The Median Nerve

Giuliano Gentili
Mario Di Napoli
The
Median Nerve
Motor Conduction Studies
123
The Median Nerve
Giuliano Gentili • Mario Di Napoli
The Median Nerve

Giuliano Gentili Mario Di Napoli
Neurological Service Neurological Service
S. Camillo de’ Lellis General Hospital S. Camillo de’ Lellis General Hospital
Rieti Rieti
Italy Italy
ISBN 978-3-319-10472-0 ISBN 978-3-319-10473-7 (eBook)

DOI 10.1007/978-3-319-10473-7
Springer Cham Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014957639
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To my mother, who taught me to love and to wait.
To my wife Maria Carla, inspiring muse and model for this book and my life.
To my little son Giulio, with the hope that he knows to wait the wonderful
things that life will reserve for him.
Giuliano
“Well, I must endure the presence of two or three caterpillars

if I wish to become acquainted with the butterflies.
It seems that they are very beautiful…”
The little prince, Antoine de Saint-Exupéry
To all persons that are in my heart…

They know where they are, so it is not necessary to remember
and thank them here for their love, patience, devotion, help, support…
and to a lasting friendship that permitted to complete this work overcoming
difficulties, exertions, troubles, and many days without sleeping…
all over the years of this long and hard work.
Thank you Giuliano; without your efforts, this work would not have come
to light.
Mario
Contents
List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Synoptic Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Motor Conduction Studies Index (by Practical Criteria) . . . . . . . . . . . . . . . . . . . . . . xvii
Part I Motor Conduction Studies: Median Nerve
M1 Elbow, Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
M2 Wrist, Elbow – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
M4 Wrist, Elbow, Axilla – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
M5 Axilla, Elbow, Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
M7 Wrist, Below Elbow, Elbow, Above Elbow, Erb’s Point – Hand . . . . . . . . . . . . 29
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
M10 Wrist, Elbow, Axilla – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
M13 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
vii
viii Contents
M14 Wrist, Elbow, Axilla, Erb’s Point – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
M15 Elbow, Wrist, Palm – Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
M16 Elbow, Wrist, Palm – Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
M17 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
M19 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
M20 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
M21 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
M22 Wrist, Palm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
M23 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
M24 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
M25 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
M26 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
M27 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
M28 Wrist, Palm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
M30 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
M31 Wrist, Elbow, Midarm, Axilla – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
M32 Palm, Wrist, Elbow – Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
M33 Wrist, Forearm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
M34 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Contents ix
M35 Wrist, Palm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
M36 Wrist, Forearm, Elbow – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Part II Motor Conduction Studies: Anterior Interosseous Nerve
(motor branch of the median nerve)
A1 Above Elbow, Below Elbow – Distal Forearm. . . . . . . . . . . . . . . . . . . . . . . . . . . 229

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
A2 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
A3 Elbow – Distal Forearm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
A4 Elbow – Distal Forearm, Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
A5 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
List of Abbreviations
BMI Body mass index

CTS Carpal tunnel syndrome
CMT Charcot-Marie-Tooth disease
CIDP Chronic inflammatory demyelinating polyradiculoneuropathy
CMAP Compound muscle action potential
DML Distal motor latency
EMG Electromyography
ENG Electroneurography
GBS Guillain-Barré syndrome
MNCV Motor nerve conduction velocity
PML Proximal motor latency
SNAP Sensory nerve action potential
SNCV Sensory nerve conduction velocity
Unit Description
cm Centimetre
Hz Hertz
kHz Kilohertz
m/s Meter per second
μs Microsecond
μV Microvolt
mA Milliampere
ms Millisecond
mV Millivolt
xi
Introduction
The median nerve is the most studied nerve during the daily routine activities in each clinical
neurophysiopathological laboratory not only for the frequency of the pathologies of which it is
affected like the carpal tunnel syndrome (CTS) but also for the simplicity to investigate that
makes it a preferred nerve in multiple disease studies. With the first studies of Dawson and
Scott (1949) and Dawson (1956) through the propagation of electrical impulses along the
median and ulnar nerves and the recording of the peripheral nervous responses by means of
electrodes applied to the skin, the knowledge process about nerve conduction in man kicked
off in the following years a number of validation studies of the electroneurographic method
allowing to determine normal and pathological ranges. The electroneurography (ENG) was
born in those years as a diagnostic method. It was initially used in the diagnosis of compressive
diseases such as the CTS or in the definition of the diabetic neuropathy, and its utility was
gradually extended to diagnose many other diseases.
This volume represents a chronological path that allows the reader to move from pilot stud-
ies on the peripheral nerve conduction in humans during the 1950s to the most recent scientific
evidence, a journey through the first conduction motor studies of the 1960s, the techniques of
motor nerve conduction to the abductor pollicis brevis (APB) muscle with added palm stimu-
lation firstly described in the second half of the 1970s, the studies of the flexor carpi radialis
(FCR) muscle introduced in the 1980s, the median-ulnar nerve motor comparative techniques
proposed in the 1990s, and the more recent conduction studies described since the early 2000s
to today.
The main attention has been given to techniques that have shown higher sensitivity and
specificity in the diagnosis of CTS and for this reason are widely used in clinical practice like
the comparison of latencies of motor responses from the second lumbrical (2 L) and interosse-
ous (INT) muscles by stimulation at the wrist.
More than 40 techniques are described in this text-atlas including methods from the original
rationale and variants and organized according to practical criteria for easy reference; all of the
tests are presented by facilitated pictures in order to make it easy to understand and follow a
reproduction of every method. There have been reports of the parameters and settings used by
the authors and the normative and pathological values cited in the entries and present in subse-
quent articles in order to enrich and update the evidence. With particular attention, it has been
reproduced in every test in the laboratory so as to present iconographically the signals acquired
in the normal subject; an effective diagnostic utility of each test was then evaluated in several
diseases and in varying degrees of the same pathology as in the CTS. All traces acquired, both
in normal and pathological subjects, are shown with different settings to adapt easily and be
more accessible to the different situations that may arise in clinical practice.
The execution of the techniques described in the manuals of electroneurography on the
market is not always able to provide a complete answer to the many clinical questions. The
nonuse of the correct technique because it is not known, incorrect use of a technique, and
the absence of normative and pathological values represent all factors that can alter the diag-
nostic power of the electroneurographic examination.
From this premise volume was born a systematic monograph of motor electroneurographic
techniques focusing on the median nerve with the aim to validate the various methods described
xiii
xiv Introduction
in the literature since the early articles of the 1950s to the present in order to define the feasibil-
ity, reproducibility, and actual usefulness in the diagnostic field. Some of these techniques,
abandoned over the years, still show their worth and deserve to be known in the clinical setting,
still not having found the right recognition in any of the manuals on the market. This text-atlas,
which is the result of over 5 years of hard work, comes from our daily neurophysiopathological
experience; we have described in detail the technique, standardization, and normal and patho-
logical values derived from the original articles and the subsequent literature as never seen in
any other work before.
We therefore hope that this text, which is useful to both the novice and the experienced
specialist, is always in a laboratory of electromyography as a valid means of ease of reference
for the study on the field.
Synoptic Table
C8
T1
R
Abductor pollicis brevis (APB)
Lower trunk Digit I

Median
nerve Medial cord
R
A
8 cm
G
– – +
+
Digit V
S1
S2 (wrist)
(palm)
A Active electrode
R Reference electrode
G Ground electrode
– Cathode
+ Anode
R Recording site
S Stimulating site
Fig. 1 Motor conduction study to the abductor pollicis brevis (APB) muscle, stimulation of the wrist (S1) and
on the palm (S2)
xv
xvi Synoptic Table
Digit I Anterior interosseous nerve

(AIN)
• FDP
FPL
PQ •
PQ • PT
• •
•
APB •
OP FCR
Digit I
• PL
•
•
1L Upper trunk C5
• • FDS C6
C7
Lateral cord C8
T1
FPB Middle trunk
Lower trunk
Digit V 2L Median
nerve Medial cord
Muscle Branch Cord Trunk Root

PT Pronator teres Median Lateral Upper/middle C6-C7
FCR Flexor carpi radialis Median Lateral Upper/middle C6-C7-C8
FDP Flexor digitorum profundus Anterior interosseous Lateral/medial Middle/lower C7-C8
FPL Flexor pollicis longus Anterior interosseous Lateral/medial Middle/lower C7-C8-T1
PQ Pronator quadratus Anterior interosseous Lateral/medial Middle/lower C7-C8-T1
PL Palmaris longus Median Lateral/medial Middle/lower C7-C8-T1
FDS Flexor digitorum sublimis Median Lateral/medial Middle/lower C7-C8-T1
APB Abductor pollicis brevis Median Medial Lower C8-T1
OP Opponens pollicis Median Medial Lower C8-T1
FPB Flexor pollicis brevis Median Medial Lower C8-T1
1L First lumbrical Median Medial Lower C8-T1
2L Second lumbrical Median Medial Lower C8-T1
Fig. 2 Muscles innervated by the median nerve (forearm and hand)

Motor Conduction Studies Index
(by Practical Criteria)
Median Nerve
Distal latency studies
M1- Technique from median thenar muscle; stimulation of the elbow and of the wrist
M2- Technique from abductor pollicis brevis and opponens pollicis muscles; stimulation
of the wrist and of the elbow
M3- Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the
elbow
M4- Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow and
of the axilla
M5- Technique from abductor pollicis brevis muscle; stimulation of the axilla, elbow
and of the wrist
M6- Technique from opponens pollicis muscle; stimulation of the wrist and of the elbow
M7- Technique from abductor pollicis brevis muscle; from abductor pollicis brevis and
opponens pollicis muscles; stimulation of the wrist, below elbow, elbow, above elbow
and of the Erb’s point
M8- Technique from median thenar muscle; stimulation of the wrist and of the elbow
elbow
M10- Technique from median thenar muscles; stimulation of the wrist, elbow and of the
axilla
M11- Technique from opponens pollicis muscle; stimulation of the wrist and of the
elbow
elbow
M13- Technique from abductor pollicis brevis and abductor digiti minimi muscles; stim-
ulation of the wrist
M14- Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow,
axilla and of the Erb’s point
M16- Technique from abductor pollicis brevis muscle; stimulation of the elbow, wrist
and on the palm
M20- Technique from second lumbrical and the abductor pollicis brevis muscles; stimu-
lation of the wrist
M23- Technique from abductor pollicis brevis and first dorsal interosseous muscles;
stimulation of the wrist
M24- Technique from abductor pollicis brevis and abductor digiti minimi muscles;
M25- Technique from first lumbrical and the abductor pollicis brevis muscles; stimulation
of the wrist
xvii
xviii Motor Conduction Studies Index (by Practical Criteria)
M27- Technique from second lumbrical and interosseous muscles; stimulation of the
wrist
elbow
M30- Technique from median thenar and ulnar thenar muscles; stimulation of the
wrist
M34- Technique from medial thenar motor muscle; stimulation of the wrist
M35- Technique from abductor pollicis brevis muscle; stimulation of the wrist and on
the palm
M36- Technique from second lumbrical muscle; stimulation of the palm, distal forearm
and of the elbow
Wrist-palm studies
M15- Technique from opponens pollicis muscle; stimulation of the elbow, wrist and on
the palm
and on the palm
the palm
the palm
and of the elbow
Forearm velocity studies
mid-arm and of the axilla
M32- Technique from abductor pollicis brevis muscle; stimulation on the palm, wrist
and of the elbow
Amplitude ratio studies
the palm
the palm
Median-median comparative studies
lation of the wrist
M25- Technique from first lumbrical and the abductor pollicis brevis muscles; stimula-
tion of the wrist
Median-ulnar comparative studies
Motor Conduction Studies Index (by Practical Criteria) xix
wrist
M30- Technique from median thenar and ulnar thenar muscles; stimulation of the wrist
M34- Technique from medial thenar motor muscle; stimulation of the wrist
F-wave studies
axilla
M12- Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the elbow
M21- Technique from abductor pollicis brevis muscle; stimulation of the wrist
Residual latency (RL), sensory-motor index (SMI) and terminal latency

index (TLI) studies
and of the wrist
elbow
the palm
elbow
elbow
Needle recording studies
elbow
of the axilla
elbow
M19- Technique from flexor carpi radialis muscle; stimulation of the elbow
M24- Technique from abductor pollicis brevis and abductor digiti minimi muscles;
Forearm: flexor carpi radialis (FCR) muscle studies
xx Motor Conduction Studies Index (by Practical Criteria)
Hand: abductor pollicis brevis (APB) muscle studies
elbow
of the axilla
and of the wrist
of the wrist, below elbow, elbow, above elbow and of the Erb’s point
elbow
elbow
axilla and of the Erb’s point
the palm
and on the palm
M21- Technique from abductor pollicis brevis muscle; stimulation of the wrist
the palm
the palm
elbow
mid-arm and of the axilla
M32- Technique from abductor pollicis brevis muscle; stimulation of the palm, wrist and
of the elbow
elbow
the palm
Hand: median thenar (MT) muscle studies
M1- Technique from median thenar muscle; stimulation of the elbow and of the wrist
axilla
M13- Technique from median thenar and ulnar hypothenar muscles; stimulation of the
wrist
M30- Technique from median thenar and ulnar thenar muscles; stimulation of the wrist
Motor Conduction Studies Index (by Practical Criteria) xxi
Hand: opponens pollicis (OP) muscle studies
M6- Technique from opponens pollicis muscle; stimulation of the wrist and of the elbow
elbow
Hand: first lumbrical (1L) muscle studies
M25- Technique from first lumbrical and the abductor pollicis brevis muscles; stimula-
tion of the wrist
Hand: second lumbrical (2L) muscle studies
lation of the wrist
wrist
and of the elbow
Anterior interosseous nerve (motor branch of the median nerve):
Forearm: flexor pollicis longus (FPL) muscle studies
A2- Technique from flexor pollicis longus muscle; stimulation of the elbow
A5- Technique from flexor pollicis longus muscle; stimulation of the elbow
Forearm: pronator quadratus (PQ) muscle studies
A1- Technique from pronator quadratus muscle; stimulation above the elbow and below
the elbow
A3- Technique from pronator quadratus muscle; stimulation of the elbow
A4- Technique from pronator quadratus and from abductor pollicis brevis muscles;
stimulation of the elbow
Part I
Median Nerve
Elbow, Wrist – Hand
Surface Recording Technique,
M1
Study from Median Thenar (MT) Muscle
Original Settings Sensitivity was 5 mV/division; sweep fibers to the small muscles of the hand had a higher threshold
speed, low-frequency filter, high-frequency filter, duration of to electrical stimulation than that of the more excitable sen-
pulse, and the machine used were not specified. sory afferent fibers from the fingers.
Position This study was performed in the supine position, Measurements Distal latency (ms) was measured from the
with the subject lying on a comfortable couch with the arm stimulus artifact to the initial deflection of the compound
slightly abducted and supported at three or four places by muscle action potential (CMAP). Authors adjusted the
broad webbing straps hung from the beam. recording electrodes positions until the nerve action poten-
tials had as near as possible the same shape whether stimu-
Recording Motor responses were recorded from median lated at the elbow or at the wrist. The motor conduction times
thenar (MT) muscle by surface electrodes (Fig. 1). Author were taken as the difference in time between the correspond-
used chloride-coated silver plates 16 by 24 mm, held on ing points on the action potentials recorded at the hand by
with adhesive tape and made contact through electrode stimulation at the elbow and at the wrist. No control of limb
paste. The active (A) electrode was placed on the motor temperature was attempted. Normal values (Table 1) were
point of the MT muscle, the reference (R) was placed dis- obtained from 10 median nerves of healthy subjects.
tally to the distal interphalangeal joint [1]. Distances
between the recording and stimulating electrodes were not Table 1 Reference values
fixed. The ground (G) electrode was placed on the dorsum Normal values [1] Mean
of the hand; the figure shows the ground electrode placed on Wrist-elbow, motor conduction time (ms) 4.76
the forearm.
Stimulation For measuring the motor conduction time from Comment

the elbow to the wrist, the author used surface electrodes Dawson [1] observed that the motor conduction time
(spherical pads 15 mm in diameter). The first stimulation derived from the first rise of the muscle action poten-
was performed at the elbow (S1); the second was performed tials was probably related to the fastest conducting
at the wrist (S2), both on the course of the median nerve. The motor fibers, and the fastest conducting motor fibers
stimulating cathode (−) was placed proximal to the recording have a lower conduction velocity than the fastest con-
site, the anode (+) was positioned distally [1]. ducting sensory fibers – a difference consistent with
Author used a different intensity of stimulation in order to the higher threshold of the motor fibers to electrical
study the threshold of excitability of nerve fibers; supramaxi- stimulation.
mal stimulation was mainly used. He showed that the motor
G. Gentili, M. Di Napoli, The Median Nerve: Motor Conduction Studies, 3

DOI 10.1007/978-3-319-10473-7_1, © Springer International Publishing Switzerland 2015
4 M1 Elbow, Wrist – Hand
Biceps brachii
(BB)
+
–
R
Median thenar (MT)
S1
(elbow)
G
Digit I
+
R A –
C8
T1
S2
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (elbow, wrist – MT muscle):
Median - (MT) Median - (MT)

2
1 3 1 3
Elbow 1 5 Elbow 1
5
4
50 ms 5 mV 41 mA 50 ms 10 mV 41 mA
4
1 3 1 3 5
5 Wrist 2 Wrist 2
4
50 ms 5 mV 41 mA 50 ms 10 mV 41 mA
4
Sensitivity 5 mV/div, sweep speed 5 ms/div Sensitivity 10 mV/div, sweep speed 5 ms/div
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the MT muscle, stimulation of the elbow (upper trace) and of the
wrist (lower trace)
Reference 5
Reference
1. Dawson GD (1956) The relative excitability and conduction veloc-
ity of sensory and motor nerve fibres in man. J Physiol 131:
431–451
Wrist, Elbow – Hand
Needle Recording Technique,
M2
Study from Abductor Pollicis Brevis (APB)
and Opponens Pollicis (OP) Muscles
Original Settings Sweep speed was 1–5 ms/division; sensi- between the wrist-stimulating electrode (-) and the record-
tivity, low-frequency filter, high-frequency filter, duration of ing needle in the muscle varied between 5 and 8 cm in
pulse, and the machine used were not specified. different subjects. The second stimulation (S2) was deliv-
ered at the elbow, just medial to the tendon of the biceps
Position This study was performed in the supine position. brachii (BB) muscle (on the antecubital fossa, just lateral
to the brachial artery). The anode was proximal. The dis-
Recording The recording electrode (A) was a coaxial nee- tance between the wrist and the elbow-stimulating posi-
dle electrode inserted into the abductor pollicis brevis (APB) tions varied from 25 to 37 cm in different subjects. For
or opponens pollicis (OP) muscles (Figs. 1 and 2), halfway stimulation, author used an EEG electrode 1 cm in diam-
between the midpoint of the distal wrist crease and the mid- eter (cathode) and a large metal plate (anode) placed over
point of the first metacarpophalangeal joint [1]. The ground the upper arm. Stimuli were delivered through an isolat-
(G) electrode was positioned between the stimulating cath- ing transformer (100–150 μs duration), one per second.
ode and the recording needle electrode to diminish the stimu- Only supramaximal stimuli were used because, despite an
lus artifact in the records (the figure shows the ground increase in the intensity of the stimulus, no increase in the
electrode positioned on the forearm). compound muscle action potential (CMAP) amplitude
was observed.
Needle Insertion For the APB muscle, with the hand in a
neutral position to full supination, the recording needle elec- Measurements Distal latency (ms) of the CMAP was
trode was inserted on the lateral aspect of the base of the measured from the stimulus artifact to the onset of the
proximal phalanx of the thumb, using a medial-directed negative deflection of CMAP. The motor conduction time
approach just anterior to the bone at the midpoint of the first of the impulse between the wrist and the elbow stimu-
metacarpal bone. For the OP muscle, with the hand in a neu- lation sites was obtained by subtraction. The length of
tral position to full supination, the recording needle electrode nerve from the stimulating cathode in each situation to
was inserted obliquely at the midpoint of the first metacarpal the recording needle-electrode was estimated by surface
shaft just lateral to the APB muscle. measurement. Symmetrical points of stimulation and
recording were compared in both arms. No control of
Stimulation The median nerve was stimulated at the temperature was attempted. Normal values (Table 1) were
wrist (S1) and at the elbow (S2). The first stimulation (S1) obtained from 25 control subjects comprising 10 normal
was delivered at the wrist, between the tendons of the subjects, 5 patients with motor neuron disease, 10 patients
flexor carpi radialis (FCR) and the palmaris longus (PL) with various muscular diseases. Pathological values
muscles (above the proximal crease on the flexor surface (Table 2) were obtained from 15 patients with suspected
of the wrist). The anode was proximal [1]. The distance carpal tunnel syndrome (CTS).

8 M2 Wrist, Elbow – Hand
Biceps brachii
(BB)
R +
Abductor pollicis brevis (APB) –
S2
G (elbow)
Digit I
•
+
–
C8
T1
S1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (wrist, elbow – APB muscle):
2 Median - (APB) 2 Median - (APB)
1 3 5 1 3 5
Wrist 1 Wrist 1
50 ms 1 mV 65 mA 30 ms 1 mV 65 mA
4 4
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
50 ms 1 mV 91 mA 30 ms 1 mV 91 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, stimulation of the wrist (upper trace) and of the
elbow (lower trace)
M2 Wrist, Elbow – Hand 9
Biceps brachii
(BB)
R
+
Opponens pollicis (OP) –
S2
(elbow)
G
Digit I
•
+
–
C8
S1 T1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (wrist, elbow – OP muscle):

2 Median - (OPP) 2 Median - (OPP)
1 4 1 4
Wrist 1 Wrist 1
50 ms 5 mV 22 mA 30 ms 5 mV 22 mA
3 3
2 2
1 4 1 4
Elbow 2 Elbow 2
50 ms 5 mV 22 mA 30 ms 5 mV 22 mA
3 3
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the OP muscle, stimulation of the wrist (upper trace) and of the
elbow (lower trace)
Table 1 Reference values

Normal values [1] Range Comment
Wrist-APB (or wrist-OP), distal latency (ms) 3–5 For Simpson [1], the investigation was not designed to test
Elbow-APB (or elbow-OP), distal latency (ms) 8–12 the reliability of these changes as a diagnostic examination
and the incidence of positive findings in the small number
of patients investigated could be of value as a confirmatory
Table 2 Reference values test. In 11 of the 15 patients in whom the carpal tunnel
syndrome was thought to be present, the latency of response
Pathological values [1] Range
was significantly increased (up to 14 ms at the wrist) on one
Wrist-APB (or wrist-OP), distal latency (ms) 3.5–14
Elbow-APB (or elbow-OP), distal latency (ms) 7.5–20
or both sides (Figs. 3 and 4). Calculation showed that the
delay could be entirely accounted for by slowed conduc-
tion distal to the wrist stimulation site, probably related to
physiological abnormality in the carpal tunnel or delay in
neuromuscular transmission. Owing to the physical limita-
tions, it was impossible to decide between these alterna-
tives by stimulation distal to the carpal tunnel.
Pathological waveform (wrist, elbow – APB muscle)
Median - (APB) Median - (APB)

2
1 3 5 1 3 5
Wrist 1 4 Wrist 1
4 50 ms 2 mV 100 mA 30 ms 5 mV 100 mA
1 3 5 1 3 5
Elbow 2 4 Elbow 2
4 50 ms 2 mV 100 mA 30 ms 5 mV 100 mA
Onset latency (wrist – APB): 7.20 ms; Onset latency (elbow – APB): 11.05 ms; Peak latency (wrist – APB): 9.20 ms; Peak latency
(elbow – APB): 13.60 ms; Onset to peak amplitude (wrist – APB): 5.6 mV; Onset to peak amplitude (elbow – APB): 5.5 mV; Peak to
peak amplitude (wrist – APB): 6.7 mV; Peak to peak amplitude (elbow – APB): 6.6 mV; MNCV (elbow – wrist): 51.9 m/s
Fig. 3 Compound muscle action potentials (CMAPs) recorded from the APB muscle in very severe CTS – grade 5 by Bland’s CTS classification
scale [2], stimulation of the wrist (upper trace) and of the elbow (lower trace)
References 11
Pathological waveform (wrist, elbow – OP muscle)

Median - (OPP) Median - (OPP)
2
1 5 1 3 5
3 Wrist 1 Wrist 1
50 ms 2 mV 68 mA 4 30 ms 5 mV 68 mA
4
1 3 5 1 3 5
Elbow 2 Elbow 2
4
50 ms 2 mV 88 mA 30 ms 5 mV 88 mA
4
Onset latency (wrist – OP): 6.60 ms; Onset latency (elbow – OP): 11.10 ms; Peak latency (wrist – OP): 9.10 ms;Peak latency (elbow –
OP): 13.65 ms; Onset to peak amplitude (wrist – OP): 5.7 mV; Onset to peak amplitude (elbow – OP): 5.6 mV; Peak to peak amplitude
(wrist – OP): 8.0 mV; Peak to peak amplitude (elbow – OP): 7.76 mV; MNCV (elbow – wrist): 48.9 m/s
Fig. 4 Compound muscle action potentials (CMAPs) recorded from the OP muscle in very severe CTS – grade 5 by Bland’s CTS classification
References
1. Simpson JA (1956) Electrical signs in the diagnosis of carpal tunnel
and related syndromes. J Neurol Neurosurg Psychiatry 19:275–280
2. Bland JDP (2000) A neurophysiological grading scale for carpal
tunnel syndrome. Muscle Nerve 23:1280–1283
M3
Study from Abductor Pollicis Brevis (APB) Muscle
Original Settings Sensitivity was 2 mV/division, sweep For stimulating cathodes (−), authors used EEG electrodes
speed was 1–5 ms/division, duration of pulse was 70–100 μs 1 cm in diameter [1]. The anode (+) was a plate electrode
and the machine used was a “stanco” double-channel elec- 2.5 cm × 5 cm placed over the flexor surface of the forearm or
tromyograph; low-frequency filter and high-frequency filter over the deltoid insertion; these anode positions were chosen
were not specified. for convenience and did not affect nerve conduction time. In
measurements of maximum conduction velocity, an isolating
Position This study was performed in the supine position. transformer was used for stimulation (on 77 subjects, authors
used a brief condenser discharge with a time constant of
Recording The recording electrode (A) was a coaxial nee- 70 μs; on 73 subjects, they used a rectangular pulse of 100 μs
dle electrode inserted into the abductor pollicis brevis (APB) duration).
muscle (Fig. 1), halfway between the midpoint of the distal
wrist crease and the midpoint of the first metacarpophalan- Measurements Distal latency (ms) of the compound mus-
geal joint [1]. In each case, the position of the needle tip in cle action potential (CMAP) was measured from the stimu-
the muscle was adjusted until the earliest response to a given lus artifact to the onset of the negative deflection of
stimulus was found and care was taken to ensure that the CMAP. The motor conduction time for the segment of nerve
initial phase of the evoked potential was similar in appear- between the two stimulating cathodes (wrist and elbow) was
ance for both proximal and distal stimuli. The ground (G) then obtained by subtraction of the shorter from the longer
position was not mentioned in the text; it can be placed figure. The length of nerve from the stimulating cathode in
between the stimulating cathode and the recording needle each situation to the recording needle electrode was esti-
electrode to diminish stimulus artifact in the records (figure mated by surface measurement. Motor nerve conduction
shows ground positioned on the forearm). velocity (MNCV) was calculated in the elbow–wrist (fore-
arm) segment and it was measured in meter per second (m/s).
Needle Insertion For the APB muscle, with the hand in a No control of temperature was attempted; all tests were per-
neutral position to full supination, the recording needle elec- formed in a warm room with the subject lying on a couch and
trode was inserted on the lateral aspect of the base of the covered with blankets. In a few subjects with cold hands, the
proximal phalanx of the thumb, using a medial-directed limbs to be tested were immersed in hot water for 5 or 10 min
approach just anterior to the bone at the midpoint of the first before the session. Normal values (Table 1) were obtained
metacarpal bone. from 25 control subjects comprising healthy subjects work-
ing in laboratory and patients presenting isolated peripheral
Stimulation The median nerve was stimulated at the wrist nerve lesions (age range 18–65 years). Subjects were divided
(S1) and at the elbow (S2). The first stimulation (S1) was into five age groups: 18–25 years (2 subjects), 26–35 years
delivered at the wrist, between the tendons of the flexor carpi (6 subjects), 36–45 years (6 subjects), 46–55 years (8 sub-
radialis (FCR) and palmaris longus (PL) muscles (2–3 cm jects), and 56–65 years (3 subjects).
above the wrist crease). The anode was proximal. The sec-
ond stimulation (S2) was delivered at the elbow (3–5 cm
above the elbow). The anode was proximal. The length of Table 1 Reference values
nerve between the two points stimulated was estimated by Normal values [1] Mean ± SD Range
surface measurement and was usually between 25 and 30 cm. Wrist-APB, MNCV (m/s) 57.2 ± 4.2 51.8–67.1

Biceps brachii
(BB)
R +
3 – 5 cm
S2
(elbow)
G
Digit I
+
• –
C8
S1 T1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord

2 2
1 3 5 1 5
Wrist1 3 Wrist 1
50 ms 5 mV 37 mA 30 ms 5 mV 37 mA
4 4
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
50 ms 5 mV 39 mA 30 ms 5 mV 39 mA
4 4
elbow (lower trace)
Reference 15
Reference
1. Thomas PK, Sears TA, Gilliatt RW (1959) The range of conduction
velocity in normal motor nerve fibres to the small muscles of the
hand and foot. J Neurol Neurosurg Psychiatry 22:175–181
Wrist, Elbow, Axilla – Hand
M4
Original Settings Sweep speed was 1–5 ms/division; sensi- between the wrist and the elbow-stimulating positions varied
tivity, low-frequency filter, high-frequency filter, duration of from 25 to 30 cm in different subjects. The third stimulation
pulse, and the machine used were not specified. (S3) was in the axilla and the distance between the elbow and
axillary positions varied from 15 to 25 cm in different sub-
Position This study was performed in the supine position. jects. For stimulation, author used a pad electrode 1 cm in
diameter (cathode) and a metal plate (anode) placed over the
Recording The recording electrode (A) was a coaxial nee- anterior aspect of the forearm or the lateral aspect of the
dle electrode placed in the abductor pollicis brevis (APB) upper arm. Stimuli were delivered through an isolating trans-
muscle (Fig. 1), halfway between the midpoint of the distal former (100–150 μs duration), the stimulus intensity being
wrist crease and the midpoint of the first metacarpophalan- always such that a further increase did not alter the size of
geal joint [1]. During stimulation, the position of the needle the muscle response (supramaximal stimulus).
was carefully adjusted to ensure that the earliest response to
the stimulus was obtained and that the initial deflection was Measurements Distal latency (ms) of the compound muscle
as sharp as possible and the same for all three positions of the action potential (CMAP) was measured from the stimulus
stimulating cathode. The ground (G) position was not men- onset to the onset of the negative deflection of the CMAP. Motor
tioned in the text; it can be placed on the dorsum of the hand conduction time for the segments of nerve between the three
or on the forearm (the figure shows the ground electrode cathode positions was obtained by subtraction. Motor nerve
positioned on the forearm). conduction velocity (MNCV) was calculated in the elbow–
wrist (forearm) and axilla–elbow (upper arm) segments; it was
Needle Insertion For the APB muscle, with the hand in a measured in meter per second (m/s). No control of tempera-
neutral position to full supination, the recording needle elec- ture was attempted. Normal values (Table 1) were obtained
trode was inserted on the lateral aspect of the base of the from 50 control subjects (age range 19–65 years) and patho-
proximal phalanx of the thumb (digit I), using a medial- logical values (Table 2) were obtained from 95 patients with
directed approach just anterior to the bone at the midpoint of suspected carpal tunnel syndrome (CTS).
the first metacarpal bone.
Stimulation The median nerve was stimulated at the wrist Comment

(S1), at the elbow (S2), and at the axilla (S3). The first stimu- In the series of 95 patients, Thomas [1] found slightly
lation (S1) was delivered at the wrist, between the tendons of more than two-thirds of the patients showed a latency
the flexor carpi radialis (FCR) and the palmaris longus (PL) from the wrist to the APB muscle that exceeded the
muscles (2–3 cm above the distal wrist crease). The anode upper limit of normal (Fig. 2). Of the patients in the
was proximal [1]. The distance between the wrist-stimulat- study who showed latencies that were within the nor-
ing electrode (−) and the recording needle in the muscle var- mal range, a few represent misdiagnoses. In the diag-
ied between 6 and 8 cm in different subjects. The second nosis of doubtful cases, the examination of the sensory
stimulation (S2) was delivered at the elbow, above the inter- nerve action potential obtained over the median nerve
condylar line and just medial to the tendon of the biceps bra- at the wrist on electrical stimulation of the index finger
chii (BB) muscle (on the antecubital fossa, just lateral to the has proved to be a valuable test [2].
brachial artery). The anode was proximal. The distance

18 M4 Wrist, Elbow, Axilla – Hand
+
S3 –
(axilla)
+
–
R
S2
G
(elbow)
Digit I
• +
–
C8
T1
S1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (wrist, elbow, axilla – APB muscle):

2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
30 ms 5 mV 100 mA 50 ms 5 mV 100 mA
4 4
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
4 30 ms 5 mV 100 mA 4 50 ms 5 mV 100 mA
2 2
1 3 1 3
5 5
4 Axilla 3 4 Axilla 3
30 ms 5 mV 100 mA 50 ms 5 mV 100 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, stimulation of the wrist (upper trace), of the
elbow (middle trace), and of the axilla (lower trace)
M4 Wrist, Elbow, Axilla – Hand 19
Table 1 Reference values Table 3 Reference values

Normal values [1] Mean ± SD Range Normal values [3] Mean ± SD
Wrist–APB, distal latency (ms) 3.8 ± 0.5 2.9–5.0 Axilla–elbow, MNCV (m/s) – 24 median nerves 67.9 ± 7.7
Elbow–wrist, MNCV (m/s) 57.5 ± 5.0 48.3–67.9 Elbow–wrist, MNCV (m/s) – 36 median nerves 56.1 ± 5.3
Axilla–elbow, MNCV (m/s) 59.8 ± 8.8 47.8–69.6 Axilla–wrist, MNCV (m/s) – 24 median nerves 60.5 ± 4.8
Normal values [3] Mean ± SD
Table 2 Reference values Axilla–elbow, negative peak amplitude (mV) – 24 18.5 ± 5.0
proximal electrode recordings
Pathological values [1] Mean ± SD Range Elbow–wrist, negative peak amplitude (mV) – 36 18.8 ± 4.9
Wrist–APB, distal latency (ms) – all patients 2.9–26.0 middle electrode recordings
Elbow–wrist, MNCV (m/s) – 47 patients 49.3 ± 6.9 36.0–65.9 Axilla–wrist, negative peak amplitude (mV) – 24 21.2 ± 4.8
Axilla–elbow, MNCV (m/s) – 22 patients 50.2 ± 8.9 34.0–63.2 distal electrode recordings
In 1964, Trojaborg [3] stimulated the median nerve at trodes for stimulation; author concluded there was no
three points along its course, at the level of the wrist (6–8 cm significant difference in conduction velocity when recording
above the leading-off electrode), the elbow (19–25 cm above (conduction velocities in the elbow–wrist segment was
the wrist), and the axilla (17–25 cm above the elbow). He 55.0 ± 5.6 m/s for surface electrodes and 53.5 ± 5.0 m/s for
measured the conduction velocities of the motor fibers of the needle electrodes, respectively) or stimulating (conduction
median nerve, using both surface and concentric needle elec- velocities in the axilla–elbow segment was 68.2 ± 1.8 m/s for
trodes for recording; also he tested surface and needle elec- surface electrodes and 67.5 ± 3.1 m/s for needle electrodes,
Pathological waveform (wrist, elbow, axilla – APB muscle):
2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
4 4
30 ms 10 mV 20 mA 50 ms 10 mV 20 mA
2 2
1 3 5 1 3 5
4 Elbow2 4 Elbow 2
30 ms 10 mV 20 mA 50 ms 10 mV 20 mA
2 2
1 3 5 1 3 5
30 ms 10 mV 16 mA 50 ms 10 mV 16 mA
Onset latency (wrist – APB): 6.40 ms; Onset latency (elbow – APB): 10.40 ms; Onset latency (axilla – APB): 13.05 ms; Peak latency
(wrist – APB): 8.80 ms; Peak latency (elbow – APB): 12.00 ms; Peak latency (axilla –APB):14.85 ms; Onset to peak amplitude (wrist –
APB): 12.5 mV-; Onset to peak amplitude (elbow – APB): 12.2 mV; Onset to peak amplitude (axilla – APB): 12.7 mV; Peak to peak
amplitude (wrist –APB): 16.1 mV; Peak to peak amplitude (elbow – APB): 15.5 mV; Peak to peak amplitude (axilla – APB): 16.8 mV;
MNCV (wrist – elbow): 57.5 m/s; MNCV (axilla –elbow): 56.6 m/s
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in severe CTS – grade 4 by Bland’s CTS
classification scale [4], stimulation of the wrist (upper trace), of the elbow (middle trace), and of the axilla (lower trace)
respectively; conduction velocities in the elbow–wrist seg- range of 36 subjects was 20–50 years, 8 subjects were over
ment was 54.5 ± 4.7 m/s for surface electrodes and 50 years, 3 subjects were below 20 years).
54.1 ± 3.6 m/s for needle electrodes, respectively; conduction
velocities in the axilla–wrist segment was 59.4 ± 2.8 m/s for
surface electrodes and 58.6 ± 2.7 m/s for needle electrodes, References
respectively) with needle and surface electrodes. The con-
duction velocity was significantly slower in the distal than in 1. Thomas PK (1960) Motor nerve conduction in the carpal tunnel
the proximal portion of the nerve; for author, the difference syndrome. Neurology 10:1045–1050
2. Gilliatt RW, Sears TA (1958) Sensory nerve action potentials in
in conduction velocities between the proximal and distal seg- patients with peripheral nerve lesions. J Neurol Neurosurg
ments was due to differences in temperature and the decrease Psychiatry 21:109–118
in fibers’ diameter from the proximal to the distal part of the 3. Trojaborg W (1964) Motor nerve conduction velocities in normal
nerve. The difference in conduction velocity between the subjects with particular reference to the conduction in proximal and
distal segments of median and ulnar nerve. Electroenceph Clin
right and left extremities in the same subject and the varia- Neurophysiol 17:314–321
tion from person to person averaged 5–10 %. For normal val- 4. Bland JDP (2000) A neurophysiological grading scale for carpal
ues (Table 3), author [3] studied 47 control subjects (age tunnel syndrome. Muscle Nerve 23:1280–1283
Axilla, Elbow, Wrist – Hand
M5
Original Settings Sensitivity was 5 mV/division; duration of voltage was raised above that necessary to elicit a just maxi-
pulse was 0.2–0.5 ms; sweep speed, low-frequency filter, high- mal response (usually less than 100 V). In normal individuals,
frequency filter, and the machine used were not specified. stimuli of greater duration than 0.5 ms frequently gave rise to
considerable pain in the distribution of the stimulated nerve
Position This study was performed in the supine position. or local skin pain at the site of stimulation. Care must be
taken in the spread of stimulation of concomitant activation
Recording The active electrode (A) was placed over the of nearby nerves (in the upper arm, the median and ulnar
belly (motor point) of the abductor pollicis brevis (APB) nerve lie close to one another) resulting in simultaneous
muscle (Fig. 1), halfway between the midpoint of the distal recording of contraction activity from nearby muscles.
wrist crease and the midpoint of the first metacarpophalan-
geal joint [1]. The reference (R) was placed slightly distal to Measurements Authors measured the “terminal conduc-
the first metacarpophalangeal joint, the proximal phalanx of tion time” and “nerve conduction velocity.” They explained
the digit I (thumb). The ground (G) electrode was placed on that by subtracting the conduction times obtained on stimu-
the forearm. lation of the same nerve at two different points, one obtains
the time taken for conduction of the nerve action potential
Stimulation The median nerve was stimulated at the axilla along the segment of the nerve between the two points, a
(S1), at the elbow (S2), and at the wrist (S3). The first stimu- true nerve conduction time. The distance between the two
lation (S1) was delivered at the axilla. The anode was proxi- points measured along the skin is a fairly accurate estimate
mal. The second stimulation (S2) was delivered at the elbow, of the length of the underlying segment of nerve. By divid-
on the antecubital fossa, just lateral to the brachial artery. ing the distance by time, the motor nerve conduction veloc-
The anode was proximal. The third stimulation (S3) was at ity (MNCV) along the nerve segment can be determined and
the wrist between the tendons of the flexor carpi radialis measured in meter per second (m/s). When conduction time
(FCR) and palmaris longus (PL) muscles, approximately at is specified as the time from the stimulus artifact to the ini-
5–9 cm from the active recording electrode [1]. The anode tial deflection, positive or negative, of the muscle potential,
was proximal. The arm was extended as much as possible this time and the corresponding calculated velocity refer
during stimulation. It was, however, difficult to stimulate in to the fastest conducting alpha motor fibers of the nerve.
the antecubital fossa without slight flexion (5–10°) at the This meaning was implicit in the term “nerve conduction
elbow, which made it possible to probe with the cathode velocity” when used in their paper. Velocities can be deter-
beneath the biceps tendon. Single-pulse, square-wave stim- mined along the proximal and distal segments or along the
uli of 0.2–0.5 ms duration were applied at half-second inter- whole nerve, for example, from the axilla to the wrist in the
vals. Effective stimulation voltages for just maximal case of the median nerve. The greater the distance and time,
responses were determined. These varied considerably for the more reproducible and accurate is the measurement.
normal individuals, both for the same and different sites of Because there was no practical way of making a direct clini-
stimulation, depending on variable skin resistances and the cal measurement of the true nerve conduction time along
amount of adipose, tendon, or muscle tissue overlying the the terminal branches of a peripheral motor nerve, for exam-
nerve at the point of stimulation. No fixed distances were ple, those distal to the wrist, “terminal conduction times”
reported in the article. In all normal controls, the stimulation (which include the motor end-plate delay), rather than the

22 M5 Axilla, Elbow, Wrist – Hand
+
S1 –
(axilla)
+
–
R
S2
G
(elbow)
Digit I
A +
R –
C8
T1
S3
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (axilla, elbow, wrist – APB muscle):

2 2
1 3 1 3
4 50 ms 5 mV 37 mA 4
30 ms 5m V 37 mA
2 2
1 3 1 3
5 Elbow 2 5 Elbow 2
4 50 ms 5 mV 37 mA 4
30 ms 5 mV 37 mA
2 2
1 3 1 3
5 Wrist 3 5 Wrist 3
4 50 ms 5 mV 37 mA 4 30 ms 5 mV 37 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, stimulation of the axilla (upper trace), of the
elbow (middle trace), and of the wrist (lower trace)
M5 Axilla, Elbow, Wrist – Hand 23
conduction velocities, have been reported for distal portions

of the median nerve. Hodes and associates [2] calculated Comment
“residual latencies” for normal ulnar and median nerves. Mavor and Libman [1] found that average conduction
The term “residual latency” refers to the difference between velocity for the proximal segments (axilla to elbow-
a measured terminal conduction time and an estimated time antecubital fossa) of 15 median nerves in 12 healthy
for propagation of the nerve action potential from the wrist subjects was 71.2 m/s (range 60.3–86.4 m/s); for the
to the motor end-plate, assuming the velocity of propaga- distal segments (elbow-antecubital fossa to wrist), they
tion to be the same in this terminal nerve segment as in a reported 60.1 m/s as average value (range 54.3–
more proximal segment of the nerve. This estimated time 65.0 m/s). The average of conduction velocities for the
is obtained by dividing the distance from the stimulation total length (axilla to wrist) of the same 15 median
point at the wrist to the active muscle-recording electrode nerves was 64.3 m/s (range 59.8–70.4 m/s) and the
by the nerve conduction velocity from the elbow to wrist. average terminal conduction time was 3.3 ms (range
Distal latency (ms) of the compound muscle action poten- 2.7–4.2 ms). Residual latencies were calculated for 8
tial (CMAP) was measured from the stimulus artifact to median nerves in 5 individuals and averaged 2.1 ms
the onset of the negative deflection of CMAP. No control (range 1.7–2.7 ms). Measurements of the MNCV in
of temperature was attempted. Each arm was in a slightly normal median nerves with the arm in full extension
different degree of extension during stimulation than dur- showed a proximo-distal gradient, velocity in proximal
ing measurement. Distances between the midpoints of each segments averaged some 10 m/s greater than that in dis-
stimulation site on the skin were measured to the nearest tal segments. Authors compared normal values obtained
millimeter. Normal values (Table 1) were obtained from 15 from 12 normal controls with motor conduction values
median nerves of 12 normal subjects (residual latency was from a sample of patients affected by chronic periph-
calculated from 8 nerves of 5 subjects). eral neuropathy; they found a marked decrease of the
conduction velocities of all nerves tested and increased
thresholds to stimulation. Frequently, in this group of
patients, authors observed prolonged duration and frag-
Normal values [1] Average Range mentation in CMAPs. In a small sample of patients (a
Axilla–elbow, MNCV (m/s) 71.1 60.3–86.4 total of four cases, two of which were bilateral) with
Elbow–wrist, MNCV (m/s) 60.1 54.3–65.0 suspected carpal tunnel syndrome (CTS), authors
Axilla–wrist, MNCV (m/s) 64.3 59.8–70.4 recorded prolonged median nerve terminal conduction
Wrist–APB, distal latency (ms) 3.3 2.7–4.2 times – range 5.0–18.7 ms (Fig. 2).
Wrist–APB, residual latency (ms) 2.1 1.7–2.7
24 M5 Axilla, Elbow, Wrist – Hand
Pathological waveform (axilla, elbow, wrist – APB muscle):

Median – (APB) Median – (APB)
2
1 3 5 1 3
50 ms 5 mV 14 mA 4
30 ms 2 mV 14 mA
2
1 3 5 1 3
4 Elbow 2 5 Elbow 2
50 ms 5 mV 34 mA 4 30 ms 2 mV 34 mA
2
1 3 1 3
4 5 Wrist 3 5 Wrist 3
50 ms 5 mV 34 mA 4
30 ms 2 mV 34 mA
Onset latency (axilla – APB): 10.50 ms; Onset latency (elbow – APB): 8.50 ms; Onset latency (wrist – APB): 5.0 ms - Peak latency
(axilla – APB): 14.75 ms; Peak latency (elbow – APB): 12.00 ms; Peak latency (wrist – APB): 8.80 ms; Onset to peak amplitude
(axilla – APB): 2.6 mV; Onset to peak amplitude (elbow – APB): 2.6 mV; Onset to peak amplitude (wrist – APB): 2.5 mV; Peak to peak
amplitude (axilla – APB): 3.8 mV; Peak to peak amplitude (elbow – APB): 3.8 mV; Peak to peak amplitude (wrist – APB): 3.7 mV;
MNCV (wrist – elbow):60.0 m/s; MNCV (axilla – elbow): 58.3 m/s
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in moderately severe CTS – grade 3 by Bland’s
CTS classification scale [3], stimulation of the axilla (upper trace), of the elbow (middle trace), and of the wrist (lower trace)
References motor axons; studies on normal and on injured peripheral nerves.

Arch Neurol Psychiatry 60:340–365
1. Mavor H, Libman I (1962) Motor nerve conduction velocity mea-
surement as a diagnostic tool. Neurology 12:733–744
2. Hodes R, Larrabee MG, German W (1948) The human electromyo-
gram in response to nerve stimulation and the conduction velocity of
M6
Study from Opponens Pollicis (OP) Muscle
Original Settings The machine used was a TECA model B; delivered at the wrist, between the tendons of the flexor carpi
sensitivity, low-frequency filter, high-frequency filter, sweep radialis (FCR) and the palmaris longus (PL) muscles. The
speed, and duration of pulse were not specified. anode was proximal. The second stimulation (S2) was
delivered at the elbow, on the antecubital fossa, just lateral to
Position This study was performed in the supine position. the brachial artery. The anode was proximal. No fixed dis-
tances were reported in the article [1].
Recording The active electrode (A) was placed over the
belly (motor point) of the opponens pollicis (OP) muscle Measurements Distal latency (ms) of the compound mus-
(Fig. 1), halfway between the midpoint of the distal wrist cle action potential (CMAP) was measured from the stimu-
crease and the midpoint of the first metacarpophalangeal lus onset to the onset of the negative deflection of
joint [1]. The reference (R) was placed slightly distal to the CMAP. Motor nerve conduction velocity (MNCV) was cal-
first metacarpophalangeal joint, the proximal phalanx of the culated in the elbow–wrist (forearm) segment and measured
digit I (thumb). The ground (G) was placed on the dorsum in meter per second (m/s). No control of temperature was
of the hand (the figure shows the ground electrode posi- attempted. Normal values (Table 1) were obtained from 47
tioned on the palm). healthy subjects. Pathological values were not reported and
the clinical application of the technique was not described.
Stimulation The median nerve was stimulated at the wrist The application in a case of carpal tunnel syndrome (CTS) is
(S1) and at the elbow (S2). The first stimulation (S1) was reported here (Fig. 2).

Biceps brachii
(BB)
+
R –
Opponens pollicis (OP)
S2
(elbow)
Digit I
+
A –
R
G C8
T1
S1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord
Median - OP Median - OP
2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
4 50 ms 5 mV 39 mA 4 30 ms 5 mV 39 mA
2 2
1 3 1 3
5 Elbow 2 5 Elbow 2
4 50 ms 5 mV 39 mA 4
30 ms 5 mV 39 mA
elbow (lower trace)

Elbow–wrist, MNCV (m/s) 56.9 ± 4.2
Pathological waveform (wrist, elbow – OP muscle):
Median - (OP) Median - (OP)
2 2
1 3 1 3
4 5 Wrist 1 45 Wrist 1
50 ms 1 mV 95 mA 100 ms 1 mV 95 mA
2 2
3 3
1 1 5 Elbow 2
4 5 Elbow 2 4
50 ms 1 mV 40 mA 100 ms 1 mV 40 mA
Onset latency (wrist – OP): 13.00 ms; Onset latency (elbow – OP): 17.00 ms; Peak latency (wrist – OP): 17.60 ms; - Peak latency
(elbow – OP): 24.85 ms; Onset to peak amplitude (wrist – OP): 0.6 mV; Onset to peak amplitude (elbow – OP): 0.7 mV; Peak to peak
amplitude (wrist – OP): 0.9 mV; Peak to peak amplitude (elbow – OP): 0.9 mV; MNCV (elbow – wrist): 47.5 m/s
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the OP muscle in very severe CTS – grade 5 by Bland’s CTS
classification scale [2], stimulation of the wrist (upper trace) and of the elbow (lower trace)
References
1. Melvin JL, Harris DH, Johnson EW (1966) Sensory and motor con-
duction velocities in the ulnar and median nerves. Arch Phys Med
Rehabil 47:511–519
Wrist, Below Elbow, Elbow,
Above Elbow, Erb’s Point – Hand M7
and Opponens Pollicis (OP) Muscles
Original Settings Duration of pulse was varied (0.1 ms at (S2), at the elbow (S3), at a point 10 cm proximal above the
the wrist, 0.2–0.5 ms below the elbow, 0.1–0.2 ms at the elbow (S4), and at Erb’s point (S5), the angle formed by the
elbow, 0.2 ms above the elbow, and 0.2–0.2 ms at Erb’s clavicle and the posterolateral fibers of the sternocleidomas-
point), rate of pulse was 1/s, and the machine used was a toid muscle [1]. The anode was proximal. Stimulus durations
TECA TE 2–7; sensitivity, sweep speed, low-frequency filter usually required were 0.1 ms at the wrist, 0.2–0.5 ms below
and high-frequency filter were not specified. the elbow, 0.1–0.2 ms at the elbow, 0.2 ms above the elbow,
and 0.2–05 at Erb’s point. For most sites, the stimuli were
Position This study was performed with the subjects lying applied at a rate of one per second while the response was
on a bed in the supine position, with the arm placed on a pad- evaluated. Such repetitive stimulation at Erb’s point was
ded arm board, and a 2.5 cm wide strip of transparent tape uncomfortable due to the vigorous muscular contractions in
was used over the palm of the hand and mid-forearm to the extremity; stimuli at this site were controlled manually at
attach the extremity to the board. about one each 5 s. This was well-tolerated by the subjects.
Recording The active needle electrode was placed over the Measurements Distal latency (ms) of the compound muscle
belly (motor point) of the abductor pollicis brevis (APB) and action potential (CMAP) was measured from the stimulus
opponens pollicis (OP) muscles (Figs. 1 and 2), halfway onset to the onset of the negative deflection of the CMAP. The
between the midpoint of the distal wrist crease and the mid- distances between the sites of stimulation were measured on
point of the first metacarpophalangeal joint [1]. The record- the skin using a steel tape measure except for measurements
ings were made separately. The ground (G) electrode was between Erb’s point and the elbow, and between Erb’s point
placed on the dorsum of the hand (the figure shows the and the site 10 cm above the elbow. These segments were
ground electrode positioned on the palm). measured by an obstetric caliper. Velocities were calculated
for the segments Erb’s point-above elbow, Erb’s point–elbow,
Needle Insertion For the APB muscle, with the hand in a elbow–wrist, below elbow–wrist. For each segment, the dif-
neutral position to full supination, the recording needle elec- ference in latencies of response to stimulation was divided
trode was inserted on the lateral aspect of the base of the into the distance between the two sites of stimulation, pro-
proximal phalanx of the thumb, using a medial-directed viding the motor nerve conduction velocity (MNCV) in m/s.
approach just anterior to the bone at the midpoint of the first No temperature recording was made, the room temperature
metacarpal bone. For the OP muscle, the recording needle was relatively constant for all examinations, and subjects
electrode was placed obliquely at the midpoint of the first were covered except for the extremity being tested. Normal
metacarpal shaft just lateral to the APB muscle. values (Table 1) were reported; author [1] studied 50 median
nerves from 50 healthy volunteer subjects (28 right and 22
Stimulation The median nerve was stimulated at the proxi- left, 29 women and 21 men, mean age 35.7 ± 10.5 years, age
mal wrist crease (S1), at a point 5 cm distal below the elbow range 18–56 years).

30 M7 Wrist, Below Elbow, Elbow, Above Elbow, Erb’s Point – Hand
S4
(above elbow) +
–
10 cm
+
–
R 5 cm
Abductor pollicis brevis (APB) + S3
– (elbow)
S2
(below elbow)
Digit I
+
• –
C8
G
S1 T1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (wrist, below elbow, elbow, above elbow, Erb’s point – APB muscle):
2 2
5 5
1 3 1 3
Wrist 1 Wrist 1
50 ms 5 mV 64 mA 30 ms 5 mV 64 mA
4
2 42
5 5
1 3 1 3
Below Elbow 2 Below Elbow 2
50 ms 5 mV 90 mA 30 ms 5 mV 90 mA
2 4 2 4
5 5
1 3 1 3
Elbow 3 Elbow 3
50 ms 5 mV 94 mA 30 ms 5 mV 94 mA
24 2 4
5 5
1 3 1 3 Above Elbow 4
Above Elbow 4
50 ms 5 mV 90 mA 30 ms 5 mV 90 mA
42 4 2
5 5
1 3 1 3 Erb's point 5
Erb's point 5
50 ms 5 mV 90 mA 30 ms 5 mV 90 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, top to bottom: stimulation of the wrist, below
the elbow, elbow, above the elbow, and of Erb’s point
M7 Wrist, Below Elbow, Elbow, Above Elbow, Erb’s Point – Hand 31
S4
(above elbow) +
–
10 cm
+
–
5 cm
R
+
Opponens pollicis (OP) – S3
(elbow)
S2
(below elbow)
Digit I
+
• –
C8
G
S1 T1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (wrist, below elbow, elbow, above elbow, Erb’s point – OP muscle):
2 Median - (OP) Median - (OP)

2
3
1 3 5 1 5
4 Wrist 1 4 Wrist 1
2 50 ms 10 mV 45 mA 2 30 ms 10mV 45 mA
1 3 5 Below Elbow 2 1 3 5
Below Elbow 2
4 50 ms 10 mV 80 mA 4 30 ms 10mV 80 mA
2 2
1 3 5 1 3 5
4 Elbow 3 4 Elbow 3
50 ms 10 mV 45 mA 30 ms 10mV 45 mA
2 2
1 3 5 1 3 5
Above Elbow 4 Above Elbow 4
4 50 ms 10 mV 63 mA 4 30 ms 10mV 63 mA
2 2
1 3 5 1 3 5Erb's point 5
4 Erb's point 5 4
50 ms 10 mV 100 mA 30 ms 10mV 100 mA
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the OP muscle, top to bottom: stimulation of the wrist, below the
elbow, elbow, above the elbow, and of Erb’s point
32 M7 Wrist, Below Elbow, Elbow, Above Elbow, Erb’s Point – Hand

Normal values [1] Mean ± SD Mean ± 2SD Range motor conduction velocities in Erb’s point–elbow and
Below elbow–wrist, MNCV (m/s) 55.1 ± 5.2 44.7 46–74 Erb’s point–above elbow segments; author suggested
Elbow–wrist, MNCV (m/s) 58.6 ± 3.8 51.0 48–66 to compare Erb’s point–elbow with the elbow–wrist
Erb’s point–elbow, MNCV (m/s) 62.8 ± 6.0 50.8 53–77 segment than Erb’s point-above elbow since it was
Erb’s point–above elbow, 62.9 ± 6.0 50.9 51–76 technically simpler. He suggested using as routine
MNCV (m/s) points of stimulation for such comparisons of Erb’s
point, the elbow, and wrist; the use of Erb’s point as
the proximal point of stimulation allows the inclusion
of a more proximal segment than does stimulation in
Comment
the axilla, thus accentuating any proximal–distal gra-
Jebsen [1] collected data only from a normal control dient. It may be useful in the diagnosis of local proxi-
sample; three case reports were included just to illus- mal neuropathy and in generalized neuropathies in
trate the clinical application of the described which a proximal–distal conduction velocity gradient
technique. In the controls, the lower limit of the may exist.
motor conduction velocity in the proximal segment of
the median nerve was approximately 50 m/s (Erb’s
point–elbow and Erb’s point–above elbow), while in
the distal segment was approximately 45 m/s; the
proximal segment exhibited a faster statistically sig-
Reference
nificant mean conduction velocity than the distal seg-
ment. The median nerve showed virtually identical 1. Jebsen RH (1967) Motor conduction velocities in the median and
ulnar nerves. Arch Phys Med Rehabil 48:185–194
M8
Original Settings Sensitivity, duration of pulse, sweep the baseline to the peak of the negative deflection. Motor
speed, low-frequency filter, high-frequency filter, and the nerve conduction velocity (MNCV) was calculated in the
machine used were not specified. elbow–wrist (forearm) segment and measured in meter per
second (m/s). Duration (ms) was measured from the onset
Position This study was performed in the supine position. to the end of the CMAP. No control of temperature was
attempted. Normal values (Table 1) were obtained from 24
Recording The active electrode (A) was placed one half the dominant wrists from 24 healthy volunteers. Pathological
distance between the metacarpophalangeal joint of the digit I values (Table 2) of 17 patients with the carpal tunnel syn-
(thumb) and the midpoint of the distal wrist crease, above the drome (CTS) were reported.
median thenar (MT) muscle (Fig. 1). The reference (R) was Kimura and Ayyar [2] evaluated MNCVs, distal laten-
placed distally to the distal phalanx of the digit I (thumb). cies, and negative-to-peak amplitudes of CMAPs in 639
The ground (G) electrode position was not specified in the extremities from 438 patients with clinical signs and symp-
original text; it showed placed distally between the digit IV toms suggestive of CTS (284 women and 154 men, age
and digit V [1]. range 18–85 years, mean age 51.4 years). Of 438 patients,
202 (46.1 %) had clinically bilateral involvement. They used
Stimulation The median nerve was stimulated at the wrist a modified protocol placing the wrist stimulation (S1) at a
(S1) and at the elbow (S2). The first stimulation (S1) was 6 cm fixed distance from the recording electrode (A) to the
performed at the wrist, with the cathode 8 cm proximal to the motor point of the abductor pollicis brevis (APB) muscle
active recording electrode (A), on the median nerve (Fig. 2). (Fig. 3).
The anode was proximal. Authors used a two-line method to They evaluated MNCVs, distal latencies, and negative
measure the distance between the active and the recording peak amplitudes of CMAPs in 175 extremities of 148 normal
electrodes (it was not specified in the text but showed clearly subjects and in a larger sample of patients with clinical signs
in article’s original figure). The second stimulation (S2) was of CTS. The MNCV of the forearm was calculated by divid-
performed at the elbow, on the antecubital fossa, just lateral ing the distance between the two stimulating sites by the dif-
to the brachial artery. The anode was proximal. Authors ference in latency measured from the stimulus artifact to the
emphasized the use of a standardized electrodiagnostic tech- onset of the CMAPs. Authors determined F-wave latencies
nique to minimize experimental errors, standardizing both with nerve stimulation at the wrist and recording the response
the placement and the distance over which stimulation was from the APB muscle. Authors used supramaximal stimula-
performed. They used only supramaximal stimulations. tion; skin and room temperature were not reported. They
studied 175 median nerves (Table 3) from 148 normal sub-
Measurements Distal latency (ms) of the compound jects (80 women and 68 men, age range 20–81 years, mean
muscle action potential (CMAP) was measured from the age 47.6 years) and 639 median nerves (Table 4) from 438
stimulus onset to the onset of the negative deflection of the patients with CTS (284 women and 154 men, age range
CMAP; amplitude (mV) of the CMAP was measured from 18–85 years, mean age 51.4 years).

Biceps brachii
(BB)
+
–
R
Median thenar (MT)
S2
(elbow)
Digit I
+
R A 8 cm –
C8
T1
S1
(wrist)
G
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (wrist, elbow – MT muscle):

1 3 1 3 5
5 Wrist 1 Wrist 1
50 ms 5 mV 45 mA 4 50 ms 10 mV 45 mA
4
1 3 1 3 5
5 Elbow 2 Elbow 2
50 ms 5 mV 45 mA 4 50 ms 10 mV 45 mA
4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the MT muscle, stimulation of the wrist (upper trace) and of the
elbow (lower trace)
C8
T1
R
Median thenar (MT)
Lower trunk
Median
nerve
Medial cord
R
A
8 cm
– +
G
Digit V
S1
(wrist)
Fig. 2 Distal stimulation at the wrist, S1 placed at 8 cm fixed distance from the active recording (A) electrode on the MT muscle

Normal values [1] Mean ± SD Range Pathological values [1] Mean ± SD Range
Wrist–APB, distal latency (ms) 3.7 ± 0.3 3.2–4.2 Wrist–APB, distal latency (ms) 5.3 ± 1.1 3.8–7.0
Wrist–elbow, MNCV (m/s) 56.7 ± 3.8 50.0–67.3 Wrist–elbow, MNCV (m/s) 52.8 ± 5.7 44.0–64.0
Wrist–APB, negative peak amplitude (mV) 13.2 ± 5.0 5.0–25.0 Wrist–APB, negative peak amplitude (mV) 9.4 ± 3.1 5.0–15.5
Wrist–elbow, negative peak amplitude (mV) 13.5 ± 4.1 5.0–23.0 Wrist–elbow, negative peak amplitude (mV) 8.9 ± 2.9 5.6–15.0
Wrist–APB, duration (ms) 7.5 ± 1.5 5.0–10.2 Wrist–APB, duration (ms) 7.4 ± 1.7 5.4–11.8
Wrist–elbow, duration (ms) 7.5 ± 1.5 4.4–10.2 Wrist–elbow, duration (ms) 7.5 ± 1.4 5.1–11.0
C8
T1 R
Digit I
Lower trunk
Median
nerve Medial cord
6 cm
– +
Digit V
S1
(wrist)
Fig. 3 Distal stimulation at the wrist, S1 placed at 6 cm fixed distance (straight line) from the active recording (A) electrode on the APB muscle

Normal values [2] Mean ± SD Comment
Wrist–APB, distal latency (ms) 3.31 ± 0.4 In 12 symptomatic hands (1.9 %) of 639, Kimura and
Wrist–APB, negative peak amplitude (mV) 8.47 ± 3.3 Ayyar [2] were not able to record the median CMAPs
from the APB muscle after stimulation of the wrist. In
98.1 % of 639 hands (627 hands), CMAPs after stimu-
Table 4 Reference values lation at the wrist were recorded. In 54.3 % of the 627
Pathological values [2] Mean ± SD Range hands, the distal motor latency (DML) was prolonged
Wrist–APB, distal latency (ms) 5.41 ± 2.41 2.2–10.8 (4.7 ms or more). The mean negative peak amplitude
Wrist–APB, negative peak amplitude (mV) 6.38 ± 4.5 was significantly decreased when compared to the nor-
mal value, and in 153 hands with no median sensory
nerve action potential (SNAP) to the digit II the ampli-
tude was 4.53 ± 3.7 mV. The MNCV of the forearm
(wrist–elbow segment) was slowed in patients, with an
observed value below 49 m/s in 22.6 % of 552 symp-
tomatic hands with CTS investigated.
C8
T1
R
Lower trunk Digit I

Median
nerve Medial cord
A
7 cm
– +
Digit V
S1
(wrist)
Fig. 4 Distal stimulation at the wrist, S1 placed at a 7 cm fixed distance (straight line) from the active recording (A) electrode on the APB muscle

Normal values [3] Mean ± SD Limit of normal Normal values [4] Mean Range Limit of normal
Wrist–APB, distal latency (ms) 3.36 ± 0.32 4.0 Wrist–APB, distal latency (ms) 3.30 ± 0.30 2.50–3.90 3.90

Pathological values [3] Mean ± SD Sensitivity
Pathological values [4] Mean Range
Wrist–APB, distal latency (ms) 5.24 ± 1.87 72 % (113 hands)
Wrist–APB, distal latency (ms) 4.64 ± 1.11 2.70–9.90
Recently, Kasius et al. [3] measured DML to the APB mus- Foresti et al. [4] using a 7 cm fixed distance (straight
cle in 47 healthy subjects (30 women – 63.8 %, 24 left hand – line) from the active recording electrode (Fig. 4) performed
51.1 % and 23 right hand – 48.9 %, mean age 41.04 ± 12.2 years) APB CMAP bilateral recordings in 25 healthy (Table 7)
and in 157 patients with clinically defined CTS (122 women – subjects (average age 42 years, age range 18–69 years,
77.7 %, 71 left hand – 45.2 % and 86 right hand – 54.8 %, male/female ratio 2.5:1) and in 100 consecutive patients
mean age 48.87 ± 13.7 years) using a 6 cm distance between (Table 8) with suspected CTS (mean age 49 ± 11.9 years,
recording and stimulating sites (Tables 5 and 6). Their values age range 27–78 years, male/female ratio 3:1) (Tables 7
were consistent with those by Kimura and Ayyar [2], and com- and 8). They used a five-channel Mystro-Plus electromyo-
paring sensitivity of several sensory and motor conduction graph. Hand temperature was monitored and, if it was less
tests in the diagnosis of CTS, they found abnormal values in than 32 °C, the limb was warmed. DML – onset latency
113/157 hands (low sensitivity – 72 %). was measured.
electrodes for recording, and stimulating median nerve 7 cm

Comment proximal to the active recording electrode (Fig. 4). They
Foresti et al. [4] in a sample of 200 hands from 100 maintained temperature of the upper limb at 32–34 °C using
patients with suspected CTS found that 159 hands with hot packs. A total of 192 arms from 155 patients (111 women
a clinical suspicion of CTS and 149 hands of these and 44 men, age range 19–94 years) were studied, 154 arms
were found to have electrophysiological signs of CTS (80 %) had a normal (≥50 m/s) median motor forearm con-
(10 hands were normal); 61 patients had bilateral duction velocity (MMFCV), whereas 38 arms (20 %) had
CTS. For the median APB DML, authors found low slowed MMFCV. Authors found a superimposed process in
values of sensibility (78.19 and 73.70 %) and high val- only 2 (14 %) of the 14 arms with mild slowing of MMFCV
ues of specificity (>99 %, 90.20 %), on the base of an (47–49.9 m/s), in 7 arms (46 %) of the 15 arms with moderate
electrophysiological Gold Standard and using a clini- slowing of MMFCV (43.0–46.9 m/s), and in 4 (44 %) of the
cal Gold Standard independent of the electrodiagnostic 9 arms with severe slowing of MMFCV (<43 m/s). They
procedures, respectively. found that superimposed processes were common in the pres-
ence of a moderate and severe slowing of MMFCV. However,
in patients with mild slowing of MMFCV (47–49.9 m/s) the
In a retrospective analysis of all cases of CTS diagnosed in incidence of a superimposed process was similar to that found
their laboratory over a 20-month period, Donahue et al. [5] in patients with a normal MMFCV.
investigated the presence of a superimposed process (i.e., The 8-cm standardization from the active recording elec-
axonal polyneuropathy, C8-T1 radiculopathy, or lower trunk/ trode (Fig. 5) was first proposed by Melvin et al. [1] and it
medial cord brachial plexopathy). Motor nerve conduction was used routinely in the EMG laboratories; the median
study to the APB muscle was performed using a Dantec motor conduction study to the APB muscle is actually one of
Counterpoint electromyograph, surface 10 mm silver disk the most commonly performed electrodiagnostic studies.
C8
T1
R
Digit I
Lower trunk
Median
nerve Medial cord
8 cm
– +
G
Digit V
S1
(wrist)
Fig. 5 Routine distal stimulation at the wrist, S1 placed at an 8 cm fixed distance (two lines), recording from the APB muscle

Normal values [6] Mean ± SD Range Limit of normal
Wrist–APB, distal latency (ms) 3.7 ± 0.5 2.8–4.8 4.5
Wrist–APB, negative peak amplitude (mV) 10.2 ± 3.6 2.0–22.0 4.1
Wrist–APB, area (μVs) 33.7 ± 12.8 6.6–93.7 12.4
Wrist–APB, duration (ms) 5.9 ± 0.9 4.1–9.6 8.0
Males – latency (ms) Mean ± SD Range Limit of normal
Age range 19–49 3.8 ± 0.4 3.0–4.6 4.6
Age range 50–79 4.0 ± 0.4 3.0–4.8 4.7
Females – latency (ms) Mean ± SD Range Limit of normal
Age range 19–49 3.5 ± 0.4 2.8–4.8 4.4
Age range 50–79 3.8 ± 0.4 2.9–4.6 4.4
Amplitude (mV) Mean ± SD Range Limit of normal
Age range 19–39 11.9 ± 3.6 2.2–22.0 5.9
Age range 40–59 9.8 ± 2.8 3.3–17.7 4.2
Age range 60–79 7.0 ± 2.6 2.0–14.3 3.8
Area (μVs) Mean ± SD Range Limit of normal
Age range 19–49 37.4 ± 12.9 8.1–93.7 14.6
Age range 50–59 30.9 ± 8.6 14.1–45.6 15.3
Age range 60–79 23.7 ± 9.3 6.6–50.9 11.9
Males – MNCV (m/s) Mean ± SD Range Limit of normal
Age range 19–39 58 ± 4 48–65 49
Age range 40–79 55 ± 5 40–78 47
Females – MNCV (m/s) Mean ± SD Range Limit of normal
Age range 19–39 60 ± 3 50–66 53
Age range 40–79 57 ± 5 43–77 51
Many authors during past years have measured normal Comment

and pathological values on a larger population of normal sub- Buschbacher [6] found the upper limit of the normal
jects and patients, respectively. In 1999 Buschbacher [6] has increase in latency from one side to the other was 0.7
recorded latency (ms), amplitude (mV), area (μVs), duration (±2 SD) ms; side-to-side upper limit of the normal
(ms), and MNCV (m/s) on a sample of 249 healthy subjects decrease in amplitude was 6.9 (±2 SD) mV. Gender was
with age from 19 to 79 years (Table 9). He placed the active found to be associated with different results for latency
electrode halfway between the midpoint of the distal wrist and MNCV. Age was found to be associated with dif-
crease and the volar surface of the first metacarpophalangeal ferent results for latency, amplitude, area, and MNCV.
joint, over the motor point of the APB muscle. The reference
electrode was placed slightly distal to the joint. The ground
electrode was placed on the dorsum of the hand (the figure Chang et al. [7], during a 1-year period, and a 2-year
shows the ground electrode placed on the palm). Wrist stimu- period [8], performed several sensory and motor conduction
lation was performed with the cathode positioned 8 cm proxi- techniques to compare the sensitivities in the diagnosis of
mal to the active electrode on a line measured first to the CTS. All studies were performed using a Nicolet Viking IV
midpoint of the distal wrist crease and then proximally to a or Dantec Keypoint 4 electromyograph, and skin temperature
point between the tendons of the flexor carpi radialis (FCR) at the hand was maintained at or above 32 °C. Conventional
and the palmaris longus (PL) muscles. In case of difficulty to motor nerve conduction study to the APB muscle was
identify the PL tendons, author suggested applying the stimu- performed in 100 control (Table 10) subjects (64 women and
lus slightly ulnar to the FCR tendon. 36 men; age range 22–65 years, mean age 47.4 years) [7] and
in 150 control (Table 11) subjects (91 women and 69 men; was negatively correlated with the median nerve DML and
age range 18–84 years, mean 53.9 years) [8]. positively correlated with the CMAP amplitude of the APB
Havton et al. [9] in 91 hands of 64 patients (54 women and muscle. Authors found that increasing severity of CTS was
10 men; age range 26–82 years, mean age 49.5 ± 11.8 years) associated with decreased median MNCV within the fore-
examined the correlation between the median forearm arm as indicated by a prolonged DML or reduced CMAP
motor nerve conduction velocity (MNCV) and the mark- amplitude. They suggested that a reduction in MNCV
ers of severity of the median neuropathy at the wrist (i.e., occurred after an acute injury to motor axons with partial
median distal motor latency and compound muscle action denervation of the thenar muscle.
potential amplitude of the APB muscle). Skin temperature Recently, in a prospective study Lee et al. [10] measured
was monitored and cool hands (<32 °C) were warmed. All DML to the APB muscle on 67 hands of 41 patients (Table 12)
patients had a clinical history of CTS confirmed by elec- with electroclinically diagnosed CTS (53 hands from 32
trodiagnosis (antidromic sensory conduction to the digit women, 14 hands from 9 men; average age 56.2 ± 11.2 years)
II <45 m/s, or 8 cm distance median distal motor latency grouped according to the severity of the carpal tunnel syn-
>4.4 ms). The conduction velocity within the forearm seg- drome (mild, moderate, and severe CTS) based on electro-
ment of the median nerve was calculated from the differ- physiological criteria by Lee and Kwon [11]. A Dantec
ence between the proximal and the distal motor latency and Counterpoint Mk2 was used for the electrodiagnostic study.
the distance between the corresponding stimulating sites.
In the CTS hands, the mean median distal motor latency
(DML) was 5.2 ± 1.7 ms, the mean APB CMAP ampli-
Comment
tude was 13.3 ± 5.2 mV, and the mean median MNCV was
For Lee et al. [10], among the median nerve motor
52 ± 4 m/s. The median MNCV within the forearm segment
branches, the recurrent branch to the APB muscle is in
Table 10 Reference values a position to be more vulnerable to carpal tunnel com-
Normal values [7] Mean ± SD Limit of normal (±2.5SD) pression than branches to the 1st (1L) and to the 2nd
Wrist–APB, distal latency (ms) 3.59 ± 0.31 <4.37 (2L) lumbrical muscles. Frequencies of DML prolon-
gation in the APB muscle recording were 60, 85, and
94 % in the mild, moderate, and severe CTS groups,
respectively (Figs. 6, 7, and 8); frequency in the mild
Normal values [8] Mean ± SD Limit of normal (±2.5SD) group was significantly lower.
Wrist–APB, distal latency (ms) 3.66 ± 0.31 <4.4

Pathological values [10] (all CTS patients – 67 hands) Mean ± SD Rate of abnormality (%_)
Wrist–APB, distal latency (ms) 5.47 ± 1.93 79
Pathological values [10] (mild CTS patients – 23 hands) Mean ± SD Rate of abnormality (%)
Pathological values [10] (moderate CTS patients – 27 hands) Mean ± SD Rate of abnormality (%)
Pathological values [10] (severe CTS patients – 17 hands) Mean ± SD Rate of abnormality (%)
Pathological waveform (wrist, elbow – MT muscle):
1 3 5 1 3 5
Wrist 1 4 Wrist 1
4 50 ms 5 mV 41 mA 50 ms 10 mV 41 mA
1 3 5 1 3 5
Elbow 2 4 Elbow 2
4 50 ms 5 mV 50 mA 50 ms 10 mV 50 mA
Onset latency (wrist – MT): 5.55 ms; Onset latency (elbow – MT): 9.45 ms; Peak latency (wrist – MT): 9.95 ms; Peak latency (elbow –
MT): 14.75 ms; Onset to peak amplitude (wrist – MT): 6.5 mV; Peak to peak amplitude (wrist – MT): 8.9 mV; Onset to peak amplitude
(elbow – MT): 6.6 mV; Peak to peak amplitude (elbow – MT): 8.9 mV; MNCV(elbow – wrist): 59.0 m/s
Fig. 6 Compound muscle action potentials (CMAPs) recorded from the MT muscle in severe CTS – grade 4 by Bland’s CTS classification
Pathological waveform (wrist, elbow – APB muscle):
2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
50 ms 5 mV 43 mA 100 ms 5 mV 43 mA
4 4
2 2
1 3 1 3
5 Elbow 2 5 Elbow 2
50 ms 5 mV 43 mA 100 ms 5 mV 43 mA
4 4
Onset latency (wrist – APB): 7.35 ms; Onset latency(elbow – APB): 11.50 ms; Peak latency(wrist – APB): 11.30 ms; Peak latency
(elbow – APB): 15.25 ms; Onset to peak amplitude (wrist – APB): 9.1 mV; Onset to peak amplitude (elbow – APB): 9.5 mV; Peak
to peak amplitude (wrist – APB): 14.4 mV; Peak to peak amplitude (wrist – APB): 14.7 mV; MNCV (elbow – wrist): 53.0 m/s
References 43
2 2
1 3 1 3
4 5 Wrist 1 4 5 Wrist 1
50 ms 5 mV 73 mA 100 ms 5 mV 73 mA
2 2
1 3 1 3
4 5 Elbow 2 45 Elbow 2
50 ms 5 mV 73 mA 100 ms 5 mV 73 mA
peak amplitude (wrist – APB): 5.0 mV; Peak to peak amplitude (wrist – APB): 4.6mV; MNCV (elbow – wrist): 38.7 m/s
scale [12] and Guillain-Barré syndrome (2 weeks of onset of symptoms), stimulation of the wrist (upper trace) and of the elbow (lower trace)
References 7. Chang MH, Wei SJ, Chiang HL et al (2002) Comparison of motor

conduction techniques in the diagnosis of carpal tunnel syndrome.
Neurology 58:1603–1607
1. Melvin JL, Schuchmann JA, Lanese RR (1973) Diagnostic speci-
8. Chang MH, Liu LH, Lee YC et al (2006) Comparison of sensitivity
ficity of motor and sensory nerve conduction variables in the carpal
of transcarpal median motor conduction velocity and conventional
tunnel syndrome. Arch Phys Med Rehabil 54:69–74
conduction techniques in electrodiagnosis of carpal tunnel syn-
2. Kimura I, Ayyar DR (1985) The carpal tunnel syndrome: electro-
drome. Clin Neurophysiol 117:984–991
physiological aspects of 639 symptomatic extremities.
9. Havton LA, Hotson JR, Kellerth JO (2007) Correlation of median
Electromyogr Clin Neurophysiol 25:151–164
forearm conduction velocity with carpal tunnel syndrome severity.
3. Kasius KM, Claes F, Verhagen WI et al (2012) The segmental
Clin Neurophysiol 118:781–785
palmar test in diagnosing carpal tunnel syndrome reassessed. Clin
10. Lee HJ, Kwon HK, Kim DH et al (2013) Nerve conduction studies
Neurophysiol 123:2291–2295
of median motor nerve and median sensory branches according to
4. Foresti C, Quadri S, Rasella M et al (1996) Carpal tunnel syndrome:
the severity of carpal tunnel syndrome. Ann Rehabil Med 37:
which electrodiagnostic path should we follow? A prospective study of
254–262
100 consecutive patients. Electromyogr Clin Neurophysiol 36:377–384
11. Lee HJ, Kwon HK (2004) Electrophysiologic classification of sever-
5. Donahue JE, Raynor EM, Rutkowe SB (1998) Forearm velocity in
ity of carpal tunnel syndrome. J Korean Assoc EMG-Electrodiagn
carpal tunnel syndrome: when is slow too slow? Arch Phys Med
Med 6:1–3
Rehabil 79:181–183
6. Buschbacher RM (1999) Median nerve motor conduction to the
abductor pollicis brevis. Am J Phys Med Rehabil 78:S1–S8
M9
Original Settings The machine used was a DISA 14C11; Stimulation The median nerve was stimulated at two dif-
sensitivity, duration of pulse, sweep speed, low-frequency ferent points [1]: at the wrist (S1) and at the elbow (S2).
filter, and high-frequency filter were not specified. The same needle electrodes that were used by authors for
stimulation of the median nerve at the wrist and elbow
Position This study was performed in the supine position. were used for recording the sensory potentials (see sensory
conduction studies).
Recording Two needle electrodes (near-nerve technique)
were placed over the belly (motor point) of the abductor pol- Measurements Distal latency (ms) of the compound
licis brevis (APB) muscle (Fig. 1), halfway between the mid- muscle action potential (CMAP) was measured from the
point of the distal wrist crease and the midpoint of the first stimulus onset to the onset of the positive or negative
metacarpophalangeal joint [1]. Authors described an alterna- deflection of the CMAP. Amplitude (mV) of the CMAP
tive technique for measuring the motor conduction using an was measured from the baseline to the peak of the negative
80 μm stainless steel wire placed transversely near the center deflection. The response recorded with a wire electrode
of the belly of the APB muscle. The ground (G) electrode was, on the average, half that recorded with a concentric
position was not mentioned in the text; authors probably electrode. Terminal latency was corrected to a standard
adjusted the ground position during the motor median evalua- distance of 6.5 cm for the median nerve following the cal-
tion, placing it between stimulation point and the needle culation formula. Skin temperature was controlled within
recording electrode (on the palm for S1 and on the forearm for 36–38 °C. Authors studied 182 normal median nerves
S2). The figure shows the ground positioned on the forearm. (Table 1) from healthy subjects (age range 20–80 years)
and 118 hands from 111 patients (Table 2) with signs and
Needle Insertion For the APB muscle, with the hand in a neu- symptoms of carpal tunnel syndrome (CTS), 84 women
tral position to full supination, the recording needle electrode and 33 men (mean age 55 years; 11 patients were 30 years
was inserted on the lateral aspect of the base of the proximal old or less); an upper or lower 95 % confidence limit was
phalanx of the thumb, using a medial-directed approach just required to accept a finding as abnormal.
anterior to the bone at the midpoint of the first metacarpal bone.

Biceps brachii
(BB)
+
–
R
S2
(elbow)
G
Digit I
+
• –
C8
S1 T1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Median - (APB)
Median - (APB)
2 2
4 1 4 5
1 5
Wrist 1 Wrist 1
50 ms 5 mV 65 mA 30 ms 5 mV 65 mA
3 3
2 2
4 4
1 5 1 5
Elbow 2 Elbow 2
50 ms 5 mV 65 mA 30 ms 5 mV 65 mA
3 3
elbow (lower trace)
Table 1 Reference values Normal values [1] Range (2SD) Limit of normal
Wrist–APB, distal latency (ms) – 20–30 years 2.2–3.7 3.0
Normal values [1] Mean

Wrist–APB, distal latency (ms) – function of age 2.85 + 0.009 × age
Normal values [1] Range (2SD) Limit of normal

Elbow–wrist, MNCV (m/s) – 20–30 years 58–74 55
Normal values [1] Mean

Elbow–wrist, MNCV (m/s) – function of age 67.3–0.11 × age

Pathological values [1] Range (2SD)
Wrist–APB, distal latency (ms) – 20–30 years 4.4–6.8
Pathological values [1] Range (2SD)
Elbow–wrist, MNCV (m/s) – 20–30 years 49–66
Elbow-wrist, MNCV (m/s) – 30–40 years 45–59
Comment
Buchthal et al. [1] in 82 % of 111 hands found a pro-
longed motor latency (above the 99 % confidence limit
of normal) from the abductor pollicis brevis muscle; in
6 % it was borderline. Latencies longer than 7 ms were
seen only in patients over 45 years of age (Fig. 2). In
one-fourth of the patients with slowing in sensory
fibers, the distal motor latency was normal.
1 4
5 1 4 5
Wrist 1 Wrist 1
20 ms 5 mV 65 mA 30 ms 10 mV 65 mA
3
2
4 4
1 5 1 5
Elbow 2 Elbow 2
20 ms 5 mV 65 mA 3 30 ms 10 mV 65 mA
Onset latency (wrist – APB): 4.50 ms; Onset latency (elbow – APB): 9.20 ms; Peak latency (wrist – APB): 6.00 ms; Peak latency (elbow
– APB): 10.45 ms; Onset to peak amplitude (wrist – APB): 9.0 mV; Onset to peak amplitude (elbow – APB): 6.9 mV; Peak to peak
amplitude (wrist – APB): 8.2 mV; Peak to peak amplitude (wrist – APB): 5.7 mV; MNCV (wrist – elbow): 55.3 m/s
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in mild CTS – grade 2 by Bland’s CTS classifica-
tion scale [2], stimulation of the wrist (upper trace) and of the elbow (lower trace)
References
1. Buchthal F, Rosenfalck A, Trojaborg W (1974) Electrophysiological
findings in entrapment of the median nerve at wrist and elbow.
J Neurol Neurosurg Psychiatry 37:340–360
Wrist, Elbow, Axilla – Hand
M10
Original Settings Sensitivity was 2–5 mV/division e lectrode position was not mentioned in the text; the figure
(M response) and 500 μV/division (F-wave), low-frequency shows the ground electrode placed on the forearm.
filter was 2–3 Hz, high-frequency filter was 10 kHz, sweep
speed was 5 ms/division, duration of pulse was 0.2–0.5 ms, Stimulation Using surface electrodes, the median nerve
and the machine used was not specified. was stimulated by the supramaximal electric shocks at the
wrist (S1), elbow (S2), and axilla (S3), both for conventional
Position This study was performed with the subject lying on motor conduction studies and F-wave studies [1]. The first
a bed with the arm and hand immobilized in a supine stimulation (S1) was delivered at the wrist, between the ten-
position. dons of the flexor carpi radialis (FCR) and palmaris longus
(PL) muscles. The second stimulation (S2) was delivered at
Recording The active electrode (A) was placed over the the elbow, on the antecubital fossa, just lateral to the brachial
belly (motor point) of the median thenar (MT) muscle artery. The third stimulation was delivered at the axilla (S3).
(Fig. 1), halfway between the midpoint of the distal wrist In all stimulations (S1, S2, S3), the anode was proximal and
crease and the midpoint of the first metacarpophalangeal the cathode was distal for conventional motor conduction
joint [1]. The reference (R) was placed slightly distal to the studies, the cathode was proximal and the anode was distal
first metacarpophalangeal joint, the proximal phalanx of the for F-wave studies. No fixed distances were reported in the
digit I (on the dorsum of the thumb). The ground (G) article.

+/–
–/+
* CMAP study / F wave study S3 *
(axilla)
*
+/–
–/+
R
Median thenar (MT)
S2
G
(elbow)
Digit I
*
+/–
A
R –/+
C8
T1
S1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (wrist – MT muscle):
Median - (MTM) 19 Median - (MTM) 19
1.9
1.10
1.11
1.12
1.18
1.15
1.11
1.9
1.16
1.14
1.12
1.10
1.13
1.13 1.17
1 mV 50 ms 1 mV
1.14
1.15
1.16
1.17
1.18
1 mV 50 ms 1 mV
Sensitivity 1 mV/div (CMAP 2 mv/div), sweep speed 5 ms/div
Fig. 1 F-waves recorded at the hand from the MT muscle, stimulation of the wrist. Raster mode, 10 stimuli (left), superimposed mode, 10 stimuli
(right)
Measurements Distal latency (ms) of the compound mus- upright position and the arm abducted to 90°. The hand was
cle action potential (CMAP) was measured from the stimu- supinated for the measurement of the median nerve so that
lus artifact to the onset of the negative deflection of stimulus points were easily accessible to the examiner stand-
CMAP. In all subjects, distance between the stimulating ing behind the subject. Stimulus points at the axilla were
points was measured along the course of the nerve and projected posteriorly across the arm in the plane perpendic-
motor nerve conduction velocity (MNCV) was calculated. ular to the axis of the arm, and distances between the pro-
The approximate length of the nerve from the stimulus jected points and the C7 spinous process were determined
points to the spinal cord was obtained by measuring the dis- by surface measurements. Skin temperature was not con-
tance from the stimulus points to the C7 spinal process. trolled; all tests were performed in a warm room. The
Surface measurements were taken along the course of the F-wave velocity of the central pathway was thus calculated
nerve from the wrist to the axilla with the subject in an as follows:
( Distance from stimulus point − C7 spine ) × 2 ( mm )

F − wave velocity ( m/s ) =
(F latency − M latency ) − 1 ( ms )
The F-wave latency (ms) measured from the stimulus d ifference between the F-wave and the M-response must
artifact to the beginning of the evoked potential was constant correspond to the time interval required for the passage of
in some but in others varied by a few milliseconds from one the impulse to and from the spinal cord plus a delay esti-
stimulus to the next. When the F-wave varied in latency, mated to be 1.0 ms for the recurrent discharge to occur at the
several trials were given at each stimulus point to determine motoneurons [2]. Motor and late responses were obtained
the response with the shortest latency. Assuming that from 33 healthy (Table 1) volunteers (age range 22–58 years,
impulses carrying the F-wave traveled at the same velocity mean age 35 years) and 8 patients (Table 2) with Charcot-
as motor impulses over the same nerve segment, the latency Marie-Tooth (CMT) disease (age range 13–67 years).

Normal values [1] Mean ± SD Pathological values [1] Mean ± SD
Wrist–MT, M-wave latency (ms) 3.5 ± 0.5 Wrist–MT, M-wave latency (ms) 7.8 ± 2.6
Elbow–MT, M-wave latency (ms) 7.8 ± 0.8 Elbow–MT, M-wave latency (ms) 20.3 ± 6.6
Axilla–MT, M-wave latency (ms) 11.3 ± 1.0 Axilla–MT, M-wave latency (ms) 29.9 ± 11.4
Elbow–wrist, M-wave latency difference (ms) 4.4 ± 0.6 Elbow–wrist, M-wave latency difference (ms) 12.7 ± 4.6
Axilla–elbow, M-wave latency difference (ms) 3.6 ± 0.5 Axilla–elbow, M-wave latency difference (ms) 10.3 ± 4.1
Elbow–wrist, MNCV (m/s) 56.0 ± 5.0 Elbow–wrist, MNCV (m/s) 21.2 ± 8.0
Axilla–elbow, MNCV (m/s) 63.3 ± 6.0 Axilla–elbow, MNCV (m/s) 23.1 ± 8.6
Wrist–MT, F-wave latency (ms) 29.1 ± 2.3 Wrist–MT, F-wave latency (ms) 73.8 ± 25.4
Elbow–MT, F-wave latency (ms) 24.8 ± 2.0 Elbow–MT, F-wave latency (ms) 60.6 ± 20.4
Axilla–MT, F-wave latency (ms) 21.7 ± 2.8 Axilla–MT, F-wave latency (ms) 52.0 ± 21.4
Elbow–wrist, F-wave latency difference (ms) 4.3 ± 0.8 Elbow–wrist, F-wave latency difference (ms) 12.7 ± 5.2
Axilla–elbow, F-wave latency difference (ms) 3.5 ± 0.5 Axilla–elbow, F-wave latency difference (ms) 10.2 ± 3.6
Wrist–spinal cord, F-wave velocity (m/s) 59.2 ± 3.9 Wrist–spinal cord, F-wave velocity (m/s) 23.2 ± 8.0
Elbow–spinal cord, F-wave velocity (m/s) 62.2 ± 5.2 Elbow–spinal cord, F-wave velocity (m/s) 24.4 ± 9.1
Axilla–spinal cord, F-wave velocity (m/s) 64.3 ± 6.4 Axilla–spinal cord, F-wave velocity (m/s) 29.0 ± 13.1
Comment
For Kimura [1], with supramaximal stimulation at the
wrist, the F-wave was widely separate from the
simultaneously recorded M-response. After proximal
stimulation at the elbow, the F-wave occurred closer to
the M-response, but these two responses were usually
still distinctly apart (Fig. 2).
Typical waveform (elbow – MT muscle):
1.2
1.3
1.4
1.6
1.7
1.8 1.12
1.7
1.17
1.2
1.18
1.11
1.10
1.5
1.4
1.15
200 µV 50 ms 500 µV
1.9
1.12
1.13
1.14
1.15
2 mV 50 ms 1 mV
Sensitivity 1 mV/div, sweep speed 5 ms/div (CMAP 2 mv/div) Sensitivity 500 µV/div , sweep speed 5 ms/div (CMAP 500 µv/div)
Fig. 2 F-waves recorded at the hand from the MT muscle, stimulation of the elbow. Raster mode, 10 stimuli (left), superimposed mode, 10 stimuli
(right)
When the nerve was stimulated at the axilla, however, the associated glycoproteine/peripheral nerve glycolipid sul-
latency difference between the M-response and F-wave was fated glucuronyl paragloboside), Lupu et al. [3] performed
normally so small that the latter appeared before the several conduction techniques in patients with neuropathy
completion of the former, making an accurate latency mea- due to IgM Abs against MAG and SGPG (MAG-SGPG-N).
surement impossible. The F-wave elicited by axillary Electrophysiologically, conduction blocks characterize the
stimulation was recorded readily by author using a “collision chronic inflammatory demyelinating polyradiculoneuropa-
technique.” With this technique, the orthodromic impulse thy (CIDP), whereas in MAG/SGPG-N conduction blocks
from the axilla and the antidromic impulse from the wrist are rarely observed. MAG-SGPG-N and hereditary sensory-
could be extinguished by collision (block of the M-response motor neuropathy type 1 (HMSN1) have similar demyelinat-
elicited by axillary stimulation by a second supramaximal ing features on nerve conduction studies, and two subtypes
stimulation at the wrist), leaving the M-response from the (HMSN1A and HMSN1B) were described. HMSN1A is the
wrist and the F-wave from the axilla intact. In most cases of most common subtype of HSMN1, and a mutation in the
the CMT disease included in the study, greatly decreased gene encoding for peripheral myelin protein 22 (PMP-22)
motor nerve conduction velocities distally were associated was observed. HMSN1B is related to genetic abnormalities
with comparable reduction in F-wave velocities in the central in myelin protein zero. Median and ulnar nerve motor con-
segment. For the authors, the study of F-wave velocity could duction studies were performed recording at 6 cm fixed dis-
be useful in evaluating the central segment of the median tance from the recording electrode placed on the abductor
nerve. The possible diagnostic value was suggested as a pollicis brevis (APB) and the abductor digiti minimi (ADM)
supplement to the ordinary motor nerve conduction studies muscles, respectively. All nerve conduction studies were
in an analysis of various neuropathies. performed at a skin temperature of 34 °C. Terminal Latency
In order to determine which nerve conduction study index (TLI), residual latency (RL), and F-wave latency ratio
(NCS) assessing the distal segments of the upper extremity were calculated. Following a modified Kimura’s method [1],
motor nerves was more useful to differentiate anti-MAG/ authors recorded F-wave latency from the median thenar and
SGPG (pathogenic IgM antibodies-Abs against myelin- ulnar hypothenar muscles after distal and proximal stimula-
tions (S1 and S2 only) at the wrist and the elbow. Minimal patients (Table 4) with MAG/SGPG-N (57 % men and 43 %
F-wave latency was determined from at least ten stimula- women, mean age 64.6 ± 9.4 years), 26 patients (Table 5)
tions, and F-wave latency was not adjusted for height with HMSN1 (58 % men and 42 % women, mean age
because this information was missing and because of lack 38.1 ± 13.7 years), and 20 patients (Table 6) with HMSN2
of normative data on F-wave latency at the elbow. They (70 % men and 30 % women, mean age 44.7 ± 14.5 years).
measured distal motor latency (DML) and proximal motor More recently, Park et al. [6] calculated the sensitivity,
latency (PML), stimulating at the wrist and at the elbow, specificity, and cutoff value of several nerve conduction
respectively. They calculated F-wave latency ratio at the parameters among groups with asymptomatic, mild, moder-
wrist (which compares spinal cord to wrist with wrist to the- ate, and severe CTS. The aim of their study was to determine
nar latency) and at the elbow (which compares spinal cord to the correlation of the calculated electrophysiological param-
elbow with elbow to thenar latency) using previously pub- eters and CTS clinical severity. They studied a total of 212
lished formulas [4], and following the method by Attarian hands from 106 patients (mean age 52.9 ± 10.3 years, range
et al. [5] authors also calculated a modified F-wave latency 25–70 years, 85 women and 21 men, 66 bilateral CTS, 24
ratio (MFR), which compares spinal cord to elbow with right-side CTS, 16 left-side CTS) using a Medelec Synergy
wrist to thenar latency, as follows: electromyographic device (Oxford Instruments Medical).
For F-wave study, the filter bandpass was 30 Hz–10 kHz, the
( F − wave at the wrist − DML − 1) sweep speed was 10 ms/division, and the sensitivity was set
F − wave wrist ratio ( Fwr ) =
2 DML at 0.2 mV/division. They recorded at least 20 consecutive
F-waves, and the Fmin (ms) was measured for both median
and ulnar nerves recording from APB and ADM, respec-
( F − wave at the elbow − PML − 1) tively. They also measured F-wave inversion (i.e., the differ-
F − wave elbow ratio ( Fel ) =
2 PML ence between the median nerve shortest F-wave and the
ulnar nerve shortest F-wave, called “F-diff M-U”) and modi-
fied F ratio (MFR). The MFR was calculated following the
( F wave at the wrist - 2 PML + DML - 1) method by Attarian et al. [5], as follows:
MFR =
2 DML
( F wave at the wrist - 2 PML + DML - 1)
Authors studied 12 healthy (Table 3) volunteers (58 % MFR =
2 DML
men and 42 % women, mean age 32.6 ± 11.3 years), 21

Normal values [3] Mean ± SD Pathological values [3] – HMSN1, 26 patients Mean ± SD
Wrist–MT, F-wave latency (ms) 27 ± 2 Wrist–MT, F-wave latency (ms) 69 ± 13
Elbow–MT, F-wave latency (ms) 22 ± 1 Elbow–MT, F-wave latency (ms) 57 ± 10
Fel (Elbow – MT) 0.9 ± 0.1 Fel (Elbow – MT) 0.8 ± 0.2
MFR 2.5 ± 0.3 MFR 2.1 ± 0.5

Pathological values [3] – MAG/SGPG-N, 21 patients Mean ± SD Pathological values [3] – HMSN2, 20 patients Mean ± SD
Wrist–MT, F-wave latency (ms) 54 ± 15 Wrist–MT, F-wave latency (ms) 33 ± 5
Elbow–MT, F-wave latency (ms) 50 ± 17 Elbow–MT, F-wave latency (ms) 27 ± 6
Fel (Elbow – MT) 0.7 ± 0.2 Fel (Elbow–MT) 0.9 ± 0.1
MFR 1.4 ± 0.5 MFR 2.2 ± 0.3
Authors divided all 212 CTS hands (Table 7) into four

Comment groups according to the clinical severity by applying a
For Lupu et al. [3] F-waves were markedly prolonged simplified four-stages historical-objective (Hi-Ob scale)

in MAG/SGPG-N (21 patients) and HMSN1 (26 scale [7]: asymptomatic (40 hands), mild CTS (103 hands),
patients). F-wave latency ratio (elbow-median thenar moderate CTS (43 hands), and severe CTS (26 hands). They
muscle) and MFR were both abnormal in the same found for MFR only significant differences between the mild
groups. Their findings were consistent with those by and moderate CTS groups, a poor indicator to determine the
Attarian et al. [5], who evaluated indexes calculated clinical severity of CTS. The application in a case of radicu-
from standard electrophysiological data in differentiat- lopathy is reported here (Fig. 3).
ing chronic inflammatory demyelinating polyradiculo-
neuropathy (CIDP). They studied 19 CIDP patients, 25 Table 7 Reference values
anti-myelin-associated glycoprotein/sulphated gluc-
Pathological values (12)
uronyl paragloboside antibodies (MAG/SGPG) Asymptomatic (40 hands) Mean ± SD
patients, 13 Charcot-Marie-Tooth disease type 1A MFR 2.06 ± 0.29
(CMT1A) patients, and 22 controls. They used MFR to
Pathological values (12)
compare the spinal cord–elbow segment (proximal Mild CTS (103 hands) Mean ± SD
segment) latency with that of the wrist–thenar muscle MFR 1.92 ± 0.35
segment (distal segment). Compared with controls,
MFR was increased in 16 CIDP patients and it was Pathological values (12)
Moderate CTS (103 hands) Mean ± SD
normal in all patients affected by CMT1A. They sug-
MFR 1.47 ± 0.31
gested using MFR index in differentiating CIDP
because they found good value of sensitivity (84 %) Pathological values (12)
Severe CTS (103 hands) Mean ± SD
and specificity (89 %).
MFR 1.26 ± 0.49
Pathological waveform (wrist – MT muscle):

1.4
1.5
1.6
1.7
1.8
1.8
1.5
1.4
1.9
1.15
1.7
1.6
1.13
1.10
1.14
1.16
1.9 5 mV
50 ms 500 µV
1.10
1.13
1.14
1.15
1.16
5 mV 50 ms 500 µV
Sensitivity 500 µV/division (CMAP 5 mV/div), sweep speed 5 ms/division
Fig. 3 Prolonged F-waves recorded at the hand from the MT muscle in a chronic C8-T1 radiculopathy (mean F-wave latency 33.20 ms), stimula-
tion of the wrist. Raster mode, 11 stimuli (left), superimposed mode, 11 stimuli (right)
References 5. Attarian S, Azulay JP, Boucraut J et al (2001) Terminal latency

index and modified F ratio in distinction of chronic demyelinating
neuropathies. Clin Neurophysiol 112:457–463
1. Kimura J (1974) F-Wave velocity in the central segment of the
6. Park KM, Shin PK, Park J et al (2014) The usefulness of terminal
median and ulnar nerves: a study in normal subjects and in patients
latency index of median nerve and F-wave difference between
with Charcot-Marie-Tooth disease. Neurology 24:539–546
median and ulnar nerves in assessing the severity of carpal tunnel
2. Renshaw B (1941) Influence of discharge of motoneurons upon exci-
syndrome. J Clin Neurophysiol 31:162–168
tation of neighboring motoneurons. J Neurophysiol 4:167–183
7. Giannini F, Cioni R, Mondelli M et al (2002) A new clinical scale
3. Lupu VD, Mora CA, Dambrosia J et al (2007) Terminal latency
of carpal tunnel syndrome: validation of the measurement and clinical-
index in neuropathy with antibodies against myelin-associated
neurophysiological assessment. Clin Neurophysiol 113:71–77
glycoproteins. Muscle Nerve 35:196–202
4. Kimura J (2001) Long and short of nerve conduction measures:
reproducibility for sequential assessments. J Neurol Neurosurg
Psychiatry 71:427–430
M11
Original Settings Sensitivity, low-frequency filter, high- (S1) and at the elbow (S2). The first stimulation (S1) was
frequency filter, sweep speed, duration of pulse, and the delivered at the wrist, between the tendons of the flexor
machine used were not specified. carpi radialis (FCR) and the palmaris longus (PL) mus-
cles. The anode was proximal. The second stimulation
Position This study was performed in the supine position, (S2) was delivered at the elbow, on the antecubital fossa,
with the elbow and fingers slightly flexed. just lateral to the brachial artery [1]. The anode was proxi-
mal. No fixed distances were reported in the article. Distal
Recording According to a previous standardized technique stimulation (S1) determined distal compound muscle
[2], author placed the active electrode (A) over the belly (motor action potential (CMAP) while proximal stimulation at
point) of the opponens pollicis (OP) muscle (Fig. 1), halfway the elbow (S2), just above the crease of the antecubital
between the midpoint of the distal wrist crease and the mid- fossa and medial to the biceps tendon at the elbow, allowed
point of the first metacarpophalangeal joint [1]. The reference determination of the forearm motor nerve conduction
(R) was placed slightly distal to the first metacarpophalangeal velocity (MNCV). In case of stimulation at the elbow
joint, the proximal phalanx of the digit I (thumb). Ground (G) (S2), authors suggested 2–4 cm separation between the
electrode position was not specified in the paper; it was prob- cathode (−) and the anode (+), using a pair of standard
ably placed over the mid-forearm or on the palm of the hand 0.6 cm diameter electroencephalograph electrodes
(the figure shows the ground electrode placed on the palm). mounted on a plastic block for stimulating the nerve.
Supramaximal stimulation was used; stimulus in all deter-
Stimulation Following the method described by Melvin minations was at least 30 % greater than that which elic-
et al. [2], the median nerve was stimulated at the wrist ited a maximum response.

Biceps brachii
(BB)
+
R –
S2
(elbow)
Digit I
+
A –
R
C8
G
S1 T1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord
2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
4 50 ms 5 mV 47 mA 4 30 ms 5 mV 47 mA
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
50 ms 5 mV 100 mA
4 4 30 ms 5 mV 100 mA
elbow (lower trace)
Measurements Distal peak latency (ms) was measured termed the “residual latency” (RL) for the motor fibers.
from the beginning of the shock artifact to the peak of the The temperature of the forearm was determined using a
negative deflection of the CMAP and it was called “termi- skin surface thermometer; all forearm temperatures
nal latency” (TL). The motor nerve conduction velocity equalled or exceeded 34 °C. Expected TL of the CMAP
(MNCV) was calculated from the nerve using stimulating recorded from the OP muscle after stimulation at the wrist
and recording sites at above the elbow and at the wrist, (8 cm segment) and RL for CMAP recorded from the OP
respectively. From this elbow–wrist conduction velocity an muscle after stimulation at the wrist (8 cm segment) were
expected terminal latency from the wrist to the OP muscle calculated as follows (distance between cathode placed at
was calculated and compared with the measured motor the wrist and the active electrode placed on the OP muscle
terminal latency. The difference between these values was was 80 mm fixed):
distance between cathode ( wrist ) and active electrode ( OP ) , ( mm )

Expected DL ( ms ) =
nerve conduction velocity ( elbow − wrist ) , ( m/s )
Residual latency, RL ( ms ) = observed TL ( ms ) − expected TL ( ms ) (age range 21–71 years, mean age 45 years) and 20 patients
(Table 2) with neuropathies selected completely at random
They measured TL and calculated RL in 20 patients from a much larger population of patients with neuropathies
(Table 1) with no history of alcoholism or diabetes as controls (age range 28–73 years, mean age 50 years).

Normal values [1] Mean ± SD Range
Wrist–OP, distal latency (ms) 3.6 ± 0.4 3.2–3.8
Elbow–wrist, residual latency (ms) 1.5 ± 0.5 1.0–2.5
Elbow–wrist, MNCV (m/s) 58 ± 5 54–61

Pathological values [1] Mean ± SD Range
Wrist–OP, distal latency (ms) 5.1 ± 4.2 4.0–8.0
Elbow–wrist, residual latency (ms) 3.4 ± 2.5 2.3–6.3
Elbow–wrist, MNCV (m/s) 52 ± 20 30–60
Comment the median motor conduction was repeated using an 8 cm

For Kaplan [1], the values for the residual latency mea- distance between the stimulation site at the wrist and the
surements in the control population in the motor con- active recording electrode. They performed conduction
duction were virtually identical with the residual studies in 50 subjects (30 women and 20 men, age range
latency measurements of the sensory conduction in the 18–62 years, average age 34 years) using a TECA TD-20
same nerve, and also from nerve to nerve. The result of electromyograph (filters from 20 Hz to 2 kHz). Skin tem-
the study indicated that the residual latency measure- peratures were measured on the palm; the limbs were
ments were as effective and as accurate as the terminal warmed when necessary to maintain at least 34 °C. Authors
latency measurements in determining the presence of a in their study suggested that RL may be increased in the
neuropathy distal to the wrist. For the author [1], resid- dominant extremity without symptoms of the median nerve
ual latency techniques seemed to be an accurate way of entrapment. In 8 hands of 7 healthy subjects (14 % of the
measuring the state of the delicately tapering nerve whole sample), they observed a prolonged RL greater than
endings distal to the wrist. 2.6 ms in subjects aged 20–29 years and greater than 2.5 in
older subjects, according to the criteria of Kraft and
Halvorson [4]. Abnormal RLs were recorded in the domi-
nant hand of 6 subjects, and in only one case was the abnor-
Redmond and Rivner [3] recorded bilateral median motor mality bilateral. The range of an abnormal residual latency
response over the thenar eminence, stimulating both at the was 2.6–3.1. Authors observed, in all instances in which a
elbow and the wrist 7 cm proximal to the recording site. unilateral increased RL was found, a prolonged absolute
From these data, a forearm conduction velocity (NCV) and motor distal latency compared with the other side. The appli-
residual latency (RL) were calculated. In subjects with an cation in a case of carpal tunnel syndrome (CTS) is reported
abnormal RL, calculated by using the Kaplan’s method [1], here (Fig. 2).
Pathological waveform (wrist, elbow – OP muscle):

2
1 3 5 1 3
4 Wrist 1 5 Wrist 1
50 ms 5 mV 94 mA
4 30 ms 2 mV 94 mA
1 3 5 1 3
4 Elbow 2 5 Elbow 2
50 ms 5 mV 94 mA
4 30 ms 2 mV 94 mA
Onset latency (wrist – OP): 5.35 ms; Onset latency (elbow – OP): 9.20 ms; Peak latency (wrist – OP): 7.40 ms; Peak latency (elbow –
OP): 11.80 ms; Onset to peak amplitude (wrist – OP): 3.7 µV; Onset to peak amplitude (elbow – OP): 3.5 µV; Peak to peak amplitude
(wrist – OP): 5.5 µV; Peak to peak amplitude (elbow – OP): 5.3 µV; SNCV (elbow – wrist): 50.6 m/s
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the OP muscle, in severe CTS – grade 4 by Bland’s CTS classi-
fication scale [5], stimulation of the wrist (upper trace) and of the elbow (lower trace)
References 3. Redmond MD, Rivner MH (1988) False positive electrodiagnostic

tests in carpal tunnel syndrome. Muscle Nerve 11:511–517
4. Kraft GH, Halvorson GA (1983) Median nerve residual latency:
1. Kaplan PE (1976) Sensory and motor residual latency measure-
normal value and use in diagnosis of carpal tunnel syndrome. Arch
ments in healthy patients and patients with neuropathy – Part 1.
Phys Med Rehabil 64:221–226
2. Melvin JL, Harris DH, Johnson EW (1966) Sensory and motor
conduction velocities in the ulnar and median nerves. Arch Phys
Med Rehabil 47:511–519
M12
Original Settings Sensitivity, low-frequency filter, high- of the hand (the figure shows ground positioned on the
frequency filter, sweep speed, duration of pulse, and the palm).
machine used were not specified.
Stimulation Using surface electrodes, the median nerve was
Position This study was performed with the subject lying on stimulated by electric shocks at the wrist (S1) and at the elbow
a bed with the arm and hand immobilized in a supinated (S2), both for conventional motor conduction studies and
position. F-wave studies [1]. For F-wave studies, authors used a supra-
maximal stimulus intensity (increased by 20 %). The first stim-
Recording The active electrode (A) was placed over the ulation (S1) was delivered at the wrist, between the tendons of
motor point of the abductor pollicis brevis (APB) mus- the flexor carpi radialis (FCR) and palmaris longus (PL) mus-
cle (Fig. 1), halfway between the midpoint of the distal cles. The second stimulation (S2) was delivered at the elbow,
wrist crease and the midpoint of the first metacarpopha- on the antecubital fossa, just lateral to the brachial artery. In all
langeal joint [1]. The reference (R) was placed to the stimulations (S1, S2) the anode was proximal and the cathode
proximal phalanx of the digit I (on the dorsum of the was distal for conventional motor conduction studies, the cath-
thumb). The ground (G) position was not mentioned in ode was proximal and the anode was distal for F-wave studies.
the text; it could be placed on the palm or on the dorsum No fixed distances were reported in the article.

Biceps brachii
* CMAP study/F wave study (BB)
*
+/–
–/+
R
S2
(elbow)
G
+/–*
Digit I
R A –/+
C8
T1
S1
(wrist)
Lower trunk
Median
Digit V nerve Medial cord
Typical waveform (wrist – APB muscle):
9 9
Median - (APB) 1.1 Median - (APB)
1.2
1.3
1.4
1.5
1.8
1.9
1.7
1.6
1.5
1.4
1.3
1.2
1.1
5 mV 50 ms 500 µV
1.6
1.7
1.8
1.9
5 mV 50 ms 500 µV
Sensitivity 500 µV/div (CMAP 2 mv/div), sweep speed 5 ms/div
Fig. 1 F-waves recorded at the hand from the APB muscle, stimulation of the wrist. Raster mode, 9 stimuli (left); superimposed mode, 9 stimuli
(right)
Measurements Distal latency (ms) of the compound response. This was found to vary slightly in given individu-
muscle action potential (CMAP) was measured from the als so that the shortest of five responses (Fmin) was chosen.
stimulus artifact to the onset of the negative deflection of In the majority of cases, no difficulty was encountered in
CMAP. Distances between the stimulating points were eliciting an F-wave; however, when necessary the response
measured along the course of the nerve, distal motor nerve could be augmented by a slight voluntary contraction of the
conduction time in this study was the difference between particular muscle from which it was being recorded. It was
the proximal and distal motor nerve latencies, which, when assumed that the central delay of the F-wave response was
divided into the distance between the two stimulating 1 ms. Skin temperature was not controlled; all studies were
points, gives the motor nerve conduction velocity of the carried out in an air-conditioned room, in which the tem-
elbow to wrist segment of the arm. The latency of the perature was maintained at between 23 and 25 °C. F-wave
F-wave response (ms) was taken as the interval between the conduction velocity was computed from the following
stimulus artifact and the first deflection of the evoked formula:
( Distance from site of stimulation − C7 spine ) ×10 ( cm )

F − wave velocity ( m/s ) =
( Fconduction time ) ( ms )
( F latency - M latency ) - 1( ms )
F conduction time ( ms ) =
2
Authors [1] studied 60 median nerves from 60 normal

(Table 1) subjects (age range 11–74 years, mean age
41.5 years) and 30 patients – age range 21–76 years (Table 2)
with carpal tunnel syndrome (CTS).

Normal values [1] Mean ± SD Pathological values [1] Mean ± SD
Wrist–APB, M-wave latency (ms) 3.42 ± 0.42 Wrist–APB, M-wave latency (ms) 5.36 ± 1.17
Elbow–APB, M-wave latency (ms) 7.78 ± 0.76 Elbow–APB, M-wave latency (ms) 10.84 ± 1.34
Elbow–wrist, M-wave latency difference (ms) 58.5 ± 4.6 Elbow–wrist, M-wave latency difference (ms) 49.0 ± 9.2
Wrist–APB, F-wave latency (ms) 26.6 ± 2.2 Wrist–APB, F-wave latency (ms) 30.8 ± 3.3
Elbow–APB, F-wave latency (ms) 22.4 ± 1.6 Elbow–APB, F-wave latency (ms) 26.1 ± 2.2
Wrist–spinal cord, F-wave velocity (m/s) 62.7 ± 3.9 Wrist–spinal cord, F-wave velocity (m/s) 57.7 ± 4.8
Elbow–spinal cord, F-wave velocity (m/s) 64.2 ± 5.1 Elbow–spinal cord, F-wave velocity (m/s) 58.6 ± 7.0
Elbow–spinal cord, conduction time (ms) 6.85 ± 0.63 Elbow–spinal cord, conduction time (ms) 7.62 ± 1.24
Comment with the controls (73 % of patients had a significantly

For Eisen et al. [1], the F-response can be evoked easily prolonged distal motor latency – greater than 4.5 ms).
by stimulation of the median nerve. An absent F-response, The F-conduction time and velocity between the spinal
or a slowed conduction between the spinal cord and elbow cord and elbow was abnormal in 23.3 % of patients,
in the presence of a normal conduction between the elbow compared with 46.7 % who had abnormally slowed motor
and wrist, is indicative of a proximal lesion. Comparison conduction velocities between the elbow and wrist.
of the F-response and the M-response latencies at a given F-waves could not be obtained by proximal (elbow)
stimulation point along the nerve is a sensitive indicator stimulation in 10 % of the patients. F-waves were obtained
of whether the lesion is proximal, distal, or at both sites. easily by distal stimulation at the wrist (Fig. 2) and, using
The mean F-wave latencies obtained by stimulation at the F-wave studies, a number of patients who o therwise have
wrist and elbow, as well as the respective mean a fairly typical CTS can be shown to have an additional
F-conduction velocities, were abnormal when compared pathology at a more proximal site.
Biceps brachii
(BB)
R
Digit I
–
R A +
C8
G S T1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Fig. 2 Routine F-wave study recording from the APB muscle, stimulation of the wrist
Fisher and Hoffen [2] analyzed F-waves results following divided into two groups: Group 1–15 normal young adults
20 supramaximal stimuli (stimulating at the wrist, and (mean age 31.6 ± 14.1 years, mean height 171.4 ± 9.2 cm),
recording to the APB muscle) in 48 median nerves from 24 and Group 2–15 normal old adults (age range 60–86 years,
patients with CTS (mean age 59 years, age range mean age 74.1 ± 7.5 years, mean height 163.4 ± 10.3 cm).
33–86 years). They found F-waves prolonged in 19 hands They stimulated the median nerve at the wrist, and recorded
from 10 patients with CTS; in all but one of these 19 hands, the F-wave responses from the APB muscle. Authors found
there was an associated prolonged DML. All hands with a positive correlation between the F-wave onset latency and
DMLs of 5.8 ms or greater (upper limit of normal 4.2 ms at age, and between the F-wave onset latency and height. They
a distance of 6.5 ms) had abnormal F-wave latencies. observed that the F-wave onset latencies in the arm (median
Dorfman and Bosley [3] performed bilateral F-wave stud- nerve) increase progressively with age at the rate of + 0.04 ms
ies – shortest of 6 stimuli (Fmin) in 30 normal (Table 3) subjects per year, explaining this prolongation as the result of slowed
(mean age 52.8 ± 24.2 years, mean height 167.4 ± 10.3 cm) conduction in peripheral motor fibers.
In 1984, Cornwall and Nelson [4] evaluated the conduc- measured from the center of the seventh cervical vertebra
tion of 40 median motor nerves from 20 healthy (Table 4) spinous process to the cathode stimulation point at the wrist,
subjects (11 women and 9 men, age range 18–34 years, mean with the subject standing with the arm abducted horizontally
age 25 years). Each subject was screened for history of dia- to 90°, the elbow fully extended, and the forearm in a supine
betes, alcoholism, renal or metabolic dysfunction, peripheral position. Authors found women had an expected and signifi-
vascular disease, myopathy, or neuropathy. They performed cantly shorter mean arm length (62.0 ± 3.4 cm) than men
all nerve conduction tests using a DISA 1500 EMG machine; (69.4 ± 3.4 cm). The significantly shorter shortest F-wave
for each test, the recording electrode was placed over the latency (SFWL) they found in women (26.7 ± 2.1 ms) com-
motor point of the APB muscle, and the reference was placed pared with men (28.8 ± 2.8 ms) was compatible with the
about 2 cm distally, near the tendon insertion. Supramaximal positive correlation between SFWL and an arm length. They
stimulation (0.1 ms duration) was applied at a rate of 1 per believed the differences in SFWL by sex, arm length, and
second over the median nerve at the wrist, with the cathode age (over 65 years) have a clinical significance and they pro-
8 cm proximal to the active recording electrode. All nerve posed these factors should be considered when making com-
conduction tests were performed in the same room at a con- parisons between the clinical conduction findings and normal
stant temperature of 19 °C. Subjects were tested in the supine values. As a guideline for determining a normal median
position with the arm at the side. nerve F-wave latency in subjects over 65 years of age, they
Using a Cadwell 7200 EMG instrument, Nelson et al. [5] proposed an upper limit of F-wave latency at the wrist of
performed a conventional F-wave study in 51 right median 31 ms for women and 34.4 ms for men (mean value ± 2 SD).
nerves from 51 healthy (Table 5) volunteers over 65 years of In order to create a normative database for median
age (33 women and 18 men, age range 67–89 years, mean nerve F-wave responses for a large subject population,
age 76.5 ± 4.8 years). They divided volunteers into a younger Buschbacher [6] studied 195 asymptomatic subjects (age
and older age group (Group 1–26 subjects, 19 women and 7 range 19–79 years) without risk factors for neuropathy
men, age range 67–74 years, mean age 72 ± 2.0 years; Group (Table 6). Author applied ten consecutive supramaximal
2–25 subjects, 14 women and 11 men, age range 75–89 years, stimuli to the wrists of each arm (8 cm distance between the
mean age 80.4 ± 3.4 years). Room temperature was recorded stimulating cathode and the recording electrode); the short-
and maintained between 23 and 25 °C. Mean skin tempera- est of ten stimuli (Fmin), the mean latency (Fmean), range of
ture recorded was 31.5 ± 1.6 °C. The arm length was latencies (Frange), and limit of normal were measured.

Wrist–APB, F-wave latency (ms) – 15 young adults 26.7 ± 2.0
Wrist–APB, F-wave latency (ms) – 15 old adults 28.4 ± 2.3
Wrist–APB, F-wave latency (ms) – all 30 adults 27.5 ± 2.3

Wrist–APB, M-wave latency (ms) 2.80 ± 0.46
Wrist–APB, F-wave latency (ms) 24.5 ± 2.2
Elbow–APB, F-wave latency (ms) 21.2 ± 2.2

Normal values [5] Normal values [6] – F-wave latency (ms), age range 19–49
All subjects Mean ± SD Height in cm (in) Mean ± SD Range Limit of normal
Wrist–APB, M-wave latency (ms) 4.1 ± 0.6 <160 (5′ 3″) 23.7 ± 1.0 22.7–25.4 25.7
Wrist–APB, M-wave, peak-to-peak amplitude (mV) 12.4 ± 4.9 160–169 (5′ 3″–5′ 6″) 25.3 ± 1.6 21.4–30.0 28.5
Elbow–wrist, MNCV (m/s) 53.2 ± 4.5 170–179 (5′ 7″–5′ 10″) 27.3 ± 1.8 23.7–31.0 30.9
Normal values [5] ≥180 (5′ 11″) 28.9 ± 2.3 26.0–34.3 33.5
Women (33 subjects) Mean ± SD
Normal values [6] – F-wave latency (ms), age range 50–79
Height in cm (in) Mean ± SD Range Limit of normal
Wrist–APB, M-wave, peak-to-peak amplitude (mV) 12.5 ± 4.5
<160 (5′ 3″) 25.2 ± 1.7 21.0–27.6 28.6
160–169 (5′ 3″–5′ 6″) 27.5 ± 1.4 25.5–30.5 30.3
Normal values [5] 170–179 (5′ 7″–5′ 10″) 28.7 ± 1.4 25.9–31.3 31.5
Men (18 subjects) Mean ± SD
≥180 (5′ 11″) 30.4 ± 1.9 26.5–33.0 34.2
Wrist–APB, M-wave, peak-to-peak amplitude (mV) 12.2 ± 5.7 Normal values [6] – F-wave latency (ms), age range 19–79
Elbow–wrist, MNCV (m/s) 50.3 ± 3.6 Mean ± SD Range Limit of normal
Normal values [5] All subjects 26.8 ± 2.4 21.0–34.3 31.6
Age 67–74 years (26 subjects) Mean ± SD
Normal values [5]
Normal values [5]
All subjects Mean ± SD
Wrist–APB, F-wave, peak-to-peak amplitude (μV) 288.3 ± 133.3
Arm length (cm) 64.6 ± 4.9
Normal values [5]
Women (33 subjects) Mean ± SD
Normal values [5]
Men (18 subjects) Mean ± SD
Normal values [5]
Normal values [5]
Wrist–APB, F-wave, peak-to-peak amplitude (mV) 288.8 ± 125.0
Normal values [5]
All subjects Limit of normal
Wrist–APB, F-wave latency (ms) – men 34.4
Wrist–APB, F-wave latency (ms) – women 31
significantly higher (29.1 ± 4.8) in the CTS group than in

Comment the controls (26.5 ± 3.6). Height and weight of controls and
Buschbacher [6], because the gender effect is small, CTS patients were not reported. They recorded ten consec-
suggested adding approximately 0.5 ms for men and utive F-waves from the APB muscle, and measured several
subtracting 0.5 ms for women to the normal range for parameters as follows: minimum (Fmin), maximum (Fmax),
latencies of the Fmin. Side-to-side differences for the and mean F-wave latencies (Fmean), frequency of the F-wave
Fmin were 1.6 ± 1.0 ms and a limit of normal of 3.0 ms. (F-persistence, Fp), chronodispersion (FCD), mean F/M
amplitude ratios (mF/M-amp), and F-wave conduction
velocity (FwCV). Fmin (ms) was the F-wave with the short-
In order to determine the alteration of F-wave parame- est latency; Fmax (ms) was the F-wave with the longest
ters in different subtypes of carpal tunnel syndrome (CTS) latency; Fmean (ms) was the mean onset latency of all
and to investigate the predictive F-wave abnormality for F-waves recorded; Fp (%) was the number of F-waves
each type (demyelinating or axonal) CTS, Aygül et al. [7] obtained with ten consecutive stimuli; FCD (ms) was the dif-
prospectively evaluated 100 hands of 57 consecutive ference between Fmax and Fmin; and the amplitude (μV)
patients (Table 7) with electrodiagnostically confirmed of each F-wave was measured peak-to-peak. The FwCV
CTS (46 ± 9.4 years) and 62 hands of 31 healthy subjects (m/s) was calculated on the base of Fmin using Kimura’s
(44.3 ± 8.3 years). Body Mass Index (BMI) was found formula [8]:
( estimated distance from site of stimulation to the spinal cord ) × 2 ( cm )

FwCV ( m/s ) =

( Fmin − mMDL ) − 1( ms )
Table 7 Reference values (continued)

Normal values [7] Pathological values [7]
All subjects Mean ± SD Moderate CTS (33 hands) Mean ± SD
Fmin (ms) 23.7 ± 1.9 Fmin (ms) 26.1 ± 1.9
Fmax (ms) 26.1 ± 2.2 Fmax (ms) 29.5 ± 1.9
Fmean (ms) 24.8 ± 2.0 Fmean (ms) 27.5 ± 1.6
Fp (%) 95 ± 6.7 Fp (%) 89 ± 12.3
FCD (ms) 2.3 ± 0.94 FCD (ms) 3.4 ± 2.2
FwCV (m/s) 72.7 ± 7.4 FwCV (m/s) 68.2 ± 6.1
Mean F-wave amplitude (μV) 0.289 ± 0.13 Mean F-wave amplitude (μV) 0.313 ± 0.12
Maximum F-wave amplitude (μV) 0.485 ± 0.22 Maximum F-wave amplitude (μV) 0.572 ± 0.32
Mean F/M amplitude ratios (mF/M-amp ratios) 0.036 ± 0.015 Mean F/M amplitude ratios (mF/M-amp ratios) 0.046 ± 0.02
Pathological values [7] Pathological values [7]
All CTS patients Mean ± SD Severe CTS (34 hands) Mean ± SD
Fmin (ms) 26.6 ± 3.1 Fmin (ms) 29.9 ± 3.0
Fmax (ms) 29.9 ± 3.5 Fmax (ms) 33.1 ± 3.5
Fmean (ms) 28.0 ± 3.1 Fmean (ms) 31.5 ± 2.8
Fp (%) 86.3 ± 15.5 Fp (%) 79 ± 19.5
FCD (ms) 3.3 ± 1.9 FCD (ms) 3.4 ± 2.0
FwCV (m/s) 68.4 ± 7.3 FwCV (m/s) 64.1 ± 7.5
Mean F-wave amplitude (μV) 0.289 ± 0.13 Mean F-wave amplitude (μV) 0.247 ± 0.10
Maximum F-wave amplitude (μV) 0.506 ± 0.26 Maximum F-wave amplitude (μV) 0.440 ± 0.21
Mean F/M amplitude ratios (mF/M-amp ratios) 0.051 ± 0.034 Mean F/M amplitude ratios (mF/M-amp ratios) 0.061 ± 0.04
Pathological values [7]
Mild CTS (33 hands) Mean ± SD
Fmin (ms) 24.7 ± 1.6
Fmax (ms) 28.0 ± 2.4
Fmean (ms) 26.1 ± 1.9
Fp (%) 90 ± 12.3
FCD (ms) 3.3 ± 1.6
FwCV (m/s) 71.1 ± 4.4
Mean F-wave amplitude (μV) 0.302 ± 0.13
Maximum F-wave amplitude (μV) 0.493 ± 0.23
Mean F/M amplitude ratios (mF/M-amp ratios) 0.046 ± 0.04
Comment features). They found the FCD a useful parameter in dis-

Aygül et al. [7] divided the CTS cases into three groups cerning CTS patients from normal subjects, but it was not
according to electrophysiological severity as follows: able to differentiate between demyelinating or axonal
Mild CTS (decreased SNCV and prolonged SDL in the subtypes. For detecting subtypes of CTS, in fact, they
digit II-wrist segment, lower SNAP amplitude) – 33 cases found the mF/M-amp ratios and Fp more sensible param-
(33 %), Moderate CTS (prolonged SDL and MDL, eters than F-wave latencies. The F-wave latencies and
decreased SNAP amplitude) – 33 cases (33 %), Severe FwCV of the median nerve indeed, influenced by the neu-
CTS (prolonged SDL and MDL, absence of SNAP and/or ronal damages due to the compression at the wrist by the
low amplitude or absent thenar CMAP) – 34 cases (34 %). carpal transverse ligament which typically occurred in the
Authors found significant differences between the CTS CTS, are useful in the CTS severity evaluation, and there-
patients and the controls. If compared with the normal fore, authors suggested introducing F-waves studies in
values, all CTS patients showed prolonged F-wave laten- the routine electrophysiological investigation of CTS. It
cies, decreased Fp, and an increased FCD. In 34 severe was also a useful parameter in evaluation of other affec-
CTS hands, F-wave was absent in eight hands (23.5 %), tions such as neuropathies and cervical radiculopathy
and the FwCV was significantly slower and the F-waves (Figs. 3 and 4). Their findings were consistent with those
latencies were significantly prolonged in severe CTS previously reported by Ozge et al. [9] in 29 hands of 23
group than moderate and mild CTS groups. Authors also patients with prominent demyelinating type CTS and 45
divided CTS patients into three subtypes: Demyelinating hands of 37 patients with prominent axonal type CTS,
Group (MDL >4.2 ms ± 2 SD, CMAP amplitude >5 mV), where a prolonged Fmin in demyelinating group and a
Axonal Group (MDL ≤4.2 ms, CMAP amplitude correlation between the amplitude of CMAP from APB
<5 mV – 2 SD), and Mix Group (demyelinating + axonal muscle and Fp were observed.
Cevik et al. [10] compared the values of ulnar and at 20 Hz–10 kHz) in 45 healthy subjects and 60 early CTS
median F-wave minimal latencies (FWML) in the diagnosis patients. For median F-wave recording, the active electrode
of CTS because in healthy subjects the median FWML was placed on the APB muscle; for ulnar F-wave recording,
occurs earlier than the ulnar FWML, a pattern that should the active electrode was placed on the ADM muscle.
reverse in patients with CTS due to the decrease in the Authors underlined the advantages provided by the F-wave
median nerve conduction velocity of the digit–wrist seg- inversion examination, since the median and ulnar nerves
ment [11]. This abnormal pattern is defined by a 1 ms or measurements were carried out on individual basis and
longer latency delay for the shortest median F-wave (Fmin) were not influenced by physiological factors such as height
in relation to the shortest ulnar F-wave (Fmin), and it is called or age. They studied 45 healthy subjects (mean age
“F-wave inversion.” They performed F-wave studies using a 37.6 ± 8.3 years, height 163.5 ± 5.5 cm) and 60 patients
Micromed Matrix Light 1002 EP machine (sensitivity was with early CTS (mean age 40.5 ± 10.6 years, height
0.2 mV/cm, sweep speed was 10 ms/cm, and filters were set 162.5 ± 8.3 cm).

Normal values [10]
Median nerve – All subjects Mean ± SD
Fmin (ms) 24.0 ± 1.15
Fmax (ms) 28.28 ± 2.72
Fmean (ms) 25.83 ± 1.46
Fp (%) 84.2 ± 10.7
F-waves minimum inversion 3 (8.6 %)
F-wave mean inversion 12 (21.8 %)
Normal values [10]
Ulnar nerve – all subjects Mean ± SD
Fmin (ms) 24.46 ± 0.93
Fmax (ms) 27.89 ± 1.64
Fmean (ms) 26.05 ± 1.09
Fp (%) 88.2 ± 10.3
Normal values [10]
Median–ulnar nerves – all subjects Mean ± SD
Fmin latency difference (ms) 0.23 ± 0.98
Fmean latency difference (ms) −0.31 ± 1.57
Median nerve – all subjects Mean ± SD
Fmin (ms) 25.16 ± 1.53
Fmax (ms) 30.19 ± 2.92
Fmean (ms) 27.28 ± 1.92
Fp (%) 80.3 ± 11.2
F-waves minimum inversion 32 (53.3 %)
F-wave mean inversion 34 (56.7 %)
Ulnar nerve – all subjects Mean ± SD
Fmin (ms) 24.01 ± 1.61
Fmax (ms) 27.78 ± 2.91
Fmean (ms) 25.86 ± 2.03
Fp (%) 84.5 ± 9.8
Median–ulnar nerves – all patients Mean ± SD
Fmin latency difference (ms) 1.15 ± 1.52
Fmean latency difference (ms) 1.41 ± 1.63
d etermine the correlation of the calculated electrophysio-

Comment logical parameters and CTS clinical severity. They studied
Cevik et al. [10] found that patients with CTS had sig- a total of 212 hands from 106 patients (Table 9) with CTS
nificantly longer FWML compared to the control (mean age 52.9 ± 10.3 years, range 25–70 years, 85 women
group. Sensitivity of the F-wave inversion was found and 21 men, 66 bilateral CTS, 24 right-side CTS, 16 left-
as 53.3 % (32/60 of early CTS patients) and specificity side CTS) using a Medelec Synergy electromyographic
was 93.3 %. F-wave inversion was also found in 8.7 % device (Oxford Instruments Medical). For the F-wave
of healthy subjects (3/45). They suggested adding study, the filter bandpass was 30 Hz–10 kHz, the sweep
F-wave inversion measurement to the routine nerve speed was 10 ms/division, and the sensitivity was set at
conduction studies in order to increase the reliability of 0.2 mV/division. They recorded at least 20 consecutive
the electrophysiological studies in early stage of CTS. F-waves, and the Fmin (ms) was measured for both median
and ulnar nerves recording from APB and ADM, respec-
tively. They also measured FWML (which they called
More recently, Park et al. [12] calculated the sensitivity, F-diff M-U) and modified F ratio (MFR). The F-diff M-U
specificity, and cutoff value of several nerve conduction was c alculated as follows:
parameters among groups with asymptomatic, mild, mod-
erate, and severe CTS. The aim of their study was to F − diff M − U ( ms ) = median nerve Fmin ulnar nerve Fmin


Asymptomatic (40 hands) Mean ± SD Range
F-waves minimum inversion 0.15 −1.30–3.05
Mild CTS (103 hands) Mean ± SD Range
Moderate CTS (43 hands) Mean ± SD Range
Severe CTS(26 hands) Mean ± SD Range
F-waves minimum inversion 7.55 3.80–16.25
Comment among the calculated electrophysiological parameter of

Park et al. [12] divided all 212 CTS hands into four conventional nerve conduction studies (NCS), the F diff
groups according to the clinical severity by applying a M-U could be a good indicator to determine the clinical
simplified four-stage historical–objective (Hi-Ob scale) severity of CTS (Figs. 5 and 6). They suggested that cut-
scale [13]: asymptomatic (40 hands), mild CTS (103 off value between asymptomatic and mild CTS group
hands), moderate CTS (43 hands), and severe CTS (26 may indicate a point of diagnosis of early CTS, the cut-
hands). They found for F diff M-U, significant differ- off value between mild and moderate CTS group may
ences among all CTS groups and the cutoff values were indicate a point of surgical treatment, and the cutoff
0.3 ms between asymptomatic and mild CTS group, value between moderate and severe CTS group may
2.3 ms between mild and moderate CTS group, and indicate a point of poor outcome of treatment in CTS
4.2 ms between moderate and severe CTS. For authors, patients.
Pathological waveform (wrist – APB muscle):
Median - (APB) 13 Median - (APB) 13
1.2
1.1
1.9
1.6
1.3
1.5
1.12
1.10
1.13 1.1
1.9
1.6
1.5
1.2
1.1
1.3
2 mV 2 mV 100 ms 500 µV
50 ms 500 µV
Sensitivity 500 µV/div, sweep speed 5 ms/div Sensitivity 500 µV/div, sweep speed 10 ms/div
(CMAP 2 mv/div)
Fig. 3 Prolonged F-waves recorded at the hand from the APB muscle, in moderately severe CTS – grade 3 by Bland’s CTS classification scale
[14] and chronic C8-T1 radiculopathy, stimulation of the wrist. Superimposed mode (10 stimuli), mean F-wave latency 38.15 ms

1.1
1.2
1.3
1.4
1.5
1.5
1.3
1.7
1.4
1.2
1.9
1.8
1.10
1.1
1.6
1.6 200 µV 100 ms 500 µV
1.7
1.8
1.9
1.10
200 µV 100 ms 500 µV
(CMAP 200 µV/div)
Fig. 4 Absent F-waves, recording at the hand from the APB muscle, in a Guillain-Barré syndrome (1 week of onset of symptoms), stimulation of
the wrist. Raster mode – 10 stimuli (left), superimposed mode – 10 stimuli (right)

Median - APB 20 Ulnar - ADM 21
1.1
1.2
1.9
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1.8 1.1
1.2
1.9
1.8
1.7
1.6
1.5
1.4
1.3
1.2
2mV 50 ms 200 µV 2 mV 50 ms 200 µV
Sensitivity 200 µV/div, sweep speed 5 ms/div

(CMAP 2 mv/div)
Fig. 5 Prolonged F-waves recorded at the hand from the APB muscle, in severe CTS – grade 4 by Bland’s CTS classification scale [14], stimula-
tion of the wrist. Superimposed mode – 10 stimuli, median nerve (left) and ulnar nerve (right). F-diff M-U = 2.85 ms (median Fmin 27.50 ms, ulnar
Fmin 24.65 ms)
Median - APB 21 Ulnar - ADM 20
1.1
1.2
1.9
1.8
1.7
1.6
1.5
1.4
1.3 1.7
1.2
1.9
1.13
1.12
1.15
1.17
1.19
1.5
1.10
1.8
1.16
1.4
1.14
1.11
1.3
1.1
1.6
1.18
1.20
2 mV 50 ms 200 µV 2 mV
50 ms 200 µV

(CMAP 2 mv/div)
Fig. 6 Prolonged F-waves recorded at the hand from the APB muscle, in very severe CTS – grade 5 by Bland’s CTS classification scale [14],
stimulation of the wrist. Superimposed mode – 10 stimuli, median nerve (left) and ulnar nerve (right). F-diff M-U = 3.95 ms (median Fmin 32.50 ms,
ulnar Fmin 28.55 ms)
References 8. Kimura J (1989) Electrodiagnosis in diseases of nerves and

muscles: principles and practice. F.A. Davis Company, Philadelphia,
pp 332–353
1. Eisen A, Schomer D, Melmed C (1977) The application of F-wave
9. Ozge A, Cömelekoglu U, Tataroglu C et al (2002) Subtypes of car-
measurements in the differentiation of proximal and distal upper
pal tunnel syndrome: median nerve F wave parameters. Clin Neurol
limb entrapments. Neurology 27:662–668
Neurosurg 104:322–327
2. Fisher MA, Hoffen B (1997) F-wave analysis in patients with
10. Cevik MU, Altun Y, Uzar E et al (2012) Diagnostic value of F-wave
carpal tunnel syndrome. Electromyogr Clin Neurophysiol
inversion in patients with early carpal tunnel syndrome. Neurosci
37:27–31
Lett 508:110–113
3. Dorfman LJ, Bosley TM (1979) Age-related changes in peripheral
11. Menkes DL, Hood DC, Bush AC (1997) Inversion of the F-waves
and central nerve conduction in man. Neurology 29:38–44
in median neuropathy at the wrist (Carpal Tunnel Syndrome). An
4. Cornwall MW, Nelson C (1984) Median nerve F-wave conduction
adjunctive electrodiagnostic method. J Contemp Neurol 5:1–8
in healthy subjects. Phys Ther 11:1679–1683
5. Nelson C, White JA, Mitchell RU et al (1990) Median nerve F-wave
conduction in healthy subjects over age sixty-five. Electromyogr
6. Buschbacher RM (1999) Median nerve f-wave latencies recorded
13. Giannini F, Cioni R, Mondelli M et al (2002) A new clinical scale of
from the abductor pollicis brevis. Am J Phys Med Rehabil 78:
carpal tunnel syndrome: validation of the measurement and clinical-
S32–S37
neurophysiological assessment. Clin Neurophysiol 113:71–77
7. Aygül R, Kotan D, Ulvi H et al (2014) The relationship of median
nerve F-wave parameters with severity and subtypes of carpal
tunnel syndrome. J Back Musculoskelet Rehabil 27:1–6
Wrist – Hand
M13
Study from Abductor Pollicis Brevis (APB) and
Abductor Digiti Minimi (ADM) Muscles
Original Settings Sensitivity was 1 mV/division, sweep opposite hands (see sensory conduction studies). Felsenthal
speed was 2 ms/division, duration of pulse was 0.2 ms, and (1) chose the same stimulation points in an attempt to achieve
the machine used was a Tektronix electromyograph; low- some standardization. During a CMAP acquisition, the stim-
frequency filter and high-frequency filter were not specified. ulation intensity was increased incrementally with careful
observation of the waveform morphology to achieve supra-
Position This study was performed in the supine position. maximal stimulation, while minimizing the likelihood of
stimulating unintended nerve segments.
Recording Following the median nerve stimulation (S1), the
active electrode (A) was placed over the belly of the abductor Measurements Distal latency (ms) was measured from the
pollicis brevis (APB) muscle (Fig. 1), halfway between the stimulus onset to the onset of the initial deflection of the
midpoint of the distal wrist crease and the midpoint of the first CMAP. Distal latency was measured for both the median and
metacarpophalangeal joint [1]. The reference (R) was placed ulnar nerves and differences between paired distal motor
slightly distal to the first metacarpophalangeal joint (over the latencies were measured in the same hand and in the oppo-
tendon of APB muscle). Following the ulnar nerve stimulation site hands in all subjects. All latencies were determined at
(S2), the active electrode was placed over the motor point of the same session and at room temperature. Skin and room
the abductor digiti minimi (ADM) muscle (Fig. 1). The refer- temperatures were not given. Author performed APB and
ence (R) was placed slightly distal to the fifth metacarpopha- ADM CMAP recording in 100 hands (Table 1) from 50 vol-
langeal joint (over the tendon of the ADM muscle). The active unteers (age range 16–61 years, mean age 33.4 years).
electrode location was adjusted over the thenar eminence and Sander et al. [2] performed two methods for median-to-
the hypothenar eminence to obtain the greatest compound ulnar motor conduction comparison in the diagnosis of
muscle action potential (CMAP) amplitude for both the median neuropathy at the wrist: the median–thenar to ulnar–
median (S1) and ulnar (S2) nerves stimulations at the wrist. thenar latency difference (TTLD) previously described by
Authors used a stainless steel disk electrode for recording. The Rhee et al. in 1979 [3] and, following the method described
ground (G) electrode was placed on the dorsum of the hand, by Felsenthal [1], the median–thenar to ulnar–hypothenar
between the recording and stimulating electrodes (the figure latency difference (THLD). They studied 34 normal hands
shows the ground electrode placed on the palm). (Table 2) from 34 asymptomatic volunteers (15 right hand
and 19 left hand, right hand dominant in 33 controls – the
Stimulation The median and ulnar CMAPs were evoked handedness of one control was not recorded, age range
with a bar stimulating electrode with the 1-cm diameter cath- 26–71 years, mean age 41 years) and 79 hands from 50
ode (−) 2 cm distal to the 1-cm diameter anode (+). The patients (Table 3) with clinically and electrophysiologically
stimulations were at the wrist, on the median nerve (S1), and diagnosed carpal tunnel syndrome (CTS), 29 bilateral CTS,
on the ulnar nerve (S2), approximately 1 cm proximal to the 16 CTS on the right side, 5 CTS on the left side, the right
proximal wrist crease [1]. Care was taken to ensure that the hand dominant in 38 CTS patients, the left hand dominant in
median and ulnar wrist stimulations were performed at the 5 CTS patients—the handedness of seven patients was not
same distance proximal to the proximal wrist crease. Author recorded (age range 26–71 years, mean age 41 years). They
used the same sites of motor stimulations at the wrist (both found both tests highly sensitive (95–98 % and 85–88 %,
median and ulnar nerves, S1 and S2, respectively) to com- respectively) if compared to the standard conduction tech-
pare median and ulnar sensory latencies in the same and niques (i.e., median nerve palm–wrist latency).

76 M13 Wrist – Hand
C8
T1 R1
Lower trunk
Digit I
Median
Medial cord
nerve Ulnar
nerve
S1
R (wrist)
A
– + Median nerve
G
– + Ulnar nerve
A
R
Digit V
S2
R2
(wrist)
Abductor digiti minimi (ADM)
Typical waveform (wrist – APB muscle, wrist – ADM muscle):
Median - ulnar (APB-ADM) Median - ulnar (APB-ADM)

2
1 3 5 1 3 5
Wrist (median) 1 Wrist (median) 1
30 ms 5 mV 14 mA 30 ms 10 mV 14 mA
4
2 4
1 3 1 3 5
5 Wrist (ulnar) 2 Wrist (ulnar) 2
4 30 ms 10 mV 14 mA
30 ms 5 mV 14 mA
4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and ADM muscles. Stimulation of the wrist: median
nerve (upper trace) and ulnar nerve (lower trace)
M13 Wrist – Hand 77

Normal values [1] – median nerve Mean ± SD Mean ± 2SD Range
Wrist–APB, distal latency (ms) 3.1 ± 0.41 3.9 2.2–4.2
Normal values [1] – ulnar nerve Mean ± SD Mean ± 2SD Range
Wrist–ADM, distal latency (ms) 2.9 ± 0.36 3.6 2.3–3.7
Normal values [1] – median nerve Mean ± SD Mean ± 2SD Range
Wrist–APB, distal latency difference (ms) – side-to-side 0.25 ± 0.18 0.61 0.0–0.9
Normal values [1] – ulnar nerve Mean ± SD Mean ± 2SD Range
Wrist–ADM, distal latency difference (ms) – side-to-side 0.22 ± 0.18 0.58 0.0–0.8
Normal values [1] – median and ulnar nerve Mean ± SD Mean ± 2SD Range
APB–ADM distal latency difference (ms) – side-to-side 0.40 ± 0.28 0.96 0.0–1.2

Limit Limit Pathological values [2] Mean ± SD Range Sensitivity (%)
Normal values [2] Mean ± SD Range of normal of normal Wrist–MDL, distal latency 4.31 ± 0.94 2.9–6.6 72
Wrist–MDL, distal 2.92 ± 0.28 2.4–3.5 3.6 3.7 (ms) – all 79 hands
latency (ms) Wrist–MDL, distal latency 4.38 ± 0.93 2.9–6.6 72
Wrist–THLD, 0.44 ± 0.30 −0.4–1.0 1.1 1.2 (ms) – one hand
distal latency (ms) Wrist–THLD, distal 2.02 ± 0.93 0.0–4.4 85
latency (ms) – all
79 hands
Wrist–THLD, distal 2.12 ± 0.88 0.7–4.4 88
latency (ms) – one hand
Comment hands were included; [2] only one hand per patient was
Sander et al. [2] measured the median–thenar distal included (only the right hand of patients affected bilater-
latency (MDL) and the median–thenar to ulnar–hypo- ally). Authors compared their THLD technique with the
thenar latency difference (THLD). The ulnar–hypothe- median palm (the wrist mixed nerve action potential
nar latency was subtracted from the median–thenar latency, MPWL). In accordance with Jackson and
distal latency to obtain the THLD. The latency of the Clifford [4], they considered MPLW abnormal if the
median–thenar CMAP (ms) was measured from the response was absent, the latency exceeded 1.7 ms or the
stimulus onset to the onset of the negative deflection of latency exceeded the ipsilateral ulnar palm–wrist latency
the CMAP. When measuring the median–thenar (MDL) by more than 0.3 ms. Among the 12 failures, the sensi-
and the ulnar–hypothenar CMAP onset latency, a small tivity of the mean THLD was 85 % in two hands (0.7 ms
premotor potential with an initial negative deflection and 0.8 ms) and 88 % in one hand (0, 0.6, 0.9, and
was occasionally present prior to the onset of the 1.1 ms). The THLD, using author’s methodology, is a
CMAP. This potential is likely generated by intramuscu- highly sensitive (85–88 %) indicator of a median neu-
lar nerve fibers. The CMAP onset latency in these cir- ropathy at the wrist in patients with a clinical diagnosis
cumstances was therefore measured at the onset of the of CTS (Figs. 2, 3, and 4), THLD test had a 100 % speci-
subsequent CMAP negativity. Amplitude of the CMAP ficity of an abnormal value (no false positives) among
was measured from the baseline to the peak of negative the normal controls. Authors chose a CTS population
deflection. Skin temperature on the hand was measured with an electrophysiological evidence of a median neu-
and maintained at or above 32 °C. The mean THLD of ropathy at the wrist to evaluate the usefulness of the
0.44 ms indicates that, on average, the ulnar–hypothe- described techniques in a set of patients with a docu-
nar latency was shorter than the median–thenar latency. mented median nerve dysfunction. The diagnostic sen-
Using this cutoff there were no false positives in the sitivity values are not directly comparable to values in
control group. Calculations involving CTS patients some other reports that determined sensitivities in a
were performed using two methods: [1] all affected population with purely clinically defined CTS.
During a 1-year period, Chang et al. [6] performed sev- compared sensitivity and specificity of some different tests
eral sensory and motor conduction techniques to compare in the diagnosis of CTS in diabetic polyneuropathy patients,
the sensitivities in the diagnosis of CTS. All studies were studying a total of 263 hands (Table 7) from 139 patients
performed using a Nicolet Viking IV or Dantec Keypoint 4 divided into three groups: Group 1 – 72 patients with CTS
electromyograph, and skin temperature at the hand was (140 hands from 72 patients, 59 women and 13 men, mean
maintained at or above 32 °C. The mean THLD was calcu- age 53.9 ± 3.5 years); Group 2 – 32 patients with polyneu-
lated in 100 control (Table 4) subjects (64 women 36 men, ropathy without associated CTS (61 hands from 32 patients,
age range 22–65 years, mean age 47.4 years). 19 women and 13 men, mean age 55.6 ± 9.5 years); Group
Lee et al. [7] described a sensitive new method, the 3 – 35 patients with polyneuropathy and associated CTS (62
median terminal latency (MTL) ratio, and compared it to that hands from 35 patients, 26 women and 9 men,
of standard conduction techniques for diagnosing CTS, like 55.5 ± 7.3 years). The sensitivities and specificities of the
the motor distal latency difference between the median–the- tests were used to compare the diagnosis of CTS in patients
nar and ulnar–hypothenar using Felsenthal’s method [1]. with diabetic polyneuropathy. A greater diagnostic accu-
They studied 100 volunteers (Table 5) and 153 patients with racy can be observed in tests with higher sensitivity and spec-
clinically suspected CTS, and a low diagnostic sensitivity ificity. Following the median–thenar and ulnar–hypothenar
(63.9 %) was found. CMAP latency comparison [1], measurement of latency of
Gazioglu and colleagues [8] performed standard nerve the median–thenar and ulnar–-hypothenar CMAPs was
conduction studies, segmental and comparative median performed using the onset of first deflection (initial negative
nerve conduction tests in 86 hands (Table 6) from 43 healthy deflection for both the median–thenar and ulnar–hypothenar
individuals (Group 4 – 32 women and 11 men, 42 right hands CMAPs), and the THLD was calculated by subtracting the
and 1 left hand, body mass index – BMI 27.5 ± 3.4, mean age ulnar–hypothenar distal latency from the median–thenar
53.7 ± 5.5 years). They used a Nihon Kohden 9100 electro- distal latency. They found normal THLD values (0.8 ± 0.2 ms)
myograph at a room temperature of 25 °C, and a palmar tem- consistent with those reported by others [6, 7].
perature maintained at approximately 32 °C. Authors

Normal values [6] Mean ± SD Limit of normal
Wrist–THLD, distal latency (ms) 0.82 ± 0.29 <1.55

men, 71 right hands and 1 left hand, body mass index –
Normal values [7] Mean ± SD Limit of normal (±2 SD)
BMI 29.0 ± 3.3, mean age 53.9 ± 3.5 years) – Group 1
Wrist–THLD, distal latency (ms) 0.76 ± 0.32 <1.40
(CTS); on a group of diabetic patients with polyneu-
ropathy without associated CTS (61 hands from 32
patients, 19 women and 13 men, 30 right hands and 2
Normal values [8] Mean ± SD Cutoff left hands, body mass index – BMI 29.1 ± 5.4, mean age
Wrist–THLD, distal latency (ms) 0.8 ± 0.2 ≤1.3 55.6 ± 9.5 years) – Group 2 (DMPNP CTS-); and on a
group of diabetic patients with a polyneuropathy with
Table 7 Reference values associated CTS (62 hands from 35 patients, 26 women
and 9 men, 26 right hands and 9 left hands, body mass
Pathological values [8] Mean ± SD
index – BMI 31.4 ± 7.1, mean age 55.5 ± 7.3 years) –
Wrist–THLD, distal latency (ms) - Group 1 2.1 ± 0.7
Group 3 (DMPNP CTS+). The sensitivities and speci-
ficities of the tests were compared in the diagnosis of
CTS in patients with diabetic polyneuropathy. The
THLD was higher in the Group 1 (CTS) than in the
group 3 (polyneuropathy with CTS), and in the Group
Comment 2 (polyneuropathy without CTS) than controls. These
Gazioglu and colleagues [8] compared sensitivity and differences were significant between the Group 3 and
specificity of some different tests in the diagnosis of CTS Group 2, and between the Group 1 and Group 3. Authors
in diabetic polyneuropathy patients on a group of patients found, using a 1.3 ms cutoff, a sensitivity of 74 % and a
with CTS (140 hands from 72 patients, 59 women and 13 specificity of 77 %.
Pathological waveform (wrist – APB muscle, wrist – ADM muscle):
2 2
1 3 1 3
5 Wrist (median) 1 5 Wrist (median) 1
4 50 ms 5 mV 33 mA 4 30 ms 5 mV 33 mA
2 2
1 3 1 3
5 Wrist (ulnar) 2 5 Wrist (ulnar) 2
50 ms 5 mV 47 mA 30 ms 5 mV 47 mA
4 4
Onset latency (median – APB): 5.55 ms; Onset latency (ulnar – ADM): 3.35 ms; Peak latency (median – APB): 9.80 ms; Peak latency
(ulnar – ADM): 7.10 ms; Onset latency difference (median APB – ulnar ADM): 2.20 ms; Onset to peak amplitude (median – APB):
6.8 mV; Onset to peak amplitude (ulnar – ADM): 11.8 mV; Peak to peak amplitude (median – APB): 10.2 mV Peak to peak amplitude
(ulnar – ADM): 17.5 mV
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and ADM muscles in moderately severe CTS – grade 3
by Bland’s CTS classification scale [5]. Stimulation of the wrist: median nerve (upper trace) and ulnar nerve (lower trace)
80 References
2 2
1 3 4 5 1 3 4 5
50 ms 5 mV 35 mA 30 ms 5 mV 35 mA
2 2
1 3 1 3
50 ms 5 mV 27 mA 30 ms 5 mV 27 mA
4 4
Onset latency (median – APB): 8.30 ms; Onset latency (ulnar – ADM): 3.35 ms; Peak latency (median – APB): 11.75 ms; - Peak latency
1.9 mV; Onset to peak amplitude (ulnar – ADM): 9.5 mV; Peak to peak amplitude (median – APB): 2.4 mV; Peak to peak amplitude
(ulnar –ADM): 14.1 mV
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and ADM muscles in very severe CTS – grade 5 by
Bland’s CTS classification scale [5]. Stimulation of the wrist: median nerve (upper trace) and ulnar nerve (lower trace)

2 2
1 3 Wrist (median) 1 1 3 Wrist (median) 1

4 5 4 5
50 ms 5 mV 47 mA
30 ms 5 mV 47 mA
2 2
1 3 5 1 3 5
Wrist (ulnar) 2 Wrist (ulnar) 2
4 4
50 ms 5 mV 47 mA
30 ms 5 mV 47 mA
Onset latency (median – APB): 10.30 ms; Onset latency (ulnar – ADM): 6.45 ms; Peak latency (median – APB): 17.20 ms; Peak latency
Fig. 4 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and ADM muscles in very severe CTS – grade 5 by
Bland’s CTS classification scale [5] and Guillain-Barré syndrome (2 weeks of onset of symptoms). Stimulation of the wrist: median nerve (upper
trace) and ulnar nerve (lower trace)
References 5. Bland JDP (2000) A neurophysiological grading scale for carpal

6. Chang MH, Wei SJ, Chiang HL et al (2002) Comparison of motor
1. Felsenthal G (1977) Median and ulnar distal motor and sensory
latencies in the same normal subjects. Arch Phys Med Rehabil
58:297–302
7. Lee KY, Lee YJ, Koh SH (2009) Usefulness of the median terminal
2. Sander HW, Quinto C, Saadeh PB et al (1999) Sensitive median-
latency ratio in the diagnosis of carpal tunnel syndrome. Clin
ulnar motor comparative techniques in carpal tunnel syndrome.
Muscle Nerve 22:88–98
8. Gazioglu S, Boz C, Altunayoglu Cakmak A (2011) Electrodiagnosis
3. Rhee S, Srinivasan S, Shafer N (1979) An additional electrodiagnos-
of carpal tunnel syndrome in patients with diabetic polyneuropathy.
tic method for carpal tunnel syndrome. Acta Neurol Scand 60:117
4. Jackson DA, Clifford JC (1989) Electrodiagnosis of mild carpal tun-
nel syndrome. Arch Phys Med Rehabil 70:199–204
Wrist, Elbow, Axilla, Erb’s Point – Hand
M14
Original Settings Sensitivity was 1 mV/division, sweep antecubital fossa, just lateral to the brachial artery. The third
speed was 1 ms/division, and duration of pulse was 0.1 ms stimulation (S3) was delivered at the axilla, and the fourth
for stimulation of the wrist and of the elbow (S1–S2) and stimulation (S4) was delivered at the Erb’s point, lateral to
0.2–0.5 ms for stimulation of the axilla and of the Erb’s point the clavicular insertion of the lateral head of the sternoclei-
(S3–S4). The machine used was a two-channel TECA model domastoid muscle (just above the clavicle). Therefore, four
TE2-7. Low-frequency filters and high-frequency filters motor latencies were obtained for each nerve tested. At all of
were not specified. the above sites of stimulation, the location of the stimulating
cathode was carefully adjusted to obtain a perfectly match-
Position This study was performed in the supine position. ing configuration of the evoked action potential for each
The subject was lying supine with his arm in 60° abduction stimulation. In all stimulations the anode was proximal. The
at the shoulder, elbow extended, and the forearm in supine voltage required to activate a maximal response was gener-
position. This position placed the brachial plexus with the ally supramaximal, the square pulses of current used for
peripheral median nerve as close to a straight line as possible stimulation were 0.1 ms duration at the wrist (S1) and at the
and to make the measurement of the Erb’s point–axilla seg- elbow (S2). At the axilla (S3) and at the Erb’s point (S4), a
ment most reliable. This position also provides an ample longer pulse duration of 0.2 or 0.5 ms was needed (Fig. 2).
approach to the axilla for the proper placement of the stimu- The latter was the more frequently used.
lator on individual nerves.
Measurements Distal latency (ms) was measured from the
Recording Surface recording electrodes (pick-up electro- stimulus artifact to the onset of the initial negative response
cardiograph electrodes, 6 mm diameter) for muscle poten- (upward deflection). Motor nerve conduction velocity
tials were placed over the motor point of the abductor pollicis (MNCV) was measured in m/s and calculated in the con-
brevis (APB) muscle (Fig. 1) and the tendon just distal to the ventional way for each of the three proximal tested seg-
metacarpophalangeal joint (cathode – A, anode – R). The ments (Erb’s point-axilla, axilla-elbow, and elbow-wrist),
ground (G) was placed on the dorsum of the hand [1]. dividing the distance by the latency difference between
the two evoked potentials. The distances between cathodes
Stimulation The median nerve was stimulated using the were measured with a tape measure, except for the distance
surface electrodes at four (4) points along its course [1]: at between Erb’s point and the axilla where a caliper was used.
the wrist (S1), at the elbow (S2), at the axilla (S3), and at the Skin temperature was not controlled; the room temperature
Erb’s point (S4). was between 25 and 26.7 °C. The subject was resting for
The first stimulation (S1) was delivered at the wrist (at a at least 30 min on a plinth before the start of the session
constant distance of 5.5 cm from the corresponding muscle and was covered with a blanket to the midchest. Authors
pickup electrode), between the tendons of the flexor carpi studied 21 median nerves from 12 healthy (Table 1) sub-
radialis (FCR) and the palmaris longus (PL) muscles. The jects (8 women and 4 men, age range 26–55 years, mean
second stimulation (S2) was delivered at the elbow, on the age 37.1 years).

84 M14 Wrist, Elbow, Axilla, Erb’s Point – Hand
Biceps brachii
(BB)
+
–
R
S2
(elbow)
Digit I
+
R A –
5.5 cm
G C8
T1
S1
(wrist)
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (wrist, elbow, axilla, Erb’s point – APB muscle):
1 3 5 1 3 5
Wrist 1 Wrist 1
4 50 ms 10 mV 40 mA 4 30 ms 10 mV 40 mA
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
4 50 ms 10 mV 41 mA 4 30 ms 10 mV 41 mA
2 2
1 3 5 1 3 5
Axilla 3 Axilla 3
4 50 ms 10 mV 32 mA 4 30 ms 10 mV 32 mA
2 2
1 3 5 1 3 5
Erb's point 4 Erb's point 4
4 50 ms 10 mV 47 mA 4 30 ms 10 mV 47 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, (bottom to top – stimulation of the Erb’s point,
axilla, elbow, and wrist)
M14 Wrist, Elbow, Axilla, Erb’s Point – Hand 85
S4
(Erb’s point)
S3
(axilla)
–
+
+
–
Fig. 2 Median proximal stimulations (S3 on the axilla, S4 on the Erb’s point), recording from the APB muscle

Normal values [1] Mean ± SD Range Mean ± 2 SD Normal values [1] Mean ± SD
Wrist–APB, distal latency 3.9 ± 0.37 3.4–4.5 Elbow–wrist, MNC Velocity difference side-to-side (m/s) 2.0 ± 1.6
(ms) Axilla–elbow, MNC Velocity difference side-to-side (m/s) 4.8 ± 4.4
Elbow–wrist, MNCV 49.0 ± 3.9 45.1–54.4 Erb’s point–axilla, MNC Velocity difference 7.5 ± 4.9
(m/s) side-to-side (m/s)
Axilla–elbow, MNCV 56.3 ± 5.1 50.0–68.3
(m/s)
Erb’s point–axilla, 65.1 ± 6.1 57.1–76.2 52.9
MNCV (m/s)
Erb’s point–axilla, 2.9 ± 0.4 2.1–3.4
conduction time (m/s)
Comment MNCV values was 14 m/s. These additional measure-

Ginzburg et al. [1] measured and compared the proxi- ments also enabled to determine that a tested nerve
mal MNCV values (Erb’s point–axilla segment) with was intact in its entire length and must be essential part
those distal (axilla–elbow and elbow–wrist segments). of the nerve conduction study in case of neuropathy
For the median Erb’s point–axilla segment, the upper (Figs. 3, 4, 5, and 6).
limit of normal difference between the right and left
Pathological waveform (wrist, elbow, axilla, Erb’s point – APB muscle):
2 2
1 3 5 1 3 5
4 Wrist 1 4 Wrist 1
50 ms 5 mV 31 mA 30 ms 5 mV 31 mA
2 2
1 3 5 Elbow 2 1 3 5
4 4 Elbow 2
50 ms 5 mV 47 mA 30 ms 5 mV 47 mA
2 2
1 34 5 Axilla 3 1 34 5
Axilla 3
50 ms 5 mV 47 mA 30 ms 5 mV 47 mA
2 2 Erb's point 4
1 3 5 1 3 5
4 Erb's point 4 4
50 ms 5 mV 69 mA 30 ms 5 mV 69 mA
Onset latency (wrist – APB): 5.80 ms; Onset latency (elbow – APB): 11.20 ms; Onset latency (axilla – APB): 14.80 ms; Onset latency
(Erb’s point – APB): 17.55 ms; Peak latency (wrist – APB): 8.10 ms; Peak latency (elbow – APB): 13.70 ms; Peak latency (axilla – APB):
17.20 ms; Peak latency (Erb’s point – APB): 20.15 ms; Onset to peak amplitude (wrist – APB): 3.0 mV; Onset to peak amplitude (elbow
– APB): 2.4 mV; Onset to peak amplitude (axilla – APB): 2.5 mV; Onset to peak amplitude (Erb’s point – APB): 2.3 mV; Peak to peak
amplitude (wrist – APB): 4.0 mV; Peak to peak amplitude (elbow – APB): 3.8 mV; Peak to peak amplitude (axilla – APB): 3.1 mV; Peak
to peak amplitude (Erb’s point – APB): 3.2 mV; MNCV (wrist – elbow): 46.3 m/s; MNCV (axilla – elbow): 45.8 m/s; MNCV (Erb’s point –
elbow): 47.3 m/s
CTS classification scale [2] and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), (bottom to top – stimulation of the Erb’s
point, axilla, elbow, and wrist)
M14 Wrist, Elbow, Axilla, Erb’s Point – Hand 87

2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
4 4
50 ms 5 mV 78 mA 30 ms 5 mV 78 mA
2 2
1 3 1 3
45 Elbow 2 4 5 Elbow 2
50 ms 5 mV 100 mA 30 ms 5 mV 100 mA
2 2
1 3 1 3
4 5 Axilla 3 4 5 Axilla 3
50 ms 5 mV 100 mA 30 ms 5 mV 100 mA
2 2
Erb's point 4
1 3 1 3 4 5
4 5 Erb's point 4
50 ms 5 mV 40 mA 30 ms 5 mV 40 mA
elbow): 37.9 m/s
Fig. 4 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in Charcot-Marie-Tooth disease (CMT) – CMTX
type (X-linked type), CMTX1 subtype (bottom to top – stimulation of the Erb’s point, axilla, elbow, and wrist)
2 Median - (APB) Median - (APB)

2
1 3
1 3 4 5 Wrist 1
5 Wrist 1
4 100 ms 10 mV 59 mA
50 ms 5 mV 59 mA
2
2
1 3
1 3 4 5 Elbow 2
5 Elbow 2
4 100 ms 10 mV 64 mA
50 ms 5 mV 64 mA
2
2
1 3
1 3 4 5 Axilla 3
4 5 Axilla 3
100 ms 10 mV 100 mA
50 ms 5 mV 100 mA
2
2
Erb's point 4 1 34 5
1 3 Erb's point 4
4 5
100 ms 10 mV 100 mA
50 ms 5 mV 100 mA
28.05 ms; Peak latency (Erb’s point – APB): 31.80 ms; Onset to peak amplitude (wrist – APB): 5.9 mV; Onset to peak amplitude ( elbow
elbow): 52.1 m/s
Fig. 5 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in very severe CTS – grade 5 by Bland’s CTS
classification scale [2], (bottom to top – stimulation of the Erb’s point, axilla, elbow, and wrist)
References 89

2
2
1 3 5 1 3 4 5
4 Wrist 1 Wrist 1
100 ms 10 mV 100 mA
50 ms 5 mV 100 mA
2
2
1 3 1 3
4 5Elbow 2 4 5
Elbow 2
100 ms 10 mV 100 mA
50 ms 5 mV 100 mA
2
3 5 2 3
1 Axilla 3 1 4 5
4 Axilla 3
100 ms 10 mV 100 mA
50 ms 5 mV 100 mA
2
3 2
1 Erb's Point 4 1 3
4 5
4 Erb's Point 4
100 ms 10 mV 100 mA
50 ms 5 mV 100 mA
Onset latency (wrist – APB): 10.50 ms; Onset latency (elbow – APB):16.95 ms; Onset latency (axilla – APB): 20.25 ms; Onset latency
(Erb’s point – APB): 23.20 ms; Peak latency (wrist– APB): 17.40ms; Peak latency (elbow – APB): 23.15 ms; Peak latency (axilla – APB):
elbow): 40.7 m/s
classification scale [2] and Guillain-Barré syndrome (2 weeks of onset of symptoms), (bottom to top – stimulation of the Erb’s point, axilla, elbow,
and wrist)
References
1. Ginzburg M, Lee M, Ginzburg J et al (1978) Median and ulnar nerve
conduction determinations in the Erb’s point-axilla segment in nor-
mal subjects. J Neurol Neurosurg Psychiatry 41:444–448
Elbow, Wrist, Palm – Hand
M15
Original Settings Sensitivity, low-frequency filter, high- muscle. The third stimulation (S3) was delivered on the
frequency filter, sweep speed, duration of pulse, rate of pulse, palm, on the midpoint of the distance from the recording
and the machine used were not specified. electrode site to the wrist stimulation site, so the length of the
short segment was 4 cm. This point, because of a 4 cm fixed
Position This study was performed in the supine position, distance from the recording electrode on the OP muscle, was
with the elbow and fingers slightly flexed. just above the flexor retinaculum, slightly distal to the distal
wrist crease (Fig. 2).
Recording According to a previous standardized technique Distal stimulation (S2) at the wrist determined distal
[1], author [2] placed the active electrode (A) over the belly compound muscle action potential (CMAP) while proximal
(motor point) of the opponens pollicis (OP) muscle (Fig. 1), stimulation at the elbow (S1), just above the crease of the
halfway between the midpoint of the distal wrist crease and antecubital fossa and medial to the biceps tendon at the
the midpoint of the first metacarpophalangeal joint [2]. The elbow, allowed the determination of the forearm motor nerve
reference (R) was placed slightly distal to the first metacar- conduction velocity. The length of the short segment (4 cm)
pophalangeal joint, the proximal phalanx of the digit I was divided by the forearm motor nerve conduction velocity
(thumb). The ground (G) electrode position was not speci- to determine the expected short segment distal latency. After
fied in the paper; it was probably placed over the mid-forearm percutaneous stimulation of the nerve at the midpalmar site,
or on the palm of the hand (the figure shows the ground elec- the observed distal latency was obtained. The difference
trode placed on the forearm). between the observed and expected distal latencies was the
short segment residual. The residual latency index (RLI) was
Stimulation The median nerve was stimulated at the elbow determined by dividing the short segment residual latency by
(S1), at the wrist (S2), and on the palm (S3). The first stimu- the residual latency for the entire terminal nerve segment. In
lation (S1) was delivered at the elbow, on the antecubital case of stimulation at the elbow (S2), authors suggested a
fossa, just lateral to the brachial artery. The anode was proxi- 2–4 cm separation between the cathode (−) and the anode
mal. The second stimulation (S2) was delivered at the wrist, (+), using a pair of standard 0.6 cm diameter electroencepha-
between the tendons of the flexor carpi radialis (FCR) and lograph electrodes mounted on a plastic block for stimulat-
palmaris longus (PL) muscles. The anode was proximal. ing the nerve. Supramaximal stimulation was used; a
Authors used an 8 cm fixed distance between the cathode stimulus in all determinations was at least 30 % greater than
at the wrist and the active recording electrode on the OP that which elicited a maximum response.

92 M15 Elbow, Wrist, Palm – Hand
Biceps brachii
(BB)
+
–
R
G
S1
(elbow)
+
A
8 cm –
R +
4 cm –
S2 C8
(wrist) T1
S3
(palm) Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (elbow, wrist, palm – OP muscle):

2 2
1 3 1 3
5 Elbow 1 5 Elbow 1
4 50 ms 5 mV 53 mA 4 30ms 5mV 53 mA
2 2
1 3 1 3 5
5 Wrist 2 Wrist 2
4 50 ms 5 mV 30 mA 4 30ms 5 mV 30 mA
2 2
1 3 Palm 3 1 3 Palm 3
5 5
4 50 ms 5 mV 30 mA 4 30 ms 5 mV 30 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded from the OP muscle, stimulation of the elbow (upper trace), wrist (middle trace),
and palm (lower trace)
M15 Elbow, Wrist, Palm – Hand 93
C8
T1
R
Lower trunk Digit I

Median
nerve
Medial cord
A
4 cm 8 cm
– + – + Median nerve
Digit V
S2
S3 (wrist)
(palm)
Fig. 2 Distal stimulations (S2 – wrist, S3 – palm), recording from the OP muscle
Measurements Authors measured distal peak latency (ms) was termed the “residual latency” (RL) for the motor fibers.
from the beginning of the shock artifact to the peak of the The temperature of the forearm was determined using a skin
negative deflection of CMAP and they called this latency surface thermistor thermometer; all forearm temperatures
value “terminal latency” (TL). The motor nerve conduction equaled or exceeded 34 °C. Expected TL of the CMAP
velocity (MNCV) was calculated from the nerve using stim- recorded from the OP muscle after stimulation at the wrist
ulus at above the elbow and at the wrist, the recording sites (8 cm segment) and RL for the CMAP recorded from the OP
placed to the OP muscle. From this elbow–wrist conduction muscle after stimulation at the wrist (8 cm segment) were
velocity an expected terminal latency from the wrist to the calculated as follows (the distance between the cathode
OP muscle was calculated and compared with the measured placed at the wrist and the active electrode placed on the
motor terminal latency. The difference between these values opponens pollicis muscle was 80 mm fixed):
distance between cathode ( wrist ) and active electrode ( OP ) , ( mm )

Expected TL ( ms ) =
Residual Latency, RL ( ms ) = observed TL ( ms ) - expected TL ( ms )

Expected short segment terminal latency (SSTL) of the stimulation on the palm (4 cm segment) were calculated as
CMAP recorded from the OP muscle after stimulation on follows (the distance between the cathode placed on the
the palm (4 cm segment) and the short segment residual palm and the active electrode placed on the opponens
latency (SSRL) for CMAP from the OP muscle after pollicis was 40 mm fixed):
distance between cathode ( palm ) and active electrode ( OP ) , ( mm )

Expected SSTL ( ms ) =
nerve conduction velocity ( wrist − OP ) , ( m/s )
Short Segment Residual Latency, SSRL ( ms ) = observed SSTL ( ms ) - expected SSTL ( ms )
short segment residual latency ( SSRL ) , ( ms )

Residual Latency Index, RLI =
residual latency ( RL ) , ( ms )
Authors [2] calculated SSRL and RLI in 20 healthy volun- tion of a product–moment correlation coefficients.
teers (Table 1) with no history of alcoholism or diabetes (age Coefficient values ≥0.48 indicated a statistically significant
range 15–74 years, mean age 45 years) and in 5 patients direct relationship. These higher correlation coefficient val-
(Table 2) with median neuropathy at or distal to the wrist ues were noted only in the control subjects, and because
(age range 26–66 years, mean age 49 years). In order to these relationships would be consistent with a homogeneous
quantitatively compare neuropathic and control populations, population, the RLI values for the control population were
RLI values were converted to numbers used in the calcula- thus standard or normative values.

Wrist–OP, residual latency (ms) – 15 subjects 1.5 ± 0.3 1.0–2.0
Palm–OP, short segment residual latency (ms) – 15 subjects 0.9 ± 0.2 0.6–1.1
Residual latency index (ms) – 15 subjects 0.60 ± 0.5 0.56–0.62
Residual latency index (ms) – standard values 0.61 0.56–0.65

Pathological values [2] Mean ± SD Range
Wrist–OP, residual latency (ms) – 5 subjects 3.3 ± 1.0 2.7–3.8
Palm–OP, short segment residual latency (ms) – 5 subjects 1.1 ± 0.6 0.8–1.4
Residual latency index (ms) – 5 subjects 0.33 ± 1.0 0.30–0.37
Residual latency index (ms) – standard values 0.36 0.30–0.45
Comment latency may be studied. Therefore, the RLI is a measure

Kaplan and Sahgal [1] compared the RLI values for the of the slowing of the motor nerve conduction velocity
neuropathic population with the standard values. In five produced at the distal short segment (4 cm distance, from
patients with a carpal tunnel syndrome (CTS), the RLI the palm to the opponens pollicis muscle). In those
decreased from 0.61 to 0.36. As a motor nerve conduction patients with neuropathy of the median nerve at the carpal
velocity in the median nerve approaches the wrist, it tunnel, the bulk of the slowing of the motor nerve conduc-
slows perceptively. Residual latencies measure the time tion velocity was seen in the proximal short segment
latency produced by that slowing (8 cm distance, from the (4 cm distance from palm to wrist). As a result, the amount
wrist to the opponens pollicis muscle), and by adding a contributed to the residual latency by the distal short seg-
midpalmar stimulation site, the contribution of the short ment decreased relative to that of the proximal short seg-
segment of the nerve distal to the wrist to the residual ment. Therefore, the RLI decreased (Fig. 2).
Pathological waveform (elbow, wrist, palm – OP muscle):
2 2
1 3 5 Elbow 1 1 3 5
4 4 Elbow 1
50 ms 5 mV 39 mA 30 ms 5 mV 39 mA
2 2
1 3 5 1 3 5
4 Wrist 2 4 Wrist 2
50 ms 5 mV 70 mA 30 ms 5 mV 70 mA
2 2
1 3 5 1 3 5
Palm 3 Palm 3
4 4
50 ms 5 mV 18 mA 30 ms 5 mV 18 mA
Onset latency (elbow – OP muscle): 9.55 ms; Onset latency (wrist – OP muscle): 5.80 ms; Onset latency (palm – OP muscle): 3.35 ms;
Peak latency (elbow – OP muscle): 12.10 ms; Peak latency (wrist – OP muscle): 9.00 ms; Peak latency (palm – OP muscle): 6.35 ms;
Onset to peak amplitude (elbow – OP muscle): 4.8 mV; Onset to peak amplitude (wrist – OP muscle): 4.3 mV; Onset to peak amplitude
(palm – OP muscle): 4.8 mV; Peak to peak amplitude (elbow – OP muscle): 6.4 mV; Peak to peak amplitude (wrist – OP muscle): 5.5 mV;
Peak to peak amplitude (palm – OP muscle): 6.4 mV; MNCV (elbow – wrist): 61.3 m/s; MNCV(wrist – OP muscle): 13.8 m/s; MNCV (palm
– OP muscle): 11.1 m/s.
Residual latency (wrist – OP muscle, 8 cm distance) calculation: MNCV (elbow – wrist): 61.3 m/s; Expected latency (wrist – OP muscle, 8 cm
distance): 1.30 ms;Observed latency (wrist – OP muscle, 8 cm distance): 5.80 ms; Residual latency (wrist – OP muscle, 8 cm distance): 4.50 ms.
Residual latency (palm – OP muscle, 4 cm distance) calculation: MNCV (wrist – OP muscle): 13.8 m/s; Expected latency (palm – OP muscle,
4 cm distance): 2.90 ms; Observed latency (palm – OP muscle, 4 cm distance): 3.60 ms; Short segment Residual latency (palm – OP muscle,
4 cm distance): 0.70 ms.
Residual latency index: 0.15 ms
Fig. 3 Compound muscle action potentials (CMAPs) recorded from the OP muscle in moderately severe CTS – grade 3 by Bland’s CTS
classification scale [3], stimulation of the elbow (upper trace), wrist (middle trace), and on the palm (lower trace)
References
1. Melvin JL, Harris DH, Johnson EW (1966) Sensory and motor
conduction velocities in the ulnar and median nerves. Arch Phys
2. Kaplan PE, Sahgal V (1978) Residual latency: new applications of
an old technique. Arch Phys Med Rehabil 59:24–27
Elbow, Wrist, Palm – Hand
M16
Original Settings Sensitivity was 2 mV/division, low-fre- the upper arm over the brachial pulse. For stimulation at the
quency filter was 20 Hz, high-frequency filter was 32 kHz, wrist (S2), the cathode was 1 cm proximal to the distal crease
and sweep speed was 0.2, 0.5 and 1 ms/division. The machine on the volar surface. The terminal portion of the median
used was a specially designed amplifier with short blocking nerve was stimulated at the midpalm (S3) over the second
time (1 ms) and low noise (0.5 μV RMS at bandwidth of metacarpal space. The anode was proximal. The palmar
2 kHz). Duration of pulse was not specified. stimulation was aimed at the thenar nerve, a recurrent branch
of the median nerve innervating the thenar muscles. In each
Position This study was performed in the supine position. hand tested, the palm was stimulated at different sites and the
most distal point of stimulation was chosen, which produced
Recording Recording electrodes for muscle potentials were an appropriate thumb twitch indicating a contraction of the
placed over the belly in the center of the abductor pollicis median innervated thenar muscles. The site of palmar stimu-
brevis (APB) muscle (Fig. 1) and tendon just distal to the lation was at about the location of the thenar nerve, usually
metacarpophalangeal joint [1]. Ground (G) was placed slightly distal to the intersecting point between a line drawn
around the forearm (author used a Velcro-strap). from the scaphoid to the radial cleft of the ring finger and the
thenar flexion crease (Fig. 2). The shock intensity was grad-
Stimulation The median nerve was stimulated using sur- ually advanced until a further increase no longer altered the
face electrodes at three [2] points along its course: at the size of muscle potentials. The voltage required to activate a
elbow (S1), at the wrist (S2), and on the midpalm (S3). At the maximal response was generally similar at different sites of
elbow (S1), shocks were applied on the anterior surface of stimulation.

Biceps brachii
(BB)
+
R –
G S1
(elbow)
Digit I
+
R A –
–
+ S2
C8
(wrist) T1
S3
(palm) Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (elbow, wrist, palm – APB muscle):

2
1 3 1 3 5
5 Elbow 1 4 Elbow 1
2 4 30 ms 10 mV 31 mA
30 ms 5 mV 31 mA
1 3 1 3 5
5 Wrist 2 4 Wrist 2
4 30 ms 5 mV 33 mA 30 ms 10 mV 33 mA
2
1 3 1 3 5
5 Palm 3 4 Palm 3
4 30 ms 5 mV 25 mA 30 ms 10 mV 25 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, stimulation of the elbow (upper trace), wrist
(middle trace), and on the palm (lower trace)
R
Digit I
Lower trunk
Median
nerve
Medial cord
R
+ – + – G
Digit V S2
S3 (wrist)
(palm)
Fig. 2 Distal stimulations (S2 – wrist, S3 – palm), recording from the APB) muscle
Measurements Distal latency (ms) was measured in steps of Table 1 Reference values
0.1 ms from the stimulus artifact to the onset of the initial neg- Normal values [1] Mean ± 2SD
ative response (upward deflection). The amplitude (mV) was Palm–APB, distal latency (ms) 1.86 ± 0.36
determined from the baseline to the negative peak. The surface Palm–APB, negative peak amplitude (mV) 7.6 ± 3.6
distance between the two stimulus sites at the wrist and palm Wrist–APB, distal latency (ms) 3.01 ± 0.44
was carefully measured in millimeters (mm) with a ruler. The Wrist–APB, negative peak amplitude (mV) 7.2 ± 3.5
motor nerve conduction velocity (MNCV), measured in meter Wrist–palm, latency difference (ms) 1.15 ± 0.21
per second (m/s), in the wrist to palm segment was determined Wrist–palm, MNCV (m/s) 56.0 ± 7.6
according to the conventional formula, dividing the distance Elbow–APB, distal latency (ms) 7.34 ± 0.78
by the latency difference between the two evoked potentials. Elbow–APB, negative peak amplitude (mV) 7.1 ± 3.4
Skin and room temperatures were not controlled. Author stud- Wrist–elbow, latency difference (ms) 4.33 ± 0.47
Wrist–elbow, MNCV (m/s) 57.0 ± 4.5
ied 50 hands (Table 1) from 25 subjects (8 healthy volunteers
and 17 patients with unrelated disorders, 13 men and 12 Limits of normal Values
women, age range 15–58 years, average age 36 years). Wrist–APB, distal latency (ms) 3.9
Wrist–palm, distal latency (ms) 1.6
Elbow–wrist, MNCV (m/s) 48
Wrist–palm, MNCV (m/s) 41
Comment two stimulus points at the wrist and palm was shorter
For Kimura [1], a delay in terminal latency may be caused (mean 64 ± 7 mm in 50 normal hands) than it was ordinar-
by an increased conduction time in the wrist–palm seg- ily recommended for calculation of MNCV; however, the
ment or in the palm–muscle segment or both. He found surface distance could be measured very accurately along
the technique of palmar stimulation useful to assess the a straight line in the wrist-to-palm segment. Further, using
conduction of the motor fibers in these two segments sep- a fast sweep speed, the latency could be determined with
arately. Palmar stimulation also allowed determination of accuracy considerably better than 0.1 ms. Therefore,
the MNCV in the segment across the carpal tunnel, the despite the short length of the nerve segment in question,
most common site of the median nerve compression. MNCV obtained by this technique should be reasonably
Kimura observed that the length of the nerve between the accurate.
Kimura [1] also performed nerve conduction studies in 20 both sides, 6 hands from the remaining patients with unilat-
symptomatic hands from 13 patients (Table 2) with carpal eral disease, 3 hands on the right and 3 on the left (10 women
tunnel syndrome (CTS), 14 hands from 7 patients affected on and 3 men, age range 38–59 years, average age 47 years).

Pathological values [1] Mean ± 2 SD
Palm–APB, distal latency (ms) 1.93 ± 0.30
Palm–APB, negative peak amplitude (mV) 5.8 ± 2.4
Wrist–APB, distal latency (ms) 3.91 ± 0.67
Wrist–APB, negative peak amplitude (mV) 4.9 ± 2.2
Wrist–palm, latency difference (ms) 1.96 ± 0.59
Wrist–palm, MNCV (m/s) 56.0 ± 7.6
Elbow–APB, distal latency (ms) 8.17 ± 0.90
Elbow–APB, negative peak amplitude (mV) 4.5 ± 1.9
Wrist–elbow, latency difference (ms) 4.35 ± 0.39
Comment than half that of the wrist-to-muscle latency, exclusion of

In some of the patients included in his study, Kimura [1] the normal conduction time in the segment distal to the
observed that the palm-to-muscle latency was appreciably palm should make it possible to demonstrate a mild con-
slower than normal, perhaps resulting from the secondary duction delay across the involved segment. Indeed, in 5
degeneration of the distal motor fibers. The selective (25 %) of 20 hands with clinical signs of the carpal tunnel
slowing of MNCV in the wrist-to-palm segment, which is syndrome, the conventional terminal latencies were nor-
the more consistent finding in the mild carpal tunnel syn- mal, yet MNCV in the wrist-to-palm segment was dis-
drome, showed conduction abnormalities limited to the tinctly slow. Palmar stimulation is a useful addition to the
carpal tunnel. Since the time required for the passage of conventional method in assessing the median motor and
impulse in the wrist-to-palm segment is normally less sensory fibers for a lesion across the carpal tunnel.
Motor nerve conduction time across the carpal tunnel CTS as controls (122 hands from 61 patients, 35 women and
and the latency difference between the two evoked poten- 26 men, age range 15–50 years, average age 43 years) and
tials elicited with stimulation at the wrist (S2) and on the 105 patients with CTS.
palm (S3) were also determined by Kimura [3] a year later. Kimura also studied 172 hands (Table 4) from 105 patients
He studied 61 patients (Table 3) with complaints unrelated to with CTS (73 women and 32 men, 134 hands from 67

Normal values [3] Mean ± 2 SD
Palm–APB, distal latency (ms) 2.11 ± 0.31
Limits of normal Values
Wrist–APB, distal latency (ms) 4.4
Wrist–palm, distal latency (ms) 2.0
Palm–APB, distal latency (ms) 2.8
Elbow–wrist, MNCV (m/s) 49
Wrist–palm, MNCV (m/s) 37
patients affected bilaterally and 38 hands from the remaining conduction test, which consists of a slightly different posi-
patients with an unilateral disease, 29 hands on the right and tion for a stimulating anode. The cathode was placed at the
9 hands on the left, age range 20–78 years, average age same site (as for the midpalm sensory stimulation), but the
48 years). Each patient was tested on both sides but the clini- anode was directed distally toward the base of the fifth digit
cally affected hands were analyzed separately from the (Fig. 3). This was done to avoid depolarizing the recurrent
asymptomatic hands. thenar nerve to the APB muscle under the anode. If unneces-
Chang et al. during a 1-year period [2] and a 2-year period sary activation of the recurrent thenar nerve under the anode
[4] performed several sensory and motor conduction tech- occurs, it might cause an erroneously short latency. They
niques to compare the sensitivities in the diagnosis of performed nerve conduction studies in 100 healthy (Table 5)
CTS. All studies were performed using a Nicolet Viking IV subjects (64 women 36 men, age range 22–65 years, mean
or Dantec Keypoint 4 electromyograph, and skin tempera- age 47.4 years) [2] and 150 healthy (Table 6) subjects (91
ture at the hand was maintained at or above 32 °C. In both women and 69 men, age range 18–84 years, mean age
works, authors proposed a variant for Kimura’s W-P motor 53.9 years) [4].

Pathological values [3] Mean ± 2 SD Normal values [4] Mean ± SD Limit of normal (±2.5 SD)
Palm–APB, distal latency (ms) 2.15 ± 0.34 Wrist–palm, MNCV (m/s) 52.43 ± 3.96 >42.5

Normal values [2] Mean ± SD Limit of normal (±2.5 SD)
Wrist–palm, MNCV (m/s) 49.3 ± 4.1 >39.0
C8
T1
R
Digit I
Lower trunk
Median
nerve
Medial cord
R
G 8 cm
– – +
+
Digit V S1
S2 (wrist)
(palm)
Typical waveform (wrist – APB muscle, palm – APB muscle):
2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
4 20 ms 10 mV 25 mA 4 30 ms 10 mV 25 mA
2 2
1 3 5 1 3 5
Palm 2 Palm 2
4 20 ms 10 mV 40 mA 4 30 ms 10 mV 40 mA
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, stimulation of the wrist (upper trace) and on the
palm (lower trace)
Comment and an SD of 2.3 mm). When the midpalm stimulation is

Chang et al. [2, 4] stimulated the median nerve at the performed, the nature of the thenar twitch should be
wrist (S1) and on the palm (S2). At the wrist (S1), the carefully observed, because stimulation of the deep
stimulator was placed 8 cm to the active recording elec- branch of the ulnar nerve could also generate a motor
trode (A) placed over the belly of the APB muscle. The response recorded over the thenar eminence. Stimulus
stimulation site of 8 cm proximal to the active recording intensity at the palmar site was slowly increased to maxi-
electrode was measured as two lines (one from the active mally stimulate the recurrent median motor nerve while
recording electrode to the distal crease and a second line avoiding the threshold for deep ulnar nerve stimulation.
directly proximal to the midpoint). To stimulate the The thenar twitch was checked, and thumb adduction
median nerve on the palm (S2), the cathode was placed at was prevented. The CMAP waveform configuration and
the same site as for the midpalm sensory stimulation; the initial deflection from the palm and wrist stimulation
anode was directed distally toward the base of the digit were compared. If an adduction of the thenar twitch and
V. A ground electrode was positioned on the dorsum of a change in the CMAP waveform configuration occurred
the hand (the figure shows the ground positioned on the as a result of costimulation of the deep branch of the
palm). For the calculation of W-P median motor conduc- ulnar nerve, the stimulation electrodes were repositioned
tion velocity (MNCV), the distance between the mid- in roughly 1-mm increments toward the thenar eminence
palm and wrist stimulation varied individually as a result until an abduction twitch was achieved. A stimulus was
of the variable course of the recurrent motor branch to the considered maximal if there was no increase in the
APB muscle, unlike the fixed distance (80 mm) used for CMAP amplitude despite an increasing intensity of the
the calculation of W-P sensory conduction velocity stimulus. The latency differences were measured at the
(SNCV). The distance to the active recording electrode palm and wrist stimulation site and calculated the M-P
ranged from 85 to 95 mm (with a mean value of 90.4 mm MCV.
In 2009, Chang et al. [5] compared the accuracy and performed using 2.1 cm diameter stainless steel disk
sensitivity of three transcarpal conduction techniques: wrist– electrodes, and sensory studies were performed using saline-
palm antidromic sensory conduction to the digit II (W-Psen soaked Velcro ring electrodes. Hand temperature was main-
CT), palm–wrist median–ulnar orthodromic mixed conduc- tained at or above 32 °C. For the wrist–palm motor conduction
tion (W-Pmix CT), and wrist–palm motor conduction to the to the APB muscle (W-Pmot CV), palmar stimulation was
APB muscle (W-Pmot CV). They studied 50 control (Table 7) performed at the midpalm with the cathode placed at the
subjects (40 women and 10 men, age range 24–81 years, same site similar to that of the midpalm sensory stimulation.
mean age 47.36 years), and 100 patients (Table 8) with CTS Latency differences between the palm and wrist stimulations
(80 women and 20 men, age range 22–77 years, mean age were recorded and the wrist–palm motor conduction velocity
48.89 years). Authors used a Nicolet Viking IV or Dantec (W-Pmot CV) was calculated. The sensitivity and specificity
Key Point 4 electromyograph. All motor studies were of each test were calculated as follows:
number of patients with electrodiagnostic positive findings

Sensitivity ( % ) = × 100
total number of patients with CTS
number of controls with a normal test

Specificity ( % ) = × 100
total number of controls

Normal values [5] Mean ± SD Cutoff Normal values [6] Mean ± SD Cutoff
Wrist–palm (W-P mot CV), MNCV (m/s) 55.23 ± 5.03 ≤42 Wrist–palm (W-P mot CV), MNCV (m/s) 60.3 ± 8.8 ≥42.8
Comment showed that the motor transcarpal conduction velocity

Chang et al. [5] set the abnormal values at 2.5 SD beyond (W-Pmot CV) and sensory transcarpal conduction time
the mean values provided by the control subjects. Among (W-Psen CT) were slightly superior to W-Pmix CT and
the 50 controls, all findings were within normal limits W-Pmix M-U CT in CTS electrodiagnosis, especially in
except for one control subject, who simultaneously mild CTS. Their data suggested that the conventional
showed abnormal values for W-Psen CT, W-Pmix CT, sensory and motor conduction studies should be per-
and W-Pmix M-U CT. Authors [5] found an abnormal formed initially in patients with suspected CTS. When
W-Pmot CV in 81 patients, showing 81 % sensitivity and conventional DSL or DSL and DML are normal, an easy-
100 % specificity. Conventional antidromic DSL to the to-perform and time-saving technique (with an additional
digit II had 74 % sensitivity and 100 % specificity, con- stimulating site on the palm) such as palm–wrist motor
ventional DML to the APB muscle had 72 % sensitivity conduction to the APB muscle (W-Pmot CV) is recom-
and 100 % specificity. The data reported in their study mended (Fig. 4).
Gazioglu and colleagues [6] performed a transcarpal diabetic polyneuropathy patients in 263 hands (Table 9) from
median motor conduction (M-P MCV) as described by 139 patients divided into groups: patients with CTS (140
Chang et al. [2], dividing the distance between the stimula- hands from 72 patients, 59 women and 13 men, mean age
tion sites by the latency difference. They stimulated the 53.9 ± 3.5 years), diabetic patients with polyneuropathy with-
median motor fibers at the wrist (S1), and in the palm (S2) out associated CTS (61 hands from 32 patients, 19 women
3–4 cm distal to the distal wrist crease. They performed stan- and 13 men, mean age 55.6 ± 9.5 years) and diabetic patients
dard nerve conduction studies, segmental and comparative with polyneuropathy with associated CTS (62 hands from 35
median nerve conduction tests in 86 hands (Table 8) from 43 patients, 26 women and 9 men, mean age 55.5 ± 7.3 years).
healthy individuals (Group 4 – 32 women and 11 men, 42 The sensitivities and specificities of the tests were used to
right hands and 1 left hand, body mass index – BMI 27.5 ± 3.4, compare the diagnosis of CTS in patients with diabetic poly-
mean age 53.7 ± 5.5 years). They compared sensitivity and neuropathy. A greater diagnostic accuracy can be observed in
specificity of some different tests in the diagnosis of CTS in tests with higher sensitivity and specificity.
Comment (DMPNP CTS-), and on a group of diabetic patients with

Gazioglu et al. [6] compared sensitivity and specificity of polyneuropathy with associated CTS (62 hands from 35
some different tests in the diagnosis of CTS in diabetic patients, 26 women and 9 men, 26 right hands and 9 left
polyneuropathy patients on a group of patients with CTS hands, body mass index – BMI 31.4 ± 7.1, mean age
(140 hands from 72 patients, 59 women and 13 men, 71 55.5 ± 7.3 years) – Group 3 (DMPNP CTS+). The sensitivi-
right hands and 1 left hand, body mass index – BMI ties and specificities of the tests were compared in the diag-
29.0 ± 3.3, mean age 53.9 ± 3.5 years) – Group 1 (CTS), on nosis of CTS in patients with a diabetic polyneuropathy.
a group of diabetic patients with polyneuropathy without The wrist–palm motor conduction velocity (M-P MCV)
associated CTS (61 hands from 32 patients, 19 women and was significantly lower in all patient groups compared to
13 men, 30 right hands and 2 left hands, body mass index – the controls. Authors found, using 42.8 m/s cutoff, a sensi-
BMI 29.1 ± 5.4, mean age 55.6 ± 9.5 years) – Group 2 tivity of 80 % and a specificity of 74 %.

Wrist–palm, MNCV (m/s) – Group 1 35.0 ± 10.4
Pathological waveform (elbow, wrist, palm – APB muscle):
2 2
1 3 5 1 3 5
4 Elbow 1 4 Elbow 1
30 ms 5 mV 43 mA 50 ms 5 mV 43 mA
2 2
1 3 1 3
4 5 Wrist 2 4 5 Wrist 2
30 ms 5 mV 43 mA 50 ms 5 mV 43 mA
2 2
1 3 5 1 3 5
4 Palm 3 4 Palm 3
30 ms 5 mV 31 mA 50 ms 5 mV 31 mA
Onset latency (elbow – APB): 9.85 ms; Onset latency (wrist – APB): 5.15 ms; Onset latency (palm – APB): 2.25 ms; Peak latency (elbow
– APB): 13.50 ms; Peak latency (wrist – APB): 9.00 ms; Peak latency (palm – APB): 4.85 ms; Onset to peak amplitude (elbow – APB):
5.5 mV; Onset to peak amplitude (wrist – APB): 5.8 mV; Onset to peak amplitude (palm – APB): 3.7 mV; Peak to peak amplitude (elbow
– APB): 6.3 mV; Peak to peak amplitude (wrist – APB): 6.9 mV; Peak to peak amplitude (palm – APB): 5.4 mV; MNCV (elbow – wrist):
51.1 m/s; MNCV (wrist – palm): 24.1 m/s
CTS classification scale [7], stimulation of the elbow (upper trace), wrist (middle trace), and on the palm (lower trace)
References 5. Chang MH, Liao YC, Lee YC et al (2009) Electrodiagnosis of

carpal tunnel syndrome: which transcarpal conduction technique is
best? J Clin Neurophysiol 26:366–371
1. Kimura J (1978) A method for determining median nerve conduc-
tion velocity across the carpal tunnel. J Neurol Sci 38:1–10
3. Kimura J (1979) The carpal tunnel syndrome: localization of con-
duction abnormalities within the distal segment of the median nerve.
Brain 102:619–635
4. Chang MH, Liu LH, Lee YC et al (2006) Comparison of sensitivity
of transcarpal median motor conduction velocity and conventional
conduction techniques in electrodiagnosis of carpal tunnel
syndrome. Clin Neurophysiol 117:984–991
Elbow – Forearm
M17
Study from Flexor Carpi Radialis (FCR) Muscle
Original Settings Sensitivity was 1 mV/division, low- Stimulation Both for the compound muscle action potential
frequency filter was 20 Hz, high-frequency filter was (CMAP) and H-reflex recording (Fig. 2), the median nerve
32 kHz, sweep speed was 5 ms/division, and duration of was stimulated at the elbow in the antecubital area, 10 cm
pulse was 0.5–1.0 ms. The machine used was not proximal to the active electrode [1]. For the CMAP record-
specified. ing the anode was proximal; for the H-reflex recording the
stimulator was inverted with the anode placed distal to the
Position This study was performed in the supine position cathode. Figure 1 shows the stimulation cathode and anode
with the elbow slightly flexed. set for CMAP recording. A rectangular pulse of 0.5–1.0 ms
of duration at a frequency not exceeding 0.5 pulses per sec-
Recording The active electrode (A) was placed over the ond was delivered with increasing voltage strength.
belly of the flexor carpi radialis (FCR) muscle (Fig. 1),
which is usually one-third the distance between the medial Measurements CMAP latency (ms) was measured from the
epicondyle and the radial styloid. The reference (R) was beginning of the stimulus artifact to the start of the reflex
placed over the brachioradialis (BR) muscle, away from the response. Amplitude of the CMAP (mV) was measured from the
other median innervated muscles in the forearm [1]. The baseline to the peak of the negative deflection. All the studies
ground (G) was placed on the forearm, between the stimula- were done at a room temperature of 70 °F. Skin temperature was
tor and the active electrode (the figure shows ground posi- not reported. Author studied 50 median nerves (Table 1) from 39
tioned on the palm). healthy subjects (27 women and 12 men, age range 15–56 years).

108 M17 Elbow – Forearm
Biceps brachii
(BB)
R
Flexor carpi radialis (FCR)
+
–
R
1/3
A S
(elbow)
2/3
Digit I
Upper trunk
C6
C7
G Lateral cord C8
Lower trunk
Middle trunk
Median
Digit V nerve Medial cord
Typical waveform (elbow – FCR muscle):
Median - (FCR) Median - (FCR)
2 2
1 3 1 3
5 Elbow 1 5 Elbow 1
30 ms 5 mV 18 mA 50 ms 5 mV 18 mA
4 4
Fig. 1 Compound muscle action potential (CMAP) recorded at the forearm from the FCR muscle, stimulation of the elbow
M17 Elbow – Forearm 109

Median - FCR 4 Median - FCR 4
1.1 1.1
42 V 42 V
1.2 1.2
2 mV 50 V 2 mV 50 V
1.3 1.3
57 V 57 V
1.4 1.4
50 ms 5 mV 67 V 100 ms 5 mV 67 V
sensitivity 5 mV – 2 mV/div, sweep speed 5 ms/div (left) – 10 ms/div (right)
Fig. 2 H-reflex recorded at the forearm from the FCR muscle, stimulation of the elbow

Normal values [1] Mean ± SD small wave, probably a mixture of both, the H-reflex-
Elbow–FCR, CMAP latency (ms) 3.0 ± 0.5 wave and the F-wave. The difference in latencies
Elbow–FCR, CMAP negative peak amplitude (mV) 7.6 ± 2.5 (ms) between both upper extremities (without facili-
Elbow–FCR, H-reflex latency (ms) 15.9 ± 1.5 tation) was calculated in 11 median nerves (04 ± 0.3).
Elbow–FCR, H-reflex negative peak amplitude (mV) 1.6 ± 0.4 In the absence of an underlying pathology, the
H-reflex was never present on one side and absent
on the other in any of the subjects investigated. The
response was always symmetrical, and the differ-
Comment ence in latency between them (without facilitation)
Jabre [1] observed H-reflex response either without never exceeded 1 ms.
an M-response or with only a very small M-response
preceding it; its latency was shortened when the
nerve was stimulated proximally, and its amplitude
was decreased with an increasing stimulation fre- Foley and Buschbacher [2], using a large and varied sub-
quency. It was possible to obtain an H-reflex with a ject healthy population (208 healthy subjects, age range
stimulation strength that was below the threshold to 19–79 years), derived a normative database for nerve con-
obtain an M-response. As the voltage strength was duction values of the median nerve to the FCR muscle
increased, a small M-response appeared. The maxi- (Table 2). In addition to the usual development of normative
mal amplitude of the H-reflex was reached when the ranges for CMAP latency and negative peak amplitude, they
stimulus evoked an M-response of similar ampli- also designed the investigation to measure other waveform
tude. When the M-response became maximal, the parameters, such as negative phase area, duration, and side-
H-reflex either disappeared or was reduced to a to-side differences of these parameters between dominant
and not dominant hand.

Elbow–FCR, CMAP latency (ms) 2.8 ± 0.4 2.1–3.8 3.6
Elbow–FCR, CMAP amplitude (mV) 10.2 ± 4.0 1.5–22.4 2.3
Elbow–FCR, CMAP amplitude (mV) – 19–49 years 11.5 ± 3.4 1.9–18.2 4.0
Elbow–FCR, CMAP amplitude (mV) – 50–79 years 8.3 ± 4.0 1.5–22.4 1.7
Elbow–FCR, area (μVs) 59.0 ± 22.3 5.3–119.0 12.9
Elbow–FCR, area (μVs) – 19–49 years 66.8 ± 19.7 11.0–107.0 15.5
Elbow–FCR, AREA (μVs) – 50–79 years 48.4 ± 21.3 5.3–119.0 6.9
Elbow–FCR, duration of negative phase (ms) 9.7 ± 1.2 6.1–13.1 11.8
References
Comment
For Foley and Buschbacher [2], the upper limit of 1. Jabre JF (1981) Surface recording of the H-reflex of the flexor carpi
normal increase in latency from one side to the other radialis. Muscle Nerve 4:435–438
was 0.7 ms; a side-to-side upper limit of normal 2. Foley BS, Buschbacher RM (2006) Establishing normal values of
the proximal median motor nerve – a study of the pronator teres and
decrease in amplitude was 53 %. The upper limit of flexor carpi radialis in healthy volunteers. J Long Term Eff Med
normal increase in the CMAP latency from one side to Implants 16:341–348
the other was 0.6 ms; the upper limit of normal decrease
in amplitude from one side to the other was 54 %. The
upper limit of normal difference between the pronator
teres (PT) and the flexor carpi radialis (FCR) CMAPs
latency in the same limb was 0.8 ms in cases where the
PT CMAP had the longer latency; it was 0.4 ms in
cases where the FCR CMAP latency was longer.
M18
Original Settings The machines used were a TECA TE4 The second stimulation (S2) was performed at the elbow,
and TE42 electromyographs. Sensitivity, low-frequency fil- on the antecubital fossa, just lateral to the brachial artery [1].
ter, high-frequency filter, sweep speed, and duration of pulse The anode was proximal. They used supramaximal stimula-
were not specified. tions, using 20 % greater voltage than required for maximal
stimulation.
Position This study was performed in the supine position.
Measurements Author determined “residual latency” (RL)
Recording The active electrode (A) was placed over the by calculating the time expected for an impulse to travel
midpoint of a line joining the center of the distal wrist crease from the stimulating cathode to the active recording elec-
with the center of the first metacarpophalangeal joint, on the trode and subtracting this time from the terminal latency
median thenar (MT) muscle (Fig. 1). The reference electrode (TL). The distal peak latency (ms) was called “terminal
(R) was placed on the distal part of the digit I (thumb). All latency” (TL), and it measured from the beginning of the
motor latencies were recorded over an 8 cm distance mea- shock artifact to the peak of the negative deflection of the
sured from the midpoint of the active recording electrode compound muscle action potential (CMAP). The amplitude
through the midpoint of the distal wrist crease and along the (mV) was determined from the baseline to the negative peak.
median nerve to the cathode [1]; authors used a two-line The forearm motor nerve conduction velocity (MNCV) was
method to measure the distance between the active and calculated from the nerve using the stimulating and record-
recording electrodes by the method of Melvin et al. [2]. The ing sites at above the elbow and at the wrist, respectively.
ground (G) electrode position was not specified in the origi- From this elbow–wrist conduction velocity an expected ter-
nal text; the figure shows the ground electrode placed distally minal latency from wrist to the MT muscle was calculated
between the digit IV (ring finger) and the digit V [2]. and compared with the measured motor terminal latency.
The difference between these values was termed the “resid-
Stimulation The median nerve was stimulated at the wrist ual latency” (RL) for the motor fibers. No control of tem-
(S1) and at the elbow (S2). The first stimulation (S1) was perature was attempted. Expected TL of the CMAP recorded
performed at the wrist, with the cathode 8 cm (80 mm) proxi- from MT muscle after stimulation at the wrist and RL for the
mal to the active recording electrode (A), on the median CMAP recorded from the MT muscle after stimulation at the
thenar (MT) muscle (Fig. 2). The anode was proximal. wrist were calculated as follows:
distance between cathode ( wrist ) and active electrode ( MT ) , ( mm )

Residual Latency, RL ( ms ) = observed TL ( ms ) − expected TL ( ms )

Biceps brachii
(BB)
+
–
R
Median thenar (MT)
S2
(elbow)
Digit I
+
R A 8 cm –
C8
T1
S1
(wrist)
G
Lower trunk
Median
nerve
Digit V Medial cord
Typical waveform (wrist, elbow – MT muscle):
1 3 1 3 5
5 Wrist 1 Wrist 1
50 ms 5 mV 45 mA 4 50 ms 10 mV 45 mA
1 3 Elbow 2 1 3 5 Elbow 2
5
50 ms 5 mV 45 mA 4 50 ms 10 mV 45 mA
4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the MT muscle, stimulation of the wrist (upper trace) and of the
elbow (lower trace)
C8
T1
R
Median thenar (MT)
Lower trunk Digit I

Median
nerve
Medial cord
R
A
8 cm
– +
G
Digit V
S1
(wrist)
Fig. 2 Distal stimulation (S1 – wrist), 8 cm fixed distance recording from the MT muscle
Table 1 Reference values advancing years may be accounted for by the reduction in
Normal values [1] Mean ± SD Range MNCV seen with aging. For authors, RL determination pro-
Wrist–MT, distal latency (ms) 3.40 ± 0.31 2.8–4.0 vides additional information about conduction in distal nerve
Elbow–wrist, MNCV (m/s) 59.90 ± 5.06 46.8–67.0 segments without requiring an additional electrical stimula-
Negative peak amplitude (mV) 4.5–17.0 tion. The RL technique may be especially valuable in evalu-
Residual latency (ms) 1.97 ± 0.27 1.3–2.6 ating a distal median nerve function in older patients.
In 1988, Redmond and Rivner [3] recorded bilateral
median motor response over the thenar eminence, stimulating
Residual latency was determined in 100 normal both at the elbow and the wrist 7 cm proximal to the record-
(Table 1) subjects (age range 15–83 years), divided as fol- ing site. From these data, a forearm conduction velocity
lows: 3 subjects – age range 10–19 years, 21 subjects – age (MNCV) and residual latency (RL) were calculated. In sub-
range 20–29 years, 27 subjects – age range 30–39 years, jects with an abnormal RL, calculated by using the Kaplan’s
20 subjects – age range 40–49 years, 14 subjects – age method, the median motor conduction was repeated using
range 50–59 years, 13 subjects – age range 60–69 years, an 8 cm distance between the stimulation site at the wrist
6 subjects – age range 70–79 years, 2 subjects – age range and the active recording electrode. They performed conduc-
80–89 years. The distribution of RLs ranged from 1.3 to tion studies in 50 subjects (30 women and 20 men, age range
2.6 ms, the mean motor RL was 1.97 ± 0.27 SD, and the nor- 18–62 years, average age 34 years) using a TECA TD-20
mal range was 1.4–2.5 ms. The mean motor terminal latency electromyograph (filters from 20 Hz to 2 kHz). Skin temper-
(TL) was 3.40 ± 0.31 ms; the range was 2.8–4.0 ms. The atures were measured on the palm; the limbs were warmed
amplitude of the CMAP ranged from 4.5 to 17.0 mV. The when necessary to maintain at least 34 °C. Authors in their
mean forearm MNCV was 59.90 ± 5.06 m/s and the normal study suggested that RL may be increased in the dominant
range was 46.8–67.0 m/s. Authors observed that the distal extremity without symptoms of the median nerve entrap-
motor peak latency increased 0.2 ms with an increasing ment. In 8 hands of 7 healthy subjects (14 % of the whole
age. However, the RLs were essentially unchanged over the sample) they observed a prolonged RL greater than 2.6 ms
years, indicating that the prolongation of DL occurring with in subjects aged 20–29 years and greater than 2.5 in older

Normal values [4] Mean ± SD Range Normal values [5] Mean ± SD Limit of normal
Residual latency (ms) 1.90 ± 0.46 0.9–3.56 Residual latency (ms) 2.06 ± 0.45 ≤2.96

Pathological values [4] Mean ± SD Range Limit of normal Pathological values [5] Mean ± sd
Residual latency (ms) 4.29 ± 1.55 2.4–10.61 ≤2.6 Residual latency (ms) 3.27 ± 0.91
subjects, according to the criteria of Kraft and Halvorson [1]. RL as an addition to conventional NCS, sensitivity, specific-
Abnormal RLs were recorded in the dominant hand of six ity, positive predictive value, and negative predictive value
subjects, and in only one case was the abnormality bilateral. were calculated as follows:
The range of abnormal residual latency was 2.6–3.1. Authors
true positive
observed, in all instances in which a unilateral increased Sensitivity =
RL was found, a prolonged absolute motor distal latency true positive + false negative
compared with the other side. For Kraft and Halvorson, the
true negative
RL tends to be consistent across each decade in a normal Specificity =
population, but the subjects with prolonged RL observed by true negative + false positive
Redmond and Rivner tended to be older (mean age 47 years).
Because authors observed a prolonged residual latency of true positive
Positive predictive value =
3.0 ms or greater, they emphasized the degree to which this true positive + false positive
method may yield a false-positive result.
Perić and Sinanović [4] determined sensitivity and speci-
ficity of terminal latency index (TLI), and compared it with true negative
Positive predictive value =
the RL and their sensory–motor index (SMI). They studied true negative + false negative
57 hands (Table 2) from 57 healthy subjects (33 women,
mean age 45.65 ± 9.68 years) and 67 hands (Table 3) from 60
patients (38 women, mean age 50.28 ± 11 years) with clinical Authors studied 76 hands of 38 healthy (Table 4) subjects
diagnosis of carpal tunnel syndrome (CTS). All nerve con- (36 women and 2 men, mean age 45.3 ± 10.9 years, age range
duction studies were performed using a France Racia 21P 22–68 years) and 102 hands of 57 patients (Table 5) with
EMG machine, and the skin temperature of the hand at mid- suspected CTS (54 women and 3 men, 45 bilateral CTS, 8 in
palm was 32 °C or higher. the right hand, 4 in the left hand, mean age 46.6 ± 12.4 years,
age range 25–71 years). All tests were performed using a
4-channel EMG machine Nihon Kohden Neuropack (2005
Comment model); recordings were made at normal room temperature
Perić and Sinanović [4] used in CTS patients several (24–26 °C) and a skin temperature above 30 °C.
fixed distances between active recording and stimulat-
ing electrode: 6.5 cm (6/67–8.96 %), 7 cm (47/67–
70.15 %), 8 cm (14/67–20.89 %). Authors found Comment
statistical significant differences between the mean For Uzar et al. [5], the RL was less sensitive (63.7 %)
values of all parameters in patients with CTS and than the conventional distal motor latency (DML) and
healthy subjects. The highest sensitivity (98.51 %) was TLI parameters (68.6 % and 90.1 %, respectively) for
found in the SMI and RL; the TLI had high sensitivity the diagnosis of the CTS. Although the RL was the less
(92.54 %) and good specificity (80.70 %). The residual sensitive motor parameter, it showed high specificity
latency had the highest specificity (91.23 %), and it (94.7 %). Authors observed higher sensitivity and
was normal in a patient (2.4). specificity results in sensory NCS, and the antidromic
sensory median–ulnar latency difference to the digit
IV (peak latencies) was the most sensitive sensory
In a prospective study, Uzar et al. [5] performed the motor parameter (91.5 %) for the CTS diagnosis. The posi-
conduction study to the APB muscle, and they compared tive predictive value for the RL in CTS patients was
sensitivity and specificity of the conventional nerve conduc- 94 %, and its negative predictive value was 66 %. For
tion studies (NCS) and of the RL and TLI in the diagnosis of authors, in some cases when median sensory NCS are
CTS. In order to determine the diagnostic validity of TLI and

Normal values [6] Mean ± SD Pathological values [6] – HMSN1, 26 patients) Mean ± SD
Residual latency (ms) 2.3 ± 0.4 Residual latency (ms) 5.8 ± 1.5

Pathological values [6] - MAG/ Pathological values [6] – HMSN2, 20 patients) Mean ± SD
SGPG-N, 21 patients Mean ± SD Residual latency (ms) 2.9 ± 0.4
Residual latency (ms) 8.5 ± 2.8
(57 % men and 43 % women, mean age 64.6 ± 9.4 years), 26

patients (Table 8) with HMSN1 (58 % men and 42 %
normal (they found RL extended values in three women, mean age 38.1 ± 13.7 years), and 20 patients
hands – 2.9 %, in which conventional sensory distal (Table 9) with HMSN2 (70 % men and 30 % women, mean
latency to the digit II was normal); the abnormality in age 44.7 ± 14.5 years). Median and ulnar nerve motor
the RL may be a guide in CTS diagnosis. conduction studies were performed recording at 6 cm fixed
distance from the recording electrode placed on the APB
and the abductor digiti minimi (ADM) muscles, respectively.
All nerve conduction studies were performed at a skin
Lupu et al. [6] performed several conduction techniques temperature of 34 °C. TLI, RL, and F-wave latency ratio
in patients with neuropathy due to IgM Abs against MAG were calculated, and RL values showed significant
and SGPG (MAG-SGPG-N) to determine which nerve differences between MAG/SGPG-N and HMSN1 patients
conduction study (NCS) assessing the distal segments of the but TLI was the most sensitive index that aids in the
upper extremity motor nerves was more useful in electro- differentiation between MAG/SGPG-N (TLI <0.26, 16
physiological evaluation of patients with anti-MAG/SGPG. patients) and HMSN1 (TLI ≥0.32, 19 patients). However,
Electrophysiologically, conduction blocks characterize the since the median nerve TLI can be lower in the CTS, authors
chronic inflammatory demyelinating polyradiculoneuropathy suggested measuring the ulnar DML to provide additional
(CIDP), whereas in MAG/SGPG-N conduction blocks are confidence in the diagnosis. The combination of the median
rarely observed. MAG-SGPG-N and hereditary sensory– TLI and ulnar DML increases the specificity and can guide
motor neuropathy type 1 (HMSN1) have similar demyelin- the diagnosis especially when median TLI was between
ating features on nerve conduction studies, and two subtypes 0.26 and 0.32 (about 25 % of patients). Their findings
(HMSN1A, and HMSN1B) were described. HMSN1A is differed from those of Trojaborg et al. [7] who studied
the most common subtype of HSMN1, and a mutation in the 15 patients with CIDP associated with anti-MAG/SGPG
gene encoding for peripheral myelin protein 22 (PMP-22) (pathogenic IgM antibodies-Abs against myelin-associated
was observed. HMSN1B is related to genetic abnormalities glycoproteine/peripheral nerve glycolipid sulfated
in myelin protein zero. Authors studied 12 normal (Table 6) glucuronyl paragloboside) and reported that RL was better
volunteers (58 % men and 42 % women, mean age than TLI at distinguishing anti-MAG/SGPG neuropathy
32.6 ± 11.3 years), 21 patients (Table 7) with MAG/SGPG-N patients.
2
2
1 3 4 5 Wrist 1 1 3
5 Wrist 1
4
50 ms 5 mV 48 mA 50 ms 2 mV 48 mA
2
2
1 3 4 5 1 3
Elbow 2 4 5 Elbow 2
50 ms 5 mV 54 mA 50 ms 2 mV 54 mA
peak amplitude (wrist – APB): 2.7 mV; Peak to peak amplitude (elbow – APB): 2.1 mV; MNCV (wrist – elbow, 23 cm distance): 44.7 m/s.
RESIDUAL LATENCY (wrist–APBmuscle, 80 mm distance) calculation:
if RL = observed TL (ms) – expected TL (ms)
then RL 15 -1.79 = 13.21 ms
classification scale [8], stimulation of the wrist (upper trace) and of the elbow (lower trace)
References 5. Uzar E, Tamam Y, Acar A et al (2011) Sensitivity and specificity

of terminal latency index and residual latency in the diagnosis of
1. Kraft GH, Halvorson GA (1983) Median nerve residual latency: carpal tunnel syndrome. Eur Rev Med Pharmacol Sci 15:1078–1084
normal value and use in diagnosis of carpal tunnel syndrome. Arch 6. Lupu VD, Mora CA, Dambrosia J et al (2007) Terminal latency
Phys Med Rehabil 64:221–226 index in neuropathy with antibodies against myelin-associated gly-
2. Melvin JL, Schuchmann JA, Lanese RR (1973) Diagnostic specific- coproteins. Muscle Nerve 35:196–202
ity of motor and sensory nerve conduction variables in the carpal 7. Trojaborg W, Hays AP, Van Den Berg L et al (1995) Motor conduc-
tunnel syndrome. Arch Phys Med Rehabil 54:69–74 tion parameters in neuropathies associated with anti-MAG antibod-
3. Redmond MD, Rivner MH (1988) False positive electrodiagnostic ies and other types of demyelinating and axonal neuropathies.
tests in carpal tunnel syndrome. Muscle Nerve 11:511–517 Muscle Nerve 18:730–735
4. Perić Z, Sinanović O (2006) Sensory-motor index is useful param- 8. Bland JDP (2000) A neurophysiological grading scale for carpal
eter in electroneurographical diagnosis of carpal tunnel syndrome. tunnel syndrome. Muscle Nerve 23:1280–1283
Bosn J Basic Med Sci 6:23–27
Elbow – Forearm
M19
Original Settings Sensitivity was 0.5 mV/division, sweep Stimulation The median nerve was stimulated at the elbow,
speed was 5 ms/division, and duration of pulse was 0.5 ms. in the cubital fossa with the bipolar surface electrodes, 10 cm
Low-frequency filter, high-frequency filter, and the machine proximal to the coaxial needle electrode [1]. The anode was
used were not specified. proximal. Square wave shocks of 0.5 ms duration were deliv-
ered at a rate of one per 5 s. The stimulus intensity was grad-
Position This study was performed in the supine position; ually increased until a maximal H-reflex was obtained.
the elbow joint was positioned at 30° flexion. Thereafter, a supramaximal stimulus was delivered to obtain
the maximal CMAP. The test can be also performed at
Recording The compound muscle action potential reverse, obtaining first the maximal CMAP by a supramaxi-
(CMAP) and H-reflex studies of the flexor carpi radialis mal stimulus, and then the H-reflex can be obtained gradu-
(FCR) muscle (Fig. 1) were performed by a coaxial needle ally decreasing the intensity of the stimulus.
electrode [1]; it was placed over the belly of the FCR mus-
cle, one-third of the distance from the medial epicondyle to Measurements The electrophysiological examination was
the radial styloid. The ground (G) electrode position was performed in an air-conditioned room with the temperatures
not mentioned in the text; it could be placed over the controlled between 23 and 25 °C. The surface temperatures
forearm. of the upper arms ranged from 32 to 34 °C. The H-reflex
latency (H-RL) was measured in ms from the displayed stim-
Needle Insertion For the FCR muscle, with the forearm in ulus artifact to the start of the maximal evoked potential.
a neutral position to full supination, the recording needle Onset latency (ms) of the CMAP was measured from the
electrode was inserted into the volar surface of the forearm stimulus onset to the start of the deflection of the
5–7 cm distal to the medial epicondyle along a line directed CMAP. Amplitude (mV) of the CMAP was measured from
toward the muscle tendon at the wrist. the baseline to the peak of the negative deflection. The inter-

Biceps brachii
(BB)
R
+
–
• S
(elbow)
G
Digit I
Upper trunk
C6
C7
Lateral cord C8
Lower trunk
Middle trunk
Median
nerve Medial cord
Digit V
Median - FCR Median - FCR 10
1.9
50 ms 2 mV 55 V
1.8
59 V
1 Elbow 1 1.7
50 ms 2 mV 53 mA 65 V
1.6
70 V
1.4
84 V
Sensitivity 2 mV/division, sweep speed 5 ms/division
Fig. 1 Compound muscle action potential (CMAP) from the FCR muscle (left) and H-reflex recorded at the forearm from the FCR muscle (right),
stimulation of the elbow
References 119
Table 1 Reference values The monosynaptic delay has been estimated to be about
Normal values [1] Mean ± SD Range Side-to-side diff. 1 ms [2]. FCR values were obtained from 52 healthy (Table 1)
H-reflex conduction 73.7 ± 7.2 75 ± 13 subjects (age range 20–85 years, mean age 50.8 years) and
velocity, H-RCV (m/s) 25 patients (Table 2) with radiation-induced brachial plexus
H-reflex conduction 0.38 ± 2.4 ≥4.8 lesions (21 women and 4 men, age range 19–74 years, mean
velocity
age 47 years).
R/L difference,
H-RCV (m/s)
H-reflex latency, 16.8 ± 1.1 17.5 ± 2.5
H-RL (ms)
Comment
H-reflex latency 0.002 ± 0.42 ≥0.85
Ongerboer de Visser et al. [1] gradually increased the
R/L difference,
H-RL (ms) stimulus intensity until a maximal H-reflex was
Inter-latency time, 13.8 ± 1.2 14.25 ± 2.75 obtained. After that a supramaximal stimulus was
ILT (ms) delivered to obtain the maximal CMAP. No significant
Inter-latency time, 0.11 ± 0.44 ≥0.9 difference was found between H-RCV, H-RL, and ILT
ILT (ms) on the two sides, therefore the right and left sides were
considered together. The mean H-RCV was
73.7 ± 7.2 m/s, the mean H-RL was 16.8 ± 1.1 ms, and
Table 2 Reference values the mean ILT was 13.8 ± 1.2 ms. A right/left difference
Pathological values [1] Mean ± SD Range Side to side diff.
of the H-RCV of 4.8 ms or more, of the H-RL of
H-reflex conduction 76.4 ± 9.1 61 ± 21.5
0.85 ms or more, and of the ILT of 0.9 ms or more was
velocity, H-RCV (m/s) considered pathological. On the side of plexopathy no
H-reflex conduction 12.9 ± 8.0 ≥4.8 H-reflex occurred in 9 patients. In 16 the reflex was
velocity present with a prolonged latency; prolonged H-RL was
R/L difference, seen in 15 and prolonged ILT in 16 patients. For
H-RCV (m/s)
authors, the recording of the H-reflex in the FCR mus-
H-reflex latency, 19.1 ± 1.9 18.5 ± 4.5
H-RL (ms)
cle was a useful tool in demonstrating a proximal
H-reflex latency 2.9 ± 1.7 ≥0.85 lesion of the median nerve in the plexus region as a
R/L difference, complication of radiation therapy.
H-RL (ms)
Inter- latency time, 16.5 ± 1.9 16.5 ± 4.5
ILT (ms)
Inter- latency time, 2.8 ± 1.8 ≥0.9 References
ILT (ms)
1. Ongerboer de Visser BW, Schimsheimer RJ, Hart AA (1984) The
H-reflex of the flexor carpi radialis muscle; a study in controls and
latency time (ILT) was calculated in ms determined by sub- radiation-induced brachial plexus lesions. J Neurol Neurosurg
tracting the latency of the maximal CMAP from the latency Psychiatry 47:1098–1101
2. Deschuytere J, Rosselle N, De Keyser C (1976) Monosynaptic
of the maximal evoked H-reflex.
reflexes in the superficial forearm flexors in man and their clinical
significance. J Neurol Neurosurg Psychiatry 39:555–565
Authors estimated the H-reflex conduction velocity
(H-RCV) in m/s utilizing the following equation:
( distance from stimulus point to C6 spine ) × 2 ( mm )
H − RCV ( ms ) =
( H − RL − CMAP latency ) − 1 ( ms )
Wrist – Hand
M20
Study from Second Lumbrical (2L)
and Abductor Pollicis Brevis (APB) muscles
Original Settings Sensitivity was 2–5 mV/division, sweep site (cathode) to the motor point of the 2L muscle (R1) and a
speed was 2 ms/division, and the machine used was a TECA distance of about 7 cm (7.2 ± 0.7 cm) between the wrist stim-
TE42 model. Low-frequency filter, high-frequency filter, and ulation site (cathode) to the motor point of the APB muscle
duration of pulse were not specified. (R2). The anode was proximal. For the calculation of the
forearm conduction velocity (MNCV), authors stimulated
Position This study was performed in the supine position. the median nerve also proximally at the elbow in the antecu-
bital fossa [1].
Recording Compound muscle action potentials (CMAPs)
from the second lumbrical (2L) and abductor pollicis brevis Measurements Distal latency (ms) was measured from the
(APB) muscles (Fig. 1) were simultaneously recorded using beginning of the stimulus artifact to the start of the reflex
surface recording electrodes (two-channel recording). For response. Amplitude (mV) of the CMAPs recorded from the
2L– recording (R1), the active recording electrode (cathode) 2L and APB muscles were measured from the baseline to the
was placed on the palm on the motor point of the 2L muscle peak of the negative deflection; ratio of 2L CMAP ampli-
(just radial to the midpoint of the third metacarpal bone). The tude/APB CMAP amplitude was calculated. MNCVs were
reference electrode (anode) was placed distally on the distal calculated in the conventional way for each of the tested seg-
phalanx of the digit III (middle finger). For APB-recording ments (2L–elbow, APB–elbow), dividing the distance by the
(R2), the active recording electrode (cathode, A) was placed latency. The distances were measured from the cathodal
over the motor point of the APB muscle (halfway between stimulation points at the wrist or elbow to the cathodes
the midpoint of the distal wrist crease and the midpoint of the placed on the motor points of the 2L and APB muscles
first metacarpophalangeal joint) and the reference electrode (straight lines). The palmar skin temperatures were not
(anode, R) was placed slightly distal to the proximal meta- allowed to fall below 31 °C. Authors studied 28 asymptom-
carpophalangeal joint of the digit I [1]. The ground (G) elec- atic hands (Table 1) from 16 normal subjects (no sex and age
trode position was not mentioned in the text; it could be information about the control group were given by authors)
placed on the palm or on the dorsum of the hand (the figure and 78 hands (Table 2) from 61 patients: 12 symptomatic
shows the ground positioned on the palm). The needle- hands in patients with suspected ulnar neuropathy, 60 con-
recorded latency of the CMAP after the median nerve stimu- secutive hands in patients with carpal tunnel syndrome
lation at the wrist was performed in seven patients with CTS (CTS) divided into two groups (CTS Group I – 48 patients
and in one asymptomatic hand; surface versus needle-elec- and CTS Group II – 12 patients), 3 hands in patients with
trode determinations of distal motor latency (DML) of brachial plexopathy affecting the median innervated hand
CMAP recorded from the 2L muscle differed in all determi- muscles, 1 hand in a patient with a median nerve lesion at the
nations by no more than 0.1 ms. level of axilla, 1 hand with a digital nerve injury affecting the
median innervated lumbrical muscles but sparing the thenar
Stimulation The median nerve was stimulated using the muscles (no sex and age information about the patients were
supramaximal stimulations at the wrist (S), at a distance of given by authors). Limit of normal for APB-2L CMAP
about 11 cm (11.2 ± 0.7 cm) between the wrist stimulation latency difference was ≤0.4 ms.

C8
T1
R2
Digit I
Lower trunk
Median
nerve
Medial cord
R
A
– +
Digit III R
S
(wrist)
R1
Second lumbrical (2L)
Typical waveform (wrist – 2L muscle, wrist – APB muscle):
Median - (2L-APB) Median - (2L-APB)
2 2
1 3 5 1 3 5
4 Wrist - 2L 1.1 4 Wrist - 2L 1.1
30 ms 5 mV 18 mA 20 ms 5 mV 18 mA
2 2
1 3 5 1 3 5
Wrist - APB 1.2 Wrist - APB 1.2
30 ms 5 mV 18 mA 20 ms 5 mV 18 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L and APB muscles, stimulation at the wrist, 2L recording
(upper trace) and APB recording (lower trace)

Normal values [1] Mean ± SD Range Comment
Wrist–APB, distal latency (ms) 3.3 ± 0.4 Logigian et al. [1] also recorded F-responses from both
Wrist–2L, distal latency (ms) 3.0 ± 0.3 the APB and 2L muscles, following 10 supramaximal
APB-2L (wrist), latency difference (ms) 0.0 ± 0.1 −0.2–0.2 median nerve stimuli at the wrist. F-responses were
Wrist–APB, negative peak amplitude (mV) 8.5 ± 3.2 recordable from the APB muscle in all 28, but from the
Wrist–2L, negative peak amplitude (mV) 1.6 ± 0.6 2L in only 16 hands. In these 16, minimum F-response
APB–2L negative peak amplitude ratio 0.21 ± 0.1 latencies from 2L and APB did not differ by more than
Elbow–APB, MNCV (m/s) 57 ± 6 1 ms. Patients with CTS were divided into two groups:
Elbow–2L, MNCV (m/s) 57 ± 7 CTS Group I – those with relative lumbrical sparing, in
APB–2L (elbow), latency difference (ms) 0±3 −4–8 whom the intrahand latency difference (APB–2L) was
≥0.4 ms (greater than 3 SD beyond the mean for the
control group); CTS Group II – those without lumbrical
sparing, in whom the intrahand latency difference
Pathological values [1] – CTS Group I Mean ± SD Range
(APB–2L) was <0.4 ms. In the CTS Group I (CTS with
lumbrical sparing), there were 48 hands including 14
Wrist–2L, distal latency (ms) 4.5 ± 1.3
with wrist–APB <4.5 ms (within 3 SD of the control
APB–2L (wrist), latency difference (ms) 1.0 ± 0.6 0.4–3.0
mean), 5 of whom had normal forearm conduction
Wrist–2L, negative peak amplitude (mV) 1.6 ± 0.7
velocity. The mean latencies and intrahand latencies dif-
APB–2L negative peak amplitude ratio 0.32 ± 0.2 ference were all significantly greater than those of the
Elbow–APB, MNCV (m/s) 49 ± 5 control group. In general, the more severe the CTS, the
Elbow–2L, MNCV (m/s) 54 ± 6 greater is the relative degree of lumbrical sparing. In one
APB–2L (elbow), latency difference (ms) −5 ± 4 −14–0 patient, no APB CMAP was recordable even with the
needle electrodes but a 2L CMAP was present (onset
Pathological values [1] – CTS Group II Mean ± SD Range
latency = 7.0 ms, negative peak amplitude = 500 μV). In
the CTS Group II (carpal tunnel syndrome without lum-
brical sparing), in 12 hands with CTS, the latency of 2L
APB–2L (wrist), latency difference (ms) 0.0 ± 0.4 −1.2–0.2
CMAP was not significantly spared, the latency DL
Wrist–2L, negative peak amplitude (mV) 1.4 ± 0.4 APB was <4.5 ms (within 3 SD of the control mean) in
APB–2L negative peak amplitude ratio 0.20 ± 0.1 3 hands, but mean latency of APB CMAP was not sig-
Elbow–APB, MNCV (m/s) 54 ± 9 nificantly different from those of CTS Group I. In the 60
Elbow–2L, MNCV (m/s) 48 ± 5 hands with CTS, lumbrical sparing was most easily
APB–2L (elbow), latency difference (ms) 6±6 0–13 demonstrated by the latency difference 2L–APB
≥0.4 ms. Therefore, the lumbrical sparing is a fairly sen-
sitive electrodiagnostic test for CTS (Fig. 2).
Pathological waveform (wrist – 2L muscle, wrist – APB muscle):
2
2
1 3 1 3 5
5 Median (2L) 1 4 Median (2L) 1
4 30 ms 1 mV 61 mA 50 ms 2 mV 61 mA
2 3 4 5 Median (APB) 2 2 34 5
1 1 Median (APB) 2
30 ms 1 mV 21 mA 50 ms 2 mV 21 mA
Onset latency (wrist – 2L): 7.95 ms; Onset latency (wrist – APB): 12.70 ms; Peak latency (wrist – 2L): 12.15 ms; Peak latency (wrist –
APB): 16.80 ms; Onset latency difference (wrist – 2L) – (wrist – APB): 4.75 ms; Onset to peak amplitude (wrist – 2L): 0.8 mV; Onset to
peak amplitude (wrist – APB): 0.2 mV; Peak to peak amplitude (wrist – 2L): 1.4 mV; Peak to peak amplitude (wrist – APB): 0.1 mV
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L and APB muscles in extremely severe CTS – grade 6 by
Bland’s CTS classification scale [2], stimulation at the wrist, 2L recording (upper trace) and APB recording (lower trace)
References
1. Logigian EL, Busis NA, Berger AR et al (1987) Lumbrical sparing
in carpal tunnel syndrome: anatomic, physiologic, and diagnostic
implications. Neurology 37:1499–1505
Wrist – Hand
M21
Original Settings Sensitivity was 200 μV/division, sweep phalanx of the digit I (on the dorsum of the thumb).
speed was 5 ms/division and 6.25 ms/division, duration of The ground (G) position was not mentioned in the text (the
pulse was 50–200 μs, rate of pulse was 1 Hz, and the figure shows ground positioned on the palm).
machines used were a Medelec MS8 and an MS6 EMG. Low-
frequency filter and high-frequency filter were not specified. Stimulation Using the surface electrodes, the median nerve
was stimulated by electric shocks at the wrist (S1), between
Position This study was performed with the subject lying on the tendons of the flexor carpi radialis (FCR) and the pal-
a bed, encouraged to relax, to minimize possible facilitating maris longus (PL) muscles. Authors performed the conven-
effects on the F-wave formation by muscle contraction. tional median motor study first, and then the cathodal
position was reversed to a proximal placement to perform the
Recording The active electrode (A) was placed over the F-wave studies [1]. For the F-wave studies, authors used a
motor point of the abductor pollicis brevis (APB) muscle supramaximal stimulus intensity (increased by 20 %); 100
(Fig. 1), halfway between the midpoint of the distal wrist stimuli were delivered at 1 Hz. In the F-wave studies, the
crease and the midpoint of the first metacarpophalangeal cathode was proximal and the anode was distal. No fixed
joint [1]. The reference (R) was placed to the proximal distances were reported in the article.

Biceps Brachii
(BB)
R
Digit I
–
A +
R
C8
T1
G
S
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (wrist – APB muscle):

1.2 1.2
1.3 1.3
1.4 1.4
1.5 1.5
1.6 1.6
1.7 1.7
1.8 1.8
1.9 1.9
1.10 1.10
1.11 1.11
1.12 1.12
1.13 1.13
1.14 1.14
1.15 1.15
1.16 1.16
1.17 1.17
1.18 1.18
1.19 1.19
1.20 1.20
5 mV 50 ms 500 µV 10 mV 50 ms 1 mV
Sensitivity 500 µV/div (CMAP 5 mv/div), sweep speed 5 ms/div – left

Sensitivity 1 mV/div (CMAP 10 mv/div), sweep speed 5 ms/div – right
Fig. 1 F-waves recorded at the hand from the APB muscle, stimulation of the wrist. Raster mode, 20 stimuli

Normal values [1] Mean ± SD Range could be within the range seen in the control group.
Wrist–APB, RF waves (%) 14.9 ± 12.2 For this reason, author calculated the RF-wave count
Wrist–APB, NFR (%) 17.3 ± 16.1 0–75 as a percentage of the F responses obtained (≥40 μV).
This value was termed a % Repeater F-wave value (%
RF-value). In the control median nerves, author found
a high F-wave frequency with only four RF-waves (low
Pathological values [1] Mean ± SD Range NFR). The % RF value was 12 %. Author found in
Wrist–APB, RF waves (%) 59.1 ± 23.5 CTS patients some different pathological patterns: [1]
Wrist–APB, NFR (%) 36.8 ± 22.6 0–97
a single delayed latency RF-wave recurred (in 100 F
sweeps, the NFR value was 32, no other RF-wave forms
Measurements The 100 sweeps were analyzed and two were obtained, and the total % RF value was 82 %);
measurements were made: [1] the number of recurring iden- [2] two high-frequency RF-waves recurred, high %
tical F-waves generated was calculated. To be regarded as RF value and high NFR were observed; [3] RF-waves
identical, each F-wave was required to have the same latency, appeared “in series,” longer latency RF-waves were
configuration, and amplitude. These recurring identical F observed. However, serial responses were rare, and
waves were termed “Repeater F-waves” (RF-waves). Only repeater waves in series were not frequently observed.
F-waves with a peak-to-peak amplitude ≥40 μV were For Macleod, care is therefore necessary in the inter-
included in the measurement [2]. The number of sweeps pretation of high % RF values. In patients with atypical
where the response was <40 μV was calculated (% RF symptoms of CTS and normal conventional studies,
waves). These sweeps were designated as a “No F-wave pathologically increased % RF values pose a problem
Response (NFR). The latency of the F-wave response (ms) of interpretation. This method for identifying a periph-
was taken as the interval between the stimulus artifact and eral nerve lesion does not allow precise localization of
the first deflection of the evoked response. All studies were its site, and similar change would be found with a more
carried out in an ambient temperature maintained above proximal median nerve lesion. So author suggested,
26 °C. If the patient’s forearm volar skin temperature was in reaching an electrodiagnosis of CTS, performing
less than 34 °C, the patient was warmed, using hot water a conventional motor study and measuring the distal
bottles and blankets to >34 °C. Authors studied 209 median motor latency (DML) first. If this does not provide an
nerves from 125 healthy (Table 1) subjects (65 women and abnormal value (approximately 66 % of cases), and
60 men, age range 17–82 years, mean age 41 years) and 147 the terminal latency index is within normal limits, a
median nerves from 111 patients (Table 2) with symptomatic sensory conduction study should be performed. If this
carpal tunnel syndrome (CTS). value proves to be within normal limits, F latencies
across the carpal tunnel should be measured, and if
these values are not clearly abnormal, the % RF value
Comment for the nerve should be calculated (Figs. 2 and 3).
For Macleod [1] the NFR, taken as an isolated param-
eter, was therefore an insensitive index of nerve com-
pression in the vast majority of cases. The number Chroni et al. [2] using an EMG Keypoint machine studied
of RF-waves obtained from an individual CTS nerve the F waves recording from the APB muscle. The low filter
also had a broad range (3–100), and characteristi- was set at 20 Hz, the high filter was set at 10 kHz, the sweep
cally, when there was a low RF-wave count, there was speed was 5 or 10 ms/division, and the sensitivity was set to
a high NFR value. When a damaged nerve backfired 0.2 or 0.5 mV/division. They applied a cathodal electrical
frequently (e.g., 95 F-waves per 100 stimuli), there pulse of 0.1 ms duration at the wrist, and a total of 20 supra-
was a high RF-wave count (e.g., 75/95 responses). maximal stimuli were delivered at a 1 Hz frequency. They
Although the CTS group contained an increased num- assessed the frequency of the RF-waves and they described
ber of RF-waves compared with the control group, the their characteristics in routine electrophysiological record-
presence of a low F-response frequency in many cases ings. They called a repeating neuron (RN) the F-waves of
meant that the RF-wave counts in damaged nerves identical shape, same latency and amplitude. The superim-
position of all 20 traces was used to confirm the identical
shape of RNs because to be included as a repeater, the entire RNs repeated themselves in order to calculate the grand total
shape, from onset to return to baseline, had to be identical. of all repeater F-waves (Total Freps) in a recording (called by
RN variables were defined as the number of different neu- Macleod “% Repeater F-waves – % RF-waves”). Authors
rons that produced repeater F-waves and the times that the calculated two indices:
100 ´ number of RN
Index RN =
number of traces with different F wave shapes in a series of 20 stimuli
100 ´ total number of F wave repeaters

Index Total Freps =
total number of traces with F waves in the same nerve
In a study of a median nerve with 20 stimuli, for example, 12 50 healthy subjects (Table 3) of three groups of patients:
traces were recorded with F-waves, identified as follows: one DM-PN Group – 49 median nerves from 50 patients (Table 4)
F-wave shape occurred twice, one occurred four times, in the with a clinically and electrophysiologically supported diag-
other six traces F-wave shapes occurred only once. The num- nosis of a diabetic polyneuropathy (DM-PN), 36 men and 14
ber of RNs was 2, and the total number of F-wave shapes women, mean age 56.8 ± 15.0 years, age range 21–82 years;
was 8. Therefore, the Index RN was 100 × (2/8), and Index ALS Group – 43 median nerves from 50 patients (Table 5)
Total Freps was 100 × (6/12). Standard parameters were also with amyotrophic lateral sclerosis (ALS), 26 men and 24
studied: the F-wave mean latency (the mean latency of women, mean age 56.8 ± 15.0 years, age range 35–87 years;
F-waves in a series of 20 stimuli minus CMAP latency), the CTS Group – 50 median nerves from 50 patients (Table 6)
F-wave max amplitude (the maximum peak-to-peak ampli- with CTS, 17 men and 33 women, mean age 54.2 ± 15.0 years,
tude of the largest F-wave in a series of 20 stimuli), the per- age range 26–83 years. All CTS patients had a distal motor
sistence of F-waves (percentage of traces with any F-wave in latency (DML) >4.2 ms and sensory conduction velocity
a series of 20 stimuli). Mean latency and max amplitude (SNCV) in the wrist–midpalm segment <37 m/s. Compared
were also measured for RN. with healthy subjects, the RN occurrence, as expressed by
To assess the frequency of the RF-waves and to describe different indices and ratios, was found to be significantly
their characteristics in a routine electrophysiological record- higher in patients with neuropathies or ALS (CTS > ALS >
ing, authors [2] performed a median nerve F-wave study on DM-PN).

Normal values [2] Mean Pathological values [2] – ALS Group Mean
F-wave, latency (ms) 24.1 F-wave, latency (ms) 27.2
F-wave, amplitude (mV) 0.8 F-wave, amplitude (mV) 0.8
Persistence of F waves 90 (75–100 %) Persistence of F waves 65 (12–99 %)
Repeating neuron (RN), latency (ms) 24.8 Repeating neuron (RN), latency (ms) 27.9
Repeating neuron (RN), amplitude (mV) 0.4 Repeating neuron (RN), amplitude (mV) 0.5
Repeating neuron (RN), nerves 7 (14 %) Repeating neuron (RN), nerves 32 (74 %)
Repeating neuron (RN), total 7 Repeating neuron (RN), total 47
Total Freps 17 Total Freps 134
Persistence of Total Freps 0 (0–15 %) Persistence of Total Freps 10 (0–44 %)

Pathological values [2] - DM-PN Group Mean Pathological values [2] – CTS Group Mean
F-wave, latency (ms) 29.3 F-wave, latency (ms) 26.0
F-wave, amplitude (mV) 0.5 F-wave, amplitude (mV) 0.6
Persistence of F waves 85 (40–100 %) Persistence of F waves 85 (50–100 %)
Repeating neuron (RN), latency (ms) 29.9 Repeating neuron (RN), latency (ms) 26.3
Repeating neuron (RN), amplitude (mV) 0.4 Repeating neuron (RN), amplitude (mV) 0.4
Repeating neuron (RN), nerves 27 (55 %) Repeating neuron (RN), nerves 42 (84 %)
Repeating neuron (RN), total 44 Repeating neuron (RN), total 68
Total Freps 112 Total Freps 209
Persistence of Total Freps 10 (0–45 %) Persistence of Total Freps 23 (0–50 %)

16 16
1.1 1.1
1.2 1.2
1.3 1.3
1.4 1.4
1.5 1.5
1.6 1.6
1.7 1.7
1.8 1.8
1.9 1.9
1.10 1.10
1.11 1.11
1.12 1.12
1.13 1.13
1.14 1.14
1.15 1.15
1.16 1.16
5 mV 50 ms 500 µV 10 mV 50 ms 1 mV
Sensitivity 500 µV/div (CMAP 5 mv/div), sweep speed 5 ms/div – left
Fig. 2 Repetitive F-waves recorded at the hand from the APB muscle in severe CTS – grade 4 by Bland’s CTS classification scale [3], stimulation
of the wrist. Raster mode, 16 stimuli (mean F-wave latency 33.82 ms)

1.8 1.8
1.9 1.9
1.10 1.10
1.11 1.11
1.12 1.12
1.13 1.13
1.14 1.14
1.15 1.15
1.16 1.16
1.17 1.17
1.18 1.18
1.19 1.19
1.20 1.20
1.21 1.21
1.22 1.22
1.23 1.23
1.24 1.24
1.25 1.25
1.26 1.26
1.27 1.27
10 mV 20 mV 100 ms 2 mV
100 ms 1 mV
Sensitivity 1 mV/div (CMAP 10 mv/div), sweep speed 10 ms/div – left

Fig. 3 Repetitive F-waves recorded at the hand from the APB muscle in very severe CTS – grade 5 by Bland’s CTS classification scale [3], stimu-
lation of the wrist. Raster mode, 20 stimuli (mean F-wave latency 40.30 ms)
References 2. Chroni E, Serrano Tendero I, Rostedt Punga A et al (2012)

Usefulness of assessing repeater F-waves in routine studies. Muscle
Nerve 45:477–485
1. Macleod WN (1987) Repeater F waves: a comparison of sensitivity
with sensory antidromic wrist to palm latency and distal motor latency
in the diagnosis of carpal tunnel syndrome. Neurology 37:773–778
Wrist, Palm – Hand
M22
Original Settings Sensitivity was 1–5 mV/division, recording electrode measuring along a line that bisected the
low-frequency filter was 20 Hz, high-frequency filter was distal wrist crease [1]. The anode (surface disk) was proxi-
10 kHz, sweep speed was 2 ms/division, duration of pulse mal. For palm stimulation (S2), the cathode was placed at the
was 0.05 ms, and the machine used was a TECA point where the tip of the flexed digit IV (ring finger) con-
electromyograph. tacts the thenar crease (lifeline on palm). The anode (ring
electrode) was placed distally at the base of the digit
Position This study was performed in the supine position. IV. Authors used 0.05 ms duration of the stimulus, and the
voltage was slowly increased until a maximal response was
Recording Using 8 mm surface disk electrodes, muscle obtained. They obtained identical values with standard sur-
potentials were recorded from the abductor pollicis brevis face bipolar stimulation.
(APB) muscle (Fig. 1). The active recording (A) electrode
was placed over the motor point of the APB muscle; the ref- Measurements Distal latency (ms) of the compound mus-
erence (R) electrode was placed on the interphalangeal joint cle action potential (CMAPs) was measured from the stimu-
of the digit I [1]. The ground (G) electrode plate was placed lus onset to the onset of the negative deflection of the
over the dorsum of the hand (the figure shows the ground CMAP. Amplitude (mV) of the CMAP was measured from
electrode placed on the palm). the isoelectrical line (baseline) to the peak of the negative
deflection. Skin temperature was measured in the palm, and
Stimulation The median nerve was stimulated using a it was at least 31 °C during the nerve conduction testing.
monopolar electromyography needle as the cathode. The tip Authors [1] studied 23 hands (Table 1) from 23 healthy
of the needle was placed in the subcutaneous tissue overlying asymptomatic subjects (age range 21–62 years) and 25 hands
the nerve. The median nerve was stimulated at the wrist (S1) (Table 2) from 25 patients with clinical and electrodiagnostic
and on the palm (S2). For wrist stimulation (S1), a monopo- evaluated carpal tunnel syndrome (CTS). No information
lar needle (cathode) was placed 8 cm proximal to the about the CTS sample was given.

132 M22 Wrist, Palm – Hand
C8
T1
R
Lower trunk
Median
nerve
Medial cord
R
A
Digit II
G
8 cm
– – + Median nerve
+
Digit IV
S1
(wrist)
S2
(palm)
Typical waveform (wrist, palm – APB muscle):
Median - (APB) W-P Median - (APB) W-P
2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
4 4
50 ms 5 mV 28 mA 30 ms 5 mV 28 mA
2 2
1 3 1 3
5 Palm 2 5 Palm 2
4 50 ms 5 mV 27 mA 4 30 ms 5 mV 27 mA
palm (lower trace)
M22 Wrist, Palm – Hand 133
C8
T1
R
Lower trunk
Median
nerve Medial cord
R
A
Digit II
G
8 cm
– – + Median nerve
+
Digit IV
S1
S2 (wrist)
(palm)
Fig. 2 Surface bipolar stimulations (S1 – wrist, S2 – palm), recording from the APB muscle

Normal values [1] Mean ± 2SD Range Comment
Wrist–APB, distal latency (ms) 3.5 ± 0.36 2.8–4.2 For Pease et al. [1], in all control subjects, the mean
Wrist–APB, negative peak 8.9 ± 3.1 3.5–15.0 CMAP onset latency after wrist stimulation was
amplitude (mV) 3.5 ± 0.36 ms and the latency range was 2.8–4.2 ms.
Palm–APB, distal latency (ms) 1.8–2.2 The CMAP amplitude after the wrist stimulation was
Palm–APB, negative peak 0.56 ± 0.74 0–2.0 8.9 ± 3.1 (8.8 mV in the results was reported), the
amplitude increase (mV)
amplitude range was 3.5–15 mV. After the midpalmar
stimulation a mean increase in amplitude was observed
Table 2 Reference values (0.56 ± 0.74 mV), with a range in amplitude of
Pathological values [1] Mean ± 2SD Range 0–2.0 mV and a range in latency of 1.8–2.2 ms. In the
Wrist–APB, distal latency (ms) 4.6 ± 1.0 25 affected hands from 25 patients with CTS of vary-
Wrist–APB, negative peak 4.2 ± 2.7 ing severity, a markedly different result was found
amplitude (mV) when comparing the CMAP after the midpalmar stim-
Palm–APB, negative peak amplitude 2.2 ± 1.7 −1.0–6.0 ulation to the CMAP after stimulation at the wrist. The
increase (mV)

result was statistically significant (mean amplitude Normal values [2] Mean ± 2SD Range
was 2.2 ± 1.7 mV, with a range of −1.0–6.0 mV) when Transcarpal MNCV (m/s) 54.6 ± 7.0
compared to the normal controls. In CTS patients the Forearm MNCV difference (m/s) 0.3 ± 4.8
mean latency was 4.6 ± 1.0 ms and the mean amplitude Palm–APB, negative peak amplitude 7.1
was 4.2 ± 2.7 mV (a value of 1.7 mV for SD was (mV)
reported in the results), suggesting that the median Wrist–APB, negative peak amplitude 7.1
(mV)
nerve had a significant degree of dysfunction. Authors
P/W CMAP amp ratio 1.0 ± 0.2 0.8–1.1
emphasized the use of midpalmar stimulation, which
permits quantitative assessment of the degree of neu-
roapraxia in a CTS patient. This assessment of neu- Table 4 Reference values
roapraxia allows comparison of the amplitudes of the
Pathological values [2] Mean ± 2SD Range
CMAP responses after stimulation proximal and distal Transcarpal MNCV (m/s) 32.3 ± 9.70
to the transverse carpal ligament. For Pease et al. [1], Forearm MNCV difference (m/s) 20.3 ± 8.5
this procedure presents an objective assessment of a Palm–APB, negative peak amplitude 7.6 ± 3.3
conduction block and the results provide important (mV)
prognostic as well as diagnostic information. Wrist–APB, negative peak amplitude 6.3 ± 2.2
(mV)
P/W CMAP amp ratio 1.2 ± 0.4 0.9–2.0
Walters and Murray [2] measured a transcarpal motor
conduction (wrist–palm segment) to the APB muscle as
described by Pease et al. [1]. They compared it with other Comment
sensory tests as an orthodromic sensory from digit II and Walters and Murray [2] found a transcarpal motor
digit III, the orthodromic median-ulnar mixed 8 cm palm– conduction velocity abnormal in 56 hands (80 %),
wrist, and motor 2L-INT latency difference test to investi- forearm transcarpal velocity difference abnormal in
gate the relative sensitivities of motor and sensory nerve tests 59 hands (84 %). The most sensitive test among all
over an equivalent short nervous segment. They studied 29 patients was a 2L-INT latency difference by Preston
control (Table 3) subjects (17 men and 12 women, mean age and Logigian [3], which was abnormal in 64 hands
47 ± 12 years) and 70 hands from 43 patients (Table 4) with (91.5 %). They hypothesized a 2L-INT higher sensi-
suspected CTS (32 women and 11 men, mean age tivity for CTS than distal motor latency to the APB
47 ± 11 years). Recordings were made using 1 cm diameter muscle with a possible earlier compression of median
silver–silver chloride discs; hand temperature was main- fascicles innervating lumbrical muscles than those
tained between 32 °C and 34 °C. Low-frequency filter was APB muscle. For authors, transcarpal motor con-
2 Hz and high-frequency filter was 10 kHz, and amplifier duction should have a role in the detection of a dis-
gain was 2 mV/division for all motor studies. Authors calcu- tal conduction block in patients with demyelinating
lated a transcarpal motor velocity by dividing the distance neuropathies, as a prognostic value in confirming that
between the stimulation sites by the latency difference, while weakness of the APB muscle is due to the conduction
the amplitude of the CMAP after the palmar and wrist stimu- block rather than the axonal degeneration.
lation was expressed as a ratio, as follows:
Palmar CMAP amplitude ( mV )

P / W CMAP amp RATIO =
Wrist CMAP amplitude ( mV )
A significant ratio abnormality (≥2SD control mean) was

identified as demonstrating evidence of a conduction block.
References 135
Pathological waveform (wrist, palm – APB muscle):

Median - (APB) W–P Median - (APB) W–P
2 2
1 3 5 1 3 5
4 Wrist 1 4 Wrist 1
50 ms 5 mV 45 mA 30 ms 5 mV 45 mA
2 2
1 3 1 3
5 Palm 2 5 Palm 2
4 50 ms 5 mV 25 mA 4 30 ms 5 mV 25 mA
Onset latency (wrist – APB): 4.95 ms; Onset latency (palm – APB): 1.60 ms; Peak latency (wrist – APB): 7.60 ms; Peak latency
(palm – APB): 5.10 ms; Onset to peak amplitude (wrist – APB): 3.5 mV; Onset to peak amplitude (palm – APB): 7.3 mV; Peak to
peak amplitude (wrist – APB): 4.7 mV; Peak to peak amplitude (palm – APB): 10.3 mV
CTS classification scale [4], stimulation of the wrist (upper trace) and on the palm (lower trace)
2. Walters RJL, Murray NMF (2001) Transcarpal motor conduction

References velocity in carpal tunnel syndrome. Muscle Nerve 24:966–968
3. Preston DC, Logigian EL (1992) Lumbrical and interossei record-
1. Pease WS, Cunningham ML, Walsh WE et al (1988) Determining ing in carpal tunnel syndrome. Muscle Nerve 15:1253–1257
neuroapraxia in carpal tunnel syndrome. Am J Phys Med Rehabil 4. Bland JDP (2000) A neurophysiological grading scale for carpal
3:117–119 tunnel syndrome. Muscle Nerve 23:1280–1283
Wrist – Hand
M23
and First Dorsal Interosseous (FDI) Muscles
Original Settings Duration of pulse was 0.2 ms and the Stimulation The median and ulnar CMAPs were evoked
machine used was a DISA 2000 M. Sensitivity, low-fre- with a bar stimulating electrode. The stimulations were at the
quency filter, high-frequency filter, and sweep speed were wrist, on the median nerve (S1), and on the ulnar nerve (S2),
not specified. proximal to the wrist crease. Author stimulated both the
median and ulnar nerves at the wrist (S1 and S2, respec-
Position This study was performed in the supine position. tively) to compare the median and ulnar sensory latencies in
the same and opposite hands [1]. Author used percutaneous
Recording Following the median nerve stimulation (S1), supramaximal rectangular stimulation. In order to measure
the active electrode (A) was placed over the belly of the the forearm velocity both for the median and ulnar nerves,
abductor pollicis brevis (APB) muscle (Fig. 1), halfway the proximal stimulation for the median nerve was applied at
between the midpoint of the distal wrist crease and the mid- the internal bicipital groove and for the ulnar nerve above the
point of the first metacarpophalangeal joint [1]. The refer- median epicondylar groove. Only subjects with normal fore-
ence (R) was placed slightly distal to the first arm velocity (over 50 m/s) were included in the study.
metacarpophalangeal joint (over the tendon of the APB mus-
cle). Following the ulnar nerve stimulation (S2), the active Measurements Distal latency (ms) was measured from
electrode was placed over the motor point of the first dorsal stimulus onset to the onset of initial negative deflection of
interosseous (FDI) muscle (R2). The reference (R) was the CMAP. Onset latency was measured for both the median
placed slightly distal to the second metacarpophalangeal and ulnar and differences between the paired distal motor
joint (over the tendon of the FDI muscle). The active elec- latencies were measured in the same hand and in opposite
trode location was adjusted over the muscular eminence to hands in all subjects. Skin temperature was tested before
obtain the greatest compound muscle action potential each investigation but temperature data were not given.
(CMAP) amplitude for both the median (S1) and ulnar (S2) Authors studied 102 normal median nerves (APB muscle)
nerves stimulations at the wrist. Author used surface elec- and 200 normal ulnar nerves (FDI muscle) from 124 healthy
trodes for recording (bar recording electrode fixed with a subjects (Table 1) composed by 26 volunteers providing 52
Velcro-strap). The distal motor latency (DML) of APB and data and 98 patients referred to the laboratory either for spas-
FDI were recorded at the same time. The ground (G) elec- mophily or for atypical paresthesia or upper limb pain with-
trode position was not specified in the text; probably it was out any clinical feature of ulnar or median nerve entrapment
placed on the dorsum of the hand (the figure shows ground- lesions providing 148 data (83 women and 41 men, age range
ing on the palm). 22–84 years, mean age 53.73 ± 13.5 years).

C8
T1
R2
First dorsal
interosseous R A
Lower trunk
(FDI)
Median
nerve Medial cord
Ulnar
nerve
R S1
(wrist)
A
Digit II
G
– + Median nerve
– + Ulnar nerve
Digit V
S2
R1 (wrist)
Typical waveform (wrist – APB muscle, wrist – FDI muscle):

Median - (APB-FDI) Median - (APB-FDI)
2 2
1 3 1 3
4 4
50 ms 5 mV 44 mA 30 ms 5 mV 44 mA
2 2
1 3 1 3
50 ms 5 mV 44 mA 30 ms 5 mV 44 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and FDI muscles, stimulation of the wrist: median nerve
(upper trace) and ulnar nerve (lower trace)

Normal values [1] Mean ± SD parison between DML to FDI muscle and motor nerve
Wrist–APB, distal latency (ms) – 102 nerves 3.398 ± 0.29 conduction velocity (MNCV) showed a logical good
Wrist–FDI, distal latency (ms) – 200 nerves 3.195 ± 0.30 correlation: MNCV 50–54 m/s – DML 3.287 (ms),
Wrist–FDI, distal latency (ms) – 52 nerves 3.17 ± 0.28 MNCV 55–59 m/s – DML 3.232 (ms), MNCV
(control group) 60–64 m/s – DML 3.157 (ms), MNCV > 65 m/s – DML
Wrist–FDI, distal latency (ms) – 148 nerves 3.20 ± 0.31 3.105 (ms). For author comparing the motor latency
(patients group)
between the median and ulnar nerves at the hand is of
APB–FDI, distal latency difference opposite hand 0.206 ± 0.15
(ms) – 76 nerves
great interest in the study of pathological entrapment
APB–FDI, distal latency difference same hand 0.22 ± 0.32 neuropathies of the median and of the ulnar nerve at the
(ms) – 102 nerves wrist (Fig. 2). Because in most of the cases, as only one
nerve is entrapped, the other one can be taken as normal
reference data, so author asserted that: (1) DML to FDI
values are pathological when they are higher than
Comment 3.8 ms and higher than DML to APB with a difference
Seror [1] found the same results in control subjects and of 0.4 ms or more; (2) DML to APB values are patho-
in normal patients, so it seemed convenient to study logical when they are higher than 4 ms and higher than
them as one homogeneous group. The DML values to DML to FDI with a difference of 0.8 ms or more.
APB were greater than those to FDI in more than 80 % Author emphasized that if a significant difference
of all cases. The mean differential value was 0.22 ms; it between DML is present, or both DML to APB and
was calculated from 102 wrist data. Mean value DML to FDI are elevated without significant difference
between the DML APB value (102 data) and DML FDI and global decrease of MNCV, the other arm has to be
value (200 data) was rather similar and equal to 0.204. examined (the difference between both arms is seldom
The study of bilateral data showed only a slight differ- more than 0.5 ms). Only then may the examiner con-
ence between the right and left arm, the mean value clude that a single or double entrapment neuropathy of
being 0.22 ms. Author found a difference of 0.5 ms or the deep branch of the ulnar nerve and the median nerve
more in 5 % of the cases only. For ulnar nerve, the com- at the wrist are present.
Pathological waveform (wrist – APB muscle, wrist – FDI muscle):
Median - (APB-FDI) Median - (APB-FDI)
2 2
1 3 1 3 5
5 Wrist (median) 1 Wrist (median) 1
4 4
50 ms 5 mV 59 mA 30 ms 5 mV 59 mA
2 2
1 3 5 Wrist (ulnar) 2 1 3 5 Wrist (ulnar) 2

4 50 ms 5 mV 55 mA 4 30 ms 5 mV 55 mA
Onset latency (median – APB): 8.55 ms; Onset latency (ulnar – FDI): 3.85 ms; Onset latency difference (median APB – ulnar FDI):
4.60 ms; Peak latency (median – APB): 11.80 ms; Peak latency (ulnar – FDI): 7.20 ms; Onset to peak amplitude (median – APB):
3.9 mV; Onset to peak amplitude (ulnar – FDI): 6.6 mV; Peak to peak amplitude (median – APB): 5.4 mV; Peak to peak amplitude
(ulnar – FDI): 9.9 mV
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and FDI muscles, in very severe CTS – grade 5 by
Bland’s CTS classification scale [2], stimulation of the wrist: median nerve (upper trace) and ulnar nerve (lower trace)
References 2. Bland JDP (2000) A neurophysiological grading scale for carpal

1. Seror P (1988) Comparison of the distal motor latency of the first
dorsal interosseous with abductor pollicis brevis. Report of 200
cases. Electromyogr Clin Neurophysiol 28:341–345
Wrist – Hand
M24
and Abductor Digiti Minimi (ADM) Muscles
Original Settings Sensitivity, low-frequency filter, high- placed at the proximal wrist both for the median (S1) and
frequency filter, sweep speed, duration of pulse, and the ulnar (S2) nerves stimulations. Authors did not use a con-
machine used were not specified. stant distance between the stimulating cathode and the
recording needle electrode [1].
Measurements Distal latency (ms) was measured from the
Recording Following the median nerve stimulation (S1), stimulus onset to the onset of the initial deflection of the
the recording needle electrode was inserted in the motor compound muscle action potential (CMAP). Onset latency
point of the abductor pollicis brevis (APB) muscle (Fig. 1), was measured for both the median and ulnar nerves, and dif-
halfway between the midpoint of the distal wrist crease and ferences between paired distal motor latencies were mea-
the midpoint of the first metacarpophalangeal joint [1]. sured in the same hand. As authors did not use a constant
Following the ulnar nerve stimulation (S2), the recording distance between the stimulating cathode and the recording
needle electrode was inserted in the motor point of the needle electrode, the range of distal motor latency was rela-
abductor digiti minimi (ADM) muscle (R2). The ground (G) tively large and the upper limits (mean ± 2SD) long. They
electrode position was not specified (the figure shows the considered a large number of subjects in each group and
ground electrode placed on the palm). therefore the distribution of the distance conducted across
was similar in each group. The room temperature was kept
Needle Insertion For the APB muscle, with the hand in a not lower than 23 °C, skin temperature data were not reported
neutral position to full supination, the recording needle elec- (authors specified that sufficient time was allowed for the
trode was inserted on the lateral aspect of the base of the patients to warm up). Normal nerve conduction values were
proximal phalanx of the thumb, using a medial-directed obtained from 102 subjects (Table 1), selected on the basis of
approach just anterior to the bone at the midpoint of the first a completely normal motor conduction of the median and
metacarpal bone. For the ADM muscle, with the hand in a ulnar nerves in the forearm (66.7 % women and 33.3 % men,
neutral position to full supination, the recording needle elec- age range 22–86 years, mean age 47.5 years); for pathologi-
trode was inserted at the midpoint between the fifth metacar- cal values authors studied 116 patients (Table 2) suffering
pophalangeal joint and the pisiform bone. from median nerve entrapment at the wrist, as proven by a
prolonged DML or distal sensory latency of the median
Stimulation The median and ulnar nerves were stimulated nerve (67.2 % women and 32.8 % men, age range 20–82
with a surface stimulator; the stimulation cathode (−) was years, mean age 49.2 years).

C8
T1
R1
Lower trunk
Median Digit I
nerve Medial cord
Ulnar
nerve S1
(wrist)
G – + Medial nerve
– + Ulnar nerve
Digit V
R2 S2
Abductor digiti minimi (ADM) (wrist)
Typical waveform (wrist – APB muscle, wrist – ADM muscle):
Median - (APB-ADM) Median - (APB-ADM)
2 2
1 3 5 Wrist (median) 1 1 3 5 Wrist (median) 1

50 ms 5 mV 67 mA 30 ms 5 mV 67 mA
4 4
2 2

4 50 ms 5 mV 100 mA 4 30 ms 5 mV 100 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and ADM muscles, stimulation of the wrist: median
nerve (upper trace) and ulnar nerve (lower trace)

Normal values [1] Mean ± SD Mean ± 2SD Range Comment
Wrist–APB, distal 3.4 ± 0.49 4.5 2.4–4.4 Mortier et al. [1] demonstrated a significant prolongation
latency (ms) of the ulnar nerve DML in patients with carpal tunnel
Wrist–ADM, distal 2.5 ± 0.43 3.4 1.6–3.6 syndrome (CTS) compared to the DML in a control
latency (ms) group. They found no relationship between the degree of
APB–ADM, distal latency 0.9 ± 0.5 1.9 −0.6–2.2 reduction of the median nerve motor conduction velocity
difference same hand (ms)
and that of the ulnar nerve, as it was demonstrated by the
absence of the correlation between the two distal motor
latencies in the patients group. Their result gave reason
to authors to doubt some methods, based on comparing
the median and ulnar nerves motor and sensory latencies,
Pathological values [1] Mean ± SD Mean ± 2SD Range used to diagnose. They suggested use of more reliable
Wrist–APB, distal latency 5.0 ± 0.84 6.7 3.2–8.8 methods, based on abnormalities in only the median
(ms)
nerve sensory conduction and amplitude [2–5], or
Wrist–ADM, distal latency 2.9 ± 0.56 4.0 1.9–5.0
(ms) abnormalities in the median nerve distal motor latency
APB–ADM, distal latency 2.1 ± 1.0 4.1 0.2–6.8 (Fig. 2) when corrected for differences in conduction in
difference same hand (ms) the forearm [6].
Median - (APB-ADM) Median - (APB-ADM)
2 2
1 3 5 Wrist (median) 1 1 3 5 Wrist (median) 1

50 ms 5 mV 59 mA 30 ms 5 mV 59 mA
4 4
2 2

50 ms 5 mV 21 mA 30 ms 5 mV 21 mA
4 4
Onset latency (median – APB): 5.30 ms; Onset latency (ulnar – ADM): 3.20 ms; Onset latency difference (median APB – ulnar ADM):
2.10 ms; Peak latency (median – APB): 7.20 ms; Peak latency (ulnar – ADM): 5.60 ms; Onset to peak amplitude (median – APB):
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB and ADM muscles in moderately severe CTS – grade 3
by Bland’s CTS classification scale [7], stimulation of the wrist: median nerve (upper trace) and ulnar nerve (lower trace)
References 4. Loong SC, Seah CS (1971) Comparison of median and ulnar

sensory nerve action potentials in the diagnosis of the carpal tunnel
syndrome. J Neurol Neurosurg Psychiatry 34:750–754
1. Mortier G, Deckers K, Dijs H et al (1988) Comparison of the distal
5. Monga TN, Shanks GL, Poole BJ (1985) Sensory palmar stimulation
motor latency of the ulnar nerve in carpal tunnel syndrome with a
in the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil
control group. Electromyogr Clin Neurophysiol 28:75–77
66:598–600
2. Buchthal F, Rosenfalck A, Trojaborg W (1974) Electrophysiological
6. Kraft GH, Halvorson GA (1983) Median nerve residual latency:
findings in entrapment of the median nerve at wrist and elbow.
3. Kimura I, Ayyar DR (1985) The carpal tunnel syndrome: electro-
physiological aspects of 639 symptomatic extremities. Electromyogr
Wrist – Hand
M25
Study from First Lumbrical (1L)
and Abductor Pollicis Brevis (APB) Muscles
Original Settings Sensitivity was 0.5–2 mV/division, ground electrode placed on the palm). The APB and the 1L
low-frequency filter was 20 Hz, high-frequency filter was CMAPs were recorded separately.
2 kHz, sweep speed was 2 ms/division, duration of pulse was
0.1–0.2 ms, and the machine used was a TECA TD10 Stimulation For the 1L muscle recording (R1), the median
electromyograph. nerve was stimulated at the wrist, 12 cm from the active
recording electrode (A) placed over the motor point of the
Position This study was performed in the supine position. 1L. The distance was measured following the course of the
median nerve from the recording electrode to the midthenar
Recording For the first lumbrical (1L) compound muscle crease and up the forearm [1]. For the APB muscle record-
action potential (CMAP) recording (R1), the active electrode ing (R2) median nerve was stimulated at the wrist, 8 cm
was placed 1 cm proximal to the midpalmar crease and to the from the active recording electrode (A) placed over the belly
radial side of the long flexor tendon. Localization of the 1L of the APB muscle, following the standard method by
muscle was done by palpating the long flexor tendon as the Melvin et al. [2]. A 25–50 % supramaximal stimulus was
subject flexes his index finger (digit II). The reference elec- delivered using a surface stimulation. Stimulus duration was
trode (R) was placed over the base of the digit II [1]. For the 0.1–0.2 ms.
abductor pollicis brevis (APB) CMAP recording (R2), the
active electrode (A) was placed over the belly (motor point) Measurements Distal latency (ms) of the CMAP was mea-
of the APB muscle, halfway between the midpoint of the sured from the stimulus onset to the onset of the negative
distal wrist crease and the midpoint of the first metacarpo- deflection of CMAP. Amplitude (μV) of the CMAP was
phalangeal joint. The reference (R) was placed slightly distal measured from the isoelectrical line (baseline) to the peak of
to the first metacarpophalangeal joint, on the proximal pha- the negative deflection. Skin temperature was measured in
lanx of the digit I (thumb). Author used a standard method the web of the first interspace between digit I (thumb) and
[2] for APB recording (Fig. 1). Authors used surface elec- digit II (index finger), and maintained above 31 °C. Authors
trodes for recordings (R1, R2): 10-mm silver disc electrodes studied 44 healthy (Table 1) subjects (age range 22–66 years,
were used as active recording electrodes; ring electrodes mean age 30 years) and 36 patients (Table 2) with carpal tun-
were used as reference electrodes. The ground (G) electrode nel syndrome (CTS) (age range 25–88 years, mean age 52
was placed over the dorsum of the hand (the figure shows the years).

C8
T1
R2
Lower trunk
Median
nerve
Medial cord
A
Digit II A
R
12 cm
– + Median nerve
Digit V
S
R1 (wrist)
First lumbrical (1L)
Typical waveform (wrist – 1L muscle, wrist – APB muscle):
1 3 5 Median (1L) 1.1

4 2
20 ms 2 mV 11 mA 1 3 5
2 4 Median (1L) 1.1
30 ms 5 mV 11 mA
Median (APB) 1.2 1 3

1 3 5 Median (APB) 1.2
20 ms 2 mV 11 mA 4
5 30 ms 5 mV 11 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the 1L and APB muscles, stimulation of the wrist: 1L recording
(upper trace) and APB recording (lower trace)

Normal values [1] Mean ± SD Mean ± 2SD Range across the carpal ligament was 105 % for 1L muscle
Wrist–APB, distal 3.6 ± 0.31 4.22 3.0–4.2 and 25 % for APB muscle. Normal median motor
latency (ms) latencies (≤4.2 ms) to both 1L and APB muscles were
Wrist–1L, distal 3.5 ± 0.34 4.18 2.6–4.1 found in 7 patients (19 %), abnormal latencies
latency (ms) (>4.2 ms) were found in both muscles in 21 patients
Wrist–APB, 9,512 ± 2,943 3,626–15,398 4,000–13,600
(58 %). Three patients (8 %) had prolonged latencies
amplitude (μV)
Wrist–1L, amplitude 2,241 ± 1,150 0–4,541 644–8,125
to the 1L muscle with a normal latency to the APB
(μV) muscle, while five patients (14 %) had a prolonged
CMAP amplitude 8 25 −7–43 latency to the APB muscle with a normal latency to the
(μV) decrease across 1L muscle. Authors found 67 % of all patients had a
the CT (%) – APB prolonged latency to the 1L muscle, and 72 % of all
CMAP amplitude 22 105 −4–70 patients had a prolonged latency to the APB muscle. In
(μV) decrease across
the CT (%) – 1L a subgroup of ten patients they also found one abnor-
mal sensory study despite normal conduction study to
the APB muscle. Three of these patients had a pro-
Table 2 Reference values longed latency to the 1L muscle, which indicated a
1L distal 1L distal more vulnerable location of the nerve fibers to the 1L
Pathological values [1] latency ≤ 4.2 ms latency > 4.2 ms muscle in these patients. In these cases, where a nor-
APB distal latency > 4.2 ms 5/36 (14 %) 21/36 (58 %) mal APB conduction study and an abnormal sensory
APB distal latency ≤ 4.2 ms 7/36 (19 %) 3/36 (8 %) study were found, authors suggested that the confirma-
tion of CTS can be obtained with an abnormal lumbri-
cal conduction study.
Comment
For Fitz et al. [1] the mean latency to the 1L was
3.5 ± 0.34 ms, while the upper limit of normal was
Foley and Buschbacher [3], for the first lumbrical (1L)
3.6 ± 0.31 ms. Authors calculated the upper limit of
CMAP recording, placed active recording electrode on the
normal for the latency to the 1L muscle to be the same
palm – slightly radial to the long flexor tendon of digit II
to the APB muscle (4.2 ms) but none of their normal
(localized by flexion of digit II) and 1 cm proximal to the
subjects exceeded this limit. The mean amplitude to
midpalmar crease (Fig. 2). They placed reference electrode
the 1L was 2,241 ± 1,150 μV. The range of their healthy
at the base of the digit II, and the ground was placed on the
subjects exceeded the 95 % confidence limit in three
dorsum of the hand (the figure shows the ground electrode
cases (7 %). The mean amplitude to the APB was
placed on the palm, between the stimulating and recording
9,512 ± 851 μV. Authors also performed the midpalmar
sites). Stimulation was at the wrist, 10 cm proximal to the
stimulation (distal to the carpal ligament at the point
active electrode placed on the palm, in a line measured first
where the ring finger touches the thenar flexion crease),
to the midpoint of the distal wrist crease and then to a point
and the mean amplitudes with midpalmar stimulation
slightly ulnar to the tendon of the flexor carpi radialis
increased to 2,744 μV in 1L muscle and to 10,301 μV
(FCR) muscle (anode proximal). Authors studied 196
in the APB muscle. The mean amplitude increase for
healthy subjects (Table 3). Skin temperature over the
the APB muscle was 789 μV (8 %). The calculated
dorsum of the hand was controlled and maintained at or
upper limits of normal for the percentage change
above 32 °C.
C8
T1
Lower trunk S
Median
nerve (wrist)
Medial cord
Digit II A
R
10 cm
– + Median nerve
Digit V
R
First lumbrical (1L)
Fig. 2 1L CMAP recording technique (10 cm fixed conduction distance)
Table 3 Reference values Normal values [3] Mean ± SD Range Limit of normal
Wrist–1L, distal latency (ms) 3.6 ± 0.4 2.7–4.8 4.4
Wrist–1L, negative peak amplitude (mV) 2.5 ± 2.0 0.7–11.2 0.8
Wrist–1L, area of negative phase (μVs) 8.3 ± 5.2 2.1–32.3 2.7
Wrist–1L, duration of negative phase (ms) 6.0 ± 1.2 3.1–10.2 9.3
Comment it was 0.6 ms in cases where the 1L was longer. The

Foley and Buschbacher [3] used a 2–3 Hz for low-fre- upper limit of the normal difference between 1L mus-
quency filter, and a 10 kHz for high-frequency filter. The cle and the APB muscle latency in the same hand was
upper limit of normal for the onset latency was 4.4 ms, 1.0 ms in cases where the APB had the longer latency
the upper limit of the normal increase side-to-side was (Fig. 3); it was 0.6 ms in cases where the 1L muscle
0.7 ms, and the upper limit of the normal decrease in latency was longer. For authors the midpalm stimula-
amplitude side-to-side was 59 %. Authors also compared tion may be difficult in persons with thick skin and care
latency of 1L muscle with other muscles of the hand, must be taken for activation of other nerve branches or
innervated by the median nerve (2L and APB muscles). muscles directly. If the CMAP elicited by the midpalm
They found that the upper limit of normal difference stimulation is significantly greater than with the wrist
between 1L muscle and 2L muscle in the same hand was stimulation, authors suggested that it may be a sign of
0.7 ms in cases where the 2L had the longer latency; neuroapraxia at the wrist.
References 149
Pathological waveform (wrist – 1L muscle, wrist – APB muscle):
2
2
1 3 1 3 5
5 Median (1L) 1 4 Median (1L) 1
4 20 ms 2 mV 21 mA 30 ms 5 mV 21 mA
1 3 Median (APB) 2 1 3
5 Median (APB) 2
5 4
20 ms 2 mV 42 mA 30 ms 5 mV 42 mA
4
Onset latency (wrist –1L): 3.45 ms; Onset latency (wrist – APB): 4.80 ms; Onset latency difference (wrist – APB) – (wrist – 1L): 1.35 ms;
Peak latency (wrist – 1L): 7.40 ms; Peak latency (wrist – APB): 7.15 ms; Onset to peak amplitude (wrist – 1L): 1.6 mV; Onset to peak
amplitude (wrist – APB): 6.1 mV; Peak to peak amplitude (wrist –1L): 3.0 mV; Peak to peak amplitude (wrist – APB): 8.2 mV
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the 1L and APB muscles in moderately severe CTS – grade 3 by
Bland’s CTS classification scale [4], stimulation of the wrist: 1L recording (upper trace) and APB recording (lower trace)
References 3. Foley BS, Buschbacher RM (2006) Establishing normal nerve con-

duction values-lumbrical and interosseous responses. J Long Term
Eff Med Implants 16:359–368
1. Fitz WR, Mysiw J, Johnson EW (1990) First lumbrical latency and
amplitude: control values and findings in carpal tunnel syndrome.
Am J Phys Med Rehabil 69:198–201
2. Melvin JL, Schuchmann JA, Lanese RR (1973) Diagnostic specific-
ity of motor and sensory nerve conduction variables in the carpal
tunnel syndrome. Arch Phys Med Rehabil 54:69–74
Elbow – Forearm
M26
Original Settings Sensitivity was 1 mV/division, low-fre- usually about a three-finger breadth proximal to the medial
quency filter was 1 Hz, high-frequency filter was 10 kHz, epicondyle and between the BB and the BR muscles. Electric
sweep speed was 5 ms/division, duration of pulse was 1.0 ms, stimulation at this site usually causes twitches in the forearm
and the machines used were a Nicolet Viking EMG unit and pronation and/or the thumb flexion. The stimulus intensity
a TECA TE4-EMG. required to elicit the reflex ranged from 3 to 10 mA. The
peak-to-peak amplitude increased gradually with increasing
Position This study was performed with the subject seated stimulus intensity up to the maximum amplitude. A further
comfortably with the arm and forearm resting on a pillow in increase of stimulus intensity showed a decrease in the peak-
the lap. to-peak amplitude of the H-reflex with an increase in the
amplitude of the earlier compound muscle action potential
Recording The active electrode (A) – cathode was placed (CMAP). All H-reflex were only elicited at the subthreshold
on the motor point of the flexor carpi radialis (FCR) muscle, level to the motor response. Authors observed that the
while the reference (R) – anode was placed about 2 cm from H-reflex from the FCR muscle was consistent during a con-
the cathode, on the brachioradialis (BR) muscle (Fig. 1). To secutive recording and showed minimal reflex jitter (up to
locate the motor point on the muscle belly, the subject was 1 ms), and the peak-to-peak amplitude of the reflex decreased
asked to flex the wrist–thumb complex with the digit I during the repetitive stimulation and increased after potenti-
(thumb) and digit IV (ring finger) in opposition, and the ating was stopped. Moreover, the peak-to-peak amplitude of
operator provided mild resistance to the flexed wrist at the the reflex increased during the phasic contraction of the
thenar muscles [1]. With the contraction of the FCR muscle, homonymous agonist muscle and decreased during a con-
the muscle belly bulged at the middle point of the upper third traction of the antagonist muscle.
of the forearm. The motor point usually can be located about
one-fourth the distance on a line drawn between the medial Measurements CMAP latency (ms) was measured from the
epicondyle and the radial styloid process (it can be easily beginning of the stimulus artifact to the start of the reflex
located in thin subjects). The ground (G) was placed on the response. Amplitude of the CMAP (mV) was measured
forearm, between the stimulator and the active electrode (in peak-to-peak. Five consecutive sweeps have been usually
the cubital fossa). Authors used a metal plate electrode (3 cm recorded to determine the maximum possible H-reflex. Skin
in diameter). temperature measured with a thermistor at the elbow crease
was 35.5 °C ± 0.1. Normal values [1] were obtained from 50
Stimulation A surface handheld bipolar stimulation elec- median nerves of 50 healthy (Table 1) subjects (age range
trode was applied at the elbow, to the medial surface of the 20–50 years). Sabbahi and Khalil [2] also studied 107
lower third of the arm above the median nerve proximal to patients – age range 20–50 years (Table 2) and evaluated the
the cubital fossa. Electrodes were positioned with the cath- H-reflex in 37 patients with C7 radiculopathy confirmed by
ode proximal to the anode and in line with the median nerve clinical examination, MRI, computed tomographic (CT)
between the BB and the BR muscles [1]. The position was scan, x-ray, and neurophysiologic studies.

Biceps brachii
(BB)
R
G
–
+
R
A
S
(elbow)
Digit I
Upper trunk
C6
C7
Lateral cord C8
Lower trunk
Middle trunk
Digit V Median
nerve Medial cord
Typical waveform (elbow - FCR muscle):

1.2 1.2
138 V 138 V
1.4 1.4
1 mV 131 V 2 mV 131 V
1.5 1.5
143 V 143 V
1.6 1.6
50 ms 2 mV 147 V 50 ms 5 mV 147 V
Sensitivity 2 mV-1 mV/div (left) – 5 mV-2 mV/div (right), sweep speed 5 ms/div
Fig. 1 H-reflex recorded at the forearm from the FCR muscle, stimulation of the elbow
References 153

Normal values [1] Mean ± SD Range limbs, reflex latencies were almost equal or within
H-reflex, latency (ms) 16.3 ± 1.7 13–19 1 ms difference. In most patients with C7 radiculopa-
Inter latency CMAP-H-reflex (ms) 12–13.5 thy [2], it was observed that the H-reflex was recorded
H-reflex, peak to peak amplitude (mV) 0.79 ± 0.1 0.3–2.5 at a threshold or suprathreshold level to the motor
response (CMAP); in this case a large CMAP could be
Table 2 Reference values recorded with a small H-reflex. Increasing the stimulus
Pathological values [2] Mean ± SD Range intensity would result in recording maximum CMAP
H-reflex, latency (ms) 19.9 ± 1.7 with blocking of the H-reflex, indicating that it was not
Inter latency CMAP-H-reflex (ms) 11.5–3.8 an F-wave. The decreased reflex amplitude in patients
H-reflex, peak to peak amplitude (mV) 0.09 ± 0.02 with radiculopathy masks the accurate measurement of
reflex latency, while the latency of CMAP showed no
measurable changes with radiculopathy, a finding that
further supported the central conduction block in the
Comment reflex arc in patients affected with radiculopathy.
Sabbahi and Khalil [1] H-reflex of the FCR is impor- Authors found correlation between the clinical symp-
tant for studying the integrity of C7 (FCR muscle is toms of a C7 root involvement and electrical signs; the
supplied by C6 and C7 spinal segments), but authors EMG showed denervation in the pronator teres (PT),
were able to record these reflexes from almost all of triceps, and extensor digitorum communis (EDC) mus-
the subjects with a normal weight only. In overweight cles, H-reflexes in most of these patients were pro-
subjects probably the subthreshold stimulation was longed or absent. Authors indicated a specificity of
insufficient to stimulate the appropriate nerve fascicle, 90 % (they elicited an H-reflex from nine of ten healthy
and the motor point of the FCR was possibly missed. It control subjects); sensitivity was not investigated.
was common to miss the FCR motor point unless the
appropriate wrist flexion maneuver was followed.
Medial or lateral electrode positioning allowed them to
record the electric activity of the flexor digitorum References
superficialis (FDS) and the brachioradialis muscles,
respectively; they also observed that displacement of 1. Sabbahi MA, Khalil M (1990) Segmental H-reflex studies in upper
the electrode distally will be positioned on the long and lower limbs of healthy subjects. Arch Phys Med Rehabil 71:
216–222
FCR tendon and the musculotendinous junction. When 2. Sabbahi MA, Khalil M (1990) Segmental H-reflex studies in upper
the FCR H-reflexes were recorded from both upper and lower limbs of patients with radiculopathy. Arch Phys Med
Rehabil 71:222–227
Wrist – Hand
M27
Study from Second Lumbrical (2L)
and Interosseous (INT) Muscles
Original Settings Sensitivity was 1–2 mV/division, sweep Measurements Distal latency (ms) of the CMAP, for both
speed was 2 ms/division, and the machines used were a 2L and INT muscles, was measured from the stimulus onset
Dantec Counterpoint and a Neuromatic 2000. Low-frequency to the onset of the negative deflection of the CMAP. Latency
filter, high-frequency filter, and duration of pulse were not difference (2L–INT DIFF) was measured between these two
specified. latencies. Amplitude (mV) of the CMAP was measured from
the baseline to the peak of the negative deflection. Palmar
Position This study was performed in the supine position. skin temperature was maintained above 31 °C. The authors
performed 2L–INT DIFF test in 51 control hands (Table 1)
Recording The active electrode (A) was placed slightly lat- from either healthy volunteers or patients (age range 18–50
eral to the midpoint of the third metacarpal space, over the years, average age 31 years) referred to the EMG laboratory
belly (motor point) of both the second lumbrical (2L) and with symptoms not referable to carpal tunnel syndrome
interossei (INT) muscles [1]. The reference (R) was placed (CTS) and 107 consecutive hands (Table 2) of patients (age
over a bony prominence of the proximal interphalangeal range 21–98 years, average age 49 years) referred with clini-
joint of the digit II (Fig. 1). The motor point to the 2L was cal symptoms and signs suggestive of CTS (patients were
identified by an initial negative deflection with the fastest divided into four groups based on the least-sensitive standard
rise time. Occasionally, the median mixed nerve potential median study needed to demonstrate CTS), female/male
was seen prior to the motor response. However, this potential ratio 3:1, right-hand/left-hand ratio, approximately 2:1. For
never obscured the initial negative deflection of the 2L com- the authors, the advantages of this technique include: (1)
pound muscle action potential (CMAP). Surface recording both 2L and INT muscles can be recorded from the same
was made with 10 mm silver disks. The ground (G) electrode active electrode in the distal palm, (2) the axons innervating
position was not mentioned in the text; it could be placed on both muscles are of similar diameter size, (3) the tempera-
the palm or on the dorsum of the hand. The figure shows the ture is comparable for each distal nerve segment and muscle,
ground positioned on the palm. (4) identical distances to each muscle are used, allowing
direct comparison of distal motor latencies, (5) 2L is rela-
Stimulation The stimulations were at the wrist, on the tively spared in CTS, even in severe CTS when the abductor
median nerve (S1) and on the ulnar nerve (S2), using an pollicis brevis (APB) muscle is completely wasted; a CMAP
identical distance for both stimulations from the active elec- can be reliably recorded from the 2L, (6) this technique cre-
trode (A) positioned on the palm (Fig. 1). No fixed distance ates an ideal internal control for the median motor studies in
was mentioned in the text (mean distance of the wrist to the which several variables are held constant (muscle and axon
active electrode was 9.5 cm, range 8–12 cm). size, temperature, and distance).

C8
T1
R1
Lower trunk
Median
nerve Medial cord
Ulnar
nerve S1
(wrist)
Digit II R
A
– + Median nerve
– +
G Ulnar nerve
Digit V
S2
R2 (wrist)
Interosseous (INT)
Typical waveform (wrist – 2L muscle, wrist – INT muscle):
Median - ulnar 2L-INT Median - ulnar 2L-INT

2
2
1 3 1 3 5
5 Median (2L) 1 Median (2L) 1
4
30 ms 2 mV 46 mA 30 ms 5 mV 46 mA
4
2
1 3 1 3
Ulnar (INT) 2 5 Ulnar (INT) 2
5 4
4 30 ms 2 mV 46 mA 30 ms 5 mV 46 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L and INT muscles; stimulation of the wrist: 2L recording (upper
trace) and INT recording (lower trace)
Table 1 Reference values Normal values [1] Mean ± SD Mean ± 2SD Range Limit of normal
Wrist–2L, distal latency (ms) 3.22 3.98 2.10–4.00
Wrist–INT, distal latency (ms) 3.15 3.91 2.00–4.00
2L–INT DIFF (ms) 0.08 0.40 (−0.30)–0.40 ≤0.4
Wrist–2L, amplitude (mV) 2.81 0.40 1.00–6.00
Wrist–INT, amplitude (mV) 6.55 1.67 2.60–13.60

Pathological values [1] Sensitivity Limit
N 2L-INT DIFF Normal values [4] Mean Range of normal
Severe CTS (58 hands) 58/107 (54 %) 57/58 (98 %) Wrist–2L, distal latency (ms) 3.30 ± 0.20 2.85–3.70 3.80
Moderate CTS (22 hands) 22/107 (21 %) 22/22 (100 %) Wrist–INT, distal latency (ms) 3.10 ± 0.20 2.25–3.50 3.80
Mild CTS (12 hands) 12/107 (11 %) 10/12 (83 %) 2L–INT latency DIFF (ms) 0.20 ± 0.20 0.00–0.60 0.60
Very mild CTS (15 hands) 15/107 (14 %) 13/15 (87 %)

Pathological values [4] Mean Range
Wrist–2L, distal latency (ms) 4.65 ± 1.17 2.95–9.65
Comment
Wrist–INT, distal latency (ms) 3.03 ± 0.35 2.20–4.15
For Preston and Logigian [1], the 2L–INT DIFF was
2L–INT latency difference (ms) 1.59 ± 1.21 0.10–5.80
abnormal in 98 % (57/58) of patients with severe CTS
(with prolonged or absent distal motor CMAP from the
APB muscle). In patients with moderate CTS (with nor- optimally placed over the motor point, the amplitudes and
mal distal motor latency of CMAP from the APB mus- rise-times of the 2L and INT were lower, and the lumbrical–
cle but prolonged latency or absent antidromic sensory interossei latency differences increased, and the commonly
to the digit II), the 2L–INT DIFF was abnormal in used cutoff values were not valid [3]. Al-Shekhlee et al. [3]
100 % (22/22) of patients. In mild CTS (with normal suggested as the optimal location for the active recording
distal motor latency of CMAP from the APB muscle electrode a site, which can be approximated by first marking
and normal latency of the antidromic sensory to the digit the midpoint of the third metacarpal (half the distance
II but prolonged median mixed-nerve palmar latency), between the distal wrist crease and the proximal skin crease
the 2L–INT DIFF was abnormal in 83 % (10/12) of of the third metacarpal–phalangeal joint) and then measuring
patients. When the only abnormal standard median 1 cm proximal and 1 cm lateral from that point.
study was the difference between the median and ulnar Foresti et al. [4], using the same distance (mean 11 cm)
mixed-nerve palmar latencies (very mild CTS), the 2L– from the active recording electrode, performed 2L–INT
INT DIFF was abnormal in 87 % (13/15) of all cases. In DIFF test in 50 hands (Table 3) from 25 healthy subjects
75 % (6/8) patients with possible CTS (normal standard (average age 42 years, age range 18–69 years, male/female
conduction studies), the 2L–INT DIFF was abnormal. ratio 2.5:1) and 100 consecutive patients (Table 4) with sus-
So, a prolonged lumbrical–interossei latency difference pected CTS (mean age 49 ± 11.9 years, age range 27–78
(2L–INT DIFF > 0.4 ms) was found to be a sensitive years, male/female ratio 3:1). They used a five-channel
indicator of CTS in all patient groups. Mystro-Plus electromyograph. The hand temperature was
monitored and, if it was less than 32 °C, the limb was
warmed. The distal motor latency (DML)–onset latency was
Muellbacher et al. [2] observed a considerable variability measured, and the DML difference between 2L onset latency
in the latency and amplitude of the CMAP in the same sub- and INT onset latency was calculated. The authors also stud-
ject by searching the optimal recording site in the distal palm ied 200 hands from 100 consecutive patients with suspected
(using identical distances from the active electrodes––8 cm, CTS (mean age 49 ± 11.9 years, age range 27–78 years, male/
10 cm, 12 cm), and if the active recording electrode was not female ratio 3:1).
hands of 105 patients with symptoms and signs of CTS (70

Comment women and 35 men, mean age 54 years, age range 23–90 years),
Foresti et al. [4], in a sample of 200 hands from 100 they found an abnormal 2L–INT DIFF test in 83 % of CTS
patients with suspected CTS, found 159 hands with a hands, while distal latency to the APB muscle was abnormal in
clinical suspicion of CTS, and 149 hands of these were 56 % only. They found a linear relation between the percentage
found to have electrophysiological signs of CTS (10 prolongation of the distal latency to the APB muscle and that to
hands were normal); 61 patients had bilateral CTS. For the 2L muscle, indicating that fibers to these muscles may be
median 2L DML, the authors found high values of sen- equally entrapped. The authors also found a correlation between
sibility (85.23 % and 80.10 %) and specificity (>99 %, the prolonged distal latency to the 2L muscle (72 % of all hands)
89.10 %), on the base of an electrophysiological Gold and the slowed orthodromic conduction velocity from the digit
Standard and using a clinical Gold Standard, indepen- II and digit III, supporting the relationship that half of the fibers
dent of the electrodiagnostic procedures, respectively. of the digit II and digit III run in a separate funiculi, close to
For the median-ulnar 2L–INT DIFF test, the authors those subserving the lumbricals [6]. The authors concluded,
found high values of sensibility (87.23 % and 87.01 %) according to their findings, that the determination of the differ-
and specificity (96.87 %, 92.50 %), on the base of an ence between latency to the second lumbrical and interossei
electrophysiological Gold Standard and using a clini- (2L-INT DIFF test) is useful when routine tests are normal,
cal Gold Standard, independent of the electrodiagnos- even in cases with the absence of the SNAPs or CMAPs.
tic procedures, respectively. In 1997, Vogt et al. [7] applied a 2L–INT DIFF test to healthy
controls and patients with CTS and polyneuropathy (PNP),
stimulating the median nerve, 2 cm proximal at the wrist, and
In a short report, Trojaborg et al. [5], studying 63 control moving laterally at exactly the same level to stimulate the ulnar
subjects (42 women, 21 men, mean age 42 years, age range nerve. Their protocol differs from the arrangement of Preston
22–82 years), found normal values (3.4 ms ± 0.1 ms and and Logigian [1], who stimulated both the nerves at equal dis-
3.2 ± 0.1 ms for 2L and INT, respectively) in agreement with tances (range 8–12 cm) from the recording electrode. They
those by Preston and Logigian [1] and Foresti et al. [4]. In 170 chose anatomical landmarks criteria (Fig. 2) because in this
C8
R1
T1
Lower trunk
Median
nerve Medial cord
Ulnar
nerve S1
(wrist)
Digit II R
A
– + Median nerve
2 cm
G – + Ulnar nerve
Digit V
S2
R2
(wrist)
Interosseous (INT)
Fig. 2 2L–INT test; conduction distance set by anatomical landmarks

Normal values [7] Mean Normal values [8] Mean ± SD Range Limit of normal
Wrist–2L, distal latency (ms) 3.8 ± 0.4 2L–INT latency DIFF (ms) 0.30 ± 0.09 0–0.5 ≤0.5
Wrist–INT, distal latency (ms) 3.3 ± 0.4
2L–INT latency DIFF (ms) 0.45 ± 0.25 Table 8 Reference values
Pathological values [8] Mean ± SD Range Limit of normal
Table 6 Reference values 2L–INT latency DIFF 0.28 ± 0.12 0–0.7 ≤0.5
Pathological values [7]––Group 1 Mean (ms)––non-CTS patients
2L–INT latency DIFF 1.47 ± 0.82 0.5–6.2 ≤0.5
(ms)––CTS patients
2L–INT latency DIFF (ms) 2.7 ± 1.4
Pathological values [7]––Group 2 Mean
To record the 2L–INT distal motor latency, Loscher et al.
[8], using the method proposed by Vogt et al. [7], stimulated
both median and ulnar nerves on points (S1, S2) 2 cm proxi-
mal to the intermediate flexure line at the wrist (anatomical
Pathological values [7]––Group 3 Mean
landmarks criteria). The authors preferred this stimulation
protocol to avoid measurement errors, and because a con-
stant relationship between the length of the nerve segments
was still maintained. CMAPs recordings were made, placing
the active electrode on the same motor point for both 2L and
way, there was a constant relationship between the lengths of INT muscles (on the palmar aspect of the second intermeta-
both nerve segments, independent of measurement errors. carpal space); reference electrode was placed on the palmar
All patients (Tables 5 and 6) were divided by Vogt et al. aspect of the proximal phalanx of the digit II. They recorded
[7] into four groups: Group 1––87 hands of 77 healthy vol- 2L–INT DIFF in 100 asymptomatic hands (Table 7) of 87
unteers, age range 25–72 years, mean age 43 years; Group healthy subjects (age range 15–86 years, mean age 47 years),
2––107 hands of 92 patients with clinical symptoms of CTS, and in a large sample (Table 8) of non-CTS patients (450
age range 29–68 years, mean age 49 years; Group 3––34 consecutive hands from 417 patients classified as 276 CTS
hands of 30 patients with PNP, age range 5–73 hands, mean and 174 non-CTS, based on clinical criteria, age range 16–92
age 52 years; Group 4––27 hands of 22 patients with PNP years, mean age 50 years) and CTS patients (276 patients).
and coexisting clinical symptoms of CTS, age range 39–72
years, mean age 58 years.
Comment
Using the 2L–INT DIFF, Loscher et al. confirmed the
Comment clinical diagnosis of CTS in 269 of 276 hands, result-
In the study by Vogt et al. [7], patients with CTS (Group ing in a sensitivity of 97.5 %. For the authors, 2L–INT
1) and PNP + CTS (Group 3) showed a markedly DIFF test was a reliable and easy-to-perform conduc-
increased 2L–INT DIFF as compared to the controls. In tion test. It was a highly sensitive method for assessing
the PNP + CTS group (Group 3), the 2L–INT DIFF was the median nerve function across the carpal tunnel,
normal in only one patient and greater than 1.5 ms in 19 similar to the combination of the standard motor and
patients (73 %). In the PNP group (Group 2), the 2L– sensory nerve conduction studies.
INT DIFF was slightly increased in 6 of 34 patients
having a 2L–INT DIFF greater than 1.0 ms (mean
1.1 ms). The 2L–INT DIFF test was significantly pro- Like Löscher et al. [8], other authors measured 2L–INT
longed in both CTS patients (Group 1) as compared to latency difference in controls and its sensitivity in patients
controls and patients with only PNP (Group 2). Setting with a clinical diagnosis of CTS, using the protocol of
the upper normal limit to 1.0 ms, the 2L–INT DIFF test Preston and Logigian [1]. Chang et al. [9] used a fixed 10 cm
was abnormal in 26 of 27 patients and was abnormal in distance (Fig. 3) from the active electrode for both sites of
only 6 of 34 patients with PNP. The specificity of the stimulation (S1––median nerve, S2––ulnar nerve); Meena
2L–INT DIFF test was 78 %. For the authors, the 2L– et al. [10] used instead a fixed 8 cm distance from the 2L–
INT DIFF test represented the best technique in the INT motor point (Fig. 4). During a 1-year period, Chang
diagnosis of CTS in patients with an underlying chronic et al. [9] performed several sensory and motor conduction
demyelinating PNP. techniques to compare the sensitivities in the diagnosis of
CTS. They used a Nicolet Viking IV or Dantec Keypoint 4
C8
T1
R1
Lower trunk
Median
Medial cord
nerve
Ulnar
nerve
S1
(wrist)
Digit II R
A
10 cm – + Median nerve
– + Ulnar nerve
G
Digit V
S2
R2
(wrist)
Interosseous (INT)
Fig. 3 2L–INT test; fixed conduction distance––10 cm
Table 9 Reference values had prolonged 2L–INT (>0.58 ms). The sensitivity of 2L–
Normal values [9] Mean ± SD Limit of normal (±2.5SD) INT was 77.5 % (124 hands).
2L–INT latency DIFF (ms) 0.15 ± 0.17 <0.58 In a prospective study, Meena et al. [10] measured 2L–
INT latency difference in controls (120 hands of 60 healthy
electromyograph, and skin temperature at the hand was subjects, age range 20–75 years, mean age 47.55 years) and
maintained at or above 32 °C. The 2L and INT CMAP its sensitivity in patients with a clinical diagnosis of CTS (250
latency difference was calculated in 100 control (Table 9) hands of 130 consecutive patients, age range 21–76 years,
subjects (64 women 36 men, age range 22–65 years, mean mean age 48.62 years), using the Preston and Logigian [1]
age 47.4 years), and the sensitivity to detect CTS was mea- protocol (Tables 10 and 11). Patients were divided into three
sured in 160 symptomatic hands from 116 patients with CTS groups, based on the least-sensitive standard median study
(86 women and 30 men, mean age 48.5 ± 6.3 years). One needed to demonstrate CTS. Nerve conduction studies were
hundred forty-nine hands were found to have had at least one performed using a Dantec Keypoint EMG machine, and limb
abnormal electrophysiological study; 11 hands (6.88 %) temperature was maintained above 31 °C. They used a fixed
were found to have normal electrophysiological results; 36 8 cm distance (Fig. 4) from the active electrode for both sites
hands (22.5 %) had normal 2L–INT, and 124 hands (77.5 %) of stimulation (S1––median nerve, S2––ulnar nerve).
C8
T1 R1
Lower trunk
Median
nerve Medial cord
Ulnar
nerve S1
(wrist)
Digit II R
A
8 cm – + Median nerve
– + Ulnar nerve
G
Digit V
S2
R2 (wrist)
Interosseous (INT)
Fig. 4 2L–INT test; fixed conduction distance––8 cm
Table 10 Reference values Patients group 2L-INT DIFF

Limit of Severe CTS (73 hands) 71/73 (97.26 %)
Normal values [10] Mean ± SD normal (+2SD) Moderate CTS (65 hands) 65/65 (100 %)
Wrist–2L, distal latency (ms) 3.25 ± 0.38 Mild CTS (111 hands) 78/111 (70.27 %)
2L–INT latency DIFF (ms) 0.12 ± 0.19 ≤0.5 Similar to all motor nerve conduction studies, the proper
2L muscle, negative peak amplitude (mV) 1.38 ± 0.67
location for the active electrode is over the motor point
INT muscle, negative peak amplitude (mV) 4.62 ± 1.53
(slightly lateral to the midpoint of the third metacarpal with
the reference electrode placed over a bony prominence of the
Table 11 Reference values proximal interphalangeal joint of the digit II). However, in
Pathological values [10] Mean ± SD Limit of normal (+2SD) the lumbrical–interossei comparison study, the 2L and
Wrist–2L, distal latency (ms) 5.44 ± 1.93 underlying INT muscles cannot be seen or palpated. The sec-
Wrist–INT, distal latency (ms) 3.03 ± 0.57 ond lumbrical (2L) muscle originates from the radial border
2L–INT latency DIFF (ms) 2.44 ± 1.81 ≤0.5 of the tendon of the flexor digitorum profundus (FDP) mus-
Wrist–2L, distal amplitude (mV) 0.88 ± 0.56 cle (to the digit III) and inserts at the proximal phalanx of the
Wrist–2L, distal amplitude (mV) 4.33 ± 1.47 digit III. The first palmar interosseous (INT) muscle originates
from the medial surface of the second metacarpal bone and

inserts on the proximal phalanx of the digit II (index finger). accurate, highly sensitive, and a specific test in the
Under the first palmar interosseous (INT) muscle is the sec- diagnosis of CTS, especially in moderate and severe
ond dorsal interosseous muscle, which is likely corecorded CTS (frequently associated with polyneuropathy),
as well during the 2L–INT latency difference study. It origi- when other standard methods fail. In agreement with
nates from the proximal lateral border of the third metacarpal Preston and Logigian [1], many authors employed the
bone and inserts on the radial base of the proximal phalanx technique in CTS; Kaul and Pagel [11] compared the
of the digit III (middle finger). sensitivity of the 2L–INT DIFF with MED-ULN
PALM DIFF, and they found equal sensitivity across a
broad range of CTS severity. They obtained 2L–INT
DIFF from 158 hands (100 %) of 158 patients with
Comment CTS (age range 18–85 years, mean age 53.4 years,
Meena et al. [10] reported test results on a total of 250 90.5 % males, 95 % white, 90 % right hand, 62 %
hands. The overall sensitivity of 2L–INT DIFF was bilateral symptoms), and they validated the technique
85.60 % (214/250), and the specificity was 96.67 %. in mild CTS in cases in which routine median and sen-
The authors, reporting results on 249/250 hands, mea- sory nerve conduction studies were normal.
sured sensitivity of the 2L–INT DIFF test in patients
with CTS divided in three groups (classified into dif-
ferent grades of severity of CTS): mild CTS (no neuro-
physiological abnormality or an abnormal difference Foley and Buschbacher [12], for the 2L CMAP recording,
between the median and ulnar mixed-nerve palmar placed the active recording electrode on the palm––slightly
latencies), moderate CTS (normal or prolonged distal radial to the midpoint of the third metacarpal, and the refer-
motor latency of CMAP from the APB muscle, and ence electrode at the base of the digit III––slightly distal to
preserved or slow SNAP), severe (very prolonged dis- the third metacarpophalangeal joint. The ground was placed
tal motor latency with low amplitude and absent on the dorsum of the hand (the figure shows the ground elec-
SNAP). The 2L–INT DIFF was abnormal in 97.26 % trode placed on the palm, between the stimulating and
(71/73) hands with severe CTS, and the excitability of recording sites). Stimulation was at the wrist, 10 cm proxi-
the second lumbrical muscle (2L) was preserved mal to the active electrode placed on the palm, in a line mea-
approximately in all hands with severe CTS, till the sured from the first to the midpoint of the distal wrist crease
most severe stages. In the moderate CTS group, 2L– and then to a point slightly ulnar to the tendon of the flexor
INT DIFF test was abnormal in 100 % (65/65) hands, carpi radialis (FCR) muscle. The anode was proximal. They
while in the mild CTS it was abnormal in 70.27 % studied 196 healthy subjects (Table 12); skin temperature
(78/11) hands. For the authors, 2L–INT DIFF was an over the dorsum of the hand was controlled and maintained
at or above 32 °C) (Fig. 5).
C8
T1
Lower trunk S
Median
nerve
(wrist)
Medial cord
Digit III
A 10 cm
R – + Median nerve
Digit V
R
Fig. 5 2L CMAP recording; fixed conduction distance––10 cm
Table 12 Reference values Normal values [12] Mean ± SD Range Limit of normal
Wrist–2L, distal latency (ms) 3.7 ± 0.4 2.7–5.1 4.5
Wrist–2L, amplitude (mV) 3.0 ± 2.0 0.7–11.7 1.0
Wrist–2L, area of negative phase (μVs) 9.4 ± 5.4 1.6–33.7 3.3
Wrist–2L, duration of negative phase (ms) 5.7 ± 1.1 3.3–10.4 8.4
Comment had the same latencies and could thus be compared to

Foley and Buschbacher [12] used 2–3 Hz for a low-fre- detect the slowing of one nerve or the other. They found
quency filter and 10 kHz for a high-frequency filter. The that the upper limit of normal difference between the
upper limit of normal for onset latency was 4.5 ms; the first lumbrical (1L) muscle and the second lumbrical
upper limit of a normal increase side-to-side was 0.8 ms; (2L) muscle in the same hand was 0.7 ms in cases where
the upper limit of a normal decrease in amplitude side- 2L had the longer latency; it was 0.6 ms in cases where
to-side was 67 %. The authors also compared the latency 1L was longer. The upper limit of normal difference
of a 2L muscle with the other muscles of the hand, between the 2L muscle and the APB muscle latency in
innervated by the median nerve (1L and APB muscles) the same hand was 1.0 ms in cases where the APB had
and the ulnar nerve (INT muscle). As the 2L and INT the longer latency; it was 0.8 ms in cases where the 2L
muscles lie superimposed in this location, the concomi- muscle latency was longer. The upper limit of normal
tant median and ulnar nerve stimulation must be difference between the 2L muscle and INT muscle
avoided. Stimulating the median nerve activates the 2L latency in the same hand was 0.2 ms in cases where the
muscle, whereas stimulating the ulnar nerve activates INT had the longer latency; it was 1.2 ms in cases where
the INT muscle, but for the authors, both the nerve studied 2L was longer.

Normal values [13] Mean ± SD Cut off Pathological values [13] Mean ± SD
2L–INT latency DIFF (ms) 0.1 ± 0.3 ≤0.5 2L–INT DIFF (ms)––CTS Group 1.2 ± 0.7
2L–INT DIFF (ms)––DMPNP CTS- Group 0.2 ± 0.3
2L–INT DIFF (ms)––DMPNP CTS+ Group 0.9 ± 0.6
Using the lumbrical–interossei recording technique in 12
control hands, in 1994, Muellbacher et al. [2] observed a con-
siderable variability in latency and amplitude of the CMAP in hands and 1 left hand, BMI 29.0 ± 3.3, mean age
the same subject by searching the optimal recording site in the 53.9 ± 3.5 years)––CTS Group on a group of diabetic patients
distal palm (using identical distances from the active elec- with polyneuropathy, without associated CTS (61 hands from
trodes––8 cm, 10 cm, 12 cm), and if the active recording elec- 32 patients, 19 women and 13 men, 30 right hands and 2 left
trode was not optimally placed over the motor point, the hands, BMI 29.1 ± 5.4, mean age 55.6 ± 9.5 years)––DMPNP
amplitudes and rise-times of the 2L and INT were lower, and CTS - Group and on a group of diabetic patients with polyneu-
the lumbrical–interossei latency differences increased, and the ropathy, with associated CTS (62 hands from 35 patients, 26
commonly used cutoff values were not valid [3]. These authors women and 9 men, 26 right hands and 9 left hands, BMI
suggested as the optimal location for the active recording elec- 31.4 ± 7.1, mean age 55.5 ± 7.3 years)––DMPNP CTS + Group.
trode a site, which can be approximated by first marking the The sensitivities and specificities of the tests were compared in
midpoint of the third metacarpal (half the distance between the the diagnosis of CTS in patients with diabetic polyneuropathy.
distal wrist crease and the proximal skin crease of the third The median–second lumbrical and ulnar–interosseous latency
metacarpal–phalangeal joint) and then measuring 1 cm proxi- difference (2L–INT DIFF) was higher in CTS Group than in
mal and 1 cm lateral from that point. DMPNP CTS+ Group (polyneuropathy with CTS), and in
Using a 2L–INT DIFF test set by anatomical landmarks DMPNP CTS- Group (polyneuropathy without CTS) than con-
(stimulation at 3 cm fixed distance, proximal to the proximal trols. These differences were significant between DMPNP
wrist crease), Gazioglu et al. [13] recently investigated sensitiv- CTS+ Group and DMPNP CTS- Group and between CTS
ity and specificity of some tests in the diagnosis of CTS in Group and DMPNP CTS+ Group. The authors found, using a
patients with diabetic polyneuropathy. They performed stan- 0.5 ms cutoff, a sensitivity of 75 % and a specificity of 82 %.
dard nerve conduction studies, segmental and comparative Following stimulation at 2 cm fixed distance, proximal to
median nerve conduction tests in 86 hands (Table 13) from 43 the proximal wrist crease [7, 8], more recently, Ozben et al.
healthy individuals (32 women and 11 men, 42 right hands and [14] investigated the contribution of this method in addition
1 left hand, BMI 27.5 ± 3.4, mean age 53.7 ± 5.5 years). They to the routine examinations in the diagnosis and staging of
used a Nihon Kohden 9100 electromyograph at a room tem- carpal tunnel syndrome (CTS). Normal values (Table 15)
perature of 25 °C, and a palmar temperature was maintained at were obtained from 81 subjects (50 healthy volunteers and
approximately 32 °C. A greater diagnostic accuracy can be 31 patients without CTS, age range 20–66 years, mean age
observed in tests with a higher sensitivity and specificity. 43.1 ± 10.2 years). A total of 92 control hands were studied
Following the median–second lumbrical and ulnar–interosse- (73 hands of women––79.34 %, 19 hands of men––20.66 %),
ous CMAP latency comparison [1], latency difference was cal- with a mean 2L motor distal latency (2L-MDL) found to be
culated by subtracting the interosseous distal latency from the 2.99 ± 0.31 ms, while 2L–INT DIFF was 0.26 ± 0.24 ms. The
second lumbrical distal latency, using a distance range from 8 authors also studied 283 CTS hands from 161 patients with
to 10 cm (Fig. 6). They found normal 2L–INT DIFF values CTS (Table 16) electrophysiologically diagnosed (242 hands
(0.1 ± 0.3 ms) consistent with the previous values reported [1]. of women––85.51 %, 41 hands of men––14.49 %, age range
The authors also compared the sensitivity and specificity of 23–73 years, mean age 47.3 ± 9.3 years), divided into six
some different tests in the diagnosis of CTS in diabetic poly- groups: CTS grade 1 (159 hands), CTS grade 2 (46 hands),
neuropathy patients on a group of patients (Table 14) with CTS CTS grade 3 (57 hands), CTS grade 4 (5 hands), CTS grade
(140 hands from 72 patients, 59 women and 13 men, 71 right 5 (14 hands), CTS grade 6 (2 hands).
C8
T1
R1
Lower trunk Second lumbrical (2L)
Median
nerve Medial cord
Ulnar
nerve S1
(wrist)
Digit II R
A
– + Median nerve
3 cm
G – + Ulnar nerve
Digit V
R2 S2
Interosseous (INT) (wrist)
Fig. 6 2L–INT test; conduction distance set by anatomical landmarks

Wrist–2L, distal latency (ms) 2.99 ± 0.31 2.30–3.65 ≤3.15
2L–INT DIFF (ms) 0.26 ± 0.24 0.00–1.65 ≤0.5

Pathological values [14] Mean ± SD Range CTS. When they took the cutoff value for 2L–MDL as
Wrist–2L, distal latency (ms) 4.18 ± 1.29 2.55–13.85 ≥3.15 ms in the diagnosis of CTS, sensitivity was
2L–INT DIFF (ms) 1.46 ± 1.21 0.00–10.30 87.3 %, specificity was 70.7 %, positive predictive
value was 90.1 %, and negative predictive value was
Pathological values [14]––CTS grade 1 Mean ± SD Range
64.4 %. As a result of these findings, they suggested in
2L–INT DIFF (ms) 0.87 ± 0.49 0.00–3.55
a routine CTS diagnosis to use not only the 2L–INT
DIFF test, but also the 2L–MDL value.
2L–INT DIFF (ms) 1.60 ± 0.68 0.70–4.05
Other authors have tested sensitivity of the 2L–INT DIFF
2L–INT DIFF (ms) 2.03 ± 0.80 0.90–4.65 test, comparing different techniques; Uncini et al. [16] com-
pared the 2L–INT test with a sensory orthodromic digit IV
(comparative median–ulnar nerves) and a sensory orthodromic
2L–INT DIFF (ms) 2.92 ± 1.59 2.00–5.75 palm (comparative median-ulnar nerves) and found a very
low sensitivity (10 %) to assess CTS in 193 hands from 113
consecutive patients (78 % women) with clinical signs of
2L–INT DIFF (ms) 4.18 ± 1.79 2.00–7.05 CTS. Preston et al. [17] compared the median–ulnar latency
difference studies to test their sensitivity in 34 patients with
Wrist–2L, distal latency (ms) 13.85 (one hand)
mild CTS (25 right hands, 9 left hands, mean age 44 years,
2L–INT DIFF (ms) 10.30 (one hand) age range 24–68 years). For the palmar mixed median–ulnar
peak latency difference, the normal value was <0.4 ms. For
the antidromic digit IV median–ulnar onset latency differ-
ence, the normal value was <0.5 ms. For the 2L–INT DIFF
test, the normal value was <0.5 ms. The palmar-mixed, digit
Comment IV, and 2L–INT DIFF studies were abnormal in 33 (97 %), 31
Ozben et al. [14] studied a total of 375 hands (201 (91 %), and 30 (88 %) patients, respectively. Two or more
right, 174 left) from 242 patients (201 women and 41 tests were abnormal in 33 (97 %), while all three tests were
men, age range 20–73 years, mean age 45.8 ± 9.8 years), abnormal in 27/34 (79 %). In the mild CTS patients, the
referred to the laboratory with a clinically diagnosed authors found that the palmar-mixed was the most sensitive
CTS. Electrophysiological CTS were diagnosed in 283 study followed closely by the antidromic digit IV and 2L–
hands of 161 patients. They found bilateral CTS in 122 INT study, and their results showed a good correlation
patients and unilateral CTS in 20 patients. According between all three tests in the mild CTS patients. The high
to the Bland’s CTS classification scale [15], 283 CTS sensitivity found for a 2L–INT DIFF test (88 %) was mark-
hands were graded between 0 and 6: 159 hands––grade edly in contrast with the very low sensitivity (10 %) found by
1 (very mild CTS), 46 hands––grade 2 (mild CTS), 57 Uncini et al. [16]. Preston et al. [17] explained the disparity
hands––grade 3 (moderately severe CTS), 5 hands–– between these studies with different patient samples (patients
grade 4 (severe CTS), 14 hands––grade 5 (very severe had clinical CTS, and also nerve conduction studies demon-
CTS), 2 hands––grade 6 (extremely severe CTS). In strated a median neuropathy at the wrist, in contrast to
patients with grade 1 CTS, the mean 2L motor distal Uncini’s study), and they used 0.3 and 0.4 ms as an upper
latency (2L–MDL) was found to be 3.54 ± 0.51 ms, limit of normal for the palmar-mixed and for 2L–INT DIFF
while the mean 2L–INT DIFF was 0.87 ± 0.49 ms; the studies, respectively (while Uncini et al. used 0.4 and 0.5 ms,
sensitivity of the test was 81.8 %, specificity was respectively). A 0.1 ms difference likely decreased the sensi-
84.8 %, positive predictive value was 90.1 %, and neg- tivity of the study, especially in the mild CTS patients.
ative predictive value was 72.9 %. In their study, Ozben In 1995, Sheean et al. [18], in 66 hands from 66 patients
et al. [14] found abnormal 2L–INT DIFF (≥0.5 ms) in (50 females, 16 males)––49 hands (74 %) with CTS con-
14 hands, which were found to be normal with the rou- firmed electrophysiologically––found abnormal 2L–INT
tine CTS tests (false-positivity), and 29 hands with the DIFF test in 48/49 cases. Their findings were in close agree-
CTS diagnosed by routine CTS tests were in normal ment with those of Preston and Logigian [1], but a marked
limits (<0.5 ms, false-negativity). The authors also variance with that of Uncini et al. [16], possibly reflecting
found a significant association between 2L–MDL and the similarity of their technique and criteria for patient selec-
tion and of 2L–INT DIFF abnormality to the former. As in
Table 17 Reference values Pathological values [21]––all CTS hands Mean ± SD Rate of abnormality (%)
2L–INT DIFF (ms) 3.13 ± 1.99 85
Pathological values [21]––Mild CTS Mean ± SD Rate of abnormality (%)
2L–INT DIFF (ms) 2.68 ± 1.29 81
Pathological values [21]––moderate CTS Mean ± SD Rate of abnormality (%)
2L–INT DIFF (ms) 2.77 ± 1.38 84
Pathological values [21]––severe CTS Mean ± SD Rate of abnormality (%)
2L–INT DIFF (ms) 4.09 ± 3.87 92
their study, Preston and Logigian [1] examined patients sus- (average age 55.0 ± 8.9 years), and 17 hands were of severe
pected of having CTS, which was subsequently confirmed degree (average age 59.3 ± 9.1 years). 2L–INT DIFF was
electrophysiologically, whereas the study by Uncini et al. 2.68 ± 1.29 ms in the mild CTS group and 2.55 ± 1.38 ms in
[16] reported only patients with a clinical diagnosis of CTS; the moderate CTS group. In the severe CTS group, the
despite this and other few little technical and methodological latency difference was 4.09 ± 3.87 ms with statistical signifi-
differences, for Sheean et al. [18], the reasons for this dis- cance compared to the other groups. The authors found the
crepancy were still not entirely clear. Like Preston and frequency of latency differences longer than 0.4 ms in 81 %,
Logigian [1], Sheean et al. [18] encountered cases where the 84 %, and 92 % in the mild CTS group, moderate CTS group,
median sensory potentials and sometimes the CMAP from and severe CTS group, respectively. Like Sheean et al. [18],
APB were absent, but a response could still be obtained from they also observed that the latency prolongation with APB
the second lumbrical; in all such cases, an abnormal 2L–INT muscle recording was significantly lower in frequency than
DIFF was found, usually quite marked, allowing localization 2L–INT DIFF test in the mild degree of CTS group. For Lee
of the lesion at the wrist. Boonyapisit et al. [19] found a pro- et al. [21], demyelination is the main pathology of the dis-
longed 2L latency (mean 9.2 ms, range 3.9–16.7 ms) and ease, which occurs in the early process of CTS; so, when the
2L–INT DIFF (mean 6.0 ms, range 0.5–13.5 ms) in 26 damage is minimal, the latency of the CMAP from the sec-
(92.8 %) of 28 hands from 23 patients with severe CTS (9 ond lumbrical (2L) muscle may appear within normal range.
men, 14 women, 5 bilateral CTS, age range 39–89 years), In the early stage of CTS, the prolonged median nerve
with absent sensory responses recording from the second latency, compared to the latency obtained from the interossei
and third digits, and absent motor responses recording from muscle (innervated by the ulnar nerve, which does not pass
the APB muscle. In 2007, Brannegan and Bartt [20] recorded through the carpal tunnel), makes 2L–INT DIFF test more
a CMAP from 2L muscle in 17 of 22 hands (77 %), in which sensitive than the latency from the abductor pollicis brevis
the CMAP from APB muscle was absent. (APB) muscle. As the disease progresses, the pathophysiol-
Recently, in a prospective study, Lee et al. [21] performed ogy of CTS changes, and due to its anatomically favorable
2L–INT DIFF test on 30 hands of normal subjects (22 position, the branch to the 2L muscle is less affected by the
women and 8 men, average age 53.3 ± 12.2 years), and on 67 conduction block or axonal injury, and is relatively preserved
hands of 41 patients (Table 17) with electroclinically diag- in the nerve conduction study. In conclusion, the authors
nosed CTS (53 hands from 32 women, 14 hands from 9 men, found that the 2L–INT DIFF test is a useful tool for increas-
average age 56.2 ± 11.2 years). A Dantec Counterpoint Mk2 ing sensitivity in CTS diagnosis, and consistent with the pre-
was used for the electrodiagnostic study. Among the 67 vious studies, as the disease progresses, 2L muscle is
hands with diagnosed CTS, 23 hands were of mild degree relatively preserved in severe degree of CTS. All these stud-
(average age 55.7 ± 9.8 years), 27 hands were moderate ies confirmed the utility of 2L–INT DIFF test to localize the
lesion at the wrist in patients with severe CTS, even with this), which may protect them somewhat from the effects of
routine absent distal median motor responses. compression [23], thus preserving them in severe cases, but
Sharma and Wilder Smith [22], employing the routinely they cannot explain the early affliction in mild cases. They had
electrodiagnostic tests, found CTS in only 66 hands (41.8 %) frequently used the 2L–INT DIFF test as a quick screening
from 158 symptomatic hands of 80 patients with end-stage assessment of the asymptomatic side, proceeding to further
renal failure on hemodialysis (age range 17–87 years, mean tests when the results were abnormal. For Brannegan and Bartt
age 57.1 years, 45 men and 35 women, 53 race Chinese, 22 [20], although the second lumbrical fibers are relatively pro-
race Malay, 5 race Indian, 64 with hypertension, 57 with dia- tected from the Wallerian degeneration in severe CTS, they
betes mellitus), but applying the 2L–INT DIFF resulted in a still show the conduction-slowing characteristic of chronic
significant increase in the incidence of median neuropathy demyelination and remyelination. In all cases they studied (22
by diagnosing an additional 59 cases and raising the total hands from 19 patients with CMAP, from the APB muscle
percentage of patients with median neuropathy to 79.1 %. absent), they found a prolonged distal latency to the 2L muscle
Their data suggested that the 2L–INT DIFF method was a (mean latency 9.1 ms). The reason why 2L fibers are affected
highly sensitive neurophysiological parameter in diagnosing early in mild CTS to produce demyelinative changes and
median neuropathy of all grades as well in the presence of a slowed conduction, and yet are resistant to an axon injury in
peripheral polyneuropathy. more advanced compression, is not completely clear.
Sheean et al. [18] found also interesting that a test in which For Sheean et al. [18], it has an advantage over screening
responses are preserved (but abnormal) in very advanced with the median–ulnar palmar comparison in that only one
cases, when other responses are unrecordable, should also be recording site is used and no special skin preparation is gen-
sensitive to mild lesions. For the authors, this seemed to sug- erally needed. It is also reportedly useful where there is a
gest that the motor fibers to the second lumbrical (2L) muscle co-existing peripheral neuropathy [1], although they did not
are more sensitive than those to the abductor pollicis brevis encounter any such cases. Another potential use of the 2L–
(APB) muscle to the effects of compression, which produces INT DIFF test is in the diagnosis of lesions of the deep pal-
conduction slowing, but that once affected are more resistant mar branch of the ulnar nerve, where the expected 2L–INT
to the total conduction block or axonal degeneration. This latency difference would be in the opposite direction (delayed
observation seemed to apply to the median sensory fibers as interosseous latency). In this case, the study can be used like
well. Anatomical factors alone are unlikely to produce this a useful adjunct in demonstrating ulnar neuropathy at the
combination of results. The fibers to the lumbrical muscles lie wrist, when the distal latency to the INT is prolonged, com-
within the center of the median nerve in the carpal tunnel (the pared to 2L [24, 25]. Some 2L-INT DIFF tests in several
fibers to the APB muscle are superficially located anterior to pathological cases are here reported (Figs. 7, 8 and 9)
Pathological waveform (wrist – 2L muscle, wrist – INT muscle):
2 Median - (2L-INT) Median - (2L-INT)
1 3 1 3
Median (2L) 1 5 Median (2L) 1
5
4 30 ms 2 mV 100 mA
2 30 ms 1 mV 100 mA
4
1 3 1 3
5 30 ms 1 mV 100 mA 4 30 ms 2 mV 100 mA
4
Onset latency (median 2L): 4.50 ms; Onset latency (ulnar INT): 3.50 ms; Onset latency difference (median 2L) – (ulnar INT): 1.0 ms;
Peak latency (median 2L): 7.40 ms; Peak latency (ulnar INT): 6.55 ms; Onset to peak amplitude (median 2L): 2.0 mV; Onset to peak
amplitude (ulnar INT): 4.1 mV; Peak to peak amplitude (median 2L): 3.3 mV; Peak to peak amplitude (ulnar INT): 5.2 mV
Fig. 7 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L and INT muscles in moderately severe CTS––grade 3 by
Bland’s CTS classification scale [15]–– onset latency delay 1.0 ms; stimulation of the wrist: 2L recording (upper trace) and INT recording (lower
trace)
Median - ulnar (2L-INT) Median - ulnar (2L-INT)
2
2
1 3 5 1 3 4 5
30 ms 1 mV 96 mA 30 ms 2 mV 96 mA
2
1 3 1 3
5
30 ms 1 mV 26 mA 4 30 ms 2 mV 26 mA
4
Onset latency (median 2L): 7.80 ms; Onset latency (ulnar INT): 3.50 ms; Onset latency difference (median 2L)- (ulnar INT): 4.30 ms;
Fig. 8 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L and INT muscles in extremely severe CTS––grade 6 by
Bland’s CTS classification scale [15]––onset latency delay 4.30 ms; stimulation of the wrist: 2L recording (upper trace) and INT recording (lower
trace)
Median - ulnar (2L-INT) Median - ulnar (2L-INT)
2
2
1 1 3
30 ms 1 mV 62 mA 30 ms 2 mV 62 mA
2
2
1 3 1 3
4 5
5 Ulnar (INT) 2
4 30 ms 1 mV 62 mA
Ulnar (INT) 2
30 ms 2 mV 62 mA
Onset latency (median 2L): 11.25 ms; Onset latency (ulnar INT): 6.50 ms; Onset latency difference (median 2L)- (ulnar INT): 4.75 ms;
Fig. 9 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L and INT muscles in extremely severe CTS––grade 6 by
Bland’s CTS classification scale [15] and Guillain–Barré syndrome (2 weeks of onset of symptoms)––onset latency delay 4.75 ms; stimulation of
the wrist: 2L recording (upper trace) and INT recording (lower trace)
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M28
Original Settings Sensitivity was 2–5 mV/division, low- due to a shock artifact, the anode was repositioned to obtain
frequency filter was 10 Hz, high-frequency filter was 10 kHz, a suitable baseline. The anode was proximal. The palmar
sweep speed was 3 ms/division, duration of pulse was 0.2 ms, motor study was performed with minimal technical prob-
and the machine used was a Dantec Counterpoint. lems. In the study, the authors also performed a sensory con-
duction study to the digit II, stimulating the median nerve at
Position This study was performed in the supine position. the wrist and on the palm.
Recording Following the usual belly-tendon montage, the Measurements Amplitude (mV) was determined from the
active electrode (A) was placed over the belly of the abduc- baseline to the negative peak. The authors calculated the
tor pollicis brevis (APB) muscle (Fig. 1), halfway between mean palm/wrist compound muscle action potential (CMAP)
the midpoint of the distal wrist crease and the midpoint of the amplitude ratio. Identical sensitivities (500 μV/division)
first metacarpophalangeal joint [1]. The reference (R) was were used for measuring latencies distal and proximal to the
placed slightly distal to the first metacarpophalangeal joint carpal tunnel. Hands were maintained at 32–35 °C during
(over the tendon of the APB muscle). The ground (G) elec- testing, utilizing a thermistor-controlled Dantec infrared
trode was placed on the dorsum of the hand (the author used heater, with the sensor placed in the midpalm. Normal values
3 cm disk electrode). The figure shows the ground electrode were obtained from 30 control hands (Table 1) of 20 healthy
positioned on the palm. adult volunteers (12 men and 8 women, age range 22–50
years, average age 36 years), and 59 consecutive hands from
Stimulation The median nerve was stimulated using sur- 45 patients (Table 2) with CTS (33 women and 12 men, age
face electrodes at two points along its course: at the wrist range 27–79 years, average age 52 years) were also studied.
(S1) and on the palm (S2). At the wrist (S1), shocks were In the 30 control hands, authors observed similar palmar and
applied proximal to the distal wrist crease, at a distance of wrist CMAP amplitudes (palm/wrist CMAP ratio 1.0 ± 0.1
7 cm from the proximal active electrode (A). The anode was SD) and a greater sensory nerve action potential (SNAP)
proximal [1]. The terminal portion of the median nerve was amplitude at the wrist (palm/wrist SNAP ratio 1.2 ± 0.2 SD).
stimulated on the palm (S2), at a distance of 7 cm from the The highest palm/wrist ratios were the ratios associated with
wrist stimulation site (S1), along a line connecting the wrist the lowest wrist action potential amplitudes; thus, the CMAP
and the web space between the digit II (index) and digit III palm/wrist ratio was inversely correlated with the wrist
(middle finger). If a palmar stimulation resulted in distortion CMAP amplitude.

C8
T1
R
Lower trunk Digit I

Median
nerve
Medial cord
7 cm
– + – +
Digit V
S1
S2 (wrist)
(palm)

2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
4 30 ms 5 mV 20 mA 4 50 ms 5 mV 20 mA
2 2
1 3 1 3
5 Palm 2 5 Palm 2
30 ms 5 mV 37 mA 50 ms 5 mV 37 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle; stimulation of the wrist (upper trace) and on the
palm (lower trace)
28 Wrist, Palm – Hand 175
Table 1 Reference values between pure conduction block and an abnormal amplitude
Normal values [1] Mean ± 2SD reduction due to an excessive temporal dispersion with phase
Wrist–APB, negative peak amplitude (mV) 10.9 ± 2.3 cancellation.
Palm–APB, negative peak amplitude (mV) 11.3 ± 2.9 They studied 88 hands (Table 3) from 69 healthy volun-
Palm/wrist amplitude ratio 1.0 ± 0.1 teers (56 % women, age range 20–86 years, mean age
40.3 ± 15.7 years) and 294 hands from 198 consecutive
patients (Table 4) presenting typical symptoms and signs of
Table 2 Reference values CTS (60 % women, age range 13–84 years, mean age
Pathological values [1] Mean ± 2SD 46 ± 13.1 years). In stimulating the recurrent median nerve
Wrist–APB, negative peak amplitude (mV) 6.2 ± 3.4 (RMN) with the palmar stimulation (S2), particular care
Palm–APB, negative peak amplitude (mV) 7.3 ± 3.4 must be taken to avoid costimulation of the deep ulnar nerve
Wrist/palm amplitude ratio 1.6 ± 1.3 (DUN), which can also generate a motor response recordable
over the APB muscle. For the authors [2], the response due
to DUN stimulation, summating to the response due to RMN
stimulation, may result in greater median CMAP amplitude
Comment from the palm than from the wrist stimulation, stimulating a
Lesser et al. [1] diagnosed patients with CTS by a stan- partial conduction block. They explained, in their experi-
dard electrophysiological criteria: abnormal median ence, how to avoid this problem: (1) using proximal palmar
motor distal latency to the APB muscle (nor- stimulation (3 cm distal to the wrist crease); (2) increasing
mal ≤ 4.4 ms), prolonged antidromic sensory peak gradually the stimulus at the palmar site in discrete steps, as
latency to the digit II (normal ≤ 3.5 ms), and/or a mixed the intensity necessary to maximally stimulate RMN is
nerve latency in the median palm–wrist segment ≥ 0.4 ms always lower than the threshold for DUN stimulation; (3)
than the ulnar palm–wrist segment. In the patient group, inspecting the thenar twitch and avoiding digit I (thumb)
the palm/wrist amplitude ratio = 1.6 (SD 1.3) was sig- adduction, which indicates the adductor pollicis contraction
nificantly greater than the control group. In 23 of 59 due to DUN costimulation; (4) comparing CMAP amplitude,
patient hands (39 %), the palm/wrist CMAP amplitude waveform configuration, and initial deflection from the palm
ratio exceeded 1.2, the upper limit of normal from the and wrist stimulation, as a change between these two sites
control hands. Mean palmar CMAP amplitude was also suggest that a different population of fibers has been stimu-
smaller in patients (7.3 ± 3.4 mV) than controls. lated. The palmar stimulation may also give rise to technical
problems in the measurement of the motor conduction veloc-
ity in the wrist–palm segment. Overstimulation of the
In 1997, Di Guglielmo et al. [2] used a slightly different branching point of the thenar nerve may activate the nerve
protocol (Fig. 2), placing an active and a reference electrode distally near the motor point, making fictitiously greater the
on the proximal and distal interphalangeal joints, respec- latency difference between the palm and wrist stimulation
tively, and a surface-stimulating median nerve at the wrist sites and resulting in an erroneously slow conduction in the
(1–2 cm proximal to the distal wrist crease) and on the palm palm–wrist tract [3]. For the authors, overstimulation
(3 cm distal to the wrist crease along a line connecting the occurred only with a stimulus intensity at the palm, at least
wrist and the web space between the digit II (index finger) three times greater than the intensity required for a maximal
and digit III (middle finger). They measured an amplitude CMAP amplitude; care must be taken with more of a distal
ratio as wrist/palm (lower limit 0.7), while Lesser at al. [1] stimulation, because, in this way, the recurrent median nerve
measured the amplitude ratio as palm/wrist (lower limit (RMN) may be activated at the anodal point, and the surface
1.0 ± 0.1). They also measured duration and duration ratio distance measured at the cathode would overestimate the
between the wrist and palm stimulations, because the case of effective nerve length, making the palm to wrist conduction
CTS data on temporal dispersion allowed the distinction erroneously fast.
C8
T1
R
Lower trunk Digit I

Median
nerve
Medial cord
3 cm
– + – +
1–2 cm
Digit V
S1
S2 (wrist)
(palm)
Fig. 2 Along a line connecting the wrist and the web space between the digit II and digit III: stimulation of the wrist (S1), 1–2 cm proximal to
the distal wrist crease and stimulation on the palm (S2), 3 cm distal to the distal wrist crease

Normal values [2] Mean ± 2SD Limit of normal Pathological values [2]––CTS Group 1 Mean ± 2SD
Wrist–APB, negative peak 10.2 ± 2.9 Wrist–APB, negative peak amplitude (mV) 7.5 ± 3.1
amplitude (mV) Palm–APB, negative peak amplitude (mV) 8.3 ± 3.2
Palm–APB, negative peak 10.5 ± 2.9 Wrist–APB, distal latency (ms) 5.4 ± 1.6
amplitude (mV)
Wrist/palm amplitude ratio 0.9 ± 0.1 0.7
Pathological values [2]––CTS Group 2 Mean ± 2SD
Wrist–APB, distal latency (ms) 3.4 ± 0.4 4.2
Wrist–palm, MNCV (m/s) 46.7 ± 5.8 35
28 Wrist, Palm – Hand 177
Comment There was no correlation between the palm CMAP

Di Guglielmo et al. [2], according to their normal val- amplitude and the respective wrist-to-palm ratio, sug-
ues obtained from 88 hands, to suspect a conduction gesting that the entity of focal demyelination is not
block, required a greater than 30 % reduction in CMAP related to the degree of axonal involvement. In conclu-
amplitude with less than a 15 % increase in the dura- sion, the segmental motor conduction studies, using
tion of proximal CMAP. CMAP amplitudes in CTS 1 palmar stimulation, are supplementary in the detection
and CTS 2 Groups after palmar stimulation were sig- of CTS; palmar stimulation in CTS, as in other com-
nificantly reduced compared to controls, indicating a pressive neuropathies, is useful to distinguish between
quota of axonal degeneration. Considering all CTS the relative quota of conduction block and axonal
hands, the amplitude ratio was less than the normal degeneration in the motor fibers (Fig. 3).
limit (mean 0.5 ± 0.2) in 21 of 294 hands (6.8 %).
2 2
1 3 5 1 3 5
4 Wrist 1 4 Wrist 1
30 ms 5 mV 48 mA 20 ms 5 mV 48 mA
2 2
1 3 1 3
5 Palm 2 5 Palm 2
30 ms 5 mV 29 mA 20 ms 5 mV 29 mA
4 4
Onset latency (wrist – APB): 5.00 ms; Onset latency (palm – APB): 2.10 ms; Peak latency (wrist – APB): 8.00 ms; Peak latency
(palm – APB): 4.40 ms; Onset to peak amplitude (wrist – APB): 3.7 mV; Onset to peak amplitude (palm – APB): 7.9 mV; Peak to
peak amplitude (wrist – APB): 5.0 mV; Peak to peak amplitude (palm – APB): 13 mV; Palm-Wrist amplitude ratio: 2.13; Wrist-Palm
amplitude ratio: 0.47; Duration (wrist – APB): 5.75 ms; Duration (palm – APB): 4.05 ms; MNCV (wrist – palm): 24.1 m/s
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in moderately severe CTS––grade 3 by Bland’s
CTS classification scale [4]; stimulation of the wrist (upper trace) and on the palm (lower trace)
References 3. Kimura J, Machida M, Ishida T et al (1986) Relation between size of

compound sensory or muscle action potentials, and length of nerve
segment. Neurology 36:647–652
1. Lesser EA, Venkatesh S, Preston DC et al (1995) Stimulation distal
to the lesion in patients with carpal tunnel syndrome. Muscle Nerve
18:503–507
2. Di Guglielmo G, Torrieri F, Repaci M et al (1997) Conduction block
and segmental velocities in carpal tunnel syndrome. Electroenceph
M29
Original Settings Sensitivity, low-frequency filter, high- proximal wrist crease (S1) and the center of the recording
frequency filter, sweep speed, duration of pulse, and the disk electrode. The ground (G) electrode position was not
machine used were not specified. specified (the figure shows the ground electrode placed on
the forearm).
Stimulation The median nerve was stimulated at the wrist
Recording Using surface electrodes, the nerve conduc- (S1) and at the elbow (S2). The first stimulation (S1) was
tion studies were performed using a conventional tech- delivered at the proximal wrist crease, between the tendons
nique. The active electrode (A) was placed over the belly of the flexor carpi radialis (FCR) and the palmaris longus
(motor point) of the abductor pollicis brevis (APB) mus- (PL) muscles, 8 cm distance from the recording electrode
cle (Fig. 1), halfway between the midpoint of the distal over the belly of the APB muscle [1]. The anode was proxi-
wrist crease and the midpoint of the first metacarpopha- mal. The second stimulation (S2) was delivered at the elbow,
langeal joint [1]. The reference (R) was placed slightly on the antecubital fossa, just lateral to the brachial artery.
distal to the first metacarpophalangeal joint, the proximal The anode was proximal. The stimulation voltage and dura-
phalanx of the digit I (on the distal tendon of the APB tion of stimuli were not specified.
muscle). The distal distance (standard 8 cm) for the com-
pound muscle action potential (CMAP) was measured in a Measurements The authors measured “terminal latency
straight line between the distal stimulation site at the index” (TLI), and it was calculated as follows:
Terminal distance, mm
TLI =
( Proximal conduction velocity, m/s ) × ( distal latency, ms )
The median TLI value is a derived measure of the distal 35.7 ± 12.0 years) and 132 median nerves from 107 patients
motor conduction as a ratio of the measured distal distance (Table 2) referred with clinical diagnosis of CTS (61 %
to the calculated distal distance (conduction velocity x women, age range 19–86 years, average age 51 ± 16 years).
motor DL). The ratio decreases as the conduction time The patients were divided into two groups, based on the
increases across the carpal tunnel due to the motor nerve results of the mixed nerve palmar stimulation studies (nor-
demyelination. Unlike the distal motor latency (DML), the mal ≤2.2 ms or median-to-ulnar peak latency difference
median TLI compensates for the distance and the conduc- ≤0.4 ms): Group 1––patients with abnormal median palmar
tion velocity of the proximal median nerve segment. peak latencies (probable CTS); Group 2––patients with nor-
Temperature and the accuracy of the distance are variables mal median palmar peak latencies (less probable CTS).
that may affect the results. A standard terminal distance was Every hand in Group 1 (107 hands from 83 patients) had an
fixed at 8 cm (80 mm). The skin temperature of the hand abnormal TLI (mean 0.24 ± 0.05, range 0.08–0.33); 24
was 32 °C or higher. The author studied 30 median nerves hands (22 %) had an abnormal TLI with a normal median
from 15 healthy (Table 1) and asymptomatic volunteers motor distal latency (MDL), while all abnormal MDL were
(56 % women, age range 21–65 years, average age associated with an abnormal TLI. In Group 2 (25 hands

Biceps brachii
(BB)
R +
S2
(elbow)
Digit I
+
A –
R
C8
T1
G
S1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord

2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
4 50 ms 5 mV 40 mA 4 30 ms 5 mV 40 mA
2 2
1 3 1 3
5 Elbow 2 5 Elbow 2
50 ms 5 mV 83 mA 30 ms 5 mV 83 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the abductor pollicis brevis (APB) muscle; stimulation of the
wrist (upper trace) and of the elbow (lower trace)
Table 1 Reference values The terminal latency index (TLI) was first described by
Normal values [1] Mean ± SD Range Limit of normal Shahani and colleagues [2] at the Sixth International
Terminal latency index 0.44 ± 0.04 0.36–0.54 ≥0.34 Congress of Electromyography (June 17–20, 1979). They
used TLI to evaluate the function of the most distal segments
of the median and ulnar nerves in relation to conduction in
Table 2 Reference values the proximal segments of the same nerve. The authors stud-
Pathological values [1]––Group 2 Mean ± SD
ied 80 hands of 54 normal healthy subjects, 10 patients with
Terminal latency index 0.24 ± 0.05
motor neuron disease (MND), 15 patients with mild axonal
neuropathy, 8 patients with Guillain–Barré syndrome (GBS),
Pathological values [1]––Group 2 Mean ± SD
12 patients with both carpal tunnel syndrome (CTS) and
mild axonal neuropathy, and 9 patients with only CTS. In
normal subjects, the TLI average was 0.433 ± 0.045, and TLI
range was 0.36–0.55. In five patients with MND and four
patients with axonal neuropathy, the authors found abnor-
from 24 patients), the median TLI was abnormal in 12 hands mality of median and ulnar TLI, suggesting that the terminal
(48 %), with otherwise normal conventional nerve conduc- segments of nerves were affected more severely in these
tion studies. TLI mean value was 0.33 ± 0.06, with a maxi- patients. Five patients with GBS (all of whom had prolonged
mum TLI value of 0.45. All patients of Group 1 (83 patients) F-wave latencies) showed severe involvement of the terminal
had a TLI below 0.33; all control subjects had a TLI above segments of the median and/or ulnar nerve (TLI <0.060). All
0.34. The authors demonstrated that in a group of patients CTS patients (21 cases) associated with a mild axonal neu-
with an abnormal median palmar study, the median TLI was ropathy (12 patients) or without neuropathy association (9
always abnormal; they believed that the median TLI is a patients) had abnormal median TLI (the authors also
useful adjunct in the evaluation of patients suspected of hav- observed in 15 of these patients a relative prolongation of
ing CTS, and being a derived value, it does not require fur- F-wave latency from the abductor pollicis brevis muscle). In
ther testing beyond the basic conventional conduction conclusion, for the authors, the TLI was a sensitive measure
studies. of function of distal segments of peripheral nerves, useful in
the diagnosis of entrapment syndromes superimposed on
peripheral neuropathies.
Comment Simovic and Weinberg [5] prospectively studied 66
For Simovic and Weinberg [1], the median TLI values patients (36 % referred by an internist, 32 % by a neurolo-
were consistent with the previously published data (in gist, 24 % by an orthopedic surgeon, 8 % by other health-
abstract form only) by Shahani et al. [2]––TLI average care professionals––69 % women, mean age 48 ± 16 years,
0.433 ± 0.045, TLI range 0.36–0.55, and by Evans and age range 19–86 years) to assess the sensitivity of the median
Daube [3]––TLI average 0.43, TLI range 0.34–0.64. nerve TLI for the diagnosis of the CTS. The normal values
The authors found that no normal subjects had a were obtained from 38 hands (Table 3) of 19 control subjects
median TLI below 0.34 (the lower limit of normal, (63 % women, mean age 40 ± 13 years, age range
mean ± 2SD). Kuntzer [4], like Simovic and Weinberg 25–68 years). The mean TLI was 0.43, and all control sub-
[1], assessed the TLI in 70 hands (mean TLI of jects had a TLI value above 0.34. Patients were divided into
0.427 ± 0.043) with a prospective design. two groups (Table 4), based upon clinical features: CTS
Group––a total of 54 hands were assigned to this group
based upon clinical features; the mean TLI was 0.26 ± 0.07,
the mean MDL was 4.7 ± 1.7; seventeen hands (31 %) had a Comment
normal MDL with an abnormal TLI; Non-CTS Group––nine Perić and Sinanović [6] used in CTS patients several
patients had normal tests (three patients had electrodiagnos- fixed distances between active recording and stimulat-
tic abnormalities consistent with CTS). For the authors, the ing electrode: 6.5 cm (6/67––8.96 %), 7 cm (47/67––
median TLI demonstrated the highest sensitivity of all tests 70.15 %), 8 cm (14/67––20.89 %). The authors found
for CTS, being abnormal in 44 of 54 hands (81.5 %) of the statistical significant differences between the mean
CTS Group, and they believed the median TLI a useful sen- values of all the parameters in patients with CTS and
sitive parameter for diagnosing CTS to incorporate into the healthy subjects. The highest sensitivity (98.51 %) was
standard diagnostic process. found in SMI and RL; TLI had high sensitivity
Perić and Sinanović [6] determined sensitivity and speci- (92.54 %) and good specificity (80.70 %). The residual
ficity of TLI, and compared it with the residual latency (RL) latency had the highest specificity (91.23 %). The TLI
and sensory–motor index (SMI). They studied 57 hands was normal in five patients (0.35 in two patients,
(Table 5) from 57 healthy subjects (33 women, mean age 0.37 in two patients, and 0.46 in a patient).
45.65 ± 9.68 years) and 67 hands from 60 patients (Table 6)
with clinical diagnosis of CTS (38 women, mean age
50.28 ± 11 years). All nerve conduction studies were per-
formed using a France Racia 21P EMG machine, and the Aygül et al. [7] performed several median sensory and
skin temperature of the hand at midpalm was 32 °C or higher. motor nerve conduction studies to evaluate prospectively the
sensitivities of conventional and new electrophysiological
Table 3 Reference values techniques and to investigate their relationship with the body
mass index (BMI). They performed electrophysiological
studies with a Medelec TECA Premiere Plus vE05 electro-
Terminal latency index 0.43 ± 0.04 0.36–0.54 ≥0.34
myograph (2 Hz–3 kHz frequency filter). All tests were done
in similar temperature conditions, and the skin temperature
at the hand was measured and maintained at or above
Table 4 Reference values 32 °C. They studied 60 hands of 30 healthy (Table 7) sub-
Pathological values [5]––CTS Group Mean ± SD Range jects (26 women and 4 men, BMI 26.5 ± 3.6, mean age
Terminal latency index 0.26 ± 0.07 0.08–0.33 44.3 ± 8 years, age range 18–62 years) and 165 hands of 92
patients (Table 8) with clinical diagnosis of CTS (81 women
Pathological values [5] – Non-CTS Group Mean ± SD Range and 11 men, mean age 45.7 ± 10.4 years, age range
Terminal latency index 0.33 ± 0.04 0.23–0.45 18–72 years). For the diagnosis of CTS, the terminal latency
index (TLI) was the most sensitive motor parameter (70.3 %),
and the antidromic sensory median–ulnar latency difference
Table 5 Reference values to the digit IV was the most sensitive sensory parameter
(77 %). For TLI, the authors observed a sensitivity of 72.6
Terminal latency index 0.39 ± 0.13 0.29–0.61 and 67.9 % in obese patients and nonobese patients, respec-
tively. These findings suggested that the obese patients had
severe CTS and high sensitivity of parameter.
Gazioglu and colleagues [8] performed standard nerve
conduction studies, segmental and comparative median
Pathological values [6] Mean ± SD Range Limit of normal nerve conduction tests, in 86 hands from 43 healthy
Terminal latency index 0.27 ± 0.06 0.16–0.38 ≥0.34 (Table 9) individuals (32 women and 11 men, mean age

Normal values [7] Mean ± SD Range Pathological values [8] Mean ± SD
Terminal latency index 0.41 ± 0.038 0.33–0.56 Terminal latency index––CTS Group 0.24 ± 0.04
Terminal latency index––DMPNP CTS- Group 0.3 ± 0.04
Terminal latency index––DMPNP CTS+ Group 0.27 ± 0.04
Pathological values [7] Mean ± SD Range Limit of normal Table 11 Reference values
Terminal latency index 0.29 ± 0.08 0.12–0.50 ≥0.33 Normal values [9] Mean ± SD Limit of normal
Terminal latency index 0.31 ± 0.02 ≥0.30

Normal values [8] Mean ± SD Cutoff Table 12 Reference values
53.7 ± 5.5 years). They used a Nihon Kohden 9100 electro-
myograph at a room temperature of 25 °C, and a palmar tem-
perature maintained at approximately 32 °C. The authors In a prospective study, Uzar et al. [9] studied 76 hands of
compared sensitivity and specificity of some different tests 38 healthy (Table 11) subjects (36 women and 2 men, mean
in the diagnosis of CTS in diabetic polyneuropathy patients. age 45.3 ± 10.9 years, age range 22–68 years) and 102 hands
A greater diagnostic accuracy can be observed in tests with of 57 patients (Table 12) with suspected CTS (54 women and
higher sensitivity and specificity. Following the terminal 3 men, 45 bilateral CTS, 8 in the right hand, 4 in the left
latency index (TLI) method, the derived ratio was calcu- hand, mean age 46.6 ± 12.4 years, age range 25–71 years).
lated; they found normal TLI values (0.33 ± 0.02) consistent All tests were performed using a four-channel EMG machine
with the previous values reported by Simovic and Weinberg Nihon Kohden Neuropack (2005 model), and recordings
[5]. Gazioglu et al. [8] performed nerve conduction stud- were made at normal room temperature (24–26 °C) and a
ies on a group of patients (Table 10) with CTS (140 hands skin temperature above 30 °C.
from 72 patients, 59 women and 13 men, 71 right hands and Uzar et al. [9] compared the sensitivity and specificity
1 left hand, BMI 29.0 ± 3.3, mean age 53.9 ± 3.5 years)–– of the conventional nerve conduction studies (NCS) and of
CTS Group; on a group of diabetic patients with polyneu- the residual latency (RL) and terminal latency index (TLI)
ropathy without associated CTS (61 hands from 32 patients, in the diagnosis of CTS. To determine the diagnostic valid-
19 women and 13 men, 30 right hands and 2 left hands, ity of TLI and RL as an addition to the conventional NCS,
BMI 29.1 ± 5.4, mean age 55.6 ± 9.5 years)––DMPNP CTS- the sensitivity, the specificity, the positive predictive value,
Group; and on a group of diabetic patients with polyneu- and the negative predictive value were calculated as
ropathy with associated CTS (62 hands from 35 patients, follows:
26 women and 9 men, 26 right hands and 9 left hands, BMI
31.4 ± 7.1, mean age 55.5 ± 7.3 years)––DMPNP CTS+ True positive
Sensitivity =
Group). The sensitivities and specificities of the tests were True positive + false negative
compared in the diagnosis of CTS in patients with diabetic
polyneuropathy. Terminal latency index (TLI) was lower in True negative
Specificity =
CTS Group than in DMPNP CTS+ Group (polyneuropathy True negative + false positive
with CTS), in DMPNP CTS+ Group (polyneuropathy with
CTS) than in DMPNP CTS- Group (polyneuropathy with- True positive
out CTS), and in DMPNP CTS- Group (polyneuropathy Positive predictive value =
True positive + false positive
without CTS) than in the controls. These differences were
all significant among the groups. The authors found, using
True negative
0.29 cutoff instead of 0.34 used by Simovic and Weinberg Positive predictive value =
True negative + false negative
[5], a sensitivity of 72 % and a specificity of 71 %.
wrist and the recording electrode placed on the belly point of

Comment the APB muscle, and the mean distance was 75.77 ± 8.17 mm
According to Uzar et al. [9], the terminal latency index for both controls and patients. The mean TLI in all the CTS
(TLI) was the more sensitive (90.1 %) than the conven- patients was 0.26 ± 0.06, which was significantly lower than
tional distal motor latency (DML) and residual latency the control mean (0.43 ± 0.05). The authors grouped the
(RL) parameters (68.6 and 63.7 %, respectively) for patients according to the severity of the carpal tunnel syn-
the diagnosis of CTS. Though the TLI was the most drome, using electrophysiological criteria. The TLI ranged
sensitive motor parameter, it showed the lowest speci- between 0.30 and 0.33 in the mild CTS group, and between
ficity (53.9 %). Uzar et al. [9] observed higher sensitiv- 0.26 and 0.29 in the moderate CTS group. All severe cases
ity and specificity results in sensory NCS, and the showed a TLI ≤0.25. A significant correlation was observed
antidromic sensory median–ulnar latency difference to between TLI and DML. The authors concluded that in CTS,
the digit IV (peak latencies) was the most sensitive especially in severe cases, the retrograde degeneration of the
sensory parameter (91.5 %) for the CTS diagnosis. The median nerve is common, and TLI can be considered a useful
positive predictive value for the TLI in CTS patients variable for showing the conduction differences in the proxi-
was 72 %, and its negative predictive value was 80 %. mal and distal segments to the carpal ligament.
For the authors, in some cases, when median sensory More recently, Park et al. [11] calculated the sensitivity,
NCS are normal (they found low TLI values in seven specificity, and cutoff value of several nerve conduction
hands––6.9 %, in which conventional sensory distal parameters among the groups with asymptomatic, mild, mod-
latency to the digit II was normal), the abnormality in erate, and severe CTS. The aim of their study was to determine
the TLI may be a guide in CTS diagnosis. the correlation of the calculated electrophysiological parame-
ters, such as TLI, RL, and modified F-wave latency ratio of the
median nerve, and CTS clinical severity. They studied a total
of 212 hands (Table 13) from 106 patients (85 women and 21
In 1999, Kabiraj et al. [10] determined the motor terminal men, 66 bilateral CTS, 24 right-side CTS, 16 left-side CTS,
latency index (TLI) of the median nerve across the carpal mean age 52.9 ± 10.3 years, age range 25–70 years), using a
tunnel in a control group of 38 healthy volunteers (19 women Medelec Synergy electromyographic device (Oxford
and 19 men, age range 20–79 years), and in 41 hands of 31 Instruments Medical). For TLI study, the filter bandpass was
patients with clinical diagnosis of CTS (21 women and 10 3 Hz–10 kHz, the sweep speed was 5 ms/division, and the sen-
men, age range 28–85 years). All recordings were made on a sitivity was set at 1–5 mV/division. They recorded CMAP
Medelec Mystro II machine. Skin temperatures were from APB and ADM muscles, after median and ulnar nerves
recorded and maintained between 32 and 34 °C. They used a stimulation at the wrist, respectively. The TLI was calculated
not fixed distance between the stimulating electrode at the using the conventional formula [1], as follows:
TLI =
( Proximal conduction velocity, m / s ) ´ ( distal latency, ms )
Table 13 Reference values Park et al. [11] divided all 212 CTS hands into four
groups, according to the clinical severity, by applying a sim-
Terminal latency index––asymptomatic (40 hands) 0.35 ± 0.04
plified four-stage historical-objective (Hi-Ob scale) scale
Terminal latency index––mild CTS (103 hands) 0.31 ± 0.05 [12]: asymptomatic (40 hands), mild CTS (103 hands), mod-
Terminal latency index––moderate CTS (43 hands) 0.23 ± 0.04 erate CTS (43 hands), and severe CTS (26 hands). They
Terminal latency index––severe CTS (26 hands) 0.19 ± 0.06 found for TLI, significant differences among all CTS groups,
and the cutoff value was 0.33 between asymptomatic and
mild CTS group, 0.27 between mild and moderate CTS
group, and 0.20 between moderate and severe CTS. For the MAG/SGPG (pathogenic IgM antibodies––Abs against
authors, among the calculated electrophysiological parame- myelin-associated glycoproteins/peripheral nerve glycolipid
ters of conventional nerve conduction studies (NCS), the TLI sulfated glucuronyl paragloboside). The authors observed a
could be a good indicator to determine the clinical severity of marked prolongation of distal motor latencies in comparison
CTS (Figs. 2 and 3). They suggested that the cutoff value to the proximal–segment conduction velocities in 76 %
between asymptomatic and mild CTS group may indicate a (16/21) of all nerves studied, and they reported ≤0.25 as the
point of diagnosis of early CTS, the cutoff value between threshold value of TLI.
mild and moderate CTS group may indicate a point of surgi- Cocito et al. [15], with their study, confirmed utility of TLI to
cal treatment, and the cutoff value between moderate and differentiate CIDP associated with anti-MAG/SGPG from other
severe CTS group may indicate a point of poor outcome of forms of CIDP and found the TLI value for median and other
treatment in CTS patients. nerves that best differentiates the different forms of CIDP. They
Several authors used TLI to diagnose and differentiate the calculated TLI in 76 healthy (Table 14) subjects (46 men and 30
different forms of chronic inflammatory demyelinating poly- women, mean age 55.5 ± 12.8 years) and in 29 consecutive
neuropathy (CIDP). In one of the first studies, Maisonobe patients (Table 15) with CIDP (21 men and 8 women, mean age
et al. [13] made a 10-year retrospective study (1985–1994) 60.8 ± 15.2 years). They diagnosed 11 patients with CIDP asso-
of 93 patients (54 men and 39 women) with chronic dysim- ciated with anti-MAG/SGPG, and the remaining 18 patients
mune demyelinating polyneuropathy (CDDP), divided into were diagnosed with another form of CIDP.
two groups: Group 1––64 patients with an idiopathic CIDP
(mean age 48.3 ± 18.5 years, age range 11–86 years) and
Group 2––29 patients with an IgM monoclonal gammopathy
of undetermined significance (MGUS) and myelin-associated Comment
glycoprotein (MAG) antibody demyelinating polyneuropa- Cocito et al. [15] obtained results very similar to those
thy. The authors calculated median nerve TLI in 181 healthy of a previous study [13] that found a significantly
subjects (0.34 ± 0.04) and in patients of both groups. Group1: lower TLI in patients with CIDP associated with anti-
they found TLI values (0.36 ± 0.23) comparable with those of MAG/SGPG than in patients with other forms of
controls, suggesting that the distal conduction was identical CIDP. Though median nerve TLI <0.26 had the highest
to the proximal conduction. Group 2: the authors found low sensitivity (90.9 %) and specificity (94.4 %), low val-
median nerve TLI value (0.22 ± 0.14), suggesting that the ues of TLI were also detected in patients with CTS. For
distal conduction was lower in comparison to the proximal this reason, they suggested that only an ulnar nerve
conduction. For the authors, low TLI value is an indicative TLI <0.33, which showed a low sensitivity (54.4 %)
pattern of a length-dependent demyelinating neuropathy, and high specificity (94.4 %), whether or not in combi-
such as was observed in anti-MAG IgM MGUS patients. nation with median TLI (<0.26), should be considered
Their findings were consistent with the previous data by in clinical practice as highly suggestive of CIDP asso-
Kaku et al. [14], who found distal accentuation of conduc- ciated with anti-MAG/SGPG.
tion slowing in four patients with CIDP associated with anti-

Normal values [15] Mean ± SD Range Limit of normal Pathological values [15]––MAG/SGPG Mean ± SD Range
Terminal latency index 0.40 ± 0.04 0.39–0.41 <0.26 Terminal latency index 0.22 ± 0.04 0.20–0.24
Pathological values [15]––other

forms of CIDP Mean ± SD Range
Terminal latency index 0.37 ± 0.08 0.34–0.40
To determine which nerve conduction study (NCS), abnormalities in myelin protein zero. The authors stud-
assessing the distal segments of the upper extremity ied 12 normal (Table 16) volunteers (58 % men and 42 %
motor nerves, was more useful to differentiate anti-MAG/ women, mean age 32.6 ± 11.3 years), 21 patients (Table 17)
SGPG (pathogenic IgM Abs against myelin-associated with MAG/SGPG-N (57 % men and 43 % women, mean
glycoproteins/peripheral nerve glycolipid sulfated gluc- age 64.6 ± 9.4 years), 26 patients (Table 18) with HMSN1
uronyl paragloboside), Lupu et al. [16] performed several (58 % men and 42 % women, mean age 38.1 ± 13.7 years),
conduction techniques in patients with neuropathy due and 20 patients (Table 19) with HMSN2 (70 % men and
to IgM Abs against MAG and SGPG (MAG-SGPG-N). 30 % women, mean age 44.7 ± 14.5 years). Median and
Electrophysiologically, conduction blocks characterize ulnar nerve motor conduction studies were performed,
chronic inflammatory demyelinating polyradiculoneu- recording at 6 cm fixed distance from the recording elec-
ropathy (CIDP), whereas in MAG/SGPG-N conduction trode placed on the abductor pollicis brevis (APB) and the
blocks are rarely observed. MAG-SGPG-N and hereditary abductor digiti minimi (ADM) muscles, respectively. All
sensory–motor neuropathy type 1 (HMSN1) have similar the nerve conduction studies were performed at a skin tem-
demyelinating features on nerve conduction studies, and perature of 34 °C. TLI, residual latency (RL), and F-wave
two subtypes (HMSN1A and HMSN1B) were described. latency ratio were calculated. The authors obtained a lower
HMSN1A is the most common subtype of HSMN1, and a limit of normal than those of Simovic and Weinberg [1, 5],
mutation in the gene encoding for peripheral myelin protein because they used a 6 cm fixed distance from the recording
22 (PMP-22) was observed. HMSN1B is related to genetic electrode placed on the APB muscle.

Normal values [16] Mean ± SD Limit of normal Comment
Terminal latency index 0.32 ± 0.04 ≥0.31 For Lupu et al. [16], TLI was the most sensitive index
that aids in the differentiation between MAG/SGPG-N
(TLI <0.26, 16 patients) and HMSN1 (TLI ≥0.32, 19
Table 17 Reference values patients). However, since the median nerve TLI can be
Pathological values [16]––MAG/ lower in CTS, the authors suggested measuring the
SGPG-N Mean ± SD Limit of normal ulnar DML to provide additional confidence in the
Terminal latency index 0.21 ± 0.06 ≥0.31 diagnosis. The combination of the median TLI and
ulnar DML increases the specificity and can guide the
diagnosis, especially when median TLI was between
0.26 and 0.32 (about 25 % of patients). Their findings
Pathological values [16]––HMSN1 Mean ± SD Limit of normal
were consistent with those by Attarian et al. [17] who
evaluated indexes calculated from standard electro-
physiological data in differentiating chronic inflamma-
tory demyelinating polyradiculoneuropathy (CIDP).
Table 19 Reference values They studied 19 CIDP patients, 25 anti-MAG/SGPG
Pathological values [16]––HMSN2 Mean ± SD Limit of normal patients, 13 Charcot-Marie-Tooth disease type 1A
Terminal latency index 0.31 ± 0.03 ≥0.31 (CMT1A) patients, and 22 controls. They used TLI to
compare the wrist-thenar muscle segment (distal seg-
ment) with the elbow–wrist conduction velocity.
Compared with controls, TLI was decreased in 21 anti-
MAG/SGPG patients, and it was normal in all patients
affected by CMT1A. They suggested the use of TLI
index in diagnosing on anti-MAG/SGPG, because they
found high value of sensitivity (93 %) and specificity
(90 %), and, because of this, it facilitates distinction
between different forms of CIDP.
2 2
1 3 Wrist 1 1 3
5 5 Wrist 1
4 4
50 ms 5 mV 100 mA 30 ms 5 mV 100 mA
2 2
1 3 1 3
5 Elbow 2 5 Elbow 2
4 4
50 ms 5 mV 100 mA
30 ms 5 mV 100 mA
Onset latency (wrist –APB): 6.0 ms; Onset latency (elbow –APB): 10.70 ms; Peak latency (wrist –APB): 9.90 ms; Peak latency
(elbow –APB): 14.80 ms; Onset to peak amplitude (wrist –APB): 4.6 mV; Onset to peak amplitude (elbow –APB): 4.7 mV ; Peak
to peak amplitude (wrist –APB): 6.3 mV; Peak to peak amplitude (elbow –APB): 6.6 mV; MNCV (wrist –elbow, 23,5 cm distance):
50.0 m/s.
Terminal latency index (wrist - APB muscle, 80 mm distance) calculation:
If TLI =
(Proximal conduction velocity, m/s) × (distal latency, ms)
80 80
Then TLI = = = 0.26
(50.0) x (6.0) 300.0
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in severe CTS––grade 4 by Bland’s CTS
classification scale [18]; stimulation of the wrist (upper trace) and of the elbow (lower trace)
2 2
1 3 5 Wrist 1 1 3 5 Wrist 1
4 4
50 ms 5 mV 65 mA 30 ms 5 mV 65 mA
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
4 4
50 ms 5 mV 93 mA
30 ms 5 mV 93 mA
Onset latency (wrist –APB): 8.30 ms; Onset latency (elbow –APB): 12.90 ms; Peak latency (wrist –APB): 12.00 ms; Peak latency
(elbow –APB): 16.40 ms; Onset to peak amplitude (wrist –APB): 5.1 mV; Onset to peak amplitude (elbow –APB): 4.9 mV; Peak to
peak amplitude (wrist –APB): 7.6 mV; Peak to peak amplitude (elbow –APB): 6.9 mV; MNCV (wrist –elbow, 24 cm distance): 52.2 m/s.
Terminal latency index (wrist – APB muscle, 80 mm distance) calculation:
If TLI =
(Proximal conduction velocity, m/s) × (distal latency, ms)
80 80
Then TLI = = = 0.18
(52.2) x (8.3) 433.26
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle, in extremely severe CTS––grade 6 by Bland’s
CTS classification scale [18]; stimulation of the wrist (upper trace) and of the elbow (lower trace)
References 10. Kabiraj MM, Al-Rajeh S, Al-Tahan AR et al (1999) Motor terminal

latency index in carpal tunnel syndrome. East Mediterr Health J
2:262–267
1. Simovic D, Weinberg DH (1997) Terminal latency index in the car-
pal tunnel syndrome. Muscle Nerve 20:1178–1180
2. Shahani BT, Young RR, Potts F et al (1979) Terminal latency index
and late response studies in motor neuron disease, peripheral neu-
ropathies and entrapment syndromes. Acta Neurol Scand 60:118
12. Giannini F, Cioni R, Mondelli M et al (2002) A new clinical scale
3. Evans BA, Daube JR (1984) Comparison of three electrodiagnostic
of carpal tunnel syndrome: validation of the measurement and
methods of diagnosing carpal tunnel syndrome. Muscle Nerve
clinical-neurophysiological assessment. Clin Neurophysiol
7:565
113:71–77
4. Kuntzer T (1994) Carpal tunnel syndrome in 100 patients: sensitiv-
13. Maisonobe T, Chassande B, Vérin M et al (1996) Chronic dysim-
ity, specificity of multi-neurophysiological procedures and estima-
mune demyelinating polyneuropathy: a clinical and electrophysio-
tion of axonal loss of motor, sensory and sympathetic median nerve
logical study of 93 patients. J Neurol Neurosurg Psychiatry
fibers. J Neurol Sci 127:221–229
61:36–42
5. Simovic D, Weinberg DH (1999) The median nerve terminal
14. Kaku DA, England JD, Summer AJ (1994) Distal accentuation of
latency index in carpal tunnel syndrome: a clinical case selection
conduction slowing in polyneuropathy associated with antibodies
study. Muscle Nerve 22:573–577
to myelin-associated glycoprotein and sulphated glucuronyl para-
6. Perić Z, Sinanović O (2006) Sensory-motor index is useful param-
globoside. Brain 117:941–947
eter in electroneurographical diagnosis of carpal tunnel syndrome.
15. Cocito D, Isoardo G, Ciaramitaro P et al (2001) Terminal latency
index in polyneuropathy with Igm paraproteinemia and anti-mag
7. Aygül R, Ulvi H, Kotan D et al (2009) Sensitivities of conventional
antibody. Muscle Nerve 24:1278–1282
and new electrophysiological techniques in carpal tunnel syndrome
16. Lupu VD, Mora CA, Dambrosia J et al (2007) Terminal latency
and their relationship to body mass index. J Brachial Plex Peripher
index in neuropathy with antibodies against myelin-associated gly-
Nerve Inj 4:12
coproteins. Muscle Nerve 35:196–202
17. Attarian S, Azulay JP, Boucraut J et al (2001) Terminal latency
index and modified F ratio in distinction of chronic demyelinating
neuropathies. Clin Neurophysiol 112:457–463
9. Uzar E, Tamam Y, Acar A et al (2011) Sensitivity and specificity of
terminal latency index and residual latency in the diagnosis of car-
pal tunnel syndrome. Eur Rev Med Pharmacol Sci 15:1078–1084
Wrist – Hand
M30
Study from Median Thenar (MT)
and Ulnar Thenar (UT) Muscles
Original Settings Sensitivity was 5 mV/division, low-fre- Measurements The authors measured the median-thenar
quency filter was 10 Hz, high-frequency filter was 10 kHz, distal latency (MDL) and median-thenar to ulnar-thenar
sweep speed was 2–5 ms/division, and duration of pulse was latency difference (TTLD). The ulnar-thenar (UT) latency
0.2 ms. The machine used was not specified. was subtracted from the median-thenar (MT) distal latency
to obtain the TTLD. Latency (ms) of the median-thenar
Position This study was performed in the supine position. CMAP was measured from the stimulus onset to the onset
of the negative deflection of the CMAP. When measuring the
Recording The active electrode (A) was placed over the median-thenar CMAP onset latency (MDL), a small premo-
belly of the abductor pollicis brevis (APB) muscle (Fig. 1), tor potential, with an initial negative deflection, was occasion-
halfway between the midpoint of the distal wrist crease and ally present prior to the onset of the CMAP. This potential is
the midpoint of the first metacarpophalangeal joint [1]. The likely generated by intramuscular nerve fibers. The CMAP
reference (R) was placed slightly distal to the first metacar- onset latency in these circumstances was therefore mea-
pophalangeal joint. The active electrode location was sured at the onset of the subsequent CMAP negativity. The
adjusted over the thenar eminence to obtain the greatest ulnar-thenar CMAP, generated by the ulnar-innervated deep
compound muscle action potential (CMAP) amplitude for thenar muscles, is volume-conducted and usually has an
both the median (S1) and the ulnar (S2) nerve stimulations initial positive deflection; because of this, the latency of the
at the wrist. The authors used stainless steel disk electrodes ulnar-thenar CMAP (ms) was measured to the first positive
for recording. Ground (G) was placed on the dorsum of the deflection from the baseline. Amplitude (mV) of the CMAP
hand (the figure shows the ground electrode placed on the was measured from the baseline to the peak of the negative
palm). deflection. Skin temperature on the hand was measured and
maintained at or above 32 °C. The authors studied 34 nor-
Stimulation The median and ulnar nerves were stimulated mal hands (Table 1) from 34 asymptomatic volunteers (15
at the wrist, on the median nerve (S1), and on the ulnar nerve right hand and 19 left hand, right-hand dominant in 33 con-
(S2), approximately 1 cm proximal to the proximal wrist trols––the handedness of one control was not recorded, age
crease [1]. CMAPs were evoked using a bar-stimulating range 26–71 years, mean age 41 years) and 79 hands from 50
electrode, with the 1-cm diameter cathode (−) positioned patients (Table 2) with clinically and electrophysiologically
2 cm distal to the 1-cm diameter anode (+). Care was taken diagnosed carpal tunnel syndrome (CTS), (29 bilateral CTS,
to ensure that the median and ulnar wrist stimulations were 16 CTS on the right side, 5 CTS on the left side, right-hand
performed at the same distance proximal to the proximal dominant in 38 CTS patients, left-hand dominant in 5 CTS
wrist crease. During the CMAP acquisition, the stimulation patients––the handedness of seven patients was not recorded,
intensity was increased incrementally with careful observa- age range 26–71 years, mean age 41 years). The mean TTLD
tion of waveform morphology to achieve supramaximal of 0.30 ms indicates that, on average, the ulnar-thenar latency
stimulation, while minimizing the likelihood of stimulating was shorter than the median-thenar latency. Using this cutoff,
unintended nerve segments. there were no false-positives in the control group.

C8
T1
R
Lower trunk
Digit I
Median
nerve Medial cord
Ulnar
nerve
S1
R
(wrist)
A
G – + Median nerve
– + Ulnar nerve
Digit V
S2
(wrist)
Typical waveform (wrist – MT muscle, wrist – UT muscle):
Median - ulnar (MT-UT) Median - ulnar (MT-UT)
2 2
1 3 1 3
4 50 ms 5 mV 26 mA 4 30 ms 5 mV 26 mA
2 2
1 3 5 1 3 5
4 4
50 ms 5 mV 26 mA 30 ms 5 mV 26 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle; stimulation at the wrist: median nerve (upper

Normal Limit Limit Normal values [4] Mean ± SD Limit of normal (±2 SD)
values [1] Mean ± SD Range of normal of normal TTLD 0.43 ± 0.28 <1.0
MDL 2.92 ± 0.28 2.4–3.5 3.6 3.7
TTLD 0.30 ± 0.21 0–0.7 0.7 0.8
TTLD 0.35 ± 0.32 −0.4–1.0
Sensitivity Pathological values [5] Mean ± SD Range Limit of normal
Pathological values [1] Mean ± SD Range (%) TTLD 1.67 ± 1.58 −0.1–8.23 ≤1.0
All affected hands (n 79)––MDL 4.31 ± 0.94 2.9–6.6 72
One affected hand for patient 4.38 ± 0.93 2.9–6.6 72
(n 50)––MDL
All affected hands (n 79)––TTLD 1.80 ± 0.88 0.3–4.1 95 The median-thenar to ulnar-thenar latency difference
One affected hand for patient 1.90 ± 0.88 0.7–4.1 98 (TTLD) was first described by Rhee and colleagues [3] at the
(n 50)––TTLD Sixth International Congress of Electromyography (June
17–20, 1979). They found that comparison between the dis-
tal latency of the median motor nerve across the carpal tun-
nel and that of the ulnar stimulation, using the recording
electrode placed on the thenar muscles for the median nerve
Comment conduction study, showed interesting consistent values. For
Sander et al. [1] performed calculations involving CTS the authors, though the ulnar course is perhaps longer than
patients using two methods: (1) all affected hands were the median nerve, and that there is a delay for volume
included; (2) only one hand per patient was included conduction since the pickup electrode remains on the
(only the right hand of patients affected bilaterally). median–nerve innervated muscles, the distal latency usually
The authors compared their median-thenar to ulnar- is about the same as that of the median nerve, or sometimes
thenar latency difference (TTLD) technique with the even shorter in normal subjects. In patients with CTS, how-
median palm–wrist mixed nerve action potential ever, a longer distal latency of evoked sensory responses
latency (MPWL). In accordance with Jackson and after the median nerve stimulation at the wrist was observed.
Clifford [2], they considered MPLW abnormal if the The limit of normal of the TTLD was 1 ms (distal latency
response was absent, the latency exceeded 1.7 ms, or plus volume conduction). The statistical analysis and indi-
the latency exceeded the ipsilateral ulnar palm–wrist vidual values were not reported (abstract only).
latency by more than 0.3 ms. Among the four failures, Lee et al. [4] investigated a new short transcarpal seg-
the sensitivity of the mean TTLD was 95 % in two ment, exploring the diagnostic value of the motor conduction
hands (0.7 ms) and 98 % in one hand (0.3 and 0.5 ms). index of the terminal latency ratio (TLR) of the wrist–palm
The TTLD, using the author’s methodology, is a highly (W-P). They compared its sensitivity to other commonly
sensitive (95–98 %) indicator of a median neuropathy used CTS techniques like the TTLD in 100 normal (Table 3)
at the wrist in patients with a clinical diagnosis of controls (mean age 48.5 ± 11.4 years).
CTS. TTLD test had a 100 % specificity of an abnor- Aygül et al. [5] performed several median sensory and
mal value (no false-positives) among the normal con- motor nerve conduction studies to evaluate prospectively
trols. The authors chose a CTS population with the sensitivities of conventional and new electrophysio-
electrophysiological evidence of a median neuropathy logical techniques and to investigate their relationship
at the wrist to evaluate the usefulness of the described with the body mass index (BMI). They performed electro-
techniques in a set of patients with documented median physiological studies with a Medelec TECA Premiere Plus
nerve dysfunction. The diagnostic sensitivity values vE05 electromyograph (2 Hz–3 kHz frequency filter). All
are not directly comparable to the values in some other tests were done in similar temperature conditions, and
reports that determine sensitivities in a population with skin temperature at the hand was measured and maintained
purely clinically defined CTS. at or above 32 °C. They studied 60 hands of 30 healthy
(Table 4) subjects (26 women and 4 men, BMI 26.5 ± 3.6,

Comment Normal values [6] Mean ± SD Cutoff
The TTLD technique was found abnormal (>1.0 ms) TTLD 0.4 ± 0.2 ≤0.8
by Aygül et al. [5] in 109 hands (66 %). The terminal
latency index (TLI) was the most sensitive motor
parameter (70.3 %) for the diagnosis of CTS. The anti- Pathological values [6] Mean ± SD
dromic sensory median-ulnar latency difference to the TTLD––CTS Group 1.8 ± 0.7
TTLD––DMPNP CTS- Group 0.6 ± 0.3
digit IV was the most sensitive sensory parameter
TTLD––DMPNP CTS+ Group 1.5 ± 0.7
(77 %) for the CTS diagnosis. Combining TTLD with
the conventional DML to the APB muscle allowed for
the detection of abnormalities in 131 hands (79.4 %).
The authors observed that the measurement of TTLD Comment
was abnormal in obese patients than in non-obese For Gazioglu and colleagues [6], a greater diagnos-
patients when compared to the BMI. tic accuracy can be observed in tests with higher sensi-
tivity and specificity. The authors compared sensitivity
and specificity of some different tests in the diagnosis
mean age 44.3 ± 8 years, age range 18–62 years) and 165 of CTS in diabetic polyneuropathy patients on a group
hands of 92 patients with clinical diagnosis of CTS (81 of patients with CTS (140 hands from 72 patients, 59
women and 11 men, mean age 45.7 ± 10.4 years, age range women and 13 men, 71 right hands and 1 left hand,
18–72 years). BMI 29.0 ± 3.3, mean age 53.9 ± 3.5 years)––CTS
Gazioglu and colleagues [6] performed standard nerve Group, on a group of diabetic patients with polyneu-
conduction studies, segmental and comparative median ropathy without associated CTS (61 hands from 32
nerve conduction tests in 86 hands from 43 healthy indi- patients, 19 women and 13 men, 30 right hands and 2
viduals (32 women and 11 men, 42 right hands and 1 left left hands, BMI 29.1 ± 5.4, mean age 55.6 ± 9.5 years)––
hand, BMI 27.5 ± 3.4, mean age 53.7 ± 5.5 years) and in DMPNP CTS- Group, and on a group of diabetic
263 hands from 139 patients (Table 5). They used a Nihon patients with polyneuropathy with associated CTS (62
Kohden 9100 electromyograph at a room temperature hands from 35 patients, 26 women and 9 men, 26 right
of 25 °C and palmar temperature maintained at approxi- hands and 9 left hands, BMI 31.4 ± 7.1, mean age
mately 32 °C. Following the median ulnar-thenar CMAP 55.5 ± 7.3 years)––DMPNP CTS+ Group. The TTLD
latency comparison [1], the measurement of latency of the was higher in CTS Group than in DMPNP CTS+
median-thenar and ulnar-thenar CMAPs was performed Group (polyneuropathy with CTS), and in DMPNP
using the onset of first deflection (initial negative deflec- CTS- Group (polyneuropathy without CTS) than in the
tion for the median-thenar CMAP, initial positive deflec- controls. These differences were significant between
tion for the ulnar-thenar CMAP), and TTLD was calculated DMPNP CTS+ Group and DMPNP CTS- Group, and
by subtracting the ulnar-thenar distal latency from the between CTS Group and DMPNP CTS+ Group.
median-thenar distal latency. They found normal TTLD Gazioglu et al. [6] found, using 0.8 ms cutoff instead
values (0.4 ± 0.2 ms) consistent with the previous values of 1.0 ms cutoff used by Sander et al. [1], a sensitivity
reported by Sander et al. [1]. of 83 % and a specificity of 74 %.
References 195
Pathological waveform (wrist – MT muscle, wrist – UT muscle):
Median - ulnar (MT-UT) Median - ulnar (MT-UT)
2 2
1 3 1 3
4 4
50 ms 5 mV 44 mA 30 ms 5 mV 44 mA
2 2
1 3 5 1 3 5
4 4
50 ms 5 mV 44 mA 30 ms 5 mV 44 mA
Onset latency (median APB, MT): 5.65 ms; Onset latency (ulnar APB, UT): 3.55 ms; Peak latency (median APB, MT): 10.05 ms; Peak
latency (ulnar APB, UT): 7.40 ms; TTLD–Onset latency difference (median APB, MT)-(ulnar APB, UT): 1.10 ms; Onset to peak
amplitude (median APB, MT): 5.2 mV; Onset to peak amplitude (ulnar APB, UT): 4.4 mV; Peak to peak amplitude (median APB, MT):
7.2 mV; Peak to peak amplitude (ulnar APB, UT): 6.6 mV
CTS classification scale [7]; stimulation at the wrist: median nerve (upper trace) and ulnar nerve (lower trace)
5. Aygül R, Ulvi H, Kotan D et al (2009) Sensitivities of conventional

References and new electrophysiological techniques in carpal tunnel syndrome
and their relationship to body mass index. J Brachial Plex Peripher
1. Sander HW, Quinto C, Saadeh PB et al (1999) Sensitive median- Nerve Inj 4:12
ulnar motor comparative techniques in carpal tunnel syndrome. 6. Gazioglu S, Boz C, Altunayoglu Cakmak A (2011) Electrodiagnosis
Muscle Nerve 22:88–98 of carpal tunnel syndrome in patients with diabetic polyneuropathy.
2. Jackson DA, Clifford JC (1989) Electrodiagnosis of mild carpal tun- Clin Neurophysiol 122:1463–1469
nel syndrome. Arch Phys Med Rehabil 70:199–204 7. Bland JDP (2000) A neurophysiological grading scale for carpal
3. Rhee S, Srinivasan S, Shafer N (1979) An additional electrodiagnos- tunnel syndrome. Muscle Nerve 23:1280–1283
tic method for carpal tunnel syndrome. Acta Neurol Scand 60:117
4. Lee KY, Lee YJ, Koh SH (2009) Usefulness of the median terminal
latency ratio in the diagnosis of carpal tunnel syndrome. Clin
Wrist, Elbow, Midarm, Axilla – Hand
M31
Original Settings The machine used was a Nicolet Viking The second stimulation (S2) was delivered at the elbow,
IV electromyograph. Sensitivity, low-frequency filter, high- on the antecubital fossa, just lateral to the brachial artery.
frequency filter, sweep speed, and duration of pulse were not The third stimulation (S3) was delivered at the midarm, and
specified. the fourth stimulation (S4) was delivered at the axilla.
Therefore, four motor latencies were obtained for each nerve
Position This study was performed in the supine position. tested. All responses were supramaximal [1].
Recording Using a surface stainless steel disk electrode Measurements Distal latency (ms) was measured from the
(1 cm in diameter), nerve conduction studies were per- stimulus artifact to the onset of the initial negative response.
formed using a conventional technique [1]. The active Amplitude (mV) of the compound muscle action potential
electrode (A) was placed over the belly (motor point) of (CMAP) was measured from the baseline to the negative peak.
the abductor pollicis brevis (APB) muscle (Fig. 1), half- Motor nerve conduction velocity (MNCV) was calculated in
way between the midpoint of the distal wrist crease and the conventional way for each of the three proximal tested seg-
the midpoint of the first metacarpophalangeal joint. The ments: elbow–wrist (forearm, FMMCV), midarm–elbow (dis-
reference (R) was placed slightly distal to the first meta- tal arm, DAMMCV), and axilla–midarm (proximal arm,
carpophalangeal joint, the proximal phalanx of the digit I PAMMCV), simply dividing the distance by the latency dif-
(on the distal tendon of APB muscle). The distal distance ference between the two evoked motor responses. It was mea-
(standard 8 cm) for the CMAP was measured as two lines sured in meter per second (m/s). Skin temperature on the hand
(one from the active recording electrode to the midpoint was controlled and maintained at or above 32 °C. Nerve con-
of the distal crease and a second line directly proximal to duction studies were performed in 20 control (Table 1) sub-
the midpoint). Ground (G) electrode was placed on the jects (13 women and 7 men, age range 20–50 years, mean age
dorsum of the hand (the figure shows the ground electrode 43.7 ± 5.0 years) and in 55 patients (Table 2) with carpal tunnel
placed on the palm). syndrome (CTS), divided into two groups (Group I––20
patients with CTS, 14 women and 6 men, age range 21–52
Stimulation The median nerve was stimulated using sur- years, mean age 43.3 ± 5.4 years, FMMCV <50 m/s; Group
face electrodes at four points along its course: at the wrist II––35 patients with CTS, 25 women and 10 men, age range
(S1), at the elbow (S2), at the midarm (S3), and at the axilla 21–52 years, mean age 42.4 ± 4.7 years, FMMCV >50 m/s). A
(S4). The first stimulation (S1) was delivered at the wrist (at conduction velocity (CV) gradient was found from distal to
a fixed distance of 8 cm from the active recording electrode), proximal limbs. A CV gradient from FMMCV (forearm) to
between the tendons of the flexor carpi radialis (FCR) and DAMMCV (distal arm) and PAMMCV (proximal arm)
palmaris longus (PL) muscles. occurred in the control group.

198 M31 Wrist, Elbow, Midarm, Axilla – Hand
+
S4 –
C8
(axilla) +
T1 –
+
–
Median
Lower trunk S3
nerve S1 (mid-arm)
Medial cord
(wrist)
Digit I
+ S2
A 8 cm
– (elbow)
R
R
Digit V
Typical waveform (wrist, elbow, mid-arm, axilla – APB muscle):
1 3 5 1 3 5
Wrist 1 Wrist 1
4 50 ms 5 mV 34 mA 4 30 ms 5 mV 34 mA
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
4 50 ms 5 mV 15 mA 4 30 ms 5 mV 15 mA
2 2
1 3 5 1 3 5
Mid-arm 3 Mid-arm 3
2 4 50 ms 5 mV 15 mA 2 4 30 ms 5 mV 15 mA
1 3 5 1 3 5 Axilla 4
Axilla 4
4 50 ms 5 mV 34 mA 4 30 ms 5 mV 34 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle; stimulation of the axilla, midarm, elbow, and
wrist (bottom to top)
M31 Wrist, Elbow, Midarm, Axilla – Hand 199

Normal values [1] Mean ± SD DAMMCV was not significant in comparison with
Wrist–APB, distal latency (ms) 4.1 ± 1.5 controls and Group II, suggesting that a significant
Wrist–APB, negative peak amplitude (ms) 9.5 ± 1.2 decrease of conduction velocity only occurred over the
Elbow–wrist, FMMCV (m/s) 56.6 ± 1.9 forearm (FMMCV) segment. Recording from the APB
Midarm–elbow, DAMMCV (m/s) 59.3 ± 1.6 muscle, the median motor nerve fibers stimulated at
Axilla–midarm, PAMMCV (m/s) 64.8 ± 2.6 the wrist, elbow, midarm, and axilla were needed to
DAMMCV–FMMCV difference (m/s) 2.7 ± 2.7 conduct through the carpal tunnel. Because of this, the
PAMMCV–FMMCV difference (m/s) 7.8 ± 3.6 authors suggested that the reduced and limited conduc-
PDAMMCV–DAMMCV difference (m/s) 5.1 ± 2.5 tion velocity observed over the forearm segment
(FMMCV <50 m/s) was due to retrograde axonal atro-
Table 2 Reference values phy rather than a conduction block of the large myelin-
ating fibers.
Pathological values [1]––Group I Mean ± SD
Wrist–APB, negative peak amplitude (ms) 7.0 ± 1.5
Elbow–wrist, FMMCV (m/s) 46.1 ± 1.8 Chang et al. [2], in a study based on the hypothesis that an
Midarm–elbow, DAMMCV (m/s) 58.4 ± 1.4 improvement in across-wrist motor conduction after surgery
Axilla–midarm, PAMMCV (m/s) 64.8 ± 2.7 (decreased MMDL and increased CMAP amplitudes) in ten
DAMMCV–FMMCV difference (m/s) 12.9 ± 1.9 patients (eight women and two men, mean age
PAMMCV–FMMCV difference (m/s) 18.7 ± 3.1 45.4 ± 6.1 years) with CTS (MMDL baseline range 6.9–
PDAMMCV– DAMMCV difference (m/s) 5.8 ± 3.1 9.4 ms, CMAP amplitude baseline range 0.5–5.8 mV) and
slowed FMMCV (baseline range 41.4–48.4 m/s) should
Pathological values [1]––Group II Mean ± SD accompany an increase in the FMMCV, if the conduction
Wrist–APB, distal latency (ms) 6.52 ± 0.9 block or axonal loss were the major cause, confirmed that an
Wrist–APB, negative peak amplitude (ms) 7.1 ± 2.1 improvement in across-wrist conduction observed 12 weeks
Elbow–wrist, FMMCV (m/s) 56.2 ± 1.5 after surgery (MMDL range 5.7–8.1 ms, CMAP amplitude
Midarm–elbow, DAMMCV (m/s) 59.3 ± 2.2 range 0.8–6.8 mV) did not parallel the improvement in
Axilla–midarm, PAMMCV (m/s) 65.0 ± 3.0 FMMCV (range 40.8–48.2 m/s), which confirmed the retro-
DAMMCV–FMMCV difference (m/s) 3.5 ± 2.7 grade axonal atrophy excluding the possibility of a large
PAMMCV–FMMCV difference (m/s) 8.9 ± 3.4 axon loss causing the proximal conduction slowing.
PDAMMCV–DAMMCV difference (m/s) 5.5 ± 3.3 Chang et al. [3], during a 2-year period, performed motor
nerve conduction study to the APB muscle in 200 healthy
volunteers (116 women, 84 men, age range 18–80 years,
Comment mean age 55.11 ± 15.24 years) and in 220 CTS patients (172
During a 2-year period, Chang et al. [1] studied 181 women, 48 men, age range 20–80 years, mean age
consecutive patients with CTS and confirmed it 51.3 ± 12.4 years). They used a Nicolet Viking Select electro-
through electrodiagnosis. They observed 28 patients myograph (filter setting was 3 kHz for the high frequency
with marked slowing of forearm conduction velocity and 10 Hz for the low frequency). The authors used 1-cm
(FMMCV). Twenty patients with CTS and slow diameter stainless steel disk electrodes for recording, and
FMMCV (<50 m/s) accepted to participate in their they stimulated the median nerve, 8 cm proximal to the distal
study, and in addition, 35 patients with CTS and nor- wrist crease, and at the elbow. Supramaximal stimulation
mal FMMCV (>50 m/s) were recruited for the purpose was characterized by a duration of 0.1 ms and an intensity of
of the study. A total of 55 patients with CTS were stud- 30–80 mA. Latency differences between the wrist and the
ied, and divided into two groups: Group I––20 patients elbow were measured, and forearm motor conduction veloc-
with CTS, 14 women and 6 men, age range 21–52 ity (FMCV) was calculated. There were significant differ-
years, mean age 43.3 ± 5.4 years, FMMCV <50 m/s; ences in the median distal motor latency (DML) and FMCV
Group II––35 patients with CTS, 25 women and 10 between the controls and the patient group (Figs. 2 and 3).
men, age range 21–52 years, mean age 42.4 ± 4.7 years, The percentage of the relative reduction in the median FMCV
FMMCV >50 m/s. The authors observed in Group I, a was 4.43 % (55.26 ± 3.56 m/s) in the patient group when
significant increase in the conduction velocity (CV) compared with the controls, and the percentage of the popu-
difference of DAMMCV–FMMCV and PAMMCV– lation with a FMCV less than the mean of the controls
FMMCV. The CV difference in the segment PAMMCV– (57.82 ± 3.9 m/s) was 78.2 % (172/200 CTS patients), in con-
trast to 60 % (120/200 controls) of the healthy volunteers.
200 M31 Wrist, Elbow, Midarm, Axilla – Hand
Pathological waveform (wrist, elbow, mid-arm, axilla – APB muscle):

2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
4 4
50 ms 5 mV 36 mA 30 ms 5 mV 36 mA
2 2
1 3 1 3
4 5 Elbow 2 4 5 Elbow 2
50 ms 5 mV 72 mA 30 ms 5 mV 72 mA
2 2
1 3 5 1 3 5
4 Mid-arm 3 4 Mid-arm 3
50 ms 5 mV 66 mA 30 ms 5 mV 66 mA
2 2
1 3 5 1 3 5
50 ms 5 mV 63 mA 30 ms 5 mV 63 mA
Onset latency (wrist – APB): 5.40 ms; Onset latency (elbow – APB): 8.85 ms; Onset latency (mid-arm – APB): 10.40 ms; Onset latency
(axilla – APB): 11.90 ms; Peak latency (wrist – APB): 9.00 ms; Peak latency (elbow – APB): 13.05 ms; Peak latency (mid-arm – APB):
14.20 ms; Peak latency (axilla –APB): 16.15 ms; Onset to peak amplitude (wrist – APB): 5.4 mV; Onset to peak amplitude (elbow –
APB): 5.0 mV; Onset to peak amplitude (mid-arm – APB): 4.8 mV; Onset to peak amplitude (axilla – APB): 3.6 mV; Peak to peak
amplitude (wrist –APB): 7.4 mV; Peak to peak amplitude (elbow – APB): 6.5 mV; Peak to peak amplitude (mid-arm – APB): 6.2 mV;
Peak to peak amplitude (axilla – APB): 4.8 mV; MNCV (wrist – elbow, 20 cm distance): 58.0 m/s; MNCV (mid-arm – APB, 9.5 cm
distance): 61.3 m/s; MNCV (axilla – APB, 9.5 cm distance): 63.3 m/s
Fig. 2 Chang et al. [1]. Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in moderately severe CTS––
grade 3 by Bland’s CTS classification scale [4] with normal FMMCV; stimulation of the axilla, midarm, elbow, and wrist (bottom to top)
References 201
Pathological waveform (wrist, elbow, mid-arm, axilla - APB muscle):

2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
4 4
50 ms 5 mV 94 mA 30 ms 5 mV 94 mA
2 2
1 3 5 1 3 5Elbow 2
4 Elbow 2 4
50 ms 5 mV 94 mA
30 ms 5 mV 94 mA
2 2
1 3 5 1 3 5
4 Mid-arm 3 4 Mid-arm 3
50 ms 5 mV 100 mA
30 ms 5 mV 100 mA
2 2
1 3 5 1 3
4 Axilla 4 4
Axilla 4
50 ms 5 mV 73 mA
30 ms 5 mV 73 mA
Onset latency (wrist – APB): 7.60 ms; Onset latency (elbow – APB): 11.90 ms; Onset latency (mid-arm – APB): 13.75 ms; Onset latency
(axilla – APB): 15.65 ms; Peak latency (wrist – APB): 11.75 ms; Peak latency (elbow – APB): 15.25 ms; Peak latency (mid-arm – APB):
16.65 ms; Peak latency (axilla – APB): 21.40 ms; Onset to peak amplitude (wrist – APB): 3.5 mV; Onset to peak amplitude (elbow –
APB): 3.4 mV; Onset to peak amplitude (mid-arm – APB): 2.7 mV; Peak to peak amplitude (wrist – APB): 5.7 mV; Onset to peak
amplitude (axilla – APB): 1.8 mV; Peak to peak amplitude (elbow – APB): 5.3 mV; Peak to peak amplitude (mid-arm – APB): 4.1 mV;
Peak to peak amplitude (axilla – APB): 3.1 mV; MNCV (wrist – elbow, 19 cm distance): 44.2 m/s; MNCV (mid-arm – APB, 9.5 cm
distance): 51.4 m/s; MNCV (axilla – APB, 9.5 cm distance): 50.0 m/s
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in very severe CTS––grade 5 by Bland’s CTS
classification scale [4] with slowed FMMCV; stimulation of the axilla, midarm, elbow, and wrist (bottom to top)
3. Chang MH, Liu LH, Wei SJ et al (2004) Does retrograde axonal

References atrophy really occurr in carpal tunnel syndrome patients with
normal forearm conduction velocity? Clin Neurophysiol 115:
1. Chang MH, Chiang HT, Ger LP et al (2000) The cause of slowed 2783–2788
forearm median conduction velocity in carpal tunnel syndrome. Clin 4. Bland JDP (2000) A neurophysiological grading scale for carpal
Neurophysiol 111:1039–1044 tunnel syndrome. Muscle Nerve 23:1280–1283
2. Chang MH, Wei SJ, Chen LW (2003) The reason for forearm con-
duction slowing in carpal tunnel syndrome: an electrophysiological
follow-up study after surgery. Clin Neurophysiol 114:1091–1095
Palm, Wrist, Elbow – Hand
M32
Original Settings The machine used was a Nicolet Viking electrode, between the tendons of the flexor carpi radialis
IV electromyograph. Sensitivity, low-frequency filter, high- (FCR) and palmaris longus (PL) muscles. The distance was
frequency filter, sweep speed, and duration of pulse were not measured as two lines (one from the active recording elec-
specified. trode to the midpoint of the distal crease and a second line
directly proximal to the midpoint). The third stimulation
Position This study was performed in the supine position. (S3) was delivered at the elbow, on the antecubital fossa, just
lateral to the brachial artery. Therefore, three motor latencies
Recording Using a surface stainless steel disk electrode were obtained for each nerve tested [1].
(1 cm diameter), nerve conduction studies were performed
using a conventional technique [1]. The active electrode (A) Measurements Distal latency (ms) was measured from the
was placed over the belly (motor point) of the abductor pol- stimulus artifact to the onset of the initial negative response.
licis brevis (APB) muscle (Fig. 1), halfway between the mid- Amplitude (mV) of the CMAP was measured from the base-
point of the distal wrist crease and the midpoint of the first line to the negative peak. The latency difference (ms)
metacarpophalangeal joint. The reference (R) was placed between the palm and wrist stimulations, and the amplitude
slightly distal to the first metacarpophalangeal joint, the prox- ratio between the wrist CMAP amplitude and the palm
imal phalanx of the digit I (on the distal tendon of APB mus- CMAP amplitude (W/P) were calculated. Motor nerve con-
cle). The distal distance (standard 8 cm) for the compound duction velocity (MNCV) was calculated in the conventional
muscle action potential (CMAP) was measured in a straight way for each of the two tested segments: wrist–palm (trans-
line between the distal stimulation site at the proximal wrist carpal across the wrist, AWMMCV) and elbow–wrist (fore-
crease (S1) and the center of the recording disk electrode. arm, FMMCV). The conduction velocity was calculated,
Ground (G) electrode was placed on the dorsum of the hand dividing the distance by the latency difference between the
(figure shows the ground electrode placed on the palm). two evoked motor responses, and it was measured in meters
per second (m/s). Skin temperature on the hand was con-
Stimulation The median nerve was supramaximally stimu- trolled and maintained at or above 32 °C. Normal values
lated using surface electrodes at three [2] points along its were obtained in 60 normal (Table 1) controls (48 women
course: at the palm (S1), at the wrist (S2), and at the elbow and 12 men, age range 20–50 years, mean age 44.3 years),
(S3). The first stimulation (S1) was delivered on the palm; and pathological values were obtained in 60 patients
the cathode (−) was placed at the same site as for the mid- (Table 2) with carpal tunnel syndrome (CTS), divided into
palm sensory stimulation, and the anode (+) was directed two groups (Group I: 20 patients with CTS, 13 women and 7
distally toward the base of the digit V, to avoid depolarizing men, age range 22–54 years, mean age 46.2 years, FMMCV
the recurrent thenar nerve to the APB muscle under the <50 m/s; Group II: 40 patients with CTS, 26 women and 14
anode. The second stimulation (S2) was performed at the men, age range 22–54 years, mean age 45.7 years, FMMCV
wrist at a fixed distance of 8 cm from the active recording >50 m/s).

204 M32 Palm, Wrist, Elbow – Hand
Biceps brachii
(BB)
+
–
R
S3
(elbow)
Digit I
+
R A 8 cm –
S2
– (wrist)
G C8
+
T1
S1
(palm)
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (palm, wrist, elbow – APB muscle):

2 2
1 3 1 3
5 Palm 1 5 Palm 1
4 50 ms 5 mV 25 mA 4 30 ms 5 mV 25 mA
2 2
1 3 5 1 3 5
Wrist 2 Wrist 2
50 ms 5 mV 25 mA 30 ms 5 mV 25 mA
4 4
2 2
1 3 5 1 3 5
Elbow 3 Elbow 3
50 ms 5 mV 35 mA 30 ms 5 mV 35 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle; stimulation of the elbow, wrist, and palm
(bottom to top)
M32 Palm, Wrist, Elbow – Hand 205

Normal values [1] Mean ± SD observed a marginally significant reduction of the
Wrist–APB, distal latency (ms) 3.6 ± 0.31 mean CMAP amplitude in Group I than in Group
Wrist–APB, negative peak amplitude (ms) 9.4 ± 1.91 II. The lower normal limit of the W/P amplitude ratio
Elbow–wrist, FMMCV (m/s) 58.2 ± 3.18 was set at 0.7, and any W/P ratio below this value was
Wrist–palm, AWMMCV (m/s) 49.26 ± 4.1 considered to be a conduction block at the wrist. The
FMMCV–AWMMCV difference (m/s) 8.01 ± 5.06 authors observed only four patients with a W/P ratio
less than 0.7 in Group I and seven patients in Group II,
Table 2 Reference values and about 80 % of patients in Group I did not have a
Pathological values [1]––Group I Mean ± SD conduction block at the wrist. Because of this, for the
Wrist–APB, distal latency (ms) 6.4 ± 1.64 authors, the decrease in CMAP amplitudes may result
Wrist–APB, negative peak amplitude (ms) 6.0 ± 2.1 from axonal loss in the wrist compression. A signifi-
Elbow–wrist, FMMCV (m/s) 46.3 ± 3.78 cant reduction in FMMCV, but not AWMMCV, was
Wrist–palm, AWMMCV (m/s) 22.8 ± 6.4 showed in Group I, and the FMMCV–AWMMCV dif-
FMMCV–AWMMCV difference (m/s) 23.6 ± 5.6 ference was significantly increased in Group II. They
Wrist/palm AMP ratio 4/20 suggested that the reduced and limited conduction
Pathological values [1]––Group II Mean ± SD velocity observed over the forearm segment (FMMCV
Wrist–APB, distal latency (ms) 5.7 ± 1.52 <50 m/s) was due to retrograde axonal atrophy rather
Wrist–APB, negative peak amplitude (ms) 7.6 ± 2.56 than a conduction block of the large myelinating fibers
Elbow–wrist, FMMCV (m/s) 54.3 ± 3.12 (Fig. 2).
Wrist–palm, AWMMCV (m/s) 23.67 ± 6.59
FMMCV–AWMMCV difference (m/s) 30.62 ± 6.87
Wrist/palm AMP ratio 7/40
Many other authors described slowing in the proximal
median motor nerve conduction between the elbow and wrist
in patients with CTS [2, 3]. In 1997, Stevens [4] indicated
Comment that 11 % of 784 patients with CTS showed proximal con-
During a 1-year period, Chang et al. [1] studied a total duction slowing (69 patients of these were associated with a
of 60 patients with CTS, divided into two groups: prolonged distal latency, and 38 % of these were found with
Group I––20 patients with CTS and FMMCV <50 m/s a decreased amplitude). Joynt [5] found a correlation between
(13 women and 7 men, age range 22–54 years, mean the low distal CMAP amplitude and the slow proximal con-
age 46.2 years) and Group II––40 patients with CTS duction and suggested that the loss of large-diameter fibers
and FMMCV >50 m/s (26 women and 14 men, age for axonal degeneration was the cause of the slow proximal
range 22–54 years, mean age 45.7 years). The authors nerve conduction velocity, and so the nerve conduction
velocity of only the small fibers was measured.
206 M32 Palm, Wrist, Elbow – Hand
Pathological waveform (palm, wrist, elbow – APB muscle):
2 2
1 3 5 Palm 1 1 3 5 Palm 1
4 50 ms 5 mV 98 mA 4
30 ms 5 mV 98 mA
2 2
1 3 5 1 3 5
4 Wrist 2 4 Wrist 2
50 ms 5 mV 100 mA 30 ms 5 mV 100 mA
2 2
1 3 5 1 3 5
4 Elbow 3 4 Elbow 3
50 ms 5 mV 100 mA
30 ms 5 mV 100 mA
Onset latency (palm– APB): 2.50 ms; Onset latency (wrist – APB): 7.75 ms; Onset latency (elbow – APB): 12.05 ms; Peak latency
(palm – APB): 4.60 ms; Peak latency (wrist – APB): 11.05 ms; Peak latency (elbow – APB): 15.85 ms; Onset to peak amplitude
(palm – APB): 5.5 mV; Onset to peak amplitude (wrist – APB): 2.5 mV; Onset to peak amplitude (elbow – APB): 2.5 mV; Peak to peak
amplitude (palm – APB): 7.2 mV; Peak to peak amplitude (wrist – APB): 4.1 mV; Peak to peak amplitude (elbow – APB): 4.0 mV;
AWMMCV (wrist – palm, 9 cm distance): 17.1 m/s; FMMCV (elbow – wrist, 20 cm distance): 46.5 m/s; FMMCV-AWMMCV Difference:
29.4 m/s
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle in very severe CTS––grade 5 by Bland’s CTS
classification scale [6] with slowed FMMCV; stimulation of the elbow, wrist, and palm (bottom to top)
References 3. Stoehr M, Petruch F, Scheglmann K et al (1978) Retrograde changes

of nerve fibers with carpal tunnel syndrome: electroneurographic
investigation. J Neurol 218:287–292
1. Chang MH, Wei SJ, Chiang HT et al (2002) The cause of slowed 4. Stevens JC (1987) AAEE minimonograph #26: electrodiagnosis of
forearm median conduction velocity in carpal tunnel syndrome: a carpal tunnel syndrome. Muscle Nerve 10:99–113
palmar stimulation study. Clin Neurophysiol 113:1072–1076 5. Joynt RL (1989) Correlation studies of velocity, amplitude, and
2. Kimura I, Ayyar DR (1985) The carpal tunnel syndrome: electro- duration in median nerves. Arch Phys Med Rehabil 70:477–481
physiological aspects of 639 symptomatic extremities. Electromyogr 6. Bland JDP (2000) A neurophysiological grading scale for carpal
Clin Neurophysiol 25:151–164 tunnel syndrome. Muscle Nerve 23:1280–1283
Wrist, Forearm – Hand
M33
Original Settings The machine used was a France Racia measured by the antidromic technique in the wrist–digit II
21P EMG machine. Sensitivity, low-frequency filter, high- segment (Fig. 2).
frequency filter, sweep speed, and duration of pulse were not
specified. Stimulation For the motor nerve conduction study,
the median nerve was stimulated at the wrist (S1) and at the
Position This study was performed in the supine position. elbow (S2). The first stimulation (S1) was delivered at
the proximal wrist crease, between the tendons of the flexor
Recording Using surface electrodes, the authors performed carpi radialis (FCR) and the palmaris longus (PL) muscles,
motor and sensory nerve conduction studies using conven- at several distal distances (6.5, 7, and 8 cm) from the record-
tional techniques [1]. For the motor nerve conduction study, ing electrode over the belly of the APB muscle (Fig. 3). The
the active electrode (A) was placed over the belly (motor anode was proximal. The second stimulation (S2) was deliv-
point) of the abductor pollicis brevis (APB) muscle (Fig. 1), ered at the elbow, on the antecubital fossa, just lateral to the
halfway between the midpoint of the distal wrist crease and brachial artery. The anode was proximal. The stimulation
the midpoint of the first metacarpophalangeal joint. The ref- voltage and duration of stimuli were not specified [1].
erence (R) was placed slightly distal to the first metacarpo-
phalangeal joint (on the distal tendon of the APB muscle). Measurements Distal latency (ms) of the CMAP from the
Several distal distances (6.5, 7, and 8 cm) between stimula- APB muscle was measured from the stimulus onset to the
tion and the recording site were used for the compound mus- onset of the negative deflection of the CMAP. Sensory nerve
cle action potential (CMAP) recordings, because of the conduction velocity (SNCV) was calculated in the conven-
different recommended criteria. The ground (G) electrode tional way (onset latency). The skin temperature of the hand
position was not specified (the figure shows the ground elec- at midpalm was 32 °C or higher. The authors calculated the
trode placed on the palm). For the sensory nerve conduction terminal latency index (TLI), following the method previ-
study, sensory nerve conduction velocity (SNCV) was ously described by Simovic and Weinberg [2], as follows:
Distal distance, mm
TLI =
( Proximal conduction velocity, m/s ) × ( distal latency, ms )
The median TLI value is a derived measure of the distal motor expected for an impulse to travel from the stimulating cath-
conduction as a ratio of the measured distal distance to the ode to the active recording electrode and subtracting this time
calculated distal distance (conduction velocity x motor DL). from the terminal latency (TL). The distal peak latency (ms)
The ratio decreases as the conduction time increases across was called “terminal latency” (TL), and it measured from the
the carpal tunnel due to the motor nerve demyelination. beginning of the shock artifact to the peak of the negative
Unlike the distal motor latency (DML), the median TLI com- deflection of the CMAP. The forearm motor nerve conduction
pensates for distance and the conduction velocity of the prox- velocity (MNCV) was calculated from the nerve, using the
imal median nerve segment. Temperature and the accuracy of stimulating and recording sites above the elbow and at the
the distance are variables that may affect the results. Following wrist, respectively. From this elbow–wrist conduction veloc-
the method by Kraft and Halvorson [3], the authors also ity, an expected terminal latency from the wrist to the APB
determined the residual latency (RL) by calculating the time muscle was calculated and compared with the measured

208 M33 Wrist, Forearm – Hand
Biceps brachii
(BB)
+
R –
S2
(elbow)
Digit I
+
A –
R
C8
T1
G
S1
(wrist)
Lower trunk
Median
Digit V nerve
Medial cord

2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
50 ms 5 mV 40 mA 30 ms 5 mV 40 mA
4 4
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
50 ms 5 mV 83 mA 30 ms 5 mV 83 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the APB muscle; stimulation of the wrist (upper trace) and of the
elbow (lower trace)
M33 Wrist, Forearm – Hand 209
Upper trunk
C6
C7
Lateral cord
Middle trunk
Median S
nerve
(wrist)
Digit II R A
– +
G
Digit V
R
(digit II)
Typical waveform (wrist – digit II):
Median - Digit II Median - Digit II
1 4 1 4
Wrist 1 Wrist 1
10 ms 10 µV 22 mA 3 10 ms 20 µV 22 mA
3 14 14
Fig. 2 Antidromic sensory nerve action potential (SNAP) recorded to the digit II; stimulation of the wrist
motor terminal latency. The difference between these values several fixed distances between active recording and stimulat-
was termed the “residual latency” (RL) for the motor fibers. ing electrode: 6.5 cm (10/57––17.54 %), 7 cm (30/57––
Expected TL of the CMAP was recorded from the APB mus- 52.63 %), 8 cm (17/57––29.81 %). They calculated the
cle after stimulation at the wrist. The authors used in controls residual latency (RL) as follows:
Distance between cathode ( wrist ) and active electrode ( MT ) , ( mm )

Nerve conduction velocity ( elbow − wrist ) , ( m/s )
Residual Latency, RL ( ms ) = Observed TL ( ms ) − expected TL ( ms )
Perić and Sinanović, in their study, described a sensory– median nerve damage degree in the carpal tunnel syndrome
motor index (SMI) for electrophysiological evaluation of (CTS), as follows:
Distal distance, cm sensory nerve conduction velocity ( SCV ) , m/s

SMI = +
Distal motor latency, ms motor nerve conduction velocity ( MCV ) , m/s
Nerve conduction studies were performed in 57 hands with clinical diagnosis of CTS (38 women, mean age
from 57 healthy (Table 1) subjects (33 women, mean age 50.28 ± 11 years).
45.65 ± 9.68 years) and in 67 hands from 60 patients (Table 2)
C8
T1
R
Digit I
Lower trunk
Median
nerve
Medial cord
A
7 cm
– +
Digit V
S1
(wrist)
Fig. 3 Distal stimulation of the wrist––7 cm fixed distance (straight line) from the active recording (A) electrode on the APB muscle
M33 Wrist, Forearm – Hand 211

Normal values [1] Mean ± SD Range Limit
Wrist–APB, distal latency (ms) 3.14 ± 0.44 2.34–4 Pathological values [1] Mean ± SD Range of normal
Wrist–elbow, MNCV (m/s) 58.6 ± 5.75 49–70.98 Wrist–APB, distal latency (ms) 5.84 ± 1.90 4–15
Wrist–digit II, SNCV (m/s) 64.36 ± 9.16 50–85 Wrist–elbow, MNCV (m/s) 49.61 ± 10.45 18.2–71
Sensory motor index 3.45 ± 0.45 2.82–4.52 Wrist–digit II, SNCV (m/s) 39.39 ± 11.42 10–69.5
Terminal latency index 0.39 ± 0.13 0.29–0.61 Sensory motor index 2.13 ± 0.37 1.42–3.15 ≥2.82
Residual latency 1.90 ± 0.46 0.9–3.56 Terminal latency index 0.27 ± 0.06 0.16–0.38 ≥0.34
Residual latency 4.29 ± 1.55 2.4–10.61 ≤2.6
Comment with CTS and healthy subjects. The highest sensitivity

Perić and Sinanović [1] used in CTS patients several (98.51 %) was found in the sensory–motor index
fixed distances between the active recording and stim- (SMI) and residual latency (RL); the residual latency
ulating electrode: 6.5 cm (6/67––8.96 %), 7 cm had the highest specificity (91.23 %).
(47/67––70.15 %), 8 cm (14/67––20.89 %). The The application in a case of CTS is reported here
authors found statistical significant differences (Figs. 4 and 5).
between the mean values of all parameters in patients
2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
4 50 ms 5 mV 33 mA 4 30 ms 5 mV 33 mA
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
4 50 ms 5 mV 35 mA 4 30 ms 5 mV 35 mA
Onset latency (wrist – APB): 6.10 ms; Onset latency (elbow – APB): 11.10 ms; Peak latency (wrist – APB, 7 cm distance): 9.10 ms;
Peak latency (elbow – APB): 13.85 ms; Onset to peak amplitude (wrist – APB): 8.1 mV; Onset to peak amplitude (elbow – APB):
6.8 mV; Peak to peak amplitude (wrist – APB): 10.9 mV; Peak to peak amplitude (elbow – APB): 9.3 mV; MNCV (elbow – wrist, 25 cm
distance): 50.0 m/s
CTS classification scale [4], stimulation of the wrist (upper trace) and of the elbow (lower trace)
Pathological waveform (wrist – digit II):
Median - Digit II Median - Digit II
2
2
1 4 1 4
3 Wrist - Digit II 1 3 Wrist - Digit II 1
10 ms 10 µV 10 mA 20 ms 20 µV 10 mA
16 16
Onset latency: 4.65 ms; Peak latency: 5.85 ms; Onset to peak amplitude: 6.3 µV; Peak to peak amplitude: 11.3 µV; SNCV (13 cm
distance): 28.0 m/s
Distal distance, cm Sensory nerve conduction velocity (SNCV), m/s

If SMI = +
Distal motor latency, ms Motor nerve conduction velocity (MNCV), m/s
7 cm 28 m/s
then SMI = + = 1.15 + 0.56 = 1.71
6.1 ms 50 m/s
Fig. 5 Antidromic sensory nerve action potential (SNAP) recorded to the digit II in moderately severe CTS––grade 3 by Bland’s CTS classifica-
tion scale [4], stimulation of the wrist
References 3. Kraft GH, Halvorson GA (1983) Median nerve residual latency:

1. Perić Z, Sinanović O (2006) Sensory-motor index is useful param-
eter in electroneurographical diagnosis of carpal tunnel syndrome.
2. Simovic D, Weinberg DH (1997) Terminal latency index in the car-
pal tunnel syndrome. Muscle Nerve 20:1178–1180
Wrist – Hand
M34
Study from Medial Thenar (MT) Muscle
Original Settings Sensitivity was 5 mV/division, low-fre- Stimulation Median and ulnar compound muscle action
quency filter was 3 Hz, high-frequency filter was 10 kHz, potentials (CMAPs) were evoked with a bipolar handheld
sweep speed was 5 ms/division, and the machine used was a surface-stimulating electrodes. Stimulations were applied at
Medelec Oxford Synergy Instrument. Duration of pulse was the wrist at the same level for both median and ulnar nerves, at
not specified. a 2 cm fixed distance proximal to the proximal wrist crease.
Position This study was performed in the supine position, Measurements Distal latency (ms) of the median MTM CMAP
with the patient examined while lying down. was measured from the stimulus onset to the onset of the nega-
tive deflection of CMAP. Amplitude (mV) of the CMAP was
Recording Following belly-tendon method, the active measured from the baseline to the peak of the negative deflection
electrode (A) was placed over the medial thenar motor [1]. The authors measured median MTM CMAP distal latency
(MTM) muscle (Fig. 1), on the junction of the middle and and ulnar–medial thenar (ulnar MTM) CMAP latency differ-
radial third of a line connecting the medial aspect of the ence. Skin temperature was measured at the palmar wrist crease,
metacarpophalangeal joint of digit I (thumb) with the pisi- and a minimum of 30 °C was required for performing all tests.
form bone [1]. The reference (R) electrode was placed just The authors studied 64 control hands from 36 healthy (Table 1)
distal to the metacarpophalangeal joint of digit I over the subjects (18 women––50 %, age range 26–74 years, mean age
first proximal phalanx. The ground (G) electrode position 40.7 years) and 68 hands from 40 patients (Table 2) with clinical
was not specified (the figure shows the ground electrode diagnosis of carpal tunnel syndrome (CTS)––26 women, age
placed on the palm). range 33–82 years, mean age 45 years.

C8
T1
R
Medial thenar (MT)
Lower trunk
Median
nerve
Medial cord
S1
R
(wrist)
Digit II A
– + Median nerve
2 cm
G – + Ulnar nerve
Digit V
S2
(wrist)
Typical waveform (wrist - MT muscle):
Median - MTM Median - MTM

2 2
1 3 1 3
5 Median (MTM) 1 5 Median (MTM) 1
4 50 ms 2 mV 22 mA 4
30 ms 2 mV 22 mA
2 2
1 3 1 3 Ulnar (MTM) 2
Ulnar (MTM) 2
5 5 30 ms 2 mV 45 mA
50 ms 2 mV 45 mA
4 4
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the MTM muscle; stimulation of the wrist: median nerve (upper

Normal values [1] Mean ± SD showed that MTM has a dual innervation by both the
Median MTM, distal latency (ms) 3.3 ± 0.3 median and ulnar nerves. In one case of CTS only,
Ulnar MTM, distal latency (ms) 3.6 ± 0.4 they recorded a CMAP from MTM with a positive
Median MTM, negative peak amplitude (mV) 5.5 ± 2.7 deflection and same onset latency of CMAP recorded
Ulnar MTM, negative peak amplitude (mV) 5.8 ± 2.6 from APB, suggesting volume conduction. A CMAP
Median–ulnar MTM, distal latency difference (ms) −0.3 ± 0.4 recorded from MTM is a motor response from the
underlying median–nerve innervated muscles—
Table 2 Reference values the flexor pollicis brevis (FPB) and opponens pol-
Pathological values [1] Mean ± SD licis (OP) muscles, and ulnar–nerve innervated
Median MTM, distal latency (ms) 5.1 ± 1.6 muscle—adductor pollicis (AP), which are fused
Ulnar MTM, distal latency (ms) 3.7 ± 0.4 together, consistent with their functional interdepen-
Median MTM, negative peak amplitude (mV) 3.5 ± 2.3 dence. For the median motor distal latency record-
Ulnar MTM, negative peak amplitude (mV) 6.0 ± 2.5 ing over MTM, the authors found a high sensitivity
Median–ulnar MTM, distal latency difference (ms) 1.4 ± 1.6 and specificity (89.6 and 98.3 %, respectively), while
for the median and ulnar latency difference record-
ing over MTM, they found lower values for sensi-
Comment
tivity and specificity (76.1 and 94.9, respectively).
Wilder Smith et al. [1] found that in all cases but
The application in a case of carpal tunnel syndrome
one of CMAP recording from the MTM site, median
(CTS) is reported here (Fig. 2).
nerve stimulation resulted in a negative CMAP; this
Pathological waveform (wrist – MT muscle):
Median - ulnar (MTM) Median - ulnar (MTM)
2 2
1 3 1 3
4 4
50 ms 2 mV 43 mA
30 ms 2 mV 43 mA
2 2
1 3 1 3
5 50 ms 2 mV 66 mA 5 30 ms 2 mV 66 mA
4 4
Onset latency (median MTM): 5.60 ms; Onset latency (ulnar MTM): 3.50 ms; Onset latency difference (median MTM) - (ulnar MTM):
2.10 ms; Peak latency (median MTM): 9.55 ms; Peak latency (ulnar MTM): 6.75 ms; Onset to peak amplitude (median MTM): 1.7 mV;
Onset to peak amplitude (ulnar MTM): 7.3 mV; Peak to peak amplitude (median MTM): 2.4 mV; Peak to peak amplitude (ulnar MTM):
10.9 mV
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the MTM muscle in moderately severe CTS––grade 3 by Bland’s
CTS classification scale [2]; stimulation of the wrist: median nerve (upper trace) and ulnar nerve (lower trace)
References
1. Wilder Smith EP, Chan YH, Kannan TA (2007) Medial thenar
recording in normal subjects and carpal tunnel syndrome. Clin
M35
Original Settings The machine used was a Nihon Kohden taking care when the midpalm stimulation is performed,
Neuropack 8 electromyograph. Sensitivity, low-frequency because stimulation of the deep branch of the ulnar nerve
filter, high-frequency filter, sweep speed, and duration of could also generate a motor response over the thenar emi-
pulse were not specified. nence. Only supramaximal stimuli were used, because
despite an increase in the intensity of the stimulus, no
Position This study was performed in the supine position. increase in the compound muscle action potential (CMAP)
amplitude was observed.
Recording The active electrode (A) was placed over the
belly of the abductor pollicis brevis (APB) muscle (Fig. 1), Measurements Distal latency (ms) was measured from the
halfway between the midpoint of the distal wrist crease and stimulus onset to the onset of the negative deflection of the
the midpoint of the first metacarpophalangeal joint [1]. The CMAP. Amplitude (mV) was determined from the baseline
reference (R) was placed slightly distal to the first metacar- to the negative peak. Skin temperature was maintained at or
pophalangeal joint, over the distal tendinous insertion of the above 26 °C. The authors calculated the wrist–palm (W–P)
APB muscle. The ground (G) electrode was placed on the motor conduction velocity (MNCV) and median terminal
dorsum of the hand. The figure shows ground electrode posi- latency ratio (TLR). The median terminal latency ratio was
tioned on the palm. calculated as the motor terminal latency at the wrist (MTL-
W) divided by the motor terminal latency on the palm (MTL-
Stimulation The median nerve was stimulated using sur- P), as follows:
face electrodes at two points along its course: at the wrist
Terminal latency at the wrist, ( ms )
(S1) and on the palm (S2). At the wrist (S1), shocks were TLR =
applied proximal to the distal wrist crease, at a distance of Terminal latency on the palm, ( ms )
8 cm from the proximal active electrode (A) placed over the
belly of the abductor pollicis brevis (APB) muscle [1]. The Nerve conduction studies were performed in 200 hands
anode was proximal. To stimulate the median motors fibers (Table 1) from 100 control subjects (85 women and 15 men,
in the palm (S2), the cathode (−) was placed at the same site mean age 48.5 ± 11.4 years) and in 274 hands (Table 2) from
used for midpalm sensory stimulation; the authors, to avoid 153 patients with clinically suspected carpal tunnel syn-
depolarization of the recurrent thenar nerve to the APB mus- drome (CTS)––121 women and 32 men, one hand from 32
cle under the anode, directed the anode (+) distally toward CTS patients, both hands from 121 patients, mean age
the base of the digit V, using Chang’s method [2]. They suggested 52.5 ± 12.3 years.

218 M35 Wrist , Palm – Hand
C8
T1
R
Lower trunk Digit I

Median
nerve Medial cord
G 8 cm
– – +
+
Digit V
S1
S2 (wrist)
(palm)

2 2
1 3 1 3
5 Wrist 1 5 Wrist 1
4 4 50 ms 5 mV 20 mA
30 ms 5 mV 20 mA
2 2
1 3 1 3 Palm 2
5 Palm 2 5
30 ms 5 mV 37 mA 50 ms 5 mV 37 mA
4 4
palm (lower trace)
M35 Wrist, Palm – Hand 219

Normal values [1] Mean ± SD Mean ± 2 SD Comment
Terminal latency ratio 1.54 ± 0.17 <1.88 Lee et al. [1] investigated a new short-segment transcar-
pal motor conduction technique, exploring the diagnos-
tic value of the motor conduction index of the terminal
latency ratio (TLR) of the wrist–palm (W–P). They
Table 2 Reference values compared its sensitivity to other commonly used CTS
Sensory conduction study Positive hands Sensitivity techniques. Among the sensory conduction studies, the
Wrist–digit II, SNCV (m/s) 244 89.1 distoproximal ratio by Padua et al. [3] was the most sen-
Wrist–digit III, SNCV (m/s) 244 89.1 sitive measure for diagnosing CTS (92.3 %). Among the
Wrist–palm, SNCV (m/s) 248 90.5 motor conduction studies, the TLR of the wrist–palm
Distoproximal ratio 253 92.3 was the most sensitive (81.8 %) and was superior to the
Terminal latency difference (ms) Positive hands Sensitivity MNCV of the P–W segment [2, 4–6], which had a sen-
Median thenar–ulnar thenar 199 72.6 sitivity of 77.7 %. To calculate the MNCV of the P–W
Median thenar–ulnar hypothenar 175 63.9 segment, some time is consumed to take the distance
Motor conduction study Positive hands Sensitivity between the palm and wrist sites of stimulation, and it
Palm, motor terminal latency (ms) 164 59.9 can be a source of error, because the median nerve in the
Wrist, motor terminal latency (ms) 165 60.2 palm has a curved course rather than linear. To calculate
Palm–wrist, MNCV (m/s) 213 77.7 the TLR of the wrist–palm segment, as in the transcarpal
Terminal latency ratio 224 81.8 motor technique, only an additional stimulus in the palm
is required to apply the formula, avoiding a calculation
error caused by the wrist–palm measurements. The
application in a case of carpal tunnel syndrome (CTS) is
reported here (Fig. 2).
220 M35 Wrist , Palm – Hand
2 2
1 3 5 1 3 5
4 Wrist 1 4 Wrist 1
30 ms 5 mV 48 mA 20 ms 5 mV 48 mA
2 2
1 3 1 3
5 Palm 2 5 Palm 2
30 ms 5 mV 29 mA
4 4 20 ms 5 mV 29 mA
Onset latency (wrist – APB): 5.00 ms; Onset latency (palm – APB): 2.10 ms
Terminal latency ratio (wrist – APB muscle, palm – APB muscle) calculation:
Terminal latency at the wrist, (ms) 5.0 ms

TLR = = = 2.38
Terminal latency on the palm, (ms) 2.1 ms
CTS classification scale [7]; stimulation of the wrist (upper trace) and on the palm (lower trace)
References 4. Kimura J (1978) A method for determining median nerve conduc-

tion velocity across the carpal tunnel. J Neurol Sci 38:1–10
1. Lee KY, Lee YJ, Koh SH (2009) Usefulness of the median terminal 5. Kimura J (1979) The carpal tunnel syndrome: localization of con-
latency ratio in the diagnosis of carpal tunnel syndrome. Clin duction abnormalities within the distal segment of the median nerve.
Neurophysiol 120:765–769 Brain 102:619–635
2. Chang MH, Wei SJ, Chiang HL et al (2002) Comparison of motor 6. Chang MH, Liu LH, Lee YC et al (2006) Comparison of sensitivity
conduction techniques in the diagnosis of carpal tunnel syndrome. of transcarpal median motor conduction velocity and conventional
Neurology 58:1603–1607 conduction techniques in electrodiagnosis of carpal tunnel syn-
3. Padua L, Lo Monaco M, Valente EM et al (1996) A useful electro- drome. Clin Neurophysiol 117:984–991
physiologic parameter for diagnosis of carpal tunnel syndrome. 7. Bland JDP (2000) A neurophysiological grading scale for carpal
Muscle Nerve 19:48–53 tunnel syndrome. Muscle Nerve 23:1280–1283
Wrist, Forearm, Elbow – Hand
M36
Study from Second lumbrical (2L) muscle
Original Settings Sensitivity was 5 mV/division, low- Measurements Distal latency (ms) of the 2L muscle’s com-
frequency filter was 3 Hz, high-frequency filter was 10 kHz, pound muscle action potential (CMAP) was measured from
sweep speed was 5 ms/division, duration of pulse was the stimulus onset to the onset of the negative deflection of the
0.5 ms, and the machine used was a Medelec Oxford Synergy CMAP. Palm and forearm conduction velocities (MNCV)
Instrument. were calculated in the conventional way for each of the tested
segments (palm–distal forearm, distal forearm–elbow), divid-
Position This study was performed in the supine position. ing the distance by the latency. The nerve conduction veloci-
ties were measured in meter per second (m/s). The distances
Recording The active electrode (A) was placed slightly lat- were measured from the cathodal stimulation points on the
eral to the midpoint of the third metacarpal bone, over the palm, at the distal forearm, and at the elbow. The hands were
belly (motor point) of the second lumbrical (2L) muscle cleaned before each test; the palmar skin was carefully mea-
(Figs. 1 and 2). The reference (R) electrode was placed over sured and maintained above 32 °C. The MNCV in the palm–
the bony prominence of the proximal interphalangeal joint of distal forearm segment (transcarpal MNCV) was performed
the digit II (index finger). If necessary, authors repositioned always at a fixed distance (range 10–14 cm). The authors also
the active (A) electrode to obtain an optimal motor point and/ calculated the MNCV ratio (2L–MC) between MNCV P–DF
or ground to improve the motor response [1]. The ground (G) (motor nerve conduction velocity in the palm–distal forearm
electrode was placed between the stimulating and recording segment) and MNCV DF–E (motor conduction velocity in the
sites to minimize the artifact. The figure shows the ground distal forearm–elbow segment) in 25 healthy subjects and 121
positioned at the middle forearm (between S2 and S3 stimu- patients with carpal tunnel syndrome (CTS), as follows:
lation points).
Stimulation The stimulations were on the midpalm (S1), MNCV palm − distal forearm, ( m/s )
2L−MC =
at the distal forearm (S2), and at the elbow (S3). On the MNCV distal forearm− elbow , ( m/s )
palm (S1), the stimulation was 4–5 cm proximal to the
recording electrode placed distally on the 2L muscle. Palm
stimulation was performed at the site where the digit IV The authors performed nerve conduction studies in 49
touches the medial region of the thenar eminence. control hands from 25 healthy subjects (Table 1) without
Stimulation at the distal forearm (S2) was performed CTS (mean age, 43 years; age range, 23–78 years) and
10–14 cm proximal (minimum 10 cm) from the palm stim- in 121 patients (Table 2) with carpal tunnel syn-
ulation (cathode–cathode). drome (CTS), divided into two groups––Moderate CTS
At the elbow (S3), stimulation was medial to the tendon Group and Mild CTS Group (95 women––78.5 % and
of the biceps brachii (BB) muscle, 3 cm lateral to the medial 26 men––21.5 %; 50 % <50 years and 90 % <65 years;
epicondyle [1]. age range, 20–79 years; mean age, 49 ± 12 years).

222 M36 Wrist, Forearm, Elbow – Hand
Biceps brachii
(BB)
S3
(elbow)
+
– Medial
epicondyle
3 cm
R
G
+
–
Digit I
10–14 cm
+ S2
A –
R (forearm) C8
4–5 cm T1
S1
(palm)
Lower trunk
Median
Digit V nerve
Medial cord
Typical waveform (palm, distal forearm, elbow – 2L muscle):

Median - (2L) Median - (2L)
2
2
1 3 1 3 5 Palm 1
5 Palm 1 4
50 ms 5 mV 20 mA
30 ms 2 mV 20 mA
4
2
2
1 3 5 1 3 5
Forearm 2 4 Forearm 2
4 30 ms 2 mV 20 mA 50 ms 5 mV 20 mA
2
2
1 3 5 1 3 5
Elbow 3 4 Elbow 3
4 30 ms 2 mV 20 mA 50 ms 5 mV 20 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L muscle; stimulation on the palm (upper trace), distal fore-
arm (middle trace), and of the elbow (lower trace)
M36 Wrist, Forearm, Elbow – Hand 223
C8
T1
R
Lower trunk
Median
nerve Medial cord
Digit II R
A 10–14 cm
– + – +
4–5 cm
Digit V
S2
S1 (distal forearm)
(palm)
Fig. 2 Stimulations on the palm (S1) and of the distal forearm (S2), at 4–5 cm and at 10–14 cm from the recording electrode (A) on the 2L muscle,
respectively

Normal values [1] Mean ± SD Pathological values [1]––Moderate CTS Group Mean ± SD
Palm–distal forearm, MNCV (m/s) 50.8 ± 2.9 Palm–distal forearm, MNCV (m/s) 27.5 ± 8.9
Distal forearm–elbow, MNCV (m/s) 52.4 ± 4.4 Distal forearm–elbow, MNCV (m/s) 52.4 ± 4.4
2L–MC (ratio MNCV) 0.97 ± 0.06 2L–MC (ratio MNCV) 0.53 ± 0.17
Pathological values [1]––Mild CTS Group Mean ± SD
Palm–distal forearm, MNCV (m/s) 45.9 ± 5.6
Distal forearm–elbow, MNCV (m/s) 51.6 ± 3.7
2L–MC (ratio MNCV) 0.89 ± 0.1
Pathological values [1] 2L–INT >0.40 ms 2L–INT ≤0.40 ms Total hands

2L–MC <80 % 103 17 120 (moderate CTS)
2L–MC ≥80 % 4 92 96 (mild CTS)
Total hands 107 (moderate CTS) 109 (mild CTS) 216
224 M36 Wrist, Forearm, Elbow – Hand
Comment consistent with moderate CTS, 109 hands of 216

Pardal-Fernández et al. [1] divided a total of 216 CTS (50.5 %) had a normal 2L–INT test (≤0.40 ms), and
hands in two groups on the basis of a differential latency these cases were consistent with mild CTS. With both
obtained in the 2L–INT DIFF test, using the same tests (2L–INT and 2L–MC), 120 of 216 hands had
10 cm distance, both for median and ulnar nerves’ stim- moderate CTS with 2L–MC <80 % (103 hands with
ulation at the wrist: Moderate CTS Group (107 hands) 2L–INT >0.40 ms, 17 hands with 2L–INT ≤0.40 ms),
with 2L–INT >0.40 ms and Mild CTS Group (109 and 96 hands had mild CTS with 2L–MC ≥80 % (4
hands) with 2L–INT ≤0.40 ms. On the basis of the hands with 2L–INT >0.40 ms, 92 hands with 2L–INT
results obtained in 2L–INT test (>0.40 ms or ≤0.40 ms), ≤0.40 ms). The authors found for the 2L–MC test a
the authors investigated the decrease in the motor con- sensitivity of 97 % with 0 % false-positives and a speci-
duction velocity in the palm–distal forearm (2L–MC) ficity of 100 % with 4 % false-negatives; using the 2L–
segment (<80 % or ≥80 %) and the velocity in the distal MC test, they diagnosed the motor involvement in 14 %
forearm–elbow proximal segment. Out of 216 hands, more hands than 2L–INT DIFF test. The application in
107 (49.5 %) had abnormal 2L–INT test (>0.40 ms) a case of CTS is reported here (Fig. 3).
Pathological waveform (palm, distal forearm, elbow – 2L muscle):
Median - (2L) Median - (2L)
2
2
1 3 5 Palm 1 1 3 5 Palm 1
4
4
30 ms 2 mV 35 mA 50 ms 5 mV 35 mA
2
2
1 3 5 1 3 5
Forearm 2 4 Forearm 2
4
30 ms 2 mV 57 mA 50 ms 5 mV 57 mA
2
2
1 3 5 1 34 5
Elbow 3 Elbow 3
4
30 ms 2 mV 38 mA 50 ms 5 mV 38 mA
Onset latency (palm – 2L): 1.75 ms; Onset latency (distal forearm – 2L): 4.65 ms; Onset latency (elbow – 2L):7.90 ms; Peak latency
(palm – 2L): 6.60 ms; Peak latency (distal forearm – 2L): 9.55 ms; Peak latency (elbow – 2L): 13.05 ms; Onset to peak amplitude
(palm – 2L): 1.5 mV; Onset to peak amplitude (distal forearm –2L): 1.0mV; Onset to peak amplitude (elbow – 2L): 1.0 mV; Peak to
peak amplitude (palm – 2L): 2.5 mV; Peak to peak amplitude (distal forearm – 2L): 1.8 mV; Peak to peak amplitude (elbow – 2L):
1.8 mV; MNCV (palm – distal forearm, distance 12 cm): 41.4 m/s; MNCV (distal forearm – elbow, distance 22 cm): 67.7 m/s
2L-MC ratio (palm – distal forearm, distal forearm – elbow) calculation:
MNCV palm – distal forearm, (m/s) 41.4 m/s

2L-MC = = = 0.61
MNCV distal forearm – elbow, (m/s) 67.7 m/s
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the hand from the 2L muscle in moderately severe CTS––grade 3 by Bland’s
CTS classification scale (2); stimulation on the palm (upper trace), distal forearm (middle trace), and elbow (lower trace)
References 225
References
1. Pardal-Fernández JM, Vega-González G, Rodríguez-Vázquez M
et al (2012) A new median motor test: comparison with conventional
motor studies in carpal tunnel syndrome. J Clin Neurophysiol
29:84–88
Part II
Anterior Interosseous Nerve
(Motor Branch of the Median Nerve)
Above Elbow, Below Elbow – Distal
Forearm A1
Study from Pronator Quadratus Muscle
Original Settings Sensitivity, low-frequency filter, high- below the elbow (S2)—proximal forearm, 10 cm below the
frequency filter, sweep speed, duration of pulse, and the level of the lateral epicondyle over the flexor digitorum
machine used were not specified. superficialis (FDS) muscle. The anode was proximal in both
stimulations. The threshold stimulus voltage was determined
Position This study was performed in the supine position, for all fibers lying beneath the stimulating electrodes, after
with the patient’s arm stabilized on the arm board attached to which a supramaximal stimulus of at least twice threshold
the examination table. was delivered [1].
Recording Using a concentric needle electrode, the anterior Measurements Latency (ms) of the compound muscle
interosseous nerve conduction studies were performed using action potential (CMAP) was measured from the stimulus
intramuscular recording [1]. The needle-recording electrode artifact to the onset of the negative deflection of CMAP. The
was placed in the pronator quadratus (PQ) muscle (Fig. 1), authors moved the needle to avoid initial positive deflection
on the dorsal aspect of the distal forearm (2–3 cm proximal until an initial negative deflection was obtained, but multiple
to the ulnar styloid in the middle). Ground (G) electrode needle placements caused discomfort for some patients, and
position was not specified (the figure shows the ground elec- in these cases, a satisfactory negative deflection was not
trode placed on the forearm). recorded (contraction of the forearm flexor muscles possibly
determined volume conducted potentials). The duration of
Needle Insertion For the PQ muscle, with the forearm in a the CMAP was measured from the onset of the negative
neutral position to full pronation, the recording needle elec- deflection to the isoelectrical point of the negative spike
trode was inserted dorsally 2–3 cm proximal to the ulnar sty- (negative deflection only). The distance from the stimulating
loid, just lateral (in the radial direction) to the ulna, to a depth cathode (−) to the recording needle electrode was determined
of 2–2.5 cm. by measuring tape, but fixed or mean distance was not
reported. Skin and room temperatures were not reported.
Stimulation The median nerve was stimulated percutane- Normal values (Table 1) were obtained in 84 anterior interos-
ously above the elbow (S1), on the ventromedial side of the seous nerves from 46 control subjects (34 women and 12
arm in the region of the biceps brachii (BB) muscle, and men, age range 9–67 years, average age 40.2 years).

230 A1 Above Elbow, Below Elbow – Distal Forearm
Middle trunk
Biceps brachii
(BB)
C7
C8
Lateral cord S2
T1 +
(below elbow) –
10 cm
Lower trunk
Median +
nerve –
Medial cord
S1
(above elbow)
G
Digit I
R
Pronator quadratus
(PQ)
PQ
Digit V
Typical waveform (above elbow, below elbow – PQ muscle):

Ant inteross - (PQ) Ant inteross - (PQ)
2 2
1 3 1 3
5 Elbow 1 5 Elbow 1
4 4
50 ms 5 mV 74 mA 30 ms 5 mV 74 mA
2 2
1 3 1 3
5 Forearm 2 5 Forearm 2
4 4
50 ms 5 mV 74 mA 30 ms 5 mV 74 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the distal forearm from the PQ muscle; stimulation above the elbow (upper
trace) and below the elbow–proximal forearm (lower trace)
A1 Above Elbow, Below Elbow – Distal Forearm 231

Normal values [1] Mean ± SD Comment
Above elbow–PQ, latency (ms) 5.1 ± 0.9 Nakano et al. [1] found a prolonged duration of the
Below elbow–PQ, latency (ms) 3.6 ± 0.8 negative deflection of the CMAP in seven patients with
Duration (ms) 3.6 ± 1.1 anterior interosseous nerve syndrome (four women
and three men, age range 9–60 years). In five of these
patients, they found a prolonged latency of the CMAP
In 1995, Shafshak and El-Hinawy [2] used PQ muscle (in the above elbow–PQ segment), while in two the
bipolar needle recording performing the technique described latency of the CMAP was normal. The amplitude was
by Nakano and colleagues [1], with a modification (Fig. 2). considerably attenuated in four patients.
They stimulated the median nerve at only one site at the
lower part of the arm (near the elbow), medial to the upper
part of the BB tendon. recordings were performed in a room temperature of 25 °C
Shafshak and El-Hinawy [2] used supramaximal stimula- and a skin temperature between 31 °C and 33 °C. They
tion (0.2 ms duration; pulse rate 1 Hz). They measured ante- compared surface [3] and needle [1] recordings techniques,
rior interosseous nerve onset latency (ms) from the stimulus both in control subjects and patients. Using needle method,
artifact to the first negative takeoff (they avoided initial posi- they studied only 20 anterior interosseous nerves from 10
tive deflection) and peak-to-peak amplitude (mV). The control subjects (from a total of 25 healthy subjects—13
Middle trunk
Biceps brachii
(BB)
C7
C8
Lateral cord
T1
+
–
Lower trunk
G
Median
nerve
Medial cord
S
Ulnar styloid
(elbow)
R
Pronator quadratus (PQ)
Digit I
Fig. 2 PQ muscle needle recording; stimulation of the elbow

women and 12 men; age range, 18–57 years; average age, 42 conduction on other nerves); Group 3—5 men (age range,
years), because it was a rather painful procedure (Table 2). 37–50 years) with diabetic mononeuritis multiplex, and
The upper limit (mean ± 2SD) for anterior interosseous unobtainable both median distal motor and sensory con-
nerve latency in the forearm segment (elbow–PQ) using duction (normal conduction on other nerves); Group 4—5
needle technique was 5.0 ms. The longest latency in con- men (age range, 23–55 years) with unilateral clinically
trols was 5.2 ms. This study was also performed by definite acute CTS and having complete denervation of the
Shafshak and El-Hinawy [2] on six different groups of thenar muscles, and unobtainable both median distal motor
patients (Table 3), as follows: Group 1—25 patients (13 and sensory conduction (normal conduction on other
women and 12 men, aged 22–40 years) with clinically defi- nerves); Group 5—11 women (age range, 27–53 years)
nite carpal tunnel syndrome (CTS), and having both con- with clinically diagnosed severe unilateral CTS, and unob-
ventional abnormal motor (4.8–13.3 ms) and sensory tainable both median distal motor and sensory conduction
(>5.0 ms) latencies (normal conduction on other nerves); (normal conduction on other nerves); Group 6—2 men (age
Group 2—11 patients (8 men and 3 women, aged 23–51 range, 21–39 years) with unilateral pronator teres syn-
years) with clinically definite polyneuropathy, and having drome (PTS).
abnormal motor distal latency (5.8–15.5 ms) and slow In 1999, Seror [4] studied 30 anterior interosseous nerves
median motor NCV (9–37 m/s) at the forearm (normal from 30 control subjects (Table 4) and 21 pathological cases.

Normal values [2] Mean ± SD Range Comment
Elbow–PQ, latency (ms) 3.95 ± 0.5 3.1–5.2 In light of their study, Shafshak and El-Hinawy [2] rec-
Elbow–PQ, latency difference 0.38 ± 0.28 0.0–0.9 ommend determining the anterior interosseous nerve
side-to-side (ms) latency (AINL) for excluding median nerve neuropa-
Elbow–PQ, peak-to-peak 9.10 ± 3.9 5.0–16.0 thy, especially in patients with normal ulnar and radial
amplitude (mV) motor and sensory conductions (which might exclude
peripheral neuropathy) but unobtainable median nerve
distal conduction. In these cases, performing AINL
gives information about the presence of CTS or entrap-
Pathological values [2] Range ment neuropathy of the median nerve at the forearm.
Elbow–PQ, latency (ms)—Group 1 3.1–5.0 The applications in cases of anterior interosseous nerve
Elbow–PQ, latency (ms)—Group 2 10.3–36 syndrome (AIN) are reported (Figs. 3 and 4).
Elbow–PQ, latency (ms)—Group 3 –
Elbow–PQ, latency (ms)—Group 4 3.9–5
Elbow–PQ, latency (ms)—Group 5 3.8–5.1
Elbow–PQ, latency (ms)—Group 6 5.4–6.2

Elbow–PQ, peak-to-peak amplitude (mV)—Group 1 4–12 Table 4 Reference values
Elbow–PQ, peak-to-peak amplitude (mV)—Group 2 1.5–4 Normal values [4] Mean ± SD Range
Elbow–PQ, peak-to-peak amplitude (mV)—Group 3 – Elbow–PQ, latency (ms) 4.1 ± 0.56
Elbow–PQ, peak-to-peak amplitude (mV)—Group 4 4–10 Elbow–PQ, latency difference 0.0–0.6
Elbow–PQ, peak-to-peak amplitude (mV)—Group 5 2.5–6 side-to-side (ms)
Elbow–PQ, peak-to-peak amplitude (mV)—Group 6 1.7–3.8 Elbow–PQ, peak-to-peak amplitude (mV) 14.7 ± 4.3 7–24
A1 Above Elbow, Below Elbow – Distal Forearm 233
Pathological waveform (above elbow, below elbow-proximal forearm – PQ muscle):
Ant inteross - PQ Ant inteross - PQ
2 2
1 3 5 Elbow 1 1 3 5 Elbow 1
50 ms 1 mV 77 mA 30 ms 1 mV 77 mA
4 4
2 2
1 3 5 Forearm 2 1 3 5 Forearm 2
50 ms 1 mV 77 mA 30 ms 1 mV 77 mA
4 4
Onset latency (above elbow – PQ): 6.15 ms; Onset latency (below elbow-proximal forearm – PQ): 4.50 ms; Peak latency (above elbow –
PQ): 8.20 ms; Peak latency (below elbow-proximal forearm – PQ): 6.90 ms; Onset to peak amplitude (above elbow – PQ): 1.1 mV;
Onset to peak amplitude (below elbow-proximal forearm – PQ): 4.9 mV; Peak to peak amplitude (above elbow – PQ): 2.0 mV; Peak to
peak amplitude (below elbow-proximal forearm – PQ): 2.1 mV; MNCV (above elbow – below elbow-proximal forearm, 11 cm distance):
66.6 m/s
Fig. 3 Compound muscle action potentials (CMAPs) recorded at the distal forearm from the PQ muscle in a case of anterior interosseous nerve
syndrome (AIN); stimulation above the elbow (upper trace) and below the elbow—proximal forearm (lower trace)
Pathological waveform (above elbow, below elbow-proximal forearm – PQ muscle):
2 2
3 3 Elbow 1
1 Elbow 1 1
50ms 1mV 100mA 30ms 1mV 100mA
2 2
5 5
1 3 Forearm 2 1 3 Forearm 2
4 4
50ms 1mV 81mA 30ms 1mV 81mA
Sensitivity 1 mv/div, sweep speed 5 ms/div Sensitivity 1 mv/div, sweep speed 3 ms/div
Onset latency (above elbow – PQ): 9.80 ms; Onset latency (below elbow-proximal forearm – PQ): 6.20 ms; Peak latency (above elbow –
PQ): 11.30 ms; Peak latency (below elbow-proximal forearm – PQ): 8.80 ms; Onset to peak amplitude (above elbow – PQ): 0.5 mV;
Onset to peak amplitude (below elbow-proximal forearm – PQ): 0.7 mV; Peak to peak amplitude (above elbow – PQ): 0.4 mV; Peak to
peak amplitude (below elbow-proximal forearm – PQ): 1.1 mV; MNCV (above elbow – below elbow-proximal forearm, 12 cm distance):
33.3 m/s
Fig. 4 Compound muscle action potentials (CMAPs) recorded at the distal forearm from the PQ muscle in a case of anterior interosseous nerve
syndrome (AIN); stimulation above the elbow (upper trace) and below the elbow—proximal forearm (lower trace)
References with unobtainable median nerve distal conduction. Arch Phys

3. Mysiw WJ, Colachis SC (1988) Electrophysiologic study of
1. Nakano KK, Lundergan C, Okihiro MM (1977) Anterior interosse-
the anterior interosseous nerve. Am J Phys Med Rehabil
ous nerve syndromes. Diagnostic methods and alternative treat-
67:50–54
ments. Arch Phys Med Rehabil 34:477–480
4. Seror P (1999) Electrodiagnostic examination of the anterior inter-
2. Shafshak TS, El-Hinawy YM (1995) The anterior interosseous
osseous nerve normal and pathological data (21 cases).
nerve latency in the diagnosis of severe carpal tunnel syndrome
Electromyogr Clin Neurophysiol 39:183–189
Elbow – Forearm
A2
Study from Flexor Pollicis Longus (FPL) Muscle
Original Settings Sensitivity was 5 mV/division, low- trode was placed over the radius between the stimulating and
frequency filter was 10 Hz, high-frequency filter was 10 kHz, recording electrodes [1].
sweep speed was 2.5 ms/division, duration of pulse was
0.1 ms, rate of pulse was 1 Hz, and the machine used was a Stimulation The median nerve was stimulated just proxi-
TECA Model B-2 electromyograph. mal to the elbow (S), with the cathode proximal to the ante-
cubital crease of the elbow and just medial to the tendon of
Position This study was performed with the subjects lying the biceps brachii (BB) muscle. The anode was proximal.
supine on a treatment table with the left arm resting comfort-
ably at their side. The shoulder was abducted about 10°, and the Measurements Latency (ms) of the compound muscle
elbow was fully extended, with the forearm in supine position. action potential (CMAP) from FPL muscle was measured
from the stimulus onset to the onset of the negative deflec-
Recording Using the surface electrodes, the anterior inter- tion of CMAP. Amplitude (mV) of the CMAP was deter-
osseous nerve conduction studies were performed using sur- mined from the baseline to the negative peak. The mean
face recording. The surface electrodes were placed over the distance from the proximal electrode to the most distal
flexor pollicis longus (FPL) muscle (Fig. 1), with the active volar crease of the wrist (38 % of the length of the fore-
(A) electrode placed optimally over the lateral distal one- arm) was 9.6 ± 0.32 cm (distance range, 9.1–10.2 cm). Skin
third of the anterior surface of the forearm at a point repre- temperature was not measured, and the room temperature
senting the distal 38 % of the forearm length, measured from was maintained relatively constant. Normal conduction stud-
the most distal volar crease of the wrist to the antecubital ies (Table 1) were performed in 25 left anterior interosse-
crease at the elbow. The reference (R) electrode was placed ous nerves from 25 healthy women (age range, 20–25 years;
distally over the tendon of the FPL muscle. Ground (G) elec- average age, 22 years).

236 A2 Elbow – Forearm
Biceps brachii
Middle trunk (BB)
C7
C8
Lateral cord
T1
+
–
G
Lower trunk
Median
nerve
Medial cord
50 % S
A (elbow)
38 %
Digit I
R
R
Flexor pollicis longus (FPL)
Digit V
Typical waveform (elbow – FPL muscle):

Ant inteross - (FPL) Ant inteross - (FPL)
2 2
1 3 1 3
Elbow 1 Elbow 1
5 5
50 ms 2 mV 35 mA 30 ms 2 mV 35 mA
4 4
Fig. 1 Compound muscle action potential (CMAP) recorded at the forearm from the FPL muscle, stimulation of the elbow
A2 Elbow – Forearm 237

Normal values [1] Mean ± SD Range Limit of normal compared forearm motor recording from flexor pollicis
Elbow–FPL, latency (ms) 2.6 ± 0.16 1.8–3.6 ≤4.0 longus (FPL) muscle with conventional motor record-
Elbow–FPL, negative 5.6 ± 1.16 3.8–7.5 ≥2.5 ing from abductor pollicis brevis (APB) muscle. The
peak amplitude (mV) mean latency of the anterior interosseous nerve from
the point of stimulation (elbow) to the proximal record-
ing site (FPL muscle at the forearm) was 37 %
(2.6 ± 0.16 ms) of the mean latency of the median nerve
from the point of stimulation (elbow) to the distal
Comment recording site (APB muscle at the hand, 7.0 ± 0.51 ms).
Craft et al. [1] compared three different sites for The mean negative peak amplitude from the FPL mus-
recording CMAP from FPL muscle: one placed at a cle recorded proximally at the forearm (5.6 ± 1.16 mV)
distal point (28 % of the forearm length), one in the was 50 % of the mean negative peak amplitude from
middle of the forearm length (33 %), and one proximal the APB muscle recorded distally at the hand
to the stimulation site (38 % of the forearm length). (11.3 ± 2.79 mV). The authors concluded that the opti-
Length of the forearm was measured, starting from the mal site for placement of the active recording electrode
distal wrist crease up to the elbow. The authors chose was over the lateral distal one-third of the anterior sur-
flexor pollicis longus (FPL) muscle, because it could face of the forearm at a point representing the distal
be more readily palpated and isolated in the forearm 38 % of the length of the forearm when the median
than the other muscles innervated by the anterior inter- nerve was stimulated just proximal to the elbow. They
osseous nerve, pronator quadratus (PQ), and flexor also suggested using a latency of 4.0 ms and an ampli-
digitorum profundus (FDP). Craft et al. [1] found tude of 2.5 mV as limits of normal motor conduction
proximal recording site (38 % of the forearm length) of the anterior interosseous nerve and negative peak
the optimal site for recording, because from the proxi- CMAP amplitude for recording from the flexor pollicis
mal point they recorded the highest CMAP negative longus (FPL) muscle, respectively. The applications in
peak amplitude, the optimum waveform, the smallest the cases of anterior interosseous nerve syndrome
possible deflection preceding the negative deflection, (AIN) are reported (Figs. 2 and 3).
the fewest phases in the waveform, the optimum laten-
cies, and conduction characteristics. The authors also
Pathological waveform (elbow – FPL muscle):
2 2
1 3 1 3
Elbow 1 Elbow 1
5
50 ms 2 mV 64 mA 30 ms 2 mV 64 mA
4 4
Onset latency (elbow – FPL): 4.85 ms; Peak latency (elbow – FPL): 8.90 ms; Onset to peak amplitude (elbow – FPL): 6.3 mV;
Peak to peak amplitude (elbow – FPL): 9.6 mV
Fig. 2 Compound muscle action potential (CMAP) recorded at the forearm from the FPL muscle in a case of anterior interosseous nerve syndrome
(AIN), stimulation of the elbow
A2 Elbow – Forearm 239
2 2
1 3 5 Elbow 1 1 3 5
4 4 Elbow 1
50 ms 2 mV 23 mA 30 ms 2 mV 23 mA
Onset latency (elbow – FPL): 6.60 ms; Peak latency (elbow – FPL): 11.70 ms; Onset to peak amplitude (elbow – FPL): 0.7 mV; Peak to
peak amplitude (elbow – FPL): 1.4 mV
(AIN), stimulation of the elbow
Reference
1. Craft S, Currier DP, Nelson RM (1977) Motor conduction of the ante-
rior interosseous nerve. Phys Ther 57:1143–1147
Elbow – Distal Forearm
A3
Study from Pronator Quadratus (PQ) Muscle
Original Settings Low-frequency filter was 20 Hz, high- The anode was proximal. Authors used a 20–25 % supra-
frequency filter was 10 kHz, duration of pulse was 0.1– maximal stimulus with 01–0.2 ms duration.
0.2 ms and the machine used was a TECA model
M. Sensitivity and sweep speed were not specified. Measurement Latency (ms) of the compound mus-
cle action potential (CMAP) was measured from the
Position This study was performed with the subject com- stimulus onset to the onset of the negative deflection of
fortably seated, the elbow flexed approximately 90°, and the CMAP. Amplitude (mV) of the CMAP was determined
forearm fully pronated (figure shows arm in a neutral posi- from the baseline to the negative peak. Duration of the
tion, elbow fully extended). CMAP was measured from the onset of the negative deflec-
tion to the isoelectrical point of the negative spike (negative
Recording Using the surface electrodes, the anterior interos- deflection only). Distances were measured with the elbow
seous nerve conduction studies were performed using surface flexed and fully pronated, and measurements of the dis-
recording [1]. The active recording electrode (A) was placed tance from the stimulating cathode (−) and active recording
over the pronator quadratus (PQ) muscle (Fig. 1), centrally electrode (A) remained equal between extremities to mini-
over the dorsum of the forearm 3 cm proximal to the ulnar mize errors in side-to-side conduction comparison (range
styloid (Fig. 2). The reference electrode (R) was placed dis- 17.5–28 cm, mean 23 cm). Temperatures of the extremi-
tally to the ulnar styloid. Ground (G) electrode was placed ties were measured over the volar aspect of the midforearm
over the dorsal surface of the forearm between the stimulating (maintained between 32 and 34 °C). Room temperatures
cathode (−) and the active recording electrode (A). were not measured. Authors performed nerve conduction
studies in 52 anterior interosseous nerves from 26 healthy
Stimulation The median nerve was stimulated at the elbow (Table 1) subjects (20 men and 6 women, age range 24–63
(S), on the antecubital fossa just lateral to the brachial artery. years, average age 30.2 years).

242 A3 Elbow – Distal Forearm
Middle trunk Biceps brachii

(BB)
C7
C8
Lateral cord
T1
+
–
Lower trunk
Median
nerve G
Medial cord
S
3 cm
Ulnar styloid (elbow)
R A
R
Digit I
Typical waveform (elbow – PQ muscle):

2 2
1 3 1 3
Elbow 1
5 5 Elbow 1
50 ms 1 mV 42 mA
30 ms 1 mV 42 mA
4 4
Fig. 1 Compound muscle action potential (CMAP) recorded at the distal forearm from the PQ muscle, stimulation of the elbow
A3 Elbow – Distal Forearm 243
Ulnar styloid
Digit V
R
3 cm
A
Digit III
R
Fig. 2 PQ muscle surface recording

Elbow–PQ, latency – right arm (ms) 3.6 ± 0.4 2.9–4.4
Elbow–PQ, latency – left arm (ms) 3.5 ± 0.4 2.8–4.3
Elbow–PQ, latency difference side-to-side (ms) 0.1 ± 0.1 0–0.4

Elbow–PQ, amplitude – right arm (mV) 3.1 ± 0.8 2.0–5.2
Elbow–PQ, amplitude – left arm (mV) 3.1 ± 0.8 2.0–5.5
Elbow–PQ, amplitude – difference (%) 11.4 ± 7.7 0–25

Elbow–PQ, duration – right arm (ms) 7.7 ± 1.3 5.5–10.4
Elbow–PQ, duration – left arm (ms) 7.8 ± 1.1 5.6–10.5
Elbow–PQ, duration – difference (ms) 0.8 ± 0.6 0–2.4
This study was also performed by Shafshak and

Comment El-Hinawy [2] on six different groups of patients, as fol-
Mysiw and Colachis [1] found latency ranged from 2.8 lows: Group 1 – 25 patients (13 women and 12 men, aged
to 4.4 ms with a mean latency for the right and left 22–40 years) with clinically definite carpal tunnel syndrome
extremity of 3.6 ± 0.4 and 3.5 ± 0.4 ms, respectively. (CTS), and having both conventional abnormal motor (4.8–
The amplitude of the CMAP recorded from PQ muscle 13.3 ms) and sensory (>5.0 ms) latencies (normal conduc-
varied between 2.0 and 5.5 mV with mean amplitude tion on other nerves); Group 2 – 11 patients (8 men and 3
of 3.1 ± 0.8 mV for both right and left extremities. The women, age range 23–51 years) with clinically definite
percentage of difference in amplitudes between arms polyneuropathy, and having abnormal motor distal latency
of the same subject differed by a mean of 11.4 ± 7.7 %, (5.8–15.5 ms) and slow median motor NCV (9–37 m/s) at
and none of the control subjects showed an amplitude the forearm (normal conduction on other nerves); Group 3 –
difference greater than 25 %. Duration measurements 5 men (age range 37–50 years) with diabetic mononeuritis
of the CMAP ranged from 5.5 to 10.5 ms with a mean multiplex and unobtainable both median distal motor and
duration for the right and left arms of 7.7 ± 1.3 and sensory conduction (normal conduction on other nerves);
7.8 ± 1.1 ms, respectively (the mean difference side-to- Group 4 – 5 men (age range 23–55 years) with unilateral
side was 0.8 ± 0.6 ms). During the final portion of the clinically definite acute CTS, and having complete denerva-
study in two control adults, authors compared surface tion of the thenar muscles and unobtainable both median
recording and needle recording techniques from PQ distal motor and sensory conduction (normal conduction on
muscle, and they found similar latencies (the latency other nerves); Group 5 – 11 women (age range 27–53 years)
between two techniques differed by less than 0.2 ms with clinically diagnosed severe unilateral CTS, and unob-
in the four control subjects examined). Because mea- tainable both median distal motor and sensory conduction
surements of distance were made with the elbow about (normal conduction on other nerves); Group 6 – 2 men (age
90° flexed and fully pronated, longer distances were range 21–39 years) with unilateral pronator teres syndrome
recorded and more rapid conduction velocities were (PTS).
calculated, as direct measurement (with the elbow
fully extended and pronated) was about 2 cm shorter. Table 2 Reference values
Elbow–PQ, latency (ms) 3.15 ± 0.47 2.6–4.4
Shafshak and El-Hinawy [2] used PQ muscle surface record- Elbow–PQ, latency difference side 0.12 ± 0.14 0.0–0.4
ing performing the technique described by Mysiw and to side (ms)
Colachis [1]. They stimulated median nerve at the elbow, at Elbow–PQ, peak to peak amplitude (mV) 3.10 ± 0.95 1.7–5.1
the lower part of the arm, medial to the upper part of the
biceps brachii (BB) tendon. The distance between the stimu- Table 3 Reference values
lating cathode and surface recording electrode remained
equal between the extremities of the same subject to allow for Elbow–PQ, latency (ms) – Group 1 2.3–4.1
side-to-side comparison (distance range 21–23 cm). Authors Elbow–PQ, latency (ms) – Group 2 7.1–23.7
measured anterior interosseous nerve onset latency (ms) from Elbow–PQ, latency (ms) – Group 3 –
the stimulus artifact to the first negative takeoff, and negative Elbow–PQ, latency (ms) – Group 4 3.1–4.2
amplitude (mV). The recordings were performed in a room Elbow–PQ, latency (ms) – Group 5 3.3–4.3
temperature of 25 °C, and a skin temperature between 31 °C Elbow–PQ, latency (ms) – Group 6 4.9–5.3
and 33 °C. Authors compared surface [1] and needle [3]
recordings techniques, both in control subjects and patients. Pathological values [2] Range
Using surface method they studied 50 anterior interosseous Elbow–PQ, amplitude (mV) – Group 1 1.5–5
nerves from 25 control subjects (13 women and 12 men, age Elbow–PQ, amplitude (mV) – Group 2 0.4–1.2
range 18–57 years, average age 42 years). The upper limit Elbow–PQ, amplitude (mV) – Group 3 –
(mean ± 2SD) for anterior interosseous nerve latency in the Elbow–PQ, amplitude (mV) – Group 4 1.5–3.7
forearm segment (elbow–PQ) using surface technique was Elbow–PQ, amplitude (mV) – Group 5 1.2–2.5
4.1 ms. The longest latency in controls was 4.4 ms. Elbow–PQ, amplitude (mV) – Group 6 0.9–2.1
A3 Elbow – Distal Forearm 245

Comment Limit
In light of their study, Shafshak and El-Hinawy [2] Normal values [4] Mean ± SD Range of normal
recommend determining the anterior interosseous Elbow–PQ, latency (ms) – Group 1 3.8 ± 0.4 3.1–4.4 4.4
nerve latency (AINL) for excluding median nerve Elbow–PQ, latency (ms) – Group 2 4.0 ± 0.4 3.5–5.1 4.8
neuropathy especially in patients with normal ulnar Elbow–PQ, latency (ms) – Group 3 4.5 ± 0.4 3.7–5.3 5.2
and radial motor and sensory conductions (which Elbow–PQ, latency (ms) – all 4.2 ± 0.5 3.1–5.3 5.1
might exclude peripheral neuropathy) but unobtain- forearm distances
Elbow–PQ, duration (ms) 7.2 ± 1.1 4.2–12.0 9.3
able median nerve distal conduction. In these cases,
performing AINL gives information about presence of
CTS or entrapment neuropathy of the median nerve at Limit
Normal values [4] Mean ± SD Range of normal
the forearm.
Elbow–PQ, amplitude (mV) – 4.4 ± 1.8 1.1–18.7 1.6
Group 1
Elbow–PQ, area (μVs) – Group 1 17.1 ± 6.0 2.9–34.9 6.0
Foley et al. [4] established normative values for the median Elbow–PQ, amplitude (mV) – 3.7 ± 1.7 1.2–12.2 1.6
nerve conduction to the PQ muscle from a large sample size Group 2
(207 healthy subjects, 112 women and 95 men, age range Elbow–PQ, area (μVs) – Group 2 13.7 ± 5.4 2.9–30.2 6.0
19–79 years, men mean age 47 ± 14 years, women mean age Elbow–PQ, amplitude (mV) – 4.3 ± 1.8 1.1–18.7 1.6
all subjects
42 ± 15 years, men mean height 176 ± 7 cm, women mean
Elbow–PQ, area (μVs) – all 16.4 ± 6.1 2.9–34.9 6.0
height 163 ± 7 cm, men mean weight 84 ± 14 kg, women mean subjects
weight 70 ± 15 kg, white 160 subjects, black 44 subjects, other
race 3 subjects). They used a XLTEK Neuromax and TECA
Sapphire 2 m electromyography instruments (sensitivity was tion to the forearm length and distance between stimulation
2 mV/division, low-frequency filter was 2–3 Hz, high-fre- and recording sites (Group 1 – forearm distance ≤23 cm;
quency filter was 10 kHz, sweep speed was 2 mV/division). Group 2 – forearm distance 23.5–24.5 cm; Group 3 – forearm
All recordings were made with the hands warm and skin main- distance ≥25 cm). For the derived normative ranges, authors
tained at greater than 32 °C. The method used was the same by found the mean ± 2SD method not optimal in some instances,
Mysiw and Colachis [1], ground electrode was placed on the particularly when the data are not distributed in a normal
dorsum of the hand. They obtained from the recorded wave- Gaussian fashion. They described the limit of normal (upper
forms: latency, negative peak amplitude, duration of negative or lower) as a percentile of observed values, taking the limit
peak, and area under the negative peak. All subjects were at the 97th (third) percentile of observed values. Pathological
grouped by age (in decades) and forearm distance subsets values were not reported and the clinical application of the
(0.5 cm increments). Negative peak amplitude (mV) and area technique was not described. Pathological waveforms and
(μVs) varied in relation to the age (Group 1 – 19–59 years, values in two cases of anterior interosseous nerve syndrome
Group 2 – 60–79 years). CMAP latency (ms) varied in rela- (AIN) are reported (Figs. 3 and 4).
Pathological waveform (elbow – PQ muscle):
2 2
1 3 1 3
5 Elbow 1 5 Elbow 1
4 50 ms 1 mV 24 mA 4
30 ms 1 mV 24 mA
Onset latency (elbow – PQ): 4.75 ms; Peak latency (elbow – PQ): 9.00 ms; Onset to peak amplitude (elbow – PQ): 1.0 mV;
Peak to peak amplitude (elbow – PQ): 1.7 mV
Fig. 3 Compound muscle action potential (CMAP) recorded at the distal forearm from the PQ muscle in a case of anterior interosseous nerve
syndrome (AIN), stimulation at the elbow
References 247
Pathological waveform (elbow – PQ muscle):
2 2
1 3 5 1 3 5
Elbow 1 Elbow 1
4 50ms 1mV 16mA 4 30ms 1mV 16mA
Onset latency (elbow – PQ): 6.50 ms; Peak latency (elbow – PQ): 12.15 ms; Onset to peak amplitude (elbow – PQ): 0.6 mV; Peak to
peak amplitude (elbow – PQ): 1.3 mV
Fig. 4 Compound muscle action potential (CMAP) recorded at the distal forearm from the PQ muscle in a case of anterior interosseous nerve
syndrome (AIN), stimulation at the elbow
3. Nakano KK, Lundergan C, Okihiro MM (1977) Anterior interosse-

References ous nerve syndromes. Diagnostic methods and alternative treat-
ments. Arch Phys Med Rehabil 34:477–480
1. Mysiw WJ, Colachis SC (1988) Electrophysiologic study of the 4. Foley BS, Roslonski ET, Buschbacher RM (2006) Reference values
anterior interosseous nerve. Am J Phys Med Rehabil 67:50–54 for median nerve conduction to the pronator quadratus. Arch Phys
2. Shafshak TS, El-Hinawy YM (1995) The anterior interosseous Med Rehabil 87:88–91
nerve latency in the diagnosis of severe carpal tunnel syndrome
with unobtainable median nerve distal conduction. Arch Phys Med
Rehabil 76:471–475
Elbow – Distal Forearm, Hand
Needle and Surface Recording Technique,
A4
Study from Pronator Quadratus (PQ)
and Abductor Pollicis Brevis (APB) Muscles
Original Settings Sensitivity was 2 mV/division, low-

frequency filter was 1 Hz, high-frequency filter was 10 kHz, Comment
duration of pulse was 0.1–0.2 ms and the machines used We obtained similar results trying surface recording
were a TECA TD 20 and a Cadwell Quantum 84. Sweep for both PQ and APB muscles (Fig. 2), in control sub-
speed was not specified. jects and patients with carpal tunnel syndrome (CTS)
and anterior interosseous nerve syndrome (AIN).
Position This study was performed in the supine position. PQ-APB surface recording protocol seemed a simpler
method than PQ-needle/APB-surface recording, and
Recording Using a concentric needle electrode (R1), the because both compound muscle action potentials
anterior interosseous nerve conduction study was performed (CMAPs) were obtained using surface electrodes, the
using intramuscular recording. The needle recording elec- comparison of latency is more reliable. It also mark-
trode was placed in the pronator quadratus (PQ) muscle edly reduced the patient’s discomfort.
(Fig. 1), on the dorsal aspect of the distal forearm (2–3 cm
proximal to the ulnar styloid in the middle). Position was
confirmed by EMG recordings. Using surface bar electrodes Supramaximal stimulus was delivered; 0.1–0.2 ms duration
(R2), median nerve conduction study was performed using was used [1].
surface recording. The active recording electrode (R2) was
placed over the belly of the abductor pollicis brevis (APB) Measurements Latencies (ms) of the compound muscle
muscle (R), halfway between the midpoint of the distal wrist action potentials (CMAPs) from both PQ and APB muscles
crease and the midpoint of the first metacarpophalangeal were measured from the stimulus artifact to the onset of the
joint (thenar eminence). The reference (R) was placed negative deflection of CMAP. Amplitudes (mV) of the CMAPs
slightly distal to the first metacarpophalangeal joint (over the were measured peak-to-peak. The distance from the stimulat-
distal tendinous insertion of APB muscle). Ground (G) elec- ing cathode (−) to the needle recording electrode (R1) and sur-
trode was placed at the elbow level [1]. face recording electrode (A) was not reported. Skin and room
temperatures were not reported. Authors obtained simultane-
Needle Insertion For the PQ muscle, with the forearm in a ous dual-channel recordings, and a comparison of the ratio of
neutral position to full pronation, the recording needle electrode the latencies of the PQ and APB muscles was calculated. They
was inserted dorsally 2–3 cm proximal to the ulnar styloid just developed a nerve conduction technique that used single stim-
lateral (in the radial direction) to the ulna to a depth of 2–2.5 cm. ulation of the median nerve and simultaneous recordings of
the compound muscle action potentials (CMAPs) from APB
Stimulation The median nerve was stimulated above the muscle (median nerve) and PQ muscle (anterior interosseous
elbow (S), proximal to the bifurcation of the anterior interos- nerve). The latencies of these CMAPs were then described as
seous nerve and the antecubital fossa, at the midhomerus a ratio of the pronator quadratus/abductor pollicis brevis,
area just medial to the biceps muscle. The anode was proximal. called the “AIM score,” as follows:
Pronator Quadratus ( PQ ) latency, ( ms )

AIM score =
Abductor Pollicis Brevis ( APB) latency, ( ms )

250 A4 Elbow – Distal Forearm, Hand
Biceps brachii
(BB)
G +
–
R2
S
(above elbow)
Digit I
R A
R1
Pronator quadratus
(PQ)
PQ
Digit V
Typical waveform (above elbow – PQ muscle, above elbow – APB):
Ant inteross - median ratio Ant inteross - median ratio
2 2
1 3 5 PQ 1 1 3 5 PQ 1
4 4
50 ms 5m V 74 mA 30 ms 5 mV 74 mA
2 2
1 3 1 3
5 APB 2 5 APB 2
4 4
50 ms 5 m V 34 mA 30 ms 5 mV 34 mA
Fig. 1 Compound muscle action potentials (CMAPs) recorded at the distal forearm from the PQ muscle – needle recording (upper trace) and at
the hand from the APB muscle – surface recording (lower trace), stimulation above the elbow
A4 Elbow – Distal Forearm, Hand 251
A prolonged latency to the PQ muscle, which could sug- range 152–190 cm, age range 17–57 years) and in 35
gested an anterior interosseous nerve injury (in the elbow– patients with CTS and 5 patients (Table 2) with clinically
wrist segment), determined an increase in the ratio; a apparent Kiloh Nevin syndrome (25 median nerves from 25
prolonged latency to the APB muscle, which could sug- patients with electrophysiologically determined severe
gested a median nerve injury distal to the bifurcation of the CTS, 10 median nerves from 10 patients with electrophysi-
anterior interosseous nerve like the carpal tunnel syndrome ologically determined mild CTS). The double standard
(in the wrist–hand segment), determined a reduction of the deviation gave a range of 0.52–0.68 (95 % of controls), the
ratio. Nerve conduction studies were performed in 100 triple standard deviation gave a range of 0.48–0.72 (99 % of
median nerves (Table 1) from 61 normal volunteers (height controls).
Biceps brachii
(BB)
G +
–
R2
S
(above elbow)
Digit I
R A
R1 R A
Pronator quadratus
(PQ)
Digit V PQ
Fig. 2 Surface recording from the PQ and APB muscles, stimulation above the elbow

Normal values [1] Mean ± SD Range (2SD) Range (3SD) Pathological values [1] Mean ± SD
AIM score 0.60 ± 0.06 0.52–0.68 0.48–0.72 AIM score – mild CTS 0.48
AIM score – severe CTS 0.38 ± 0.06
AIM score – Kiloh Nevin syndrome 0.76
Comment CTS (25 severe CTS, 10 mild CTS) and observed a low AIM
For Rosenberg [1] the amplitude of the CMAP recorded score (0.48 for mild CTS, 0.38 ± 0.06 for severe CTS); in
from the PQ muscle using a needle electrode was 4.5 ± 1.0 mV Kiloh Nevin syndrome they observed higher AIM score than
and the amplitude of the CMAP from the APB muscle using in controls (0.76). They found this simple test useful in both,
surface electrodes was 10.5 ± 4.0 mV. Author evaluated AIM diagnosis of an anterior interosseous nerve injury or carpal
score in patients with electrophysiologically determined tunnel syndrome (Figs. 3, 4, and 5).
Pathological waveform (above elbow – PQ muscle, above elbow – APB muscle):
2 2
1 3 1 3
5 PQ 1.1 5 PQ 1.1
4 4
50 ms 5 mV 58 mA 30 ms 5 mV 58 mA
2 2
1 3 APB 1.2 1 3
5 5 APB 1.2
4 4
50 ms 5 mV 58 mA
30 ms 5 mV 58 mA
Onset latency (above elbow – PQ): 3.90 ms; Onset latency (above elbow – APB): 8.40 ms; Peak latency (above elbow – PQ): 8.80 ms;
Peak latency (above elbow – APB): 11.85 ms; Onset to peak amplitude (above elbow – PQ): 3.5 mV; Onset to peak amplitude (above
elbow – APB): 6.1 mV; Peak to peak amplitude (above elbow – PQ): 5.3 mV; Peak to peak amplitude (above elbow – APB): 8.3 mV
AIM score (above elbow – PQ, above elbow – APB) calculation:
Pronator quadratus (PQ) latency, (ms) 3.90 ms

AIM score = = = 0.46
Abductor pollicis brevis (APB) latency, (ms) 8.40 ms
the hand from the APB muscle – surface recording (lower trace) in a mild CTS – grade 2 by Bland’s CTS classification scale [2], stimulation above
the elbow
A4 Elbow – Distal Forearm, Hand 253
2 2
1 3 1 3
5 PQ 1.1 5 PQ 1.1
4 4
50 ms 5 mV 75 mA 30 ms 5 mV 75 mA
2 2
1 3 5 1 3 5
APB 1.2 APB 1.2
4 50 ms 5 mV 75 mA 4 30 ms 5 mV 75 mA
Onset latency (above elbow – PQ): 4.05 ms; Onset latency (above elbow –APB): 10.15 ms; Peak latency (above elbow – PQ): 8.15 ms;

the hand from the APB muscle – surface recording (lower trace) in a severe CTS – grade 4 by Bland’s CTS classification scale [2], stimulation
above the elbow
2 2
1 3 1 3
5 PQ 1 5 PQ 1
4 4
50 ms 2 mV 50 mA 30 ms 2 mV 50 mA
2 2
1 3 1
APB 2 3
5 5 APB 2
50 ms 2 mV 100 mA
30 ms 2 mV 100 mA
4 4
Onset latency (above elbow –PQ): 5.20 ms; Onset latency (above elbow – APB): 3.45 ms; Peak latency (above elbow – PQ): 11.80 ms;

Fig. 5 Compound muscle action potentials (CMAPs) recorded at the distal forearm from the PQ – needle recording (upper trace) and at the hand
from the APB muscle – surface recording (lower trace) in a case of anterior interosseous nerve syndrome, stimulation above the elbow
References
1. Rosenberg JN (1990) Anterior interosseous/median nerve latency
ratio. Arch Phys Med Rehabil 71:228–230
Elbow – Forearm
A5
Study from Flexor Pollicis Longus (FPL) Muscle
Original Settings Sensitivity was 5 mV/division, low- Stimulation The median nerve was stimulated just proximal
frequency filter was 2 Hz, high-frequency filter was 10 kHz, to the elbow (S), with the cathode proximal to the antecubital
sweep speed was 2 ms/division, and the machine used was an fossa, just medial to the tendon of the biceps brachii (BB)
Oxford Teca Synergy or a Sapphire Premiere. Duration of muscle and to the pulsation of the brachial artery. The anode
pulse and rate of pulse were not specified. was proximal [1].
Position This study was performed with the subject sitting Measurements Latency (ms) of the compound muscle
on a chair with the elbow extended and supinated. action potential (CMAP) from FPL muscle was mea-
sured from the stimulus onset to the onset of the negative
Recording Using the surface electrodes, the anterior interos- deflection of CMAP. Amplitude (mV) and area (mVms)
seous nerve conduction studies were performed using surface of the CMAP were determined from the baseline to the
recording [1]. The surface electrodes were placed at the fore- negative peak. The distance from the stimulating cath-
arm, with the active (A) electrode placed over the motor point ode and recording electrode, and forearm circumference
of the flexor pollicis longus (FPL) muscle (Fig. 1), 6–8 cm were measured. Average distance between the stimulat-
proximal to the radial styloid as determined by palpation of ing to recording electrode was 17.7 ± 2.2 cm. Skin tem-
the belly of the FPL muscle [1]. The reference electrode (R) perature was controlled at 32 °C; room temperature was
was placed distally on the radial styloid. Initial positive not reported. Authors studied 100 anterior interosseous
deflection was avoided moving slightly the active electrode. nerves from 50 healthy (Table 1) subjects (28 women and
Ground (G) electrode was placed on the volar aspect of the 22 men, average age 50.9 ± 14.9 years).
forearm, proximal to the active recording electrode (A).

Middle trunk Biceps brachii

(BB)
C7
C8
Lateral cord
T1
+
–
Lower trunk
G
Median
nerve
Medial cord
A S
Digit I 6–8 cm (elbow)
R
R
Flexor pollicis longus (FPL)
Digit V
Typical waveform (elbow – FPL muscle):
2 2
5 5
50 ms 2 mV 20 mA
30 ms 2 mV 20 mA
4 4
Fig. 1 Compound muscle action potential (CMAP) recorded at the forearm from the FPL muscle, stimulation of the elbow
References 257

Normal values [1] Mean ± 2SD Range Comment
Elbow–FPL, latency (ms) 3.9 ± 1.2 3.0–5.9 For Vucic and Yiannikas [1] the mean CMAP ampli-
Elbow–FPL, latency difference 5.1 ± 13.4 0–38 tude was 5.7 ± 1.0 mV (range 4.0–8.5 mV), with a
side-to-side (%) mean interside difference of 0.7 ± 0.4 mV (range
Elbow–FPL, amplitude (mV) 5.7 ± 2.0 4.0–8.5 0–1.7). Mean CMAP area was 22.8 ± 3.9 mVms (range
Elbow–FPL, amplitude difference 0.7 ± 0.8 0–1.7 15–30 mVms), with a mean interside difference of
side-to-side (mV) 8.8 ± 7.8 % (range 0–19 %). Mean CMAP onset latency
Elbow–FPL, area (mVms) 22.8 ± 7.8 15–30
was 3.9 ± 0.6 ms (range 3.0–5.9 ms), with a mean inter-
Elbow–FPL, area difference 8.8 ± 15.6 0–19
side-to-side (%)
side difference of 5.1 ± 6.7 %. Authors observed higher
CMAP amplitude values from FPL muscle than other
amplitude values obtained from PQ muscle reported in
Mysiw and Colachis [2]. Because of the highest ampli-
tude they found CMAP from FPL muscle more sensi-
tive than CMAP from PQ muscle in a pathological
setting (Fig. 2), and authors suggested to use both
motor conduction studies from PQ and FPL muscles in
future diagnosis of anterior interosseous nerve palsy.
2 2
3 3
50 ms 2 mV 91 mA 30 ms 2 mV 91 mA
Onset latency (elbow – FPL): 6.30 ms; Peak latency (elbow – FPL): 13.45 ms; Onset to peak amplitude (elbow – FPL): 0.7 mV; Peak to
peak amplitude (elbow – FPL): 0.8 mV
(AIN), stimulation at the elbow
References
1. Vucic S, Yiannikas C (2007) Anterior interosseous nerve conduc-
tion study: normative data. Muscle Nerve 35:119–121
2. Mysiw WJ, Colachis SC (1988) Electrophysiologic study of the
anterior interosseous nerve. Am J Phys Med Rehabil 67:50–54
Glossary
Amplitude When referring to an action potential, the Antidromic It is the propagation of a nerve impulse in the
amplitude is the maximum voltage difference between direction opposite to physiological (Fig. 3). Most sensory
the two points, usually baseline to peak or peak to peak. nerve conduction studies are performed antidromically
By convention, the amplitude of potentials which have an because of the higher amplitude of the sensory nerve
initial negative deflection from the baseline such as the action potentials (SNAPs) than the orthodromic studies,
compound muscle action potential (CMAP) and the anti- with the contrary of orthodromic (Fig. 5).
dromic sensory nerve action potential (SNAP) is measured Artifact A voltage change generated by a biological or non-
from the baseline to the most negative peak (also called biological source other than the ones of interest, which
“negative peak amplitude”), and the amplitude measured may precede or overlap the activity of interest. The stim-
from the most positive peak to the most negative peak is ulus artifact, also called “shock artifact,” represents a
called “peak-to-peak amplitude” (Fig. 1). cutaneous spread of a stimulating current to the recording
Amplitude Decay The percentage change in the amplitude electrode.
of a compound muscle action potential (CMAP) or a com- Axonal Degeneration It is the degeneration of the segment
pound sensory nerve action potential (SNAP) between of the nerve distal to the cell body with preferential distal
two different stimulation points along the nerve (Fig. 2). pathology.
Axonotmesis It is a disruption of nerve cell axons resulting
Distal amplitude − proximal amplitude
Decay = 100 in axonal degeneration distal to the injury site. Compare
Distal amplitude neuroapraxia, neurotmesis.
Median - Dig II Median - PT
2
2
1 4
Wrist 1 1 3
10 ms 10 µV 24 mA 5 Antecubital 1
3 14 30 ms 5 mV 23 mA
4
Sensitivity 1 µV/div, sweep speed 1 ms/div Sensitivity 5 mV/div, sweep speed 3 ms/div
Fig. 1 Antidromic sensory nerve action potential (SNAP) recorded to 1–2 – negative-peak amplitude (μV); markers 2–3 – peak-to-peak
the digit II – left, and compound muscle action potential (CMAP) amplitude (μV). CMAP: markers 1–2 – negative-peak amplitude (mV);
recorded from the pronator teres (PT) muscle – right. SNAP: markers markers 2–4 – peak-to-peak amplitude (mV)

DOI 10.1007/978-3-319-10473-7, © Springer International Publishing Switzerland 2015
260 Glossary
distal amplitude – proximal amplitude

Decay = 100
distal amplitude
2 2
1 3 5 Wrist 1 1 3 5
4 4 Wrist 1
30 ms 5 mV 48 mA 20 ms 5 mV 48 mA
2 2
1 3 1 3
5 Palm 2 5 Palm 2
30 ms 5 mV 29 mA 20 ms 5 mV 29 mA
4 4
Fig. 2 Compound muscle action potentials (CMAPs) recorded at the hand from the abductor pollicis brevis (APB) muscle in a CTS patient,
stimulation at the wrist −50% amplitude decay (upper trace) and on the palm (lower trace)
3−4 cm +
Antidromic –
S2
Digit I
(elbow)
2 cm +
–
S1
14 cm
(wrist)
A
4 cm
R R
(digit III)
Digit V
Fig. 3 Sensory antidromic conduction recording to the digit III, stimulation at the wrist (S1) and at the elbow (S2)
Glossary 261
Baseline In an electrophysiological recording, the baseline Carpal Tunnel Syndrome (CTS) It is a mononeuropathy
is the display of zero potential differences between the affecting the median nerve at the wrist. The nerve is sub-
two input terminals of the recording instrument. It is also ject to compression as it passes through the carpal tunnel,
called isoelectric line. a space bounded dorsally by the bones of the wrist, later-
Brachial Plexus An anatomical structure composed of roots, ally by the forearm tendons, and volarly by the transverse
trunks, divisions, cords, and terminal nerves. It is formed by carpal ligament. Any of these structures can compress the
the spinal roots from C5 to T1, traverses the shoulder region, median nerve, and repetitive hand and wrist movement is
and culminates in the named peripheral nerves in the arm thought to contribute to the compression.
(Fig. 4). Chronic Inflammatory Demyelinating Polyradiculo-
neuropathy (CIDP) A polyneuropathy or polyradiculo-
Upper trunk C5
neuropathy characterized by a generalized demyelination
C6 of the peripheral nervous system. In most cases, there
is also a component of axonal degeneration. It is dis-
C7
tinguished from an acute inflammatory neuropathy or
C8 Guillain-Barré syndrome.
Lateral cord
CMAP It is an abbreviation for compound muscle action
T1
potential.
Collision The interaction of the two action potentials propa-
gated toward each other from opposite directions on the
same nerve fiber during a nerve conduction study so that
Middle trunk the refractory periods of the two potentials prevented
propagation past each other.
Compound Muscle Action Potential (CMAP) The summa-
Lower trunk tion of a nearly synchronous muscle fiber action potential
recorded from a muscle commonly produced by stimu-
Median
nerve lation of the nerve supplying the muscle either directly
Medial cord or indirectly. In each compound muscle action potential
(CMAP), some parameters as baseline-to-peak amplitude,
Fig. 4 Brachial plexus, median nerve: spinal roots C5-T1, upper-
middle-lower trunks, lateral and medial cords latency, and duration can be measured (Figs. 6 and 7).
Median - ortho - dig II Median - (OP)
2
1 3 5
4 Elbow 1
30 ms 10 mV 52 mA
2 2
1 3 4 Digit II 1
1 3 5
10 ms 10 µV 28 mA 4 Wrist 2
8 30 ms 10 mV 52 mA
2
1 3 4 5 Palm 3
30 ms 10 mV 29 mA
Sensitivity 10 µV/div, sweep speed 1 ms/div Sensitivity 10 mV/div, sweep speed 3 ms/div
Fig. 5 Orthodromic sensory nerve action potential (SNAP) recorded at abductor pollicis brevis (APB) muscle in a CTS patient, stimulation at
the wrist in a CTS patient (stimulation to the digit II) – left; compound the elbow (upper trace), at the wrist (middle trace) and on the palm
muscle action potentials (CMAPs) recorded at the hand from the (lower trace) - right
262 Glossary
2 2
1 3 5 1 3 5
4 Wrist 1 4 Wrist 1
50 ms 5 mV 31 mA 30 ms 5 mV 31 mA
2 2
1 3 5 1 3 5
4 Elbow 2 4 Elbow 2
50 ms 5 mV 47 mA 30 ms 5 mV 47 mA
2 2
1 34 5 1 34 5
Axilla 3 Axilla 3
50 ms 5 mV 47 mA 30 ms 5 mV 47 mA
2 2
1 34 5 1 34 5
50 ms 5 mV 69 mA 30 ms 5 mV 69 mA
Fig. 6 Compound muscle action potentials (CMAPs) recorded at the hand from the abductor pollicis brevis (APB) muscle in a patient with CTS
and associated CIDP, stimulation on the Erb’s point, at the axilla, at the elbow and at the wrist (bottom to top)
Median - (FCR) Ant inteross - (FPL)
2
2
1 3
Elbow 1
5
50 ms 2 mV 20 mA
1 3
5 Elbow 1 4
30 ms 5 mV 18 mA
4
Fig. 7 Compound muscle action potentials (CMAPs) recorded from the flexor carpi radialis (FCR) muscle (left) and from the flexor pollicis
longus (FPL) muscle (right)
Conduction Block It is the failure of an action potential to Conduction Velocity It is the speed of propagation of an
propagate past a particular peripheral nerve point, whereas action potential (sensory, mixed, or motor) along a nerve.
conduction is possible below the point of the block. It is For a nerve trunk, the maximum conduction velocity is
documented by a demonstration of a reduction in the area calculated from the latency of the evoked potential at a
of a compound muscle action potential greater than that maximal or supramaximal intensity of stimulation at two
normally seen with stimulation at two different points on different points. The distance between the two points
a nerve trunk. (conduction distance measured in mm) is divided by the
Glossary 263
Median - dig III Median - dig III
2
2
4 Digit III - palm 1
1 3 10 ms 10 µV 13 mA 4 Digit III-palm 1
16 1 3
10 ms 10 µV 16 mA
11
2 2
1 Digit III-Wrist 2
1 4 Digit III - Wrist 2 3
3 10 ms 10 µV 62 mA
10 ms 10 µV 20 mA 10
13
Fig. 8 Orthodromic sensory nerve action potentials (SNAPs) recorded on the palm (upper trace) and at the wrist (lower trace), digit III stimula
tion: in a normal subject – left, and in a CTS patient (distoproximal ratio 1.50) – right
difference between the corresponding latencies (conduc- ment (digit – palm), and it is always <1.0. This ratio is
tion time measured in ms). The calculated result is the reversed (>1) in a patient with CTS.
conduction velocity of the fastest fibers and is usually Duration The interval from the beginning of the first deflec-
expressed as meters per second (m/s). For the sensory and tion from the baseline to its final return to the baseline of
mixed nerve conduction studies, the conduction velocity an action potential or waveform unless otherwise speci-
(SNCV) can be calculated using a single site of stimula- fied. For example, the duration of a sensory nerve action
tion and measuring the distance between the stimulat- potential (SNAP) or a compound muscle action potential
ing and recording electrodes, while for the motor nerve (CMAP) may refer to the interval from the deflection of
conduction studies, two different sites of stimulation are the first negative phase from the baseline to its return to
used, and only dividing the distance between the sites by the baseline. Motor potentials have longer duration than
the difference in latency represents the conduction veloc- sensory potentials (Fig. 9).
ity (MNCV) of the portion of the nerve which does not Electrode A conducting device used to record an electric
include the neuromuscular junction or the muscle. potential (recording electrode) or to deliver an electric
Demyelination It represents the disease process affecting current (stimulating electrode). In addition to the single
the myelin sheath of central or peripheral nerve fibers, ground electrode used in clinical recordings, two elec-
manifested by conduction velocity slowing, conduction trodes (bipolar configuration) are always required either
block, or both. to record an electrical potential or to deliver an electrical
Distoproximal Ratio The calculation of the distoproximal stimulus.
ratio allows comparison of a sensory nerve action velocity Electromyography (EMG) It is the recording and study of
(SNCV) in the distal median nerve segment (SNCV digit insertion and spontaneous and voluntary activity of mus-
III – wrist) with that of the proximal segment (SNCV cle with a coaxial needle recording electrode (Fig. 10).
palm – wrist) of the same nerve. The distoproximal ratio Electroneurography (ENG) It is the recording and study
is calculated comparing digit-palm and palm-wrist sen- of the action potentials of a peripheral nerve. It is synony-
sory nerve conduction velocities (SNCV) as follows: mous with nerve conduction studies.
Electroneuromyography (ENG) It represents the com-
Digit − palm ( m / s ) bined studies of electromyography and electroneurogra-
Disto　 proximal ratio =
Palm − wrist ( m / s ) phy. It is synonymous with clinical electromyography, a
term which describes the scientific methods of recording
In normal hands, the SNCV in the proximal segment and analysis of biological electrical potentials from the
(palm – wrist) was higher than the SNCV of the distal seg- human peripheral nerve and muscle.
264 Glossary
Median - dig III Median - (APB)

2
2
1 1 3 5
4 Wrist 1 Wrist 1
3 15 ms 10µV 28 mA 4 30 ms 5 mV 40 mA
18
2
2
1 1 3 5
4 Elbow 2 Elbow 2
3 30 ms 5 mV 83 mA
15 ms 10µV 53 mA 4
16
Sensitivity 1 µV/div, sweep speed 1.5 ms/div Sensitivity 5 mV/div, sweep speed 3 ms/div
Fig. 9 Antidromic sensory nerve action potentials (SNAPs) recorded stimulation at the wrist (upper trace) and at the elbow (lower trace).
to the digit III (left), compound muscle action potentials (CMAPs) SNAPs: markers 1–4 – duration (ms), CMAPs: markers 1–5 – dura-
recorded from the abductor pollicis brevis (APB) muscle (right), tion (ms)
ABD POLL BREVIS FLEX CARPI RAD
1 1
1s 1mV 1s 1mV
100 ms 1 mV 100 ms 1 mV
Sensitivity 1 mV/div, sweep speed 10 ms/div
Fig. 10 Voluntary EMG activity recorded from the abductor pollicis brevis (APB) muscle (left), and from the flexor carpi radialis (FCR) muscle
(right)
EMG An abbreviation for electromyography. than the M wave. It can be evoked in many muscles of
ENG An abbreviation for electroneurography. the upper (e.g., the abductor pollicis brevis muscle) and
ENMG An abbreviation for electroneuromyography. lower extremities, and the latency is longer with more
Entrapment Neuropathy In general, it is a mononeurop- distal sites of stimulation (Figs. 11, 12 and 13). Named
athy caused by the compression of a nerve as it passes “F wave” by Maglader and McDougal in 1950, it was
through an area of anatomical narrowing (e.g., carpal tun- first recorded from the foot muscles. It is one of the late
nel syndrome). responses (i.e. H wave, M wave).
F Wave An action potential evoked intermittently from Far Field It is a region of electrical potentials where the
a muscle by a supramaximal electrical stimulus to the isopotential voltage lines associated with a current source
nerve due to an antidromic activation of motor neurons. change slowly over a short distance. The term far-field
When compared with the maximal amplitude of the M potential is sometimes used to designate a potential that
wave, it is smaller (1–5 % of the M wave) and has a vari- does not change in latency, amplitude, or polarity over
able configuration. Its latency is longer and more variable infinite distances. Compare with near field.
Glossary 265

1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.3
1.1
1.11
1.5
1.2
1.7
1.4
1.14
1.13
1.12
1.10
1.8
1.6
1.9 2 mV 50 ms 500 µv
1.10
1.11
1.12
1.13
1.14
2 mV 50 ms 500 µv
Fig. 11 Normal F-waves (mean latency 28.40 ms) recorded at the hand from the abductor pollicis brevis (APB) muscle in a normal subject, stimu-
lation at the wrist; raster mode −14 stimuli (left), superimposed mode −14 stimuli (right)

1.4
1.5
1.6
1.7
1.8
1.8
1.5
1.4
1.9
1.15
1.7
1.6
1.13
1.10
1.14
1.16
1.9 5 mV 50 ms 500 µV
1.10
1.13
1.14
1.15
1.16
5 mV 50 ms 500 µV
Fig. 12 Abnormal F-waves (mean latency 33.20 ms) recorded at the hand from the abductor pollicis brevis (APB) muscle in a CTS patient, stimu-
lation at the wrist; raster mode −11 stimuli (left), superimposed mode −11 stimuli (right)
Filters Filters are electronic circuits that perform the func- to the type of conduction test) should be set as recom-
tion of processing the body signals removing unwanted mended because a change in the filter range will affect
electrical noise. Electrodiagnostic studies use low-fre- the amplitude and latency of the potentials. Several differ-
quency (high-pass) and high-frequency (low-pass) fil- ences have been observed between the motor and sensory
ters to exclude high- and low-frequency electrical noise responses: The amplitude is affected more by narrowing
to reproduce the signal of interest. Specific filter ranges the lower frequency limit than the higher frequency limit
have been selected to ensure exact reproduction of the in the former (because of the longer duration of the motor
responses, and in practice the frequency range (according potentials); conversely in the latter, in which the high
266 Glossary
1.1
1.2
1.3
1.4
1.5
1.10
1.9
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
200 µV 100 ms 500 µV 1.6
1.7
1.8
1.9
1.10
200 µV 100 ms 500 µV
Fig. 13 Absent F-waves recorded at the hand from the abductor pollicis brevis (APB) muscle, stimulation at the wrist; raster mode −10 stimuli
(left), superimposed mode −10 stimuli (right) in a Guillain-Barré syndrome (1 week of onset of symptoms)
frequency limit is more important because of the shorter amplitude M wave reduces or abolishes the H wave. It is
duration of the sensory potentials. In the motor nerve most reliably elicited with a stimulus of a long duration
conduction study, the recommended filter range is 2 Hz (500–1,000 μs). It is due to a spinal reflex, with an electri-
(high-pass) to 10 kHz (low-pass), while in the sensory cal stimulation of afferent fibers in the mixed nerve and
nerve conduction study, the filter range to be used is 20 Hz activation of motor neurons to the muscle mainly through
(high-pass) to 2–3 kHz (low-pass). For the electromyog- a monosynaptic connection in the spinal cord. It is syn-
raphy (EMG), the suggested filters are 20 Hz for the low- onymous with H reflex (Fig. 15). Compare the F wave.
frequency filter and 10 Hz for the high-frequency filter. Inching A nerve conduction study technique consisting of
Frequency The number of complete cycles of a repetitive applying stimuli at multiple short-distance increments
waveform in 1 s measured in Hertz (Hz). along the course of a nerve. This technique is used to local-
Ground Electrode It is a connection from the patient to the ize an area of focal slowing or a conduction block, and it can
earth, used as a common return for an electric circuit and be performed using orthodromic or antidromic methods.
as an arbitrary zero potential reference point. In general, Following the antidromic method, the sensory nerve
to avoid shock artifact due to current stimulation spread, action potentials (SNAPs) can be recorded to the digit II
the ground electrode should be placed between stimula- (index finger), stimulating the median nerve percutaneously
tion and recording sites. at 12 points between the midpalm and the distal forearm in
Guillain-Barré Syndrome (GBS) It is an eponym for an 1 cm increments (Figs. 16 and 17).
acute, monophasic polyneuropathy. It is characterized by Interpotential Interval It is the time between two differ-
a time course of progression to a maximum deficit within ent potentials. Measurement should be made between the
4 weeks of onset of symptoms (Fig. 14). The most com- corresponding parts of each waveform (e.g., onset latency,
mon clinical presentation is an ascending sensory-motor peak latency). The difference between the peak latencies of
neuropathy. Electrodiagnostic studies most commonly two components of a waveform is called interpeak interval
reveal evidence for demyelination, but axonal degen- (Fig. 18).
eration also occurs. Eponym for an acute inflammatory Latency It is an interval between a stimulus and a response.
neuropathy. Distinguish from the chronic inflammatory The onset latency is the interval between the onset of a
demyelinating polyradiculoneuropathy (CIDP). stimulus and the onset (usually the negative phase) of the
H Wave It is a compound muscle action potential (CMAP) evoked potential. The peak latency is the interval between
with a consistent latency recorded from the muscles after the onset of a stimulus and a specific peak (usually the
stimulation of the nerve. It compares later than the M negative peak of the negative phase) of the evoked poten-
wave. Stimulus intensity sufficient to elicit a maximal- tial. The sensory onset latency represents the time for
Glossary 267

2 2
1 3 5 1 3 5
4 Wrist 1 4 Wrist 1
100 ms 5 mV 100 mA 50 ms 5 mV 100 mA
2 2
1 3 1 3
4 5 Elbow 2 4 5Elbow 2
100 ms 5 mV 100 mA 50 ms 5 mV 100 mA
2 2
3 3 5
1 5 1 Axilla 3
4 Axilla 3 4
100 ms 5 mV 100 mA 50 ms 5 mV 100 mA
2 2
3 3
1 5 1 Erb's Point 4
4 Erb's Point 4 4
100 ms 5 mV 100 mA 50 ms 5 mV 100 mA
Fig. 14 Compound muscle action potentials (CMAPs) recorded at the associated CTS, stimulation on the Erb’s point, at the axilla, at the
hand from the abductor pollicis brevis (APB) muscle in a patient with elbow, and at the wrist (bottom to top)
Guillain-Barré syndrome (2 weeks of onset of symptoms) and
1.2 1.2
138 V 138 V
1.4 1.4
1m V 131 V 2 mV 131 V
1.5 1.5
143 V 143 V
1.6 1.6
50 ms 2 mV 147 V 50 ms 5 mV 147 V
Sensitivity 2 mV-1 mV/div (left) – 5 mV-2 mV/div (right), sweep speed 5 ms/div
Fig. 15 H-reflex recorded at the forearm from the flexor carpi radialis (FCR) muscle, stimulation at the elbow
conduction through the largest and fastest cutaneous sen- Mixed Nerve Action Potential A compound nerve action
sory fibers, while the sensory peak latency represents a potential is recorded from a mixed nerve when an electri-
mix of large and small fibers. The motor distal latency cal stimulus is applied to a segment of the nerve that con-
(MDL) represents the conduction time from the stimula- tains both afferent (sensory) and efferent (motor) fibers.
tion site to the neuromuscular junctions, the time delay Some parameters, like amplitude, latency, duration, and
across the neuromuscular junction, and the depolarization number of phases, should be noted for every mixed nerve
time across the muscle (Fig. 19). action potential (Fig. 20).
268 Glossary
R
(digit II)
Inching
Digit II R A
–6 –5 –4 –3 –2 –1 0 12345 Median nerve
Digit V
S
(Palm-distal forearm)
Fig. 16 Antidromic sensory technique (inching) to the digit II, serial stimulation from the palm to the distal forearm
2
1
2
Median - inching 1
Median - inching
4 4
2 3 –6 1 2 3 –6 1
20 ms 50 µV 18 mA 10 ms 50 µV 18 mA
1 4 8 1 4 8
3 –5 2 3 –5 2
2 20 ms 50 µV 25 mA 2 10 ms 50 µV 25 mA
1 4 8 1 4 8
3 –4 3 3 –4 3
2 20 ms 50 µV 36 mA 2 10 ms 50 µV 36 mA
1 3 4 8 1 3 4 8
–3 4 –3 4
2 20 ms 50 µV 45 mA 2 10 ms 50 µV 45 mA
8 8
1 1
2 3 4 –2 5 2 3 4 –2 5
20 ms 50 µV 32 mA 10 ms 50 µV 32 mA
8 8
1 1
2 3 4 –1 6 2 3 4 –1 6
20 ms 50 µV 32 mA 10 ms 50µV 32 mA
1 4 8 1 4 8
2 3 0 7 2 3 0 7
20 ms 50 µV 6 mA 10 ms 50 µV 6 mA
1 8 1 8
2 4 +1 8 2 4 +1 8
3 3
20 ms 50 µV 13 mA 10 ms 50 µV 13 mA
1 8 1 8
3 4 +2 9 3 4 +2 9
2 20 ms 50 µV 20 mA 2 10 ms 50 µV 20 mA
8 8
1 1
3 4 +3 10 3 4 +3 10
2 20 ms 50 µV 41 mA 2 10 ms 50 µV 41 mA
1 8 1 8
3 4 +4 11 3 4 +4 11
2 20 ms 50 µV 47 mA 2 10 ms 50 µV 47 mA
1 12 1 12
3 4 +5 12 3 4 +5 12
20 ms 50 µV 62 mA 10 ms 50 µV 62 mA
8 8
Fig. 17 Antidromic sensory nerve action potentials (SNAPs) recorded to the digit II (inching) in a CTS patient (1.10 ms delay between positions
“−3” and “−2”), serial stimulation from the palm to the distal forearm
Glossary 269
Median - ulnar - digit IV Median - ulnar digit IV
2
2 1 3 4 Median 1
10 ms 10 µV 39 mA
1 4 Median 1 8
3 10 ms 10 µV 21 mA
8
2 2
1 1 4
4 3 Ulnar 2
3 Ulnar 2 10 ms 10 µV 39 mA
10 ms 10 µV 24 mA 8
8
Fig. 18 Median-ulnar nerves comparative sensory conduction study, nerve (lower trace); a normal subject (left), a CTS patient – interpoten-
antidromic sensory nerve action potentials (SNAPs) recorded to the tial interval-onset latency 1.10 ms (right)
digit IV, stimulation at the wrist: median nerve (upper trace) and ulnar
Median - dig II Median - OP

2
2
1 4 Wrist 1
3 20 ms 10 µV 28 mA 1
8 3 5 Wrist 1
4 30 ms 5 mV 39 mA
2
2
1 1 3
4 Elbow 2 5 Elbow 2
3 20 ms 10 µV 28 mA 4 30 ms 5 mV 39 mA
8
Sensitivity 10 µV /div, sweep speed 2 ms/div Sensitivity 5 mV/div, sweep speed 3 ms/div
Fig. 19 Orthodromic sensory nerve action potential (SNAP) recorded tor pollicis brevis (APB) muscle in a CTS patient, stimulation at the
at the wrist in a CTS patient, (stimulation to the digit II) – left; compound elbow (upper trace), at the wrist (middle trace) and on the palm (lower
muscle action potentials (CMAPs) recorded at the hand from the abduc- trace) – right. Marker 1: onset latency (ms); marker 2: peak latency (ms)
270 Glossary
Median - W-E orthodromic Median - W-E orthodromic
4 Wrist 1 2
10 ms 10 µV 24 mA 1 3 4
1 3 16 Wrist 1
10 ms 10 µV 41 mA
16
Fig. 20 Orthodromic mixed median nerve responses recorded at the elbow, stimulation at the wrist: a normal subject (left), a patient with diabetic
polyneuropathy (right)
1 3 5 Wrist 1 1 3 5 Wrist 1
4 50 ms 10 mV 40 mA 4 30 ms 10 mV 40 mA
2 2
1 3 5 Elbow 2 1 3 5 Elbow 2
4 50 ms 10 mV 41 mA 4 30 ms 10 mV 41 mA
2 2
1 3 5 Axilla 3 1 3 5 Axilla 3
4 50 ms 10 mV 32 mA 4 30 ms 10 mV 32 mA
2 2
1 3 5 1 3 5
4 50 ms 10 mV 47 mA 4 30 ms 10 mV 47 mA
Fig. 21 Compound muscle action potentials (CMAPs) recorded at the hand from the abductor pollicis brevis (APB) muscle, stimulation on the
Erb’s point, at the axilla, at the elbow and at the wrist (bottom to top)
M Wave It is a compound muscle action potential (CMAP) the time from stimulation (ms) to the onset of the first
evoked from a muscle by an electrical stimulus to its motor phase (positive or negative) of the M wave; (2) the ampli-
nerve. By convention, the M wave elicited by a supramax- tude (mV), which is the baseline-to-peak amplitude of the
imal stimulus is used for motor nerve conduction studies. first negative phase; (3) the duration (ms), which refers to
Ideally, the recording electrodes should be placed so that the duration of the first negative phase. It is also referred
the initial deflection of the evoked potential from the base- to as the motor response (Figs. 21 and 22).
line is negative. The measurement commonly includes (1) MNCV Abbreviation for motor nerve conduction velocity
the latency, commonly called the motor latency, which is (m/s). See conduction velocity.
Glossary 271

2
1 3 5 1 3 5
30 ms 5 mV 14 mA 30 ms 10 mV 14 mA
4
2 4
1 3 1 3 5
5 Wrist (ulnar) 2 Wrist (ulnar) 2
4 30 ms 10 mV 14 mA
30 ms 5 mV 14 mA
4
Fig. 22 Median-ulnar nerves comparative motor conduction study, abductor digiti minimi (ADM) muscle (lower trace), stimulation of the
compound muscle action potentials (CMAPs) recorded at the hand median and ulnar nerves at the wrist
from the abductor pollicis brevis (APB) muscle (upper trace), and the
Motor Point Also called the “belly point,” it is the place technique). The coaxial needle electrode is indeed the
where muscle depolarization first occurs. The motor electrical device that is positioned inside the muscle, and it
point is very important in motor nerve conduction studies measures an electrical potential difference between a cen-
because if the recording electrode is not placed here, nerve trally insulated wire and the cannula of the needle through
conduction studies can be artificially abnormal because which it runs. It is synonymous with a concentric needle
the CMAP amplitude may appear artificially reduced. It electrode, and it is used mainly in electromyography.
can be useful to ask the patient an a ppropriate voluntary Nerve Conduction Study (NCS) It is a recording and anal-
muscle contraction. If an initial positive deflection (which ysis of electrical waveforms of biological origin elicited
makes the onset latency difficult to accurately measure) is in response to electrical or physiological stimuli (sensory
observed, the recording electrode can be moved slightly or mixed nerve action potentials). It is possible under
in order to obtain a clear negative deflection of the CMAP. standardized conditions to establish normal ranges for
Multifocal Motor Neuropathy A disease characterized amplitude, latency, and duration of the waveforms and
by a selective focal block of motor nerve conduction in to calculate the maximum conduction velocity of sensory
multiple nerves. Motor nerve conduction studies may per- nerves. Synonymous with electroneurography.
mit the identification and localization of the segments of Nerve Conduction Velocity (NCV) The speed of action
nerve affected by the underlying pathology. potential propagation along a nerve fiber or nerve trunk.
NCS An abbreviation for nerve conduction study. Generally assumed to refer to the maximum speed of
NCV An abbreviation for nerve conduction velocity. See propagation, unless otherwise specified. See conduction
conduction velocity. velocity.
Near Field It is a region of electrical activity where the iso- Neuroapraxia A clinical term used to describe the reversible
potential voltage lines associated with a current source motor and sensory deficits produced by focal compres-
change rapidly over a short distance. The terms near field sive or traction lesions of large myelinated nerve fibers.
and far field are arbitrary designations as there are no It is due to a conduction block most often caused by focal
agreed-upon criteria defining where the near field ends demyelination but, when very short lived, presumably
and the far field begins. Compare with far field. caused by focal ischemia. The axon is not injured at the
Needle Electrode It is an electrical device used for record- lesion site. Compare with axonotmesis and neurotmesis.
ing or stimulating that is positioned near the tissue of Neuropathy It is a disorder of the peripheral nerves
interest by penetration of the skin. Needle electrodes and is classified according to the anatomical structure
are used in electroneurography (near-nerve recording of the nerve most affected by the disease: cell body
272 Glossary
(
neuronopathy), axon (axonopathy), or myelin sheath Sensory Nerve Action Potential (SNAP) A compound
(demyelinating neuropathy). It may selectively affect nerve action potential recorded from the afferent fibers of
motor or sensory nerves or both simultaneously. The eti- a sensory nerve. It can also be recorded from a sensory
ology may be hereditary, metabolic, inflammatory, toxic, branch of a mixed nerve or in response to stimulation of
or unknown. a sensory nerve. It may also be elicited when an adequate
Neurotmesis It is a partial or complete nerve severance, stimulus is applied synchronously to sensory receptors.
including the axons, associated myelin sheaths, and sup- Commonly, in electrodiagnostic medicine, the compound
porting connective tissues, resulting in axonal degenera- sensory nerve action potentials (SNAPs) are recorded dis-
tion distal to the injury site. Compare with axonotmesis, tally to the digits after proximal stimulation at the wrist
neuroapraxia. (the antidromic method); conversely, sensory potentials
Noise It is the electrical activity not related to the signal are recorded at the wrist after stimulation is applied to the
of interest (i.e., all waveforms generated by electrodes, digits (the orthodromic method). The amplitude, latency,
cables, amplifiers, or storage media and unrelated to poten- duration, and configuration should be noted. Generally,
tials of biological origin). The signal-to-noise ratio is the the amplitude is measured as the maximum peak-to-peak
ratio of the desired signal power to the background noise voltage (peak-to-peak amplitude) when there is an ini-
signal power. A common background noise is 50–60 Hz tial positive deflection or from the baseline to the peak
(depending on the countries) from electrical devices in (negative peak amplitude) when there is an initial negative
the surrounding environment. Since the signals recorded deflection. The latency is measured as either the time to the
during nerve conduction studies (NCS) are based on the initial deflection or the negative peak and the duration as
differences between the active and references electrodes, the interval from the first deflection of the waveform from
making sure that the two electrodes have the same imped- the baseline to its final return to the baseline (Fig. 26).
ance (which is the opposition to current flow) and placing Stimulating Electrode A device used to deliver an electrical
the ground electrode between the stimulator and record- current. All electrical stimulation requires two electrodes;
ing sites will decrease the background noise. A good the negative (−) terminal of the stimulator is the cathode
signal-to-noise ratio can be obtained using electrodes of (where the current flows out), and the positive (+) termi-
the same type and having intact wires, good connections, nal of the stimulator is the anode (where the current flows
and the underlying skin clean and intact. in). Electrical stimulation for nerve conduction studies
Orthodromic It is the propagation of a nerve impulse in the generally requires application of the cathode in the vicin-
same direction as a physiological conduction. The ortho- ity of the neural tissue to produce depolarization (Fig. 27).
dromic nerve conduction studies were performed using a Depolarization of a nerve occurs under the cathode (the
stimulus directed in the way the nerve normally depolar- negative terminal), and the depolarization proceeds from
izes, for example, stimulating a sensory nerve away from the the cathode (both orthodromically and antidromically).
sensory receptor (Fig. 23). In clinical practice, sensory anti- The cathode should be placed closer to the active record-
dromic nerve conduction studies are the preferred methods ing electrode than the anode because the anode has the
because of higher sensory nerve action potentials (SNAPs) potential to hyperpolarize the nerve and block the depo-
amplitude than orthodromic sensory nerve conduction stud- larization caused by the cathode. This could cause the
ies (Fig. 24). Motor nerve conduction studies are orthodromic recorded potential to be reduced or absent. By conven-
since the stimulus is always directed toward the neuromuscu- tion, the stimulating electrodes are called bipolar if they
lar junctions and muscles. In contrast with antidromic. are encased or attached together (e.g., pad electrodes fixed
Radiculopathy It is any disease of the spinal nerves and on a plastic bar) and are called monopolar if they are not.
roots. The resulting clinical syndrome may include pain, Stimulus In clinical nerve conduction studies, stimulus is
sensory loss, paresthesia, weakness, fasciculations, and an electrical stimulus applied to a nerve. It is described
muscle atrophy. If more than one spinal root is involved, in absolute terms or with respect to the nerve-evoked
the term polyradiculopathy may be used as a descriptor. potential. In absolute terms, it is defined by duration
Recording Electrode In a bipolar configuration, two elec- (ms), waveform (square, exponential, linear, etc.), and
trodes were used to record the electrical potential differ- strength or intensity measured as voltage (V) or current
ence. The electrode close to the source of the electrical (mA). With respect to the evoked potential, the stimulus
activity to be recorded is the active electrode, and the other is graded as subthreshold, threshold, submaximal, maxi-
recording electrode is the reference electrode (Fig. 25). mal, or supramaximal. A threshold stimulus is one just
Residual Latency (RL) The calculated time difference sufficient to produce a detectable response. Stimuli less
between the measured distal latency of a sensory nerve than the threshold stimulus are termed subthreshold. The
and the expected latency, calculated by dividing the dis- maximal stimulus is the stimulus intensity after which
tance between the stimulating cathode and the active a further increase in intensity causes no increase in the
recording electrode by the maximum conduction velocity amplitude of the evoked potential. Stimuli of intensity
measured in a more proximal segment of the nerve. below this level but above threshold are submaximal.
Glossary 273
Orthodromic
R
A
R2
(elbow)
R
A
G R1
(wrist)
–
+
Digit III
S
(digit III)
Fig. 23 Sensory orthodromic conduction, recording at the wrist (R1) and at the elbow (R2), stimulation to the digit III
Median - ulnar digit II-V Median - ulnar digit II-V
1 4 1 4
Wrist (median) 1 3 Wrist (median) 1
3 10 ms 10 µV 20 mA 10 ms 20 µV 20 mA
8 8
2
2
1 4 1 4
Wrist (ulnar) 2 3 Wrist (ulnar) 2
3 10 ms 10 µV 47 mA 10 ms 20 µV 47 mA
8 8
Fig. 24 Triphasic waves. Median-ulnar nerves comparative sensory conduction study, antidromic sensory nerve action potentials (SNAPs)
recorded to the digit II and to the digit V, stimulation at the wrist: median nerve (upper trace) and ulnar nerve (lower trace)
274 Glossary
C8
T1
R
Digit I
Lower trunk
Median
nerve
Medial cord
G 8 cm
– – +
+
Digit V
S1
S2 (wrist)
(palm)
Fig. 25 Recording technique from the abductor pollicis brevis (APB) muscle, bipolar configuration: A – active electrode (on the motor point of
APB muscle), R – reference electrode (on the tendinous insertion of APB muscle)
Median - digit II Median - dgit II
1 4 1 4
Wrist 1 Wrist 1
3
10 ms 10 µV 22 mA 10 ms 20 µV 22 mA
3 14 14
Fig. 26 Antidromic sensory nerve action potential (SNAP) recorded to the digit II (wrist stimulation) marker 1: onset latency (ms); marker 1–2:
negative peak amplitude (μV); markers 2–3: peak to peak amplitude (μV); markers 1–4: duration (ms)
Glossary 275
C8
T1
R
Lower trunk Digit I

Median
nerve
Medial cord
8 cm
– +
G
Digit V
S1
(wrist)
Fig. 27 Recording technique from the abductor pollicis brevis (APB) muscle, stimulation of the wrist (S1) and on the palm (S2): negative (−)
terminal – anode, positive (+) terminal – cathode
Stimuli of intensity greater than the maximal stimulus are conduction studies. For late responses, commonly a
defined supramaximal. Ordinarily, supramaximal stimuli sweep speed of 5 to 10 ms/division is used for F waves
are used for nerve conduction studies. By convention, an or 10 ms/division for H reflex study. In electromyogra-
electrical stimulus of approximately 20 % greater voltage/ phy, a higher sweep rate (10–100 ms/division) is used
current than required for the maximal stimulus is used for than in electroneurography in order to analyze muscle
supramaximal stimulation. The frequency, number, and activity at rest and during minimal and maximal con-
duration of a series of stimuli should be specified. traction (Fig. 28).
Sweep Time Also called “time base,” it represents the lin- Voltage A potential difference between two recording sites.
ear time scale with which the potentials are displayed. Expressed in volts (V) or millivolts (mV).
In clinical practice, the sweep speed usually ranges Waveform A transient change in voltage represented as a
from 2 to 5 ms/division for motor nerve conduction line of differing directions over time, describing the shape
studies and from 1 to 2 ms/division for sensory nerve of a wave.
276 Glossary

2 2
1 3 5 1 3 5
Wrist 1 Wrist 1
50 ms 5 mV 40 mA 30 ms 5 mV 40 mA
4 4
2 2
1 3 5 1 3 5
Elbow 2 Elbow 2
50 ms 5 mV 83 mA 30 ms 5 mV 83 mA
4 4
Fig. 28 Compound muscle action potentials (CMAPs) recorded at the hand from the abductor pollicis brevis (APB) muscle, displayed at different
sweep speed (3 ms/div – left, 5 ms/div – right) and identical sensitivity, stimulation at the wrist (upper trace) and at the elbow (lower trace)
Index
A H
Abductor digiti minimi (ADM), 52, 75, 141 H-reflex, 107, 117, 151
Abductor pollicis brevis (APB), 7, 13, 17, 21, 29, 33, 45, 52, 61, H-reflex conduction velocity (H-RCV), 119
75, 83, 97, 121, 125, 131, 137, 143, 147, 173, 179, 191, H-reflex latency (H-RL), 117
197, 203, 207, 217, 249 Hypothenar, 75
Amplitude ratio, 175, 203
Anterior interosseous nerve syndrome (AIN), 232, 237, 245, 2249
I
Interossei (INT), 155
B
Body mass index (BMI), 164, 182, 193
K
Kiloh Nevin syndrome, 251
C
Carpal tunnel syndrome (CTS), 7, 17, 23, 25, 33, 45, 59, 63, 77,
95, 101, 114, 123, 129, 133, 145, 147, 157, 164, 182, 195, L
203, 210, 213, 217, 221, 232, 242, 249 Latency difference, 191
Chronic inflammatory demyelinating polyradiculoneuropathy
(CIDP), 52
Collision technique, 52 M
Compound muscle action potential (CMAP), 23, 25, 29, 33, 45, 51, Medial thenar motor (MTM), 213
57, 63, 75, 91, 107, 111, 117, 131, 137, 141, 145, 151, 155, Median thenar (MT), 3, 33, 49, 111
173, 179, 191, 203, 207, 213, 217, 221, 229, 235, 241, 249 Motor conduction time, 3, 7, 13, 17
Motor conduction velocity, 217, 221
Motor nerve conduction time, 100
D Motor nerve conduction velocity (MNCV), 13, 17, 21,
Diabetic polyneuropathy, 78, 164, 194 25, 29, 33, 51, 57, 59, 83, 93, 99, 111, 139,
Distal latency, 3, 7, 13, 17, 23, 25, 29, 33, 45, 51, 63, 75, 83, 99, 121, 197, 203
131, 138, 141, 145, 155, 194, 197, 203, 207, 213, 217, 221
Duration, 33, 241
O
Opponens pollicis (OP), 7, 25, 29, 57, 91
F
First dorsal interosseous (FDI), 137
First lumbrical (1L), 145 P
Flexor carpi radialis (FCR), 107, 117, 151 Pronator quadratus (PQ), 229, 241, 249
Flexor pollicis longus (FPL), 235, 255 Pronator teres syndrome (PTS), 232, 244
Forearm conduction velocity, 113, 121, 219
F-wave, 49, 61, 125
inversion, 53 R
latency, 51 Repeater F-waves (RF-waves), 127
latency ratio, 53 Residual latency (RL), 23, 59, 93, 111, 210
velocity, 51 Residual latency index (RLI), 91
G S
Guillain-Barré syndrome (GBS), 181 Second lumbrical (2L), 121, 155, 221

DOI 10.1007/978-3-319-10473-7, © Springer International Publishing Switzerland 2015
278 Index
T Thenar, 75
Terminal conduction time, 21 Transcarpal motor conduction, 134, 219
Terminal latency (TL), 59, 93, 111, 207
Terminal latency index (TLI),
179, 207 U
Terminal latency ratio (TLR), 217 Ulnar hypothenar, 52

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The Median Nerve - Motor Conduction Studies 2015

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Giuliano Gentili

ISBN 978-3-319-10472-0 ISBN 978-3-319-10473-7 (eBook)

Library of Congress Control Number: 2014957639

© Springer International Publishing Switzerland 2015

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

“Well, I must endure the presence of two or three caterpillars

To all persons that are in my heart…

Motor Conduction Studies Index (by Practical Criteria) . . . . . . . . . . . . . . . . . . . . . . xvii

Part I Motor Conduction Studies: Median Nerve

M1 Elbow, Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

M14 Wrist, Elbow, Axilla, Erb’s Point – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

M35 Wrist, Palm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

A1 Above Elbow, Below Elbow – Distal Forearm. . . . . . . . . . . . . . . . . . . . . . . . . . . 229

BMI Body mass index

Lower trunk Digit I

Digit I Anterior interosseous nerve

FPB Middle trunk

Muscle Branch Cord Trunk Root

Fig. 2 Muscles innervated by the median nerve (forearm and hand)

Distal latency studies

Forearm velocity studies

Amplitude ratio studies

Median-median comparative studies

Median-ulnar comparative studies

Residual latency (RL), sensory-motor index (SMI) and terminal latency

Needle recording studies

Forearm: ﬂexor carpi radialis (FCR) muscle studies

Hand: abductor pollicis brevis (APB) muscle studies

Hand: median thenar (MT) muscle studies

Hand: opponens pollicis (OP) muscle studies

Hand: ﬁrst lumbrical (1L) muscle studies

Hand: second lumbrical (2L) muscle studies

Anterior interosseous nerve (motor branch of the median nerve):

Forearm: ﬂexor pollicis longus (FPL) muscle studies

Forearm: pronator quadratus (PQ) muscle studies

Stimulation For measuring the motor conduction time from Comment

G. Gentili, M. Di Napoli, The Median Nerve: Motor Conduction Studies, 3

Median - (MT) Median - (MT)

G. Gentili, M. Di Napoli, The Median Nerve: Motor Conduction Studies, 7

Typical waveform (wrist, elbow – APB muscle):

2 Median - (APB) 2 Median - (APB)

Typical waveform (wrist, elbow – OP muscle):

Table 1 Reference values

Pathological waveform (wrist, elbow – APB muscle)

Median - (APB) Median - (APB)

Pathological waveform (wrist, elbow – OP muscle)

G. Gentili, M. Di Napoli, The Median Nerve: Motor Conduction Studies, 13

Typical waveform (wrist, elbow – APB muscle):

Median - (APB) Median - (APB)

Stimulation The median nerve was stimulated at the wrist Comment

G. Gentili, M. Di Napoli, The Median Nerve: Motor Conduction Studies, 17

Typical waveform (wrist, elbow, axilla – APB muscle):

Median - (APB) Median - (APB)

Table 1 Reference values Table 3 Reference values

Pathological waveform (wrist, elbow, axilla – APB muscle):

Median - (APB) Median - (APB)