Clinical Neurophysiology 121 (2010) 13731375

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Clinical Neurophysiology
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Editorial

Whither needle EMG?

Electromyography has a long and proud history. The rst needle EMG studies were undertaken in cats by Adrian and Bronk (1929), using a concentric needle electrode not unlike those used today. This Editorial highlights selected reports that have appeared over the past 12 decades in this journal and focuses on one of the most inuential developments in modern clinical neurophysiology, Single Fibre EMG. Diagnostic needle EMG studies date from the 1930s when Lindsley (1935) reported changes in motor unit morphology during effort in myasthenia gravis, and spontaneous potentials, the cardinal feature of denervation, were documented by Denny-Brown and Pennybacker (1938). The basic techniques used by many electromyographers have changed little since. Of course, the present focus on needle EMG does not imply that surface EMG recordings are of little value. They are used for completely different purposes. Surface recordings of on-going background EMG are more suitable for long-term recordings, and are, for example, used to power prostheses or as a control signal for computers and other devices. Stimulus-evoked activity provides the mainstay of most studies in motor control (e.g., Pierrot-Deseilligny and Burke, 2005; Dideriksen et al., 2009; see Special Section on Motor Control, Trker, 2010). The properties of the motor unit including the propagation velocity of its muscles bres can be probed in surface EMG recordings (e.g., Yamada et al., 1987; Grassme et al., 2003), and the recording can be decomposed into the constituent motor unit potentials (Nawab et al., 2010). Surface recordings are not selective, though specic techniques may be used to minimise crosstalk (van Vugt and van Dijk, 2001). Ultrasound can identify brillation in denervated muscle (Pillen et al., 2009), but surface EMG recordings cannot do so and, whatever the future advances, they will never supplant the need for reliable needle EMG studies. However, as with many tests, the results are only as good as the technique used to record them: there is no substitute for scrupulous adherence to technique and experience in distinguishing genuine abnormality from artefact. Needle EMG has a number of uses. Botulinum toxin and other agents are increasingly being administered by needle EMG-guided injection, and the effects have been measured quantitatively using EMG (see Erdal et al., 1999). Some clinicians still use needle EMG much as rst described in the pioneering studies in the eld (e.g., Buchthal and Clemmesen, 1941; Kugelberg, 1947, 1949; Petersn and Kugelberg, 1949; Buchthal and Madsen, 1950; Lambert et al., 1954; Jones et al., 1955). The Copenhagen group introduced quantication of motor unit potential parameters, measuring individual units by hand (e.g., Pinelli and Buchthal, 1951), but most clinicians have relied on subjective scoring, based on auditory feedback and eye-balling a freely running oscilloscope screen, with their interpretation based on experience (see Stlberg, 2004). The reproducibility of these essentially unquantitative methods leaves a lot to be desired: merely increasing the volume control on the audioamplier can cause the inexperienced electromyographer to report larger (neuropathic) units. The pattern of recruitment and the density of the interference pattern lend themselves to quantitation. There is a linear relationship between mean power frequency and muscle bre propagation velocity (Arendt-Nielsen and Mills, 1985). Analysis of the power spectrum of the interference pattern is based on the nding that there is greater power at high frequencies in myopathies and at low frequencies in chronic partial denervation (Christensen and Fuglsang-Frederiksen, 1986), much as might be expected from the typical sound in such circumstances (Stlberg, 2004). However, the spectrum is inuenced by motor unit ring rate (Fuglsang-Frederiksen and Rnager, 1988). The most widely used techniques for quantication of the interference pattern are modications of Willisons turns/amplitude method (Stlberg et al., 1983; Fuglsang-Frederiksen et al., 1984; Pfeiffer and Kunze, 1992; Strempel et al., 1999). However, valuable though the information that comes from the studying the patterns of recruitment at different contraction levels and the interference pattern with strong effort, one learns little from them about the morphology of the constituent motor units. Well-validated quantitative methods for assessing motor unit morphology and motor unit recruitment are now used extensively, and have been the subject of authoritative reports and reviews in this journal (e.g., Finsterer and Fuglsang-Frederiksen, 2001; Cengiz et al., 2002; Podnar, 2004, 2009; Boe et al., 2006; Fuglsang-Frederiksen, 2006). With triggering and sweep delay, motor unit morphology can be studied, though admittedly only during contractions that recruit few units, insufcient to produce interference. Automatic decomposition of the EMG activity produced by a weak voluntary contraction allows more units to be dened, but not >6 for any one site, and the technique tends to be disappointing when instability of the waveform causes spike components to be blurred in the averaged waveform, even though they can be clearly recognised in a triggered sweep. Nandedkar et al. (1988) demonstrated that, in addition to the traditional parameters (MUAP amplitude, duration and number of phases), the thickness of the motor unit, i.e., its area divided by its amplitude, was a useful in diagnostic EMG. This is based on ndings that amplitude is markedly affected by the distance from the closest muscle bre, more so than duration of the MUAP, while the area/ amplitude ratio is less affected by electrode position. Surprisingly, within limits, the size of the lead-off surface of the concentric needle electrode (paediatric, 0.03 mm2 versus adult, 0.07 mm2) has little inuence on motor unit parameters as studied using quantitative techniques (Brownell and Bromberg, 2007). Perhaps the greatest advances in electromyography came from explorations of the microphysiology of the motor unit (Stlberg et al., 1986, 2010). These advances built on the achievements of

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Editorial / Clinical Neurophysiology 121 (2010) 13731375

Buchthal in Copenhagen, but extended them into hitherto-unexplored areas. Single bre EMG now has a long history and it is easy to forget the controversy and opposition that this elegant technique initially provoked, largely resolved at a landmark symposium of the 4th International Congress of Electromyography, organised by John Desmedt and held in Brussels in 1971. This technique has spawned other developments that provide insight into the motor unit structure and function and the remodelling that occurs in disease. These developments are documented in the recently published 3rd Edition of a classic text Single Fibre Electromyography: Studies in Healthy and Diseased Muscle, by the leading proponents of the e Trontelj and Donald Sanders technique, Erik Stlberg, Joz (Edshagen Publishing House, Fiskebckskil, Sweden, 2010). It is essential reading for anyone interested in peripheral nerve and muscle disease, particularly if undertaking electromyography, even if they themselves do not provide a single bre EMG service. It contains the distillation of the lifetime experience of Stlberg and his colleagues, with a wealth of information about technical issues, EMG in general, the physiological processes that underlie the changes seen in routine EMG, and the changes seen in different pathologies all fully illustrated, both artefacts and abnormalities. In patients with possible disorders of neuromuscular transmission, jitter studies are clearly superior to repetitive nerve stimulation (Chapter 6), even when both can be performed on the same muscle (Sonoo et al., 2001). Stimulated single bre EMG has become a popular alternative to the original method of recording during a weak voluntary contraction because the electromyographer can control the discharge rate. This allows the technique to be extended to young or uncooperative patients and those with profound weakness. There is no need to seek pairs of muscle bres innervated by the same motor axon, because the recordings rely on measuring the jitter of a single bre relative to the stimulus. However, the technique is not without pitfalls (Trontelj and Stlberg, 1992) and, again, stringent attention to technique is required for reliable results, as detailed in Chapter 5.2. A problem that I nd particularly relevant with stimulated single bre EMG is mentioned on page 39, but is often not appreciated by clinicians. Axons hyperpolarise when they are active. This occurs whether the activation is due to voluntary effort (Vagg et al., 1998) or electrical stimulation, and occurs whether the stimulation is at high frequency (Bostock and Bergmans, 1994) or low frequency (8 Hz; Kiernan et al., 2004). The hyperpolarisation can increase the threshold of the axon by 40%, and this will inevitably result in intermittent failure to activate the axon and thereby the muscle bre. This would result in a spurious increase in jitter and conduction block in stimulated single bre EMG studies. Single bre EMG has led to other spin-offs. Macro EMG is performed using a modied single bre EMG electrode (Stlberg and Fawcett, 1982; see Chapter 11), and has a slightly better diagnostic yield than multi-MUAP analyses, at least in chronic neurogenic disorders (Sandberg et al., 1999). Similarly scanning EMG is dependent on the use of a single bre EMG electrode but requires an additional conventional concentric needle electrode. It can provide insight into motor unit remodelling (Chapter 10), but does not differentiate neurogenic cases from myogenic (Stlberg and Dioszeghy, 1991). Multi-electrode recordings can be made using specially constructed electrodes with a number of recording leads within the same cannula, each exiting in a line along the length of the cannula. This special electrode is used to map the territory of muscle bres within a motor unit and thereby the motor unit territory (Chapter 12). These spin-off techniques can provide valuable additional insights, but the techniques may be beyond a busy diagnostic service. The major downside to single bre EMG studies in the present decade lies in the single bre EMG electrode. On the one hand, sin-

gle-use disposable electrodes are not available while, on the other hand, there are issues in many countries with sterilisation. The recording surface is a side port in the shaft of the electrode, positioned so that muscle bres damaged by the bevelled tip are not in the recording eld or are remote from it. It is argued that the interface between the cannula, the insulation and the recording surface cannot be sterilised with 100% certainty, that some coagulated blood products can adhere there, and that this then represents a risk of transferring blood-borne disease. This risk is small. However it has led many departments in countries where medico-legal systems can be punitive to eschew re-sterilisation of concentric needle electrodes that have been previously used. Many electromyographers have turned to the use of ordinary concentric needle EMG electrodes to perform a study comparable to single bre EMG. As pointed out in Chapter 17 of this book, such recordings rarely involve single muscle bres and jitter measurements commonly underestimate the true single bre jitter. However, provided that appropriate techniques are used, jitter studies can be made with a reliability that approaches that of true single bre EMG. The recording surface should be small and the bandpass restricted (say 1 5 kX) and, because the recording surface is on the bevelled tip, recordings from damaged bres are more likely. This chapter is a must-read chapter, but to read it alone is to do so out of context: the other chapters contain a wealth of insight and experience necessary to get the most from the presented views. The chapter expands on data presented elsewhere on jitter studies performed with concentric needle electrodes on motor units activated voluntarily and by stimulation of the innervating nerve (Stlberg and Sanders, 2009). Electromyography will continue to have pride of place in the clinical neurophysiologists armamentarium. It may be invasive but it is unusual for it not to be tolerated: a thorough needle EMG study may be moderately uncomfortable but it does not increase blood-pressure or heart-rate, irrespective of known arterial hypertension (Finsterer, 2007). Quantitative methods and, in particular single bre EMG and its derivatives, may prolong a diagnostic study, but the information gained can be critical in the management of the patient provided of course that the techniques used are sufciently scrupulous that reliance can be put on the results. To this end, a satellite meeting on SFEMG/QEMG (XIXth International SFEMG and QEMG Course and the XIth QEMG Conference) will be held in October in Kobe, Japan as a lead into the 29th International Congress of Clinical Neurophysiology. Among other talks at it, Stlberg will address jitter measurements made with concentric needle electrodes. References
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David Burke Institute of Clinical Neuroscience, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW 2006, Australia Tel.: +61 2 9036 3091; fax: +61 2 9036 3092 E-mail address: david.burke@sydney.edu.au