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Amyotroph Lateral Scler. 2010;11(1-2):67-75. doi: 10.3109/17482960903171128.

Prospective, blind study of the triple stimulation technique in the diagnosis of ALS.

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Radboud University Nijmegen Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Clinical Neurophysiology, Nijmegen, The Netherlands. <>



To evaluate the diagnostic yield of magnetic cortical stimulation with the triple stimulation technique (TST) to identify upper motor neuron (UMN) involvement in patients suspected of having ALS.


Fifty-nine patients were recruited to undergo TST in addition to the standard work-up for suspected motor neuron disease. TST combines transcranial magnetic stimulation of the motor cortex with collision studies, which results in a higher sensitivity in detecting UMN involvement. Primary outcome was the number of abnormal TST results in patients with possible ALS. The positivity rate was converted to the number needed to test with TST (NN-TST) for one extra diagnosis of ALS.


Fifty patients underwent TST. In the total group (n=59), 18 patients had a motor neuron disorder but did not fulfil criteria for 'probable' or 'definite' ALS. In four of these patients TST was abnormal (NN-TST, 4.5). One TST was erroneously interpreted as abnormal. TST findings were normal in inclusion body myositis and peripheral nerve disorders.


This prospective and blind study confirms open studies of TST in the evaluation of ALS. We suggest that TST can be used to arrive at a diagnosis of 'probable' or 'definite' ALS in patients lacking UMN signs in the upper extremities.

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