EMG DANTEC

Review

•1
EMG Basics
• Electromyography (EMG)
• Evoked Potential (EP)

•2
Introduction to EMG
• What is EMG?
− Assessing electrical activity of muscles
− Normally performed with another test that measures the conducting function of
nerves - nerve conduction study (NCS)
− Both tests performed at the same office visit and by the same physician – NCS
often performed by EDx tech
− Muscular movement involves action of muscles and nerves and needs an
electrical current (this electrical current is much weaker than the one in your
household wiring)
− In some medical conditions the electrical activity of the muscles or nerves is not
normal
− Finding and describing these electrical properties in muscle or nerve helps
diagnose condition
− The instrument used is called an electromyograph

•3
Introduction to EMG
• History of EMG
− 1666 - Francesco Redi documented highly specialized muscle of the
electric ray fish generates electricity
− 1773 - Walsh demonstrates Eel fish’s muscle tissue could generate a
spark of electricity
− 1792, - Luigi Galvani documents that electricity could initiate muscle
contractions
− 1922 - Gasser and Erlanger use an oscilloscope to show electrical
signals from muscles
− 1930 – 1950 – Research continues
− 1980s - advanced techniques allow production of the required small
and lightweight instrumentation and amplifiers

•4
Introduction to EMG
• When is EMG testing performed?
− Find the cause of weakness, paralysis, or muscle twitching
− Diseases that damage muscle tissue, nerves, or the junctions between nerve
and muscle (neuromuscular junctions). These include amyotrophic lateral
sclerosis (ALS), or myasthenia gravis (MG), muscular dsytrophy, etc.
• When is NCS testing performed?
− Identify the cause of abnormal sensations, such as numbness, tingling, or pain
− Find damage to the peripheral nervous system, which includes all the nerves
that lead away from the spinal cord and the smaller nerves that branch out from
those nerves
− Includes nerve disorders, such as carpal tunnel syndrome or Guillain-Barré
syndrome, etc.

•5
Introduction to EMG
• How is EMG testing performed?
− Small pins or needles are inserted into muscles to measure electrical activity
− The needles are small and solid, not hollow like hypodermic needles
− Patient asked to contract muscle by moving a small amount
− Muscle activity is monitored on a display screen and through a speaker - Sounds
like a popping or soft roaring noise.

•6
 Electromyography
Electromyography

EMG Recruitment

Turns / Amplitude Analysis

MUP Analysis

•7
 Electromyography (EMG)
Electromyography is widely used to
Concentric needle insertion
distinguishEMG Needles
weakness due to muscle Fasciculus
Recording area Active
disease, neuropathy or other causes.
Bipolar concentric
Muscle fibers Reference
The EMG is recorded by means aof
Active
15°
special concentric or monopolar EMG
Concentric EMG needle
needle inserted in the muscle.
Reference
Motor units, in a given muscle, vary
Orientation marker
with respect to territory and fiber
density, and with respect to physiologic Peripheral
motor nerve
properties such as contraction time, Motoneuron
Muscle fibers
fatigability,Monopolar
rise time of the spike and Orientation marker
order of recruitment. Active Motor unit Neuromuscular junction

Motor Unit Potential (MUP)

Main electromyographic criteria: Perpendicular insertion
to muscle fibers
 Activity at rest
External reference
 surface electrode
Interference pattern
100 ms

 Motor unit potentials analysis

5 ms
•8
 Motor Unit Potential (MUP)
A group of muscle fibers generates MUPs.
Turns (changes in signal direction)
Different innervations, different MUPs.
Segments (part of the curve
between 2 turns)

Baseline crossing

Amplitude
Satellite
Phase

Criteria
 Single potential: # of phases ≤ 4 Rising time

 Polyphasic potential: # of phases ≥ 5

Duration
•9
 Muscular Contraction
In a normal patient, the EMG is proportional
to the effort in amplitude and in number of MUPs
(recruitment of muscular fibers). 3
see Neurophysiology – Muscle Contraction
Maximum
contraction
All MUPs activated

Just a reminder
Neuromuscular
Axon junctions 2
Moderate
The Electromyography EMG needle contraction
test records action 4 MUPs

potentials originate from

Muscle fiber 1
synapses (Neuromuscular
Discrete
junctions) Myofibrils contraction
1 MUP
Ground
0
No
contraction
0 MUP
3 2 0
1
•10
 Normal
Pathologies in Striated Muscle
Neuropathy Reinnervation Myopathy
Recording with the same moderate
force to the same muscle, different Normal
pathologies gives
 different recordings
 different sounds
Neuropathy

EMG needle

Myopathy

 Normal EMG  Nerve degeneration  Muscle reinneration  Cell degeneration

 Few innervated fibers  Many fibers innervated  Smaller fibers Myasthenia
 Few MUPs by the same nerve  More tissue
 Amplitude increased
Ground  Synchronic potentials  Motor conduction:
 Polyphasic potentials • Amplitude decreased
2 Neuromuscular junction
• Normaldisease
latency
(see Repetitive Nerve Stimulation).

•11
 EMG Tests vs Pathologies
CENTRAL
In WEAKNESS
percentage of patients
Spinal cord - Brain
(simplified model)

Myopathy EEG - EP Neuropathy

Progressive muscular dystrophy: Peripheral neuropathy
Duchenne, limb-girdle, facio-scapulo-humeral. Motoneuron disease
myotonic dystrophy and polymyositis

Pronounced myopathy 5% Severe denervation

NSS SFEMG 10%

At this level of pathology,

80% advanced EMG techniques allow for differentiating Myopathy from Neuropathy

T/A MUP
90% 50% 70%
MYOPATHY NEUROPATHY
Muscle fibers EMG Recruitment Axon - Myelin or both

MUP Increased Increased # with interference pattern

Duration Decreased Polyphasic with discrete activity
NORMAL
•12
Next: EMG Recruitment
 EMG Recruitment – Interference
Pattern (IP)
>50 ms ( 20 Hz )

MAXIMUM
Settings EFFORT
Peak/Peak
Filters amplitude
High pass 5 – 20 Hz
Low pass 10 – 20 KHz

Sensitivity Amplitude depends on the muscle, >3 mV

Spontaneous Act. 0.2 mV/Div.
Pull Interference Pattern 1 mV/Div.
MUP 1 mV/Div. Auditory control of:
 Resting silence
Sweep Speed  Focused insertion in the muscle
Spont. and IP 10 – 20 ms/Div.
 Frequency firing (<20Hz)
MUP 5 ms/Div.

At rest:
EMG Needles:  Normally no potentials “Flat recording”
 If fibrillation potentials:
- Disposable concentric • Partial denervation
- Disposable monopolar • Myopathy
Amplitude: 100 - 200 µV
• Polymyositis
•13
Next: Turns / Amplitude
 Turns / Amplitude (T/A) Analysis 1 second

Force 1

Turns / Amplitude
Force 2
Force 1 second recording Myopathy

Force 3
Pull Amplitude
Turns

Force 4
100 µV
Amplitude
segment 1
S1 S2

Neuropathy
Up to 20 measurements
 Concentric or monopolar needle
Mean Turns Amplitude

Neuropathy
at different forces
Amplitude
 Settings:
 A turn issee EMG recruitment
a change in signal direction ( ) Turns
 1second
A segment is delimited
of EMG signalby two valid turns
 A turn is valid if segment amplitude is >100 µV,
 Few sites in the
represented bysame muscle
 This MUP has 3 turns and 2 segments (S1 & S2)
 Graphical representation of normal Myopathy
values are established for the most
commonly investigated muscles. Number of Turns / s

•14
Next: Number of Small Segments
 Motor Unit Potential (MUP)
 The interference pattern is a sum of motor unit potentials.
 The number of recruited MUPs depends on the contraction.
 Each motor nerve innervates
Identification of MUPs one or more muscle fibers,
and generates simple or polyphasic compound motor action potentials
Slope (CMAP).
> 30µV /0.1 ms
 From the same MUP, the maximum
firing
Example: 1 second pattern recorded with moderated
> 30µV contraction.
frequency criteria is 400 Hz (2.5 ms)
 To be a MUP, the negative amplitude1 second
should be >30 µV ( >50 µV pp) and
 First slope (depolarization) is >300 µV/1 ms
or 30 µV/0.1 ms > 2.5 ms
(see Neurophysiology – Peripheral Nerve)

10000
Analysis
All potentials in thisAsimple
graphical depiction can
recording of easily be identified
2 SD
and classified.
normal values is established 1000 1 SD

Amplitude (µV)
3 main criteria: for each main investigated
muscle. 100
1stAmplitude
Main MUP 2nd Main MUP Isolated MUP Isolated MUP
 Duration  Regular
• Green points: within the   Irregular firing
Regular firing firing 10
Irregular
firing
 Constant amplitude normal range
Constant amplitude  3 phases  2 phases
 Number of phases
and duration • Red points: outside 2 SD
and duration 1
 5 phases  2 phases
• Cross: mean of all 0 5 10 15
Duration (ms)
20

•15
 MUP Recording
3 methods to collect MUPs

Moderate  Manual selection from the 5 seconds recording,

force Automatic recognition Slope
> 30µV /0.1 ms

Pull 1 – Identification of MUPs Amp. 612 µV

> 30µV Dur. 19.8 ms
then individual analysis of each potential
 As previously described (Time consuming method) Phases 5

 Triggering selection
Averaging (AVG) &
Trigger level > 2.5 ms
Analysis of selection
2 – Classification of MUPs Amp. 612 µV
Dur. 19.8 ms
(Limited to high amplitude MUP)
To be in the same MUP classification, Phases 5
potentials must have Central slope
 Multi-MUP,Amplitude
automatic recognition and AVG (the fastest method)
µV/µs
 Same amplitude µV

Recording method:
 Same central slope
 5 seconds analysis
  Same
Settings: see EMG #recruitment
of phases
 Moderate contraction AVG
 Few sites in the same muscle
Amplitude, Duration, # of Phases, etc… and Firing frequency

•16
Next: Power Spectrum
 FFT – Power Spectrum
In needle EMG, the frequency distribution
shifts slightly from high to low frequency Normal Fatigue
with increasing force. 0dB 0dB

In presence of neuromuscular fatigue, the

power (dB) decreases (all frequencies). -60
dB 5 kHz
-60
dB 5 kHz

Myopathy: The distribution of frequencies is

Myopathy Neuropathy
shifted towards higher frequencies 0dB 0dB

Neuropathy: The distribution of frequencies is

shifted towards lower frequencies
-60 -60
dB 5 kHz dB 5 kHz

The relative power at 1400 Hz:

 Increased in myopathic muscle
 Decreased in neurogenic muscle
•17
Next: Keypoint Program
Introduction to EMG
• Stages of needle EMG exam
− Insertional activity
− Muscle at rest (spontaneous)
− Motor units/recruitment
− Maximal effort (interference pattern)

•18
Introduction to EMG
• Nerve Conduction Studies (NCS)

•19
 Nerve Stimulation
Nerve Stimulation

Electrical Current
 Nerve Stimulation
A nerve is a Chain of Polarized Membrane Segments (Myelin Action).
Stimulation in one point generates a depolarization.

Myelin Axon
Peripheral nerve Muscle

Antidromic Orthodromic
Motor latency

Motor response

Once a nerve is depolarized at one point, a wave of depolarization

Nerve
passesStimulation
in both directions from that point.
Antidromic (to depolarization
The Successive spinal cord) ofand Orthodromic
each (to muscle).
segment is followed by a repolarization.

The time before repolarization is called the Refractory Period (see Neurophysiology – Peripheral Nerve).
Motor Latency is the propagation time from stimulus site to
During this time a nerve cannot be depolarized.
muscle contraction (motor response). Motor Latency is expressed in ms

•21
Next: Electrical Current
 Electrical Constant Current
A current stimulator is a voltage generator (V) with
a predefined constant current (I).

I known
I Z Impedance
Reference unknown
set by user

V Variable

Constant Current
The reference automatically adjusts the voltage to reach the preset
 A constant current offers
current the advantage
through to always
the tissues. Thekeep the sameofreference
impedance of stimulation
the tissues (Z) variesfor any patient.
from site to site and from patient to patient.
 If the impedance of the tissues is too high, you will be informed by an alarm. Then you have to clean and
sometimes brush the skin.
V
Ohm Law I =
Z
•22
 Cross section of the wrist

The
Current Stimulation
medianImpulse
Stimulus nerve at the wrist, as an example.
Median nerve
Ulnar nerve

The stimulus impulse is characterized by:

 Surface electrodes
Amplitude (current) inare
mAnot in direct contact with
 Duration
the nerve. in µs Quantity of Electricity

The
The current has to go through the skin (incl. fat,
stimulation is performed Intensity
tendon and other tissues) before QE is
mA the nerve
with a quantity of electricity.
actually stimulated.
Duration µs
+ -
 And, the surface impedance of the skin, between Skin, Tissues
Fat, Tendon
10 KΩ

You will get the same performance of stimulation with

the two electrodes, represents a short circuit to the Median nerve
20 mA / 100µs and 10mA / 200µs (same QE 2.10 -12 As).
stimulus. In normal condition this impedance is
around
Remind 10! KΩ. %I

 Long duration gives larger stimulus artifact. Acceptable

InHigh
best conditions, the true current applied to the
intensity is painful. Bad Good
nerve is in reality reduced to 15% of the selected
 Short duration
displayed current.reduces the QE max. of the system,
a limitation when stimulating deep nerves and fat
 If liquid or gel is used to reduce the impedance
patients.
contact, be careful
 It is always to clean the interval between the
better for the patient to reduce the
twonumber
electrodes.
of stimuli. Skin surface impedance K

•23
 Rheobase and Chronaxy
Rheobase is the property whereby a current value
Nerve potential
mV
action potential
must reach a minimum value before depolarization ms
will occur, no matter how long the current may flow.
Depolarization
threshold level

Chronaxy is the property whereby a current must

Notice
flow for a minimum time before the nerve tissue will Rheobase
depolarize.
When you reach If thea current
sensory flow is below
threshold this time
(low speed then
fibers), Stimulus
noit isstimulation will aoccur
better to select no matter
stimulus durationhow high the
of around 1 ms
Chronaxy
current value may
(see application: be. Conduction - H-Reflex).
Nerve

The chronaxy time is about 80 µsec in motor nerve.

Alternative Stim. Amp.

Instead of setting a long duration pulse, if your equipment Low speed

fibers
High speed
allows the possibility, you can set a short train of pulses: fibers Threshold curves,
Chronaxy is defined as the stimulus duration at the Rheobase, Chronaxy
i.e.: Train of 3 pulses, 0.2 ms duration each, train frequency 2.0
point where the threshold amplitude is two times the
< 25 Hz. (total duration of the train 1.2 ms Chronaxy
Rheobase. Chronaxy
1.0
2x Rheobase

High Speed Fibers like Motor Nerve Fibers Rheobase Duration

0 ms
Low Speed Fibers like Sensory Nerve Fibers 0 0.5 1.0 1.5 2.0
80µsec

•24
 Motor Response
Stimulation
Let us consider a Electrodes
stimulation of the median nerve at the wrist.
Hand-Held Digital Ring
Click to start motion
Surface

Felt tips 2 3
Surface electrodes are used to stimulate
Velcroa nerve
1 “Blue dot”
Springs 4
from theActive
surface
handel of the skin (see Acc. blue dot).
(Sensory)
DIN connector 1.5 mm TPC

Current stimulator mA
with surface electrodes
Nerve Stimulation and Stimulus strength
Motor Response
mV
+ -Threshold
+ Minimal
-
 The motor threshold corresponds to Skin, Tissues
the minimal intensity to reach a Fat, Tendon
beginning of response. Median nerve

 The motor response increases as

the stimulus intensity is increased.
 The necessary current
1. Insufficient to reach
current toago through tissues and stimulate the nerve.Maximal
maximal response depends on
2. The
the depth andnerve is of
the size partially stimulated – slight deflection of the thumb.
the nerve.
Supramaximal
 The supramaximal
3. The nerveintensity is arbitrarily
is entirely stimulated – complete deflection of the thumb.
25% above the maximal value.
4. Supramaximal stimulation – deflection cannot be increased. ms

•25
Introduction to EMG
• How is NCS testing performed?
− Motor NCS performed by electrical stimulation of a peripheral nerve and
recording from a muscle supplied by this nerve.
− The time it takes for the electrical impulse to travel from the stimulation to the
recording site is measured. This value is called the latency and is measured in
milliseconds (ms).
− The size of the response - called the amplitude - is also measured. Motor
amplitudes are measured in millivolts (mV).
− By stimulating in two or more different locations along the same nerve, the
velocity (NCV) across different segments can be determined.

•26
Introduction to EMG
• How is NCS testing performed?
− Sensory NCS are performed by electrical stimulation
of a peripheral nerve and recording from a purely-
sensory portion of the nerve, such as on a finger.
− Like the motor studies, sensory latencies are also
measured in ms. Sensory amplitudes are measures
in microvolts (ųV). The sensory NCV is calculated
based upon the latency and the distance between
the stimulating and recording electrode.

•27
Introduction to EMG
• How is NCS Testing performed?
− F-wave study uses stimulation of a motor nerve and recording of action
potentials from a muscle supplied by the nerve
− This is not a reflex, potential travels from the site of the stimulating electrode in
the limb to the spinal cord and back to the limb in the same nerve that was
stimulated
− The F-wave study evaluates conduction velocity of nerves between the limb and
spine, whereas the motor and sensory nerve conduction studies evaluate
conduction in the limb itself

•28
Introduction to EMG
• How is NCS Testing performed?
− Repetitive Stimulation study uses stimulation of a motor nerve and recording of
action potentials from a muscle supplied by the nerve
− Often called “Decrement” study. Used to evaluate changes in muscle response to
series of stimulations due to neuromuscular junction disease – Myasthenia Gravis,
Eaton-Lambert

− A protocol of testing and exercise are used to determine if muscle weakness

progresses over very short periods of time.

•29
Introduction to EMG
• How is NCS Testing performed?
− H-reflex study uses stimulation of a nerve and recording the reflex electrical
discharge from a muscle in the limb. This also evaluates conduction between the
limb and the spinal cord, but in this case, the afferent impulses (those going
towards the spinal cord) are in sensory nerves while the efferent impulses
(those coming from the spinal cord) are in motor nerves.

•30
 Nerve Conductions
Nerve Conduction Reflexes

Motor Nerve

Sensory Nerve

Carpal Tunnel

F-Waves

Exit
 Nerve Conduction
A nerve is a chain of polarized membrane segments (myelin action).
Reminder
Stimulation at one point generates a depolarization.

Myelin Axon
Peripheral nerve Muscle

Antidromic Orthodromic
Motor latency

Nerve Stimulation Motor response

Once
The successive
a nerve isdepolarization
depolarized ofateach
somesegment
point, ais wave
followed
of by a repolarization.
depolarization
passes inbefore
The time both directions from
repolarization that point.
is called the Refractory Period (see Neurophysiology – Peripheral Nerve).
During this time
Antidromic (to aspinal
nerve cord)
cannotand
be depolarized.
Orthodromic (to muscle).
Temperature Effect
Motor Latency is the propagation time from stimulus site to
 Cool temperature slows nerve conduction and interferes with the size of responses.
Not onlycontraction
muscle that, they can affect response).
(motor nerves in anMotor
asymmetrical
Latencyfashion, sometimes
is expressed in mimicking
ms individual
nerve injuries.
•32
 Nerve Conduction Studies
Nerve Conduction Studies (NCS) are an essential part of an EMG examination.
Nerve Conduction Study

Median nerve APB muscle

Motoneuron
Stimulation 2 Stimulation 1
The clinical usefulness of NCS in the diagnosis
of diffuse and local neuropathies has been
Peripheral motor nerve
thoroughly validated since the 1940’s.

Distance

Recording responses
The findings reflect the functional state of:
Neuromuscular junction
• the myelinated motor nerves, Stim. 1
• the neuromuscular
Conduction velocity transmission,
• thethe
of muscle fibers.
median nerve Stim. 2
Muscle fibers

EMG equipment

•33
 Motor Response
Four parameters to characterize a motor response: Latency, Amplitude, Duration and Area

Latency Area Amplitude

Negative peak
Be coherent in measurements !
Negative Negative
Latency is measured at the onset. Measurement at peak is sometimes necessary in
deflection
presence of large stimulus artifact, generally due to a wrong technique.
Onset Total
Amplitude, the negative deflection is the most important, some schools use peakPeak to peak
to peak
value – then careful with reference values.
Duration of negative deflection is measured in coherence with the negative deflection of
the amplitude, if not, the total duration is measured.
Area is measured in coherence with duration (negative deflection or total).

Negative

Total
Stimulation
artifact Duration
•34
 Pathologic Responses
Pathology Latency Amplitude Duration

Just a reminder
Normal Normal Normal Normal

Motoneuron Peripheral Nerve Muscle Fibers

Axonal
Nucleus Membrane
Neuromuscular
junctions
degeneration

Axon MyelinConduction
Schwann cell Node of Ranvier
block
Severe
AXON and MYELIN are main demyelination
players in the transfer of NERVE IMPULSES

Focal slowing Normal Normal

Myelin damaged

•35
 Stimulation & Recording Rules
By convention,
 Black lead is the cathode of the stimulator and the active electrode for recording.
 Red lead is the anode of the stimulator and the reference electrode for recording.
 Organization: “Black to Black”, stimulation polarity: Negative

Motor Conduction Stimulation

Artifact Reduction Median nerve
Recording: Surface electrodes Anode Cathode
To reduce stimulation artifact as much
Stimulation: Handgrip
as possible, the ground electrode must Ground
surface electrode
be placed “between” Stim. & Rec. sites Reference
as shown in sensory
Orthodromic conduction.
stimulation Recorder
Active
In some difficult cases Recording electrodes
the placement of the
Sensory Conduction
ground below record. LIMB
Median nerve
electrodes offers a
Large ground elect.
good alternative.
Recording: Surface electrodes Anode
Cathode
Stimulation: Digital ring
See other possibilities in the Reference
electrodes Recorder Stimulation
chapter “Nerve Stimulations” Active
Orthodromic technique Ground

•36
 Stimulation Points Extremities
Nerve
Site

Stimulation points and Recording responses

Crural

Plexus Sciatic
Axillaries
Stimulation point 3 Stimulation point 2 Stimulation point 1 Recording responses
Elbow Wrist Palm
Median nerve Radial

Ulnar
Tibial Stim. 1
Above Elbow
Median Popliteal Fossa
Ulnar Elbow Stim. 2
Below Elbow Peroneal
Peroneal Stim. 3
Ulnar
Wrist
APB muscle EMG equipment
Median
Wrist
Sural
Stimulation points are located on the- most
Median Ulnar accessible pathway of each nerve,
above and below joints. Palm
Posterior
Tibial

•37
 Stimulation Points Head & Trunk

Erb’s Point
Higher

F Thora-
a Medium codorsalis
c
i
Lower
a
l
Long Thoracic
Trunk

Auricular Posterior

Crural
Spinal XI

Phrenic

Erb’s Point

•38
Next: Motor Nerve Conduction
Motor Nerve Conduction
Technique
With a normal patient and well performed technique,
Median nerve
these two responses would be superimposable.

 Direct response Click

Click
Click
to
Click
check
to
tostim.
to
stim.
velocity
performance
at
atelbow
wrist
 Amplitude 0.5 mV to 5 mV
 Normally biphasic
 Duration 1 to 3 ms. Latency
 Latency depends on stimulation site
Stimulator Recorder
Settings
Wrist Wrist 3.5 ms
 Sensitivity : 5 mV/Div.
 High Frequency Filter : 2-5 KHz
 Low Frequency Filter : 20 Hz
 Sweep Speed : Higher Extremities 2 ms/Div.
Lower Extremities 5 ms/Div.
 Stimulation current: Supramaxima
Distance measurement
depends on nerve and site, between
between 10 - of
2 points 30stim.
mA,
with 200 µs stim. duration.
Elbow 8.2 ms
Performance
Performance is normally controlled by amplitude
and area comparisons ofElbow
the two responses. Distance: 240 mm Diff.: 4.7 ms
Conduction Velocity (CV) = 51 m/s
Difference must not exceed 3%.
To keep a clear picture, the ground
electrode is not represented.
•39
 Sensory Nerve Conduction
Technique Orthodromic method
Ulnar nerve
 Direct response for high potentials
otherwise the averager is needed (see techniques) ClickClick
Click
to record
Click
to
to stim.
stim.
toatvelocity
Digit
at
at Digit
Digit
V - IV
V
Elbow
 Amplitude 5 µV to 35 µV
 Normally biphasic
 Duration 1 to 3 ms. Averaging
 Latency depends on stimulation site
Stimulator:
Digital rings Distance measurement
Settings [Avg = Averager]
between Rec. and Stim. Digit IV
Lat. 3.1 ms
Dist.175 mm
 Sensitivity (input) : 10 µV/Div. Wrist
 Wrist (Avg) : 5-10 µV/Div.
Sensitivity CV 56 m/s
Recorder Ch 1
 Avg Epochs : 10-20
 High Frequency Filter : 2-5 KHz Lat. 2.6 ms
 Low Frequency Filter : 20 Hz Digit V Dist.155 mm
 Sweep Speed : 2 ms/Div. Wrist
 Stimulation current (3 timesDistance measurement
threshold), CV 60 m/s
depends on nerve and site, between
between Wrist
5 - 15and
mA,Elbow
with 200 µs stim. duration. Lat. 6.4 ms
 Stim. Frequency : 1-3 Hz Digit V Δ Lat.3.8 ms
Recorder Ch 2
Latency Elbow
Elbow measurement Dist.235 mm
(below)
Some universities prefer measurement at negative CV 62 m/s
peak. This is due to reference values performed
with old equipments with which the measurement
at theTo
onset
keepwas difficult
a clear or impossible.
picture, the ground
electrode is not represented.
•40
 Recording Electrodes
Sensory Nerve ConductionAntidromic method
Ulnar and Median nerves
Surface or Digital rings
Click
Clicktoto
Click
stim.
stim.
toatat
velocity
Median
Ulnar Nerve
Nerve

Recorder
Stimulator
Technique
 Direct response Distance measurement
Digit IV Lat. 2.3 ms
 Amplitude 20 µV to 100 µV between Rec. and Stim.
 Normally biphasic Wrist- Dist.130 mm
 Duration 1 to 3 ms. Wrist Ulnar CV 57 m/s
 Latency depends on stimulation site
 Stimulation current depends on nerve and site,
between
Ulnar 5 - 10 mA, Median
with 200 µs stim. duration.
Digit IV Lat. 2.2 ms
Note Wrist- Dist.130 mm
Note Median CV 59 m/s
A too high current stimulation will stimulate motor
 Response
fibers to a
which add stim.
motorat Elbow cantobethe
response recorded.
sensory
 Latencies will be little be higher with digital
response.
rings – Be careful with normal values.

To keep a clear picture, the ground

electrode is not represented.
•41
 Lower Extremities
Stimulation 1

Peroneal nerve
Recorder
Motor Conduction

Stimulation 2

14 cm

Sural nerve

Sensory Conduction
Recorder

Stimulation

•42
 Some Normal Values
The most sensitive normal value for a particular NCS is usually obtained by performing the
same NCS on the corresponding nerve in the contralateral limb (assuming it is normal).
 A decrease of more than 50% in amplitude is considered abnormal.
The results of NCS - Motor, Sensory must be compared to some normal values.
 These must be age-related as well :
 Infants and young children: Quite slow conduction rate.
 Adults: Amplitudes and conduction rate decrease with age.

Age 20-50 Motor NC Sensory

NC
Amp. Lat. C.V. Amp. Lat. C.V.
Nerve mV ms m/s µV ms m/s

Median >6 < 4.0 > 50 > 20 < 3.4 > 50

Median (palm) < 2.2
Ulnar > 15 < 3.1 > 50
Ulnar (palm) < 2.2
Radial > 18 < 2.7
Sural > 6 < 4.5 > 40
Peroneal >3 < 5.5 > 40 < 4.5
Tibial (post.) >8 < 6.0 > 40

•43
Next: Carpal Tunnel Syndrome
 Carpal Tunnel Syndrome
 Carpal Tunnel Syndrome (CTS) is a condition, in which the
median nerve is compressed within the carpal tunnel, where it Median nerve is
Carpal
passes underTunnel Syndrome
the trans-carpal ligament (flexor retinaculum). compressed at the
 Symptoms are numbness in the first, second, third and the Median nerve
wrist, resulting in
radial aspect of the fourth digit, andpopulation
sometimes pain in the hand numbness or pain.
Approximately 0.2% of the
and arm.
undergo surgery every year.
 The condition is well-known, and has been diagnosed since the
1960ies by neuro-physiological methods (Thomas & al., 1967).
Transverse carpal
Old method ligament released

 A large group is not subject to surgery, but treated

 Patients •with
with various devices to immobilize the wrist.
CTS constitute the largest single patient group investigated
• with the injection of steroids into the carpal tunnel
by neurophysiologists (up to 70% in some countries).
 Therefore many labs try to shorten the time to diagnose this condition by various
methods.

Pictures, all rights reserved: ADAM

•44
C7-8
F – Waves
Voluntary contralateral
motor action to facilitate F
Settings
Ulnar nerve Superimposition
 Split Sensitivity : M 5 mV/Div. F 0.5 mV/Div.
 High Frequency Filter : 2-5 KHz Direct response Indirect response
 Low Frequency Filter : 20 Hz “M” motor “F” wave
 Sweep Speed : 5-10 ms/Div.
 Stimulation current: Supramaximal
Motoneuron
F – Waves Click on “Motion” button first
 Stim. Frequency : Manual or 1 Hz
 Can be elicited fromSplit
Sensitivity any motor nerve (upper or lower extremity).
5 ms/Div. 0.5 ms/Div.
 Supramaximal stimulation – Action potentials travel bidirectionally.
A-Waves
PCTAn A-wave is a compound action potential
 Proximally, potentials sometimes reach motor neuron which
backfire (recurrent discharge) and produce 30-50 ms later a
evoked consistently from a muscle by A
small motor response (depending upon the nerve and rec. site).
submaximal electric stimuli to the nerve and
frequently abolished by supramaximal stimuli.  The F-Waves typically consists of a series of small potentials,
dispersed somewhat in time.
An A-wave amplitude is similar to that of the Block
F-wave, but the latency is more Stimulator
constant.  The shortest F latency is normally considered.
Wrist occurs before the F-wave,
An A-wave usually
but may occur afterward.  The peripheral conduction time (PCT) is determined by the
Kimura’s formula:
The A-wave is due to normal or pathologic
PCT = (FLat + MLat - 1) / 2 (The backfire takes 1 ms)
axonal branching.
Rec.
M F Latency 30 to 50 ms
Motion Record Click on “Record” button

•45
Kimura Jun MD. - Kyoto University-Japan
 Reflexes
Reflex studies are performed to detect a
H - Reflex
lesion involving the efferent arc of reflex.
(see Neurophysiology – Somatic System)
Blink Reflex
Spinal cord

Sensory nerve
Tendon
InterneuronReflex (T-Waves)

Arc of Reflex Sensory stimulation

Motor nerve

Stimulation

Motor Action Potential

Click in the window to close it !

S1
H – Reflex Tibial nerve
Settings Normal Values (H latency)
Direct response Reflex response
 Sensitivity : 10 mV/Div. Flexor Carpi Radialis Lat. 15.9 ms ± 1.5
“M” motor Amp.1.6“H” mV ± 0.4
 High Frequency Filter : 2-5 KHz
 Low Frequency Filter : 20 Hz Gastrocnemius
 Sweep Speed : 5 ms/Div.
Increasing
+ (0.46stimulus
x LL cm)strength
 Stimulation current H – Reflex ms = 9.14 + (0.1 x A years)
Click on “Motion” buttons first
• Precision “Fine” (0.01 mA) Sensory threshold
Soleus
Motor nerve
 Motion H
• Duration 1 ms (see Nerve Stim. – Chronaxy)
Sensory nerve PHMotor
(147-160 cm): 28.5 ms ± 1.8
 Stim. Frequency : Manual Stimulation threshold
level a little bit above Sensory Threshold.
PH (163-175 cm): 29.9 ms ± 2.12
Motor nerve is PH
not(178-193
depolarized.
cm): 31.5 ms ± 1.2 H Max


Motion M-HLL = Leg Length, A = Age, PH = Patient Height in cm
Cathode Stimulation level higher the Motor Threshold.
Technique M response appears. H amplitude decreased because the partial
Popliteal Fossa Other Methods
collision takes effect between efferent M and sensory reflex.
1. Find
Stimulator the stimulation point with M response.
 Motion M diagnose an axonal degeneration (dying-back
2. Start from current level 0 mA. Amplitude ratio M/H (for Soleus) arguments to
3. Increase current by steps of 0.02 mA until Stimulation level increased to maximal M response.
the H “sensory threshold” and continue until phenomenon).
Motion Total collision – H response disappears.
H
Motion
H Max.
increase current to Latencies: M M
4. After H-Max you can Recorder
 “H index” formula (
≈ 10 ms H ≈ 30 ms (depends
Max
(Guilhéneuc-France)
PH
) 2
x 2 collision
HLat - MLaton patient
Total height)
M-H 0.5-1 mA until M Max response.
For practical purposes, H-Responses are of major value only in
Motion detecting generalizedAdult ≈ 100
polyneuropathies R/L Diff.
and <7
lumbosacral radi-
M culopathies involving the S1 roots.

Record
MLat HLatbutton
Click on “Record”

•47
 Blink Reflex Blink responses are performed to assess the 5th and the 7th cranial
Stim. left
nerves. They are abnormal, for example, with unilateral facial paralysis,
such as Bell’s palsy.
Settings (eachFacial
channel)
Motor nerve
Normal Values
Indirect Reflex (Contra)
Indirect Reflex (Ipsi)
Ch1
 7th µV/Div.
Sensitivity : 100 Cranial nerve Stimulator Latencies
Ipsi
Stimulation
 High Frequency Filter : 2-5 KHz R1 10.6 ms
5th Cranial nerve
±2.5
TrigeminalAbnormal >13.0 ms
 Low Frequency Filter
Supraorbital nerve: 20 Hz
R1 11.5
R2 31.1 ms
 Sweep Sensory
Speed :nerve
10 ms/Div. R /msL diff. < 1.2 ms Supraorbital nerve

R2 Brain
Ch2 ipsi Stem 31 ms ±10 Abnormal >40 ms
 Current stimulation Contra
R2 contra 32 ms Direct±11
Resp. (Ipsi)
Abnormal >41 msmotor nerve
Facial
Stim. Right • Duration 0.1
Stim. ms
Left 7th Cranial nerve
 Stim. Frequency : Manual R2i / R2c R2
diff.31.7
< ms
5 ms
Orbicularis Oculi
Amplitude
Blink responses are action potentials (AP) muscle
recorded from theR1orbicularis oculi
Stim. right
0.4 muscle.
mV ±0.2
Technique Rec. Ch1
These facial muscle
R2 AP result 0.55
from mV
stimulation
±0.2 of the supraorbital nerve,
Repeat stimulation at least 3 times per site. one of the sensory nerves derived from the 5 th cranial.
Blink responses are reflex studies.
Ground Ch1
Stimulus alternative
Orbicularis Oculi muscle Rec.
ContraElectrodes alternativeIpsilateral side
Contalateral side
A 0.1 ms duration is painless, but for some patients Instead of surface electrodes, concentric needles
it is difficult to obtain responses. offer the advantage of sharpR2recordings.
32.6 ms

Some universities perform a stimulation with a short Ch2

train of 3 pulses of 0.1 ms duration andRec.
high Ch2 UseIpsi
very thin needles with 0.3 mm diameter.
R2 indirect R1 direct R2 indirect
frequency in the train.
R1 10.2 ms
R2 30.8Action
see also : Neurophysiology – Somatic Reflex ms

Recall Record Click in the window to close it !

•48
Next: Tendon Reflex
 Tendon Reflex (T-Wave) Recorder
The T-Wave is a compound action potential,
evoked from a muscle by rapid stretch of its
tendon.

Settings Normal Values

The stimulation is performed with a special
 Sensitivity : 1 mV/Div.
hammer which trigs the recorder.
 High Frequency Filter : 2-5 KHz
 Low Frequency Filter : 20 Hz Quadriceps Femoris
 Sweep Speed : 50-100 ms/Div.
Lat. 31ms ±5 Amp. > 2mV pp
 Stimulation
• Tendon hammer connected to Trig In Triceps Surae
 Stim. Frequency : Manual
Lat. 44ms ±8 Amp. > 2.5mV pp

Technique Note: The latency depends also on the time response

Repeat stimulation at least 3 times. of the tendon hammer – Check your ref. values.

Latency measurement

Motion

•49
Next: MUNE
Introduction to EP
• What is EP?
− Tests that measure electrical activity in certain areas of the brain and spinal cord
− Electrical activity is produced by stimulation of specific sensory nerve pathways
− Types of EP’s
• Brainstem Auditory Evoked Potential (BAEP) - Checks the pathway from the ear to the
brain.  The BAEP test may help uncover the cause of hearing and balance problems, and
other symptoms.
• Visual Evoked Potential (VEP) - Checks the pathway from the eyes to the brain.  May
help find the cause of certain vision problems and other conditions.
• Somatosensory Evoked Potential (SEP or SSEP) - Checks the pathway from the nerves in
the limbs to the brain.  It is a way to study the function of the nerves, the spinal cord
and brain.

•50
Introduction to EP
• BAEP – Why and How?
− Used to diagnose hearing losses, assess high freq hearing, determine brain
death, monitor brainstem function during surgery
− Can distinguish damage to the acoustic nerve pathways within the brainstem
− Headphones used to deliver series of clicks to one ear at a time. A masking or
static sound is played into the other ear. Each ear is usually tested twice, and the
entire procedure takes approximately 30-45 minutes

•51
Introduction to EP
• VEP – Why and How?
− Used to evaluate optic neuritis,
optic tumors, retinal disorders,
and demyelenating diseases such
as multiple sclerosis
− The patient sits before a screen on
which an alternating checkerboard
pattern is displayed
− Each eye tested separately
− Each eye is usually tested twice, and the entire
procedure takes approximately 30-45 minutes.

•52
Introduction to EP
• SSEP – Why and How?
− Evaluate the nerve pathway from the arms and legs through
the spinal cord to the brain
− Identify spinal cord injuries/diseases, neuromuscular and
demyelineating diseases. Monitor patients during surgery
on the spine
− Electrodes are attached to the wrist, the back of the knee
− Mild electrical stimulus is applied through the electrodes
− Electrodes on the scalp determine the time it takes current
to travel along the nerve to the brain
− Procedure takes approximately 30 minutes

•53
•54
Evoked Potentials (EP)
General Information
Dawson’s averager, first
demonstrated in 1951,
Somatosensory EP formed a new area in
clinical neurophysiology, -
the area of Evoked
Auditory EP
Potentials.
Links between Evoked
Visual EP
Potentials and clinical
practice are firmly
Motor EP established in neurology,
neurosurgery,
Event Related Potentials ophthalmology, otology,
pediatrics, psychiatry and
urology.
Pitfalls
General Information : Averager (AVG)
Direct signal

Recording potential on spinal cord and/or cortex

issued from Somatosensory, Auditory or Visual AVG group I

stimulation, the averaging technique is used to AVG group II

extract a revealed potential (RP) buried in an
activity (EEG and/or muscle noise).
AVG I + II

 RP amplitude: 0.1-5 µV Etc.. up to more

 Amplitude of activity: 100-2,000 mV than 2,000 times

Averaged signal

Amplified

•56
 General Information : Recording &
Form and latency depend on the type of the EP and
the recording site.
Latencies SEP Tibial nerve
Recording sites are identified by
anatomic abbreviations Cpz-FPz

 Active electrode Cpz (first)

 Reference electrode Fpz
P40

Latencies are identified by

N145
 Peak orientation
VEP
• Negative N.. N75

• Positive P..
Oz-Cz
 Normal value
N75 Negative at around 75 ms
P100 Positive at around 100 ms P100

•57
 20%

Anatomic Cortical Abbreviations

10-20 system diagram 20%

Cz Fz
20%
20%

Cz
20%

C3 C4
20% Pz 20%
Pz Fpz 10%
20%

Nasion T3 Oz T4
Oz
A : Auricular 10% 10%
C : Central 10%
A2 Pg2 A1 A2
Inion
F : Frontal
Fp : Frontal-polar
O : Occipital
P : Parietal
T : Temporal 10%
Nasion Nasion
Pg1 Pg2 20%
-z : Midline 25%
Odd no. : Left side Fp1 Fp2 Fp1 Fp2
Even no.: Right side 20%
F7 F3 Fz F4 F8 F7 Fz F8
25%

Left A1 T3 C3 Cz C4 T4 A2 Right Left A1 T3 C3 Cz C4 T4 A2 Right

25% P3 Pz P4 Pz
T5 T6 T5 T6 20%
O1 O2 O1 O2
25%
Inion Inion
20%
10%
•58
Next: Somatosensory EP
 Somatosensory Evoked Potentials (SEPs)
Thalamo-cortical potentials Somatosensory EPs offer a look at
“physiologic anatomy”. They provide a
Cervico-medullary potentials
sensitive tool for assessment of spinal
Upper Brachial plexus potentials cord and brainstem posterior columns,
extremities
as well as medial lemniscal tracts and
nearby structures.
SEPs are performed on both sides.
Cauda equina
Lower cord potentials

Somatosensory EPs are used to test:

 the PNS (nerves and roots)
Lower
 the large-fiber sensory tracts in the CNS
extremities

PNS: Peripheral Nervous System

CNS: Central Nervous System
(see Neurophysiology)

•59
Recording SEP – Lower Extremities
Ref. Ch1 & Ch2
Left Tibial nerve
L FPz R
AVERAGING
Act. Ch3
Settings Fz
Accessories Ch1
Cortex Other Scalp needlesCPi-Fpz
5 cm
C5S Cz
Filters Ref. Ch3 Disposable
2 cm (iron)
High pass 0.5 Hz 20 Hz Ø 0.3 mm length 10 mm
CPi CPz CPc Reusable (platinum) P37
Low passGround 1 KHz 3 KHz Ch2
Act. Ch2
Sensitivity 5 µV/Div. 5 µV/Div. Scalp surfaceCPz-Fpz
Sweep Speed Act. Ch4 10 ms/Div. Act. Ch1
length 100 cm

Nuprep
TPC 1.5mm P37
T12S AVG sensitivity 0.5 µV/Div. 72cm
µV/Div.
7 cm
N34
No of Epochs 200-500 - Ten20 for fixing and contact
Ch3
L4 Stim. Duration Placement
0.1-0.2 ms of electrodes
- NuPrep for skin preparation
Fpz-C5S
IC Current Level 1.5 x Check
Motor threshold
impedancesDisposable surface P31
Stim. Frequency 3 Hz
Ref. Ch4 (ICi + ICc) Length 50 cm
Blue dot LP Area 9 x 6 mm
Ch4TPC 1.5mm LP: Lombar Potential
Electrodes T12S-IC
Recording Stimulation Stimulation surface
Cortex EP needles Frequency : 3 Hz
or EP surface
Level : 1.5 time motor threshold
- Handheld electrode
20 40 60 ms
Other Disposable surface
- Elastic strap for fixing
Stimulating Averaging : 200-500 epochs Normal Latency ms
--i ipsilateral Surface Values Mean SD Range
--c contra lateral LP 10.8 ±0.9 8.6-13.1
N34 33.5 ±1.5 30.3-41.3
Stimulation P37 36.3 ±2.4 30.5-41.7
•60
 Recording SEP – Upper Extremities Left Median nerve
L FPz R AVERAGING
N19
Settings Fz Accessories Ch1
C5S Act. Ch3 5 cm CPc-Cpi
Cortex Other
Cz Scalp needles
Epc Epi 2 cm
Filters Disposable (iron)
High pass
Act. Ch4 0.5 HzCPi 20
CPzHzCPc Ø 0.3 mm length 10 mm
Low pass 1 KHz 3 KHz Reusable
Act. Ch1 (platinum) N18
Ch2
Ref. Ch2, Ch3 & Ch4
Sensitivity 5 µV/Div. 5 µV/Div. Scalp surface CPi-Epc
Ref. Ch1
Sweep Speed 5 ms/Div. length 100 cm

Nuprep
7 cm 7 cm TPC 1.5mm P14
AVG sensitivity 0.5 µV/Div. 2 µV/Div.
No of Epochs 200-500 -Act.
Ten20
Ch2 for fixing and contact N13
Ch3
Stim. Duration 0.1-0.2 ms of electrodes - NuPrep for skin preparation
Placement C5S-Epc
Current Level 1.5 x Motor threshold
Disposable surface
Stim. Frequency Check
3 Hz impedances
EP
Length 50 cm
Stimulation Blue dot Area 9 x 6 mm
Ch41.5mm
TPC
Electrodes Epi-Epc
Stimulation Stimulation surface
Recording
Frequency : 3 Hz
Cortex EP needles or EP surface
Level : 1.5 time motor threshold
- Handheld electrode
Other Disposable surface 10 20 30 ms
Averaging : 200-500- Elastic
epochsstrap for fixing
Normal Latency ms Amplitude µV
Stimulating
--i ipsilateral Values Mean SD Mean SD
--c contra lateral Surface
EP 9.6 ±0.7 5.4 ±2.5
N13 13.2 ±0.8 2.9 ±1.3
N19 18.9 ±1.0 2.8 ±1.6
•61
Next: Auditory EP
Brain Stem Auditory Evoked Responses
BAERs evaluate the function of several levels
(BAERs) of the peripheral and brain stem auditory
Primary auditory cortex
system, including auditory nerves, the pons,
and mid-brain.
VII
V

IV
VI
III
II
Mid-Brain I VI
V VII
Brain Stem

IV
Pons
III I Distal spiral ganglia and auditory nerve
Ear
II II Proximal auditory nerve (cochlea nucleus)
I III Ventral cochlear nucleus in pons
Auditory Nerves IV Inferior lateral lemiscus in pons
V Lateral lemiscus in lower mid-brain
Auditory Nervous System VI Medial geniculate nucleus (upper mid-brain)
(see Neurophysiology – Brain Functions)
VII Primary auditory cortex

•62
 Hearing Sensitivity
Absolute silence 0 dB peSPL Pressure Pascal
Wegel’s Curves (1922)
Decibel dB SPL
10 5 194
(peak-equivalent Sound Pressure Level) Atmospheric Pressure
equal 20.10-6 Pa. 104 174

103 154
Hearing Level depends on sound B
102 l 134
frequency (A) – This is the eve
sL
rou
normal hearing level (nHL). 10 nge 114
Da
1 94

Increasing sound intensity 10-1 0 74

dB
! (dB or pressure), we do not 10-2
nH
L 54
hear the sound, but get a A
pain sensation. This is the 10-3 0 dB OHL 34

dangerous level (B): above 120 dB 10-4 14

0 dB peSPL = 20.10 -6
Pascal
peSPL (confirmation requested above 10 -5
0

this limit – maximum 132 dB peSPL).

8 16 32 64 128 256 512 1024 2048 4096 8192 16384 Freq. Hz
In Audiometry (ENT specialists),
Frequency band
0 dB  30 dB peSPL, which is called used in audiometry
0 dB OHL (Objective Hearing Level).
See also Nerve & Brain Stimulations – Pulsed Sound

•63
Next: BAER testing
 BAER Testing Cz (dB peSPL)
Stimulating left
V AVERAGING

Settings L FPz R Ground

Accessories IV
III
Ch1 & 2 Scalp needles
Ref. Ch1 II
Left Filters Right Ch1 I
Cz Disposable (iron)
Cz-A1 VI
A1 High passA2 0.5 Hz A1 A2 Ø 0.3 mm length 10 mm VII
Low pass 1 KHz Reusable (platinum) Run 1
M1 M2
Ref. Ch2
Sensitivity 2-5 µV/Div. Scalp surface
Sweep Speed 1 ms/Div. length 100 cm Run 2

Nuprep
Act. Ch1 & Ch2
TPC 1.5mm
AVG sens. 0.1-0.2 µV/Div.
No of Epochs 1000-4000 - Ten20 for fixing and contact
Stimulus unfiltered click - NuPrep for skin preparation
Ch2

 The BAER is performed on10

Stim. Frequency Hz ear.
each Stimulation: Headset
Cz-A2

 Duration
Two runs must Normalon
be performed
Infant
100each
µs ear.
50 µs
(see Nerve & Brain Stimulation – Pulsed Sound)
 A white noise is applied on the contralateral
Polarity Rarefaction
ear (40-80 (condensation
dB), to mask oftenthe effect
enlarges the of bone
wave I)
Normal Values 5 10 ms
conduction (contralateral to ipsilateral).
Electrodes placement (Click 90 dB SPL) Latencies Amplitudes Inter Peaks
In some difficult cases,impedances.
electrodes are Peaks ms SD µV SD ms
1. Place electrodes and check
placed on mastoid (M1 and M2) instead Shielded I Standard
1.7 0.15
Tubal 0.28 0.14
Bone conductor I-III 2.2
2. Headset in place (Red/Right).
of A1 and A2. Look for the headset II headset
2.8 insert
0.17 0.23 0.12 III-V 1.8
patient hearing level (normally around 35 dB). III 3.9 0.19
Red: right ear Blue: left ear0.25 0.12
IV 5.1 0.24 0.40 (Bone0.13
vibrator)
Also R-L
3. Add 50-60 dB to the hearing level value. V 5.7 0.25 0.47 0.16 difference
Wait min. 30 s. before the recording is started. VI 7.3 0.29 0.43 0.16
•64
Next: OHL testing
 OHL Testing
Objective Hearing
Latency ms
(dB OHL)
Level (OHL) Normative data (60 dB OHL) 80 dB
11
Latency/Intensity Function (LIF)

is useful in auditory screening.

The appearance
10
of wave V 10
serves as an indicator of the
auditory9 threshold.

Latency to Wave V (ms)

9
60 dB
8
 The OHL is performed on each ear.
 Four or7five runs are performed at 8

different stimulus levels. 40 dB

6 Wave V
 ENT practitioners are familiar with 7
dB OHL, 5 0 dB OHL ≈ 30 dB peSPL.

 Stimulus4 is generally a filtered click

20 dB
6
commonly 1000 Hz – Rarefaction –
Duration3 100 µs – Rate 13 pulses/s. 0.25 µV

(see Nerve 5
2 & Brain Stimulation – Pulsed Sound) 0 5 10 ms dB OHL 20 40
Wave I 60 80 100

 Electrode setup as BAER testing. Wave V marker

1
Depending on the patient, test is As stimulus intensity decreases, Wave V, LIF plotted
started by a stimulus level
29-30 31-32 of 100
34-34 35-36 37-38 39-40the amplitude
4-9 9-14of14-19
wave19-24
V decreases
24-29 29-34 from the intensity series.
or 80 dB. Weeks and latency increases.
Months Normal values in grey
Adult
area.
•65
Next: Visual EP
Visual Evoked Potential (VEP)
Visual information is conveyed from
Optic Nerve
the retina to occipital lobes via optic
nerves, optic chiasm, and lateral
Optic Chiasm geniculate bodies.
Optic Tract

Lateral Geniculate VEP peaks typically recorded

Body
following pattern-reversal stimulation
(see Nerve & Brain Stimulation – Flashed Light)
Occipital Lobe are N75, P100 and N145 over the
occiput. The P100 response is the
Visual Nervous System most consistent peak.
(see Neurophysiology – Brain Functions)

Important clinical uses of VEP are

VEP
N145
screening for: multiple sclerosis and other
demyelinating disorders; optic nerve
N75
injury after compressive injury from
trauma, hemorrhage, or tumor; hysterical
blindness; and, visual function in patients
P100
who cannot be tested directly, such as
those in coma, infants.
100 ms

•66
 VEP Testing Cz Distance to patient and check size:
see Nerve & Brain Stimulation
Flashed Light – Visual Field Angle
1. Place electrodes and check impedances.
2. Stimulation rate 1 Hz – Maxi. 2 Hz.
Fpz
Settings Accessories
O’1 O’2 Stimulation right eye AVERAGING
2 cm Ch1, 2, 3 & 4
Scalp needles
Filters
O1 Oz O2
High pass 0.5 Hz Disposable
Ch1(iron) Run 1
A1 Ref. Ch1, Ch2 & Ch3 Ø 0.3 mm length 10 mm
Low pass A2 1 KHz O1-Cz
Reusable (platinum) Run 2
Act. Ch4
Sensitivity 5 µV/Div. Act. Ch3
N145
Sweep Speed 30 ms/Div. Scalp surface N75
Act. Ch2
Ch2 length 100 cm
AVGneedles,
sens. 1-2 µV/Div.

Nuprep
With scalp Act. Ch1 Oz-Cz
TPC 1.5mm
Noless
O’ line is of painful
Epochs 200-500 Ground
Ref. Ch4 - Ten20 for fixing and contact
Pattern Stimulation P100
 The VEP isStimulus:
performed with checkerboard
monocular stimulation - NuPrep for
Ch3 skin preparation
reversing pattern
O2-Cz
and recording
Size with
of CRTa minimum
Monitor of
17”four channels.
(Diag. 43 cm)
 Number
Two runs must beofperformed
Checks 48 onxeach
64 eye. Stimulation:
 StimulationDistance to patient
with a reversing 70 cm
checkerboard pattern.(see Nerve & Brain Stimulation – Flashed Light)
Stim. Frequency 1 Hz Ch4
Use flash or LED goggles for patients who cannot Cz-A1 N100
focus on screen
Screen(see Nerve & Brain
W angle 26.3°Stimulation).
 The distance between
Screen H anglethe subject
20.3° and screen, and
the check size influence
Checks angle visual27’responses. 100 200 ms
Normal value: Full-field, screen size 9°, check size 26’
 Smaller checks stimulate central vision more Checkerboard LED
Flash
Ambient luminosity Dark room pattern Latency
goggles ms Amplitude µV
selectively than do larger checks.
Mean SD Range Mean SD Range
 Luminosity directly influences amplitude and P100 102.3 ±5.1 89-114 10.1 ±4.2 3-21
latency of VEP, and thus is kept constant. R/L diff 1.3 ±2.0 0-6 1.6 ±1.4 0-5.5
•67
Next: Motor EP
 Motor Evoked Potentials (MEPs) In clinical medicine, single-pulse Magnetic
stimulator
transcranial magnetic stimulation (TMS) is
primarily used to evoke motor responses in
slightly activated target muscles. Coil

The procedure records single-stimulus

Motor
Tracts induced muscle twitches called motor
evoked potentials (MEP). (see Nerve & Brain Stimulation: Magnetic Field)

CNS
Efferent
motor pathway
Motor EPs are used to test the
Motor nerve efferent motor pathway:
 PNS (nerves and roots)
Root
 Motor tracts in the CNS

PNS
Reminder:
Motor Nervous System Left side extremities are controlled by
(see Neurophysiology – Nervous System)
PNS: Peripheral Nervous System
the right side cortex and vice versa.
CNS: Central Nervous System
•68
Cortical Magnetic Stimulation Stimulation of a specific area
Coils and Coil orientation Power and Motor response
of motor cortex

Knee
Trunk
Hip
Shoulder
Elbow
Upper limb: over the left

Wr
Ha

ist
5
40% hemisphere for recording on

nd
Cortical stimulation 3

4 F
Ankle
2
the right limb.

in
Th

ge
Ne umb Toes

rs
c
Ey k ( b
eb a
50%
Eye row ck) Lower limb: over the vertex
s
Fac
e
Motor cortex
1/2 Lips Motor cortex
Here, tibial area…
45° Jaw 60%
organization
Tongue
Swallowing

70%

The straightforward performance and

easy interpretation of the MEPs
CNS With Figure-8 coil, With Circular
Motorcoil, thePotential As stimulation
Evoked
compare power increases,
favorably with the afferent
the best response maximum is obtained the amplitude of the response
is obtained at 45° at ≈ 1/2 of the evoked potentials (SEPs) or reflex
increases.
external border studies and are suitable for assessing
See also Nerve & Brain Stimulation the CNS.

•69
MEP Considerations Amplitude consideration
Amplitude Large variations ! Latency Strongly influenced ! Area Generally enlarged !
The amplitude ratio MEP / Distal response is frequently calculated.
A ratio comprised between 20 and 30% is considered as normal!

Latency consideration
Muscles Latencies ms ± SD

These published normal Biceps brachii 13.0 ± 1.4

The MEPs show marked amplitude Abductor pollicis brevis 20.7area
The ± 1.3can reflect the number of
values
variation between normalare given as an
subjects Abductor digiti minimi 20.0 ± 1.5
indication and are excited motoneurons more faithfully
and from one stimulus to another. Quadriceps femoris 22.3the
than ± 2.0
amplitude, compensating
strongly influenced. Tibialis anterior 29.3 ± 2.4
partially for the temporal dispersion.
To reduce confounding factors of The latency of MEPs has a
Extensor digitorum brevis 38.2 ± 2.6
peripheral pathology, the examiner considerable peripheral
Measuring the area instead of
preferably uses the ratio of the CMAP component that is strongly
To minimize influence influenced
from: amplitude may be inaccurate for
from cortical stimulation to that from by body stature or
other reasons.
maximal peripheral (distal)
- arm length, limb length and possible
nerve
or leg
stimulation. abnormality of peripheral nerve With strong cortical stimuli and high
- body stature,
conduction. voluntary background contraction,
- and
In principle, these possible
relative MEP peripheral conduction slowing as a confounding some factor,
motoneurons tend to fire more
amplitudes should reflect the than once in response to a stimulus
the CCT
number of conducting centraldefined as time from the motor cortex to the spinal
induced corticospinal volley, and this
motoneurons. motoneurons, is usually assessed. enlarges the measured MEP area.
CCT : Central Conduction Time (see this chapter)

Ref. C.W. Hess – Magnetic Stimulation in Clinical Neurophysiology . (2005) 83-103

•70
Next: Phrenic nerve MEP
Phrenic Nerve MEP
TMS stimulation
0.1mV/D
5ms/D

Settings Monophasic stimulus

One channel recording
Filters Cz With a monophasic stimulus, you have Cortical stim. Cz
High pass 20 Hz to stimulate with a circular coil.
Low pass 2 KHz
Sensitivity 0.1 mV/Div.
Sweep Speed 5 ms/Div.
C2
(neck)
Cervical stim. C2
Stimulation
Stimulus Magnetic
Pulse Biphasic
Coil Circular or Parabolic

Power And, in Cz stimulation, you have to

Cortical ≈ 70-80% select the correct side of the coil for
Root ≈ 40-60% the left or right side recording.
Lat Amp
Record
Diaphragm ms µV
Stim. Frequency: Manual CorticalLeft
(Cz)side 13.5 ± 1.4 269 ± 144
Cervical (C2) 8.3 ± 1.2 281 ± 128
REPEAT STIMULATION AT LEAST
Use EP Needles Right side
3 TIMES FOR REPRODUCIBILITY
Facilitation: Cz
Stimulation at the end of a forced inspiration.

•71
Next: ERPs
 Event-Related Potentials (ERPs)
Right Brain ERPs
The right side is mainly attributed to learn allow
actions, to qualify
spatial projections and the
musicrelationship
art.
between somatosensory, auditory (P80),
Somatosensory cortex visual, frontal cortex (N100 and P200) and
Parietal lobe
Frontal lobe parietal cortex (cognitive potentials – P300).

Auditory cortex
ERPs (Event-Related
Potentials) are performed with
Visual cortex
various stimuli like pictures,
sounds and/or phrases.

With an EMG-EP recorder,

ERPs analysis is limited to
standard audio and current
stimuli, and depends on the
See also Neurophysiology – Brain Functions
possible configurations of
stimulators.

•72
 Active P300
Active P300 is one way to diagnose alterations P80: Middle latency
of cognitive functions. N1, P2: Long latency responses
Clinical case P3: P300 Cognitive response

Cz Ground N1
Myotonic
FPzDystrophy
BAEP
Ref. Ch1 N2
Cz-A12 Action
N1 Cz
Action
A1 A2
Left Right P80

N2 M1 M2
Cz-A12 Act. Ch1 P2
Reaction time
P2
L P3 R 5 µV
P3

-100 0 500 ms
 Binaural stimulation - Rarefaction – 70 dB SPL
Stim.  Rate -100
0.5 Hz0 500 ms

 Standard: 1000 Hz Burst (10/100/10 ms), occurrence 80% Settings

 Randomized oddball: 2000 Hz Burst (10/100/10 ms), Filters
N1 and
occurrence 20%P2 are not affected (exogen). High pass 0.05 - 0.1 Hz
N2 and P3 are significantly disturbed. Low pass 0.1 KHz
Recording: Sensitivity 5 µV/Div.
 Patient has to perform an action (handheld switch) while Sweep Speed 100 ms/Div.
oddball stimulus appears.
AVG sensitivity 2 - 5 µV/Div.
 Averaged recording is performed on the oddball stimulus. No of Epochs 30 – 50
 30 epochs are normally sufficient.
 Reaction time can be measured with a switch marker (action).
•73
Passive P300
Passive P300 is one way to qualify the degree
Anoxic Patient: Awaked D20
of evolution of a coma.
(post-anoxic coma)
Standard
Cz FPz Ground
Cz-A12
Ref. Ch1

A1 Cz A2
Left Right
M1 M2
N1
Act. Ch1
Oddball
Cz-A12 N2
L R
P2
 Monoral stimulation – Rarefaction – 80 dB SPL 3 µV
 Rate 0.5 Hz P3
 Standard: 1000 Hz Burst (10/100/10 ms), occurrence 80%
 Randomized oddball: 2000 Hz Burst (10/100/10 ms), -100 0 250 500 750 1000 ms
occurrence 20%
 2 channel recording – alternated Standard/Oddball
Record P3: P300 cognitive response
Settings (2 channels) N1 and P3 presence can evaluate the
Filters
degree of chance for re-awakening of
High pass 0.05 - 0.1 Hz
Low pass 0.1 - 0.05 KHz the patient.
Sensitivity 5 µV/Div. AVG sensitivity 1 - 2 µV/Div.
Sweep Speed 100 ms/Div. No of Epochs 30 – 50
•74
 Contingent Negative Variation (CNV)
CNV is aPsychiatric
large negative change
clinical cases
type of event-related potential, believed to indicate attention, consisting of a
in potential
Normal young voltage across the cerebral cortex, especially in the
subject (30-50)
µV
frontal lobe,
- 20 that develops slowly in a person who is actively expecting the occurrence
of some- significant
10 stimulus requiring a response.
0
Action
+ 10
µV
- 20
+ 20 Cz Ground
FPz
0 2000 4000 ms - 10
Ref. Ch1
µV
Non-demented old subject
Cz 0
Left- 20 Right (70-80) A1 A2
M1 M2
- 10 + 10
Act. Ch1 S1 S2
0

+ 10 L R + 20

0 1000 2000 ms
+ 20

0 2000 4000 ms
 Binaural stimulation - Rarefaction – 80 dB SPL Settings
Stim. Oldstimulus
subject with primary Filters
 RandomizedµVpaired (manually 5 to 60 seconds)

- 20 degenerative senile dementia
1000 Hz click (S1) followed 1” later by long 500 Hz burst (S2). High pass 0.05 - 0.1 Hz
- 10 Low pass 0.1 KHz
Technique:0 Sensitivity 5 µV/Div.
 Patient+ 10has to perform an action (handheld switch) Sweep Speed 200 ms/Div.
while the burst stimulus appears. AVG sensitivity 2 - 5 µV/Div.
+ 20
 Averaging on 30 epochs are normally sufficient. No of Epochs 30 – 50
0 2000 4000 ms

•75
 Motor Related Potential (MRP)
MRP is a variance of CNV test. “Hit”

Application: skilled performance tasks. RP Readiness Potential

MCP Motor Cortex Potential
P200 Decline of EMG
MCP SPP Skilled Performance
Cz FPz Ground Positivity

Ref. Ch1 RP
10 µV

A1 Cz A2 Cz-A12
Left Right P200
M1 M2
Act. Ch1

L R SPP

100 µV
EMG

Oddball
 Binaural stimulation - Rarefaction – 70 dB SPL
Stim.
 Randomized Rate 3 – 10” manually
-1000 -500 0 500 1000 ms
 Randomized paired standard/oddball stimulus (0.8-1”)
 Standard: 1000 Hz Burst (10/100/10 ms), occurrence 80% Settings Cortex EMG
 Oddball: 2000 Hz Burst (10/100/10 ms), occurrence 20% Filters Integrated
High pass 0.05 - 0.1 Hz 20 Hz
Technique: Low pass 0.1 KHz 2 KHz
 Trigger recording is only performed on “Hit” stimuli. Sensitivity 5 µV/Div. 100 µV/Div.
 Patient “hit” an handheld switch when the oddball Sweep Speed 200 ms/Div. 200 ms/Div.
stimulus appears.
 Averaging on 30 epochs are normally sufficient. AVG sensitivity 2 - 5 µV/Div.
No of Epochs 30 – 50
•76
Pitfalls
 Stimulation frequency too high (SEP, AEP & VEP)
 Stimulus intensity too high (SEP, AEP & MEP)
 Electrode impedance too high
 Patient not relaxed (muscle activity)
 Eyes movement
 Too much light in the room (VEP)
 Too much noise in the room (AEP)
 Confusion between dBSPL & dBOHL (AEP)
 Interference with other instruments (artifact)
See also “Techniques”

•77
Introduction to EMG
• Thank you!
• Questions?

•78