SECTION7: 7.

INSTRUMENTATION

EMGMachineComponents

NerveandmuscleactionpotentialsarerecordedanddisplayedforanalysisbytheEMGmachine. Basicinstrumentationincludes:1)electrodestodetectthesignals,2)amplifierstoincreasesignal strength,3)filterstoreducestraysignals,4)anoscilloscopetoviewthesignals,and5)fornerve conductionstudiesanelectricalstimulatorisrequiredtoactivatethenerve(Figure7.01).Modern EMGinstrumentsarebasedondigitalcomputers,andtheoriginalanalogsignalsareconverted todigitalsignalsandplacedintemporarymemorystorage,andcanbeviewedonacomputer screenorareavailableforfurtherprocessing.Specialprocessingcapabilitiesinclude:6)signal averagingtosharpenwaveforms,and7)voltagetriggeranddelaylinestoenhanceviewingof needleEMGsignals.AllEMGinstrumentshavethesamebasicelements,anddifferonlyinthe positioningofthecontrolsandthedisplayarrangements. 7.2 RecordingElectrodes

Arecordingelectrodeconsistsoftwoelectrodesrequiredtomeasurethepotentialdifferences betweentosites.Themostcommonarrangementofthetwoelectrodesisforonetobecloseto thenerveormusclefibersunderstudy(theactive,exploring,stigmaticorG1electrode)torecord ioniccurrentsflowingfromactionpotentials,andtheotherelectrodetobeplacedfaraway(the indifferent,referenceorG2electrode)soastobetheoreticallyunaffectedbytheioniccurrents flowingfromactionpotentialsattheactivesite.Althoughtheflowofioniccurrentsandthe subsequentchangesinpotentialsoriginateatspecificsitesalongnervesandmuscles,potential differencescanstillbedetectedatadistancefromthesource.Thus,theneutralityofthe indifferentelectrodeisonlyrelative,butwithproperattentiontoelectrodepositioningthesignalis rarelycontaminatedtoasignificantdegree. Therearemanypossibleconfigurationsofrecordingelectrodes,andtheirdesignisbasedonthe typeofinformationdesired.Allelectrodesrepresentacompromisebetweenselectivityforcertain electricalfeaturesandinclusionofallelectricalactivity.Forelectrodiagnosistwobasicelectrode configurationsareused,surfaceandintramuscular,withvariationsdescribedbelow. 7.21 SurfaceRecordingElectrodes

Forrecordingsensorynerveactionpotentials(SNAP),thetwoelectrodesareplaced longitudinallyalongthenerve,withtheactiveelectrodepositionedtoseethearrivingaction potentialsandthereferenceelectrodesomedistancebeyondtorecordtheretreatingpotentials (Figure7.02).Becausethetravelingwholenerveactionpotentialis30to40mminlengthalong thenerve,changesinthedistancebetweenthetworecordingelectrodesaffectstheamplitudeof thesensorynerveactionpotential.Themaximalamplitudewillberecordedwhenoneelectrode seesthemaximalpotentialandtheotherelectrodeseesazeropotential.Interelectrode distancesof30to40mmareoptimal,withlittlechangeoccurringwithgreaterdistances(Figure 7.03).Tenmmdiskelectrodesareusedtorecordfromsensorynervesinlimbsandring electrodestorecordfromdigits(Figure7.03). Forrecordingmuscleactionpotentials(CMAP),theactiveelectrodeisplacedovertheendplate regionandthereferenceoverthetendon(bellytendonrecording)(Figure7.02).However,end plateswithinamusclearedistributedoveranarea(Figure2.01),andmusclescommonly recordedfromrepresentagroupofmusclesinnervatedbythesamenerve(medianinnervated thenarmusclegroup,ulnarinnervatedhypothenarmusclegroup,tibialinnervatedintrinsic muscles)andeachmuscleinthegroupwillhaveitsownendplateregion(Figure7.04).The positionoftherecordingelectrodeisimportant.Movingtheactiveelectrodeawayfromtheend plateregionchangestheshapeofthecompoundmuscleactionpotential,leadingtoalower amplituderesponse,andaninitialpositivedeflectionmayappeariftheelectrodeismarkedlyout

ofposition(Figure7.05).Ifallendplateswerefocusedinoneregion,anelectrodeoverthispoint wouldseethesumofmusclefiberactionpotentialsleavingthissite.Thus,optimalelectrode placementisacompromiseamongseveralendplatezones.Sincethemaximalamplitudeis recordedwhentheelectrodeisovertheaggregateendplatezone,thispointcannotbe anatomicallydefined,andwillcoincidewithasteeprisingphaseofthecompoundmuscleaction potential.Tenmmdiskelectrodesarecommonlyused(7.02),butselfadhesiveECGelectrodes arealsoused. 7.22 RoutineIntramuscularRecordingElectrodes

IntramuscularelectrodesforroutineEMGstudiesareeitheramodifiedhypodermicneedle (concentricelectrode)orasharpenedsolidwire(monopolarelectrode)(Figure7.06).Theterms concentricandmonopolarrefertothelocationoftheactiverecordingelectrode.With concentricelectrodestheactiveelectrodeisawirewithin,butinsulatedfrom,thehollowneedle. Theendoftheneedleiscutata15degreeangleandtheactiveelectrodesurfaceisanellipse. Thereferenceelectrodeisthehypodermicneedle(cannula).Thuswithconcentricelectrodesthe activeandreferenceelectrodesareinfixedrelationshiptoeachother. Monopolarelectrodesaresolidsharpenedneedlesinsulatedexceptforanactiverecording surfaceatthetipintheshapeofacone.Thereferenceelectrodeisaseparateelectrode,either anotherneedlejustundertheskinoradiskelectrodeonthesurfaceoftheskin.Thuswith monopolarelectrodesactiveandreferenceelectrodescanbeatvaryingdistancesfromeach otherandcanincludestraysignals. Everyelectrodehasadistanceoverwhichitcandetectbioelectricsignals,calledtherecordingor uptakeradius.Therecordingradiusislimitedbytheattenuationofthesignalduetoresistanceof thetissue.Signalamplitudeisreducedbyafactorequaltothesquareofthedistancebetween thesignalandtheelectrode.Althoughconcentricandmonopolarelectrodesdifferinshapeand sizeoftherecordingsurface,bothelectrodesrecordshavearecordingradiusof5001,000 microns.Whenthisdistanceisappliedtothedistributionofmusclefiberswithinamotorunit, fromsevento15musclefibersofamotorunitarerecordedfrombothelectrodes. 7.23 SpecialIntramuscularRecordingElectrodes

Specialpurposeelectrodesareavailabletoanswerspecificquestions.Theyrepresenta compromisebetweenselectivityandsensitivity. Singlefiberelectrodesarehypodermicneedles,buttheactiveelectrodeisawirewhoseexposed surfaceisthroughaholeorportalongthesideofthehypodermicneedleandthereference electrodeisthecannula(Figure7.06).Theactiverecordingsurfaceisverysmall,smallerthan thewireelectrodeinconcentricelectrodes,andhasarecordingradiusof<300microns. Accordingly,actionpotentialsfromonlyoneortwomusclefibersofamotorunitareincluded. MacroEMGElectrodesaresimilartosinglefiberelectrodesbutonlytheterminal15mmofthe cannulaisbareandtheremainingproximalportionisinsulated(Figure7.06).ThemacroEMG electrodeisadualelectrode:1)Thefirstelectrodeisasinglefiberelectrodewiththeactive recordingelectrodeatthesideportandthereferenceelectrodeisthecannula.2)Thesecond electrodeusestheuninsulated15mmofthecannulaastheactiveelectrodeandaseparate electrodeservesasthereferenceelectrode.ThemacroEMGelectroderequirestwoamplifiers, onerecordssinglefiberactionpotentialsfromthesideportelectrodewhiletheotherrecords activityfromthewholemotorunitfromthecannula. Nearnerveelectrodesaresimilartomonopolarelectrodesbutwithgreaterrecordingsurface area.Theyaremaneuveredundertheskintobeclosetoanerveandareusuallytorecord sensorynervepotentials.

7.3

AMPLIFIERS

Amplifiersincreasethestrengthofthebioelectricsignalspickedupbytheelectrodes.Action potentialsfromnerveandmuscleareoflowamplitude(microvoltstomillivolts)andmustbe amplifiedforviewingontheoscilloscopescreen.Thetwowireleadsfromtheelectrodesare connectedtotheamplifier.ThetermsG1andG2refertothegridinputstovacuumtubes from olderamplifiers,andarenowmorecommonlyusedinthevocabularyofEEGandevoked potentials.OnEMGmachines,G1leadsandtheconnectorstheyplugintoareusuallyblackin colorandG2redincolor.Despitethechangesinnomenclaturetheconceptsareimportantfor understandinghownerveandmusclepotentialsareamplified. Bioelectricsignalsrecordedwiththeelectrodesreflectthepotentialatonesiterelativetothe potentialattheothersite.Absolutevoltages,basedonthepotentialdifferencewithrespecttothe earthorground(becausetheearthcanabsorbanddistributeaninfinitenumberofions)arenot considered. 7.31 DifferentialAmplifiers AdifferentialamplifierisusedinEMGmachines,andconsistsoftwoamplifiersthatare interconnected(Figure7.07)suchthatthesignalenteringoneamplifier(G2)issubtractedfrom thesignalenteringtheotheramplifier(G1).IfG2istheindifferentleadandisnotinfluencedby thebiologicvoltagechangetobemeasured,thentheoutputoftheamplifierprimarilyreflects voltagechangesatG1(Figure7.08).However,ifG2alsopartiallyseesthesamevoltageas doesG1,theoutputwillbereduced.Theconventionisforamplifierstorepresentanegative voltageatG1asanupwarddeflection.Sincethemainextracellularspikecomponentofboth nerveandmusclefiberactionpotentialsarenegative,thewaveformspikestracemainlyupward patterns. 7.32 CommonModeRejectionRatio

Strayelectromagneticvoltagesintheenvironmentcanbelargeinamplitudeandcoulddistortthe bioelectricsignals.Themostcommonstraysignalcomesfromalternatingcurrent(AC)currentin theroom,andcanbereadilyrecognizedbyits60Hzfrequency.Anadvantageofthedifferential amplifieristhatitcancanceloutmoststray60Hznoise.SincebothG1andG2inputswillbe influencedsimilarly,the60Hznoiseinoneinputwillbeinvertedandcancelwiththenoiseinthe otherinput(Figure7.09).Theabilityofadifferentialamplifiertorejectsignalscommontoboth inputsiscalledthecommonmoderejectionratio.However,thetwocomponentamplifierswithin thedifferentialamplifier(Figure7.07)arenotabsolutelyidenticalintheirgains,resultinginsome degreeofunequalsubtractionofthecommonsignals.Therejectionratioisameasureof amplifiermismatch,andhighvaluesarepreferable,e.g.,10,000to1.Whenstray60Hzsignals areofveryhighamplitudesomepartofthecommonsignalwillbepresentandthebioelectric signalwillbesuperimposedonit.Agroundelectrodeisimportantbecauseittiestheamplifierto earthandhelpsreducestraynoise. 7.33 ElectrodeandAmplifierImpedance

Electrodesandamplifiersofferresistanceorimpedancetocurrentflowwhichcouldaffectsignals, althoughtheseissueshaveusuallybeenhandledbytheequipmentcompanies.Thevoltages fromnerveandmusclefiberactionpotentialsareconveyedfromtissuetooscilloscopeby electroniccircuitsconsistingofelectrodesandamplifiers.ByOhmslaw,currentandvoltageare relatedtoeachotherbythefactorofresistance.Resistiveelementsimpedetheflowofcurrent, buttherearetwotypesofresistance.Resistanceisunaffected(remainsconstant)whenthe frequencyofthevoltageinthesignalchanges.Impedanceisresistancethatisaffected(varies invalue)whenthefrequencychanges.Sinceactionpotentialsandotherbioelectricsignalsvary withtime,theresistivefactorofinterestisimpedance.

Impedanceisimportantattwositesinthecurrentflowfromthetissue,throughtheelectrodeand intotheamplifier.Foragivenvoltagefromthetissue,therewillbeavoltagedrop(loss)across theelectrodeproportionaltotheelectrodeimpedance,andadropacrosstheamplifier proportionaltotheamplifierimpedance.Thesetwovoltagedropsmustsumtoequalthevoltage fromthetissue.Accordingly,theimpedanceoftheamplifiermustbehigherthanthatofthe electrodesothatmoreofthevoltagedropoccursacrosstheamplifier,andhenceisamplifiedand displayed. Whencomparingtwoelectrodes,theonewiththehigherimpedancewillbemoresusceptibleto straysignals.Thisisbecauseastrayvoltagewillinducealargercurrentacrossanelectrodeof highimpedance.Asapracticalexample,monopolarelectrodeshavehigherimpedancethan concentricelectrodesCHECK. 7.4 Filters

Itwouldbeidealtorecordpurenerveandmusclefiberactionpotentialwaveforms,butmany factors,includingtheimpedancepropertiesoftheelectrodes,thepotentialsfromotheractive nervesandmuscle,andthestrayvoltagesintheatmospherecontributetocontaminatesignals withunwantedwaveformcomponents.Filterscanreduceunwantedcomponentsinthe waveform,buthavetheriskofdistortingthesignal.Accordingly,filtersrepresentacompromise andfiltervaluesmustbeselectedwithanunderstandingofthecomponentsthatmakeup waveformsandhowfiltersaffectthem. 7.41 WaveformComponents Anywaveformcanbedecomposedintoanumberofsinewavesofdifferentfrequenciesand amplitudesandphaserelationships.Onemathematicaltechniquetoidentifytheconstituent waveformsiscalledFourieranalysis.Theoretically,aninfinitenumberofappropriatesinewaves arerequiredtoregenerateagivenwaveform,butagoodreproductionofawaveformcanbe constructedbycombiningthemostinfluentialfivetosevendifferentsinewaves(Figure7.10). Thisindicatesthattherearerelativelyfewprincipalcomponentsinanywaveformsuchasthe SNAP,CMAPandMUAP. 7.42 FilterFunction Filtersexerttheirinfluencebyreducingtheprincipalsinewavecomponentsinawaveformbased ontheirfrequency.Afilterattenuates(reduces)theamplitudeofcomponentsinewaves.The degreeoramountofattenuationvariesfrom0%(noeffectonthewaveform)to100%(no contributiontothewaveform).Filteringisaccomplishedbyselectingthefrequencycomponentto bereduced.Therearefiltervaluesforhighandlow frequencycomponents. Filtercircuitsaremadefromresistorsandcapacitorsandthereareanumberofdifferentfilter circuitsthatcanbeconstructed,andButterworthfiltersarethetypemostcommonlyusedinEMG instruments.Althoughafiltersettingisdesignatedbyaspecificfrequencyvalue(eg,10Hz, 10,000Hz,etc),afilterfunctionstoattenuatethesignaloverarangeoffrequenciesthatare centeredatthedesignatedfrequency.Thus,foranyparticularfiltersettingthereisafrequency attenuationcurve(Figure7.11).Forlowfrequencyfilters,therewillbea33%reductionofthe signalatthenominalfrequencywithgreaterattenuationatlowerfrequenciesandlessattenuation athigherfrequencies.Forhighfrequencyfilters,therewillbea33%attenuationatthenominal frequencywithgreaterattenuationathigherfrequenciesandlessatlowerfrequencies.Note, thereisalternativenomenclature"highfrequency"filtersarealsocalled"lowpass"filters,and "lowfrequency"filterscanbeconsideredtobe"highpass"filters.The33%reduction,when expressedasonalogscale,isalsocalleda3decibel(db)attenuation. ThereisaspecialfilteravailableonmanyEMGinstruments,calledanotchfilter,thatselectively filtersout60Hznoise(Figure7.11).Thesefiltersaredesignedtomainlyreduces60Hz,butthey alsoattenuatetolesserdegreesotherfrequenciesaboveandbelow60Hz.

7.42 FrequencyComponentsofWaveformsandNoise Filtersettingsareselectedtoreducenoisebutnotchangethesignalwaveformtoappreciable degrees.TheSNAPandMUAPwaveformshavethehighestfrequencycomponentwaveforms andtheCMAPthelowest(Figure7.12).Ifhighfrequencyfiltersettingswereloweredduringthe recordingofSNAPandMUAP,thesteeprisetimeandhighamplitudeofthewaveformwouldbe reduced.TheCMAPwaveformhaslowerfrequencycomponents,andIflowfrequencyfilter settingswereraisedduringtherecordingofCMAP,theamplitudeanddurationwouldbereduced. Themostcommonnoiseis60Hz,butitisusuallypossibletoreduceitbypositioningofthe groundelectrode,anda60Hznotchfilterisrarelynecessary(Figure7.13).Thereisaveryhigh frequencynoisedueprimarilytoinherentelectronicandbioelectricfactors.Thisisobservedmost commonlyduringsensorystudiesduetothehighdisplaysensitivitiesrequired.Thereisalsoa verylowfrequencynoiseduetoinadvertentbodymovementssuchasthepatientsrespiration andcardiacmovementsandmovementsoftheelectromyographershandholdingthestimulator andEMGneedleduringthestudy. 7.43 FilterSettings Sensorynerveconductionstudiesarerecordedathighgain(20V)andtheSNAPissusceptible tohighfrequencynoise,andthehighfrequencyfilterisloweredto2KHztoreduceit.Thereare veryfewlowfrequencycomponentsintheSNAP,andthelowfrequencyfilterissetto20Hzto eliminateslowmovementrelatedvoltagechanges. Motornerveconductionstudiesarerecordedatlowdisplaysettings(5mV)andtheCMAPis muchlessaffectedbynoise.TherearelowerfrequencycomponentsintheCMAPandthelow frequencyfilterissetlow(2Hz)soasnottoexcludethem.Therearefewhighfrequency componentsintheCMAP,butthehighfrequencyfilteristraditionallysethigh(10KHz). NeedleEMGstudiesarerecordedatavarietyofdisplaysettings,from20V/divforassessment ofabnormalspontaneousactivityto2mV/divforassessmentofMUAPrecruitment.Abnormal spontaneousactivity(positivewavesandfibrillationpotentials)andtheMUAPhavearangeof componentfrequencies.Thefiltersettingsarethereforebroad,from20Hzlowfrequencyvalues to10KHzhighfrequencyvalues.Thereisaspecialsituationwhenitisdesirabletofilterout mostlowfrequencycomponents,andthatiswhenmakingjitterandfiberdensitymeasurements withasinglefiberelectrode.Underthesecircumstances,thelowfrequencyfilterissetto500Hz whichintentionallydistortsthelowfrequencycomponentsandbringsoutthehighfrequency sharpcomponentsattheexpenseofthelowfrequencycomponents. Sudomotorresponsesareameasureofsmallfiberautonomicnervefunction.Theymeasure veryslowpotentialchanges(~0.1Hz)duetochangesinskinmoisture(sweat).Accordingly,the lowfiltersettingissettothelowestpossiblevalue. CommonfiltersettingsarelistedinTable7.1. 7.5 WaveformDisplay

Anoscilloscopeisadevicethatdisplayswaveforms.ItconsistsofascreenthatformsanXY graph,withtimeontheXaxisandvoltageontheYaxis(Figure7.13).Thescreenhasgraph markingsthatformeitherasquareorrectangulargrid,andmarkingsarecalleddivisions.While theoriginaloscilloscopewasbasedonanelectronbeammovingbackandforth,current oscilloscopesinEMGmachinesarecomputerscreensthatemulateoscilloscopes. Thebeamoftheoscilloscopesweepsacrossthescreenfromlefttorightataconstantrate.Units fortheXaxisareinmillisecondsperdivision(msec/div).SynonymsfortheXaxisinclude"time base"and"sweepspeed".Thebeamcansweepacrossintwomodes:1)Inthe"freerun"or "continuoussweep"modes,whenthebeamreachestherightsideofthescreen,itimmediately returnstotheleftsideofthescreenandstartsanewsweep,andthusrunsfreelyorsweeps

continuously.Thereturnorflybackofthebeam,althoughnotinstantaneous,canbeconsidered soincomparisontothesweeptime.Thisallowsonetolookforandobserveeventsinrealtime orastheyhappen.MostneedleEMGstudiesusethismodetoobserveeventsastheyoccurin time.2)Inthe"triggeredmode",thebeamsitsattheleftsideofthescreenoutofsightuntilitis triggeredtosweepacross.Itimmediatelyreturnstotheleftsidebutdoesnotsweepagainuntilit isagaintriggered.Thismodepermitstimingthesweeptocaptureanevent.Thetimingcanbe settocatchthewaveformwhenthesweepisinthemidportionofthescreen.Allnerve conductionstudiesusethetriggeredmodepressingthestimulusbuttonsimultaneouslysends thestimulustothepatienttoactivatethenerveandtotheoscilloscopetotriggerthesweep.The triggeredmodeisalsousefulduringtheneedleexaminationtocapturemotorunitaction potentialsforexaminationingreaterdetail. 7.52 Amplitude

UnitsfortheYaxisareinportionsofavoltperdivision(mV/divorV/div).SynonymsfortheY axisinclude"gain","amplitude","volts",and"sensitivity".Gainreferstotheamplificationbythe amplifier,andsensitivityreferstothesettingsforthedisplay.Althoughtechnicallytheyreferto differentoperations,practicallytheyareequivalent,andwhichoperationisaccomplishedby changingthesettingsvariesamongEMGmachines. Amplitudesettingsareadjustedtoobservethewholewaveform,withincreasingthesettingsfor lowamplitudesignalsanddecreasingitforhighamplitudesignals.Thereisanorderof magnituderangeofamplitudesettingsforthevariouswaveforms(Figure7..14).Biologicand electronicnoisehasanamplitudeof~45V,anditisdifficulttoextractbiologicsignals<5V withoutusingaveragingtechniques. 7.53 DisplaySettingsforNerveConductionStudies

Thegoalistodisplaywaveformsoptimally,thatis,maximallyspreadoutintimeandvoltage acrossthegrid.MostnerveconductionandEMGwaveformsfallintolimitedrangesoftimeand voltageandappropriateXandYaxisvaluesareeasilydetermined. MostnewEMGmachines automaticallyselecttheappropriatedisplaysettings.Attimesitisadvantageoustochangethe settingstoobservecertainphenomena. Timebase:Distallatencyvaluesfromstimulatingatthewristoranklefornormalsensoryand motornerveconductionstudiesareupto6msec,andmostproximallatencyvaluesfrom stimulatingattheelbowandkneeareupto13msec.Xaxissettingsof2msec/divprovide20 msecoftotalviewingtime,whichisusuallyadequatetoobservethewaveforms(Figure7.15). Withstimulationatmoreproximalsites,suchastheaxillaandfromErb'spoint,latenciesmay exceed20msec,requiringachangeto5msec/div.However,someneuropathieshavea prominentcomponentofdemyelinationresultinginveryslowconductionvelocities,anddistal latenciesmaybelongerthan20msec,andthesweepspeedshouldbeincreasedto5msec/div whenademyelinatingneuropathyisaconsideration. Fwavelatenciesare28msecorgreaterforupperextremitynervesand48msecorgreaterfor lowerextremitynerves.Sweepspeedsmustbeadjustedaccordingly,to5msec/divforupper and10msec/divforlowerextremitynerves. Amplitude:Normalsensorynerveactionpotential(SNAP)amplitudesrangefrom6to30 microvolts(V)andasensitivityof10v/divisappropriate.Midpalmarsensoryresponsesmay reachamplitudesgreater100v,andadjustmentsmustbemadeaccordingly.VerylowSNAP responses,<4V,aredifficulttorecordfrombecausethenoiselevelis~4V,andaveraging techniquesarenecessary., Normalmotornervecompoundmuscleactionpotential(CMAP)amplitudesrangefrom2to12 millivolts(mv)andasensitivityof2mv/divisappropriate(Figure7.15).CMAPresponsesmaybe

ofverylowamplitudeinpathologicstates,andthedisplaysensitivityshouldbeincreasedto500 V/divisaxonalpathologyissuspected. Fwaveamplitudesare100to500v,andsettingthegainorsensitivityto200v/divis reasonable. 7.54 DisplaySettingsforNeedleEMGStudies

Timebase:TheneedleEMGstudyiscommonlyviewedinafreerunorrealtimemode.Itis practicaltousea10msec/divsweepspeedbecauseat5msec/divsuccessivetraces superimposeoveranditisdifficulttodiscernactivityclearly,andat20sec/divtherearegapsin thetraceasitmovesalong(Figure7.16).Anadditionaladvantageofusing10sec/divsweep speedsisthatthedischargefrequencyofmotorunitactionpotentials(MUAP)canbeestimated (seeSectionX). MUAPscanbeisolatedandviewedingreaterdetailusingavoltagetriggeranddelayline(see SectionX).Undertheseconditions,asweepspeedof2to5msec/divgivemaximaldetail. Amplitude:TheneedleEMGisperformedintwostages.Thefirstisassessmentofabnormal spontaneousactivityperformedinthefreerunmode.Abnormalspontaneousactivity,intheform ofpwavesandfibrillationpotentials,hasawideamplituderange,from5toover200v.Inorder todetectlowamplitudeabnormalspontaneousactivityitmaybenecessarytouse20v/div.The secondisassessmentofMUAPrecruitmentpatternsandgeneralMUAPwaveform configurations.TheamplitudeofnormalMUAPsvariesamongmuscles,andrangesfrom800to 1500v.Itisreasonabletoslowlyincreasethesensitivityinsteps,untiltheMUAPsoccupythe wholescreen,asopposedtoimmediatelychangingto200v/div.Inthetriggeredmode,the sensitivityshouldbeadjustedtoviewtheMUAPmaximally. CommontimeandvoltagesensitivitysettingsareinTable7.2. 7.55 RasterandSuperimposedSweeps

Sweepscanbedisplayedindividually,andrewrittenuntiltheappropriatewaveformisobtained andthensaved.Alternatively,thesame(orsimilar)sweepscanbesavedconsecutivelyasa raster(Figure7.17).Thisisroutinelyusedfornerveconductionstudieswherewaveformsfrom stimulatingatdifferentsitesalongthenervecanbecompared.Itcanalsobeusedduringneedle EMGstudiestoobserveMUAPwaveforminstability.Thesamewaveformscanbecombined togetherinasuperimposedmodefordirectcomparison(Figure7.17). 7.56TriggerandDelayLine InthefreerunsweepmodeduringneedleEMG,waveformactivityisobservedcontinuously. Usually,therearemultiplemotorunitsdischarging,sometimespresentatthesametimeand superimposingonthemselves,makingseparatedobservationdifficult.Further,thesweepspeed isusuallyrelativelyslow(10msec/div)anddetailsofthewaveformsaredifficulttodiscern.There aretwoelectronicfeaturesoftheEMGmachinethatcanbeusedtocaptureseparatemotorunit waveformsanddisplaythemingreaterdetail. Thereisanadjustablevoltagetriggerthatcanbesetsothatwhenthevoltageofthewaveform exceedsthesetvaluethesubsequentportionsofthewaveformoccurringlaterintimecanbe displayedonasecondoscilloscopescreen(Figure7.19).Thevoltagethresholdcanbesetfor eithernegativeorpositiveportionsofthewaveform.Itisthereforepossibletoadjustthetrigger thresholdup(negativeonthescreen)ordown(positiveonthescreen)todetectamotorunit waveformandisolateitfromothermotorunitsifsomecomponentexceedsvoltagelevelsof surroundingmotorunits.

Oneproblemisthatcomponentsoftheisolatedwaveformthatoccurredbeforethevoltage crossedthetriggerthresholdwillnotbecaptured(Figure7.19).Thiscanberesolvedbyuseof thedelayline.EMGmachineshaveamemorymodule(Figure7.01)thatstoresalimitedtime segmentofdata.Thus,atthetimethatthevoltagecrossesthetrigger,themachinecanretrieve theearliercomponentsofthewaveform.Generallyitissufficienttolookbackintime4to8msec toseethewholemotorunitwaveform.Itisalsopossibletoincreasethetimebaseofthe capturedmotorunittoseeitingreaterdetail. 7.57 WaveformAveraging

Whenabiologicsignaliscontaminatedbyrandomnoise,signalaveragingcanreducesomeof thevariabilityduetonoiseandprovideamoreaccuratewaveform.Theprincipleofaveragingis basedonthefactthattheportionofthesignalattributedtonoisewillberandomwhereasthe biologicsignalwillbeinvariant.Thus,ifthesignalisaveragedtherandomchangeswillaverage tozeroandthebiologicchangeswillbepreserved(Figure7.20).Averagingisusefultodelineate lowamplitudesensorysignalsandtoclarifytheonsetandterminationportionsofMUAP waveforms. 7.6 NerveStimulation

Electricalstimulationofanerveisperformedtoassessconductionvelocityandestimatethe numberoffunctioningnervefibers.Twopolesofastimulatingelectrodeareappliedtotheskin overthenerve(percutaneousstimulation).Squarewavepulsesofcurrentaredelivered.Both thedurationandtheamplitudeofthepulsescanbeadjustedpulsedurationrangesfrom0.01to 1.0msecandamplitudefrom0to100mA.Thetwopolesoftheelectrodearetheanode (positive)andcathode(negative).Thepulseofcurrentpassesthroughtheskinandnerve coverings.Forasinglenervefiber,thecurrentcausinganexcessofpositivechargesunderthe anoderesultinginhyperpolarizationofthenervefibermembrane,andasubsequent depolarizationofthememebraneunderthecathode(Figure7.21).Whenthedegreeof depolarizationatanodeofRanvierissufficienttoopenvoltagegatedsodiumchannelsinthe nervemembrane,anactionpotentialisgeneratedandpropagatesinbothdirectionsalongthe fiber.Attheanode,theactionpotentialwillreacharegionofhyperpolarizationandmaydieout. Thusitisimportanttoorientthestimulatingelectrodesuchthatthecathodeisclosertothe recordingelectrodestopreventanodalblockofimpulses. Electricalstimulationisappliedtoawholenerve,activatingallnervefibers.However, measurementsoftiming(distallatency,conductionvelocity,Fwavelatency)assessonlythe fastestconductingfibers.Thedurationoftheresponseprovidessomemeasureofthe conductionvelocitiesoftheremainingfibers.Theamplitudeoftheresponseisanestimateofthe numberofnervefiberscontributingtotheresponse. Thegoalduringnerveconductionstudiesistousetheleastcurrentthatactivatesallfibersinthe nerve.However,inthecontextofclinicalnerveconductionstudiesthetermsupramaximal stimulationcurrentis120%ofthatneededtoachieveamaximalresponse(Figure7.18). Currentsabovesupramaximalresultsinanodaljumpingwhichshortensthelatency,andpossible activationofactivateneighboringnerves.Itisrarelynecessarytousestimulationcurrents>50 mAinamplitudeor>0.1msecinduration,exceptinpathologicalconductions.

SECTION7: INSTRUMENTATIONFIGURES

Figure7.01 ComponentsofanEMGmachine:differentialamplifier,filters,digitalanalogconverter,computer withsoftwareprograms,oscilloscope(display),andelectricalstimulator.

Figure7.02 DiskandringelectrodesusedtorecordSNAPfromnerveandCMAPfrommuscle.

Figure7.03 ChangeinSNAPamplitudewithdifferentdistancesbetweenrecordingandreferenceelectrodes. Left:Changeindistancebetweenringelectrodes.Right:Changeindistancebetweendisk electrodes.

Figure7.04 Compositedrawingofmusclesinthethenareminence.Themotorpointofeachmuscleisunique tothatmuscle.A:Abductorpollicis.B:Flexorpollicisbrevis.C:Opponenspollicis.The optimumpositionoftherecordingelectrodeforallmusclesisdeterminedempirically.

Figure7.05 ChangeinCMAPwaveformwithdifferentrecordingelectrodepositionsoveramuscle.By convention,deflectionbelowbaselineispositiveanddeflectionabovebaselineisnegative. Waveformwithinitialpositivedeflectionindicatesrecordingelectrodesomedistanceawayfrom motorpoint.Waveformswithinitialnegativedeflectionindicateproperrecordingelectrode position,butoptimumelectrodepositionnotedbyhighestamplitudeandsteepestslopetothe waveform.

Figure7.06 Intramuscularelectrodesshowingarrangementofactiveandreferenceelectrodes.A:Concentric electrodewithcentralactiveandcannulareferenceelectrodes.B:Monopolarelectrodewith activeconicaltipelectrodeandseparatereferenceelectrode.C:Singlefiberelectrodewithsmall activeelectrodeatsideportandreferencecannula.D:Macroelectrodewithlargecannulaas activeelectrodeandseparatereferenceelectrode.Asinglefiberelectrodeactsasseparate electrodetomarkthemotorunit.

Figure7.07 Diagramofdifferentialamplifier.A:Internalarrangementconsistingoftwoamplifiersconnected ininverserelationship.B:Mergedintooneamplifier.

Figure7.08 Operationofdifferentialamplifier.A:Active(G1)inputreceivesbiologicnegativevoltageand reference(G2)receiveszerovoltage,resultinginoutputshowingfullbiologicvoltage.B:Active inputreceivesbiologicvoltage,butreferencealsoreceivespartialbiologicvoltage,resultingin outputshowingreducedvoltage.

Figure7.09 Commonmoderejectionfeatureofdifferentialamplifier.Activeinputreceivesbiologicsignal superimposedon60Hzsinenoiseandreferenceinputreceivesonly60Hzsinewavenoise, resultinginrejectionofcommon60Hznoise.

Figure7.10 ConstituentsinewaveformsidentifiedbyFourieranalysis. A:Originalsquarewaveformcanbe decomposedintocomponentsinewavesthatcanberecombinedtoapproachoriginalwaveform (onlythreecomponentsshown).B:Similardecompositionandrecombinationformorecomplex waveform.Waveformstotherightrepresentpartialrecombinations.

Figure7.11 Filterfrequencycurves.Xaxis:Filterfrequencyfromlow(left)tohigh(right)values.Yaxis: Amplitudeoffilteredresponsebasedonoriginal(unfiltered)amplitude.Lowfrequency(high pass)filtercurveattheleft,andhighfrequency(lowpass)filtercurveattheright.Nomenclature istodesignatefiltervaluewherethesignalisreducedby30%.60Hznotchfiltercurveinthe middle.

Figure7.12 SinewavecomponentsofSNAP,CMAPandMUAPwaveforms.Beloweachwaveformarea seriesofsinewavesofdifferentfrequenciesandamplitudesthatrepresentthedominant componentfrequencies.

Figure7.13 Oscilloscopegrids.Top:SquaregridwithXaxisindicatingtime(msec/div)andYaxisindicating voltage(mVorV/div).Bottom:Rectangulargrid.

Figure7.14 Scaleofwaveformamplitudeswithrangeofnormalvalues.Noise:<5V.SNAP:6to50V. CMAP:2000to20000V(2to20mV).MUAP:600to2000V(.6to2mV).

Figure7.15 OptimizingXaxisandYaxissettingsinnerveconductionstudies.A:Xaxissettings.Top:5 msec/div,tracecompressed.Middle:2msec/dib,usualsweepspeed.Lower:1msec/dib,trace toospreadout.B:Yaxissettings.Top:2mV/div,traceamplitudeexceedsdisplaycapabilities andwaveformisclipped.Middle:5mV/div,usualsetting.Bottom:10mV/dib,tracecompressed.

Figure7.16 EffectofdifferentXaxissweepspeedsduringneedleEMGstudy.A:5msec/divwithoverlapof successivesweeps.B:10msec/divwithseparationofsweeps.C:20msec/divwithxx

Figure7.17 Rasterandsuperimposedwaveformdisplay.Topfourwaveformsinrasterformatbottomfiber superimposeddisplayofthefourwaveforms.A:CMAPshowingprogressionoflatenciesand waveformswithstimulationatsuccessivelymoreproximalsites.B:MUAPshowingvariabilityof satellitepotential.

Figure7.19 Voltagetriggeranddelayline.A:Sweepinfreerunmode.Horizontallineatleftindicates voltagetriggerlevel.B:B1showssweepthatoccursafterwaveformhascrossedtriggervoltage level.However,theearlyportionofthewaveformislost.B2andB3showstheeffectsofthe delayline(memory)allowingsuccessivelyearlierportionsofthewaveformtobedisplayed.C: WaveforminA,nowcapturedbythevoltagetriggeranddelaylineanddisplayedat2msec/div.

Figure7.20: Effectsofaveraging.A:SNAP.1and2:Verylowamplitudesignal(20V/div).3:SNAP presentbutcontaminatedbynoise(5V/div).4:Signalaveraged6timesresultinginmoreclear inflectionpoints.B:MUAP.1:Averagedwaveformwithclearboundariesformarking(vertical lines).2:Superimposedwaveformsthoseinboldwereusedintheaverage,thoseinlightwere not.Notethevariabilityofwaveformsinlightthatwouldhavecontaminatedthewaveform.

Figure7.21 Ioncurrentsinvolvedinelectricalstimulationofanerve.Anode:Membranehyperpolarization. Cathode:Membranedepolarization,andifsufficienttoexceedathresholdanactionpotentialis generated.

Table7.1 Commonfiltersettingsforelectrodiagnosticstudies. Mode Sensorynervestudies Motornervestudies Sudomotorpotentialstudies NeedleEMGstudies Singlefiberneedlestudies Lowfrequency(Highpass) 20Hz 2Hz 0.2Hz 20Hz 500Hz Highfrequency(Lowpass) 2KHz 10KHz 1.5KHz 10KHz 10KHz

Table7.2 Commontimeandvoltagesensitivitysettingsforelectrodiagnosticstudies. Mode Sensorynervestudies Motornervestudies Fwavestudies Sudomotorpotentialstudies NeedleEMGstudies Singlefiberneedlestudies Timebase 2msec/div 2msec/div 5or10msec/div 1sec/div 10msec/div 1msec/div Voltage 10V/div 5mV/div 200V/div 500V/div 20to200V/div 200V/div