Myasthenia Gravis C&P Exam Prep

Manual Muscle Testing (MMT) - Upper Extremities

What it measures: Strength of elbow flexors/extensors, wrist flexors/extensors, grip, and pinch strength bilaterally using the Medical Research Council (MRC) 0-5 scale

What to expect: The examiner will ask you to resist force applied to your arm, wrist, and hand in various positions. Testing will be done on both sides. For Myasthenia Gravis, fatigability on repetitive testing is as important as initial strength - ask the examiner to retest after sustained effort if your strength declines.

Pain considerations: Myasthenia Gravis does not typically cause pain; however, document any associated myalgias, joint pain from compensatory postures, or neck pain from ptosis-related head positioning

Manual Muscle Testing (MMT) - Lower Extremities

What it measures: Strength of knee extensors, ankle dorsiflexors and plantar flexors bilaterally; deep tendon reflexes at knee and ankle

What to expect: The examiner will test leg strength with you seated or supine. Reflex testing uses a reflex hammer. In MG, lower extremity weakness is less common than upper but can be significant - document any difficulty climbing stairs, rising from chairs, or walking distances.

Pain considerations: Document any hip or knee pain resulting from compensatory gait changes due to neuromuscular weakness

Pulmonary Function Testing (PFT) - FVC and FEV1

What it measures: Forced Vital Capacity (FVC) and Forced Expiratory Volume in 1 second (FEV1) as markers of neuromuscular respiratory compromise - critical in Myasthenia Gravis due to risk of respiratory failure

What to expect: You will breathe forcefully into a spirometer. The examiner may have recent PFT results from your treating neurologist. If not, advocate for formal testing, particularly if you have any dyspnea, orthopnea, or history of myasthenic crisis.

Pain considerations: Respiratory muscle fatigue may present as chest tightness or a sensation of heavy breathing - describe this accurately if present

Gait and Station Assessment

What it measures: Ability to walk normally, stability, coordination, and need for assistive devices

What to expect: The examiner will observe you walking, possibly on heels and toes, and assess station (standing balance). Note whether ptosis, diplopia, or vestibular effects from MG impact balance.

Pain considerations: Describe any musculoskeletal pain that further limits ambulation, especially if secondary to MG-related weakness and compensatory postures

Speech and Bulbar Function Assessment

What it measures: Presence of dysarthria (slurred speech), dysphonia (hoarseness), aphonia (no voice), and dysphagia (swallowing difficulty) reflecting bulbar muscle involvement in MG

What to expect: The examiner will listen to your speech and may ask you to swallow or describe swallowing difficulties. In MG, speech may worsen with sustained talking - a key fatigability marker.

Pain considerations: Throat discomfort or pain with swallowing should be reported accurately

30%

Minimum rating assigned when Myasthenia Gravis is confirmed with ascertainable residuals under 38 CFR 4.124a DC 8025. This is the floor - subjective residuals including fatigability, weakness, and ptosis are accepted as consistent with the diagnosis per 38 CFR 4.124a Note. A rating in excess of 30% requires citation of additional diagnostic codes reflecting specific disabling manifestations.

From 38 CFR: 38 CFR 4.124a DC 8025: Minimum rating 30. Subjective residuals (fatigability, dizziness, headaches) are accepted when consistent with MG and not more likely attributable to other disease.

60%

Ratings above 30% for MG require citation of additional diagnostic codes under 38 CFR 4.124a for specific manifested residuals. A 60% level may be supported by rating MG at 30% combined with additional codes for significant dysphagia (e.g., DC 7203), respiratory impairment, or limb weakness. Significant functional limitation with moderate-severe residuals supports this combined level.

From 38 CFR: Per 38 CFR 4.124a Note: When ratings in excess of minimum are assigned, diagnostic codes utilized as bases of evaluation must be cited in addition to the codes identifying the diagnoses. Combine MG (DC 8025 at 30%) with codes for dysphagia, respiratory impairment, limb paralysis, or other objectively documented manifestations.

100%

A 100% combined or analogous rating for MG is supported by severe generalized weakness, respiratory failure requiring ventilatory support, inability to communicate by speech, documented myasthenic crises requiring hospitalization, severe dysphagia requiring tube feeding, or total occupational and social impairment. Each disabling manifestation must be separately coded and rated, with all codes cited.

From 38 CFR: 38 CFR 4.124a: Acute phase febrile neurological disease = 100%. For chronic MG, 100% is reached through combination of MG minimum (30%) plus additional coded residuals (respiratory failure, paralysis, dysphagia, speech impairment). VA must consider SMC under 38 U.S.C. 1114 for loss of use of extremities or need for aid and attendance.

Muscle Fatigability and Weakness

How to describe it: Describe how your strength declines specifically with repeated or sustained activity - not just constant weakness. Explain the pattern: 'I can lift my arm the first few times, but after 4-5 repetitions I cannot raise it above my shoulder.' Quantify activities: how many stairs before weakness stops you, how long you can hold a fork, how many words you can speak before your voice fades.

Example: On my worst days, I cannot lift my arms above my head to wash my hair, I drop objects because my grip gives out without warning, I cannot climb a single flight of stairs without resting, and even sitting upright becomes exhausting by mid-afternoon. My neck muscles are so weak that I have to support my head with my hand.

Examiner listens for: Fluctuating weakness with a clear fatigability component, worsening later in the day or with exertion, improvement after rest - the classic MG pattern. The examiner should note this is distinct from fixed weakness seen in other neuromuscular diseases.

Avoid: Do not say 'I'm just a little tired' or 'I manage okay.' Instead say: 'My muscles physically give out with use - this is not ordinary tiredness. I have to plan every activity around my energy because once my muscles fatigue, they do not recover quickly.'

Ptosis and Ocular Symptoms

How to describe it: Describe whether one or both eyelids droop, when it occurs (morning vs. afternoon, after sustained gaze), whether it obstructs your vision, and whether you experience double vision (diplopia) and how it affects your ability to read, drive, or navigate safely.

Example: On my worst days, my left eyelid droops so severely that it covers my pupil and I cannot see out of that eye. I have double vision that makes it impossible to drive or safely navigate stairs. I have to physically hold my eyelid up to function.

Examiner listens for: Ptosis that worsens with sustained upgaze (positive fatigability test), diplopia from extraocular muscle weakness, need to tilt the head to compensate, and functional vision impairment from ocular MG.

Avoid: Do not minimize ocular symptoms as 'my eye droops sometimes.' Explain the functional consequences - inability to drive, read for more than a few minutes, or the safety risk of vision loss at unpredictable times.

Dysphagia and Bulbar Symptoms

How to describe it: Describe difficulty chewing or swallowing, especially with sustained chewing (jaw fatigue during meals), nasal regurgitation of liquids, choking episodes, and any dietary modifications you have made (soft foods, thickened liquids, cutting meals short due to jaw fatigue).

Example: On my worst days, I cannot finish a meal because my jaw muscles give out after a few bites. I have choked on thin liquids and had liquid come out of my nose. I have had episodes where food stuck and I could not swallow - I now eat only soft foods and cannot eat in public because I am afraid of choking.

Examiner listens for: Jaw fatigability with meals, nasal regurgitation (palatal weakness), documented aspiration episodes, dietary modifications made for safety, weight loss secondary to dysphagia, and need for daily medications to manage swallowing.

Avoid: Do not say 'swallowing is a little hard sometimes.' Specify: 'I have modified my diet out of necessity, I have choked on [specific foods/liquids], and I have had aspiration episodes documented by my doctor.'

Speech and Voice Impairment

How to describe it: Describe how your voice changes with sustained speaking - becoming hoarse, nasal, or inaudible. Quantify: how many sentences or minutes before your voice gives out, whether people ask you to repeat yourself, whether you avoid speaking situations due to dysarthria.

Example: On my worst days, I lose my voice entirely after speaking for two or three sentences. My speech becomes so slurred and nasal that my family cannot understand me on the phone. I have stopped making phone calls and attending social gatherings because I cannot communicate reliably.

Examiner listens for: Progressive dysarthria or dysphonia with sustained speech, nasal quality from palatal weakness, aphonia, and functional communication limitations in work and social settings.

Avoid: Do not minimize as 'my voice gets tired.' Describe the functional impact: 'I am unable to hold conversations of normal length, I cannot use the telephone effectively, and my impaired speech has affected my ability to work.'

Respiratory Symptoms

How to describe it: Describe any shortness of breath, difficulty breathing when lying flat (orthopnea), difficulty taking a deep breath, or anxiety about breathing - particularly any history of myasthenic crisis with respiratory failure. Note any BiPAP, CPAP, or supplemental oxygen use.

Example: On my worst days, I cannot lie flat in bed because I feel like I am suffocating - I sleep in a recliner. I become severely short of breath walking from my bedroom to the bathroom. I was hospitalized [number] times and placed on a ventilator because my breathing stopped due to MG.

Examiner listens for: Orthopnea as a marker of diaphragmatic weakness, exertional dyspnea disproportionate to cardiac cause, history of myasthenic crisis, documented respiratory failure, need for ventilatory support, and reduced PFT values.

Avoid: Do not omit hospitalization history or intubation events - these are the strongest evidence of severity. Saying 'I get winded sometimes' understates the life-threatening nature of MG respiratory involvement.

Functional Impact on Daily Activities and Employment

How to describe it: Describe specific activities you can no longer perform or can only partially perform: cooking, driving, personal hygiene, dressing, grocery shopping, childcare, employment. Use concrete time and quantity examples. Explain how MG has changed your occupational capacity.

Example: On my worst days, I cannot shower standing up - I use a shower chair. I cannot prepare a meal because holding my arms up to cook causes immediate exhaustion. I cannot work my previous job as [occupation] because I cannot sustain the required physical or vocal demands. I had to leave work entirely/reduce hours because of MG.

Examiner listens for: Loss of gainful employment, inability to perform sedentary work due to fatigue and weakness, dependence on others for ADLs, and social isolation due to physical and communication limitations.

Avoid: Do not say 'I get by.' Specify: 'I rely on my spouse/caregiver for [specific tasks] because my MG prevents me from doing them safely or at all.'

Exacerbations, Crises, and Hospitalizations

How to describe it: Provide specific dates, triggers, hospital names, and outcomes for any myasthenic crises or significant exacerbations. Describe what triggered them (infection, medication change, stress, heat), how they were treated (IVIG, plasmapheresis, intubation), and how long recovery took.

Example: I have been hospitalized [number] times for myasthenic crisis. My most recent hospitalization in [month/year] required intubation and mechanical ventilation for [number] days. Recovery took [number] weeks before I returned to my baseline, which itself is significantly impaired.

Examiner listens for: Frequency and severity of crises, need for IVIG or plasmapheresis, ICU admissions, intubation history, and the trajectory of the disease - whether it is stable, improving, or progressive.

Avoid: Do not omit any hospitalization, ER visit, or crisis - even if it was years ago. All documented crises establish the severity and volatility of your condition.