Basic Ep Emg Sec1 - Curnt

EP/EMG-Basics
NOV 2004
Nihon Kohden Corporation
Prepared by Kyuzo Iwai
Sampath Kumar 2nd edition
Steven Lee 3rd edition
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Nihon Kohden Corporation, 2000
Basics of EP, EMG and NCS
Nervous System
 Our nervous system is composed
of the central nervous system,
the cranial nerves, and the
peripheral nervous System.
 The network of nerves that
connect at different levels of the
spinal cord control both
conscious and unconscious
activities.
 It is through the spinal cord that
information flows from these
nerves to the brain and back
again.
Central Nervous System and

Peripheral Nerves
 The brain and spinal cord
comprise the central
nervous system.
 The cranial nerves connect
the brain to the head.
 The four groups of nerves
that branch from the
cervical, thoracic, lumbar,
and sacral regions of the
spinal cord are called the
peripheral nerves.
Brain
corpus callosum cerebrummid brain brain stem
hypothalamus thalamus pontes
medulla oblongata
skull
cerebellum
spinal cord
Spinal Cord Cross Section

Sensory System Skin Sensors
Many types of sensors receive information and

send it to the brain through the nerves
Motor System
Movement commands are generated by the brain and
transmitted to muscles through the spinal cord and nerves.
Basics of EP, EMG and NCS: Basic Nerve Elements
Basic Nerve Elements
 Cell and Action Potential

 Neuron
 Synapse
 Motor Unit
 Endplate (Neuromuscular Junction)
 Motor and Sensory Nerves
Basics of EP, EMG and NCS: Membrane & Action Potential
Cell Membrane Potential

 Electrical Potential
Existing between the
cell membrane
 Cells such as nerve
cells are excitable
 Transmits
Electrochemical
impulses along the
membrane
Basics of EP, EMG and NCS: Membrane & Action Potential
Action Potential
 Membrane Potential
remains at -70 mV
(Resting Potential)
 Any factor increases
Na permeability
cause sequence of
changes in MP
 This sequence of
changes is called AP
Basics of EP, EMG and NCS: Action Potential Conduction
AP Conduction
 AP excites
adjacent part of
membrane
 Propagation of AP
on membrane is
called conduction
Basics of EP, EMG and NCS:Conduction in VC
Conduction in Volume conductor

 Nerves in body
function as a Volume
Conductor
 There are positive
deflections before &
after negative Spike
Basics of EP, EMG and NCS: Nerve Types
Nerve Types
 Unmyelinated
Nerve
 Myelinated Nerve
Basics of EP, EMG and NCS: Myelinated Nerve conduction
Nerve Types
 Myelin sheath is an insulator
 Nodes of Ranvier is 500 times permeable to ions
 Impulses jumps- node to node (“Saltatory
Conduction” Saltare - Jumps)
Basics of EP, EMG and NCS: CV Vs Nerve Size & Temperature
Effect of CV with Temp

 Faster in Myelinated Nerve
 Increases with Nerve Diameter
 Increases with Nerve temperature (Body)
 CV must be compared at same Temp.
Basics of EP, EMG and NCS: Nerve Excitation
Stimulation and polarity

 Potential at outside of membrane is Negative
 Current at cathode is Cathode current.
 Cathode current excites the fiber
 Anode current makes the fiber more resistant
Stimulus Intensity, SupraMaximal

Stimulus
 Stimulus Graded as Sub Threshold,
Threshold, Maximal or Supramaximal
Threshold.
 Sub Threshold level
 Supramaximal Threshold
Threshold
 Weak Cathode potential cannot excite

 Level at which excitation is Threshold level
 During Supramaximal stimulation, intensity is increased 20% after
amplitude peak is reached
 This varies fiber to fiber
Refractory Period
 Re-excitation on the
same point do not
occur immediately
until the charges in
membrane build up
again
 The interval of in
excitability is called
refractory period.
Compound Action potential

 Multi peaked action potential is called
compound action potential
 Is the property of mixed nerves stimulated
 Activity is fast conducting fibers, arrives at
the recording electrodes sooner than the
activity in slower fibers
Neuron
 The neuron (nerve cell) is the basic unit of the nervous system.
A neuron consists of a cell body, axon (nerve fiber), etc.
 Electric impulses are generated by the neuron and travel on the
axon. The impulse travels faster where the axon is covered by
myelin.
Synapse
The synapse is the
neuron to neuron
junction. Signal
processing is done at the
synapse. Synapse
Motor Unit
The motor unit consists of an anterior horn cell, its axon, and
all the muscle fibers innervated by that axon and its branches.
Nucleus Soma Endplate
Muscle
fiber
Axon Muscle fiber

Dendrites Myelin
Endplate (Neuromuscular
Junction)
When impulses reach the
endplate, the muscle
fibers contract.
Motor and Sensory Nerves

A motor neuron connects to muscle fibers (other cells).
A sensory neuron has a sensor, but it is part of the same
cell.
Basics of EP, EMG and NCS: Conduction and Transmission
Conduction and Transmission
 Basics
 Transmission
 Conduction Velocity
 Nerve Types, Diameter and Conduction Velocity
 Comparison of Conduction Velocities
Basics
 In neural networks, information is expressed by

electric impulses.
 Impulses travel on the nerve and are relayed at
nerve to nerve junction points (synapses) or at the
endplates of nerve-muscle connection points.
 "Conduction" is impulses traveling on one nerve.
 "Transmission" is impulses traveling across a
junction.
Transmission
 At the junction point, it takes time for signal

transmission. This must be clearly
distinguished from conduction time.
Conduction Velocity
 There are several types of nerves.
 A nerve consists of many fibers (axons).
 The velocity of myelinated (covered with myelin) n
erve fiber is higher than non-myelinated fiber.
 Conduction velocity is higher in thicker nerve fiber
than thinner nerve fiber.
 Each fiber has its own velocity, different than other
fibers.
 The higher the temperature, the higher the velocity.
Nerve Types, Diameter and

Conduction Velocity
The thicker the nerve, the higher the conduction velocity.
Comparison of Conduction
Velocities
Neural Pathways
Receptors, nerve, brain and
effectors circuit
Sound
Brain
Muscle
Vision
Heart
Touch
Heat
Pressure
Neural pathways Muscle
Sensations have their
own pathways.
Taste Smell
Clinical Test Menus
 What (physiology, anatomy, outline of test)

 Why (purpose, pathology)
 How (method)
Routine Tests
 EMG  SEP (somatosensory
(electromyography) evoked potential)
 MCS (motor nerve  Blink reflex
conduction studies)  BAEP (brain stem
 SCS (sensory nerve auditory evoked
conduction studies) potential) (ABR)
 F-wave, H-reflex  VEP (visual evoked
 Nerve repetitive potential)
stimulation (NRS)
EP
Equipment Basics
EP
The acquired signal is amplified in the electrode junction box and digitized. The
digitized signal is filtered by the DSP (digital signal processor) and averaged in the
computer in the system. The computer displays the signal on the screen, records it on
the printer and saves it in memory. The analog circuit is only used for the differential
amplifier in the first circuit and signal amplifier in the second circuit. After this,
signal processing is performed by the computer (software processing). As the
performance of the system is determined by the differential amplifier in the first
circuit, a low noise and high performance differential amplifier is required. In the
digital signal processing circuit, the accuracy of the A/D converter, filter
characteristics, and setting of the number of the averaging times are the important
items.
EP
EP System Block Diagram
Stimulators
Amp
Averager
A/D Converter
EP
Conditions to set during acquisition

• Sensitivity – Sets the sensitivity of the acquired wave.
Voltage/division
• Filter – Sets the bandwidth, and also AC filter for acquisition
• Analysis Time – Sets the period of acquisition
• Trigger – Sets the type of trigger (Recurrent, random, signal, foot

switch, external)
• Delay time – Sets the delay time before acquiring response wave
• Reject level – Sets the reject level for averaging
EP (Evoked Potential)
EP
Why Is the EP Test Done?

 To find abnormal parts in the neural
pathway
Pathway
EP
What Is EP?
 Stimulation (evoked) causes an electric potential change in the
nervous system, etc. This is called evoked potential. Evoked
Potential
Visual
stimulation
EP
Characteristics of EP Signals (1)

 Evoked potential is electrical activity of the nervous
system, brain, nerve, muscle, etc. that is induced
(evoked) by specific stimulation.
 Amplitude of EP signals picked up from head, deep
nerve is very small compared to EEG (1 v, cf. EEG
100 v) and difficult, impossible to see on EEG.
 EP always appears at the same time after stimulation
(latency) and its signal polarity is always the same.
On the other hand, EEG appears at random and its
polarity randomly changes.
EP
Characteristics of EP Signals (2)

EP signals exist in EEG, but they are very small.
Evoked
Potential
EEG
Visual
stimulation
EP
How the EP Test Is Done

Stimulate, amplify signal, average, display
Sound EP system
Ear
Response
Eye
Pattern Stimulator
Amplifier
Averager
Electric stimulation
EP
Averaging (1)
Analog to Digital
Visual Response
stimulation Conversion Memory
1st Average: Response (1+2)

Repeat
nth Average: Response (1+2+…(n+1))
EP
Averaging (2)
EEG (Random)
1st Signal
2nd Sig
Memory
Add 1st and 2nd

Random signals cancel each other!!
After addition 1st Average
3rd Sig
1st Avg. + 3rd Sig 2nd Average
3 Average
rd
Repeat
100th Average
VEP
EMG and NCS (Nerve
Conduction Studies)
EMG/NCS
What Is EMG and Nerve

Conduction Study? (1)
 Electrodiagnosis is the study of nerve functi
on and integrity.
 EMG/NCS is a useful diagnostic tool which
assesses the integrity of the peripheral nerv
ous system.
 Most commonly, the EMG/NCS is perform
ed to evaluate peripheral nerve lesions such
as peripheral neuropathies, myopathies.
EMG/NCS
What Is EMG and Nerve

Conduction Study? (2)
 In addition to identifying peripheral nerve i
njuries, EMG/NCS is also helpful to differe
ntiate between acute or chronic/ongoing ner
ve lesion.
 Furthermore, active reinervation or denervat
ion can be identified as well as the extent, th
e location, the age, and the prognosis for rec
overy.
EMG/NCS
Application of EMG and NCS

Sensory nerve
EMG and NCS

can examine the
peripheral
nervous system
including
muscles, nerves,
endplates, and
Motor nerve
Endplate spinal cord.
Electric Stimulation
Key Points
 For NCS, electric stimulation is used.

 Stimulation technique is very important for
effective examination.
Stimulation Intensity and

Responses Muscle fibers A nerve consists of
Motor units many fibers. There are
fast and slow fibers.
Slow fiber Also, different fibers
have different
Nerve excitabilities.
The response that
Fast fiber
appears at the electrode
is the summation of the
electric potentials of
Electrode area several fibers.
Summation
Response amplitude
Time
Nerve Anatomy
Electric Stimulation and Response

Response amplitude Maximal Supramaximal
mV Stimulation stimulation
mA
0 100% 120%
Stimulation intensity
Supramaximal Stimulation
 A nerve consists of many nerve fibers which have
different velocities and excitabilities.
 For exact latency measurement, all fibers must be
excited.
 The MCS signal is the summation of the action
potentials of all the muscle fibers.
 To confirm that all nerve fibers are excited, the
nerve is stimulated at 120% intensity of maximal
stimulation level.
 Maximal stimulation level is maximal amplitude
level of response.
Median Nerve Stimulation and

Electrode Setup for MCS
Ground electrode
Reference recording must be placed
electrode on the same side
Active recording as stimulation to
electrode
avoid possibility
Cathode Ground
of leakage current
Anode - through the heart
+ electrode
and induce micro
shock in case of
Stimulator product failure.
Median Nerve
How To Find the Best Electrode

2. Fix the anode (+) electrode
Position at one position and rotate
the cathode (-) across the
nerve to find the maximum
1. Put paste on response.
the electrode 3. Slightly slide the electrodes along
tips. Don't the nerve to find the maximal point.
short the 4. To avoid uncomfortable high
electrodes voltage electric shock, keep the
with too electrodes touching the skin when
moving them.
much paste.
-
Stimulator
+
Nerve is excited by
negative polarity
(cathode). Median nerve
Stimulation Practice
 Stimulate yourself and find your median nerve pos

ition.
 At what intensity level does your thumb start twitc
hing?
 What is the maximal and supramaximal intensity?
 How is the feeling?
 What is the speaker sound difference before and af
ter your thumb starts twitching?
Break
MCS (Motor Nerve Conduction
Study)
MCS
What Is MCS?
• MCS measures motor nerve conduction (not

transmission) velocity (MCV).
• Motor nerves originate at the spinal cord
and end at an endplate.
MCS
Motor Nerve
Muscle control signal
Muscle
fibers Spinal
cord
Motor nerve Anterior Horn Cell

MCS
MCS Procedure
 Electrically stimulate two points at supramaxim
al intensity.
 Measure latency at the two points.
 Measure the distance between the two (cathode)
stimulation points.
 Calculate the interval time between the two late
ncies.
 Calculate the velocity from the time interval and
distance.
MCS
Stimulation at Two Points -

Responses and Normal Values
MCS
MCS Waveform
Stimulus
artifact Peak to peak
amplitude
Stimulation at
Wrist
Latency
Stimulation at
Elbow
MCS
Why Must Two Points Be

Stimulated for MCS?
 The signal recorded in MCS is from a muscle, not
from a motor nerve.
 Latency includes conduction time of the motor
nerve (what we want to measure) from stimulation
point to endplate and transmission time (delay
time) at endplate.
 Stimulation at different points, and calculation,
lets us eliminate transmission time.
MCS
Motor Nerve Conduction Velocity

Latency includes conduction time and delay time at endplate.
Latency 1 (L1) = C1 + D
Conduction time 1 (C1)

Stimulation Endplate
S1 Motor Nerve Delay time at
S2 endplate (D)
Distance D
Latency 2 (L2) = C2 + D
Conduction time 2 (C2)
Conduction time between S1 and S2 =

C1 - C2 = L1 - L2
Conduction Velocity = D/(L1-L2) m/sec

MCS
Conduction Velocity Calculation

Conduction velocity (m/s) =
Latency S2 (ms)
Distance/(Latency S1 – Latency S2)
Latency S1 (ms)
S2
S1
Distance
(mm)
MCS
Terminal Latency
 For the examination of nerves on the palm,

the stimulation point and pickup electrode
distance is short and it is impossible to
stimulate at two points. In such case,
terminal latency is used instead of
conduction velocity.
 Normal terminal latency is less than 5 ms.
MCS
Carpal Tunnel Syndrome

The carpal tunnel is the area under a
ligament (a tough, elastic band of tissue
that connects bones and organs in place)
in front of the wrist. The median nerve,
which passes through the carpal
tunnel, supplies the thumb side of the
hand. Repetitive movements of the hand
and wrist can cause inflammation of
structures (such as tendons and their
coverings) that surround the median
nerve. The inflammation may compress
this nerve, producing numbness, tingling,
and pain in the first 3 fingers and the
thumb side of the hand--a condition
known as carpal tunnel syndrome.
F Wave
F Wave
What Is F Wave?
Impulses travel in both directions on a nerve. Impulses
reaching the cell body in the spinal cord excite the cell body.
The excited cell makes impulses that return on the same
nerve to the connected muscle. This signal is the F wave.
Stimulato
r
M
F
F Wave
Why Is F Wave Test Done?

 F waves can provide information about not only
distal motor nerve, but also proximal motor nerve
and the anterior horn cells in the spinal cord.
F Wave
F Wave Test Setup
 Same electrode position as MCS, but cathod

e stimulation electrode must be proximal.
 Stimulation level must be supramaximal int
ensity.
F Wave
F Wave Example
M wave (5 mV/Div) F wave (0.5 mV/Div)
F waves randomly
appear after M
(muscle) waves at
different points and
in different shapes.
Amplifier
sensitivity must be
high to observe F
wave because
amplitude is small.
F Wave
Characteristics of F Waves
 Appear at higher level stimulation.

 Small amplitude.
 Unstable in latency, appearance and shape.
 Affected by higher level control (voluntary
tension of muscle).
F Wave Different sensitivity
F Wave Screen settings to see both M and
F waves
M-wave F-wave
10 mV/Div 0.2 mV/Div
F Wave
F Wave Conduction Velocity and

Ratio
F: shortest latency
of F wave
M: M wave latency
D: distance
between
stimulation site
and spinal cord
1: anterior horn cell
reflex (1 ms)
H Reflex
H Reflex
What Is H Reflex? (1)
Stim
.
H reflex
H Reflex
What Is H Reflex? (2)

 The H reflex has proved to be a particularly valuable experi
mental tool for evaluating spinal cord circuitry in a non-inv
asive manner. It is really just a controlled version of the cla
ssic "tendon tap" reflex test performed during a routine me
dical examination.
 In that test, a trained medical doctor is able to roughly judg
e the response of muscle stretch receptors, nerve conductio
n, spinal neuron activity and muscle contractions.
 H reflex is useful in the diagnosis of S1 and C7 root lesions
as well as the study of proximal nerve segments in either pe
ripheral or proximal neuropathies.
 H reflex is visible in tibial nerves of adults. For child, it is p
resent in several nerves
H Reflex
H reflex
H Low
Reflex
Wave-
form
Stimulus level
High
M wave
H Reflex
Stimulus Intensity Vs. H Reflex

and M Wave Amplitude
Amplitude
M wave
H reflex
Stimulus intensity
Firstly H reflex
Repetitive Stimulation
What Is Repetitive Stimulation?

 Repetitive stimulation (also called NRS, jolly test,
etc.) Is a method to diagnose myasthenia gravis.
 Usually 5-10 impulses (pulse train) at 3 Hz
repetition rate are given to the nerve and EMG
signals are recorded.
 The amplitude and area of each EMG waveform
are compared to the first waveform.
Myasthenia Gravis (1)
 To maintain muscle tension, motor neurons

continuously send impulses to end plates
and muscle fibers to maintain contraction.
 Myasthenia gravis is a disease caused by
problems with the endplates. Patients
cannot maintain muscle contraction even
for a short period.
Myasthenia Gravis (2)

Repetitive Stimulation Procedure

 Same electrode position as MCS.
 Stimulation level is supramaximal intensity.
 Before measurement, find the best stimulati
on point and hold it.
 Pause for several seconds after the trial stim
ulation to let muscles recover from fatigue.
 After pause, give pulse train and record.
Repetitive Stimulation Responses
Normal case: there is no amplitude decrement.

SCS (Sensory Nerve Conduction
Study)
SCS
What is SCS?
 SCS measures conduction velocity of sensory

nerves.
SCS
Orthodromic (Dromic) and

Antidromic Method (1)
 The orthodromic method stimulates at the distal point
of a nerve and picks up the response at the proximal
point. Impulses travel in the same direction as
spontaneous impulses.
 On the other hand, the antidromic method stimulates
at the proximal point and picks up at the distal point.
 The antidromic method is easier than the dromic
method.
SCS
Orthodromic (Dromic) and

Antidromic Method (2)
Orthodromic Recording
sensory electrode
Stimulus
Recording
electrode
Antidromic
sensory
Stimulus
SCS
Characteristics of SCS Signals

 The signal is from stimulated nerve fibers. Its
latency does not include transmission time so
conduction velocity can be directly calculated with
latency and distance.
 Amplitude is small compared to MCS (MCS is
from muscles), so electrode impedance must be
low and you must be careful of artifacts.
 Averaging may be required, depending on the case.
SCS
SCS Test Setup (Dromic and

Median)
SCS
SCS Method
 To reduce impedance, clean skin where electro
des are attached.
 Gradually increase stimulation level and find th
e best position. Measure latency (L) at suprama
ximal intensity.
 Measure distance (D) between cathode electrod
e and active pickup electrode
 Calculate conduction velocity CV = D/L m/sec.
SCS
SCS Waveform Peak

latency
Stimulus
artifact Peak-to-peak
amplitude
Onset
latency
SCS
SCS Screen
SCS
Inching
 One SCS method is to stimulate at every one
inch (or 1 cm) along the nerve and compare
responses. If a lesion exists, latency and/or
amplitude may change at this point.
1 inch (or 1 cm) -
+
Stimulator
SCS
Nerve Diseases
There are two type of peripheral nerve diseases:
(A) segmental demyelination
(B) axonal degeneration
Conduction velocity, signal amplitude and waveform
change appears depends on these diseases.
Axon
Normal Demyelination: Axonal degeneration:

Myelin
Random loss and Axon is dying.
attenuation of myelin
internodes.
SCS
NCS and Peripheral Neuropathy

MCV SCV
Normal
Demyelination
Prolonged latency, duration, and low
amplitude
Axonal degeneration
Low amplitude, but no delay of latency
Blink Reflex
Blink Reflex
What is Blink Reflex?
 Examination of polysynaptic reflex

consisting of two components: afferent of
the trigeminal sensory branches and efferent
of facial nerve motor fibers.
Blink Reflex
Trigeminal nerve (afferent) Facial nerve (efferent)
Trigeminal nerve is internally

connected to facial nerve in brain stem.
Blink Reflex
Blink Reflex Setup

Blink Reflex
Normal Blink Reflex Waveforms
R1 appears only on stimulated side, but R2 appears on both

sides because trigeminal V and facial nerves VII are
internally connected in the brain stem.
Blink Reflex
Blink Reflex Waveforms

Stimulations are done
at least 5 times for each
side to ensure
repeatability in the
response waves.
Between each
stimulation, allow
more than 2 seconds of
rest to prevent
habituation of patient
Auditory EP (AEP)
AEP Measurement
 Usually from 3 sites in the auditory pathway
 the cochlea
 the brainstem
 the cortex
 AEP tests are classified according to their

latencies from the onset of stimulation
 Early response (0-10ms, ABR and Ecoch tests)
 Middle response (10-50ms, MLR test)
 Late response (50-500ms, SVR test)

Auditory Pathway
Auditory Brainstem EP (ABR)
ABR
What Is ABR
 It is performed to help diagnose hearing los

s, acoustic neuroma, dizziness and demyelin
eating diseases, such as multiple sclerosis a
nd other nervous-system abnormalities.
 Evokes response from the brainstem
ABR
Auditory Pathway
Auditory signals
generated in an ear travel
to the same (ipsilateral)
and opposite
(contralateral) sides in the
brainstem to the cortex.
When signals pass
through this circuit, an
electric potential is
generated at several
points. This recording is
BAEP.
ABR
BAEP Signal and Its Origins
The BAEP waveform

has several peaks, named
I to VII. The origin of
each peak has been
studied and used for
diagnosis of the auditory
pathway. The important
peaks are I, III, V
ABR
BAEP Setup
ABR
Auditory Stimulation
For examination of hearing over a wide frequency range, tone
burst stimulation must be used. The frequency component of
a single click is too narrow (4-6 kHz).
Click and tone burst
Condensation, rarefaction, and alternate
Masking
When one ear is stimulated, white noise is applied to the
non-stimulated ear to mask leakage sound.
ABR
Characteristics of BAEP Signal
 Signal amplitude is very low.

 The lower the stimulation intensity, the
lower the amplitude and the longer the
latency.
 Latency and amplitude are not affected by
consciousness and ordinary anesthesia.
ABR
How To Attach Electrodes

 Clean skin with alcohol soaked cotton.
 Mastoid is recommended for A1, A2
electrode positions: easy to scrub; electrodes
are covered by earlobes and not easily
detached when headphone is applied.
 Put some paste on skin and rub with finger.
 Put paste on electrodes. Attach to skin so
paste on electrode aligns with paste on skin.
 Make impedance less than 5 K.
ABR
BAEP Method
 Ask patient to adjust headphone fitting by
him/herself.
 Explain how test will be done and let patient
listen to sound to reduce anxiety.
 Make patient relaxed.
 Start averaging several seconds after
stimulation start.
 Start at high level stimulation and lower it.
ABR
BAEP Peaks Latency Normal

Values
Middle Latency Response (MLR)
MLR
What is MLR?
 The MLR is used to provide information

about low frequency hearing and auditory
perceptual dysfunction in central nervous
system disorders.
 The response is generated between the
brainstem and cortex.
MLR
Auditory Pathway
 When an auditory stimulatio
n (click) is presented to an ea
r, an auditory response wavef
orm with a latency of 10 to 5
0 msec after stimulation is re
corded from the scalp electro
de. This response waveform i
s called middle latency respo
nse (MLR)
 It is generated in between the
thalamus and auditory sensor
y area.
MLR
Measurement method – Electrode
placement
 Vertex electrode, Cz i
s used as active elect
rode
 Left and right earlob
e electrodes used as r
eference electrodes f
or 2 channels (ch1 : l
eft, ch2 : right)
MLR
Measurement method – Settings &
Cautions
 Click sound of 80nHL to

either ear, and masking noise
to the other ear.
 Rest of the settings are

shown on the right diagram
 In MLR recordings, a large

potential with the latency of
about 13 ms is sometimes
recorded. This response
disappears when the
stimulation intensity is
reduced.
MLR
Points of measurement
 Negative peaks latency No, Na,

Nb, and positive peaks latency
Po and Pa are obtained
 In MLR, the latency and latenc
y difference between the left an
d right sides are evaluated
Slow Vertex Response (SVR)
SVR
What is SVR?
 The main clinical application of this response is

the objective estimation of the auditory hearing
threshold. It may be most conveniently
considered as the electrophysiological equivalent
of the pure tone audiogram (PTA).
 The response is generated in the auditory cortex.
 This is seldom used because of low reproducibility
SVR
Auditory Pathway
 When an auditory stimulati
on (tone burst) is presented
to an ear, an auditory respo
nse waveform with a latenc
y of 50 to 500 msec after sti
mulation is recorded from t
he scalp electrode. This res
ponse waveform is called sl
ow vertex response (SVR)
 It is generated in auditory c
ortex
SVR
Measurement Method – Electrode

Placement
 Vertex electrode,
Cz is used as activ
e electrode
 Left and right earl
obe electrodes use
d as reference elec
trodes for 2 chann
els (ch1 : left, ch2
: right)
SVR
Measurement method – Settings &
Cautions
 Tone burst in alternating phase is applied
at a stimulation rate of 0.5Hz (random)
 Rest of the settings are shown on the

right diagram
 In MLR recordings, waveform is not

stable and changes significantly
depending on patient’s consciousness.
Therefore it is useful to apply random
stimulation instead of fixed stimulation
(in some cases, the patient is requested to
read a book or perform some other
activities to stay awake).
SVR
 Latencies of the response is ac

quired after the stimulation
 Latencies are labelled as 1, 2,
3, an so on, to show appearanc
e orders.
 N1-P2 are the most stable resp
onses. These are used for estim
ating hearing threshold using th
e input/output functions.
Electrocochleograph (EcochG)
EcochG
What is EcochG?
 EcochG is used to test the response to

sound from the Cochlea.
 Can be used to evaluate balance problems
and other auditory problems.
 Problems in the Cochlea can be detected
using this test
EcochG
Auditory Pathway
Sound is transferred to the tympanic membrane
as vibratory waves in the air which is in turn
converted to mechanical vibration in the ossicles.
This mechanical vibration is transferred to the
hair cell in the liquid of the cochlea. The hair cell
generates an action potential. This action
potential is transmitted toward the center. When
a tone burst sound is applied to the ear, action
potentials are obtained with the external or
internal auditory meatus derivation. A cochlea
microphonic potential (CM) is generated in the
hair cell of the cochlea and an action potential
(AP) is delivered to the cochlea nerve. When the
frequency of the tone burst sound changes,
different action potentials corresponding to the
frequency are observed. When a click sound is
applied, a summated potential (SP) and action
potential (AP) are observed. These potentials are
called EcochG and show the function of the
middle and inner ear.
EcochG
Measurement methods
 Can be recorded with internal or external meatus der
ivations.
 In external derivation, a silver ball electrode is attac
hed to the tympanic membrane as the active electrod
e.
 In the internal derivation, a thin needle electrode is a
ttached to the promontory of tympanic cavity. With t
he attached needle, headphone cannot be used.
 Topical anesthesia is required for both derivations.
 Cardiocream is applied to the silver ball electrode to
ensure good contact.
 During stimulation, masking noise is applied to the o
ther ear.
EcochG
Measurement methods
 For tone burst stimulation, the Act
ion Potential (AP) and Cochlea m
icrophonic potential (CM) is obtai
ned
 For click stimulation, the AP and
Summated Potential (SP) is obtain
ed
 Stimulation needs to be done in c
ondensation and rarefaction phase
s
 Refer to the diagram on the right f
or the settings
EcochG
 To obtain the results, seperately av
erage the condensation and rarefac
tion phases.
 To enhance AP/SP, add rarefactio
n and condensation phases.
 To enhance CM, subtract condens
ation phase from rarefaction phas
e.
 Presence or absence of AP is an in
dicator of hearing ability at the co
chlea level
 CM indicates middle ear function
 SP/AP amplitude ratio is acquired
for analysis of Menier’s disease
Somatosensory EP (SEP)
Short SEP (SSEP)
SEP/SSEP
Why Are SEP and SSEP Done?
 Diagnose lesions in the sensory pathway

from the peripheral nerve to the brain.
 Used to evaluate the function of afferent
fibers in peripheral nerves and spinal cord.
SEP/SSEP
Somatosensory Pathway
Somatosensory information goes to opposite side of brain cortex.
SEP/SSEP
Somatosensory cortex
receives information from
skin receptors,
distinguishing different types
of sensations.
SEP/SSEP
 Information goes to specific part of cortex. For example,

information on left hand goes to right side area on brain
surface (cortex) 7 cm lateral from the center. Information
on foot goes to the center of cortex.
 Therefore, electrode must be attached on corresponding
position on the head.
SEP/SSEP
Spinal Cord and Distribution of

Sensors on Skin
SEP/SSEP
Two Point Discrimination

SEP/SSEP
SSEP by Median Nerve

Stimulation
SEP/SSEP
SEP/SSEP
SEP/SSEP
SEP/SSEP
Erb's Point
Erb’s Point
Clavicular head of
sternomastoid muscle
2.3 cm
Clavicle
SEP/SSEP
SSEP and Normal Waveform by

Median Nerve Stimulation
SEP/SSEP
Near field and far field potential

Near and far field potential usually
used in EP
• Near field potential has a limited
distribution. It is the response
generated with the electrode close
to the stimulating site
• Far field potential has a broad
distribution. It is the response
generated with the electrode further
from the stimulation site
SEP/SSEP
Measurement method – Cortical SEP

Electrode Placement
• Surface disc electrodes are
used
• CPc is used for active electrode
• Reference electrode at Fpz or
A1+A2
• Stimulation settings are shown
on the right
SEP/SSEP
Points of measurement – Cortical SEP

In SEP recording, the amplitude
difference between the N20 and P24
potentials, and between the P24 and N33
potentials at the left and right sites are
used to see whether an interhemipheric
difference are present.
SEP/SSEP
Measurement method – SSEP upper extremity

Electrode Placement
• 2 sets of recommended montage (by Japanese
Society of Clinical Neurophysiology), montage
A and montage B
• Montage A record action potentials on the
neck and head with bipolar derivation. Fz acts
as reference electrodes. Smaller artifact, but Fz
potential may include some unwanted potentials
• Montage B record far-field potential with
monopolar derivation. Larger artifacts, but Fz
potentials not included in the measurement.
Reference electrode is usually attached to
contralateral side of the Erb's point (Epc) of the
stimulated arm. This reference produces a
clearer and more accurate waveform.
Electrode Placement
In 8 channel measurement, it is possible

to obtain more details about the
somatosensory evoked action potentials
between the periphery and spinal cord
and between the spinal cord and cortical
sensory area. The Japanese Society of
Clinical Neurophysiology recommends
selecting the only necessary derivations
from these 8 which meet the clinicians
purpose, as the full 8 channel recording
requires more sophisticated recording
techniques, more electrodes and longer
testing time.
Measurement method – SSEP Upper
Extremity Stimulation site & intensity
1. To find stimulation site. Record a sensory nerve

action potential of the index finger using the
same procedure as antidromic sensory nerve
conduction measurement and find the simulation
site where large sensory nerve action potential is
obtained with lower stimulation intensity.
2. To find stimulation intensity. Use the same
stimulation placement, then select the
supramaximal stimulation so that the maximum
amplitude of the sensory nerve action potential
is obtained.
SEP/SSEP
Points of measurement – SSEP Upper Extremity
Waveform on the right shows the results from Montage A.
In SSEP, the waveforms between the left and right sides are
examined for differences in latency, peak latency and
amplitude.
Epi – Ep
Ep potential of 9ms is the near field potential when evoked nerve
action potential passes through the brachial plexus
C5S – Fz
Shows the potential difference between the CS5 and Fz electrodes.
N9 – Far field potential generated when evoked nerve action
potential passes through the shoulder to the neck, which have
different volume conduction
N11 – Near field potential when evoked nerve action potential
passes through the cervical spinal cord funiculus posterioir
N13 – Compound of near field potential generated in a synapse
posterior horn neuron of the cervical vertebae and far field potential
when evoked nerve action potential passes through the medial
lemniscus. Complex potential consisting of response from
brainstem and spinal cord.
SEP/SSEP
Points of measurement – SSEP Upper

Extremity
CPc-Epc
The P9 potential is the far field potential that originates from
the same source of the N9 potential in the C5S-Fz derivation.
The P11 potential is the far field potential and is probably
generated in the cervical spinal cord funiculus posterior.
The P13 potential is the far field potential generated in the
medial lemniscus.
Cpc-Fz
The N20 potential with large amplitude is the near field
potential generated in the cerebral cortex. This is the first
cortical waveform generated by the median nerve conduction
from the periphery.
Central conduction time (CCT)

The central conduction time is the nerve conduction time from
the spinal cord to the cortical sensory area in the head.
• Can be derived from latency difference between N20 and
N13. However, as N13 is a compound wave, there is
ambiguity in the results.
• Therefore, it is recommended to derive from the latency
difference between P11 (or N11) onset to N20 onset.
SEP/SSEP
Measurement method – SSEP lower extremity
Electrode Placement
• Details of far field potential is not investigated because
it cannot be obtained correctly due to artifacts
• Right diagram shows a 4 channel recording
recommended by Japanese Society of Clinical
NeuroPhysiology
• Channel 4:
The N21 potential from the Tibial nerve to the cauda equina is
obtained as the near field potential. After this, the activity enters the
central nervous system. The T12S electrode is on the spinous
process of the 12th thoracic spine.
• Channel 3:
The P31 potential is obtained as the far field potential that is
generated in the medial leminiscus and gracile nucleus.
• Channel 2:
The P38 potential is obtained as the near field potential. This shows
the cortical somatosensory projection of the lower extremity.
• Channel 1:
The P38 potential is obtained as in the channel 2. This derivation is
used to distinguish a large positive potential generated on the same
side of the stimulation from the potential generated by the median
nerve conduction.
Electrode Placement
It is possible to see the

ascending evoked action
potentials through the spinal
cord. It is not necessary to use
all 8 channels every time.
Select the only derivations
appropriate to the measurement
purpose. Multi-channel
recording requires more
sophisticated recording
techniques, many electrodes
and longer measurement time.
Measurement method – SSEP Lower
Extremity Stimulation site & intensity
1. Find the stimulation site by observing the muscle

contraction.
2. Adjust the stimulation site so that all the toe muscles
contract.
3. Reduce the stimulation intensity until the patient feels
only a mild paresthesia (itching and/or tingling).
4. Set the stimulation intensity to twice the level where the
patient feels paresthesia.
5. High stimulation rate causes pain to the patient, which in
turn causes EMG interference. When patient feels pain,
reduce stimulation rate instead of stimulation intensity.
SEP/SSEP
SSEP by Leg Stimulation

SEP/SSEP
Points of Measurement – SSEP Lower Extremity
In lower extremity SSEP measurement,
• Latency difference between N21 and P31 used as spinal conduction time.
• Latency difference between the P31 and P38 potentials is used as the central
conduction time from the upper brainstem to the cortical sensory area
• Latency is not affected by levels of awakeness, consciousness and
medication, but varies with the pathway length (such as height, length of the
arm or foot) and temperature
SEP/SSEP
ECG Triggered SSEP Measurement
• Technique used to reduce ECG artifact on SSEP measurement
• One channel can record up to 26 stages of response waveforms
ECG artifact is particularly

apparent when trying to
record spinal potentials or
when recording far-field
potentials using long inter-
electrode distances
encompassing the heart
SEP/SSEP
ECG Triggered SSEP Measurement – Electrode
Placement
SEP/SSEP
ECG Triggered SSEP Measurement – Stimulation
procedure and settings
• Before starting measurement, the ECG trigger level should be set. The trigger
level should be set on the peak of R from the ECG waveform
• Ensure that during averaging, sweeps are not time locked to the termination
of the QRS complex. This may result in T wave contamination of the
subsequent recordings
• For patients with tachycardia, long inter-electrode distances and close
proximity of recording electrodes to the heart should be avoided.
Evoked Spinal Cord Potential
(ESCP)
ESCP
What is ESCP?
• Known as Evoked Spinal Cord Potential
• Evoked potentials arising in the cauda equina and spinal cord afferent
pathways can be recorded from surface electrodes attached to the skin
over the spine
• Used to monitor spinal cord functions, most importantly to prevent
spinal cord ischemia during surgery
A posterior recording of evoked potentials
from a 51 year old patient showing a partial
conduction block at C5–6 (left), and an
anterior recording from an 85 year old
patient with a complete block at C3–4
(right). The focal conduction block (asterisk)
was identified by an abrupt reduction in the
negative peak (thick arrows pointing down)
with a concomitant augmentation of the
initial positive peak (thin arrows pointing
down).
Visual EP (VEP)
VEP
Visual Pathway
VEP
Visual Angle and Distance of

Object
VEP
VEP
Pattern Reversal VEP

Electro Retinogram (ERG)
ERG
What is ERG?
• A measure of the eye’s electrical response to a flash of
light
• Records the electrical changes in the eye after stimulation
by light
• Useful in distinguishing between a variety of retinal
disorders, such as cone dystrophy and retinitis
pigmentatosa
• Performed in a dark room after patient adapts to darkness
Important Note : Do not perform skin-electrode impedance check when

performing ERG. This may injure the patient’s eyes as impedance check
current is applied.
ERG
Measurement method – Electrode placement

& Test Environment
Electrodes & settings
• Active electrode – Placed on the forehead
• Reference electrodes – Contact lens
electrodes
• Settings should follow the diagram on the
right
Testing Environment
• Patient should be placed in a dark
environment
• Allow 15 to 30 minutes for patient to adapt
to darkness, otherwise baseline drift
• Flash lamp should be placed 30cm away
from the patient
ERG
Measurement method – Tests methods

Scotopic ERG
• Used to check the function of the rod
• A 10W intensity white or blue light is
used
Photopic ERG
• Used to check function of the cone
• A high intensity red light is used
ERG
Points of Measurement
• Amplitude and latency of a and
b waves are measured
• Amplitude of a wave is from
peak of a wave to baseline
• Amplitude of b wave is from
peak of b wave to peak of a wave
• Oscillatory potentials are noted
for their presence/absence
Electrooculogram (EOG)
ERG
What is EOG?
• Variation of the eyeball static potential derived from both
the lateral and medial canthi by tracing a view target of the
view target reciprocating motion unit (such as SLE-5100) with
the head immobilized
• Electrical measurement of eye
movement
• EOG abnormalities can reflect either
dysfunction of the rod
(photoreceptors), or primary RDE
diseases
• Used with Nystagmo stimulator,
SLE-5100
Eye Muscles
Nystagmo Stimulator
ERG
Measurement Method – Electrode placement
and Settings
ERG
EOG waveforms
EOG -horizontal
EOG - vertical
Electromyography (EMG)
EMG
Purpose of EMG
 Examination of motor units.

 Determine if the cause of disease is in
muscle fiber itself, motor nerve or
neuromuscular junction.
 In case of nerve, determine if cause is
between muscle and anterior horn cell, or at
a higher level in the spinal cord.
EMG
Needle Exam Description
There are five stages in the examination of a muscle

by needle electrode:
 Insertion of needle into muscle
 Muscle at rest
 Muscle during mild effort
 Muscle during moderate effort
 Muscle during full voluntary effort

EMG
Motor Unit
The motor unit consists of an anterior horn cell, its axon, and all the
muscle fibers innervated by that axon and its branches. Muscle fibers
belonging to one motor unit are not closely packed together. They are
scattered over a small area of muscle and intermingled with fibers
belonging to other motor units.
EMG
MUAP
 The motor unit action potential (MUAP) is the

electrical field generated by muscle fibers
belonging to one motor unit as recorded by the tip
of the nearby needle electrode.
 Normally muscle fibers belonging to one motor
unit are all depolarized and repolarized somewhat
synchronously.
 Amplitude, duration, number of phases, rise time,
and firing rates characterize a motor unit potential.
EMG
Motor Unit Action Potential

EMG
Monopolar Needle
EMG
Concentric EMG Needle

EMG
Concentric Bipolar Needle

EMG
Single Fiber Needle

EMG
Normal Insertion and

Spontaneous Activity
Insertion activity
Spontaneous activity
EMG
MUP at Mild, Moderate and Full

Effort Contraction
Mild effort
Moderate effort
Full effort (Interference pattern)

AC Artifact and Minimization
AC Artifact Sources
AC artifacts are
induced by
electrostatic,
electromagnetic
induction and
leakage current.
How to Minimize AC Artifacts

 Connect earth terminal
of systems to one
ground terminal.
 If possible, disconnect
electric equipment at
outlet.
 Bundle electrode lead
wires into one cable.
 Put main unit as far as
possible from patient,
Also refer to "Data electrodes and input
Acquisition Noise Reduction box.
Checklist".
AC Artifact Types
Thank you

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What is the purpose and scope of the document?

What is the purpose and scope of the document?

What are the main components of the nervous system discussed in the document?

What are the main components of the nervous system discussed in the document?

EP/EMG-Basics

such as customers or competitors.

file to other party, including copyright issues.

without the written permission of NKC.

Central Nervous System and

Spinal Cord Cross Section

Sensory System Skin Sensors

Many types of sensors receive information and

Basic Nerve Elements

 Cell and Action Potential

Cell Membrane Potential

Conduction in Volume conductor

Effect of CV with Temp

Stimulation and polarity

Stimulus Intensity, SupraMaximal

 Weak Cathode potential cannot excite

Compound Action potential

Axon Muscle fiber

Motor and Sensory Nerves

Conduction and Transmission

 In neural networks, information is expressed by

 At the junction point, it takes time for signal

Nerve Types, Diameter and

Clinical Test Menus

 What (physiology, anatomy, outline of test)

EP System Block Diagram

Conditions to set during acquisition

• Trigger – Sets the type of trigger (Recurrent, random, signal, foot

Why Is the EP Test Done?

Characteristics of EP Signals (1)

Characteristics of EP Signals (2)

How the EP Test Is Done

1st Average: Response (1+2)

Add 1st and 2nd

What Is EMG and Nerve

What Is EMG and Nerve

Application of EMG and NCS

EMG and NCS

 For NCS, electric stimulation is used.

Stimulation Intensity and

Electric Stimulation and Response

Median Nerve Stimulation and

How To Find the Best Electrode

 Stimulate yourself and find your median nerve pos

• MCS measures motor nerve conduction (not

Motor nerve Anterior Horn Cell

Stimulation at Two Points -

Why Must Two Points Be

Motor Nerve Conduction Velocity

Conduction time 1 (C1)

Conduction time 2 (C2)

Conduction time between S1 and S2 =

Conduction Velocity = D/(L1-L2) m/sec

Conduction Velocity Calculation

 For the examination of nerves on the palm,