Fundamentals of Neuroim-

4 aging and Electrodiagnosis

As recently as in the 1970s, the diagnosis of most disorders, particularly

those affecting the nervous system, depended mainly on clinical
examination. Some of these disorders, such as brain tumors, often required
exploratory surgery, aspiration or biopsy for visible or histological or
biochemical evidence of disorders. The risks of infection, anesthesia, and
imperfect healing weigh against exploratory surgery, but the diagnostic
benefits make the risk worth taking. In the last few decades, however, a
variety of medical imaging and electrodiagnosis techniques, among other
advanced procedures have made most exploratory surgery and other
invasive procedures redundant and has greatly accelerated progress in
neuro-medicine. Although the basic principles of some of these techniques
have been known for quite some time, they did not become clinically
useful until computer technology had advanced for enough to process
data into clear images of the body.
As a primary caregiver a physiotherapist must be conversant with the
fundamentals of these investigative procedures and be capable of understanding
their interpretations for facilitating process of rehab goal setting and planning
therapeutic interventions.

COMPUTED TOMOGRAPHY (CT)

Formerly called a CAT scan, computed tomography (CT) is a more
sophisticated use of X-rays to produce finely detailed images. The patient
is moved through a machine that emits low-intensity X-rays on one side
and receives them with a detector on the other side. By imaging body
slices as thin as a few millimeters, CT scans show less overlap of organs
than conventional X-rays and thus produce sharper images. CT scans are
useful for identifying tumors, aneurysms, cerebral hemorrhages, kidney
stones, and other disorders. In a brain CT, a beam of X-rays is shot
straight through the brain. As it comes out the other side, the beam is
blunted slightly because it has hit dense living bone on the way through.
Blunting or “attenuation” of the X-ray comes from the density of the
tissue encountered along the way. Very dense tissue like bone blocks lots
 50 Handbook of Practical Neurophysiotherapy

of X-rays, grey matter blocks some and fluid even less. X-ray detectors
positioned around the circumference of the scanner collect attenuation
readings from multiple angles. A computerized algorithm then
reconstructs an image of each slice (Fig. 4.1 and Photo gallery).

MAGNETIC RESONANCE IMAGING (MRI)

With magnetic resonance imaging (MRI), a cylindrical device surrounds
the body with a magnetic field three thousand to sixty thousand times as
strong as Earth’s. Hydrogen atoms align themselves with this field. The
patient is then irradiated with radio waves. Hydrogen ions absorb this
energy and align in a new direction. When the radio waves are turned
off, they realign to the magnetic field and emit energy at rates that vary
with the type of tissue. This emitted energy is received by a detector and
analyzed by a computer into an image of the body’s interior. MRI can see
through cranial and vertebral bone to visualize brain and spinal cord
tissue in finer detail than CT (Fig. 4.2 and Photo gallery).

How an MRI Image is Formed

• When protons in the body tissue are placed in a magnetic field, they
oscillate.
• The frequency at which they oscillate depends on the strength of the
magnetic field.
• Protons are capable of absorbing energy if exposed to electromagnetic
field at the matching frequency of oscillation.
• After they absorb energy, the nuclei release this energy so that they
return to their initial state of equilibrium.
• This re-radiation of energy by the nuclei as they return to their initial
state is what is observed as the MRI signal.
• The return of the nuclei to their equilibrium state does not take place
instantaneously, but rather takes place over two stages within a period
of time.
• The return of the nuclei to their initial state is governed by two
physical processes:
– The relaxation back to equilibrium of the component of the nuclear
magnetization which is parallel to the magnetic field.
– The relaxation back to equilibrium of the component of the nuclear
magnetization which is perpendicular to the magnetic field.
• The time that it takes for these two relaxation processes to take place
is roughly equal to:
– Time T1 for the first process
– Time T2 for the second process.
• The strength of the MRI signal depends primarily on three parameters.
– Density of protons in a tissue: The greater the density of protons,
the larger the signal will be.
 Fundamentals of Neuroimaging and Electrodiagnosis 51

– T1
– T2
• The contrast between brain tissues is dependent upon how these 3
parameters differ between tissues.
• For most “soft” tissues in the body, the proton density is very
homogeneous and therefore does not contribute in a major way to
signal differences seen in an image.
• However, T1 and T2 can be dramatically different for different soft
tissues, and these parameters are responsible for the major contrast
between soft tissues.
• T1 and T2 are strongly influenced by the viscosity or rigidity of a
tissue. Generally speaking, the greater the viscosity and rigidity, the
smaller the value for T1 and T2.
• It is possible to manipulate the MR signal by changing the way in
which the nuclei are initially subjected to electromagnetic energy.
• This manipulation can change the dependence of the acquired signals
on the three parameters: proton density, T1 and T2. Hence, one has
a number of different MR imaging techniques (“weightings”) to
choose from, which accentuate some visual characteristics of the tissue
and not others (Table 4.1).

Table 4.1: Key to interpretation of X-ray / CT / MRI: A simplified tabulation of

tissue image characteristics
Normal tissue MR-T1 MR-T2 X-ray / CT
Dense bone Dark Dark Bright
Air Dark Dark Dark
Fat Bright Bright Dark
Water Dark Bright Dark
Brain tissue “Anatomic” Interim. Interim.
Abnormal tissue
Infarction Dark Bright Dark
Hemorrhage Bright Bright Bright
Tumor Dark Bright Dark
Glial plaques in MS Dark Bright Dark

Image characteristics Tissue abnormality

Dark on T1 weighted images
Bright on T1 weighted images
Dark on T2 weighted images
Bright on T2 weighted images
Edema, tumor, infarctions, inflammation,
infections, hemorrhage, calcification
Fat, sub-acute hemorrhage, stasis of blood,
laminar necrosis following infarctions
Calcification, fibrous tissue, pus
Fat, sub-acute sub-dural hemorrhage, edema,
tumor, Infarctions, inflammation, infections,
hemorrhage, calcification
 52 Handbook of Practical Neurophysiotherapy

Bright means high signal intensity, high density/high attenuation of

X-rays. Dark means low signal intensity, density and attenuation. Interim
means intermediate Anatomic- Gray matter appears gray, white matter
white.
To detect bleeding in brain- for MR use gadolinium; for CT, iodinated
contrast material.

POSITRON EMISSION TOMOGRAPHY (PET) (FIG. 4.3)

Positron emission tomography (PET) is used to visualize the metabolic
state of a tissue. The patient receives an injection of radioactively labeled
glucose, which emits charged particles called positrons. When a positron
and electron meet, they annihilate each other and give off gamma rays
that are picked up by a detector and analyzed by computer. The result
is a color coded image that shows which tissues were using the most
glucose that is, where most metabolically active is taking place at the
time. In cardiology, a PET scan can show the location and extent of dead
heart tissue. In neuroscience, it can show which parts of the brain are
active from moment to moment as a person engages in various sensory,
motor, or intellectual tasks.

SPECT/PET Scans (Single Photon/Positron Emission Computed

Tomography) (Fig. 4.4)
When radio-labeled compounds are injected in tracer amounts, their
photon emissions can be detected much like X-rays in CT. The images
made, represent the accumulation of the labeled compound. The
compound may reflect, for example, blood flow, oxygen or glucose
metabolism, or dopamine transporter concentration. These images are
shown with a color scale as depicted in plate at the right.

Functional MRI (F MRI)

A new variation of MRI, functional MRI (f MRI) detects the anaerobic
activity of active neurons of the brain. It can pinpoint brain activity to
within 1 or 2 millimeters, and is even more precise and useful than PET
scans for studies of brain function. It also has the advantage of requiring
no injections or radioactive isotopes, and it is much quicker than a PET
scan. The PET and f MRI techniques not only have been valuable for
clinical diagnosis but have added enormously to our knowledge of brain
function, pinpointing abnormalities correlated with depression,
schizophrenia, and attention deficit disorder. They have also provided
images of the mind at work, so to speak, identifying areas involved in
consciousness, memory, thought, musical perception, reading, motor
control, and speech.
The changing face of imaging technology- photo gallery (Figs 4.1
to 4.6)
 Fundamentals of Neuroimaging and Electrodiagnosis 53

Fig. 4.1: CT scan – A computerized tomography is a special X-ray used as second

line of investigation. X-ray beams that passes to the different slices of the brain
(like a knife through a loaf of bread) is picked up by a detector and fed into a
computer which reads the information. Brain fluid shows up black and the brain
appears in different shades of gray on CT scan. This test is used to check for
stroke, tumor, infection or bleeding

Fig. 4.2: MRI scan – A MRI measures
radio-waves which are detected by the
machine and feeds the information to the
computer to construct the brain images.
This test is used to check for brain
tumor, infection or cyst
Fig. 4.3: PET – Positron emission
tomography scans to see the chemical
activity in the brain. This test uses
radioactive glucose to measure brain
activity. Low brain activity is colored blue,
medium activity is yellow, and high
activity is pink
 54 Handbook of Practical Neurophysiotherapy

Fig. 4.4: SPECT/PET scans (Single photon/positron emission tomography)

Fig. 4.5: Arteriogram – This procedure is used to study the blood vessels of the
brain. The imagologist injects dye into a major artery to outlines the arteries of the
brain. Then it is possible to see if these blood vessels have a bulging weakness of
the wall (aneurysm) or blockage or a break, all of which may causes a stroke

Fig. 4.6: X-ray skull – A plain X-ray is used primarily to take a picture of bony
skull vault to detect if one has broken or fractured the skull
 Fundamentals of Neuroimaging and Electrodiagnosis 55

Photo Gallery of Typical CT Scan Images (Figs 4.7 to 4.18)

Fig. 4.7: The CT scan image of a normal brain

Fig. 4.8: CT scan showing cerebral infarction of the left hemisphere

Fig. 4.9: CT scan of the brain showing left cerebral hemorrhage

 56 Handbook of Practical Neurophysiotherapy

Photo Gallery of Typical MRI Scans Images

Fig. 4.10: Normal MRI of the brain showing landmarks in the brain viewed in
coronal section

Fig. 4.11: MRI of a massive cerebral Fig. 4.12: Acute cerebral hemorrhage
hemorrhage of the left hemisphere of the can be seen in MRI below in the left
brain, which had been fatal hemisphere of the brain
 Fundamentals of Neuroimaging and Electrodiagnosis 57

Fig. 4.13: MRI showing acute cerebral

infarction the right pre-central gyrus.
Abnormally bright signal is seen here
because of the presence of excess water
which has a prolonged relaxation time.
As tissue has become infarcted and
edematous, the sulcus is no longer
identifiable. Compare the infarcted side
with the normal right side

Fig. 4.14: MRI of a metastasis of adeno- Fig. 4.15: Metastasis of bronchogenic

carcinoma, note clear encapsulation with carcinoma- note the diffuse margins
well defined margins of the SOL

Figs 4.16A and B: Comparison of MRI and CT scans

of hypertensive encephalopathy
 58 Handbook of Practical Neurophysiotherapy

Figs 4.17A and B: Comparison between PET and enhanced MRI of the same
condition as shown above

Fig. 4.18: MRI showing stenosis of cervical spine. The cervical cord is markedly
compressed. The patient also had degenerative disease of C3-4 and C4-5

RADIOGRAPHY
Radiography, use of X-rays, is the oldest imaging technique (Fig. 4.6). In
the term “X-ray” can refer either to the type of radiation used or to the
photographic image produced (the radiogram). X-rays were discovered
in 1885, and Marie Curie (1867–1934) trained military doctors in the use
of X-ray machines in World War I. X-rays are relatively simple and
inexpensive to make, and they are commonly used in dentistry,
mammography, chest examinations, and diagnosis of fractures. They are
best used for dense structures such as bone, but hollow organs can be
visualized by filling them with a radiopaque substance such as barium,
 Fundamentals of Neuroimaging and Electrodiagnosis 59

given by swallow or enema to X-ray the stomach or colon. Angiography

is the X-ray visualization of blood vessels after injection with a radio-
paque dye.
Photo Gallery of Some Typical X-rays (Figs 4.19 to 4.21)

Fig. 4.19: A normal cervical spine X-ray

Fig. 4.21: Compressive myelopathy

detected by X-ray of cervical spine lateral
view in extreme flexion showing
Fig. 4.20: A prolapsed disc anterolysthesis at C4 and C5 with C5 and
between C6 and 7 C6
 60 Handbook of Practical Neurophysiotherapy

ELECTRO-DIAGNOSTIC STUDIES: EEG, EMG AND NCV’S

A. Electroencephalogram (EEG)
Introduction
The electroencephalogram (EEG) is a recording of the electrical activity
of the brain from the scalp (Fig. 4.22). The first recordings were made by
Hans Berger in 1929 although similar studies had been carried out in
animals as early as 1870.
The waveforms recorded are thought to reflect the activity of the
surface of the brain, the cortex. This activity is influenced by the electrical
activity from the brain structures underneath the cortex.
The nerve cells in the brain produce signals that are called action
potentials. These action potentials move from one cell to another across
a gap called the synapse. Special chemicals called neuro-transmitters
help the signals to move across the gap. There are two types of neuro-
transmitters; one will help the action potential to move to the next cell,
the other will stop it moving to another nerve cell.

Fig. 4.22: Tracing of an electroencephalogram

The brain normally works hard to keep an equal amount of each of

these neurotransmitters in the brain.
EEG activity is quite small, measured in micro volts (µV) with the
main frequencies of interest up to approximately 30 Hertz (Hz).

EEG Electrodes
Small metal discs called electrodes are placed on the scalp in special
positions. These positions are identified by the operator who measures
the head using the International 10/20 System (Fig. 4.23). This relies on
taking measurements between certain fixed points on the head. The
electrodes are then placed at points that are 10% and 20% of these
distances.
Each electrode site is labeled with a letter and a number. The letter
refers to the area of brain underlying the electrode, e.g. F – Frontal lobe
and T – Temporal lobe. Even numbers denote the right side of the head
and odd numbers the left side of the head.
 Fundamentals of Neuroimaging and Electrodiagnosis 61

Fig. 4.23: 10/20 System of electrode placement

There is a great variety of electrodes that can be used. The majorities
are small discs of stainless steel, tin, gold or silver covered with a silver
chloride coating. These normally have a lead attached. Alternative
methods consist of a cap in which the electrodes are already embedded.

Montages
EEG machines use a differential amplifier to produce each channel or
trace of activity. Each amplifier has two inputs (Fig. 4.24). An electrode
is connected to each of the inputs.
Differential amplifiers measure the voltage difference between the
two signals at each of its inputs. The resulting signal is amplified and
then displayed as a channel of EEG activity.

EEG Applications
One of the major roles of EEG is as an aid to diagnose epilepsy. Abnormal
patterns such as spikes, sharp waves and/or spike and wave complexes
can be seen. The type of activity and the area of the brain that it is
recorded from will assist the physician in prescribing the correct
medication for that type of epilepsy.

Fig. 4.24: EEG machine

 62 Handbook of Practical Neurophysiotherapy

Patients with epilepsy that can not be controlled by medication will

often need surgery in order to remove the damaged tissue. The EEG
plays an important role in localizing this tissue. Special electrodes can be
inserted through the cortex or alternatively a grid of electrodes placed
directly on the surface of the cortex. These recordings, often called Long
Term Monitoring for Epilepsy (LTME), can be carried out for periods
ranging from 24 hours to 1 week. The EEG recorded will indicate which
areas of the brain should be surgically removed.
EEG studies can also be used in patients who are deeply unconscious,
to distinguish between brain death and possible reversible conditions.
Electrocerebral inactivity (ECI) or electro-cerebral silence (ECS) is
defined as no EEG activity over 2 µV in amplitude when recording from
electrodes on the scalp, that are 10 cm or more apart.
Using the 10/20 International System of electrode placement, the
average distance between electrodes in an adult is 6 to 6.5 cm. Activity
recorded using these distances and at a normal display sensitivity may
suggest ECS. However if the same activity was recorded using longer
inter-electrode distances, some activity might be seen. Therefore some
double distance electrode linkages are recommended, e.g. FP1-C3, F3-P3,
C3-O1 etc.
Display sensitivities of a minimum of 2 µV/mm are required.
However digital EEG systems have the added advantage of having
sensitivity values of 1.5 and 1 µV/mm. This 50-100% increase in sensitivity
will allow a more confident assessment of the presence or absence of a
2 µV signal.
The EEG is also used to investigate other conditions that may affect
brain function such as strokes, brain injuries, liver and kidney disease
and dementia.

EEG Activity
EEG activity can be broken down into 4 distinct frequency bands:
Beta activity > 13 Hz (Fig. 4.25).
Beta activity is a normal activity present when the eyes are open or
closed. It tends to be seen in the channels recorded from the center or
front of the head. Some drugs will increase the amount of beta activity
in the EEG.
Alpha activity 8 Hz-13 Hz (Fig. 4.26).

Fig. 4.25: Beta activity

Fig. 4.26: Alpha activity

 Fundamentals of Neuroimaging and Electrodiagnosis 63

Alpha activity is also a normal activity when present in waking adults.

It is mainly seen in the channels recorded from the back of the head. It
is fairly symmetrical and has amplitude of 40-100 µV. It is only seen
when the eyes are closed and should disappear or reduce in amplitude
when the eyes are open.
Theta activity 4 Hz-7 Hz (Fig. 4.27).

Fig. 4.27: Theta activity

Theta activity can be classed as both a normal and abnormal activity

depending on the age and state of the patient. In adults it is normal if the
patient is drowsy. However it can also indicate brain dysfunction if it is
seen in a patient who is alert and awake. In younger patients, theta
activity may be the main activity seen in channels recorded from the
back and central areas of the head.
Delta activity < 4 Hz (Fig. 4.28).

Fig. 4.28: Delta activity

Delta activity is only normal in an adult patient if they are in a

moderate to deep sleep. If it is seen at any other time it would indicate
brain dysfunction. Abnormal activity may be seen in all or some channels
depending on the underlying brain problem.
There are a number of other waveforms which tend to be a little
more specific to certain conditions. For example spike and wave activity
indicates a seizure disorder and may be seen in the EEG even if the
patient is not having an epileptic seizure.
Other epileptic conditions may be diagnosed if spikes or sharp waves
(Fig. 4.29) are seen.
Tri-phasic waves are sometimes seen if the patient has severe liver
or kidney disease that is affecting brain function.
These are just brief descriptions of some of the simpler waveforms
that may be seen in any one EEG recording. Combinations of any of the
above patterns are possible which can make interpretation of the record
difficult. Abnormal activity is not always specific to any condition and
may suggest a few different diagnoses.
 64 Handbook of Practical Neurophysiotherapy

Fig. 4.29: Spike and wave activity

EEG Recording
The EEG recording can last from anything between 15 minutes to 1 hour
or longer depending on the patient. Typically the patient will be lying
down or sitting relaxed in a chair. Most of the recording is taken with the
eyes closed, although the patient will be frequently asked to open the
eyes for short periods.
Most patients will be asked to carry out a period of deep breathing
for approximately 3 minutes. This may produce some abnormal activity
which would not be seen while the patient is relaxed. The physiological
effect of deep breathing is to increase the amount of carbon dioxide
(CO2) being removed from the bloodstream. This fall in CO2 produces a
fall in blood pressure and at the same time blood vessels in the brain
become constricted. This reduces blood flow and the delivery of oxygen
and glucose to the brain. This in turn may produce some abnormal brain
activity not seen in the resting record.
Photo stimulation is also carried out. A strobe lamp is placed 30 cm
from the patient’s eyes. Brief flashes of light (2-5 seconds in duration) at
a number of different flash frequencies are delivered to the patient with
both eyes open and eyes closed. A continuous flash with increasing and
decreasing flash frequencies is sometimes used.
Some patients who are sensitive to flashing lights may show abnormal
activity in the EEG.
Throughout the test, the operator is constantly annotating the record
with any patient movements, or tasks that they are carrying out.
Other signals may also be recorded in conjunction with the EEG
such as heart rate (ECG), respiration, eye movements (EOG), and muscle
activity (EMG).

EEG Analysis
The EEG reports consist of a number of different sections. The operator
may prepare a report describing the type of activity seen in the record
together with changes produced by deep breathing and photo stimulation.
They will also comment on the patient’s state during the recording. The
physician will then interpret these changes with regard to the medical
problem being investigated.
With an increase in the number of long recordings being carried out,
many clinical and law enforcement specialties may make use of detection
algorithms such as spike and seizure detection..
 Fundamentals of Neuroimaging and Electrodiagnosis 65

Other methods of analyzing EEG data include Power Spectrum

Analysis. A Fast Fourier Transform (FFT) is performed on sections of
EEG data to determine the power content of the four main frequency
bands. The resulting waveforms can be displayed as a brain map which
will show the scalp distribution of the power within each frequency
band.
The amplitude of the different waveforms at a single point can also
be displayed in a similar format.
This type of display provides a more objective analysis of the EEG
activity compared to a subjective visual analysis by a physician.

Video Monitoring
Simultaneous video monitoring of the patient during the EEG recording
is becoming more popular. It allows the physician to closely correlate
EEG waveforms with the patient’s activity and may help produce a more
accurate diagnosis.
Domestic video recorders and cameras can be connected to an EEG
machine using a time code generator. This records an accurate time signal
onto the videotape. When the videotape and EEG are reviewed together
the two signals are accurately synchronized together.
Video monitoring is always used for Long-term Monitoring recordings
as the patient is unattended. The patient may also have an event button
connected to the EEG machine so that times when the patient thought
they were having an epileptic attack can be easily identified.

Sleep Studies
The EEG is frequently used in the investigation of sleep disorders
especially sleep apnea. EEG activity together with other physiological
signals such as heart rate, airflow, respiration, oxygen saturation and
limb movement are measured simultaneously. These recordings are
usually carried out overnight although some sleep studies can be carried
out in the department during the day under strictly controlled conditions.
The EEG record can be broken down into epochs which are normally
of 30 seconds duration. Using the EEG activity, each epoch is classified
into one of 5 sleep stages. This is displayed visually as a Sleep Histogram.
Respiration and airflow are used to look for periods of apnea which
occur when the patient stops breathing. These are then correlated with
the sleep stage in which they occurred and the level of the oxygen
saturation fell to during the apnea.

Electromyogram (EMG) and Nerve Conduction Velocity (NCV)

Studies
Electromyography (EMG) and Nerve Conduction Velocity (NCV) studies
are done to evaluate for injury or disease of muscle, nerve roots, and
 66 Handbook of Practical Neurophysiotherapy

peripheral nerves. These studies are normally done together and are
usually performed as a workup for complaints of pain, weakness,
numbness, or tingling.
Unlike radiographic or imaging tests that evaluate structure, electro-
diagnostic studies assess physiology or biochemical function.
Think of a malfunctioning telephone. A photograph of the phone
would miss the problem entirely, but with a volt-ohm meter a technician
could determine if there was a bad connection in the cable or in the
phone itself or the phone line, or at the telephone pole.

Nerve Conduction Studies

• During the nerve conduction study, mild electrical impulses are sent
along the course of a nerve in the arm or the leg. The electrical
impulse will make the muscles in the arm and leg contract. The
patient feels an electric shock every time the nerve is stimulated by
the NCV stimulator.
• Electrode patches are placed along the known course of the nerve, as
shown in the above illustration (Fig. 4.30).
• When the nerve is stimulated, it must transmit the signal along its
course.
• An electrode placed further down the arm or leg captures the signal
as it passes by. A healthy nerve will transmit the signal faster and
stronger than a sick nerve.

Fig. 4.30: Electrode placement for NCV study

 Fundamentals of Neuroimaging and Electrodiagnosis 67

• Nerve conduction velocity studies (NCV) look at the efferent and

afferent function of peripheral nerves. They measure the conduction
velocity of an electrical impulse along the axon (or trunk) of a
peripheral nerve. It tells us to what degree a nerve is physically
“pinched” or damaged.
• The nerve is tested at various points to determine if there is a “block”
along the direction of travel.
In order to understand nerve conduction studies we need to
understand how nerves respond to injury. Nerves are compound
structures consisting of many individual wires in an insulating covering
called “myelin”.
When there is compression on a nerve, a “conduction block” will
occur as shown in the Figure 4.31. This often temporarily blocks the
nerve impulse from traveling along the axon of the nerve. This happens
when you cross your legs and your foot falls asleep. When the pressure
is removed, the nerve usually returns to normal function. This “reversible
conduction block” is short-term and most often results in no permanent
neurological deficit. It will usually yield a normal NCV test.
If pressure remains on the nerve for a long enough period of time,
the nerve will lose some of its myelin sheath. This will cause the nerve
to conduct impulses more slowly, causing an increased conduction time
or decreased velocity. This will usually yield a slowed speed of conduction
along a nerve or what’s called an “increased latency” in an NCV test.
This may or may not result in permanent neurological deficit depending
upon the degree and extent of injury.
If pressure remains on a nerve for long enough, the nerve will die.
This will result in a decrease in amplitude of the overall “nerve signal”
as well as a decrease in velocity along the nerve axon. This usually results
in some degree of permanent neurological deficit and/or atrophy of the
innervated muscle.

Fig. 4.31: Progressive degeneration of nerves

 68 Handbook of Practical Neurophysiotherapy

Electromyography

• The needle EMG study involves the insertion of very thin pin
electrodes into the skin.
• The electrode is moved around slightly after its insertion.
• There are two kinds of electrodes used for EMG studies: Concentric
and Monopolar. Monopolar electrodes are designed for minimal pain
and discomfort.
• Muscles normally receive constant electrical signals from healthy
nerves, and in return “broadcast” their own healthy electrical signals.
• Once inserted into a muscle, the EMG electrodes record the resting
electrical potentials generated by the muscle.
• If the muscle is diseased or injured, or if it does not receive adequate
signals from its nerve supply, then the muscle signals that are
broadcast back through the EMG electrode will show the abnormal
insertional and resting potential activity.
• EMG confirms what is seen on the NCV and will often help
determine the difference between a nerve root and peripheral nerve
problem.
• It the nerve to a muscle is damaged, the muscle will start to atrophy
or degenerate. As it atrophies, its outer sheath (the sarcolemma)
becomes more sensitive, often causing the muscle to fire
spontaneously.
• In the beginning, this occurs in just a few muscle fibers so it can’t
been seen with the naked eye but is seen on the EMG. After sufficient
degeneration, one can often visually see the muscle firing; this is
called a fasiculation.
• Degeneration causes the muscle to become weaker and when it
contracts, will have an incomplete or diminished ability to contract,
also seen with the EMG.
• As the muscle gains its nerve supply back, it does so with larger
motor units, increasing the muscles action potential amplitude which
is also measurable.
• EMG helps us to see if a nerve and muscle are damaged, and whether
it is improving or getting worse.
• Nerves can heal. As long as the epineural sheath (the outer covering
of the nerve) remains intact, the nerve may regenerate some of its
myelin sheath, sprout new axons to innervate the muscle and return
to normal function. Since nerves usually grow at a rate of
approximately one inch per month, electrodiagnostic studies can
answer the following:
1. Location of the lesion- muscle or nerve?
2. Status of the lesion- improving or not
3. Nature of the lesion
4. How long it is likeley to take to recover?
 Fundamentals of Neuroimaging and Electrodiagnosis 69

EVOKED POTENTIALS
Electronic averaging has permitted the recording of low amplitude
potentials evoked by different types of sensory stimulus. These responses
are commonly used in the diagnosis of Multiple Sclerosis (MS), a relapsing
and remitting condition which is characterized by patchy inflammation
affecting the myelin sheath of the central nervous system. The object is
to demonstrate abnormalities in regions of the nervous system not known
from clinical manifestations to be involved -silent lesions. For example,
the finding of abnormal VEPs or BAEPs in a patient with paraparesis
would demonstrate abnormalities in at least 2 sites of the central nervous
system characteristic of MS.

Visual Evoked Potentials (VEPs)

The visual evoked potential is a gross electrical signal recorded from the
occipital cortex in response a systematic change in some visual event
such as a flashing light or an alternating chequered pattern. The recording
electrode is placed over the occipital cortex and the amplitude and latency
of the waveform generated can be measured (Fig. 4.32).

Figs 4.32A to C: Normal VEP in adults with 20/20 vision

 70 Handbook of Practical Neurophysiotherapy

This method currently provides the most sensitive means of detecting

subclinical lesions of the optic nerve and may enable a diagnosis of MS
to be made at an earlier time. Abnormality in the VEP is also encountered
with compressive lesions of the anterior visual pathways. In the pediatric
age group, the flash.
VEP may be used as a screening test for the visual pathway.

Brainstem Auditory Evoked Potentials (BAEP)

If one could record directly from several different levels of the subcortical
auditory pathway, one would see during the first 10 milliseconds
following an appropriate acoustic stimulus, a series of potentials
corresponding to the sequential activation of peripheral, pontomedullary,
pontine and midbrain portions of the pathway. When these acoustic nerve
and brainstem potentials are volume conducted to surface recording
electrodes at the vertex and earlobe, they form a composite series of
waves known as brainstem auditory evoked potentials. Since the
amplitude of these responses are very small (about 1/100 of spontaneous
EEG activity), special computer averaging technique is required.
The neurologic applications of BAEPs have been proven useful in
the diagnosis of MS. It may be used as a screening test for early detection
of acoustic neuromas and in the assessment of comatose patients. Like
the VEPs, it may also be a useful screening test for hearing in the pediatric
age group such as neonatal screening and those who do not cooperate
sufficiently with behavioral testing.

Somatosensory Evoked Potentials (SSEP) (Fig. 4.33)

SEPs can be recorded from electrodes placed over the somatosensory
cortex of the cerebral hemisphere contralateral to the applied stimulus.
Automatic averaging techniques are used to facilitate recording of these
small potentials. In the upper limb, the stimulus is usually applied to the
median or ulnar nerve whereas in the lower limb the tibial nerve is most
frequently used. Stimulation of the median nerve at the wrist elicits a
response at the brachial plexus at about 9 msecs (N9), the cuneate nucleus
12 msec (N12) and somatosensory cortex at 20 msec (N20).

Clinical uses of SSEP

The SSEP findings may help in the detection and localization of lesions
of the central somatosensory pathways but are not pathognomonic of
specific diseases. In Multiple Sclerosis (MS) the presence of SSEP
abnormalities may reveal subclinical lesions involving the central
somatosensory pathways thus aiding in early diagnosis. In patients with
definite MS, the incidence of SSEP abnormality is about 80% whereas in
the category of possible MS, the yield is only about 30%. The interpretation
of electrophysiologic results must therefore always be taken in a clinical
context.
 Fundamentals of Neuroimaging and Electrodiagnosis 71

Fig. 4.33: Normal SEPs elicited by stimulation of the median nerve and recording
at Erb’s point (EP), the 7th and 2nd cervical spine (CV7 and CV2) and
somatosensory cortex (C4)

ACKNOWLEDGEMENT
1. Radio-images and their interpretations were kindly contributed by Dr Sanjay
Sahu MD (Radiodiagnosis), Silliguri.