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Electromyography and Nerve

Conduction Studies
Updated: Aug 20, 2018
Author: Stephen Kishner, MD, MHA; Chief Editor: Jonathan P Miller, MD

Overview

Background
Electrodiagnostic testing encompasses a range of specialized tests, including nerve conduction studies (NCS) and needle
electromyography (EMG), that are used to evaluate the conduction of electrical impulses along peripheral nerves. These
tests should be considered and performed only after a careful history and physical examination, which are sometimes
sufficient to establish a diagnosis of neuromuscular dysfunction without further testing. However, in some cases, the subtlety
of sensory or motor deficits necessitates further workup for a conclusive diagnosis.[1]

Nerve conduction studies and needle EMG are commonly performed by physical medicine and rehabilitation or neurology
specialists to assess the ability of the nervous system to conduct electrical impulses and to evaluate nerve/muscle function
to determine if neuromuscular disease is present.

Nerve conduction studies

For this test, a series of surface electrodes are placed at different locations along specific peripheral nerves. The nerve is
stimulated at one site and recorded at a different site to determine if the nerve is conducting electrical impulses
appropriately.

Each electrical stimulation is recorded as a waveform on a computer and analyzed by the electromyographer performing the
test.[2]

Standard nerve conduction studies typically include motor nerve conduction, sensory nerve conduction, F waves, and H
reflexes.

Sensory and motor nerve conduction studies involve analysis of specific parameters, including latency, conduction velocity,
and amplitude. Onset latency is the time it takes for the stimulus to initiate an evoked potential and reflects the conduction
along the fastest fibers. Peak latency is the latency along the majority of axons and is measured at the peak amplitude.[3]
Both are affected by the state of the myelination of the nerve.

The conduction velocity along the nerve also depends on the state of myelination and is often decreased in disorders or
trauma that affects nerve myelination, although it may be normal if a few myelinated axons remain intact. Reduction of
amplitude of recorded responses generally indicates a loss of axons.[4]

These studies, in conjunction with the physical examination and correlation to a set of normative values, assist the
electromyographer in diagnosing a multitude of nerve disorders, including entrapment neuropathies, brachial plexopathies,
and polyneuropathies.

It is often important to distinguish between sensory and motor nerves, as certain disease processes can affect one or both.
Radiculopathy produces motor deficits but does not affect sensory nerves since the anatomic location of the damage is
proximal to the dorsal root ganglion. When a lesion is distal to the dorsal root ganglion, such as in brachial plexopathies,
both motor and sensory nerves are affected.

Sensory nerve conduction studies

Sensory nerve conduction studies are performed via stimulation of a nerve (ie, sufficient to produce an action potential) at
one point and measurement of the action potential at another point along the course of the nerve.[5] Peripheral sensory
nerves can be used to localize a lesion in relation to the dorsal root ganglion that contains the cell body of the nerve,
allowing differentiation of preganglionic disorders (eg, radiculopathies, cauda equina lesions, posterior column disease) from

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postganglionic disorders (eg, neuropathies, plexopathies). With a preganglionic lesion, the sensory nerve action potential is
normal (although clinically abnormal) because axonal transport from the cell body to the peripheral axon remains intact.[6]

Motor nerve conduction studies

In motor nerve conduction studies, motor nerves are stimulated and the compound muscle action potential from the muscle
is recorded. This corresponds to the integrity of the motor unit. Results of this study can be affected by any process that
damages the anterior horn cell body or axon, Schwann cells, the neuromuscular junction, or the muscle cell itself.[7] Also
analyzed are the size, shape, and morphology of the compound muscle action potential to determine the state of
myelination, the number of functioning muscle fibers, and the function of the neuromuscular junction. Since the cell body of
motor nerves is located in the anterior horn of the spinal cord, the motor nerve conduction is abnormal in both preganglionic
and postganglionic injuries.

Late responses

Distal nerve segments are relatively easy to analyze since they can be studied directly. To study proximal nerve segments,
late responses based on conduction along the proximal nerve are used. Late responses include F waves and H reflexes.

F waves

The F wave is a late response involving the motor axons that can be elicited in most upper and lower extremity muscles. A
stimulus is applied to a distal motor nerve that travels antidromically from the peripheral nerve, to the anterior horn cell, and
a response fires back down the motor neuron and is recorded as a muscle response that occurs after the compound muscle
action potential. F waves tend to have lower sensitivity for radiculopathy but can be useful in the assessment of
polyneuropathy.

H reflexes

The H reflex is basically an electrophysiologically recorded Achilles muscle stretch reflex. It is performed by stimulating the
tibial nerve in the popliteal fossa. From there, the stimulus goes proximally through the reflex arc at that spinal segment,
then distally from the anterior horn cell and the motor nerve. It can be recorded over the soleus or gastrocnemius muscles.
The H reflex is most commonly used to evaluate for an S1 radiculopathy or to distinguish from an L5 radiculopathy.

Needle EMG is used to assess both nerve and muscle function. A small-diameter monopolar pin or coaxial needle is placed
into a muscle to evaluate insertional activity, resting activity, voluntary recruitment, morphology, and size of motor units, as
well as motor unit recruitment. The needle electrode examination provides valuable information about the electrical
characteristics of individual muscle fibers and motor units, as well as the integrity and innervation of muscle fibers. This test
can be uncomfortable for the patient.

Insertional activity

Insertional activity is the electrical activity present as the electrode is passed through muscle cells. These are discharge
potentials provoked by the disruption of the cell membrane itself. Careful attention is given to the duration and amount of
electrical noise after each movement of the needle. This activity is decreased in atrophied muscle or fatty tissue.
Conversely, it is also increased in many abnormal conditions that cause membrane instability, such as neuropathies,
radiculopathies, and inflammatory myopathies.

Spontaneous activity at rest

Resting or spontaneous activity is the electrical activity present when the muscle is at rest and the electrode is not being
moved. This includes both normal and abnormal spontaneous activity.

Normal muscle should be silent after the needle is inserted; however, if the needle happens to be near the neuromuscular
junction, miniature endplate potentials or endplate potentials may be heard or seen. The most common abnormal
spontaneous activity is reported as a gradation of either positive sharp waves (PSWs) or fibrillation potentials on a scale of
1+ (transient but reproducible discharges) to 4+ (abundant spontaneous potentials).

Fibrillations result from motor axonal loss that is not balanced by reinnervation. Conditions that cause this include any nerve
disorder that affects the motor axon, inflammatory myopathies, and direct muscle injury. Depending on the amplitude of the
PSWs and/or fibrillation potentials, the electromyographer can determine how recently the injury to the nerve occurred. Low-
amplitude fibrillation potentials suggest that denervation occurred in the remote past, whereas high-amplitude fibrillation
potentials suggest an ongoing active denervation process.

Voluntary muscle recruitment

Recording of voluntary recruitment of motor unit action potentials can provide additional information. Reduced recruitment
signifies motor axonal loss or functional dropout due to focal demyelination or conduction block. By contrast, increased
recruitment with a small voluntary force can be seen with myopathy.

Interpretation

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The information gathered from needle EMG is combined with that provided by nerve conduction studies to determine the
overall interpretation. The results of the analysis of the collective studies often permits delineation of the type of underlying
pathologic process, such as a polyneuropathy, mononeuropathy or entrapment neuropathy, radiculopathy, plexopathy,
disordered neuromuscular transmission, or myopathic process. In many cases, one diagnosis explains the abnormalities
found on the study, but, occasionally, more than one diagnosis is necessary to complete the interpretation of the
electrodiagnostic findings.

Indications
EMG and nerve conduction studies are an extension of the physical examination. They can be useful in aiding in the
diagnosis of peripheral nerve and muscle problems. This can include peripheral neuropathies[8] , entrapment
neuropathies[9] , radiculopathies[10] , and muscle disorders.

Contraindications
Electrodiagnostic (EDX) studies should never be performed on patients with external wires like external pacing wires,
guidewires, and so on. Central lines are not a contraindication, but the contralateral limb should be used. Patients with
implanted cardiac pacemakers and cardioverter-defibrillators are not a contraindication to nerve conduction studies (NCS).
Several studies have shown no pacemaker inhibition during NCS, but there has been one reported case of pacemaker
failure due to peripheral nerve stimulation. There are no reported cases of implantable automatic cardioverter-defibrillators
(IACDs) being triggered by NCS. For patients with IACDs, stimulation should not be performed near the implanted device
and the contralateral extremity should be used when possible. Stimulation intensities should be kept under 1 Hz and pulse
width under 0.2 ms duration because, theoretically, it could be confused by the device as a QRS complex/cardiac rhythm.
Repetitive stimulation should also be avoided.

Patients with bleeding disorders or who are anticoagulated are not a contraindication to EMG. However, extra care should
be taken during the needle exam. There is a lack of official guidelines, but there are some general recommendations: the
smallest gauge needle available should be used, study should be limited to superficial muscles, avoid deep muscles that
could compress neurologic structures, and avoid muscles with large vasculature nearby.[11]

Common Nerve Conduction Study/Electromyography Findings

Radiculopathy

Radiculopathy is a pathologic process that affects nerves at the root level, often presenting as pure sensory complaints
since the sensory fibers are much larger and more easily injured, but sensorimotor or pure motor complaints are also
possible.[6] A pure sensory lesion will have negative EMG and sensory NCS results, even though the patient is experiencing
a clinical sensory deficit. Other possible findings include normal sensory nerve action potential (SNAP) and a compound
motor action potential (CMAP) that is normal to reduced.

An H reflex could be abnormal with an S1 radiculopathy, but F waves are neither sensitive nor specific for a radiculopathy.
EMGs show PSWs and fibrillation potentials in at least two different muscles innervated by two separate peripheral nerves
with the same root.

Chronology of radiculopathy findings

Upon injury to a nerve root, the patient may begin to report clinical symptoms immediately, but abnormalities in EMG/nerve
conduction studies do not appear right away.[3] Thus, although a physician may be tempted to obtain an EMG/nerve
conduction study, the electrodiagnostic evidence may be insufficient to confirm or exclude the diagnosis.

A few days after the injury, there may be decreased recruitment and prolonged late responses. After one week, there may
be decreased CMAP and some abnormal spontaneous activity in the paraspinals. At 2-3 weeks, abnormal spontaneous
activity may be seen in the limbs and paraspinals, and this is when an EMG/nerve conduction study is appropriate. Around
5-6 weeks, reinnervation begins, demonstrated by increased amplitude from the reinnervated motor unit.

Table 1. Findings of Nerve Conduction Studies and EMG in Carpal Tunnel Syndrome [1] (Open Table in a new window)

Severity of Carpal Needle EMG

Sensory Nerve Action Potential Compound Motor Action Potential
Tunnel Activity

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Mild Prolonged latency Normal Normal

Prolonged latency and decreased

Moderate Prolonged latency Normal
amplitude

Prolonged latency and decreased Abnormal

Severe Absent
amplitude activity

Table 2. Common Disorders [2] (Open Table in a new window)

Conduction Amplitude of the

Disorder Distal Motor Latency Distal Sensory Latency
Velocity Evoked Response

Motor neuron
Normal Normal Normal Reduced
disease

Axonal Slight
Normal Normal Reduced
polyneuropathy decrease

Demyelinating
Prolonged Prolonged Decreased Normal
polyneuropathy

Normal (may be prolonged Normal (May be prolonged Decreased May be decreased

Entrapment if this is a distal entrapment if this is a distal entrapment at the when stimulating
neuropathy such as carpal tunnel such as carpal tunnel entrapment proximal to the site
syndrome) syndrome) region of entrapment

Motor response
Radiculopathy Normal Normal Normal
may be decreased

Decreased motor
Myopathies Normal Normal Normal
amplitudes

Technical Considerations
Limb temperature is a very important factor during electrodagnostic studies. Skin temperature should be between 32º C and
34º C. During nerve conduction studies cooler temperatures can lead to prolonged distal latencies, slowed nerve conduction
velocities, increased amplitude, and increased duration potentials. Temperatures below 32º C can also lead to increased
duration, amplitude, and phases of motor unit action potentials during the needle study. Ideal limb temperature can be
maintained using warm water, heating lamp, warm packs, or hydrocollator.

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Age is another important factor to consider during electrodiagnostics. Young children have slower conduction velocities
because the process of myelination of peripheral nerves becomes completed between the ages of 3 and 5 years.
Additionally, conduction velocities begin to decrease after the age of 60 years at a rate of 0.5 to 4.0 m/s/decade.

Electrodiagnostic testing is very sensitive and can be subject to the electrical noise in the environment. Flourescent lights,
computers, fans, and so on that generate 60 Hz are common sources of electrical disturbance. To minimize this
interference, the examiner should ensure that skin is clean from dirt and oil, has sufficient electrode jelly, the electrodes are
firmly in contact with the skin, and that the ground is between the stimulator and recording electrodes.[12]

Periprocedural Care

Patient Education and Consent

Patient instructions

No patient preparation is necessary, but patients should remove their jewelry and avoid using any skin lotions on the day of
testing.

Consent

Verbal or written consent must be obtained from patient or caretaker if the patient lacks decision-making capacity.
Diagnostic purpose and benefits should be explained. The patient should also be informed about what to expect from
different components of the exam to help reduce anxiety that may occur. With EMG, there is a risk of minimal bleeding and
hematoma and the patient should disclose any bleeding disorders or use of anticoagulants. The patient should also disclose
whether they have implanted electrical devices such as pacemakers, defibrillators, AICDs, spinal cord stimulators, and so
on. There is minimal risk of infection from needle insertion and any recent infections or use of antibiotics should be
disclosed.[13]

Equipment
Many commercial EMG and nerve conduction study units are available.

Several manufacturers produce computer-based EMG equipment. This generally includes a stimulator, amplifier,
preamplifier, speaker, computer, printer, and many different electrodes.

Patient Preparation
EMG and nerve conduction studies are routine studies done in a physician’s office or ambulatory clinic. No special
preparation is necessary except that patients should refrain from using any skin lotions prior to the test.

Patients should be thoroughly evaluated to plan the study. The procedure should be explained to the patient prior to
commencing the study.

Anesthesia
No anesthesia is generally used for this procedure.

Positioning
The patient will have to move in different positions depending on what areas of the body are examined.

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Monitoring & Follow-up

There is no recovery period as anesthesiology is generally not used.

Technique

Nerve Conduction Study

The typical sensory nerve setup is illustrated in the image below.

Median sensory nerve conduction set up

The image below depicts the typical sensory nerve response.

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Median sensory nerve response

For motor nerves, more than one site is stimulated, as shown in the images below, which depict distal and proximal motor
nerve stimulation.

Distal median motor nerve conduction set up

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Proximal median motor nerve conduction set up

The corresponding motor nerve responses are seen below.

Median motor nerve responses.

Contributor Information and Disclosures

Author

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program
Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and
Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

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Disclosure: Nothing to disclose.

Coauthor(s)

Lindsay Elliott, DO Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State University
School of Medicine in New Orleans

Lindsay Elliott, DO is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Benjamin D Hefner, DO, MS Resident Physician, Department of Physical Medicine and Rehabilitation, Louisiana State
University Health Science Center

Benjamin D Hefner, DO, MS is a member of the following medical societies: American Academy of Physical Medicine and
Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, Sigma Sigma Phi

Disclosure: Nothing to disclose.

Chief Editor

Jonathan P Miller, MD Director, Functional and Restorative Neurosurgery, Director of Epilepsy Surgery, Attending
Neurosurgeon, University Hospitals Cleveland Medical Center; Director, Functional and Restorative Neurosurgery Center,
UH Cleveland Medical Center Neurological Institute; Associate Professor of Neurosurgery, Fellowship Director, Functional
and Stereotactic Neurosurgery, Associate Residency Program Director, Department of Neurosurgery, Surgical Director,
Neuromodulation Center, Case Western Reserve University School of Medicine

Jonathan P Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of
Neurological Surgeons, American College of Surgeons, American Epilepsy Society, American Society for Stereotactic and
Functional Neurosurgery, Congress of Neurological Surgeons, International Neuromodulation Society, North American
Neuromodulation Society, Ohio State Neurosurgical Society, Society of Neurological Surgeons

Disclosure: Nothing to disclose.

References

1. DeLisa JA, Gans BM. Physical Medicine and Rehabilitation: principles and practice. 4th ed. Lippincott Williams & Wilkins:
Philadelphia; 2005.

2. Braddom RL, Chan L, Harrast MA. Physical medicine and rehabilitation. Saunders/Elsevier. 4th ed. Philadelphia; 2011.

3. Kimura J. Electrodiagnosis in diseases of nerve and muscle : principles and practice. Ed. 3. New York: Oxford University Press;
2001.

4. Oh SJ. Clinical electromyography : nerve conduction studies. 3rd ed. Lippincott Williams & Wilkins: Philadelphia; 2003.

5. Weiss LD, Silver JK, Weiss J. Easy EMG : a guide to performing nerve conduction studies and electromyography. Butterworth-
Heinemann, Edinburgh. New York: 2004.

6. Aminoff MJ. Aminoff's electrodiagnosis in clinical neurology. 6th ed. Saunders: Philadelphia; 2012.

7. Daube JR, Rubin DI. Clinical neurophysiology. 3. ed. New York: Oxford University Press; 2009.

8. de Souza RJ, de Souza A, Nagvekar MD. Nerve conduction studies in diabetics presymptomatic and symptomatic for diabetic
polyneuropathy. J Diabetes Complications. 2015 Aug. 29 (6):811-7. [Medline].

9. Galamb AM, Minea ID, Rogozea L. Electrodiagnostic approach in entrapment neuropathies of the median and ulnar nerves. Pak
J Med Sci. 2015. 31 (3):688-93. [Medline].

10. Pawar S, Kashikar A, Shende V, Waghmare S. The study of diagnostic efficacy of nerve conduction study parameters in cervical
radiculopathy. J Clin Diagn Res. 2013 Dec. 7 (12):2680-2. [Medline].

11. Preston DC, Shapiro BE. Chapter 40: Electrical safety and Iatrogenic Complications of Electrodiagnostic Studies.
Electromyography and Neuromuscular Disorders. 3rd ed. China: Elsevier Inc.; 2013. 614-623.

12. Preston DC, Shapiro BE. Chapter 8: Artifacts and Technical Factors. Electromyography and Neuromuscular Disorders. 3rd ed.
China: Elsevier; 2013. 62-89.

13. [Guideline] Abel NA, De Sousa EA, Govindarajan R, Mayer MP, Simpson DA. Guidelines for Ethical Behavior Relating to Clinical
Practice Issues in Neuromuscular and Electrodiagnostic Medicine. aanem.org. Available at
http://www.aanem.org/getmedia/256196af-cb06-4015-87f1-68a86a62f111/Ethical-Guidelines_2015.pdf. 2015 Jun 10; Accessed:
2018 Aug 12.

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