Utility of Dissociated Intrinsic Hand Muscle Atrophy in the Diagnosis of Amyotrophic Lateral Sclerosis

Summary

Dissociated atrophy of intrinsic hand muscles, termed the split hand, appears to be a specific feature of amyotrophic lateral sclerosis (ALS). Consequently, a novel neurodiagnostic test, termed the split hand index, was developed to quantify the clinical phenomenon of the split hand, which differentiated ALS from mimic disorders.

Abstract

The split hand phenomenon refers to predominant wasting of thenar muscles and is an early and specific feature of amyotrophic lateral sclerosis (ALS). A novel split hand index (SI) was developed to quantify the split hand phenomenon, and its diagnostic utility was assessed in ALS patients. The split hand index was derived by dividing the product of the compound muscle action potential (CMAP) amplitude recorded over the abductor pollicis brevis and first dorsal interosseous muscles by the CMAP amplitude recorded over the abductor digiti minimi muscle. In order to assess the diagnostic utility of the split hand index, ALS patients were prospectively assessed and their results were compared to neuromuscular disorder patients. The split hand index was significantly reduced in ALS when compared to neuromuscular disorder patients (P<0.0001). Limb-onset ALS patients exhibited the greatest reduction in the split hand index, and a value of 5.2 or less reliably differentiated ALS from other neuromuscular disorders. Consequently, the split hand index appears to be a novel diagnostic biomarker for ALS, perhaps facilitating an earlier diagnosis.

Introduction

The split hand, refers to preferential atrophy of the thenar complex group of intrinsic hand muscles [abductor pollicis brevis (APB) and first dorsal interosseous (FDI)], with relative preservation of hypothenar muscles, and is a specific and early clinical feature of amyotrophic lateral sclerosis (ALS)^1-4. The finding that the split hand sign is specific for ALS, suggests a potential role for the split hand sign as a diagnostic biomarker in ALS³.

Quantification of the split hand sign, through the development of a novel neurophysiological biomarker, may further aid in ALS diagnosis. ....

Protocol

1. Patient Preparation

1. Recruit patients prospectively and consecutively. Note: The following protocol is approved by the Sydney West Area Health Service Human Research Ethics Committees. Informed consent was provided by all patients. Patients were recruited prospectively and consecutively from the ALS/neuromuscular clinic at Westmead Hospital.
2. Determine suitability of ALS patients for testing. Exclude patients who are not diagnosed with ALS or a neuromuscular disorder.
3. Exclude patients with a coexistent focal neuropathy, median neuropathy at the wrist or ulnar neuropathy at elbow.
4. Exclude patients with a generalized neuropathy....

Results

Clinical Phenotype

In total, 44 ALS patients were studied, of which 76% (N=33) were classified as definite or probable and 24% (N=11) as possible ALS according to the Awaji criteria¹¹. The diagnosis of ALS was confirmed in the “possible” cohort after extensive investigations and clinical follow-up for up to 3 years and 53% died during this period. Bulbar-onset disease was evident in 41%, while limb-onset in 59% of ALS patients. At the time of assessment, mean disease duration.......

Discussion

The present study reports on the diagnostic utility of the split hand index in ALS, a novel neurophysiological diagnostic biomarker. The SI reliably distinguished ALS from neuromuscular disorders, with an optimal diagnostic cut-off value of 5.2. The reduction in the SI was most prominent in limb-onset ALS patients. Importantly, a substantial proportion of ALS patients that were classified in the diagnostic “possible” category as per the recently developed diagnostic criteria¹¹, exhibited an abnorma.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Abrasive gel (Nu Prep)	Weaver and Company	N-TA\/P\H-3 ENG	Skin preperation
Alcohol wipe	Triad Disposables	103101	Skin preperation
Recording gel (Ten20 Conductive gel)	Weaver and Company	N-TA\/P\H-3 ENG	Recording motor responses
Amyotrophic lateral sclerosis rating scale-revised questionnaire	Publication	Experimental builder	Stage disease
Medical Research Council muscle strength scale	Medical Research Council-UK	Experimental builder	Stage disease
Equipment	Company	Catalog number	Comments
Nerve conduction machine (Synergy/Nicolet EDX)	CareFusion	SA110106M	To measure split hand index
Synergy software	CareFusion	765654679	To measure split hand index
Tem millimeter gold cup disc electrodes	Grass Technologies	F-E5GH-60	To record motor responses
Neural earth plate	Westmead Hospital	Experimental builder	To record limb temperature
Thermometer	Westmead Hospital	Experimental builder	To record limb temperature