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Reduced
Interference Pattern (IP) in ALS? |
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Is
reduced IP seen in the beginning of ALS or only later
on? (Is it one of the first things to appear on EMG with
ALS patients?) |
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Answer |
I would
think that reduced IP is perhaps a "later" EMG
sign in ALS. However, it's appearance early or late, on
one the hand, does not have a diagnostic value similar
to spontaneous activity. On the other hand, a reduced
IP may be variable and changes with the patient's cooperation,
the strength of the muscle, pain and the presence or absence
of disease of the upper motor neuron such as spasticity.
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Can
we depend only on EMG “without NCV” in diagnosis
of ALS? |
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Is
it possible to have an EMG test checking for ALS without
an NCV? (I understand that by leaving out the NCV part
other possibilities may be undetected, but the major concern
is ALS) |
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Answer |
I
am afraid we cannot do that because a normal sensory nerve
conduction studies are essential part in electromyographic
findings in ALS.
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Abnormal
foot movements after EMG & NCV; is it due to the test?
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I
had an EMG and nerve conduction test done for ALS because
of some minor fasciculations The EMG found fasciculations,
no fibrillations, so the neurologist felt I was clean.
But just 4 days after the test my foot, where most of
the testing was done on, (at least five separate sets)
started vibrating and fasciculating like crazy. It then
spread after a month to my other foot. Is this not an
uncommon reaction to the test? |
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Answer |
This
is not a common reaction to the test; in fact I have never
seen it happen. I cannot tell you what this is due to
but if you feel that this is way out of the ordinary for
you (and it has lasted this long) I would get in touch
with your doctor and tell him/her about it.
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Time
lag before detection of positive sharp waves |
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In
your quite lucid explanation you make mention that fibrillations
cannot be picked up until about 2 months after injury.
I was wondering how long a lag exists till the EMG can
pick up positive sharp waves. Also, I've seen differing
opinions as to whether patients can actually feel the
fibrillations and the waves themselves. What is your opinion
on this? Thanks very much. |
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Answer |
Fibs
and positive waves are seen at about the same time. In
fact it's been argued that fibs are positive waves, which
are seen from a different vantage point by the needle.
People cannot feel either fibs or positive waves, what
you are referring to is fasciculations, which are much
larger contractions of muscle, and which patients can
usually feel.
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Fasciculations
Frequency “definition” |
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I
have read in "principles of neurology" that
benign fasciculations tend to be more frequent and constant
in location than the malignant ones. What do they mean
by FREQUENT? 1. More frequent in EMG: once it fires the
frequency of each "muscular jump" is higher
(shorter intervals between each fasciculation) 2. Or,
maybe they mean the clinical way: that the patient gets
them more, feels more fasciculations in a given muscle
-the frequency of each such "battery" of fasciculations
is higher. HE gets more twitches?
What do you think they mean 1 or 2? |
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Answer |
It
is 2, referring to frequency in clinical way
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Comment |
So
according to your clinical experience: the random twitchers,
those who get them few times a day only and every time
in totally different location (a twitch in the calf muscle
once every hour or less, for example)- these are the twitchers
who should worry more about als? * More than the twitchers
who have them continuously in the same muscle? |
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Answer |
Yes,
this is true, it is good clinical assumption to follow,
but it is not perfect, as surprisingly some patients with
ALS are oblivious to their fasciculations.
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Contraction
fasciculation versus spontaneous ones |
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I
have read there are two types of fasics: spontaneous ones
that fire with no relation to contraction of muscles and
the contraction ones: which are rhythmic firing of motor
unit - observed during weak contraction. The latter are
seen in ALS and a compression of nerve root.
My question is: 1. So, are there two kinds of fasics.
Both happen in the course of als?? (or the spontaneous
happen less) 2.The contraction fasics-How will they be
heard electromyographically (rhythmic popping??) I am
a bit puzzled because I once read that fasciculation are
random pops in EMG while normal motor unit firing are
rhythmic popping and that is the way to distinguish fasciculation
from normal motor units activity - so How come contraction
fascics (malignant!) also produce rhythmic popping? |
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Answer |
You are
right, there is something called contraction fasciculations,
BUT this has nothing to do with ALS and it is not spontaneous.
As a matter of fact we should not confuse it with the
usual spontaneous fasciculation. This contraction fasciculation
is merely a motor unit contraction visible underneath
skin seen initially during a slight voluntary muscle effort.
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Comment |
1.What exactly
are the contraction fasciculation (I read they are rhythmic
twitches seen in weak contraction - Is that true?) 2.what
is their pathological significance? Are they never consisting
a part of ALS or other LMN degeneration? 3. How do you
here them in the EMG (rhythmic popping)?? |
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Answer |
Practically
I do not look for it in ALS and I have not seen among
the EMG criteria to diagnose ALS. Historically, it was
described by Denny-Brown and Pennybacker in 1938 (Brain
1938;61:311-334) and also by Milner-Brown et al, J. physiology
(London)1973,228:285-306.
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Fasciculations
following muscle activity with normal EMG |
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I
have had muscle twitching all over my body for 3 months
now. I have had about 4 normal neuro exams and 2 negative
EMG's so far. I have noticed that many of my fasciculations
occur directly after applying force to the muscle (i.e.
when I lean on my elbow I get a twitch in my elbow, or
when I make a muscle in my arm I often follow with a twitch
in my bicep). Is this pattern more concerning than fasciculations
that occur randomly in a muscle while at rest?
Thanks for your help |
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Answer |
Please be
reassured that these kind of twitching or fasciculations
are not worrying at all, this is supported by the normal
neurological examination and negative EMG on 2 occasions
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Benign
fasciculation syndrome (BFS) |
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Would
you know the answer to this question? I have asked my
neurologist, asked the MDA, and looked at a lot of reference
material and cannot seem to find the answer. I checked
your site, but still no luck. I have been diagnosed with
Cramp-fasciculation syndrome/Benign fasciculation syndrome
(BFS). On my EMGs, there were positive sharp waves from
two different muscles (normal nerve recoupment and no
fasciculations noted); my NCVs are all normal. I thought
with BFS my EMGs should be normal and my NCVs abnormal?
Thank you. |
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Answer |
The
term benign fasciculation syndrome (BFS) is used when
the patient has fasciculation but no neuromuscular disorder
is found. In this case the EMG may show fasciculations
only but no positive sharp waves or fibrillations. The
nerve conduction study (NCS) is normal, while the Cramp/fasciculation
syndrome may have muscle aching, cramps, stiffness, and
exercise intolerance. Again in this condition as BFS,
the EMG may show fasciculations only, otherwise, no other
EMG signs, and the NCS is also normal.
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Comment |
Thank
you, but I am confused. My two EMGs clearly had positive
sharp waves in two different muscles. My NCS were all
normal. At first my doctors were thinking early signs
of ALS. It has now been a year and a half but still no
weakness. I have tremors in my hands when I try to hold
something; sharp, very localized pains in my arms above
and below my elbows and in my hands, fasciculations virtually
everywhere from my feet to my face, and have become very
exercise intolerant. I can still lift a lot of weight,
etc., but just can't do any repetitions. With my EMG findings,
how could I have BFS or Cramp/fasciculation syndrome?
Thanks in advance. |
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Answer |
May
I know what muscles had the positive sharp waves?
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Comment |
Sure:
Quoting my medical records: May 17: "Right triceps:
plus two positive sharp waves with trains of positive
sharp waves present demonstrating increased insertional
activity. The motor recruitment while having many small
motor units, showed no evidence of increased polyphasic
motor activity or abnormal recruitment patterns."
Left triceps: "plus one positive sharp waves with
trains of positive sharp waves present. This demonstrated
increased insertional activity. The motor recruitment
was normal, with no evidence of increased polyphasic motor
activity or abnormal recruitment patterns.
March 26: Triceps, right, 2-3+ positive waves and 1+ fibrillations
March 5: Triceps, right, plus 2 positive sharp waves,
motor recruitment normal; - right medial gastrocnemius
- one train of positive sharp waves, motor recruitment
normal.
I have consistently had increased insertional activity
in most muscles tested in each of my 4 EMGs. My last EMG
noted no positive sharp waves - just increased insertional
activity. In each of the muscles that have had positive
sharp waves I have a "stabbing" feeling - in
the triceps above the elbow; and the same localized pain
in the forearm below the elbow.
I have had a spinal tap to rule out MS; all sorts of blood
work to rule out heavy metal poisoning, etc.; brain scan;
c-spine MRI (showing a slight stenosis but no impingement
of the spine). I am a Persian Gulf Veteran and have tested
positive by an DNA PCR test for the mycoplasm fermentans
that has been linked to "Gulf War Syndrome"
and am on a 1 year course of antibiotics in a study on
that. |
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Comment
2 |
'm
sorry, I also forgot the following: Feb. 5 - my NCS noted
mild slowing for the ulnar motor nerve across the elbow;
during exam, very active positive Tinel signs present
over the median nerve on the right and the left wrist
and over the ulnar nerve over the right and left elbow
- my reflexes are consistently +3 all over; once I was
noted as having a Babinski reflex, once a Hoffman reflex
- when I exercise, after a few minutes I get a burning
sensation (like if I were lifting weights and got to the
point of muscle failure)
- I have a tingling sensation in my 4th and 5th fingers
of my right hand, sometimes my right index finger.
In reading about ulnar neuropathies, I seem to have some
of the symptoms - the tingling of the 4th and 5th fingers,
elbow soreness (about 1 inch above the elbow), there is
a history of diabetes in my family, and I used to lean
on my elbows alot while I type (I have stopped doing that).
Are my EMGs/NCS consistent with ulnar neuropathies?
Again, I have no weakness, no bulbar signs of ALS (occasional
slurring of words, but I have always done that when I
am tired); lots of fasciculations; and a lot of pain from
those very specific parts (feels like someone comes up
and stabs me with an ice pick - when it strikes, I will
drop what I am holding, etc.).
I am currently on Gabapentin for the tremors (I would
pick up something, and sometimes my hand, fingers, etc.
would start to tremor, the more I held on, the worse it
would get). |
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Answer |
Do
you recall the sounds of the sharp positive waves and
fibrillations in your EMG, how did they sound like?? How
long each has lasted
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Comment |
It
just sounded like a lot of static, no popping or anything,
just loud static. That is all I remember; before each
EMG I had an NCS, which when I was shocked in my arm,
my leg, would fly up, etc. By the time I had the EMGs,
all of my nerves were on end, and the EMGs really hurt,
a lot!! |
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Answer |
Now
that I think of it, the static at times would sound liking
rapid popping - no break in between - this would occur
on the muscles where the sharp waves were
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Answer
2 |
How
did the fibrillation sound like?? You say static. Could
you distinguish what it was made of or was it just static
sound like a "dead heart" on ECG? Most importantly,
about the duration - was it short duration (3,4 seconds)
and stopped quickly or was it for a long time??
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Comment |
I'm
sorry; can't remember the exact sound. It continued the
entire time the needle was in - it did not stop. |
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Answer |
Here
is a link that actually shows videos of fibs, ps waves
etc.
http://www.med.ohio-state.edu/physmed/videos/EMGvideos.html
Here is a link to more videos of fibs, ps waves etc:
http://www.casaengineering.com/EMGsampl.htm
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Answer
2 |
Thank
you for detailed information about your medical problem.
I agree that it cannot be a pure BFS or cramp/fasciculation
syndrome or ALS.
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Comment |
Thank
you for your time. I guess I will just have to wait and
see what develops. Hopefully I can report back in a few
years that it is benign! |
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Can
Fasciculations result from overexertion & how to exclude
ALS?
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I
am a 49 year old, that works out all of the time and for
the last 5 months have had fasciculations especially in
my calfs. I had a normal Nerve Conduction and now they
want to do an EMG. The only physical change is that I
gained about 15 lbs after beginning to lift weights in
February.
I never noticed the Fasics
until my Flight Surgeon looked for them at my last flight
physical.
My question is do you find
that over exertion causes fasciculations, and is there
something else I can try before the test? I'm also finding
that I get cramps in my calfs and some soreness, (probably
from to much exercise). According to my trainer my strength
has increased substantially.
These are questions that are
hard to ask and I am quite tentative about a "
lose - lose " diagnosis. If its BFS there is nothing
that can be done about it, and if it isn't there isn’t.
Any Suggestions?
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Answer |
Too
much exertion, or stopping exertion after having exercised
for a long period, can cause fasciculations. Usually calf
fasciculations and cramps tend to be benign. An EMG however
would be a very good idea because it may explore whether
or not you have fasciculations (that you are not aware
of) in other muscles.
In the work-up for ALS there are many other signs and
symptoms than fasciculations that lead to a diagnosis;
so a good EMG and and a good neurological work-up are
of the utmost importance before making a diagnosis.
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Comment |
I
had the NCS it was negative, and a EMG and the Dr. stated
" I needled the tibialis anterior, peroneus longus,
gastrocnemius or soleus on either side, quadriceps, hamstrings,
deltoid, biceps, triceps, and first dorsal interosseous
on the left side. Most of the muscles showed small fasciculation
potentials. No runs of fibrillation potentials or positive
waves. No bizarre high frequencies discharges. No Myotonic
potentials. The motor units that I saw were of normal
amplitude and duration."
He then suggested I stay with Acupuncture for a few
weeks and see what happens. He also did a lower back
MRI which was normal and a spinal X-ray and the only
statement was” Small anterior Osteophytes are seen
at T12 -L1 and L2-L3.
So my question is what do suggest I do about the Fasciculations
/ twitches and the leg stiffness that goes with it.
I have been taking creatine 5 mg a day, and many non-synthetic
vitamins prescribed by my nutritionist. Also I am working
out with weights and seeing definite gains in strength,
other than my legs.
What are your thoughts on acupuncture for this problem.
I am a pilot and taking certain medications is not
an option, I would be glad to pay for your time for
a phone consultation, if that is an option...
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Answer
1 |
I
would suggest continuing the acupuncture. In general the
presence of fasciculations without other EMG findings
by itself is not significant. I do not suggest any specific
therapy in your case for fasciculations. |
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Answer
2 |
Findings
such as the ones you describe could well be benign fasciculations.
Usually, you would like to see large fascics and some
other signs of denervation such as fibs and positive waves
for this to be significant. A normal MRI and spine x-rays
just indicate that the symptoms are most likely not coming
from your back.
Is the EMGer that did the test on you your neurologist?
Per my previous reply to your post, I had indicated
that EMG is only a part of the work-up, it takes an
experienced neurologist to put all of these findings
together (and exclude other possibilities) to rule out
ALS.
I usually advise patient with symptoms and findings
such as yours to seek the advice of an experienced neurologist
to look at the whole picture.
I can't tell you what to do with the fascics. I usually
recommend decreasing (not stopping) the weight training
for a couple of weeks to see if the fascics change.
That would be a way to find out.
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