Analyse et traitement du signal en électrophysiologie périnéale

Sound

Amplifiers
Program
Pr. G. Amarenco Ergonomy
Managment
Service de Neuro-Urologie et d’Explorations Périnéales Calculation
Hôpital Tenon APHP. GRC UPMC 01 Screen

A/D - D/A Converters

Recording

32 bits - 48 KHz
Electrode

Memory
F.E.B. ! - Processor

Generator
Current
Printer

Optical Fibers
VAEPS

DIU NEURO-UROLOGIE, Annecy, Vendredi 30 Mars 2012

Stimulation Dedicated Keyboard Archive

Optical Fibers
Electrode Amplification - Stimulation
Averager - Pause/Save

EMG Signal & Concentric Needle

Digital Conversion Sampling
Active 1 < Z < 100 K! - Z must be as lower as possible
Time Sampling of one or more magnitudes
Needle Electromyographic Signals
Amplitude Amplitude Amplitude Act.
Reference
Z Ohms

A A A R1 106
Muscle R2
105
R2 Action
Surface Treatment
C R1 Action
104 C Action Elect. Treatment
Electrolytic Treatment
B N N Signal 103

Sampling Frequency Low Frequency Acceptable Frequency

Z2 Ref.
1 10 102 103 104
F Hz
0 t+1 t+2 t+3
Time
0 t+1 t+2 t+3
Time
0
Time
Z1
Non focused trace
Damped noise
Frequency 5 times (minimum) the highest frequency to be sampling Ground High impedance
Used Needle
Binairy conversion (12 bits)
Z3 Focused trace
(t+1) 5mV amplitude that is 000000000l0l
Incisive and curt
(t+n) 100mV amplitude that is 00000ll00l00 noise STOP

Preamplifier and Environnement Patient is Antenna ! Interferences are transfered

Environnemental Interferences penetrate Patient
Patient Must Be Grounded Neon - Variactors Radiology
Surgery
Balanced Inputs
50 - 60 Hz 5000 mV

EMG : 1 !V to 1 mV

Active 50 - 60 Hz counterbalanced 50 - 60 Hz Sharp Waves

- V+ + V- = 0 Power Lines Sharp Waves

Differential 50 - 60 Hz

Reference
+ High freq. PW
Spikes

High freq. PW Radio

Ground

High Input Impedance >1500 MOhms and Rejection >100 dB Central Servers AM/FM Power Supply

Mobil Phone Radio CB

1
 Rec. Surface Electrode Impedance Band Pass and Filters
Ag/AgCl Electrode % Amplitude 10 ms
!V
Ref. Gel Act.
110
Z1 Surface = Imped. Some Gels 100
Z2 Surface = Focal ! can start up 90
Z3 skin irritations !
Imped. = Amp. 70

Nerve/Muscle
ZRef ZAct
1 ms 180 ms
ms
LF HF Freq. Hz
ZR = ZA Correct ZR = ZA 50/60 Hz
Amplitude of EMG or EP signal depend of •! Many frequencies in the Red signal
20 ms 50 Hz
Baseline not stabile ? 16 ms 60 Hz
filter adjustment.
•! Role of filters isolate suitable frequencies
ZRef = ZAct A precise adjustment provide a better trace
without unsuitable frequencies as : In this case 10 and 180 ms
•! Skin contact Frequencies 100 Hz and 5.5 Hz
•! Muscular noise
•! Dry electrode •! External interferences HF minimum 100 x 2 = 200 Hz
•! Poor electrode quality •! Unsuitable brain activity
•! etc.. FB maximum 5.5 / 2 = 3 Hz
•! Defective cable With Stimulation Electromyography
•! Defective Input Connector

Routine Setup in Practice Stimulators Constant Voltage - Constant Current

EMG NC Evoked Potentials

Electrode CN-MN Special Special Surface EP Needles or Surface Constant Voltage

MUP SF Macro SNC SEP AEP VEP V I unknown Z Impedance

IP MNC A1-A2 O1-O2-Oz Adjusted unknown
Tests T/A F- H by User
SF Canula Blink Cortex Others AEP P300
Decremt Nerve Stimulation Intensity Unknown : No Reference
High
FQ 10 10 10 2 2 1 2 2 0,1
[KHz] 200 Constant Current K
E
Low or More or More or More
FQ
I I known Z Impedance
Y
P
Reference unknown O
[Hz] 10 500 500 5 20 0,5 20 50 0,2 0,5 Set by I
Sweep User N
See T
ms/Div
10 - 20 1-2 1 10 Applications 10 5/10 1 100 30 V Variable

Stim. Surface Electrode Impedance Stim. Surface Electrode Shunt Action

Anode Cathode Z1 Z2 Z3 Zshunt Action on Current Stimulation i

Cathode
Felts Z1
15
Surface
Skin
Z2
Z3 V I Z Zs Zsk Zn i Stim.
Nerve 12
Damp Area
i = % of I

Anode 9
ZS Z'1 Z'2 Z'3
6
Zsk
ZN 3
With Z1 ~ 0,5 K! Z2 ~ 1 K! Z3 ZSK ZN ~ 0,2 K!
0
i Stim. = 0,15 x V x ZS (1 + ZS) 0.01 0.1 1 10 100
Zs en KOhms

Zs i Stim. = 0 mA
In damp area, Current Stimulation must be higher,
Higher current = more artifacts !
Zs i Stim. = V/7 mA

2
 Stimulation Artifact balanced Impedances Intensity & Duration Stimulation

Correct No Latency Uncertain Latency

Stimulation is defined by Intensity and Duration :
? Quantity of Electricity (QE)

You get the same QE with : Intensity mA

QE
10 mA / 0,2 ms and 20 mA / 0,1 ms

Za = Zc Za > Zc Za < Zc Duration ms

Reminder :

Unbalanced impedance !! Long Duration gives Larger Stimulus Artifact

between Zanode and Proximity !! Higher Intensity is painful
Zcathode give positive Technic !! Short Duration, Limitation in Max. of QE
or negative variation of R ( depth nerves - Fat patient )
stimulus artifact !
90° angle !! It!s better (for patient) to reduce the number of stimuli
S

Averager Principle Smoothing Technics

Extract a revealed potential buried in an activity
1000 times greater or more. Post-Calculation
1 Mean Value of 3 points
Two methods: Then Interpolation of points

2 More smoothing =
Sum-Mean
•! Latency displacement
n is set before to start •! Amplitude decreasing
1+2+n Wait n reached 1+2 /2
n (3)
K
K
Normalized
4
E
Post-Digitized
E Digitized Frequencies
Y (3)+4 /2 Y Re-Digitized Signal
1+2 Possibility to stop P with new pass-band
P
2 +3 averager at any time. n
/n O
O +n 1
More smoothing =
2 n is an actual value I
I
N 2 N Unsuitable Frequencies
•! Amplitude decreasing
T T
Amplified

Ground Stimulation & Recording Rule

As Possible, Ground must be placed between Stim. & Rec.

STIMULATION RECORDING
Anode Cathode Active Reference
GROUND

Nerve

BLACK TO BLACK MNC - SNC - F.WAVES - INCHING

Stimulation Polarity : NEGATIVE

3
 Stimulation Current Stimulation
Nerve is a Chain of Polarized Cells (Myelin Action)
Stimulation in one point generate a depolarization. + -
- + - - + - + - + - + - + - + - + - + - + + NERVE - - + - + - + - + - + - + - + - + - + - + +

A Nerve could be Depolarized by : Supramaximal Stimuli

Electrical Choke Mini. 3 Times Sensory Threshold

Mechanical Compression

Magnetic Field

Depolarization Propagation - Refractory Period

+ - + -
NERVE + - - - + + - - + - + - + - + - + - + - + + NERVE - - + - + + - + + + - - - - + - + - + - + +

Propagation by Succesive Depolarizations

Once a Nerve is Depolarized at some point,
Followed by Repolarization
a Wave of Depolarization passes in
Time before repolarization is called
Both Directions from that point.
Refractory Period

Motor Latency Conduction Velocity

Motor Response Motor Response
+ - + - + -
NERVE - - + - + - + - + - + - + - + - + + + - - + NERVE - - + - + - + - + - + - + - + + + + - - - +

S1 S2 M
Distance mm
MOTOR LATENCY
S M
in ms = VELOCITY in m/s
Propagation Time S1
from S to M Distance
Latency S1 - Latency S2
S2 L1
Normal Value : 45 to 65 m/s
Depend. of : Nerve - Age - T°
L2

4
Motor Response Recording
SURFACE ELECTRODES
Peak
Latency Amplitudes

Negative
Onset Deflection To Recording
Latency Input
Area
!
NEEDLE ELECTRODE
Peak to Peak

Stimulation Duration
Artifact To Recording
Input

Pathologic Responses Stimulation & Recording RULE

Amplitude Duration Latency

As Possible, Ground must be placed between Stim. & Rec.
Normal Nl Nl Nl

STIMULATION RECORDING
Axonal Nl+/- Anode Cathode Active Reference
Degeneration GROUND

Conduction Nl+/- Nerve

Block
Severe Demyelination
BLACK TO BLACK

Focal Nl Nl Stimulation Polarity : NEGATIVE

Slowing
Myelin Damaged Nl = Normal

Motor & Sensory General Remarks Motor Conduction Median Nerve

Latency
MOTOR
Rec.
•! Amplitude minimum 1 mV - Direct response
•! Form normally biphasic Wrist 3,5 ms
•! Duration 1 to 3 ms - Latency depend of stimulation site
•! Stimulation Current depend nerve and site, 15 - 30 mA Stim. 1

SENSORY
Distance

•! Amplitude 5 !V to 35 !V
Stim. 2
•! Indirect response - Averager needed Elbow
8,2 ms
•! Direct response for high amplitude potentials
•! Form normally biphasic
•! Duration 1 to 3 ms - Latency depend of stimulation site
•! Stimulation Current depend nerve and site, 5 - 15 mA Diff.: 4,7 ms Dist.: 240 mm C.V. : 51 m/s

5
 F-Waves Ulnaris Nerve Sensory Conduction Ulnaris Nerve

Contralateral
motor action M F
Rec. Negative Stim.
to facilitate F

ce
Stim. Latence : 3,1 ms

tan
Dis
CV = 39 m/s
M
Rec.
!
Stim.
F Positive Stim.
Latence : 3,5 ms
block
CV = 34 m/s
Pathologic

Distance = 120 mm
F Latence 30 to 50 ms

Inching Ulnaris Nerve Pudendal Nerve Latencies

Palm Stimulation Right Side: at 8 o!!clock

Left Side: at 4 o!!clock
Right
Rec. Responses are inverted by
rotation of the electrode !
Stim. 1 inch dist.
between Wrist Left
Stim. Sites
No Stim.
Record

Motor Action Potential

Increased Latency Lat. typ. 2 ms
Stim.
(nl < 5 ms)
Latency St Mark !s Amp. 1 mV
Others Graphics with Amplitudes and Durations Pudendal Electrode

Sensory Conduction Dorsal Nerve Penis

Recording across
the base of penis

Stimulation
Sensory Potential
Penil Nerve Typ. Lat. 1,5 ms EMG - T/A - MUP - DECREMENT - SFU - MACRO
across gland
Amp. 5 !V
CV. 40 m/s

6
 Electromyography Pathologies in Muscle STOP

Normal
Striated Muscle Concentric Needle
or Same Effort, Same Muscle,
Motor Unit
Monopolar Needle Different Pathologies

1
Neuropathy
2
CNEMG

Myopathy
Recruitment EMG
100 ms

Motor Unit Potentials

(1) and (2) 20 ms
Myasthenia
Ground
5 ms 1 2

Neuropathy - Reinnervation Myopathy

Normal Neuropathy Reinnervation Normal Myopathy

Cells Degeneration
Smaller Fibers
More Tissue

Motor Conduction :
Latency OK
Low Amplitude

cn EMG cn EMG Duchenne Myopathy

Pathologies ( Classification ) EMG TESTS Versus Pathologies

CENTRAL WEAKNESS
Spinal Cord - Brain EEG - EP
CENTRAL WEAKNESS
Spinal Cord - Brain

Pron. Myopathy Complete Denerv.

EMG - NSS
NEUROPATHY

NEUROPATHY

++
Axon - Myelin or both

Axon - Myelin or both

MYOPATHY
MYOPATHY

NORMAL NORMAL
Muscle Fibers
Muscle Fibers

EMG - T/A - MUP

Loss of MU
+

Decrement
Partial Denerv.
Mod. Neuro.
MYASTHENY MYASTHENY
Neuromuscular Junction Neuromuscular Junction

7
 EMG - Recruitment STOP
Motor Unit Potential (MUP)
Single Potential, Phases < 3
EMG Needles :
< 50 ms ( 20 Hz ) Polyphasic Potential, Phases > 3
- Disposable Concentric
- Disposable Monopolar
Segment Turns

MAXIMUM EFFORT Baseline Crossing

Amplitude Phase
Satellite

Amplitude depends of Muscle, > 3 mV

DCN EMG

Loudspeaker
Group of Muscle Fibers 7 Turns
Auditory control of :
generate MUPs. 3 Phases
- Resting Silence
Different Fibers
Rising Time
6 Segments
- Focused in the muscle
- Frequency Firing different MUPs. Duration

MUP Analysis STOP

Turns/Amplitude
•! 1 seconde EMG signal
Polymyositis
Myopathy tib ant
•! Concentric or Monopolar Needle
Amplitude
•! Few sites in same muscle
•! 20 measurments at diff. force Turns
Multi-MUP - Averaging Manual Selection Single - Triggering
•! Number of Turns > 100 !V
•! Mean Amplitude of Turns

T2
A = Amplitude Polio Sequele
S = Segment Neuropathy tib ant

S2 T4
S1
A2
A1
A3
S3
S4 Amplitude
A4

T3 Turns
•! Moderate Contraction
T1
•! Simple/Polyphasic Potentials Ratio T5
•! Amplitude Change in signal direction = Turn
Segment Amplitude > 100 !V
•! Duration

Short Segments / Amplitude / Activity Decrement Myasthenia Gravis - Lambert-Eaton

•! 500 ms EMG signal then x 2 Neuromuscular Junction
Amplitude Decrease >20% - Receptor number
•! NSS Number of Small Segments Receptors
•! UCA Upper Centile Amplitude Myopathy
1 ". 10
Small Segment
NSS Amplitude Duration Acetylcholine Released
Yes < 0,5 mV < 1,5 ms
Yes 0,5 > < 2mV < 3 ms Normal Myasthenia Gravis
No > 2 mV < 5 ms
Stim.
Amplitude Increase >90% - Calcium flux
Activity Neuropathy

Rec.

Sum of activity periodes Stimulation : Supra Maximal + 25% Normal Lambert-Eaton

in % of full IP
Train 10 Stimuli - Frequency 3 Hz

8
 Single Fiber EMG Macro EMG Application : Fiber density

Special Needle •! 4 - 5 insertions in 1 Triggering

A
the same muscle 2 2 EMG Channel Single Fiber EMG
A Jitter
•! Moderate contraction 1 2
B Single Fiber
B •! Minimum 20 potentials Needle Averaging
Normal Macro EMG
•! Analyse on 2 - 3 muscles

25!m MCD MSD

C C
4 Fibers
Biceps : 15,6 5,9
Tibialis ant. : 32,1 15.0 Concentric
Reinnervation 1 ms Needle

5 mm 1 2 Averaging 200 Potentials / each record

Trigger Recording 10 times in different position of SFN

100 ms

Multi-Channel EMG Oscilloscope Program EMG (Oscilloscope) Botox or Dysport Injection (ENT)

Walking Studies Non Focused In Muscle

Synchronization between
Agonist & Antagonist
45°
Muscles INJECTION
Vocal Cords

30° Botulique Toxin Injection

- Spasmodia Dysphonia (voiceless)
- Laryngeal Dyspnea (suffocation)
Special Needle :
EMG + Injection Channel

Auditory control of
Focused in the muscle
Recording Time : 20 seconds

H - Reflex Polyneuropathies
Tibial Nerve - Root S1 Radiculopathies

Stimulation H Max Ampl.

Dur. 1 ms
Int. from 0 mA
H to M Max.
M Max Ampl.

Increment
H Stim. step 0,2 mA

H - BLINK - T - BCR
Rec.

Latencies M : 10 ms H: 30 ms depend height

9
Bulbocavernous Reflex
Stimulation R1 R2
Penil Nerve

Current
Stimulation
Increased
Recording Needle

( Needle Electrode)

m. Bulbocavernous

Stimulation
Clitoral Nerve Recording Reflex SEP - VEP - BAEP - AEP - P300 - MEP - IOM
Latency R1
typ. 33 ms

Recording Surface Anal Sphincter

Somatosensory E.P. Upper Extremities Somatosensory E.P. Lower Extremities

N 7 cm Median Nerve N 7 cm Tibial Nerve

N20
C5S Fpz Fpz
Epc Epi L Fz R CPc-CPi C5S
L Fz R CPi-Fpz

C3 C4 5 cm Cz 5 cm
2 cm 2 cm P37
N18
C'3 C'4 CPi-Epc C'3 Cz-2 C'4
T12S CPz-Fpz

I P14 I P37
Stim. MS N34
N13 IC
C5S-Epc

Fpz-C5S P31
EP

LP

Epi-Epc T12S-IC

Stim. MI

SEP - Pudendal Nerve Motor E.P.

Magnetic Stimulation
Maglite Compact
Stimulation
Penil Nerve

Cz-2 - FPz

P40

Stimulation
Clitoral Nerve Descending
Record on Scalp with Scalp Needle
or Surface Electrode
Averaging : 200

FPz Ground
Latency P40 Motor
2 cm typ. 39 ms Trigger
Nerve
Cz-2 Record
(nl < 44 ms) Muscle

Keypoint

10
 Sympathetic Skin Response Autonomic

Stim.

20"

Rec.
Free Running : Oscilloscope Program
SSR - R:R INTERVALES - PELVIC

Sympathetic Skin Response Autonomic R - R Interval Autonomic Heart Rate

R
R R

P T

Stim. Rec. Q
S

5"

Synchronized Recording : Program SSR

Pelvic SSR Sexology Studies Autonomic Pelvic Responses Sphincters

Ring Electrode Stimulation

mounted on Bladder Neck or
Foley catheter
Urethral Mucous

Recording :
Surface electrodes
Across Penis

Typ. Lat. 1,5 s

Amplitude : 2 - 3 mV
Recording Junction Reflex
Recording :
Surface electrodes
Stimulation Median nerve, Intensity 3 times
sensory threshold.
Averaging : 50 to 200
Act. Vaginal Lips Typ. Lat. 55 - 70 ms
Ref. Pelvic area Recording:
Anal Plug Electrode

11
 Disposable EMG Needles and Cables Surface Electrodes Disposable
Disposable Concentric Needles - 25 pcs 0,7mm GEL 9015B4111
8 cm
Orange
9013L0202 Pack 50 pcs - Adhesive Area 7 x 4 mm
9013S0011 25mm Ø 0.3mm
Green 9013S0211 Pack 12 pcs - Pre-Gelled Adhesive Area 20 x 15 mm
9013S0021 25mm Ø 0.45mm 8 cm
9013C0011 Length 1 m Blue Area 20 x 15 mm
9013S0031 37mm Ø 0.45mm
15 cm
9013C0021 Length 2 m Red 9013S0221 Pack 12 pcs - Pre-Gelled Adhesive
9013S0041 50mm Ø 0.45mm Neuro-Urology Active & Reference Area 26 x 20 mm
Yellow
9013S0051 75mm Ø 0.45mm
9021S0231 Pack 12 pcs - Pre-Gelled Adhesive
15 cm

Neuro-Urology Ground

Disposable Monopolar Needles - 48pcs 10 cm

9013S0241 Pack 12 pcs - Pre-Gelled "Blue Dot" Area 9 x 6 mm

2 mm Area 9 x 6 mm
Ref. 9013R0801 20mm Ø 0.35mm 1,5mm Female
9013P0812 Length 1 m Ref.
50 cm
9013R0811 20mm Ø 0.35mm
9013R0821 30mm Ø 0.35mm 9013L0452 Pack 12 pcs - Pre-Gelled "Blue Dot"
Act.
9013P0722 Length 76 cm 9013R0841 30mm Ø 0.45mm
Act. 9013R0851 40mm Ø 0.45mm Tab for Cable
1,5 mm 9013R0861 50mm Ø 0.45mm 9013S0231 Pack 100 pcs Diam. 10 mm
Female CARETM 610 with Clip
9013R0871 60mm Ø 0.45mm
9013R0881 75mm Ø 0.45mm TM CARE is a trademark of Kendall, Chicopee, MA

HushTM Cables and Electrodes

0,7 mm Connector
9013L0202
9013C0111 Length 1 m 9013S0211
9013C0121 Length 2 m 9013S0241
9013R0312
DIN Connectors

9013L0701
9013C0131 Length 1 m
9013C0141 Length 2 m 9013L1701
Disposable
Sensory Needle
Autoclaveable
9013C0211 Length 1 m Sensory Needle
9013C0221 Length 2 m

9013S0231
9013C0231 Length 1 m

Clip Connector

12