Dynamic Surface Electromyography (SEMG) Information Sheet Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objective diagnostic tool that allows us to visualize and objectively quantify muscle spasm in the neck and back. With this technology the muscular component of a soft tissue injury can be documented thus enabling one to go beyond subjective patient and doctor reports. Similar to an electrocardiogram (ECG) which measures heart activity, dynamic SEMG measures paraspinal muscle activity (those on either side of the spine). Utilizing adhesive surface electrodes and by having the individual move through a range of motion, normal or abnormal muscle activity can be determined. Dynamic SEMG can determine the extent of muscle hypertonicity and dysfunction. This aids the practitioner in developing an accurate course of rehabilitation. There are many documented research papers substantiating the validity of the dynamic SEMG (available upon request); it has also been extremely successful in correlating with patient symptoms. I am a licensed chiropractor and have been the head clinician of Central Chiropractic Group since my graduation from the Canadian Memorial Chiropractic College (CMCC) in 1990. I am also founder and clinical director of the Welcome Back Spinal Care Center. I have taught undergraduate courses in orthopedics at the Canadian College of Naturopathic Medicine (CCNM), and applied physiological therapeutics at both CCNM and CMCC. I am a Fellow of the Academy of Traditional Acupuncture and was selected in 2006 to serve as a peer-assessor in x-ray evaluation for the College of Chiropractors of Ontario. I am certified in surface electromyography through the National College of Chiropractic in Chicago and have been providing independent surface electromyography assessments and interpretation for other doctors and rehabilitation clinics since 1993. I have written several articles on this diagnostic modality and have aided others in their research using dynamic SEMG as an outcome measure. Dynamic SEMG is an accepted diagnostic procedure that is billable within the scope of chiropractic. If you have any questions, please do not hesitate to contact me. Sincerely, Dr. Arnie Deltoff welcome-back@sympatico.ca (see next page for patient information)
Cervical Spine Ranges of Motion Analyzed Flexion Bending the head forward, relaxing and re-extending to the neutral position - utilizes both left and right paraspinal muscles evenly. Lateral Flexion (Side Bending) Bending the head to the left utilizes the left paraspinal and left SCM (sternocleidomastoid) muscles. Bending the head to the right utilizes the right paraspinal and right SCM muscles. Rotation Turning the head to the left utilizes the left paraspinal and right SCM muscles. Turning the head to the right utilizes the right paraspinal and left SCM muscles. Lumbar Spine Flexion Bending the torso forward, relaxing and re-extending to the neutral position - utilizes both left and right paraspinal muscles evenly. Lateral Flexion (Side Bending) Bending the torso to the left utilizes the left paraspinal muscles. Bending the torso to the right utilizes the right paraspinal muscles. Rotation Turning the torso to the left utilizes the left paraspinal muscles. Turning the torso to the right utilizes the right paraspinal muscles.
Patient Name: Dynamic Surface Electromyography (semg) Summarized Results Test Subject Date of Study: January 6, 2010 Accident Date: December 1, 2009 Claim #: abc123 Tests Performed: Cervical and Lumbar Flexion/Re-extension, Lateral Bending and Rotation Dr. Arnie Deltoff, 2009 Cervical Spine Study (note: PS=paraspinal, SCM=sternocleidomastoid) Criteria Patient Values Normal Values Flexion / Re-extension Flexion-Relaxation Response Left - marked loss Present - full flexion value is equal or lower Right - marked loss than value at rest Re-extention Peak to Flexion Peak Ratio Left - 1.27 abnormal Normal > 3.2 Abnormal < 1.8 Right - 1.20 abnormal Full Flexion Value Left - 4.86 normal Normal < 10 uv Abnormal > 15 uv Right - 7.82 normal Irritability Left - marked jitter Graph is smooth (no jitter) Right - marked jitter Symmetry relative symmetry <20% difference between L & R Consistency Left - consistent trials Each repetition is similar in shape and Right - consistent trials amplitude Lateral Bending Activation Patterns Lt. PS - relatively normal Rt. PS - abnormal Ipsilateral paraspinal and Lt. SCMs - abnormal Rt. SCMs - abnormal sternocleidomastoid activity Co-contraction Lt. PS - no co-contraction Rt. PS - co-contraction No antagonistic muscles contraction Lt. SCMs - co-contraction contraction Rt. SCMs - mild co-contractioncontraction Irritability Lt. PS - marked jitter Rt. PS - marked jitter Graph is smooth Lt. SCMs - marked jitter Rt. SCMs - marked jitter Symmetry Paraspinal muscles - increased left activity Relatively equal values between Sternocleidomastoids - increased right activity left and right activity Rotation Activation Patterns Lt. PS - normal Rt. PS - relatively normal Ipsilateral paraspinal and Lt. SCMs - normal Rt. SCMs - normal contralateral SCM activity Co-contraction Lt. PS - mild co-contraction Rt. PS - co-contraction No antagonistic muscles contraction Lt. SCMs - mild co-contraction Rt. SCMs - mild co-contraction Irritability Lt. PS - marked jitter Rt. PS - marked jitter Graph is smooth Lt. SCMs - marked jitter Rt. SCMs - marked jitter Symmetry Paraspinal muscles - increased left activity Relatively equal values between Sternocleidomastoids - relatively symmetrical left and right activity Based on the criteria above, the cervical spine demonstrates the following levels of dysfunction / muscle guarding: Flexion 61% rated as moderate to marked dysfunction Lateral Bending 73% rated as moderate to marked dysfunction Rotation 50% rated as moderate dysfunction Overall 72% rated as moderate to marked dysfunction
Patient Name: Summarized Results - Page 2 Test Subject Date of Study: January 6, 2010 Dr. Arnie Deltoff, 2009 Lumbar Spine Study Criteria Patient Values Normal Values Flexion / Re-extension Flexion-Relaxation Response Left - marked loss Present - full flexion value is equal or lower Right - complete loss than value at rest Re-extention Peak to Flexion Peak Ratio Left - 1.04 abnormal Normal > 3.2 Abnormal < 1.8 Right - 1.34 abnormal Full Flexion Value Left - 51.63 abnormal Normal < 10 uv Abnormal > 15 uv Right - 54.05 abnormal Irritability Left - jitter Graph is smooth Right - jitter Symmetry relative symmetry <20% difference between L & R Consistency Left - consistent trials Each repetition is similar in shape and Right - consistent trials amplitude Lateral Bending Activation Lt. PS - abnormal Rt. PS - relatively normal Ipsilateral paraspinal activity Co-contraction Lt. PS - co-contraction Rt. PS - mild co-contraction No antagonistic contraction Irritability Lt. PS - jitter Rt. PS - marked jitter Smooth graph Symmetry Paraspinal muscles - increased right activity Relatively equal L/R activity Rotation Activation Lt. PS - relatively normal Rt. PS - normal Ipsilateral paraspinal activity Co-contraction Lt. PS - co-contraction Rt. PS - co-contraction No antagonistic contraction Irritability Lt. PS - jitter Rt. PS - marked jitter Smooth graph Symmetry Paraspinal muscles - increased right activity Relatively equal L/R activity Based on the criteria above, the lumbar spine demonstrates the following levels of dysfunction / muscle guarding: Flexion 74% rated as moderate to marked dysfunction Lateral Bending 67% rated as moderate to marked dysfunction Rotation 60% rated as moderate to marked dysfunction Overall 79% rated as marked dysfunction
Dynamic Surface Electromyography (semg) Analysis Dr. Arnie Deltoff, 2009 Patient Name: Test Subject Date of Study: January 6, 2010 Accident Date: December 1, 2009 Claim #: abc123 Interpretation Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objective diagnostic tool that allows us to visualize and objectively quantify muscle spasm in the neck and back. With this technology the muscular component of a soft tissue injury can be documented thus enabling one to go beyond subjective patient and doctor reports. Muscle dysfunction may manifest as hypertonicity (increased muscle tone), spasm (little difference between rest and activity), guarding (protective muscle contraction) or fasciculations (twitches) for example. These can all be measured electrically. There is direct correlation to general pain and joint dysfunction. Muscle dysfunction may be caused by multiple factors. It is important to note that the absence of muscle dysfunction may not mean the absence of pain. The information provided here will help guide the practitioner in the patient's rehabilitation by directing them to the muscles and ranges of motion that demonstrate dysfunctional patterns. As well, in the case of positive examination findings, future testing will allow the practitioner to gauge the efficacy of their treatment. Research has indicated that the flexion test is of utmost importance and, therefore, the result of this part of the examination has slightly more 'weighting' in the overall dysfunction score. All results rated as moderate* dysfunction or above are deemed The cervical spine demonstrates: moderate to marked dysfunction in forward flexion moderate to marked dysfunction in lateral flexion moderate dysfunction in rotation Overall the cervical spine demonstrates a 72% dysfunction which relates to moderate to marked dysfunction There is also indication of the following: hypertonicity spasm guarding fasciculations With this degree of dysfuction: A combination of passive therapy and muscle strengthening is recommended. The patient may benefit from further assessment (eg. neurological, MRI, CT, US) of the cervical spine as signs and symptoms dictate The lumbar spine demonstrates: moderate to marked dysfunction in forward flexion moderate to marked dysfunction in lateral flexion moderate to marked dysfunction in rotation Overall the lumbar spine demonstrates a 79% dysfunction which relates to marked dysfunction There is also indication of the following: hypertonicity spasm guarding fasciculations With this degree of dysfuction: More passive therapy may be beneficial. The patient may benefit from further assessment (eg. neurological, MRI, CT, US) of the lumbar spine as signs and symptoms dictate Dr. Arnie Deltoff, DC, FATA Myodynamics Inc. 230-4915 Bathurst Street Toronto, ON M2R 1X9 Phone: 416-512-2225 Fax: 416-512-2226 Note: Dysfunction levels are to be used for comparative purposes and to guide the practitioner in the rehabilitative process. All information must be correlated with clinical observations. Testing was performed according to established protocols using the Myovision dynamic multi-channel semg. * ie. moderate, moderate to marked, marked and severe
Normal Studies for Comparison Flexion / re-extension (any region) 1 2 3 4 5 6 Peak to peak ratio the peak value of re-extension is greater than 3.2 times the peak value of flexion peak Full flexion value (marks 1,3,5) is below 10 microvolts peak ratio Flexion-relaxation response presence of this phenomenon is indicated when the full flexion value is even with or below resting value Cervical Lateral Flexion Cervical Rotation left right left right left right left right paraspinal muscles paraspinal muscles Sternocleidomastoid muscles Sternocleidomastoid muscles left right left right right left right left Lumbar Lateral Flexion or Rotation Activity Pattern in the neck, lateral bending involves left right left right activation of the same-sided paraspinals and SCM muscles; rotation involves the activation of the samesided paraspinals and opposite-sided SCM muscles. In the low back, however, both lateral bending and rotation involves the activation of same-sided paraspinal muscles. General Considerations Co-contraction there should be little to no activity of the opposite-sided muscles during lateral bending or rotation Symmetry the right and left should be equally active for their respective motions Irritability all graphs should be smooth; spiky movement indicates muscle fasciculations Consistency all trials should be relatively equal in shape and amplitude
Exam Date: Jan 06, 2010 02:30:15 PM MyoVision Dynamic semg Flexion Study Background and Explanation A dynamic EMG flexion study was performed utilizing the semg system with electrodes attached to the skin. The system utilizes 25-500 Hz filtering system which allows measurement of the muscle fibers utilized in maintaining posture. The basic principle of the dynamic flexion study is simple. When in full flexion of the cervical or lumbar spine, normal individuals display semg values (in microvolts) which drop to very low levels as ligaments instead of muscles are used to maintain the full flexed position. This is known as the flexion relaxation phenomenon. In patients with low back pain, semg values maintain high levels in full flexion and do not relax as with normals. This is known as an absence of flexion relaxation. A landmark study titled "Electric Behavior of Low Back Muscles During Lumbar Pelvic Rhythm in Low Back Patients and Healthy Controls" (Sihoven, Partanen, Hanninen Soimakallio; The Archives of Physical Medicine and Rehabilitation vol 72, Dec 1991) was published on the flexion relaxation phenomenon. The following results were reported: 1. Surface EMG pattern yielded more information than needle EMG. 2. There was a clearly noticeable increase in semg activity in LBP patients. 3. There was only a partial decrease in semg readings in LBP patients while in full flexion, in contrast with normals which demonstrated marked decreases in semg activity. 4. The ratio of the mean maximum semg level reached in flexion to the mean maximum semg level in re-extension was lower in LBP patients than in normal controls. The ratios were 3.2 in normals, and 1.8 in LBP patients. 5. Test-retest reliability was very high (0.92 flexion, 0.97 extension) It is important to note that the results of this test should be correlated with other exams, and should not be used on its own to determine disability. Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2
Exam Date: Jan 06, 2010 02:30:15 PM A dynamic semg flexion study was performed on ******************* on Jan 06, 2010. The graph is labeled Dynamic Cervical Flexion. PERCENT DIFFERENCE TEST semg activity in the Left Cervical was 2% LESS than the Right Cervical. FLEXION/RE-EXTENSION RATIO TEST (Table 1) This test quantifies the ratio of the peak in flexion (FLEX PEAK)to the peak in re-extension (REEX PEAK). Research has found that in general, normals produce ratios greater than 3.2, with symptomatic patients less than 1.8. The results of this test should be examined in combination with the FLEXION TEST (Table 2). The patient produced a(n) UNEXPECTED ratio of 1.27 in the Left Cervical and a(n) UNEXPECTED ratio of 1.20 in the Right Cervical. Table 1: Peak Analysis Data (Average of three (3) trials) SITE FLEX PEAK REEX PEAK RP/FP RATIO STD DEV RESULTS Left Cervical 6.88 8.72 1.27 9 UNEXPECTED Right Cervical 8.49 10.16 1.20 0.12 UNEXPECTED FLEXION TEST (Table 2) semg values in full flexion should be very low. The flexion test measures the averaged semg value of three trials of flexion. Normal readings are below 10uV, BORDERLINE between 10 and 15uV, and ABNORMAL above 15 microvolts. Normal semg readings in standing neutral (NEUTRAL MIN) should be below approximately 9 uv. Higher readings correlate with disorders of the spine. Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 3
Exam Date: Jan 06, 2010 02:30:15 PM The patient demonstrated averaged readings in the Left Cervical of 4.86 indicating a(n) NORMAL reading in flexion. The patient demonstrated averaged readings in the Right Cervical of 7.82 indicating a(n) NORMAL reading in flexion. Table 2: Flexion Test Site FLEX MIN STD DEV CONDITION NEUTRAL MIN Left Cervical 4.86 0.95 NORMAL 3.70 Right Cervical 7.82 0.66 NORMAL 3.00 Results of the study should be correlated with other exams and should not be used alone to determine disability or treatment protocol I have examined the data and the analysis performed, and agree with the reported findings. Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 4
Office Information: Patient Information: ID: Sept 9, 2009 Exam Date: Jan 06, 2010 02:30:15 PM Protocol Name: Dynamic Cervical Flexion 14.7 Left Cervical Right Cervical 1 2 3 4 5 6 11.8 8.8 5.9 2.9 4.9 9.8 14.6 19.5 24.4 Protocol Name: Dynamic Cervical Flexion Page Name: Left-Right C2 T1 Sites Markers 1, 3, 5 -> Flexion Markers 2, 4, 6 -> Neutral Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
Office Information: Patient Information: ID: Sept 9, 2009 Exam Date: Jan 06, 2010 02:33:07 PM Protocol Name: Dynamic 4 Ch Cerv Lat Flex & Rotation 18.5 Left Cervical Right Cervical 1 2 3 4 5 6 7 8 14.8 11.1 7.4 3.7 6.0 11.9 17.9 23.8 29.8 18.4 Left SCM Right SCM 1 2 3 4 5 6 7 8 14.7 11.0 7.3 3.7 6.0 11.9 17.9 23.8 29.8 Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Lateral Flexion Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
Office Information: Patient Information: ID: Sept 9, 2009 Exam Date: Jan 06, 2010 02:33:07 PM Protocol Name: Dynamic 4 Ch Cerv Lat Flex & Rotation 16.1 Left Cervical Right Cervical 1 2 3 4 5 6 7 8 12.9 9.7 6.5 3.2 5.6 11.2 16.9 22.5 28.1 10.6 Left SCM Right SCM 1 2 3 4 5 6 7 8 8.5 6.4 4.2 2.1 5.6 11.2 16.9 22.5 28.1 Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Rotation Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2
Exam Date: Jan 06, 2010 02:20:38 PM A dynamic semg flexion study was performed on ******************* on Jan 06, 2010. The graph is labeled Dynamic Lumbar Flexion. PERCENT DIFFERENCE TEST semg activity in the Left Lumbar was 7% LESS than the Right Lumbar. FLEXION/RE-EXTENSION RATIO TEST (Table 1) This test quantifies the ratio of the peak in flexion (FLEX PEAK)to the peak in re-extension (REEX PEAK). Research has found that in general, normals produce ratios greater than 3.2, with symptomatic patients less than 1.8. The results of this test should be examined in combination with the FLEXION TEST (Table 2). The patient produced a(n) UNEXPECTED ratio of 1.04 in the Left Lumbar and a(n) UNEXPECTED ratio of 1.34 in the Right Lumbar. Table 1: Peak Analysis Data (Average of three (3) trials) SITE FLEX PEAK REEX PEAK RP/FP RATIO STD DEV RESULTS Left Lumbar 71.33 74.46 1.04 5 UNEXPECTED Right Lumbar 62.49 83.56 1.34 0.13 UNEXPECTED FLEXION TEST (Table 2) semg values in full flexion should be very low. The flexion test measures the averaged semg value of three trials of flexion. Normal readings are below 10uV, BORDERLINE between 10 and 15uV, and ABNORMAL above 15 microvolts. Normal semg readings in standing neutral (NEUTRAL MIN) should be below approximately 9 uv. Higher readings correlate with disorders of the spine. Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 3
Exam Date: Jan 06, 2010 02:20:38 PM The patient demonstrated averaged readings in the Left Lumbar of 51.63 indicating a(n) ABNORMAL reading in flexion. The patient demonstrated averaged readings in the Right Lumbar of 54.05 indicating a(n) ABNORMAL reading in flexion. Table 2: Flexion Test Site FLEX MIN STD DEV CONDITION NEUTRAL MIN Left Lumbar 51.63 10.87 ABNORMAL 17.00 Right Lumbar 54.05 0.91 ABNORMAL 19.17 Results of the study should be correlated with other exams and should not be used alone to determine disability or treatment protocol I have examined the data and the analysis performed, and agree with the reported findings. Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 4
Office Information: Patient Information: ID: Sept 9, 2009 Exam Date: Jan 06, 2010 02:20:38 PM Protocol Name: Dynamic Lumbar Flexion 88.0 Left Lumbar Right Lumbar 1 2 3 4 5 6 70.4 52.8 35.2 17.6 4.9 9.8 14.7 19.6 24.5 Protocol Name: Dynamic Lumbar Flexion Page Name: Left - Right L1 L5 Sites Markers 1, 3, 5 -> Flexion Markers 2, 4, 6 -> Neutral Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
Office Information: Patient Information: ID: Sept 9, 2009 Exam Date: Jan 06, 2010 02:23:04 PM Protocol Name: Dynamic Lumbar Lat Flex & Rotation 31.5 Left Lumbar Right Lumbar 1 2 3 4 5 6 7 8 25.2 18.9 12.6 6.3 5.6 11.2 16.8 22.4 28.0 Protocol Name: Dynamic Lumbar Lat Flex Rotation Page Name: L/R Lateral Flexion Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
Office Information: Patient Information: ID: Sept 9, 2009 Exam Date: Jan 06, 2010 02:23:04 PM Protocol Name: Dynamic Lumbar Lat Flex & Rotation 32.4 Left Lumbar Right Lumbar 1 2 3 4 5 6 7 8 25.9 19.5 13.0 6.5 5.4 10.7 16.1 21.4 26.8 Protocol Name: Dynamic Lumbar Lat Flex Rotation Page Name: L/R Rotation Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2