EMG

Introduction

Recording of electrical activity of muscle

Active
reference reference Skin surface

Active

Uses of EMG

Localization of lesion Specific diagnostic information Severity of lesion In treatment

Source generators

Source
Motor neuron Terminal axon NMj Muscle fiber Multiple muscle fiber

Insertional activity

Brief burst for several milliseconds Important for confirmation Increased when
Last

longer than 300ms. Other than end plate potential

Decreased when muscle replaced by fat and fibrous tissue

Spontaneous activity
Miniature end plate potential Muscle fiber Multiple muscle fiber Motor unit

Morphology

Spontaneous activity

Stability

Firing charecteristics

Morphology

Spontaneous activity

Stability

Stable unstable

Firing charecteristics

Morphology Spontaneous activity

Stability Firing charecteristics

Firing rate Firing pattern

NORMAL ACTIVITY

End plate noise

Miniature end plate potentials Result from spontaneous exocytosis of AcH across NMJ Low amplitude, monophasic, negative potential Irregular at 20-40 Hz Seashell sound

End plate spikes

Nerve potentials or muscle fiber action potential (MFAP) due to irritation of terminal nerve leading MFAP Biphasic (triphasic) with initial negative deflection Duration 1-5 ms with low amplitude Irregular at 50 Hz

ABNORMAL ACTIVITY

Fibrillation potential
Extracellular record of single muscle fiber Spontaneous depolarization of muscle fiber Marker of active denervation Duration- 1-5ms Low amplitude- 10-100V (chronic <10V) Regular at 0.5- 10 Hz Sounds like rain on roof Differentiate from end plate spikes

Positive sharp waves

Due to mechanical deformation of muscle fiber and membrane inexcitability. Long duration Amplitude 10-100V Regular at 0.5-10 Hz Sound like dull pop

Differentiate from voluntary contraction

0- none present +1 - persistent single trains of potential in at least 2 areas +2 - moderate potential in 3 or more areas +3 - many potential in all areas +4 full interference pattern of potential +4 seen in nerve lacerations, vasculitis where all fibers denervate simultaneously

Complex repetitive discharge

Depolarization of single muscle fiber followed by spread to adjacent denervated muscle fiber i.e. muscle membrane to membrane High frequency 20-150 Hz Perfectly repetitive in nature Machine like sound Common in myopathies along with denervation

Myotonic discharge

Firing rate is 20-150 Hz Waxing and waning of both amplitude and frequency Positive wave or brief spike morphology Revving engine sound Common in myopathies
Differentiate from positive wave and fibrillation potential

Fasciculation potentials

Single, spontaneous, involuntary discharge of individual motor unit Fire slow and irregularly at1-2 Hz Generated from motor neuron or axon Corn popping sound Complex and large in case of reinnervation

Difeerentiate in voluntary action and BENIGN potential

Doublets, triplets, multiplets

MUAP fire in group of two, three or multiples Seen with fibrillation potential Seen in neuropathic conditions, spasms

Myokymic discharge

Grouped, repetitive, rhythmic discharge of same motor unit Firing at 5-60 Hz Due to spontaneous depolarisation along the demylinated segments of nerve Common in radiation injuries (plexopathies), brainstem lesions (MS)

Cramps

Painful, involuntary contraction of muscle Repetitive and irregular firing at 40-75 Hz Associated with benign conditions, neuropathic, metabolic, endocrinologic conditions.

Neuromyotonic discharges

Decrementing, repetitive discharge of single motor unit High frequency- 150-250 Hz Pinging sound Generated by peripheral motor axons
Differentiate from myotonia

Tremors

Bursting of MUAPs seperated by silence MUAPs difficult to assess in tremors

Differentiate from myokymia

Physiology of motor unit

1. 2. 3. 4. 5.

Extracellular compound potential of the muscle fiber of motor unit Size principle Size of axon Thickness of myelin sheath Conduction velocity of axon Threshold to depolarization Type of muscle fiber

Morphology

MUAP showes normal variability MUAP duration is shorter in proximal muscles Larger in adults Loss of 1% year after third decade

Duration

Time for initial deflection from baseline to final return to baseline. Between 5-15 ms Indicate number of muscle fibers in motor unit and dispersion of their depolarization varies directly with age Inversely with temperature Long duration- dull and thuddy Short duration- crisp like

Polyphasia

Measure of synchrony 5-10% normal (deltoid 25%) High frequency clicking sound Serrations indicate less synchronus firing

Satellite potential

Linked or parasite potential Seen in early reinnervation Small, unmylinated Collateral sprouts having slow conduction time and increased distance After reinnervation it becomes phase of main complex

Amplitude

1.
2.

3.
4.

Greater than 100 V Reflect fibers nearest to the needle (2-12) Factors influencing amplitude Proximity of needle Increased number of muscle fiber Increased diameter synchronisation

Major spike

Largest positive to negative component of MUAP Affected by surrounding tissue MUAP parameter should measured only when needle is very close to motor unit

Stability

MUAPs are usually are stable Unstable MUAP result in NMJ disorder Change in amplitude and number of phases During reinnervation unstable MUAPs are formed due to newly matured, imature NMJ

Firing pattern

MUAP fire in semi rhythmic pattern

Type MUAP Positive sharp waves Fibrillation potential Complex repetative discharge Myotonic discharge Fasciculations Firing pattern Semi rhythmic pattern Regular Perfectly regular Waxing and waning irregular

Interference pattern

Muscle force is increased by

Increasing

firing rate Addition of motor units

Ratio of firing frequency to MUAP is 5:1 Maximal firing frequency is 30-50 Hz

Activation refers to ability to increase firing rate

Central

process Due to CNS lesions, pain, poor cooperation

Recruitment refers to ability to add motor units as the firing increases

Seen

in neuropathic conditions, end stage myopathies

Early recruitment

Due to drop out of muscle fiber from motor unit Motor units become small generating lesser force Hence many motor units fire to generate smaller force.

Neuropathic disorder
Spontaneous activity Acute axonal Chronic axonal N Fibr potn + wave
MUAP morphology Duration Amplitude Phases MUAP interference Activation Recruitment

N N N N

N N N N

N N N N

N N N N N

N N

CV slowing N Conduction N block Early Fibr potn innervation + wave CNS N

Myopathic disorders
Spontaneous activity Acute N Fibr potn myotonia N Fibr potn CRD N Fibr potn CRD MUAP morphology
Duration Amplitude Phases

MUAP interference
Activation Recruitment

N/ early

Chronic

N/ early

End stage

NMJ disordes
Spontaneous activity Increased N jitter Fibr potn Intermitt + waves ant block Severe block N MUAP morphology
Duration Amplitude Phases

MUAP interference
Activation Recruitment

N N/ U

N N/ U

N N/ early

N/ U N

Thank you!