future. J Clin Invest. 2006 Nov 1; 116(11):2843-54.
  2. Mc Grogan, Sneddon S, de Vries CS. The incidence of myasthenia gravis: a systematic literature review. Neuroepidemiology. 2010;34(3):171-83.
  3. Bedlack RS, Sanders DB. How to handle myasthenia crisis. Essential steps in patient care. Postgrad Med. 2004 Apr;107(4):211-4,220-2.
  4. Patrick J, Lindstrom J. Autoimmune response to acetylcholine receptor. Science. 1973 May 25;180(4088):871-2.
  5. Téllez-Zenteno JF, Hernández-Ronquillo L, Salinas V, Estanol B, et al. Myasthenia gravis and pregnancy: clinical implications and neonatal outcome. BMC Musculoskelet Disord. 2004 Nov 16;5:42.
  6. Selvan VA. Single-fiber EMG: A review. Ann Indian Acad Neurol.2011 Jan; 14(1): 64–67.
  7. Losen M, Stassen MH, Martínez-Martínez P, Machiels BM et al. Increased expression of rapsyn in muscles prevents acetylcholine receptor loss in experimental autoimmune myasthenia gravis. Brain. 2005 Oct; 128 (Pt 10): 2327–37.
  8. Juel VC. Myasthenia gravis: management of myasthenic crisis and perioperative care. Semin Neurol. 2004 Mar; 24 (1): 75–81.
  9. Cup EH, Pieterse AJ, Ten Broek-Pastoor JM, Munneke M, et al. Exercise therapy and other types of physical therapy for patients with neuromuscular diseases: a systematic review. Arch Phys Med Rehabil. 2007 Nov; 88 (11): 1452-64.
  10. Seybold ME. The office Tensilon test for ocular myasthenia gravis. Arch Neurol. 1986 Aug; 43 (8): 842–3.

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Last updated: 2018-06-22 06:48