Zarif A. Ladak, BS
Second Year Medical Student
Rowan-Virtua SOM
Voorhees Township, New Jersey, United States
Milan Patel, BS
Medical Student
Touro College of Osteopathic Medicine-Middletown
Newburgh, New York, United States
Anish Myneni, BS
Medical Student
Kansas City University
Johns Creek, Georgia, United States
Melissa Schwartz, MD
Resident
Johns Hopkins Hospital Department of Physical Medicine and Rehabilitation
BALTIMORE, Maryland, United States
R. Samuel S. Mayer, MD, MEHP
Professor, Dept of PM&R
Johns Hopkins U SOM
Baltimore, Maryland, United States
A 72-year-old woman with known bulbar MG developed an exacerbation of dysphonia, dysarthria, and swallowing difficulties following a midline prone cervical laminectomy with fusion and instrumentation for a C3-C6 spinal stenosis. Anesthesia and surgical stress were suspected triggers for the myasthenic crisis. Initial treatment included intravenous immunoglobulin (IVIG) therapy alongside speech and physical therapy. The patient was placed in Acute Comprehensive Inpatient Rehabilitation(ACIR), but made limited progress and was then discharged to a subacute rehabilitation(SAR).
Discussions:
Balancing rehabilitation with potential fatigue is imperative in MG management. While occupational, physical, and speech therapy are beneficial and can lead to increased muscle strength, intensive ACIR programs that involve three hours of therapy five times a week can worsen fatigue significantly in cases of severe MG. Patients with mild-moderate MG typically tolerate and benefit from intensive therapy, while severe cases might require SAR, outpatient therapy, or home programs that have lower requirements for therapy time. This case emphasizes the importance of individualizing rehabilitation intensity based on disease severity. Initially, concerns arose regarding the patient's suitability for ACIR due to symptom severity. However, her strong motivation led to a trial in ACIR with close therapy tolerance monitoring. The patient made minimal improvements in the ACIR and was later transferred to a SAR for a program more suited for her therapy tolerance.
Conclusions:
MG rehabilitation demands a personalized approach that considers patient motivation and therapy tolerance. Early identification of myasthenic crisis and appropriate rehabilitation intensity are crucial for successful recovery. Closely monitoring patients' exercise ability is imperative to achieve optimal rehabilitation outcomes.
