ELECTROMYOGRAPHY

EMG- BIOFEEDBACK

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ELECTROMYOGHAPHY
ELECTRO + MYO + GRAPHY

ELECTRICITY MUSCLE WRITE

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DEFINITION
` Study of motor unit activity
` Recording of AP of muscle fibres
firing near the needle electrode in
a muscle

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 INTRODUCTION
Luigi Galvani ± 1791
EMG
Ä Clinical EMG
Ä Kinesiology EMG

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MOTOR UNIT

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SIZE PRINCIPLE

The muscle contraction depends on

the ³size principle´
It states that ³the motor neurons are
recruited in order of size from small
to large´

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MOTOR UNIT ACTION
POTENTIAL


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Recording an EMG includes u phases
system
Input phase
Processor phase
Output phase

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INSTRUMENTATION
ELECTRODES
Surface electrodes
Needle electrodes
Fine wire indwelling electrodes

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FINE WIRE INDWELLING
ELECTRODE

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SURFACE ELECTRODES

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NEEDLE ELECTRODES
CONCENTRIC
MONOPOLAR
SINGLE FIBRE
MACRO

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u ELECTRODES ARE USED
ACTIVE ELECTRODE

REFERENCE ELECTRODE

GROUND ELECTRODE

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CONCENTRIC NEEDLE
ELECTRODE
Commonly used
à2-àKgauge needle with a fine wire in
its lumen
Oval recording area of 1à4-40ßmà
Active electrode is referred to the
shaft of the needle thus reducing the
noise of the muscle

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1
 MONOPOLAR
Solid
àà-u0 gauge Teflon coated
needle with a bare tip of
approx 400 ßm
MUPs are of slightly higher
amplitude and longer
duration compared to
concentric
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 ADVANTAGES-
1. Less painful
à. Cheaper
DISADVANTAGES-
1. Need for a reference electrode
à. Greater background noise

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à1
 SINGLE FIBER
Steel cannula of 0.4-0.K mm diameter
inside which 1-12 insulated platinum or
silver wires are placed and taken out at a
side port 1-umm behind the tip
Electrodes are embedded in epoxy resin
SFN electrode records from a small area
of à4ßm
àà
The recording area is referred to the shaft
of the needle
DISADVANTAGES- It records from a
small area hence it cannot be used for
estimation of the motor unit size.
To study neuromuscular transmission
abnormality and fibre density.
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à2
MACRO NEEDLE
ELECTRODE
Made of a 14mm shaft of a needle
Records from a large number of muscle
fibres which are innervated by a number
of motor units along the shaft of the
needle
The recording from one motor unit is
separated by using a single fibre needle
attached to macro electrode in the mid
shaft. à4
àK
AMPLIFYING THE EMG SIGNAL
Amplifier- converts the electrical
potential seen by electrodes to a voltage
signal large enough to be displayed

Differential amplifier-Rejects common

mode voltages which appear between
both input terminals and common
grounds
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Common mode rejection ratio- It is a
measure of how much the desired
signal voltage is amplified relative to
the unwanted signal

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Signal-to-noise ratio- It is the ratio of the
wanted signal to unwanted signal
Gain- Ratio of output signal level to
input level. A higher gain will make a
smaller signal appear larger on the
display

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 Input impedence-
It is a resistive property, opposing current
flow, which occurs in alternating current
circuits.
Affected by-
Ë Electrode material
Ë Electrode size
Ë Length of the leads
Ë Electrolyte

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 Frequency bandwidth- Bandwidth is
the difference between highest and
lowest frequency that will be
processed.
Ë Amplifier must be able to respond to
signals between 10 and 10000 Hz

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Displaying the EMG signal
The form of
output used is
dependent on the
type of
information
desired and
instrument
available
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WAVEFORM DISPLAY
à forms are used
1. Analog
oscilloscope
display
à. Computer based
digital video
display

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EMG- RECORDING &
DISPLAY

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FACTORS AFFECTING OUTCOME
OF RECORDING
Age of the patients
Properties of the muscle under study
Limb temperature
Electrical specifications of the needle
electrodes and the recording
apparatus. e.g. filter settings

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INDICATIONS
Neurogenic disorders
Neuromuscular junction disorders
Myogenic disorders
Metabolic disorders

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CONTRAINDICATIONS
Recurrent systemic infections
Bleeding disorders ± hemophilia,
thrombocytopenia, patient on
anticoagulant therapy
Localized inflammation
Skin lesions

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—serum creatinine kinase level- repeated
examination causing inflammation and
focal myopathic changes.
Transient bacterimia following needle
examination may lead to endocarditic in
patients with valvular disease or prosthetic
valves.

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ELECTROMYOGRAPHY
EXAMINATION
Select the muscle

Locate the needle insertion point

Insert the needle quickly in a relaxed state

Patient briefly activates the muscle to confirm

the placement

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ACTIVITIES
Insertional Activity
Spontaneous Activity
Minimal Volitional Activity
Maximal Volitional Activity

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INSERTIONAL ACTIVITY
It is the measure of muscle excitability.
Spontaneous burst of potentials (muscle
fibre depolarization) usually lasting less
than u00ms after needle movement ceases.
Positive and negative high frequency
spikes in a cluster are seen.

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2à
2u
REDUCED IA
Fibrotic muscles- Myopathies
Periodic paralysis in case of
attacks

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 INCREASED IA
Denervated muscles

Inflammation

Myotonia

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SPONTANEOUS ACTIVITY
MINIATURE END PLATE
POTENTIALS(MEPP): End plate
noise
END PLATE SPIKES- Nerve
potentials

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 MEPP
Low amplitude negative waves
< 100µv
Monophasic
Duration - 1-ums
Fire irregularly at à0 ± 20 Hz
Characteristic ³sea shell´ sound
Frequently seen in association with end
plate spikes

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END PLATE SPIKES
Spiky , rapid
Low amplitude
Biphasic
Initial negative deflection
Fire irregularly at 40Hz
Characteristic sound ± sputtering or
crackling
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4à
ABNORMAL SPONTANEOUS
ACTIVITY
FIBRILATION POTENTIAL
POSITIVE WAVES
COMPLEX REPETITIVE
DISCHARGES
MYOTONIC DISCHARGES
FASCICULATION

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MYOKYMIC DISCHARGES
CRAMPS
NEUROMYOTONIA

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FIBRILLATION POTENTIAL
` Muscle fibre
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 COMPLEX REPETITIVE
DISCHARGES
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MINIMAL VOLITIONAL
ACTIVITY
Motor unit action potential-
voluntary contraction
Recruitment

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MOTOR UNIT ACTION
POTENTIAL

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Age
Inherent properties of motor unit
itself
Spatial relationship between the
needle and the individual muscle
fibres
Resistance and capacitance of
intervening tissues
Intramuscular temperature
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Type of needle electrode

Size of the recording surface
Electrical properties of the
amplifier
Choice of oscilloscope sensitivity
Sweep or filters
Methods of storage and display
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 MUAPs

Morphology -Amplitude, duration,

phase, initial deflection
Stability
Firing characteristic

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AMPLITUDE
It is measured from peak to peak .
100ßV-àmV
It is determined by
` Primarily by limited number of fibres
located close to the electrode tip.
` Size and density of the muscle fibre
` Synchrony of firing .
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¬ Age of the subject

¬ Muscle examined

¬ Muscle temperature-Decreasing muscle

temperature results in higher amplitude
and longer duration of MUPs

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DURATION
Measured from initial take off to the
point of return to the baseline.
Usually 4-14 ms
It reflects the number of muscle fibres
within a motor unit and is the most
reliable measure to use when judging
MUAP morphology.

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 The duration of MUP is a measure of
` Conduction
` Length of muscle fiber
` Membrane excitability
` Synchrony of different muscle fibres
of a motor unit

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Duration increases with age and cold
temperature.

Distal muscles have longer duration

MUAPS than proximal ones .

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RISE TIME OF MUP
It is the duration from initial positive
to subsequent negative peak
Indicator of the distance of needle
electrode from the muscle fibre
<400µs is acceptable

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A greater rise time is due to resistance
and capacitance of the intervening
tissue which acts as high frequency
filter and results in dull sound on the
loudspeaker of EMG equipment. This
indicates the need to reposition needle
closer to the muscle fibres
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PHASE OF MUP
It is defined as the portion of MUP
between departure and return to the
baseline.i.e no. of baseline
crossings +1.
Typical shape of an MUAP is
diphasic or triphasic.

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A MUP more than 2 phases is
called as polyphasic.
The normal MU will fire up to
14 sec with strong contraction.

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SATTELITE POTENTIAL
They are the late potentials which are
time locked to the main motor unit
potential.
The satellite potential is generated by
a muscle fibre in a motor unit with a
long nerve terminal, narrow diameter
or distant end plate region

Stable
Semi-rhythmic firing pattern

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MAXIMAL VOLITIONAL
ACTIVITY
` Interferance Pattern

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 The spike density and average amplitude
of the summated response are
determined by a number of factors:
` Descending input from the cortex
` Number of motor units capable of
discharging
` Firing frequency of each motor unit
` Waveform of individual potentials
` Probability of phase cancellation
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VARIABILITY IN MUP
Short duration
Long duration
Polyphasic
Mixed pattern
Doublets and multiplets

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SHORT DURATION
The short duration MUPs are those
with a duration shorter than that for
the muscle of corresponding age

Usually have low amplitude and have

rapid recruitment at minimal effort

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They are found in the disorders
associated with loss of muscle fibres
à chief pathologies are-
` Myopathies and neuromuscular
junction disorders
` Early stage of reinnervation after
nerve damage
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LONG DURATION MUPS
The duration of MUPs exceeds the
normal values for the corresponding
muscle & age
Have high amplitude & poor recruitment
Associated with increase in fibre density,
loss of synchrony of firing of muscle
fibre & increase in the number of muscle
fibre

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Seen in
` Motor neuron disease
` Axonal neuropathies with collateral
sprouting
` Chronic radiculopathies
` Neuropathies
` Chronic myositis ±polymyositis

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POLYPHASIC MUP
There is 2 or more phases in a MUP
Seen in myopathies where there is
regeneration of fibres and increased
fibre density.

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MIXED PATTERN
Comprises of short ,long, polyphasic
MUPs
Found in both Myogenic and
Neurogenic abnormalities

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DOUBLETS OR TRIPLETS
MUPs are fired à or more times at an
interval of 10-u0 ms
Seen when there is hyperventilation,
tetany, motor neuron disease, other
metabolic diseases ischemia

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CLINICAL IMPLICATIONS OF
EMG

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 REFERANCES
PHYSICAL REHABBILITATION: ASSESSMENT
AND TREATMENT
Susan B.O¶sullivan
CLINICAL NEUROPHYSIOLOGY
UK Mishra
DIAGNOSTIC TESTING IN NEUROLOGY
Randolph W. Evans
ELECTRODIAGNOSTIC TESTING
Kimura

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EMG-BIOFEEDBACK

10à
DEFINITION
` A technique of using equipment (usually
electronic) to reveal human beings some of
their internal psychological events, normal
and abnormal, in the form of visual and
auditory signals in order to teach them to
manipulate these otherwise involuntary or
unfelt events by manipulating the displayed
signals.
John V.Basmajian

10u
 OBJECTIVES AND GOAL

` TO IMPROVE MOTOR PERFORMANCE

BY FACILITATING MOTOR LEARNING

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PRINCIPLES OF MOTOR
LEARNING

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MOTOR LEARNING
` SCHIMDT defined it as ³a set of processes
associated with practice or experiences
leading to relatively permanent changes in
the capacity for responding´

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` Four primary factors that influence motor
learning are
1. Stage of learner
à. Type of the task
u. Feedback
2. Practice

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TYPES OF FEEDBACK
` INTRINSIC FEEDBACK
` EXTRINSIC FEEDBACK-
1. KNOWLEDGE OF RESULTS
à. KNOWLEDGE OF PERFORMANCE

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EQUIPMENTS USED
` The basic EMG biofeedback device
includes one ground and two surface
electrodes, an amplifier, an audio speaker
and a video display.

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The quality of the machine and its
output are chiefly governed by
` Electrodes used
` Input impedance
` Common mode rejection ratio
` Bandwidth
` Gain
` Noise level
` Ability to cope with non EMG artifacts
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TECHNICAL LIMITATIONS
` RELEVANCY
` ACCURACY
` RAPID TO ENHANCE MOTOR
LEARNING

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BIOFEEDBACK IN
REHABILITATION

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When using the biofeedback the
patient should

` Understand
` Practice
` Perform

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` CLOSE LOOP
` OPEN LOOP
` SCHEDULED LOOP

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Biofeedback can assist rehabilitation
process by:
1. Providing a clear treatment outcome
à. Permitting the therapist and patient to
experience with various strategies that
generate motor patterns
u. Reinforcing appropriate motor behavior.
2. Providing a process oreinted, timely and
accurate KP or KR of the patients¶ efforts.

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CONDITIONS
` STROKE
` SPINAL CORD INJURIES
` CP AND TBI
` MULTIPLE SCLEROSIS
` DYSTONIAS AND DYSKINESIS
` PERIPHERAL NERVE DENERVATION
` PAIN MANAGEMENT
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THERAPEUTIC
INTERVENTION

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TREATMENT SESSION
` PATIENTS FUNCTIONAL
ASSESSMENT
` PROBLEM IDENTIFICATION
` THERAPEUTIC INTERVENTION

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 REFERANCES
PHYSICAL REHABBILITATION:
ASSESSMENT AND TREATMENT
Susan B.O¶sullivan
BIOFEEDBACK PRINCIPLES AND
PRACTICE FOR CLINICIANS
John V. Basmajian
PHYSICAL MEDICINE AND
REHABILITATION-PRINCIPLES &
PRACTICE
Joel A. Delisa 119
THANK YOU

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