NCV STUDY

On diabetic neuropathy

By: D.Yasas Chandra Reddy, MPT (ortho)

 Nerve conduction velocity (NCV)
A nerve conduction velocity (NCV) test is used to assess nerve damage and
dysfunction. Also known as a nerve conduction study, the procedure measures
how quickly electrical signals move through your peripheral nerves.
Your peripheral nerves are located outside of your brain and along your spinal
cord. These nerves help you control your muscles and experience the senses.
Healthy nerves send electrical signals more quickly and with greater strength than
damaged nerves.
The NCV test helps your doctor differentiate between an injury to the nerve fiber
and an injury to the myelin sheath, the protective covering surrounding the nerve. It
can also help your doctor tell the difference between a nerve disorder and a
condition where a nerve injury has affected the muscles.
Making these distinctions is important for proper diagnosis and determining your
course of treatment.
 Who gets an NCV test?
◦ An NCV test can be used to diagnose a number of muscular and neuromuscular disorders,
including:
o Guillain-Barre syndrome
◦ carpal tunnel syndrome
◦ Charcot-Marie-Tooth (CMT) disease
◦ herniated disk disease
◦ chronic inflammatory polyneuropathy and neuropathy
◦ sciatic nerve problems
◦ peripheral nerve injury
◦ If your doctor suspects you have a pinched nerve, they may recommend an NCV test.
o An electromyography (EMG) test is often performed alongside an NCV test. An EMG test records
the electrical signals moving through your muscles. This helps detect the presence, location, and
extent of any disease that may damage the nerves and muscles.
 How to prepare for an NCV test
◦ When scheduling this test, your doctor will ask about conditions, medications, or behaviors that
might affect the results. These include:
◦ alcohol abuse
◦ use of certain neurologic medications, such as muscle relaxants, opioids, or psychotropic
medications
◦ diabetes
◦ hypothyroidism
◦ systemic diseases
◦ It’s also important for your doctor to know if you have a pacemaker. The electrodes used in the
NCV test may affect the electronic impulses of your medical device.
◦ Stop using any lotions or oils on your skin a few days before the test. These creams can prevent
the electrode from being properly placed on the skin. Fasting usually isn’t necessary, but you may
be asked to avoid caffeine beforehand.
Diabetic neuropathy
 Diabetic neuropathy
◦ Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood
sugar (glucose) can injure nerves throughout your body. Diabetic neuropathy most often damages
nerves in your legs and feet
◦ Four main types of neuropathy can impact on the nervous system, including:
◦ Peripheral symmetric neuropathy: This affects the feet and hands. It is the most common form of
diabetic neuropathy.
◦ Autonomic neuropathy: This occurs in the nerves that control involuntary functions of the body,
such as digestion, urination, or heart rate.
◦ Thoracic and lumbar root, or proximal, neuropathy: This damages nerves along a specific
distribution in the body, such as the chest wall or legs.
◦ Mononeuropathies: These can affect any individual nerve.
 Peripheral neuropathy

◦ The symptoms of peripheral neuropathy include:

◦ numbness, pain, tingling, and burning sensations starting in the toes and fingers then continuing
up the legs or arms
◦ loss of muscle tone in the hands and feet
◦ not being able to feel heat, cold, or physical injury
◦ loss of balance
◦ Charcot's joint, in which a joint breaks down because of nerve issues, often in the feet
◦ Peripheral neuropathy that affects the feet can make it difficult for a person to stand and walk. It
can increase the risk of falling.
◦ When a person cannot feel heat, cold or injury, this can lead to new problems.
◦ For example, a blister on the foot can become ulcerated because the person did not feel pain in
the early stages. As the infection progresses, gangrene can develop.
◦ Eventually, amputation may be necessary.
 Mechanism of peripheral neuropathy

◦ Neuropathy is the most common complication of diabetes. As a consequence of

longstanding hyperglycemia, a downstream metabolic cascade leads to peripheral
nerve injury through an increased flux of the polyol pathway, enhanced advanced
glycation end‐products formation, excessive release of cytokines, activation of
protein kinase C and exaggerated oxidative stress, as well as other confounding
factors
 ANATOMY AND VASCULAR SUPPLY OF PERIPHERAL NERVOUS SYSTEM

◦ Anatomical characteristics of the peripheral nervous system might explain why

the pathogenesis of neuropathy is distinct from other microvascular
complications. Peripheral nerves are covered by perineurium, where only a few
trans perineurial arterioles penetrate into the endoneurium The vascular supply in
peripheral nerves is sparse and blood flow is likely to be compromised and lacks
autoregulation. This system makes peripheral nerves vulnerable to ischemia.
Endo neural microvessels are tightly connected with endothelial cells on their
inner surface, but when destroyed they are leaky and affect the endoneurial
tissue components. Leaky vessels are mainly located in the ganglion with
fenestrated vessels, and nerve terminals on the distal side are directly exposed to
environments not covered by perineurium and are susceptible to traumatic injury..
Vascular supply of the peripheral nervous system is sparse and trans perineurial arteriole
penetrates into endoneurium. Autonomic nerve endings contact with the wall of arterioles, but
vascular autoregulation is lacking in peripheral nerves as a result of sparse innervations. In
diabetes, autonomic nerve endings to the arteriole are likely to be lost and therefore vasoregulation
is further impaired
◦ Innervation of epineurial microvessels is involved in diabetes, resulting in
impaired blood supply in diabetic nerves. Endoneurial microvessels show
thickened and multilayered basement membranes, cell debris of pericytes, as well
as disrupted endothelial cells, and thus constitute salient structural changes in
diabetic nerves.
◦ Independent of vascular supply, three dimensions of neuronal architecture
specific to the peripheral nervous system might account for the reason why the
most distal side is susceptible in diabetes. Ganglion cells have extensively long
axons covered by Schwann cells. The neuronal cell body is relatively small
compared with the extremely long distance of axonal neurites, and thereby distal
axons are innately too weak to support themselves for the long transport of
nutrients, nerve trophic factors, as well as other signals.
◦ The most distal axons of small fibers distribute in the epidermis of the skin, sensing pain or
pricking. Currently, punched skin biopsy immunostained with protein gene product (PGP) is
widely used for the evaluation of peripheral neuropathy

| Epidermal innervation in diabetic patients as shown by immunostaining with PGP9.5. (a) In a normal subject (a 32-year-old
man), small branching fibers (arrows) penetrating to basal lamina (arrowhead) derived from dermis distribute diffusely and
end in the surface of the epidermis of the skin. (b) In contrast, in a type 2 diabetic subject with symptomatic neuropathy (a 52-
year-old woman with 15 years duration of diabetes), fibers in the epidermis are completely lost. Only a few fibers are sparsely
left in the dermis. Vascular systems also develop in the upper dermis (red color of tortuous structure). Bar, 100 mm.
 Ncv of common peroneal nerve
Nerve course :Usually, CPN which is a branch of sciatic nerve supply both anterior and peroneal
compartment of the leg, begin at the apex of popliteal fossa and on reaching fibula neck, this CPN
nerve curve round the neck deep to peroneus longus. It divide into superficial and deep peroneal
nerve distal to fibular neck.
Material and Method
On the basis of past and present history, selection of
subject was made and Median nerve NCV was done to
avoid possible subclinical neuropathy.
Motor NCV
1. Active surface electrode – placed over the digitorum Brevis.
2. Reference surface electrode – Placed over the base of little toe.
3. Ground surface electrode – Placed over the dorsum aspect of foot.
◦ Before Appling surface electrode on the skin , the skin was cleaned with spirit. The disposable
electrode was placed as mention above. The stimulus was given to the Nerve at two point with the
help of stimulator. First distally at the ankle which is 2 cm distal to the fibular neck later to the
anterial tibial tendon. Secondly proximally in the lateral part of popliteal space. Using
supramaximal stimulus, the recording of the nerve was made. The distance between active
electrode and stimulating point was measured which was latter used to calculate NCV of concern
segment. Latency, Amplitude, CV parameters.
Thank you