1. John Gambin, M.D.

2. NMJ Fiber Types InvolvedPathologyTemporal Course Sensory Motor Mixed Axonal Demyelinating Acquired Inherited Hyperacute Acute Subacute Chronic Severity Goals of the EDX Study Muscle Nerve Localization

3. Neuronopathy Radiculopathy Plexopathy Mononeuropathy Multiple Mononeuropathies Polyneuropathy CNS Proximal Distal Generalized Cranio-bulbar Presynaptic Postsynaptic Localization Myopathic NMJNeuropathic

5. Elements of the Peripheral Nervous System

6. Neurons of the Peripheral Nervous System Sensory Nerve Motor Nerve

7. Post Synaptic Membrane

8. Muscle Contraction

9. Motor Unit MUAP

10. Indications for Nerve Conduction  Peripheral entrapment  Suspicion of polyneuropathy  Suspicion of Myasthenia Gravis  Nerve Trauma Indications for EMG  Suspicion of disorder  Brachial plexus injury  Lumbosacral plexus pathology  Muscle disorder

12. Patterns of Nerve Conductions Stimulation

13. Types of Nerve Damage

14. Nerve Recovery Patterns Muscle Demyelinating Other- Mixed Injury

15. Measurement Parameters (DML) (PML) Conduction Velocity = Distance (Proximal - Distal) Time (PML –DML)

16. Entrapment Sites

18. Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Right Med/Uln/Rad Nerve Patient:Patient ATest Date:02/02/10 Age:49 Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL R L RLR Wrist2.93.314.8 16.0 80 80 ACF6.16.613.6 15.7 190 19560.059.1 Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL R L R LR Wrist2.62.719.5 17.1 80 80 B.Elbow5.45.518.5 16.2 175 17562.563.3 A.Elbow7.27.017.4 15.4 110 11563.575.0 Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm) C.V. (m/s) Rec SiteL RL R L R L R MedMidPM1.8 2.084.3 70.7 80 80 43.640.0 UlnMidPlm1.9 1.743.7 52.0 80 80 42.946.2 MedSenAnt3.1 3.1111. 69.0 140 140 45.745.2 UlnSenAnti3.4 3.148.0 73.0 140 140 41.245.2 Summary/Interpretation: Normal nerve conduction studies of the upper extremities. Left Median Nerve Left Med/Uln/Rad Nerve Normal Study – Upper Extremities

19. Patient:Patient CTest Date:10/01/09 Age:87 Motor Nerve Study Left Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist8.22.880 ACF11.72.918552.9 Mid Palm1.74.740 Motor Nerve Study Left Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist4.29.780 B.Elbow7.68.619556.8 A.Elbow9.28.78554.3 Sensory Nerve Study Left Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec Site MedMidPM3.819.08021.2 UlnMidPlm2.530.08032.0 MedSenAnt5.615.314025.1 UlnSenAnti4.418.014031.8 Summary/Interpretation: Nerve conduction studies of the left upper extremity demonstrate a severe left carpal tunnel syndrome. Left Median Nerve Left Ulnar Nerve Left Med/Uln/Rad Nerve Severe Carpal Tunnel Syndrome

20. Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve Patient:Patient DTest Date:11/04/09 Age:24 History/Comments: Pain and numbness in both upper extremities, right greater than left. Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLRL R L R L R Wrist3.33.916.4 15.0 80 80 ACF6.76.916.3 15.0 195 190 61.6 61.3 Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLRL R L R L R Wrist2.82.817.2 15.1 80 80 B.Elbow5.45.716.5 14.7 175 185 67.3 63.1 A.Elbow7.47.615.8 14.0 125 125 62.5 67.0 Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm) C.V. (m/s) Rec SiteLRL RL R L R MedMidPM1.92.2144. 140.80 80 42.1 36.4 UlnMidPlm1.81.567.5 51.780 80 43.6 53.3 MedSenAnt3.33.676.7 70.0140 140 42.9 38.5 UlnSenAnti3.23.368.3 48.3140 140 43.8 42.0 Summary/Interpretation: Nerve conduction study of both upper extremities shows minimal slowing across the right carpal tunnel. Left Median Nerve Very Minimal or Mild Carpal Tunnel Syndrome

21. Left Median Nerve Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad NerveRight Med/Uln/Rad Nerve Patient:Patient E Test Date:10/06/09 Age:82 Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist5.85.311.0 12.98080 ACF9.89.610.4 12.420521551.3 50.4 Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist3.84.114.5 12.98080 B.Elbow7.88.014.8 11.721020052.1 50.8 A.Elbow10.310.013.6 13.110511043.2 55.9 Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec SiteLRL RLRL R MedMidPM3.72.920.7 160.808021.6 27.6 UlnMidPlm2.42.08.9 19.0808033.8 40.0 MedSenAnt6.24.87.6 7.314014022.6 29.2 UlnSenAnti4.84.36.7 14.014014029.0 32.6 Summary/Interpretation: Nerve conduction studies of both upper extremities show changes of a bilateral carpal tunnel syndrome, moderately severe, left worse than right, superimposed on a modest generalized polyneuropathy. Carpal Tunnel Syndrome With Underlying Mild Neuropathy

22. Patient:Patient F Age:87 History/Comments: Numbness and tingling in both hands, right greater than left. Motor Nerve Study Median Nerve Rec Site: APBLat (ms) Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLR L R L R L R Wrist4.85.5 9.8 9.280 80 ACF9.510.0 9.3 9.1245 225 54.0 48.6 Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms) Amp (mV) Dist (mm) C.V. (m/s) Stim SiteLR L R L R L R Wrist3.03.3 14.6 17.7 80 80 B.Elbow7.08.0 14.1 17.3 220 235 55.5 50.0 A.Elbow9.610.4 13.5 16.1 130 125 50.6 52.1 Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms) Amp (uV) Dist (mm) C.V. (m/s) Rec SiteLR L R LR L R MedMidPM3.03.6 30.3 13.7 80 80 27.0 22.2 UlnMidPlm2.22.2 26.0 79.3 80 80 36.4 38.7 MedSenAnt4.55.8 27.7 8.0 140 140 31.3 24.3 UlnSenAnti3.63.6 28.3 17.3 140 140 39.3 38.9 Summary/Interpretation: Nerve conduction study of both upper extremities reveals bilateral carpal tunnel syndromes, severe on the right and moderate on the left. Left Median NerveRight Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad Nerve Right Med/Uln/Rad Nerve Carpal Tunnel Syndrome Severe on the right / Moderate on the left

23. Ulnar Nerve The most common place for nerve entrapment is in the elbow. Ulnar Neuropathy Cubital Tunnel Tardy Ulnar Palsy

24. Left Median Nerve Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad NerveRight Med/Uln/Rad Nerve Patient:Patient GTest Date:01/05/10 Age:57 History/Comments: Possible ulnar neuropathy. Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist3.43.810.8 9.48080 ACF7.17.310.3 9.322020059.5 56.1 Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRL RLRL R Wrist3.73.416.3 16.58080 B.Elbow6.36.516.2 16.618518063.8 60.7 A.Elbow8.58.112.4 16.88011036.9 71.7 Sensory Nerve Study Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec SiteLRL RLRL R MedMidPM2.22.479.7 72.0808036.9 32.9 UlnMidPlm2.11.930.7 25.7808042.9 38.7 MedSenAnt3.43.8124.2 38.714014041.6 36.8 UlnSenAnti3.83.522.5 34.714014037.5 37.2 Summary/Interpretation: Nerve conduction study of both upper extremities shows an ulnar neuropathy with significant drop in the velocity across the elbow. Ulnar Neuropathy

25. Patient:Patient I Test Date:11/24/09 Age:57 Motor Nerve Study Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteL RL R L RL R Wrist4.4 3.812.7 12.080 80 ACF8.3 7.7 12.7 12.3215 23559.7 62.4 Motor Nerve Study Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteL RLRL RLR Wrist4.0 3.710.416.780 80 B.Elbow7.7 7.09.415.5230 22061.666.0 A.Elbow11.5 9.11.814.7100 14026.568.9 Sensory Nerve Study Left Med/Uln/Rad Nerve Stim Site: Wrist Lat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec Site MedMidPM 2.4125.78033.8 UlnMidPlm 2.221.68036.4 MedSenAnt 3.728.314038.2 UlnSenAnti 3.944.714035.9 Summary/Interpretation: Nerve conduction studies of the upper extremities show: 1. Severe ulnar neuropathy at the left elbow, (amplitude and velocity drop). 2. Mild left carpal tunnel syndrome. Right Median Nerve Left Ulnar NerveRight Ulnar Nerve Left Med/Uln/Rad Nerve Left Median Nerve Severe Ulnar Neuropathy and Mild Carpal Tunnel

26. Patient:Patient J Test Date:10/05/09 Age:60 Motor Nerve Study Right Median Nerve Rec Site: APBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist3.912.780 ACF8.212.221049.6 Motor Nerve Study Right Ulnar Nerve Rec Site: ADMLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim Site Wrist5.01.480 B.Elbow11.0.96720033.3 A.Elbow19.51.110011.8 Sensory Nerve Study Right Med/Uln/Rad Nerve Stim Site: WristLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Rec Site MedMidPM2.336.78034.8 UlnMidPlmNR MedSenAnt3.843.714036.8 UlnSenAntiNR Summary/Interpretation: Nerve conduction studies of the right upper extremity show changes of a severe neuropathy at the elbow, predominantly axonal. Right Ulnar Nerve Right Med/Uln/Rad Nerve Right Median Nerve Severe Ulnar Neuropathy

27. Peroneal Neuropathy Neurology December 2005 MRI Detection of Cysts in the Knee Causing Common Peroneal Neuropathy. Donald J. Iverson, M.D.

28. Patient:Patient K Test Date:01/29/10 Age:67 Motor Nerve Study Peroneal Nerve Rec Site: EDBLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR Ankle6.15.4.3831.18080 B.Fibular16.816.1.408.61731529029.527.2 A.Fibular19.419.4.433.5839011033.833.0 Motor Nerve Study Tibial Nerve Rec Site: AHLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR Ankle5.75.9.100.1178080 Pop.Fos.21.520.3.333.30047042029.729.3 Motor Nerve Study Peroneal@AT Nerve Rec Site: Ant TibialisLat (ms)Amp (mV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR B.Fibular3.53.610.18.9 A.Fibular6.26.510.19.79011033.837.7 Sensory Nerve Study Peroneal Nerve Rec Site: dors.ftLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR Lower leg4.74.13.32.014014030.033.9 NOTES: Left side: not reliable Right side: not reliable Sensory Nerve Study Sural Nerve Rec Site: AnkleLat (ms)Amp (uV) Dist (mm)C.V. (m/s) Stim SiteLRLRLRLR mid calf4.54.24.22.714014031.133.1 NOTES: Left side: not reliable Right side: not reliable Summary/Interpretation: Nerve conduction study of both lower extremities shows severe length dependent mixed axonal greater than demylenating polyneuropathy. Right Peroneal Nerve Left Tibial Nerve Right Tibial Nerve Left Peroneal@AT Right Peroneal@AT Left Peroneal Nerve Sensory waveforms not shown. Severe (Length Dependent) Polyneuropathy

29. EMG Studies

30. Johnny Gambin Age 5

32. MUAP Morphologies

33. Spontaneous Waveform Generators

34. Interference Patterns

35. End Plate Spikes

36. Fibrillations

37. Positive Sharp Waves

38. Fibrillation Potentials + 1

39. Fibrillations + 4

40. Myotonic Discharge

41. Complex Repetitive Discharge

42. Fasciculation Potentials

43. Fasciculation with Reinnervated Potentials

44. Myokymic Discharge

45. Cramp

46. Rest Tremor

47. Normal Activation and Recruitment

48. Reinnervation - Long Duration & Polyphasic

49. Moderately Decreased Recruitment

50. Myopathic Brief Duration

51. Abnormal Neuromuscular Function The possible sites of abnormal function of the peripheral nerves and muscle are: Motor neuron cell body, sensory neuron cell body, or both Root Plexus nerve axons, peripheral nerve axons, or both Plexus nerve myelin, peripheral nerve myelin, or both Neuromuscular junction Muscle

52. Sites of Damage in Nerve and Muscle Site Disorder Neuron cell bodyAmyotrophic lateral sclerosis RootCervical or lumbar radiculopathy Axonal neuropathyToxic neuropathy Demyelinating neuropathyGuillain-Barre syndrome Neuromuscular junctionMyasthenia Gravis MuscleMuscular dystrophy

53. The End Thank you!

55. Patterns of Nerve Conductions Normal Axonal Demyelinating Demyelinating with conduction block Distal Latency = 3.0 msec Conduction Velocity = 59 m/sec Distal Latency = 4.4 msec Conduction Velocity = 51 m/sec Distal Latency = 12.7 msec Conduction Velocity = 12 m/sec Distal Latency = 12.7 msec Conduction Velocity = 12 m/sec 5 mV 5 msec

57. Amplitude Duration Distal Latency Proximal Latency Measurement Parameters