How is bulbar als diagnosed?

Dear doctor

I am a female in my mid 40's who has had a major als scare for the last 7 months.

My symptoms started with stiff arms, legs and fingers, and twitching in calves and feet.

I have seen a neuro and had an emg and ncs. both exams were normal and the neuro found nothing abnormal in the clinical exam.

However, I have speech issues which make me concerned that I may have bulbar onset als. I don't think I am slurring my words and I am not hoarse or lacking in volume, its just that often it feels difficult getting the words out, like I have to make a lot of effort to make them sound right. No-one else has noticed anything.

The neuro didn't do an emg of my tongue or jaw, just my limbs

Would you be so kind as to answer the following:

1. If twitching started (seven months ago) in the limbs, would it show on an emg as abnormal

2. Is it unlikely that bulbar onset begins with twitching limbs (I realise it would spread to limbs eventually, but can it start in limbs?)

3. How long would it normally take before slight speech problems make themselves obvious in bulbar als?

4. If one thought one had speech problems, but tongue strength was excellent (very strong, neuro was completely unconcerned), is it possible that stress may be the cause?

5. would a clean emg give doubt to even bulbar onset? If not, what other signs and symptoms would have to be present for a diagnosis?

and lastly, if it were my worst fears, would 7 months with no progression to speak of be considered slow onset?

Thank you for your help and apologies for length of post

[CCF-Neuro-M.D.-PW]

1) most likely yes if done adequately
   Twitching in the absence of muscle wekaness or wasting is unlikely to be ALS.

2) unlikely
   Tiwtching is more widespread from onset in benign cases

3) The course is usuallly fiarly rapid, so within a few weeks to months, the clinical picture

4) its possible, but there may be other causes such as drug or toxic side effects, etc

5) EMG is hard to do in teh bulbar region, hence the diagnosis is based more on the clinical history and exam. An experienced neurologist shoudl be able to discus the risks with you.

Good luck