Muscle Twitches and EMG Results: A Neurology Perspective

Q: Muscle Twitches and EMG Results: A Neurology Perspective

Hello： Generally speaking, about 70% of patients with motor neuron disease present with limb weakness, while around 20% exhibit weakness in the bulbar region as their clinical manifestation. <br>In terms of limb involvement, the initial presentation is usually asymmetric hand wea

Muscle twitching and electromyography-related issues?

Hello Doctor,
Since around June 2017, I began to notice slight tremors in both of my hands, and when lying flat, I felt a sensation of my body vibrating.
In July, I visited a neurologist for the first time, and the doctor observed fasciculations on my tongue.
From then until November, I gradually noticed the following symptoms: my cheeks, lips, and neck tremble when exerting force; my hands tremble when raised or exerting effort; my biceps and abdominal muscles tremble when straining; my knees and thighs tremble when bending over or squatting.
In short, many muscles in my body start to shake with minimal exertion.
Additionally, I experience a pins-and-needles sensation on the outer side of my left thigh, soreness in the gastrocnemius and behind the knee on my left leg, tremors when rotating my ankles, and generalized muscle twitching.

In November, I underwent my first electromyography (EMG), nerve conduction studies (NCS), and lumbar X-rays.
The doctor reported the following: "NCV study indicates left peroneal and sural axonopathies; EMG study indicates chronic lower lumbar and S1 radiculopathies." After the examinations, until the end of 2017, the tremors and muscle twitching symptoms did not show significant improvement.
Furthermore, my left hand's ring finger and toes, as well as the sole of my left foot, make a cracking sound when stretched, and the stretching does not feel as smooth as with my other fingers.

The most troubling aspect is the frequent muscle twitching in my left calf, sole of the foot, and chest, occurring dozens of times within an hour, sometimes visibly noticeable.
It feels as if my entire body is like an electric motor, continuously vibrating subtly.
Due to the muscle twitching, I am concerned whether this could be ALS.
After discussing with my doctor, I underwent another EMG in January 2018.
This examination focused on the same areas as the previous one, specifically the L5 and S1 paraspinal regions, and the results were normal.
The muscles in my left calf are much softer than those in my right calf, but currently, there is no significant weakness or atrophy throughout my body.
I have taken muscle relaxants and medications for essential tremor for over a month, but there has been no noticeable improvement.

I would like to ask the doctor a few questions:
1.
If the EMG only examined the L5 and S1 paraspinal regions and the results were normal, can this be interpreted as benign muscle twitching in the thigh, calf, and sole of the left foot?
2.
Regarding the facial spasms and lip twitching, as well as the fasciculations of the tongue, are these considered normal? It seems that the physician does not plan to investigate this further.

3.
Should I undergo additional EMG or nerve conduction studies in other areas? Thank you!

Niming, 20~29 year old female. Ask Date: 2018/01/12

Dr. Jiang Junyi reply Neurology

Hello: Generally speaking, about 70% of patients with motor neuron disease present with limb weakness, while around 20% exhibit weakness in the bulbar region as their clinical manifestation.
In terms of limb involvement, the initial presentation is usually asymmetric hand weakness, and leg weakness can lead to gait instability.
The symptoms of muscle weakness progressively worsen and affect an increasing number of body areas.
Respiratory issues typically arise in the later stages, primarily due to diaphragm and intercostal muscle weakness leading to respiratory failure, which is often exacerbated by aspiration pneumonia resulting from swallowing difficulties.
Regarding your questions: (1) If the electromyography (EMG) only examines the L5 and S1 paraspinal muscles and the results are normal, can this be interpreted as benign muscle activity in the thigh, calf, and sole of the left foot? (2) Concerning the facial twitching and lip movements, as well as the fasciculations of the tongue, are these considered normal? It seems that the physician currently does not plan to investigate this aspect.
These two issues can be viewed as systemic muscle instability symptoms, as ALS is a type of motor neuron disease that typically does not present with sensory abnormalities.
You mentioned that the tingling sensation in the legs may be due to compression of the lumbosacral nerves.
(3) I would like to ask if there is a need for additional EMG or nerve conduction studies in other areas? Motor neuron disease requires the exclusion of many related potential diagnoses, such as compression or damage to the motor conduction pathways in the brain or spine, which would show active denervation in three or more limbs on EMG, while nerve conduction studies should be normal.
I suggest consulting a neurologist for discussion and treatment.
PS: In this field, authoritative physicians in Taiwan include Professor Lin Gong-Ping from Taipei Veterans General Hospital and Professor Yang Zhi-Chao from National Taiwan University...
Wishing you good health and peace.
Dr.
Tao from Neurology is concerned about you.

Reply Date: 2018/01/12

More Info

Hello! Thank you for your detailed inquiry regarding your symptoms and EMG results. It’s understandable to feel concerned about muscle twitches and the implications they may have on your health, especially when considering conditions like ALS (Amyotrophic Lateral Sclerosis). Let’s address your questions one by one and provide some additional context regarding muscle twitching and EMG findings.

1. Interpretation of EMG Results: If your EMG results for the L5 and S1 paraspinal muscles were normal, it suggests that there is no significant nerve damage or muscle disease affecting those specific areas. This can indeed indicate that the muscle twitching in your left thigh, calf, and foot may be benign, especially if there are no accompanying signs of muscle weakness or atrophy. Benign fasciculation syndrome is a condition characterized by muscle twitching without weakness, and it can often be exacerbated by stress, fatigue, or caffeine intake. However, it’s essential to correlate these findings with your clinical symptoms and history.

2. Facial and Lip Twitches: The twitching you experience in your face, lips, and tongue, particularly the fasciculations of the tongue, can be concerning but are not uncommon. Fasciculations can occur in healthy individuals and may not necessarily indicate a serious underlying condition. However, if these twitches are persistent or accompanied by other neurological symptoms (like weakness or atrophy), it would be prudent to discuss further evaluation with your neurologist. Sometimes, these symptoms can be related to anxiety or stress, which can exacerbate muscle twitching.

3. Need for Further Testing: Whether additional EMG or nerve conduction studies are warranted depends on the progression of your symptoms and the clinical judgment of your healthcare provider. If your symptoms change or worsen, or if new symptoms develop, further testing may be necessary to rule out other conditions. It’s essential to maintain open communication with your neurologist about your concerns and any changes in your symptoms.

Additional Considerations: Muscle twitching can result from various factors, including stress, fatigue, dehydration, electrolyte imbalances, or benign conditions like benign fasciculation syndrome. It’s also worth noting that certain medications, including muscle relaxants, can sometimes lead to muscle twitching as a side effect.

In terms of ALS, while muscle twitching can be a symptom, it is typically accompanied by muscle weakness and atrophy. The absence of significant weakness or atrophy in your case is reassuring. ALS is diagnosed through a combination of clinical examination, EMG, and sometimes muscle biopsy, and it is essential to consider the entire clinical picture rather than isolated symptoms.

Lifestyle Modifications: To help manage your symptoms, consider incorporating stress-reduction techniques such as mindfulness, yoga, or gentle exercise. Staying hydrated and maintaining a balanced diet rich in electrolytes can also support muscle function.

In conclusion, while your symptoms are understandably concerning, the normal EMG results for the L5 and S1 regions provide some reassurance. Continue to monitor your symptoms and maintain regular follow-ups with your neurologist to ensure any changes are appropriately evaluated. If you have further questions or concerns, don’t hesitate to reach out to your healthcare provider. Your health and peace of mind are paramount.

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