Validity of electromyograms and tension as a means of motor unit number estimation

The role of novel motor unit magnetic resonance imaging to investigate motor unit activity in ageing skeletal muscle

Sarcopenia is a progressive and generalized disease, more common in older adults, which manifests as a loss of muscle strength and mass. The pathophysiology of sarcopenia is still poorly understood with many mechanisms suggested. Age associated changes to the neuromuscular architecture, including motor units and their constituent muscle fibres, represent one such mechanism. Electromyography can be used to distinguish between different myopathies and produce counts of motor units. Evidence from electromyography studies suggests that with age, there is a loss of motor units, increases to the sizes of remaining units, and changes to their activity patterns. However, electromyography is invasive, can be uncomfortable, does not reveal the exact spatial position of motor units within muscle and is difficult to perform in deep muscles. We present a novel diffusion-weighted magnetic resonance imaging technique called 'motor unit magnetic resonance imaging (MUMRI)'. MUMRI aims to improve our understanding of the changes to the neuromuscular system associated with ageing, sarcopenia and other neuromuscular diseases. To date, we have demonstrated that MUMRI can be used to detect statistically significant differences in fasciculation rate of motor units between (n = 4) patients with amyotrophic lateral sclerosis (mean age ± SD: 53 ± 15) and a group of (n = 4) healthy controls (38 ± 7). Patients had significantly higher rates of fasciculation compared with healthy controls (mean = 99.1/min, range = 25.7-161.0 in patients vs. 7.7/min, range = 4.3-9.7 in controls; P < 0.05. MUMRI has detected differences in size, shape, and distribution of single human motor units between (n = 5) young healthy volunteers (29 ± 2.2) and (n = 5) healthy older volunteers (65.6 ± 14.8). The maximum size of motor unit territories in the older group was 12.4 ± 3.3 mm and 9.7 ± 2.7 mm in the young group; P < 0.05. MUMRI is an entirely non-invasive tool, which can be used to detect physiological and pathological changes to motor units in neuromuscular diseases. MUMRI also has the potential to be used as an intermediate outcome measure in sarcopenia trials.

Assessment of the F wave technique for motor unit number estimation in normal dogs

Motor unit number estimation (MUNE) is an electrophysiological technique to quantify the number of motor units in a muscle. A previous study examining MUNE in dogs used an incremental method. The purpose of this study was to examine the use of the F wave method in dogs and to provide information about this technique. Seven healthy laboratory dogs were examined using the F wave method by stimulating either a single site or multiple sites. In the multiple site stimulation F wave (MSS-F) method, the nerve was stimulated at several close sites along the deep peroneal nerve innervating the extensor digitorum brevis muscle. Test-retest was performed with a 1 week interval in all dogs using both techniques. In this preliminary study, median MUNE values were 88 (range 27-187) using the single site stimulation F wave (SSS-F) method and 68.5 (range 47-106) using the MSS-F method. The intra-class correlation coefficients between the two sets of data for each method were 0.20 and 0.09 for left and right SSS-F, respectively, and 0.77 and 0.69 for left and right MSS-F, respectively. MSS-F had less intra-individual variability of MUNE values and was more reproducible. These results indicate that MSS-F can be performed in dogs. MUNE using MSS-F might help with quantitative evaluation of motor neurone dysfunction and progression of diseases affecting motor neurones.

The Potential Role of Motor Unit Number Estimation as an Additional Diagnostic and Prognostic Value in Canine Neurology

Motor unit number estimation (MUNE) is an electrophysiological technique to assess the number of motor units innervating a single muscle or muscle group of interest. It may quantify axonal loss in any disease involving injury or degeneration of ventral horn cells or motor axons. Since MUNE has rarely been used in veterinary medicine, our study aimed to evaluate its potential role as an additional diagnostic and prognostic parameter in canine neurology. Therefore, we examined five healthy dogs and seven dogs suffering from diseases that necessitated general anesthesia for further diagnostics and treatment and that were not expected to interfere with the results of electrodiagnostic testing. By using the incremental technique to study MUNE in the cranial tibial muscle, we determined the number of motor units, the size of the compound muscle action potential, and the mean size of individual motor unit potentials of each dog as well as the mean values for each group. Moreover, we studied the correlation between these parameters. Taking the results into consideration, we addressed the difficulties and limitations of this technique. We, furthermore, pointed out possible fields of application for MUNE in canine neurology, and emphasized several aspects that future studies should focus on when applying MUNE to canine patients.

Motor Unit Number Estimation in Neuromuscular Disease

Motor unit number estimation (MUNE) is an electrophysiological method designed to quantify motor unit loss in target muscles of interest. Most of the techniques are noninvasive and are therefore well suited for longitudinal monitoring. In this brief review, we describe the more commonly used techniques and their applications in amyotrophic lateral sclerosis, poliomyelitis, spinal muscular atrophy and hereditary sensorimotor neuropathies. Findings in some of these studies offer important pathophysiological insights. Since conventional electrophysiologic methods are not sensible measures of motor neuronal loss, MUNE could play a potentially important role in the diagnosis, monitoring of disease progression and response to treatment in neuromuscular diseases in which motor unit loss is a major feature.

The relationship between Bayesian motor unit number estimation and histological measurements of motor neurons in wild-type and SOD1(G93A) mice

OBJECTIVE

To assess the relationship between Bayesian MUNE and histological motor neuron counts in wild-type mice and in an animal model of ALS.

METHODS

We performed Bayesian MUNE paired with histological counts of motor neurons in the lumbar spinal cord of wild-type mice and transgenic SOD1(G93A) mice that show progressive weakness over time. We evaluated the number of acetylcholine endplates that were innervated by a presynaptic nerve.

RESULTS

In wild-type mice, the motor unit number in the gastrocnemius muscle estimated by Bayesian MUNE was approximately half the number of motor neurons in the region of the spinal cord that contains the cell bodies of the motor neurons supplying the hindlimb crural flexor muscles. In SOD1(G93A) mice, motor neuron numbers declined over time. This was associated with motor endplate denervation at the end-stage of disease.

CONCLUSION

The number of motor neurons in the spinal cord of wild-type mice is proportional to the number of motor units estimated by Bayesian MUNE. In SOD1(G93A) mice, there is a lower number of estimated motor units compared to the number of spinal cord motor neurons at the end-stage of disease, and this is associated with disruption of the neuromuscular junction.

SIGNIFICANCE

Our finding that the Bayesian MUNE method gives estimates of motor unit numbers that are proportional to the numbers of motor neurons in the spinal cord supports the clinical use of Bayesian MUNE in monitoring motor unit loss in ALS patients.

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.

Validation of an incremental motor unit number estimation technique in rabbits

Motor unit number estimation (MUNE) allows for quantitative assessment of functional motor units in a nerve. Several techniques have been applied to human studies. Although MUNE has been performed in animals to study neurological disorders, reproducibility has not been addressed. We analyzed the test-retest reproducibility of an incremental MUNE technique in rabbits and performed histological correlation. A peroneal MUNE was performed in 9 rabbits on two occasions separated by 30 days. MUNE was then performed on 18 rabbits prior to euthanize. A count of total fibers and a second count of large myelinated fibers were performed on nerve cross-sections. Test-retest reproducibility revealed an intraclass correlation coefficient (ICC) of 0.75. The average test-retest relative difference was 26.6%. Comparison of MUNE and histomorphometrical counts revealed a correlation coefficient (r) of 0.21 (total fiber counts) and 0.27 (large fibers). Although incremental MUNE has a high degree of reproducibility in rabbits, there is poor correlation with histological fiber counts.

Motor unit number estimation in the rat tail using a modified multipoint stimulation technique

Motor unit number estimation (MUNE) of the rodent hindlimb has been used mainly for following the progression of motor neuron disorders. By performing MUNE in the tail, however, progression of axonal neuropathy could also be assessed, as both proximal and distal regions would be available for study. In this investigation, three raters performed a modified multipoint stimulation MUNE technique in the tails of 14 healthy adult rats. The technique was straightforward to perform, with a relatively narrow range of motor unit number estimates of 40 +/- 16 (standard deviation) for the proximal tail and 21 +/- 11 for the distal tail. Intrarater reliability coefficients were 0.31 (P = 0.033) and 0.32 (P = 0.028) for the proximal and distal tail, respectively. Interrater reliability coefficients were 0.22 (P = 0.086) and 0.44 (P = 0.004). These reliability assessments, along with the relatively low motor unit estimates and narrow range of values, support the idea that rat tail MUNE may have utility in the evaluation of rodent models of neuromuscular disease, including length-dependent neuropathy.

New mathematical approach for approximating the baseline of F-waves using spreadsheet software

OBJECTIVE

The aim of this study was to see if curved baselines of F-waves could be mathematically approximated with universal spreadsheet software.

METHODS

The subjects were 3 healthy persons and 3 patients with cervical myelopathy. Supramaximal electrical stimuli were applied 200 times to the median nerve at the wrist. Compound muscle action potentials (CMAPs) of the abductor pollicis brevis were recorded. To make polynomial approximation equations that represent latter part of the M-waves, records without F-waves were analyzed.

RESULTS

There were 193 CMAPs without F-waves out of all 1,200 records. Polynomial equations were made for each record. Determinant coefficients for all the approximation equations were greater than 0.998, and the overall standard deviation of the difference between original data and approximated value was 3.05 microV.

CONCLUSIONS

Curved baselines of F-waves were represented by approximation curves. Baselines of the F-waves could be approximated as flat lines by subtracting calculated values from the original data.

SIGNIFICANCE

This method was useful for analyzing waveforms of F-waves.

Motor unit number estimation in facial paralysis

The value of motor unit number estimation (MUNE) in determining the prognosis of acute peripheral facial paralysis (PFP) was evaluated in 89 patients with PFP on days 6, 8, 11, 14, 20, and 30 of PFP and repeated once per month until complete recovery or the end of the first year. The symptomatic/asymptomatic side ratios of the compound muscle action potential (CMAP) amplitudes recorded from nasalis muscles and MUNEs studied using the incremental method by recording from the same muscle were assessed with regard to three outcome groups (Group I, complete recovery; Group II, mild dysfunction; Group III, moderate-moderately severe dysfunction). CMAP and MUNE ratios were parallel to each other in all patient groups throughout the observation period with lower values in the more severe groups. However, CMAP amplitude loss was significantly greater than the MUNE loss in the first 3 weeks of PFP. The MUNE method is not superior to CMAP size in determining prognosis in PFP. However, the significant disparity between the CMAP and MUNE ratios in the early period may have some physiological relevance with regard to the pathophysiology of the Wallerian degeneration process and deserves further research into its potential sources.

Automated characterization of nerve fibers labeled fluorescently: determination of size, class and spatial distribution

Morphological classification of nerve fibers could help interpret the assessment of neural regeneration and the understanding of selectivity of nerve stimulation. Specific populations of myelinated nerve fibers can be investigated by retrograde tracing from a muscle followed by microscopic measurements of the labeled fibers at different anatomical levels. Gastrocnemius muscles of adult rats were injected with the retrograde tracer Fluoro-Gold. After a survival period of 3 days, cross-sections of spinal cords, ventral roots, sciatic, and tibial nerves were collected and imaged on a fluorescence microscope. Nerve fibers were classified using a variation-based criterion acting on the distribution of their equivalent diameters. The same criterion was used to classify the labeled axons using the size of the fluorescent marker. Measurements of the axons were paired to those of the entire fibers (axons+myelin sheaths) in order to establish the correspondence between so-established axonal and fiber classifications. It was found that nerve fibers in L6 ventral roots could be classified into four populations comprising two classes of Aalpha (denoted Aalpha1 and Aalpha2), Agamma, and an additional class of Agammaalpha fibers. Cut-off borders between Agamma and Agammaalpha fiber classes were estimated to be 5.00+/-0.09 microm (SEM); between Agammaalpha and Aalpha1 fiber classes to be 6.86+/-0.11 microm (SEM); and between Aalpha1 and Aalpha2 fiber classes to be 8.66+/-0.16 microm (SEM). Topographical maps of the nerve fibers that innervate the gastrocnemius muscles were constructed per fiber class for the spinal root L6. The major advantage of the presented approach consists of the combined indirect classification of nerve fiber types and the construction of topographical maps of so-identified fiber classes.

Motor unit number estimation in the assessment of performance and function in motor neuron disease

Motor unit number estimation (MUNE) is a unique electrophysiologic test used to estimate the number of surviving motor units in a muscle or group of muscles. It is used most frequently to monitor lower motor neuron loss in amyotrophic lateral sclerosis and spinal muscle atrophy. Of particular interest is its use as an endpoint measure in clinical trials for these diseases. This article describes the principles of MUNE and the factors that need to be considered, and reviews several techniques that have been used in clinical trials and in monitoring progression. It then reviews experience with MUNE in clinical trials for amyotrophic lateral sclerosis and spinal muscle atrophy and discusses how MUNE correlates with measures of function.

Method for counting motor units in mice and validation using a mathematical model

Weakness and atrophy are clinical signs that accompany muscle denervation resulting from motor neuron disease, peripheral neuropathies, and injury. Advances in our understanding of the genetics and molecular biology of these disorders have led to the development of therapeutic alternatives designed to slow denervation and promote reinnervation. Preclinical in vitro research gave rise to the need of a method for measuring the effects in animal models. Our goal was to develop an efficient method to determine the number of motor neurons making functional connections to muscle in a transgenic mouse model of amyotrophic lateral sclerosis (ALS). We developed a novel protocol for motor unit number estimation (MUNE) using incremental stimulation. The method involves analysis of twitch waveforms using a new software program, ITS-MUNE, designed for interactive calculation of motor unit number. The method was validated by testing simulated twitch data from a mathematical model of the neuromuscular system. Computer simulations followed the same stimulus-response protocol and produced waveform data that were indistinguishable from experiments. We show that our MUNE protocol is valid, with high precision and small bias across a wide range of motor unit numbers. The method is especially useful for large muscle groups where MUNE could not be done using manual methods. The results are reproducible across naïve and expert analysts, making it suitable for easy implementation. The ITS-MUNE analysis method has the potential to quantitatively measure the progression of motor neuron diseases and therefore the efficacy of treatments designed to alleviate pathologic processes of muscle denervation.

Assessment of disease progression in motor neuron disease

Motor neuron disease (MND) is characterised by progressive deterioration of the corticospinal tract, brainstem, and anterior horn cells of the spinal cord. There is no pathognomonic test for the diagnosis of MND, and physicians rely on clinical criteria-upper and lower motor neuron signs-for diagnosis. The presentations, clinical phenotypes, and outcomes of MND are diverse and have not been combined into a marker of disease progression. No single algorithm combines the findings of functional assessments and rating scales, such as those that assess quality of life, with biological markers of disease activity and findings from imaging and neurophysiological assessments. Here, we critically appraise developments in each of these areas and discuss the potential of such measures to be included in the future assessment of disease progression in patients with MND.

Motor unit number estimation: new techniques and new uses

MUNE is a unique neurophysiologic tool because it can quantitatively estimate the number of motor neurons innervating a muscle or group of muscles. All other neurophysiologic techniques are influenced by collateral reinnervation and provide only a qualitative estimate of motor unit loss. Further, the S-MUPs obtained with MUNE provide quantitative information about the whole motor unit. Other routine neurophysiologic techniques provide information restricted to a portion of the motor unit. These unique features of MUNE have been applied to neurogenic disorders to yield a better understanding of disease processes. Various modifications are being developed that will provide more data and ease of use. It is anticipated that the availability of MUNE on EMG machines will grow and it use will expand from a research tool to a routine neurophysiologic test.

Statistical motor unit number estimation: from theory to practice

Statistical motor unit number estimation (MUNE) is one of several experimental techniques used to estimate the number of lower motor neurons innervating a given muscle. All are fairly reproducible and have been applied successfully in monitoring neurogenic disease progression. Quantitating the number of lower motor neurons is important, since the compound muscle action potential (CMAP) and strength may not change as rapidly over time due to the confounding effect of reinnervation. MUNE techniques differ in the way they obtain samples of surface-recorded motor unit potentials (SMUP). Statistical MUNE is based on Poisson statistics, uses surface stimulation, and is useful in testing distal, superficial nerves. This review focuses on the theory behind the development of the technique, critiques the publications resulting from applying the technique in control and disease subjects, and discusses the future developments needed for clinical utility.

Motor unit number estimation

Since its introduction 30 years ago, MUNE techniques have increasingly been refined and applied to a wide variety of neuromuscular disorders. Differences of opinion remain among MUNE investigators as to which method is best; however, statistical and MPS MUNE are currently the most widely used. Numerous methodologic issues remain, including the development of detailed universal standards for each technique and the implementation of modifications for the enhancement of reproducibility. These issues are the subjects of ongoing investigation. Despite technical variability, the MUNE values obtained using different methods show good agreement in studies of normal subjects and in patients with a variety of neurogenic processes. MUNE has been applied most successfully to patients with amyotrophic lateral sclerosis and to animal models of motor neuron disease, providing significant insight into the pathophysiology of these disorders. These techniques are increasingly being incorporated into clinical therapeutic trials. MUNE offers promise in the study of neuromuscular disease, enabling the collection of novel data in the living patient unobtainable by any other method.

Longitudinal study of functional spinal alpha motor neuron loss in amyotrophic lateral sclerosis

Using a microstimulation technique for obtaining motor unit number estimates (MUNEs) of the hypothenar and extensor digitorum brevis (EDB) muscles, we performed a longitudinal study on the natural course of change in the clinical rating scale (Appel score) and of loss of functional spinal alpha motor neurons in amyotrophic lateral sclerosis. The Appel score increased to about 150% of normal at 12 months after onset, about 225% at 18 months after onset, and about 370% at 24 months after onset. By contrast, MUNEs decreased to about 27% of normal at 12 months after onset, about 12% at 18 months after onset, and about 5% at 24 months after onset. The relative merits of these different approaches in detecting changes in the disease process in its early phase are discussed.

Motor unit number estimation in human neurological diseases and animal models

Motor unit number estimation (MUNE) was introduced in 1971 as a way of providing an objective and meaningful estimate of axon loss in diseases affecting the motor system. Over the last 30 years, different methods of MUNE have been proposed, with each having specific strengths and limitations. The goal of this paper is to review the available methods, and to present data generated using MUNE in a variety of disease entities. The incremental, multiple point stimulation, spike-triggered averaging, F-wave, and statistical methods of MUNE are reviewed, along with data obtained using these methods in patients with neuropathy, motor neuron disorders, and muscle disease. All methods reviewed have theoretical concerns associated with them. However, with the exception of the spike-triggered averaging method, all give results in normal subjects that are quite similar. MUNE has been of great value in assessing progression of motor neuron disease, and has also shown promise in the assessment of generalized neuropathy. Despite the lack of a perfect method for performing MUNE, it has great clinical value in the assessment of progressive motor axon loss. Further refinements in the method will likely increase its utility in the future.