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Shin-Yi Lin C, Howells J, Rutkove S, Nandedkar S, Neuwirth C, Noto YI, Shahrizaila N, Whittaker RG, Bostock H, Burke D, Tankisi H. Neurophysiological and imaging biomarkers of lower motor neuron dysfunction in motor neuron diseases/amyotrophic lateral sclerosis: IFCN handbook chapter. Clin Neurophysiol 2024; 162:91-120. [PMID: 38603949 DOI: 10.1016/j.clinph.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/07/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
This chapter discusses comprehensive neurophysiological biomarkers utilised in motor neuron disease (MND) and, in particular, its commonest form, amyotrophic lateral sclerosis (ALS). These encompass the conventional techniques including nerve conduction studies (NCS), needle and high-density surface electromyography (EMG) and H-reflex studies as well as novel techniques. In the last two decades, new methods of assessing the loss of motor units in a muscle have been developed, that are more convenient than earlier methods of motor unit number estimation (MUNE),and may use either electrical stimulation (e.g. MScanFit MUNE) or voluntary activation (MUNIX). Electrical impedance myography (EIM) is another novel approach for the evaluation that relies upon the application and measurement of high-frequency, low-intensity electrical current. Nerve excitability techniques (NET) also provide insights into the function of an axon and reflect the changes in resting membrane potential, ion channel dysfunction and the structural integrity of the axon and myelin sheath. Furthermore, imaging ultrasound techniques as well as magnetic resonance imaging are capable of detecting the constituents of morphological changes in the nerve and muscle. The chapter provides a critical description of the ability of each technique to provide neurophysiological insight into the complex pathophysiology of MND/ALS. However, it is important to recognise the strengths and limitations of each approach in order to clarify utility. These neurophysiological biomarkers have demonstrated reliability, specificity and provide additional information to validate and assess lower motor neuron dysfunction. Their use has expanded the knowledge about MND/ALS and enhanced our understanding of the relationship between motor units, axons, reflexes and other neural circuits in relation to clinical features of patients with MND/ALS at different stages of the disease. Taken together, the ultimate goal is to aid early diagnosis, distinguish potential disease mimics, monitor and stage disease progression, quantify response to treatment and develop potential therapeutic interventions.
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Affiliation(s)
- Cindy Shin-Yi Lin
- Faculty of Medicine and Health, Central Clinical School, Brain and Mind Centre, University of Sydney, Sydney 2006, Australia.
| | - James Howells
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Seward Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sanjeev Nandedkar
- Natus Medical Inc, Middleton, Wisconsin, USA and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christoph Neuwirth
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Roger G Whittaker
- Newcastle University Translational and Clinical Research Institute (NUTCRI), Newcastle University., Newcastle Upon Tyne, United Kingdom
| | - Hugh Bostock
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, Queen Square, WC1N 3BG, London, United Kingdom
| | - David Burke
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Tankisi H, Versace V, Kuppuswamy A, Cole J. The role of clinical neurophysiology in the definition and assessment of fatigue and fatigability. Clin Neurophysiol Pract 2023; 9:39-50. [PMID: 38274859 PMCID: PMC10808861 DOI: 10.1016/j.cnp.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/24/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
Though a common symptom, fatigue is difficult to define and investigate, occurs in a wide variety of neurological and systemic disorders, with differing pathological causes. It is also often accompanied by a psychological component. As a symptom of long-term COVID-19 it has gained more attention. In this review, we begin by differentiating fatigue, a perception, from fatigability, quantifiable through biomarkers. Central and peripheral nervous system and muscle disorders associated with these are summarised. We provide a comprehensive and objective framework to help identify potential causes of fatigue and fatigability in a given disease condition. It also considers the effectiveness of neurophysiological tests as objective biomarkers for its assessment. Among these, twitch interpolation, motor cortex stimulation, electroencephalography and magnetencephalography, and readiness potentials will be described for the assessment of central fatigability, and surface and needle electromyography (EMG), single fibre EMG and nerve conduction studies for the assessment of peripheral fatigability. The purpose of this review is to guide clinicians in how to approach fatigue, and fatigability, and to suggest that neurophysiological tests may allow an understanding of their origin and interactions. In this way, their differing types and origins, and hence their possible differing treatments, may also be defined more clearly.
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Affiliation(s)
- Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Denmark
| | - Viviana Versace
- Department of Neurorehabilitation, Hospital of Vipiteno (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Vipiteno-Sterzing, Italy
| | - Annapoorna Kuppuswamy
- Department of Clinical and Movement Neuroscience, Institute of Neurology, University College London, WC1N 3BG London, UK
- Department of Biomedical Sciences, University of Leeds, UK
| | - Jonathan Cole
- Clinical Neurophysiology, University Hospitals Dorset (Poole), UK
- University of Bournemouth, Poole, UK
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Zhu Y, Bai J, Li M, Wang H, Wang J, Huang X. Repetitive nerve stimulation on survival in amyotrophic lateral sclerosis. Front Neurol 2023; 14:1244385. [PMID: 37662046 PMCID: PMC10469011 DOI: 10.3389/fneur.2023.1244385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Objective No previous studies investigated the association between decrement of low-frequency repetitive nerve stimulation (LF-RNS) and amyotrophic lateral sclerosis (ALS) survival. We aim to study the relationship between decrement and survival in ALS. Methods Sporadic ALS patients diagnosed at the Department of Neurology, the First Medical Center, Chinese PLA General Hospital from January 2018 to December 2019 were enrolled in this study. Experienced neurologists followed up the participants regularly every 6 months until January 2022. A decremental response of 10% or greater at least in one muscle was considered positive. According to the decrement, the participants were divided into LF-RNS (+) and LF-RNS (-) groups. Results One hundred and eighty-one sporadic ALS patients were recruited in our study, including 100 males and 81 females. Among them, 10 cases (5.5%) were lost to follow-up, 99 cases (54.7%) died, and 72 patients (39.8%) were still alive at the last follow-up. The median survival time of all ALS patients in this study was 42.0 months. There was no significant difference of median survival in LF-RNS(+) group and LF-RNS(-) group (p = 0.159, Kaplan-Meier method). In multivariate Cox regression analysis, age of onset, diagnostic delay, and ALS Functional Rating Scale-Revised (ALSFRS-R) score were associated with ALS survival, but the decrement was not correlated with ALS survival (p = 0.238). Conclusion The decrement in accessory and ulnar nerves was not associated with the survival of ALS. The decrement of LF-RNS could not be an electrophysiological marker to predict ALS survival.
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Affiliation(s)
- Yahui Zhu
- Medical School of Chinese PLA, Beijing, China
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiongming Bai
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
- College of Medicine, Nankai University, Tianjin, China
| | - Mao Li
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hongfen Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiao Wang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xusheng Huang
- Medical School of Chinese PLA, Beijing, China
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Alteration of the Neuromuscular Junction and Modifications of Muscle Metabolism in Response to Neuron-Restricted Expression of the CHMP2Bintron5 Mutant in a Mouse Model of ALS-FTD Syndrome. Biomolecules 2022; 12:biom12040497. [PMID: 35454086 PMCID: PMC9025139 DOI: 10.3390/biom12040497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/12/2022] [Accepted: 03/21/2022] [Indexed: 02/04/2023] Open
Abstract
CHMP2B is a protein that coordinates membrane scission events as a core component of the ESCRT machinery. Mutations in CHMP2B are an uncommon cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD), two neurodegenerative diseases with clinical, genetic, and pathological overlap. Different mutations have now been identified across the ALS-FTD spectrum. Disruption of the neuromuscular junction is an early pathogenic event in ALS. Currently, the links between neuromuscular junction functionality and ALS-associated genes, such as CHMP2B, remain poorly understood. We have previously shown that CHMP2B transgenic mice expressing the CHMP2Bintron5 mutant specifically in neurons develop a progressive motor phenotype reminiscent of ALS. In this study, we used complementary approaches (behavior, histology, electroneuromyography, and biochemistry) to determine the extent to which neuron-specific expression of CHMP2Bintron5 could impact the skeletal muscle characteristics. We show that neuronal expression of the CHMP2Bintron5 mutant is sufficient to trigger progressive gait impairment associated with structural and functional changes in the neuromuscular junction. Indeed, CHMP2Bintron5 alters the pre-synaptic terminal organization and the synaptic transmission that ultimately lead to a switch of fast-twitch glycolytic muscle fibers to more oxidative slow-twitch muscle fibers. Taken together these data indicate that neuronal expression of CHMP2Bintron5 is sufficient to induce a synaptopathy with molecular and functional changes in the motor unit reminiscent of those found in ALS patients.
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Ma JY, Liu XY, Zhang S, Fan DS. Ultra-early amplitude decrement after repetitive nerve stimulation supports early neuromuscular junction injury in amyotrophic lateral sclerosis: a prospective cross-sectional study. Neural Regen Res 2022; 17:655-660. [PMID: 34380907 PMCID: PMC8504376 DOI: 10.4103/1673-5374.320998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The dying-back hypothesis holds that the damage to neuromuscular junctions and distal axons in amyotrophic lateral sclerosis occurs at the earliest stage of the disease. Previous basic studies have confirmed early damage to neuromuscular junctions, but it is difficult to obtain such evidence directly in clinical practice. In this prospective cross-sectional study, we recruited 22 patients with early amyotrophic lateral sclerosis with disease duration < 12 months and with clinical symptoms limited to the upper limbs. We also recruited 32 healthy controls. Repetitive nerve stimulation was performed, and patients were followed for 12 months. We found a significant change in the response to repetitive nerve stimulation in amyotrophic lateral sclerosis patients without spontaneous electromyographic activity. Patients that were prone to denervation had an increased decrement response of target muscles after repetitive nerve stimulation. These results suggest that changes in response to repetitive nerve stimulation may occur before denervation in amyotrophic lateral sclerosis patients. The damage to lower motor neurons is more obvious in patients with a higher percentage of repetitive never stimulation-related amplitude decrements. This study was approved by the Institutional Ethics Committee of Peking University Third Hospital (approval No. M2017198) on August 24, 2017.
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Affiliation(s)
- Jing-Yue Ma
- Department of Neurology, Peking University Third Hospital; Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Diseases, Beijing, China
| | - Xiang-Yi Liu
- Department of Neurology, Peking University Third Hospital; Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Diseases, Beijing, China
| | - Shuo Zhang
- Department of Neurology, Peking University Third Hospital; Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Diseases, Beijing, China
| | - Dong-Sheng Fan
- Department of Neurology, Peking University Third Hospital; Beijing Municipal Key Laboratory of Biomarker and Translational Research in Neurodegenerative Diseases, Beijing, China
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Shang L, Chu H, Lu Z. Can the Large-Scale Decrement in Repetitive Nerve Stimulation Be Used as an Exclusion Criterion for Amyotrophic Lateral Sclerosis? Front Neurol 2020; 11:101. [PMID: 32184752 PMCID: PMC7059024 DOI: 10.3389/fneur.2020.00101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/29/2020] [Indexed: 11/23/2022] Open
Abstract
Objective: The objectives of this work were to identify the characteristics of repetitive nerve stimulation (RNS) in patients with amyotrophic lateral sclerosis (ALS) and further verify the electrophysiological exclusion criteria of ALS. Methods: A total of 150 patients with ALS who were admitted to the Department of Neurology of Renmin Hospital of Wuhan University from January 2015 to December 2018 were enrolled. Clinical and electrophysiological data of the enrolled patients were collected. The differences in the amplitudes of the compound muscle action potential (CMAP) between the trapezius muscle (Trap) and the abductor digiti minimi (ADM) in low-frequency RNS were compared. Furthermore, we analyzed the associations between decremental responses and gender, onset age, duration of disease, onset site, Amyotrophic Lateral Sclerosis Functional Rating Scale—Revised (ALSFRS-R), disease progression rate, and CMAP amplitude. Results: A significant decrement (≥20%) in at least one muscle was observed in 11.3% of the ALS patients, while decrements (≥10%) in at least one muscle were observed in 41.3%. The decremental percentage in the trapezius muscle was significantly higher than that in the abductor digiti minimi (P < 0.001). The onset age, duration of disease, onset site, and disease progression rate did not affect decremental responses. The decremental responses in RNS were more significant in ALS patients with low ALSFRS-R scores (P = 0.01). Moreover, there was a positive linear correlation between the CMAP amplitude and the decremental percentage of Trap and ADM in ALS patients. Conclusions: CMAP decremental responses in RNS were common in ALS patients, suggesting abnormalities of neuromuscular junctions (NMJs). It is worthy of further discussion whether to consider a decrement >20% in RNS as a diagnostic exclusion criterion for ALS.
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Affiliation(s)
- Li Shang
- Department of Neurology, Renmin Hospital, Wuhan University, Wuhan, China
| | - Hong Chu
- Department of Neurology, Renmin Hospital, Wuhan University, Wuhan, China
| | - Zuneng Lu
- Department of Neurology, Renmin Hospital, Wuhan University, Wuhan, China
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Zhang D, Zhao Y, Yan C, Cao L, Li W. CMAP decrement by low-frequency repetitive nerve stimulation in different hand muscles of ALS patients. Neurol Sci 2019; 40:2609-2615. [PMID: 31375938 DOI: 10.1007/s10072-019-04027-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To study compound muscle action potential (CMAP) decrement by low-frequency repetitive nerve stimulation (RNS) in different hand muscles of amyotrophic lateral sclerosis (ALS) patients and the relationship with split hand phenomenon and clinical manifestation. METHODS Clinical and decrement data of 51 ALS patients who had done RNS in different hand muscles were retrospectively reviewed from November 2016 to July 2017. Decrement data of 24 myasthenia gravis (MG) and 20 Lambert Eaton myasthenia syndrome (LEMS) patients was also reviewed to compare decrement pattern with hand muscles of ALS patients. RESULTS There was statistical significance between the decrement ratio of abductor digiti minimi (ADM) and abductor pollicis brevis (APB) as well as ADM and first dorsal interosseous (FDI). The decrements of the APB, ADM, and FDI were negatively correlated with their amplitude of CMAPs respectively. The difference between the decrement ratio of the APB and ADM was negatively correlated with the division ratio (CMAPAPB/CMAPADM). The decrement ratio of APB and FDI was negatively correlated with their muscle strength. There was a mild correlation between decrement ratio of APB and disease course. There was no statistical significance in the decrement pattern of the three-hand muscles of ALS patients. There was statistical significance in decrement pattern between APB of ALS and LEMS patients. CONCLUSION Dysfunction of neuromuscular transmission was found in hand muscles of ALS patients, APB was involved most significantly. The dysfunction of neuromuscular transmission might be involved in the formation of the split hand phenomenon.
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Affiliation(s)
- Dong Zhang
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Yuying Zhao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, 250012, China.
| | - Chuanzhu Yan
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, 250012, China.,Brain Science Research Institute, Qilu Hospital, Shandong University, Jinan, 250012, China.,Mitochondrial Medicine Laboratory, Qilu Hospital (Qingdao), Shandong University, Qingdao, 266035, China
| | - Lili Cao
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Wei Li
- Research Institute of Neuromuscular and Neurodegenerative Diseases and Department of Neurology, Qilu Hospital, Shandong University, Jinan, 250012, China
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Alanazy MH, Hegedus J, White C, Korngut L. Decremental responses in patients with motor neuron disease. Brain Behav 2017; 7:e00846. [PMID: 29201547 PMCID: PMC5698864 DOI: 10.1002/brb3.846] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/11/2017] [Accepted: 08/28/2017] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Involvement of the neuromuscular junction (NMJ) in amyotrophic lateral sclerosis (ALS) has been reported and is increasingly recognized as an important pathophysiological aspect. The relationship between decrement and clinical measures for possible application as a biomarker has not been comprehensively explored. METHODS We performed routine repetitive nerve stimulation (RNS) of three nerves on patients with ALS. We captured measures of muscle strength, grip strength, fatigability, and calculated slow vital capacity (SVC) rates of change assessing for associations. RESULTS In 42 subjects, 210 muscles were studied. Negative correlation was found between the percentage of decrement and compound muscle action potential (CMAP) amplitude. Approximately half of the patients with hand weakness did not have decrement. There was no significant correlation between decrement and handgrip fatigue, SVC < 80% predicted, or more rapid worsening of SVC over time. CONCLUSIONS Abnormal decremental responses are well described in ALS. We report that the degree of decremental response does not correlate with the degree of weakness. Abnormal decrement is only rarely present in nerve-muscle pairs with normal motor power. Our findings did not support a correlation between abnormal decrement and clinical measures suggesting that RNS may not be useful as a biomarker to monitor ALS progression.
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Affiliation(s)
- Mohammed H Alanazy
- Department of Internal Medicine King Saud University Medical City and College of Medicine King Saud University Riyadh Saudi Arabia
| | - Janka Hegedus
- Division of Neuromuscular Department of Clinical Neurosciences University of Calgary Calgary Alberta Canada
| | - Chris White
- Division of Neuromuscular Department of Clinical Neurosciences University of Calgary Calgary Alberta Canada
| | - Lawrence Korngut
- Division of Neuromuscular Department of Clinical Neurosciences University of Calgary Calgary Alberta Canada
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