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Question re proximal presentation of ALS

question re proximal presentation of ALS
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Answered in 5 minutes by:
3/2/2013
Dr. Garg
Dr. Garg, Other
Category: Neurology
Satisfied Customers: 45
Experience: Neurologist. Expertise in MS, Dementia, Parkinson's Disease, Stroke, Peripheral Nerve Disorders
Verified
Dr. Garg :

Hello

Dr. Garg :

Please let me know what your question is, I'd be happy to answer

Customer:

my question is this - with limb onset ALS, I realize that the typical progression is distal (ie hands, feet) to proximal. how often does it happen the other way around? specifically, how often do you see a presentation that begins in one shoulder? i'm quite scared...

Customer:

and by quite scared, I mean petrified :(

Dr. Garg :

Hello

Dr. Garg :

Could you please repeat what you typed earlier

Dr. Garg :

It was cut off my by my chat window

Customer:

my question is this - with limb onset ALS, I realize that the typical progression is distal (ie hands, feet) to proximal. how often does it happen the other way around? specifically, how often do you see a presentation that begins in one shoulder? i'm quite scared...

Dr. Garg :

Have you been diagnosed with limb onset ALS?

Customer:

no

Dr. Garg :

Are you concerned that you may have limb onset ALS?

Customer:

yes

Dr. Garg :

Why is this?

Customer:

left shoulder weakness

Dr. Garg :

Have you had an MRI of the neck, EMG?

Customer:

I've not had an mri. I have had a total of 6 emgs since sept 2011

Customer:

the most recent was two weeks ago

Dr. Garg :

I'd love to answer yor question

Dr. Garg :

but I just want to clarify

Dr. Garg :

you have NOT been dx with limb onsetALS

Customer:

no, i'm just scared of it

Customer:

I can elaborate a bit, if you would like

Dr. Garg :

sure

Customer:

all of my emgs have been at my request, firstly.

Customer:

what else would you like to know?

Dr. Garg :

MR?

Customer:

sorry, MR?

Dr. Garg :

MRI

Customer:

no, just emgs

Dr. Garg :

Have you had an evaluation from a Neurologist?

Customer:

yes

Dr. Garg :

what did he / she say?

Customer:

that i'm fine

Customer:

but, back to my original question. how often do you see initial presentation in one shoulder, for upper limb onset?

Dr. Garg :

So there are no exact studies on how fast it will progress

Dr. Garg :

typically lower limb will progress faster

Dr. Garg :

than upper limb

Customer:

okay, but how often does the presentation FIRST begin with a shoulder (proximal) versus hand/fingers (distal)?

Dr. Garg :

its not common to be honest to present in upper limb

Customer:

...and to begin in the shoulder of the upper limb?

Dr. Garg :

when it does present in the upper

Dr. Garg :

limb

Dr. Garg :

its mostly the hand

Customer:

my only concern is weakness in the left (dominant) shoulder

Dr. Garg :

Its not common for isolated shoulder weakness

Customer:

I had an emg of that arm & shoulder two weeks ago.

Dr. Garg :

with normal EMG

Customer:

if there was something going on with that shoulder, would the emg have picked it up?

Dr. Garg :

yes if it was neuropathic

Dr. Garg :

EMG is pretty good

Customer:

sorry, that's what I meant

Dr. Garg :

at picking up stuff like that

Dr. Garg :

The EMG would have shown something if it was ALS

Customer:

I was told that I have a rotator cuff issue, but i'm still scared of als

Dr. Garg :

I understand

Dr. Garg :

but the EMG is normal

Customer:

so I should rely on that?

Dr. Garg :

as a neurologist I would

Dr. Garg :

:)

Customer:

the values on the report were all zeros

Dr. Garg :

I'm sorry I was just confused by your questio

Dr. Garg :

since the EMG are normal

Customer:

meaning, you were wondering why I would still be worried?

Dr. Garg :

yes

Dr. Garg :

its like someone telling me they have a heart attack when the EKG is normla

Customer:

i don't know...guess afraid that the emg was wrong, or the doctor saw some values that he simply did not report.

Dr. Garg :

yes but 6 EMGs are normla?

Customer:

yes

Customer:

but they weren't ALL in this shoulder.

Dr. Garg :

but I mean the shoulder one was normal

Dr. Garg :

honeslty I don't think this is ASL

Dr. Garg :

*ALS with a normal EMG

Customer:

I've had a total of three in the shoulder - dec 2011, march 2012, and the one from two weeks ago

Customer:

the one from two weeks ago involved four needle insertions, from the lower arm to the top, and then the back of the shoulder.

Customer:

when i asked the doctor if the emg would have picked something up, if something were there, he looked at me as though i was insane.

Dr. Garg :

The EMG is normal, you chance of limb associated ALS is low

Customer:

the doctor told me that if i were already experiencing symptoms, there is no way the emg wouldn't have picked it up. is that right?

Dr. Garg :

the EMG is pretty good

Dr. Garg :

at picking up stuff like this

Customer:

does four needle insertions (instead of only one) make it even more reliable, or does it not matter?

Dr. Garg :

well it depends what you're looking for

Customer:

well, als

Dr. Garg :

ALS is diagnosed based on history and exam

Dr. Garg :

and also EMG

Dr. Garg :

so if they looked at one muscle in teh shoulder and it was normal

Dr. Garg :

then I assume they wouldn't want to waste time with the other muscles

Customer:

he did anyway, just to be thorough

Customer:

but he said that it really didn't matter where he put that needle in the arm. if there was anything going on anywhere, it would pick it up. correct?

Dr. Garg :

thats correct

Customer:

you can appreciated, i'm quite worked up here

Customer:

i'm having trouble believing the emg was correct, and that the shoulder weakness is from a rotator cuff issue.

Dr. Garg :

I can

Dr. Garg :

I can sense it

Dr. Garg :

do you have any other questions?

Customer:

a little more, yes. sorry, i just don't want to have to come back on later.

Dr. Garg :

sure

Customer:

so in your experience, the upper limb presentations you've seen have begun in the distal part of the limb?

Dr. Garg :

typically yes

Dr. Garg :

hand weakness

Dr. Garg :

but this is rare stuff

Customer:

okay. i don't have any of that.

Customer:

as well...to get an idea of how the weakness is...

Dr. Garg :

of the hand?

Customer:

from what I've been told, it's like you're telling your body part to move, and it just won't do what you want, despite feeling "normal" by other accounts. is that right?

Dr. Garg :

thats the sense i get from patients also

Customer:

my weakness is more that i can do whatever it is i'm wanting to do, it's just more difficult

Dr. Garg :

is there anything else I can help you with?

Customer:

what i understand is that with als, patients don't FEEL anything is off, they just don't understand why something ceases working.

Dr. Garg :

thats correct - they want to move the limb, but it doesn't move

Customer:

okay

Customer:

so you don't think i need another emg?

Dr. Garg :

having not seen the official EMG report

Dr. Garg :

i cant' answer that

Dr. Garg :

but if your doctor said it was normal

Dr. Garg :

i dont' know how another study would help

Customer:

i saw the report - the values beside all of the columns were all zeroes

Dr. Garg :

i don't see how another study would help

Customer:

for fibs, fasciculations, positive waves, etc

Customer:

okay...

Customer:

should i try to calm down?

Dr. Garg :

yes

Dr. Garg :

:)

Dr. Garg :

please PM if you have any questions. feedback is appreciated, we're only compensated for excellent feedback

Customer:

great, thanks dr

Dr. Garg
Dr. Garg, Other
Category: Neurology
Satisfied Customers: 45
Experience: Neurologist. Expertise in MS, Dementia, Parkinson's Disease, Stroke, Peripheral Nerve Disorders
Verified
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Dr. Garg
Dr. Garg
Dr. Garg, Other
Category: Neurology
Satisfied Customers: 45
45 Satisfied Customers
Experience: Neurologist. Expertise in MS, Dementia, Parkinson's Disease, Stroke, Peripheral Nerve Disorders

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