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Dynamic Surface Electromyography (SEMG) Information Sheet
Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objective diagnostic tool that allows us to visualize and objectively quantify muscle spasm in the neck and back. With this technology the muscular component of a soft tissue injury can be documented thus enabling one to go beyond subjective patient and doctor reports. Similar to an electrocardiogram (ECG) which measures heart activity, dynamic SEMG measures paraspinal muscle activity (those on either side of the spine). Utilizing adhesive surface electrodes and by having the individual move through a range of motion, normal or abnormal muscle activity can be determined. Dynamic SEMG can determine the extent of muscle hypertonicity and dysfunction. This aids the practitioner in developing an accurate course of rehabilitation. There are many documented research papers substantiating the validity of the dynamic SEMG (available upon request); it has also been extremely successful in correlating with patient symptoms. I am a licensed chiropractor and have been the head clinician of Central Chiropractic Group since my graduation from the Canadian Memorial Chiropractic College (CMCC) in 1990. I am also founder and clinical director of the Welcome Back Spinal Care Center. I have taught undergraduate courses in orthopedics at the Canadian College of Naturopathic Medicine (CCNM), and applied physiological therapeutics at both CCNM and CMCC. I am a Fellow of the Academy of Traditional Acupuncture and was selected in 2006 to serve as a peer-assessor in x-ray evaluation for the College of Chiropractors of Ontario. I am certified in surface electromyography through the National College of Chiropractic in Chicago and have been providing independent surface electromyography assessments and interpretation for other doctors and rehabilitation clinics since 1993. I have written several articles on this diagnostic modality and have aided others in their research using dynamic SEMG as an outcome measure. Dynamic SEMG is an accepted diagnostic procedure that is billable within the scope of chiropractic. If you have any questions, please do not hesitate to contact me. Sincerely, Dr. Arnie Deltoff [email protected] (see next page for patient information)
Ranges of Motion Analyzed
Cervical Spine
Lumbar Spine
Flexion
Bending the head forward, relaxing and re-extending to the neutral position - utilizes both and
paraspinal muscles evenly.
left right
Lateral Flexion (Side Bending)
Bending the head to the utilizes the paraspinal and SCM (sternocleidomastoid) muscles.
Bending the head to the utilizes the paraspinal and SCM muscles.
left left left
right right right
Rotation
Turning the head to the utilizes the paraspinal and SCM
muscles.
Turning the head to the utilizes the paraspinal and SCM muscles.
left left
left
right
right right
Lateral Flexion (Side Bending)
Bending the torso to the utilizes the paraspinal muscles.
Bending the torso to the utilizes the paraspinal muscles.
left left
right right
Rotation
Turning the torso to the utilizes the paraspinal muscles.
Turning the torso to the utilizes the paraspinal muscles.
left left
right right
Flexion
Bending the torso forward, relaxing and re-extending to the neutral position - utilizes both and
paraspinal muscles evenly.
left right
© Dr. Arnie Deltoff, 2009
Patient Name: Date of Study:Accident Date: Claim #:Tests Performed: Cervical and Lumbar Flexion/Re-extension, Lateral Bending and Rotation
Cervical Spine Study (note: PS=paraspinal, SCM=sternocleidomastoid)
Criteria Patient Values Normal Values
Flexion-Relaxation Response Left - marked loss Present - full flexion value is equal or lowerRight - marked loss than value at rest
Re-extention Peak to Flexion Peak Ratio Left - 1.27 abnormal Normal > 3.2 Abnormal < 1.8Right - 1.20 abnormal
Full Flexion Value Left - 4.86 normal Normal < 10 uV Abnormal > 15 uVRight - 7.82 normal
Irritability Left - marked jitter Graph is smooth (no jitter)Right - marked jitter
Symmetry relative symmetry <20% difference between L & RConsistency Left - consistent trials Each repetition is similar in shape and
Right - consistent trials amplitude
Activation Patterns Lt. PS - relatively normal Rt. PS - abnormal Ipsilateral paraspinal andLt. SCMs - abnormal Rt. SCMs - abnormal sternocleidomastoid activity
Co-contraction Lt. PS - no co-contraction Rt. PS - co-contraction No antagonistic muscles contractionLt. SCMs - co-contraction Rt. SCMs - mild co-contraction
Test Subject January 6, 2010December 1, 2009 abc123
Flexion / Re-extension
Lateral Bending
Dynamic Surface Electromyography (sEMG)Summarized Results
Lt. SCMs co contraction Rt. SCMs mild co contractionIrritability Lt. PS - marked jitter Rt. PS - marked jitter Graph is smooth
Lt. SCMs - marked jitter Rt. SCMs - marked jitterSymmetry Paraspinal muscles - increased left activity Relatively equal values between
Sternocleidomastoids - increased right activity left and right activity
Activation Patterns Lt. PS - normal Rt. PS - relatively normal Ipsilateral paraspinal andLt. SCMs - normal Rt. SCMs - normal contralateral SCM activity
Co-contraction Lt. PS - mild co-contraction Rt. PS - co-contraction No antagonistic muscles contractionLt. SCMs - mild co-contraction Rt. SCMs - mild co-contraction
Irritability Lt. PS - marked jitter Rt. PS - marked jitter Graph is smoothLt. SCMs - marked jitter Rt. SCMs - marked jitter
Symmetry Paraspinal muscles - increased left activity Relatively equal values betweenSternocleidomastoids - relatively symmetrical left and right activity
Based on the criteria above, the cervical spine demonstrates the following levels of dysfunction / muscle guarding:
Flexion 61% rated as moderate to marked dysfunctionLateral Bending 73% rated as moderate to marked dysfunctionRotation 50% rated as moderate dysfunction
Overall 72% rated as moderate to marked dysfunction
Rotation
© Dr. Arnie Deltoff, 2009
Patient Name: Date of Study:
Lumbar Spine Study
Criteria Patient Values Normal Values
Flexion-Relaxation Response Left - marked loss Present - full flexion value is equal or lowerRight - complete loss than value at rest
Re-extention Peak to Flexion Peak Ratio Left - 1.04 abnormal Normal > 3.2 Abnormal < 1.8Right - 1.34 abnormal
Full Flexion Value Left - 51.63 abnormal Normal < 10 uV Abnormal > 15 uVRight - 54.05 abnormal
Irritability Left - jitter Graph is smoothRight - jitter
Symmetry relative symmetry <20% difference between L & RConsistency Left - consistent trials Each repetition is similar in shape and
Right - consistent trials amplitude
Activation Lt. PS - abnormal Rt. PS - relatively normal Ipsilateral paraspinal activityCo-contraction Lt. PS - co-contraction Rt. PS - mild co-contraction No antagonistic contractionIrritability Lt. PS - jitter Rt. PS - marked jitter Smooth graph
Flexion / Re-extension
Lateral Bending
Summarized Results - Page 2
Test Subject January 6, 2010
Irritability Lt. PS jitter Rt. PS marked jitter Smooth graphSymmetry Paraspinal muscles - increased right activity Relatively equal L/R activity
Activation Lt. PS - relatively normal Rt. PS - normal Ipsilateral paraspinal activityCo-contraction Lt. PS - co-contraction Rt. PS - co-contraction No antagonistic contractionIrritability Lt. PS - jitter Rt. PS - marked jitter Smooth graphSymmetry Paraspinal muscles - increased right activity Relatively equal L/R activity
Based on the criteria above, the lumbar spine demonstrates the following levels of dysfunction / muscle guarding:
Flexion 74% rated as moderate to marked dysfunctionLateral Bending 67% rated as moderate to marked dysfunctionRotation 60% rated as moderate to marked dysfunction
Overall 79% rated as marked dysfunction
Rotation
© Dr. Arnie Deltoff, 2009
Patient Name: Date of Study:Accident Date: Claim #:
The cervical spine demonstrates: moderate to marked dysfunction in forward flexionmoderate to marked dysfunction in lateral flexionmoderate dysfunction in rotation
Interpretation
Analysis
Test Subject
Dynamic Surface Electromyography (sEMG)
abc123January 6, 2010
December 1, 2009
Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objectivediagnostic tool that allows us to visualize and objectively quantify muscle spasm in the neck and back. With this technology themuscular component of a soft tissue injury can be documented thus enabling one to go beyond subjective patient and doctor reports.
Muscle dysfunction may manifest as hypertonicity (increased muscle tone), spasm (little difference between rest and activity), guarding (protective muscle contraction) or fasciculations (twitches) for example. These can all be measured electrically. There is direct correlation to general pain and joint dysfunction. Muscle dysfunction may be caused by multiple factors. It isimportant to note that the absence of muscle dysfunction may not mean the absence of pain.
The information provided here will help guide the practitioner in the patient's rehabilitation by directing them to the muscles and ranges of motion that demonstrate dysfunctional patterns. As well, in the case of positive examination findings, future testing will allow the practitioner to gauge the efficacy of their treatment.
Research has indicated that the flexion test is of utmost importance and, therefore, the result of this part of the examination has slightly more 'weighting' in the overall dysfunction score. All results rated as moderate* dysfunction or above are deemed
moderate dysfunction in rotationOverall the cervical spine demonstrates a 72% dysfunction which relates to moderate to marked dysfunction
There is also indication of the following: hypertonicity spasm guarding fasciculations
With this degree of dysfuction: A combination of passive therapy and muscle strengthening is recommended.The patient may benefit from further assessment (eg. neurological, MRI, CT, US) of the cervical spine as signs and symptoms dictate
The lumbar spine demonstrates: moderate to marked dysfunction in forward flexionmoderate to marked dysfunction in lateral flexionmoderate to marked dysfunction in rotation
Overall the lumbar spine demonstrates a 79% dysfunction which relates to marked dysfunction
There is also indication of the following: hypertonicity spasm guarding fasciculations
With this degree of dysfuction: More passive therapy may be beneficial.The patient may benefit from further assessment (eg. neurological, MRI, CT, US) of the lumbar spine as signs and symptoms dictate
Dr. Arnie Deltoff, DC, FATAMyodynamics Inc.230-4915 Bathurst StreetToronto, ON M2R 1X9Phone: 416-512-2225 Fax: 416-512-2226
Note: Dysfunction levels are to be used for comparative purposes and to guide the practitioner in the rehabilitative process. All information must be correlated with clinical observations. Testing was performed according to established protocols using the Myovision dynamic multi-channel sEMG.
* ie. moderate, moderate to marked, marked and severe
Normal Studies for Comparison
Flexion / re-extension (any region) 1 2 3 4 5 6 Peak to peak ratio – the peak value of
re-extension is greater than 3.2 times the peak value of flexion
peak Full flexion value (marks 1,3,5) – is below 10
microvolts peak ratio Flexion-relaxation response – presence of this phenomenon is indicated when the full flexion value is even with or below resting value
Cervical Lateral Flexion Cervical Rotation left right left right left right left right paraspinal paraspinal muscles muscles Sternocleido- Sternocleido- mastoid mastoid muscles muscles left right left right right left right left Lumbar Lateral Flexion or Rotation Activity Pattern – in the neck, lateral bending involves left right left right activation of the same-sided paraspinals and SCM
muscles; rotation involves the activation of the same-sided paraspinals and opposite-sided SCM muscles. In the low back, however, both lateral bending and rotation involves the activation of same-sided paraspinal muscles. Co-contraction – there should be little to no activity of the opposite-sided muscles during lateral bending or rotation
General Considerations Symmetry – the right and left should be equally active for their respective motions Irritability – all graphs should be smooth; “spiky” movement indicates muscle fasciculations Consistency – all trials should be relatively equal in shape and amplitude
MyoVision Dynamic Report
Patient: Exam Date: Jan 06, 2010 02:30:15 PM
MyoVision Dynamic sEMG Flexion Study Background and Explanation
A dynamic EMG flexion study was performed utilizing the sEMG system with electrodes attached to the skin. The system utilizes 25-500 Hz filtering system which allows measurement of the muscle fibers utilized in maintaining posture.
The basic principle of the dynamic flexion study is simple. When in full flexion of the cervical or lumbar spine, normal individuals display sEMG values (in microvolts) which drop to very low levels as ligaments instead of muscles are used to maintain the full flexed position. This is known as the flexion relaxation phenomenon. In patients with low back pain, sEMG values maintain high levels in full flexion and do not relax as with normals. This is known as an absence of flexion relaxation.
A landmark study titled "Electric Behavior of Low Back Muscles During Lumbar Pelvic Rhythm in Low Back Patients and Healthy Controls" (Sihoven, Partanen, Hanninen Soimakallio; The Archives of Physical Medicine and Rehabilitation vol 72, Dec 1991) was published on the flexion relaxation phenomenon.
The following results were reported:
1. Surface EMG pattern yielded more information than needle EMG.2. There was a clearly noticeable increase in sEMG activity in LBP patients.3. There was only a partial decrease in sEMG readings in LBP patients while in full flexion, in contrast with normals which demonstrated marked decreases in sEMG activity.4. The ratio of the mean maximum sEMG level reached in flexion to the mean maximum sEMG level in re-extension was lower in LBP patients than in normal controls. The ratios were 3.2 in normals, and 1.8 in LBP patients.5. Test-retest reliability was very high (0.92 flexion, 0.97 extension)
It is important to note that the results of this test should be correlated with other exams, and should not beused on its own to determine disability.
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2
MyoVision Dynamic Report
Patient: Exam Date: Jan 06, 2010 02:30:15 PM
A dynamic sEMG flexion study was performed on ******************* on Jan 06, 2010. The graph is labeled Dynamic Cervical Flexion.
PERCENT DIFFERENCE TESTsEMG activity in the Left Cervical was 2% LESS than the Right Cervical.
FLEXION/RE-EXTENSION RATIO TEST (Table 1)This test quantifies the ratio of the peak in flexion (FLEX PEAK)to the peak in re-extension (REEX PEAK).Research has found that in general, normals produce ratios greater than 3.2, with symptomatic patients less than 1.8. The results of this test should be examined in combination with the FLEXION TEST (Table 2).
The patient produced a(n) UNEXPECTED ratio of 1.27 in the Left Cervical and a(n) UNEXPECTED ratio of 1.20 in the Right Cervical.
Table 1: Peak Analysis Data (Average of three (3) trials)
SITE FLEX PEAK REEX PEAK RP/FP RATIO STD DEV RESULTS
Left Cervical 6.88 8.72 1.27 0.09 UNEXPECTEDRight Cervical 8.49 10.16 1.20 0.12 UNEXPECTED
FLEXION TEST (Table 2)
sEMG values in full flexion should be very low. The flexion test measures the averaged sEMG value of three trials of flexion. Normal readings are below 10uV, BORDERLINE between 10 and 15uV, and ABNORMAL above 15 microvolts. Normal sEMG readings in standing neutral (NEUTRAL MIN) should be below approximately 9 uV. Higher readings correlate with disorders of the spine.
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 3
MyoVision Dynamic Report
Patient: Exam Date: Jan 06, 2010 02:30:15 PM
The patient demonstrated averaged readings in the Left Cervical of 4.86 indicating a(n) NORMAL readingin flexion.The patient demonstrated averaged readings in the Right Cervical of 7.82 indicating a(n) NORMAL reading in flexion.
Table 2: Flexion TestSite FLEX MIN STD DEV CONDITION NEUTRAL MIN
Left Cervical 4.86 0.95 NORMAL 3.70Right Cervical 7.82 0.66 NORMAL 3.00
Results of the study should be correlated with other exams and should not be used alone to determine disability or treatment protocol
I have examined the data and the analysis performed, and agree with the reported findings.
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 4
MyoVision Dynamic ReportOffice Information: Patient Information:
Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:30:15 PMProtocol Name: Dynamic Cervical Flexion
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
14.7
0.0
11.8
4.9
8.8
9.8
5.9
14.6
2.9
19.50.0
24.4
1 2 3 4 5 6
Markers 1, 3, 5 -> Flexion Markers 2, 4, 6 -> NeutralProtocol Name: Dynamic Cervical Flexion Page Name: Left-Right C2 T1 Sites
Left Cervical Right Cervical
MyoVision Dynamic ReportOffice Information: Patient Information:
Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:33:07 PMProtocol Name: Dynamic 4 Ch Cerv Lat Flex & Rotation
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
18.5
0.0
14.8
6.0
11.1
11.9
7.4
17.9
3.7
23.80.0
29.8
1 2 3 4 5 6 7 8
Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Lateral Flexion
Left Cervical Right Cervical
18.4
0.0
14.7
6.0
11.0
11.9
7.3
17.9
3.7
23.80.0
29.8
1 2 3 4 5 6 7 8
Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Lateral Flexion
Left SCM Right SCM
MyoVision Dynamic ReportOffice Information: Patient Information:
Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:33:07 PMProtocol Name: Dynamic 4 Ch Cerv Lat Flex & Rotation
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2
16.1
0.0
12.9
5.6
9.7
11.2
6.5
16.9
3.2
22.50.0
28.1
1 2 3 4 5 6 7 8
Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Rotation
Left Cervical Right Cervical
10.6
0.0
8.5
5.6
6.4
11.2
4.2
16.9
2.1
22.50.0
28.1
1 2 3 4 5 6 7 8
Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Rotation
Left SCM Right SCM
MyoVision Dynamic Report
Patient: Exam Date: Jan 06, 2010 02:20:38 PM
A dynamic sEMG flexion study was performed on ******************* on Jan 06, 2010. The graph is labeled Dynamic Lumbar Flexion.
PERCENT DIFFERENCE TESTsEMG activity in the Left Lumbar was 7% LESS than the Right Lumbar.
FLEXION/RE-EXTENSION RATIO TEST (Table 1)This test quantifies the ratio of the peak in flexion (FLEX PEAK)to the peak in re-extension (REEX PEAK).Research has found that in general, normals produce ratios greater than 3.2, with symptomatic patients less than 1.8. The results of this test should be examined in combination with the FLEXION TEST (Table 2).
The patient produced a(n) UNEXPECTED ratio of 1.04 in the Left Lumbar and a(n) UNEXPECTED ratio of 1.34 in the Right Lumbar.
Table 1: Peak Analysis Data (Average of three (3) trials)
SITE FLEX PEAK REEX PEAK RP/FP RATIO STD DEV RESULTS
Left Lumbar 71.33 74.46 1.04 0.05 UNEXPECTEDRight Lumbar 62.49 83.56 1.34 0.13 UNEXPECTED
FLEXION TEST (Table 2)
sEMG values in full flexion should be very low. The flexion test measures the averaged sEMG value of three trials of flexion. Normal readings are below 10uV, BORDERLINE between 10 and 15uV, and ABNORMAL above 15 microvolts. Normal sEMG readings in standing neutral (NEUTRAL MIN) should be below approximately 9 uV. Higher readings correlate with disorders of the spine.
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 3
MyoVision Dynamic Report
Patient: Exam Date: Jan 06, 2010 02:20:38 PM
The patient demonstrated averaged readings in the Left Lumbar of 51.63 indicating a(n) ABNORMAL reading in flexion.The patient demonstrated averaged readings in the Right Lumbar of 54.05 indicating a(n) ABNORMAL reading in flexion.
Table 2: Flexion TestSite FLEX MIN STD DEV CONDITION NEUTRAL MIN
Left Lumbar 51.63 10.87 ABNORMAL 17.00Right Lumbar 54.05 0.91 ABNORMAL 19.17
Results of the study should be correlated with other exams and should not be used alone to determine disability or treatment protocol
I have examined the data and the analysis performed, and agree with the reported findings.
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 4
MyoVision Dynamic ReportOffice Information: Patient Information:
Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:20:38 PMProtocol Name: Dynamic Lumbar Flexion
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
88.0
0.0
70.4
4.9
52.8
9.8
35.2
14.7
17.6
19.60.0
24.5
1 2 3 4 5 6
Markers 1, 3, 5 -> Flexion Markers 2, 4, 6 -> NeutralProtocol Name: Dynamic Lumbar Flexion Page Name: Left - Right L1 L5 Sites
Left Lumbar Right Lumbar
MyoVision Dynamic ReportOffice Information: Patient Information:
Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:23:04 PMProtocol Name: Dynamic Lumbar Lat Flex & Rotation
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 1
31.5
0.0
25.2
5.6
18.9
11.2
12.6
16.8
6.3
22.40.0
28.0
1 2 3 4 5 6 7 8
Protocol Name: Dynamic Lumbar Lat Flex Rotation Page Name: L/R Lateral Flexion
Left Lumbar Right Lumbar
MyoVision Dynamic ReportOffice Information: Patient Information:
Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:23:04 PMProtocol Name: Dynamic Lumbar Lat Flex & Rotation
Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2
32.4
0.0
25.9
5.4
19.5
10.7
13.0
16.1
6.5
21.40.0
26.8
1 2 3 4 5 6 7 8
Protocol Name: Dynamic Lumbar Lat Flex Rotation Page Name: L/R Rotation
Left Lumbar Right Lumbar