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Koysuren A, Temucin CM. Concentric needle jitter analysis of the genioglossus muscle in patients with motor neuron disease. Neurol Res 2024; 46:578-582. [PMID: 38591728 DOI: 10.1080/01616412.2024.2339096] [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: 11/29/2023] [Accepted: 03/30/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES Difficulty relaxing the genioglossus muscle makes the evaluation of spontaneous activity problematic in patients with motor neuron disease (MND). We performed jitter analysis using conventional disposable concentric needle electrodes (CNEs) of the voluntarily activated genioglossus muscle in patients with and without MND to detect the denervation-reinnervation process. METHODS CNE jitter analysis was performed at the genioglossus muscle in 21 MND(+) patients and 22 MND(-) subjects. The jitter analysis was considered abnormal if the jitter values exceeded these limits for the mean consecutive difference (MCD) or the individual MCD in more than 10% of readings. RESULTS Seventeen MND(+) patients (81%) had at least three abnormal individual jitter values whereas denervation findings were obtained in eleven of them during the needle electromyographic examination at genioglossus muscle. None of the MND(-) subjects showed CNE jitter abnormality. CONCLUSION CNE jitter analysis of genioglossus muscle may provide an useful information that may be suggestive of a diagnosis of MND/ALS.
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Affiliation(s)
- Aydan Koysuren
- Department of Neurology, Hacettepe University Medical School, Ankara, Turkey
| | - Cagri Mesut Temucin
- Department of Neurology, Hacettepe University Medical School, Ankara, Turkey
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Kouyoumdjian JA, Estephan EDP. Electrophysiological evaluation of the neuromuscular junction: a brief review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:1040-1052. [PMID: 38157872 PMCID: PMC10756823 DOI: 10.1055/s-0043-1777749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
The nerve terminal and muscle membrane compose the neuromuscular junction. After opening the voltage-gated calcium channels, action potentials from the motor axons provoke a cascade for the acetylcholine release from synaptic vesicles to the synaptic cleft, where it binds to its receptor at the muscle membrane for depolarization. Low amplitude compound muscle action potential typically presents in presynaptic disorders, increasing by more than 100% after a 10-second effort in the Lambert-Eaton myasthenic syndrome and less in botulism. Needle electromyography may show myopathic motor unit action potentials and morphological instability ("jiggle") due to impulse blocking. Low-frequency repetitive nerve stimulation (RNS) is helpful in postsynaptic disorders, such as myasthenia gravis and most congenital myasthenic syndromes, where the number of functioning acetylcholine receptors is reduced. Low-frequency RNS with a decrement >10% is abnormal when comparing the 4th to the first compound muscle action potential amplitude. High-frequency RNS is helpful in presynaptic disorders like Lambert-Eaton myasthenic syndrome, botulism, and some rare congenital myasthenic syndromes. The high-frequency RNS releases more calcium, increasing the acetylcholine with a compound muscle action potential increment. Concentric needle records apparent single-fiber action potentials (spikes). A voluntary activation measures the jitter between spikes from two endplates. An electrical activation measures the jitter of one spike (one endplate). The jitter is the most sensitive test for detecting a neuromuscular junction dysfunction. Most neuromuscular junction disorders are responsive to treatment.
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Affiliation(s)
- João Aris Kouyoumdjian
- Faculdade de Medicina de São José do Rio Preto, Departamento de Ciências Neurológicas, Psiquiatria e Psicologia Médica, São José do Rio Preto SP, Brazil.
| | - Eduardo de Paula Estephan
- Faculdade de Medicina de São José do Rio Preto, Departamento de Ciências Neurológicas, Psiquiatria e Psicologia Médica, São José do Rio Preto SP, Brazil.
- Universidade de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.
- Faculdade de Medicina Santa Marcelina, São Paulo SP, Brazil.
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Sanders DB, Kouyoumdjian JA, Stålberg EV. Single fiber electromyography and measuring jitter with concentric needle electrodes. Muscle Nerve 2022; 66:118-130. [PMID: 35694863 DOI: 10.1002/mus.27573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 11/07/2022]
Abstract
This monograph contains descriptions of the single fiber electromyography (SFEMG) method and of the more recently implemented method of recording jitter with concentric needle electrodes (CNEs). SFEMG records action potentials from single muscle fibers (SFAPs), which permits measuring fiber density (FD), a sensitive measure of reinnervation, and jitter, a sensitive measure of abnormal neuromuscular transmission (NMT). With voluntary activation, jitter is measured between two SFAPs with acceptable amplitude and rise time. With activation by axon stimulation, jitter is measured between the stimulus and individual SFAPs. Pitfalls due to unstable triggers and inconstant firing rates during voluntary activation and subliminal stimulation during axon stimulation should be identified and avoided. In CNE recordings, spikes with shoulders or rising phases that are not parallel are produced by summation of SFAPS; these should be excluded and reference values for CNE jitter should be used. CNE and SFEMG have similar and very high sensitivity in detecting increased jitter, as in myasthenia gravis and other myasthenic conditions. However, jitter is also seen in ongoing reinnervation and some myopathic conditions. With SFEMG, these can be identified by increased FD; however, FD cannot be measured with CNE, and conventional electromyography should be performed in muscles with increased jitter to detect neurogenic or myogenic abnormalities. Jitter is abnormal after injections of botulinum toxin, even in muscles remote from the injection site, and can persist for 6 mo or more. This can complicate the detection or exclusion of abnormal NMT.
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Affiliation(s)
- Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - João A Kouyoumdjian
- Department of Neurological Sciences, State Medical School (FAMERP), São Paulo, Brazil
| | - Erik V Stålberg
- Department of Clinical Neurophysiology, Academic Hospital, Uppsala, Sweden
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Sanders DB, Kouyoumdjian JA, Stålberg EV. Single fiber EMG and measuring jitter with concentric needle electrodes. Muscle Nerve 2022. [PMID: 35652573 DOI: 10.1002/mus.27572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/08/2022]
Abstract
This monograph contains descriptions of the single-fiber electromyography (SFEMG) method and of the more recently implemented method of recording jitter with concentric needle electrodes (CNE). SFEMG records action potentials from single muscle fibers (SFAPs), which permits measuring fiber density (FD), a sensitive measure of reinnervation, and jitter, a sensitive measure of abnormal neuromuscular transmission (NMT). With voluntary activation, jitter is measured between two SFAPs with acceptable amplitude and rise time. With activation by axon stimulation, jitter is measured between the stimulus and individual SFAPs. Pitfalls due to unstable triggers and inconstant firing rates during voluntary activation and subliminal stimulation during axon stimulation should be identified and avoided. In CNE recordings, spikes with shoulders or rising phases that are not parallel are produced by summation of SFAPS; these should be excluded and reference values for CNE jitter should be used. CNE and SFEMG have similar and very high sensitivity in detecting increased jitter, as in myasthenia gravis and other myasthenic conditions. However, jitter is also seen in ongoing reinnervation and some myopathic conditions. With SFEMG, these can be identified by increased FD; however, FD cannot be measured with CNE, and conventional EMG should be performed in muscles with increased jitter to detect neurogenic or myogenic abnormalities. Jitter is abnormal after injections of botulinum toxin, even in muscles remote from the injection site, and can persist for 6 mo or more. This can complicate the detection or exclusion of abnormal NMT.
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Affiliation(s)
- Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - João A Kouyoumdjian
- Department of Neurological Sciences, State Medical School (FAMERP), São Paulo, Brazil
| | - Erik V Stålberg
- Department of Clinical Neurophysiology, Academic Hospital, Uppsala, Sweden
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Anagnostou E, Dimopoulou P, Sklavos S, Zouvelou V, Zambelis T. Identifying jitter outliers in single fiber electromyography: Comparison of four methods. Muscle Nerve 2020; 63:217-224. [PMID: 33067835 DOI: 10.1002/mus.27093] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Little is known about how different outlier estimation methods affect cutoff limits for outliers in single fiber electromyography. METHODS We compared in a prospective fashion the established 18th jitter value (18thjv) method to three, whole-distribution based, outlier detection methods: the interquartile range (IQR), the log-normal, and the Z-score method. The reference limits were probed in a normal cohort and in myasthenia gravis (MG) patients. RESULTS Differences in outlier cutoff values between the different methods were in the range of 2 μs. The number of abnormal muscles according to the computed criteria was similar for all four methods in the control group. Classification metrics (sensitivity, specificity, Youden's statistic, and predictive values) were also similar among the different methods. In the MG group, however, the Z-score method failed to identify the abnormal jitter values. Accordingly, Kappa agreement was substantial to perfect (0.658 to 1) between the three methods (18thjv, IQR, and log-normal), but was equivalent to chance between the three methods and the Z-score in the MG group. CONCLUSIONS The established 18thjv method proved largely robust when compared to whole-distribution based methods, and its use in clinical practice is justified. Simple estimation of outlier limits by adding two SDs to the mean of the data, leads to unacceptable deviations from the true cutoff values. Moreover, in a clinical scenario in which the final electrodiagnosis depends only on the number of outliers, it is meaningful to accept a tolerance zone of about 2 μs, which is the approximate variation range among the different methods.
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Affiliation(s)
- Evangelos Anagnostou
- Department of Neurology, University of Athens, Eginition Hospital, Athens, Greece
| | - Panagiota Dimopoulou
- Department of Neurology, University of Athens, Eginition Hospital, Athens, Greece
| | - Sokratis Sklavos
- Department of Neurology, University of Athens, Eginition Hospital, Athens, Greece
| | - Vasiliki Zouvelou
- Department of Neurology, University of Athens, Eginition Hospital, Athens, Greece
| | - Thomas Zambelis
- Department of Neurology, University of Athens, Eginition Hospital, Athens, Greece
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Lee I, Sanders DB, Nandedkar SD, Kazamel M. Single-institutional reference values for concentric needle jitter analysis using the extrapolated reference values procedure: Comparison to published reference values. Muscle Nerve 2020; 63:113-116. [PMID: 33063851 DOI: 10.1002/mus.27092] [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: 05/21/2020] [Revised: 10/03/2020] [Accepted: 10/10/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The extrapolated reference values procedure (E-Ref) was used to compare data from a single institution with the recently published reference value (RV) for concentric electrode jitter. METHODS Data from voluntarily activated concentric needle jitter studies in the frontalis muscle were obtained using retrospective chart review. All measured signals were reviewed for acceptable quality. Cutoff values for increased jitter were calculated using E-Ref, and compared with the published RVs. RESULTS At total of 1501 apparent single-fiber action potential (ASFAP) pairs were reviewed; 1371 ASFAP pairs were determined to have acceptable quality. The cutoff value identified by E-Ref from all reviewed ASFAP pairs was 36 microseconds and the cutoff for acceptable pairs was 35 microseconds. Using either of these cutoff values (36 or 35 microseconds) did not result in a significant difference in percentage of jitter recordings considered normal when compared with the recently published RV (38 microseconds). DISCUSSION The single-institution jitter cutoff value obtained by E-Ref gives results that are not significantly different from the reported RV.
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Affiliation(s)
- Ikjae Lee
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Donald B Sanders
- Department of Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Musa AMM, Ahmed AEM. Reference Jitter Values for Concentric Needle Electrode of Orbicularis Oculi and Frontalis Muscles Using Voluntary Activation Method in Sudanese Population. Sci Rep 2020; 10:1031. [PMID: 31974444 PMCID: PMC6978519 DOI: 10.1038/s41598-020-58037-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 01/09/2020] [Indexed: 11/18/2022] Open
Abstract
Single fibre electromyography is the most sensitive neurophysiological test for the diagnosis of neuromuscular junction disorders, particularly myasthenia gravis. The study aimed at establishing concentric needle (CN) normal jitter values for voluntarily activated orbicularis-oculi (V-OOc) & Frontalis (V-FRO) muscles in Sudanese population. 57 healthy volunteers (20 males & 37 females) were included in the study (mean Age 43.6 ± 14.2 years, range 18–70 years). V-OOc and V-FRO were tested in the same individual using CN. Jitter values were expressed as the mean consecutive difference (MCD) of 30 potential pairs in microseconds. The mean jitter, mean individual fibre pairs jitter & mean outliers jitter values with (upper 95% Confidence Limit-CL) for [OOc] were [26.9 ± 3.3 (31.97), 26.1 ± 8.9 (41.8) & 38.5 ± 5.7 (49.0) µs] & for [FRO] were [27.1 ± 3.0 (31.32), 26.4 ± 9.4 (42.9) & 39.9 ± 5 (49.2) µs] respectively. The suggested practical upper limits for mean jitter & for outliers were (32, 49 µs) for OOc & (31, 49 µs) for FRO. Our CN-jitter values were within the range of the few published studies. The study was unique in that it established and compared between CN reference jitter values of two voluntarily activated facial muscles (V-OOc & V-FRO) in the same individual in large number of healthy subjects.
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Affiliation(s)
- Afraa M M Musa
- Department of Physiology, Faculty of Medicine, University of Khartoum, El Qasr Street, Khartoum, P.O. BOX 102, Sudan.
| | - Ammar E M Ahmed
- Department of Physiology, Faculty of Medicine, University of Khartoum, El Qasr Street, Khartoum, P.O. BOX 102, Sudan
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Sanders DB, Arimura K, Cui L, Ertaş M, Farrugia ME, Gilchrist J, Kouyoumdjian JA, Padua L, Pitt M, Stålberg E. Guidelines for single fiber EMG. Clin Neurophysiol 2019; 130:1417-1439. [PMID: 31080019 DOI: 10.1016/j.clinph.2019.04.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/30/2019] [Accepted: 04/06/2019] [Indexed: 12/13/2022]
Abstract
This document is the consensus of international experts on the current status of Single Fiber EMG (SFEMG) and the measurement of neuromuscular jitter with concentric needle electrodes (CNE - CN-jitter). The panel of authors was chosen based on their particular interests and previous publications within a specific area of SFEMG or CN-jitter. Each member of the panel was asked to submit a section on their particular area of interest and these submissions were circulated among the panel members for edits and comments. This process continued until a consensus was reached. Donald Sanders and Erik Stålberg then edited the final document.
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Affiliation(s)
| | - Kimiyoshi Arimura
- Department of Neurology and Geriatrics, Kagoshima University, Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
| | - LiYing Cui
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.
| | | | | | - James Gilchrist
- Southern Illinois University School of Medicine, Springfield, IL USA.
| | | | - Luca Padua
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Department of Geriatrics, Neurosciences and Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Matthew Pitt
- Department of Clinical Neurophysiology, Great Ormond Street Hospital, London, UK.
| | - Erik Stålberg
- Department of Clinical Neurophysiology, Uppsala University, Uppsala, Sweden.
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Concentric or monopolar electrode for jitter determination in orbicularis oculi. Clin Neurophysiol 2018; 129:2552-2556. [DOI: 10.1016/j.clinph.2018.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 08/29/2018] [Accepted: 09/23/2018] [Indexed: 11/20/2022]
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10
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Pitfalls and errors in measuring jitter. Clin Neurophysiol 2017; 128:2233-2241. [DOI: 10.1016/j.clinph.2017.09.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/24/2017] [Accepted: 09/10/2017] [Indexed: 11/23/2022]
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Liu MS, Niu JW, Li Y, Guan YZ, Cui LY. Quantitating Changes in Jitter and Spike Number Using Concentric Needle Electrodes in Amyotrophic Lateral Sclerosis Patients. Chin Med J (Engl) 2017; 129:1036-40. [PMID: 27098787 PMCID: PMC4852669 DOI: 10.4103/0366-6999.180533] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Single-fiber electromyography (SFEMG) has been suggested as a quantitative method for supporting chronic partial denervation in amyotrophic lateral sclerosis (ALS) by the revised EI Escorial criteria. Although concentric needle (CN) electrodes have been used to assess jitter in myasthenia gravis patients and healthy controls, there are few reports using CN electrodes to assess motor unit instability and denervation in neurogenic diseases. The aim of this study was to determine whether quantitative changes in jitter and spike number using CN electrodes could be used for ALS studies. Methods: Twenty-seven healthy controls and 23 ALS patients were studied using both CN and single-fiber needle (SFN) electrodes on the extensor digitorum communis muscle with an SFEMG program. The SFN-jitter and SFN-fiber density data were measured using SFN electrodes. The CN-jitter and spike number were measured using CN electrodes. Results: The mean CN-jitter was significantly increased in ALS patients (47.3 ± 17.0 μs) than in healthy controls (27.4 ± 3.3 μs) (P < 0.001). Besides, the mean spike number was significantly increased in ALS patients (2.5 ± 0.5) than in healthy controls (1.7 ± 0.3) (P < 0.001). The sensitivity and specificity in the diagnosis of ALS were 82.6% and 92.6% for CN-jitter (cut-off value: 32 μs), and 91.3% and 96.3% for the spike number (cut-off value: 2.0), respectively. There was no significant difference between the SFN-jitter and CN-jitter in ALS patients; meanwhile, there was no significant difference between the SFN-jitter and CN-jitter in healthy controls. Conclusion: CN-jitter and spike number could be used to quantitatively evaluate changes due to denervation-reinnervation in ALS.
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Affiliation(s)
| | | | | | | | - Li-Ying Cui
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Stålberg E, Sanders DB, Ali S, Cooray G, Leonardis L, Löseth S, Machado F, Maldonado A, Martinez-Aparicio C, Sandberg A, Smith B, Widenfalk J, Aris Kouyoumdjian J. Reference values for jitter recorded by concentric needle electrodes in healthy controls: A multicenter study. Muscle Nerve 2015; 53:351-62. [DOI: 10.1002/mus.24750] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/19/2015] [Accepted: 06/24/2015] [Indexed: 11/07/2022]
Affiliation(s)
- Erik Stålberg
- Department of Neuroscience; Clinical Neurophysiology, Uppsala University; Uppsala Sweden
| | - Donald B. Sanders
- Department of Neurology; Duke University Medical Center; Durham North Carolina USA
| | - Sajjad Ali
- Department of Clinical Neurophysiology; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Gerald Cooray
- Clinical Neurophysiology, Karolinska University Hospital; Stockholm Sweden
- The Wellcome Trust for Neuroimaging, University College of London; London UK
| | - Lea Leonardis
- Institute of Clinical Neurophysiology, University Medical Center Ljubljana; Ljubljana Slovenia
| | - Sissel Löseth
- Department of Clinical Medicine; The Artic University of Norway; Tromsø Norway
- Department of Clinical Neurophysiology; University Hospital of North Norway; Tromsø Norway
| | - Flavia Machado
- Department of Neurology and Neurosurgery; Medical School, Universidade de São Paulo; São Paulo Brazil
- Fleury Medicina e Saúde; São Paulo Brazil
| | - Antonio Maldonado
- San Rafael University Hospital; Granada Spain
- Department of Clinical Neurophysiology; Ibermutuamur; Granada Spain
| | - Carmen Martinez-Aparicio
- Department of Clinical Neurophysiology; Vithas Virgen del Mar Hospital; Almeria Spain
- Doctoral Program in Clinical Medicine and Public Health; University of Granada; Granada Spain
| | - Arne Sandberg
- Department of Neuroscience; Clinical Neurophysiology, Uppsala University; Uppsala Sweden
| | - Benn Smith
- Department of Neurology, Mayo Clinic College of Medicine; Scottsdale Arizona USA
| | - Johan Widenfalk
- Department of Neuroscience; Clinical Neurophysiology, Uppsala University; Uppsala Sweden
- Department of Neuroscience; Karolinska Institutet; Stockholm Sweden
| | - João Aris Kouyoumdjian
- Neuromuscular Investigation Laboratory; Faculdade Medicina São José do Rio Preto; São Paulo Brazil
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