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Easy EMG
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T H I R D E D I T I O N
Easy EMG
A Guide to Performing Nerve
Conduction Studies and
Electromyography
Authors Illustrator
LYN D. WEISS MD DENNIS J. DOWLING
Chair of Physical Medicine and Rehabilitation DO FAAO
NYU Langone Hospital Long Island
Director of Osteopathic Medicine
Professor of Rehabilitation Medicine
Services
NYU Long Island School of Medicine
Department of Physical Medicine and
Mineola, NY, USA
Rehabilitation
Family Medicine Department
JAY M. WEISS MD Nassau University Medical Center
Long Island Physical Medicine and East Meadow, NY, USA
Rehabilitation Director of OMM Assessment
Jericho, NY, USA National Board Osteopathic Medical
Associate Professor of Clinical Physical Examiners
Medicine and Rehabilitation Conshohocken, PA, USA
State University of New York Stony Brook
College of Medicine
Stony Brook, NY, USA
JULIE K. SILVER MD
Associate Professor
Department of Physical Medicine and
Rehabilitation
Harvard Medical School
Boston, MA, USA
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CONTENTS
Preface vii
Dedication ix
Video Table of Contents xi
1. What Is an EMG? 1
Julie K. Silver
2. Why Perform Electrodiagnostic Studies? 5

Julie K. Silver
3. About the Machine 9

Julie K. Silver
4. Nerve Conduction Studies 17

Lyn D. Weiss n Jay M. Weiss
5. Electromyography 37
Lyn D. Weiss n Jay M. Weiss
6. Injuries to Peripheral Nerves 67

Lyn D. Weiss
7. How to Plan Out the Examination 73

Lyn D. Weiss
8. Pitfalls 99
Lyn D. Weiss
9. Carpal Tunnel Syndrome 109

Lyn D. Weiss
10. Ulnar Neuropathy 117

Lyn D. Weiss
11. Radial Neuropathy 125

Julie K. Silver
12. Radiculopathy 131

Lyn D. Weiss
13. Spinal Stenosis 139

Lyn D. Weiss
14. Fibular (Peroneal) Neuropathy 141

Julie K. Silver
15. Tarsal Tunnel Syndrome 147

Julie K. Silver n Jay M. Weiss
16. Peripheral Polyneuropathy 151

Lyn D. Weiss
v
vi Contents
17. Myopathy 157

Julie K. Silver
18. Brachial Plexopathies 161

19. Lumbosacral Plexopathies 171

20. Motor Neuron Diseases 179

Lyn D. Weiss
21. Critical Illness Neuropathy and Myopathy 181

Lyn D. Weiss
22. Inflammatory Neuropathies 185

Lyn D. Weiss
23. Neuromuscular Junction Disorders 189

Lyn D. Weiss
24. How to Write a Report 193

Lyn D. Weiss
25. Tables of Normals 199

Lyn D. Weiss
26. Reimbursement 203

Jay M. Weiss
GLOSSARY OF EMG TERMS 209

APPENDIX 1: Figures for Table 4.3 (Nerve Conduction Studies Setup) 211
APPENDIX 2: Figures for Table 5.4 (Common Muscles—Innervation, Location,
and Needle Placement) 219
APPENDIX 3: Summary of Electrodiagnostic Findings in Specific Clinical
Conditions 263
Index 273
PREFACE
We realize that many residents struggle with learning the basics of electrodiagnostic testing. We
hope that this book provides a foundation that is easy to understand. This is not meant to be a
comprehensive text. It is meant, rather, to serve as a bridge to more in-depth textbooks.
This third edition includes updates and additional chapters. In addition, we hope that the video
clips will clarify the technical aspect of electrodiagnostic testing. The first three chapters are intro-
ductory in nature. They briefly review what electromyography (EMG) testing is and why we do it.
Chapter 4 assesses nerve conduction studies. The needle portion of the examination is discussed
in Chapter 5. Chapter 6 reviews the effects of injuries on peripheral nerves. Suggestions on how
to plan out the examination are reviewed in Chapter 7. Chapter 8 examines some of the pitfalls
that all electromyographers should recognize.
Chapters 9 through 20 review some of the commonly encountered clinical entities that the
beginning electromyographer might encounter. Chapter 24 gives suggestions on how to write
a complete electrodiagnostic report. Chapter 25 details the commonly accepted normal values
for electrodiagnostic laboratory tests. It should be stressed, however, that each laboratory should
develop its own set of normals based on its own particular patient population and electrodiagnostic
equipment. Reimbursement issues are discussed in Chapter 26.
It should be noted that this book does not represent the complete spectrum of electrodiag-
nostic testing. Since this book is specifically targeted at novices in the field, some of the more
complex testing, including somatosensory evoked potentials, blink reflex, and single-fiber EMG,
is not discussed.
Although this text does review a great deal of technical information, the most important les-
son one can learn, which is stressed repeatedly throughout the text, is that the electrodiagnostic
test is an extension of the history and physical examination. We are physicians, first and foremost,
with obligations to provide our patients with compassionate and quality care. We hope this book
inspires lifelong learning.
Lyn D. Weiss MD
Jay M. Weiss MD
Julie K. Silver MD
vii
The authors would like to dedicate this book to our teachers,
to our mentors, and especially to our students.
Jay and Lyn Weiss want to thank the people who have taught us
the most about what is important in life—our children
(Ari, Lauren, Helene, Kyle, Stefan, Becca, Rachel, Benjamin,
Olivia, Levon, Evelyn, and Mason).
V I D E O TA B L E O F C O N T E N T S
Table 4.3:
Video 4.1 Median Nerve Motor Conduction Study.
Video 4.2 Median Sensory Study.
Video 4.3 Ulnar Nerve Motor Conduction Study.
Video 4.4 Dorsal Ulnar Cutaneous Nerve Sensory Conduction Study.
Video 4.5 Ulnar Nerve Sensory Conduction Study.
Video 4.6 Radial Nerve Sensory Conduction Study.
Video 4.7 Radial Motor Nerve Conduction Study.
Video 4.8 Lateral Antebrachial Cutaneous Nerve Conduction Study.
Video 4.9 Medial Antebrachial Cutaneous Nerve Conduction Study.
Video 4.10 Musculocutaneous Nerve Motor Conduction Study.
Video 4.11 Axillary Nerve Motor Conduction Study.
Video 4.12 Fibular Nerve Motor Conduction Study.
Video 4.13 Sural Nerve Sensory Conduction Study.
Video 4.14 Tibial Motor Nerve Conduction Study.
Video 4.15 Superficial Fibular Nerve Sensory Conduction Study.
Video 4.16 Medial and Lateral Plantar Mixed (Sensory Orthodromic) Nerve.
Video 4.17 H-Reflex Study.
Table 5.4:
Video 5.1 Needle EMG Basics.
Video 5.2 Needle Insertion for the Deltoid.
Video 5.3 Needle Insertion for the Biceps.
Video 5.4 Needle Insertion for the Triceps.
Video 5.5 Needle Insertion for the Brachioradialis.
Video 5.6 Needle Insertion for the Pronator Teres.
Video 5.7 Needle Insertion for the Abductor Pollicis Brevis (APB).
Video 5.8 Needle Insertion for the Abductor Digiti Minimi (ADM).
Video 5.9 Needle Insertion for the First Dorsal Interosseous (FDI).
Video 5.10 Needle Insertion for the Vastus Medialis.
Video 5.11 Needle Insertion for the Medial Hamstring.
Video 5.12 Needle Insertion for the Biceps Femoris Short Head.
Video 5.13 Needle Insertion for the Tibialis Anterior.
Video 5.14 Needle Insertion for the Extensor Digitorum Brevis (EDB).
Video 5.15 Needle Insertion for the Gastrocnemius.
xi
C H A P T E R 1
What Is an EMG?
Julie K. Silver
Electrodiagnostic studies seem confusing at first. Remember this: the entire purpose of electrodi-
agnostic studies is to help you figure out whether there is a problem with nerves, muscles, or both,
and if so, where the problem is occurring (Fig. 1.1). The American Association of Neuromuscu-
lar and Electrodiagnostic Medicine uses the term electrodiagnostic medicine (which is sometimes
abbreviated to EDX) to define the medical subspecialty that utilizes neurophysiologic techniques
to diagnose, evaluate, and treat patients who are believed to have or who have documented physi-
cal impairments of the nervous, neuromuscular, and/or muscular systems.
We all recognize that the nervous system is a complicated part of our anatomy. Indeed, many
medical students, residents, and fellows find their initial exposure to these tests and the courses
in which they are taught overwhelming. However, the truth is that they are fairly straightforward
and easy to understand.
If you do not believe this, think back to when you were a small child learning to read. At first,
all of the letters in the alphabet did not make sense. Some had loops, some had straight lines,
some had angled lines, and some had all of these. However, once you figured out all the letters,
suddenly you could look at them anywhere and they made sense to you. Of course, you still could
not read; that came later. Even after you learned the alphabet, the higher-level task of reading (at
some point not too long after you learned the alphabet) eventually became a breeze. So, too, will
electrodiagnostic studies become a breeze.
Think of the first half of this book as learning the alphabet. You will need to simply memorize
some terms and try to understand when to use them and in which context they are meaning-
ful—just like the alphabet letters. The second half of this book is the part where you learn to read
or to put the things you have memorized to use in a logical way so that when electrodiagnostic
studies are ordered, you can understand what information is being conveyed and how to perform
the study. Keeping with the alphabet/reading example, more advanced electrodiagnostic textbooks
(and clinical experience under experienced electromyographers) will teach you the equivalent of
grammar and higher-level skills that are extremely important. Nevertheless, you do not need to
know all that at first. Go through every chapter in this book, and just like you learned the alphabet
and then learned to read, you will begin to become literate in electrodiagnostic studies—only it
will happen much faster this time!
The term electrodiagnostic studies really encompasses a lot of different tests. The most common
tests done (and the ones that will be presented in this book) are nerve conduction studies (NCS)
and electromyography (EMG). Often people refer to both NCS and EMG as just EMG because
these two tests are nearly always done together. But when you are talking with people who are
familiar with electrodiagnostic testing, to avoid confusion it is best to speak of and write about
(especially in your medical record documentation) these components separately. The tests can
provide different information; however, both tests assess the electrical functioning of nerves and/
or muscles.
It is interesting to note that electrodiagnostic studies originated in the 19th century but have
been used consistently only within the past 30 to 40 years. This is because the machines became
1
2 EASY EMG
Sensory nerve root
Dorsal root ganglion
Motor
neuron
Motor nerve root
Peripheral nerve
Sensory Motor nerve

nerve
Neuromuscular junction
Muscle
Fig. 1.1 The goal of electrodiagnostic studies is to determine whether there is a problem along the peripheral
nervous system pathway and/or in the muscles and, if so, where the problem is. Examples of locations of
possible lesions and associated diagnoses include:
Motor nerve cell body (anterior horn cell): amyotrophic lateral sclerosis
Root: cervical or lumbar radiculopathy
Axon: toxic neuropathy
Myelin: Guillain–Barré syndrome
Neuromuscular junction: myasthenia gravis
Muscle: muscular dystrophy
more sophisticated with computerization and, at the same time, easier to use. Highly refined tech-
niques enhanced diagnostic applications and encouraged people to use these tests.
One of the things that will make it much easier for you to learn both EMG and NCS is
to understand that they are really extensions of the neurologic and musculoskeletal examination. The
more you know about the basic anatomy of the nerves and muscles, the easier it will be for you to
learn about electrodiagnostic studies. If you are just beginning to learn about which nerves sup-
ply which muscles, this will be a slightly more complicated subject, but still very manageable. Just
keep reading.
Table 1.1 is a summary of the process of performing electrodiagnostic studies. The rest of this
chapter is devoted to explaining the two basic tests: EMG and NCS. You will simply need to
memorize some of this; but hopefully, as you read, it will start to make sense.
Nerve Conduction Studies

NCS are done by placing electrodes on the skin and stimulating the nerves through electrical
impulses (Fig. 1.2). To study motor nerves, electrodes are placed over a muscle that receives its
innervation from the nerve you want to test (stimulate). The electrical response of the muscle
is then recorded, and you can determine both how fast and how well the nerve responded. This
1—What Is an EMG? 3
TABLE 1.1 n The Electrodiagnostic Process
1. Evaluate the patient by doing a history and physical examination, with the goal of developing a dif-
ferential diagnosis.
2. Select the appropriate electrodiagnostic tests you want to perform to rule in or out diagnoses on your
list.
3. Explain to the patient what the test will feel like and why it is being done.
4. Perform the study in a technically competent fashion, usually starting with NCS and then proceeding
with EMG.
5. Interpret the results to arrive at the correct diagnosis or to narrow your list of differential diagnoses.
6. Communicate the test results to the referring physician in a timely and meaningful manner.
EMG, Electromyography; NCS, nerve conduction studies.
Hand Wrist
stimulation stimulation
Active
electrode
Reference
electrode
Ground
Sensory Amplitude
nerve
action
potential Takeoff latency
Peak latency
Fig. 1.2 This is the basic setup for a sensory nerve conduction study. The machine gives a tracing of the
sensory nerve action potential (SNAP). The amplitude and latency can be measured easily.
is very valuable information and can help you determine whether the patient’s condition is
stemming from a problem with the nerve or with the muscle.
NCS are broken down into two categories: motor and sensory nerve conduction testing. The
autonomic nervous system can be tested, but it rarely has clinical applications and is beyond the
scope of this text. NCS can be performed on any accessible nerve, including peripheral nerves and
cranial nerves.
The basic findings are generally twofold: (1) How fast is the impulse traveling (e.g., How well
is the electrical impulse conducting?)? And (2) What does the electrical representation of the
nerve stimulation (action potential morphology) look like on the screen (e.g., Does there appear to
be a problem with the shape or height that might suggest an injury to some portion of the nerve,
such as the axons or the myelin?)?
The terms you need to memorize in NCS are listed in Table 1.2. EMG terms are listed and
explained in Chapter 5, Electromyography.
4 EASY EMG
TABLE 1.2 n Nerve Conduction Study Terms
Action potential: This is the waveform you see on the screen. (To give more details about what you
are describing, more specific terms may include compound nerve action potential, compound motor
action potential, or sensory nerve action potential.)
Amplitude: The maximal height of the action potential.
Antidromic: When the electrical impulse travels in the opposite direction of normal physiologic conduc-
tion (e.g., conduction of a motor nerve electrical impulse away from the muscle and toward the
spine).
Conduction velocity: How fast the fastest part of the impulse travels (can also be referred to as a mo-
tor conduction velocity or a sensory conduction velocity).
F-wave: A compound muscle action potential evoked by antidromically stimulating a motor nerve from
a muscle using maximal electrical stimulus. It represents the time required for a stimulus to travel
antidromically toward the spinal cord and to return orthodromically to the muscle along a very small
percentage of the fibers.
Latency: The time interval between the onset of a stimulus and the onset of a response (can also be
referred to as a motor latency or a sensory latency).
H-reflex: A compound muscle action potential evoked by orthodromically stimulating sensory fibers,
synapsing at the spinal level and returning orthodromically via motor fibers. The response is thought
to be due to a monosynaptic spinal reflex (Hoffmann reflex) found in normal adults in the gastrocne-
mius–soleus and flexor carpi radialis muscles.
Orthodromic: When the electrical impulse travels in the same direction as normal physiologic conduc-
tion (e.g., when a motor nerve electrical impulse is transmitted toward the muscle and away from the
spine, or when a sensory impulse travels toward the spine).
Electromyography
EMG is the process by which an examiner puts a needle into a particular muscle and studies the
electrical activity of that muscle. This electrical activity comes from the muscle itself—no shocks
are used to stimulate the muscle. EMG also differs from NCS because it does not involve actu-
ally testing nerves. However, you do get information about the nerves indirectly by testing the
muscles. (Remember that all muscles are supplied by nerves, so if you can identify which muscles
are affected by a disease process, then you simultaneously obtain information about the nerves that
supply those muscles.)
So the EMG is different from NCS in the following ways:
1. In EMG, you use a needle and put it into the muscle rather than placing electrodes on the
skin (NCS).
2. In EMG, you do not use any electrical shocks; rather, you are looking at the intrinsic electri-
cal activity of the muscle.
3. In EMG, you get direct information about the muscles and indirect information about the
nerves that supply the muscles you test.
C H A P T E R 2
Why Perform Electrodiagnostic
Studies?
Julie K. Silver
Electrodiagnostic testing is an important method for physicians and other healthcare profession-
als to distinguish among many nerve and muscle disorders. One of the ways to think of electromy-
ography (EMG) and nerve conduction studies (NCS) is to consider them pieces of a puzzle. The
puzzle may be complicated with many pieces, or fairly straightforward with few pieces needed to
solve it. To understand what you are seeing, whether it is a real puzzle or a figurative medical puz-
zle, the more pieces you can put into place, the clearer the picture becomes. In medicine, some of
the other puzzle pieces are the history, physical examination, laboratory tests, and imaging studies.
An important thing to remember is that electrodiagnostic studies represent a physiologic piece
of the diagnostic puzzle. For example, unlike an magnetic resonance imaging (MRI) or an x-ray,
which one can think of as sophisticated photographs, EMG and NCS provide information in real
time about what is occurring physiologically with respect to the nerve and the muscle. This is not
to say that imaging studies are not useful, but rather to explain that these tests complement each
other and that each has a role in helping establish the correct diagnosis in neuromuscular disorders.
The take-home message is this: Electrodiagnostic studies are sometimes essential in establishing a par-
ticular diagnosis and are sometimes not useful at all. As a clinician, it is important to understand when
to recommend these studies, just as it is important to know when to order an imaging study. The more you
learn about EMG and NCS, the more familiar you will become with their diagnostic usefulness.
In a practical sense, you can consider electrodiagnostic testing in any of the following circum-
stances:
1. A patient is complaining of numbness.
2. A patient is complaining of tingling (paresthesias).
3. A patient has pain.
4. A patient has weakness.
5. A patient has a limp.
6. A patient has muscle atrophy.
7. A patient has depressed deep tendon reflexes.
8. A patient has fatigue.
Of course, it would be ridiculous to rely solely on any one of these signs or symptoms when
recommending NCS and/or EMG. For example, a young woman comes in complaining of arm
pain. The differential diagnosis should immediately include trauma as a source of the pain. Upon
questioning you learn that in fact she fell, and on physical examination you note a large abrasion
that explains her pain. To even consider electrodiagnostic studies in this situation is absurd. The
point here is that a list of signs and symptoms does not lead you to automatically order electro-
diagnostic studies. Rather, these tests can be thought of as extensions of the history and physical
examination when someone has any one or more of the listed signs or symptoms that cannot be
explained by the history and physical examination alone.
Clearly electrodiagnostic studies are useful to establish the correct diagnosis, but they are also
useful to determine whether someone should have surgery and are often preferred over imaging
5
6 EASY EMG
studies when certain types of surgery are being considered. They are also done for prognostic rea-
sons to follow the course of recovery (or deterioration) from an injury.
In summary, electrodiagnostic studies are used to:
1. Establish the correct diagnosis.
2. Localize the lesion.
3. Determine treatment even if the diagnosis is already known.
4. Provide information about the prognosis.
Consider the following examples:
Example 1
A man comes in with hand pain, paresthesias, and numbness that are most prominent in the index
and long fingers. Upon questioning, he also reveals he has neck pain. The physical examination is
inconclusive. The differential diagnosis includes carpal tunnel syndrome (median nerve compres-
sion at the wrist) and cervical radiculopathy. EMG and NCS are the studies of choice to establish
the correct diagnosis.
Example 2
Another man comes in with the same symptoms, but he does not have neck pain. In the past, he
was diagnosed with carpal tunnel syndrome and underwent an injection with local corticosteroid
into the carpal tunnel, which completely alleviated his symptoms for a few months. (A good
response to a corticosteroid injection in the carpal tunnel is both therapeutic and diagnostic for
carpal tunnel syndrome.) Now, however, his symptoms are back with a vengeance. In this case of
carpal tunnel syndrome, electrodiagnostic studies can be recommended to determine the sever-
ity of his condition and to help decide whether conservative management or surgery is the most
appropriate course of treatment.
Example 3
A third man comes in; he had carpal tunnel surgery 3 months ago. His symptoms are much bet-
ter, but he is still quite weak. Before his surgery he had EMG and NCS that demonstrated a very
severe injury to the median nerve. Now he is a candidate for repeat electrodiagnostic studies to
provide information about the prognosis. The new study can be compared to the old study, and
information can be extrapolated about the current status of the median nerve and predicted future
improvement.
The Skilled and Compassionate Electrodiagnostician

The reason you are reading this book is because skill matters. If you are going to perform electro-
diagnostic studies on patients, you need to become an expert in electrodiagnostic medicine. The
American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) provides
information and recommendations on the qualifications for physicians and laboratory directors.
For example, the AANEM recommends that physicians undergo at least 6 months of full-time
supervised training during a physical medicine and rehabilitation (PM&R) or neurology resi-
dency or fellowship, and complete a minimum of 200 studies. To take the board examination
offered by the American Board of Electrodiagnostic Medicine (ABEM), physicians must also
have a minimum of 1 year’s experience following their training. Reading this book, other text-
books, and journal articles, as well as studying anatomy in the context of electrodiagnostic medi-
cine and performing a significant number of studies—at first with supervision and then on your
own—will help turn you into an expert.
Even if electrodiagnostic studies become easy for you, they are not easy on your patients. Many
patients are afraid to have electrodiagnostic studies. They may have heard that these tests are
2—Why Perform Electrodiagnostic Studies? 7
extremely painful, or they may have a genuine needle phobia. To get the information you need
from these tests, it is important for you to be both technically skilled and able to put the patient
at ease. The following suggestions will help lessen the patient’s anxiety:
1. Avoid keeping the patient waiting, because that will only increase their anxiety.
2. Before you start, explain to the patient what you are going to do. Be sure the patient
understands that the electrical stimulation occurs only with NCS and not with EMG.
3. Explain that these tests will be useful in determining the diagnosis.
4. Reassure the patient that you will stop the test at any point if they request you to do so. Be
sure to honor that request should it occur.
5. Start with the area of greatest interest—especially if you suspect that the patient will not
tolerate the entire study.
6. Although not typically used, analgesic or sedating medication can be given (particularly in
pediatric patients).
7. During the test, distract the patient with conversation. It is usually easy to distract some-
one by asking them questions about what they like to do, where they like to go, and other
similar questions. Some electromyographers play music of the patient’s choosing during
the test.
8. In most instances, it is best not to show patients the needle because many people associate
more pain with a long needle rather than with a larger diameter. (The EMG needle is long,
thin, and coated with Teflon, which moves through skin and muscle with less resistance,
so it does not hurt as much as a larger-diameter conventional needle.) In addition, most
patients feel more comfortable with the term electrical stimulation rather than electrical shock,
which conjures up images of torture.
9. Assure the patient that you will minimize the length of the examination, doing only what
is absolutely necessary to obtain the required information.
10. Keep the room warm. This serves two purposes. First of all, the patient is generally dressed
in a gown and therefore is prone to being cold, so keeping the room warm will make them
more comfortable. Second, the results of your electrodiagnostic test may be affected if the
patient’s extremity is cool (see Chapter 8, Pitfalls).
SPECIAL PRECAUTIONS
There are a number of clinical situations that deserve special mention. These are cases where
electrodiagnostic studies can be safely done, as long as the physician takes measures to ensure the
safety of the patient (and the physician) and the accuracy of the test.
Morbid Obesity
In patients who are overweight, it may be difficult (or impossible) to localize specific muscles.
Care must be taken to ensure the needle is indeed placed in the appropriate muscle. Extra-long
needles may be needed.
Thin Individuals
In thin patients, it is important not to insert the needle too far, because it can injure other tis-
sues (e.g., a needle placed in the thoracic paraspinal muscles may penetrate the lung and cause a
pneumothorax).
Bleeding Disorders
Individuals with known bleeding disorders or who are on anticoagulation therapy should be
assessed on an individual basis and the risks and benefits of the test evaluated. It may be helpful
8 EASY EMG
to have recent laboratory testing for coagulation parameters. Therapeutic levels of anticoagulation
are not a contraindication to EMG.
Blood Precautions
It is imperative to always practice safe needle-stick procedures to protect yourself and the patient
from injury. These include always wearing gloves for the needle portion of the test, using a sterile
disposable needle for the EMG, using a one-handed technique if needed for needle recapping,
and immediately disposing of all sharps in an appropriate container.
CONTRAINDICATIONS
Strict contraindications to electrodiagnostic testing are relatively few. Obviously anyone who has
a severe bleeding disorder or whose anticoagulation therapy is out of control should not undergo
EMG. NCS are contraindicated in those with automatic implanted cardiac defibrillators. A
patient with a cardiac pacemaker should not receive direct electrical stimulation over the pace-
maker. Someone with an active skin or soft tissue infection (e.g., cellulitis) should not have a
needle EMG anywhere near the infection.
COMPLICATIONS
Complications from electrodiagnostic studies are extremely rare when performed by a skilled
clinician. Complications may include infection, bleeding, and accidental penetration of the needle
into something other than the intended muscle (e.g., lung or nerves).
CONTROVERSY
As with nearly every test in medicine, there is controversy about when to do electrodiagnos-
tic studies. There is no doubt that EMG and NCS provide valuable information and in many
instances are worthwhile tests to pursue. However, they must be judiciously performed—as is the
case with all medical testing. Of course, there would not be any controversy if these studies were
painless, completely safe, and free, but this is not the case. They do cause some patient discomfort
(although this can be minimized with a skilled and compassionate approach), and they are rela-
tively expensive tests to perform.
Although these tests are generally safe, as with any injection there is a very small risk of com-
plications. In instances where there is potential beneficial information from the test, then the
risk–benefit ratio will fall in favor of performing the test. If the test is not realistically likely to be
helpful in treatment then the risks (even if minimal) may outweigh the potential benefits.
The AANEM Recommended Policy For Electrodiagnostic Medicine note “minimum stan-
dards.” First of these is the test should be medically indicated.1 This would imply that the test
would potentially enhance the patients care. Therefore it is important every time you consider
performing electrodiagnostic studies to assess whether the test is necessary; whether it will help
you determine the diagnosis, treatment, or prognosis of a patient’s condition; and whether there
is another test that might be less invasive and/or more cost-effective or that will provide the same
information. It is important to always remember to first do no harm.
Reference
1. AANEM Recommended Policy For Electrodiagnostic Medicine. Approved by the American Association of Neuromuscu-
lar & Electrodiagnostic Medicine: September 1997; updated 1998, 1999, 2000, 2001, 2002, 2004, 2014,
and 2017. Updated on November 2019.
C H A P T E R 3
About the Machine
Julie K. Silver
The Basic Machine

Modern electrodiagnostic equipment consists of a computer and the associated hardware and
software (Fig. 3.1). The hardware is fairly standard and typically includes a visual monitor, a key-
board, and computer hardware and software. The software varies in the same ways that all software
varies—ease of use, ability to perform specific functions, and ability to interface with other soft-
ware. However, all basic electrodiagnostic software allows the clinician:
n to perform both electromyography (EMG) and nerve conduction studies (NCS),
n to collect data,
n to analyze the results (through automatic calculations that are usually preprogrammed), and
n to store the information.
Data entry is done using a keyboard and/or a mouse. Machines have varying degrees of word pro-
cessing functions and generation of reports through templates. When you are performing NCS,
the information you need is displayed on a screen. During EMG studies, you will have the same
visual screen information, but there also will be audio (sounds) that you will hear. Both the visual
and the audio data are critical to properly interpreting EMG findings.
RECORDING ELECTRODES
It is important to understand electrode terms used in electrodiagnostic studies. Table 3.1 lists the
common terms and in which studies they are used.
Surface Electrodes
Surface electrodes are used for routine NCS. The electrodes are typically either ring or disk elec-
trodes (Fig. 3.2). They are also either disposable or nondisposable. The nondisposable electrodes
are made of stainless steel, silver, or, rarely, gold that is soldered to multistrand conducting wires.
These electrodes stick to the skin by using adhesive tape and can be reused. They should be cleaned
between patients. It is necessary to use conducting gel with nondisposable electrodes to reduce
impedance and prevent artifact (due to irregularities in the skin and the presence of hair follicles).
Disposable electrodes have a sticky underside and a built-in conductive medium that allows them
to adhere to the skin and to conduct electrical signals without the need for tape or gel.
Three surface electrodes are used in NCS: active and reference recording electrodes and ground
electrodes. In EMG studies, surface electrodes are used for the ground and (in the case of a mo-
nopolar needle electrode) for the reference-recording electrode.
Needle Electrodes
Needle electrodes are generally reserved for EMG but are occasionally used in NCS. Needle elec-
trodes are disposable and are used only on one patient (one-time use). Needle electrodes are classified
as monopolar 3,3a, bipolar 3.3b, or concentric. Monopolar needles are typically less expensive, less
9
10 Easy EMG
Fig. 3.1 Picture of an electromyography (EMG) machine. (Courtesy of Cadwell Laboratories.)
TABLE 3.1 n Electrodes Used in NCS and EMG
NCS
Active (surface electrode—this is also referred to as the pickup electrode)
Reference (surface electrode)
Ground (surface electrode)
EMG
Active (needle electrode)
Reference (surface electrode)a
Ground (surface electrode)
a
A separate reference is used in EMG studies only if you are using a monopolar needle. Concentric needles
have a reference built into the needle, so there is no need for a separate reference.
EMG, Electromyography; NCS, nerve conduction studies.
painful (due to a narrower diameter and a Teflon coating on the shaft of the needle), and less elec-
trically stable than bipolar or concentric needle electrodes. With a monopolar needle, you need a
separate surface reference electrode, whereas with a concentric needle, the reference is the barrel
of the needle and you do not need a separate surface reference electrode. There are also EMG
needles that allow for injections (e.g., botulinum toxin injections; see Fig. 3.3c). See Chapter 5,
Electromyography, for further description of the needles.
AMPLIFIERS
Amplifiers are very complicated parts of the electrodiagnostic machinery, but their concept is
fairly simple. Amplifiers magnify the signal so that it can be displayed (Fig. 3.4). Integrated circuits or
chips perform most amplification. Preamplifiers attenuate the biological signal before it ever gets
to the amplifier to (1) make sure that the filters have sufficient signal voltage to deal with and (2)
ensure that the level of signal voltage is much higher than that of system noise. The signal travels
first to the preamplifier, then to the filters, and then to the amplifier. The differential amplifier is
used extensively in electrodiagnostic studies, because it has the advantage of common mode rejection.
What this means is that unwanted signals are rejected rather than being amplified to the same
3—About the Machine 11
Fig. 3.2 (A) Disk electrode; (B) Ring

electrode; (C) Ground electrode. (Cour-
tesy of Cadwell Laboratories.) C
degree as the biological signals that you are trying to study. The most common unwanted signal
in the clinic is 60-Hz activity, which is caused by line voltage passing through electrical circuits.
The differential amplifier takes the electrical impulses from the active electrode and amplifies
them. It then takes the impulses from the reference electrode, inverts them, and amplifies them. It
then combines these two potentials. In this way, any common noise to both electrodes (extraneous
electrical activity, distant myogenic noise, and EKG artifacts) is eliminated. Differences between
the two electrodes, however, are amplified. This is the desired signal. Any common factors such
as extraneous noise would be rejected, leading to the term common mode rejection. The common
mode rejection ratio is a measure of how well an amplifier eliminates this type of common noise.
Filters
Filters are used to faithfully reproduce the signal you want while trying to exclude both high- and
low-frequency electrical noise. All waveforms represent a summation of waves with different ampli-
tudes, latencies, and frequencies. Every signal in both NCS and EMG passes through both a
low-frequency and a high-frequency filter before being displayed. Low-frequency filters are
called high pass because they let high-frequency signals pass through. The range at which there is
12 Easy EMG
C
Fig. 3.3 (A) Photo of monopolar needle; (B) Photo of concentric needle; (C) Photo of an injectable needle.
(Courtesy of Cadwell Laboratories.)
a cut-off of low-frequency signals depends on how you set the filter. Similarly, high-frequency
filters are called low pass because they let low-frequency signals through. It is important to under-
stand that there is always a trade-off when you use filters. The signal you want will be altered to
some degree. For example, as the low-frequency filter is reduced, more low-frequency signals pass
through and the duration of the recorded potential will be slightly longer. Likewise, if the high-fre-
quency filter is decreased, more high-frequency signals are excluded and the latency of the recorded
potential may be delayed. Table 3.2 summarizes the role of filters and gives the usual settings
in NCS and EMG.
Fig. 3.4 Preamplifier. (Courtesy of Cadwell Laboratories.)
TABLE 3.2 n Filters
Low frequency High pass Filter out low-frequency signals that, if present, cause a wandering
baseline
High frequency Low pass Filter out high-frequency signals that, if present, can obscure signals
such as sensory nerve action potentials or fibrillation potentials and can
cause a “noisy” baseline, especially on sensory studies
Display System
Display systems for electrodiagnostic studies are via a video computer screen. There are two set-
tings on the display system with which you must be acquainted: the sweep speed and sensitivity
(also sometimes called the gain). The primary purpose of adjusting the sweep speed and sensitivity
is so that you can optimally see the signal displayed on the screen. The horizontal axis is the sweep
speed and is shown in milliseconds (msec). There are 1000 msec in a second (Fig. 3.5). The vertical
axis is the sensitivity, and this represents response amplitude (millivolts [mV] in motor studies and
microvolts [µV] in sensory studies; Fig. 3.6). There are 1000 µV in a mV and 1000 mV in a volt
(V). Suggested motor NCS settings are listed in Table 3.3. The initial settings for sensory NCS
are listed in Table 3.4.
14 Easy EMG
5 mV (gain)
3.0 msecs 2 msec / division (Sweep)
5 mV (gain)
1 msec / division (Sweep)
3.4 msecs
5 mV (gain)
0.8 msec / division (Sweep)
3.5 msecs
Fig. 3.5 Effects of latency with changes in sweep speed. (Adapted from Preston DC, Shapiro BE. Electromy-
ography and Neuromuscular Disorders. London: Butterworth-Heinemann; 1998.)
5 mV
(gain)
3 msec
1 mV
(gain)
3 msec
100 V
(gain)
3 msec
2.9 3.4
3.1 Sweep in msec
Fig. 3.6 Effect of increasing the sensitivity (gain) of a compound muscle action potential (CMAP). (Adapt-
ed from Preston DC, Shapiro BE. Electromyography and Neuromuscular Disorders. London: Butterworth-
Heinemann; 1998.)
TABLE 3.3 n Initial Motor NCS Settings

Sweep speed 2–3 msec/division
Sensitivity (gain) 5000 µV/division (this means the same as 5 millivolts, 5 mV, or 5000 microvolts)
Low-frequency filter 10 Hz
High-frequency filter 10 kHz
NCS, Nerve conduction studies.

Adapted from Misulis K. Essentials of Clinical Neurophysiology. London: Butterworth-Heinemann; 1997.
TABLE 3.4 n Initial Sensory NCS Settings
Sweep speed 1–2 msec/division—generally 10 divisions are present in a horizontal screen.

Sensitivity (gain) 20 µV/division
Low-frequency filter 2–10 Hz
High-frequency filter 2 kHz
NCS, Nerve conduction studies.

Adapted from Misulis K. Essentials of Clinical Neurophysiology. London: Butterworth-Heinemann; 1997.
Stimulus 29V Amplitude

artifact 2.1 msec Latency
38 V Amplitude
2.0 msec Latency
45 V Amplitude
1.9 msec Latency
20 V
2 msec
Stimulus artifact
Fig. 3.7 Large stimulus artifact may falsely decrease the amplitude and increase the latency. (Adapted from
Preston DC, Shapiro BE. Electromyography and Neuromuscular Disorders. London: Butterworth-Heinemann;
1998.)
ARTIFACTS AND TECHNICAL FACTORS

Stimulus Artifact
This is an electrically recorded response that is elicited directly from the stimulator. It occurs in all
NCS; however, it only becomes a problem when the trailing edge of the recorded artifact overlaps
with the potential being recorded (Fig. 3.7). Making sure the ground is between the recording and
stimulating electrodes can minimize stimulus artifact.
Filters
Filters were discussed earlier in this chapter, but they are mentioned here because they can signifi-
cantly contribute to the quality of your study. It is important to remember that the role of filters
is to faithfully reproduce the signal you want while trying to exclude both high- and low-frequency
electrical noise. The better the ratio of the recorded biologic signal to the unwanted electrical noise
(signal-to-noise ratio, or s/n ratio), the clearer the electrical tracing and the more accurate the
recorded potentials.
Electrode Placement
There are many issues that occur when electrodes are improperly placed. This discussion will be
detailed throughout the rest of the book. Suffice it to say here that proper electrode placement is
a critical part of performing accurate electrodiagnostic studies.
16 Easy EMG
STIMULATION
An important concept in NCS is to understand supramaximal stimulation. The bottom line is
this: nearly all measurements made in NCS are done with the assumption that the strength of
the stimulus is high enough to depolarize every axon in the nerve (H-reflexes being a notable
exception). This is achieved by gradually increasing the stimulus strength until you reach the point
where the amplitude of the waveform is no longer increasing. That is the point of supramaximal
stimulation. If supramaximal stimulation is not achieved at a distal site, then you might mistakenly
interpret this recording as signifying axonal loss due to the low amplitude. At a proximal site, this
might appear to be conduction block (failure of an action potential to be conducted past a particular
point, whereas conduction is possible below the point of the block). In both instances, anomalous
innervation or nerve injury may be suspected incorrectly.
Of course, the old adage “too much of a good thing is not good” applies to many things in
life. When it comes to stimulation in NCS, too much stimulation may cause co-stimulation of
adjacent nerves or may stimulate nerves farther from the site (falsely lowering the latency). So,
the goal is to reach supramaximal stimulation without applying so much stimulation that adjacent
nerves are also stimulated.
MEASUREMENTS
The machine will do most of the calculations for you, but you still need to measure the distance
between stimulations and between the stimulation and the recording electrode when you are
determining the conduction velocity. It is imperative that the measurements are done accurately.
Other than a simple oversight of not correctly recording the distance with your tape measure,
measurement errors can occur across joints if the patient’s limb is moved in different positions,
which changes the distance you are measuring. This commonly occurs in ulnar nerve studies when
the elbow is straight and then becomes flexed. Therefore, during an ulnar nerve study, it is best to
keep the elbow flexed and in the same position for the duration of that particular study (and at
the same angle on both sides). Skin measurements are major sources of error in electrodiagnostic
studies. This can be minimized by increasing the distance of the nerve segment being studied (i.e.,
the shorter the distance, the greater the effect of a measurement error). In general, when measur-
ing distance, follow the course of the nerve rather than measuring the shortest distance between
the stimulating and recording electrodes.
Besides a tape measure, another necessary measurement device in an electrodiagnostic lab is
a thermometer. This is generally an infrared thermometer or a contact thermometer on the skin,
which records the skin temperature. Abnormally cold extremities can falsely increase latencies and
alter (generally increase) amplitudes, particularly of sensory nerves.
SWEEP SPEED AND SENSITIVITY

Both the sweep speed and sensitivity can affect your NCS results. As the sensitivity is increased,
the onset latency will decrease. So, it is important to record all of your latency measurements using
the same sensitivity and sweep speed.
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"Us must face a stormy night, my dear," said William; "but 'twill pass,
however long. Fetch up a good lot of peat, and keep the hot milk and the
sago pudden down here; and trust me, if your eyes close, to be on the
watch."
"They won't close," promised Auna.
"I've stopped the cuckoo clock," explained William, "because the noise
vexed him. We'll be still as death to-night, for silence is physic in itself."
He ate and drank and she bade him take a stiff glass of spirits and water.
"You've done wonders, and I'll never forget it, and no more will father
when he's well again," declared Auna. "You smoke your pipe now and have
a rest down here, and I'll fetch up the easy, wicker chair, so you'll sit up
there comfortable. But you mustn't smoke in his room, Mr. Marydrew."
She went out presently, to feed the ponies, while William lit his pipe,
with an ear cocked lest the sufferer should wake.
"Dark and still, and a fox barking far ways off," said Auna when she
returned.
Jacob did not wake till nearly midnight and then they wrestled with him
for an hour, but made him take his food and physic. He was in agony, yet
his mind seemed a little clearer and he restrained himself. Then fever
dreams swept over him. Under the light of the shaded lamp, hidden in a
corner, he could see his daughter, and still he believed her Margery; but
Margery come from beyond the grave. He thought his wife's spirit was
beside him and the belief acted as an anodyne.
"Say you've come for me! Say you've come for me! Say you are going
to forgive me and fetch me home!" he cried. And then Auna saw that he
wept; so she bent over him and wiped away his tears. Her own fell, too, and
when he had lapsed again into insensibility, she crept away and sobbed
silently in a corner. This happened in the dead of the night and William,
despite his resolutions, was sound asleep beside the fire at the time. She was
glad that he slept and had not seen her cry.
She pulled herself together and took heart, mended the fire and sat alert
between the two unconscious men while the long night drained away.
Jacob did not waken until four o'clock, with a shout that brought
William to his feet.
"Dang my old wig, if I haven't had forty winks," he said, "why for did
you let me drop off, Auna?"
CHAPTER XI
JACOB LIVES
A trained nurse arrived before noon on the following day and Dr.
Cousins drove her up. The physician found that Jacob was responding to his
remedies and no special symptoms of any gravity had appeared. The
disease promised to run its course, but whether it would destroy the patient
remained to be seen. He was dangerously ill and still delirious. Jacob could
not state his case, but the doctor inclined to hope that he suffered less of
acute pain. He assured Auna that she had every reason to be hopeful and the
nurse, at a later hour in the day, declared the same. She was chiefly
concerned with the sick man's reserves of strength and, seeing his powerful
frame, felt sanguine.
William went home on his pony after the doctor's visit, and an hour later
John Henry and Peter came up together, bringing fresh milk and other
comforts. They did not see their father, but they stopped with Auna for an
hour or two and spoke of the Huxams.
Great decisions had been made and their grandparents were returning to
the post-office, while Jeremy and Jane would occupy the new house for the
present, until the time came to let it furnished for the summer.
John Henry now saw through his uncle and spoke scornfully of him.
"A worthless waster—that's all he is—and no good for anything. All

talk and smiles and fine manners; and under 'em nothing. He ain't got any
brains and he ain't got any guts; and everybody in the land knows it but
grandmother."
"Does she like going back?" asked Auna.
"Yes—else she wouldn't go. I believe she's been at a loose end ever
since she left the shop. She hates doing nothing and being waited on. It's
contrary to her nature, and she's been very queer lately and frightened
grandfather off and on. She'll be jolly glad to get back into the midst of
things, and so will he. There's a lot of work in 'em both yet and it's good for
their money and for the rest of the family that they're going back. There
wouldn't have been any business left if Uncle Jeremy had messed about
there much longer."
"To think we thought him such a wonder when we were little!" said
Peter.
"When you get up to be a man yourself, you soon see what most men
are worth," answered John Henry. "He'll never do anything and, if his
children are like him, they'll all go in the workhouse soon or late; and if
they're workers, then he'll live on them come he grows old."
Auna asked after her sister and heard that she was well. Then the
brothers departed and Peter promised to return ere long.
"In about three days Nurse Woolcombe says we shall know for certain if
father's going to live," Auna told them; "but I know now. I'm positive sure
he's going to live."
"'Tis doubtful if it would be a good thing," declared John Henry. "I

speak for himself, of course. I'm sure nobody wants him to die."
"It will be the turning point for father perhaps," thought Peter. "He
might quiet down after a shaking like this."
Jacob Bullstone suffered for many days and it was a fortnight before
Auna could find herself sleeping natural sleep and waking without dread.
The sick man mended and fell back again. His strength wore down and a
first relapse found him in the gravest danger, for his heart was weary. But
he pulled up again with devoted nursing and skilled attention. To Auna,
Nurse Woolcombe became as a goddess, and she sealed a friendship with
the widow that lasted for life. They worked together and the younger was
skilful and understanding.
The head symptoms continued distressing and Bullstone lapsed into

delirium on several occasions after periods of sanity. His temperature
puzzled the nurse and she strove to distract the patient's mind from himself.
But, for a time, he continued impatient and declared that no friendly hand
would have desired to prolong his life. Then he grew more reasonable, and
when the crisis was past and his sons were permitted to see him, while
secretly amazed at the sight of the pallid and shrunken ghost they called
their father, both found him peaceful and in a frame of mind they hardly
remembered.
His face was white and a growth of beard also helped to disguise the
countenance they knew; but his great, dark eyes no longer roamed restlessly
over them. They were dimmed by much pain, yet they were gentle and
steady. He spoke little and his voice had weakened to a whisper; but he
listened and nodded affirmation. His chief concern was with Avis.
"Is her child born?" he asked thrice, at intervals.
"The child's due," said John Henry, "and she's very well, so Bob tells
me."
He looked up at the great lads solemnly.
"John Henry and Peter," he said—"my two sons come up to see me.
That's good."
"And lots to show you when you're about again, father. You'll be
surprised at 'Red House Rover's' new puppies."
"The old dog ran home. He thought I was going to die; but he didn't
bargain for doctor and Auna. They've saved me I suppose."
"The Lord of Hosts have saved you, father," declared John Henry, who
had great faith in his God.
"Believe it if you can," said Jacob.
They spoke of the Huxams, but found him not interested.
"Is the child of Avis born?" he asked again.
They left him and told Auna that they were well pleased and that he had
been kind to them.
"He won't die now; but I expect he'll be a bed-lier for evermore. You've
got to face that, Auna," said John Henry.
"So long as he lives till he's at peace, nothing else matters," she
answered. "But he'll be better than a bed-lier. Nurse says he'll walk in a
month and get back his nature mighty quick, when he can eat strong food
again."
Jacob mended slowly and the weather held against him, for the spring
was harsh and chill. The light increased with the cold and early March
found snow on the moors and a harsh spell of wind from the north-east. The
doctor begged Jacob to return to Red House, that his cure might be
hastened; but this he declined to do. He was calm and patient now, though
very weak. He liked to be alone and he expressed a great desire to see
William Marydrew.
Then came good news and Auna had the joy of telling him.
"Avis has got a girl baby, father; and 'tis a beautiful, perfect little child
with Bob's eyes. And Avis is doing well and the baby's going to be called
'Margery.' And Margery Elvin's a pretty name Nurse Woolcombe says; and
so it is."
The news did Bullstone good service and occupied his mind.
"The name of 'Margery' will be upon my tongue again," he said, "and I

must school myself to speak it and hear it, Auna. I shall be very glad to see
the little creature. You're worthy to be your mother's daughter, and that's the
highest praise you'll ever get from human lips. And may the child of Avis
be worthy to be her granddaughter."
Auna felt very happy.
"It never rains but it pours, father," she said. "I've had a letter to-day—a
letter from Great-Uncle Lawrence Pulleyblank. His writing's gone very
spindley and up and down, because he's so old; but when you're equal to it
he wants you to travel to Plymouth for the sea air; and if you won't go, then
he wants for me to go, when you can spare me for a week or two."
"Wishful for me to go?"
She began to speak, but stopped, since her words would have to deal
with the incidents of her mother's death.
"I dearly hope you'll do it when you can."
"No, no; but thank the man. You shall go to him. I won't be so selfish
about you as I have been. I've kept your light under a bushel too long,
because you were all I had left. Others must share you, I reckon. You're pale
as a davered rose through so much nursing. You shall go presently and
make a good holiday with the old chap."
He asked constantly for William, and hoped that each fine day might
bring him.
"I've got a wonderful thing to tell him, that only such a man would
understand," he explained to Nurse Woolcombe.
They concealed the fact that Mr. Marydrew had been ill with bronchitis.
Then Auna went to see him and was able to tell her father that Billy had
returned to health, after a chill.
"He's all right and is coming up the first soft day in May," she promised.
Jacob himself began to regain strength, and there fell a morning when
Auna went to Brent to bid a barber climb to Huntingdon and shave him.
"He's a proper ghost, and you mustn't be frightened, Mr. Prynn," she
said; "but he's going on all right, and now he's wishful to have his beard
away."
Yet, before the barber came, Jacob changed his mind again.
"I'll wear it for a sign," he said. "I'll let it be."
At last William arrived and Jacob greeted him with affection. The old
man and Auna sat one on each side of his chair and Auna held her father's
hand.
"I'm going downstairs again next week," explained Jacob. He was

sitting by the fire.
William expressed great pleasure at his appearance,
"A far different creature from what I left," he said. "Then you was a
burning, fiery furnace, my dear. But now you be glad for a bit of fire
outside yourself. Can you catch heat from it?"
"And you—you've been bad, too, I'm vexed to learn."
"Only the tubes," explained William. "My tubes was filled up, so as I
had to fight for air a bit; but us old oaks takes a lot of throwing. I'm good
for another summer anyway. Spring's afoot down the vale."
"I've had great thoughts in the shadow of death, William. I've come
through, as you see, and shall live a bit longer. At death's door I knocked
and they wouldn't let me enter in. You can't get so close, though, without
learning many things. Yet I wouldn't be without what I know. It points to
peace—a withered sort of peace, where no hope is."
"You can't live without hope, my dear man. It's so needful as the air you
breathe."
"Yes, you can live without it; you can do your duty without it. I heard a
laugh yesterday night—'twas myself. Nature made me laugh, because to be
without hope is almost beyond reason, and anything outside reason makes
us laugh."
William regarded him doubtfully.
"I thought to find you'd thrown over all these silly fancies," he said.
"You must keep a hand on yourself, Jacob, now you've come through and
are going to live. It's bad to laugh when there's nothing to laugh at. You
mustn't do that. Emma Andrews laughed for three days; and she went down
to the river and drowned herself on the fourth."
"I'm all right. Between ourselves, Billy, I had bats in the belfry for a
time after my wife died. I know it now and I'm surprised that none marked
it. After the trial came a great flash of light to my mind. From within it
came and made all the past look dark—burned it to dust and cinders. Only
the future mattered, and it wasn't the judge and jury showed me I had been
wrong—it wasn't them at all. It was the flash of light. Then hope got hold
on me like a giant and I hoped too much. That was my punishment—to
hope too much and not see hope had died. But my sickness has drained the
poison out of me, and though my frame is weak, my brain is clear. I see and
I can put things together. I've come to a great thought—a shattering thing
but true."
"A comforting thing then."
"No—truth is seldom comforting. But it puts firm ground under you and
shows you where to stand and how to protect yourself against hope. I'm a
well-educated man, William, and though I've fallen far below all that I was
taught as a boy, I've risen again now. But life's too short for most of us to
learn how to live it. Too short to get away from our feelings, or look at it all
from outside. But I can now. I've reached to that. I can look at myself, and
skin myself, and feel no more than if I was peeling a potato."
William began to be uneasy.
"Leave yourself alone. Have you seen your granddaughter yet?"
"No; but my heart goes out to her. Don't look fearful: I'm all right. I
haven't done with my children, or their children. I'm human still. I can take
stock of myself, thanks to my forgotten wisdom—lost when Margery died,
and found again. A bit ago I was growing awful cold. I felt not unkindly to
the world, you must know, but cold was creeping into me, body and soul. I
didn't love as I used, nor hate as I used, nor care as I used. I didn't want to
see what I couldn't see, nor do what I couldn't do. All was fading out in a
cold mist. Then I had my great illness, and there was no more mist, and I
began to link up again with the world. Nothing could have done it but that.
And then I got the bird's-eye view denied to most of us, but reached by me
through great trials.
"For look at it, Billy. First there was my faulty nature and little
experience. No experience of life—an only son, kept close by loving
parents—and with the awful proneness to be jealous hid in me, like poison
in a root. Then fate, or chance, to play trick after trick upon me after
marriage and build up, little by little, the signs of my great, fancied wrong.
Signs that another man would have laughed at, but proofs—deadly proofs
of ruin to my jaundiced sight. And the cunning, the craft to heap these
things on my head—all shadows to a sane man; but real as death to me!
First one, then another—each a grain of sand in itself, but growing,
growing, till the heap was too heavy for me to bear.
"And whose work was it? 'God' you say, since He's responsible for all
and willed it so. God, to plan a faulty man and start him to his own
destruction; God, to make me love a woman with a mother like Margery's,
so that, when the wounds might be healed, there was that fiend ever ready
and willing and watchful to keep 'em open. God, to will that I should never
hear my wife forgive me, though she had forgiven me; God, to let her die
before I could get to her and kneel at her feet!
"No, William, a tale like this leaves a man honest, or else mad. And I'll
be honest and say that no loving, merciful, all-powerful Father ever treated
his children so. Mark how calm I am—no fury, no lamentation, no rage
now. Just clear sight to see and show the way of my downfall. Your God
could have given me a pinch of fine character to save me. He could have
made me more generous, more understanding of my pure wife, less
suspicious, less secret, less proud, less mean. He could have built me not to
head myself off from everything and bring back night and ruin on my head.
But no.
"We'll allow I got all I deserved—we'll confess that as I was made

cracked, I had to break. But what about Margery? Did she get what she
deserved? Did she earn what she was called to suffer—a creature, sweet as
an open bud, to be drawn through dirt and horror and things evil and foul to
early death? Was that the work of the all powerful and all just?"
"Always remember there's the next world, Jacob."
"Can fifty next worlds undo the work of this one? Can eternity alter
what I did and what she suffered here? The next world's no way out,
William. The balance isn't struck there, because evil never can turn into
good, either in earth, or heaven. You can wipe away tears, but you can't
wipe away what caused them to flow. And where have I come to now, think
you? Another great light I've seen, like the light that blazed to Paul; but it
blazed a different story to me. When I see a man praising God, I'm
reminded of a mouse that runs to hide in the fur of the cat that's killing it. I
no longer believe in God, William, and I'll tell you why. Because I think too
well of God to believe in Him. D'you understand that? I wish He existed; I
wish we could see His handicraft and feel His love; but let us be brave and
not pretend. The sight of my little life and the greater sight of the whole
world as it is—these things would drive God's self into hell if He was just.
He'd tumble out of His heaven and call on the smoke of the pit to hide Him
and His horrible works. And so I've come to the blessed, grey calm of
knowing that what I suffered there was none to save me from. It's a sign of
the greatness of man that he could give all his hard-won credit to God,
William, and invent a place where justice would be done by a Being far
nobler, finer, truer and stronger than himself. But proofs against are too
many and too fearful. The world's waiting now for another Christ to wake
us to the glory of Man, William, because the time has come when we're old
enough to trust ourselves, and walk alone, and put away childish things. We
deserve a good God—or none."
The ancient listened patiently.
"Your mind is working like a river—I see that," he answered. "But be

patient still, Jacob. Keep yourself in hand. You'll find yourself yet; you be
on the right road I expect; and when you do find yourself, you'll find your
God was only hid, not dead."
He uttered kindly thoughts and they talked for an hour together. Then
Auna and William descended to the kitchen and he ate with her. He was
happy at what he had seen rather than at what he had heard.
"Forget all your father says," begged William. "He's going to be a strong
and healthy man. I mark the promise in him. A great victory for doctor and
you and nurse. There's a bit of fever in his mind yet; but the mind be always
the last to clean up again after a great illness. His talk be only the end of his
torments running away—like dirty water after a freshet."
"Do you think, if we could get him down to see Margery Elvin
christened, it would be a useful thing, Mr. Marydrew?" asked Auna, and
William approved the idea.
"By rights he ought to go to Church and thank God for sparing him," he
said. "But, be that as it will, if he saw his grandchild made a faithful
follower and heard a hymn sung out and the organs rolling, it might all help
to do the good work."
"I'll try to bring it about, though it may be a very difficult thing to
manage," she said.
"You make a valiant effort," urged William, "and tell your sister to hold
over the event till her father's man enough to come down and lend a hand."
He returned to Jacob before he left Huntingdon.
CHAPTER XII
THE CHRISTENING
On a day six weeks later, Jacob went down among men and, at the
desire of his children, attended the baptism of his grandchild. The families
assembled and the time was afternoon on Sunday. All interested, save
Judith Huxam, were present, and after the ceremony ended, a little company
trailed up the hill to Owley, that they might drink tea together and cut the
christening cake. Avis and Auna walked side by side and Auna carried the
baby; while behind them came Peter, Robert Elvin and his mother. John
Henry had joined his Aunt Jane Huxam and her little boys; Jeremy and
Adam Winter followed them and Jacob Bullstone, with Barlow Huxam,
walked fifty yards in the rear. They talked earnestly together and Barlow
had the more to say.
He was full of great anxieties, yet did not fail to express regret at his
son-in-law's illness and satisfaction that he had been restored to health.
"A triumph for your constitution and the doctor's skill. I've thought
upon you and not left you out of my prayers," he said.
"Yes; I've come through; and it was worth while. Time will show,"
answered Jacob.
"A thoughtful moment, when first you see yourself as grandfather,"
commented Barlow, "and still more so when you've only got to wait till a
little one can talk to hear yourself called 'great-grandfather.' That's how it is
with me now."
"How d'you find yourself taking up the reins at the post-office once
again?"
"The power is still there, thank God," answered Mr. Huxam. "But time
don't stand still. Life goes pretty light with me, but in confidence I may tell
you it doesn't go so light with my wife. You don't understand her and I don't
expect you to do it, Jacob; and she don't understand you; but you've been
through heavy waters; you've brought forth deep things out of darkness, in
Bible words, and I may tell you that all's not right with my wife. She was a
bit cheerfuller at first, when we went back into harness and let Jeremy and
his family go to the residence, but it was a flash in the pan. Judy's brooding
again and speaking in riddles, and I'm much put about for the future—the
future here below I mean—not in the world to come."
Bullstone spoke quietly of his own thoughts on the subject of his

mother-in-law.
"I've hated your wife with a deadlier hate than I thought was in my
nature," he said. "But not now. Before I had my great illness, I always
hoped to see her face to face once more and have speech with her; because I
was much feared of a thing happening, Barlow. I'd meant to see her alone
and warn her, by all that she held sacred, to play fair if she got to Margery
before I did. Such was my blinded sight, then, that I thought it might lie in
her power, if she went on before, to poison my wife's mind in heaven, as
she did on earth, so that if I came I'd still get no forgiveness. But that was
all mist and dream and foolishness, of course. If there was a heaven, there
would be no bearing false witness in it. But there's no heaven and no
meetings and no Margery. It's all one now. Things must be as they are, and
things had to be as they were, because I'm what I am, and Judith Huxam is
what she is."
"A very wrongful view," replied Huxam. "But, for the minute, your
feelings are beside the question, Jacob, and I'm not faced in my home with
any fog like that, but hard facts. And very painful and tragical they may
prove for me and all my family. You'll understand that she never could
forgive the fearful day we journeyed to Plymouth—you and me; and she
held that I'd gone a long way to put my soul in peril by taking you there to
see your dying wife. That's as it may be, and I've never been sorry for what
I did myself, and I don't feel that it put a barrier between me and my Maker.
But now the case is altered and I'm faced with a much more serious matter.
Judy don't worry about me no more and she don't worry about any of us,
but, strange to relate, she worries about herself!"
"I've heard a whisper of it."
"You might say it was the Christian humility proper to a saint of God;
but this mighty gloom in her brain gets worse. Once, between ourselves, it
rose to terror, at half after three of a morning in last March. She jumped up
from her bed and cried out that Satan was waiting for her in the street.
That's bad, and I spoke to Dr. Briggs behind her back next day."
"Her religion was always full of horrors, and the birds are coming back
to roost."
"That's a very wrong view and I won't grant it," answered Barlow.
"Who can look into the heart of another? Who can know the driving
power behind us?"
"It's not her heart: it's her poor head. Briggs is watching over her and he
don't like it any more than I do. There's a well-known condition of the
human mind called 'religious melancholy,' Jacob; and it's a very dangerous
thing. And it's got to be stopped, or else a worse state may over-get her."
"She looks back and mourns maybe? Perhaps it's only her frozen
humanity thawing with the years."
"She don't look back. Never was a woman less prone to look back. She
looks forward and, owing to this delusion of the mind, she don't like what
she sees and it makes her terrible glum. Her eyes are full of thunder, and her
voice is seldom heard now."
"We reap what we sow."
"Not always. She's walked hand in hand with her God ever since she
came to years of understanding, and it's a hard saying that such a woman
deserved to lose her hope and suffer from a disordered mind."
"It's not a disordered mind that loses hope, Barlow—only a clear one.
Hope's not everything."
"Hope is everything; and if the mind weakens, then the life of the soul
stops and there's nothing left but an idiot body to watch until its end. I've
got to face the chance of Judy's immortal part dying, though her clay may
go on walking the earth for another twenty years; so you'll understand I'm
in pretty deep trouble."
"It may not happen."
"It may not. But I'm warned."
Jacob expressed no great regret, for the things that now entered his mind
he could not, or would not, utter.
Mr. Huxam pursued his own grey thought.
"Sometimes it happens that these people who are overthrown by

religion, by the dark will of their Creator, have got to be put away from
their friends altogether; because too much religion, like too much learning,
topples over the brain."
"Perhaps it's only conscience pricking her."
"In a lesser one it might be that; but to hear such a woman as her
wondering in the small hours whether, after all, she is redeemed, that's not
conscience—it's a breakdown of the machinery. 'Could I lose my own soul
by saving Margery's?' she asked me once, and such a question of course
means a screw loose."
Bullstone did not answer and Barlow presently feared that he might
have said too much. He sighed deeply.
"Keep this from every human ear," he begged. "I may be wrong. There
may be a high religious meaning in all this that will come to light. We must
trust where only we can trust."
"You'll find where that is, if you live long enough and suffer long
enough," was all the other answered.
A cheerful spirit marked the little celebration at Owley and, for the first
time, Jacob held his granddaughter in his arms. He had brought a gift—a
trinket of silver with a moonstone set in it—that he had purchased before
their marriage for Margery.
Auna and her father walked home together afterwards up the long slope
from Owley to the moor. He was calm and gracious and they spoke of the
girl's coming visit to her great-uncle.
"I wish you'd change your mind even now and come along with me,"
she said. "You'd do Uncle Lawrence good very like."
"No, I shouldn't do him good, and a town's too great a thought for me
yet a while. Not but what I want to do a bit of good, to return a little of all
that's been done for me. But opportunity doesn't lack. I'll get in touch with
my fellow-creatures slow and gradual, one by one. They frighten me too
much all together. They always did; but I'll come back to them, like a ghost,
presently."
"You're not a ghost any more. Look how fine you stood among the
people to-day, and how pleased they were to see you," said Auna.
"Jeremy's going to drive up and fetch you Monday week. He's a

gentleman at large for the minute. Idleness always finds that man at his
best."
"But he'll be a chemist next, and he's reading about it already. He says
that the goal's in sight, and he feels that, as a dispensing chemist, he will
come out like the sun from behind a cloud."
"A very ornamental man, but would have done better as a tree, Auna.
There's many a human would have given more pleasure and less trouble as
a tree in a wood."
Auna laughed.
"He'd have been a very good-looking tree—one of the silver birches

perhaps."
"Margery Elvin is now of the Household of Faith," said Jacob suddenly.
"And weren't she good when parson took her, father?"
"I shouldn't wonder, if all goes well, whether I don't go down and see
her again when you're away."
"I do hope you will then, and write me a letter to say how you are."
"I shall be full of thinking about you. I have thoughts about you. I am
going to make you happy."
"Be happy yourself and I shall be."
"No, that can't happen; but I'll make you happy another way than that. I
can look ahead as I never did before. It will come in good time. Patience is
greater than happiness. I'll go back into the world some day. But my soul
must be quiet—quite quiet for a little longer yet, Auna, please."
Jeremy came at the appointed time to drive his niece into Brent. She
was going to spend one night with her Aunt Jane at the villa and proceed
next morning to Plymouth. To the last moment she was busy with
arrangements for Jacob's comfort. They had a milch cow at Huntingdon,
and Bullstone milked it himself. A red dog had also settled down with him.
Jeremy was anxious about his mother, but turned to another subject as
he and his niece journeyed down the hills together. Auna had waved her last
farewell to her father and he had waved back. Then Jeremy touched a
personal matter.
"I want for you to sound Uncle Lawrence about his money," he said.
"You're a clever and understanding girl and can be trusted. It's time his
family knew his intentions, Auna, and you might be doing a useful thing if
you were able to get a word out of him."
"If he says anything I'll remember it," she promised.
"I hope he'll live for a long time yet; and when he's got to go, I hope
you'll have the money, if you want it."
"I'm thinking not of myself, but my children, Auna, and your Aunt
Jane."
"I'll send the boys post-card pictures from Plymouth," she promised,
"and I'm hopeful to send some fine fishes to father if I can."
CHAPTER XIII
THE PROMISE
Three men were talking at Shipley Bridge, and one prepared to leave the
others and ascend to the Moor. But he was in no great hurry. Adam Winter
and old William listened to George Middleweek, who had come from Red
House. His talk concerned the Bullstones and he spoke of Peter.
"He's wise for his years, but I laugh to see the real boy moving and
feeling behind the parrot cry of what he's been taught to say and feel. A
young woman has turned him down at Brent. She loves somebody else and
haven't got no use for Peter; and he damns his luck one minute, and the next
says that everything that happens must happen. But it's taking him all his
time to believe it as well as say it, and, meanwhile, nature will out and a
dog or two have had to yelp for Master Peter's troubles. The sorrows of the
dog-breeder be often visited on the dog I reckon."
"Life runs over a lot of innocent dogs, no doubt," said William, "and
leaves 'em mangled and wondering what they've done to be disembowelled,
just as they thought they was being so good and faithful."
"To a man of Peter Bullstone's mind, the thought that a girl could refuse
him is very vexatious I expect," admitted Adam. "His mother's family ain't
out of the wood yet. My Aunt Amelia tells me that Judith Huxam was
catched by Barlow going to the police-station to give herself up for fancied
crimes! It looks like they'll have to put her away."
"That's what God brings His Chosen Few to, Adam!"
"No, George. You mustn't say things like that in my hearing, please. All
that happens is part of the pattern, and who can judge of the pattern from
the little piece under his own eye? Not the wittiest man among us."
"Cant!" answered George. "But if that woman's drove mad—her, who

have driven so many others the same way—then that's one to the good for
your precious Maker, Adam: a bit of plain justice that us common men can
understand."
They spoke of Jacob Bullstone.
"He'll be excited to-day I shouldn't wonder," said George, "because his

daughter is going back to him this evening. Peter drives in for her
presently."
"Auna wrote me a letter full of woe," William told them. "She's one of
they young hearts from which even us frozen old blids can catch heat. What
d'you think? Her Great-Uncle Pulleyblank's minded to make her his heir,
and she's prayed him to leave his money to her Uncle Jeremy, because he
wants it and she don't! But Pulleyblank knows his Jeremy too well I hope."
"And Jacob seems as if he was more in tune too," declared William.

"He's doing kind things to lonely people—such as don't run up against
much kindness as a rule," explained Adam. "The lonely have a way to smell
out the other lonely ones. He sits very quiet now for hours at a time,
perched on a moor-stone so still as a heron."
The master of Shipley got upon his horse, which stood tethered under an
oak beside the hedge. Then he rode off to climb the waste lands, while the
others went on their way.
Winter had come to dinner with Jacob, and he found him cheerful and
exalted before the thought of his child's return.
He explained his hopes and purposes, but with diffidence.
"If men, such as you and Marydrew, still think well of it, I don't say but
what I might slip back again to some quiet spot," he said. "I shouldn't feel
that I'd got any right, exactly, to thrust in again among folk—such a thing as
I've grown to be; but if it was only for William's sake, I'd come. He always
held out that I'd be saved for some usefulness, and I'd like to make good his
words."
"Come then," urged Winter, "don't go back on it."
"I'm a thought clearer sighted than I have been, Adam, and more
patient. How's Samuel? I understand him now so well as you do yourself."
They talked of common interests, but Bullstone grew restless as the sun
went westerly, and he did not seek to stay his guest when the farmer rose to
return.
"I've got everything in fine fettle for her—for Auna," he explained.

"She's coming back from her sea-faring to-day. Peter goes in for her and
she'll walk along alone from Shipley, and the boy will be up with her box
to-morrow morning. The moor's in a cheerful mind to-night, but I dread to
hear her say she likes the sea better."
"No fear of that while you kennel up here. But I hope we shall have you
both down before autumn."

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Easy EMG: A Guide to Performing

Nerve Conduction Studies and

For additional online content visit expertconsult

London, New York, Oxford, Philadelphia, St Louis, Sydney, Toronto

EASY EMG, THIRD EDITION ISBN: 978-0-323-79686-6

Copyright © 2023 by Elsevier, Inc. All rights reserved.

Previous editions copyrighted 2016, 2004.

Library of Congress Control Number: 2021944559

Content Strategist: Humayra R. Khan

Last digit is the print number: 9 8 7 6 5 4 3 2 1

2. Why Perform Electrodiagnostic Studies? 5

3. About the Machine 9

4. Nerve Conduction Studies 17

6. Injuries to Peripheral Nerves 67

7. How to Plan Out the Examination 73

9. Carpal Tunnel Syndrome 109

10. Ulnar Neuropathy 117

11. Radial Neuropathy 125

12. Radiculopathy 131

13. Spinal Stenosis 139

14. Fibular (Peroneal) Neuropathy 141

15. Tarsal Tunnel Syndrome 147

16. Peripheral Polyneuropathy 151

17. Myopathy 157

18. Brachial Plexopathies 161

19. Lumbosacral Plexopathies 171

20. Motor Neuron Diseases 179

21. Critical Illness Neuropathy and Myopathy 181

22. Inflammatory Neuropathies 185

23. Neuromuscular Junction Disorders 189

24. How to Write a Report 193

25. Tables of Normals 199

26. Reimbursement 203

GLOSSARY OF EMG TERMS 209

Sensory nerve root

Dorsal root ganglion

Motor nerve root

Sensory Motor nerve

Nerve Conduction Studies

TABLE 1.1 n The Electrodiagnostic Process

EMG, Electromyography; NCS, nerve conduction studies.

TABLE 1.2 n Nerve Conduction Study Terms

The Skilled and Compassionate Electrodiagnostician

The Basic Machine

Fig. 3.1 Picture of an electromyography (EMG) machine. (Courtesy of Cadwell Laboratories.)

TABLE 3.1 n Electrodes Used in NCS and EMG

Fig. 3.2 (A) Disk electrode; (B) Ring

Fig. 3.4 Preamplifier. (Courtesy of Cadwell Laboratories.)

TABLE 3.2 n Filters

TABLE 3.3 n Initial Motor NCS Settings

NCS, Nerve conduction studies.

TABLE 3.4 n Initial Sensory NCS Settings

Sweep speed 1–2 msec/division—generally 10 divisions are present in a horizontal screen.

NCS, Nerve conduction studies.

Stimulus 29V Amplitude

ARTIFACTS AND TECHNICAL FACTORS

SWEEP SPEED AND SENSITIVITY

"They won't close," promised Auna.

"A worthless waster—that's all he is—and no good for anything. All

"Does she like going back?" asked Auna.

"'Tis doubtful if it would be a good thing," declared John Henry. "I

The head symptoms continued distressing and Bullstone lapsed into

"Is her child born?" he asked thrice, at intervals.

Stimulus 29V Amplitude