Nerve conduction

studies and
Electromyography
• Nerve conducting study:-
This test is measure how well and
how fast the electrical signal travel down
the nerve, it is used to evaluate the type
and degree of the abnormality of nerve.
Nerve conducting study:-
It measure by conducting velocity each
nerve fiber has varies of conducting velocity
but it range between 0.25 m/s from small
unmyelinated nerve fiber to-100 m/s large
myelinated nerve.
Conducting velocity depend on:-
1- Fiber diameter
2- Degree of myelination
3- Internodal distance
Note :- When the axon become increase in size the myelinated
sheath become thicker and the internodal distance become
longer and the conduction therefore become faster. The
diameter of the axon varies between 0.2-20µ
Impulses conduction:-
The action potential conduction is originated
in the axon propagated in either direction from
its site of origin.
There is two type of conduction:-
1-Continuous conduction in unmyelinated.
2-Salutatory conduction in myelinated.
There are many factors affected on the
C.V.:-
1- Temperature(if it increase C.V increase and
inversely)

2- Age (C.V lower in children and old people than

adult)

3- Height (because the shorter nerves conduct faster

than longer nerves of the same age group )

4- Limb(upper limb has heigher C.V than lower )

Conducting velocity:-
It is studying by the St. (stimulating) the nerve in two
different points and it determined by distance between two
points of Stimulation proximally and distally divided by
the difference in the latency of the response.

C.V.=distance between two points of St. in mm = m/s

latency difference in ms
NORMAL VALUES:-
OCITY

⚫UL latency amplitude velocity

⚫MOTOR N. < 4.0 ms 5-10 mV 50-60 m/s

⚫SENSORY N. <3.2-3.4 ms 5-50 µV 50 m/s

⚫LL

⚫MOTOR N. <5.2 ms 2-10 mV 40-50 m/s

⚫SENSORY N. <3.5-4.0 ms 5-40 µV 35-40 m/s

Purpose of NCV:- (important)
1- It useful in the cases if there is injuries or damage of
the nerve or demyelination.

2- It useful of diagnosis of damage of all the nerve that

lead away from spinal cord to the smaller nerve that
branch out from them.

3- It useful to locate abnormal sensation like numbness

tingling or pain.
The nerve conducting study involves:-
• The study of motor and sensory conduction:-

A- The measurement of motor nerve includes onset latency,

duration and amplitude of compound muscle action
potential (CMAP) and nerve conduction velocity.

This is achieved by St. (stimulation) the nerve at two points

along its course, the conduction velocity is calculated by
measuring the distance between two points of St. in mm,
which divided by the latency difference in ms.
 ELECTRODE PLACEMENT

⚫ ACTIVE ELECTRODE : placed on the

motor point of the muscle
⚫ REFERENCE ELECTRODE : placed
nearby tendon or bone
⚫ GROUND ELECTRODE : in between
active and reference electrode
Nerve conducting study
Tibal motor nerve conduction
Nerve conduction in the motor median
nerve

Recording electrodes

Stimulator

Ground
electrode
Carpal tunnel syndrome
 Sensory nerve conduction:-
Similar to the motor nerve conduction study
measurement of sensory nerve includes onset latency,
duration and amplitude of sensory nerve action potential
(SNAP) and nerve conduction velocity. But the
conduction can be measured orthodromically or
antidromically. 14 cm standard distance is used

❑ In orthodromic conduction the distal portion of the nerve

is St. (stimulated) and sensory nerve action is recorded at
proximal point.
Sensory nerve conduction:-
⚫The latency of orthodromic potential is measured from the St.
to initial positive or subsequent negative peak has triphasic
feature.
⚫In antidromic sensory nerve conduction is St. at the proximal
point and recorded at distal point. initial positivity is absent in
antidromatic it have negative phase. Conduction velocity is
calculated the distance between the St. and recording site
dividing by the latency.
An Idealized Sensory Waveform

S = Stimulus point, T = Takeoff point, P = Peak

The time (latency) from S to T is typically about 3 milliseconds.

The amplitude would be measured in micro volts (μV).
Ulnar nerve conduction

Recording
electrodes
 Sural nerve sensory

Stimulator

Recording
electrode
Sural sensory nerve conduction
Radial nerve sensory
Ground
electrode Recorded
electrode
Stimulator
Method requirement:-
⚫ Stimulating electrods
⚫ Recording electrods
⚫ Oscillscope ray cathode
⚫ Spirit
⚫ Stimulator
⚫ preamplifier
Procedure:-
• Clean the area of skin overlying the nerve to be tested
at proximal and distal ends.

• Place the electrodes on the skin overlying the muscle

supplied by the nerve.

• St. the nerve at the distal ends with Stimulating

electrodes and see the action potential on the
oscilloscope and recorded it on the proximal point.
Procedure:-
Then St. the nerve at the proximal ends with
Stimulating electrodes and see the action potential on
the oscilloscope and recorded it on the distal point.
May feel a quick burning pain a tingling feeling and
the twitching of the muscle each time stimulated.
Procedure:-

Measure the distance between the points

of stimulating. Calculate the conduction
velocity by dividing the distance between
two point mm by latency period ms which
represent the time. Express m/s.
Electromyography (important)
It measure the electrical activity of the muscle at rest
and contraction.

Purposes of the EMG:-

1- To diagnosis disease or damage of the muscle tissue or nerve
and neuromuscular junction.

2- Useful in diagnosis different disease that causes a weakness of

the muscle especially in legs and arms.

3- Helpful in cases of parasthesias; numbness, atrophy, cramp,

spasticity, deformity.
4- It useful to determine the cause of symptoms due to
muscle disease or neurological disorder.
5- Helpful in finding the causes of involuntary of
twitching, paralysis.

❖ Motor unit:- A single motor of neuron and a group of

muscle fiber innervated by it is known as a motor unit.
❖ Motor unit potential:- Is the sum of action potential
produced by muscle supplied by anterior horn cell.
Motor unit potential characterized by:-
A-Duration:-

It measure from initial take off to point return back to the base
line it is shorter in children and long in elderly its measure:-

1-conducting velocity

2-membrane excitability

3-length of muscle fiber

4- synchrony of different muscle fiber of a motor unit

B- Phase:- the MUP is triphasic, positive, negative,
positive which defined as it is a portion of MUP
between departure and return to the baseline. If there
is more than four phase it is called polyphasic.

C- Amplitude:- it measure the maximum peak of the

positive phase to maximum peak of negative phase.
Amplitude depend on :-
1- Size of the muscle fiber
2- Density of the muscle fiber

3- Temperature

4- Age of patient

5- Synchrony of firing

D- Rise time:- duration from the initial positive phase to

subsequent negative peak usually less than 500µ
There is five type of motor unit potential:-
1- Short MUP it has low amplitude but rapid
recruitment seen in myopathey.
2- Long MUP it has high amplitude and slow
recruitment seen in neuropathy
3- Poly phase MUP seen in myopathies where there is
regeneration of muscle fiber and increased fiber
density. Also in neurogenic disease where there is
regeneration of axon.
Type of motor unit potential
4- Mixed pattern of MUP, short duration, long duration,
and poly phase occur this seen in neuropathies,
myopatheis.

5- The rhythm of MUP in some diseased condition is

disturbed and occurs in bursts of two or more at an
interval of 10-30 millisecond these called doublets,
triplets depending on the number of bursts seen in
muscle ischemia, motor neuron disease.
Factors that affect on MUP:-
A-Technical factor:-

1- Type of needle electrode.

2-Characteristics of recording surface.
3-Method of recording.
4-Electrical characteristics of cable.
5- Preamplifier and amplifier.
Factors that affect on MUP:-
B-Physiological factor:-
1-Age of patient.
2-Muscle examined.
3-Temperature.
Requirement Method of EMG:-

⚫ Cathode ray oscilloscope

⚫ Preamplifier and amplifier
⚫ Recording electrodes
⚫ Electrode paste
⚫ Spirit
Procedure for surface EMG
⚫ Clean the area of skin overlying the muscle to be
tested.

⚫ Place three electrodes on the skin overlying the

muscle with a small amount of electrode paste.

⚫ Connect the electrode through the preamplifier to

oscilloscope.

⚫ Observe the rest potentials on the oscilloscope.

⚫ Ask the patient to contract the muscle and observe the potential.

Procedure for needle EMG :-

⚫ Clean the area of skin overlying the muscle to be tested.

⚫ Fix the ground electrode on the skin overlying the muscle.

Insert the concentric needle electrode into the muscle to be
tested.

⚫ Observe the potentials in the oscilloscope during insertion.

⚫ Ask the subject to contract the muscle, and observe the

potentials on the oscilloscope.
⚫ Move the needle in different direction
in the muscle and record the potential.
Observation:-
what can we see on the oscilloscope
1- Insertional activity.
2-Spontaneous activity.
3-Voluntary activity.