PRACA ORYGINALNA / ORIGINAL ARTICLE

KORELACJA PARAMETRÓW ELEKTROFIZJOLOGICZNYCH NERWÓW OBWODOWYCH A SPRAWNOŚĆ MANUALNA U PACJENTÓW ZE STWARDNIENIEM ZANIKOWYM BOCZNYM

Jacek Hübner1, Ilona Hübner1, Sławomir Kroczka2

1 LABORATORY OF NEUROPHYSIOLOGY, NEUROLOGY UNIT, DISTRICT HOSPITAL IN RADOMSKO, RADOMSKO, POLAND

2 LABORATORY OF NEUROPHYSIOLOGY, CHAIR OF CHILD AND YOUTH NEUROLOGY COLLEGIUM MEDICUM, JAGIELLONIAN UNIVERSITY IN KRAKOW, KRAKOW, POLAND

ABSTRACT

Introduction: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease affecting upper and lower motor neurons, presenting with various manifestations, leading to progressing disability, with poor prognosis, and with no options for successful treatment. In its classic form the central and peripheral motor neurons are simultaneously affected at the beginning; the bulbar-onset ALS successively involving other parts of the nervous system is slightly less common.

The aim: To demonstrate a correlation between electrophysiological parameters of peripheral nerves and loss of manual dexterity in the ALS.

Materials and methods: The analysis covered results of electrophysiological tests of motor conductivity in median and ulnar nerves, and results of the Mira Stambak and Rene Zazzo tests normally used to evaluate lateralisation, while in this study they were adapted to verify manual dexterity. The study covered 20 patients with clinically confirmed or possible ALS determined on the basis of the EI Escorial criteria. Half (10 people) of the studied group had limb-onset ALS, while the other half had the bulbar-onset ALS.

Results: When evaluating a correlation between the results of electrophysiological tests and the results of the Mira Stambak and Rene Zazzo tests, a significant relationship was found between a reduction in an amplitude of the compound muscle action potential (CMAP) and deterioration in manual dexterity in the subjects, with a tendency for progression in these deviations, but with their interdependency maintained.

Conclusions: 1. A loss of motor cells in the anterior horns of the spinal cord is reflected in the deterioration of manual dexterity in ALS patients.

2. A significant correlation is found between a loss in manual dexterity and an increase in changes in motor conductivity.

 

STRESZCZENIE

Wstęp: Stwardnienie zanikowe boczne (SLA) jest chorobą neurozwyrodnieniową dotyczącą górnego i dolnego neuronu ruchowego, występującą w różnych postaciach, prowadzącą do postępującej niesprawności, o złym rokowaniu i braku możliwości skutecznego leczenia. Klasyczna postać ma początek dotyczący jednocześnie ośrodkowego i obwodowego neuronu ruchowego, nieco rzadziej istnieje postać o początku opuszkowym z zajmowaniem kolejnych części układu nerwowego w trakcie choroby.

Cel pracy: Wykazanie korelacji pomiędzy parametrami elektrofizjologicznymi nerwów obwodowych a ubytkiem sprawności manualnej w przebiegu SLA.

Materiał i metody: Analizie poddano wyniki badań elektrofizjologicznych przewodnictwa ruchowego w nerwach pośrodkowych i łokciowych oraz wyniki testów Miry Stambak i Rene Zazzo służących do oceny lateralizacji, a w niniejszych badaniach przystosowanych do oceny sprawności manualnej. Badaniami objęto 20 dorosłych z klinicznie pewnym lub prawdopodobnym SLA ustalonym na podstawie kryteriów El Escorial. W tej grupie połowa (10 osób) miała postać kończynową, a druga połowa postać opuszkową.

Wyniki: Oceniając korelację między wynikami badań elektrofizjologicznych a wynikami testów Miry Stambak i Rene Zazzo, wykazano istotny związek pomiędzy redukcją amplitudy złożonej odpowiedzi mięśniowej (CMAP) a upośledzeniem sprawności manualnej badanych, z tendencją do progresji tych odchyleń, ale jednocześnie z dalszym pozostawaniem ich we wzajemnej zależności.

Wnioski: 1. Ubytek komórek ruchowych rogów przednich rdzenia kręgowego znajduje odzwierciedlenie w upośledzeniu sprawności manualnej pacjentów z SLA.

2. Stwierdza się istotną zależność ubytku sprawności manualnej z nasilaniem zmian przewodnictwa ruchowego.

 

Wiad Lek 2018, 71, 4, -814

 

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a progressing neurodegenerative disease of unknown aetiology and pathogenesis, affecting cells of central and peripheral motor neurons. Its average incidence is 5.2/100,000, with 1.8/100,000 cases per annum. Usually, the disease develops in the sixth and the first half of the seventh decade of life; however, cases with earlier or later onset were also reported. Currently, an increase in the number of earlier onset cases is noted. It is more common in men; however, it has been reported that bulbar-onset ALS predominates in women [1–6]. Sporadic ALS represents about 90-95% cases, with the remaining cases considered familial ALS. Inheritance of most forms of familial ALS is autosomal dominant. The following forms are distinguished: classic − with simultaneous involvement of the upper and lower motor neurons; progressive muscular atrophy (PMA ) – with symptoms limited to the lower motor neurons; primary lateral sclerosis (PLS) – with symptoms limited to the upper motor neurons, and bulbar-onset ALS [4, 7, 8]. A diagnosis is based on the clinical presentation confirmed with an electrophysiological test [2, 3, 6, 8–11]. Considering the variety of clinical presentations at the early stages of the disease and lack of diagnostic tests enabling an unequivocal diagnosis, a set of criteria was developed for a clinical classification of ALS. At present, modified EI Escorial criteria of 1998, also referred to as the Airlie House criteria, are most commonly used [4, 12–19].

In its classic form, the disease begins with a simultaneous involvement of the upper and lower motor neurons; in some cases, the disease onset may affect only the upper or the lower motor neuron. It may also have a bulbar onset with a successive involvement of other parts of the nervous system, or it may begin with an involvement of respiratory muscles. Regardless of the nature of the disease onset – either simultaneous involvement of the upper and lower motor neurons, or only upper or lower motor neuron, or bulbar onset with subsequent involvement of other parts of the nervous system during the disease – it always leads to a deterioration in the quality of the patient’s life [4, 6]. With the disease progress, the motor functions deteriorate, affecting performance of basic daily activities, including personal hygiene, washing, dressing, toileting, eating or verbal contact. For ALS patients, the quality of life usually deteriorates to such degree that they become dependent on others [20–23].

The Aim

The aim of this study was to demonstrate a correlation between electrophysiological parameters of the peripheral nerves and manual dexterity during ALS. The authors undertook this research, since they wanted to make observations on whether peripheral nerve function disorders were reflected in the impairment of fitness in patients with ALS during the course of the disease.

MATERIALS AND METHODS

The study covered 20 people, 5 women and 15 men, of 43 to 85 years of age (mean age: 65.5 years; standard deviation: 13), with clinically confirmed or possible diagnosis of amyotrophic lateral sclerosis (ALS), determined on the basis of the EI Escorial criteria. Patients who did not show any obvious paresis in the area of upper limbs and were able to carry out the clinical tests were examined. Patients reported for diagnosis in a random manner which resulted in a situation where men were much more numerous than women. The patients were divided into those in whom the first symptoms included muscular atrophy with fasciculations and reduced muscle strength in limbs (this group was referred to as ‘patients with limb-onset ALS’) and those with predominating bulbar symptoms (‘patients with bulbar-onset ALS’) . No comorbidities that could impair the physical fitness were found in any of the patients. No patient with bulbar-onset ALS reported a sense of limb weakening.

All patients underwent a full neurological examination, with assessment of the lower and upper motor neurons, with particular focus on manual dexterity.

For objective evaluation of the patients motor dexterity, two tests used for lateralisation assessment in children and teenagers were used, that is the Rene Zazzo card test and the Mira Stambak crosshatch test [24]. In this case the control group consisted of 20 healthy people of 20 to 86 years of age. During each study in both tests, the more dexterous hand was selected, and its results were analysed in reference to the control group. In the case of the Rene Zazzo card test, it was found that the lower the result, the better the manual dexterity, and in the case of the Mira Stambak crosshatch test, the higher the result, the better the manual dexterity.

The patients underwent three clinical and neurophysiological examinations in the period of six months.

At the time of the first clinical examination, the disease duration (counted from the moment of noticing the first symptoms to the patient’s visit to a neurologist), took between 2 and 11 months (6 months on average). The initial measurement is denoted with the letter A, the subsequent measurement after three months – with the letter B, and the final measurement three months after measurement B – with the letter C.

At the same time, in a period of six months an electroneurographic examination was performed three times using standard methods. Motor conductivity was evaluated in both median and ulnar nerves. The conductivity rate, distal latency, amplitude of the compound muscle action potential (CMAP) and minimal F wave latency were evaluated.

The results of performed conductivity tests in peripheral nerves were referred to own laboratory standards created in a group of 25 healthy persons of 20 to 70 years of age. The control group comprised persons without any diseases which could affect in any way the parameters of nerve conduction. Those were patients without the motor neuron disease or polyneuropathy.

The results of clinical and electrophysiological examinations were analysed for the entire studied group, and separately for the bulbar-onset and limb-onset groups.

The obtained results were analysed statistically using descriptive and statistical inference methods. To specify the average value for quantitative parameters, the arithmetic mean (M) was calculated with the standard deviation (SD) used as a deviation measure.

Conformance of the quantitative parameters distribution to the normal distribution was evaluated using the Shapiro-Wilk test and the skewness, kurtosis and standard deviation analyses, as well as based on a visual evaluation of their histograms and Q-Q diagrams. As the distributions of the variables were consistent with the normal distribution, the parametric analysis of variance in the intragroup scheme (ANOVA for repeatable measurements) was used in the study. The spherical assumption was verified with Mauchly’s test, and in the absence of preserved sphericity – Greenhouse – Geisser or Huynh – Feldt adjustment was applied, respectively. The Levene’s test was used to evaluate variance equality in samples. The Bonferroni correction was applied to multiple post-hoc comparisons. For all analyses, the maximum Type I error, α =0.05 was assumed, and p ≤ 0.05 (test significance level) was considered statistically significant.

To verify relationships between the amplitude level for specific motor nerves and the results of the Rene Zazzo card test and the Mira Stambak crosshatch test in the subjects, the r-Pearson correlation analysis, with ‘r’ being a result of the Pearson linear correlation, was conducted during A, B and C measurements.

The value of r <0.4 was treated as no correlation, the value within the range of 0.4< r <0.6 was considered a moderate correlation, the ‘r’ value within the range of 0.6< r <0.8 was considered a strong correlation, and the r >0.8 was treated as a very strong correlation.

All subjects gave their oral consent to the electrophysiological examination of the nerves and to the tests evaluating their manual dexterity.

The research did not require an opinion or a consent of the bioethical commission, since it was not experimental research, but diagnostic research, aimed at monitoring the course of the disease.

RESULTS

With regard to the standards of the laboratory, during the preliminary measurement, the results of some of the electrophysiological measurements of the examined motor nerves were within the standard, and the rest exceeded it. The results are shown in Table I.

The conductivity analysis in the sensory fibres of median and ulnar nerves did not disclose any significant anomalies.

During the initial examination all subjects had abnormal results for the Rene Zazzo card test and the majority (60%) of the subjects had abnormal results for the Mira Stambak crosshatch test.

An analysis of the electrophysiological examinations results and of tests used to verify motor dexterity of the patients in the studied group during six months showed statistically significant differences between individual measurements for the CMAP amplitude in the left median, left ulnar and right ulnar nerves. Multiple comparisons showed that in the subjects, the CMAP amplitude in the left median nerve was lower during measurements B and C, versus measurement A (p=0.044), and the CMAP amplitude in the left and right ulnar nerves was lower during measurements B and C versus measurement A (left p=0.007, right p=0.002) (Fig. 1).

No statistically significant differences between individual measurements were found for other electrophysiological parameters in motor neurons (p >0.05).

The analysis of results of tests verifying the manual dexterity in a period of six months showed that in the subjects undergoing the Rene Zazzo card, test result was lower during measurement A than during measurement B (p =0.036) and measurement C (p =0.03). For the Mira Stambak crosshatch test, the analysis showed that the result during measurement A was higher than during measurement B (p=0.005) and measurement C (p=0.007) (Figs. 2 and 3).

The evaluation of electrophysiological parameters and the analysis of the Rene Zazzo card test and the Mira Stambak crosshatch test results in patients with limb-onset ALS in a period of six months did not show significant differences between individual A, B and C measurements.

In patients with the bulbar-onset form, however, the same analysis demonstrated that the CMAP amplitude in the left (p=0.001) and right (p=0.032) median nerves and the left (p<0.001) and right (p<0.001) ulnar nerves was lower during measurements B and C, versus measurement A [Fig. 1]. Other electrophysiological parameters of motor nerves in these patients did not differ during the initial measurement – A, the measurement after 3 months – B, and the measurement after 6 months – C. Also the analysis of results of the tests used to verify the motor dexterity showed that the result of the Reno Zazzo card test was lower during measurement A versus measurement B, and during measurement B versus measurement C, while the result of the Mira Stambak crosshatch test was higher during measurement A versus measurement B, and during measurement B versus measurement C (Figs. 2 and 3).

An analysis of correlations between amplitudes of the compound muscle action potential (CMAP) of the right median nerve, the left median nerve, and the right and left ulnar nerves and the results of the tests verifying manual dexterity (the Rene Zazzo card test and the Mira Stambak crosshatch test) showed significantly significant relationships in the studied group. This means that during the initial measurement (A), the higher the CMAP amplitude in the right and left median nerves and the right and left ulnar nerves found in the subjects, the lower was their result in the Rene Zazzo card test (right median nerve r = -0.55, p<0.005; left median nerve r = -0.54, p<0.005; right ulnar nerve r = – 0.68, p<0.001; left ulnar nerve r = -0.62, p<0.01). This correlation was moderate for the median nerves, and strong for the ulnar nerves. It was also demonstrated that the higher the CMAP amplitude in the right ulnar nerve in the subjects, the higher their result in the Mira Stambak crosshatch test (r=0.49, p<0.05) – a moderate correlation. During a subsequent measurement, after three months, the conducted analyses showed: the higher the CMAP amplitude in the right and left median nerves and the right and left ulnar nerves found in the subjects, the lower was their result in the Rene Zazzo card test (right median nerve r= -0.51, p<0.005; left median nerve r= -0.51, p<0.005; right ulnar nerve r= -0.61, p<0.01; left ulnar nerve r = -0.53, p<0.05). This correlation was moderate for both median nerves and the left ulnar nerve, and strong for the right ulnar nerve. Analyses of relationships during the last measurement after six months (C) showed that the higher the CMAP amplitude in both median nerves and ulnar nerves found in the subjects, the lower their result in the Rene Zazzo card test (right median nerve r= -0.65, p<0.01; left median nerve r= -0.77, p<0.001; right ulnar nerve r = -0.52, p<0.05; left ulnar nerve r= -0.62, p<0.01). The observed correlation was strong for both median nerves and the left ulnar nerve, and moderate for the right ulnar nerve. A relationship was also found between the CMAP amplitude of the right and left median nerve and the result of the Mira Stambak crosshatch test (r = 0.51, p <0.05; r = 0.6 , p < 0.01, respectively) – the higher the amplitude, the higher the crosshatch test result. In both cases, this correlation was moderate.

In the group of patients with bulbar-onset ALS, during measurement A, a statistically significant relationship was found between the CMAP amplitude in the right ulnar nerve and the result of the Rene Zazzo card test – the higher the amplitude, the lower the card test result (r = -0.67, p<0.05), signifying a strong correlation. During measurement B, the correlation analyses did not demonstrate any statistically significant relationship between the amplitude in the studied nerves and the results of the card and the crosshatch tests. During measurement C, a strong correlation was found between the CMAP amplitude in the right median nerve and the left ulnar nerve and the result of the Rene Zazzo card test (r=-0.77, p< 0.01; r = -0.7, p< 0.05, respectively) – the higher the CMAP amplitude, the lower the card test result.

In the subjects with limb-onset ALS, during the initial measurement (A), a statistically significant relationship was demonstrated between the CMAP amplitude in the left median nerve and right and left ulnar nerves, and the Rene Zazzo card test result (r= -0.66, p<0.05; r = -0.7, p<0.05; r= -0.71, p<0.05, respectively) – the higher the CMAP amplitude, the lower the card test result obtained by the subjects, signifying a strong correlation. A relationship was also found between the CMAP amplitude of the right median and ulnar nerves and the result of the Mira Stambak crosshatch test (r= 0.63, p<0.05; r = 0.64, p< 0.05, respectively) – the higher the amplitude, the higher the crosshatch test result obtained by the subjects, signifying a strong correlation. During a subsequent examination performed after 3 months (B) the correlation analyses demonstrated a statistically significant relationship between the CMAP amplitude in the left median nerve and the result of the Rene Zazzo card test (r=-0.85, p<0.01) – the higher the CMAP amplitude, the lower the card test result, signifying a very strong correlation. During measurement C it was demonstrated that the higher the CMAP amplitude in the left and right median nerves and the left ulnar nerve, the lower the Rene Zazzo card test result (r= – 0.7, p<0.05; r= -0.89, p<0.001; r= – 0.74, p<0.05, respectively), signifying a strong correlation for the right median and the left ulnar nerves, and a very strong correlation for the left median nerve. Furthermore, a strong relationship (0.6< r <0.8) was found between the CMAP amplitude of the right and left median nerves and the result of the Mira Stambak crosshatch test (r= 0.67, p<0.05; r = 0.77, p< 0.01, respectively) – the higher the amplitude, the higher the crosshatch test result obtained by the subjects with the limb-onset ALS.

DISCUSSION

Earlier reports concerning the electrophysiological evaluation and physical fitness of ALS patients indicate a loss of axons and injury in proximal sections of the motor fibres in peripheral nerves, and a deterioration in physical capacity [4, 20, 21].

In own studies, during the initial evaluation we found a decrease in the amplitude of the compound muscle action potential (CMAP) in the studied nerves in the majority of our patients. We also observed the increased latency of F waves or their disappearance, with the normal conductivity rate and slightly increased terminal latencies. The obtained results, similarly to observations of other authors, indicate injury of motor fibres in proximal sections or of anterior spinal roots [25, 26]. Furthermore, they indicate a significant and progressing loss of motor axons.

The results of such parameters as distal latency and conduction velocity in motor fibres of the examined nerves were correct in the majority of our patients, which confirmed that ALS was characterised by axonal neuropathy, and not demyelinating neuropathy.

The natural ALS progress always results in a loss of manual dexterity. At a certain stage of the disease, patients become unable to live independently, they require help from the people around them to perform basic everyday activities, i.e. walking, washing oneself or eating [4, 6, 8, 12, 22, 23]. The results of the Rene Zazzo card test and the Mira Stambak crosshatch test obtained by us during the first examination showed that nearly all subjects presented with deteriorated manual dexterity. The results were abnormal in 100% of the cases for the Rene Zazzo card test, and for 60% of the cases in the Mira Stambak crosshatch test. Our results seem to confirm previous clinical reports.

The results of electrophysiological examinations obtained during measurement A, implying axonal motor neuropathy, were reflected in abnormal results of tests verifying manual dexterity in those patients.

According to de Carvalho, electrophysiological examinations are used to diagnose and monitor the disease [10, 11, 13]. van Dijk et al. used in their study an analysis of the compound muscle action potential (CMAP) amplitude and the ALS Functional Rating Scale to evaluate progression of amyotrophic lateral sclerosis, and they demonstrated that the progressing loss of dexterity is reflected in the reduced CMAP amplitude [27]. The authors also used the electrophysiological evaluation of peripheral nerves to evaluate the disease progression, and, additionally, they used the above-mentioned tests for a clinical evaluation of the disease progression. The results of our examinations conducted three times during a period of six months are consistent with the observations of van Dijk et al. In own studies, a statistically significant reduction in the amplitude of the compound muscle action potential (CMAP) was demonstrated in successive examinations after 3 and 6 months, as well as a deterioration in the manual dexterity of the subjects, as reflected in the results of the card and the crosshatch tests. The results presented above are also consistent with reports of Turner et al. [22], who are of the opinion that amyotrophic lateral sclerosis is characterised by progressing motor neuropathy, leading to the gradual reduction in the muscle strength.

Our results of the CMAP analyses and dexterity tests are also similar to the results obtained by Liu et al. [28].

A separate analysis of patients with limb-onset and bulbar-onset ALS revealed the absence of significant differences with regard to the electrophysiological parameters of the examined nerves and tests in patients with the former form. On the other hand, in the second group, the examinations showed a significant decrease in the compound muscle action potential (CMAP) of the examined nerves as well as deterioration of manual dexterity in the course of a six-month observation. This illustrated a more rapid progression of the disease in patients suffering from bulbar-onset ALS, which was consistent with conclusions of other authors [6, 22].

When evaluating the correlation between the CMAP amplitude level in the nerves of the upper limbs and the results of the Rene Zazzo card test and the Mira Stambak crosshatch test we demonstrated that these parameters were statistically significantly correlated in the studied group. This correlation was particularly visible between the CMAP amplitude levels in the relevant nerves and the card test results.

Although no significant deterioration was found in electrophysiological parameters and clinical tests, in patients with the limb-onset ALS this relationship between the above-mentioned parameters was more pronounced versus the bulbar-onset patients, in whom the electrophysiological and clinical progression was definitely clearer.

The results we obtained illustrate that progressive damage to the motor neuron, which occurs in the course of ALS, leads to progressive disability of the examined patients. This confirmed the conclusions of Wijeseker et al. that lateral amyotrophic sclerosis was an incurable disease with a progressive course, leading to disability and shortly to death [6]. Also, Bäumer et al. characterised ALS as a disease with progressive electrophysiological disorders with concurrent intensification of neurological symptoms, leading to impaired fitness [4].

The available reports mainly present a correlation between the myasthenia test by electrical stimulation and the dexterity[29, 30]. The authors of this report would like to emphasise the results of the correlations analysed, indicating a possibility for monitoring the clinical progress of ALS by the evaluation of the CMAP amplitude.

CONCLUSIONS

1. A loss of motor cells in the anterior horns of the spinal cord is reflected in the deterioration of manual dexterity in ALS patients.

2. A significant correlation is found between the loss in manual dexterity and increase in changes in motor conductivity.

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Address for correspondence

Jacek Hübner

Department of Neurology, District Hospital, Radomsko, Poland

Jagiellońska Street 36, 97-500 Radomsko

tel.: 608585230

e-mail: dymiatko@op.pl

Received: 21.02.2018

Accepted: 23.04.2018

Table I. Structure of normality for the electrophysiological evaluation of a motor nerve during initial measurement and in a period of six months in the studied group (N = 20).

Motor nerve

Parameter

Measurement moment

Abnormal value

N

M

SD

N

%

Median left

Distal latency
[ms]

A

7

35.00

20

4.08

0.41

B

7

35.00

20

4.23

0.7

C

7

35.00

20

4.06

0.56

Amplitude
[mV]

A

14

70.00

20

4.1

2.14

B

17

85.00

20

3.37

1.5

C

14

70.00

20

3.78

1.75

Conduction velocity
[m/s]

A

0

0.00

20

53.52

2.37

B

1

5.00

20

53.97

2.68

C

0

0.00

20

53.92

2.81

Minimal F wave latency
[ms]

A

3

15.00

15

25.36

1.83

B

4

20.00

15

25.99

1.97

C

4

20.00

15

25.12

1.63

Median right

Distal latency
[ms]

A

9

45.00

20

4.26

1.03

B

9

45.00

20

4.3

1.02

C

8

40.00

20

4.28

1.03

Amplitude
[mV]

A

14

70.00

20

4.18

2.56

B

16

80.00

20

3.62

2.26

C

14

70.00

20

3.9

2.43

Conduction velocity
[m/s]

A

1

5.00

20

53.46

3.19

B

3

15.00

20

53.63

4.13

C

2

10.00

20

53.94

4.13

Minimal F wave latency
[ms]

A

6

30.00

15

25.99

3.02

B

5

25.00

15

25.89

2.13

C

3

15.00

15

24.83

1.89

Left ulnar

Distal latency
[ms]

A

1

5.00

20

3.19

0.35

B

2

10.00

20

3.14

0.31

C

0

0.00

20

3.12

0.23

Amplitude
[mV]

A

8

40.00

20

5.46

2.79

B

10

50.00

20

4.89

2.7

C

11

55.00

20

4.42

2.76

Conduction velocity
[m/s]

A

0

0.00

20

57.79

4.03

B

4

20.00

20

55.7

3.54

C

2

10.00

20

57.94

6.05

Minimal F wave latency
[ms]

A

2

10.00

16

27.6

2.42

B

4

20.00

16

26.43

2.7

C

4

20.00

16

26.66

1.71

Right ulnar

Distal latency
[ms]

A

0

0.00

20

3.1

0.35

B

2

10.00

20

3.03

0.44

C

0

0.00

20

3.11

0.18

Amplitude
[mV]

A

7

35.00

20

6.25

3.38

B

8

40.00

20

5.72

3.21

C

13

65.00

20

4.21

2.75

Conduction velocity
[m/s]

A

2

10.00

20

57.41

3.4

B

1

5.00

20

58.41

4.52

C

2

10.00

20

57.44

4.86

Minimal F wave latency
[ms]

A

3

15.00

17

26.71

2.02

B

3

15.00

17

26.2

2.83

C

3

15.00

17

25.92

2.59

N – number

M — mean

SD – standard deviation

A – measurement A

B – measurement B

C – measurement C

Fig. 1. The median left, the median right, the left ulnar and the right ulnar nerves – an average CMAP amplitude in a studied group and in a group with the bulbar form in a period of six months.

Fig. 2. Rene Zazzo card test – an average test result in a studied group and in a group with the bulbar form in a period of six months.

Fig. 3. Mira Stambak crosshatch test – an average test result in a studied group and in a group with the bulbar form in a period of six months.