Timing of fasciculations and EMG in ALS

[Ico]

I have heard it said that fasciculations appear in ALS some time after the muscle has been damaged due to denervation. As a result, I have been told that an ALS sufferer would experience profound weakness in any muscle before they feel any fasciculations in that muscle. In addition, I have been informed that, if you are feeling twitches in certain muscles, these would be certain to appear on any EMG taken if they were as a result of ALS. My queries are as follows:

1. In ALS, would a person notice profound weakness before noticing any fasciculations?

2. Once a person has noticed muscle twitching in certain areas of the body, would these show up on a EMG that covered these muscles or is there a chance that they just didn't occur during the EMG?

3. After fasciculations have appeared, does a completely normal EMG rule out a diagnosis of ALS and, if not, how much time should one leave?

3. In ALS, do fasciculations come and go (being more regular on certain days than others)or do they increase consistently?

4. Is there a certain type of twitch/fasciculation that is associated with ALS that is distinct from a benign twitch?

5. What is the usual progression of weakness and atrophy in ALS?

I have not set out my own precise symptoms because I realise that this forum is an educational tool. However, I would be grateful if you could answer these points as I have heard conflicting information about them.

With Best Wishes

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

Please keep in mind that I am unable to diagnose you since I am unable to examine you, this forum is for educational purposes only. Concern over fasicualtions (twitch in a group of muscle fibers that does not cause movement across a joint) is a common referal to neurologists for concerns of motor neuron disease(MND).  Fasicualtions are often normal responses of muscles to exertion or less use in a previously atheletic person.  They are also found after viral infections and called benign fasiculations.  Fasiculations do occur in motor neuron disease (MND), but are not specific to this disease, they can also be seen in any lower motor neuron lesion (below the level of the spinal cord).  Motor neuron diease diagnosis is made on the basis of history, weakness, atrophy and characteristic EMG findings.  The presence or absence of fasiculations would not change a diagnosis.  Fasicualtions are not an "early indicator" of motor neuron disease and are only an associated finding.  Therefore, if you do not have EMG findings characteristic of motor neuron disease, does not mean you will not develop MND in the future, but means none is detected at this time. If characteristic changes are seen to suggest MND we also often see widespread fasicualtions.  MND can present in many different ways, but a classic presentation is a foot drop, followed by progressive leg weakness, dropping things, wrist drop and atrophy noticed on exam. This generally progresses to complete paralysis and inability to breathe without assistance within 2-5 year (although some cases extend much longer). EMG does not always catch fasicualtions and they are often missed on EMG, because of their intermittent nature. This does not impact the result like other changes such as fibrillations and motor unit changes. That being said, EMGs are very subjective and if you are given a diagnosis such as MND a second opinion is expected.  In addition, if you suspect MND you should seek out a neurologist with an established reputation in MND EMG. I hope this has been helpful.

[ajg5446]

If possible, to "supplement" the great questions asked above, what if someone is having twitches all over their body (arms, legs, hands, back, eyes, ribs/abdomen, etc.) and have been for a number of months (3 to 5) with no signs of weakness/atrophy, etc....no EMG performed, but neuro checks by family doctor all are fine including reflexes, coordination, etc....would this duration of twitches (more times than not) rule out ALS or most other serious motor neuron diseases?  Your time and response are greatly appreciated...

[ajg5446]

What brought on your twitches?  Viral infection?  Stress/anxiety?  Did it start in one area and move to other areas, or did it start with twitches all over the place?

Mine started with twitching in a hand (back in Aug/Sept 2005) and during a high stress/anxious time, the twitches kicked in full force around April of this year and basically haven't subsided since.  However, over the past month they do "come and go" and the frequency of them appears to be slowly declining, however there's no limitation on where I have these twitches.  Absolutely all over the place.

I have no signs, whatsoever, of weakness or atrophy, and my doctors have said that they are more than likely related to stress.  Just a bit tough to believe since I had nothing like this for 35 years...and now, all of a sudden, they are a part of my life.

Thanks...

[Ico]

I was fairly stressed from about October last year and did develop a virus. For a while afterwards I had a very foggy head and had trouble concentrating and reading. This in turn increased my stress. I'd say I first noticed the twitching in Jan/Feb this year but only became concerned in about April. I'm worried because I'm convinced my hands are showing weakness but I have seen a neuro who thinks otherwise. I don't remember where the twitching started but now it occurs mostly in the thigh, arms and, to a lesser extent, the abdomen. In truth it occurs all over. I am taking medication to lower my anxiety and am hoping this will work.

[SJSmith]

Sorry, this one is a long one, hang in there please!

I was 37 years old and first started seeing a Dr. in May of 1998 for a persistant twitch in my left forefinger/thumb, it didn't hurt but would involuntarily pully them towards each other in a fairly rapid succession of twitches. I lived in Utah at the time. My Dr. referred me to a neurologist but due to a long appointment wait it was November
of 1998 before I was seen. By this time I had deleloped VERY pronounced random muscle fasciculation’s that were all over my body with no specific problem area, this included my tonque as well. These twitches/faciculations were observed by the Dr. at the time of my visit. Over the next 6 month I had 2 different unremarkable MRI's, and 2 different needle EMG's which were basically normal but he did comment that they were "a little slow" (he did not share much info with me which was frustrating). When the MRI's came back he noticed a small white area (pea sized) in my left frontal lobe area near my speach center which he felt was a small benign brain tumor, I had a second opinion and the second Neurologist dissagreed and said that it was instead a venous annomoly (naturally swollen or odd sized blood vien in my brain) He said it appeared "safe" and should not be the cause of my symptoms or future worries, following MRI's showed no change. He concluded that my twitching was caused by benign muscle fasiculations.

Another year passed and by fall I had basically the same symptoms which came and went but did not worsen. I did have a new symptom that was a surprise. As a teen I had a couple instances of migraine headaches, typical retna dialation, color flashes/light sqiggles, and dead blotches in my vision field, then a powerful headache for a couple hours, then everything was fine. I had a few of these over a few month period and none since, seemingly unrelated to my twitching problems. After being seen for this my Dr. suggested a routine of injections of vitamin B-12 to help with the twitching, after 6 months of this there was no noticeable change in frequency or severity. Another year passed and still no dramatic changes, no muscle loss or noticeable weakness anywhere, no foot drop or trouble swallowing, etc. Then in 2003 I went in for another test, this time a lower lumbar punture (spinal tap) was done. The results were inconclusive as I had an unusual result of an "unusual looking" presence of oligoclonal bands (poorly defined as he described it) which were also found in my blood serum. He suggested it showed a defensive process in my cerebrial/spinal fluid but it was not specific enough (in the bands and due to the blood serum also having it) to determine the cause.

Now 3 years later: (7 plus years from my first thumb twitching symptoms) I now live in Spokane Washington.

I have been in Spokane Washington for nearly 20 months since leaving Utah, my symptoms have come and gone over that period but never really worsened. I have no trouble swallowing or speaking; I have not had any difficulty tripping, etc. and do not notice any loss of muscle. I was a power lifter as a teen and am still a pretty strong guy but have not lifted weights for years so my muscles are out of shape and get sore after a short weight lifting session (typical of being out of shape) but have not "wasted" or anything, I do get tired a bit quicker than I used to but this could simply be due to age (43 now).

Lately the twitching in my left forefinger and thumb has been more active and I have had my typical fasciculation’s, randomly over my body, but more so in my extremities, most in my calves and thighs, and arms, pretty much as before, just more frequently. My calf muscles also sometimes have that twitching best described as a “Corn popping” feeling under the skin, it doesn’t hurt but it’s annoying and disturbs my sleep, this seems to worsen with excersize. I also have more fasciculation’s in my tongue than I used to have (I had them when I first visited you but they are a little more noticeable now) the difference now is that rather than a twitching/tingling feeling, these muscle faciculations feel more like multiple "mini-cramps" they don't hurt like a cramp but seem to be affect the function of my tonque slighlty which they had not done before, again, no slurred speach, or swallowing/speach problems, just different and more noticable.  

Here’s what’s new:

A new sensation began in my left foot about 6 months ago, it comes and goes but has been more and more frequent, it is a pulsing feeling of the nerves in the core of my instep, sort of a tingle, no pain or true "numbness" just a electrical feeling that pulses on and off, no stretching or exsorcize seems to effect it in any way. Now for the past several months I get frequent cramps on the insides of both hands between the little finger and the wrist which seems to be brought on by doing simple tasks.  I get similar cramps on the soles of my feet but less frequently, either cramps can be worked out pretty easily but they seem to re-cramp if I continue whatever I was doing. The final problem I’ve had is that when I run more than about 3 miles on unevern ground (outdoors, hills, trails, etc.) my calves swell up and feel tight, it does not cause my feet to swell but this gets to the point that blood to my feet gets slowed and they go numb forcing me to stop running, I have not noticed this when running on flat ground or a treamill. I have noticed this off and on for about a year.  

Of course I’m dreading that I may have ALS as I can find no other disease that these symptoms match. I have an appointment with a new neurologist in Spokane but since his appoinment time won't allow my first visit for 6 more weeks I thought I'd ask you forum members for some input.

Thank you!

[kealoha17]

I started twitching in March one week after having the stomach flu.  It frightened me so I saw a doctor twice, and a nuerologist.  They all said I didn't need to have any sort of test done that I was fine and Diagnosed me with having begnign muscle fasiculations (all over my body with some cramping).

The twitching had happened for two months before I couldn't stand it any longer so even though I am young and have always been very healthy,  I decided to change my life style.  I stopped drinking coffee (Which I only used to drink one cup a day).  I stopped drinking alcohol (even though I only drank about a glass of wine once a week at the most), I started taking a multivitamin and started to do some light excercising.  I also made sure to hydrate myself with water (smart water is great because it has electrolytes)which I found one of the most important things to do.  I had always been in great shape and I am only 29.  Oh, actually the most important thing is that I said a prayer and left it in Gods hands.  Within 2 weeks the twitching had almost completely stopped.  I only start twitching if I have a cup of coffee every now and then (It's hard to resist Starbucks frappacino's in the summer), or if I have a glass of alcohol.  Even though I only have one cup I know that I will twitch for a couple of days..

To all of you who feel alone and afraid because of these muscle fasciculations, I just want to say don't let it overcome you!  You have the power to make yourself feel better, especially if your doctor has diagnosed you with begnign muscle fasciculations, you can make them stop for the most part and begin to live a normal life with them.  Good Luck and God Bless.