EMG Results?

[curtis]

Hello Doctor:

I am a 38 year old male who has been having some disturbing symptoms over the last nine months.  I began having fasciculations over most of my body in May of 1999 but they seemed to mostly be in my calves and feet.  In June my neurologist and I noticed some mild atrophy of my right foot.  An EMG was normal except for a slightly slowed velocity of my right tibial nerve (40.6 vs a normal of >41).  All amplitudes were normal.  In October I began having a strange "dull" sensation in my left arm and things also began feeling heavier in that arm.  In November I had another EMG on that arm which was normal.  The sensation soon went away but the "weakness" and fasiculations  remained.  In January, the sensation returned along with some mild transiant dexterity problems in my left hand.  I just recently had another EMG which unfortunatlly showed a rather dramatic drop of amplitude of my left median nerve (13 down to 4). The signal was also "dispersed".  The needle exam was normal (including no fibs or fasics) except for some mild "myopathic changes" in my left deltoid and flexor carpi ulnaris muscles (decreased size, duration; increased frequency). By the way, my right tibial nerve was normal.

I am somewhat concerned about ALS. My grandfather died of it while he was in his late fifties.  Two seperate neurologist do not think I have ALS but cannot give me an explanation for my problems.

My questions are as follows:

1. What can cause a quick and dramatic drop of amplitude and can you experience fasiculations and weakness before anything bad shows up on an EMG (such as a drop in amplitude)?

2.  Can you have atrophy and still have a normal EMG?

3.  Can famial ALS miss one generation and then hit the next?

4.  If you have a low amplitude that is causing weakness and fasiculations, shouldn't something be seen on the needle exam?

5.  If you are having weakness and fasiculations due to ALS, shouldn't you also be seeing fibulations or do they tend to appear later?

Thank you very much for this great service and I look forward to your response.

Curtis

[dave]

In my case,David, the clonus I have refers to a type of bouncing down reflex at my feet that is somehow activated at the ankles. 2 doctors out of 7 that tested me didn't find it while the other 5 found it quite easily.They said it's an upper motor sign. (I should have asked for an oil change) I think sometimes clonus can refer to continuous bouncing with no control. I fortunately don't have that type. But I'm just learning about this stuff.

[david]

What exactly is clonus? I hear so many different definitions of this...What exactly is the foot or hand or bodypart doing that indicates this?

Thank You.

[CCF Neuro[P] MD, RPS]

Dear Lavon:

ALS is both upper and lower motor neuron disease, as you describe.  Dave had upper motor neuron symptoms such as clonus, increase DTRs and lower motor neurons symptoms of easy muscle fatigue that is visable on neurological exam.

Sincerely,

CCF Neuro MD

[lavon]

I'm curious as to what signs would indicate Dave has ALS?  What is a "quiet EMG"?  I also have hyperactive reflexes, fatigue, clonus in both left ankle and wrist, and stiffness but understand these are upper motor signs and ALS must be both upper and lower.  The diagnosis I was given was Primary Lateral Sclerosis which I understand is considered a separate process by most and certainly more hopeful than ALS.  Oh, I also have fasciculations in many muscles but normal EMG and a normal muscle biopsy.  The ALS specialist I saw in Houston indicated the EMG and/or biopsy would have been different had I had ALS.

[dave]

Thank you very much. I apologize for intruding on the Q&A's of the others. Just a note, I'm enjoy my life more than ever now, and I guess my main confusion over progression is that other than extreme fatigue and stiffness, I'm OK...other symptoms are subtle and slowly progressing. I don't have the Bulbar signs yet.I go back to my boxing days...as long as I'm in the ring I'm going to fight. I usually lost to knock outs though. Thanks again. You guys are great.

[CCF Neuro[P] MD, RPS]

Dear Dave:

I am very, very sorry to hear that you have ALS.  Although ALS can vary in the time of onset to the conclusion of the disease, usually it is somewhere between 3-5 years.  Many times it is diagnosed late and the time is shorten.  If you have what we call bulbar signs (difficulty swallowing, incr salvia, difficulty chewing food) the time is even shorter.  This is a disease that one has to think about family. How far do you want to take medical management and what you think how much can you tolerate.  The issues of mechanical ventillation, living wills, measures that you will except and won't except must be dealt with, by you, your physician, and your family.  

Again, I am really sorry about your disease.

Sincerely,

CCF Neuro MD