Several Questions..

[sunnygal]

I have a few questions regarding ALS.  I have had 3 EMG's since March of 2002.  1st:  right arm, 2nd:right leg, 3rd:left arm and left leg.  All was normal, EXCEPT for my 3rd EMG, 10/02, which was done on L deltoid, biceps, pronator teres, ext dig comm, ext ind proplus, first dorsal inter, and abd poll brevis.  The motor recruitment was all normal, however in the denervation column, one muscle group, abd poll brevis, shows an upgoing arrow in the insert column.  Could you tell me what this means, and if it indicates anything?  I also have bilateral hoffman's sign.

I have had swallowing difficulty for about 1 year now, had modified swallow, manometry, EGD.  All normal with exception to GERD, loose hiatus, and slightly low resting pressure of the UES.  I have told the neuros that I have swallowing issues, yet, I do not believe they have ever done an EMG that includes that area.  The only one close was the paraspinal of my right arm.  I seem to have excess saliva, and often wipe it from the corners of my mouth, not down my chin or anything, but, in the corners.  I have difficulty speaking, but, am not sure if that may be from general nervousness.  Should I be concerned about bulbar onset?

Thanks for your time and response.

Sunnygal

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

As I have never personally examined you nor did I perform the EMG myself, I cannot give you an accurate medical opinion regarding a specific diagnosis and the tests that have been completed. Also keep in mind that the interpretation of the EMG is highly dependent on the skill, training, and experience of the person who did the EMG.  We rarely rely on outside EMG reports except for those done at major academic centers with strong neuromuscular programs. Having said that:

1.Increased insertional activity doesn't mean anything necessarily except perhaps there is some irritability of the muscle fiber.  In the APB which is a muscle in the meaty part of your palm at the base of the thumb, this could be due to local trauma (if you're a driller or use a jack hammer or anything that results in repetitive palm pressure) or can be seen in carpal tunnel syndrome. Does not mean ALS.

2.Bilateral Hoffman's is seen in a percentage of the normal population, especially younger patients in their teens and 20s as well as diseases that affect the spinal cord. One of my colleagues who is completely normal neurologically has this and we see this all the time in normal patients.  If there are other neurological abnormalities, then it comes into play.

3. There is no muscle in the throat or oropharynx that we can check for by EMG for swallowing specifically, but we do check the tongue if there is weakness/fasciclations or difficulty talking.

4.Bulbar onset ALS at one year out from symptoms usually results in marked difficulty swallowing (not just excess saliva) but actually choking on liquids and solids as well as slurred speech that is not just from nervousness.  Patients often sound drunk at the onset and many then go on to completely lose their ability to speak permanently.
Hope that helps.

[sunnygal]

Sorry, I forgot to add, I also have neck and shoulder pain, and fatigue? or weakness?.  My tongue hurts alot, not sure about this either.  I also experience lower lip numbness, and numbness in the bridge of my nose.