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Vacchiano V, Morabito F, Bonan L, Teodorani L, Faini C, Rizzo G, Liguori R. Reverse Split Hand as a Neurophysiological Hallmark of Spinal Muscular Atrophy. J Clin Med 2024; 13:6881. [PMID: 39598025 PMCID: PMC11594792 DOI: 10.3390/jcm13226881] [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: 09/24/2024] [Revised: 10/21/2024] [Accepted: 11/11/2024] [Indexed: 11/29/2024] Open
Abstract
Objective: Motor unit number estimation (MUNE) methods are crucial for estimating lower motor neuron loss in motor neuron diseases. The MScanFit MUNE (MScanFit) is a novel method that estimates MUNE values from compound motor action potential (CMAP) scans, demonstrating high sensitivity and reproducibility in detecting motor unit loss in amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA). In this study, we aimed to characterize the pattern of motor unit loss in the hand intrinsic muscles of SMA patients compared to ALS patients and healthy controls (HC) using MScanFit MUNE. Methods: Patients diagnosed with ALS, adult SMA patients, and HC were prospectively enrolled. MScanFit examinations were performed on the abductor pollicis brevis (APB) and abductor digiti minimi (ADM) muscles. To focus on the different patterns of motor neuron degeneration in the intrinsic hand muscles, the ratio of CMAP amplitude of APB to ADM (CMAP ratio) and the ratio of MUNE values of APB to those of the ADM muscle (MUNE ratio) were calculated. Results: The study included 46 ALS patients, 16 SMA patients, and 23 HC. MScanFit MUNE revealed distinct patterns of motor unit degeneration in SMA patients, notably more severe in the ADM than in the APB muscle, indicating a "reverse" split-hand phenomenon. Both CMAP and MUNE ratios demonstrated high diagnostic accuracy in distinguishing ALS from SMA, with the MUNE ratio performing better. Conclusions: MScanFit MUNE is a valuable tool for exploring distinct patterns of motor neuron degeneration in patients with different types of motor neuron diseases.
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Affiliation(s)
- Veria Vacchiano
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.M.); (R.L.)
- Centro Clinico NeMO, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Francesca Morabito
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.M.); (R.L.)
| | - Luigi Bonan
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40139 Bologna, Italy; (L.B.); (L.T.); (C.F.)
| | - Luca Teodorani
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40139 Bologna, Italy; (L.B.); (L.T.); (C.F.)
| | - Claudia Faini
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40139 Bologna, Italy; (L.B.); (L.T.); (C.F.)
| | - Giovanni Rizzo
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.M.); (R.L.)
| | - Rocco Liguori
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy; (F.M.); (R.L.)
- Centro Clinico NeMO, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, 40139 Bologna, Italy; (L.B.); (L.T.); (C.F.)
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Vacchiano V, Di Stasi V, Teodorani L, Faini C, Morabito F, Liguori R. Comparative assessment of MScanFit MUNE and quantitative EMG in amyotrophic lateral sclerosis diagnosis: A prospective study. Clin Neurophysiol 2024; 166:66-73. [PMID: 39126873 DOI: 10.1016/j.clinph.2024.07.017] [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: 04/19/2024] [Revised: 05/28/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Motor Unit Number Estimation (MUNE) techniques are crucial in assessing lower motor neuron loss. MScanFit MUNE (MScanFit) is a novel tool which estimates MUNE values from compound muscle action potential (CMAP) scans by considering the probabilistic nature of motor unit firing. We conducted a prospective study to evaluate the diagnostic utility of MScanFit compared to quantitative electromyography (qEMG) in ALS patients. METHODS We enrolled 35 patients diagnosed with amyotrophic lateral sclerosis (ALS) and 14 healthy controls, assessing qEMG and MScanFit MUNE in abductor pollicis brevis, abductor digiti minimi and tibialis anterior muscles. RESULTS We found higher sensitivity of qEMG in detecting abnormalities compared to MScanFit, with a high concordance rate between the two techniques. Notably, a few muscles exhibited abnormal MUNE but normal qEMG findings, suggesting a potential complementary role for MScanFit in ALS diagnosis. Neurophysiological parameters from MScanFit showed good correlations with qEMG measures. Subclinical neurophysiological involvement was observed in muscles with normal strength, emphasizing the importance of sensitive diagnostic tools. CONCLUSION MScanFit demonstrated validity in distinguishing ALS patients from healthy subjects and correlated well with qEMG parameters. SIGNIFICANCE Our study confirmed the diagnostic utility of MScanFit MUNE in ALS, highlighting its role as a supplementary diagnostic tool.
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Affiliation(s)
- Veria Vacchiano
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; Centro Clinico NeMO, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
| | - Vitantonio Di Stasi
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luca Teodorani
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
| | - Claudia Faini
- Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
| | - Francesca Morabito
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Rocco Liguori
- UOC Clinica Neurologica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; Centro Clinico NeMO, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy; Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
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Boran HE, Alaydin HC, Arslan I, Kocak OK, Kılınc H, Cengiz B. Exploring the effect of the nerve conduction distance on the MScanFit method ofmotor unit number estimation (MUNE). Neurophysiol Clin 2024; 54:102991. [PMID: 38970866 DOI: 10.1016/j.neucli.2024.102991] [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: 12/22/2023] [Revised: 05/18/2024] [Accepted: 05/18/2024] [Indexed: 07/08/2024] Open
Abstract
OBJECTIVE MScanFit motor unit number estimation (MUNE) is a sensitive method for detecting motor unit loss and has demonstrated high reproducibility in various settings. In this study, our aim was to assess the outputs of this method when the nerve conduction distance is increased. METHODS MScanFit recordings were obtained from the abductor digiti minimi muscle of 20 healthy volunteers. To evaluate the effect of nerve conduction distance, the ulnar nerve was stimulated from the wrist and elbow respectively. Reproducibility of MUNE, compound muscle action potential (CMAP), and other motor unit parameters were assessed using intraclass correlation coefficients (ICCs). RESULTS Motor unit numbers obtained from stimulation at the wrist and elbow did not significantly differ and exhibited strong consistency in the ICC test (120.3 ± 23.7 vs. 118.5 ± 27.9, p > 0.05, ICC: 0.88). Similar repeatability values were noted for other parameters. However, the Largest Unit (%) displayed notable variability between the two regions and exhibited a negative correlation with nerve conduction distance. CONCLUSION Our findings indicate that MScanFit can consistently calculate motor unit numbers and most of its outputs without substantial influence from nerve conduction distance. Exploring MScanFit's capabilities in various settings could enhance our understanding of its strengths and limitations for extensive use in clinical practice.
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Affiliation(s)
- H Evren Boran
- Department of Neurology, Faculty of Medicine, Gazi University, Ankara, Turkey; Department of Neurology, Section of Clinical Neurophysiology, Faculty of Medicine, Gazi University, Ankara, Turkey; Neuroscience and Neurotechnology Center of Excellence, Ankara, Turkey.
| | - Halil Can Alaydin
- Department of Neurology, Section of Clinical Neurophysiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ilker Arslan
- Department of Neurology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ozlem Kurtkaya Kocak
- Department of Neurology, Section of Clinical Neurophysiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hasan Kılınc
- Neuroscience and Neurotechnology Center of Excellence, Ankara, Turkey
| | - Bulent Cengiz
- Department of Neurology, Faculty of Medicine, Gazi University, Ankara, Turkey; Department of Neurology, Section of Clinical Neurophysiology, Faculty of Medicine, Gazi University, Ankara, Turkey; Neuroscience and Neurotechnology Center of Excellence, Ankara, Turkey
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Vacchiano V, Morabito F, Faini C, Nocera G, Not R, Scarpini G, Romagnoli M, Pini A, Liguori R. Motor unit number estimation via MScanFit MUNE in spinal muscular atrophy. Muscle Nerve 2024; 70:71-81. [PMID: 38549445 DOI: 10.1002/mus.28091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 03/06/2024] [Accepted: 03/16/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION/AIMS MScanFit MUNE (MScanFit) is a novel tool to derive motor unit number estimates (MUNEs) from compound muscle action potential (CMAP) scans. Few studies have explored its utility in 5q spinal muscular atrophy (SMA5q) patients, assessing only the abductor pollicis brevis (APB) muscle. We aimed to assess different distal muscles in pediatric and adult SMA5q patients, further evaluating clinical-electrophysiological correlations. METHODS We analyzed MScanFit parameters reflecting the extent of denervation (MUNE; N50) and parameters of collateral reinnervation in APB, abductor digiti minimi (ADM), and tibialis anterior (TA) muscles. SMA patients were clinically evaluated using standardized motor function clinical scales, including the Hammersmith Functional Motor Scale - Expanded and the Revised Upper Limb Module. RESULTS A total of 23 SMA5q (9 SMA type 2 and 14 SMA type 3) and 12 age-matched healthy controls (HCs) were enrolled. SMA patients showed lower MUNE and N50 values and higher parameters of collateral sprouting in all muscles compared to HC (p < .001). SMA type 2 patients demonstrated lower MUNE and higher collateral reinnervation values in APB and TA compared to SMA type 3 (p < .05). Walker patients showed higher values of MUNE and N50, and lower parameters of reinnervation in all muscles compared to sitters (p < .05). MScanFit parameters showed strong correlations (Rho-values ranging from .72 to .83) with clinical measurements. MUNE values were abnormal in muscles that were not clinically affected. DISCUSSION MScanFit parameters showed promise as an outcome measure. Further studies, particularly longitudinal ones, are needed to evaluate MScanFit in measuring response to treatments.
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Affiliation(s)
- Veria Vacchiano
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Francesca Morabito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Claudia Faini
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - Giovanna Nocera
- UOC Neuropsichiatria Infantile Attività Territoriale (NPIA), Azienda USL di Bologna, Bologna, Italy
| | - Riccardo Not
- UO DATeR Riabilitazione Territoriale, AUSL Bologna, Bologna, Italy
| | - Gaia Scarpini
- Pediatric Neuromuscular Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Martina Romagnoli
- Programma di Neurogenetica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Antonella Pini
- Pediatric Neuromuscular Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Rocco Liguori
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
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Lu Z, Chen M, Zong Y, Huang C, Li X, Zhou P. Sensitivity Analysis of CMAP Scan Step Index to Different Stimulation Parameters and Examination of Muscles Affected by Spinal Cord Injury. IEEE Trans Biomed Eng 2023; 70:2834-2840. [PMID: 37756167 PMCID: PMC11057332 DOI: 10.1109/tbme.2023.3266327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Step index (STEPIX) is a recently developed compound muscle action potential (CMAP) scan method for evaluating motor unit loss and remodeling changes. This study investigates the influence of different stimulation parameters during CMAP scan on STEPIX and its examination of muscles affected by spinal cord injury (SCI). CMAP scan of the first dorsal interosseous (FDI) muscle was performed using different stimulus pulse widths (0.1 ms, 0.2 ms) and different numbers of stimuli (500, 1000) in 12 neurologically intact subjects. STEPIX was derived from each CMAP scan of all subjects. A significantly higher STEPIX was obtained using 1000 stimuli than 500 stimuli, while no significant difference in STEPIX was observed using 0.1 and 0.2 ms stimulus pulse widths. STEPIX was further applied to process CMAP scans of the FDI muscle from 13 tetraplegia and 13 healthy control subjects using the same stimulation parameter setting (0.1 ms, 500 stimuli), along with other methods including MScanFit motor unit number estimation (MUNE) and D50. STEPIX was significantly lower for the SCI subjects compared with the healthy control subjects. STEPIX was significantly correlated with MscanFit MUNE and D50, but had a smaller relative width of the overlapping zone (WOZ%) between tetraplegic and healthy control groups compared with MScanFit MUNE and D50. The findings of the study highlight the importance of maintaining a consistent stimulation parameter setting in CMAP scan studies and confirm the usefulness of STEPIX as a convenient CMAP scan parameter for examination of motor unit number changes.
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Lu Z, Chen M, Zong Y, Li X, Zhou P. A Novel Analysis of CMAP Scans From Perspective of Information Theory: CMAP Distribution Index (CDIX). IEEE Trans Biomed Eng 2023; 70:1182-1188. [PMID: 36197873 PMCID: PMC11057325 DOI: 10.1109/tbme.2022.3212312] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The compound muscle action potential (CMAP) scan is a useful technique for examination of neuromuscular disorders. The objective of this study is to develop a novel analysis of CMAP scans from the perspective of information theory. METHODS A novel index parameter called CMAP distribution index (CDIX) was developed to characterize CMAP scan based on calculation of the information entropy. The performance of CDIX was evaluated using CMAP scan data from healthy control and spinal cord injury (SCI) subjects, and compared with D50 and MScanFit motor unit number estimation (MUNE). RESULTS CDIX was significantly lower for the SCI subjects compared with the healthy control subjects (p < 0.001). A significant correlation ( R2 = 0.58, p < 0.001) was found between CDIX and MScanFit MUNE. Among all tested parameters (maximum CMAP, D50, MScanFit MUNE and CDIX), CDIX achieved the smallest relative width of the overlapping zone (WOZ%) between SCI and healthy control subjects. CONCLUSION CDIX can be inferred as a useful index reflecting motor unit loss and muscle fiber reinnervation changes.
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Song X, Cui L, Zong Y, Chen M, Lu Z, Xie Q, Zhou P. A single center report of MScanFit motor unit number estimation in five muscles of healthy subjects. Front Hum Neurosci 2023; 16:1078848. [PMID: 36733893 PMCID: PMC9886876 DOI: 10.3389/fnhum.2022.1078848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
The objective of this study was to estimate the number of motor units in 5 muscles from healthy individuals using the MScanFit program based on compound muscle action potential (CMAP) scan recordings. The examined muscles included first dorsal interosseous (FDI), abductor pollicis brevis (APB), abductor digiti minimi (ADM), second lumbrical (SL), and abductor hallucis (AH). CMAP scans were recorded from a total of 24 healthy participants. Motor unit number estimation (MUNE) values were derived from the MScanFit program. The average MUNE was 136.1 ± 31.1 (mean ± standard deviation) for the FDI, 134.9 ± 37.4 for the APB, 127.3 ± 32.3 for the ADM, 39.6 ± 8.3 for the SL, and 143.9 ± 28.9 for the AH muscles. Findings of the study provide useful information of the MScanFit MUNE for the examined muscles of healthy subjects from a single center.
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Affiliation(s)
- Xiaohui Song
- Department of Rehabilitation, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lijun Cui
- Department of Rehabilitation, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Zong
- Department of Rehabilitation, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Maoqi Chen
- School of Rehabilitation Science and Engineering, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Zhiyuan Lu
- School of Rehabilitation Science and Engineering, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China
| | - Qing Xie
- Department of Rehabilitation, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,*Correspondence: Qing Xie ✉
| | - Ping Zhou
- School of Rehabilitation Science and Engineering, University of Health and Rehabilitation Sciences, Qingdao, Shandong, China,Ping Zhou ✉
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Tankisi DA, Alaydin HC, Boran E, Cengiz B. Feasibility and reliability of MScanFit motor unit number estimation in peroneus longus muscle. Muscle Nerve 2022; 66:503-507. [PMID: 35763284 DOI: 10.1002/mus.27667] [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: 01/31/2022] [Revised: 06/16/2022] [Accepted: 06/18/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIM Motor unit number estimation (MUNE) methods may be valuable to detect motor involvement earlier than compound muscle action potential (CMAP) amplitude. The most recent MUNE method, MScanFit has been shown to have advantages compared to the previously described methods. However, MScanFit has only been applied in a few lower extremity muscles. We aimed in this study to examine the feasibility and reliability of MScanFit in peroneus longus muscle. METHODS Twenty healthy controls (16 males and 4 females, mean age: 36.05 ± 2.58) were examined twice within a 1-2 week interval. Fibular nerve was stimulated at the knee and CMAP scans were recorded from peroneus longus muscle. From this, MScanFit MUNE and size parameters were calculated as well as the CMAP amplitude. The reliability was examined using coefficient of variation (CV) and intraclass correlation coefficient (ICC). MUNE was correlated with CMAP amplitude using linear regression analysis. RESULTS The CV between sessions was higher for CMAP amplitude (11.63 ± 1.88 %) than MScanFit MUNE (3.13 ± 0.78%). Among the size parameters, mean unit amplitude (μV) showed the lowest CV (11.46 % ± 1.77). Using ICC, CMAP amplitude exhibited good reliability (0.787) whereas that of MScanFit MUNE was excellent (0.902). Reliability was good for all size parameters. There was no significant correlation between MScanFit MUNE and CMAP amplitude (R= 0.25, p>0.05). DISCUSSION MScanFit MUNE is feasible in the peroneus longus muscle with high test-retest reliability in healthy subjects. Studies in patients are needed to examine the sensitivity of this muscle in disease. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Deniz Alp Tankisi
- Department of Neurology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
| | - Halil Can Alaydin
- Department of Neurology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
| | - Evren Boran
- Department of Neurology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
| | - Bulent Cengiz
- Department of Neurology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
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Alaydin HC, Turkmen N, Boran HE, Cengiz B. Estimating the motor unit number of the flexor carpi ulnaris muscle with MScanFit MUNE. Muscle Nerve 2022; 66:212-215. [PMID: 35621353 DOI: 10.1002/mus.27650] [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: 12/08/2021] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION/AIMS MScanFit motor unit number estimation (MUNE) is a promising method for motor unit estimation and is reported to have good reliability in distal and small muscles. In this study, we investigated the reliability of MScanFit MUNE in a proximal forearm muscle, the flexor carpi ulnaris. METHODS Twenty healthy volunteers were included in this study and 15 participants were re-evaluated in a second session. The ulnar nerve was stimulated at the elbow and a compound muscle action potential (CMAP) scan from the flexor carpi ulnaris (FCU) muscle was recorded from each arm. CMAP, MUNE and other motor unit parameters were obtained. Reproducibility was evaluated using intraclass correlation coefficients. RESULTS The average MUNE from 40 FCU muscles was 90.9 (SD: 16.4). MScanFit MUNE and CMAP were not significantly different between the dominant and non-dominant sides. The intraclass correlation coefficient indicated good reliability between sessions for each side (0.81 and 0.8 respectively). DISCUSSION Our results indicate that MScanFit MUNE is a feasible method with good reproducibility for MUNE of the FCU muscle. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Halil Can Alaydin
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey.,Department of Neurology, Clinical Neurophysiology Division, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nur Turkmen
- Clinic of Clinical Neurophysiology, Tekirdag Dr. Ismail Fehmi Cumalioglu City Hospital, Tekirdag, Turkey
| | - H Evren Boran
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey.,Department of Neurology, Clinical Neurophysiology Division, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Bulent Cengiz
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey.,Department of Neurology, Clinical Neurophysiology Division, Gazi University Faculty of Medicine, Ankara, Turkey
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