Clinical Neurophysiology 115 (2004) 27762782

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Repetitive nerve stimulation in myasthenia gravisrelative

sensitivity of different muscles
Joao Costaa, Teresinha Evangelistaa, Isabel Conceicaoa,b, Mamede de Carvalhoa,b,*
a
Department of Neurology, Hospital de Santa Maria, Av. Prof. Egas Moniz, 1649 Lisbon, Portugal
b
Laboratory of Electromyography, Centro de Estudos Egas Moniz, Faculty of Medicine, Institute of Molecular Medicine, Lisbon, Portugal
Accepted 24 May 2004
Available online 18 September 2004

Abstract
Objective: To correlate repetitive nerve stimulation (RNS) decrement in different muscles with the predominant clinical presentation in
myasthenia gravis (MG), and to study single fibre EMG (SFEMG) sensitivity in ocular MG.
Methods: Sixty-nine, untreated, consecutive patients suspected for MG were observed prospectively for a minimum of 6 months.
Those who improved on medical treatment were diagnosed as MG. The others, in whom the neurophysiological studies were normal and that
did not improve on medical treatment served as a control group, from which normative data for RNS and SFEMG was obtained. The MG
patients were further classified in 3 subgroups according to the predominant clinical presentation: group I (ocular); group b (bulbar);
and group a (axial). We performed RNS in nasalis, trapezius, anconeus, and abductor digiti minimi. All patients with ocular MG underwent
jitter determination of the orbicularis oculi muscle.
Results: Thirty-seven patients were diagnosed as MG (group I, 15; group b, 13; group a, 9). In group I, RNS was abnormal in 33% of the
patients. RNS studies disclosed at least one abnormal muscle response in every patient in groups a and b. Trapezius was significantly more
sensitive in group a, and anconeus and nasalis in group b P , 0:01: Jitter was abnormal in all patients in group I, and the most sensitive
parameter was an increased number of unstable pairs, 100%.
Conclusions: Based on these observations, we recommend that a shoulder muscle, as the trapezius, should be studied first in the limb-axial
presentation of MG, and the anconeus nasalis muscles in predominant bulbar MG. In ocular MG, RNS is not sensitive and jitter should be
performed in facial muscles.
Significance: This paper shows the unequal sensitivity of several muscles to RNS in different forms of MG.
q 2004 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.
Keywords: Myasthenia gravis; Repetitive nerve stimulation; Single-fibre EMG; Jitter

1. Introduction
Repetitive nerve stimulation (RNS), introduced by
Harvey and Masland (1941), has become the most routinely
used test for the diagnosis of myasthenia gravis (MG)
(Keesey, 1989; Stalberg, 1980). RNS is commonly available
in neurophysiology laboratories and shows a good
correlation with the clinical assessment of disease severity
(Keesey, 1989). Most often recordings are from the small
hand muscles, although proximal muscles have been shown
to be more sensitive than distal ones (Claussen et al., 1995;
Kennett and Fawcett, 1993; Krarup, 1977; Ozdemir
* Corresponding author. Tel.: 351-21-780-5219; fax: 351-21-752-
0801.
E-mail address: mamedemg@mail.telepac.pt (M. de Carvalho).
1388-2457/$30.00 q 2004 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.clinph.2004.05.024
and Young, 1976; Stalberg, 1980), and facial muscles are
more sensitive in ocular MG (Oey et al., 1993).
Overall RNS is abnormal in more than 70% of patients
with MG when proximal muscles are investigated (Oh et al.,
1992). This value is significantly lower in patients with mild
generalized MG (Claussen et al., 1995; Stalberg and
Sanders, 1981), and in patients with ocular MG the
abnormality rate can be less than 30% of the tested subjects
(Claussen et al., 1995; Stalberg, 1980). RNS studies in
proximal muscles are more painful and more prone to
artefactual changes (Claussen et al., 1995; Stalberg, 1980),
but stimulation of the upper trapezius or anconeus muscles
are better tolerated than stimulation of other proximal
muscles at Erbs point, in the axilla or in the leg (Claussen
et al., 1995; Keesey, 1989; Kennett and Fawcett, 1993;
Schumm and Stohr, 1984).
 J. Costa et al. / Clinical Neurophysiology 115 (2004) 27762782
Ocular symptoms (fluctuating diplopia and ptosis) are the
most common presenting complaints of patients with MG.
However, predominant bulbar features (dysphagia, dyspho-
nia, oral muscle fatigue) can occur in up to one-quarter of
the patients with MG at onset (Emilia-Romagna Study
Group, 1998). In 15 20% of the patients the first complaint
is weakness of the arm or hand muscles, or of the legs.
(Oosterhuis, 1997).
No previous study tried to correlate the decrement to RNS
in different muscles with the predominant clinical presen-
tation. Our study aimed to investigate the decrement to RNS
of various proximal and distal muscles in patients with
different presenting forms of MG (ocular, bulbar, or
axial/limb-girdle).
2. Population and methods
2.1. Population
We enrolled all consecutive patients referred to our centre
from May 1998 to July 2002 with a clinical diagnosis of
possible MG. A total of 94 patients were included at this phase.
Later on, 21 patients were excluded: 4 of them suffered from
other medical conditions: two with polyneuropathy and two
with oncological disease, one was on anticoagulant
medication, 4 did not cooperate, 3 were already on
pyridostigmine, and 9 were lost for follow-up. A group of 4
patients with probable MG was not included, because they
were followed for a short period of time. The remaining 69
patients were selected for this prospective study, for which
they gave informed consent. No patient included in this study
was medicated with pyridostigmine or with any immunosup-
pressive drug before the neurophysiological evaluation.
The protocol was approved by the local Ethics Committee.
All of the 69 patients who were included in this study
were followed for a minimum of 6 months after the
neurophysiological study. They were treated with
pyridostigmine, often associated with oral steroids.
The non-responsive patients stopped the medication early
but remained on follow-up. They formed the control group,
from which the normative data for RNS and SFEMG was
obtained. The patients with fluctuating motor weakness,
predominantly oculo-bulbar, with positive serum antibodies
to human acetylcholine receptor (AchR), and those who
consistently improved by anticholinesterase medications
formed the group of patients with MG. Some of them had a
partial clinical response and were submitted to a more
aggressive treatment. Thymectomy was performed in those
with thymoma, or in young-adults with generalized MG.
The thymus was removed after clinical improvement by
drug medication. The patients diagnosed as MG were
divided in 3 sub-groups according to the predominant
symptoms and signs at the time of the neurophysiologic
investigation: group I (ocular); group b (bulbar, including
2777
those with mild, moderate and severe disease); group a
(axial, limb-girdle, including those with mild, moderate and
severe disease). Our classification is in agreement with the
criteria from the Myasthenia Gravis Foundation of America
(MGFA) (Jeretzki et al., 2000), which was published after
the onset of this study. There were small number of subjects
and all of them were with mild and moderate MG. So, we
did not subclassify them by disease severity.
All patients of both groups underwent routine blood tests,
thyroid function tests, thoracic CT scan, and determination
of serum antibodies to human AchRassayed following the
standard immnunoprecipitation method using purified
human Ach-R (abnormal . 0.4 nmol/l). Selected cases
were submitted to CT scan or MRI of the head, in particular
patients with ocular MG.
2.2. RNS and nerve conduction velocities
The following nerve muscle systems were studied in
every patient: facial nerve nasalis, accessory nerve
trapezius, radial nerve anconeus, ulnar nerve abductor
digiti minimi (ADM). The ulnar nerve was stimulated at the
wrist (Niks et al., 2003), the radial nerve just above the
elbow (Kennett and Fawcett, 1993), the accessory nerve
behind the sternocleidomastoid muscle (Schumm and Stohr,
1984; Claussen et al., 1995), and the facial nerve at the
mandibular angle (Ruys-Van Oeyden and Dijk, 2002),
following standard methods (Oh et al., 1992; Tim and
Sanders, 1994). In some patients the median nerve was also
investigated, stimulated at the wrist and the motor response
recorded from the abductor pollicis brevis (APB) (Tim and
Sanders, 1994).
Bipolar surface electrodes were used to deliver square
wave pulses of 0.2 0.3 ms duration. Surface recording
Ag AgCl electrodes (model 13L20, Medtronic, Skvolunde,
Denmark) were placed in a belly-tendon montage. The filter
was set to 10 Hz 10 KHz. The stimulus intensity was 25%
supramaximal for single stimuli. Trains of 9 stimulus were
given at a rate of 2 Hz. The peak-to-baseline amplitude and
the negative peak area of the motor response potential were
measured automatically, and the percentage decrement was
calculated by comparing the 4th response with the first
response. The test was done twice or three times on each
muscle to assess the reproducibility of the response. Among
these two or three responses, we chose one with the largest
amplitude and area decrement for the analysis. In muscles
with higher-than-normal decremental response, a U-shaped
decrement was necessary in order to accept it as an
abnormal result (the two last motor responses showed a
lower decrement than the 4th and 5th responses).
The movements induced by muscle contraction were
prevented by convenient fixation. Skin temperature was
maintained above 32 8C in the tested muscle, by using a
heating lamp distally and warm water proximally.
In every patient the motor and sensory conduction
studies of the right ulnar nerve was performed to exclude
2778 J. Costa et al. / Clinical Neurophysiology 115 (2004) 27762782

polyneuropathy. Post-exercise stimulation of the ulnar nerve
was done to rule-out the presence of incremental response
(. 50% increase in area or amplitude). Post-activation
exhaustion was not tested in this study.
All neurophysiological studies were performed by the
same neurophysiologist (M de C) with the same equipment
(Keypoint, Medtronic, Skvolunde, Denmark).
2.3. Single-fibre EMG (SFEMG)
These patients were diagnosed with different disorders
during the follow-up: cranial nerve palsy, ocular myopathy,
congenital ptosis, blepharospasm, alternating strabismus,
metabolic myopathy, depression and chronic fatigue
syndrome. Control subjects were well matched with MG
patients for age (Student t-test, P . 0:05) and gender
(x2 ; P . 0:05). From these patients we obtained our
normative material for RNS and SFEMG.

All patients who were included with the clinical
diagnosis of ocular MG underwent SFEMG study of the
orbicularis oculi (OO), bilaterally. A standard method was
used (Sanders and Stalberg, 1996). The SFEMG needle
electrode was inserted at the edge of the muscle. The patient
was asked to maintain the muscle on slight contraction.
Amplifier settings were at 500 Hz 10 KHz. Single-fibre
responses were selected based on short rise times
(, 300 ms), clear separation from other discharges,
and stable wave forms with an amplitude above 150 mV.
The mean jitter was calculated from 20 accepted single-fibre
responses (10 pairs per side), although in patients with clear
abnormalities in this test a smaller number was accepted
(minimum of 10 pairs).
In a selected number of patients with generalized MG
and abnormal decremental responses, SFEMG studies of the
extensor digitorum communis was performed with the same
method, as described elsewhere (Sonoo et al., 2001).
3.1.1. RNS studies results
The neurophysiological results obtained in this group are
summarized in Table 1.
In all individually tested muscles, the area decrement
was significantly higher than the amplitude decrement
(Student t-test, P , 0:05). Decrement of the area and
amplitude was smaller for the ADM as compared with the
other muscles (one-way ANOVA, P , 0:05; post-hoc
Tuckey test , 0.05), but no differences were found between
anconeus, trapezius, nasalis and APB muscles P . 0:05:
Decrement of the amplitude did not show normal distri-
bution, but decrement of the area did (Kolmogorov
Smirnov, P . 0:05). For this last reason we decided to use
the decrement of the area for further analysis and
comparisons. Based on our results we set 7% as the upper
limit for area decrement of the 4th response in all tested
muscles (Table 1).

3.1.2. SFEMG studies results

3. Results
The jitter values obtained from the OO in this control
3.1. Controls population are detailed in Table 2. Inter-subject variation of
the mean jitter value was small, which established the upper
Thirty-two patients (mean age 52, ranging from 22 to 86) limit of normal as 32 ms MCD. We found no correlation
formed this group. No patient had thymus abnormality or between the mean jitter and age P . 0:05: More than two
positive antibody testing to AchR. Most of these patients unstable pairs or any blocking pair from the analysed group
were referred with the diagnosis of ocular MG. of 20 was also set as abnormal.
Table 1
Normative values for RNS

Total number 32, n % Decrement % Decrement ULN for ULN for area
(F:M 18:14) of amplitude, of area, mean ^ SD amplitude decrement(%)
mean (range) (range) decrement (%)

RNS ADM 32 0.2 (01)a 1.8 ^ 1.3 (05)b 5c 2.27d

RNS anconeus 32 0.9 (03)a 2.2 ^ 1.5 (05)b 5c 2.4-7d
RNS trapezius 32 1.1 (04)a 3 ^ 1.8 (06)b 5c 2.7-7d
RNS nasalis 32 0.9 (04)a 2.2 ^ 1.6 (05)b 5c 2.57d
RNS APB 17 1.2 (05)a 3.3 ^ 1.6 (17)b 5c 2.87d

RNS, repetitive nerve stimulation; n; number; ADM, abductor digiti minimi; APB, abductor pollicis brevis; ULN, upper limit of normal; SD, standard
deviation. The values between brackets represent the range of the results.
a
Non-normal distribution.
b
Normal distribution.
c
Taking into account that amplitude has a non-normal distribution and one control subject showed a value of 5% for the amplitude decrement in the APB, we
set as 5% the upper limit of normal.
d
The first value corresponded to mean value 3D. However, since one control subject showed a value of 7% for the area decrement in the APB we set as 7%
the upper limit of normal.
 J. Costa et al. / Clinical Neurophysiology 115 (2004) 27762782 2779

Table 2 The area decrement of the trapezius was larger in group a

Normative values for Jitter OO
Mean jitter Pairs with Pairs with
increased jitter blocking
Total number 30, 22.6 ms MCD (3.0) 0.2 (0.4) 0.0 (0)
(F:M 17:13)
ULN 31.6 ms MCD 2.0a 0b
MCD, mean consecutive differences; OO, orbicularis oculi; ULN,
upper limit of normal. The values between brackets are the standard
deviation of the mean.
a
Two controls had two pairs with increased jitter (.35 ms MCD), aged
43 and 51.
b
No control had blocking.
3.2. Patients
Thirty-seven patients were diagnosed as MG. No patient
was classified as severe. According to their predominant
symptoms, patients were classified into the following
groups: group I (ocular) 15 patients; group a (axial, limb-
girdle) 9; group b (bulbar) 13 (Table 3). Data on antibodies
testing and thoracic imaging are presented in Table 3. We
found no differences between these subgroups regarding
age, symptoms duration, or follow-up period (one-way
ANOVA, P . 0:05).
3.2.1. RNS studies results
In all individually tested muscles, no difference was
found between area and amplitude decrement (Student t-test,
P . 0:05).
In group I, RNS was abnormal in only 5 patients (33%), the
trapezius was abnormal in all of these 5 patients, the anconeus
in two and the nasalis in one. In group I, no differences were
found in all studied muscles P . 0:05 (Fig. 1), or in group I
and the control group P . 0:05: RNS studies disclosed at
least one abnormal muscle response in every patient included
in groups a and b. In group a, trapezius showed the highest area
decrement (mean of 33.9% ^ 19.3, one-way ANOVA,
P , 0:05; post-hoc Tuckey test , 0.05). In group b, anconeus
(41.6% ^ 15.3) and nasalis (40.9% ^ 19.4) had the highest
decrement of the area (one-way ANOVA, P , 0:01; post-hoc
Tuckey test , 0.01), without significant difference between
them P . 0:05 (Fig. 1).
than in groups b or I (one-way ANOVA, P , 0:01; post-hoc
Tuckey test , 0.01). The area decrement of the nasalis
and anconeus were higher in group b than in groups a and I
(one-way ANOVA, P , 0:01; post-hoc Tuckey
test , 0.01). ADM demonstrated a larger decrement in
group b (14.4% ^ 10.1, one-way ANOVA, P , 0:01;
post-hoc Tuckey test , 0.01), than in groups a and I,
however, APB tended to show a higher decrement
(22.0% ^ 11.3) than the ADM.
The same results for these comparisons were obtained
when amplitude decrement was used in the statistical analysis.
On individual as well as group level, RNS sensitivity of
different muscles was quite consistent (Table 4). In group a,
the trapezius was significantly more sensitive than any other
muscle (Fisher Exact test, P # 0:001) but no difference was
found between the others. In group b, the anconeus and the
nasalis were equally sensitive P 0:9 but more sensitive
than any other P # 0:01:
3.2.2. SFEMG studies results
In 14 out of 15 patients included in group I, 20 pairs of
potentials were studied in OO bilaterally. In one patient 10
pairs were investigated, because we observed marked
abnormalities. In all these patients the jitter was abnormal:
mean jitter 41 ms MCD, (ranging from 21 to 100); mean
number of unstable pairs 9 (from 3 to 16); mean number of
blocking pairs 1.8 (from 0 to 6). An increased number of
unstable pairs was the most sensitive parameter, 100%.
Abnormal mean jitter was observed in 67% of the patients in
this group I.
In 7 out of the 9 patients in group a, and in 5 of the 13
patients in group b the jitter determination of the EDC was
performed. The results were abnormal in all, with increased
mean jitter value (. 40 ms MCD), more than 10% of pairs
showing instability (. 55 ms MCD), and blocking (Sanders
and Stalberg, 1996).
4. Discussion
This prospective study followed the guidelines proposed
by the American Association of Electrodiagnostic Medicine

Table 3
Myasthenic patientsclinical data

1 n Sex: F:M Age, mean Symptom duration, Follow-up, median Positive AchR-Ab Thymoma
(SD) range median (months) (months) range (%) (%)
range (months) (months)

I 15 7:8 39 (19), 1874 4, 130 19, 663 38 17

b 13 10:3 47 (24), 1878 5.5, 224 18, 661 91 9
a 9 3:6 48 (22), 2480 6, 2228 17, 663 86 25
Total 37 20:17 44 (21), 1880 5, 1228 18, 663 70 16

Class, classification; I, ocular; b, predominant bulbar symptoms; a, axial/limb-girdle type; M, male; F, female; SD, standard deviation; AchR-Ab,
acetylcholine antibodies.
2780 J. Costa et al. / Clinical Neurophysiology 115 (2004) 27762782

Fig. 1. Mean area decrement of the different muscles to RNS.

(AAEM Quality of Assurance Committee 2001a,b). slightly lower than the described elsewhere (Bromberg and
In particular, this study has two important characteristics: Scott, 1994; Sanders and Stalberg, 1996).
all patients were studied before treatment and the final In one previous experience comparing the stimulation rate
diagnosis was clinical, supported by the positive serum at 2 vs. 3 Hz in 10 patients with MG we did not find any
antibodies against AchR and the treatment response. difference regarding the area/amplitude decay P , 0:05;
The main limitation of this study is the small number of but the rate of 2 Hz was better tolerated in proximal
patients included. muscles (not published), for this reason we decided to
Pseudofacilitation, an increase in amplitude on RNS due perform this study using a stimulation rate of 2 Hz. In our
to synchronization of muscle fiber conduction (Stalberg, hands, stimulus duration of 0.1 ms augments inter-trial
1980; Lo et al., 2003) was more evident in controls than in variability, for this reason we decided to use 0.2 0.3 ms
patients with MG. In our population of MG patients area stimulus duration.
decrement did not provide a higher yield than amplitude, in
opposition to the report of Lo et al. (2003).
Table 4
The control values for RNS calculated from our Diagnostic sensitivity of different muscles in groups a and b
non-myasthenic population are identical to those published
by other authors (AAEM quality assurance committee, RNSmuscle that Number of patients (%)
showed the highest
2001b; Desmedt, 1973; Oey et al., 1993; Oh et al., 1992;
area decrement
Kennett and Fawcett, 1993; Ruys-Van Oeyden and Dijk, Group a, Group b, Fishers exact
2002; Schumm and Stohr, 1984; Stalberg, 1980). We did not n 9 n 13 test (MG group
include deltoid in our protocol, although this is probably a a vs. group b)
very sensitive muscle to show abnormalities in MG
(Yiannikas et al., 1994). However, there is reduced Trapezius 8 (89%) 0 (0%) P # 0:0001
Anconeus 1 (11%) 6 (46%) P 0:09
information on this muscle in the literature (AAEM Quality Nasalis 0 (0%) 7 (54%) P # 0:01
of Assurance Committee, 2001b) and in our experience Anconeus or Nasalis 1 (11%) 13 (100%) P , 0:0001
many patients do not tolerate this investigation, as ADM 0 (0%) 0 (0%) P1
experienced by others (Claussen et al., 1995; Keesey, Note: no comparisons were made for Group I since RNS was abnormal
1989; Kennett and Fawcett, 1993; Schumm and Stohr, in only 5 of these patients (33%). Trapezius showed the highest area
1984). The jitter value of the OO in our population is decrement in 3, anconeus in 1, and nasalis in 1.
 J. Costa et al. / Clinical Neurophysiology 115 (2004) 27762782
In our population the sensitivity of RNS in group I was
lower than reported in some studies (Stalberg, 1980),
although similar to other reports (AAEM quality
assurance committee, 2001b). We cannot discuss the role
of post-activation exhaustion upon these differences,
since we did not include this technique in our study.
However, SFEMG of the OO proved to be a very sensitive
technique in ocular MG, as reported before in studies
involving facial muscles (Stalberg, 1980; AAEM quality
assurance committee, 2001b; Oh et al., 1992; Padua et al.,
2000). In our study the number of unstable pairs was the
most sensitive index. This paper confirms that the less
sensitive test for ocular MG is the presence of positive
AchR-Ab (Oh et al., 1992).
In our patients with generalized MG, hand muscles were
not as sensitive as described by others (Niks et al., 2003; Oey
et al., 1993; Ozdemir and Young, 1976; Shumm et al., 1984).
Probably, this is due to the absence of patients with severe
disease in our population. The APB tended to be more
sensitive than the ADM (mean area decrement of 9.4 and 22.0
for the APB, as compared with 4.8 and 14.4% for the ADM,
in groups a and b, respectively). However, RNS of the
proximal muscles proved to be a significantly more sensitive
method to confirm generalised MG (AAEM quality assur-
ance committee, 2001b; Desmedt, 1973; Jeretzki et al., 2000;
Kennett and Fawcett, 1993; Krarup, 1977; Ozdemir and
Young, 1976; Pavesi et al., 2001; Stalberg, 1980; Shumm,
1984).
This study shows for the first time that the trapezius
muscle is more sensitive in myasthenic patients presenting
with limb-girdle and axial weakness, and that anconeus or
nasalis are more sensitive in patients presenting with
predominant bulbar features. It is well known that weakness
may vary from one muscle to another in patients with MG,
and that close anatomically related muscles can show
unequal results on neurophysiological studies (Kennett and
Fawcett, 1993). Our results clearly demonstrate that
different clinical presentation has different responses on
RNS. This finding is relevant when investigating patients
not tolerant to the electrical stimulation or children, in
whom the most sensitive muscle should be assessed first.
The AAEM has recently disclosed practice
recommendations for electrodiagnostic studies when
laboratory confirmation of a neuromuscular junction
disorder is desired (AAEM quality assurance committee,
2001a). Our study fulfils all proposed criteria for class A
evidence: prospective; diagnosis based on clinical criteria
independent of the electrodiagnostic procedure; description
of the electrodiagnostic procedure; limb temperature
monitored; reference values obtained with concomitant
studies of a reference population; criteria for abnormal
findings clearly stated and derived from the reference
population. The present recommendations for MG
electrodiagnostic (based on class B evidence) are: (1) to
perform RNS of a nerve supplying a symptomatic muscle;
(2) if the RNS is normal and there is high suspicious of MG,
2781
perform SFEMG of at least one symptomatic muscle.
Another recommendation (based on class C evidence) was
provided for patients with very mild or solely ocular
symptoms and when it is believed that RNS will be
normal, recommending SFEMG test as the initial electro-
diagnostic test.
Although we have studied a small population of patients
with MG, our results suggest some changes to those
recommendations. These suggestions are only appropriate
after excluding the diagnosis of pre-synaptic neuromuscular
transmission defect by investigating incremental response
after muscle contraction or with high-repetitive stimulation
(Maddison et al., 1998). Taking into account the
patient tolerability, we propose that: (1) RNS of the
trapezius (or probably another shoulder muscle) should
be performed first in patients with predominant limb-axial
fatigue; (2) anconeus and nasalis muscles should be tested
first in patients with predominant bulbar presenting features;
(3) RNS of the ADM is not helpful in the electrodiagnostic
of MG, although it can be quite valuable to exclude
pre-synaptic transmission defect (Maddison et al., 1998);
(4) in patients with pure ocular MG, RNP it is not sensitive
and SFEMG of the facial muscles could be tested first in
laboratories where this technique is available.
Acknowledgements
The authors are grateful to Ana Macedo for statistical
advice and to Professor Jose Ferro for referring some
patients.
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