ELECTROMYOGRAPHY

EMG- BIOFEEDBACK
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ELECTROMYOGHAPHY
ELECTRO + MYO + GRAPHY

ELECTRICITY

MUSCLE

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DEFINITION 


Study of motor unit activity Recording of AP of muscle fibres firing near the needle electrode in a muscle

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INTRODUCTION
Luigi Galvani ± 1791 EMG  Clinical EMG  Kinesiology EMG

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MOTOR UNIT

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SIZE PRINCIPLE
The muscle contraction depends on the ³size principle´ It states that ³the motor neurons are recruited in order of size from small to large´
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MOTOR UNIT ACTION POTENTIAL 8 .

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Recording an EMG includes 3 phases system Input phase Processor phase Output phase 10 .

INSTRUMENTATION ELECTRODES Surface electrodes Needle electrodes Fine wire indwelling electrodes 11 .

FINE WIRE INDWELLING ELECTRODE 12 .

SURFACE ELECTRODES 13 .

NEEDLE ELECTRODES CONCENTRIC MONOPOLAR SINGLE FIBRE MACRO 14 .

3 ELECTRODES ARE USED ACTIVE ELECTRODE REFERENCE ELECTRODE GROUND ELECTRODE 15 .

CONCENTRIC NEEDLE ELECTRODE Commonly used 24-26gauge needle with a fine wire in its lumen Oval recording area of 125-580Qm2 Active electrode is referred to the shaft of the needle thus reducing the noise of the muscle 16 .

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MONOPOLAR Solid 22-30 gauge Teflon coated needle with a bare tip of approx 500 Qm MUPs are of slightly higher amplitude and longer duration compared to concentric 19 .

2. 2.1. ADVANTAGESLess painful Cheaper DISADVANTAGESNeed for a reference electrode Greater background noise 20 . 1.

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5-0.SINGLE FIBER Steel cannula of 0.6 mm diameter inside which 1-14 insulated platinum or silver wires are placed and taken out at a side port 1-3mm behind the tip Electrodes are embedded in epoxy resin SFN electrode records from a small area of 25Qm 22 .

It records from a small area hence it cannot be used for estimation of the motor unit size.The recording area is referred to the shaft of the needle DISADVANTAGES. To study neuromuscular transmission abnormality and fibre density. 23 .

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Made of a 15mm shaft of a needle Records from a large number of muscle fibres which are innervated by a number of motor units along the shaft of the needle The recording from one motor unit is separated by using a single fibre needle attached to macro electrode in the mid shaft. MACRO NEEDLE ELECTRODE 25 .

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Amplifier.converts the electrical potential seen by electrodes to a voltage signal large enough to be displayed Differential amplifier-Rejects common mode voltages which appear between both input terminals and common grounds AMPLIFYING THE EMG SIGNAL 27 .

It is a measure of how much the desired signal voltage is amplified relative to the unwanted signal 28 .Common mode rejection ratio.

A higher gain will make a smaller signal appear larger on the display 29 .It is the ratio of the wanted signal to unwanted signal Gain.Signal-to-noise ratio.Ratio of output signal level to input level.

Affected byElectrode material Electrode size Length of the leads Electrolyte 30 . which occurs in alternating current circuits. opposing current flow.    Input impedenceIt is a resistive property.

Bandwidth is the difference between highest and lowest frequency that will be processed. Amplifier must be able to respond to signals between 10 and 10000 Hz 31 . Frequency bandwidth.

Displaying the EMG signal The form of output used is dependent on the type of information desired and instrument available 32 .

WAVEFORM DISPLAY 1. 2 forms are used Analog oscilloscope display Computer based digital video display 33 . 2.

EMG- RECORDING & DISPLAY

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FACTORS AFFECTING OUTCOME OF RECORDING
Age of the patients Properties of the muscle under study Limb temperature Electrical specifications of the needle electrodes and the recording apparatus. e.g. filter settings
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INDICATIONS
Neurogenic disorders Neuromuscular junction disorders Myogenic disorders Metabolic disorders

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thrombocytopenia. patient on anticoagulant therapy Localized inflammation Skin lesions 37 .CONTRAINDICATIONS Recurrent systemic infections Bleeding disorders ± hemophilia.

repeated examination causing inflammation and focal myopathic changes.oserum creatinine kinase level. 38 . Transient bacterimia following needle examination may lead to endocarditic in patients with valvular disease or prosthetic valves.

ELECTROMYOGRAPHY EXAMINATION Select the muscle Locate the needle insertion point Insert the needle quickly in a relaxed state Patient briefly activates the muscle to confirm the placement 39 .

ACTIVITIES Insertional Activity Spontaneous Activity Minimal Volitional Activity Maximal Volitional Activity 40 .

Positive and negative high frequency spikes in a cluster are seen. 41 . Spontaneous burst of potentials (muscle fibre depolarization) usually lasting less than 300ms after needle movement ceases.INSERTIONAL ACTIVITY It is the measure of muscle excitability.

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REDUCED IA
Fibrotic muscles- Myopathies Periodic paralysis in case of attacks

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INCREASED IA Denervated muscles Inflammation Myotonia 46 .

Nerve potentials 47 .SPONTANEOUS ACTIVITY MINIATURE END PLATE POTENTIALS(MEPP): End plate noise END PLATE SPIKES.

1-3ms Fire irregularly at 20 ± 40 Hz Characteristic ³sea shell´ sound Frequently seen in association with end plate spikes 48 .MEPP waves Low amplitude negative < 100µv Monophasic Duration .

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rapid Low amplitude Biphasic Initial negative deflection Fire irregularly at 50Hz Characteristic sound ± sputtering or crackling 50 .END PLATE SPIKES Spiky .

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ABNORMAL SPONTANEOUS ACTIVITY FIBRILATION POTENTIAL POSITIVE WAVES COMPLEX REPETITIVE DISCHARGES MYOTONIC DISCHARGES FASCICULATION 53 .

MYOKYMIC DISCHARGES CRAMPS NEUROMYOTONIA 54 .

brief spike potential Duration.regular 55 .1 to 5 ms Stable Firing pattern.FIBRILLATION POTENTIAL       Muscle fibre Low amplitude(10 ± 100 V) Initially positive.

    Firing rate-.5 -10 Hz Often slow down just before stopping Electro physiologic markers of denervation RAIN ON THE ROOF 56 .

10Hz DULL POP 57 .5.POSITIVE WAVES        MUSCLE FIBRE Brief initial positivity followed by long negative phase Amplitude ± variable(10-100 v) Stable Firing pattern regular Firing rate-0.

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may change in discrete jumps 60 COMPLEX REPETITIVE DISCHARGES .    Multiple muscle fibre time locked together High frequency(20.150 Hz) Multiserrated repetitive discharges with an abrupt onset and and termination Usually stable .

MACHINE GUN LIKE SOUND 61 .   Perfectly regular firing pattern Electrophysiologic marker of chronic denervation.

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MYOTONIC DISCHARGES      MUSCLE FIBRE Brief spike or a positive wave Waxing and waning of amplitude and frequency Firing rate.20-150Hz DIVE BOMBER 64 .

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.FASCICULATION      MOTOR UNIT Fire slowly and irregularly Firing rate. LOW PITCHED THUMP 66 .1-10Hz Usually has the morphology of a simple MUAP. but can be large and complex.

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MYOKYMIC DISCHARGES      MOTOR UNIT Fire in a burst pattern.5 -60 Hz (intraburst) 1-5 Hz (intraburst) The burst recur at regular intervals of 0.1 to 10/ sec MARCHING 68 .

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CRAMPS  MOTOR UNIT   Spontaneous discharges of potentials.20-150 Hz(high frequency) Interference pattern or several individual units 70 .

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Decrementing amplitude PINGING 72 .NEUROMYOTONIA     MOTOR UNIT Repetitive discharges of a single MUAP that fire at very high frequency of 150250Hz.

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MINIMAL VOLITIONAL ACTIVITY Motor unit action potentialvoluntary contraction Recruitment 74 .

MOTOR UNIT ACTION POTENTIAL 75 .

PHYSIOLOGIC FACTORS Age Inherent properties of motor unit itself Spatial relationship between the needle and the individual muscle fibres Resistance and capacitance of intervening tissues Intramuscular temperature 76 .

NON PHYSIOLOGIC FACTORS Type of needle electrode Size of the recording surface Electrical properties of the amplifier Choice of oscilloscope sensitivity Sweep or filters Methods of storage and display 77 .

phase.MUAPs Morphology -Amplitude. initial deflection Stability Firing characteristic 78 . duration.

Size and density of the muscle fibre Synchrony of firing . 79 .AMPLITUDE It is measured from peak to peak . 100QV-2mV It is determined by    Primarily by limited number of fibres located close to the electrode tip.

Age of the subject Muscle examined Muscle temperature-Decreasing muscle temperature results in higher amplitude and longer duration of MUPs 80 .

Usually 5-15 ms It reflects the number of muscle fibres within a motor unit and is the most reliable measure to use when judging MUAP morphology.DURATION Measured from initial take off to the point of return to the baseline. 81 .

    The duration of MUP is a measure of Conduction Length of muscle fiber Membrane excitability Synchrony of different muscle fibres of a motor unit 82 .

Duration increases with age and cold temperature. 83 . Distal muscles have longer duration MUAPS than proximal ones .

RISE TIME OF MUP It is the duration from initial positive to subsequent negative peak Indicator of the distance of needle electrode from the muscle fibre <500µs is acceptable 84 .

This indicates the need to reposition needle closer to the muscle fibres 85 .A greater rise time is due to resistance and capacitance of the intervening tissue which acts as high frequency filter and results in dull sound on the loudspeaker of EMG equipment.

86 .PHASE OF MUP It is defined as the portion of MUP between departure and return to the baseline. of baseline crossings +1.i.e no. Typical shape of an MUAP is diphasic or triphasic.

87 .A MUP more than 4 phases is called as polyphasic. The normal MU will fire up to 15/sec with strong contraction.

The satellite potential is generated by a muscle fibre in a motor unit with a long nerve terminal. narrow diameter or distant end plate region 88 .SATTELITE POTENTIAL They are the late potentials which are time locked to the main motor unit potential.

Stable Semi-rhythmic firing pattern 89 .

MAXIMAL VOLITIONAL ACTIVITY  Interferance Pattern 90 .

     The spike density and average amplitude of the summated response are determined by a number of factors: Descending input from the cortex Number of motor units capable of discharging Firing frequency of each motor unit Waveform of individual potentials Probability of phase cancellation 91 .

VARIABILITY IN MUP Short duration Long duration Polyphasic Mixed pattern Doublets and multiplets 92 .

SHORT DURATION The short duration MUPs are those with a duration shorter than that for the muscle of corresponding age Usually have low amplitude and have rapid recruitment at minimal effort 93 .

They are found in the disorders associated with loss of muscle fibres 2 chief pathologies are  Myopathies and neuromuscular junction disorders Early stage of reinnervation after nerve damage 94 .

The duration of MUPs exceeds the normal values for the corresponding muscle & age Have high amplitude & poor recruitment Associated with increase in fibre density. loss of synchrony of firing of muscle fibre & increase in the number of muscle fibre 95 LONG DURATION MUPS .

Seen in  Motor neuron disease  Axonal neuropathies with collateral sprouting  Chronic radiculopathies  Neuropathies  Chronic myositis ±polymyositis 96 .

97 .POLYPHASIC MUP There is 4 or more phases in a MUP Seen in myopathies where there is regeneration of fibres and increased fibre density.

polyphasic MUPs Found in both Myogenic and Neurogenic abnormalities 98 .MIXED PATTERN Comprises of short .long.

tetany.DOUBLETS OR TRIPLETS MUPs are fired 2 or more times at an interval of 10-30 ms Seen when there is hyperventilation. other metabolic diseases ischemia 99 . motor neuron disease.

CLINICAL IMPLICATIONS OF EMG 100 .

O¶sullivan CLINICAL NEUROPHYSIOLOGY UK Mishra DIAGNOSTIC TESTING IN NEUROLOGY Randolph W.REFERANCES PHYSICAL REHABBILITATION: ASSESSMENT AND TREATMENT Susan B. Evans ELECTRODIAGNOSTIC TESTING Kimura 101 .

EMG-BIOFEEDBACK 102 .

Basmajian 103 .DEFINITION  A technique of using equipment (usually electronic) to reveal human beings some of their internal psychological events. normal and abnormal. in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals. John V.

OBJECTIVES AND GOAL  TO IMPROVE MOTOR PERFORMANCE BY FACILITATING MOTOR LEARNING 104 .

PRINCIPLES OF MOTOR LEARNING 105 .

MOTOR LEARNING  SCHIMDT defined it as ³a set of processes associated with practice or experiences leading to relatively permanent changes in the capacity for responding´ 106 .

3. Four primary factors that influence motor learning are Stage of learner Type of the task Feedback Practice 107 . 2. 4. 1.

INTRINSIC FEEDBACK EXTRINSIC FEEDBACKKNOWLEDGE OF RESULTS KNOWLEDGE OF PERFORMANCE 108 .TYPES OF FEEDBACK   1. 2.

an audio speaker and a video display. 109 . an amplifier.EQUIPMENTS USED  The basic EMG biofeedback device includes one ground and two surface electrodes.

The quality of the machine and its output are chiefly governed by        Electrodes used Input impedance Common mode rejection ratio Bandwidth Gain Noise level Ability to cope with non EMG artifacts 110 .

TECHNICAL LIMITATIONS    RELEVANCY ACCURACY RAPID TO ENHANCE MOTOR LEARNING 111 .

BIOFEEDBACK IN REHABILITATION 112 .

When using the biofeedback the patient should Understand  Practice  Perform  113 .

   CLOSE LOOP OPEN LOOP SCHEDULED LOOP 114 .

3. Providing a process oreinted. Providing a clear treatment outcome Permitting the therapist and patient to experience with various strategies that generate motor patterns Reinforcing appropriate motor behavior. 2.Biofeedback can assist rehabilitation process by: 1. 4. timely and accurate KP or KR of the patients¶ efforts. 115 .

CONDITIONS        STROKE SPINAL CORD INJURIES CP AND TBI MULTIPLE SCLEROSIS DYSTONIAS AND DYSKINESIS PERIPHERAL NERVE DENERVATION PAIN MANAGEMENT 116 .

THERAPEUTIC INTERVENTION 117 .

TREATMENT SESSION    PATIENTS FUNCTIONAL ASSESSMENT PROBLEM IDENTIFICATION THERAPEUTIC INTERVENTION 118 .

O¶sullivan BIOFEEDBACK PRINCIPLES AND PRACTICE FOR CLINICIANS John V. Basmajian PHYSICAL MEDICINE AND REHABILITATION-PRINCIPLES & PRACTICE Joel A. Delisa 119 .REFERANCES PHYSICAL REHABBILITATION: ASSESSMENT AND TREATMENT Susan B.

THANK YOU 120 .