Lower motor neuron involvement examined by quantitative electromyography in amyotrophic lateral sclerosis

Spontaneous activity in electromyography may differentiate certain benign lower motor neuron disease forms from amyotrophic lateral sclerosis

There is limited data on electromyography (EMG) findings in other motor neuron disorders than amyotrophic lateral sclerosis (ALS). We assessed whether the distribution of active denervation detected by EMG, i.e. fibrillations and fasciculations, differs between ALS and slowly progressive motor neuron disorders. We compared the initial EMG findings of 43 clinically confirmed, consecutive ALS patients with those of 41 genetically confirmed Late-onset Spinal Motor Neuronopathy and 14 Spinal and Bulbar Muscular Atrophy patients. Spontaneous activity was more frequently detected in the first dorsal interosseus and deltoid muscles of ALS patients than in patients with the slowly progressive motor neuron diseases. The most important observation was that absent fibrillations in the first dorsal interosseus muscle identified the benign forms with sensitivities of 66%-77% and a specificity of 93%. The distribution of active denervation may help to separate ALS from mimicking disorders at an early stage.

Sensitivity and specificity of threshold tracking transcranial magnetic stimulation for diagnosis of amyotrophic lateral sclerosis: a prospective study

BACKGROUND

Diagnosis of amyotrophic lateral sclerosis (ALS) remains problematic, with substantial diagnostic delays. We assessed the sensitivity and specificity of a threshold tracking transcranial magnetic stimulation (TMS) technique, which might allow early detection of upper motor neuron dysfunction, for the diagnosis of the disorder.

METHODS

We did a prospective study of patients referred to three neuromuscular centres in Sydney, Australia, in accordance with the Standards for Reporting of Diagnostic Accuracy. Participants had definite, probable, or possible ALS, as defined by the Awaji criteria; or pure motor disorder with clinical features of upper and lower motor neuron dysfunction in at least one body region, progressing over a 6 month follow-up period; or muscle wasting and weakness for at least 6 months. All patients underwent threshold tracking TMS at recruitment (index test), with application of the reference standard, the Awaji criteria, to differentiate patients with ALS from those with non-ALS disorders. The investigators who did the index test were masked to the results of the reference test and all other investigations. The primary outcome measures were the sensitivity and specificity of TMS in differentiating ALS from non-ALS disorders; these measures were derived from receiver operator curve analysis.

FINDINGS

Between Jan 1, 2010, and March 1, 2014, we screened 333 patients; 281 met our inclusion criteria. We eventually diagnosed 209 patients with ALS and 68 with non-ALS disorders; the diagnosis of four patients was inconclusive. The threshold tracking TMS technique differentiated ALS from non-ALS disorders with a sensitivity of 73·21% (95% CI 66·66-79·08) and specificity of 80·88% (69·53-89·40) at an early stage in the disease. All patients tolerated the study well, and we did not record any adverse events from performance of the index test.

INTERPRETATION

The threshold tracking TMS technique reliably distinguishes ALS from non-ALS disorders and, if these findings are replicated in larger studies, could represent a useful diagnostic investigation when combined with the Awaji criteria to prove upper motor neuron dysfunction at early stages of ALS.

FUNDING

Motor Neuron Disease Research Institute of Australia, National Health and Medical Research Council of Australia, and Pfizer.

Quantifying disease progression in amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) exhibits characteristic variability of onset and rate of disease progression, with inherent clinical heterogeneity making disease quantitation difficult. Recent advances in understanding pathogenic mechanisms linked to the development of ALS impose an increasing need to develop strategies to predict and more objectively measure disease progression. This review explores phenotypic and genetic determinants of disease progression in ALS, and examines established and evolving biomarkers that may contribute to robust measurement in longitudinal clinical studies. With targeted neuroprotective strategies on the horizon, developing efficiencies in clinical trial design may facilitate timely entry of novel treatments into the clinic.

Presymptomatic electrophysiological tests predict clinical onset and survival in SOD1(G93A) ALS mice

INTRODUCTION

We assessed the predictive value of electrophysiological tests as a marker of clinical disease onset and survival in superoxide-dismutase 1 (SOD1)(G93A) mice.

METHODS

We evaluated the accuracy of electrophysiological tests in differentiating transgenic versus wild-type mice. We made a correlation analysis of electrophysiological parameters and the onset of symptoms, survival, and number of spinal motoneurons.

RESULTS

Presymptomatic electrophysiological tests show great accuracy in differentiating transgenic versus wild-type mice, with the most sensitive parameter being the tibialis anterior compound muscle action potential (CMAP) amplitude. The CMAP amplitude at age 10 weeks correlated significantly with clinical disease onset and survival. Electrophysiological tests increased their survival prediction accuracy when evaluated at later stages of the disease and also predicted the amount of lumbar spinal motoneuron preservation.

CONCLUSIONS

Electrophysiological tests predict clinical disease onset, survival, and spinal motoneuron preservation in SOD1(G93A) mice. This is a methodological improvement for preclinical studies.

Endomicroscopy and electromyography of neuromuscular junctions in situ

Objective

Electromyography (EMG) is used routinely to diagnose neuromuscular dysfunction in a wide range of peripheral neuropathies, myopathies, and neuromuscular degenerative diseases including motor neuron diseases such as amyotrophic lateral sclerosis (ALS). Definitive neurological diagnosis may also be indicated by the analysis of pathological neuromuscular innervation in motor-point biopsies. Our objective in this study was to preempt motor-point biopsy by combining live imaging with electrophysiological analysis of slow degeneration of neuromuscular junctions (NMJs) in vivo.

Methods

We combined conventional needle electromyography with fiber-optic confocal endomicroscopy (CEM), using an integrated hand-held, 1.5-mm-diameter probe. We utilized as a test bed, various axotomized muscles in the hind limbs of anaesthetized, double-homozygous thy1.2YFP16: Wld^S mice, which coexpress the Wallerian-degeneration Slow (Wld^S) protein and yellow fluorescent protein (YFP) in motor neurons. We also tested exogenous vital stains, including Alexa488-α-bungarotoxin; the styryl pyridinium dye 4-Di-2-Asp; and a GFP conjugate of botulinum toxin Type A heavy chain (GFP-HcBoNT/A).

Results

We show that an integrated EMG/CEM probe is effective in longitudinal evaluation of functional and morphological changes that take place over a 7-day period during axotomy-induced, slow neuromuscular synaptic degeneration. EMG amplitude declined in parallel with overt degeneration of motor nerve terminals. EMG/CEM was safe and effective when nerve terminals and motor endplates were selectively stained with vital dyes.

Interpretation

Our findings constitute proof-of-concept, based on live imaging in an animal model, that combining EMG/CEM may be useful as a minimally invasive precursor or alternative to motor-point biopsy in neurological diagnosis and for monitoring local administration of potential therapeutics.

Cortical hyperexcitability precedes lower motor neuron dysfunction in ALS

OBJECTIVE

To determine whether cortical hyperexcitability preceded the development of lower motor neuron (LMN) dysfunction in sporadic amyotrophic lateral sclerosis (ALS).

METHODS

Cortical excitability studies were undertaken in 24 ALS patients with motor evoked potential (MEP) recorded over the abductor pollicis brevis (APB) muscle. In the same sitting, LMN function of the target APB muscle was assessed utilising qualitative and quantitative electromyography techniques along with axonal excitability studies.

RESULTS

At time of assessment, the anatomical and functional integrity of the lower motor neuronal circuits innervating the target APB muscle was preserved in all patients, confirmed by a normal CMAP amplitude (P=0.37), absence of fasciculations, or features of neurogenic change. Despite this apparent 'normality' cortical dysfunction was evident, with significant reduction of short interval intracortical inhibition (P<0.01), resting motor threshold (P<0.05) and cortical silent period duration (P<0.001), along with increases in MEP amplitude (P<0.05) and intracortical facilitation (P<0.05).

CONCLUSION

The findings in the present study suggest that cortical hyperexcitability occurs upstream to a seemingly intact lower motor neuronal system.

SIGNIFICANCE

Corticomotoneuronal dysfunction appears to be a primary event in ALS, suggesting a cortical origin of the disease.

Changes in motor unit properties in SOD1 (G93A) rats

INTRODUCTION

In amyotrophic lateral sclerosis (ALS), progressive death of motor neurons results in denervation and reinnervation of muscles. It is not clear how ALS affects the properties of motor units (MUs).

METHODS

Properties of single MUs in the medial gastrocnemius (MG) muscle of rats bearing the human mutated superoxide dismutase gene type 1 (SOD1) were determined at 3 stages: asymptomatic (ALS I); early symptomatic (ALS II); and terminal (ALS III).

RESULTS

In ALS II, higher proportions of FF (fast fatigable) and S (slow) MUs were observed, whereas in ALS III higher percentages of S and lower percentages of FF MUs were noted compared with controls. S motor neurons reinnervated fast muscle fibers, and those MUs gained some properties of fast MUs, including lower fatigue resistance, greater force generation, and higher action potential amplitudes.

CONCLUSION

Changes in MU properties of SOD1 rats have progressive and multidirectional character and speed depending on the MU type.

[Epidemiology, clinical spectrum of ALS and differential diagnoses]

Amyotrophic Lateral Sclerosis (ALS) is the most common motor neuron disease in adults. Its incidence in France is estimated at 2.5 per 100,000 population and its prevalence between 5 and 8 per 100,000 inhabitants. Good prognostic factors are age of early onset, a longer time to diagnosis, initial damage to the spinal onset, early management of undernutrition and restrictive respiratory failure. The diagnosis of ALS is primarily clinical and is based on the evidence of involvement of the central motor neuron and peripheral neuron (NMP) in different territories or spinal or bulbar. The EMG confirms the achievement of NMP, shows the extension to clinically preserved areas and allows to exclude some differential diagnoses. The clinical spectrum of ALS is broad: conventional forms beginning brachial, lower limb or bulbar onsets, rarer forms to start breathing, pyramidal forms, forms with cognitive and behavioural impairment. In 5-10% of cases, ALS is familial. In 15% of cases, it is associated with frontotemporal degeneration rather than orbito-frontal type. The main differential diagnoses are guided by the clinic: combining pure motor neuropathy with or without conduction block, post-polio syndrome, cramp-fasciculation syndrome, myasthenia gravis, paraneoplastic syndromes, Sjögren syndrome, retroviral infections, some endocrine disorders, some metabolic diseases, genetic diseases (Kennedy and SMA) and inclusion body myositis.

Spreading of amyotrophic lateral sclerosis lesions--multifocal hits and local propagation?

OBJECTIVE

To investigate whether or not the lesions in sporadic amyotrophic lateral sclerosis (ALS) originate from a single focal onset site and spread contiguously by prion-like cell-to-cell propagation in the rostrocaudal direction along the spinal cord, as has been hypothesised (the 'single seed and simple propagation' hypothesis).

METHODS

Subjects included 36 patients with sporadic ALS and initial symptoms in the bulbar, respiratory or upper limb regions. Abnormal spontaneous activities in needle electromyography (nEMG)-that is, fibrillation potentials, positive sharp waves (Fib/PSWs) or fasciculation potentials (FPs)-were compared among the unilateral muscles innervated by different spinal segments, especially between the T10 and L5 paraspinal muscles, and between the vastus medialis and biceps femoris. Axon length and the proportion of muscle fibre types, which are both related to motoneuronal vulnerability in ALS, are similar in the paired muscles.

RESULTS

Fourteen of 36 patients showed a non-contiguous distribution of nEMG abnormalities from the onset site, with skipping of intermediate segments. In eight of them, the non-contiguous pattern was evident between paired muscles with the same motoneuronal vulnerability. The non-contiguously affected lumbosacral lesions involved motoneuron columns horizontally or radially proximate to one another, appearing to form a cluster in four of the eight patients. FPs, known to precede Fib/PSWs, were shown more frequently than Fib/PSWs in all the lumbosacral segments but L5, suggesting that 2nd hits occur at L5 and then spread to other lumbosacral segments.

CONCLUSIONS

In sporadic ALS, the distribution of lower motoneuron involvement cannot be explained by the 'single seed and simple propagation' hypothesis alone. We propose a 'multifocal hits and local propagation' hypothesis instead.

Reliability of spike triggered averaging of the surface electromyogram for motor unit action potential estimation

INTRODUCTION

The reliability of estimated motor unit parameters using spike triggered averaging (STA) of the surface electromyogram (sEMG) has not been tested thoroughly. We investigated factors that may induce amplitude bias in estimated motor unit action potentials (MUAPs) and shape variations.

METHODS

An sEMG record was simulated. MUAPs were then estimated from the STA of the simulated EMG.

RESULTS

Variations in MUAP duration led to under-estimation of real MUAP amplitude, while synchronized firing led to over-estimation of amplitude. Spurious firing resulted in over-estimation of the amplitude of small motor units but under-estimation of the amplitude of large ones. Variability in amplitude and high firing rates had minimal influence on amplitude estimation. High firing rates and variation in MUAP duration led to large variations in MUAP shape. Estimation errors also correlated with shape variations.

CONCLUSIONS

Recommendations to enhance the accuracy of the STA estimates have been proposed.

Intra-rater reliability of motor unit number estimation and quantitative motor unit analysis in subjects with amyotrophic lateral sclerosis

OBJECTIVES

To assess the intra-rater reliability of decomposition-enhanced spike-triggered averaging (DE-STA) motor unit number estimation (MUNE) and quantitative motor unit potential analysis in the upper trapezius (UT) and biceps brachii (BB) of subjects with amyotrophic lateral sclerosis (ALS) and to compare the results from the UT to control data.

METHODS

Patients diagnosed with clinically probable or definite ALS completed the experimental protocol twice with the same evaluator for the UT (n=10) and BB (n=9).

RESULTS

Intra-rater reliability for the UT was good for the maximum compound muscle action potential (CMAP) (ICC=0.88), mean surface-detected motor unit potential (S-MUP) (ICC=0.87) and MUNE (ICC=0.88), and for the BB was moderate for maximum CMAP (ICC=0.61), and excellent for mean S-MUP (ICC=0.94) and MUNE (ICC=0.93). A significant difference between tests was found for UT MUNE. Comparing subjects with ALS to control subjects, UT maximum CMAP (p<0.01) and MUNE (p<0.001) values were significantly lower, and mean S-MUP values significantly greater (p<0.05) in subjects with ALS.

CONCLUSIONS

This study has demonstrated the ability of the DE-STA MUNE technique to collect highly reliable data from two separate muscle groups and to detect the underlying pathophysiology of the disease.

SIGNIFICANCE

This was the first study to examine the reliability of this technique in subjects with ALS, and demonstrates its potential for future use as an outcome measure in ALS clinical trials and studies of ALS disease severity and natural history.

The puzzling case of hyperexcitability in amyotrophic lateral sclerosis

The development of hyperexcitability in amyotrophic lateral sclerosis (ALS) is a well-known phenomenon. Despite controversy as to the underlying mechanisms, cortical hyperexcitability appears to be closely related to the interplay between excitatory corticomotoneurons and inhibitory interneurons. Hyperexcitability is not a static phenomenon but rather shows a pattern of progression in a spatiotemporal aspect. Cortical hyperexcitability may serve as a trigger to the development of anterior horn cell degeneration through a 'dying forward' process. Hyperexcitability appears to develop during the early disease stages and gradually disappears in the advanced stages of the disease, linked to the destruction of corticomotorneuronal pathways. As such, a more precise interpretation of these unique processes may provide new insight regarding the pathophysiology of ALS and its clinical features. Recently developed technologies such as threshold tracking transcranial magnetic stimulation and automated nerve excitability tests have provided some clues about underlying pathophysiological processes linked to hyperexcitability. Additionally, these novel techniques have enabled clinicians to use the specific finding of hyperexcitability as a useful diagnostic biomarker, enabling clarification of various ALS-mimic syndromes, and the prediction of disease development in pre-symptomatic carriers of familial ALS. In terms of nerve excitability tests for peripheral nerves, an increase in persistent Na⁺ conductances has been identified as a major determinant of peripheral hyperexcitability in ALS, inversely correlated with the survival in ALS. As such, the present Review will focus primarily on the puzzling theory of hyperexcitability in ALS and summarize clinical and pathophysiological implications for current and future ALS research.

Neurophysiological approach to disorders of peripheral nerve

Disorders of the peripheral nerve system (PNS) are heterogeneous and may involve motor fibers, sensory fibers, small myelinated and unmyelinated fibers and autonomic nerve fibers, with variable anatomical distribution (single nerves, several different nerves, symmetrical affection of all nerves, plexus, or root lesions). Furthermore pathological processes may result in either demyelination, axonal degeneration or both. In order to reach an exact diagnosis of any neuropathy electrophysiological studies are crucial to obtain information about these variables. Conventional electrophysiological methods including nerve conduction studies and electromyography used in the study of patients suspected of having a neuropathy and the significance of the findings are discussed in detail and more novel and experimental methods are mentioned. Diagnostic considerations are based on a flow chart classifying neuropathies into eight categories based on mode of onset, distribution, and electrophysiological findings, and the electrophysiological characteristics in each type of neuropathy are discussed.

From El Escorial to Awaji: where do we go next with the amyotrophic lateral sclerosis criteria?

SUMMARY Making an early and accurate diagnosis in amyotrophic lateral sclerosis is important for patients and their families and for entry in clinical trials. Amyotrophic lateral sclerosis remains a clinical diagnosis, requiring the presence of upper and lower motor neuron symptoms and signs in multiple body regions, in patients with a progressive disease course and after exclusion of other diseases that can mimic the clinical presentation. Research criteria have been developed to allow uniform diagnosis. The original El Escorial criteria have been revised twice to improve the sensitivity. In this report, the current scientific status of these criteria is reviewed and suggestions for further adaptations are made.

Electrophysiological analysis of a murine model of motoneuron disease

OBJECTIVE

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by loss of motoneurons of the primary motor cortex, the brainstem and the spinal cord, for which there are not effective treatments. Several transgenic mice that mimic motoneuron disease have been used to investigate potential treatments. The objective of this work is to characterize electrophysiologically the SOD1(G93A) transgenic mouse model of ALS, and to provide useful markers to improve early detection and monitoring of progression of the disease.

METHODS

We performed nerve conduction tests, motor unit number estimation (MUNE), H reflex tests and motor evoked potentials (MEPs) in a cohort of transgenic and wild type mice from 4 to 16 weeks of age.

RESULTS

The results revealed dysfunction of spinal motoneurons evidenced by deficits in motor nerve conduction tests starting at 8 weeks of age, earlier in proximal than in distal muscles of the hindlimb. MUNE demonstrated that spinal motoneurons loss muscle innervation and have a deficit in their sprouting capacity. Motor evoked potentials revealed that, coexisting with peripheral deficits, there was a dysfunction of central motor tracts that started also at 8 weeks, indicating progressive dysfunction of upper motoneurons.

CONCLUSIONS

These electrophysiological results provide important information about the SOD1(G93A) mouse model, as they demonstrate by the first time alterations of central motor pathways simultaneously to lower motoneuron dysfunction, well before functional abnormalities appear (by 12 weeks of age).

SIGNIFICANCE

The finding of concomitant dysfunction of upper and lower motoneurons contributes to the validation of the SOD1(G93A) mouse as model of ALS, because this parallel involvement is a diagnostic condition for ALS. Electrophysiological tests can be used as early markers of the disease and to evaluate the potential benefits of new treatments on both upper and lower motoneurons.