1
|
López-Navarro C, Serrano-Valero M, Fages-Caravaca EM, Martínez-Payá JJ, Del Baño-Aledo ME, Ríos-Díaz J. Dynamic analysis of muscles and the internal structure of the peripheral nerve as biomarkers of amyotrophic lateral sclerosis: A pilot study with ultrasound imaging. Neurologia 2024; 39:457-466. [PMID: 37116686 DOI: 10.1016/j.nrleng.2021.10.007] [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: 08/10/2021] [Accepted: 10/25/2021] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine the behaviour of ultrasound biomarkers of fascicle density and muscle strength in patients with amyotrophic lateral sclerosis (ALS). METHODS We conducted an observational, cross-sectional pilot study of 14 patients with ALS (28.6% women) and 14 controls. Bilateral cross-sectional ultrasound scans were performed in the abductor pollicis brevis (APB) and tibialis anterior (TA) muscles, with recording of muscle thickness (MT) at rest and in contraction, and the difference in thickness. In the median, sciatic, and common peroneal nerves, we analysed the cross-sectional area (CSA), number of fascicles (NF) and fascicle density (FD). Analyses were nested by laterality. RESULTS Intra- and interrater agreement regarding NF was very good, with a minimum detectable error of < 0.7%. In patients with ALS, MT was lower in the APB both at rest (P = .003; g-Hedges = 1.03) and in contraction (P = .017; g-Hedges = 0.78) and in TA at rest (P = .002; g-Hedges = 0.15) and in contraction (P = .001; g-Hedges = 0.46), with lower thickening capacity. In the nerves, patients displayed lower CSA, with lower NF and higher FD. Significant correlations were found between MT of the ABP and Medical Research Council (MRC) scores for muscle strength (r = 0.34; r2 = 12%; P = .011) and with revised ALS Functional Rating Scale scores (r = 0.44; r2 = 19%; P < .001). The difference in TA thickening correlated with MRC scores (r = 0.30; r2 = 15%; P = .003) and with revised ALS Functional Rating Scale scores (r = 0.26; r2 = 7%; P = .049). NF in the sciatic nerve showed a significant correlation with MRC scores (r = 0.35; r2 = 12%; P = .008). CONCLUSION MT measurements derived from dynamic testing together with NF and FD may be useful biomarkers for monitoring patients with ALS and establishing a prognosis.
Collapse
Affiliation(s)
- C López-Navarro
- Departamento de Fisioterapia, Facultad de Medicina, Campus de Espinardo 30100, Universidad de Murcia, Murcia, Spain
| | - M Serrano-Valero
- Departamento de Fisioterapia, Facultad de Medicina, Campus de Espinardo 30100, Universidad de Murcia, Murcia, Spain
| | - E M Fages-Caravaca
- Departamento de Neurología, Hospital General Universitario Santa Lucía, Cartagena, Spain
| | - J J Martínez-Payá
- Departamento de Fisioterapia, Facultad de Medicina, Campus de Espinardo 30100, Universidad de Murcia, Murcia, Spain.
| | - M E Del Baño-Aledo
- Departamento de Fisioterapia, Facultad de Medicina, Campus de Espinardo 30100, Universidad de Murcia, Murcia, Spain
| | - J Ríos-Díaz
- Centro de Ciencias de la Salud San Rafael, Fundación San Juan de Dios, Universidad de Nebrija, Madrid, Spain
| |
Collapse
|
2
|
Nasr-Eldin YK, Cartwright MS, Hamed A, Ali LH, Abdel-Nasser AM. Neuromuscular Ultrasound in Polyneuropathies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1181-1198. [PMID: 38504399 DOI: 10.1002/jum.16447] [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: 09/29/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/21/2024]
Abstract
Neuromuscular ultrasound is a painless, radiation-free, high-resolution imaging technique for assessing the peripheral nervous system. It can accurately depict changes in the nerves and muscles of individuals with neuromuscular conditions, and it is therefore a robust diagnostic tool for the assessment of individuals with polyneuropathies. This review will outline the typical ultrasonographic changes found in a wide variety of polyneuropathies. In general, demyelinating conditions result in greater nerve enlargement than axonal conditions, and acquired conditions result in more patchy nerve enlargement compared to diffuse nerve enlargement in hereditary conditions. This review is data-driven, but more nuanced anecdotal findings are also described. The overall goal of this paper is to provide clinicians with an accessible review of the ultrasonographic approaches and findings in a wide variety of polyneuropathies.
Collapse
Affiliation(s)
| | - Michael S Cartwright
- Neurology Department, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ahmed Hamed
- Rheumatology and Rehabilitation Department, Minia University, Minia, Egypt
| | - Lamia Hamdy Ali
- Clinical Pathology Department, Minia University, Minia, Egypt
| | | |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Avidan R, Fainmesser Y, Drory VE, Bril V, Abraham A. The Sensitivity of Quantitative Sonographic Assessment of Muscle Thickness for Amyotrophic Lateral Sclerosis Diagnosis. J Clin Neurophysiol 2023; 40:529-534. [PMID: 35066529 DOI: 10.1097/wnp.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE In the current proof-of-concept study, we aimed to examine the sensitivities and specificities of previously reported normal values for muscle ultrasound thickness in amyotrophic lateral sclerosis. METHODS Muscle ultrasound was performed in 65 healthy control subjects and 91 amyotrophic lateral sclerosis patients using a standardized assessment of eight relaxed muscles and four contracted muscles. Normal values for muscle thickness were determined as values above the 5th percentile stratified by age and gender using the weighted average method. Sensitivity for amyotrophic lateral sclerosis diagnosis was determined for muscles with and without the addition of muscle contraction. RESULTS Amyotrophic lateral sclerosis patients showed reduced muscle sum thickness both in relaxed and in contracted states compared with control subjects. Muscle ultrasound of muscles with and without contraction showed excellent diagnostic accuracy for differentiating amyotrophic lateral sclerosis patients from control subjects (area under curve = 0.96, sensitivity: 93%-95%, specificity: 84-87). Muscle ultrasound sensitivity was lower within 6 months of symptom onset (83%) compared with longer disease duration (>92%). CONCLUSIONS Quantitative sonographic assessment of muscle thickness can be complementary in the diagnosis of amyotrophic lateral sclerosis with excellent accuracy for differentiating patients from healthy subjects, and might be useful in other neuromuscular disorders, although additional studies are required.
Collapse
Affiliation(s)
| | - Yaara Fainmesser
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Vivian E Drory
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Alon Abraham
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| |
Collapse
|
5
|
Fan J, Li Y, Niu J, Liu J, Guan Y, Cui L, Liu M. The cross-sectional area of peripheral nerve in amyotrophic lateral sclerosis: A case-control study. Clin Neurol Neurosurg 2023; 231:107847. [PMID: 37364449 DOI: 10.1016/j.clineuro.2023.107847] [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: 07/26/2022] [Revised: 01/30/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE A growing body of literature recognises the importance of peripheral nerve ultrasound in neuromuscular disorders. Several attempts have been made to differentiate amyotrophic lateral sclerosis (ALS) from multifocal motor neuropathy (MMN) using peripheral nerve ultrasound. A much-debated question is whether the cross-sectional area (CSA) of peripheral nerve in ALS patients is significantly smaller compared to healthy controls. This study aims to determine the CSA of peripheral nerves in patients with ALS. METHODS One hundred and thirty-nine patients with ALS and 75 healthy controls were recruited. Ultrasound of the median, ulnar, and trunks of the brachial plexus and cervical nerve roots was undertaken in ALS patients and controls. RESULTS Compared to controls, ALS patients had mild reductions of the median nerve, most sites of the ulnar nerve, trunks of the brachial plexus and cervical nerve roots. Another important finding of this study is that the median nerve tends to have a more significant reduction than the ulnar nerve in ALS patients, especially at the proximal. CONCLUSIONS Ultrasound could be sensitive to nerve motor fibre loss in patients with ALS. CSA at the proximal Median nerve may be a promising biomarker in patients with ALS.
Collapse
Affiliation(s)
- Jing Fan
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Yi Li
- The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jingwen Niu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Jingwen Liu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Yuzhou Guan
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Liying Cui
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Beijing, China.
| |
Collapse
|
6
|
The Sensitivity and Specificity of Split-Hand Index Using Muscle Sonography. Can J Neurol Sci 2023; 50:228-233. [PMID: 35190003 DOI: 10.1017/cjn.2022.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The split-hand index (SHI) (first dorsal interosseous (FDI) × abductor pollicis brevis (APB)/abductor digiti minimi muscle (ADM)) has been suggested as a useful measure for amyotrophic lateral sclerosis (ALS) diagnosis, using electrophysiological and sonographic indices. In the present study, we aimed to explore the specificity of SHI derived by muscle ultrasound (MUS) for the diagnosis of ALS and spinal muscular atrophy (SMA). METHODS Healthy controls (n = 65) were prospectively recruited at the Prosserman Family Neuromuscular clinic at Toronto General Hospital, from October to December 2018. In addition, 181 patients with ALS (n = 91), SMA (n = 33), polyneuropathy (n = 35), and myopathy (n = 22) were prospectively recruited at the neuromuscular clinic at Tel Aviv Sourasky Medical Center, from December 2018 to December 2020. All subjects underwent quantitative sonographic evaluation of muscle thickness, including the right APB, FDI, and ADM muscles. Area under curve (AUC), sensitivity, and specificity were determined for differentiating between groups. RESULTS Although SHI showed good to excellent accuracy for differentiating each patient subgroup from controls (AUC 0.83-0.92), poorer diagnostic accuracy was shown for differentiating between different patient subgroups (AUC 0.54-0.74). CONCLUSIONS Sonographic SHI is useful for differentiating patients from healthy controls, but might be not specific for motor neuron disease.
Collapse
|
7
|
Occupational therapy using a robotic-assisted glove ameliorates finger dexterity and modulates functional connectivity in amyotrophic lateral sclerosis. J Clin Neurosci 2023; 107:144-149. [PMID: 36411175 DOI: 10.1016/j.jocn.2022.11.004] [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: 07/07/2022] [Revised: 11/01/2022] [Accepted: 11/08/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Although rehabilitation is recommended for amyotrophic lateral sclerosis (ALS), improvement of functional decline has hardly been achieved. We investigated the effect of occupational therapy that uses a robotic-assisted glove (RAG) on hand dexterity and the functional connectivities found in the brain of ALS patients. METHOD Ten patients diagnosed with ALS and admitted to the Shiga University of Medical Science (SUMS) Hospital from December 2018 to December 2021 participated in the study. These participants chose the hand side to wear RAG and exercised for two weeks. A sham movement was performed on the other side. We administered several functional assessments, including the Simple Test for Evaluating Hand Function (STEF), grip strength, pinch meter for grip strength, Canadian occupational performance measure (COPM), as well as nerve conduction study (NCS) before and after the exercise, and evaluated the results. We also analyzed six patients' resting-state functional magnetic resonance imaging (rs-fMRI). RESULTS Two-week robotic rehabilitation improved the STEF, grip strength, and COPM scores when compared with those of the other side. However, no significant effect was observed in the pinch meter and the NCS results. The rs-fMRI data analysis revealed that the robotic rehabilitation augmented two functional connectivities between the left pallidum-right supplementary motor cortex and right insular cortex-right sensorimotor network among the patients, which had beneficial effects. CONCLUSION The occupational therapy using RAG displayed improved hand dexterity. The enhanced functional connectivities around the sensorimotor network might be associated with the improvement in hand dexterity because of the RAG.
Collapse
|
8
|
Lu WZ, Lin HA, Hou SK, Lee CF, Bai CH, Lin SF. Split-hand index for amyotrophic lateral sclerosis diagnosis: A frequentist and Bayesian meta-analysis. Clin Neurophysiol 2022; 143:56-66. [PMID: 36116424 DOI: 10.1016/j.clinph.2022.08.020] [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: 04/12/2022] [Revised: 08/02/2022] [Accepted: 08/21/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Preferential wasting of the thenar muscles, the split-hand sign, may be used for early diagnosis of amyotrophic lateral sclerosis (ALS). METHODS Electronic databases were searched for studies assessing the split-hand index (SHI) and the compound muscle action potential (CMAP) amplitudes of abductor pollicis brevis (APB), first dorsal interosseous (FDI), and abductor digiti minimi (ADM). The SHI was obtained by multiplying CMAP amplitudes of APB and FDI and dividing the product by the CMAP amplitude of ADM. The Bayesian analysis was used for validation. RESULTS In total, 17 studies and 1635 patients were included. Our meta-analysis revealed that ALS patients had significantly decreased SHI (standardized mean difference [SMD], -1.60, P < 0.001), CMAP of the APB (SMD, -1.67, P < 0.001), FDI (SMD, -1.12, P < 0.001), and ADM (SMD, -1.09, P < 0.001). The binormal receiver operating characteristic curve analysis showed a threshold of < 7.4 for SHI, and cutoff values of < 6.4 mV for APB and < 8.4 mV for FDI, respectively. The Bayesian analysis validated decreased SHI in ALS patients (posterior mean difference of - 5.91). CONCLUSIONS An SHI of < 7.4 can be used facilitating earlier diagnosis of ALS. SIGNIFICANCE SHI can be used as a standard neurophysiological biomarker for early diagnosis.
Collapse
Affiliation(s)
- Wei-Zhen Lu
- Department of Emergency Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Fan Lee
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Nutrition Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sheng-Feng Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
9
|
Quantitative muscle ultrasound assessment using automatic thresholding methods in amyotrophic lateral sclerosis. Clin Neurophysiol 2022; 142:236-243. [DOI: 10.1016/j.clinph.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022]
|
10
|
López-Navarro C, Serrano-Valero M, Fages-Caravaca E, Martínez-Payá J, del Baño-Aledo M, Ríos-Díaz J. Análisis dinámico muscular y de la estructura interna del nervio periférico como biomarcadores para la esclerosis lateral amiotrófica: estudio piloto mediante ecografía. Neurologia 2022. [DOI: 10.1016/j.nrl.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
11
|
Pechirra G, Swash M, de Carvalho M. The senile hand: age effects on intrinsic hand muscle CMAP amplitudes influence split-hand index calculations. Muscle Nerve 2022; 65:463-467. [PMID: 34993957 DOI: 10.1002/mus.27489] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIMS Age can affect hand muscles non-uniformly. We investigated the influence of age on the compound muscle action potential (CMAP) amplitude of the hand muscles and the derived split-hand index (SHI). METHODS We studied 244 subjects investigated for myasthenia gravis but without neuromuscular disorders. Abductor pollicis brevis (APB), first dorsal interosseous (FDI), and abductor digiti minimi (ADM) CMAPs were obtained by supramaximal stimulation at the wrist, recording with surface electrodes while checking the best recording site. We applied Tukey's HSD and Kruskal-Wallis one-way analysis of variance for comparing age groups defined by median and inter-quantile ranges (IQR). Spearman's rank correlation coefficient and linear regression were used for testing age-dependence of measurements. RESULTS Median age was 61.5 years (1st IQR 44.5, 3rd IQR 72.0, range 18-89). Age and neurophysiological measurements were similar between genders. APBCMAP , FDICMAP , ADMCMAP and SHI were correlated with age (p < 0.001). Median and cut-off values were significantly different between age groups. APBCMAP , FDICMAP and ADMCMAP decreased by 0.8/0.7/0.3 mV/year, respectively, and SHI decreased 0.15/year. DISCUSSION The CMAP amplitudes of hand muscles and derived SHI were strongly age-dependent, although this effect was less in ADM. This represents a physiological phenomenon. Future studies using the SHI should consider age effects. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Gonçalo Pechirra
- Faculdade de Medicina-Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
| | - Michael Swash
- Departments of Neurology and Neuroscience, Queen Mary University of London, UK.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
| | - Mamede de Carvalho
- Faculdade de Medicina-Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
| |
Collapse
|
12
|
Corcia P, Bede P, Pradat PF, Couratier P, Vucic S, de Carvalho M. Split-hand and split-limb phenomena in amyotrophic lateral sclerosis: pathophysiology, electrophysiology and clinical manifestations. J Neurol Neurosurg Psychiatry 2021; 92:1126-1130. [PMID: 34285065 DOI: 10.1136/jnnp-2021-326266] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/05/2021] [Indexed: 11/03/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder affecting the upper and lower motor neurons. A key clinical feature of ALS is the absence of accurate, early-stage diagnostic indicators. 'Split-hand syndrome' was first described in ALS at the end of the last century and a considerable body of literature suggests that the split-hand phenomenon may be an important clinical feature of ALS. Considering the published investigations, it is conceivable that the 'split-hand syndrome' results from the associated upper and lower motor neuron degeneration, whose interaction remains to be fully clarified. Additionally, other split syndromes have been described in ALS involving upper or lower limbs, with a nuanced description of clinical and neurophysiological manifestations that may further aid ALS diagnosis. In this review, we endeavour to systematically present the spectrum of the 'split syndromes' in ALS from a clinical and neurophysiology perspective and discuss their diagnostic and pathogenic utility.
Collapse
Affiliation(s)
- Philippe Corcia
- Centre Constitutif de Référence SLA, CHU Bretonneau, Tours, France
| | - Peter Bede
- Computational Neuroimaging Group, Trinity College Dublin, Ireland.,Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Pierre-François Pradat
- Neurology, Hopital Pitie-Salpetriere, Paris, France.,LIB, Université Pierre et Marie Curie Faculté de Médecine, Paris, Île-de-France, France
| | | | - Steve Vucic
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mamede de Carvalho
- Instituto de Fisiologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisbon, Lisbon, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisboa, Portugal
| |
Collapse
|
13
|
Hannaford A, Higashihara M, Pavey N, van den Bos M, Geevasinga N, Vucic S, Menon P. Split-hand index: A diagnostic and prognostic marker in amyotrophic lateral sclerosis across varying regions of onset. Clin Neurophysiol 2021; 132:2130-2135. [PMID: 34284248 DOI: 10.1016/j.clinph.2021.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The split-hand index (SI), a reliable diagnostic marker of amyotrophic lateral sclerosis (ALS), was prospectively assessed for differences across ALS subtypes and between the onset side of clinical symptoms or the dominant and contralateral sides. In addition, the prognostic utility of the SI was longitudinally assessed. METHODS Two hundred and forty-five ALS patients underwent measurement of SI on both sides compared with 126 neuromuscular mimic disorders (NMD). A subset of patients (N = 45) underwent longitudinal assessment of SI. RESULTS The SI was significantly reduced (SI RIGHT ALS 5.47(4.2), SINMD 9.0 (5.0); P < 0.001; SILEFT ALS 5.5 (4.1), SI NMD 9.4 (5.0), P < 0.001) on both sides in all ALS patients with prominent reduction on the onset side in upper limb onset ALS (SI RIGHT P < 0.001; SI LEFT P < 0.05) and in Awaji definite/probable diagnostic category (SI RIGHT P < 0.05; SI LEFT P < 0.05). Longitudinal studies disclosed that the rate of SI decline correlated with the decline in ALSFRS-R (r = 0.21, P < 0.05). CONCLUSION The SI is reduced in all ALS subtypes most prominently in upper limb onset disease, on the side of clinical onset, and in patients with Awaji definite/probable diagnostic category. SIGNIFICANCE The split-hand index is a reliable diagnostic and outcome biomarker across ALS subtypes and may have potential utility in a clinical trial setting, although further multicenter studies are required to confirm this.
Collapse
Affiliation(s)
- Andrew Hannaford
- Westmead Hospital, Sydney, Australia; University of Sydney, Australia
| | - Mana Higashihara
- Westmead Hospital, Sydney, Australia; Tokyo Metropolitan Geriatric Hospital, Japan
| | - Nathan Pavey
- Westmead Hospital, Sydney, Australia; University of Sydney, Australia
| | - Mehdi van den Bos
- Westmead Hospital, Sydney, Australia; University of Sydney, Australia
| | | | - Steve Vucic
- Westmead Hospital, Sydney, Australia; University of Sydney, Australia
| | - Parvathi Menon
- Westmead Hospital, Sydney, Australia; University of Sydney, Australia.
| |
Collapse
|
14
|
Hu N, Wang J, Liu M. Split hand in amyotrophic lateral sclerosis: A systematic review and meta-analysis. J Clin Neurosci 2021; 90:293-301. [PMID: 34275566 DOI: 10.1016/j.jocn.2021.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/05/2021] [Accepted: 06/06/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the frequency of split hand (SI) and its diagnostic performance in amyotrophic lateral sclerosis (ALS). METHODS PubMed, EMBASE, OVID and other databases were searched systematically up to March 2021 for relevant reports about the split hand syndrome. Two reviewers screened and selected the titles and abstracts of the studies independently during the database searches and performed full-text reviews and extracted available data. In our study, AACMAP was calculated by AACMAP = APBCMAP/ADMCMAP and split-hand index (SI) was calculated by SICMAP = (APBCMAP × FDICMAP)/ADMCMAP. The mean differences (MD) in APB/ADMCMAP and SICMAP between patients with ALS and control group were calculated (APB the abductor pollicis brevis muscle; ADM the abductor digiti minimi muscle; CMAP compound muscle action potentials). Meta-analysis was performed to determine summary sensitivity, specificity, and area under the curve (AUC) with 95% confidence intervals (CI) for SICMAP. RESULTS Pooled results of five studies including 339 patients showed that 50% (95%CI: 35%-65%) of patients with ALS presented split hand. APB/ADMCMAP in patients with ALS was significantly lower than healthy population (MD: -0.38, 95%CI: -0.48, -0.28). SICMAP in patients with ALS was significantly lower than healthy controls (MD: -5.87, 95%CI: -6.28, -5.46) and neuromuscular controls (MD: -5.60, 95%CI: -5.78, -5.42). Receiver operating characteristic curve analysis showed that the AUC was 0.860 [95%CI: 0.808, 0.911] for SICMAP. The sensitivity and specificity for SICMAP were 78% and 81% (cut-off value: 5.2-11.8), respectively. CONCLUSION Half of ALS patients might show split hand sign. SICMAP could be a potential biomarker in the diagnosis of ALS.
Collapse
Affiliation(s)
- Nan Hu
- Department of Neurology, Peking Union Medical College Hospital, Beijing 100730, China
| | - Jingyi Wang
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
| | - Mingsheng Liu
- Department of Neurology, Peking Union Medical College Hospital, Beijing 100730, China.
| |
Collapse
|
15
|
Fasciculation score: a sensitive biomarker in amyotrophic lateral sclerosis. Neurol Sci 2021; 42:4657-4666. [PMID: 33704599 DOI: 10.1007/s10072-021-05166-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 03/04/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of our study was to elucidate the characteristic of fasciculation distributions in amyotrophic lateral sclerosis (ALS) using a fasciculation score (FS) of muscle ultrasound (MUS) and to compare the diagnostic values of three MUS fasciculation parameters in patients. METHODS Thirty ALS patients, 16 ALS mimics, and 10 healthy subjects were involved. MUS of unilateral 10 muscles in each patient and needle electromyography (EMG) of total 204 muscles were performed to detect fasciculations and spontaneous activity respectively in ALS. Control groups underwent only MUS. Fasciculation was graded semiquantitatively with FS. RESULTS Three hundred fifty muscles in ALS and 260 in controls were examined. The fasciculation detection rates, total FS, the number of muscles with fasciculation, and the total number of fasciculations in ALS were all significantly higher than those of controls (P < 0.001). ALS patients exhibited a multifocal continuous pattern of fasciculation in limbs, whereas there were few fasciculations in controls. Compared with other parameters, total FS had the largest area under the curve (AUC) (AUC = 0.899, P < 0.001) in ALS diagnosis. The detection rates of lower motor neuron (LMN) acute lesions by MUS (70.6%) and EMG (72.1%) were nearly the same, and a positive correlation between the FS and spontaneous activity grades (P < 0.001, r = 0.359) was proved. CONCLUSIONS ALS patients exhibited the multifocal continuous pattern of fasciculation in limbs. FS showed high sensitivity and specificity in differentiating ALS from non-ALS patients, and the optimal cut-off value was determined as 4. The combination of MUS and EMG can provide additional information about specific muscles.
Collapse
|
16
|
Abraham A, Fainmesser Y, Drory VE, Bril V. Split-hand phenomenon in motor neuron diseases: Sonographic assesment of muscle thickness. Clin Neurophysiol 2020; 131:1721-1725. [PMID: 32504931 DOI: 10.1016/j.clinph.2020.04.163] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 03/21/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To explore the diagnostic accuracy of the split-hand index (SHI) for amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA) using sonographic assessment of muscle thickness. METHODS We performed a prospective sonographic assessment of hand muscle thickness in 59 controls, 87 patients with ALS, and 33 patients with SMA. We determined the diagnostic accuracy of SHI for differentiating patients with ALS and SMA from controls. RESULTS Patients with ALS and SMA had significantly lower muscle thickness and SHI values compared with controls. SHI showed excellent diagnostic accuracy for differentiating ALS from controls, and good diagnostic accuracy for differentiating SMA from controls. CONCLUSIONS SHI determined by sonographic measurement of hand muscle thickness seems to be a promising tool for the diagnosis of ALS and may be added easily when performing neuromuscular ultrasound. SIGNIFICANCE SHI determined by sonographic measurement of hand muscle thickness can differentiate between healthy subjects and patients with ALS and SMA.
Collapse
Affiliation(s)
- Alon Abraham
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Yaara Fainmesser
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Vivian E Drory
- Neuromuscular Diseases Unit, Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Canada; Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| |
Collapse
|
17
|
Intrarater and Interrater Reliability of Heckmatt Scoring System in Amyotrophic Lateral Sclerosis. J Clin Neurophysiol 2020; 38:293-298. [DOI: 10.1097/wnp.0000000000000690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
18
|
Barnes SL, Simon NG. Clinical and research applications of neuromuscular ultrasound in amyotrophic lateral sclerosis. Degener Neurol Neuromuscul Dis 2019; 9:89-102. [PMID: 31406480 PMCID: PMC6642653 DOI: 10.2147/dnnd.s215318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 06/14/2019] [Indexed: 12/20/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disorder characterized by dysfunction at multiple levels of the neuraxis. It remains a clinical diagnosis without a definitive diagnostic investigation. Electrodiagnostic testing provides supportive information and, along with imaging and biochemical markers, can help exclude mimicking conditions. Neuromuscular ultrasound has a valuable role in the diagnosis and monitoring of ALS and provides complementary information to clinical assessment and electrodiagnostic testing as well as insights into the underlying pathophysiology of this disease. This review highlights the evidence for ultrasound in the evaluation of bulbar, limb and respiratory musculature and peripheral nerves in ALS. Further research in this evolving area is required.
Collapse
Affiliation(s)
- Stephanie L Barnes
- Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia.,St Vincent's Clinical School, School of Medicine, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Neil G Simon
- St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
19
|
Hobson-Webb LD, Simmons Z. ULTRASOUND IN THE DIAGNOSIS AND MONITORING OF AMYOTROPHIC LATERAL SCLEROSIS: A REVIEW. Muscle Nerve 2019; 60:114-123. [PMID: 30989697 DOI: 10.1002/mus.26487] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 12/28/2022]
Abstract
Neuromuscular ultrasound is complementary to electrodiagnostic (EDx) testing and is useful in enhancing the diagnosis of mononeuropathies, peripheral nerve trauma, and demyelinating polyneuropathies. There is increasing interest in using ultrasound both to aid in the diagnosis of amyotrophic lateral sclerosis (ALS) and to monitor its progression. In this article we review the relevant literature on ultrasound in ALS. Ultrasound is more sensitive than EDx in identifying fasciculations in patients with ALS. It can detect decreased muscle thickness, increased muscle echointensity and echovariance, and reduced peripheral nerve size in these patients. Ultrasound is also a helpful tool in assessment of diaphragm function. Although additional studies are required to define the exact role of ultrasound in the evaluation and monitoring of ALS, it can improve the diagnostic yield in patients when ALS is suspected, but insufficiently supported, by clinical and EDx examinations. Muscle Nerve 60: 114-123, 2019.
Collapse
Affiliation(s)
- Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University Medical Center, DUMC 3403, Durham, North Carolina 27710, USA
| | - Zachary Simmons
- Department of Neurology, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| |
Collapse
|
20
|
Quantitative neuromuscular ultrasound analysis as biomarkers in amyotrophic lateral sclerosis. Eur Radiol 2019; 29:4266-4275. [PMID: 30666448 DOI: 10.1007/s00330-018-5943-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/09/2018] [Accepted: 11/30/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess the differences in morphological and texture parameters of median nerve (MN) and abductor pollicis brevis (APB) between amyotrophic lateral sclerosis (ALS) patients and controls. METHODS The cross-sectional area (CSA) of the MN and the muscle thickness (MTh) of APB were measured bilaterally in 59 recently diagnosed ALS patients and 20 matched healthy controls. Echointensity (EI), echovariation (EV) and grey-level co-occurrence matrix (GLCM) texture features of both structures were also analysed. Correlations between these parameters and clinical variables (muscle strength and disability) were analysed. RESULTS The CSA of MN was significantly lower in ALS patients (MD = - 1.83 mm2 [95% CI = 2.89; - 0.77 mm2]; p = 0.01). ALS patients showed significantly lower MTh (- 2.23 mm [3.16; - 1.30 mm]; p < 0.001) and EV (- 7.40 [11.5; - 3.33]; p = 0.004) and higher EI (21.2 [11.9; 30.6]; p < 0.001) in the APB muscle. No relevant differences were detected in GLCM features for this muscle. The model including all parameters (CSA for MN and MTh, EI and EV for APB) showed an AUC of 82% (sensitivity 87%; specificity 42%). Muscle strength and disability correlated with APB muscle ultrasound parameters but not with those of the MN. CONCLUSIONS APB muscle ultrasound biomarkers (especially MTh and EI) showed better discrimination capacity and correlation with clinical variables than MN biomarkers. However, the combination of both biomarkers increased their ability to detect LMN impairment, suggesting that both biomarkers could be used in a complementary manner for the diagnosis and progression monitoring in ALS. KEY POINTS • Abductor pollicis brevis muscle and median nerve impairment is detectable by ultrasound in amyotrophic lateral sclerosis patients, even in those without clinical impairment. • Muscle ultrasound biomarkers show better discrimination capacity than nerve biomarkers in amyotrophic lateral sclerosis. • Quantitative neuromuscular ultrasound biomarkers could be useful in a general amyotrophic lateral sclerosis population early on the disease.
Collapse
|
21
|
Caress JB, Cartwright MS. Neuromuscular ultrasound as a biomarker in amyotrophic lateral sclerosis. Muscle Nerve 2018; 58:747-748. [DOI: 10.1002/mus.26343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/07/2018] [Accepted: 09/09/2018] [Indexed: 11/11/2022]
Affiliation(s)
- James B. Caress
- Department of Neurology; Wake Forest School of Medicine; Winston-Salem NC 27157 USA
| | | |
Collapse
|
22
|
Walker FO, Cartwright MS, Alter KE, Visser LH, Hobson-Webb LD, Padua L, Strakowski JA, Preston DC, Boon AJ, Axer H, van Alfen N, Tawfik EA, Wilder-Smith E, Yoon JS, Kim BJ, Breiner A, Bland JDP, Grimm A, Zaidman CM. Indications for neuromuscular ultrasound: Expert opinion and review of the literature. Clin Neurophysiol 2018; 129:2658-2679. [PMID: 30309740 DOI: 10.1016/j.clinph.2018.09.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/10/2018] [Accepted: 09/02/2018] [Indexed: 12/11/2022]
Abstract
Over the last two decades, dozens of applications have emerged for ultrasonography in neuromuscular disorders. We wanted to measure its impact on practice in laboratories where the technique is in frequent use. After identifying experts in neuromuscular ultrasound and electrodiagnosis, we assessed their use of ultrasonography for different indications and their expectations for its future evolution. We then identified the earliest papers to provide convincing evidence of the utility of ultrasound for particular indications and analyzed the relationship of their date of publication with expert usage. We found that experts use ultrasonography often for inflammatory, hereditary, traumatic, compressive and neoplastic neuropathies, and somewhat less often for neuronopathies and myopathies. Usage significantly correlated with the timing of key publications in the field. We review these findings and the extensive evidence supporting the value of neuromuscular ultrasound. Advancement of the field of clinical neurophysiology depends on widespread translation of these findings.
Collapse
Affiliation(s)
- Francis O Walker
- Department of Neurology at Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA.
| | - Michael S Cartwright
- Department of Neurology at Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA.
| | - Katharine E Alter
- Department of Rehabilitation Medicine, National INeurolnstitutes of Health, Bethesda, MD 20892, USA.
| | - Leo H Visser
- Departments of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University School of Medicine, Durham, NC, USA.
| | - Luca Padua
- Don Carlo Gnocchi ONLUS Foundation, Piazzale Rodolfo Morandi, 6, 20121 Milan, Italy; Department of Geriatrics, Neurosciences and Orthopaedics, Universita Cattolica del Sacro Cuore, Rome, Italy.
| | - Jeffery A Strakowski
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA; Department of Physical Medicine and Rehabilitation, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA; OhioHealth McConnell Spine, Sport and Joint Center, Columbus, OH, USA.
| | - David C Preston
- Neurological Institute, University Hospitals, Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Andrea J Boon
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA.
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena 07747, Germany.
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Eman A Tawfik
- Department of Physical Medicine & Rehabilitation, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Einar Wilder-Smith
- Department of Neurology, Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Neurology, Kantonsspital Lucerne, Switzerland; Department of Neurology, Inselspital Berne, Switzerland.
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Republic of Korea.
| | - Byung-Jo Kim
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Ari Breiner
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Canada.
| | - Jeremy D P Bland
- Deparment of Clinical Neurophysiology, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK.
| | - Alexander Grimm
- Department of Neurology, University Hospital Tuebingen, Tuebingen, Germany.
| | - Craig M Zaidman
- Division of Neuromuscular Medicine, Department of Neurology, Washington University in St. Louis, 660 S. Euclid Ave, Box 8111, St. Louis, MO 63110, USA.
| |
Collapse
|