AACE - All Right Reserved. Normal and Abnormal EMG 163-P
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1 Normal and Abnormal EMG 163-P 1
2 Normal and Abnormal EMG This class is part of Stage 1 Normal and Abnormal EMG The objectives of this lecture are: Demonstrate a patient-centered and ethical approach in planning and conducting the EMG/NCS exam Discuss techniques to optimize patient comfort and reduce anxiety during the EMG/NCS exam Discuss Henneman's Size Principle in regards to recruitment of motor units. Identify reasons for excess noise during EMG exam 2
3 Normal and Abnormal EMG The objectives of this lecture are (cont): Explain and demonstrate the quadrant technique for EMG testing Perform motor unit analysis during EMG testing - correctly identify motor unit amplitude, duration, morphology, and frequency. State normal and abnormal values for motor unit amplitude, duration, and firing frequency Discuss and demonstrate the four testing conditions during an EMG exam Identify end-plate noise/end-plate spikes during an EMG exam Normal and Abnormal EMG The objectives of this lecture are (cont): Recognize and explain the significance of the following: Positive sharp waves and fibrillation potentials Complex repetitive discharges Smaller than normal and larger than normal motor unit potentials Abnormal recruitment Polyphasic potentials Be able to differentiate acute, subacute, vs. chronic conditions based on EMG findings. 3
4 EMG Technique, Normal, and Abnormal Findings EMG Parameters Observe and Attempt to Quantify These: Insertional Activity Activity at Rest MUAP Morphology, Amplitude & Duration with slight contraction Recruitment Pattern with slight to maximal contraction 4
5 EMG Parameter: Insertional Activity (IA) Electrical Activity Due to Insertion or Movement of a Needle in Muscle Normal= 50 msec after needle stops Normal, Inc, Dec or Prolonged Inc IA Associated with Spontaneous Potentials. Dec IA Indicates Reduced # of Healthy Muscle Fibers Due to Chronic Denervation (Fibrosis) or Muscle Necrosis = Poor Prognosis EMG Parameter: Spontaneous Potentials Fibrillation Potentials (Fibs) Positive Sharp Waves (PSWs) Complex Repetitive Discharge (CRD) Myotonic Discharges Fasciculation Potentials (Fascics) Myokymic Discharges **KEY POINT: These occur at rest** 5
6 Spontaneous Potentials Remember that NORMAL resting muscle should be electrically silent at rest Exceptions: End-plate spikes (initial upward- negative- deflection) End-plate noise (sea-shell sound) EMG Parameter: Fibrillation Potentials Fibs and PSWs Generally Thought to be Physiologically the Same Generator: Single muscle fiber Due to Either Muscle Fiber Denervation Severity Graded +1 to +4 - Grossly Reflects Amount of Denervation Amplitude: Acute = microvolts; Chronic < microvolts Shape: Biphasic (positive then negative). **Important to differentiate from end-plate spikes Rate: 1-50 Hz 6
7 EMG Parameter: Positive Sharp Waves Generator: Single muscle fiber Due to Either Muscle Fiber Denervation Severity Graded +1 to +4 - Grossly Reflects Amount of Denervation Amplitude: Acute = microvolts; Chronic < microvolts Shape: Positive deflection followed by rounded negative deflection Rate: 1-50 Hz Fibrillation Potentials and Positive Sharp Waves in the Tibialis Anterior Muscle 7
8 Grading of PSWs, Fibs 0 No PSWs or Fibs 1+ Persistent/unsustained single trains in at least two muscle regions 2+ Moderate numbers in 3 or more muscle areas 3+ Many in all muscle regions 4+ Baseline obliterated with potentials in all areas of muscle examined EMG Worksheet: Report 3 Electromyography: monopolar needle Motor Unit Insertional Muscle Side Nerve Root Resting Activity Morphology, Amplitude Recruitment Activity Deltoid Rt Axillary C5,6 normal bi-,triphasic, 1-4 mv complete normal 1 st Dorsal Interosseous Rt Ulnar C8,T1 1+ PSW/FIB (sm. Amp.) bi-,triphasic, 1-4 mv complete increased Deltoid L Axillary C5,6 normal bi-,triphasic, 1-4 mv complete normal 1 st Dorsal Interosseous L Ulnar C8,T1 2+ PSW/FIB (sm. Amp.) bi-,triphasic, 1-4 mv complete increased Vastus Medialis Rt Femoral L2,3,4 normal bi-,triphasic, 1-4 mv complete normal 1 st Pedal Interosseous Rt Tibial S1,S2 1+ PSW/FIB (sm. Amp.) bi-,triphasic, 1-4 mv partial interference pattern increased 8
9 EMG Parameter: Complex Repetitive Discharge Occur in a Wide Variety of Chronic, Progressive Neurogenic and Myopathic Disorders To Include some Chronic Denervating Conditions Generator: Ephaptic muscle fiber conduction (we think) Amplitude: microv Shape: Polyphasic or serrated Abrupt stop/ start (**differentiate from myotonic) Rate: Hz Complex Repetitive Discharge in the Infraspinatus Muscle 9
10 EMG Parameter: Myotonic Discharges Occur in Disorders of Myotonia (Delayed Muscle Relaxation) Can occur in other myopathic or chronic neuropathic disorders Generator: Muscle fibers Rhythm: Waxes and wanes in amplitude and firing rate (**differs from CRDs) Amp: microv Rate: Hz Most Common Due to the Myopathic Form: Myotonic Dystrophy - Most Common of All Myotonias EMG Parameter: Fasciculation Potentials Most Commonly Seen in Chronic Neurogenic Disorders Esp. Lower Motor Neuron Diseases ALS, Jakob-Cruetzfeldt, Chronic Root Compression, Peripheral Neuropathy, or NORMAL Generator: Motor Unit Spontaneous intermittent firing (1 Hz to several per minute) **Characterized by the company they keep 10
11 Fasciculation Potential in FDI EMG Parameter: Myokymic Discharges Vermicular (worm-like) discharges Rare. May occur in chronic nerve Dz Bursts of 2-10 normal appearing motor units firing at Hz Generator: Ephaptic axonal discharges of groups of motor units (we think) Rate:.1-10 Hz semi-rhythmic for each burst Amp: >300 microv 11
12 Technique: Gentle contraction Motor Unit Analysis Identify and hone in on first few Motor Unit Potentials (MUPs) by slightly moving needle Good location if rise time <1 msec for monopolar or <.5 msec for concentric needle Listen for crisp sound Motor Unit Analysis Normal parameters vary widely based on particular muscle and needle type: Amp (peak to peak): microv Duration: 7-12 msec on avg. Phases (baseline crossings): <4* Recruitment: Small to large MUPs. First MUP initiates at 5 Hz. Subsequent MUPs occur at about every 5 Hz increase in firing rate. **Note: <20% polyphasic MUPs is normal 12
13 Motor Unit Analysis Machine Settings: Start at gain 200uV/sweep evaluate first few units, firing rate, small to large recruitment, morphology - submax contraction (may need to increase the gain to 500uV if waves are off the screen) Normal Motor Unit Potential 13
14 Motor Unit Reinnervation Two Means of Reinnervation: Collateral Sprouting Direct Regeneration of the Original Nerve Terminal Collateral Sprouting Collateral Sprouts Terminal Branches of an Intact Axon Sprout to Reinnervate Motor Fibers of Another Degenerated Axon/Motor Unit 14
15 Direct Reinnervation Direct Reinnervation Axons of a Degenerated Motor Unit Regenerate to Directly Reinnervate Its Same Motor Fibers EMG Parameter: Phases, Amplitude & Duration Polyphasicity, Amplitude and Duration Relate to the Type and Amount of Reinnervation Large Amp, Long Duration, Polyphasic MUP = Reinnervation Via Collateral Sprouting Small Amp, Short Duration, Polyphasic MUP = Direct Regeneration, Early Collateral Sprouting or Myopathic Disorders (Fiber Splitting) 15
16 Collateral Sprouting Terminal Sprouts Conducting Slower than Normal Normal MUP Polyphasic Motor Unit Potential Larger Amp and Duration Polyphasic MUAPs 16
17 Direct Regeneration Normal MUP Terminal Sprouts Conducting Slower than Normal Polyphasic Motor Unit Potential Smaller Amp Short Duration Giant MUP = Matured Collateral Sprouting Mature Terminal Sprouts Conducting at Normal Speed Giant Motor Unit Potential > 12,000 microvolts (Non-Polyphasic, Long Duration ) 17
18 Mature Direct Regeneration Leads to Normal MUP Mature Regenerated Terminal Nerve Endings Normal Motor Unit Potential Normal Amp and Duration Recruitment Next at gain 500uV/sweep msec Have patient perform a mild to mod to max contraction (gradually increasing) Look for gradually increasing amplitude of motor units Recruitment of new motor units Frequency of firing 18
19 Normal Recruitment Recruitment How does the nervous system increase force of contraction? 19
20 EMG Parameter: Recruitment Pattern The Gradual Increase in the Number of MUPs Recruited With In Relation to the Rate of Firing and the Increased Force of Contraction (i.e. Size Principle) 1st: Small MUs Recruited and Fire at a Max Rate of ~ 5-10Hz 2nd: Other Larger MUs Are Then Recruited at Same Rate EMG Parameter: Recruitment Pattern Types Neurogenic = Reduced Recruitment Rate of Individual MUs Firing will be out of Proportion to the Total Number That Are Firing Fast firing rate (>20 Hz): look closely at first few MUPs Fewer Units available and the Remaining Ones Increase Their Rate to Increase Force Seen in Disorders of Axonal Destruction/Block May Be Only Sign in Neurapraxia 20
21 EMG Parameter: Recruitment Pattern Types Myopathic = Rapid Recruitment More MUs activated than suspected for the force of contraction. Seen when the motor fiber can not generate normal force (i.e. in Myopathic Disorders) Rate firing is normal but Amp is Small Avg. Motor unit duration (non-polyphasics) is <6 msec Normal Recruitment 21
22 EMG Parameter: Interference Means By Which to Evaluate the Relationship Between the Number of Firing MUs and the Muscle Force Exerted With Maximal Effort Full Pattern - Baseline Is Obscured By MUPs With Max Effort Discrete Pattern - Individual MUPs Are Recognizable With Max Effort Neurogenic Disorder EMG Parameter: Interference Reduced or Discrete Interference Pattern Myopathic Disorder Full Interference Pattern 22
23 Full Interference Full Interference Discrete Interference with fast firing rate (>20 Hz) 23
24 Review Neurogenic Disorders (Cont.) Insertional Activity Acute - Increased Chronic - Reduced PSWs/Fibs Acute - Inc. and Larger Amplitude Chronic - Dec. Compared to Acute Stage and Small Amplitude Go away with reinnervation CRD Review Neurogenic Disorders (Cont.) Chronic Denervating Conditions Fasciculations In Chronic LMN Disorders 24
25 Review Neurogenic Disorders (Cont.) EMG Polyphasia, Amplitude and Duration Large Amp, Long Duration, Polyphasic MUP = Reinnervation Via Collateral Sprouting Small Amp, Short Duration, Polyphasic MUP = Direct Regeneration, Early Collateral Sprouting Amp & Dur Inc and Polys Dec With Chronicity for Both of These Situations Review Neurogenic Disorders (Cont.) Recruitment Pattern - Reduced, fast firing rate Interference Pattern - Reduced or Discrete 25
26 PSWs/Fibs Review Myopathic Disorders Inc in inflammatory myopathies, muscular dystrophy's and some other primary muscle Dx CRD Inc in inflammatory myopathies, muscular dystrophy's and some other primary muscle Dx Myotonic Discharges Myotonias Review Myopathic Disorders (Cont.) EMG Polyphasia, Amplitude and Duration Small Amp, Short Duration (<6 msec), Polyphasic MUP = Myopathic Disorders (Fiber Splitting) Rapid Recruitment Pattern Full Interference Pattern 26
27 Insertional Activity NEUROGENIC LESION MYOGENIC LESION NORMAL LOWER UPPER MYOPATHY MYOTONIA MOTOR MOTOR Normal Increased Normal Normal/ Myotonic increased Discharge Resting Activity Silent Fibs, PSWs Silent Fibs, PSWs or Silent Minimal Contraction Maximal Contraction µv, 5-15 ms Screen fill Large amplitude, Polyphasic Reduced, fast firing rate Normal Reduced, slow firing rate Low amplitude, early recruitment Full, low amplitude Fibs, PSWs, myotonic discharges, or Silent Myotonic Discharge Full, low amplitude Summary/Questions u Remember to examine 3 depths at 4 quadrants u You may have to examine multiple sites within the same muscle depending upon your clinical judgement and the suspected pathology u Take your time, be safe and methodical u Questions?????????? 27
28 Normal and Abnormal EMG There will be a quiz on this lecture There will also be video clips uploaded with abnormal and normal EMG findings review these. 28
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