Prepared by: Floriza P.

de Leon, PTRP

 Concerned

with the study of electrical activity in motor units when stimulated by electrical pulses Results maybe interpreted for diagnosis/prognosis

 Intensity

of current necessary to produce a minimal perceptible and palpable contraction, using a prolonged pulse duration Taken by:
Place cathode on the motor point, or use bipoloar

technique with the cathode on the distal end of the mm Use square pulses, 100-300 ms/1000 ms Find intensity that will produce minimal perceptible and palpable contraction (in mA/V) (N) value = 2-18 mA; 5-35 V

Factors Affecting Rheobase

Skin Resistance and subcutaneous tissue Palm/skin over lower leg -- R; therefore I After denervation, skin becomes dry and scaly alters rheobase Each person has each own rheobase Obese - R Edema and Inflammation Makes it difficult for current to pass through because the excess fluid dissipates the current Therefore, intensity which is uncomfortable for many pxs Ischemia and underlying pain Temperature Heat - rheobase Cold - rheobase Therefore treat px with IRR before ES

 Diagnosis:

Denervation
rheobase (around 59% of (N)) May also be found to -- due to other factors Falls below (N), 10-20 days after denervation and remains low

Partial denervation no change Degeneration Re-innervation

rheobase 10-15 days after nerve lesion Sharp rise in rheobase (5-6x (N)) which then slowly falls After nerve repair, threshold increases abruptly when nerve have reached mm, then returns to (N)

Time to induce minimal visible contractions with a stimulus 2x the strength of the rheobase (N) value = < 1 ms; 0.05-0.5 ms Birth 10x (N) 3rdmos lower than at birth 18th -20th mos (N) Proximal mm - Distal mm - Facial mm low chronaxie - excitable of mm Factors affecting chronaxie
Skin texture - Dry skin alters or makes it difficult to obtain chronaxie Ischemia decrease in blood blow; decrease mm excitability; 100%

increase in chronaxie Edema difficult to obtain chronaxie; fluid dissipates heat Fatigue 2x chronaxie, then goes back to (N) Electrode positioning when not on motor point, you get 10x (N) chronaxie

 Diagnosis

Denervation
partial denervation little change re-innervation
if whole mm is affected 50-200x increase (up to 25 ms) decrease to 15 ms by 30th-40th day after denervation

progressive decrease of chronaxie decreased chronaxie does not precede recovery and does not give an indication of recovery chronaxie is the last criterion to reach (N); voluntary movement precede (N) chronaxie level

 Formula (N)

= 3-6 Denervated = below 3 No accommodation 1 or below

 Formula (N)

= little or no difference (<2.2:1) Denervated = >2.5:1 Complete degeneration = no response to 1 ms pulse

 Formula (N)

= 3.5 -6:1 Denervation 1.5-1:1 Degeneration 10:1 after 30 day, then decreases until it reaches 1:1 Regeneration 20:1, then decreases to (N) value; voluntary contractions precede reaching (N) value

Determines excitability and conduction of a nerve trunk Uses square pulse of 0.1 or 1 ms pulse duration, f= 1 Hz Threshold value to produce a minimal perceptible contraction is determined Factors affecting nerve excitability test

Heat - values; cold - values Thickness of soft tissue if thick, R therefore values Electrode positioning Movement and tension of mm Note
Daily assessment is made from 3rd day after onset until 10th day; if changes are noticed continue until 14th day (B) sides are assessed and the difference in values is noted

Progressive increase in value in 6 days indicates swelling around the nerve; indicates decompression by surgery

neuropraxia Denervatio/axonosten osis Denervation/axonotme 5-7 sis Neurotmesis/severe nil axonotmesis

Difference In values (mA) 1-2 3-4

(V) 2-4 8-12

12-18
Nil

Facial nn anterior to the mastoid process Erbs point lower inner angle of the supraclavicular fossa (results to contraction of deltoids, biceps, brachialis and brachioradialis brachial plexus) Ulnar nn upper point (medial epicondyle); lower point just above the wrist, ulnar border Radial nn halfway down the arm posteriorly Tibial nn above center of popliteal crease Deep peroneal nn just behind head of fibula Superficial peroneal nn 1 cm below deep peroneal nn

Curve obtain by joining pts that graphically represent the threshold values X= duration; y = threshold value (intensity) How?
Use pulse duration = 0.02-1000 ms (longest duration must be at least

100 ms) Intensity needed to produce minimal visible and palpable contraction is noted and plotted in the graph At least 6-10 pulses are taken

Done 10-14 days after injury Individual mm is stimulated Factors affecting SDC

Skin temperature cold decreases threshold Edema Ischemia Deeply placed mm invalid results Electrode positioning cathode is on motor points

 Presence or absence of excitable mm fiber

Complete denervation only long pulse duration will produce response; increase intensity is needed for shorter pulse duration
If with atrophy no response to short duration pulses, no horizontal part

Partial denervation revealed by presence of kinks discontinuities; with an innervated and denervated components

Signs of re-innervation
1st sign of recovery in completely denervated mm is presence of kinks May appear 3-4 mos before return of voluntary activity Also shown by movement of the kink to the left (good sign of reiinervation)

Chronaxie Progress of lesion Utilization time px at which the curve begins to flatten; probable

pulse duration suitable for electrical stimulation of mm

 Factor of accommondation of mm and nerve is

utilized Ensures stimulation of denervated mm only with long duration pulses

Denervation threshold drops (5-10x lower than (N)) during 1st 30 days (nerve easily responds to increasing intensity
with progressive atrophy threshold rises curve is displaced to the right and upwards

partial denervation presence of kinks (noticeable); shift of utilization time to the right