A few questions

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A few questions

Postby randallt on October 2nd, 2014, 12:46 pm

Hello, I am new to the boards and this is my first post. I have many questions that I cannot get answers for and was hoping those on here could give insight to some of these things.

My twitching began in late May. I had an EMG done in early August. Was this done too soon? Also, is it true that an EMG in one limb (right leg) would detect any *** activity between the brain and the leg, for example, the arm?

What is the difference between an atrophied muscle and one that just may be a little smaller than the one on the other side of the body. I was told my right tricep muscle is atrophied. However, I still have equal strength in that arm. The neurologist that did the test also said I had no tricep reflex but two other doctors have been able to find it.

Upon waking in the morning I have two symptoms that have occurred only since the twitching began: a "brain fog" that dissipates if I do some cardio exercise, and a buildup of phlegm in my throat. Do any others have either of these things?

Finally, if the twitches are caused by ***, how long does it generally take for weakness to follow? I know it's different for everyone but wondered if there was a general time frame.

Thank you!
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Re: A few questions

Postby LKP1231 on October 3rd, 2014, 5:52 am

Sorry you have not got responses yet, I'm sure you will. The only think I can tell to about the emg being too early is that from my understanding if disease is present the emg will pick it up from the onset. After months you also would have true clinical weakness. Hope someone will get back to you with other answers!
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Re: A few questions

Postby guitarguy11 on October 3rd, 2014, 8:16 am

This is my understanding too. My now, I would think you would be showing signs of clinical weakness. In VERY, VERY rare cases, my understanding is that twitching can begin before weakness, BUT I would still think by now you would be showing weakness.
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Re: A few questions

Postby TwitchyDoc on October 3rd, 2014, 9:30 am

randallt wrote:Also, is it true that an EMG in one limb (right leg) would detect any *** activity between the brain and the leg, for example, the arm?


No, of course not. Exceptionally, I will not use medical terminology but a simple analogy - imagine your spine is nothing than a set of pairs of sockets on each vertebrae. Muscles are connected to these sockets with their plugs. When the plug does not fit correctly into the socket or either is damaged, you have a problem but this problem affects only the muscles that are supplied by this socket. Apparently, sockets are independent on each other and hence you cannot detect damage of the plug C2 if you are examining a muscle supplied by the plug C3.

randallt wrote:My twitching began in late May. I had an EMG done in early August. Was this done too soon?

Seems like quite a sufficient time span in majority of cases. If you doctor does not recommend a follow up, I do not think it is necessary unless your symptoms change dramatically.

randallt wrote:Finally, if the twitches are caused by ***, how long does it generally take for weakness to follow? I know it's different for everyone but wondered if there was a general time frame.

Mostly, those with ALS will exhibit other symptoms within a few months after the onset of fasciculations. There is no general timeframe. One of the most comprehensive studies on this subject (Eisen, Krieger) mentioned 7.2 months being an average timeframe. But if I remember correctly, those were patients with already detected changes on the EMG who just did not show any weakness despite pathological readings. So it does not apply to you ;)

randallt wrote:Upon waking in the morning I have two symptoms that have occurred only since the twitching began: a "brain fog" that dissipates if I do some cardio exercise, and a buildup of phlegm in my throat. Do any others have either of these things?

This is why it is important for you not to simply accept "this is BFS" as some here often suggest. These symptoms point away from MND of any kind but may be present with other, treatable disorders that might not even be neurological in their nature.

Hope it helps.
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Re: A few questions

Postby Bibi on October 3rd, 2014, 10:08 am

TwitchyDoc wrote:
randallt wrote:Also, is it true that an EMG in one limb (right leg) would detect any *** activity between the brain and the leg, for example, the arm?


No, of course not. Exceptionally, I will not use medical terminology but a simple analogy - imagine your spine is nothing than a set of pairs of sockets on each vertebrae. Muscles are connected to these sockets with their plugs. When the plug does not fit correctly into the socket or either is damaged, you have a problem but this problem affects only the muscles that are supplied by this socket. Apparently, sockets are independent on each other and hence you cannot detect damage of the plug C2 if you are examining a muscle supplied by the plug C3.

Sorry to break in here , but Can i ask A question ? I i have Beeing twitching for 5 months , and The neuro saw The ones in my left foot. I had an EMG on left leg ( not the foot) and arm , Would The EMG in my left leg have picked up if The twitches in my foot comes from A.. ?

randallt wrote:My twitching began in late May. I had an EMG done in early August. Was this done too soon?

Seems like quite a sufficient time span in majority of cases. If you doctor does not recommend a follow up, I do not think it is necessary unless your symptoms change dramatically.

randallt wrote:Finally, if the twitches are caused by ***, how long does it generally take for weakness to follow? I know it's different for everyone but wondered if there was a general time frame.

Mostly, those with ALS will exhibit other symptoms within a few months after the onset of fasciculations. There is no general timeframe. One of the most comprehensive studies on this subject (Eisen, Krieger) mentioned 7.2 months being an average timeframe. But if I remember correctly, those were patients with already detected changes on the EMG who just did not show any weakness despite pathological readings. So it does not apply to you ;)

randallt wrote:Upon waking in the morning I have two symptoms that have occurred only since the twitching began: a "brain fog" that dissipates if I do some cardio exercise, and a buildup of phlegm in my throat. Do any others have either of these things?

This is why it is important for you not to simply accept "this is BFS" as some here often suggest. These symptoms point away from MND of any kind but may be present with other, treatable disorders that might not even be neurological in their nature.

Hope it helps.
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Re: A few questions

Postby Bibi on October 3rd, 2014, 11:03 am

Sorry to break in here , but Can i ask A question ? I i have Beeing twitching for 5 months , and The neuro saw The ones in my left foot. I had an EMG on left leg ( not the foot) and arm , Would The EMG in my left leg have picked up if The twitches in my foot comes from A.. ?
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Re: A few questions

Postby randallt on October 3rd, 2014, 11:35 am

Thank you all for the responses. One other question (and I know it's been asked millions of times but I'll ask it again): Random twitching all over the body, pops here, there, and everywhere, are not the general *** manifestation, correct?
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Re: A few questions

Postby Xina535 on October 5th, 2014, 5:43 pm

Hello,

For twitchydoc: you said no, about an EMG being able to detect *** activity between the brain and leg, but now I am confused since I read on here and was told many times the opposite. I had an EMG on my left side and was told it would have been able to pick up any activity, even if anything sinister were happening on my right side. What you said naked sense about the plug, but would you be able to clarify? I can pull at least 2-3 times it is written on here that an EMG would pick up anything no matter where it's performed.

Side question I've been meaning to ask about EMGs: do you need to be twitching in that muscle which is stabbed with the needle for the EMG to determine what kind of twitch it is (benign vs. bad news)? Example, if I want to determine if my right hand is twitching for benign or harmful reasons, if I get an EMG done there and while the needle is in it, it does not twitch at all, then the EMG will be normal because it did not have any twitch to evaluate VS. if it did twitch with the needle then it can tell something? Because in those 5 minutes, my hand may not twitch...
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Re: A few questions

Postby Yuliasir on October 6th, 2014, 12:09 am

Xina, I am not sure, but looks like EMG can pick up UMN damage regardless of where the needle is stuck, as it is a central brain damage. LMN and bulbar signs are definitely limited to the related spinal segments and glottal nerve.
However let's the Docen answer your question, as he knows in details.
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Re: A few questions

Postby Xina535 on October 6th, 2014, 12:25 am

Thanks Yulia, so lower motor neuron damage os bulbar onset? And the EMG would need to be done specifically in the neck?

Also, is twitching a factor? What if no twitching occurs when the needles are in?
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Re: A few questions

Postby TwitchyDoc on October 6th, 2014, 2:05 am

Xina, Yulia:

EMG cannot pick up any UMN damage. UMN damage can be assessed only by clinical exam (or autopsy). EMG detects only lower motor neuron signs, be it in bulbar muscles or in a leg.
It has been discussed many times and there are a few papers showing that there is no way how to distinguish benign vs malignant fasciculations accurately. There some clues (polyphasia, fire rate, instability) but mere fasciculations are not enough for diagnosis. It is the company they keep - signs of ongoing denervation and-or reinervation.

Whoever told you that EMG can pick up damage between brain and leg, is simply wrong or maybe you misunderstood the answer. EMG has nothing to do with the brain, it detects the activity of peripheral nerve that originates from the spinal cord (anterior horn cells) and supplies the muscle.

Hence, it is not true that one side would show signs if the other side was affected - that is why EMGs for ALS are specifically designed to be done on both sides. Only later in the disease one could expect that. But generally no, EMG of a muscle on the left cannot detect activity of a muscle on the right. Paraphrase from the "Basics of electromyography" - If one side appears normal, move to the other side."
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Re: A few questions

Postby Xina535 on October 8th, 2014, 7:29 am

Hi Docen, I very much appreciate and value your time and advice!

TwitchyDoc wrote:Xina, Yulia:

EMG cannot pick up any UMN damage. UMN damage can be assessed only by clinical exam (or autopsy). EMG detects only lower motor neuron signs, be it in bulbar muscles or in a leg.


I am sorry, I do not know what UMN damage is and what is refers to. Upper Motor Nerve damage - is that what causes twitching? :oops: :oops:

It has been discussed many times and there are a few papers showing that there is no way how to distinguish benign vs malignant fasciculations accurately. There some clues (polyphasia, fire rate, instability) but mere fasciculations are not enough for diagnosis. It is the company they keep - signs of ongoing denervation and-or reinervation.


Ok this helps, thank you! I was mainly wondering if the EMG would be of any value even if you are not twitching when they perform it. Like they stick the needle in my hand and I am not twitching so the EMG is clean, but then right when the needle is out, there goes a twitch, so if the needle had been in while it twitched, maybe the EMG would not have been normal. :?:

Whoever told you that EMG can pick up damage between brain and leg, is simply wrong or maybe you misunderstood the answer. EMG has nothing to do with the brain, it detects the activity of peripheral nerve that originates from the spinal cord (anterior horn cells) and supplies the muscle.

Hence, it is not true that one side would show signs if the other side was affected - that is why EMGs for ALS are specifically designed to be done on both sides. Only later in the disease one could expect that. But generally no, EMG of a muscle on the left cannot detect activity of a muscle on the right. Paraphrase from the "Basics of electromyography" - If one side appears normal, move to the other side."


So here, I am nervous again. My neuro only did my left side, even when I was having symptoms in my right hand. When I asked him why he did that, he said it is a system wide disease and the left side would have shown abnormalities if it was present on my right. And also, then either I am getting these posts confused with something else, but it's written in the "Why you don't have ALS Part 1 and 2" posts by Aaron on here, and then I found at least one more time it was told to me. Below:


viewtopic.php?f=3&t=11435

You want my personal advice from years of experience with this stuff? Mind you, I have watched thousands of people on the site with BFS come and go now..... You need to get out and quit dwelling on this stuff!!! You have had numerous tests in several places. You do NOT need to test each and every spot! ALS is a nerve PATHWAY disease so if you have twitching and weakness BECAUSE of ALS in something like your little toe, and you get an EMG ANYWHERE BETWEEN that toe and your brain, it WILL show-up on the EMG because it is looking at the PATHWAYS BETWEEN that toe and your brain. ALS is also a body wide disease BEFORE it spreads to NOTICABLE symptoms. It is there long before 99% of the sufferer's even notice it, (contrary to what a lot of rookies will tell you). The twitching in ALS means it has already been there a while, has DONE damage and now the muscles are reacting by quivering. Twitches do not “cause” ALS by any stretch of the imagination, nor are “twitches” even a sign of ALS. It is the whole enchilada that has to be looked at with CLINICAL weakness and a bad EMG. Without ALL of those symptoms (and then some), you have ALS about as much as someone with a common headache has a brain tumor.

This is why doctors don't test everywhere on your body, and why "rookies" with BFS think a doctor should test exactly where the twitching occurred. It does NOT have to be tested in the finger, hand or even the limb where the twitching occurred.



also on that page

]Re: Sorry, need advice

Dude, twitching in ALS is a direct result of the disease running it's course. It is NOT a pre-curser symptom! In other words, if you have twitches that are associated with ALS, it means the disease is ALREADY running its course because muscles diseased with ALS don't begin to twitch UNTIL micro fibres begin to die and disconnect. With that, ANY EMG at ANY TIME would CLEARLY show the disease, no matter how far along, or how early you THINK you are. There is no "incubation time" or "window frame" once ALS twitches have started. If it's ALS and you are twitching, the disease is ALREADY well into running it's course, and of course, will ALWAYS show up on an EMG, no matter where it is performed on your body.

If you have a cold sore on your lip, do you need to get a blood test ON your lip to diagnose it as Herpes? No! Why? Because it is IN your blood. Just because the symptom is on your lip doesn’t mean you can’t detect it elsewhere. Actually it (Herpes virus) resides in your spinal cord.

With that, just because you twitch in one small place on your body doesn't mean ALS isn't running all through it. Nerve pathways run the entire length of your body. You can get tested just about anywhere and it will show-up, just like getting a blood test will show why you have a cold sore, even though a cold sore almost always appears and re-appears in the same exact location, over and over again, it is STILL running through your whole body, just like ALS is.


By Red Raider
viewtopic.php?p=154670#p154670

Xina
If you had ALS anywhere in your body and you have been having twitches as long as you have had an EMG would of picked it up anywhere. I've read, my ALS specialist I see in Dallas TX who is ahead of the MDA/ALS clinics for Baylor and UT Southwestern said if you have a drop of ALS let say in your big toe for example and they tested your right hand it would pick it up so please rest easy and tell that ghost to go away. Now this is what my doctor told me and he is one of the best in the country beside places like Mayo, Emory, or Duke you have been going on to long with this I wish I was in your shoes with amount of time I'm only 6 months in and scared to death. I don't wish any of this on anybody keep your head up girl and stay positive and strong
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Re: A few questions

Postby TwitchyDoc on October 8th, 2014, 8:03 am

No worries Xina, you are welcome. Yes, UMN refers to upper motor neurons - there is no relation to twitching. UMN syndrome is spasticity, hyperreflexia etc.

As for the quotes you mentioned, they are over-simplified and I would take this one as an example:

ALS is a nerve PATHWAY disease so if you have twitching and weakness BECAUSE of ALS in something like your little toe, and you get an EMG ANYWHERE BETWEEN that toe and your brain, it WILL show-up on the EMG because it is looking at the PATHWAYS BETWEEN that toe and your brain.


ALS is not a nerve pathway disease, it is a disease of anterior horn cells. ALS does not affect the nerve itself, just the anterior horns. It has nothing to do with the pathway from the brain to the toe, as far as EMG is concerned. The claim that "ALS in your big toe would be picked up by EMG of your hand" is a nonsense - only later in the course of the disease it could happen but there would have to be a separate lesion... If that was the case, one spot anywhere would be enough :) In reality, when ALS is suspected, a thorough EMG is done with 15-25 muscles sampled. But it has to be suspected, which is not your case!

As for your question, you do not need to be nervous because you twitch long enough for a potential lesion to involve both sides. I assume that is what you doctor meant. When ALS is clinically suspected in a person with weakness and hyperreflexia and one side is clear, it is obligatory to check the other side. ALS does not start in a symmetric manner but quickly becomes widespread.

So you can be reassured if your EMG was clean.
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Re: A few questions

Postby Yuliasir on October 8th, 2014, 8:23 am

Twitchydoc,
how's about upper motor neuron degradation in ALS? Does it exist? My understanding was that it is a disease of BOTH upper and lower motor neurons, that is why affected people may have UMN degradation signs? Looks like degradation of upper motor neurons still is included in diagnostic criteria?
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Re: A few questions

Postby TwitchyDoc on October 8th, 2014, 8:24 am

Yulia, yes, of course - ALS is defined as degeneration of both upper and lower motor neurons. But upper motor neuron lesions cannot be detected by the EMG. Actually the "lateral" in ALS refers to lateral columns and their sclerotization (not sure if that is correct in English), while amyotrophic refers to LMN signs - loss of nutrition of the muscles (involvement of the anterior horns).
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Re: A few questions

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