Status
Not open for further replies.
So here are the results to the EMG. Does it matter who performs the EMG? The doctor had his fellow preform it. My dad said he was extremely anxious during the test. I having problems really understanding what all this means so maybe someone here could help me out. Thanks!

Diagnostic impression: 59yo male with muscle twitches and cramps for 1 year. Neuro exam pertinent for tendon hyperreflexia and increased tone in the lower extremities. EMG/NCT suggestive of a widespread disorder of lower motor neurons, with active axonal loss (fibrillations, positive waves) and motor unit irritability (fasciculations, cramps) evident more in bilateral lumbar and less in cervical myotomes.
 
Eric, as I mentioned above--
""The diagnoses of ALS requires the presence of
1. Signs of lower motor neuron (LMN) degeneration by clinical, electrophysiological or neuropathologic examination,
2. Signs of upper motor neuron (UMN) degeneration by clinical examination, and
3. Progressive spread of signs within a region or to other regions, together with the absence of:
o Electrophysiological evidence of other disease processes that might explain the signs of LMN and/or UMN degenerations; and
o Neuroimaging evidence of other disease processes that might explain the observed clinical and electrophysiological signs."

The results were--"Neuro exam pertinent for tendon hyperreflexia and increased tone" which are UMN signs.
"EMG/NCT suggestive of a widespread disorder of lower motor neurons" which are LMN signs.
The "fibrillations, positive waves" show that the denervation process is acute (current).

Obviously I am not a doctor, but I would say that none of that is good news and explains the doctors suspicions about ALS. Your father would still need to show "progression" and every other disease has to be ruled out--remember, ALS is a diagnosis of elimination... and everything else has to be ruled out before a neuro can say absolutely, "It's ALS." This ruling out everything else is the part where it's easy for a neuro to say he suspects ALS--and gets it on the table early--but it's very hard to say with 100% certainty that it's ALS. This can take a long time, be more than a little frustrating, and cause a lot of heartache. But your father needs to follow through with all the other test to rule out everything else. Another opinion can certainly be helpful (mentally and medically) along the way. (If you try U of M, let me know as I may want another center when I'm in that part of the state.)

And, yes, to your first question, I think it can matter who does the EMG. The big centers all have fellows or someone similar do the EMGs. I somehow get a better feeling when my own neuro is sticking in the needles, listening to the crackling and will answer questions. (The fellows, or techs doing the NCSs, generally seem to be forbidden from answering questions.) But truthfully, does it make a real difference? Probably not.

Good luck, patience and courage.
And remember, I am not a doctor, and all of your questions need to be asked of your father's neuros.
 
Can they mess up on the findings of dennervation. If the test wasn't preformed properly can there be false positives for that?
 
Dusty I know you are only here to help and you have to be honest, but your post really scares me. What else could cause something like this to show up on an EMG? Is this pointing strongly at ALS?
 
Of course an EMG could be wrong. Not likely, but possible. That's why everybody should get a second opinion.
Denervation is denervation. It's not ALS. There is no test that positively identifies ALS. The diagnosis of ALS is a diagnosis of elimination. Every other possibility must be eliminated and there are still many, many possibilities. In my non-doctor opinion, the EMG moves you closer to the diagnosis but your father is not there yet. And this started with your questioning the second neuro's snap diagnosis. Given that the first neuro turned to him and probably said something like, "I have a patient showing UMN signs with an abnormal EMG. Will you look at it and tell me what you think." In that scenario, early stage ALS would probably not be a bad opinion. Opinion, not diagnosis.
Now, there are some positive things. You say he is not sowing any clinical weakness. Since clinical weakness is the primary first symptom with most PALS, that is very unusual and your (next) neuro needs to consider other mimic diseases that are still out there.
Remember, I am only trying to help you understand what they told you, not scare you. In my opinion, the EMG and clincal findings are not good news, but I am not a doctor. Hopefully, my information will help you understand a little more and help you shape your questions for your father's doctors.
 
To make a determination of ALS from an EMG, the neurologist wants to see active denervation in muscles that have chronic (old) denervation. From what you've written, the EMG only shows active denervation (fibrillations and sharp waves).

Active denervation can appear on EMG weeks after denervation starts. Chronic denervation starts appearing up to 4 months after denervation starts.

The neurologist may be saying early ALS because no chronic denervation has appeared yet. If their was chronic denervation, it would be indicated by large motor unit potentials (MUPs) in the table in the report. Do you have a table with the report?

My guess is that the other neurologist will want to repeat the EMG in 3 - 6 months to see if chronic denervation appears.
 
My husband was diagnosised two years ago. It took 1 year of testing and visits to Neurologist before the doctors here in New York would give me a diagnosis of ALS. I got three opinions. My husband did have muscle lose but didn't have twitching. There is not one test that can tell you that you have ALS. If it was that easy they could find a cure. Everyone is different and many things need to be ruled out before that diagnosis like lyme disease. My husbands progression is slow and he is living with ALS. I agree with the previous post that diet is so important. It is my believe that ALS comes from the toxins in our environment which includes what we put in our bodies and the air that surrounds us. I am surprised that more people aren't diagnosised with ALS.
Best of luck to you.

Of course an EMG could be wrong. Not likely, but possible. That's why everybody should get a second opinion.
Denervation is denervation. It's not ALS. There is no test that positively identifies ALS. The diagnosis of ALS is a diagnosis of elimination. Every other possibility must be eliminated and there are still many, many possibilities. In my non-doctor opinion, the EMG moves you closer to the diagnosis but your father is not there yet. And this started with your questioning the second neuro's snap diagnosis. Given that the first neuro turned to him and probably said something like, "I have a patient showing UMN signs with an abnormal EMG. Will you look at it and tell me what you think." In that scenario, early stage ALS would probably not be a bad opinion. Opinion, not diagnosis.
Now, there are some positive things. You say he is not sowing any clinical weakness. Since clinical weakness is the primary first symptom with most PALS, that is very unusual and your (next) neuro needs to consider other mimic diseases that are still out there.
Remember, I am only trying to help you understand what they told you, not scare you. In my opinion, the EMG and clincal findings are not good news, but I am not a doctor. Hopefully, my information will help you understand a little more and help you shape your questions for your father's doctors.


I know you are not trying to scare me. This whole process is pretty scary in itself. I appreciate all the time you have taken to respond to me. I'm as just trying to stay calm at let the whole process run it's course.
 
To make a determination of ALS from an EMG, the neurologist wants to see active denervation in muscles that have chronic (old) denervation. From what you've written, the EMG only shows active denervation (fibrillations and sharp waves).

Active denervation can appear on EMG weeks after denervation starts. Chronic denervation starts appearing up to 4 months after denervation starts.

The neurologist may be saying early ALS because no chronic denervation has appeared yet. If their was chronic denervation, it would be indicated by large motor unit potentials (MUPs) in the table in the report. Do you have a table with the report?

My guess is that the other neurologist will want to repeat the EMG in 3 - 6 months to see if chronic denervation appears.


Yes there are a ton of charts on all the papers. I don't have any idea how to read them
So I didn't even try. Not having chronic denervation is a good thing, right?
 
If there is only active denervation, in theory, that leaves the door open that it could be something other than ALS.

For example, active denervation is sometimes found in certain foot muscles of people without ALS due to the wear and tear feet receive. And sometimes it can appear in other muscles due to radiculopathy or other reasons. It is worrisome, howevever, if active denervation is widespread without a known cause.

Maybe the neuro will recommend a lumbar MRI to see if there are disk herniations in the lower back because the denervation seems to be concentrated in the lumbar region bilaterally. But you should check the report to see which muscles had abnormalities.

You can ingore the charts that have to do with the Nerve conduction study, if one was performed.

In the EMG section, the first column in the left side of the chart should list the muscles tested. The subsequent columns (the order may differ) should have headings for Insertional Activity, Spontaneous Activity, MUPs, and Polyphasics... or some variation of that.

Insertional Activity should say Normal or Abnormal for each muscle.

Spontaneous Activty should be broken out into subsections for Fibrillations, PSW (sharp waves) and Fasiculations. In the muscles where those items were found, there should be plus signs (+) or something else to indicate they were found.

MUPs should read abnormal, large, or + in muscles that had chronic denervation.

Polyphasics would show a percentage if the MUPs were polyphasic. Anything above 15% of total MUPs for the muscle is abnormal.
 
I agree with what Bluedog said.

Ignoring the graphs that go with the NCS, focus on the chart for the EMG if there is one. My columns for the EMG are Ins Act and Spont Fib (both excellent indications of active denervation), then Fasc. After that comes the MUP stuff for chronic (long term) denervation--Recruitment Act, Rec, Duration Long, Duration short), Amplitude high, Ampliude low, Phases %, Turns.

Long duration, high amplitude, Phases% and Turns all, I believe, are good indications of chronic denervation.

The EMG you have may show enough to indicate both active and chronic denervation, but you are still a long way from the end of the story. Only 1 dirty EMG. I have 5.
UMN signs only seen by one neuro and UMN signs are somewhat subjective.
Why no weakness? ALSA.org say, "Muscle weakness is a hallmark initial sign in ALS, occurring in approximately 60% of patients."
Which muscles did the EMG?
Is this a widespread problem showing up in 3 regions (lumbosacral, thoracic, cervical and bulbar)? Or is it localized? Maybe a radiculopathy?
Too many questions, and they're pones that need experts to answer them.

As Bluedog said, the other neuro may want to follow up in 3-6 months to look for chronic denervation. On the other hand, you can seek a second (third?) opinion sooner than that.

Good luck! Let us know if there is any more info on the EMG.
 
I agree with what Bluedog said.

Ignoring the graphs that go with the NCS, focus on the chart for the EMG if there is one. My columns for the EMG are Ins Act and Spont Fib (both excellent indications of active denervation), then Fasc. After that comes the MUP stuff for chronic (long term) denervation--Recruitment Act, Rec, Duration Long, Duration short), Amplitude high, Ampliude low, Phases %, Turns.

Long duration, high amplitude, Phases% and Turns all, I believe, are good indications of chronic denervation.

The EMG you have may show enough to indicate both active and chronic denervation, but you are still a long way from the end of the story. Only 1 dirty EMG. I have 5.
UMN signs only seen by one neuro and UMN signs are somewhat subjective.
Why no weakness? ALSA.org say, "Muscle weakness is a hallmark initial sign in ALS, occurring in approximately 60% of patients."
Which muscles did the EMG?
Is this a widespread problem showing up in 3 regions (lumbosacral, thoracic, cervical and bulbar)? Or is it localized? Maybe a radiculopathy?
Too many questions, and they're pones that need experts to answer them.

As Bluedog said, the other neuro may want to follow up in 3-6 months to look for chronic denervation. On the other hand, you can seek a second (third?) opinion sooner than that.

Good luck! Let us know if there is any more info on the EMG.


Ok so I was wrong. I don't have my dads charts. I saw charts somewhere, but I've been reading so much they could have been something from the Internet. I did see an area though where it specifically says EMG results and this is what it says....

EMG/NCS: The electrophysiologic findings are suggestive of a widespread disorder of lower motor neurons with active axonal loss (fibrillations, positive waves) and motor unit irritability (fasciculations, cramps), evident more in bi lateral lumbar, and less in cervical myotomes. These findings can be seen in disorders of anterior horn cells or extensive polyridiculopathies. No evidence of myopathy.

Again a lot of this I cannot make sense of. You guys seem very
Knowledgable, so maybe you could help me out? Thanks again for all your help and support!
 
Also he got a 5/5 on every aspect of his strength test. It also notes he can stand on his toes and heels.
 
Eric I am sorry for what brings you here. Given how your father's symptoms were I can only imagine how much of a shock this is. I understand you are desperate to make sense of this and also to find another answer. Does your dad have an appointment with neuro 1? I know he is not a neuromuscular specialist but he should be able to answer a lot of your questions. He should see your dad quickly too. Did you say you were going to UMiami for second opinion? That sounds like a great idea. At this point he definitely should see an ALS specialist and I think neuro 1 will say that too. I wonder if neuro 2 is in fact an EMG specialist and does not follow patients for regular care. My sister was also given diagnosis at time of EMG and that was the case there. He also had zero compassion

How is your dad dealing with this? And the rest of your family? He is lucky to have you for sure.
 
I would also like to say to the anxious people who will use this as a case of he only had twitching and now he has ALS that although Eric's dad only NOTICED twitching he had an abnormal clinical exam with CLINICAL weakness ( read the whole thread and see where Eric mentions this in spite of the 5/5 on the report) and Upper motor neuron signs.
Sorry to interject this here Eric but felt needed to be said. Thank you
 
I would also like to say to the anxious people who will use this as a case of he only had twitching and now he has ALS that although Eric's dad only NOTICED twitching he had an abnormal clinical exam with CLINICAL weakness ( read the whole thread and see where Eric mentions this in spite of the 5/5 on the report) and Upper motor neuron signs.
Sorry to interject this here Eric but felt needed to be said. Thank you

Where did I say he had clinical weakness?
 
Status
Not open for further replies.
Back
Top