myopathies and their electrodiagnosis1 randall l. braddom, m.d., m.s. clinical professor robert wood...
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Myopathies and their Electrodiagnosis1Myopathies and their Electrodiagnosis1
Randall L. Braddom, M.D., M.S.
Clinical Professor
Robert Wood Johnson Medical School and the New Jersey Medical School
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The Five Steps of EMG First published by Johnson and
Melvin in 1971. Johnson EW, Melvin JL. Value of
electromyography in lumbar radiculopathy. Arch Phys Med Rehabil (June) 1971. 52: 239-243
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THE FIVE STEPS OF EMG THE FIVE STEPS OF EMG
STEP I (muscle at rest) Put the pin in the muscle Sit back, relax Watch for spontaneous potentials
Fibrillations, Fasciculations, Complex Repetitive Discharges, Myotonic Potentials
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THE FIVE STEPS OF EMG THE FIVE STEPS OF EMG
STEP II (insertional activity) Insert the pin with quick, one mm. movements Baseline should be quiet when needle stops Insertional Activity lasts about 50 msec. After the “movement noise”, watch for:
Positive Waves All Spontaneous Potentials
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GRADING INSERTIONAL ACTIVITY NORMAL
Easy to find, lasts 50 msec. DECREASED
Hard to find, usually due to muscle loss INCREASED
Easy to find, lasts longer than 50 msec. Some include positive waves, fibs, etc
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THE FIVE STEPS OF EMG THE FIVE STEPS OF EMG
STEP III Isolate one motor unit, focus on it Study the MUAP
Frequency of firing Amplitude Duration Phases
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MUAP ANALYSIS MUAP ANALYSIS
Only a few fibers near the pin produce the amplitude (2-12 fibers within 0.5 mm)
The fibers distant from the pin produce the early and late components of the duration
Due to Henneman size principle, almost all MUAP’s analyzed will be Type I
Use wide band width filter: (at least 10-10,000 Hz)
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MUAP ANALYSIS MUAP ANALYSIS
Amplitude (peak to peak) Duration Phases
# of baseline crossings plus one 5 or more phases is polyphasic 10-32% of MUAP’s are polyphasic
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Motor Unit Action PotentialMotor Unit Action Potential
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MUAP ANALYSIS MUAP ANALYSIS Rise Time
Dumitru recommends 0.5 msec. or less
Turns Change in direction
without baseline crossing
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MUAP ANALYSIS MUAP ANALYSIS Satellite Potentials
Time locked (usually a few msec later) Normal: 10% of MUAP’s Myopathy: 45% of MUAP’s Neuropathic: Slightly more than normal Don’t include in MUAP duration Probably due to fiber splitting and slow
conduction along immature terminal sprouts
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MEAN MUAP DURATIONS MEAN MUAP DURATIONS
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MUAP ANALYSISMUAP ANALYSIS
Myoneural Junction problems can cause Variability in amplitude Drop-out of MUAP’s
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Five Steps of EMGStep IV
RecruitmentInterference Pattern
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RECRUITMENT Rule of Fives RECRUITMENT Rule of Fives Isolate one MUAP
Begins at 3 Hz and can fire in stable manner at 5-7 Hz
Note firing frequency of first potential when second one begins...usually 10 Hz
Freeze the screen and measure time between the two potentials (recruitment interval) (usually 100 msec, corresponding to 10 Hz)
The second potential appears firing at 5 Hz Third potential appears when first is at 15 Hz and
second at 10 Hz
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RECRUITMENT RECRUITMENT Experienced EMG’ers can hear this Easy quantitative method
Freeze the screen with a number of motor units firing Determine frequency of fastest firing
MUAP Divide by the number of MUAP’s seen
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Recruitment Examples Normal
Fastest potential is 20 Hz, 4 MUAP’s present Recruitment ratio is 5
MYOPATHIC Ratio Low: 4 or less
NEUROPATHIC Ratio High: Usually 10 or more
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INTERFERENCE PATTERN INTERFERENCE PATTERN
Ask the patient to maximally recruit the muscle
Watch for: Holes in the Interference Pattern Amplitude of the Interference Pattern Observe the frequency of firing to
make sure you are seeing a maximal effort by the patient
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THE FIVE STEPS OF EMG THE FIVE STEPS OF EMG
STEP V: The Cerebral Step Put together all the steps to reach
conclusions Do the findings support your clinical
hypothesis? Determine how to proceed from this
point in the study (Dynamic rather than protocol approach)
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FASCICULATIONS FASCICULATIONS
Spontaneous firing of all or part of a motor unit Denny-Brown and Pennypacker
1938
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FASCICULATIONS FASCICULATIONS Step I (Muscle at Rest) Irregularly Irregular Origin anywhere in the lower motor neuron Usually look like polyphasic MUAP, but
can be any size and shape Often normal, but also common in anterior
horn cell disease
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FIBRILLATIONS FIBRILLATIONS Spontaneous
firing of a single muscle fiber
Best seen Step I 1-50 Hz Regular pattern
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FIBRILLATIONS FIBRILLATIONS
Spontaneous oscillations in membrane potential of a denervated or injured muscle fiber
Diphasic or triphasic with initial positivity
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FIBRILLATIONSFIBRILLATIONS 1-5 msec duration 20-1000 uV amplitude Can be initially negative near end plates Usually indicate denervation, but occur
with any muscle membrane irritability “Tick” or sound like rain on a tin roof
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FIBRILLATIONS Most important factor
Regular rhythm This separates them from end plate
spikes and voluntary motor unit action potentials and fasciculations
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GRADING FIBRILLATIONS GRADING FIBRILLATIONS
0 None (or isolated fib)
1+Found in at least two muscle regions
2+Moderate # found in three muscle regions
3+Many in all muscle areas tested
4+Baseline obliterated by fibrillations
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POSITIVE WAVES POSITIVE WAVES
Same as Fibrillation Recorded by pin next to muscle fiber
Seen best in Step II Due to muscle membrane irritability,
often because of denervation
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POSITIVE WAVES POSITIVE WAVES Frequency 1-50 Hz Regular Sharp positive
deflection, then long negative phase
Duration 1-5 msec Amplitude to 1 mV “Thumping” sound
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Positive Waves and Fibs New Trend in nomenclature They are both the same thing The shape is the only difference Some now calling both fibrillations
Positive waves now called fibrillations with positive wave shape
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MYOPATHIC CHANGES MYOPATHIC CHANGES
Decreased amplitude Decreased duration Increased number of phases Increased # of motor units firing per
strength of contraction Some refer to this as increased recruitment
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MYOTONIC DISCHARGES MYOTONIC DISCHARGES
Wax and Wane in frequency and amplitude
20-80 Hz Two types: can resemble fibrillations or
positive waves Due to repetitive discharges of single
muscle fibers
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EMG Separates Myopathies into Three GroupsEMG Separates Myopathies into Three Groups
Inflammatory Muscle membrane irritability Rapid destruction of muscle fibers
Non-Inflammatory Little muscle membrane irritability Slow destruction of muscle fibers
Myotonic
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INFLAMMATORY MYOPATHIESINFLAMMATORY MYOPATHIES
Muscle membrane irritability Usually involve myositis Examples:
Dermatomyositis Polymyositis Trichinosis
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NON-INFLAMMATORY MYOPATHIESNON-INFLAMMATORY MYOPATHIES
Few or no positive waves/fibrillations
Often only slowly progressive Examples:
FSH-MD Steroid Myopathy
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MYOTONIC MYOPATHIESMYOTONIC MYOPATHIES
All have the myotonic phenomenon Examples
Myotonic dystrophy Myotonia congenita
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NON-INFLAMMATORY MYOPATHIESNON-INFLAMMATORY MYOPATHIES
From an EMG standpoint, non-inflammatory merely means that the electrical membranes are sufficiently stable that there are no Fibrillations Positive Waves
Motor units will look myopathic
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INFLAMMATORY MYOPATHIESINFLAMMATORY MYOPATHIES
These typically have High sedimentation rate High muscle enzymes Relatively acute history Rapid onset of weakness Toxic symptoms
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5 STEPS OF EMG5 STEPS OF EMG Slowly progressive myopathy
I: Normal II Normal III Reduced amplitude, duration of
MUAP’s IV Increased # of motor units firing per
strength of contraction Normal interference pattern
NCV’s usually normal
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5 STEPS OF EMG 5 STEPS OF EMG
Rapidly progressive myopathy Step I Reduced and Fibrillations Step II Positive Waves, Fibrillations Step III Reduced amplitude, duration Step IV Increased # of motor units firing per
strength of contraction
NCV’s typically normal except for reduced amplitude of the evoked potential in motor studies
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MUAP CHANGES IN MYOPATHYMUAP CHANGES IN MYOPATHY
Shorter duration Due to less contribution from distant fibers of
same motor unit
Lower amplitude Less contribution from fibers close to the pin
Polyphasic Less integrated potential due to drop out of some
fibers
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Myopathy’s Recruitment Change Myopathy’s Recruitment Change
Remember the “Rule of Fives” Determine frequency of fastest firing MUAP Divide by number of MUAP’s seen If fastest is at 20 Hertz and four are present,
recruitment ratio is 5 Myopathy typically has recruitment ratio
of 4 or less
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Step III Problem in MyopathyStep III Problem in Myopathy
Major Clue that myopathy might be present When doing Step III, it will be difficult to
isolate a single MUAP Since all are MUAP’s are weak, the patient
will tend to fire more than one at a time Hard for the patient to fire only one MUAP
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RememberRemember
STEROIDS QUIET MUSCLE MEMBRANES
EMG PIN CAN CAUSE PROBLEMS WITH MUSCLE BIOPSY