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Electrophysiological Evaluation Procedures

Electrophysiological Evaluation Procedures

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ELECTRODIAGNOSTIC PROCEDURES 
Sagar Naik,
 
PT
 2
 Electrophysiological Evaluation (Electrodiagnosis)
Sagar Naik,
PT
 
Changes in Electrical Reactions: 
When there is disease or injury of motor nerves or muscles, alterations are liable to occur in their response to electrical stimulation.
Reduction or loss of voluntary power of a muscle may be due to:
A lesion of the upper motor neuron
A lesion of the lower motor neuron
 
Damage to the muscle itself 
 
A fault at the neuromuscular junction (NMJ)
A functional disorder
 
 
Upper motor-neuron lesions:
 
When there is a lesion of the upper motor neuron, there are no changes in the lower motor neuron, which would lead to altered electrical reactions.
 
Consequently, a normal type of response is obtained with electricalstimulation, although sometimes the nerve and muscle are hyper-excitable andreact to a lower intensity of current than that normally required.
 
 Lower motor-neuron lesions:
 
 Damage to a lower motor neuron may involve either the anterior horn cell  or the fibres of the nerve roots or peripheral nerves.
 
Lesions involving the nerve-fibres can be classified into three groups:
 
 Neurapraxia (First-degree Injury):
 
 It is a condition in which bruising or pressure renders the nerveincapable of conducting impulses past the site of the lesion, but the damage is not severe enough to cause degeneration of the fibres.
 
If the electrical reactions are tested on the affected muscles a normal typeof response is obtained, but there is loss of response to a stimulus applied tothe nerve trunk above the lesion.
As there is no permanent damage recovery occurs rapidly in few days orweeks.
 
 Axonotmesis (Second-degree Injury):
 
 More severe compression injury may cause sufficient damage to the nerve axon so that it is unable to support the metabolic processes of its distal part, resulting in degeneration of the whole length of the nerve
 
ELECTRODIAGNOSTIC PROCEDURES
Sagar Naik,
 
PT
 3
 fiber, including the myelin sheath, distal to the lesion.
This process iscalled
Wallerian Degeneration
.
It takes some days to extend throughout the distal part of the nerve so thatfor perhaps 3 or 4 days or more the distal section of the nerve remainsexcitable and can conduct impulses.
The fibrous framework of the bundle of nerve fibres remains intact and fillswith a chain of Schwann cells so that ultimately nerve are guided in theirproper channels to reform the complete nerve processes.
This kind of injury is called an
 axonotmesis
.
The length of time needed for full recovery to occur will depend on the siteof the lesion and the length of nerve that has to grow.
An example of this type of lesion may be observed in a radial nerve palsyassociated with fractured shaft of the humerus.
 
 Neurotmesis (Third-degree Injury):
 
 If, instead of compression, the injury is such as to disrupt all tissues of  the nerve fiber – such as a cut through the nerve – then the distal  segment will degenerate completely.
 
Since the tissues are totally disrupted the axon filaments will not readilyfind correct channels down which to regrow so that recovery is at bestimperfect.
This lesion is called a
 neurotmesis
.
Such lesions often require surgery to ensure that the two cut ends aresufficiently approximated to allow successful growth.
A lesion of this type would be observed if ulnar nerve were severed by acut on the front of the wrist.
All these types of nerve lesion may be partial or complete, and there may bea combination of two of them.
If all the nerve fibres supplying a muscle degenerate, the reactionscharacterizing
 complete denervation
are observed, while if only some of thefibres degenerate the reaction is that of 
 partial denervation
.
 
The reactions observed in lesions of the anterior horn cells depend on theextent of the damage.
 
 Defects of the Neuromuscular Junction (NMJ):
Occasionally, as in the disease
 myasthenia gravis
, reduction of voluntarypower is due to faulty conduction at the neuromuscular junction.
Methods other than electrical stimulation provide the most satisfactory aids todiagnosis of such conditions.
 
ELECTRODIAGNOSTIC PROCEDURES
Sagar Naik,
 
PT
 4
 
 
 Muscle Lesions:
 
 If reduction of voluntary power is due to weakness or disease of the muscle and there is no degeneration of the motor nerve, the reactions to electrical  stimulation are of normal type but are reduced in strength.
 
Should the lesion be so severe that there is complete loss of muscle tissue;there will be no response to electrical stimulation.
This absence of response may occur in such conditions as ischaemiccontracture or in the advanced stages of the myopathies, or may be duefibrosis of muscles in longstanding denervation.
[
Myopathy:
Any abnormality of the muscular tissue especially involvingthe skeletal muscles is known as myopathy.]
 
Functional Disorders:
Loss of voluntary power may be due to
 hysterical paralysis
, in which casethere is no alteration in the electrical reactions.
[
Hysterical Paralysis:
Loss of movement without any organic cause isknown as hysterical paralysis.]
Strength – Duration Curves: 
The plotting of strength – duration curves, which indicate the strength of impulses of various duration required to produce contraction in a muscle, is the most method for the testing of electrical reactions in peripheral nerve lesions. The advantages of this method of testing electrical reactions are that it is simple and  reliable and indicates the proportion of denervation, while a series of tests shows changes in the condition. Its disadvantages are that in large muscles only a proportion of the fibres may respond so that the full picture is not clearly shown, and that it does not indicate the site of the nerve lesion.
However, the site may bedetermined by testing nerve conduction.
The strength – duration relationship can be determined by applying rectangular pulses of differing pulse widths to a peripheral nerve. The current required to produce a muscle twitch is recorded along with the relationship between the intensity of the current required to produce a muscle contraction and  the time for which it is applied. This test has clinical applications and can be used  to determine the state of innervation and to monitor reinnervation of skeletal  muscle following trauma to peripheral nerves.
Strength – duration tests are used mainly for motor nerve assessment,although similar methods can be employed in sensory nerve testing.

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