Amanda Peltier, MD MS Department of Neurology of EMG 2013.pdfBasic Tenets of Electromyography (EMG)...
Transcript of Amanda Peltier, MD MS Department of Neurology of EMG 2013.pdfBasic Tenets of Electromyography (EMG)...
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Fundamentals of Electromyography
Amanda Peltier, MD MS Department of Neurology
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Importance of EMG Studies
n Diagnosis n Localization n Assist in further testing (i.e. identify
potential biopsy sites) n Prognosis n Use in Research
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Basic Tenets of Electromyography (EMG) n EMG (even more than nerve conduction
studies) is an extension of the physical exam n When in doubt, reexamine the patient (or
check the equipment) n When in doubt, do not overcall n Electrodiagnostic (EDX) findings should be
reported in the context of the symptoms and referral doctor’s question
n EDX are uncomfortable. Always stop when the patient asks.
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Types of Needles
n Monopolar
Pictures from www.casaengineering.com
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Types of Needles
n Concentric
Pictures from www.casaengineering.com
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The Anti-coagulated Patient n Only 2 reported cases of anticoagulated (warfarin)
patients with hematomas following EMG n 4 cases of incidental paraspinal hematomas found on
MRI after EMG in non-coagulated patients (Caress et al. Neurology 1997).
n AANEM practice guidelines cite need for caution, examine small superficial muscles first and maintain pressure on needle sites.
n Recent survey of EMG Laboratories reported only 5 cases of hematomas after EMG requiring medical intervention in anticoagulated patients.
n No reports of significant bleeding in patients on anti-platelet therapy.
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Technique n Alcohol before skin puncture n Identify muscle n Introduce needle-ask patient to contract if necessary
to confirm placement (Motor unit action potentials (MUAPs) should be crisp and sharp)
n Move needle 5-10 times, allow at least 3-5 seconds recording to identify spontaneous activity
n Ask patient to activate muscle minimally then increase force slowly to evaluate recruitment
n Remove needle
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Morphology
n Motor unit action potential (MUAP) varies based on muscle, age n Duration often shorter in proximal muscles n Amplitude greater in adults than children
(bigger fibers) n MUAP size larger in older individuals
(probably from dropout of motor units with some “normal” reinnervation)
n Phases: # of baseline crossings plus 1 n Serrations (turns):# of changes in
direction of potential not crossing baseline
10 msec/div, timebase 2MV/vertical segment
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Duration
n One of the most important measurements n Best reflects number of muscle fibers within a
motor unit n Typical duration between 5 and 15 ms n Defined as time from initial deflection from
baseline to final return of MUAP to baseline n Correlates with pitch (shorter duration with
higher pitch, longer duration with lower pitch
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Amplitude n Most MUAPs have amplitude between 100 μV to 2
mV n Larger in larger fibers (may not see large type II fiber
MUAPs unless patient contracting forcefully) n Depends greatly on needle and needle placement
n Difficult to assess amplitude directly with monopolar needle n Further away the needle, the smaller the amplitude, less
crisp the sound n Amplitude correlated with volume (bigger the unit,
louder the sound) n Often (but not always) correlates with duration
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Polyphasia
n Measure of synchrony: extent to which the muscle fibers within a unit fire at the same time
n Typically motor units have 2-4 phases n Some degree of polyphasia nomral (5-
10% in any muscle, up to 25% in deltoid
n Although abnormal, not specific
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Firing pattern n Can only be assessed in conscious patients n Firing pattern important in differentiating
spontaneous from voluntary discharges n **During muscle contraction, to increase force you
either fire more rapidly or recruit more units n Firing rate in normal muscle between 4 to 12 hz
before second unit begins to fire n Ratio of firing frequency measure of recruitment
n Firing frequency to number of different MUAPs firing
n Normally 5:1 (ie when rate reaches ~10 hz second unit starts firing, when 15 hz third unit firing)
n Easiest to assess when patient contracting less than full contraction
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Recruitment n Recruitment: Ability to add more units as
firing rate increases n Low recruitment: Ratio greater than 5:1 (ie a
single unit firing 30 hz would be 30:1 n Ratio increases as recruitment drops n Most important in differentiating neurogenic
from myopathic processes n Be careful not to confuse activation with
recruitment
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Activation
n Activation: Ability to increase firing rate. n Is a central process (ie abnormal
secondary to upper motor neuron disorders, pain, poor cooperation/functional)
n **Does not affect ratio of firing frequency (poor activation in normal subject will have ratio of 5:1)
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Interference Pattern
n Interference pattern: Maximum voluntary contraction when no single motor unit can be distinguished (typically 30-50 hz)
n If abnormal either from reduced recruitment or from reduced activation
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Pattern of EMG changes in Neuropathic Disorders n Immediate: Morphology normal, recruitment
decreased or absent (depending on severity of injury) n Same pattern seen in demyelinating disorders with
conduction block n 10-14 days: Spontaneous activity present (wallerian
degeneration has taken place) n After 6 weeks morphology becomes more
neuropathic (remodeling has occurred): n Decreased recruitment, larger amplitude, polyphasic
n Satellite potentials: small, short duration, unstable units time locked to another larger unit
n Nascent units: Small amplitude short duration units with decreased recruitment (recruitment distinguished from myopathic units)
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Minutes Hyper-acute (<3 days)
Acute (>1 week, <3 weeks)
Subacute (>3weeks < 2 months)
Subacute-Chronic (>2 months, <6 months)
Chronic (>6 months)
Clinical findings
Abnormal Abnormal Abnormal
Abnormal
Abnormal
Normal/ Abnormal
Nerve conduction studies
Normal Normal
Abnormal
Abnormal
Abnormal
Normal/ Abnormal
MUAP recruitment
Decreased Decreased Decreased Decreased Decreased Decreased
Spontaneous activity
Normal Normal Normal Abnormal Abnormal Normal
MUAP morphology
Normal Normal Normal Normal Re-innervated
Re-innervated
MUAP, motor unit action potential
Table adapted from Preston and Shapiro, 2nd edition
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Pattern of EMG changes in Myopathic Disorders n Myopathy: number of functioning muscle fibers
decreased—units smaller, shorter duration. n Abnormal firing causes polyphasia n Acute: short duration, small amplitude units with
normal or early recruitment n Chronic: (some denervation often occurs) long-
duration, high amplitude MUAPS can be seen (often with short-duration, small units)
n Recruitment is still normal or early until end stage
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Spontaneous activity
n Normal: n Insertional activity: brief depolarization no
longer than 300 ms n Endplate noise (seashell noise): low
amplitude negative potentials firing irregularly at 20 to 40 hz. = MEPPs
n Endplate spikes: muscle fiber action potential firing irregularly up to 50 hz
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Abnormal Spontaneous Activity
n Fibrillation potentials:spontaneous depolarizations
n Positive sharp waves: same significance as fibrillation potentials
n Complex repetitive discharges: depolarization of a single fiber followed by ephaptic spread (muscle membrane to muscle membrane)
n Myotonic Discharge: spontaneous discharge of msucle fiber with waaxing and waning of amplitude and frequency (rate between 20 and 150)
n Fasciculation: Single, spontaneous, involuntary discharge (slow rate 1-2 hz)
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Videos of Spontaneous Activity
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Videos of Spontaneous Activity
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Videos of Spontaneous Activity
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Conclusions
n Use your ears (more sensitive than your eyes)
n EMG is only as good as the electromyographer