Reproducibility of statistical motor unit number estimates in amyotrophic lateral sclerosis: Comparisons between size- and number-weighted modifications

Far-field potential of the compound muscle action potential as a reliable marker in amyotrophic lateral sclerosis

INTRODUCTION/AIMS

Reliable neurophysiological markers in amyotrophic lateral sclerosis (ALS) are of great interest. The compound muscle action potential (CMAP) amplitude has been a conventional marker, although it is greatly influenced by the electrode position. We propose the far-field potential of the CMAP (FFP-CMAP) as a new neurophysiological marker in ALS.

METHODS

Patients with ALS and age-matched healthy controls were enrolled. We used a proximal reference (pref) in addition to the conventional distal reference (dref). Routine CMAP was recorded from the belly-dref lead and FFP-CMAP from the dref-pref lead for the ulnar and tibial nerves. Multiple point stimulation motor unit number estimation (MUNE) was also examined in the ulnar nerve. Inter-rater reproducibility was evaluated by two examiners, and some patients were followed up every 3 mo for 1 y.

RESULTS

We tested 17 patients with ALS and 10 controls. The amplitudes of routine CMAP and FFP-CMAP in the ulnar and tibial nerves, and hypothenar MUNE value in the ulnar nerve were significantly decreased in ALS compared to controls. Ulnar FFP-CMAP achieved the highest inter-rater intraclass correlation coefficient (ICC) value (0.942) when compared with routine CMAP (0.880) and MUNE (0.839). The tibial FFP-CMAP had a higher ICC value (0.986) than the routine CMAP (0.697). In this way, the FFP-CMAP showed high inter-rater reproducibility because its shape was not much influenced by the electrode position. During 1-y follow-up, decline of CMAP, FFP, and MUNE showed significant correlations with the Amyotrophic Lateral Sclerosis Functional Rating Scale - Revised (ALSFRS-R).

DISCUSSION

The FFP-CMAP shows promise as a reliable marker for ALS.

Decline of compound muscle action potentials and statistical MUNEs during Wallerian degeneration

AIM OF THE STUDY

In two previous studies, we found that the compound muscle action potential (CMAP) amplitude loss was significantly higher than the loss of estimated motor unit numbers in the course of Wallerian degeneration (WD). In order to overcome some drawbacks of the method previously used, we performed a similar CMAP vs MUNE comparison by using the statistical motor unit number estimation (MUNE) method.

PATIENTS AND METHODS

Initial electrophysiological studies on 6 patients were performed between 22 and 98 hours after the injuries; it was possible to make repeated examinations, four times in 1 nerve, twice in 1 nerve and three times in 4 nerves, before the eventual complete disappearance of the CMAPs.

RESULTS

The transected/intact (T/I) side CMAP ratios declined steeply as WD evolved. They were significantly lower than the relatively stable MUNE ratios 48 hours after the injury.

CONCLUSION

This study, performed with the use of statistical MUNE, strengthens our previous observation by the incremental method that might have some relevance to the pathophysiology of early WD. CMAP amplitude loss that is more than expected from the amount of axonal degeneration may indicate a considerable amount of inactive muscle fibers in the motor units innervated by the nerve fibers, which are undergoing degeneration but still retain their excitability. Although technical sources of error cannot be totally excluded, our findings could more likely be explained by the failing of neuromuscular synapses in an asynchronous order before complete unresponsiveness of the motor unit ensues.

Asymmetry of motor unit number estimate and its rate of decline in patients with amyotrophic lateral sclerosis

This study was performed to investigate the asymmetry of motor unit number estimate (MUNE) and its longitudinal course in patients with amyotrophic lateral sclerosis. A modified statistical MUNE was performed at the hypothenar muscles bilaterally in a total of 135 patients, and 18 of these patients underwent a follow-up study. The degree of asymmetry varied considerably among those patients whose average MUNE of both sides was moderately reduced, whereas it tended to be low in those whose average MUNE was either severely reduced or close to normal. The rate of motor unit loss was also asymmetric, and two distinct patterns were identified. In patients whose MUNE was greater than 30 in both sides (n = 7), the rate of motor unit loss tended to be greater in the initially more affected side compared with the contralateral one, yielding the so-called lead phenomenon. In contrast, the other patients (n = 11) tended to show the opposite pattern of "catch-up," that is, MUNE declined faster in the initially less affected side compared with the contralateral one. This study shows that not only the MUNE but also the rate of motor unit loss are frequently asymmetric in amyotrophic lateral sclerosis patients.

Test-retest reliability of v-wave responses in the soleus and gastrocnemius medialis

This study was designed to assess the reliability of the first volitional (V) wave, which can be used as a measure of efferent neural drive, while also reflecting reflex excitability. Ten subjects volunteered for one familiarization session followed by an experimental test session and an identical retest session spaced 3 to 8 days apart. V-waves were evoked in the tibial nerve during plantar flexion maximal voluntary isometric contractions (MVCs). Test-retest reliability was assessed using the intraclass correlation coefficient (ICC), along with standard error of measurement and 95% confidence intervals for the following variables: MVC force, surface electromyogram activity (EMG), and the peak-to-peak V-wave amplitude in soleus (SOL) and gastrocnemius medialis (GM). The superimposed M-wave (MSUP) accompanying V-wave stimulation was also obtained for normalization purposes. Substantial reliability was documented for V/MSUP in both SOL (ICC = 0.86) and GM (0.90), as well as for the non-normalized V-wave in SOL (0.92). Moderate reliability was displayed for the non-normalized V-wave response in GM (0.78). Substantial reliability was also established for EMG/MSUP (>0.82) and MVC force (0.98). This study provides novel evidence that V-wave responses can be consistently measured in the SOL and GM, thus advocating its continued use in future research.

Motor unit number estimation in evaluating disease progression in patients with amyotrophic lateral sclerosis

We investigated the availability of motor unit number estimation (MUNE) as a quantitative method to assess the severity and clinical progression of amyotrophic lateral sclerosis (ALS). The 143 ALS patients were evaluated by statistical MUNE and the revised amyotrophic lateral sclerosis functional rating scale (ALSFRS-R). By using mean values of MUNE according to disease duration, regression equation between mean MUNE and disease duration was presented as a formula. The individual MUNE ratio was calculated by dividing individual MUNE value by mean MUNE value. All patients were classified into 2 groups (MUNE ratio <1 vs. MUNE ratio >or=1) according to the MUNE ratio. Comparison between the 2 groups revealed that the patients in MUNE ratio <1 group or MUNE ratio >or=1 group were respectively assigned to rapid progression or slow progression. We recommended informative mean values of MUNE and best regression equation in ALS patients according to disease duration. These values allow us to evaluate the severity and rapidity of progression in ALS.

Standard and modified statistical MUNE evaluations in spinal-bulbar muscular atrophy

Motor unit number estimation (MUNE), a technique used in amyotrophic lateral sclerosis (ALS) clinical trials to quantitatively assess motor neuron loss, should also be valuable in assessing progression in spinal bulbar muscular atrophy (SBMA), an x-linked neuronopathy. In ALS, instability of single motor units (SMUP) prompted Shefner et al.6(6) to modify the statistical MUNE method to exclude SMUPs < or = 40 microV. It is unknown if there is similar SMUP instability in the more chronic degenerative disease of SBMA. In this study the standard parameter of excluding SMUP < 10 microV was compared with the exclusion of SMUP < 40 microV in the calculation of the statistical MUNE. The mean statistical MUNE, using the standard method and the Shefner et al. method, was 60 +/- 21 to 47 +/- 23, respectively. Similar to ALS, SBMA showed an increased proportion (17%) of individual SMUPs < or = 40 microV compared to normal controls. In conclusion, excluding SMUPs < or = 40 microV from the statistical MUNE calculations is appropriate for SBMA subjects because their SMUP, characteristics are similar to ALS. Exclusion of the low-amplitude SMUPs reduces the calculated MUNE.

Motor unit number estimation may be a useful method to evaluate motor function recovery after spinal cord transection in rats

STUDY DESIGN

Experimental rat study.

OBJECTIVE

To investigate changes in motor unit number estimation (MUNE) value of the medial gastrocnemius (MG) muscle after thoracic spinal cord transection in rats and to correlate the MUNE with hindlimb motor function recovery.

SETTING

China Rehabilitation Research Center, Beijing, China.

METHODS

Twelve rats were subjected to spinal cord transection or sham surgery and then evaluated by MUNE and the Basso, Beattie and Bresnahan (BBB) behavioral scale 56 days after the surgery.

RESULTS

The MUNE values of the MG muscle were significantly decreased from baseline at 14-49 days after surgery. However, they returned to near pre-injury levels after 56 days. Rats recovered progressively from the severely impaired hindlimb motor function induced by spinal cord injury, as indicated by a gradual increase in BBB score during days 3-49 after surgery. However, this behavioral recovery was only partial and reached a plateau on day 49. Finally, there was a U-shape-like correlation between changes in MUNE values and BBB scores after thoracic spinal cord transection.

CONCLUSIONS

Time-dependent changes in the functional motor unit number may occur in spinal segments caudal to the transection level, and MUNE could be a useful method to evaluate motor function recovery.

Statistical MUNE: a comparison of two methods of setting recording windows in healthy subjects and ALS patients

OBJECTIVE

To address the issue as to how best to perform statistical MUNE, we applied two different approaches and compared results in healthy subjects and ALS patients.

METHODS

Twelve normal subjects (women 8, mean age 52years) and 11 ALS patients (women 4, mean age 54years) underwent two consecutive MUNE studies, which differed in terms of setting and modifying the recording window. These are referred to as the 'expansion' and 'narrowing' methods, respectively. Size-weighted average (Av) SMUP and MUNE values were obtained using the two methods, and compared in control and patient groups.

RESULTS

Expansion method-derived Av SMUP sizes and MUNE values differed only slightly from those obtained using the narrowing method in healthy subjects, whereas the narrowing method resulted in significantly larger Av SMUP sizes and smaller MUNE values than the expansion method in ALS patients (Wilcoxon signed ranks test, p=0.003). The sizes of tested areas (mean+/-SD) were significantly larger for the narrowing method than the expansion method in both subject groups with much greater difference in ALS patients; 9.6+/-3.1% vs. 7.9+/-1.7% in healthy subjects and 16.1+/-5.1% vs. 11.2+/-3.0% in ALS patients (Student t-test, p<0.01).

CONCLUSIONS

The present study shows, unlike that found in normal subjects, that the results of statistical MUNE in ALS patients are heavily dependent on the approach used to set and modify recording windows.

SIGNIFICANCE

The expansion method using a 10%-sized window is likely to suffer from systemic errors due to the ceiling effect and the sampling of artifactually small motor units in ALS patients. The authors recommend that the narrowing method be considered as an alternative that avoids these problems.

Reliability of techniques to assess human neuromuscular function in vivo

The purpose of this study was to comprehensively evaluate the reliability of a large number of commonly utilized experimental tests of in vivo human neuromuscular function separated by 4-weeks. Numerous electrophysiological parameters (i.e., voluntary and evoked electromyogram [EMG] signals), contractile properties (i.e., evoked forces and rates of force development and relaxation), muscle morphology (i.e., MRI-derived cross-sectional area [CSA]) and performance tasks (i.e., steadiness and time to task failure) were assessed from the plantarflexor muscle group in 17 subjects before and following 4-weeks where they maintained their normal lifestyle. The reliability of the measured variables had wide-ranging levels of consistency, with coefficient of variations (CV) ranging from approximately 2% to 20%, and intraclass correlation coefficients (ICC) between 0.53 and 0.99. Overall, we observed moderate to high-levels of reliability in the vast majority of the variables we assessed (24 out of the 29 had ICC>0.70 and CV<15%). The variables demonstrating the highest reliability were: CSA (ICC=0.93-0.98), strength (ICC=0.97), an index of nerve conduction velocity (ICC=0.95), and H-reflex amplitude (ICC=0.93). Conversely, the variables demonstrating the lowest reliability were: the amplitude of voluntary EMG signal (ICC=0.53-0.88), and the time to task failure of a sustained submaximal contraction (ICC=0.64). Additionally, relatively little systematic bias (calculated through the limits of agreement) was observed in these measures over the repeat sessions. In conclusion, while the reliability differed between the various measures, in general it was rather high even when the testing sessions are separated by a relatively long duration of time.

Motor unit number estimates correlate with strength in polio survivors

Motor unit number estimation (MUNE) has been proposed as an outcome measure in clinical trials for the motor neuron diseases. One major criticism of MUNE is that it may not represent a clinically meaningful endpoint. We prospectively studied a cohort of polio survivors over a period of 15 years with respect to MUNE and strength. We identified a significant association between thenar MUNE and arm strength, extensor digitorum brevis MUNE and leg strength, and the summated MUNE and global strength of the polio survivors. These findings confirm the clinical relevance of MUNE as an outcome measure in the motor neuron diseases and provide further validation for its use in clinical trial research.