Handbook of Clinical Neurology, Vol.

160 (3rd series)

Clinical Neurophysiology: Basis and Technical Aspects
K.H. Levin and P. Chauvel, Editors
https://doi.org/10.1016/B978-0-444-64032-1.00016-3
Copyright © 2019 Elsevier B.V. All rights reserved

Chapter 16

Needle electromyography: Basic concepts

DEVON I. RUBIN*
Department of Neurology, Mayo Clinic, Jacksonville, FL, United States

Abstract
Needle electromyography (EMG) is the technique of recording and analyzing the electrical signals derived
from individual muscle fibers of motor units, at rest and during voluntary contraction, using a needle
recording electrode inserted into the muscle. Needle EMG entails inserting a needle electrode into a
muscle, recording and amplifying the electrical signals generated from resting or contracting muscle
fibers, and interpreting the signals to determine the function of the muscle fibers and motor units. Many
factors affect the recorded signals during needle EMG, including the types of needle electrodes and filters
and amplifier settings. Different semiquantitative and quantitative methods of analysis of the recorded
signals are available, each with advantages and disadvantages. While needle EMG is a safe technique,
potential risks include pain, bleeding, and pneumothorax.

NEEDLE ELECTROMYOGRAPHY
OVERVIEW
The primary goals of an electrodiagnostic examination
are to determine the presence and type of neuromuscular
disease, as well as provide information about the locali-
zation, temporal course, pathophysiology, and severity
of the disorder. Nerve conduction studies (NCSs) pro-
vide some information about the integrity of the motor
unit by recording the summated electrical field generated
from muscle fibers over the surface of a muscle following
nerve stimulation. While a reduction in the amplitude
of this recorded compound muscle action potential can
suggest a problem involving the peripheral nerve, neuro-
muscular junction, or muscle, an NCS alone cannot
define the type of disorder.
Needle electromyography (EMG) is the technique of
recording and analyzing the electrical signals derived
from individual muscle fibers of motor units, at rest
and during voluntary contraction, using a needle record-
ing electrode inserted into the muscle. Needle EMG pro-
vides information that cannot be obtained through an
NCS alone, about the function and distribution of muscle
fibers and motor units. In some conditions, such as focal
mononeuropathies or polyneuropathies, an NCS may
provide more useful information than needle EMG, such
as localizing to a focal site along a nerve or determining
whether the primary pathology is demyelination or axo-
nal loss. In other situations, such as radiculopathies,
myopathies, or motor neuron diseases, the needle exam-
ination provides more useful, and sometimes the only,
diagnostic information. In most cases, the combination
of findings from an NCS and needle EMG is necessary
to fully determine the presence, underlying pathophysi-
ology, chronicity, and severity of a neuromuscular
disease.
Many factors contribute to the waveform morphol-
ogies recorded during needle EMG. These include tech-
nical factors, including the type of needle electrode,
amplifier, and filter settings, as well as the muscle exam-
ined, patient age, and location of the needle electrode rel-
ative to the end-plate zone. Technical skills, such as
needle movement, ability to isolate individual potentials,
and the examiner’s pain reduction techniques, also con-
tribute to the quality of the recorded signals. Knowledge
of the technical factors, as well as muscle anatomy and
innervation, appropriate pain reduction skills, and the
ability to recognize and understand the significance of
the electrical signals that are recorded from normal

*Correspondence to: Devon I. Rubin, M.D., Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224,
United States. Tel: +1-904-953-7104; Fax +1-904-953-0757, E-mail: rubin.devon@mayo.edu
244 D.I. RUBIN
muscles and those affected by neuromuscular disorders,
are necessary for accurate performance of needle
EMG. This chapter reviews the basic concepts of needle
EMG. Subsequent chapters will detail the types of spon-
taneous EMG waveforms and voluntary motor unit
potentials (MUPs).
ANATOMIC AND PHYSIOLOGIC
CONCEPTS FOR NEEDLE EMG
Needle EMG records the electrical signals derived from
the action potentials of individual muscle fibers. The
motor unit—defined as one anterior horn cell, its motor
axon and nerve branches, their neuromuscular junctions,
and all of their innervated muscle fibers—forms the basic
functional structure from which all of the signals are
recorded (Buchthal, 1957; McComas et al., 1971;
Enoka, 1995). Some recorded waveforms that occur in
a resting muscle are generated from only single muscle
fibers (e.g., fibrillation potentials or end-plate spikes),
but the waveforms recorded during voluntary activation
are generated from numerous muscle fibers of a motor
unit. The anatomic configuration and distribution of
motor units and their innervated muscle fibers within a
muscle, along with the recording area of the needle elec-
trode, contribute to the signals recorded during needle
EMG. Each muscle is composed of a variable number
of motor units, ranging from 100 to 500 in extremity
muscles (McComas et al., 1971). The number of muscle
fibers innervated by each individual motor unit varies
widely, ranging from less than 10 in extraocular muscles
to over 2000 in the medial gastrocnemius (Feinstein
et al., 1955; Gath and Stalberg, 1981). Furthermore,
the territory of any one motor unit, or the distribution
of the fibers throughout the muscle, is approximately
2–10 mm in many limb muscles and the fibers of at
least 6 or more different motor units are interspersed
with one another in a single region of a muscle, with
approximately 3 fibers/mm2 (Buchthal, 1957; Hilton-
Brown et al., 1985; Stalberg et al., 1986; Stalberg and
Dioszegy, 1991). These factors—number of motor units,
density of fibers of a single motor unit in a region of the
muscle, and spatial distribution of the fibers of a single
motor unit through the muscle—contribute to the number
of individual fibers recorded with a needle electrode.
Muscle fibers are electrically “silent” at rest outside of
the end-plate zone. The resting membrane potential of a
muscle fiber is approximately 90 mV, resulting from
unequal distribution of sodium and potassium across the
membrane and the role of the ATP-dependent Na+/K+
pump. When voltage-gated Na+ channels in the sarco-
lemma are activated following release of acetylcholine
from the nerve terminal, a change in the membrane poten-
tial results in the generation of an action potential, which
subsequently propagates along the muscle fiber, produc-
ing an electrical field that can be recorded. The electrical
fields generated by these shifts in sodium and potassium
ions during action potential development and propagation
along the muscle fibers are influenced by the fiber diam-
eter (Stalberg and Karlsson, 2001). The average diameter
of a normal muscle fiber varies between muscles, ranging
from 5 to 90mm. The electrical fields are most concen-
trated close to the muscle fiber membranes and the
strength of the electrical signals drops significantly the fur-
ther the distance from the muscle fiber membrane
(Stegeman et al., 1994). Simulation studies have demon-
strated a linear and prominent decrease in spike amplitude
of a motor unit with electrode distances up to 1 mm from
the muscle fibers, and the spike amplitude is primarily
determined by the electrical signals of fibers within
0.5 mm of the electrode (Nandedkar et al., 1988b). While
these electrical signals can be recorded with surface elec-
trodes, they may be distorted by intervening tissue and dis-
tance between the muscle fibers and the skin. Therefore,
surface electrodes are less reliable than needle electrodes
in displaying the morphology of individual action poten-
tials. An evidence-based review of the utility of surface
electromyography in the diagnosis of neuromuscular dis-
eases concluded that there was insufficient evidence to
determine the clinical utility of surface EMG over conven-
tional needle EMG in distinguishing between neurogenic
and myopathic disorders (Meekins et al., 2008). Surface
EMG is used primarily in the assessment of movement
disorders, such as during tremor analysis, and may be use-
ful in the assessment of fatigue in post-polio syndrome or
studying electromechanical coupling in myotonic dystro-
phy (Meekins et al., 2008). Needle electrodes are most
commonly used during clinical EMG. When recording
the MUPs, since the innervation ratio, distribution of
fibers though the muscle, and muscle fiber diameter vary
within and across muscles, the recorded signals are par-
tially dependent on the type, and specifically the recording
(or pick up) area, of the electrode.
NEEDLE RECORDING ELECTRODES
In most clinical practices, needle electrodes are used to
record the electrical signals from muscle fibers. Needle
electrodes have the advantage of recording the electrical
field immediately adjacent to the fiber membranes
generating the action potentials, thereby recording the
highest amplitude potentials that can be most reliably
analyzed. There are several types of needle EMG record-
ing electrodes, each possessing different characteristics,
including recording surface and pickup areas, sizes, and
costs (Fig. 16.1; Table 16.1). Monopolar and concentric
needle electrodes are most commonly used in clinical
practice.
 NEEDLE ELECTROMYOGRAPHY: BASIC CONCEPTS 245

Fig. 16.1. Schematic of the recording area of a monopolar (A), concentric (B), and single-fiber (C) recording electrode.

Table 16.1
Differences in Recording Electrodes

Monopolar Concentric Single fiber Macroelectrode

w (mm2) 0.28–0.34 0.03–0.07 (25–50 mm needle) 0.0005 26.0

(25–50 mm needle)
Recording radius (mm) 1.5 1.5 0.3 >20
MUP size Larger than concentric Smaller than monopolar Very small Large
(single muscle fiber) (entire motor unit)
Costa $7/needle $11/needle $414/needle
a
NatusNeuroStore, 2017.

Monopolar electrodes
The monopolar electrode is composed of a solid Teflon-
coated fine stainless steel 22- to 30-gauge needle. The
bare tip of the electrode is the active recording site and
is approximately 500 mm in diameter. The recording area
is symmetric, oval shaped, and approximately 0.3 mm2.
Current EMG machines use differential amplifiers to
amplify the difference in the electrical signals between
the active recording site of an electrode and a reference
site, which has the benefit of reducing signals that are
common to both sites such as nonphysiologic noise.
When a monopolar electrode is used, the reference is usu-
ally a surface electrode placed on the skin surface of the
limb being examined.
The MUPs recorded by a monopolar electrode are of
slightly longer duration (up to 1.86 longer) and higher
amplitude (up to 2 higher) than with a concentric needle
electrode (Chu et al., 1986; Howard et al., 1988; Chan and
Hsu, 1991; Dumitru et al., 1997). This difference results
from several factors, including: (1) a larger recording
surface, (2) recording from the entire area around the
needle tip rather than the fibers primarily facing the bevel,
and (3) the longer distance between the active and refer-
ence electrodes, which produces less cancellation of the
signals from distant muscle fibers (Guld, 1951; Buchthal
et al., 1954a,b; Stalberg et al., 1986; Chan and Hsu, 1991;
Dumitru et al., 1997) (Fig. 16.1A). The number of poly-
phasic MUPs recorded with monopolar needles compared
to concentric needles has been shown to be increased
in some studies, but others have not shown significant
differences between the two (Chu et al., 1986; Chan and
Hsu, 1991). Monopolar electrodes are less expensive than
concentric needle electrodes and, depending on the tech-
nique of needle movement, may be better tolerated by
246 D.I. RUBIN
patients (Strommen and Daube, 2001). Since the distance
between the active recording needle tip and the reference
surface electrode is longer than in concentric needles,
more electrical interference and less stable baselines are
recorded than concentric needles.
Concentric electrodes
The concentric needle electrode is composed of a bare,
24- to 28-gauge (0.30–0.45 mm diameter) hollow needle
with a beveled tip. The electrode contains a fine, insulated
wire down the center, which is exposed at the bevel and
is the active recording surface (125mm  580mm). Concen-
tric needles are produced in different sizes. The smallest
electrodes have a length of 25 mm (30 gauge) and are used
in infants, during examination of small, thin muscles such as
facial muscles, and during concentric needle single-fiber
EMG. The largest electrodes have a length of 75mm (23
gauge) and are used in obese patients, particularly when
some deep muscles need to be examined. The majority of
muscles in most patients can be reached adequately with
a 50-mm (26 gauge) concentric needle electrode. While
direct comparison of the recorded signals between all sizes
of the concentric needle electrode has not been systemati-
cally made, a comparison of the 25-mm to the 37-mm needle
demonstrated no clinically significant or consistent differ-
ences in MUP features (Brownell and Bromberg, 2007).
In concentric needle electrodes, the active recording
site is referenced to the electrode shaft. This very close
proximity of the active to the reference sites results in
cancellation of noise common to both recording sites,
but also cancels out signals of some of the more distant
muscle fibers (Fig. 16.1B). This, along with the asym-
metric pickup area, results in MUPs that are slightly
lower in amplitude and shorter in duration than the MUPs
recorded with a monopolar needle (Chan and Hsu, 1991).
In general, the concentric needle records muscle fiber
action potentials that are within about 2.5 mm from the
recording needle tip. During voluntary MUP analysis,
the fibers that are closest (within 0.5 mm) to the tip gen-
erate the main spike and the amplitude of the MUP, while
those that are between 0.5 and 2.5 mm contribute more of
the “tails” of the MUP (Stalberg et al., 1986).
Single-fiber electrodes
Single-fiber electrodes are used primarily for assessment
of neuromuscular transmission or fiber density. The
single-fiber electrode is composed of a stainless steel,
0.4–0.6 mm diameter needle with a very small insulated
central recording wire of 25 mm, which exits the long side
of a beveled shaft. The recording surface has a similar
diameter to that of a muscle fiber (Polgar et al., 1973).
The active recording site is referenced to the needle shaft.
The very small recording surface, along with higher
low-frequency filter settings, allows for the recording of
only one or a few muscle fiber action potentials at a single
site (Fig. 16.1C). Therefore assessment of the size of a
motor unit cannot be reliably made with a single-fiber
electrode. This electrode is used for jitter analysis to deter-
mine adequacy of neuromuscular transmission, or to
determine the fiber density within small regions of a mus-
cle. Single-fiber electrodes are expensive to manufacture
and therefore are usually sterilized following each use
and reused. As a result of the cost and theoretical risk of
transmissible infections with reusable needles, many
laboratories now perform single-fiber EMG with small,
disposable concentric needle electrodes.
Macroelectrodes
Monopolar and concentric needle electrodes record from
a relatively small region of a muscle and therefore only
record electrical signals from a subset of the fibers of an
individual motor unit. Macroelectrodes record from a
larger region of the muscle and can be used to better
determine the size and changes of entire motor units.
The macroelectrode is a larger needle electrode in which
the active recording surface consists of 15 mm of the
shaft of a needle referenced to a separate surface elec-
trode (Stalberg, 1980). The macroelectrode records from
a large number of muscle fibers of multiple motor units in
a cylinder along the shaft of the needle. This recording
summates the activity of many MUPs, which cannot
be differentiated from one another. The potential from
a single motor unit is isolated by simultaneous recording
potentials from single muscle fibers with a 25-mm diam-
eter single-fiber electrode halfway along the shaft of the
macroelectrode on a second channel. The electric activity
recorded from the macroelectrode at the time of the firing
of the single fiber potential on the small electrode is aver-
aged (spike-triggered averaging) over multiple dis-
charges, resulting in an averaged potential from all
muscle fibers along the macroelectrode that are inner-
vated by the same motor unit as the single muscle fiber
(Milner-Brown et al., 1973; Stalberg, 1980). The aver-
aged potential gives an estimate of the activity in a larger
portion of the muscle fibers of the motor unit. Macroelec-
trodes, and macro-EMG, are not routinely used in clini-
cal practice but can provide information about fiber
density and jitter (from the single-fiber recording site)
as well as data on the size and number of motor units.
AMPLIFICATION OF RECORDED
SIGNALS
The electrical signals recorded from muscle fibers are
small (mV) and must be amplified and displayed on a mon-
itor for analysis. The amplifiers in commercial EMG
machines are differential amplifiers, which amplify the
 NEEDLE ELECTROMYOGRAPHY: BASIC CONCEPTS 247
difference in the voltages between two recording sources, FREQUENCY FILTERS
called grid 1 and 2 (G1 and G2) or electrode 1 and 2
The waveforms recorded during needle examination are
(E1 and E2). A separate electrode, commonly referred
composed of sinusoidal waves of mixed frequencies.
to as the green ground electrode or E0, serves as an elec-
Since other physiologic (nonmuscle) or nonphysiologic
trical reference for the E1 and E2 electrodes through which
(artifactual) electrical signals with different waveform
the difference between E1-E0 and E2-E0 is amplified.
frequencies may also be recorded by the electrode, elec-
Using the common mode rejection property of the differ-
trical filters are incorporated in EMG equipment to more
ential amplifiers, the “ground” electrode (E0) helps to
selectively amplify the signals generated from the muscle
reject electrical signals that are common to both recording
fibers. Filter settings play an important role in the analysis
electrodes, such as 60-Hz electrical artifact, and eliminate
of MUPs since the waveform size and morphology may be
them from the final output signal displayed by the instru-
altered by the filters (Brownell and Bromberg, 2009).
ment, thereby allowing for more accurate analysis of the
While filter settings are not usually altered during a routine
physiologic muscle signals (Robinson et al., 2016).
EMG study, their contribution to and effect on the MUP
The different distances between E1 and E2 recording
morphology are significant. Low-frequency (high-pass)
sites of monopolar and concentric needle electrodes result
filters reduce the amplification of the lower frequency
in differences in the number of muscle fibers composing
components of the waveforms, but also reduce the contri-
the MUP. In concentric needle electrodes, the signals of
bution of slow needle movement artifact or sympathetic
more distant fibers have similar amplitudes and timing
skin responses, which can produce excess baseline sway.
and are effectively recorded equally between E1 and E2
High-frequency (low-pass) filters reduce the effect of the
and are canceled by the effect of the differential amplifier.
very high frequencies. For routine EMG recordings, filter
In contrast, fewer distant-fiber electrical signals are can-
settings of 20–30 and 10,000–20,000Hz are most com-
celed by the monopolar electrode, which has a distant sur-
monly used. When formal MUP quantitation is performed
face E2, resulting in a larger sized MUP. Additionally,
and the results are compared with older normative data,
since the E1 and E2 electrodes are much closer together
the low-frequency filter is set at 2–3 Hz (Buchthal and
in concentric needle electrodes, external or nonmuscle
Rosenfalck, 1955; Sacco et al., 1962). Reducing the low-
physiologic artifact is recorded equally and is more likely
frequency filter has the effect of introducing more low-
to be rejected, resulting in more stable baselines during
frequency noise and baseline sway, making the baseline
recording.
less stable. Increasing the low-frequency filter, such as
The final amplified signal is displayed on a monitor for
during single-fiber EMG, will eliminate the lower fre-
detailed analysis. The display sensitivity refers to the
quency components of a MUP that are recorded from
degree of amplification of the potentials displayed on
distant muscle fibers and will effectively shorten the
the screen (Fig. 16.2). The terms sensitivity and gain both
duration and slightly lower the amplitude of the MUP.
refer to the vertical amplification on the screen; sensitivity
In determining the effect on the MUP parameters of lower
is defined as the output per division and gain is defined as
frequency filter settings of 500, 1000, and 2000 Hz
the output divided by input. The sensitivity is displayed as
compared to 10Hz, the greatest reduction in the duration,
a mV per division and is usually set at 50 mV when asses-
amplitude, and area occurred with 500-Hz filtering, and
sing smaller spontaneous waveforms such as fibrillation
there was little effect on the number of turns (Brownell
potentials, and 100–200 mV when assessing voluntary
and Bromberg, 2009) (Fig. 16.3).
MUP. Since the display sensitivity affects the placement
of the duration markers, when quantitative EMG is per-
formed for MUP assessment, the sensitivity should be TECHNIQUE OF NEEDLE EMG
set the same as that used for the normative data collection The needle EMG technique consists of sampling the
(usually 100 mV/division) (Buchthal, 1957). electrical signals from different muscle fibers and

Fig. 16.2. A single motor unit potential displayed at two different sensitivities, 200 mV/division (A) and 50 mV/division (B).
248 D.I. RUBIN
Fig. 16.3. A single motor unit potential recorded with two different low-frequency filters (LFF), 20 Hz (A) and 1000 Hz (B). The
amplitude and duration are significantly lower at higher LFF settings.
requires needle insertion and movement through multi-
ple regions of a muscle to completely assess the muscle.
Depending on the clinical problem, a variable number
and distribution of muscles are examined during a com-
plete study. In patients with focal complaints, such as
unilateral hand numbness or arm pain, the muscles
selected will usually be isolated to the affected limb. In
patients with generalized symptoms, such as diffuse weak-
ness, muscles in more than one limb may be examined.
Most muscles can readily be examined with standard
length (50 mm) EMG needles. Superficial muscles are
easier to identify from surface anatomy or palpation than
deep muscles. Muscles that are relatively easy for the
patient to activate (e.g., anterior tibialis or deltoid) are
ideal muscles for examination, whereas muscles that are
small, deep, or covered by superficial muscles (e.g., flexor
pollicis longus or short head of the biceps) may be more
difficult to examine. In those muscles, selective activa-
tion of the muscle as the needle is being inserted helps
to ensure that the needle is in the appropriate muscle.
Ultrasound has been demonstrated to be more effective
in accurate identification of some deeper or more risky
muscles and is becoming increasingly incorporated in
EMG laboratories (Rathi et al., 2015; Wininger et al.,
2015; Yun et al., 2015).
Since neuromuscular diseases do not affect all muscle
fibers or motor units within a muscle equally, assessment
of multiple sites in a wide area of the muscle is necessary
using small needle movements through the depth of a
muscle. The technique of needle movement is important
in minimizing patient discomfort and maximizing sam-
pling of the muscle (Buchthal and Rosenfalck, 1955;
Strommen and Daube, 2001). Needle movement in a
straight line in one direction through a muscle, using very
small (<1 mm) needle movements helps to minimize
pain (Fig. 16.4) (Strommen and Daube, 2001). When
assessing the signals in a resting muscle, a pause of at
least 1 s after each movement is necessary to identify
waveforms that may fire at very low rates, such as slow
fibrillation potentials or fasciculation potentials. Each
muscle is examined by several needle passes through
the muscle to allow for adequate sampling of the activity.
When MUPs are assessed, the needle electrode is first
withdrawn to the subcutaneous tissue overlying the mus-
cle prior to voluntary muscle contraction. Single MUP
analysis requires muscle contraction at a low effort fol-
lowed by needle movement through the muscle as mul-
tiple MUPs are assessed. The muscle remains in a
constant, steady level of contraction through the exami-
nation. In laboratories that assess the “interference
pattern” of MUPs during strong or increasing levels of
contraction, the needle is withdrawn to the superficial
muscle layers prior to increasing force in order to avoid
needle bending and to reduce pain.
During MUP assessment, since MUPs vary in size
and morphology, it is necessary to record different indi-
vidual MUPs from different regions in the muscle. At
least 20 different positions, separated by at least 3 mm,
have been recommended (Buchthal and Rosenfalck,
1955; Buchthal, 1957). The number of different MUPs
analyzed affects the diagnostic accuracy of a study, with
sample sizes of 20 or more different MUPs having been
shown to reduce variability in the assessment and
increase the sensitivity of detecting changes outside of
normal reference values (Engstrom and Olney, 1992;
Podnar and Mrkaic, 2003).
 NEEDLE ELECTROMYOGRAPHY: BASIC CONCEPTS
Fig. 16.4. Schematic of the distance of needle insertion and movement through a muscle. The needle is initially inserted into the
subcutaneous layer under the skin and moved in very small movements in a straight line through the depth of the muscle.
METHODS OF EMG SIGNAL ANALYSIS
Analysis of the signals recorded during needle EMG can
be performed using various methods. Each method has
advantages and disadvantages and different methods
may be used at various times depending on the clinical
problem and severity of the findings.
Origin of recorded EMG potentials
Regardless of the method of analysis, every physiologic
EMG waveform originates from the action potentials of
individual muscle fibers. These single muscle fiber
action potentials fire either in isolation or in groups
linked together by their location adjacent to one another
or by their common innervation from the same anterior
horn cell. Since these single muscle fiber action poten-
tials are recorded extracellularly by the needle electrode
in a medium (the extracellular tissue between muscle
fibers) that conducts the electrical field, the propagating
action potentials produce a positive–negative–positive
field. When this electrical signal travels along the fiber,
the morphology of the recorded potential depends on
where the recording needle is relative to the propagating
potential. When the needle is located at a distance along
the fiber from the site of the action potential initiation, a
249
triphasic (positive–negative–positive) spike is recorded;
when the needle is at the site of generation, a negative–
positive biphasic spike is seen (Fig. 16.5). In some cases,
where a muscle fiber is damaged from compression by
the needle electrode or from disease, the electrical field
of the propagating action potential cannot pass the elec-
trode and is recorded as a large biphasic positive–
negative potential (Fig. 16.6). The amplitude of a single
muscle fiber action potential reflects the diameter of the
muscle fiber from which it is recorded as well as the prox-
imity of the needle electrode to the fiber. Since the ampli-
tude is proportional to the distance between the electrode
and the fiber, the amplitude (and the rise time increase) is
reduced exponentially as the distance increases
(Nandedkar et al., 1988b). While the morphology of a
single waveform can be assessed, complete analysis of
a muscle requires assessment of many different dis-
charges in different sites within a muscle and comparison
of waveforms to expected normal waveforms.
PATTERN RECOGNITION AND
AUDITORY ANALYSIS
Each type of waveform recorded during needle EMG
fires in a unique pattern. Pattern recognition is the basic
EMG waveform analytic skill required to identify each of
250 D.I. RUBIN

Fig. 16.5. The effect of the needle electrode position relative to the site of initiation of a muscle fiber action potential on the
recorded waveform morphology.

Fig. 16.6. A triphasic single muscle fiber action potential (top) and a positive waveform potential recorded from a fiber that has
been compressed by the needle electrode (bottom).

the different firing patterns based on the changes in the
interpotential intervals of successively firing spikes,
and therefore to determine the types of discharge
(Fig. 16.7). Fibrillation potentials repeat in a definable,
regular pattern, typically with a linear increase in the
interspike interval. End-plate spikes fire in an irregular
pattern, with no definable change in successive inter-
spike intervals. Voluntary MUPs fire in a semirhythmic
pattern, with interspike interval changes of less than
10%. These firing patterns can be determined by visual
or auditory analysis, although once mastered, auditory
pattern recognition may be more efficient and accurate.
Through recognizing the sounds of the different firing
patterns (regular, irregular, and semirhythmic) and the
similarities of the various sounds of each waveform to
common, everyday sounds (e.g., fibrillation potential
sounds like a ticking clock, end-plate noise sounds like
a seashell, and complex repetitive discharge sounds like
a jackhammer), each of the waveforms can be readily
and quickly recognized, even without seeing the screen.
Pattern recognition does not include any quantitative
assessment of the discharges, but is only used to distin-
guish the type of waveform. During MUP analysis, dif-
ferent methods are used to assess individual MUP
parameters and the average size of a group of MUPs
within a muscle, and to compare the calculated values
with reference values.
SEMIQUANTITATION OF MUP
Analysis of MUPs requires assessing parameters of MUP
firing (recruitment) and morphology and comparing the
findings in each muscle to reference values. Most elec-
tromyographers assess these parameters by semiquanti-
tative methods. In contrast to quantitative analysis
(described later), semiquantitation consists of analyzing
parameters without actually measuring them or deter-
mining the precise value of the parameter. This technique
requires mastering auditory semiquantitation skills, such
as learning to recognize different firing rates, rise times,
 NEEDLE ELECTROMYOGRAPHY: BASIC CONCEPTS
Fig. 16.7. Firing patterns of EMG waveforms.
durations, phases, and stability of a MUP by the changes
in the sound, and visually confirming the estimated
values (Okajima et al., 2000). Once multiple MUPs are
estimated, the electromyographer mentally averages
the parameters of each muscle and grades the mean of
each parameter on a qualitative scale (usually 1+ to 4+).
Through appropriate training and practice, the skill of
auditory semiquantitation can be mastered and this
method can be performed with nearly as much accuracy
as formal quantitative analysis. In patients with severe neu-
romuscular disorders where there are prominent needle
EMG changes, such as markedly long duration, high
amplitude, and polyphasic MUPs with reduced recruit-
ment, semiquantitation is sufficient to recognize the
underlying process and determine the general severity.
However, in mild or borderline disorders, semiquantitative
analysis may be less sensitive at detecting abnormalities.
The advantages of semiquantitative methods are the
rapidity and efficiency with which a muscle can be exam-
ined. Limitations include the training time to learn the
technique, potential examiner bias in selective focus on
the larger MUPs, and possibly less sensitivity in mild cases.
QUANTITATIVE METHODS
Quantitative analysis refers to measuring and determin-
ing actual numerical values of parameters of individual
MUPs, calculating the mean values of each parameter,
and comparing the mean to reference values. Several dif-
ferent quantitative techniques have been developed, each
251
providing different types of information, methods of data
collection, and limitations (Stalberg et al., 1996). Quan-
titation in needle EMG is primarily used when assessing
voluntary MUP to determine whether there is a neuro-
genic or myopathic disorder. Some laboratories perform
formal quantitation of MUP in every muscle while others
only use these techniques in cases with mild or borderline
abnormalities when semiquantitative findings are not
definitive. Comparative studies of quantitative methods
and semiquantitative methods have shown good correla-
tion between the two types of methods (Barkhaus et al.,
1990). Quantitative analysis has the benefit of reducing
examiner bias in data collection and providing numerical
values that can be followed and compared over time or
between laboratories, as long as the same technique
and recording parameters are used.
Single motor unit potential analysis. Single MUP
analysis refers to measuring individual single MUPs,
determining the mean values of each parameter, and
comparing the measured values with normative data
(Buchthal et al., 1954a,b; Buchthal, 1957). Using this
technique, the electromyographer records 20–30 differ-
ent MUPs and calculates the mean values of duration,
amplitude, and number of phases of all potentials. The
mean values are compared with normative data, such
as data collected by Buchthal decades ago (Buchthal
et al., 1954a,b; Sacco et al., 1962). Mean values greater
than or less than the mean normal durations suggest a
neurogenic or myopathic disorder, respectively. In some
disorders such as chronic myopathies, a single muscle
252 D.I. RUBIN
may contain MUPs with a wide variation in sizes—some
short duration, low amplitude and some long duration,
high amplitude. In these cases, the calculated mean
parameter values of 20 MUPs will fall into normal range
and result in a false negative study. Outlier analysis of
MUP is a different method that can be used to assess indi-
vidual MUPs. With this method, normal MUP 95% con-
fidence limits are collected for parameters of groups of
20 MUPs (e.g., the 3rd smallest and 18th largest MUP)
in normal muscle. During an examination, MUPs that
fall outside of these values are considered outliers, and
an increased number of outliers (typically more than
10% of MUPs) is considered abnormal. While outlier
analysis does not calculate a mean value of parameters
for a muscle, it can provide additional information to
formal quantitation and may demonstrate abnormal find-
ings when formal quantitation is normal (Stalberg and
Erdem, 2002).
During MUP quantitation, duration is the parameter
that has been shown to more accurately assess the overall
size of the motor unit than amplitude; other measures such
as MUP amplitude, area, area/amplitude ratio (thickness),
size index, and MUP instability (jiggle) can also be
quantified (Nandedkar et al., 1988a,b; Stalberg and
Sonoo, 1994; Campos et al., 2000; Sonoo, 2002). Single
MUP quantitation is more time consuming than semi-
quantitative analysis, because it requires measuring many
individual MUPs with sharp rise times and ensuring that
the measurement markers for each MUP are placed
correctly. Additionally, single MUP quantitation may be
affected by examiner bias in the selection of MUPs to
be included in the analysis.
Automated MUP analysis. Several automated quantita-
tive programs, such as automated decomposition EMG,
decomposition quantitative EMG, and multi-MUP
analysis, have been developed to select and measure
individual MUP from a segment of voluntary activity in
which more than one individual MUP are present
(Dorfman et al., 1988; Bischoff et al., 1994; Nandedkar
et al., 1995; Stalberg et al., 1995; Boe et al., 2005). These
programs decompose electrical signals based on the shape
of the spikes and, through various template-matching
algorithms, average similar spike activity to separate out
individual MUPs. Specific criteria, such as a short rise
time and amplitude greater than 50 mV, are required for
inclusion of a MUP. Decomposition analysis techniques
allow for assessment of MUPs in a moderately contracting
muscle when 3–6 different MUPs are firing, which has the
advantage of including some of the higher threshold
motor units. After assessment of several areas of a muscle
at moderate contraction, over 20 different MUPs are
averaged and a mean of the potentials is determined, sim-
ilar to single MUP quantitative methods. While automated
MUP analysis programs have been shown to be reliable
and have the advantage of more efficiently analyzing a
muscle, caution in ensuring that the MUPs are accurately
measured needs to be taken (Boe et al., 2005, 2010).
Additionally, unstable MUPs, such as those seen in
neuromuscular junction disorders or reinnervating disor-
ders, may result in signal distortion and inaccurate
measurement of the averaged MUP. Additionally, low-
amplitude, short-duration MUPs, such as in myopathies,
may be obscured by the larger MUP and may not be
accurately identified. As a result, automatic programs
may take longer than semiquantitative analysis by an
experienced electromyographer.
Interference pattern analysis (IPA). It is a quantitative
method used to assess MUPs during stronger contrac-
tion. With IPA, the MUP signals are recorded at multiple
different sites within a muscle with the patient contract-
ing at increasing levels of force, from minimal to strong.
Instead of analyzing the individual parameters of single
MUPs, IPA assesses the number of spikes or baseline
crossings (called “turns” in IPA) and the amplitude of
the signals. Various methods for analyzing the signals of
the interference are used by automated programs, includ-
ing the average amplitude, number of spikes per unit
time, and power spectrum frequency analysis (Fuglsang-
Frederiksen and Ronager, 1990; Sanders et al., 1996;
Fuglsang-Frederiksen, 2000). A commonly used method
is turn/amplitude analysis, in which the turns/amplitudes
are plotted against turns per second for each level of con-
traction at each site. The points are displayed as a “cloud”
of points, which are then compared to normative data
(Stalberg et al., 1983). When >10% of data points fall
above or below the normal “cloud,” a neurogenic or
myopathic disorder may be confirmed, respectively.
Studies have shown that IPA techniques have a similar,
or occasionally increased, diagnostic yield of identifying
myopathic and neurogenic disorders as single MUP anal-
ysis (Fuglsang-Frederiksen et al., 1976, 1977; Yu and
Murray, 1984; Liguori et al., 1992; Nirkko et al., 1995;
Fuglsang-Frederiksen, 2000). The IPA methods have the
advantage of rapidly assessing the electrical signals within
a muscle through the entire range of type I and type II
muscle fibers. However, they are limited in their ability
to identify changes in individual parameters, such as the
stability of MUPs.
INDICATIONS OF NEEDLE EMG
Since needle EMG provides different types of informa-
tion than NCSs, and the information obtained from each
technique is complementary and necessary in determin-
ing the type of neuromuscular disorder, needle EMG is
indicated in nearly every electrodiagnostic study. While
NCSs are required to assess the function of sensory
nerves, determine the presence of demyelination in
 NEEDLE ELECTROMYOGRAPHY: BASIC CONCEPTS
peripheral nerves, and contribute to the assessment of
neuromuscular transmission with repetitive stimulation,
they are limited in the type of information they can pro-
vide about muscle fiber and motor neuron function. For
example, a low compound muscle action potential ampli-
tude identified on a motor NCS could result from disease
of the anterior horn cell, nerve roots, motor axons, neu-
romuscular junction, or muscle. The findings of needle
EMG provide more information about the muscle fibers
and motor units and will differ among those different
types of diseases. Similarly, an NCS may be entirely nor-
mal in mild disease while subtle abnormalities will still
be identified on needle EMG (such as early lower motor
neuron involvement in ALS, a mild or subacute radicu-
lopathy, or mild myopathy). In some situations, needle
EMG is the only method available to assess for specific
localization, such as in thoracic radiculopathies or hypo-
glossal neuropathies where there are no reliable NCSs.
Needle EMG also provides additional information about
the temporal course or severity of disease in situations
where an NCS can only help to define localization, such
as carpal tunnel syndrome.
LIMITATIONS OF NEEDLE EMG
Needle EMG has several limitations. While needle EMG
provides information about the muscle fibers and motor
units, it is usually not able to provide definitive informa-
tion about the etiology of disease. For example, a patient
with diffuse weakness who demonstrates fibrillation
potentials and long duration, polyphasic MUP with
reduced recruitment on needle EMG could have any type
of motor neuron disease or axonal polyradiculopathy.
Similarly, a patient with proximal weakness, the presence
of fibrillation potentials, and short-duration MUP on
needle EMG confirms a myopathy, although the pattern
of findings could occur with many different etiologies.
However, in rare cases, the needle EMG findings are
able to suggest an etiology, such as radiation-induced
nerve injury when myokymic discharges are recorded
or a muscle channelopathy in the presence of myotonic
discharges.
Needle EMG alone is unable to determine whether
an underlying neuromuscular disorder affects sensory
nerves. Furthermore, some neuromuscular diseases,
particularly those that affect type 2 muscle fibers (e.g.,
steroid-induced myopathy) or are due to metabolic
disturbances in the muscle (e.g., disorders of lipid metab-
olism) may not demonstrate any abnormalities on
needle EMG. Finally, needle EMG will not demonstrate
abnormalities in situations where there may be irritation
of nerves without focal conduction block or axonal
degeneration. This commonly occurs in patients referred
for evaluation of suspected cervical or lumbosacral
253
radiculopathy in whom the symptoms consist only of
pain or paresthesias. The sensitivity of EMG for radicu-
lopathy has been studied extensively and ranges from
approximately 50% to up to 86% (Dillingham, 2013).
RISKS AND CONTRAINDICATIONS
OF NEEDLE EMG
Needle electromyography is a relatively safe technique.
However, since needle EMG entails inserting and
moving a needle electrode through a muscle, potential
risks exist, including pain, bleeding and hematoma for-
mation, infection, and development of pneumothorax
(Al-Shekhlee et al., 2003; London, 2017).
Pain
The primary generator of pain during the needle exami-
nation is needle movement through the muscle (London,
2017). Pain results from injury of muscle fibers or irrita-
tion of the terminal nerve endings in the end-plate zone.
Several studies have assessed the role of the needle elec-
trodes (monopolar vs concentric) and the technique of
needle movement in the generation and reduction of pain
during the needle examination (Strommen and Daube,
2001; Walker et al., 2001). Monopolar needles have a
sharper, conical needle tip, resulting in less “crush”
injury to the muscle fibers than concentric needle elec-
trodes. While monopolar electrodes are generally consid-
ered to be less painful, studies have suggested that the
needle-handling technique and length of needle move-
ments have more of an effect on pain than the type of
electrode (Strommen and Daube, 2001). When small
needle movements of <1 mm are used, there is no signif-
icant difference in pain experienced with a monopolar
compared to a concentric needle electrode (Strommen
and Daube, 2001). With large needle movements, mono-
polar needles are less painful than concentric needles.
Bleeding risk
Needle electrodes are fine needles with small gauges
and therefore the risk of bleeding or hematoma formation
is minimal in most patients. However, when muscles
adjacent to vessels are examined or when patients are
on anticoagulants or antiplatelet agents, there is a poten-
tial risk of increased bleeding (Gruis et al., 2006).
Despite these theoretical risks, studies using magnetic
resonance imaging and ultrasound following needle
EMG have shown that the risk of clinically symptomatic
hematoma formation, even in patients on antiplatelet or
anticoagulation therapy and in muscles considered
“high risk” muscles that neighbor vascular structures,
is very low (Lynch et al., 2008; Gertken et al., 2011;
Boon et al., 2012; London et al., 2012). While there is
254 D.I. RUBIN
no absolute contraindication to performing needle exam-
ination when patients are on therapeutic doses of medi-
cations that increase the risk of bleeding, limiting the
number of needle passes and ensuring extra pressure over
a puncture site are methods that may minimize excess
bleeding.
Infection
The risk of infecting a patient from skin bacteria during
needle EMG is minimal and similar to the risk of infec-
tion following repeated blood draws. Patients do not
require prophylactic antibiotics prior to the needle exam-
ination. Most electromyographers cleanse the skin with
alcohol prior to needle insertion, although evidence to
support the efficacy of alcohol preparation in preventing
infection is lacking (London, 2017). The needle elec-
trode is not inserted into infected skin, such as in a region
of cellulitis.
Pneumothorax
When the needle examination is performed in muscles
adjacent to the pleura, such as the diaphragm, serratus
anterior, or thoracic paraspinals, there is a risk of a deeply
inserted needle puncturing the pleura and causing a pneu-
mothorax. In experienced laboratories, this risk is very
low (Kassadjian et al., 2016). Muscles most associated
with a pneumothorax are the serratus anterior (especially
using the posterior, infrascapular approach), rhomboid,
and diaphragm (Kassadjian et al., 2016). Knowledge
of anatomic structures and small needle movement to
allow for identification of a respiratory firing pattern
can help to avoid this complication. Additionally, the
use of neuromuscular ultrasound in the EMG lab may
also allow for identification of the muscle and pleural
space, and maximum safe depth of needle insertion
(Boon et al., 2008; Shahgholi et al., 2014).
Needle stick injuries
Since a complete needle examination requires repeatedly
inserting the needle electrode into multiple muscles in a
patient, there is a potential risk of inadvertent needle stick
to the performing physician. In one survey, needle stick
injuries were reported to occur at least once in up to 64%
of electromyographers responding (Mateen et al., 2008).
Universal precautions should always be taken and
disposable gloves should be worn during every study.
While the risk of transmission of bloodborne disease is
low, since the needle electrode is composed of a solid-
bore rather than a hollow-bore needle, special care
should be taken in patients with transmissible, blood-
borne diseases.
SUMMARY
Needle electromyography is a technique that provides
important information about the function of muscle
fibers and motor units within a muscle. The performance
of needle EMG requires knowledge of equipment, mus-
cle anatomy, recording techniques and limitations, and
also requires the skills of needle handling and patient
interaction. Different methods can be used to analyze
the recorded waveforms. When interpreted in conjunc-
tion with NCSs, the findings from needle EMG are used
to determine the presence of a neuromuscular disease.
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