autonomic testing

7/31/2019 Autonomic Testing

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MANUEL ZWECKER, MD

Department of Neurological Rehabilitation,

Sheba Medical Center, Tel Hashomer

Email: [email protected]


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Autonomic testing


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Sympathetic Skin Response (SSR)

reflects the activity of the sympatheticnervous system

is affected by cognitive thinking anddecision making

does not depend on residual motor function

SSR

Sound

EmotionRespiration

Light Temperature


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Sympathetic Skin Response

It is a measure of skin voltage, which, like skinresistance (galvanic skin response) isdependent on sudomotor activity.

Correlated best with unmyelinated axons Polysynaptic response

Hypothalamic, brainstem, spinal circuits,postganglionic sympathetic sudomotor axons

Generated in deep layer of skin bysympathetically mediated activation of sweatglands


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Clinical Use of SSR

Stimulation

On median or tibial nerve afferants

Intensity: 3threshold

Acoustic stimulation

Easy to measure with EMG equipments

Controversial clinical criteria

Lack of SSR -> abnormal

50% of healthy over 60 -> no SSR from lowerextremities

Little correlation with severity of autonomic dysfunction


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Factors affecting SSR Temperature

Attention

Fatigue

Predictability

Consecutive yes generation

Training? (not proven yet)


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Sympathetic skin response


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Thermal detection threshold

Cold-detection threshold

Warmth-detection threshold

Method of limits

Method of levels (forced choice)


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Hand

Warmth detection threshold 2.4,

Cool detection threshold 1.9,

Difference 4.3 Foot

Warmth detection threshold 5.9,

Cool detection threshold 3.0,

Difference 7.2


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Body parts, age

Semi-quantitative, subjective reporting

Not specific for small fibers

Reaction time (method of limits)

Heat-induced pain 46

Cold-induced pain


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Quantitative sensory testing (QST)

Thermal detection and pain threshold (WDT, CDT, HPT, CPS, PHS)

- warm (C-warm-fiber);cold (A-cold-fiber)

-heat pain (C-nociceptors), cold pain (C- or A-nociceptors)

-paradoxical heat sensation during cold (C-nociceptors)

Mechanical detection threshold (MDT, A-low threshold mechanoreceptors, v. Frey hairs)

Mechanical pain threshold (MPT, A-fiber)

Mechanical pain sensitivity/MPS for pinprick (A-mechanonociceptors)

Mechanical pain sensitivity/MPS for light touch (A-low threshold mechanoreceptors)

Wind-up ratio (WUR, trains of single pinprick stimuli)

Vibration detection threshold (VDT) (A-fiber)

Pressure pain threshold (PPT, deep pain, deep (muscle) nociceptors)

* Protocol of the German Research Network on Neuropathic Pain

TSA


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Evaluation of organic neurogenic

erectile dysfunction

The bulbocavernosus reflex (BCR)

Pudendal nerve Somatosensory evokedpotentials (SSEPs)


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Bulbocavernosus reflex (BCR)

The electrophysiologically inducedBCR measures the somatic reflexpathway from the dorsal nerve ofthe penis by means of the sensorypudendal afferent limb, the spinal

sacral segment S2 through S4,and the motor pudendal efferentlimb.

There will be no response whenthe BCR arcs are interrupted, and

the BCR will be prolonged whenafferent and efferent limbs are notcompletely destroyed.


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Pudendal Somatosensory Evoked

Potentials

Pudendal SSEPprovides an objectivemean of testing the

afferent pathways fromthe dorsal nerve of thepenis to the sensorycortex


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Pudendal Somatosensory Evoked

Potentials


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Evaluation of fecal incontinence

Anal sphincter EMG


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Evaluation of the respiratory

system

Phrenic nerve conduction study

EMG of the diaphragma


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Phrenic nerve conduction study


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EMG of the diaphragma


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Needle

EMG


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Diaphragmatic studies

Diaphragm EMG

Phrenic nerve stimulation

DML


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Evaluation of the larynx

Vocalis muscle EMG


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Unilateral vocal cord paralysis

Stridor

Laryngospasm

Dyspnoea

Cause by abnormal innervation of nervebranches into adductor fibers


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Anatomy

Recurrentlaryngeal nerve

0.5% right non-recurrent

laryngeal nerve Muscles

Lateralcricoarytenoid

Posterior

cricoarytenoid Thyroarytenoid

Interarytenoid


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Etiology

Dysfunction at

Brain and

brainstem nuclei

Vagus nerve

Recurrent laryngeal

nerve


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Causes

Post Thyroid surgery

Post cervical disc surgery

After Herpes simplex virus with cranial nerve

involvement

Fibre optic laryngoscopy showed affected

vocal cord immobile


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Etiology: Traumatic

Iatrogenic: Surgical Thyroidectomy

Anterior cervical spineprocedures

Esophagectomy

Thymectomy Carotid endarterectomy

Cardiothoracic surgery

Aortic surgery Coronary artery

bypass grafting Pulmonary lobar

resection Mediastinoscopy

Iatrogenic: Non-surgical

Endotrachealintubation Arytenoid

dislocation,subluxation

Tapias syndrome

Nasogastric tubeplacement1

Non-iatrogenic

Blunt or penetratingtrauma to the neck

Brousseau et al. A rare but serious entity: nasogastric tube syndrome. Otolaryngol HeadNeck Surg. 2006 Nov;135(5): 677-679.


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Evaluation Laryngeal

electromyography (LEMG)

Needle electrodeplacement intothyroarytenoid and

cricothyoid muscle Assess

Muscle at rest

Voluntary motor unitrecruitment

May not be useful indiagnosis

.1Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000Aug;33(4):759-70.

.2Sataloff et al. Practice parameter: laryngeal electromyography (an evidence-based review). Otolaryngol HeadNeck Sur 2004; 130: 770-779.


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Demystifying Electrodiagnostic

Studies

I.D.#: 2797


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History/Comments:

Left upper extremity pain and parethesias.

Motor Nerve Study

Left Median NerveRec Site: APB Lat (ms) Norm Lat Dur (ms) Amp (mV) Area (mVms) Dist (mm) C.V. (m/s)STIM SITEWrist 4.7


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Thank You

autonomic testing

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