Annie,

You may think it's ridiculous, and so may I , but according to the paper I cited, which was published in a reasonably good journal, true fatigable weakness doesn't fit MG.

I may have not made it clear, but according to my understanding, this is the major conclussion of this paper.

unless I have developed some severe cognitive dysfunction and can't understand what I read. I read it twice, and marked all the pertinent parts, because I couldn't believe that I have understood it correctly.

it's like I would write a paper saying that patients with leukemia have normal blood counts, and if their blood counts are not normal, it has nothing to do with their illness. My proof for that would be, that I have checked the blood counts of 20 patients after treatment with chemo, and even those that still had some blasts in their bone marrow had completely normal blood counts. some recieved blood transfussions before, but this was unimportant. So, although leukemia is considered to be a disease in which there is supression of the bone marrow, and decrease in blood counts, this does not seem to be the case. further studies are needed to understand this discrepancy.

I am sure that had I sent this paper to a reasonable journal, I would be declared a lunatic. But, this paper was accepted for publication!

this is the abstract-

"Myasthenia gravis (MG) is characterized by fatigue and fluctuating muscle weakness resulting from impaired neuromuscular transmission (NMT). The objective of this study was to quantify, by direct measurement of muscle force, the strength and fatigue of patients with MG. A maximal voluntary isometric contraction protocol of shoulder abductors was used in conjunction with conventional fatigue and disease-severity instruments. Results from patients with (D-MG) and without (ND-MG) decrement on repetitive nerve stimulation (RNS) of the spinal accessory and axillary nerves were compared with healthy controls. Patients with MG reported greater fatigue than controls. Muscle strength was lowest in the D-MG group, followed by the ND-MG group and controls. Normalized shoulder abduction fatigue and recovery values did not differ between the D-MG and ND-MG groups or controls. The RNS decrement appears to relate best to disease severity and muscle weakness but not to objective measures of fatigue in this population. Muscle Nerve, 2009"

and thse are a few citations from the paper itself-

In summary, subjective appraisal of the degree of fatigue experienced between ND-MG and D-MG groups was similar, with both patient groups describing greater fatigue than controls

In summary, clinical evaluation of both patient groups indicated that the D-MG group had greater disease severity, but similar baseline upper extermity strength, when compared with the ND-MG group.

The major findings of this study are that, despite higher levels of experienced fatigue in patients with MG, objective measurements of muscle fatigue and recovery using a force dynamometer did not differ between patients and controls. However, the baseline MVIC strength did differ between groups. The D-MG group produced the lowest MVIC force, followed by the ND-MG group and controls, respectively.

It was also of considerable interest to note that an experienced clinician detected weakness in the deltoid muscle in 9 of the 12 patients in the D-MG group. The same clinician detected fatigable deltoid weakness on MMT in all patients in the D-MG group, but also in over half of those in the ND-MG group, among whom there was no weakness present at baseline.

In keeping with previous studies that showed a higher rate of experienced fatigue in patients with neuromuscular diseases, some patients may have central weakness as a result of lack of effort, and this is sometimes difficult to differentiate from true fatigable weakness.

The apparent discrepancy between experienced fatigue and measured muscle fatigue also needs to be resolved. The contributions of this investigation to the understanding of weakness and fatigue in patients with MG who present with varying RNS results have provided a foundation for future studies.


so now this experienced clinician knows that even in patients which he thinks have true weakness, it may not be "real". and due to central weaness as a result of lack of effort, which is difficult to differentiate from "true" fatigable weakness.

the opposite (that he may be interperting true weakness and fatigability as due to central weakness, because of this difficulty) does not seem to bother him, nor any of the other authors of this paper.

nor did it bother the world leading expert that sent me home with rapidly declining respiratory muscle tests, that were not "real" as this was due to central weakness as a result of lack of effort.

So, if two world leading experts reach the same conclusions independently, we only need a third one to verify it beyond doubt, and I am sure that person will soon be found.

alice