2007

Needle Electromyography Study

Jong Seok Bae Department of Neurology Inje University College of Medicine

Contents

1. Recording technique 2. Waveform identification & analysis - During resting - During activation : minimal/moderate/maximal 3. Interpretation

Needle electrodes

Needle electrodes (Cont.)

Monopolar needle Pickup surface Recording area Electrical stability Sharpness Sensitivity for recording spontaneous activity MUAP Amplitude Area Duration turns Phases Polyphasic MUPs (%) 1.5-2 times larger 1.5 times larger 1.2 times larger 1.2 times more 1.2 times more 1.5 times higher Smaller Smaller Shorter Fewer Fewer Fewer 2-3 times larger Variable after repeated use Less, hence noiser Sharper & less painful Increased Less sharp Decreased Concentric needle Smaller Constant even after repeated use

Needle EMG technique

1. Explanation of the procedure & discomforts 2. Preparation for relaxed & comfortable position 3. Needle insertion through the skin briskly with one quick thrust into the muscle. 4. Verification of the needle location 5. Sampling four different quadrants from insertion site at various depths. 6. Deeper insertion along the same axis (corridor)

Simplified step of clinical needle EMG

Insertional activity
Normal -Normal insertional activity Abnormal -Increased insertional activity -Decreased insertional activity

Spontaneous activity
Normal -End plate noise -End plate potential Abnormal -Fibrillation -PSW -CRD -Fasciculation -Myokymia -Myotonia

Voluntary activity
Normal -Normal recruitment -Full interference Abnormal -Reduced recruitment -Early recruitment -Moderate / discrete interference

Insertional & spontaneous activity: muscle activity at rest

Information provided by abnormal spontaneous activities

1. Distribution of abnormal spontaneous activity Localization of disease 2. Type of spontaneous activity Association of specific disease 3. Degree or amount of spontaneous activity Severity of disease

Generators of spontaneous activity

Abnormal muscle fiber potentals - Fibrillation - Positive sharp wave - Complex repetitive discharge - Myotonic discharge Abnormal motor unit potential - Fasciculation potentials - Doublets, triplets, & multiplets - Myokymic discharges - Neuromyotonic discharges - Cramps - Rest tremor

Analysis of spontaneous activity

Insertional activity
Increased vs decreased insertional activity

Spontaneous activity: end plate noise

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern

Miniature endplate potential (monophasic negative) Sea shell, hissing sound 20-40 Hz Irregular (hissing)

Spontaneous activity: end plate spike

Source generator / morphology

Sound on loud speaker Stability Firing rate Firing pattern

Muscle fiber initiated by terminal axonal twig (brief spike, diphasic, usually initial negative) Sputtering like fat in a frying pan Stable 5-500 Hz Irregular (sputtering)

Spontaneous activity: normal

End plate noise vs endplate spike

Fibrillation potentials

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern Mechanism

Muscle fiber (brief spike, diphasic, initial positive) Rain on a tin roof or tick-tock of a clock Stable 0.5-10 Hz (occasionally up to 30Hz) Regular Denervation hypersensitivity

Fibrillation potentials (Cont.)

Positive sharp waves

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern Mechanism

Muscle fiber (diphasic, initial positive, slow negative) Dull pops, rain on a tin roof, or tick-tock of a clock Stable 0.5-10 Hz (occasionally up to 30Hz) Regular Denervation hypersensitivity

Positive sharp waves (Cont.)

Grading of abnormal spontaneous potentials

0 +1 +2 +3 +4

None present Persistent single trains of potentials (>2-3 seconds) in at least two areas Moderate number of potentials in three or more areas Many potentials in all areas Full interference pattern of potentials

Pitfalls in fibrillation & PSW

Absence of fibrillation or PSW even in denervation process - Insufficient time (< 2~4 weeks) - Primary demyelinating neuropathy without secondary axonal degeneration - Too low temperature or poor circulation of muscle - Severe atrophy or degeneration of muscle - Reinnervation already in progress Presence of fibrillation or PSW in a substantial number of asymptomatic subjects - Intrinsic foot muscles: 6%~29% of normal subjects - Lumbar paraspinal muscles: 15% of normal subjects (30% in elder than 40 years old) Fibrillation & PSW in these muscles are not necessarily indicative of denervation process

Myotonic discharges

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern Mechanism

Muscle fiber (brief spike, initial positive, or positive wave) Reviving engine, dive bomber Waxing/waning amplitude 20-150 Hz Waxing/waning Spontaneous (constant) depolarization of muscle membrane

Myotonic discharges (Cont.)

Myotonic discharges (Cont.)

Complex repetitive discharge (CRD)

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern Mechanism

Multiple muscle fibers time linked together Machine motor boat, motor cycle Usually stable; may change in discrete jumps 5-100 Hz Perfectly regular (unless overdriven) Ephatic activation of adjacent muscle fibers

Complex repetitive discharge (CRD) (Cont.)

Complex repetitive discharge (CRD) (Cont.)

Fasciculation potentials

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern Mechanism

Motor unit (motor neuron/ axon) Corn popping Stable Low (0.1-10 Hz) Irregular Ephatic firing of MUPs

Fasciculation potentials (Cont.)

Benign vs malignant fasciculation

Distinguishing benign from malignant fasciculations on a clinical basis is nearly impossible Benign are not associated with muscle weakness, wasting, or any abnormalities of reflexes. Benign tend to fire faster and to affect the same site repetitively

Doublets, triplets, & multiplets

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern Mechanism

Motor unit (motor neuron/ axon) Horse trotting Usually stable; may change in number of potentials Variable (1-50 Hz) Bursts of twos, threes, or a few potentials Hyperexcitable motor neuron

Doublets, triplets, & multiplets (Cont.)

Myokymic discharges

Source generator / morphology Sound on loud speaker Stability

Motor unit (motor neuron/ axon) Marching soldiers Usually stable; number of potentials may change within the burst 1-5 Hz (interburst) 5-60 Hz (intraburst) Bursting of the same individual motor unit potential Ephatic firing of MUP

Firing rate Firing pattern Mechanism

Myokymic discharges (Cont.)

Disorders commonly associated with myokymic discharges

Radiation injury (usually brachial plexopathy) Guillain-Barre syndrome (facial) Multiple sclerosis (facial) Pontine tumors (facial) Hypocalcemia Timber rattlesnake envenomization And occasionally seen in
- Gullian-Barre syndrome (limbs) - Chronic inflammatory demyelinating polyneuropathy - Nerve entrapments - Radiculopathy

Neuromyotonic discharges

Source generator / morphology Sound on loud speaker Stability Firing rate Firing pattern

Motor unit (motor neuron/ axon) Pinging Decrementing amplitude Very high (150-250 Hz) Waning

Neuromyotonic discharges (Cont.)

Disorders commonly associated with neuromyotnia

Isaacss syndorme Familial continuous muscle fiber activity syndrome And occasionally seen in
- SMA - Peripheral neuropathy - Tetany - Artificially induced ischemia or electrical stimulation / tapping of nerve

Spectrum of abnormal spontaneous activity generated in motor nerve/neuron

Voluntary activity: muscle activity at contraction

Motor unit (MU) as a generator of MUP

The basic element of the PNS Defined as an individual motor neuron, its axon, & associated NMJ & muscles fibers. MU size = number and diameters of MFs in the MU The number and size of MUs vary among different muscles

Myths of MUP
MUP dose NOT represent the electrical activity of the whole MU MU size may NOT be proportionate to the relative size of the MUP Measured parameters of MUPs are affected by the type of needle electrodes

Myths of MUP (Cont.)

Needle electrode recording surface

Anterior horn cell

Peripheral nerve

muscle

MUP analysis

1. Minimal contraction: wave form analysis of MUP 2. Moderate contraction: Firing pattern analysis of MUP 3. Maximal contraction: Interference pattern of MUP

Limitation of routine EMG & need for quantitative method

Subjective analysis Inter examiner variance Paucity of objective criteria for abnormality Equivocal results in minimally affected case Difficulty in assessment of progression

Objective analysis Minimize observer bias Precise interpretation of the findings Comparison of results across time, individuals, laboratories and methodologies Statistical analysis

Recognition of genuine near-field MUP

Genuine near-field MUPs can be recognized by their sharp, crisp sound and short rise time (usually < 500 sec)

Manual method

Manual method

amplitude duration 3 phases

Typical MUP measurement

: : Waveform Waveform analysis analysis

Amplitude
: : Waveform Waveform analysis analysis

150 V~3 mV (CN) vs 500 V~5mV (MN) Peak to peak measurement Amplitude only reflects not the number of MFs in MU but those few fibers nearest to the needle It increases as - The needle moves closer to the MU - The number of MFs in a MU increases - The diameter of MFs increase - The better synchronized the firing

Duration
: : Waveform Waveform analysis analysis

Typical MUP duration is between 515 msec The time from the initial deflection from baseline to the time the MUP returns to baseline The number of MFs within a MU Also significantly affected by distant muscle fibers The most important MUP parameter in differentiation between myopathy and denervation process

Duration
: : Waveform Waveform analysis analysis

Potentials from 2-15 muscle fibers summate to give duration (within a 2.5mm from the needle)

Rise time & major spike

: : Waveform Waveform analysis analysis

Major spike : the largest positiveto-negative component of MUP Rise time : the time from the maximum negative peak to the maximum positive peak that precedes it It reflects the distance between the recording tip of electrode and depolarized muscle fiber It is essential for the recognition of genuine near-field MUP It occurs when the major spike rise time is < 0.5 msec, indicating proper needle placement.

Phases
: : Waveform Waveform analysis analysis

Polyphasia - Normally, 3 or rarely 4 phases - Can easily be calculated by adding 1 to the number of baseline crossings of the MUP - Measure of synchrony - Nonspecific measure - Increased polyphasia in up to 5-10% of potentials is considered normal

Phases
: : Waveform Waveform analysis analysis

Serrations (turns) - >50 V, Do not subsequently cross the baseline. - Increased polyphasia and serrations have similar meanings Satellite potentials (linked potentials, parasite potentials) - Seen in early reinnervation - By collateral spouts from adjacent intact MUs - Time locked potentials - Becomes an additional phase or serration

Phases
: : Waveform Waveform analysis analysis

Potentials from 2-15 muscle fibers summate to give turns and phases

MU structural remodeling
: : Waveform Waveform analysis analysis

Normal

Neuropathy

Myopathy

High-amplitude long-duration(HALD) MUPs

: : Waveform Waveform analysis analysis

Shape Initial deflection Duration Amplitude Frequency Sound Key findings Generator Significance Diseases(essential) Diseases(common)

HALD monophasic or diphasic MUAs, often with HALD polyphasic MUPs Any deflection >17ms; >20ms in polyphasic MUPs >5mV with monopolar and >3mV with concentric needle >15Hz No special sound characteristic HALD MUPs with reduced recruitment Large MU territory; type grouping Chronic denervation Chronic denervation Amyotrophic lateral sclerosis, spinal muscular atrophy, chronic myelopathy involving anterior horn cells, radiculopathy, chronic peripheral neuropathy, chronic mononeuropathy, IBM

Small-amplitude short-duration(SASD) MUPs

: : Waveform Waveform analysis analysis
Shape Initial deflection Duration Amplitude Frequency Sound SASD monophasic or diphasic MUPs, often with many SASD polyphasic MUPs Any deflection 0.5-4ms; up to 6ms in small-polyphasic MUPs 50-300uV with monopolar and 25-200uV with concentric needle Early recruitment Sharp rasping scratchy sound from newspaper rubbing between two fingers or needle on a cracked old 78 gramophone slow-play record SASD MUPs with early recruitment Either histological or physiological functional loss of random of muscle fibers Myopathy and neuromuscular transmission disorders Myopathy Myotonic dystrophy, MG, LEMS, botulism, periodic paralysis

Key findings Generator Significance Diseases(essential) Diseases(common)

Diseases with mixed SASD MUPs and HALD MUAPs

: : Waveform Waveform analysis analysis

Diseases in which this potential is commonly observed: Anterior horn cells diseases Myopathy 1. Rapidly progressing motor neuron diseases 2. Spinal muscular atrophy 3. HMSN type II Inclusion body myopathy (IBM)

Bimodal distribution of MUP in myopathy

: : Waveform Waveform analysis analysis

Stability
: : Waveform Waveform analysis analysis

Diseases with MUPs with varying amplitude Neuromuscular transmission disorders: Diseases in which this potential is commonly observed: 1. Myasthenia gravis 2. LEMS 3. Botulism 1. Rapidly progressing axonal degeneration 2. Reinnervation following nerve injury

Activation / recruitment

Activation - Ability to fire MUs faster - Central process Recruitment - Ability to add MUs as firing rate Both decreased activation and recruitment may be present in the same patient

Physiologic aspect of muscle force generation

Frequency modulation - MU firing Recruitment - Additive activation of the other MUs Size principle - Type1 MU type2 MU - Low threshold, small size

Measurement
: : Firing Firing pattern pattern analysis analysis

Manual method from 500msec epoch Iterdischarge interval (IDI) Firing rate (Hz) = 1000/IDI Recruitment ratio Rate of fastest MUP / No. of MUPs Cf. Onset frequency, Recruitment frequency

Measurement
: : Firing Firing pattern pattern analysis analysis

IDI = 154 msec

Firing rate = 1000/IDI = 1000/154 = 6.5Hz

Recruitment ratio Rule of five

: : Firing Firing pattern pattern analysis analysis

> 10 Hz

10 Hz

< 10 Hz

Recruitment ratio Rule of five

: : Firing Firing pattern pattern analysis analysis

Recruitment ratio = 14/3 = 4.7

Recruitment ratio = 16/2 = 8

MU Remodeling with recruitment

: : Firing Firing pattern pattern analysis analysis

Normal 10 days 3-4 weeks 2-4 months After 6 months

Reduced recruitment
: : Firing Firing pattern pattern analysis analysis

Early recruitment
: : Firing Firing pattern pattern analysis analysis

Subjective assessment at maximal effort

: : Interference Interference pattern pattern analysis analysis

Reduced recruitment & discrete interference

: : Interference Interference pattern pattern analysis analysis

Early recruitment & full interference

: : Interference Interference pattern pattern analysis analysis

Characteristic needle EMG pattern

: : Interpretation Interpretation

Fibrillation & PSW Active (subacute or ongoing) neuropathic Profuse

MUP Markedly polyphasic, normal amplitude & duration HALD MUP with relatively unremarkable polyphasic MUP SASD MUP; markedly polyphasic SASD MUP with less polyphasic MUP

Interference Moderately or highly reduced

Pathology Axonal degeneration

Typical diseases Nerve injury, ALS, WerdnigHoffman dz. Axonal neuropathy, plexopathy SMA, KugelbergWelander dz. CIDP, CMT1 PM, alcoholic myopathy, IBM

Chronic (inactive) neuropathic Active myopathic

No or little

Greatly reduced; rapid firing Normal or excessive

Reinnervation, type grouping

Profuse

Profuse myopathy

Inactive myopathic

No

Normal or excessive

Minimal myopathy

Benign congenital myopathy

Take home message

No single parameter identifies a target muscle as myopathic, neuropathic, or associated with an NMJ disorder
cf. Myotonia, duration of MUP

Rather, specific patterns of abnormalities in morphology and firing pattern of spontaneous or voluntary activity reflect the specific disorder