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NERVE CONDUCTIONVELOCITY

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PRINCIPLES

ACTION POTENTIAL

AXONAL TRANSPORT TYPES OF CONDUCTION

CMAP

SNAP VARIABLES

BASICS

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PRINCIPLES

Proximal and distal rule

Same nerve roots but different peripheral

nerves to localize the changes to one or theother

Until normal values

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Proximal and Distal Rule

Proximal-distal rule: motor neurons that innervate

distal muscles (e.g., hand muscles) are located

lateral to motor neurons that innervate proximal

muscles (e.g., trunk muscles)

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TYPES OF CONDUCTION

ORTHODROMIC:

Normal physiological direction

ANTIDROMIC:

Opposite to normal physiological direction

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Motor unit

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VARIABLES AFFCTING NCV

PHYSIOLOGICAL

AGE

TEMPARATURE SEX

DIGIT

CIRCUMFERANCE

UPPER VERSUS

LOWER LIMB

TECHNICAL :

STIMULATION;

FAULTY LOCATIONOF STIMULATOR

FAT AND OEDEMA

BRIDGE

FORMATION

BETWEEN ANODEAND CATHODE

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TECHCONTD.

RECORDING:

BREAK IN THECABLE

WRONGLYCONNECTEDAMPLIFIER

WRONG SETTINGSOF GAIN

,SWEEP,FILTER INCORRECT

POSITION OFACTIVE ORREFERANCE

IN ADVRETANT

STIMULATION OF

UNWANTED NERVE :

VOLUME

CONDUCTION

ANAMOLUS

CONDUCTION

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NERVE CONDUCTION VELOCITY

The speed at which the nerve conduct an

impulse

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TYPES OF NCV

MNCV

SNCV

LATE RESPONSES

H REFLEX

F WAVE

AXON REFLEX

BLINK REFLEX

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TYPES

NCV

MNCV SNCV LATE RESPONSES

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MNCV

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PRINCIPLES OF MNCV

Orthodromic

Motor or mixed nerve is stimulated at least at

two points along it course

Pulse is adjusted to get CMAP

A Biphasic action potential should be

recorded Supra maximal stimulation should be used

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MACHINE SETTING

Square wave pulse

Duration-0.1ms

Frequency-1 pulse /sec

Intensity-5 40mA or 100 -300 V

Diseased nerve-75mA or 500 V

Filter setting-5HZ 10KHZ

Sweep speed-2 -5 ms/div

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MEASUREMENTS

Onset latency

Duration

Amplitude

Conduction velocity

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WAVE FORMS

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LATENCY

Time in ms from the stimulus artifact to the

first negative deflection of CMAP

Measure of fastest conducting motor fibers

It includes RESIDUAL LATENCY

Measured in ms

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AMPLITUDE

Base line to negative peak

Peak to peak

Co relates with the number of nerve fibers

Measured in mV

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DURATION

Initial take off from the base line to final return

to the baseline

Co relates with the density of small nerve

fibers Measured in ms

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CONDUCTION VELOCITY

Conduction velocity is determined by dividing

the distance between the two cathodal

stimulation points by the difference between

the two latenciesConduction distance

CV =

Proximaldistal latency Meters / seconds

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NORMAL VALUES

In between 45-70 m/sec

Upper limbs-60 m/sec (average)

Lower limbs -50 m/sec (average)

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SNCV

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PRINCIPLES OF SNCV

Orthodromic or Antidromic

Orthodromic:

Digital nerve is stimulated and SNAP recorded

at a proximal point along the nerve

Antidromic: The nerve is stimulated at a proximal point

and SNAP recorded distally.

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ELECTRODE PLACEMENTS

ORTHODROMIC STUDY

Ring electrodes Stimulation

Surface electrodes - recording

Stimulating : Cathode 1st IP joint

Anode 3cm distal

Recording : Pick up proximal point Reference 3cm proximal

Ground in b/w stimulating and recording

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ANTIDROMIC STUDY (REVERSE)

Surface electrodes stimulating

Ring electrode recording

Stimulating :

Cathodeproximal point

Anode -3 cm proximal

Recording :

Pick up 1st pip joint reference -3 cm distal

Groundin b/w stimulating and recording

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MACHINE SETTINGS

Filter 10 Hz 2kHz

Sweep speed -1-2ms/div Gain 1-5 V /div

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MEASUREMENTS

Onset latency

Amplitude Duration

Conduction velocity

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WAVE FORM

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ONSET LATENCY

Stimulus artifact to the initial positive or

subsequent negative peak

Measured in ms

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DURATION

Initial take off from the baseline to final return

to the baseline

It represents the number of slow conducting

fibers Measured in ms

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AMPLITUDE

Base line to negative peak or Positive to

negative peak

It represents the density of nerve fibers

Measured in mV

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CONDUCTION VELOCITY

SNCV is calculated dividing the distance

(mm) between stimulating and recording site

by the latency

Distance

CV =

latency

Meters / seconds

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ABNORMAL NCV

Degeneration amplitude reduction

Demyelination latency prolongation

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M wave

A compound action potential evoked from a muscle by a singleelectric stimulus to its motor nerve.

By convention, the M wave elicited by supramaximal stimulation isused for motor nerve conduction studies.

Ideally, the recording electrodes should be placed so that the

initial deflection of the evoked potential is negative. The latency, commonly called the motor latency, is the latency (ms)

to the onset of the first phase (positive or negative) of the Mwave.

The amplitude (MV) is the baseline-to-peak amplitude of the firstnegative phase, unless otherwise specified.

The duration (ms) refers to the duration of the first negativephase, unless otherwise specified.

Normally, the configuration of the M wave (usually biphasic) is quitestable with repeated stimuli at slow rates (1-5 Hz). See repetitivenerve stimulation

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F wave

A compound action potential evoked intermittently from a muscleby a supramaximal electric stimulus to the nerve.

Compared with the maximal amplitude M wave of the same muscle,the F wave has a smaller amplitude (l%-5% of the M wave), variableconfiguration, and a longer, more variable latency.

The F wave can be found in many muscles of the upper and lowerextremities, and the latency is longer with more distal sites ofstimulation.

The F wave is due to antidromic activation of motor neurons. Itwas named by Magladery and McDougal in 1950. Compare the Hwave and the A wave

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H wave

A compound muscle action potential having a consistent latencyevoked regularly, when present, from a muscle by an electricstimulus to the nerve.

It is regularly found only in a limited group of physiologicextensors, particularly the calf muscles.

The H wave is most easily obtained with the cathode positionedproximal to the anode.

Compared with the maximum amplitude M wave of the same muscle,the H wave has a smaller amplitude, a longer latency, and a loweroptimal stimulus intensity.

The latency is longer with more distal sites of stimulation.

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A stimulus intensity sufficient to elicit a

maximal amplitude M wave reduces orabolishes the H wave.

The H wave is thought to be due to a spinalreflex, the Hoffmann reflex, with electricstimulation of afferent fibers in the mixednerve to the muscle and activation ofmotor neurons to the muscle through a

monosynaptic connection in the spinal cord. The reflex and wave are named in honor of

Hoffmann's description (1918). Comparethe F wave

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H-reflex

Originally described by Piper in 1912

More clearly elucidated by Hoffman in 1922

Studied the gastrocnemius by electrically

stimulating the main trunk of the tibial nerve

Magladery and McDougal (1950) credited

with designating the reflex response the

Hoffman reflex

Shortened to the H-reflex

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Therory 1

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Theory 2

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H-reflex Theory.3

Confirms the integrity of the afferent - efferent

nerve connections

Amplitudes (mV) provide an index of alpha

motoneuron excitability at the spinal cordlevel

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H-reflex Uses.1

First used as a clinical/diagnostic tool

Most frequently used to study the tibial nerve

in the posterior compartment of the thigh

Gastrocnemius usually studied Compare latencies between M-waves and H-

reflex bilaterally

Correlates with leg length - range = 22.64 - 40.14

msec (tibial nerve)

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H-reflex Uses.2

Examples - Clinical/Diagnostic Use

Assess the integrity of the S1-2 nerve roots with

suspected foraminal encroachment (Braddom

& Johnson, 1974) Takamori (in Braddom & Johnson, 1974)

studied patients with spasticity and

Parkinsons disease

Magladery & McDougal (1950) studied nervedisorders secondary to ischemia

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H-reflex Uses.3

More recently the H-reflex has been used in

clinical and basic research

Tibial, common peroneal, femoral, median

and ulnar nerves have been studied withvarying degrees of success

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H-reflex - Uses.4

Mongia (1972) studied the femoral nerve and

quadriceps

Bulbulian & Bowles (1992) studied eccentric

contractions in downhill running Kennedy et al. (1982); Spencer et al. (1984);

and McDonough & Weir (1996) studied reflex

inhibition in the quadriceps secondary to knee

joint capsular swelling

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Neurophysiological Overview.1

After the nerve (e.g., femoral, tibial, etc.) has

been identified and stimulating electrodes are

applied over the nerve, and after recording

EMG electrodes are applied over themuscles motor point

A galvanic stimulator simulates the nerve

(group Ia afferents) directly thereby by-

passing the spindle

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Neurophysiological Overview.2

Group Ia fibers monosynaptically connect with

alpha motoneurons in the anterior horn of the

spinal cord

The alpha motoneurons activate extrafusal(somatic) fibers in the homonymous muscle

Recording EMG electrodes pick-up electrical

activity in the muscle

A twitch contraction is elicited

Similar is appearance to a DTR response

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EMG Response - Vastus Medialis

Stimulus artifact

M-wave H-reflex

Latency

msec

EMG Response - Vastus Medialis

Stimulus artifact

M-wave H-reflex

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Potential Confounding Influences

Head/neck position

Mental/emotional/alertness state

Cognitive state

Ambient temperature

The specific nerve being studied

Stimulating electrode conditions

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LATE RESPONSES

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Late responses are the potentialsappearing after motor response (M wave)following a mixed nerve stimulation

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TYPES

H reflex

F wave

Axon reflex

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F WAVE

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F WAVE

It is a late response resulting from Antidromic

activation of alpha motor neuron involvingconduction to and from spinal cord and occurs atthe interface between the peripheral and central

nervous system

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PHYSIOLOGY OF F WAVE

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WAVE FORMS

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HISTORICAL BACKGROUND

Magladery and mc dougal 1950 ( CMT )

Small muscles in the foot

De afferented man

Not a reflex

Proximal motor pathway

FACTORS AFFECTING

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FACTORS AFFECTING

F WAVE

Renshaw cell inhibition

Maximum voluntary contraction

Tension

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METHODS

Supra maximal stimulation ( 25 % )

Stimulus rate more than 0.5

Cathode should be proximal to anode

It is recorded from any distal muscle by

stimulating appropriate nerve

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RECORDING

Electrode placements same as MNCV

Machine settings:

Amplifier gain 200 -300 microvolts /division

Sweep speed 5-10 ms / division

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PROCEDURE

Relaxed

slight voluntary contraction

Amplitude of more than 20 micro volts

10 20 responses

persistence

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PARAMETERS

Latency

Chronodispersion

Persistence

Amplitude

F/M ratio

Conduction velocity

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WAVE FORMS

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LATENCY

Minimal latency

Maximal latency

Mean or median latency

Age, height, limb length

31 ms in hand, 61 ms in foot

Right to left symmetry is more than 2 ms inhand and 4 ms in foot abnormal

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CHRONODISPERSION

Difference between minimal latency and

maximal latency

Measure ofrange of conduction of F waveABP 3.6 +/- 1.2

ADM 3.3 +/- 1.1

EDB 6.4 +/- 0.8

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PERSISTENCE

Number of occurrence divided by number of

stimuli

Measure ofantidromic excitability of particularmotor neuron pool

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AMPLITUDE

Depends on the number and size of the

motor unit

5 % of M wave Mean amplitude

Excitability of alpha motor neuron

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F/M RATIO

Proportion of motor neuron pool activated by

antidromic stimulation

To use mean rather than maximum Famplitude for calculating F/M ratio

ADM O.8

Ad H 0.9

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CONDUCTION VELOCITY

stimulus site to C7 spinous process via theaxilla and mid clavicular point

Stimulus site to T12 spinous process via knee

and greater trochanter of the femur( 2D )

FWCV =

( F M 1 )

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CLINICAL APPLICATIONS

Proximal motor pathway

Segmental motor neuron excitability

It is more precise for assessment of

segmental motor neuron excitability than H

and T reflex

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LMN

latency

Changes in peripheral nerve and root lesion

F/M ratio

Increased in both poly neuropathy and spasticity

persistence

Absent or reduced in GBS, ALS, proximal nerve root

injury

choronodispersion Increased in poly neuropathy ( demyelinating )

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UMN

Amplitude and Persistence

Initial stage Decreased

Chronic stage Increased

latency also prolonged while duration andamplitude increased in UMN

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H REFLEX

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H- REFLEX

The H - reflex is a monosynaptic reflex elicited

by sub maximal stimulation of the tibial nerve

and recorded from calf muscles

Hoffman 1918

PHYSIOLOGY OF H REFLEX

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PHYSIOLOGY OF H REFLEX

A C

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REFLEX ARC

1 a fibers

Spinal cord

Alpha motor neuron

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It does not include muscle spindle

H reflex is larger at submaximal stimulation

Inhibited by stronger stimulation

Due to collision of orthodromic impulses byantidromic conduction in motor axons

MODIFYING FACTORS

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MODIFYING FACTORS

Renshaw cell inhibition

Supraspinal mechanism

Inhibition by adjacent motor neuron

VARIATIONS

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VARIATIONS

In normal adults other muscles except small

muscles of hand and feet In childrens below 2 years

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METHODS


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Position :

Semi reclining or prone

Recording :

Active - Distal edge of calfReference - Tendon

Stimulating :

popleteal fossa

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MACHINE SETTINGS

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MACHINE SETTINGS

STIMULATION

Square wave pulse of 1 ms

Stimuli below 0.1 ms will stimulate motor

axons Cathode is kept proximal to anode

Stimulus frequency should not exceed 1 in 5

seconds

PROCEDURE

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PROCEDURE

The stimuli is adjusted to evoke maximum Hresponse amplitude

At this strength a small M response may also

present M response help to monitor the strength of

stimuli

At least 5 H response required for analysis

By increasing the stimuli strength to supra

maximal maximum M responses can be

recorded

3 M responses required for analysis

PARAMETERS

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PARAMETERS

latency

H - amplitude

M wave H / M ratio

H - Vibratory inhibition

H TA Conduction velocity

WAVE FORMS

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WAVE FORMS

NORMAL VALUES

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NORMAL VALUES

Latency 30.3 +/- 1.7

Amplitude 9.8 +/- 6.1

M wave 24.6 +/- 6.6

H/M ratio 0.4 +/- 0.2

H vib 42.9 +/- 18.2

H - TA 39.9 +/- 31.1

LATENCY

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LATENCY

Measured in ms

Soleus 35 ms, FCR 20 ms

Age, height, limb length Right to left asymmetry up to 1.5 ms

Latency in full term infant is 15.94 +/- 1.45

AMPLITUDE

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AMPLITUDE

Base to peak of the negative phase

Measured in mVAlpha motor neuron excitability

H / M RATIO

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H / M - RATIO

The ratio of peak to peak maximum H reflex

to maximum M amplitude

To estimate the motor neuron pool activation Less than 0.7

TONIC VIBIRATION REFLEX

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TONIC VIBIRATION REFLEX

VIBIRATORY INHIBITION

Achilles tendon is vibrated for 1 minute at 100

Hz

Normal amplitude decreases UMN lesion there is no decrease in

amplitude

Due to the vibratory inhibition is less than

normal

VIBRATORY INHIBITION

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VIBRATORY INHIBITION

RECIPROCAL INHIBITION

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RECIPROCAL INHIBITION

CONDUCTION VELOCITY

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CONDUCTION VELOCITY

The distance between knee and T11 by the

latency difference between H reflex and M

response


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PNS

To evaluate proximal sensory motor pathway

Helpful in plexopathies ,radiculopathies and

neuropathieslatency

S1 radiculopathy Absent

C5 - C6 radiculopathy Absent GBS - absent or delayed or dispersed

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CNS

Understanding the patho physiology

Excitability of alpha motor neuron

Amplitude, H/M ratio, H - vibratory inhibition,H - reciprocal inhibition

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DIFFERENCE

BETWEEN H REFLEX AND F WAVE

H reflex F wave

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H reflex F wave

Nature Monosynapticreflex

Not a reflex butdue to antidromic

activation of alpha

motor neuron

Best elicited in Soleus, FCR,VM Any distal muscle

Stimulus Sub maximal Supra maximal

Persistence Persistent Variable

Amplitude 50 100 % of M

wave

5 % M wave

Useful in Neuropathy,radicul

opathy,spaticity

Neuropathy,radicul

opathy

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BLINK REFLEX

BLINK REFLEX

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BLINK REFLEX

The electrical analog of corneal reflex

Kugelberg in 1952

To evaluate trigeminal and facial

Supra orbital nerve

Orbicularis oculi

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PHYSIOLOGY OF BLINK REFLEX

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PHYSIOLOGY OF BLINK REFLEX

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METHOD


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Recording :

Recording - bilaterally over orbicularis oculi

Reference - side of nasal bone

Ground - over chinStimulating :

Cathode - supra orbital notch over supra

orbital nerveAnode - directed somewhat laterally

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MACHINE SETTINGS

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MACHINE SETTINGS

Gain - 200 500 mV/division

Sweep speed - 10 ms /division

Stimulus rate - 1 in 3 seconds

Avoid prolonged studies - R2 Habituated

Aberrant innervation - lower facial muscles

RESPONSES

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RESPONSES

Ipsilateral side - R1 and R2

Contra lateral - R2

WAVE FORMS

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WAVE FORMS

PHYSIOLOGICAL MECHANISM

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PHYSIOLOGICAL MECHANISM

R 1 - Monosynaptic pathway R2 - Poly synaptic pathway

NORMAL VALUES

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NORMAL VALUES

Ipsilateral side R1 less than 13 ms

R2 -- less than 40 ms

Contra lateral side

R2 less than 41 ms


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Abnormal R1 and R2 on the paretic side with

normal contra lateral R2 - ipsi lateral facial

nerve lesion

Documents

3-4 Mpt 1st Year