NERVE CONDUCTION VELOCITY

BASICS
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PRINCIPLES ACTION POTENTIAL AXONAL TRANSPORT TYPES OF CONDUCTION CMAP SNAP VARIABLES

PRINCIPLES
 Proximal and distal rule  Same nerve roots but different peripheral

nerves to localize the changes to one or the other
 Until normal values

Proximal and Distal Rule Proximal-distal rule: motor neurons that innervate distal muscles (e.g. trunk muscles) . hand muscles) are located lateral to motor neurons that innervate proximal muscles (e.g...

TYPES OF CONDUCTION  ORTHODROMIC:  Normal physiological direction  ANTIDROMIC:  Opposite to normal physiological direction .

Motor unit .

 FAULTY LOCATION OF STIMULATOR  FAT AND OEDEMA  BRIDGE FORMATION BETWEEN ANODE AND CATHODE .VARIABLES AFFCTING NCV  PHYSIOLOGICAL       TECHNICAL :  AGE TEMPARATURE SEX DIGIT CIRCUMFERANCE UPPER VERSUS LOWER LIMB STIMULATION.

SWEEP. RECORDING:     BREAK IN THE CABLE WRONGLY CONNECTED AMPLIFIER WRONG SETTINGS OF GAIN .FILTER INCORRECT POSITION OF ACTIVE OR REFERANCE IN ADVRETANT STIMULATION OF UNWANTED NERVE :   VOLUME CONDUCTION ANAMOLUS CONDUCTION .TECH………CONTD…….

NERVE CONDUCTION VELOCITY  The speed at which the nerve conduct an impulse .

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TYPES OF NCV  MNCV  SNCV  LATE RESPONSES    H REFLEX F WAVE AXON REFLEX  BLINK REFLEX .

TYPES

NCV MNCV SNCV LATE RESPONSES

MNCV

PRINCIPLES OF MNCV
 Orthodromic
 Motor or mixed nerve is stimulated at least at

two points along it course  Pulse is adjusted to get CMAP  A Biphasic action potential should be recorded  Supra maximal stimulation should be used

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red  STIMULATING :   .ELECTRODE PLACEMENTS  RECORING :    PICK UP : Muscle belly (motor points) REFERENCE :Tendon(3 cm distal to pick up) GROUND : In between pickup and stimulating Cathode – active – black .closer to pick up Anode – inactive .

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1ms  Frequency-1 pulse /sec  Intensity-5 – 40mA or 100 -300 V  Diseased nerve-75mA or 500 V  Filter setting-5HZ – 10KHZ  Sweep speed-2 -5 ms/div .MACHINE SETTING  Square wave pulse  Duration-0.

MEASUREMENTS  Onset latency  Duration  Amplitude  Conduction velocity .

WAVE FORMS .

LATENCY  Time in ms from the stimulus artifact to the first negative deflection of CMAP  Measure of fastest conducting motor fibers  It includes RESIDUAL LATENCY  Measured in ms .

AMPLITUDE  Base line to negative peak  Peak to peak  Co relates with the number of nerve fibers  Measured in mV .

DURATION  Initial take off from the base line to final return to the baseline  Co relates with the density of small nerve fibers  Measured in ms .

CONDUCTION VELOCITY  Conduction velocity is determined by dividing the distance between the two cathodal stimulation points by the difference between the two latencies Conduction distance  CV = Proximal –distal latency  Meters / seconds .

NORMAL VALUES  In between 45-70 m/sec  Upper limbs-60 m/sec (average)  Lower limbs -50 m/sec (average) .

SNCV .

.PRINCIPLES OF SNCV  Orthodromic or Antidromic  Orthodromic:  Digital nerve is stimulated and SNAP recorded at a proximal point along the nerve  Antidromic:  The nerve is stimulated at a proximal point and SNAP recorded distally.

ELECTRODE PLACEMENTS
ORTHODROMIC STUDY  Ring electrodes – Stimulation  Surface electrodes - recording  Stimulating :
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Cathode – 1st IP joint Anode – 3cm distal
Pick up – proximal point Reference – 3cm proximal Ground – in b/w stimulating and recording

 Recording :
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ANTIDROMIC STUDY (REVERSE)
 Surface electrodes – stimulating

 Ring electrode
 Stimulating :

– recording

Cathode –proximal point Anode -3 cm proximal Pick up – 1st pip joint reference -3 cm distal Ground –in b/w stimulating and recording

 Recording :


MACHINE SETTINGS  Filter – 10 Hz – 2kHz  Sweep speed -1-2ms/div  Gain – 1-5 µV /div .

MEASUREMENTS  Onset latency  Amplitude  Duration  Conduction velocity .

WAVE FORM .

ONSET LATENCY  Stimulus artifact to the initial positive or subsequent negative peak  Measured in ms .

DURATION  Initial take off from the baseline to final return to the baseline  It represents the number of slow conducting fibers  Measured in ms .

AMPLITUDE  Base line to negative peak or Positive to negative peak  It represents the density of nerve fibers  Measured in mV .

CONDUCTION VELOCITY  SNCV is calculated dividing the distance (mm) between stimulating and recording site by the latency Distance  CV = latency  Meters / seconds .

ABNORMAL NCV – amplitude reduction  Demyelination – latency prolongation  Degeneration .

LATE RESPONSES .

 Late responses are the potentials appearing after motor response (M wave) following a mixed nerve stimulation .

TYPES  H reflex  F wave  Axon reflex .

F WAVE .

F WAVE It is a late response resulting from Antidromic activation of alpha motor neuron involving conduction to and from spinal cord and occurs at the interface between the peripheral and central nervous system .

PHYSIOLOGY OF F WAVE .

WAVE FORMS .

HISTORICAL BACKGROUND  Magladery and mc dougal – 1950 ( CMT )  Small muscles in the foot  De afferented man  Not a reflex  Proximal motor pathway .

FACTORS AFFECTING F WAVE  Renshaw cell inhibition  Maximum voluntary contraction  Tension .

METHODS  Supra maximal stimulation ( 25 % )  Stimulus rate more than 0.5  Cathode should be proximal to anode  It is recorded from any distal muscle by stimulating appropriate nerve .

RECORDING  Electrode placements – same as MNCV Machine settings:  Amplifier gain – 200 -300 microvolts /division  Sweep speed – 5-10 ms / division .

PROCEDURE  Relaxed  slight voluntary contraction  Amplitude of more than 20 micro volts  10 – 20 responses  persistence .

PARAMETERS  Latency  Chronodispersion  Persistence  Amplitude  F/M ratio  Conduction velocity .

WAVE FORMS .

61 ms in foot  Right to left symmetry is more than 2 ms in hand and 4 ms in foot – abnormal . limb length  31 ms in hand.LATENCY  Minimal latency  Maximal latency  Mean or median latency  Age. height.

0.1  EDB – 6.4 +/.8 .3 +/.6 +/.1.CHRONODISPERSION  Difference between minimal latency and maximal latency  Measure of range of conduction of F wave  ABP – 3.1.2  ADM – 3.

PERSISTENCE  Number of occurrence divided by number of stimuli  Measure of antidromic excitability of particular motor neuron pool .

AMPLITUDE  Depends on the number and size of the motor unit  5 % of M wave  Mean amplitude  Excitability of alpha motor neuron .

F/M RATIO  Proportion of motor neuron pool activated by antidromic stimulation  To use mean rather than maximum F amplitude for calculating F/M ratio  ADM – O.9 .8  Ad H – 0.

CONDUCTION VELOCITY  stimulus site to C7 spinous process via the axilla and mid clavicular point  Stimulus site to T12 spinous process via knee and greater trochanter of the femur ( 2D )  FWCV = (F–M–1) .

CLINICAL APPLICATIONS  Proximal motor pathway  Segmental motor neuron excitability  It is more precise for assessment of segmental motor neuron excitability than H and T reflex .

LMN latency  Changes in peripheral nerve and root lesion F/M ratio  Increased in both poly neuropathy and spasticity persistence  Absent or reduced in GBS. proximal nerve root injury choronodispersion  Increased in poly neuropathy ( demyelinating ) . ALS.

UMN Amplitude and Persistence  Initial stage – Decreased  Chronic stage – Increased  latency also prolonged while duration and amplitude increased in UMN .

H REFLEX .

REFLEX The H .H.reflex is a monosynaptic reflex elicited by sub maximal stimulation of the tibial nerve and recorded from calf muscles  Hoffman 1918 .

PHYSIOLOGY OF H REFLEX .

REFLEX ARC  1 a fibers  Spinal cord  Alpha motor neuron .

 It does not include muscle spindle  H reflex is larger at submaximal stimulation  Inhibited by stronger stimulation Due to collision of orthodromic impulses by antidromic conduction in motor axons .

MODIFYING FACTORS  Renshaw cell inhibition  Supraspinal mechanism  Inhibition by adjacent motor neuron .

VARIATIONS  In normal adults – other muscles except small muscles of hand and feet  In childrens – below 2 years .

METHODS .

Tendon  Stimulating : popleteal fossa .ELECTRODE PLACEMENTS  Position : Semi reclining or prone  Recording : Active .Distal edge of calf Reference .

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1 ms will stimulate motor axons  Cathode is kept proximal to anode  Stimulus frequency should not exceed 1 in 5 seconds .MACHINE SETTINGS STIMULATION  Square wave pulse of 1 ms  Stimuli below 0.

PROCEDURE  The stimuli is adjusted to evoke maximum H response amplitude  At this strength a small M response may also present  M response – help to monitor the strength of stimuli  At least 5 H response required for analysis  By increasing the stimuli strength to supra maximal maximum M responses can be recorded  3 M responses required for analysis .

PARAMETERS  latency  H .amplitude  M wave  H / M ratio  H .Vibratory inhibition  H – TA  Conduction velocity .

WAVE FORMS .

4 +/.6 0.2 39.0.31.7 9.6.3 +/.1.18.6.1 24.8 +/.6 +/.9 +/.2 H vib H .1 .NORMAL VALUES Latency Amplitude M wave H/M ratio 30.9 +/.TA 42.

FCR – 20 ms  Age.5 ms  Latency in full term infant is 15.45 .1.94 +/.LATENCY  Measured in ms  Soleus – 35 ms. height. limb length  Right to left asymmetry up to 1.

AMPLITUDE  Base to peak of the negative phase  Measured in mV  Alpha motor neuron excitability .

7 .RATIO  The ratio of peak to peak maximum H reflex to maximum M amplitude  To estimate the motor neuron pool activation  Less than 0.H / M .

TONIC VIBIRATION REFLEX VIBIRATORY INHIBITION  Achilles tendon is vibrated for 1 minute at 100 Hz  Normal – amplitude decreases  UMN lesion – there is no decrease in amplitude  Due to the vibratory inhibition is less than normal .

VIBRATORY INHIBITION .

RECIPROCAL INHIBITION .

CONDUCTION VELOCITY  The distance between knee and T11 by the latency difference between H reflex and M response .

C6 radiculopathy – Absent  GBS .CLINICAL APPLICATIONS PNS To evaluate proximal sensory motor pathway Helpful in plexopathies .radiculopathies and neuropathies latency  S1 radiculopathy – Absent  C5 .absent or delayed or dispersed .

reciprocal inhibition . H .CNS  Understanding the patho physiology  Excitability of alpha motor neuron  Amplitude. H/M ratio. H .vibratory inhibition.

DIFFERENCE BETWEEN H REFLEX AND F WAVE .

radicul opathy.spaticity opathy .VM Stimulus Persistence Amplitude Sub maximal Persistent 50 – 100 % of M wave Supra maximal Variable 5 % M wave Useful in Neuropathy.H reflex Nature Monosynaptic reflex F wave Not a reflex but due to antidromic activation of alpha motor neuron Any distal muscle Best elicited in Soleus. FCR.radicul Neuropathy.

BLINK REFLEX .

BLINK REFLEX  The electrical analog of corneal reflex  Kugelberg in 1952  To evaluate trigeminal and facial  Supra orbital nerve  Orbicularis oculi .

REFLEX ARC  Afferent – trigeminal nerve – pons  Efferent – facial nerve  Centre .

PHYSIOLOGY OF BLINK REFLEX .

METHOD .

side of nasal bone .over chin supra orbital notch over supra orbital nerve directed somewhat laterally .ELECTRODE PLACEMENTS Recording :  Recording  Reference  Ground Stimulating :  Cathode  Anode .bilaterally over orbicularis oculi .

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10 ms /division  Stimulus rate .200 – 500 mV/division  Sweep speed .1 in 3 seconds  Avoid prolonged studies .lower facial muscles  Gain .MACHINE SETTINGS .R2 Habituated  Aberrant innervation .

R1 and R2  Contra lateral .RESPONSES  Ipsilateral side .R2 .

WAVE FORMS .

PHYSIOLOGICAL MECHANISM  R 1 .Monosynaptic pathway  R2 .Poly synaptic pathway .

less than 40 ms Contra lateral side  R2 – less than 41 ms .NORMAL VALUES Ipsilateral side  R1 – less than 13 ms  R2 -.

CLINICAL APPLICATIONS  Abnormal R1 and R2 on the paretic side with normal contra lateral R2 .ipsi lateral facial nerve lesion .

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