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PT Notes: Electrodiagnostic Procedures: Traditional Electrical Evaluation Tests

The document discusses various electrodiagnostic procedures used to evaluate the peripheral nervous system including nerve conduction studies, EMG, H-reflex testing, and evoked potentials. Key details provided include parameters for stimulation and recording, normal versus abnormal findings, and factors that influence test results like temperature.

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Faisal Qureshi
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274 views4 pages

PT Notes: Electrodiagnostic Procedures: Traditional Electrical Evaluation Tests

The document discusses various electrodiagnostic procedures used to evaluate the peripheral nervous system including nerve conduction studies, EMG, H-reflex testing, and evoked potentials. Key details provided include parameters for stimulation and recording, normal versus abnormal findings, and factors that influence test results like temperature.

Uploaded by

Faisal Qureshi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PT notes: Electrodiagnostic Procedures

Traditional Electrical Evaluation Tests


us ed before EMG

Reaction of Degeneration Test


"Faradic-Galvanic Excitability Test"
apply firs t the faradic current (20-50 Hz with 1 ms puls e duration) followed by galvanic current (IDC with 100 ms
duration)
done 10 days after ons et of problem
only for gros s as s es s ment; cannot differentiate or identify location of pathology
Results
Innervation
Normal
Partial RD

Faradic (AC)
Sooth tetanic

Galvanic (DC)
Bris k twitch

Decreas ed tetanic Decreas ed, s luggis h contraction

Complete RD No contraction

Very s low contraction

Absolute RD

No contraction

No contraction

Strength-Duration Curve
done 10-14 days after ons et of les ion; s erial tes ting is done every 2-3 weeks
A graphic repres entation of threshold values of stimulation along the y-axis for various duration of stimulus
dis played along the x-axis
6 to 10 puls es are needed
longes t puls e duration mus t be at leas t 100 ms
has a characteris tic and cons tant s hape; pres ence of kink or dis continuity in the curve indicate either partial denervation
or reinnervation
us ually appears between 3 and 10 ms
s ens itive tes t for the pres ence or abs ence of denervated fibers
s ufficient degree of reliability
time to perform is minimal when the procedure has been mas tered
caus es leas t dis comfort to the patient of all electrodiagnos tic procedures
does not reveal precis e location of the nerve les ion
Rheobas e
leas t amount of intens ity needed to elicit vis ible mus cle contraction for an indefinite duration (5-35 volts / 2-18 mA)
Chronaxie
minimum time required to produce a mus cle contraction with an intens ity s et at twice the rheobas e (0.05-0.5 ms
or < 1 ms )

Galvanic Twitch-Tetanus Ratio Test


meas ures the relations hip between the current intens ity needed to produced a brief muscle contraction and the
current intens ity required to elicit a sustained contraction with a puls e duration of 100 ms
normal value = 1:3.5-6.5
denervated = values approaches unity
no longer us ed d/t advent of more accurate methods
may be very uncomfortable for patients (es p. at higher intens ities )

Nerve Excitability Test


us es a rectangular puls ed low frequency current with s hort duration (0.3 - 1 ms ) to determine the s tate of excitability
and coordination of a nerve trunk
primarily for Bells Pals y patients
applied to both s ides of the face for comparis on
variation of 2-6 mA or 4-8 volts is normal

Contemporary Evaluation Procedures


Evoked Potentials
Nerve Conduction Velocity Studies
tes ts integrity of peripheral motor and s ens ory neurons on both orthodromic and antidromic res pons es

es timates the rate of movement of the induced impuls e along the cours e of the nerve
reduced in compres s ion les ions (eg. CTS, PNI) and Demyelinating/axonal dis orders
us es supramaximal stimulation
20% greater than that required for max CMAP
determines :
peripheral nerve involvement
motor or s ens ory involvement (or both)
location and number affected fibers
magnitude (partial or complete les ion)
Increas ing/Decreas ing impairment
Localized/Sys temic dis order
Stimulating Electrodes
2 s mall electrodes applied to the nerve fixed on the s kin about 2 cm apart
handheld electrodes
puls e duration = 0.05-2 ms with 1-2 Hz frequency
rectangular monophas ic PC
cathode is placed dis tal to the anode, clos es t to the mos t proximal recording electrode
Recording Electrodes
Active - over the s timulated mus cle or nerve
Reference - dis tally over the tendinous ins ertion
Ground - between the s timulating electrodes and recording electrodes (on a bony area)
M-wave
compound mus cle action potential (CMAP)
s et of voltage changes recorded from a nerve or group of mus cle fibers
res ults from the orthodromic propagation of the action potential in the motor neuron
F-wave
s econd CMAP
us ed to examine conduction in the proximal nerve s egments
variable latencies
s maller in amplitude compared to M-wave
Latency
conduction time between s timulus and the s tart of mus cle contraction
time elaps ed between the ons et of the s timulus and the beginning of the CMAP
meas ured in ms ec
Dis tance
linear dis tance between two points along the cours e of a nerve
meas ured in mm
General Principles
examine both motor and s ens ory conduction when pos s ible
performed over s everal s egments of the nerve/s s us pected to be involved
performed on nerves contralateral to thos e s us pected of being involved
examination of nerves in both upper and lower limbs may be appropriate
performed at the appropriate time in context of the s us pected dis order
Factors to consider
body Temperature
increas ed temp = increas ed conduction velocity and decreas ed dis tal latency
environmental temp = 21-23C
s kin temp = 28-30C
proximal s egments as us ually fas ter-conducting than dis tal s egments
UE normally 7-10 m/s ec fas ter than the LE
age
3-5 y/o = NCV as low as 50% of avg normal adults
after age of 40 = gradual s lowing
6th & 7th decade = 10 m/s ec les s than middle-aged

H-reflex
Hoffman reflex
electrically-elicited monos ynaptic reflex
tes ting a s tretch reflex by electrically s timulating the afferent (Ia) fibers from the mus cle s pindles us ing a low-intens ity
puls e with s hort duration (0.1 ms )

as s es s proximal conduction
afferent s ide of the s tretch reflex is s timulated beyond the s pindles , leading to a mus cle twitch which is recorded
electromyographically and appears after a delay of 30 ms
mos t evident in mus cles that have many mus cle s pindles predominantly compos ed of s low-twitch motor units (eg.
s oleus )

Neuromuscular Junction transmission


as s es s es the function of the neuromus cular junction
"Repetitive Nerve Stimulation Test (RNS)" or "Jolly Test"
Myas thenia gravis , myas thenic s yndrome

Blink Reflex
functional integrity of both the trigeminal (CN V) and the facial nerve (CN VII)
Stimulating electrodes are placed over the s upraorbital branch of trigeminal nerve
Recording electrodes are placed bilaterally over the orbicularis oculi
Bells pals y, GBS, MS, Cerebellar pontine les ion

Centrally-Evoked Potentials
Somatos ens ory Evoked Potential (SSEP)
Vis ual Evoked Potential (VEP)
Brains tem Auditory Evoked Potential (BAEP)

Volitional Potentials
Us e of s ome cons cious effort on the part of the patient/ s ubject to perform a function
Electromyography/electromyogram EMG

EMG
Directly monitors electrical activity of mus cle; no electrical s timulation needed
mus cle at res t, mild contraction and maximal contraction
active and reference electrodes
"s ens or"
s ilver-s ilver chloride/gold-bas ed electrodes
s urface or s ubcutaneous electrodes
ground electrode
placed over bony s urface
minimizes nois e
Normal EMG
At rest

Abnormal EMG

(+) ins ertion activity

fibrillations and fas ciculations

miniature endplate action potentials

pos itive s harp waves

no mus cle action potentials

complex dis charges


reduced and prolonged
ins ertional activity

Mild
us ually biphas ic or triphas ic mus cle action potentials
contraction motor unit potentials (MUP) are obs erved with s mall-amplitude potentials
recruited firs t followed by progres s ively large-amplitude potentials

polyphas ic, amplitude either


increas ed or decreas ed

Maximal
increas e frequency until interference pattern is formed
contraction normal s tepwis e increas e interference patterns

decreas e interference pattern

altered recruitment patterns


early full interference pattern

action potentials overlap one another s o that it is impos s ible to dis tinguis h the
s hape and form of individual potentials

EMG-Biofeedback
Biofeedback: training technique that enables an individual to gain s ome element of voluntary control over mus cular or
autonomic nervous s ys tem functions us ing a device that produces auditory or vis ual s timuli
a tool, not a treatment in its elf
no current is applied
Phys iologic proces s es are recorded from the patient
BP
s kin temperature
EMG activity
Uses
control over defective mus cle activity or movement

control over s tres s -related conditions


Integration
the s umming of the s ignal over s ome period of time
"s moothing of the s ignal"
Time cons tant
determines the rate at which the integrated EMG s ignal will increas e or decreas e
Shaping
modification of the thres hold level up or down as the patient changes his control over the targeted mus cle during BF
treatment
Hypomobile or weak
us e s hort time cons tant or low thres hold
goal: increas e recorded activity
Hypermobile or spastic
us e long time cons tant or high thres hold
goal: decreas e recorded activity

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