exam 3 question

[Katelynn Mcfall]

Hi – I have a question about rationale for the answer to this question from exam 3.

A 30-year-old female complains of intermittent muscle weakness. She reports that she fatigues easily with all activities and is unable to participate in recreational activities like she used to. Muscle testing at the beginning of the evaluation reveals 4-5/5 grossly in bilateral lower extremities. The patient reported return of weakness at the end of session following balance and functional testing. Muscle strength was re-tested and noted to be grossly 3-/5 to 4-/5 bilaterally. What condition might she have?
a. Myasthenia gravis
b. Guillain-Barre syndrome
c. Multiple sclerosis
d. Malingering

The answer was A. myasthenia gravis – but I also feel like the answer could be C. multiple sclerosis. I understand the rationale behind myasthenia gravis being correct, but I also just finished a course about fatiguability in the MS population. One of the points they emphasized was re-testing MMT/outcome measures at the end of a session since fatiguability may reduce MMT and outcome measure scores (especially in our younger, less severe MS patients where initial strength, balance, outcomes testing may look great while they are fresh but can decline significantly with fatigue). I believe the case study they talked about in this course was a 30-year-old female runner with MS who presented to outpatient with chief complaint of fatigue and frequent tripping at the end of her daily 2 miles runs. Would love to know your thoughts on this. Thanks!

[Chrissy Durrough Lugge]

Hi Katelynn,

I did a quick literature search and wasn’t able to find the case study you’re referring to. Please send it along if you can find it. My suspicion is that the 30-year-old runner with MS experienced more weakness and poorer scores at the end of exercise sessions where she was engaging in moderate-high intensity exercise.

The patient in this case participated in only balance and functional testing, which I doubt would be enough to cause such a dramatic drop in a person with MS’s MMT scores unless they were in an active relapse.

The extreme fluctuations in fatigue and weakness within a short period of time are the hallmark of myasthenia gravis.

[Katelynn Mcfall]

Thank you for your response! The course was on Medbridge titled “Advanced Physical Therapy Management of Multiple Sclerosis” – and the case study was presented in Chapter 2. “Mild MS Diability”. Looking back through this, it does say that she had relapsing-remitting MS and was in week 2 of a relapse period.

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