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Dr. Frank
Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 7201
Experience:  Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
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HI, I am back with additional questions. I have been examined

Resolved Question:

HI, I am back with additional questions. I have been examined by two neurologists, one i february and one in april. They both said that they could not find signs of ALS, though I experienced the first exam as wery breif. The second neurologist was more thorough, but I did not have any fasciculations when the minutes hee looked for them. I have done two EMG:s, one in januari and one in may. They came back totally clean.
Since I wrote the last time, I have had severe weakness in my hips (gluteus medius) confirmed by two physioterapists.
No needles were put in the gluteus medius in the EMG:s, nore in the inside foot area, where the fasciculations are most frequent. Since my last neurology visit (april) and my last EMG (middle of may) I have developed some difficulty swalloing and my talking feels stranged, like the tounge gets tired wery easily. I have an extermely unplesant feeling in my throat all the time. My litte fingers in both hands have also began to curve in when hands are relaxed/closed. I feel tired in my arms and hands and the tremble. My right hip is so week that it is almost impossible to lean on it when I stand up. I have an overall difficulty standing without support and my legs are shaky. The fasciculations have spread to calves and top of foot (especially on my right side). The last EMG was done on the area between index finger and thumb, calves, thigh muscle above knee (both sides), left side of face close to mouth, left side of tongue and left shoulder (trapeziuz ?). After that examination I got a letter which said that I was good to go.
Are the EMG sufficient though it was not done on the area were I am weak/have most fasciculations?
Should I seek a THIRD opinion?
Thanks!
Submitted: 1 year ago.
Category: Neurology
Expert:  Dr. Frank replied 1 year ago.

neuromd2012 :

Welcome to Just Answer. I am an Adult Neurologist and was contacted to answer your question.

neuromd2012 :

Hello again. Sorry to hear you continue to have problems.

neuromd2012 :

There is no question that the weakness you describe does not correlate with "normal" EMG's

neuromd2012 :

I would ask if the weakness was evident during the time of the last EMG at all????

neuromd2012 :

was there any sense of hip flexor or gluteus weakness that the neurologist found on exam?

neuromd2012 :

if not, then you really are back to square one, you need a diagnosis for your hip weakness, be it

neuromd2012 :

lumbar nerve problems, or hip problems, or Motor neuron disease

neuromd2012 :

In my opinion, you cannot have marked weakness in those thigh muscles with a normal EMG of those muscles

Customer:

That is the thing, the neurophysiologist who performed the EMG did not put the needle in the gluteus medius at alla, just the other areas that i mentioned. The neurologist I wisited, who referred me to the EMG, did not do any specific examination of my hips. The weakness is confired by physiotheraphists.

Customer:

When I tried to get an answer to why no needle was put in gluteus medius, I was told that they follow a special protocol.

neuromd2012 :

well the gluteus are large muscles, with very large motor unit areas, so the sensitivity for finding MND (ALS, etc) is not

neuromd2012 :

as good as the smaller muscles.

neuromd2012 :

like the first dorsal interosseus between your index finger and thumb, and the face, and tongue

neuromd2012 :

that is why they have a protocol

neuromd2012 :

so they can maximize there chance of finding a problem

neuromd2012 :

if you have problems swallowing, you need another examination,

neuromd2012 :

and if you have weakness in your hips, and a normal EMG, you need a muscle biopsy

neuromd2012 :

something does not add up here

neuromd2012 :

so that is about all I can say

Customer:

Okay, so ju think It could be ALS or something?

neuromd2012 :

I really cannot say from here. I would need to examen you. But I would say that if you have weakness noted by physiotherapists, than you need an answer as to why

Customer:

I have tried to get hold of the neurologist who referred me, but I am told by the nurses that I should take up my problems with my GP.

neuromd2012 :

you can have normal EMG;s in the initiation of ALS, but after a few months it usually is fairly obvious, so with 2 emg's being normal, statistically I would say unlikely you have ALS

Customer:

My EMG was done about 5 months after my fasciculations started in the foot, and about three months after the hip weakness was confirmed.

Customer:

but then again, the needle was not put in the weak muscle.

Customer:

should there have been signs in other muscles too? That was what the neuropsysology doctor who performed the test said, that at least one of the examined muscle would have shown someting.

Customer:

At the neurology exam I was told that i did not have any reflex abnormality or spacicity.

neuromd2012 :

there should be signs in muscles that are not effected. No question about that.

neuromd2012 :

so this is puzzling from here. That is why sometimes you can have normal EMG findings, and have muscle disorders giving rise to weakness

neuromd2012 :

and you need the muscle biopsy

neuromd2012 :

without spasticity or hyperreflexia, it is also highly unlikely that you have ALS in the setting or present weakness

neuromd2012 :

I hope that answers your questions, please get back to me if you have additional questions and I will return with a reply

neuromd2012 :

Dr Frank t

Customer:

okay, I am not sure what hyperreflexia means, I have brisk reflexes, buth both neurologist seem to think that they were normal.

neuromd2012 :

hyperreflexia is brisk reflexes, that can also be normal if that is the way you are, and not acquired over time

Customer:

And also: should my inside foot muscle, where the fasciculations is ongoing almost 24/7, be examined by biopsy? And what about the fingers I mentioned, Is that phenomenon linked to ALS?

neuromd2012 :

no

neuromd2012 :

you biopsy would be from larger muscles as you do not want to damage smaller muscles in your foot.

neuromd2012 :

if you have hip weakness, and fasciculations, that would be the place to do the biopsy

Customer:

Okay. Is there any point in having an EMG of the inside of the foot? I do not have wery much fasciculations in the gluteus area, just random, like I have in other muscles.

Customer:

Your "no-answer", was that about the fingers or about the biopsy?

Customer:

I am sorry I have to go in a minute.

neuromd2012 :

no biopsy in the fingers or feet

neuromd2012 :

your hand muscles have very fine motor units, if the needle exam is clean in those areas, it really suggests you do not have ALS

neuromd2012 :

that is the idea I am trying to get across,

Customer:

Is the finger phenomenon linked to ALS

neuromd2012 :

no

neuromd2012 :

curling of your fingers, suggest a peripheral nerve problem.

neuromd2012 :

it is called "main en griffe"

Customer:

okay, soon have to go, so I should not ask for EMG of the foot?

Customer:

Thank you

neuromd2012 :

very unlikely to be abnoral

neuromd2012 :

you are welcome

neuromd2012 :

good luck

neuromd2012 :

bye

neuromd2012 :

Dr Frank t

Dr. Frank, Board Certified Physician
Category: Neurology
Satisfied Customers: 7201
Experience: Board certified general Adult Neurologist, with experience in experimental neuroimaging and neurodiagnostics.
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