Chapter 18 ELECTRO DIAGNOSIS ooo ermelectrodiagnosis means to roys neuromuscular disorders een ofelectrical stimulation, The y i ignostic studies started long time a put it has been brought in use in # gtnerapy since past 1 ~ 2 decade. farous techniques have developed in Metrodiagnosis like EMG, Nerve eduction velocity studies, Evoked prea, SD. curve test ete: In 1970, Pyexmade be first visible lectromyograph. ‘thet NEUROMUSCULAR CONDUC- TION / ELECTRO PHYSIOLOGY As we know that the basic excit- able tissues in our body are nerves and muscles therefore the principle of action Potential generation in both of them is nearly the same. The only difference is thatthe duration of action potential gen- ‘rtion in a muscle is more than that of he ae The muscle contracts when it mulated either directly or by a nerve. R ‘sting Membrane Potential amentgt all the living cells have branes. Al ifference across their mem- shape i the cells have a negative “elle ti € as compared to the extra- In the absence ofa stimulus, ~~ the cell is in the -esting state, which has a high concentration of potassium ions (K*) in the intra-cellular fluid and that of sodium ions 1 a’) inthe extra-cellular fluid thereby making the intracellular fluid negative in comparison to the extracellular fluid. This ionic balance is maintained by two phenomenon. i, Sodium — Potassium Pump. There occurs an active transport of K* and Na* by this pump. The pump uses ATP to move three Na’ outside and two K° inside the cell, thereby making the inside of the cell more negative and the outside more positive. ii, Selective Permeability: As we know that the cell membrane is selec- tively permeable, thus it allows the trans- port of some selective ions across it only. The cell membrane has channels for important ions like Na’, Cr, K’, which are important to maintain the resting membrane potential. These ions have an unequal distribution across the cell mem- brane, Na’ & CI are concentrated more outside while K* is concentrated more inside. At rest, the Cl- channels remain closed while the Na‘ and K’ remain open. ‘The transfer of Na’ and K’ is active i-e., i Scanned with CamScannerSODIUM POTASSIUM PUMP against the concentration gradient (Na* from inside to outside and K* from out- side to inside). Since, the transport of these ions is against their concentration gradient, therefore Na* tends to diffuse back into the intracellular fluid and K* to the extracellular fluid through leak channels. To prevent this, the Na’ leak channels are almost closed during rest and K* leak channels are opened. Pas- sive efflux of K’ is much more than the passive influx of Na*, so the potential inside the cell is positive as compared to. outside. This condition of the muscle / nerve i.e., the resting state of muscle / nerve is called as the polarized state. The potential at this state is called as resting membrane potential, which is — 80 to — 90 mv. Action Potential: This is generated in a nerve mse when it is stimulated, occurs due ts series of electrical changes occuriaga the nerve / muscles cell. The action po- tential generation occurs in two phass Phase I Depolarization: When impulse reaches a muscle, its polarize state (— 90 mV) is altered. In otherwers its resting membrane potenti changed. The intracellular potent comes positive and the extracel becomes negative. This condition cell is called as the “state of dep? tion”. ation: Wit Phase 11 Repotaricati™ be a a short time, the muscle co aa ei electrical potential once a jie of the muscle becomes nF Scanned with CamScannerfe change of potential occurs jonic activity occurring in the sjular and the extracellular fluid. ce to the es development of action potential, as wltage gated potassium and sodium es play a very important role. same bthe muscle starts to depolar- sathere occurs @ slight influx of Na’. ‘hen action potential reaches to—15 mV p-10 mY, the opening of the sodium annels becomes faster. This rate goes on increasing till the firing level is reached and the over shoot occurs. But, the problem with the sodium channels isthat they open and close very quickly because they have rapid inactivation. This causes limitation in the stage of (polarisation. Atthis time, the potassium chan- telsstarts opening and they remain open ‘orlonger duration than the sodium chan- nels, They also remain open for some uilieeonds even after depolarisation is eee This results in more efflux inde Pees a more negative charge fon,” hs is called as hyper polariza- Ati i ‘°n Potential Generation Curve lig ae Seneration of action poten- vided into the following stages: LResei, Potent Membrane Potential: \tis the ist of the cell membrane when inside °° Clectrical activity going on cell i.e., the cell is electrically — silent. It is recorded asa straight in the graph with a value of -90 mV. 2. Stimulus Artifact; During the appli- cation ofa stimulus, a slight irregular de- flection is seen in the base line, which is due to the leakage of the current from the stimulating electrode to the ground electrode. This is called as the stimulus artifact, 3. Latency Period: This follows the stimulus artifact. It is period of a very short duration approximately 0.5 to 1 milliseconds, which has no electrical activity. 4. Firing Level: By the end of the la- tency period, the Na* channels starts opening, starting. the depolarization of the cell. The initial depolarization is very slow upto -15 mV. After this, there is a sudden increase in the rate of depolari zation due to the fast opening of the Na” channels. The potential at which the rate of depolarization suddenly increases is called as the firing level. 5. Over Shoot: Due to increased rate of depolarization, the curve reaches the isoelctric or zero potential line and then crosses or shoots over to the positive side upto +55 mV. This is called as over shoot. 6. Spike Potential: At 55 mV, the proc- ess of depolarization gets completed with the closing of sodium channels and the repolarization starts with the opening of potassium channels. The initiation of Scanned with CamScannerWw Opening of Na+ Channels Starts Opening of many Ne+ Channels Closure of Net Channels @ Opening of K+ Channels ‘Anplitude Chosue offer (nV) [o* Channels 8 Isoelectric line &e & 8 ‘After depolarization Latency period RPM Surface Artifact After hyperpolatization -——-— - — +--+ 0 1 2 3 4 ACTION POTENTIAL, EN; Time (msec) ERATION IN SKELETAL MUSCLES repolarization is sudden ‘ but slow: Bradually The rapid rise ofcuess oN" larization and rapid fallin repo °PO™ a Saledasspike potential. hss ragess % Mer Depoarizaion: Tht NSS forabout fallin the spike potential is 0.4 milliseconds. Scanned with Cam@eannerpolarization pro\ ed as after depolarisation er potential. Its duration jive alter Ms ae -4 milliseconds. or Hyper larization: ‘When the tial difference reaches back to over! . ar “9 mV during repolarization, the po- jum channels close and the potential falls down t© amore negative value than the resting membrane potential. This is called as hyper-polarization or positive afer polarization. It lasts for more than 30 milliseconds after which the normal resting membrane potential is reached. INSTRUMENTATION ‘An electrodiagnostic unit com- prises of different separate components ramely the input phase, the processor phase and the output phase. phase L The Input Phase: ‘The input gives the stimulation to the nerve/ muscle and record the electrical activity going on inside, This unit includes the electrodes and the stimulators. A, Electrodes: An electrode is a trans- ducers device for converting one form of energy into another. Inclectrodiagnosis three electrodes are used. These electrodes are: - Active electrode - Reference electrode Ground electronic Active and reference electrodes are used for measurements of ‘action potential and ground electrode is used for ‘cancellation of the interference of ‘external electrical noise. Ground electrode serves ‘asa zero voltage reference point. “There are various types of elee- trodes used in eleeto diagnosis «a Surface Electrode: Surface electrodes are used for Kinesiological ( canned with CamScannerinvestigation, nerve conduction studies, and motor evoked potential studies. These electrodes stick to the skin by using adhesive tape. These electrodes are disposable and non-disposable. The non-disposable electrodes can be reused. These electrodes are made up of sel, silver and gold (very rare), Non-disposable electrodes should be cleaned between the patients afier every use. These electrodes are in the form ofdisc, cup or ring. E.g.: Silver-silver chloride surface electrode. 5. Needle Electrode: Needle elec- trodes are most commonly used in EMG, but are occasionally used in nerve conduction studies (NCS) and evoked Potential studies (EPS). Needle electrodes Sy Ground Electrode Surface Electrodes Po disposable © i les ane oq¢ disposable clecttodes are ug, sed it Patient. These electrode, ate en stainless steel, and ty Platinum ang po, needle electrodes ae lay ied Th 'ypesaccording to thei: make the x i. Monopolar Needie f° The monopolar ne edle electrode « stainless steel so} isa ft coated o; st Teflon except forthe baren met electrode, Separate reference ‘and, fay electrode are required. ‘The needa typically 12-75 mm in diameter,03-4¢ mm in length and 0.15 ~0.6 mm reoning surface. A monopolar electtoder Teor th Voltage changes between the tip of the eles. trodes and the reference, This a electrode has a lesser diameter than concentric needle . electrode, so it is less pant Disc Electrode This electrode is cheaper than concentric needle electrodk. ii, Standard or Cov centric Needle Electrott These are most commonly} electrodes. The concentrie needle electrode is a hollo® stainless steel hypodeme needle witha central platin or nichrome sil rounded by oro y ire acts as ac o and the needle cans e the reference elect difference in potenti ye them is recorded. A Scanned with CamScanners OTHERAPY ‘Vol. IT ofl sph # Fea rode serves as the grove potential difference between two bare tips He rele and See 7 is recorded. These electrodes are more eo eis eas monopolar needle uncomfortable than a monopolar electrode e i resssy an ne monopolar because of more diameters and there is # oil and provides a clear signal. more risk of interference. These electrodes ) il Bipolar Concentric Needle are primarily used inser, ot inoue | glcrode: The cannula of the bipolar clinical studies. : | eles contains two fine stainless steel or in Single Fiber Needle Electro C poi wire wi baretips. Herethecannula These electrodes are modified concentric serves 25 4 ground electrode and the needle electrodes. Single fiber needle 6 am Recording Reference 4 Bp om 4 Monopolar Needle Recording Reference PB crowns Concentric Single Needle Electrode ference Ground | Recording, A | } Bipolar Needle Electrode | Fine Wire Needle Blectose y | NEEDLE ELECTRODES \ { —_ — & Scanned with CamScanner~~” electrode is a steel cannula of 0.5—0.6 mm diameter inside of which 1 — 14 insulated. platinum or silver wire are placed and take out at side-port | - 3 mm behind the tip which is opposite to bevelled surface of the needle. It records very small area 25 mm, opposite to the bevelled surface and several millimeters from the tip. c. Macro Electrode: It records a large number of muscle fibers that are innervated by a number of motor units along the shafi of the needle, Macro elec- trode is made up of a 15 mm shaft of a needle referred to surface electrode. d. Fine Wire Indwelling Elec- trodes: These are made up of two strands ofsmall diameter wire (100 mm) and have the coating of nylon insulation and poly- urethane needle. The needle is inserted into the muscle belly and immediately withdrawn leaving the wire embedded in the muscle. These electrodes are used for the study of small and deep muscle for kinesiologic point view. E.g,: Soleus, finger flexors, B. Stimulators: The stimulators are re- quired for various nerve conduction stud- ies and evoked potential studies. Two types of stimulators are used in these tests. a. Constant Current Stimulator: A constant current stimulator delivers a constant current outputs for each stimu- lus irrespective of the resistance between the skin and cathode or anode. A constant current stimulates is effectively a variable Diag, = iN voliage stimulator, This y ~ preferred when cong ig uantification of currents Cure E.g.: Somatosensory oo" Mite i 0 Studies and repetitive nore Po Stir A cons vole ein ge Stimulato, the same voltage With each st; , Clive ifthe resistance between the kin ee stimulator changes. 4 compen tte crease or decrease in Current i So as to maintain the same Voltage | A constant voltage stimulator ey tively a vatiable current stimulans The electrical stimulator ‘yi. cally generate voltage between 0 30 V and current 0 ~ 100 milliampes Fe effective nerve Stimulation, a stimulys duration of 50 ms ~ 100 ms are requind An important problem associated with stimulators is the shock or stimulates artifact. Yin ide Methods for reducing artifvetar i. The skin surface must be dy and any perspiration, body lotion, makeup or other surface conductors should be removed. ; ii, A ground electrode is to between the stimulator site and ! tiverecordingelectrode. ast recovery amplifie be used ele iv. Avoid bridging bet’ ih ca “— v. Rotate the anode about the ode tie! vic Wire lead between te? Scanned with CamScanneriso ERAPY ml ipl wate a to ie ne potentials belt sometimes along 4 Pr ofcapaciti eeeere ee signal; thenoise iyo recorded from th ia nosh phase:_The proces- activity inthe airand oven ne ym v0 5 to process the signals tial amplifier controls the noise, which tte amplifies the signals per- transmitted to the anpliferaseeomnon ne sn the body and filters out the mode signal. The derived signal is potential signals. This unit includes the difference between two electrodes. If the iiers and the filters mainly and in two electrodes receives equal signals, no cases also the converters, which activity is recorded at the important points to convert one form of signal considered under the amplifier as per their funtion working in the processor phase are ~ spanother. ‘A, Amplifier: The biological signals i. Common Mode Rejection Ra- perceived by the machines input phase tio (CMRR): We can measure how much ae in the order of millivolts or micro the desired signal voltage is amplified ] yolts. Thus, these signals need to be relative to the ‘unwanted signal by using amplified to make them readable. For CMRR. For example, if the MRR is this purpose the electrodiagnostic ma- 1000:1, this shows that the wanted sig- chines are served with amplifiers. nalamplifies 1000 timesmore then unwanted j “an amplifier is a device, which signals. magnifies the small myoelectric signals 1000:1 =60dB. ; j to the electrical potentials so that it can ‘A good differential amplifier te displayed on the Cathode Ray OsciF should have a CMRR more than loscope (CRO)”. 100000:1 __ Eleetrodes convert the bioele 7 tric signals produced due to the depo- it Signal to Noise Ratio Sis larization ay the musete or nerve ino a (0701 rato isthe ratio of wanted electric potential. This electric ‘potential nate srnwanted signal. If theres the ee 10° to 10° times to be dis- ve Se played. The potential difference is meas" rite oh sO ability at the ‘wedinvolt tude or hei ts tis eat the amplitude or ertotimitthe nose inrelation tothe Meaed be eevatt 10" V) The a differential amplifier is used extensive” anplifedsiens cones u a agnostic studies, because si, Gain: The term gain refers“ ignas. Gain jgnal tothe gainifthe ‘chante of common moderejection 1 Fi ‘iret empierampliiestiee= theamplifersability tamil | impulses on the active electrode amd eine ratio of output level of i 4 _Teference electrodes, Then, iteomPe® saputlevelof signal Tete willbe Scanned with CamScannerTHERAPY Vol. Il physio Goel! jimulator should be separated to pe stim capacitive interaction poof eaP processor Phase:_The proces- jp, The works to process the signals «or pS? amplifies the signals per- oe from the body and filters out the ented sens This unit includes the jifiers and the filters mainly and in an cases aso the converters, which function to convert one form of signal to another. A. Amplifier: The biological signals ved by the machines input phase ae in the order of millivolts or micro yolts. Thus, these signals need to be amplified to make them readable. For is purpose the electrodiagnostic ma- anes are served with amplifiers. “An amplifier is a device, which ifies the small myoelectric signals tothe electrical potentials so that it can be displayed on the Cathode Ray Oscil- loscope (CRO)”. __ Electrodes convert the bioelec- i seule produced due to the depo- pie at the muscle or nerve into an i lectric potential. This electric potential s amplified 10° to 10° times to be dis~ Hae The potential dtference is meas- \sinvots eattheamplitue ore ie in microvolt (10° v). The dk ae amplifier is used extensively in ach liagnostic studies, because it has vantage of common mode rejection. The imei amplferamplfesthe ce ference rom the active electrode and electrodes, Then, it combines i these two wih he ceoromyopepic sige ne : yerapl al the noi is also recorded from the static electrical activity in the air and power lines. Differen- tial amplifier controls the noise, which is transmitted to the amplifier as acommon mode signal. The derived sienal is potential difference between two electrodes. If the two electrodes receives equal signals, no activity is recorded at the important points considered under the amplifier as per their working in the processor phase are — i. Common Mode Rejection Ra- tio (CMRR): We can measure how much the desired signal voltage is amplified relative to the unwanted signal by using CMRR. For example, if the CMRR is 1000:1, this shows that the wanted sig- nalamplifies 1000 times more then unwanted signals. 1000:1 = 60 dB. ‘A good differential amplifier should have a CMRR more than 100000:1. ji, Signal to Noise Ratio Signal to noise ratio is the ratio of wanted sig- mal to the unwanted signal Ifthere is the tunwanted signal oF MOiSe produced inthe vent the oseiloseope eve sound at the noise, which shows ability at the amplifier to fimittheno#se relation tothe amplified signals. ji, Gain: The term gain refers (0 theamplifiersability toamplity si s. Gain js the ratio of output level of signal 0 the input level of: signal. There will be gain ifthe = Scanned with CamScanner7 amplifier succeeded in amplify small signal. Asaresult, these signals appear large on the display. In clinical EMG, large gain is required because individual motor unit must be distinctly visible and their am- plitude can be measured. iv, Impedance: Impedance is the resistive property present in the alternat- ing current circuit. It resists the current flow. Impedance is present at the input of the amplifier as well as the output of the electrodes. They are directly related to the voltage. If the impedance at the amplifier is more than the impedance at the electrode, the voltage drop will be more. If the impedance at the electrode is more than the impedance at the am- plifier, the voltage drop will be less, i.e., very less of electrical energy is transmit- ted to the amplifier. Impedance is meas- ured in unit (Q) ohms. IMPEDANCE a VOLTAGE The impedance depends upon many fac- tors, such as- - Skin resistance - Electrode material - Size of electrode - Length of the heads - Electrolyte - Blood and adipose tissue. v. Frequency Bandwidth: The fre- quency bandwidth describes the highest and lowest frequency component that will be processed or the upper and lower cut-off ff one, nthe form of way, in phy, but it has limit, For clin diagnosis amplifiers shou se Tespond to signals between i : Hato accurately record ners Potentials. The frequency «etm electrodiagnostic signal arr" cleetrode separation, distange it Proportional. The frequen ™*h extends from 1010 1000 Hyg 2 electrode and 10 to S00 ify nh electrodes. The filter red ae s ces th lowand high frequency atifac, a electron ity Me B. Filter: “Filter is a device which mits desired signals and restricts thes quency of signals which contain noise”, The main function, of filters reduce noise. Two types of filters ze used in electrodiagnosis: i. Low Frequency or High Pas Filter: Low frequency filter restricts te low frequency signals and permits pa sage for high frequency signals. Therefor, itis also called as high pass filter. ii, High Frequency or Low be Filter: High frequency filtersrestist high frequency signalsand permis for low frequency signals Therefore also called as low pass filters . Every signal is dle tically tests passed through to frequency and a high frequ before being displayed. Scanned with CamScanneranism, the desired ed becomes promi- jgats ae jomly occuring noi apd the randomly O° ing noise pat and ut The desired signals are ory of equipment. js mech: gored in mer The sequ' athematically SU displayed The signal to noist pends upon: - Signal amplitude “Noise amplitude _ Number of sweeps ential responses are mmated, averaged and e ratio de- Signal to Noise Ratio= (Gignal Amplitude + No. of Sweeps/Noise Amplitude) SIN={(S x vh) +N} Where, S-Signal n—Number of sweeps N-Noise ea The number of sweeps has t0 in- oa four times to double the SNR. say the noise signals can be also ae ‘ed. These can be rejected by using P rejection criterion. m1. gives utpat Phase: The output unit ceived, ee of electrical signal pet Tene dese displays are of diferent EE ‘can be either an audio display, video Aisplay Y and graphical. For this, the unit includes, a CRO (Cathod: le Ray Oscillo- scope) for visual display, a speaker foraudi oe or acomputer monitor for digital isplay or a printing machine fo recording. dees A. Visual Display: The amplified sig- nals are displayed by two techniques: _—_ i The Analogue Oscilloscope Display: Inthis technique the signals are displayed following amplification and filtering. The signals are displayed on a cathode ray tube. The cathode ray oscil- loscope or tube consists of the electron gun, screen, horizontal and vertical plates. The working of the CRO is, the ‘hich projects the electron electron gun, WI beam towards the screen interiorly is phosphorescent in nature. The election beam passes there is deflection at the vertical plate and sweep at the horizon- wn at vertical plate tal plate. This is sho signal voltage in microvolts (mv) and sweep at the horizontal plate shows the duration of signal in millisecond, but by conversion there is positive a5 swell as negative deflection above and below the base line. Camera can be connected to the CRO and then photographs Fal be made for: permanent record. The cathode ray tube hhas the advantage ‘ofhaving no mechanical limitation in dynamic high frequency response and provides a0 optimal means of displaying rapidly changing amplitude against time. ‘The analogue display has the roducing the details of is limited by its inability’ of quantification of waveforms, which is — Scanned with CamScannerF Electron Vertical plate Horizontal plate gun (Amplifier) (Sweep current) Cathode Ray Oscilloscope possible in digital display, ii, Computer Based Digital Video Display: In digital display an analog to digital converter (ADC) and digital Processing techniques are required. The continuously varying signal is sampled at discreet time intervals and the ampli- tude of the signal is converted to a number of amplifications and filtering, This process is called as analog to dig. ital conversion. The unit of ADC is ‘Bit’, which is a binary digit ie, Oor 1. The analog to digital conversion Process involves sampling the signal at a frequency at least 1 KHz ‘and converting it into numerical form with a 10 bitor 12 bit orhigher. In Ato D conversion, Process, it isnecessa Iry (0 specify the sampling rate Sor EMG data acquisition, Nyquist Sampling Rate (NSR); According to NSR, select a sam- pling rate that is atleast twice of the highest frequency Components of the signal. The surface EMG signals may have frequency Components as high as 300 to 500 Hz: a sampling rate of at least 1000 Hz should be selected. Ifthe sampling rate is specified lower than the NSR, the si i distorted. al wl The electrical played visually on a monitor for analysis. Computer has herd. ware and software. The Computer hard. Ware includes a visual monitor, key. board, and hard and floppy disk drives, The computer software helps the clini. cians to: Signal can be dis CRO ot computer ~ Perform both EMG and NCS - Collect data > Analysis ofthe results > Store the information B. Audio Display: Speakers are the au- dio part of the output units. Biological signals are transmitted to speakers ee filter. There, the analysis of both amma abnormal potentials isdone. The normal ! abnormal potentials have: cisinoivesouns | that are helpful in distinguishing them. me Practitioner hears an abnormal sound bet viewing iton the display. The Laoeen ey arelatively good speaker so as ea iia Present the sound associated wi biological signals. Scanned with CamScannerAPY Vol. IIT 7 puvstoTHER pL _ for recording purpose, goood f recorders are used in Cys PES 5 They ae: wom : ( ie Recorders: This re- i, Grp nent written record of onde sive traphic recorders such as pen 508 Ores. An oscilloscope is of opt eco junction with a pen re- ten SE alow visual inspection of raw 10 all acts. The graphic record- ios emeral) used today because sare m0 d computers and of the advance tions. ar Machine Interpretable Record- as: This recorders store information in ‘om that cannot be read ot analyzed ‘out a machine interface. Machine inerpreable records such as FM mag nelc tape recorder or digital recorders aeused. The FM magnetic recorder can sore the signals in its original analog form. Digital recorders can store data on digital magnetic tape or disc following A to Deonversion at the signal. They can also provide direct input to a computer for ‘alysis and display. The accuracy of digital recorder depends on the performance of ‘he A~D converter. The digital recorder Converts the noise and distortion of problem ofFM recorders, Settings of Display System: ..__i. Sweep Time and Gain (Sensi- -'NY):The primary purpose of sweep time thet setingsthat we can optimally eng, 4! displayed on the screen. The Yand duration measurements of an — = Scanned with CamScanner ion potential are influenced by th ime and gain. On high sweep or latency measurements are decreased. So, it is important to record all latency measurements using the same sensitivity and sweep speed. ii. Signal Trigger and Delay line: These settings are useful for isolating and displaying the motor unit potentials for their quantitative analysis, Delay line continuously samples and stores into the memory ongoing EMG activities. When the MUP exceeds the triggering value (the triggering event is fixed and timed locked relative to the start of sweep). It is extracted from memory and displayed.ELECTROMYOGRAPHY Definition: ; ; Electromyography is a technique used in studying the electrical activity of the muscle for the diagnosis of neuromuscular diseases, This examination is used to assess the function ofneuromuscular system, which includesmuscle fibers, end plates, peripheral nerves, neuromuscular junction, radicles, upper motor neurons and lower motor neurons, MOTOR UNIT: “A motor unit comprises of an anterior hom cell, the axons arising from it, its neuromuscular junction and the muscle fibers which the axon: innervates.” Asingle axon therefore it is quiet Possible that the fibers of different motor unit intermingle with each other. When one Motor unit contracts, then, since its depolarizing fibers are dispersed, itis not €asy to place the electrodes all the signals, which react Plifier, while the rest of the signals tha do not reach the electrode are not recorded even though they are present, +h them to the am- Antetior Hom cop Amn Motor Unit Muscle Fiber MOTOR UNIT The electrical activity produced by the individual muscle fiber is summed 0? because they reach the electrodes: a neously; the electrodes record all Potential reaching them without dle ating their origin, Thus, if two or more a . units contract at the same time, ! electrodes will summate all the ele activities reaching to it into one large unit action potential, canned with CamScanneriG FENG os namel ur tyPe EI i ee EMG (Needle EMG) me ici sioloBi¢ EMG (Surface ii. Je Fiber EMG (SFEMG) MG ai) i. sine vy Macro E R NEEDLE EMG: cunt cA EMG, electrical activ- a ies studied by inserting a ve ‘pode into it. The motor unit caste (MUAP) picked up by the sonnet jsplayed on an oscilloscope deal analysis oF are acoustically fed hrougha loudspeaker system. Inthis procedure, We get information bing muscle diseases or the extent of rervedinjury. muscl EMG Recording Techniques: Theskin over the areas to be tested iscleaned with an antiseptic solution. An eketode that combines the reference point andaneedle for recording is inserted into the specific muscle to be tested and ‘tached by wires to the recording machine. Once the electrodes are in place, the Saualatity inthat muscle is recorded (doton ‘muscle is at rest. Then the examiner igi ate patient gradually increas- mt teeta activity in the ieee =e recorded, The needle may Becerra number oftimesto record i vity in different areas or in ‘erect muse les, T , ise ioe electrical activity in the lng on Played as wavy and spiky Special video monitor (oscil- ae on magnetic tape, When th pleted the needle and the skin electrodes are removed and those areas of the skin where a needle was inserted are cleaned. Patient may be given a pain reliever if any of these areas where a needle was inserted aresore. An EMG technique may take 30-60 minutes. The equipment setup for EMG recordings is as follows: - Low frequency filter: 10-30 Hz - High frequency filter: 10-20 KHZ ~ Sweep speed: 5 - 10 milliseconds/divi- sion ~ Amplifier sensitivity: 50 — 100 .v/division I. Insertion Activity Muscle at rest is electrically si- lent; during this part of examination, the muscle being tested should be at rest. On insertion of needle electrode in a relaxed muscle, there is a spontaneous burst of potentials due to mechanical damage by needle movement. The needle movement breaks the muscle fiber membrane. This activity is called insertion activity. The sound produced at the time of needle movement is called “crisp”. Needle movement appears as positive or nega- tive high frequency spikes, easily visu- alized in the monitor. The needle is repositioned but it lasts for less than 300 milliseconds. The needle movement should be done in four different quadrants and at four different depths, The duration of insertional activity a Scanned with CamScanners from one examiner to another. Insertional activity may be decreased or prolonged in duration, Normal insertional activity typically only lasts few hundred milliseconds, just barely longer than the needle movement itself, Decreased insertional activity occurs when the needle is inserted in muscle that have become atrophied and replaced by fat or become fibrotic. Mus- cles that have become electrically silent such as during attacks of periodic paraly- sis also have reduced insertional activ- ity. Prolonged or increased insertional activity may be due to pathology of muscles. Incase of denervated muscle and myotonia, increase in insertional activity is noted, The On before cy Positive sharp waves or fi fore P or fibrillation ipparent. Increased Insertional usually considered to be proten i membrane activity lasting mone liseconds after theneedle move IL. Spontaneous Aetivity: (ya of Muscle at Rest) minty A normal muscle i silent after needle insertion, baa seconds, there are spontaneous ete 7 discharges that are seen without we movement or voluntary contraction, Th are called as spontaneous activity, This activity is seen after each needle movenes when the needle is stationary. Forrecor of spontaneous activity, the muscle sna Normal Muscle “tin Increased Insertional Activity INCREASED INSERTIONAL ACTIVITY OF MUSCLE EEE Scanned with CamScanner- a ort PHYSIOTHERAPY VoL gestil a spontaneous activity is re~ pear the end plate zone (end plate corded end plate noise) is normal. End site ne js the point where the nerve a he muscles. The end plate zone enter inful area and insertion of needle isa rea increases the discomfort of theexarnination. End plate potentials are monophasic negative waves of less ‘than {00 uv and duration of 1 ~ 3 millisec- onds. The end plate potentials are usu- ally seen with an irregular baseline and called as end plate noise (sea shell sound). In the end plate region, action potentials, which are brief spiky, rapid and irregular with an initial negative de- flection, are known as end plate spike (sputtering rhythm). End plate spikes are due to mechanical activation of termi- nal by the needle. The needle should be inserted slightly away from motor point to avoid the normal spontaneous activity. Spon- Nonral (with muscle at rest) Wy A" Needle in Endplate Region neous ac typically abnormal and occurs in the presence of any pathology, Normal muscle has a resting membrane potential of—80 my relative to the extra- cellular fluids but after injury or denervation, it becomes more positive due to an influx of Na’ into the damaged cell membrane. The cell resting mem- brane potential :eaches upto —60mv. This leads to the generation of abnormal spon- taneous action potential. I. Fibrillations: “Fibrillation potentials are spon- taneously occurring action potentials from a single muscle fiber”. This occurs in the presence of impaired innervation. The denervated muscle gives spontane- ous discharges because they are hyper- sensitive to the circulating acetyl choline. EMG Records of Fibrillation Potential Phase: Biphasic or triphasic Amplitude: 20 - 1000 pv MINIATURE ENDPLATE POTENTIAL (MEPP) > Scanned with CamScannerGenerated by Muscles 1. Fibrillations 2. Positive sharp waves 3, Myotonic discharges 4. Complete repetitive discharges 5, Fasciculations Duration: 1-5 milliseconds Frequency: 0.5 — 15 Hz Sound: High pitched sound (rain- drop falling on tin roof) FIBRILLATION POTENTIAL 2. Positive Sharp Waves: Positive sharp waves are the forms of electrical potential associated with fibrillating muscle fibers, which are recorded asa long duration biphasic potential with initial sharp positive phase followed by a long durational negative phase. It appears like a “saw tooth”. These waves are characteristic features of denervated muscles, EMG Records of Positive Sharp Waves: Phase: Monophasic or biphasic 2. Neuromyotonic discharges 3. Cramps T. Myotonic discharges Duration: 10-30 mil liseconds Frequency: 0. 2 Sound: Dull thuds POSITIVE SHARP WAVE Causes of Fibrillation and Positive Sharp Waves: a. Neurogenic - Anterior horn cell lesions - Radiculopathies ~ Axonal neuropathies - Plexopathies , - Peripheral neuropathies - Entrapment neuropathies b. Neuromuscular junction: - Botulism Scanned with CamScannerPHYSIOTHERAPY Yo _ Congenital myopathies - [nflammatory myopathies “Trichinosis - Muscle trauma 4 Complex Repetitive Discharges (CD smplex repetitive discharges are repetitive and synchronous firing ofa groupofi ‘muscle”. Repetitive: discharges are also called as bizarre high frequency discharges. They appear as a run of simple arcomplex spike patterns that repeat in a regular pattern. These potentials start and stop abruptly. Most commonly found in Duchennes Muscular Dystrophy (DMD). EMG Records of CRDs: Amplitude: $0 pv — 1 mv. Duration: 50-100 milliseconds. Frequency: 5 — 100 Hz. Sound: Dive Bomber. Causes of CRDs: a. Myogeni - Inflammatory - Polymyositis - Muscular Dystrophy - Myxoedema - Schwartz Jampel Sundrome b. Neurogenic. - Poliomyelitis - Spinal muscular atrophy - Chronic neuropathies - Chronic radiculopathies - Motor neuron diseases 4. Fasciculation: Fasciculation potentials are spon- taneous contraction of a number of mus- cle fibers belonging to whole or a part of motor unit. Fasciculations are often visible through the skin as a small twitch. Fasciculation can occur in normal indi- vidual particularly in calf muscle, eye, hand and feet. EMG Records of Fasciculation. Phase: Diphasic, triphasic, polyphasic ‘Amplitude: 300 jv — 5 mv Duration: 3 - 16 milliseconds COMLEX REPETITIVE DISCHARGE ee Scanned with CamScannerSound: Low pitched thump Causes of Fasciculation. a, Neurogenic disorders. / - Amyotropic lateral sclerosis - Rediculopathy - Peripheral neuropathies - Syringomyelia - Spinal muscular atrophy b. Metabolic disorder: - Tetany - Thyrotoxicosis - Due to anticholinesterase drugs - Uremia c. Normal: - Benign Fasciculation - Muscle cramps 5. Myotonic Discharges: “Myotonic discharges are the action potentials of muscle fibers firing in a prolonged period after external ex- citation”, These potentials are the results of delayed relaxation of a muscle after a forceful contraction, Myotonic dis- charges have two potential forms: : harp wave Brief spikes The frequency of myotonieg charges ranges between 40 and 100 rd This variation in frequency Produce, “Dive Bomber" sound. These potentige appear in a waxing and waning pater in both amplitude and frequency, Causes of Myotonic Discharges: - Myotonic dystrophy, - Myotonia congenita, ~ Paramyotonia. - Polymyositis. ~ Hyperkalamic periodic paraly. sis. 6. Myokymic Discharges: “Myokymic discharges are the group of spontaneous muscle potentials with regular firing pattern and rhythm’ The term myokymia is used clinically to describe a “worm like quivering of the muscle”. These discharges occur in bursts of 2 10 potentials firing at 40 - 60 Hz and reoccur at regular intervals of 0.1 10 seconds. It produces a sound like so! (waxing & waning pattern) MYOTONIC DISCHARGES Scanned wit amscannerol Jectromy ¥ aig is used for studying ec wits and helps inestablishing the leat for specific activ- user it muscles for speci differen" leo it scaluseof kinesiologic electromyo- ini ga oe isavastrole ofkinesiologic elec- omyosraphy inthe clinic. Electromyogra- ,jsused to examine muscle function dur- ingspecific purposeful task or therapeutic reaimes. Thisis not limited to examination afsingle motor unit potential but also con- siders : = -Pattems of muscle response in rela- tionto effort. - Type of muscle contraction. -Position. - Onset and cessation of the activity. ‘These activities help the therapist to plan ‘treatment, Clinical applications : z Use of electromyography helps the “atin assessment as well as planning eae as it provides the informa- ut the effectiveness of a specific ‘ocedure, : io Selection of a muscle : ie acti funignat od the general movement or Miele ge «ovement performed by a 4 Broup of muscles is seen . It very difficult to see the function ofa single muscle responsible for the movement, there- fore choose the muscles that are represen- tative of the group that are considered as prime movers. The therapist must determine that, which muscle is combined to perform the movement because the surface elec- trodes should be kept over the muscle belly, when we want to see the activity of single muscle, 2. Motor control : Electromyography helps in measuring the level of motor unit activity but cannot mea- sure the tone of muscles. Motor unit activ- ity is facilitated by stimulus suchas passive stretch by treatment modality or with change in position and voluntary contrac- tion and reflex activity gives the same re- sult. Electromyography also monitors asso- ciated reactions or exercise overflow. E ercise overflow means electromyography activity recorded in unexercised muscle during contraction in another body part. It may be ipsilateral or contralateral. These ac- tivities are observed during resisted exer- cise, during position changes or applying load. But cryotherapy, resisted exercise, positioning will generally not interfere with valid electromyography recording, i) While doing manual muscle testing electromyography can be used to evaluate the degree of effort. Associated reactions may also be recorded at the electrodes. Electrodes should be kept at different places around the muscle to get the differentiation. ii) When the patient is sitting or stand- ing, the electromyography is used to assess Scanned with CamScannerihe pattems of response by seeing thi plitude and tuning of onset of the activ s The aim of doing electromyography is to facilitate or inhibit specific muscle group to enhance balance reactions and weight shift- ing, ii) Gait - Electromyography can be usefil to assess muscle activity during gait, This is done by film, video tape, electrogoniometres or contact foot switches for delineating swing and should also be considered while seeing the effect onelectromyographic activity, 3. Passive movements : Electromyography can help to identify whether movements are truly positive. If Passive movements are done in a normal relaxed muscle, we will not get the appro- priate electromyography results but if the Patient voluntarily relaxes to allow full pas- sive movementit will give better results, 4. Movement Patterns : Therapist can use electror serve the effect of treatment on patterns of muscle response, Electromyography helps when itis difficult to observe the movement, Ithelpsin examination of agonist and an- tagonist, co-contraction or reciprocal inhi- bition or: activity like mat exercise. and trac- tion, PNF patterns isokinetic exercises as well, but it has controlled velocity of move- ment. myography to ob- LE FIBER EMG . SFEMG is amethod Of) action potential of a sin, extracellularly within the same meta et Inthis technique, a single fiber Reedle cles trode (25im*recording area) ig inserted, asteel cannula during. slight voluge 8 traction and the Tecording is take, single site. In SFEMG, the electrode records potentials from (Wo fibers in the ‘mo. tor unit. A trigger is used to control the tracing of these pote: tials allowing the measurement of latency between the two discharges. The time interval between these two potentials varies from, One discharge to another. This inter Potential difference is called as the “jitter” TInanormal Muscle contraction, the mean value of jitter is 5— 60is. gle mu: 1 froma SFEMG is indicated in re ~ in. nervation, neuro— muscular transmission disorders, myopathies and motor neuron diseases. This technique is also useful to assess the changes in the muscle mor- phology. D. MACRO EMG: Macro — EMG is a technique of recording action potential of the entire motor unit. In this technique, macros electrodes are used which have 0.55 a diameter steel cannula that is Lae upto 1.5 cm from the needle tip. It 25-im diameter platinum wire en in a side port 7.5 mm proximal a side tip. The recording process in oa EMG occurs in two channels. one a nel records the potential differen Scanned with CamScannerpHYSIOTHERAPY Vol. IIT MYOKYMIC DISCHARGES dersmarching. 4 Causes of Myokymic Discharges: -Bell’s palsy ~Multiple sclerosis - Chronic nerve compression Radiation plexopathy 7. Cramps: “Cramps are sustained and possi- blemuscle contractions of multiple motor units lasting for seconds or minutes”. They may appear in normal person or in specific disease, Spontaneous discharge of potentials occurs at 40 - 60 Hz in cramps. Causes of Cramps: - Myxoedema - Pregnancy - Uremia - Salt depletion - Chronic neurogenic atrophy Causes in normal individual: - Exercise - Abnormal positioning ~ Maintaining a fixed position for 4 prolonged period of time ee 8. Multiple motor unit potentials: Normally motor unit potentials are discharged asa single potential in a semi- rhythmic pattern but some times they are fired two or more times atan interval of 10 —30 milliseconds. If the motor unit fires twice, itis referred to as a “doublet”, three times denote a “triplet” and more than three times firingis called a “mudtiplet”. Causes of MMUPs: -Hyperventilation -Tetany - Motor neuron diseases - Metabolic diseases IIL. Motor Unit Analy After muscle insertion activity and examination at rest, the motor unit itself should be analyzed. During this part of the test, the patient is asked to mini- mally contract the muscle. This minimal contraction causes individual motor unit to fire. Finally the patient is asked to progress the number of contractions. If the muscle is fully contracted, it is al- most impossible to isolate and therefore analyze an individual motor unit. __ Scanned with CamScanneri (MUP) e summation of electrical potentials from Sresmeecrt tei auptelby atreke anteriorhor cell”. The MUP therefore has ahigheramplitudeand longer duration than action potential produced by a single muscle fiber. Te MUP can be characterized by their firing pattem and appearance. On mild contraction they fire at 5 — 15 Hz. For analysis of motor units, the sweep speed should be set at 10 milliseconds/division and the gain should be 200 ~ 500 jiv/ division. The trigger and delay lines are necessary for a detailed analysis of the motor units. The trigger is set to record a tracing when certain amplitude is reached. The delay line determines the Position of the potential on: the screen, COMP, MOTOR UNIT i Pe oN ELECTRO DIAGNO si, 3 4) morphology is any under following componentg, "2d - Amplitude ~ Rise time - Duration - Phases i. Amplitude: MUP is measured fro) to the negative peak the maximal height tial. Amplitude of the motor units may be normal, increased or decreased. [tig increased in neuropathies and decreased in myopathies, ii. Rise time; “The rise time of MUP is the duration from initial posi. tive to the subsequent negative peak”, Rise time indicates distance between the The amplitude of m the POSitive Peak or the amplitude js of the action poten, ONENTS OF CTION POTENTIAL Scanned with CamScanner£0.5 7 quantitative assessment of eater rise time is at- ti sist fo able wer litude. A Bt n the resistance and capacitance of buted t© ang tissue; act as a high fre- ; gervening tissue; the inte filter. A unit accepted for quali- ene) essment should produce sharp a greater rise time produce dull sound. This ee eee e reposition the needle electrode 10 the muscle fibers. F iii, Duration: “The duration of MUP is measured from the initial take off from baseline to the point of return to the back line”. Normal duration is about 5 - 15 milliseconds, Duration de- pends upon age of patient, muscle ex- amined and temperature. Duration in- crease in neuropathic process and de- creased in myopathic disorders. iv, Phase: “The phase is defined as the portion of MUP between depar- ture and return to the baseline, i.e., number of baseline crossing +1”. If the motor unit potential have more than 4 phases is called as polyphasic potential. Some potentials show directional ae without crossing the baseline. Hed e known as turns. Polyphasic me suggest desynchronized ba = of individual muscle fiber. inh ‘Se Components of MUPs are Pe maa {echnical and physiologi- T chnical variables are: : Bade needle electrode “cabin surface ~Pre-amplifierandamplifier sound, but The physiological variables are: - Age - Muscle temprature ~ Muscle to be studied - Location of needle in the mus- cle (superficial or deep or endplate re- gion) - Activation procedure (degree of muscle contraction, reflex or electrical stimulation) TV. Recruitment: “The term recruitment refers to the orderly addition of the motor unit to increase the force ofa contraction”. The motor units are recruited in the order of smallest appearing first, larger later and the largest still later. In motor unit analysis, the patient is asked to think about the contracting muscle and the analysis should begin. A muscle contraction becomes stronger in two ways: a. Increased rate of firing b. Additional motor unit firing For analysis of recruitment, the machine should be set at a sweep of 10 milliseconds/division and a gain of 200 — 500 jrv/division. Normally the motor unit will fire in a regular pattern at about 5 Hz. Reduced or Decreased Recruitment: The rate of firing of individual potential dur- ing muscle contraction will be out of proportion to the number of firing is called reduced recruitment or discrete recruitment. Scanned with CamScanner_—_— ——™ ae TRO DIAGNOsis 383 3 Gition, decreased In neuropathic con Indication of Cli EM recruitment isse°- 1. Disorder of peripheral nerve reased Recruitment: Ifa large a, Neuropraxia units are recruited for b. Axonotmesis thenitis called early or c. Neurotmesis nt, This recruitment is 2. Polyneuropathies Early or Incr number of motor ‘minimal contraction’ i jitmen Sy oe 3. Motor neuro diseases : a, Syringomyelia Normal Recruitment: If ‘only a few motor b. Poliomyelitis units are firing but they are firing at normal c. Amyotropic lateral sclerosis . ae muscular atrophy . Progressive bulbar palsy Recruitment Ratio: f. Spinal muscular atrophies Thisratio istherateoffiring ofthe 4. Myopathies mostrapidlyfringmotor nit inHz)divided 5. Myofonia bythenumber of units firing. Therecruitment 6. Myasthenia gravis ratio more than 8 is considered abnormal 7. Radiculopathy andissuggested asneurogenic processand 8. Spinal cord compression the ratio below 3 is suggested as the a. Spinal cord tumors b. Syringomyelia c. Cervical spondylosis d. Lumbardisc lesion 9. Facial nerve palsy 10, Movement disorders a. Spasticity b. Rigidity c, Tremors rate, recruitment is normal. myopathic process. Decreased Recruitment Increased Recruitment RECRUITMENTSTHERAPY Vo IIT sspHYSIO” okt on reflex) The Action Potential: The action potential is a summa- tion of multiple potentials. A compound muscle action potential (CMAP) is the summation of motor units (Muscle fibers) that are firing each with its own amplitude and slightly different conduc- tion velocities. The summation of the potential yields a characteristics (usually bell shape) curve. The part of the curve that be- gins to rise first represents the components from the fastest fiber. Components of the nerve action poten- tial: i, Latency: “The latency is define as the time interval between the onset of a stimulus and the onset of response”. It represents the time taken from the stimulation ofanerve to the measurement of the beginning of the sensory nerve action potential (SNAP) or the CMAP. Ina CMAP, the onset latency represents the arrival time of the fastest conducting nerve fiber. There is a normal variation in the conduction velocity of the individual nerve fiber producing a temporally depressed curve. This is usually bell shaped curve representing the number of fibers (amplitude) and how fast they are traveling, In sensory nerves, the latency dependent on the speed of conduction of the fastest fibers and the difference the wave of depolarization travels. In motor nerve, the latency dependent on the speed of the nerve, the distance traveled and the Scanned with CamScannerinter muscular conduction. Usually the la- tency is measured to the negative (upward) departure from baseline. ii, Conduction velocity: Conduction velocity is the speed of propagations of an action potential along a nerve. It can be calculated by- Conduction Velocity= (Conduction Dis- tance + Conduction Time) ‘The calculated velocity represents the conduction velocity of the fastest axon inthe nerve. Normal conduction velocities average above 50m/sec in the upper extremities and above 40 mvsec in the lower extremities iii. Amplitude The maximal height of the action potential is the amplitude. In CMAP, the amplitude is most often measured from the base line to the negative peak or from the Positive to the negative peak. Motor nerve amplitude is measured in millivolts, ‘The amplitude of CMAP represents the sum of the amplitudes of individual potentials. The amplitude is therefore dependent on the integrity of the axons, the muscle fiberit depolarizes and the extent of Variability of the conduction velocity of individual fibers. When the CMAP is with longer duration and| lowamplitude, itoccurs because of temporal dispersion or due to decreased number. of axons. iv. Duration Durations the from the basen othe final wae baseline or the time fx bbe fom the onset j to the terminal latency. The duration be increased in neuropathies time from dg May i 3 Tine ralzecond) COMPONENTS OF NERVE ACTION POTENTIAL Recording Technique The test may be perfomed technologist or by a Doctor see nt in neurological diseases oF bY °F. otherapist in rehabilitation coh iy instrumentation includes stim Ne addition to all the eee EMG already described cai 5 In this test, the sufOee are used most commonly but ae situ trode may be used in some sPeHY! OTHERAPY Vol. IT

Large fast conducting group la afferent fibers > Spinal cord where afferent fibers synapse with alpha motor neuron. > Efferent motor fibers supply- ingthe muscle. The H-reflex does not in- clude muscle spindle activation but rest of the are Ir tO t by muscle stretch. don reflex produce Recording Technique: The H-reflex is sensitive so it can be affected by number of variables. The latency of H-reflex is dependent on the age and leg length of the patient the H-reflex is often absent in individual over the age of 60 Years, so careful attention to the technique is very essential. Patient Position. Patient should be semi reclining comfortably or lie ina prone position with leg and thigh firmly supported. The feet should hang freely with dorsum atright angle to tibia. Electrode Placement: The active surface electrode is placed at the distal edge of the calf muscle and the reference electrode on the Achilles tendon. The ground electrode is placed between the active electrode and the stimulation site. Stimulating electrode Recording electrode a } ‘Ground electrode H- REFLEX SETUP Scanned with CamScannéStimulation: Stimulation h Poplitial fossa, slightly lateral tothe mi ~ line. The cathode is placed proximal to the anode to avoid anodal block. A stimulus just greater than that, to evoke a minimal M — response is applied to the Posterior tibial nerve in the center of the Poplitial crease, A square wave pulse of | ms duration is used for preferential stimula- tion of large sensory fibers and a stimulus below 0.1 ms duration is used for motor fibers. Stimulus frequency should not exceed | in Sseconds to exclude any effect of prior stimulus. Atleast 5 H-responses should be studied foranalysis, Measurements: The lateney of H— reflex is meas- ured from the stimulus artifact to the first deflection from the base line. The am- plitude is measured from the base to the peak ofthe negative phase. The upper limit of the H-reflex latency of soleusis 35 msand that of flexor Carpi radialis is20 ms in adults, The latency of the H ~reflex is related to the age and height orlimb length ofthe patient according tothe following ‘equation; H ~ reflex latency = 2.74 *0.05(age) + 0.14(height in cm) + 1.4 Clinical application: | Rediculopathies: Ins, rediculopathy, the Soleus H — reflex may be absent, Inc, - C,rediculopathy, the flexor carpi radialis H =Teflex may be abnormal, 2.Gullian Barré syndrome: 1 ~ reflex may be absent, delayed or dep ressed, a Variables, in Pinay 4. Plexopathy, © F-Wave: The F — wave was g . ‘8S first gi, by “Maglandary and ye ae 1950. Itwas named eben ‘Was noted in the intrinsic footm '. F-—wave is alate response esti the antidromie activation ot the ne heuronsinvolving conduetion aig the spinal cord, It occurs at the between the peripheral and the cent us system. The F — wave pe small amplitude, a variable Configuration ands Variable lateney. The F—wavecan bes inmany muscles if the upperand the lover extremities, inter Recording Technique: Electrode placement and F wave se. up: Recording electrode is placedina belly tendon montage. Anamplir in of 200-500 iV/division ata Sweep speed Of 5 ~ 10 ms/division is recommended Recording is done in a relaxed muscle Stimulation: F—wave can be recorded fiomany distal musele by stimulating the approptat herve. A supramaximal sinuses to stimulate the nerve using aa Md electrode placements. The cathodes always proximal to anode to avoi anodal block. Scanned with CamScannerpavslOTHERAPY ‘Vol. IL 's otl! tion: ar atl Abnormal. wep endrome: Stowingof the cin ere an Bar on sera! if ere pathies: ; Rein Ojateral sclerosis. j nora outlet syndrome. é uropathy: Abnormal. ave (axon reflex): ‘anon reflex is a late potential qenly appearing between M and F hes. Axon reflex occurs due to collat- eal branching in the proximal portion site nerve. On sub maximal stimula foo, if only one branch is stimulated without stimulating the other, the im- pulse travels antidromically and turns wound to descend down the un — stimu- lated branches to produce a potential that isknown as “Axon reflex”. It is present invarious neurogenic disorders such as Diabetic neuropathy, Brachial plexus le- sion, Amyotropic lateral sclerosis, Carpel ‘unel syndrome, Ulnar nerve palsy, etc. @ ACW NARIABLES AFFECTING THE ERVE CONDUCTION STUDIES Physiological variables; - i. Temperature: Increase in the tem- erature causes an j ; tec aminereaseinthe cond iiAge as ‘Anomalies: Martin Gruber Anas- Thnical variables: iStimulation: Pe julator ridge formation between anode and cathode. ii, Recording: -Break in cable -Wrong setting of gain, sweet, filter and amplifier iii, Electrode placement: -The ideal spacing between the active and the reference electrode is 3cm with the reference electrode is placed over asilent electrical area, iv. Artifact. INDICATION OF NERVE CON- DUCTION STUDIES 1. Neuropathies: -Metabolic -Hereditory -Degenerative 2.Myopathies: -Myotonic -Dermatomyositis -Congenital myopathies -Polymyopathies 3. Motor Neuron Diseases 4, Neuromuscular Junction Disorder 5. Rediculopathies: “Cervical Rediculopathy -Lumbosacral Rediculopathy 6. Carpe] Tunnel Syndrome and other nerve entrapments. 7. Plexopathies -Idiopathic -Traumatic -Infiltration ee ee Scanned with CamScannerEVOKED POTENTIALS ential is an electrical Evoked Pe fiom the brain, the ded rer heral nerve that 01 vin r the peripl ee a by various external stimuli cu eae auditory, somatosensory, ‘recording electrodes are placed ver the scalp, neck or spine surface, hich vary depending on the type of stimulus modality to be tested. The recording potential may only be of a few micro - volts having lots of background disturbances such as cardiac & skeletal muscle potentials, ongoing ECG spinal cord activity, ocular move- ments, corneoretinal potentials, CCF volume conduction potentials and arti- fact from the electronic circuit. By ap- plying averaging, the recording can be perfected and properly interpreted. Evoked potential studies are used routinely asa clinical tool for diagnostic and therapeutic determinants in patient care. Itisstilladeveloping science. The citcuit of evoked potential studies includes electrodes, amplifier, filter, and averager and display system. The evoked potentials most commonly used in the neurological diagnosis are: } ee Potentials (VEPs), (BAEPs) fem auditary evoked potentials 3. Somatosensory (SEPs). 4. Motor evoked Potentials (MEPs), such as etc. The evoked potentials PATHWAYS OF EVOKED Dongs 4 1. Visual evoked potentia VEPs are evoked by visual sing and recorded from the scalp, The; reproducible with an identical pater stimulation. Normal cortical responses obtained if the entire visual system ising and disturbance anywhere in the visu) system can produce abnormal VEPs Therefore the localizing value of VEPsis limited. This test examines the integrity of visual pathway from retina to occipit cortex, where visual input is perceivedin the brain. During the test the patientisasked to watch the vedio screen, which presents moving checkboard patterns. If the patieat wears glasses, VEPs should be tested wit the best-corrected glasses. Each eye 8 tested separately. The preparation for VE? takes about 20 minutes and recordingti™® of 30 minutes. Clinical application of VEP: Multiple sclerosis i « Ischaemic optic neuroP®™ © Optic neuritis : © Nutritional and toxic ropathy pticne” Scanned with CamScanner> e's pHYSIOTHERAPY Vol IIT ‘oeL’S nd degenerative dis: jereditary eases m auditory evoked 3, Brainste pie se are the potentials recorded ar and vertex, which can be an auditory, stimulus. The sound enters the ear canal and stimulates theauditory nerve. The electrical impulses travel from the auditory nerve through the hrainstem to the auditory cortex. During seating the patient hears repetitive click sounds through earphones. Each ear is tested separately. The testing time of BAEP js20minutes: and the recording time is about 30minutes. fiom the & evoked by Clinical application: Brainstem tumors * Multiple sclerosis * Coma * Brain death * Stroke 3.Somatosensory evoked potentials These are the cerebral potentials re- corded from the scalp, subsequent to stimulation from a mixed perepheral nerve, dermatome, motor end point or the radicals With appropriate stimuli. The stimulus trav- els through the Ia group of fibres of the Perepheral nerve, then through the dorsal Columns of the spinal cord and through the brainstem of sensory cortex. The common stimulus used is an electrical square wave Pulse, SEPs are useful in assessing the integrity of the somatosensory pathway. are generally obtained by stimulating ‘Median nerve in the upper extremity and the posterior tibial nerve in the lower extremity, The preparation time for SEP is about 30 minutes and the recording time is about 30-60 minutes. Clinical applications: ¢ Trauma © Vascular lesions ¢ Multiple sclerosis Acute transverse myelitis Potts paraplegia * Cervical spondylosis Hereditary ataxia ¢ Coma Brain death 4. Motor evoked potentials ‘These are the potentials recorded from the muscles, nerve or spinal cord in response to the stimulation of the motor cortex or the motor pathway. The motor cortex can be stimulated trans-cra- nially either by an electrical stimulus or magnetically resulting in compound muscle action potentials recorded peripherally from the muscle. Deep lying structures like the spinal cord; roots, plexi and even perepheral nerve have now become assessable for study with magnetic stimula- tion. Clinical applications: Demyelinating diseases - G.B.Syndrome = Multifocal motor neuropathy - Multiple sclerosis © Stroke © Degenerative diseases - Motorneuron diseases Scanned with camScannerHereditary ataxi Cervical spondylosis e Parkinson’s disease © Spinal cord injury. © Inflammatory diseases - Acute transverse myelitis. - Potts paraplegia. - Encephalitis. S.D. CURVE TEST (Strength Duration Test) Itis the test to determine neuromuscular excitability. Itis used mainly for motornerve assessment. In this test a minimal detectable contraction is used as the standard re! needed to elicit that response at. different ‘sponse and the current as voltage pulse length is plotted on a graph known as Strength duration curve. The advantage of this method is that, it is simple and reliable and indicates the Proportion of denervation, Me @ ° lethod for Performing S.D. Test: The patient is reassured by adequate explanation about the test. The area to be treated should be immly supported. Warm an the skin passed, The indifferent electrode is placed over Some convenient area, usually over the origin of muscle group. Theactive elec muscle bulk u obtained. d wet the skin so as to lower Fesistance, when current is trode is moved over the intil a good contraction is Current is applied using the longest CT: unti observable contra ‘The muscle contr : Lisually, or palpated phyet Mfg both can be done," Physical"! © The magnitude of the is noted and the impuls ata This procedure is repeate for ent length of stimulus in tum ach © The magnitude of as required, © Theminimum Observable contraction; used to detect change in strength and; i: very important that the active: electrode isheldon the same point of them, throughout the test. © The strength duration Curve between duration and Voltage or current is plotted from the results of the test, the curentis; increase The apparatus used for obtaining §.. test applies rectangular impulse of different duration. Impulse with duration of 0.01, 0.03, 0.1, 0.3, 1.3, 10, 30, 100, 300 ms are required. Two types of stimulation are used:~ 1. Constant Current. 2. Constant Voltage. The constant current stimulation produces the more accurate results but the ee Voltage stimulation is more comforttep patient, The S.D. curve will be furhe: the left with the constant voltage, the constant current stimulator. Different Type of S.D. ae 4. Normally Innervated Muscle The curve of normal innervated 'ypical in shape because the same st of stimulusis required to produce araratiol with all the impulses of long’ “real Ber quite While those of shorter duration re4) scleis ngth Scanned with CamScanner> pHySIOTHERAPY ‘Vol. HL ih ofthe stimulus a po oga1 03 1 3 10 30 100 30 Millisec IN CONSTANT VOLTAGE a ga 5 om og301 03 1 3 Millisec IN CONSTANT CURRENT 10 30 100 300 2 Complete Denervated Muscle : Httscase, forall impulses with a duration ms or less, the strength of the healing Must be increased each time, the tion is reduced and no response is to impulse of very short duration. ‘stimul — steeply & furth: right to that of innervated muscle. 100 ae Dia 00100301 03 1 3 10 30 100 200 Milisec A. IN CONSTANT VOLTAGE | re oe ee 00100301 03 1 3 10 30 100 30 Millisec B, IN CONSTANT CURRENT 3. Partially Innervated Muscle : In this case the impulses of longer duration stimulate both innervated and denervated muscle fibres, thus low intensity is required for contraction. With the impulses of short Scanned with CamScannerthe innervated fibre respond to weaker stimulus and denervated fibre will not respond. Innervated Fibres Position of Kile ‘oor 0001 03 1 3 19 30 100 m0 Pulse Lengths (ns) SD. CURVE OF PARTIALLY DENERVATED MUSCLE Thus right hand part of the curve- For denervation Left hand part of the curve - Forinnervation kink is seen at the point where two curves meet. © If large denervated fibres - Curve rises steeply, kink will be towards right. © I large innervated fibres - Curve is lower and flattened. Kink will be towards left. © Progressive innervated - Kink will appear and curve will move down and towards left. © Progressive denervated - Kink will appear with an increase in slope and 4 shift of the curve to the right. 109} 901 00301 03-135 20 ite Milisee a SD CURVE SHOWMIG VARYING Deere DENERVATION: TORE OF Rheobase Rheobase is a term used for a minimum Current or voltage, which can Produce ‘minimum muscle contraction when alge duration impulse (or infinite duration)is applied. In case of denervation, the Rheobase will be less than an innervated muscle and itincreases as re-innervations occurs. The Rheobase varies considerably in different muscles & according to skin resistance & temperature of a part. It may rise due to fibrosis of muscle. Chronaxie It is denoted as the pulse duration © millisecond, to cause a minimal coe contraction with an intensity (cum voltage) twice of rheobase. 2 Chronaxie of innervated aon an s than that of denervated much Tie muscle become innervated. risa should be gradually shortene Scanned with CamScanner7 ysiOTHERAPY Vol HI st jon yefothe ph Rheobase of innervated muscle 35 po B25 Rheobase of & denervated muscle # 20 2 gu 0.1/0.3 1.0 3.0 10) 30 100 300 Chronaxie Chronaxie S.D. CURVE SHOWING RHEOBASE & CHRONAXIE OF INNERVATED & DENERVATED MUSCLE Uses of S.D. Curve 1. Demonstrate the presence of innervated fibres in the muscle being tested. 2. Demonstrate changes in innervation by means of successive graphs. 3. Indicates the value of rheobase, chronaxie and utilization time. ad Scanned with CamScannerOPAC Nos, COMPARISON OF CONVENTIONALSD~ CURVE 4g Ei EM SD-—-Curve test Electromyogr 1. It isa graphical correlation of strength of the current and duration of stimulation used to determine the neuromuscular excitability. moar apy I. Itisa recording techni studying the electrical actiy 1 Used in” —~] ity of diseases, 2. The test requires stimulation. muscle for agnosis of netromu “ular 2. The test does not requires e quire a stimulation, 7 3. Only surface electrodes are used in this technique. needle electrodes are use, 4, Two types of electrodes are used here i.e. the active and the indifferent electrodes. 3. In this technique, both surface ang” —~ d. | 4. Three types of elect ie. the active, indiffer electrodes, Hodes ate usedhas~ ent and the ground 5. SD— Curve measures only the correlation between the strength of the current and duration of stimulation. 5. In EMG, the muscle potential is -—— evaluated under the following 7 parameters: ° Phase * Amplitude © Duration. © Frequency, «Sound. 6. The SD — curve demonstrates the presence of innervated fibers in the muscle being tested. 6. EMG is used for diagnosis of the specific diseases. 7. This technique cannot be used for large muscles since only a small proportion of fibers respond to the stimulation, 7. EMG can be easily applied to large muscles and the complete picture ofthe | muscle can be obtained. 8. The technique does not show the site of lesion in the nerve. 8. The technique shows the site of lesion 9. The test is mainly used for motor nerve assessment. 9. The test is used for neuromuscular 10. The output obtained is only in the form of a graphical representation, assessment. : gots pHYSIOTHERAPY Vol IIL cTRODL [AGNOSTIC ANALYSIS Bo OMMON PATHOLOGICAL is oF TION! cones of Peripheral Nerves Flectrodiagnostic techniques play tant role in diagnosis of peripheral infs dzordes. The Seddon classification ofnerve injuries divided peripheral nerve disorder into three categories- Neuropraxia ‘Axonotmesis and Neurotmesis. impor a. Neuropraxia: ‘When there is distraction injury or blockage in the myelin sheath, conduction above and below the blockage is usually normal, In Neuropraxia lesions; the compression disorder are most common eg bell’spalsy (facial nerve), Saturday night palyy (radial nerve), compression in spiral groove, pressure over the peroneal nerve at the fibular head, carpal tunnel syndrome (median nerve entrapment), tarsal tunnel syndrome (tibial nerve entrapment). Electrodiagnostic findings: Peg edn Inacute condition when there is no vation the EMG will be normal at rest. itmentis normal accept in conduction block, where itis decreased. » Nes: ss Inthis lesion, the nerve conduction tog ine Useful to detect the demyelina- In demyeratison to axonal degeneration. Yalination, both sensory and motor ~— i on velo will be decreased. MUAP amplitude will be reduced due to temporal dispersion and not because of axonal damage. b. Axonotmesis: Axonotmesis occurs when the nuclei or cell of the axon is destructed or due to long ~ standing neuropraxia or from a traumatic lesion. Electrodiagnostic findings > EMG: In spontaneous activity, fibrillation potentials and positive sharp waves are present. Motor unit recruitment is decreased. > NCS: Both motor and sensory conduc- tion velocities will be decreased. Distal latencies will be increased. c. Neurotmesis: This occurs when the nerve fiber is completely cut. There is total loss of axonal function with disruption of neural tube. Conduction ceases below the level of lesion. Electrodiagnostic findings: > EMG: In spontaneous activity, fibrillation potentials and positive sharp waves will be seen with the muscle at rest. Activity will be produced with the attempted voluntary con- traction. Motor unit recruitment is decreased. > NSC: Here nerve conduction studies - Scanned with CamScanner2. Poly Neuropathy: ; Inpoly neuropathy, there is sensory change, distal weakness and hyporeflexia. There occurs demyelination and damage of the axons. The NCSs and EMG studies have animportantrole in evaluation of these diseases. Electrodiagnostic findings: > EMG: The MUAP duration and amplitude may be reduced. If there is axonal damage, then fibrillation, positive sharp waves and fasciculations are present. The motor unit recruitment is decreased. > NCSs: In demyelination, the NCSs pro- vide useful information. Sensory nerve con- duction velocity may be decreased. The evoked potential will be typically reduced inamplitude, 3. Myopathy: Itisa disorder of muscles, which is of the following types: congenital, inflam- matory, metabolic and muscular dystrophies. There occurs primarily the weakness of the muscles. Electrodiagnostic findings: > EMG: : In early stages, slow and prolonged insertional activity is seen. Spontaneous ac- tivity can be frequently noted here. In common myopathies, positive sharp waves Inadvanced stages of polymyona, YoPathies muscular dystrophy, there ig cor absence of electrical activity, in yr MUAP is usually of short duration fl amplitude, and polyphasic and har recruitment. “a > NCS: Motor nerve conduction is typical normal although the amplitude of they_ wave is decreased due to few fibey responding to the stimulation. Sensory neve conduction should be normal and late responses are usually of no help. 4, Radiculopathy: It is a lesion of a specific neve root and is generally caused by root com- pression, Imaging studies (MRI) and electrodiagnosis, both are helpful incon- firming the diagnosis of radiculupathy. Patient usually complains if pain inthe back of the neck radiating to the arm (cervial radiculopathy) or pain in the back radiating to the legs (lumbo — sacral radiculopathy) Electrodiagnostic findings: > EMG: aa Insertion activity is increased: spontaneous activity, fibeillation potentials and positive sharp hone present. In early stages, low amplitude rt —phasic potentials and in later: ae amplitude poly —phasie potentials Recruitment abnormality is see? creased recruitment. Scanned witl CameeannetRAPY Vol. IIL Electrodiagnostic findins ; - > EMG: - and sensory condue- > EMG: 3S goin motor ae normal and are notmore In abnormal spontaneous activity fi- ul nses give some informa- brillation potentials are present along with wi pate res involvement, H-reflex positive sharp waves, Fasciculations and dos!" wave is normal. complex repetitive discharges may also be om gine a noted. MUAP may show increased aay: duration, large amplitude and polyphasic srisepat al plexopathy and lumbo— potentials, Recruitment is decreased. is thy are difficult to examine soo lexeP inthe anatomy. Common > NCS: ney plexopathy are tumors, Motor nerve conduction is normal f pl . aists © gical damage nd trauma. with normal lateney and deereased ampli- tude, SNCV is normal. Late responses are orodiagnostic findings: not helpful here. EMG: 7 Ein abnormal spontaneous activ- 7, Spinal stenosis: iy fibrillation potentials are present Spinal stenosis can be defined as sng with positive sharp waves. In thenarrowing of the vertebral canal that can | ctonic lesions, MUAP is of long dura- affect any spinal level. Patients with spinal { ion high amplitude and polyphasic. Re- stenosis usually complain of back or neck critment is usually decreased in all af- pain radiating to one or both of the feted muscles. extremities, > Ns: Both sensory and motornervecon- Electrodiagnostic findings: dation velocities are normal but theampli- > EMG: Bélbdesreased, H —reflex and F — wave Inacute neural compression, fibril- | "ethelpfulin diagnosis of plexopathy. lation and positive sharp waves are present | ‘Motor ne : in spontaneous activity. In chronic neural | ‘uron diseases (MND): compression, MUAP with large amplitude, athavethe eet BrOUp of diseases polyphasic and increased durational is espinal, cond Try Pathology located in present. Srrand net Hsease affects both the fitaseg Gyryetmotorneurons. These > NCS: reaencinde Poliomyelitis, Motor nerve conduction velocity POSS bua PE lateral sclerosis, and amplitude is normal. If the disease igs Palsyand spinal muscular has progressed to a point where there is significant axonal damage, motor nerve { OO Scanned with CamScannerconduction amplitude i nerve conduction velo normal and unaffected because the sensory nerve ganglion is located outside the spinal canal. In late responses, the H —reflex may be prolonged or absent bilaterally. Ifthe S, nerve root is affected, then F — wave can- nothelp in diagnosing the disease, 8. Myotonia: It is a disorder characterized by delayed relaxation of the previously con- tracted muscle that results in stiffness of the muscle. The disorder includes Myotonic dystrophy and myotonia congenital. Electrodiagnostic findings: > EMG: In spontaneous activity, high fre- quency repetitive discharges are present with altemately increasing and decreasing amplitude, Myotonic discharges are present and are provoked by needle insertion or movement. > NCS: Motor nerve conduction velocity is decreased and there is a marked reduction in the motor unit ity ang Sensory nerve conduction ye - decreased. In late respon F—wave latencies, en, lociyiget Ses H ttle % AE prolongeq Mt 9, Myasthenia Gravis: This is an autoimmune g characterized by weakness ang, oe fatigability confined to o¢y pharyngeal muscles. Itisa qj —muscular transmission ¢| weakness followed contraction. Ces le plasty isorde of haracterin bY tepetit Electrodiagnostic findings. > EMG: Inspontaneous: activity, fibriliog and positive sharp waves may be pegy inseverely affected muscle indicating ig of innervation. MUAP shal appea nom at first and then shall progressively dere inthe amplitude with continued eft > NCS: MNCV and SNCV, both ae no mal. Repetitive stimulation duriags nerve conduction test will cause proges sive decrease in the amplitude of M= wave, Late responses are not helpilit diagnosis of these diseases, a ~ Scanned with Cameeanner