Should i do another EMG / Second opinion

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lastime20151

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Hello all. I would like to mention that I am incredible grateful to the people who are posting on this forum and helping others with diagnosis and postdiagnosis. I would like to mention that before I posted this, I went through stickies couple of times.

I am 34 year old male, and on December 27 after I woke up I started having weird sensation in my left hand, like its not part of my body. The orthopedist in my home country told me that the reason is possible shoulder impingement. I started taking Mydocalm (muscle relaxer) and Arcoxia (anti-inflammatory) as prescribed. Few rehabilitation sessions were done.

However in the meantime I couldn't not notice that my left (dominant) hand is also weaker (holding phone, sometimes clumsy). I can't be sure that anxiety at this point is not affecting this (but then why just 1 hand). However I did not panic (yet) since I was not experiencing any twitches.

So I went to neurologist, where he said we will do EMG to see if there is any nerve damage. His pre-diagnosis after clinical test is ulnar nerve entrapment. Other neurologist/technician did EMG and results below are from yesterday. During the test the other neurologist did also notice small atrophy on the side of the hand under the pinky finger.

As you probably can guess, i did some search and my concern is this:

1. Can Mydocalm affect anyhow the EMG test result since it is muscle relaxer.
2. My worry are max. values on MUP in each segment. He tested hand, wrist, elbow, neck. Since it is not localized, I am worried.
3. Does no evidence of major denervation or re- innervation mean no ALS? Why he says no evidence when he put MUP +4 in each segment (on the machine he could choose between values 0 - 4).
4. Should I look for second opinion (considering the appointment this Saturday the primary neuro will stick to his ulnar theory)?

Obviously I am little scared since one orthopedist says upper back issues, other says shoulder impingement and neuro says ulnar nerve entrapment.

Thank you very much for your replies and god bless you all.
 

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Nikki J

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1 no
2 don’t be
3 no denervation on emg is no ALS yes and ncs abnormalities point to another issue
4 up to you but your symptoms of “ weird feeling” and perceived weakness in a hand that had a normal emg / abnormal ncs do not sound like ALS For any future visits you should say I have these symptoms what is wrong with me?
 

lastime20151

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thank you Nikk with your quick response. I really appreciate it. And I understand why that to some people especially PALS it is difficult to answer or takes time.. i will also update this post for other potentially anxious people what doctor says on Saturday and I have decided also to donate some money for good cause since now I am aware about this dreadful disease.

but if anyone could follow up on point 3 please, would you consider this as normal EMG? What about the high MUP values in all tested areas?
 

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Honestly, Nikki answered you that this is a normal EMG regarding ALS and she should know.
I think your biggest issue is that you don't wish to believe a doctor that has done years and years of study and experience, but think you can get on google for a bit and work it out.
Please, don't try to become your own medical expert from the internet and ask strangers to support you in doing that.
I hope it goes well on Saturday.
 

johnny5

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ulnar nerve entrapment is a reasonable diagnosis from what you said

also, look at cervical (C6-C8) involvement if it is both hands

entrapment can result in radiculopathy, which also can cause atrophy from crush injury

atrophy will cause weakness anywhere below the crush site

ulnar nerve goes down the backside of the arm to the pinky finger half of your hand

without any more symptoms, you have nothing to worry about

no idea how long ago the injury happened, but if it were recent you could still recover

nerves grow 1-2 mm per day, figure 6 months if all is not healed, it is permanent

neuro-junction, where the nerve connects to the muscle, would tend to die off between 6-12 months
 

lastime20151

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As promised I wanted to follow up with the results.. it might help out people who are actually going through these fears/anxiety as I am.
neurologist interprets the results as potential ulnar nerve entrapment (as expected) and recommended physiotherapy. But yes, i have doubts, since:
1. he didn't really want to go into discussion regarding the high MUP in all tested areas, said just these are just numbers and he is there to interpret them and he says mine are normal (even though everywhere i have MUP +4). But I am not here to challenge that, I just wanted to understand.
2. Still can't explain the weakness I am having. Even when i hold something like my phone (160grams), in left hand and right hand makes great difference, feels 5x heavier in the affected hand/arm. But can I use my fingers, my arms, my hands? Yes I can.
3. And I still don't know why I have these dents in my left hand.

BUT!:
Yesterday I went to play some golf. After couple of beers I realized that I stopped feeling any weak sensation. I was checking my grip and arm strength all the time. And this morning I woke up with terrible sensation/pain of my left arm, persistent the whole day. I really have no idea what causes this, might be psycho-somatical, might be that it comes from the injured bicep which happened month ago when tried to climb over a wall , but at this point, I feel I need to move with my life. I will even cancel the appointment regarding the second opinion of other neurologist. The reason is that yes, I have anxiety if my EMG results are actually considered clean. But I am not a doctor nor neurologist to interpret them and I feel that I need to put in statistical perspective (age - I am 34, no clinical weakness as far as I am concerned, clean EMG i hope... what are actually the chances that everything is against my favors). Might do follow up with orthopedist regarding the bicep, but I decided not to feed these fears with another neuro appointment.

I would like to thank to those who replied (or will reply). I wish you the best and I really pray that with additional funding (Biden signed the ALS act right?) the cure or at least treatment to make ALS livable condition is near.

And for those of you who are facing the same issue as I am, please read this:
 

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Great, moving on from this is the best thing you can do for yourself now. All the best.
 

johnny5

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MUP can increase due to re-innervation.

Nerve entrapment can result in damage to the ulnar nerve which would trigger re-innervation. It can also trigger re-innervation if the ulnar nerve entrapment did no damage but only had intermittently blocked the nerve without damage. The nerve growth factor (NGF) can be triggered in unusual circumstances that could cause the increased MUP. It cannot rule in or rule out ALS especially in the absence of other results. ALS must have denervation which would be reflected in fibrillation, sharp waves, and fasciculation potentials. In the absence of denervation, the neurologist should look in another direction for a proper diagnosis.
 

lastime20151

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Thanks Johnny for very detailed answer. If I understand correctly you are saying that the emg can’t be assessed only by high Mups, which I agree. But he also mentions in the report “no major denervation or reinervation”. So even these MUPs +4 without other findings are not a sign of major reinervation?

But I still can’t get over the fact if the emg presented was normal/correct since I was using last couple of days mydocalm (aka tolperisone, 150mg 3x daily, muscle relaxer). I know I might be crucified for my next comment, but I couldn’t resist and Dr Google says that at least 3-5 days you should stop using any muscle relaxers so the clinicial can give you correct results. So no idea who is right and how big can be the impact of this medicine on emg. Additionally I drank coffee just before emg, which by the way you should also avoid before the test.
 

Nikki J

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If the source from Google was correct ( often they are not) what was meant is that the doctor’s clinical exam of you in the office might be affected as a muscle relaxer could potentially mask signs of spasticity. It would not / could not affect the EMG. You are clearly not a doctor and your interpretation of what you think you read appears to be flawed. Please ask your doctor directly to confirm that meds do not matter. If a muscle relaxer fixed denervation every PALS would be taking them and cured
 

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This is what we call desperately clutching at straws now.
 

lastime20151

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well, with all due respect I am not sure if you are right. What I had in mind is that the muscle relaxant will may affect the EMG in a way that if you have fasciculation/twitches any the relaxant might reduce these and therefore may interfere how neurologist interprets the results? what I am asking/not sure about is if the muscle relaxant can actually have that significant affect (see my report, PSW 0, Fasc 0, PosV 0, Poly - N).
here is the link:


good news is that I started physiotherapy and had two sessions. physio assessed there is a weakness in my left arm or shoulder (when i tried to push my arm up when he blocked it, but he said he feels there might be improvement compared to the first session, very subjective though). worrying is that i do not think i have pain, just weakness.

still do not know if i should see the other neurologist that actually has experience neuromuscular diseases.
 

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That is old boilerplate, perhaps based on older drugs and lack of research, and you can see it cut and pasted elsewhere. More modern instructions, included those updated a week ago on drugs.com, call for not smoking or taking in caffeine 2-3 hours prior -- that's about it. I searched PubMed for fun and found no documentation of this alleged interference. In fact, many docs write a benzo, e.g. Valium, to cover those patients who are anxious about the test. Of course, you do have to stay awake.

Remember, the test is about assessing how well the nerves transmit current (the NCS) and how they control the muscles they are assigned to (EMG), which goes on whether you are relaxed or not. When you have a buzz on, you can still lift things, walk, etc. The muscles are still working and so are the nerves that control them. When you are buzzed, you're sluggish or wired because of effects on your central nervous system. But a night of partying doesn't damage your neurons the way that ALS, MS, or muscular dystrophy does.
 

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Let us know how you go. Returning with the final diagnosis is really helpful to those that come after and find this thread when searching.
Please do remember you can search on google until you find some weblink that supports whatever you are sure is happening.
We know ALS, but hey.
 

Nikki J

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As Laurie says this is old and if you look written by some patient education company in 2000 not freshly written by a Cedars neurologist. I bet the Cedars ALS doctors don’t look at these things. I once found terribly outdated/ wrong information on the website of a big ALS center. I knew someone there and messaged him. Once they saw it of course they took it down and were very embarrassed

as a genetic carrier I have had a number of EMGs for research performed by leading emg doctors including the director of the emg lab at NIH. No one restricted meds -or caffeine for that matter. Smoking wasn’t mentioned either but they may have known I don’t smoke. Lastly, I know somebody who posed the question of meds and emgs to a neurologist at the Massachusetts General ALS clinic he said there were no meds that could mask ALS on EMG
 
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