Enzimas séricas e eletromiografia em doenças Neuromusculares: estudo comparativo de 817 casos

Werneck, Lineu Cesar

doi:10.1590/S0004-282X1995000200001

Resumos

Foram estudadas as enzimas séricas (creatinaquinase, desidrogenase láctica, aldolase, aspartato e alanina aminotransferase) de 817 pacientes e eletromiografias (EMG) de 588 casos de portadores de doenças neuromusculares. As enzimas e as EMG foram relacionadas utilizando testes de estatística descritiva e do qui-quadrado. Foi encontrado aumento importante das enzimas séricas relacionadas com EMG de padrão miopático (mais importante com a creatinaquinase, seguido da aldolase, desidrogenase láctica, aspartato aminotransferase e alanina aminotransferase), e, inversamente, normalidade ou discreto aumento nas EMG normais ou com padrão de desinervação. As EMG com padrões de desinervação não têm qualquer relação com a elevação das enzimas séricas.

enzimas séricas; eletromiografia; doenças neuromusculares

This study reports the relationship of the serum enzymes (creatinekinase 817 cases, lactic dehydrogenase 784 cases, aldolase 718 cases, aspartate aminotransferase 767 cases and alanine aminotransferase 760 cases) and electromyography (EMG) of 588 cases (20 normal, 299 with myopathic pattern, 209 with denervation and 69 with neuromyopathic pattern) in several neuromuscular disorders. The relationships were studied using descriptive statistic and chi-square tests. It was found a statistical significance with the increased serum enzyme level with the myopathic EMG pattern and an inverse relationship with the denervation EMG. This relation was more important with the creatinekinase, following aldolase and lactic dehydrogenase. The EMG denervation pattern did not have any relation with serum enzyme levels.

serum enzyme; electromyography; neuromuscular disorders

Enzimas séricas e eletromiografia em doenças Neuromusculares: estudo comparativo de 817 casos

Serum enzyme and electromyography in Neuromuscular disorders: a correlation study of 817 cases

Lineu Cesar Werneck

Professor Titular de Neurologia

RESUMO

Foram estudadas as enzimas séricas (creatinaquinase, desidrogenase láctica, aldolase, aspartato e alanina aminotransferase) de 817 pacientes e eletromiografias (EMG) de 588 casos de portadores de doenças neuromusculares. As enzimas e as EMG foram relacionadas utilizando testes de estatística descritiva e do qui-quadrado. Foi encontrado aumento importante das enzimas séricas relacionadas com EMG de padrão miopático (mais importante com a creatinaquinase, seguido da aldolase, desidrogenase láctica, aspartato aminotransferase e alanina aminotransferase), e, inversamente, normalidade ou discreto aumento nas EMG normais ou com padrão de desinervação. As EMG com padrões de desinervação não têm qualquer relação com a elevação das enzimas séricas.

Palavras chaves: enzimas séricas, eletromiografia, doenças neuromusculares

SUMMARY

This study reports the relationship of the serum enzymes (creatinekinase 817 cases, lactic dehydrogenase 784 cases, aldolase 718 cases, aspartate aminotransferase 767 cases and alanine aminotransferase 760 cases) and electromyography (EMG) of 588 cases (20 normal, 299 with myopathic pattern, 209 with denervation and 69 with neuromyopathic pattern) in several neuromuscular disorders. The relationships were studied using descriptive statistic and chi-square tests. It was found a statistical significance with the increased serum enzyme level with the myopathic EMG pattern and an inverse relationship with the denervation EMG. This relation was more important with the creatinekinase, following aldolase and lactic dehydrogenase. The EMG denervation pattern did not have any relation with serum enzyme levels.

Key words:serum enzyme, electromyography, neuromuscular disorders.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Aceite: 25 - novembro - 1994.

Trabalho realizado no Serviço de Doenças Neuromusculares da Especialidade de Neurologia do Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná (UFPR), Curitiba, PR:

Dr. Lineu César Werneck - Serviço de Doenças Neuromusculares, Especialidade de Neurologia, Hospital de Clínicas, UFPR - Rua General Carneiro, 181 - 80069-155 Curitiba PR - Brasil

1. Amador E, Dorfman LE, Wacker WEC. Serum lactic dehydrogenase activity: an analytical assessment of current assays. Clin Chem 1963, 9:391-399.
2. Black JT, Bhatt GP, DeJesus PV, Schotland DL, Rowland LP. Diagnostic accuracy of clinical data, quantitative electromyography and histochemistry in neuromuscular diseases. J Neurol Sci 1974, 21:59-70.
3. Blanton PL, Lehr RP, Martin JH, Biggs NL. Further observations on the histologic response of rat skeletal muscle to EMG fine wire-electrodes: significance of insulation. Electromyography (Louvain) 1971, 11:475-478.
4. Blanton PL, Lehr RP, Moreland JE, Biggs NL. Observation on the histological response of rat skeletal muscle to EMG indwelling wire electrodes. Electromyography (Louvain) 1971, 11:465-478.
5. Bodensteiner JB, Engel AG. Intracellular calcium accumulation in Duchenne dystrophy and other myopathies: a study of 567,000 muscle fibers in 114 biopsies. Neurology 1976, 28:439-446.
6. Brusa A, Loeb C, Moretti G, Sacco G. A comparison of histologic and electromyographic findings in various neuromuscular disorders. Neurology 1963, 13:630-640.
7. Buchthal F. An introduction to electromyography. Gyldendal-Kobenhavn: Scandinavian University Books, 1957.
8. Bichthal F. The electromyogram: its value in the diagnosis of neuromuscular disorders. World Neurol 1962, 3:16-34.
9. Buchthal F, Clemmesen S. On the differentiation of muscle atrophy by electromyography. Acta Psychiatr Neurol 1941, 16:143-181.
10. Buchthal F, Kamieniecka Z. The diagnostic yield of quantified electromyography and quantified muscle biopsy in neuromuscular disorders. Muscle & Nerve 1982, 5:265-280.
11. Castaigne P, Cathala DP, Rouques C, Beaussart-Boulenge L, Dannane P, Jarnot N. Confrontation de données electromyographiques et histoenzymologiques musculaires en pathologie neuro-musculaire humaine. Rev Neurol (Paris) 1974, 130:5-19.
12. Chappel JB, Perry SV. Creatine phosphokinase: assay and application for the micro-determination of the "adenine nucleotides. Biochem J 1954, 57:421-427.
13. Cherrington ME, Lewin E, McCrimmon A. Serum creatine phosphokinase changes following needle electromyographic studies. Neurology 1968, 18:271-272.
14. Chrissian SA, Stolov WC, Hongladarom T. Needle elctromyography: its effect on serum creatine phosphokinase activity. Arch Phys Med Rehabil 1976, 57:114-119.
15. Colton T. Statistics in medicine. Boston: Little, Brown, 1974.
16. Danowski TS, Sabeh G, Vester JW, Alley RA, Robbins TJ, Tsai CT, Pazirandeh M, Sekaran K. Serum CPK in muscular dystrophy and myotonia dystrophica. Metabolism 1968, 17:808-817.
17. Dawson DM. Leakage of enzyme from denervated and dystrophic chicken muscle. Arch Neurol 1966, 14:321-325.
18. Drachman DB, Murphy SR, Nigam MP, Hills Jr. "Myopatic" changes in chronically denervated muscle. Arch Neurol 1967, 16:14-24.
19. Ebashi S, Toyokura Y, Momoi H, Sugita H. High creatine phosphokinase activity of sera with progressive muscular dystrophy. J Biochem (Tokyo) 1959, 46:103-104.
20. Engel AG, Yamamoto M, Fischbeck KH. Dystrophinopathies. In Engel AG, Franzini-Armstrong. Myology: basic and clinical. New York: McGraw-Hill 1994.
21. Engel WK. Focal myopathic changes produced by electromyographic and hypodermic needles, "needle myopathy". Arch Neurol 1967, 16:509-511.
22. Fowler WM, Pearson CM. Diagnostic and prognostic significance of serum enzymes: 1. Muscular dystrophy. Arch Phys Med Rehabil 1964, 45:117-124.
23. Goodgold J, Eberstein A. Electrodiagnosis of neuromuscular diseases. Baltimore: Williams & Wilkins, 1977.
24. Hausmanowa-Petrusewicz I, Emeryk B, Wasowicz B, Kopec A. Electromyography in neuro-muscular diagnostics. Electromyography (Louvain) 1967, 7:203-225.
25. Hausmanowa-Petrusewicz I, Jedrzejowska H. Correlation between electromyographic findings and muscle biopsy in cases of neuromuscular disease. J Neurol Sci 1971, 13:85-106.
26. Heick H, Laudhan G. Diagnóstico diferencial das distrofias musculares com referência especial às alterações enzimáticas. Arq Neuropsiquiatr 1967, 25:71- 86.
27. Hess JH, MacDonald RP, Frederick RJ, Jones RN, Neely J, Gross D. Serum creatine phosphokinase (CPK) activity in disorders of heart and skeletal muscle. Ann Intern Med 1964, 61:1015-1028.
28. Hughes BP. Serum enzymes changes in muscle disease and their relation to tissue change. Proc R Soc Med 1963, 56:179- 182.
29. Humphry JG, Shy GM. Diagnostic electromyography. Arch Neurol 1962,6: 339-352.
30. Kimural J. Electrodiagnosis in diseases of nerve and muscle: principles and practice. Philadelphia: F.A.Davis, 1989.
31. Levy JA. Classificação das miopatias. In Levy JA(ed). Doenças musculares: estudo clínico e diagnóstico. São Paulo: Atheneu, 1984.
32. Mayens E, Pitner SR. Effect of electromyography on CPK and aldolase levels. Arch Neurol 1968, 19:538-539.
33. McCrimmon A, Lewin E. Serum creatine phosphokinase: a useful tool in muscle disease. Am J Med Technol 1967, 33:269- 274.
34. Mokri B, Engel AG. Duchenne dystrophy: electron microscopic Findings pointing to a basic or early abnormality in the plasma membrane of the muscle fiber. Neurology 1975, 25:1111-1120.
35. Munsat TL, Baloh R, Pearson CM, Fowler W Jr. Serum enzyme alterations in neuromuscular disorders. JAMA 1973, 226:1536-1543.
36. Nichol CJ. Serum creatine phosphokinase measurements in muscular dystrophy studies. Clin Chim Acta 1965, 11:404- 407.
37. Niebrój-Dobosz I, Jedrzejowska H, Hetnarska L. Blood enzymes in Duchenne's progressive muscular dystrophy and their correlation with the clinical and histological pictures. Acta Med Pol (Warszawa) 1970, 11:387-393.
38. Okinaka S, Kumagai H, Ebashi S, Sugitah, Momoi H, Toyokura Y, Fujie Y. Serum creatine phosphokinase. Arch Neurol 1961, 4:520-525.
39. Paakkari I, Mumenthaler M. Needle myopathy: an experimental study. J Neurol (Berlin) 1974, 208:133-138.
40. Pearce JMS, Pennington RJ, Walton JN. Serum enzyme studies in muscle disease: II. Serum creatine kinase activity in muscular dystrophy and in other myopathic and neuropathic disorders. J Neurol Neurosurg Psychiatry 1964, 27:96-99.
41. Pennington RJT. Biochemical aspects of muscle disease. In Walton J. Disorders of voluntary muscle.Edinburgh: Churchill Livingstone, 1981.
42. Percy ME, Thompson MW. - Creatine kinase - "No phospho-, please!". Muscle & Nerve 1981, 4:271.
43. Sandstedt PER. Effects of a previous eletromyographic examination studied by frequency analysis, muscle biopsy and creatine kinase. Acta Neurol Scand 1981, 64:303-309.
44. Schwartz RA, Archibald KC, Hagstrom JWC. Correlative findings by electromyography and muscle biopsy in neuromuscular disorders. Arch Phys Med Rehabil 1966, 47:653-658.
45. Shaw RF, Pearson CM, Chowdhury SR, Dreifus FE. Serum enzymes in sex-linked (Duchenne) muscular dystrophy. Arch Neurol 1967, 16:115-122.
46. Siegell S. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill, 1956.
47. Singh RS, Agrawal SP, Dikshit SK. Study of creatine phosphokinase, lactic dehydrogenase and transaminases in neuromuscular diseases. Indian J Pediatr (New Delhi) 1973, 40:35-38.
48. Stryer L. Biochemistry. New York: W.H.Freeman, 1988.
49. Swaiman KF, Sandler B. The use of serum creatine phosphokinase and other enzymes in the diagnosis of progressive muscular dystrophy. J Pediatr 1963, 63:1116- 1119.
50. Takahashi K, Kameyama M. Electromyography and histopathology of muscle and spinal cord: analysis of 105 skeletal muscle from 31 autopsy cases. J Neurol Sci 1972, 16:465-479.
51. Tanzier ML, GilvargI C. Creatine and creatine kinase measurement. J Biol Chem 1959, 234:3201-3204.
52. The Committee on Enzyme of the Scandinavian Society for Clinical Chemistry and Clinical Physiology. Recommended methods for the determination of four enzymes in blood. Scand J Clin Lab Invest 1974, 33:291-300.
53. The Committee on Enzyme of the Scandinavian Society for Clinical Chemistry and Clinical Physiology. Recommended methods for the determination of creatine kinase in blood. Scand J Clin Lab Invest 1974, 36:711-723.
54. Vassela F, Richtterich R, Rossi E. The diagnostic value of serum creatinekinase in neuromuscular and muscular disease. Pediatrics 1965, 35:322-330.
55. Walton JN. Clinical examination of the neuromuscular system. In Walton JN. Disorders of voluntary muscle. Ed.4. Edinburgh: Churchill Livingstone, 1981.
56. Warmolts JR, Engel WK. Open-biopsy electromyography: I.Correlation of motor unit behavior with histochemical muscle fiber type in human limb muscle. Arch Neurol 1972, 27:512-517.
57. Wemeck LC. Estudo comparativo entre biópsias musculares e eletromiografias. Tese (Doutorado), Escola Paulista de Medicina. São Paulo, 1985.
58. Werneck LC , Lima JGC. Muscle biopsy correlated with electromyography: study of 100 cases. Arq Neuropsiquiatr 1988, 46:156-165.
59. Werneck LC, Lima JGC, Koehler H. Correlation between specific histological and electromyographic findings in neuromuscular disorders. Arq Neuropsiquiatr 1988, 46:264-271.
60. Zatz M, Shapiro LJ, Campion DS, Oda E, Kaback MM. Serum pyruvate-kinase (PK) and creatine-phosphokinase (CPK) in progressive muscular dystrophies. J Neurol Sci 1978, 36:349-362.

Datas de Publicação

Publicação nesta coleção
20 Jan 2011
Data do Fascículo
Jun 1995

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Amador E, Dorfman LE, Wacker WEC. Serum lactic dehydrogenase activity: an analytical assessment of current assays. Clin Chem 1963, 9:391-399.

[2] 2. Black JT, Bhatt GP, DeJesus PV, Schotland DL, Rowland LP. Diagnostic accuracy of clinical data, quantitative electromyography and histochemistry in neuromuscular diseases. J Neurol Sci 1974, 21:59-70.

[3] 3. Blanton PL, Lehr RP, Martin JH, Biggs NL. Further observations on the histologic response of rat skeletal muscle to EMG fine wire-electrodes: significance of insulation. Electromyography (Louvain) 1971, 11:475-478.

[4] 4. Blanton PL, Lehr RP, Moreland JE, Biggs NL. Observation on the histological response of rat skeletal muscle to EMG indwelling wire electrodes. Electromyography (Louvain) 1971, 11:465-478.

[5] 5. Bodensteiner JB, Engel AG. Intracellular calcium accumulation in Duchenne dystrophy and other myopathies: a study of 567,000 muscle fibers in 114 biopsies. Neurology 1976, 28:439-446.

[6] 6. Brusa A, Loeb C, Moretti G, Sacco G. A comparison of histologic and electromyographic findings in various neuromuscular disorders. Neurology 1963, 13:630-640.

[7] 7. Buchthal F. An introduction to electromyography. Gyldendal-Kobenhavn: Scandinavian University Books, 1957.

[8] 8. Bichthal F. The electromyogram: its value in the diagnosis of neuromuscular disorders. World Neurol 1962, 3:16-34.

[9] 9. Buchthal F, Clemmesen S. On the differentiation of muscle atrophy by electromyography. Acta Psychiatr Neurol 1941, 16:143-181.

[10] 10. Buchthal F, Kamieniecka Z. The diagnostic yield of quantified electromyography and quantified muscle biopsy in neuromuscular disorders. Muscle & Nerve 1982, 5:265-280.

[11] 11. Castaigne P, Cathala DP, Rouques C, Beaussart-Boulenge L, Dannane P, Jarnot N. Confrontation de données electromyographiques et histoenzymologiques musculaires en pathologie neuro-musculaire humaine. Rev Neurol (Paris) 1974, 130:5-19.

[12] 12. Chappel JB, Perry SV. Creatine phosphokinase: assay and application for the micro-determination of the "adenine nucleotides. Biochem J 1954, 57:421-427.

[13] 13. Cherrington ME, Lewin E, McCrimmon A. Serum creatine phosphokinase changes following needle electromyographic studies. Neurology 1968, 18:271-272.

[14] 14. Chrissian SA, Stolov WC, Hongladarom T. Needle elctromyography: its effect on serum creatine phosphokinase activity. Arch Phys Med Rehabil 1976, 57:114-119.

[15] 15. Colton T. Statistics in medicine. Boston: Little, Brown, 1974.

[16] 16. Danowski TS, Sabeh G, Vester JW, Alley RA, Robbins TJ, Tsai CT, Pazirandeh M, Sekaran K. Serum CPK in muscular dystrophy and myotonia dystrophica. Metabolism 1968, 17:808-817.

[17] 17. Dawson DM. Leakage of enzyme from denervated and dystrophic chicken muscle. Arch Neurol 1966, 14:321-325.

[18] 18. Drachman DB, Murphy SR, Nigam MP, Hills Jr. "Myopatic" changes in chronically denervated muscle. Arch Neurol 1967, 16:14-24.

[19] 19. Ebashi S, Toyokura Y, Momoi H, Sugita H. High creatine phosphokinase activity of sera with progressive muscular dystrophy. J Biochem (Tokyo) 1959, 46:103-104.

[20] 20. Engel AG, Yamamoto M, Fischbeck KH. Dystrophinopathies. In Engel AG, Franzini-Armstrong. Myology: basic and clinical. New York: McGraw-Hill 1994.

[21] 21. Engel WK. Focal myopathic changes produced by electromyographic and hypodermic needles, "needle myopathy". Arch Neurol 1967, 16:509-511.

[22] 22. Fowler WM, Pearson CM. Diagnostic and prognostic significance of serum enzymes: 1. Muscular dystrophy. Arch Phys Med Rehabil 1964, 45:117-124.

[23] 23. Goodgold J, Eberstein A. Electrodiagnosis of neuromuscular diseases. Baltimore: Williams & Wilkins, 1977.

[24] 24. Hausmanowa-Petrusewicz I, Emeryk B, Wasowicz B, Kopec A. Electromyography in neuro-muscular diagnostics. Electromyography (Louvain) 1967, 7:203-225.

[25] 25. Hausmanowa-Petrusewicz I, Jedrzejowska H. Correlation between electromyographic findings and muscle biopsy in cases of neuromuscular disease. J Neurol Sci 1971, 13:85-106.

[26] 26. Heick H, Laudhan G. Diagnóstico diferencial das distrofias musculares com referência especial às alterações enzimáticas. Arq Neuropsiquiatr 1967, 25:71- 86.

[27] 27. Hess JH, MacDonald RP, Frederick RJ, Jones RN, Neely J, Gross D. Serum creatine phosphokinase (CPK) activity in disorders of heart and skeletal muscle. Ann Intern Med 1964, 61:1015-1028.

[28] 28. Hughes BP. Serum enzymes changes in muscle disease and their relation to tissue change. Proc R Soc Med 1963, 56:179- 182.

[29] 29. Humphry JG, Shy GM. Diagnostic electromyography. Arch Neurol 1962,6: 339-352.

[30] 30. Kimural J. Electrodiagnosis in diseases of nerve and muscle: principles and practice. Philadelphia: F.A.Davis, 1989.

[31] 31. Levy JA. Classificação das miopatias. In Levy JA(ed). Doenças musculares: estudo clínico e diagnóstico. São Paulo: Atheneu, 1984.

[32] 32. Mayens E, Pitner SR. Effect of electromyography on CPK and aldolase levels. Arch Neurol 1968, 19:538-539.

[33] 33. McCrimmon A, Lewin E. Serum creatine phosphokinase: a useful tool in muscle disease. Am J Med Technol 1967, 33:269- 274.

[34] 34. Mokri B, Engel AG. Duchenne dystrophy: electron microscopic Findings pointing to a basic or early abnormality in the plasma membrane of the muscle fiber. Neurology 1975, 25:1111-1120.

[35] 35. Munsat TL, Baloh R, Pearson CM, Fowler W Jr. Serum enzyme alterations in neuromuscular disorders. JAMA 1973, 226:1536-1543.

[36] 36. Nichol CJ. Serum creatine phosphokinase measurements in muscular dystrophy studies. Clin Chim Acta 1965, 11:404- 407.

[37] 37. Niebrój-Dobosz I, Jedrzejowska H, Hetnarska L. Blood enzymes in Duchenne's progressive muscular dystrophy and their correlation with the clinical and histological pictures. Acta Med Pol (Warszawa) 1970, 11:387-393.

[38] 38. Okinaka S, Kumagai H, Ebashi S, Sugitah, Momoi H, Toyokura Y, Fujie Y. Serum creatine phosphokinase. Arch Neurol 1961, 4:520-525.

[39] 39. Paakkari I, Mumenthaler M. Needle myopathy: an experimental study. J Neurol (Berlin) 1974, 208:133-138.

[40] 40. Pearce JMS, Pennington RJ, Walton JN. Serum enzyme studies in muscle disease: II. Serum creatine kinase activity in muscular dystrophy and in other myopathic and neuropathic disorders. J Neurol Neurosurg Psychiatry 1964, 27:96-99.

[41] 41. Pennington RJT. Biochemical aspects of muscle disease. In Walton J. Disorders of voluntary muscle.Edinburgh: Churchill Livingstone, 1981.

[42] 42. Percy ME, Thompson MW. - Creatine kinase - "No phospho-, please!". Muscle & Nerve 1981, 4:271.

[43] 43. Sandstedt PER. Effects of a previous eletromyographic examination studied by frequency analysis, muscle biopsy and creatine kinase. Acta Neurol Scand 1981, 64:303-309.

[44] 44. Schwartz RA, Archibald KC, Hagstrom JWC. Correlative findings by electromyography and muscle biopsy in neuromuscular disorders. Arch Phys Med Rehabil 1966, 47:653-658.

[45] 45. Shaw RF, Pearson CM, Chowdhury SR, Dreifus FE. Serum enzymes in sex-linked (Duchenne) muscular dystrophy. Arch Neurol 1967, 16:115-122.

[46] 46. Siegell S. Nonparametric statistics for the behavioral sciences. New York: McGraw-Hill, 1956.

[47] 47. Singh RS, Agrawal SP, Dikshit SK. Study of creatine phosphokinase, lactic dehydrogenase and transaminases in neuromuscular diseases. Indian J Pediatr (New Delhi) 1973, 40:35-38.

[48] 48. Stryer L. Biochemistry. New York: W.H.Freeman, 1988.

[49] 49. Swaiman KF, Sandler B. The use of serum creatine phosphokinase and other enzymes in the diagnosis of progressive muscular dystrophy. J Pediatr 1963, 63:1116- 1119.

[50] 50. Takahashi K, Kameyama M. Electromyography and histopathology of muscle and spinal cord: analysis of 105 skeletal muscle from 31 autopsy cases. J Neurol Sci 1972, 16:465-479.

[51] 51. Tanzier ML, GilvargI C. Creatine and creatine kinase measurement. J Biol Chem 1959, 234:3201-3204.

[52] 52. The Committee on Enzyme of the Scandinavian Society for Clinical Chemistry and Clinical Physiology. Recommended methods for the determination of four enzymes in blood. Scand J Clin Lab Invest 1974, 33:291-300.

[53] 53. The Committee on Enzyme of the Scandinavian Society for Clinical Chemistry and Clinical Physiology. Recommended methods for the determination of creatine kinase in blood. Scand J Clin Lab Invest 1974, 36:711-723.

[54] 54. Vassela F, Richtterich R, Rossi E. The diagnostic value of serum creatinekinase in neuromuscular and muscular disease. Pediatrics 1965, 35:322-330.

[55] 55. Walton JN. Clinical examination of the neuromuscular system. In Walton JN. Disorders of voluntary muscle. Ed.4. Edinburgh: Churchill Livingstone, 1981.

[56] 56. Warmolts JR, Engel WK. Open-biopsy electromyography: I.Correlation of motor unit behavior with histochemical muscle fiber type in human limb muscle. Arch Neurol 1972, 27:512-517.

[57] 57. Wemeck LC. Estudo comparativo entre biópsias musculares e eletromiografias. Tese (Doutorado), Escola Paulista de Medicina. São Paulo, 1985.

[58] 58. Werneck LC , Lima JGC. Muscle biopsy correlated with electromyography: study of 100 cases. Arq Neuropsiquiatr 1988, 46:156-165.

[59] 59. Werneck LC, Lima JGC, Koehler H. Correlation between specific histological and electromyographic findings in neuromuscular disorders. Arq Neuropsiquiatr 1988, 46:264-271.

[60] 60. Zatz M, Shapiro LJ, Campion DS, Oda E, Kaback MM. Serum pyruvate-kinase (PK) and creatine-phosphokinase (CPK) in progressive muscular dystrophies. J Neurol Sci 1978, 36:349-362.