Repetitive nerve stimulation is a useful technique for evaluating neuromuscular transmission. In diseases in which such transmission is impaired, the muscle response to repetitive nerve stimulation may show abnormal alterations in size or area. In myasthenia gravis, a progressive decrement in the response may occur with repetitive stimulation (especially at 2 to 3 Hz), or an initial decrement may be followed by a leveling off of the response at a reduced size. Abnormalities are more likely to be found in proximal rather than distal limb muscles and in facial rather than limb muscles. Normal findings do not exclude the diagnosis. By contrast, in patients with Lambert-Eaton myasthenic syndrome or botulism, the response to a single stimulus is abnormally small and stimulation at a slow rate leads to a further reduction in response size; with rapid rates of stimulation, a progressive increase in size of the response occurs.
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