The clinical presentation somewhat varies on the subtype of MND, but progressive muscle weakness, muscle atrophy and a variety of bulbar and pseudobulbar symptoms are present [1] [2]:

• In ALS, initial weakness in distal extremities progresses to involve all limbs, together with features of both UMN and LMN injury. Fasciculations, hyperreflexia, fatigue, stiff movement and weight loss are common manifestations. As the disease goes on, chewing, swallowing and speech issues appear, together with increased salivation and involuntary emotional outbursts. It is important to note that the senses, voluntary functions of the oculomotor nerve and both urinary and anal sphincters are almost never involved.
• Progressive muscular atrophy has a somewhat milder course and primarily involves LMN injury, with fasciculations, muscle wasting and eventual generalized weakness are main clinical features.
• Progressive bulbar palsy is characterized by involvement of UMNs, mainly the corticospinal and corticobulbar tracts. Impaired gag reflex, movement of the tongue and palate, together with severe dysphagia are most commonly observed in patients.
• Primary lateral sclerosis has a somewhat similar clinical presentation to progressive muscular atrophy, but it is often accompanied with pseudobulbar symptoms. Progressive pseudobulbar palsy has an almost identical presentation to primary lateral sclerosis.

In final stages of MNDs, respiratory failure eventually occurs and is the main cause of death across all subtypes.

• Fatigue

  All studies assessed fatigue using the Fatigue Severity Scale (FSS; scale from 9 to 63, higher scores indicate more fatigue). [ncbi.nlm.nih.gov]

  Slurring of speech Cramps, pains and twitching in the muscles Change in voice Fatigue and muscles wasting. The weakness of the muscles of legs leads to clumsy and awkward gait. Such patients are typically seen walking with “dropped Foot”. [askdrshah.com]

  Symptoms of motor neurone disease (MND) The physical effects of motor neurone disease can include: muscle aches, cramps, twitching clumsiness, stumbling weakness or changes in hands, arms, legs and voice slurred speech, swallowing or chewing difficulty fatigue [betterhealth.vic.gov.au]

• Weight Loss

  We describe a 52-year-old man with body weight loss and bulbar palsy, who exhibited muscle atrophy and weakness with fasciculation especially in the respiratory muscles 4 years prior to death, necessitating respiratory support for 4 years, but who was [ncbi.nlm.nih.gov]

  loss – your arms or leg muscles may have become thinner over time difficulty stopping yourself crying or laughing in inappropriate situations Who gets it and why Motor neurone disease is an uncommon condition that mainly affects people in their 60s and [nhs.uk]

  […] average weight loss of 0·46kg [1·01lbs] in the high-fat high-calorie diet group). [sciencedaily.com]

  loss emotional lability – for example, where a slight upset can cause an exaggerated response, such as crying or laughing cognitive change (changes in thought processes) respiratory changes. [betterhealth.vic.gov.au]

• Asymptomatic

  The prevalence of electrophysiological and immunological abnormalities in asymptomatic relatives of patients with myasthenia gravis. Ann N Y Acad Sci. 1987;505:407. 9. [analysefortegnelsen.dk]

  These parents are likely to be asymptomatic (without symptoms of the disease). Autosomal recessive diseases often affect more than one person in the same generation (siblings or cousins). [web.archive.org]

  Asymptomatic patients are also present. [emedicine.medscape.com]

• Pathologist

  A person with MND will usually require assistance from a number of health care professionals including a GP, neurologist, occupational therapist, physiotherapist, speech pathologist, psychologist, home care nurse and social worker. [brainfoundation.org.au]

  Speech Language Pathologist (SLP) - The SLP is able to assist you primarily with eating safely and communicating with family and friends. [healthcare.utah.edu]

  Clinical Testing and Workup Doctors will take samples of affected tissue and a special doctor called a pathologist will study the tissue for changes caused by disease (histopathology). This can show the presence of mold. [rarediseases.org]

  Given the progressive nature of the neurodegenerative diseases, speech-language pathologists must be aware of appropriate augmentative and alternative communication equipment at the early stage of the disease course. [jkslp.org]

• Difficulty Walking

  In addition to changes in behavior, personality and language skills that characterize FTD, people with ALS and FTD also have difficulty walking, standing, using their hands, speaking, swallowing, or breathing. [theaftd.org]

  The second lowest score was obtained in the locomotion subdomain (71% of the highest possible score), suggesting that patients with MPS develop difficulty walking, a factor that further accentuates the level of dependence among these subjects. [scielo.br]

• Cough

  Pulmonary symptoms (eg, productive cough, high fever, dyspnea) are severe. [msdmanuals.com]

  Coughing blood (occasionally) Fever Shortness of breath Symptoms of gastrointestinal mucormycosis include: Abdominal pain Blood in the stools Diarrhea Vomiting blood Symptoms of kidney (renal) mucormycosis include: Fever Pain in the upper abdomen or [medlineplus.gov]

  'He can't walk, he can't use his right arm, and he has a machine to clear his lungs because he can't even cough for himself. 'We love cars and motorbikes and we are hoping to make Silverstone this weekend but I don't know if we'll make it.' [dailymail.co.uk]

  Pulmonary mucormycosis is often a rapidly progressive disease characterized by fever and a cough that does produce any mucous (nonproductive cough). [rarediseases.org]

  […] effectiveness (weak cough being a sign of potential respiratory impairment) potentially by measuring cough peak flow. [pathways.nice.org.uk]

• Hoarseness

  We present a 19-year-old female patient complaining of hoarseness and eyelid drooping. [ncbi.nlm.nih.gov]

  A progressive deterioration of nervous system occurs, as weakness and atrophy eventually affect all limbs, together with the onset of fasciculations, dysphagia, dysarthria, hoarseness and excessive salivation. [symptoma.com]

  Other symptoms include hoarseness, dysphagia, and slurred speech; because swallowing is difficult, salivation appears to increase, and patients tend to choke on liquids. [merckmanuals.com]

• Nasal Voice

  The muscles innervated by cranial nerves and corticobulbar tracts are predominantly affected, causing progressive difficulty with chewing, swallowing, and talking; nasal voice; reduced gag reflex; fasciculations and weak movement of the facial muscles [merckmanuals.com]

• Vomiting

  […] skin above sinuses Sinus pain or congestion Symptoms of lung (pulmonary) mucormycosis include: Cough Coughing blood (occasionally) Fever Shortness of breath Symptoms of gastrointestinal mucormycosis include: Abdominal pain Blood in the stools Diarrhea Vomiting [medlineplus.gov]

  Side effects of riluzole include: nausea, vomiting, weakness, rapid heartbeat (tachycardia), drowsiness, headaches, and dizziness. Very occasionally, riluzole has been known to damage the liver. [hse.ie]

  Symptoms can include abdominal pain and vomiting of blood (hematemesis). Lesions can develop that cause a hole to form in the stomach or intestines (perforation). [rarediseases.org]

• Nausea

  You may experience some side effects when you start taking SSRIs, including: nausea, headache, sleep problems, and anxiety. These side effects usually improve over time. [hse.ie]

  […] versus usual care (MD 0.20, 95% CI -10.98 to 11.38; very low-quality evidence).Three participants in the modafinil group dropped out of the modafinil study, two citing issues with headache and one with chest tightness; other adverse effects were anxiety, nausea [ncbi.nlm.nih.gov]

• Fasciculation of the Tongue

  Neither atrophy nor fasciculation of the tongue was observed. Both cases showed rapid progression to mutism within a few years. Neuropathologically, frontal lobe degeneration including the precentral gyrus was observed. [ncbi.nlm.nih.gov]

  Fasciculations of the tongue, which are a prominent feature of SMA, are helpful in making this distinction. [neuropathology-web.org]

  Bulbar onset: The first sign is usually slurring of the speech (impaired tongue movement). Wasting and fasciculation of the tongue. Dysphagia (usually a late feature with significant speech difficulties). [patient.info]

  The motor picture is usually dominated by bulbar symptoms (dysarthria, dysphagia, wasting, and fasciculations of the tongue). [dx.doi.org]

• Muscular Atrophy

  Patients with spinal muscular atrophy may appear to be stable for long periods, but improvement should not be expected. Some MNDs, such as ALS and some forms of spinal muscular atrophy, are fatal. [ninds.nih.gov]

  Primary lateral sclerosis has a somewhat similar clinical presentation to progressive muscular atrophy, but it is often accompanied with pseudobulbar symptoms. [symptoma.com]

  The Repository also banks subjects with MNDs that have known genetic causes, including Spinal Bulbar Muscular Atrophy (Kennedy’s Disease) and Spinal Muscular Atrophy. [coriell.org]

  It is a rare form of muscular atrophy leading to weakness. Although it is not classed as one of the types of MND, it is included in the conditions supported by the MND Association. It only affects men, but women may carry the mutation. [imnda.ie]

  atrophies (NMAs) and compared these patterns to mouse models of neurogenic muscular atrophy. [ncbi.nlm.nih.gov]

• Muscle Weakness

  […] wasting and weakness, absent reflexes, loss of weight and muscle twitching. [mndnsw.asn.au]

  RESULTS: All patients had slowly progressive muscle weakness and wasting in combination with downbeat nystagmus, which was clinically most obvious in downward and lateral gaze. [ncbi.nlm.nih.gov]

• Muscle Twitch

  A 69-year-old man with long-standing depression and failing memory presented with muscle twitches of 8 months' duration. He was found to have choreoathetoid movements and distal weakness on neurological examination. [ncbi.nlm.nih.gov]

  […] wasting and weakness, absent reflexes, loss of weight and muscle twitching. [mndnsw.asn.au]

  twitches of 8 months' duration. [jamanetwork.com]

  Usually, the first things people notice are: weakness in the hands and grip slurred speech weakness in the legs, and a tendency to trip weakness of the shoulder, making lifting difficult cramps and muscles twitching Later on, people with MND: have little [healthdirect.gov.au]

• Myopathy

  INTRODUCTION: Chorea-acanthocytosis (ChAc) is a rare autosomal recessive disease characterized by involuntary movements, seizures, cognitive changes, myopathy, and axonal neuropathy. [ncbi.nlm.nih.gov]

  Distinguishing the Cause of Muscle Weakness: Lower Motor Neuron Dysfunction vs Myopathy* Feature Lower Motor Neuron Dysfunction Myopathy* Distribution of weakness Distal > proximal Proximal > distal Fasciculations May be present Absent Reflexes Diminished [merckmanuals.com]

  SMA1 must be distinguished from other causes of neonatal hypotonia which include CNS malformations, metabolic diseases, infections, and congenital myopathies. [neuropathology-web.org]

  Thyrotoxicosis with associated myopathy. Spinal cord tumours. Cerebrovascular disease and stroke. Polymyositis or dermatomyositis. Glioma of brainstem. HIV-associated neuropathy/myopathy/radiculopathy (as one of the complications of HIV). [patient.info]

• Slurred Speech

  The early symptoms are slurred speech and stumbling. [sciencemuseum.org.uk]

  Usually, the first things people notice are: weakness in the hands and grip slurred speech weakness in the legs, and a tendency to trip weakness of the shoulder, making lifting difficult cramps and muscles twitching Later on, people with MND: have little [healthdirect.gov.au]

  The progression of the disease varies but most people with MND generally experience problems with their grip, the shoulder muscles (making it difficult to lift the arms up), dragging feet or a foot drop, or slurred speech. [alsnewstoday.com]

  Early symptoms can include: weakness in your ankle or leg – you might trip, or find it harder to climb stairs slurred speech, which may develop into difficulty swallowing some foods a weak grip – you might drop things, or find it hard to open jars or [nhs.uk]

• Clumsiness

  Early symptoms may be noticed as weakness or clumsiness of the hand. Most people live for more than five years. [imnda.ie]

  The patient had noted clumsiness and weakness in all extremities 5 years before presentation of abnormal eye movements. The results of electromyography and muscle biopsy were compatible with ALS. [ncbi.nlm.nih.gov]

  Generally, symptoms consist of stiffness, clumsiness, and awkward movements, usually affecting first the mouth, throat, or both, then spreading to the limbs. [merckmanuals.com]

  The weakness of the muscles of legs leads to clumsy and awkward gait. Such patients are typically seen walking with “dropped Foot”. It means their foot goes on dragging along the ground while walking. [askdrshah.com]

• Limb Weakness

  Selective distal upper limb muscle weakness and atrophy with non-significant lower limb weakness during follow-up was the most frequent motor pattern, present in 18 patients - in 15 of them associated with severe dysphagia. [ncbi.nlm.nih.gov]

  Limb weakness and dysphagia eventually become disabling, although some patients have a primarily bulbar pattern of weakness with relative sparing of limb strength. [emedicine.medscape.com]

  Signs LMD dysfunction in the limbs manifests as weakness, atrophy, fasciculations and hyporeflexia. The thighs are often a site of marked fasciculation. [patient.info]

  Symptoms Initial stage: Clumsiness Tiredness Muscular pain Cramps A weakening of grip, so that picking up or holding objects may become hard Twitching Slurred or difficult to understand speech Limb weakness Advanced stage: Weakness in the muscles, in [newhealthadvisor.com]

  However, continued progression of limb weakness following surgical correction argues against its contribution to the patient's symptoms. Therefore, we suggest that motor neuron disease could be one of the presenting features of HD. [jamanetwork.com]

• Tremor

  Clinical examination revealed postural tremor at the right hand, mild tongue atrophy with diffuse fasciculations and brisk tendon reflexes without other muscular weakness or atrophies. [ncbi.nlm.nih.gov]

  Symptoms may include hypotonia (severely reduced muscle tone), diminished limb movements, lack of tendon reflexes, fasciculations, tremors, swallowing and feeding difficulties, and impaired breathing. [web.archive.org]

• Hyperreflexia

  We report a 13-year-old Hispanic boy with rapidly progressive weakness, muscle atrophy, tremor, and tongue fasciculation, along with upper motor neuron findings of hyperactive gag reflex, hyperreflexia, and cog-wheel rigidity. [ncbi.nlm.nih.gov]

  Clinical manifestations include progressive weakness, atrophy, fasciculation, hyperreflexia, dysarthria, dysphagia, and eventual paralysis of respiratory function. [icd9data.com]

  Fasciculations, hyperreflexia, fatigue, stiff movement and weight loss are common manifestations. As the disease goes on, chewing, swallowing and speech issues appear, together with increased salivation and involuntary emotional outbursts. [symptoma.com]

  Lower motor neuron (LMN) findings include muscle atrophy and fasciculations, and upper motor neuron (UMN) findings include hyperreflexia, spasticity, muscle spasm, and abnormal reflexes.Pure upper motor neuron diseases, or those with just UMN findings [en.wikipedia.org]

To make the diagnosis of a MND, the following diagnostic criteria should be fulfilled [3]:

• Evidence of LMN injury on electromyography (EMG studies)
• Evidence of UMN injury on electromyography
• Marked progression of symptoms within a specific region
• Absence of EMG findings and brain MRI that suggest other causes of symptoms.

Prior exclusion of various more common and possibly treatable conditions should be made. Infectious diseases, such as Lyme disease, hepatitis C and neurosyphilis should be excluded by appropriate serological testing, while myasthenia gravis, dermatomyositis, lead poisoning, multiple sclerosis, disorders of the thyroid and adrenal gland and spinal muscular atrophy are some of the conditions that may present with similar symptoms [1] [3]. To exclude these conditions, a complete blood count, serum and urine protein immunofixation, levels of electrolytes and creatine kinase, while a lumbar puncture may be useful as well, especially if the presence of leukocytes is established. The cornerstone, however, is EMG studies together with MRI, which may reveal the presence of typical changes in nerve conduction and potential presence of tumors or other structures that may be responsible for the development of symptoms, respectively.

There is no cure for MNDs and the focus of treatment currently remains on supportive measures. A multidisciplinary approach is necessary to manage neurological, respiratory and psychiatric symptoms [2]. Baclofen may be effectively used for management of spasticity, while anticholinergic drugs may be given to reduce excessive salivation. Antidepressants such as amitriptyline and other serotonin-selective reuptake inhibitors [2]. Since the majority of patients die of respiratory failure, ensuring adequate ventilation is key in prolonging the patient's life for at least some time. Riluzole is a drug that has shown to prolong survival rate in patients with ALS due to its antagonistic effects to glutamate, but only for a few months.

The prognosis for virtually all forms of MNDs are very poor, as these conditions are universally fatal. In the case of ALS, 5-year survival rates are 20% and 10-year survival rates are 10% [11], while studies show a median survival rate of approximately 4 years [12]. Progressive bulbar palsy is fatal within 1-3 years in the vast majority of patients, as dysphagia becomes intolerable and various respiratory complications occur, but progressive muscular atrophy has a somewhat better prognosis, since patients can reach up to 25 years [1]. Primary lateral sclerosis results in total disability within several years, indicating that these conditions present as a significant burden to patients and their families.

It is hypothesized that a combination of genetic and environmental factors contribute to development of MNDs [2]. The majority of cases are sporadic, meaning that mutations develop de novo, but approximately 10% of cases are familial. Familial MND is considered to be transmitted by autosomal dominant pattern of inheritance and in approximately 20% of patients, SOD mutations have been observed [3]. Additionally, mutations of various genes and compounds, including TDP43, FUS, angiogenin, dynactin, vesicle-associated membrane-protein and several other have been documented [2]. On the other hand, sporadic forms have shown a strong association with alterations in vascular endothelial growth factor and apolipoprotein A4 [6]. The exact events that lead to progressive neuronal death, however, require further studies.

Incidence and prevalence rates currently rely on isolated studies that reflect the overall burden of the disease. In the United Kingdom, studies have established that prevalence rates of ALS, progressive muscular atrophy and primary lateral sclerosis combined are approximately 6 per 100,000 individuals, with an incidence rate of 1-2 per 100,000 [3]. Similar reports are seen in Italy and Canada, where a crude incidence rate of 2.5 per 100 000 has been established [7] [8]. When looking at ALS alone, studies report an annual incidence rate of 1.5-2.5 per 100,000 [9]. MNDs are slightly more frequent among males and the onset is usually after 50 years [1]. Risk factors are currently unknown, but smoking has shown to be one of the most prominent candidates for sporadic ALS [10].

Changes observed in MNDs invariably include pathological events in both UMNs and LMNs. Lower motor neurons include the cells in the anterior horn of the spinal cord and motor nuclei of certain cranial nerves, while upper motor neurons constitute the motor cortex and the corticospinal and corticobulbar tract. Although the exact pathophysiological mechanisms of disease are not understood, damage of nervous tissue occurs via several mechanisms. Oxidative stress, as a result of SOD mutations, excessive stimulation of NMDA receptors by glutamate in the CNS, mitochondrial injury, as well as intracellular protein and filament aggregation have all been observed in both human and animal models [2]. The end-result is apoptosis and progressive, irreversible death of neuronal cells which significantly impairs normal signal conduction throughout the body. In the setting of LMN damage, hyporeflexia, atrophy, decreased muscle tone and fasciculations develop, while diseases that affect UMNs cause spasticity, increased muscle tone, hyperreflexia and atrophy in later stages of disease, but fasciculations are absent [1].

Current prevention strategies do no exist, as the exact pathophysiologic basis of these disease remain unknown. Having in the fact that these conditions are managed by supportive measures only, little can be done regarding prevention and treatment.

Motor neuron disease (MND) is a term that comprises several neurodegenerative disorders - amyotrophic lateral sclerosis (ALS), primary lateral sclerosis (PCS), progressive bulbar palsy, progressive pseudobulbar palsy and progressive muscular atrophy, although ALS is most extensively studied [1]. ALS (also known as Lou Gehrig's disease) is the most common MND, with an approximate incidence of 1.5 per 100 000 individuals. The sixth and seventh decade of life is the period of most frequent onset [2]. The hallmark of all MNDs is progressive degeneration of upper and lower motor neurons (UMN and LMN, respectively), depending on the subtype. The cause remains unknown. The majority of MNDs develop sporadically, but up to 10% of cases are classified into familial forms and their clinical presentation is identical [3]. Several mutations have been described, such as genes encoding superoxide dismutase (SOD), one of the main enzymes involved in suppressing free-radical injury, certain RNA-binding proteins such as FUS/TLS and TDP43, whereas alterations in promoter genes, angiogenin, apolipoprotein E4 and several other have been established as well [4] [5]. Although the etiology of MNDs are not known, nerve damage is thought to be a result of several pathophysiological changes. In addition to oxidative stress, excessive glutamate stimulation that leads to neuronal death and aggregation of proteins and neurofilaments that are supposedly toxic to cells leads to apoptosis and cell death [2]. As a result of these changes, progressive degeneration of neuronal tissue is observed in patients suffering from MNDs and gives rise to the appearance of symptoms that may involve both lower and upper motor neurons. The clinical presentation somewhat varies depending on the subtype of MND, but weakness and muscle atrophy are usually seen in all disorders. A progressive deterioration of nervous system occurs, as weakness and atrophy eventually affect all limbs, together with the onset of fasciculations, dysphagia, dysarthria, hoarseness and excessive salivation [1]. Pseudobulbar affects are commonly observed and are characterized by excessive laughter, yawning and crying [2]. In the setting of ALS, a distinguishing feature from other disorders is the fact that the senses, urinary sphincters, oculomotor nerve functions and cognition are almost always spared, for unknown reasons. Making the diagnosis of MND is difficult, as there are no specific diagnostic tests, but also because numerous conditions may present with similar symptoms. Myasthenia gravis, polymyositis, Lyme disease and many other have to be excluded in the workup [1]. Electromyography, magnetic resonance imaging, serum and urine protein electrophoresis and genetic testing, as well as numerous other tests to exclude other conditions, should be included in the diagnostic protocol. Treatment rests on supportive measures, as there is no cure for neither of MNDs and is primarily aimed at ensuring adequate respiratory function and acceptable everyday life. The overall prognosis of patients with MND is quite poor, as these disorders are universally fatal. 3-year survival rate for ALS is 50% after onset, progressive bulbar palsy is universally fatal within 1-3 years, while patients suffering from progressive muscular atrophy may live up to 25 years [1].

Motor neuron disease (MND) is a term that encompasses several neurodegenerative disorders that affect the nerves that are responsible for innervation of muscles and various other structures in the central nervous system. Amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease) is the most common MND, occurring in approximately 2 per 100,000 individuals, while progressive bulbar palsy, progressive pseudobulbar palsy, primary lateral sclerosis and progressive muscular atrophy are other subtypes. Their cause remains unknown, but it is hypothesized that a combination of various genetic factors is responsible for the development of these diseases. Namely, mutations in enzymes that are responsible for fighting free radicals, superoxide dismutase (SOD), have been identified in a significant number of patients, while alterations in several other genes have been documented. Moreover, approximately 10% of all MNDs are familial, meaning that some inherited factors may also play a role. Risk factors are currently not established, but some studies have associated smoking and MNDs. These disease are slightly more commonly encountered in males and their onset is usually between 50-70 years. Patients may present with diverse symptoms, the most prominent being muscle weakness and atrophy. Because these diseases are progressive in nature, gradual worsening of symptoms and appearance of various other complaints is the usual clinical course. Main neurological symptoms include either diminished or increased reflexes and abnormal muscle tone, while difficulties chewing, eating, talking, as well as voice changes and clumsiness are all frequently observed in patients. In some MNDs, such as progressive bulbar palsy, significant emotional reactions may be observed, such as intense involuntary crying or laughing. To make the diagnosis, it is necessary to perform electromyography, a procedure that evaluates nerve conduction signaling, but various other conditions that may present with similar symptoms have to be excluded. Myasthenia gravis, syphilis, hepatitis C, Lyme disease, lead poisoning, diseases of the thyroid gland and many other may mimic MNDs, which is why a thorough diagnostic workup is necessary, often including various laboratory studies and magnetic resonance imaging (MRI) of the head. Treatment, unfortunately, is focused on supportive measures, as there is no cure for these universally fatal diseases. The prognosis of MNDs are very poor and all subtypes eventually lead to fatal outcomes. Approximately 50% of patients suffering from ALS die within 3 years, whereas the majority of patients with progressive bulbar palsy die within 1-3 years after the onset of symptoms. A somewhat better prognosis is seen in progressive muscular atrophy, where patients live up to 25 years. Overall, MNDs cause a rapidly progressive deterioration of the nervous system that always leads to fatal outcomes.

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