SFEMG Signal Atlas - Highlights - Voluntary - Bad Signals
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1) The document provides guidelines for recording jitter with a concentric needle electrode (CNE), including definitions of acceptable CNE signals, techniques for voluntary and electrical stimulation activation, and potential errors in jitter measurements.
2) Examples are given of CNE recordings from different muscles that demonstrate normal voluntary activation, effects of varying stimulation frequency, axon reflex responses, and individual fiber blocking that is analyzed to determine jitter values.
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The patient has clinical features consistent with myasthenia gravis including fatigable neck and leg muscles as well as symptoms affecting swallowing and voice. Repetitive nerve stimulation and SFEMG testing would help confirm the diagnosis. Positive voltage-gated calcium channel antibodies also support MG. The diagnosis is myasthenia gravis (option a).QUIZ SFEMG
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- To detect neurogenic jitter on SFEMG, you need to record 4 spikes simultaneously. If only 3 spikes are recorded, the jitter may be due to triggering issues rather than a neurogenic cause.
- To ascertain that distal and proximal stimulation is of the exact same axon during conduction velocity testing, stimulate distally and proximally simultaneously. If the proximal response disappears with dual stimulation, it indicates collision and the same axon was stimulated.NCS special
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The document contains questions and answers regarding neurophysiology techniques. Some key points discussed include:
- Voluntary activity does not influence CMAP amplitude at supramaximal stimulation, except for effects of muscle shortening.
- CMAP satellites can be distinguished from extra discharges by superimposing traces after 3Hz stimulation - satellites will be stable while extra discharges will be variable.
- If CMAP amplitude is unexpectedly low with no nerve damage or PNP, steps should be taken to check stimulation strength, equipment, skin conditions, and perform activation maneuvers before considering anomalies.
- F waves are usually normal in C8 radiculopathy but may be abnormal on the affected side in an ulNCS routine
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The document provides guidance on interpreting various neurography results. It discusses potential reasons for low amplitude compound muscle action potentials including carpal tunnel syndrome, lumbar epidural mass, technical problems, and polyneuropathy. It also discusses diagnoses for other neurography findings including possible carpal tunnel syndrome based on abnormal sensory findings in fingers 1-3 with normal motor amplitudes. Other sections discuss distinguishing between lumbar root lesions versus plexopathies and evaluating possible myasthenia gravis. The document aims to instruct on drawing conclusions from neurography studies.EMG special
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A 21-year-old man presented with slowly progressive proximal muscle weakness and pain over 1 month. Neurography was normal. EMG showed myopathic motor unit potentials, interference patterns, and fibrillations. Ultrasound revealed hyperechogenicity and increased vascularization in the deltoid muscle. A muscle biopsy showed fiber diameter variation but no grouping. The likely diagnosis is polymyositis or dermatomyositis given the clinical presentation, normal neurography, myopathic EMG, and muscle biopsy findings.EMG routine
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The document discusses various EMG findings including: fibrillation potentials and positive sharp waves that are generated in the axon or individual muscle fibers with irregular firing rhythm and always signify axonal pathology; findings expected in demyelinating neuropathies with conduction block such as reduced MUP amplitudes and interference pattern; what complex repetitive discharges represent; and EMG findings in acute weakness such as Guillain-Barr辿 syndrome where early on there would be normal CMAPs and CVs with reduced interference pattern. It also addresses discrepancies that can occur on EMG and the diagnostic methods of choice for various conditions.RNS
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2. It provides criteria for possible, probable, or definite myopathy based on spontaneous activity, motor unit potential morphology and instability, and involvement of muscle groups on EMG.
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This document discusses different types of EMG electrodes used to measure jitter, including concentric needle electrodes and single fiber EMG electrodes. It presents data from studies measuring jitter with these electrodes in various muscles. Specifically, it shows jitter measurements are higher with concentric needle electrodes than single fiber electrodes in muscles from myasthenia gravis patients. The document also reviews the sensitivity of different diagnostic tests for myasthenia gravis, with jitter analysis and repetitive nerve stimulation having high sensitivity to detect the condition.20. Late resp F H
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This document discusses electromyography (EMG) techniques for evaluating myopathies. It describes how EMG can detect spontaneous muscle fiber activity like fibrillation potentials, myotonic discharges, and complex repetitive discharges that indicate a myopathy. It also discusses EMG analysis of motor unit potential amplitudes and frequencies, interference patterns, and muscle fiber characteristics like splitting that provide clues about normal and diseased muscle. While EMG is sensitive in detecting many myopathies, it is not always specific for differentiating between specific muscle disease subtypes. EMG combined with other clinical findings can help classify myopathies and distinguish myopathic from neuropathic processes.TM
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2) Examples of regional and international telemedicine collaborations, including video conferencing for consultations, remote supervision of testing, and quality assurance.
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- Propagation velocity along muscle fibers was measured, showing it decreases with activity and fatigue.
- The jitter phenomenon at the neuromuscular junction was identified as the source of variability in muscle fiber activation times.
- Technical developments like improved electrodes, filters, triggers and delay lines allowed more accurate measurement and understanding of single muscle fiber properties and motor unit organization.
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1) Neurophysiological tests play an important role in diagnosing and monitoring motor neuron disease (MND) such as amyotrophic lateral sclerosis (ALS).
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3) Nerve conduction studies can exclude other neuropathies but often find only mild or no sensory involvement in ALS patients. Motor unit number estimation quantifies the loss of motor units over time in ALS.
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- To detect neurogenic jitter on SFEMG, you need to record 4 spikes simultaneously. If only 3 spikes are recorded, the jitter may be due to triggering issues rather than a neurogenic cause.
- To ascertain that distal and proximal stimulation is of the exact same axon during conduction velocity testing, stimulate distally and proximally simultaneously. If the proximal response disappears with dual stimulation, it indicates collision and the same axon was stimulated.NCS special
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The document contains questions and answers regarding neurophysiology techniques. Some key points discussed include:
- Voluntary activity does not influence CMAP amplitude at supramaximal stimulation, except for effects of muscle shortening.
- CMAP satellites can be distinguished from extra discharges by superimposing traces after 3Hz stimulation - satellites will be stable while extra discharges will be variable.
- If CMAP amplitude is unexpectedly low with no nerve damage or PNP, steps should be taken to check stimulation strength, equipment, skin conditions, and perform activation maneuvers before considering anomalies.
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The document provides guidance on interpreting various neurography results. It discusses potential reasons for low amplitude compound muscle action potentials including carpal tunnel syndrome, lumbar epidural mass, technical problems, and polyneuropathy. It also discusses diagnoses for other neurography findings including possible carpal tunnel syndrome based on abnormal sensory findings in fingers 1-3 with normal motor amplitudes. Other sections discuss distinguishing between lumbar root lesions versus plexopathies and evaluating possible myasthenia gravis. The document aims to instruct on drawing conclusions from neurography studies.EMG special
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A 21-year-old man presented with slowly progressive proximal muscle weakness and pain over 1 month. Neurography was normal. EMG showed myopathic motor unit potentials, interference patterns, and fibrillations. Ultrasound revealed hyperechogenicity and increased vascularization in the deltoid muscle. A muscle biopsy showed fiber diameter variation but no grouping. The likely diagnosis is polymyositis or dermatomyositis given the clinical presentation, normal neurography, myopathic EMG, and muscle biopsy findings.EMG routine
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The document discusses various EMG findings including: fibrillation potentials and positive sharp waves that are generated in the axon or individual muscle fibers with irregular firing rhythm and always signify axonal pathology; findings expected in demyelinating neuropathies with conduction block such as reduced MUP amplitudes and interference pattern; what complex repetitive discharges represent; and EMG findings in acute weakness such as Guillain-Barr辿 syndrome where early on there would be normal CMAPs and CVs with reduced interference pattern. It also addresses discrepancies that can occur on EMG and the diagnostic methods of choice for various conditions.RNS
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This document describes several classification systems for analyzing electromyography (EMG) results:
1. It classifies the degree of acute or subacute denervation seen on EMG as slight, moderate, or severe based on the duration of symptoms and EMG findings like fibrillation potentials and insertional activity.
2. It provides criteria for possible, probable, or definite myopathy based on spontaneous activity, motor unit potential morphology and instability, and involvement of muscle groups on EMG.
3. It outlines a quantitative EMG scoring system for evaluating myopathic changes with criteria in several categories.
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This document discusses various late responses and reflexes that can be measured using electrophysiological testing, including F-waves, A-waves, H-reflexes, and flexion reflexes. It provides information on the generator site, mechanism, and normal values for many of these late responses. Examples of abnormal late responses are shown in various neurological conditions like diabetic neuropathy, radiculopathy, amyotrophic lateral sclerosis, and myasthenia gravis. The document aims to characterize the typical electrophysiological features of late responses and reflexes.11. Myopati
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This document discusses electromyography (EMG) techniques for evaluating myopathies. It describes how EMG can detect spontaneous muscle fiber activity like fibrillation potentials, myotonic discharges, and complex repetitive discharges that indicate a myopathy. It also discusses EMG analysis of motor unit potential amplitudes and frequencies, interference patterns, and muscle fiber characteristics like splitting that provide clues about normal and diseased muscle. While EMG is sensitive in detecting many myopathies, it is not always specific for differentiating between specific muscle disease subtypes. EMG combined with other clinical findings can help classify myopathies and distinguish myopathic from neuropathic processes.TM
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The document discusses the use of telemedicine and networks in a neurophysiology laboratory. It describes:
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2) Examples of regional and international telemedicine collaborations, including video conferencing for consultations, remote supervision of testing, and quality assurance.
3) The future potential for telemedicine to develop national services, use smaller portable equipment, enable home monitoring, and facilitate international collaboration between individuals and research groups.Macro EMG
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This document discusses macro electromyography (EMG), a technique used to study motor unit potentials (MUPs). Macro EMG involves inserting a cannula electrode into a muscle to record the electrical activity from many motor units at once, producing a macro motor unit potential (Macro MUP). The document also mentions multiunit triggered averaging, which averages Macro MUP signals to analyze individual motor unit characteristics from the combined signal.History SFEMG
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This document discusses the development of single fiber electromyography (SFEMG) over time. Some key findings from SFEMG research include:
- SFEMG suggested that motor unit fibers are organized randomly rather than in subgroups, challenging previous theories.
- Propagation velocity along muscle fibers was measured, showing it decreases with activity and fatigue.
- The jitter phenomenon at the neuromuscular junction was identified as the source of variability in muscle fiber activation times.
- Technical developments like improved electrodes, filters, triggers and delay lines allowed more accurate measurement and understanding of single muscle fiber properties and motor unit organization.
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SFEMG Signal Atlas - Highlights - Voluntary - Bad Signals
- 1. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Signals of non-acceptable quality Voluntary activation
- 2. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Voluntary Activation Acceptable spikes are based only on the parallel rising lines. Interpotential vs. inter-discharge interval without correlation. Cannot be used for the peak algoritm Orbicularis Oculi - 50 袖V / 0.5 ms IPI (袖s) vs response number IPI (袖s) vs rIDI (ms)
- 3. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Extensor Digitorum - 0.2 mV / 0.5 ms Trigger MCD = 19 袖s Trigger here, reveals that the rising segments are not paralell cSFAP Not acceptable signals Voluntary Activation
- 4. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Extensor Digitorum - 0.3 mV / 0.3 ms Trigger Measuring jitter accurately is impossible when there is significant variation in amplitude. cSFAPs Cannot be used for jitter estimation Voluntary Activation
- 5. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Extensor Digitorum - 3 mV / 0.8 ms Extensor Digitorum - 1 mV / 0.8 ms * Trigger MCD = 40 袖s cSFAPs The first spike cannot be used for jitter estimation Voluntary Activation
- 6. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Extensor Digitorum - 50 袖V / 0.5 ms Trigger cSFAPs The second spike cannot be used for jitter estimation as it represents acitivity from different fibers Voluntary Activation
- 7. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg cSFAPs Voluntary Activation The spikes to the left are non-acceptable. The first three spikes to the right are acceptable, but not the last one. Extensor Digitorum 0.1 mV / 0.5 ms Trigger MCD = 16 袖s ** Extensor Digitorum 0.5 mV / 0.5 ms Trigger (by level) * MCD = 108 袖s signal not acceptable since the triggering spike is a summation ** first three spikes OK but not the last one
- 8. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Damaged fiber The second signal is after discharge from the first fiber, likely generated by a irritation of the muscle membrane Not used for jitter assessment Voluntary Activation MCD = 77 袖s (FALSE) Extensor Digitorum - 200 袖V / 1 ms
- 9. 息2024 J.A. Kouyoumdjian, D.B. Sanders, E.V. St奪lberg Triangular after-potential ,Damaged fiber The second signal is after- discharge from the first fiber, likely generated by a irritation of the muscle membrane Not used for jitter assessment Voluntary Activation MCD = 77 袖s (FALSE) Extensor Digitorum - 200 袖V / 1 ms