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Neurophysiology and Instrumentation Other AANEM Learning Opportunities Course Books Monographs Coding Resources Neurophysiology and Instrumentation Lecture Series Case Reports Invited Reviews Workshop Handouts EDXSAEs/NMSAEs Case Studies Educational CD/DVDs Podcasts Practice Guidelines Over 160 educational resources available at www.aanem.org 2010 Course AANEM 57th Annual Meeting Québec City, Québec, Canada 10EX Advancing neuromuscular, musculoskeletal, & electrodiagnostic medicine American Association of Neuromuscular & Electrodiagnostic Medicine Neurophysiology and Instrumentation Daniel Dumitru, MD, PhD Sanjeev D. Nandedkar, PhD Brett L. Netherton, MS, CNIM AANEM 57th Annual Meeting Québec City, Québec, Canada Copyright © October 2010 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 Printed by Johnson Printing Company, Inc. AANEM Course Neurophysiology and Instrumentation iii Neurophysiology and Instrumentation Contents CME Information iv Faculty v Motor and Sensory Nerve Conduction: Technique, Measurements, and Anatomic Correlation 1 Sanjeev D. Nandedkar, PhD Anatomy, Physiology, and Pathology of the Neuromuscular System 9 Daniel Dumitru, MD, PhD Electrodiagnostic Medicine Instrumentation Pitfalls: Interelectrode Separation and Filters 15 Daniel Dumitru, MD, PhD Electrodiagnostic Instrumentation: Understand and Manage It 21 Brett L. Netherton, MS, CNIM Glossary of Terms 29 iv Course Description This course is designed to highlight the basic principles of electrodiagnostic studies. It is suitable for electrodiagnostic technologists and physicians. The first lecture will explain the physiologic basis for the electrical activity of nerve and muscles cells. The various disease processes affecting the peripheral neuromuscular system will be reviewed. The second talk will be on the principles of nerve conduction studies. It will describe the proper recording and measurement techniques. The relationship between the measurements and the anatomic generators of the signals will be discussed. The last two pre- sentations will discuss instrumentation and strategies to reduce noise and artifact. The effect of filters on the nerve conduction studies will be presented. Together, these presentations will give a review of the nerve conduction studies, and its applications to study the pathophysiology of the peripheral nervous system. Intended Audience This course is intended for Neurologists, Physiatrists, and others who practice neuromuscular, musculoskeletal, and electrodiagnostic medicine with the intent to improve the quality of medical care to patients with muscle and nerve disorders. Learning Objectives Upon conclusion of this program, participants should be able to: (1) discuss the basic anatomy and physiology of the neuromuscular system. (2) apply the motor and sensory nerve conduction study techniques to their practice. (3) identify and avoid technical pitfalls. Activity Profile This enduring material activity is a reproduction of the printed materials from a course at the AANEM Annual Meeting (October 6-9, 2010). Physician participation in this activity consists of reading the manuscript(s) in the book and completing the clinical and CME questions. Release Date: January 10, 2011 Expiration Date: January 10, 2014. Your request to receive AMA PRA Category 1 Credits™ must be submitted on or before the credit expiration date. Duration/Completion Time: 2 hours Accreditation and Designation Statements The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AANEM designates this enduring material for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit com- mensurate with the extent of their participation in the activity. AANEM Course Neurophysiology and Instrumentation v v Neurophysiology and Instrumentation Faculty Daniel Dumitru, MD, PhD Sanjeev D. Nandedkar, PhD Professor Clinical Application Specialist University of Texas Health Science Center at San Antonio CareFusion San Antonio, Texas Middleton, Wisconsin Dr. Dumitru currently serves as professor with tenure in the Department Sanjeev received his bachelor of engineering (electronics) degree from the of Rehabilitation Medicine at The University of Texas Health Science Birla Institute of Technology and Science (BITS), India, in 1977 and his Center at San Antonio. He also serves as professor in the departments of PhD degree in biomedical engineering from the University of Virginia Occupational Therapy and Physiology at The University of Texas Health in 1983. He worked as a research engineer at the Uppsala University in Science Center at San Antonio. Dr. Dumitru completed his MD at the Sweden in 1981-1982. He spent the next 7 years at the Duke University University of Cincinnati College of Medicine in 1980 and his residency EMG Laboratory to develop computer models for electromyography in physical medicine and rehabilitation at the University of Texas Health (EMG) waveform analysis and new methods for quantifying needle EMG Science Center at San Antonio in 1983. Dr. Dumitru received his PhD signals. Over the last 2 decades he has worked with EMG manufacturing from the University of Nijmegen, The Netherlands in 1999. He has held companies to develop and promote new generation EMG instruments. At numerous administrative positions as medical director in San Antonio and present, he is a senior consultant for CareFusion. He has published over Norfolk, Virginia. He is board certified by both the American Board of 50 scientific articles, written chapters in many text books, and performed Electrodiagnostic Medicine and the American Board of Physical Medicine workshops in over 20 countries. He also edits the “EMG on DVD” series and Rehabilitation (AAPM&R). Dr. Dumitru continues to be active in in collaboration with AANEM. His research interest is in quantitative many professional organizations including the American Association of analysis and motor unit number estimation. He received the AANEM's Neuromuscular and Electrodiagnostic Medicine (AANEM), of which he Distinguished Service Award in 2002. was president, the Association of Academic Physiatrists (AAP), and the American Academy of Physical Medicine and Rehabilitation (AAPM&R) of which he was president, as well. He served as a member of the edito- rial board of Muscle & Nerve and on the editorial board of the American Journal of Physical Medicine and Rehabilitation and Archives of Physical Medicine and Rehabilitation. He has received the AANEM’s Distinguished Researcher Award, the University of Texas Health Science Center at San Antonio President’s Award for Excellence in Teaching, and the AAP’s Distinguished Academician Award. His major focus for research is clinical neurophysiology with an emphasis in volume conductor theory. He has numerous publications in textbooks and significant peer review journals as well as his comprehensive textbook Electrodiagnostic Medicine, 1st and 2nd Editions. Dr. Nandedkar is on Employee of CareFusion. Any conflict of interest was resolved according to ACCME Standards. All other authors/faculty have nothing to disclose. Course Chair: Sanjeev D. Nandedkar, PhD The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AANEM. vi Brett L. Netherton, MS, CNIM Technical Director ROCWorks, LLC Prosperity, South Carolina Mr. Netheron brings a diverse educational and entrepreneurial background to electrodiagnostics. With a bachelor’s degree in electrical engineering and a master’s degree in physiology, he was drawn to the study of spinal pattern generators in graduate school, which led to a career in intraoperative neuromonitoring (IOM). He spent several years as an IOM clinician and gained CNIM certification prior to returning to his entrepreneurial roots. In 2007, Mr. Netheron sold his majority interests in his third company, Rhythmlink International. Currently, after starting his fourth company, Rocworks, Mr. Netheron focuses his time on publications, education, and research and gives numerous presentations each year, generally focus- ing on electrical aspects of neuromonitoring and the technical aspects of the electrode to tissue interface. Mr. Netheron is currently on the Board of Directors of the American Society of Neurophysiological Monitoring (ASNM) as well as chair of the ASNM Vendor Relations Committee. AANEM Course Neurophysiology and Instrumentation 1 Motor and Sensory Nerve Conduction: Technique, Measurements, and Anatomic Correlation Sanjeev D. Nandedkar, PhD Clinical Application Specialist CareFusion Middleton, Wisconsin INTRODUCTION Motor neuron Axo n Terminal Nerve conduction studies (NCSs) are performed on almost all pa- branches tients referred for electrodiagnostic (EDX) studies. These tests are useful to study the continuity, excitability, anatomic course, and size A B (i.e., number of nerve fibers) of the tested nerve. The NCS is also useful to localize and characterize the lesion (e.g., axonal, demyeli- Muscle fiber &and end endplate-plate nating, focal, or diffuse), define distribution (e.g., proximal versus distal), grade severity, and perhaps make a prognosis.2,3 The useful- ness of these procedures can be realized only when the procedure Sensory Proximal Distal Sensation Spinal cord ganglion Plexus is performed properly. Also, one must understand the relationship Muscle between the
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