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AMYOTROPHIC LATERAL SCLEROSIS (ALS) / MOTOR NEURON DISEASE (MND) | PAGE 2
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  Reduced Interference Pattern (IP) in ALS?  
       
  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?)  
       
  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.
 
     
       
  Can we depend only on EMG “without NCV” in diagnosis of ALS?  
       
  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)  
       
  Answer I am afraid we cannot do that because a normal sensory nerve conduction studies are essential part in electromyographic findings in ALS.
 
     
       
  Abnormal foot movements after EMG & NCV; is it due to the test?  
       
  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?  
       
  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.
 
     
       
  Time lag before detection of positive sharp waves  
       
  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.  
       
  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.
 
     
       
  Fasciculations Frequency “definition”  
       
  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?
 
       
  Answer It is 2, referring to frequency in clinical way
 
       
  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?  
       
  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.
 
     
       
  Contraction fasciculation versus spontaneous ones  
       
  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?
 
       
  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.
 
       
  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)??  
       
  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.
 
     
       
  Fasciculations following muscle activity with normal EMG  
       
  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
 
       
  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
 
     
       
  Benign fasciculation syndrome (BFS)  
       
  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.  
       
  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.
 
       
  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.  
       
  Answer May I know what muscles had the positive sharp waves?
 
       
  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.
 
       
  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).
 
       
  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
 
     
  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!!  
       
  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
 
     
  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??
 
       
  Comment I'm sorry; can't remember the exact sound. It continued the entire time the needle was in - it did not stop.  
     
  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

 
       
  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.
 
       
  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!  
     
   
 
  Can Fasciculations result from overexertion & how to exclude ALS?
 
       
  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?

 
       
  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.

 
       
  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...

 
       
  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.  
       
  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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