Resolved question:
It is much appreciated if I get consultation from a neurologist as I have a few questions on ALS. I also understand that it's not possible to diagnose someone over internet. But your thoughts or experience in this kind of situation will be very helpful:
I am 27 years old male, Indian, Bengali (East India).I am doing PhD and presently in Canada for 2 years. About 6 months months back (May,2014 end) I have developed widespread twitching but more often on right arm, right thigh, right back shoulder and left arm (just two weeks after I started taking Cipralex due to my anxiety suggested by my GP as I have been hypochondriac with ALS). My general practitioner suggested me to a neurologist. I had two thorough neurological exams which were normal except grade 1 reflexes (at knees, hamstrings and Achilles as well as in upper extremities like biceps, triceps and Bronchioradialis).
Next, an EMG/NCV was performed (right deltoid, medial gastrocnemias, vastus medialis and rectus femoris) which came out to be normal (normal insertional activity, no spontaneous activity, normal motor unit action potentials with full recruitment pattern) as well. Also had MRI which was normal (head and lumbar spine). This was done in August end after 3 months of symptoms. I have been given a follow up but in April 2015.
Here is what I am writing to you for :
My twitching is still there with a bit reduced intensity and frequency I believe but developed a very infrequent tongue twitch sometime which I cant see but can feel. My questions are :
1. Does normal emg (even at very early stage) rules out LMN ALS or classic case of ALS?
2. I have no Babinski, hoffman or brisk reflexs at the the neuro exam. Nor do I feel any spasticity in limbs (but some stiffness in lower back). Does this suffices to rule out UMN predominant ALS (even at very early stage)?
3.Does EMG on biceps can pick up bulbar symptoms? I am not slurring till now or having swallowing issue. Could Bulbar symptom in ALS start with twitch?
Also I have never been athletic in my life.
I am very anxious all the time and cannot get ALS out of my head. I have already read loads of research paper on ALS and still could not find a consistent answer. Please help.
Submitted:
4 Days
Category:
Neurologist, Medical
Hello Mr. Sandip,
Thank you for your query at DoctorSpring.com
With a normal neurological evaluation and MRI, ALS can be safely ruled out.
The twitchings that you're experiencing can be a part of your anixety or could be due to electrolyte disturbances. To answer your query yes normal EMG does rule out ALS. There are no obvious signs of muscle atrophy, which is the commonest presenting feature. The muscle bulk will differ, and that causes suspicion, but there is nothing like that in your case.
Bulbar symptoms do not start with twitching. The commonest presentation is muscle atrophy in ALS. Bulbar symptoms, in 25 % of cases approximately commonly present with slurring of speech, and difficulty in swallowing.
Please do not worry about ALS.
Continue the vitamin supplement, and discuss with your local physician about good anti anxiety medications.
Regards.
Respected Dr. Sudhir,
Thanks for your invaluable comments and I really appreciate it much.
Just a couple of follow up questions:
1. How early can an EMG detect abnormality? I mean can it detect very early in the course of disease also?
2. Can subclinical hypothyroidism cause twitching and muscular pain?
3. Do you think I should also request for a bulbar EMG?
4. Though I have some idea, but how common is ALS below age 30 for a person who is non-athletic and not a veteran of war or have family history of ALS?
Sorry, these are my last few questions. Thanks again for your time.
Regards,
Sandip
Hello,
Thank you for your follow up.
To answer your questions :
1) EMG is the first reliable diagnosis that we order if we suspect ALS. It can pick up ALS, even in the earliest stage. Apart from EMG, we also rely on Nerve Conduction Study ( NCV ). These two tests can effectively rule out ALS.
2) Subclinical hypothyroidism does not cause twitching per se, but can cause fatigue, leading to muscle pain. Also at times the reflexes can be slower, such as knee reflex.
3) You do not need Bulbar EMG. You have signs or symptoms suggestive of ALS.
4) ALS itself is very rare. The prevalence is around 1-2 cases per 1,00,000 population. It got a lot of publicity with the recent Ice bucket challenge, hence such awareness. But in reality there are lots of other issues to focus on before ALS.
Please do not worry Sandip. Continue your vitamin supplements.
Wish you great health!
Regards.
Hi Dr. Sudhir,
Thank you very much, sorry to bother again, just one final question.
My EMG was done on right arm and leg, but if there is a problem on the left hand can it still recognize the problem? I am asking this because my left palm twitches sometimes and don't know why there seems to be a bit less muscle bulk in the thenar area. If it is something ominous, could I still use my left hand fingers properly?
Thanks for your support.
Regards,
Sandip.
Hello,
ALS mostly involves both limbs, so if it has been ruled out in one limb, it is ruled out for the other too.
See through EMG a lot of things are inferred, such as abnormal motor units, number of fasciculation potentials, e.t.c
So EMG won't be normal if there were signs of ALS in either limb.
As per the less muscle bulk in the thenar area, it needs to be reviewed by a neurologist there. But i can assure you in ALS, in almost all cases there is bilateral symmetrical wasting. And apart from thenar muscles, other muscles like supraspinatus/infraspinatus and deltoid are also affected.
Regards.