ELECTROMYOGRAPHY

Is a technique for the observation, analysis, and interpretation of

the bioelectrical activity of muscle and nerve in response to
volitional activation or electrical stimulation.

Electromyography (EMG) and nerve conduction studies (NCSs) are

valuable diagnostic tools that help neurologists locate and determine
the causes of diseases that affect muscles and peripheral nerves. In
EMG, a small needle is inserted into a muscle in order to measure
electrical activity. In nerve conduction studies, electrodes are placed
on the skin overlying a nerve, and other recording electrodes are
attached at a different point over the same nerve.
A small shock is applied, and the electrical impulse is recorded.
While EMG and NCSs are different tests, they're often used together
because the information gained from each test.

terms you may encounter in an EMG or NCS report include the

following:
Amplitude: The electrical signal is represented as a wave, and the
amplitude is its height.
 Conduction Velocity (CV): The conduction velocity describes the
speed at which the electrical impulse travels along the nerve.
Duration: This describes the width of an electrical wave.

Conduction Block: The diminution of signal across an anatomical

region such as the wrist. This suggests nerve entrapment, as in
carpal tunnel syndrome.
These measures give information about both motor and sensory components
of the peripheral nervous system. They also suggest whether the axon or the
myelin sheath of nerves is more damaged by a neuropathy. Myelin helps
action potentials travel faster, and so in problems of myelin (myelinopathies),
conduction velocity is more decreased. In problems with the axon
(axonopathies), fibers that are intact can conduct signals at normal speeds,
but there are fewer fibers, which leads to a weaker signal and decreased
amplitude.
When an EMG is performed, electrical activity from muscle fibers is
measured and demonstrated as waves on a screen and static-like noises
played on a speaker.

The technician listens to these sounds and watches the monitor in order to
detect abnormalities.

When a nerve stimulates a muscle to contract, the result is a brief burst of

electrical activity called a motor unit action potential (MUP). In diseases of
peripheral nerves, muscles sometimes start having spontaneous activity on
their own. This can be detected by EMG as fibrillations and positive sharp
waves on the monitor. Sometimes the abnormality causes visible muscle
twitches called fasciculations.
If a nerve has been injured and then regrows, the nerve tends to branch out
to include a wider area. This causes abnormally large MUPS.

In contrast, MUPS are abnormally small or brief, and suggest the presence
of a disease of a muscle (amyopathy ).

Interpreting EMG results may also mention the term "recruitment pattern."
As a muscle is contracted, nerve fibers signal more and more bits of muscle
(called motor units) to join in and help. In a neuropathic disorder, the
amplitude of different motor units is strong, but there are fewer of them
because the nerve is unable to connect to as many units. In myopathies, the
number of motor units is normal, but the amplitude is smaller.

The pattern of electrical discharges from the muscle can give additional
information as to the cause of the problem, and may even help determine
how long a problem has been present.
 NERVE CONDUCTION STUDIES
The electrical signal sent along the axon of a nerve is called an action potential.
In nerve conduction studies, these action potentials are artificially generated by
electrical stimulation in order to assess how the axon responds.

There are two main portions to a nerve conduction study: sensory and motor.
Recording from a sensory nerve gives a sensory nerve action potential (SNAP),
and recording from a muscle yields a compound muscle action potential
(CMAP).
 It assess peripheral motor and sensory nerve function by
recording the evoked potential generated by electrical
stimulation of a peripheral nerve.

Nerves that are easier to test and commonly examined include

the median and ulnar nerves in upper extremity, and the
peroneal, posterior tibial and sural nerves in the lower
extremity.

It is used clinically to know whether :

Peripheral nerve fibers are involved? are both sensory and
motor fibers involved?
Location of the peripheral lesion?
Lesion is complete or partial?
If the impairment is increasing or decreasing with time?
Median Nerve Motor Conduction (Abductor pollicis brevis)

One recording electrode (active) is placed over the APB

motor point.

The second electrode (reference) is placed distally over the

tendinous insertion area of the muscle.

Third electrode ( ground) is placed between the stimulating

electrodes and the recording electrodes on a bony area such as
the dorsum of the wrist.

Stimulation is provided by use of handheld bipolar electrode,

produces a rectangular, monophasic pulsed current with an
adjustable amplitude.
 The response is amplified, filtered and recorded on an
oscilloscope.

By increasing the current amplitude until the maximal

amplitude of the recorded compound muscle action potential.

Supramaximal stimulus must be delivered to the nerve to

record maximal response.
 The time between the onset of the stimulus and the beginning
of the CMAP is called the latency of the response. Latency
values are one of the primary measurements taken in motor
nerve conduction studies.

The recorded latency is proportional to the distance between

the stimulating and recording electrodes.
 Since median nerve stimulation at the wrist is the most distal
point of stimulation of this nerve the latency is referred to as
the distal latency.

Motor nerve conduction velocity in the segment of the median

nerve lying between the elbow and the wrist, the latency is L1.

The CMAP evoked from the APB appears later on the display
screen, and the longer latency is recorded as L2.

The conduction velocity is expressed in units of length divided

by units of time(m/s).
 Conduction velocity of the forearm segment of the median
nerve is calculated :

Conduction velocity = distance/ time = forearm segment

length(mm)/L2-L1(msec)

o If length of the forearm segment of median nerve is measured

as 235mm

o The distal latency L1 from wrist to APB is 3.5msec

o Proximal latency from elbow to APB is 7.8msec ie;

235/7.8msec-3.5msec = 54.7m/sec
 General principles of nerve conduction testing

Examine both motor and sensory conduction when possible.

Performed over segments of nerves suspected to be involved.
Test should be performed on nerves contralateral side.
Test should be performed at appropriate time in context of
suspected disorders.

Factors affecting motor and sensory conduction

Body temperature (28-30 degrees skin temeprature)
Proximal segment of peripheral nerves faster conducting than
distal segment.
Infants and children have conduction velocities as low as 50%.
Gradual slowing of conduction appear after age of 40.
 evoked-potential studies

The function of three different CNS sensory areas can be

evaluated.
 Somatosensory evoked potential
Stimuli are applied with surface electrodes.
Stimulation is provided first unilaterally near a particular
nerve and later bilaterally.
 The sensory action potential are elicited by placing the active
surface recording electrodes over Erbs point , spinal cord or
cortex.

SSEPs are so small that 2000 responses must be averaged in

order to clearly visualize the response on display device.

Used in demyelinating diseases and spinal cord, cortical and

brainstem dysfunction.
 Brainstem auditory evoked potential

Are electric waveforms recorded from the brain elicited in

response to sound.

A click like sound is applied through one ear.

Surface scalp electrodes are applied over the vertex on the

same side as stimulation.

Evoked potentials are small , up to 2000 responses to stimuli

may be needed in order to visualize the evoked waveform.

Used in demyelination, neuromas, tumors, or other disorders

of auditory pathways.
 Visual evoked potential

Are bioelectric potentials recorded during electrical activity in

the occipital lobe cortex in response to light stimuli.

It is easier to record.

Surface electrodes are placed on the scalp overlying the

occipital cortex.

A controlled light pattern generator is used to stimulate either

one eye or both eyes simultaneously.

Used in determining the integrity an conduction of visual

pathways.
 Contraindications/Precautions in

Extreme swelling
Abnormal blood clotting
Dermatitis
Uncooperative patient
Recent myocardial infarction
Blood-transmittable disease
Immune-suppressed condition
Pacemakers
Hypersensitivity to stimulation
 Recent Advances

Utilization of Nerve Conduction studies for the Diagnosis of

Polyneuropathy in patients with Diabetes: A Retrospective Analysis
of a Large Patient Series-the study cohort consisted of a total of
63,779 electrodiagnostic encounters performed by 3468 physician
practices. The most common abnormality was F-wave latency
(33.6%). The sural nerve response latency and amplitude parameters
had similar abnormality rates (58.3% and 62.7%). This study
demonstrated that NCS using comupter based electrodiagnostic
equipment was a suitable tool for the diagnosis of DPN.
Use of surface electromyography in phonation studies; an
integrative review to investigate the current state of knowledge
regarding the use of surface electromyography for evaluation of the
electrical activity of the extrinsic muscles of the larynx during
phonation. Articles that were published from 1980 to 2012 which
described surface emg and voice, surface emg and phonation and
surface emg and dysphonia were selected. 27 papers were selected,
it showed differences in electrical activity between the studied
groups. There is no predictive value as a diagnostic test. The
standardization of assessment techniques should be established.