Repeating Emg

Doctors.  I recently read a post in your forum which stated a concern regarding bublar onset als.  The answer from the doctor stated that this form of onset is sometimes difficult to detect and that time is needed to see if indeed this is als.  I know that you all have no criteria or no time or guarantees however at what point do you believe that bulbar onset als would show denervation in other areas of the body?  For example, if your twitching in the legs,  wouldn't this be devervation if ALS. Or can twitching be taking place while only denervation is not picked up by emg because it's to early in the disease to see the fibbrillations, etc.  As I understand it ,  doesn't twitching come after denervation begins.  ???????


Could you answer these questions if you could/


1.  How long after bublar onset als would emg show up.  In limbs, throat area's etc.  What would be the longest time in interval months that you would think that we all could feel safe in assuming that the chances are that our twitching is not als.  If there a time frame in which nuero's go by?  For instance ,  a year, six months etc.  I know cases are different in all people however,  I would like an opinion on what you all believe would be the longest period of time that bublar onset could be taking place before denervations presents itself in other limbs?  Thanks for you anticipated answer and I am sorry if I sound full of anxiety, but I am stressed and am doeing the best I can to deal with this fear.

[CCF Neuro[P] MD, RPS]

Dear John:

If you had bulbar signs with ALS, then the EMG would be positive for the muscles involved in swallow,chewing, etc.  It would show normal sensory conduction, abnormal motor conduction, with muscle signs of fibrillations and fasciculations.  However, to meet the criteria of EMG diagnosis, one needs three different areas to be positive.  However, if the EMG were positive and the clinical exam fits the diagnosis would be ALS and your neurologist would have given you the diagnosis of ALS.  We find that with bulbar type ALS, the parasaggitals are usually also involved.  It would very, very unlikely that you would have only selective bulbar signs, without EMG findings and have ALS.  In fact, you would probably be the first.  

Unless there is EMG evidence, fasciculations are not diagnostic for any disease that we know the etiology of.  Benign fasciculations occur without EMG changes or muscle weakness.  They go away on their own (most of the time) and do not increase your chances of coming down with ALS.  

If you truely have ALS with bulbar onset, the average lifespan is less than 1 year.  So the onset of other signs on EMG would be quick.  But, frankly, there would be other EMG changes in other muscle groups.  People would notice the drooling, difficulty with chewing and swallowing and would have changed their diet to soft so they could chew.  There would be episodes of choking-like occurances due to poor swallowing etc.  The neurologist usually would have a feel for ALS upon the clincal examination.

I hope I answered your question.  

Sincerely,

CCF Neuro MD

[Dennis]

John,

I think what the doctor meant about difficulties making the dx of ALS was that there are certain criteria (El Escorial) for making a dx of ALS; namely upper and lower motor neuron involvement in three spinal areas. So at onset if a patient had only bulbar symptoms and the other areas of their body were not yet affected, the dx of definite ALS cannot be given. Especially when other diseases like Kennedy's can present this way.

There are less strict criteria for making a diagnosis of possible or probable ALS. For example if you only have UMN and LMN signs in one area or UMN signs in two areas the diagnosis of possible ALS can be made.

However I am sure no doctor likes to give a dx of ALS for a patient unless there is absolutely no other possible cause.

I have a small question that is related to Johns, so I hope that it won't be violating the rule about secondary questions. Since the EMG is the standard tool for diagnosing or ruling out MND, what is considered a thorough EMG, in terms of numbers of muscles(or root levels) studied and number of insertions or MUP's per muscle.

Thanks so much.

[Joh Akt]

Thanks Doctors.  One more clarification if you would be so kind.  Does this mean that twitching in legs if als would of been picked up on on emg. And since my emg was normal on limbs that even though the bublar area was not tested that I don't have als in limbs that are twitching since emg was normal?   Thanks for your answers and I do appreciate this forum.  I was just wondering if bulbar onset, with twitching in limbs, would show denervation or atleast abnormal emg in limbs twitching if als.  Thanks



john

[Mark Anthony... is that you?]

It sure sounds like you. I thought you'd gotten control of yourself?

[concerned reader]

Mark,

You already had these questions answered by ccf under about 4 other names, why keep asking the same thing over?  If you need that much reassurance, please check the archives and re-read your answers so other people can ask theirs.

[kaytee]

I agree, its very unfair. Only so many questions a day are allowed and it pains me to think there are people looking for answers to non-twitch related subjects. As a mother I keep imagining somebody with a neurologically sick child trying to post!

[Mark Anthony]

This post was not me!  I agree with Kay's opinion that repeated
questions and answers should be avoided!!!! Archives are a great source of information people.

[CCF Neuro[P] MD, RPS]

Dear Dennis:

You are correct in that I am not suppose to answer your posting.  Actually, upper motor neuron disease is usually only inferred from the EMG as only muscle spasticity is present.  However, the astute EMGer would pick up a strictly UMN.  For the EMG diagnosis of ALS, three different muscle groups need to be affected with muscle dying.  Kennedy's disease would be infered from the clinical exam and not be a problem with an EMG diagnosis.  Also, the triplet repeat would be found.  

Each lab sets their own number of muscles tested for a routine exam.  So, the number various between labs.  We have a baseline routine exam of number of muscles tested depending on the disease expected.  For an ALS workup we do about 10 different groups and more if needed.  The number of insertions per muscle varies according to the EMGer.  At least 2-3 are necessary to define irritability of the muscle.

I hope this helps.

CCF Neuro MD

[CCF Neuro[P] MD, RPS]

Dear John:

If the EMG is normal then the twitching or fasciculation you see or feel is not pathological.  Therefore, it cannot be ALS.

CCF Neuro MD

[CCF Neuro[P] MD, RPS]

As you know, we are only answering a few questions a day.  Since some people ask their questions over and over, that means that less people get to ask their questions.  It is very selfish to reask questions that we have given answers to already.  If you need your questions answered again and again, please use another forum.

CCF Neuro MD

[CCF Neuro[P] MD, RPS]

Touche

CCF Neuro MD

[Dennis]

Dear RPS,

Thanks for taking the time to answer my question. I would appreciate one small clarification if you have time. Regarding number of insertions wher you stated: "At least 2-3 are necessary to define irritability of the muscle." Do you define a single insertion as the actual needle insertion through the skin irregardless of the number of directions tested after insertion? Or does testing in multiple directions in the muscle after insertion through the skin count as multiple insertions.

The reason I ask is it seems like thorough EMG's are hard to come by, even at places like MDA clinics.

Thank you for your time and expertise.

Dennis

[CCF Neuro[P] MD, RPS]

Dear Dennis:

Insertions can be either complete new insertions or just movement of the needle in a new direction.  Yes, many places the EMG is not done thoroughly.  It is often due to Rehab people doing the EMG or people who are not trained in EMG.

I hope I have helped you.

Sincerely,

CCF Neuro MD

[Wayne]

Dear CCF MD:



I've had it. I've "twitched" in most of my limbs for MONTHS following spine surgery (herniated disc). I can't take it anymore. Two neurologists in New York have dismissed my symptoms but I remain anxious about ALS, uncomfortable from the twitching, unable to resume my old exercise routine, and seriously depressed. I'd gladly come to Cleveland to see someone but I need to know who, where, and to know that I can come there and get this all behind me. I'm convinced I could handle almost any diagnosis but i can't stand the pain in my leg and foot, twitching, and anxiety. What to do? Please respond...

[CCF Neuro[P] MD, RPS]

Dear Wayne:

You can call 1-800-CCF-Care to make an appointment.  I would see one of our muscle experts, such as Dr. Levin, or Shields.

CCF Neuro MD

[Dennis - Thanks RPS. You are great]

Dear RPS,

Thanks for your reply. I really appreciate your taking the time to answer my questions.

Kindest regards,

Dennis

[CCF Neuro[P] MD, RPS]

Your welcome.

CCF Neuro MD