Dr. Aida Abaz Quka
Neurology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I am concerned regarding the symptoms of ALS. I have muscle twitching in my right leg, foot, calf, thigh, and knee. Along with tingling and popping sensations, I have a weakness-type feeling in my right leg and foot. Kindly go through the attachment. I also have twitching in my left arm, shoulder, and back. I have weakness in my right hand and wrist with pins and needles while sitting or lying. I have tightness and restricted feeling in my throat. I seem to have some inability to speak properly with a change in voice.
It seems to be hoarse without slurred speech. My tongue seems to be strange and large. I have a lumpy type feeling in my throat while swallowing. I can still able to swallow and eat. Along with this, I have an imbalance in my body with unsteadiness. My legs appear thin. I have constant fatigue and weight loss. I consulted a neurosurgeon and got a diagnosis of Chiari malformation type 1.
I did an EMG in my left leg, calf, and thigh. I did another EMG in my right leg, left arm, biceps, and forearm. The neurologist told me that it does not show any evidence of ALS. What is the problem? My grandmother had ALS while she was 68 years old. Please suggest.
Hi,
Welcome to icliniq.com.
I have gone through the attached photo (attachment removed to protect patient identity). Your EMG (electromyography) is normal. We can exclude ALS (amyotrophic lateral sclerosis) in your case. It is necessary to do some investigations to rule out the possible cause. For this, you need to do vitamin D, vitamin B12 plasma levels, thryoid hormone levels, blood electrolytes including magnesium and calcium, PCR (polymerase chain reaction), ESR (erythrocyte sedimentation rate), and complete blood count. You do not have any abnormal thinning in your legs. If the above-mentioned results are normal, then you can have a diagnosis of benign fasciculation syndrome. Clonazepam can be taken in low doses to reduce muscle twitching.
Patient's Query
Thank you doctor,
I have done all the blood tests suggested by you and they are normal. Can I have ALS? My EMG showed some fasciculations with some physical symptoms. Is it enough to diagnose ALS? I have done my first EMG in my left leg. I did not have any issues at that time. I have done my second EMG on my right leg and three other places in my body. Does EMG with fasciculations and physical symptoms is enough to diagnose ALS? Do you see any muscle wasting and atrophy in your legs?
Hi,
Welcome back to icliniq.com.
I cannot see any leg wasting or atrophy. Atrophy and muscle wasting will not get started in this region. It usually begins in the feet and hands. As you have done EMG in three other places, so it is enough to exclude ALS. In the case of ALS, it should show some denervation and reinnervation pattern with muscle fibrillation (spontaneous acitivity with fasciculations) in more than three regions of the spinal cord innervated muscles. You can have a diagnosis of benign fasciculation syndrome. I suggest you do yoga and physical activity regularly. If you have muscle twitching persistently, then I suggest you start taking Clonazepam in low doses. It helps to reduce muscle twitching.
Patient's Query
Thank you doctor,
Does spontaneous activity is same as fasciculations? I have done EMG on my thoracic back, legs, arms, hands, and under the chin with a needle. Do these come under spinal regions?
Hi,
Welcome back to icliniq.com.
Spontaneous activity in EMG is evident as fasciculations in the muscle. These regions are related to three different levels of the spinal cord. So it helps to exclude ALS.
Patient's Query
Thank you doctor,
What happens if EMG was not done in the area showing denervation and reinnervation patterns? Is this possible?
Hi,
Welcome back to icliniq.com.
No, you are wrong. ALS is a progressive disease and it goes through different stages in a year or two. The EMG changes are first observed on the spinal cord and then it spreads to other parts. Even in the first stage, we can be able to detect a diagnosis of ALS and a follow-up with EMG is necessary to see the progression.
Patient's Query
Thank you doctor,
I am concerned about my leg wasting present on my right side. If I had a slight wasting at the EMG point, can it be able to detect it? Kindly go through the attachment.
Hi,
Welcome back to icliniq.com.
There is no wasting seen in these photos. Wasting usually occurs in advanced stages of ALS and the diagnosis can be confirmed by doing EMG (electromyography) and ENG (electroneurography).
Patient's Query
Thank you doctor,
Do these symptoms are atypical of ALS?
Hi,
Welcome back to icliniq.com.
Your symptoms are not typical of ALS as you do not have muscle weakness and bulbar signs. You do not have any difficulty in speaking or chocking food.
Patient's Query
Thank you doctor,
I have some tightening feeling in the throat consistently. I have some strange feeling in my tongue and it makes me hard to speak. But still, I can eat and drink. Do these symptoms indicate bulbar signs?
Hi,
Welcome back to icliniq.com.
This is not a bulbar sign. The tightening feeling in the throat occurs due to anxiety. There is no tongue thinning and you do not need to think about ALS.
Patient's Query
Thank you doctor,
It is not tight but I feel like I cannot swallow my food. My voice seems to be hoarse and I feel tightness in my throat while speaking. Kindly go through the attached photo of the tongue. Please suggest whether I have tongue thinning.
Hello,
Welcome back to icliniq.com.
Your tongue is perfectly normal. There is nothing to be worried.
Patient's Query
Thank you doctor,
I have this feeling in my throat after four months. Can I have a loss of function to swallow or speak?
Hi,
Welcome back to icliniq.com.
Yes, you can have some difficulty in swallowing in the future.
Patient's Query
Thank you doctor,
Kindly go through the attached image.
Hi,
Welcome back to icliniq.com.
There is nothing abnormal in the image of your legs. They appear in a good shape. You can check your leg diameter manually with a flexible meter. A small difference can be considered normal. Regarding anxiety, I suggest you repeat your ENG after six months. Regarding tightness, I suggest you do a thryoid gland ultrasound soon.
Patient's Query
Thank you doctor,
I have measured my leg using tape and my calves measure the same. What does this suggest? I have done two EMGs already. I have done my thyroid test with blood tests. I had a TSH of 3.27 mIU/L and a free T4 of 175 ng/dL. Please suggest.
Hi,
Welcome back to icliniq.com.
You seem to have normal thyroid levels. You do not have any muscle wasting. As your second EMG was normal, then it shows that you do not have ALS.
Patient's Query
Thank you doctor,
My symptoms are getting worse for the past three months. I have some feeling in my throat with hoarseness in my voice. I feel like something is stuck in my throat. I have weakness in my legs and foot. But I am still able to walk, raise my tiptoes and heel. Please advise. Can I have ALS genetically?
Hi,
Welcome back to icliniq.com.
I suggest you start taking magnesium supplements 300 to 400 mg daily and Clonazepam 0.5 mg twice daily. If this situation gets improved, then it is benign fasciculation syndrome.
Patient's Query
Thank you doctor,
I have done an EMG and the neurologist told me that it does not show ALS. Can I have these symptoms due to ALS?
Hi,
Welcome back to icliniq.com.
Your symptoms does not suggest ALS. You do not have any signs of damaged nerves or muscles. There is nothing to be worried. You need to increase the dose of Clonazepam to 2 mg twice daily.
Patient's Query
Thank you doctor,
Does EMG was not able to pick the damage of nerves and muscles? Whether it was done soon or it was not able to pick it? Is this possible?
Hi,
Welcome back to icliniq.com.
ENG can detect nerve damage if it was present. So I suggest you repeat ENG after six months.
Patient's Query
Thank you doctor,
If I had some muscle wasting, will it have detected the damage? You are saying me to repeat the ENG after six months. Do these symptoms suggest ALS?
Hi,
Welcome back to icliniq.com.
Your ENG will shows normal results. Please do not be worried.
Patient's Query
Thank you doctor,
If I had muscle wasting, will my EMG have shown more fasciculations?
Hi,
Welcome back to icliniq.com.
As mentioned above, muscle wasting occurs in advanced stages but ENG can detect early changes even when wasting is not present.
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Neurology
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