EMG; clinical practice. Erik Stålberg
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1 EMG; clinical practice Erik Stålberg
2 What do we want to express Muscle membrane function - spontaneous Muscle fibre characteristics; diameter MU organisation number of fibres grouping N-M transmission # motor units total activation; pattern, fullness Stålberg
3 Steps in EMG analysis at rest - spontaneous activity fibs, psw, myotonia, complex rep discharges fasciculations, myokymia at slight voluntary contraction - MUP shape parameters, stability (jiggle), behaviour at strong contraction - interference pattern recruitment, fullness, MUP parameters
4 At rest No electrical activity, NOTE, muscle position for complete rest EXCEPTIONS (we may hear something!) insertion activity motor end-plate noise nerve spikes few positive waves in end-plate region
5 Spontaneous EMG activity Spontaneous activity generated in the muscle»insertional activity»end-plate spikes Myotonic discharges CRD Myogenic doublets Spontaneous activity generated in the nerve or anterior horn cell»fasciculations Fasciculations»Double discharges Double discharges Neurotonic discharges Myokymic discharges Double discharges Cramp discharges Synkinesis
6 Generated in the muscle fibre End plate spikes 100 uv 500 ms Seen in end-plate region also in normal muscle: irrgular, with initial negativity
7 Generated in the muscle fibre Fibrillation potentials 500 ms 100 uv Positive waves 50 uv Myotonic discharges 50 ms 100 uv Complex repetitive discharge 100 ms 100 uv 100 ms
8 Generated in the nerve/motor neurone Cramp discharge 200 uv 100 ms Neurotonic discharges 100 uv 50 ms
9 Hemifacial spasm Generated in the nerve/motor neurone Myokymic discharge 200 ms 200 uv 200 ms Fasciculation potentials 200 uv 500 ms 200 uv
10 Slight contraction Pinch the skin at insertion point (distraction) Ask for slight contraction. Move the electrode a little to reach focus, sharp signals Move the needle to new position 2 mm deeper 2 mm deeper out and then new direction--pyramid 2-3 skin insertions, total 30 MUPs
11 A B C 0,5 mv Fig. 1
12 EMG - interference pattern Normal Myopathy Neuropathy 1 mv 1 s
13 Myopathy spont (m) fib/psw myotonic CRD spont (n) neurotonia myokymia MUP normal ampl dur ampl dur shape normal poly jiggle normal recruitment normal early late TA/FFT normal neurog myopathic fullness normal no activity FD normal jitter normal Stålberg
14 Inactive neurogenic spont (m) fib/psw myotonic CRD spont (n) neurotonia myokymia MUP normal ampl dur ampl ampl shape normal poly jiggle normal recruitment normal early late TA/FFT normal neurog. myopathic fullness normal no activity FD normal jitter normal Stålberg
15 Subacute neurogenic spont (m) fib/psw myotonic CRD spont (n) neurotonia myokymia MUP normal ampl dur ampl ampl shape normal poly jiggle normal recruitment normal early late TA/FFT normal neurog. myopathic fullness normal no activity FD normal jitter normal Stålberg
16 Myasthenic pattern spont (m) (fib/psw) myotonic CRD spont (n) neurotonia myokymia MUP normal ampl dur ampl ampl shape normal poly jiggle normal recruitment normal early late TA/FFT normal neurog. myopathic fullness normal no activity FD normal jitter normal Stålberg
17 Central weakness spont (m) fib/psw myotonic CRD spont (n) neurotonia myokymia MUP normal ampl dur ampl ampl shape normal poly jiggle normal recruitment normal early late irregular TA/FFT normal neurog. myopathic fullness normal no activity FD normal jitter normal Stålberg
18 Practical hints - the patient inform the patient about reason for EMG explain expected discomfort do not display the electrode term pin (or similar) better than needle keep bloody tissues away do not state number of remaining muscles inform about soreness for 1-2 days inform the patient about next step
19 Practical hints - the examiner medical consultation read referral before you see the patient check history, phys exam formulate strategy inform the patient about the progress have all supplies ready before exam use gloves
20 Practical hints - the investigation no skin preparation is necessary support your hand on patients extremity electrode perpendicular to the skin small but brisk insertion through the skin do not go very deep, just beneath the fascia investigate the muscle at rest (denervation), slight contraction (MUP) and strong contraction (IP)
21 EMG and neurography in nerve-muscle disorders Assesses: site - central, nerve, nmj, muscle pathophysiology distribution degree of pathology dynamics (active - inactive) specific findings (myotonia cond. block) changes over time - monitoring (quantitatively) guidance for biopsy Stålberg
Steps in EMG analysis
Steps in EMG analysis at rest - spontaneous activity fibs, psw, myotonia, complex rep discharges fasciculations, myokymia at slight voluntary contraction - MUP shape parameters, stability (jiggle), behaviour
Parameters to quantify. shape of individual MUPs jiggle fullness recruitment (early, reduced) dynamic changes with time (fatigue) 2 normal motor units
2 normal motor units STÅLBERG Reinnervated motor unit Myopathy STÅLBERG STÅLBERG Muscle membrane function - spontaneous Muscle fibre characteristics; diameter MU organisation number of fibres grouping
Parameters to quantify. shape of individual MUPs jiggle fullness recruitment (early, reduced) dynamic changes with time (fatigue) 2 normal motor units
2 normal motor units STÅLBERG Reinnervated motor unit STÅLBERG STÅLBERG Muscle membrane function - spontaneous Muscle fibre characteristics; diameter MU organisation number of fibres grouping N-M transmission
CNEMG. Myopathy, Stålberg. At rest denervation and spec spontaneous activity (myotonia, CRD, neuromyotonia) MUP number of fibres in recorded area
clincial heredity biochem MYOPATHY biopsy Erik Stålberg Uppsala, Sweden imaging genetics Electrodes A B C MU D E Conc EMG signals from 2-15 muscle fibres CNEMG At rest denervation and spec spontaneous
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What can we assess with EMG? Erik Stålberg Uppsala Sweden Muscle membrane function - spontaneous Muscle fibre characteristics; diameter MU organization number of fibers grouping N-M transmission Motor
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