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Theory of NCS/EMG
EMG
Is an extension of the neurological examination. The EMG examination is a diagnostic tool used in the evaluation of pain, weakness, sensory disturbance, fatigue and atrophy The EMG examination includes two components: Nerve Conduction Studies (NCS) and the needle electromyographic (EMG) study.
NMJ
Muscle
NCS
In NCS or electrical studies, response amplitudes and latencies are evaluated. Nerve Conduction Velocity (NCV) studies may be used to evaluate axonal, segmental and focal peripheral nerve problems. Other NCS techniques may be used to evaluate problems in the neuromuscular junction (NMJ), nerve root and even central nervous system.
Nerve Studies
Focal and Segmental neuropathy (CTS, GB, CMT, Heavy metal poising):
NCV: MNC, SNC
Other (MG):
MNC, SNC, F-wave, Rep. Stim., H-wave, Blink, MUNE
MNC
Supramaximal stimulation at the Wrist produces a Compound Muscle Action Potential (CMAP) from the thenar muscles. The distal latency (W) includes the terminal axon transmission time + the delay time at the NMJ including the time required for generation of the CMAP after depolarization of the motor end plate.
MNCV
Supramaximal stimulation at the Elbow produces a Compound Muscle Action Potential (CMAP) from the thenar muscles. The nerve conduction time from the elbow to the wrist equals the latency difference between the distal latency (W) and the proximal latency (E). The Motor Nerve Conduction Velocity (MNCV) is calculated by dividing the distance between the two cathode stimulation points by conduction time.
F-waves
Supramaximal stimulation required. With each stimulus, <5% of motor axons in nerve produce a F-wave. From each stimulus a different population of motor axons produce f-waves. F-waves are evoked single Motor Unit Action Potentials (CMAP) Latency variation is due to variation in conduction velocity of individual motor axons.
H-waves
A mono-synaptic response analogous to the Achilles tendon tap reflex. Do not vary in latency. Must be larger than M-wave.
Blink Reflex
Repetitive Stimulation
Supramaximal Stimulation. 4 to 10 stimuli at 2-3 Hz. Maximal amplitude drop by 4th or 5th response. Amplitude and Area should both decrement. Typical test sequence: pre-exercise, 30-60s exercise, 3 s post-exercise, 2 min postexercise, 10 min post-exercise Movement related artifact (bottom) from changes in the muscle shape during recording.
Needle Exam
The needle EMG examination is used to evaluate problems in muscle, the NMJ and The Motor Unit.
Needle Studies
Routine needle EMG
SPA, MUP, MVA: Radicular lesions, Axonal degeneration, Muscle weakness
Quantitative EMG
QMUP, AMUP, IPA: Axonal degeneration, muscle weakness
SFEMG
SFEMG: MG, Myasthenic Syndrome, Botulinum intoxication, Tetany, Myotonia, MD, Polymyositis.
EMG Findings
Spontaneous Activity
Insertion Activity:
Fibrillation Potentials:
End-Plate Activity:
Complex Repetitive Discharge (CRD): A polyphasic or serrated action potential that may begin or end abruptly. They are uniform in shape and amplitude. They may spontaneously change configuration.
Cramp Discharge: Arise from involuntary repetitive firing of the motor unit action potential at a high rate (up to 150 Hz). Each trace is 5 s long.
Myogenic Lesion
Typical Findings
Insertional Activity: Normal Spontaneous Activity: None MUAPs: Small, Polyphasic with early recruitment Interference Pattern: Full, low amplitude pattern at less than maximal effort