*2.2.6 Neurological examination*

During physical examination, the characteristics of the apparent neuromuscular disease can indicate OSA and hypoventilation. For example, progressive muscular atrophy and hand or tongue fasciculations can indicate amyotrophic lateral sclerosis. In amyotrophic lateral sclerosis, phrenic nerve dysfunction is common; during rapid eye movement sleep (REM) it leads to diaphragmatic paralysis due to significant hypoventilation. Furthermore, coexisting OSA can reveal itself during amyotrophic lateral sclerosis with bulbar involvement. In poliomyelitis, there is weakness of thoracoabdominal muscles and accessory muscles of respiration; this can frequently be accompanied with kyphoscoliosis. Postpolio syndrome demonstrated itself with muscular dystrophies; myasthenia gravis and metabolic myopathies exhibit themselves with weaknesses of chest wall muscles and the diaphragm. Myasthenia gravis can as well involve facial structures resulting in OSA. In myotonic dystrophy or muscular dystrophy, there can be craniofacial abnormalities; macroglossia can also be seen (e.g., in Duchenne muscular dystrophy). Lastly, obesity (e.g., steroid use or inactivity) and being overweight can contribute to sleep apnea during the course of a neuromuscular disease [23, 24].
