Month: January 2020

Electromyography EMG Test & Nerve Conduction Study Results #2 Jamie Boyle Guillain Barre Syndrome

I saw Jamie Boyle, a 41 year old gentleman, in the Electrodiagnostic Lab at the Dr. Everett Chalmers Regional Hospital on October 23, 2019 for an Electromyography EMG test & nerve conduction study and again today January 31st, 2020. As you know, he had progressive rapid muscle weakness in his extremities which started on August 2nd, 2019. He reported having an episode of gastroenteritis with acute diarrhea which lasted a week before his muscle weakness. He was admitted to the Dr. Georges Dumont Hospital and since the muscle weakness rapidly progressed, he was intubated and transferred to the ICU. He was on mechanical ventilation on August 3rd, 2019. Guillain Barre Syndrome was diagnosed by a neurologist and he received IVIG to treat this condition. Subsequently, he did develop a few nosocomial complications such as urosepsis, ileus, acute renal failure, pneumonia, bronchitis and tracheitis. He was eventually transferred to The Stan Cassidy Rehabilitation Centre for rehabilitation. He received two more IVIG courses.

Since there was no significant improvement on the symptoms and he was completely quadriplegic, I recommend plasma exchange followed by IVIG. He accepted and received five courses of plasma exchange in the Saint John Regional Hospital. After plasma exchange, he received IVIG and stayed on a rehab program in Stan Cassidy. He feels some improvement on the movement of the upper extremities and minimal improvement in the lower extremities. The muscle strength in the proximal parts have been having some improvement but not significantly.

PHYSICAL EXAMINATION

Mental status was unremarkable. Language was normal. Extraocular movement was normal. No ptosis. No facial palsy. Tongue protruded in the midline without fasciculation or atrophy. In the motor exam, shoulder abduction was 3/4, elbow flexion was 3/5, and finger flexion was 1/5. In the lower extremities, hip flexion was 2/5. Knee flexion and extension, as well as feet flexion and extension, were 0/5. Deep tendon reflexes were absent. He had interosseous muscle atrophy which was more dominant compared to the previous exam.

He underwent electrophysiologic study for comparison to Electromyography EMG test & nerve conduction study results for Jamie Boyle on October 23, 2019.

NERVE CONDUCTION STUDIES:

In the right upper extremity, median motor distal latency was 4 msec with amplitude at 2 millivolts. It was o.4 millivolts in the previous study. Conduction velocity was 45 m/s. It was 34 m/s in the previous study.

Ulnar motor distal latency was 4.5 msec with amplitude at o.2 millivolts. Conduction velocity was 39 m/s in the forearm and across the elbow. It was not obtainable in the previous study.

Sensory potential of the median, ulnar and radial nerves had normal peak latency and amplitude. It was also normal in the previous study.

In the right lower extremity, peroneal motor as well as tibial action were not obtainable, which was similar to the previous study. Superficial peroneal sensory latency was 4.3 msec with amplitude at 3.7 microvolts. It was not obtainable in the previous study.

Sural sensory peak latency was 4.1 msec with amplitude at 10 microvolts which was similar to the previous study.

Electromyography EMG Test STUDIES:

A concentric needle EMG was performed on the right deltoid, extensor digitorum, extensor carpi ulnaris, first dorsal interosseous, biceps, flexor digitorum superficialis, anterior tibialis, gastrocnemius, vastus medialis, and lateralis. Insertion activity was increased in all the muscles in the exam. There active denervation between 2 and 3+ in all muscles in the exam. In the deltoid and biceps, recruitment was full. Motor unit on these muscles had longer duration. In the extensor carpi ulnaris, there was 1 motor unit, and recruitment was significantly reduced at -4. The rest of the muscles in the upper extremities did not have any voluntary contractions.

In the lower extremity muscles, insertional activity was increased with 2+-3+ positive sharp wave. In the gastrocnemius muscle, there 1 motor unit and recruitment was reduced significantly at -4. There was no motor unit in the other muscles on the lower extremities. CRD was seen in the anterior tibialis.

In summary, in needle EMG, there was significant improvement in the proximal muscles of the upper extremities without any sign of voluntary contraction in the distal muscles. In the lower extremities, there was just 1 motor unit in the gastrocnemius muscle.

Electromyographic findings were improved compared to previous.

IMPRESSION AND RECOMMENDATION:

This is an abnormal Electromyography/nerve conduction study and would be consistent with severe motor demyelinating and axonal type polyneuropathy. Compared to the prior study, there is some improvement in the nerve conduction study findings, as well as electromyography in the proximal muscles.

With respect to treatment, I do not believe he needs any further IVIG treatments at this time. There is no documented study which shows that repeating IVIG or plasma exchange can improve the outcome of Guillain Barre in the long term. Very rarely, CIDP can present in the beginning as an acute neuropathic syndrome but it is very unlikely for him regarding to him having such rapid progression of symptoms in the beginning with quadriplegia in two days and also there is deterioration over the last two months at least without immunosuppressive medications. I believe rehabilitation program is the main part of his management at this time. He has clinically, as well physiologically, improved some without any complications at least since he has been at Stan Cassidy Centre. For sure, in the case of any deterioration of symptoms, repeating IVIG or plasma exchange will be indicated.

I would recommend repeating the electromyography/nerve conduction study in six to nine months for comparison and I leave this decision to your capable hands and clinical judgement.

Jamie asked me about steroid therapy and I mentioned that it is an old treatment for Guillain Barre Syndrome and is not indicated at least over the past twenty years. The risks of steroid therapy are much more and there is no clear benefit for this treatment.

I have not arranged any further follow-up appointment at this time but would be happy to see him again if you have any questions or concerns, in particular if he develops any progression of the weakness.

I explained my diagnostic consideration and treatment plan with him in detail and he expressed understanding my explanation and satisfaction with today’s interview. I tried to explain all of his questions in detail.

Thank you once again for involving me in the care of this very pleasant gentleman. Please do not hesitate to call me if you have any questions or concerns.

Sincerely yours,

Shahram Abootalebi, MD Neurologist

Today I had my nerve conduction study, EMG test, Electromyogram, to see how my nerve damage from GBS is coming. This is the test I’ve been waiting to see. I previously had an EMG test done in November which had poor results. The previous one showed nerve damage not only to the myelin but axonal as well due to the severe case of GBS. Unfortunately I have Guillain Barre Syndrome AMSAN, the worst GBS variant which severely damaged my nerves.

Nerve Conduction Study EMG

The nerve conduction study, EMG test, is a medical diagnostic test to assess nerve damage and dysfunction and the health of muscles and nerves that control them. For the nerve conduction study it measures the speed and strength of signals traveling between two points. I had the same nerve conduction technician as last time. She performs the first part of it by placing electrode stickers on my skin, arm and leg. The neurologist came in later to do the EMG part of the test with needles.

EMG Test – Electromyogram

For the EMG portion of the test results can reveal nerve dysfunction, muscle dysfunction or problems with the signal transmission between the nerves and the muscles. My neurologist then places a needle electrode inserted directly into a muscle which then records the electrical activity in that muscle. He placed it in my lower leg, upper leg, hand and also in different muscles in my arm. Does this part of the EMG hurt? Not really, little discomfort only.

Nerve Conduction Study EMG Test Results

After the nerve conduction study and EMG test was completed the neurologist went over the results with me. There has been improvement since last time but there is still no response for quite a few nerves. There was severe damage due to the variant of a GBS that I had.

In my lower right leg he was able to get response on one nerve fibre which I didn’t have last time. The hope is that the nerves will all continue to heal. My upper arm is strong, more muscle growth and activity probably due to all the wheeling I do in my wheelchair. My lower arm still no response or not much at all. I have muscle wasting between my thumb and index finger. He says that I’ve improved a lot from last time. The hope is that my nerves will heal in time. My next neurologist appointment with him will be in 6-9 months.

Hope Going Forward

My hope is that I will continue to see improvements going forward as I recover from Guillain Barre Syndrome. I hope my nerves continue to heal. My fear is my lower arms, hands and wrists. Right now I don’t have much in them. I cannot grab or squeeze anything with my hands or lift up my wrists. There is some movement but not much.

I continue to improve so I can only hope that it will continue going forward. I’m doing more now then I thought I ever would such as getting up out of bed. With Guillain Barre Syndrome recovery is slow, but progress continues to happen. Hopefully my drive, will and determination will lead me to full recovery. My recovery from GBS goes on.

GoFundMe Jamie Boyle Fight 
With Guillain Barre Syndrome – GBS

For my knee pain in Physiotherapy my physiotherapists used ultrasound therapy and kinesiology taping to treat it today. With ultrasound therapy it uses sound waves to treat medical problems like inflammation from injuries.

Kinesiology taping was also done to help alleviate pain and help improve healing in soft tissues. It’s a technique widely used in sports for prevention and treatment of sporting injuries.

Well today was definitely also a first for me. I had to have my leg shaved for the kinesiology taping treatment. We shared a few laughs about it but I think they enjoyed it too much. lol If it will help get my knee better and back up walking between parallel bars again, I’ll shave my whole leg. In other words I don’t want anything delaying my recovery from Guillain Barre Sydrome AMSAN GBS variant.

Before taping my knee with kinesiology tape my physiotherapist did ultrasound therapy. I’m really hope that both of these techniques will help my knee recover and get better. I want to get back to full physio so I can continue to work towards walking.

My recovery from Guillain Barre Syndrome will continue on Monday. If my knee is not better by then I’ll be going for an MRI. Hopefully the rest over the weekend will help, we’ll see next week.

GoFundMe Jamie Boyle Fight 
With Guillain Barre Syndrome – GBS

Well today I had some more knee pain during my physiotherapy session today which can slow down my recovery from Guillain Barre Syndrome. I noticed this when I went walking today between the parallel bars. It didn’t take me long before I started experiencing some pain in my knee. This happened yesterday as well.

The doctor yesterday said they were going to order an x-ray however after a physical examination today they canceled it. They are going to keep an eye on it going forward. An X-ray won’t show anything, an MRI is what will be needed if done.

During my physiotherapy session today after I experienced more pain the physiotherapist started treating my knee. She used ultrasound to do so. Going forward there won’t be any more walking between the parallel bars this week and she’s hoping that over the weekend might give my knee a rest.

My physiotherapist talked to the doctor and if my knee is still bothering me next week an MRI is going to be ordered. She’s also going to look at give me a brace for my left knee or taping it up to give it more support.

After standing up last week and supporting my own weight I’m not happy about my knee pain. I’ve been making some great progress and this could impact my recovery from Guillain Barre Syndrome by slowing it down. I’m supposed to be going forward. Hopefully my knee feels better next week. I definitely don’t want anything slowing down my progress.

Well today I was informed that I have Guillain Barre Syndrome AMSAN, a rare GBS variant, the most severe form. AMSAN, acute motor and sensory axonal neuropathy is a rare axonal variant of Guillain Barre Syndrome. I suspected this all along but the doctors never told me there was different variants of GBS until I did more research and discovered this on my own. When the doctor did his morning rounds I asked him what type or variant of GBS do I have. The doctor then confirmed with me that I have the most severe type of GBS.

Guillain Barre Syndrome AMSAN GBS Variant

AMSAN is considered the most severe form of GBS as the severe symptoms happen very quickly. This form of Guillain Barre causes severe weakness in all four limbs, basically completely paralyzing you in as little as 7 days. For me it basically happened in around 24 hrs. My breathing became so compromised that they had to put me in an induced coma along with mechanical ventilator. The risk of mortality with this form is high. I’m actually quite lucky to be alive thanks to the care provided by the doctors, nurses and respiratory therapists at the Dr. Georges L. Dumont Hospital in Moncton.

The Cause of Guillain Barre

There is little known research as to the cause of Guillain Barre but is suspected to occur following a gastrointestinal virus or infection. As for me I had diarrhea about 7 days before I became ill with GBS. It lasted for about 4 days, then 3 days later after it cleared up I was hit with Guillain Barre. Guillain Barre Syndrome is however known to brought on by the flu shot. Know the risk before getting one.

With me knowing that I do indeed have the most severe variant of GBS doesn’t change anything. I am going to continue to work hard and try to get better. On day 40 I was already told I wasn’t going to make a complete recovery by one neurologist. Others have seen me afterwords and based on my progress they don’t see a reason why I shouldn’t. When someone tells me I’m not going to achieve something, it makes me work that much harder. I’ve been making great progress I’m going to continue to do so. I know nothing is guaranteed in life however I need to have faith that I will recover from the worst variant of Guillain Barre Syndrome known as AMSAN. Only time will tell, till then it’s hard work and determination that will drive me forward.

GoFundMe Jamie Boyle Fight 
With Guillain Barre Syndrome – GBS

In Physiotherapy today they focused on my legs which included leg lifts and leg extension exercises. I’ve been going on the mat more lately to further work on the strengthening of my legs.

These are just some of the types of exercises they have me doing up here at The Stan Cassidy Rehabilitation Centre in Fredericton. I work on leg strengthening and muscular endurance on the SciFit bike as well as the mat exercises.

All of these exercices will therefore help me towards walking again. I also go between the parallel bars pretty much everyday now that my legs are getting stronger and improving. I was also able to stand up in the sling a few days ago supporting all my weight. I’m pretty happy with my progress.

One thing I noticed lately is my right leg is stronger then my left leg. My left leg is weaker. In the videos above as well as the photos slings are used to eliminate gravity. This also allows me to do the exercise as with gravity I can’t quite yet for some. My right leg I can do leg lifts and lower leg extensions without the sling. However on my left leg I can’t that much.

Hopefully with all the exercises I’m doing will help strengthen my legs further. Last week I noticed a little discomfort in my left knee. I’m hoping it’s nothing. Also I don’t need anything holding me back from my recovery from Guillain Barre Syndrome. Hoping it’s just nothing.

Today in Physiotherapy cardio class I had a new best on the SciFit bike. I did 4.16 miles in 30 minutes, no breaks. New week, new goals! I remember when I first went on the SciFit when I first arrived at The Stan Cassidy Rehabilitation Centre I could barely push the pedals down and only did 0.11 miles. So you can see improvements made as I get better from Guillain Barre Syndrome.

SciFit Bike Physiotherapy Progress Along The Way

Before my treatments with plasma exchange in St. John at the end of October and also the IVIG treatments in Fredericton that started on November 4th I only did o.11 miles, 0.18 miles and 0.24 miles on the SciFit bike.

November 12 1.0 miles in 18 minutes with many breaks

November 13 1.2 miles in 15 minutes with one break

November 14 1.5 miles in 22 minutes no breaks

November 19 2 miles in 25 minutes no break

November 20 1.35 miles in 13.5 minutes no breaks

So now I look at it today and I did 4.16 miles in 30 minutes. Therefore I’m getting better from GBS. I still have lots of work to do but from being diagnosed with Guillain Syndrome, completely paralyzed head to toe to where I am today, things are looking up. 🙂

In occupational therapy they are doing hand and finger stretching board exercises with me. The reason they are doing this is that my fingers have been tight lately. Some of my fingers on my right hand are curling inwards towards the inside palm of my hand. The pinky finger more then the others.

The tendons in my hand and fingers are tight so they are trying to stretch them out. The occupational therapists at The Stan Cassidy Rehabilitation Centre built this board to do such tasks. They have individual elastics that pulls each finger inwards towards the inside my palm. It’s a joke between myself and the occupational therapist by calling it the torture board. 🙂 Let’s put it this way, it’s a good stretch, hurts at times, but gets the job done.

With Guillain Barre Syndrome people can develop what they refer to as claw hands. I’m hoping to prevent this as my hands have been great up until recently. After basically six months I wasn’t having any issues. Therefore I’m hoping all these hand, finger stretching techniques my occupational therapist is using will address these issues.