by Little Lost on August 20th, 2014, 4:32 pm
Can I add something.
The department I attend is a large teaching hospital that diagnoses approx 60 cases of ALS a year. It is a specialist spinal unit taking in patients from all over UK. Its outpatient department runs 5 all singing dancing EMG machines for 8hours a day. They EMG over a thousand patients a year. In UK all EMGs have to be done by fully trained neurophysiologists.
Head of this department told me fasciculations are routinely recorded in healthly muscles of healthy people.. He said biceps and muscles of the hands are popular places, along with calves, and they are not clinically relevant in isolation. He said as well as recording them as fasciculation potentials, the ones near the surface won't show up on your EMG, but patient can see them.
Concerning Tic vs Fasciculation he said that visually, and from patients description, it is generally easy for neurologist to tell the difference. Tics tend to continually affect one focal area only, not really move or become widespread. They often start in childhood staying in or around one zone. They are predictable in location, duration and rhythm. Fasciculations are Random, irregular described as a Bag of worms feeling, or popping popcorn, vibrations, rippling etc. As one neurologist said. ' under examination conditions the buggers always happen when you are not looking for them, best to sneak up on them, catch them out the corner of your eye. They also seem to shy away from the needle_, go into one muscle and they happily wink at you from another...tricky things indeed.'
They only take on significance if other signs are present. He explained it as follows. ( nothing to do with ALS) ...imagine a patient goes to his gp with a cough.
...... Patient 1 presents with a cough, non productive, no other symptoms, feels healthy can still run about no breathlessness. He is worried about the cough, it makes him panic a bit, drys his throat out so he coughs a bit more. Extensive testing shows nothing of concern. 2 years pass and still no other symptoms. Just a cough, good some days, bad others. Repeated work up still shows no pathology.
.........Patient 2 presents with a cough and breathlessness, some blood brought up. He has lost weight is very tired suffers nighttime sweats.,, A few weeks later while awaiting further tests he is rushed in with pneumonia, imaging shows in addition he has large shadow on left Lung. Additional masses detected in bile duct and patient has developed jaundice.
Clearly patient 1 and 2 have coughs but patient 2 has additional symptoms. Fasciculations are like the cough. They can mean nothing or everything, and how they are interpreted like the cough is by what company they keep. Importantly they are too general a symptom to be diagnostic on their own, I.e. like the cough.
People fasciculate, the increasing application of ultrasound demonstrates this. The drive is on to use ultrasound instead of EMG for some muscle disorders. This way they can scan larger areas, it is non invasive, cheaper and does not require doctors to carry it out. One major problem is that when used to detect fasciculations, they find them everywhere. ( EMG is hit and miss ). So to determine if fasciculations are an issue they are trying to devise programmes to quantify them. You don't get a black and white reading of. ...... NO FASCICULATIONS vs FASCICULATIONS, ........it is low vs med vs high. This kind of contradicts the neurologists that say fasciculations are rare out with the calves. If that was the case why the need for such low/ med/high indexes.
Concerning the idea that tongue fasciculations are usually of concern. I am not aware of any studies that have looked at this, I.e. studies in which compare healthy controls vs BFS vs ALS etc. Without such a study we can ask as many experts as we want, but we are not going to get a defined answer. It has not been evaluated. Instead we will get an opinion based on clinical experience. However in this case the clinical picture is very skewed. Let me try to explain.
Think about it logically... WHO GETS AN EMG of tongue. How many healthy people undergo it. It is not routine even in those having limb EMGs. Probably the vast majority of patients who have the bulbar region is examined are people who alteady have symptoms like slurred speech, swallowing problems. So the doctors data is skewed. They are basing their clinical conclusions on skewed data. So of course neurologists will say fasciculations of the tongue are bad news, that's because they probably don't often look or EMG the tongues of many normal people, and there is no real data on healthy tongues, and certainly not BFS tongue muscles to directly compare it too. Sweeping statements based on clinical observations of patients undergoing bulbar assessment due to prior slurring or speech problems, not very balanced data.
This forum has over 10 years experiences and drawing on its data you can say the opposite i.e. that fasciculations of the tongue are common in BFS sufferers. Remember this forum has seen more BFS cases in its time that most neurologists will see in their full working career.
Hx
Last edited by
Little Lost on August 20th, 2014, 6:44 pm, edited 1 time in total.