Surface Electromyography (SEMG)

in
Craniomandibular Dysfunction
Objective - Learn to:
1. Understand some of the implications of
the muscular system in clinical decision making.
2. Objectively measure neuromuscular components to
enhance clinical making decisions
Put EMG/Instrumentation in the Proper Context!
Copyright Todd Shewman
All rights reserved
Readers Digest Version
Only so much time
Why was this Written?
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Clinically, the
determination of the
presence or absence of
TMD does not appear to be
enhanced by the use of
SEMG.
Klasser GD, Okesan JP.
J Am Dent Assoc. 2006
Jun;137(6):763-71.
MuShin Marking Territory
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Will EMG/Instrumenation Make You Rich?
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Will EMG/Instrumentation Make You
Famous?
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Patients Talk MORE About Failures
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Dr.Kaye McArthur
Why do we strive to be
Exceptional in a world
where mediocre rules??
Not for Money
Not for Fame
Not to be Mediocre
Because theres more?
To Be Exceptional!
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Copyright Todd Shewman-
All rights reserved
HEALTH CRITICALLY ILL
Homeostatis
The ability or tendency of an
organism or cell to maintain
internal equilibrium by
adjusting its physiologic
processes.
Copyright Todd Shewman-All
rights reserved
WHY Does.Rate of Breakdown EXCEEDS the Rate of Repair?
WHY?
Whats your philosophy?
Copyright Todd Shewman
All rights reserved
Goal of Clinicians
To increase the patients
ability to adapt
NOT
rely on it!
Presentation Topics
Part I
History of SEMG in Craniomandibular Dysfunction
(CMD)
Advantages and Limitations of SEMG in CMD
Part II
Basic SEMG Processing and Instrumentation
Artifacts and Recording Error Sources
Troubleshooting
Normalization and its Importance
Then What?
Other technologies (Jaw Motion and Joint Sound)
and how can they help us?
Overview
Craniomandibular dysfunction (CMD)
a group of disorders of the masticatory muscles,
temporomandibular joint and associated areas. (Thilander)
Approx 60 - 70% of the general population has at least one
sign of CMD.
These include:
Pain in the preauricular region Temporomandibular Joint (TMJ),
masticatory muscles, cervical and shoulder muscles.
Limitation or deviations in mandibular ROM.
TMJ sounds during mandibular function.
Iva Alajbeg, Melita ValentiE-Peruzovi, Ivan Alajbeg, Davor Ille, Dubravka Knezovi-Zlatari, Marina Katunari
History of SEMG in
Craniomandibular Dysfunction
CMD
TMD nomenclature has dominated the literature
SEMG used in classic biofeedback to promote
relaxation of orofacial muscles associated with
C/TMD (Canniststraci, Gervitz)
These approaches presumed a cyclical relationship
between dysfunctional oral habits such as jaw
clenching or bruxism, aberrant biomechanical
loading of articular and periarticular structures,
psychological stress, and pain. (Nicholson)
Copyright Todd Shewman-
All rights reserved
Faulty Joint
and/or tooth
Position
Reflexive and
postural
responses
Muscular
Response
Faulty Joint Function
Tonic (long
term)
influences on
muscles, and
joints
Faulty Joint
Movement
Pain
Teeth Joints and Muscles?
Psychologic
Stress
History of SEMG in CMD
Contd
CMD patients engage in unconscious oral
behaviors that include chronic hyperactivity
of masseter and temporalis muscles with
little conscious awareness of their habit. (Flor,
Glaros)
SEMG feedback techniques have been used
to assist patients with awareness and
resolution of muscle hyperactivity. (Turk, Hijzen)
SEMG has been used in dental investigations
of normal and aberrant neuromuscular
relationships around the temporomandibular
joints for many years.
Historical Overview
Muscle disorders may precede Temporomandibular
Joint (TMJ) problems and both disorders may coexist
and often influence each other.
Schiffman EL, 1990.
Naeije M, 1986.
Laskin D, 1969.
Juniper R, 1984.
Current evidence demonstrates a strong relationship
between temporomandibular dysfunction TMD/CMD,
muscle activity and dental occlusion (teeth
intercuspation).
Occlusal variables influence natural masticatory muscle
function and thus affect the temporomandibular joint.
(Bjork et al)
Still no standard definition! Chasing a disorder?
To Share - Why Im Here
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Occlusal features can
affect the electrical
signals recordings of
masticatory muscles.
Francesca Trovato, Bruno Orlando, Mario Bosco
Occlusal features and masticatory muscles activity. A
review of electromyographic studies Stomatologija,
Baltic Dental and Maxillofacial Journal, 2009, Vol.
11, No. 1
..is the study of muscle function
through the inquiry of the electrical
signal the muscles emanate.
Basmajian&DeLuca, Muscles Alive 1985, page 1
Electromyography
...
What is it?
Origin of the EMG Signal
From: Kumar/Mital 1996, p. 61, 64
Muscle Fibers
Nervous system command produces a muscle
action potential on the muscle membranes
Muscle Contraction / Muscular Work
SEMG = A window
into components of
this physiologic
process
What Is Surface Electromyography SEMG?
Surface
Electromyography
(SEMG) is the recording
of the algebraic sum of
voltages associated with
muscle action potentials
within their detection
zone from the skin
surface. (Basmajian)
SEMG Advantages
The subject is free to assume any position
Perform any functional movement that is
desired.
Recordings can be made from most any skin
surface. (e.g. extra/intraorally, pelvic floor)
Muscle activity is easily evaluated where
dynamometers would be impractical. (e.g.
facial muscles).
Surface recordings are non-invasive and
painless.
Where Can Electrodes be Placed?
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SEMG Advantages (Contd)
Recordings are extremely sensitive to:
1. Muscle activity at rest
2. Small changes in muscle activity
3. Low levels of muscle activity
4. To forceful contractions.
Within certain limits, the activity of particular
muscles or muscle groups can be distinguished
and quantified.
Set up is relatively quick and uncomplicated.
SEMG Limitations
Individual motor units cannot be reliably
discriminated with SEMG
Electrical activity of deep muscles may not be
isolated
SEMG can NOT diagnose neuropathologies
Is Surface Electromyography
Reliable/ Reproducible?
Amplitude:
Castroflorio T, 2005, Bigland and Lippold, 1954; Goldensohn, 1966; Lloyd, 1971; Mitani and
Yamashita, 1972; Molin, 1972; Moss, 1974; Ahlgren, 1975; Milner-Brown and Stein, 1975;
Moller, 1975; Mitani and Yamashita, 1978; Hermens et al., 1986; Kydd et al., 1986; Burdette
and Gale, 1987; Christensen, 1989; Neill, 1989; Van Eijden, et al., 1990; Dean et al., 1992
Frequency Analysis:
Barker GR, Wastell DG, Duxbury AJ. Spectral analysis of the masseter and anterior
temporalis: an assessment of reliability for use in the clinical situation. J Oral Rehabil.
1989 May;16(3):309-13.
Thomas NR: The effect of TENS on the EMG mean power frequency. In: Bergamini M,
ed. Pathophysiology of Head and Neck Musculoskeletal Disorders. Front Oral Physiol
Basel: karger; 1990;162-170.
Buxbaum J, Mylinski N, Parente FR. Surface EMG reliability using spectral analysis. J
Oral Rehabil. 1996 Nov;23(11):771-5.
Test-Retest Reliability
Komi and Buskirk
- Inserted electrodes - .62
- Surface electrodes - .88
Statistical results confirmed that
Surface electrodes are more reliable
than intramuscular on day to day
investigations
Giroux B, Lamontagne M. Electromy Clin Neurophysiol 1990 Nov 30(7):397-405
What Do We Do Now?
Movements are observed
Relevant muscles are palpated
Limiting
Subjective
Purely Qualitative
May predispose the clinician to a false diagnosis if derived
from palpation alone. Paesani D, 1992.
Correlation between masseter muscle palpation and its
electromyographic activity was very low. Biasotto et al
Manual Muscle Testing is an alternative
with some degree of quantification (0-5)
Techniques are:
Unpopular for TMJ region.
Insensitive to small changes
in tension.
Insensitive to muscle activity
near resting levels.
Unable to monitor between
synergists and antagonists
Insensitive to muscle activity
patterns during dynamic
functional activities.
Limited to static /small window of
moments in time. When teeth are
together, or close together.
Does not reveal information
regarding muscle activity. Or
muscle Dynamically.
Tends to be bulky and may
influence natural path of closure.
Intraoral/occlusal pressure distribution
technology can be used to measure
resultant occlusal forces and
contact(s) with greater accuracy
Jaw Kinematics Devices
Documentation of kinematic movement and velocity
Limited in terms of quantification of muscle activity at rest,
during movement, and timing of specific muscle groups.
Joint Vibration/Sounds
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Imaging techniques
(e.g. X-rays) are used to
evaluate:
Osseous and dental
structures
Disease
Alignment of the jaw,
skull, and neck area
Help to determine
skeletal anomalies and
asymmetries
Limited to static situations, fixed postures and do not
provide information regarding muscle activity.
SEMG
Used to assess the magnitude and timing of overall
muscle contraction.
Examines the ensemble of motor events that subserve
useful activity. E.G. Posture, clenching, swallow.
Functional muscle activity.
What does Surface
Electromyography (SEMG) Offer?
SEMG offers a window to the movement
system that cannot be replicated by any other
means.
Glenn Kasman MS PT
Philosophical, Scientific and Clinical
View
SEMG and CMD
SEMG activity associated with occlusal and CMD
dysfunction has been investigated, compared
to normal subjects and, expressed in terms of:
Baseline/Postural amplitude
Asymmetry
Timing
Mandibular elevator ratios (synergists)
Ferrario VF, Sforza C, Miani A Jr, DAddona A, Barbini E. J Oral Rehabil. 20:271-280;1993.
Visser A, McCarroll RS, Oosting J, Naeije M. J Oral Rehabil 1994 Jan;21(1):67-76
Ferrario VF, Sforza C, Colombo A, Ciusa V. J Oral Rehabil. 2000 Jan;27(1):33-40.
Abekura H, Kotani H, Tokuyama H, Hamada T. J Oral Rehabil 1995 Sep;22(9):699-704
Naeije M, McCarroll RS, Weijs WA. J Oral Rehabil 1989 Jan;16(1):63-70
Cline Bodr, Say Hack Ta, Marie Agnes Giroux-Metges and Alain Woda. Pain Volume 116, Issues 1-2, July 2005, Pages 33-41.
When to Consider SEMG in the
CMD patient
Start With
Clinical Exam
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When to Consider SEMG
in the CMD Patient
When to Consider SEMG in the
CMD Patient
SEMG Evaluation is indicated
if:
Functional limitations and disability are clearly
identified.
Neuromuscular impairments are a suspected
component.
Serious medical or psychologic pathology is
unlikely, or, is concurrently being addressed by a
care provider.
Information regarding muscle activity is likely to
assist with insight into the case and have an impact
on treatment planning.
Common Recording Sites 4-8 Generally used:
Temporalis Anterior
Masseter
Suprahyoid
Sternocleidomastoid
Temporalis Posterior
Cervical Paraspinals (C4)
Upper Trapezius
What Muscles Should be Measured?
QUESTIONS, COMMENTS, DISCUSSION
SEMG Instrumentation
The Boring and
Necessary
Information
Understand the
research
To Understand
Clinical information
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ISEK Proceedings 2006
Quality of reporting EMG studies in
evaluating masticatory muscles is poor!!
Appropriate report and use of EMG
technique is necessary to provide more
accurate results and conclusions.
Quality of Reporting Masticatory Muscle
Electromyography
Because of the general poor quality of reporting
of the analyzed studies, findings of studies
using surface electromyography of
masticatory muscles should be interpreted
with caution.
OLIVO, 2007
Basic EMG Processing
EMG is a Random BIPOLAR Signal
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Differential
Amplifier
Display
Unit
Depolarisation wave
Electrodes
T1 T2 T3 T4 T5
+ - + - + - + - + -
Potential difference
between electrodes
Differential
Amplifier
Display
Unit
Depolarisation wave
Electrodes
T1 T2 T3 T4 T5
+ - + - + - + - + -
Potential difference
between electrodes
Basic EMG Processing
RAW EMG signal Alternating current .
Needs to be made positive for
meaningful calculation.
Rectification The RAW signal
negatives made positive.
RMS Root mean square - Reflects
mean power of the signal - most
common.
Moving Average - estimator of the
amplitude behavior. Relates to
information about the area under the
selected signal epoch /window
Raw
Rectified
Smoothing
RMS - 50ms
Moving Average
Smoothing - 50ms
Frequency Bandpass Filter
Allows a range of signal frequencies and rejects those
outside that range
Necessary Knowledge
Power density function of the EMG signals has negligible
contributions outside the range 5-10 Hz to 400-450 Hz
EXCEPT Facial!!!! 500Hz
Majority between 10-250 Hz except masticatory muscles.
Frequency bandpass filter should be within the range of; high pass 5
Hz, and low pass 500 Hz. (ISEK, SENIAM)
E.G. 10-500, 20-500, 25-450
Take Home Message Know the Band-pass Filter!
Is there missing information?
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Power spectrum of masseter muscle
EMG During MVC
Yuen 1989
Do you want
this
information?
Sampling Rates
International Society of Electrophysiology and
Kinesiology (ISEK)
Dr. Roberto Merletti, Politecnico di Torino, Italy
The bandwidth of the amplifier-filter should be within this
range (high pass 5 Hz, low pass 500 Hz).
At least TWICE the highest frequency cut-off of the
bandpass filter, e.g., if a bandpass 10-400 Hz - minimal
sampling rate at least 800 Hz (per channel).
Ask what is sampling rate of each channel with all channels
running at the same time.
What was the band-pass and sampling rate?
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Sampling Frequency
The minimal acceptable sampling rate is at
least twice the highest frequency cut-off of
the bandpass filter per channel for amplitude
and frequency domains.
(ISEK, SENIAM, Soderberg, DeLuca, Konrad)
E.G. If high cut-off of bandpass is 425 Hz, it
is sampling rate must be at least 950 Hz per
channel to avoid signal loss.
What was sampling rate of each
channel with all channels running
Frequencies sampled too slowly (lower traces)
results in:
Significant Loss of Signal Information
Hardware Notch Filter
Eliminates designated frequencies successively
Filtered Out
~30%
Notch Filter
Filtered Out
~30%
Effect of notch Filter on Amplitude
Without and with Notch Filter
Hardware notch filters are not recommended
(ISEK, SENIAM, Soderberg, Konrad, Raez, Robertson)
Was there a Notch Filter??
Read More than just the Outcome
What was the sampling Rate?
What was the bandpass filter?
Was there a Notch Filter
Was there amplification (by how much)?
Electrode placement preparation?
Electrode Type?
Inter Electrode distance?
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Knowing limitations is JUST as important
as outcome of data!
Troubleshooting Basics
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SEMG curves should be linked to
voluntary movement/recruitment.
Be suspicious of major amplitude
deviations not appear linked to
patient behavior.
Be alert for any rhythmic
waveform activity (e.g. respiration
or heart-rate artifact).
Common Artifacts
Stable Baseline- Raw Data
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Common Artifacts
Stable Baseline - RMS
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50/60 Hz Hum/Noise
Wall power/ground noise results in
increased baseline noise (50/60 Hz
noise.
Often another device (old buildings)
causes this problem.
Ground all devices.
Change the power plug.
Avoid multiple plug connectors and
cable drums for the EMG amplifier.
Telemetry EMG device - Often
bypasses this issue.
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Undesired Movement Artifact
Generally not as much of an issue
with CMD unless more extensive
evaluation.
1. blink of the eyes is often
seen from the temporalis
anterior
2. Involuntary swallow from the
suprahyoid site.
Not considered noise, this type
of artifact is generally reduced
through proper patient
instructions.
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Poor Electrode or Lead
Contact
Generally resolved by
cleaning the electrode
site and replacing the
electrode
Ensuring a proper lead
contact to the electrode
and instrumentation.
Other possibilities
include patient cable or
hardware damage.
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Electrode bridging
Poor lead contact
Heart Rate Artifact
Cervical paraspinal and
trapezius sites.
Biological artifact
Often cannot be avoided.
Reduced by:
Good skin preparation
Modified position of the
ground electrode.
State-of-the-art signal
processing routines can
clean these bursts without
destroying the regular EMG
characteristics.
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Sternocleidomastoid With ECG Artifact
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Sternocleidomastoid With ECG Artifact
Removed
General Troubleshooting
Expect it WILL happen!
Do one thing at a time
Look carefully at the display for clues
Check the most likely things first
Check things sequentially (electrode, lead, connection
to hardware/PC, software)
Replace /clean electrode or replace lead if necessary
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QUESTIONS, COMMENTS, DISCUSSION
Normalization
What is it?
Why is it important?
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Importance of Normalization
Many normal Microvolt/uV values have been
proposed for the masticatory and cervical
muscles, all of which are DIFFERENT!
Using absolute amplitude values for
distinguishing facial pain patients from non-
pain control subjects may be a component of
ambiguous results!
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Importance of Normalization
Data are strongly influenced by the detection conditions.
Strongly Varies:
Between electrode sites
Subjects
Day-to-day measures of the same muscle site.
Differences in adipose tissue between subjects (impedance) obese
or exceptionally lean individuals exhibit different tissue impedance
factors. They ALL affect amplitude values.
These factors may negate the validity of currently available normative
data!!
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Absolute microvolt values should not be compared
across manufacturers!
Different:
Electrode characteristics
Sampling characteristics
Frequency bandpass filters
Microvolt amplitude quantification methods
Other processing characteristics
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Absolute amplitude values cannot be compared across
subjects and days!
Different:
Adipose characteristics across subjects
Skin impedance characteristics
Unintended variations in electrode placement
Fascial thickness
Example:
10 uV from the same muscle between 2 people does not mean the same
thing!
10 uV from the temporalis anterior in one person probably does NOT
mean the same thing as 10 uV from the temporalis anterior in another
person.
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What can we do about it?
Normalize!
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Normalization Procedure
First, a standardized isometric procedure (e.g. functional clench) is
identified and performed for a defined period, (e.g. such as 2-3
seconds). Clench convenient and standard part of CMD protocol.
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Maximal Clench Values:
Right Temporalis Anterior
(RTA) 207uV
Left Temporalis Anterior (LTA)
164uV
Right Masseter (RMAS)
180uV
Left Masseter (LMAS) 217uV
SEMG activity is then averaged for a fixed period during the peak values (e.g. peak 500-1000ms of
a 2 second contraction). This mean becomes the normalization reference value for the muscle.
Normalization Procedure
The evaluation task of clinical interest is performed. The clinical task mean
is divided by the MVIC mean and multiplied by 100 to complete the
calculation.
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Normalization Procedure
First, a standardized isometric procedure (e.g. functional
clench) is identified and performed for a defined period,
(e.g. such as 2-3 seconds). Clench convenient and
standard part of CMD protocol.
SEMG activity is then averaged for a fixed period during
the peak values (e.g. peak 500-1000ms of a 2 second
contraction). This mean becomes the normalization
reference value for the muscle.
The evaluation task of clinical interest is performed. The
clinical task mean is divided by the MVIC mean and
multiplied by 100 to complete the calculation.
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Normalized Comparisons for Symmetry
For symmetry documentation, activity of one
muscle is compared with that of its
contralateral partner. (E.G. Left/Right
Masseter)
Muscle activity among homologous pairs is
expected to be simultaneously symmetric for
bilateral simultaneous symmetrical
movements (e.g. mandibular depression and
elevation).
Reciprocally symmetric SEMG activity
patterns are expected for reciprocally
symmetric movements (e.g. left and then
right lateral excursions).
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R L
Normalized Comparisons for Symmetry
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Does R L ?
Normalized Comparisons for Symmetry
Percent difference in peak or average
activity produced during a movement.
Example:
Peak or avge activity = 40.7 uV on left
Peak or avge activity = 83.1uV on right
Right side - left side/right side x 100
High side Low Side/High side x 100
Example: Asymmetry during a functional clench.
83.1 - 40.7 83.1 x 100 = 51% Rt > Lt.
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High Side - Low Side High Side X 100 = Percent Asymmetry
83.1uV - 40.7 uV 83.1uV x 100 = 51% Asymmetry Rt. > Lt.
Asymmetry Index
Using standard asymmetry (15%) evidence held up for Right
side TMD patients. Left side did not (~10% asymmetry).
Combined ~170uV (Pain group Control Group ~279uV).
What was resting activity?
Resting for pain group would have to be less than ~3uV
across all sites.
Non-Pain group ~ 6uV
Take Home Message Never rely on ONE piece of data!
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U. Santana-Mora Changes in EMG activity during clenching in chronic pain patients
with unilateral temporomandibular disorders. Journal of Electromyography and Kinesiology 19 (2009) e543e549
Qualitative Analysis
Is the muscle active?
Quickly answered with yes or no.
Ensure quality of the SEMG baseline allows a clear
identification of active SEMG.
Knowledge of the instrumentation must be known to the user.
Noise may be interpreted as increased activity.
Post movement, a healthy subject tends to exhibit prompt
return to baseline levels.
If activity remains elevated, this can be qualitatively described
as a delay in returning to original baseline levels.
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Qualitative Analysis Baseline Values
Baseline values from non-postural muscles should be relatively
close to the internal noise levels of the instrumentation.
Limits uV values to within the same session (assuming
electrodes are not removed and replaced).
Relative microvolt (uV) values may be expressed as long as
they are not compared across sessions and subjects.
Timing parameters (when it turns on/off)
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Qualitative Analysis
Is the muscle hyperactive or hypoactive?
Requires at least one comparison item. Contralateral partner.
Expressed as minimally, moderately or severely elevated.
A very strict electrode application technique is needed to create
suitable conditions for such comparisons.
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Qualitative Analysis
When is the muscle active?
Timing characteristics of a muscle may be qualitatively described
within a certain movement event or in comparison to other
muscles.
Described qualitatively as prompt and smooth or aberrant
May also be described relative to the contralateral side.
e.g. masseter activity significantly delayed relative to the
temporalis anterior during mandibular elevation of a swallow.
Timing characteristics are quantitative - milliseconds (ms) not
microvolts (uV)
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Common Recording Sites 4-8
Generally used:
Temporalis Anterior
Masseter
Suprahyoid
Sternocleidomastoid
Temporalis Posterior
Cervical Paraspinals
(C4)
Upper Trapezius
SEMG Protocols
What Muscles Should be Measured?
Tomorrows SEMG Technique/Recording Topics
Electrode placement, Seated and standing baseline
techniques - basic interpretation
Functional clench technique - basic interpretation
Swallow, prolonged clench techniques - basic
interpretation
SEMG a window into The role of additional healthcare
practitioners in CMD patients
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QUESTIONS, COMMENTS, DISCUSSION