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PT notes / Electrodiagnostic Procedures

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Electrodiagnostic Procedures
last edited by

PBworks 6 years ago

Tags: diagnosis.test, guidelines.electrotherapy

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Traditional Electrical Evaluation Tests

used before EMG

Reaction of Degeneration Test

"Faradic-Galvanic Excitability Test"
apply first the faradic current (20-50 Hz with 1 ms pulse duration) followed by galvanic current
(IDC with 100 ms duration)
done 10 days after onset of problem
only for gross assessment; cannot differentiate or identify location of pathology
Results
Innervation
Normal
Partial RD

Faradic (AC)
Sooth tetanic

Galvanic (DC)
Brisk twitch

Decreased tetanic Decreased, sluggish contraction

Complete RD No contraction

Very slow contraction

Absolute RD No contraction

No contraction

Strength-Duration Curve
done 10-14 days after onset of lesion; serial testing is done every 2-3 weeks
A graphic representation of threshold values of stimulation along the y-axis for various
duration of stimulus displayed along the x-axis
6 to 10 pulses are needed
longest pulse duration must be at least 100 ms
has a characteristic and constant shape; presence of kink or discontinuity in the curve indicate
either partial denervation or reinnervation
usually appears between 3 and 10 ms
sensitive test for the presence or absence of denervated fibers
sufficient degree of reliability
time to perform is minimal when the procedure has been mastered
causes least discomfort to the patient of all electrodiagnostic procedures
does not reveal precise location of the nerve lesion
Rheobase
least amount of intensity needed to elicit visible muscle contraction for an indefinite
duration (5-35 volts/ 2-18 mA)
Chronaxie
minimum time required to produce a muscle contraction with an intensity set at twice the
rheobase (0.05-0.5 ms or < 1 ms)

Galvanic Twitch-Tetanus Ratio Test

measures the relationship between the current intensity needed to produced a brief muscle
contraction and the current intensity required to elicit a sustained contraction with a pulse
duration of 100 ms
normal value = 1:3.5-6.5
denervated = values approaches unity
no longer used d/t advent of more accurate methods
may be very uncomfortable for patients (esp. at higher intensities)

Nerve Excitability Test

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uses a rectangular pulsed low frequency current with short duration (0.3 - 1 ms) to determine
the state of excitability and coordination of a nerve trunk
primarily for Bells Palsy patients
applied to both sides of the face for comparison
variation of 2-6 mA or 4-8 volts is normal

Contemporary Evaluation Procedures

Evoked Potentials

Nerve Conduction Velocity Studies

tests integrity of peripheral motor and sensory neurons on both orthodromic and antidromic
responses
estimates the rate of movement of the induced impulse along the course of the nerve
reduced in compression lesions (eg. CTS, PNI) and Demyelinating/axonal disorders
uses supramaximal stimulation
20% greater than that required for max CMAP
determines:
peripheral nerve involvement
motor or sensory involvement (or both)

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PT notes / Electrodiagnostic Procedures

motor or sensory involvement (or both)

location and number affected fibers
magnitude (partial or complete lesion)
Increasing/Decreasing impairment
Localized/Systemic disorder
Stimulating Electrodes
2 small electrodes applied to the nerve fixed on the skin about 2 cm apart
handheld electrodes
pulse duration = 0.05-2 ms with 1-2 Hz frequency
rectangular monophasic PC
cathode is placed distal to the anode, closest to the most proximal recording electrode
Recording Electrodes
Active - over the stimulated muscle or nerve
Reference - distally over the tendinous insertion
Ground - between the stimulating electrodes and recording electrodes (on a bony area)
M-wave
compound muscle action potential (CMAP)
set of voltage changes recorded from a nerve or group of muscle fibers
results from the orthodromic propagation of the action potential in the motor neuron
F-wave
second CMAP
used to examine conduction in the proximal nerve segments
variable latencies
smaller in amplitude compared to M-wave
Latency
conduction time between stimulus and the start of muscle contraction
time elapsed between the onset of the stimulus and the beginning of the CMAP
measured in msec
Distance
linear distance between two points along the course of a nerve
measured in mm
General Principles
examine both motor and sensory conduction when possible
performed over several segments of the nerve/s suspected to be involved
performed on nerves contralateral to those suspected of being involved
examination of nerves in both upper and lower limbs may be appropriate
performed at the appropriate time in context of the suspected disorder
Factors to consider
body Temperature
increased temp = increased conduction velocity and decreased distal latency
environmental temp = 21-23C
skin temp = 28-30C
proximal segments as usually faster-conducting than distal segments
UE normally 7-10 m/sec faster than the LE
age
3-5 y/o = NCV as low as 50% of avg normal adults
after age of 40 = gradual slowing
6th & 7th decade = 10 m/sec less than middle-aged

H-reflex

Hoffman reflex
electrically-elicited monosynaptic reflex
testing a stretch reflex by electrically stimulating the afferent (Ia) fibers from the muscle spindles
using a low-intensity pulse with short duration (0.1 ms)
assess proximal conduction
afferent side of the stretch reflex is stimulated beyond the spindles, leading to a muscle twitch
which is recorded electromyographically and appears after a delay of 30 ms
most evident in muscles that have many muscle spindles predominantly composed of slowtwitch motor units (eg. soleus)

Neuromuscular Junction transmission

assesses the function of the neuromuscular junction

"Repetitive Nerve Stimulation Test (RNS)" or "Jolly Test"
Myasthenia gravis, myasthenic syndrome

Blink Reflex

functional integrity of both the trigeminal (CN V) and the facial nerve (CN VII)
Stimulating electrodes are placed over the supraorbital branch of trigeminal nerve
Recording electrodes are placed bilaterally over the orbicularis oculi
Bells palsy, GBS, MS, Cerebellar pontine lesion

Centrally-Evoked Potentials

Somatosensory Evoked Potential (SSEP)

Visual Evoked Potential (VEP)
Brainstem Auditory Evoked Potential (BAEP)

Volitional Potentials

Use of some conscious effort on the part of the patient/ subject to perform a function
Electromyography/electromyogram EMG

EMG
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PT notes / Electrodiagnostic Procedures

EMG
Directly monitors electrical activity of muscle; no electrical stimulation needed
muscle at rest, mild contraction and maximal contraction
active and reference electrodes
"sensor"
silver-silver chloride/gold-based electrodes
surface or subcutaneous electrodes
ground electrode
placed over bony surface
minimizes noise
Normal EMG
At rest

(+) insertion activity

miniature endplate action potentials
no muscle action potentials

Mild
usually biphasic or triphasic muscle action potentials
contraction motor unit potentials (MUP) are observed with small-amplitude
potentials recruited first followed by progressively largeamplitude potentials

Abnormal EMG
fibrillations and
fasciculations
positive sharp waves
complex discharges
reduced and
prolonged insertional
activity
polyphasic, amplitude
either increased or
decreased
altered recruitment
patterns

Maximal
increase frequency until interference pattern is formed
decrease interference
contraction normal stepwise increase interference patterns
pattern
action potentials overlap one another so that it is impossible to early full interference
distinguish the shape and form of individual potentials
pattern

EMG-Biofeedback
Biofeedback: training technique that enables an individual to gain some element of voluntary
control over muscular or autonomic nervous system functions using a device that produces
auditory or visual stimuli
a tool, not a treatment in itself
no current is applied
Physiologic processes are recorded from the patient
BP
skin temperature
EMG activity
Uses
control over defective muscle activity or movement
control over stress-related conditions
Integration
the summing of the signal over some period of time
"smoothing of the signal"
Time constant
determines the rate at which the integrated EMG signal will increase or decrease
Shaping
modification of the threshold level up or down as the patient changes his control over the
targeted muscle during BF treatment
Hypomobile or weak
use short time constant or low threshold
goal: increase recorded activity
Hypermobile or spastic
use long time constant or high threshold
goal: decrease recorded activity
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