Harnessing historical data to derive reference limits - A comparison of e-norms to traditionally derived reference limits.

Objective: Nerve conduction studies (NCS) require valid reference limits for meaningful interpretation. We aimed to further develop the extrapolated norms (e-norms) method for obtaining NCS reference limits from historical laboratory datasets for children and adults, and to validate it against traditionally derived reference limits. Methods: We compared reference limits obtained by applying a further developed e-norms with reference limits from healthy controls for the age strata's 9-18, 20-44 and 45-60 years old. The control data consisted of 65 healthy children and 578 healthy adults, matched with 1294 and 5628 patients respectively. Five commonly investigated nerves were chosen: The tibial and peroneal motor nerves (amplitudes, conduction velocities, F-waves), and the sural, superficial peroneal and medial plantar sensory nerves (amplitudes, conduction velocities). The datasets were matched by hospital to ensure identical equipment and protocols. The e-norms method was adapted, and reference limit calculation using both ±2 SD (original method) and ±2.5 SD (to compensate for predicted underestimation of population SD by the e-norms method) was compared to control data using ±2 SD. Percentage agreement between e-norms and the traditional method was calculated. Results: On average, the e-norms method (mean ±2 SD) produced slightly stricter reference limits compared to the traditional method. Increasing the e-norms range to mean ±2.5 SD improved the results in children while slightly overcorrecting in the adult group. The average agreement between the two methods was 95 % (±2 SD) and 96 % (±2.5 SD). Conclusions: The e-norms method yielded slightly stricter reference limits overall than ones obtained through traditional methods; However, much of the difference can be attributed to a few outlying plots where the raters found it difficult to apply e-norms correctly. The two methods disagreed on classification of 4-5% of cases. Our e-norms software is suited to analyze large amounts of raw NCS data; it should further reduce bias and facilitate more accurate ratings. Significance: With small adaptations, the e-norms method adequately replicates traditionally derived reference limits, and is a viable method to produce reference limits from historical datasets.

Effect of gender on orthodromic sensory nerve action potential amplitude.

OBJECTIVE: Studies in the literature have demonstrated a gender effect on sensory nerve action potential (SNAP) amplitude for the median and ulnar nerves by use of the antidromic method of recording. The objective of this study was to determine if performing orthodromic sensory nerve stimulation eliminates the gender bias by removing the finger circumference as a variable. METHODS: Fifty-five healthy subjects participated in the study. The mean age of the subjects was 37.8 +/- 5.9 yr and 35.3 +/- 5.9 yr for men and women, respectively. Orthodromic sensory nerve conduction studies were performed for the median and ulnar nerves measuring the SNAP amplitude by use of standard electrophysiologic technique. RESULTS: The mean finger circumference of the third digit was 6.5 +/- 0.58 cm for men and 5.9 +/- 0.47 cm for women, and for the fifth digit, it was 5.6 +/- 0.41 cm for men and 5.3 +/- 0.37 cm for women. The median SNAP amplitude and their percentiles of 2.5 and 97.5 for the median nerve were 30.0 microV for men and 28.0 microV for women. For the ulnar nerve, they were 16.5 microV for men and 16.0 microV for women. CONCLUSION: The study confirmed that orthodromic sensory nerve stimulation did not have any significant effect on SNAP amplitude between men and women.

An EMG study of functional cortico-motoneuronal connections in humans.

We set out to decompose the EMG signal into its constituent motor unit action potential components to track motor unit firing rates with a high degree of accuracy and extract their average firing rate. We were able to show that this average firing rate tracks the subject's force trajectory from beginning to end. We propose that this average firing rate is a volitional control signal pointing to the existence of a 'volitional unit'. This volitional unit has to do with the projection of a group of functionally related cortico-motoneurons on a group of spinal motoneurons in the motoneuronal pool of a muscle. Our study of motor unit firing patterns during their steady state showed that spinal motoneurons respond to a descending central input in a Gaussian manner. We have further shown that the central drive itself, as represented by the average firing rate of the active motor units, also displays a Gaussian firing behavior. We have also described the existence of a 'translation factor', highly correlated to the motor unit size, which is unique to each spinal motoneuron and determines the motoneuronal response, and its resulting firing rate, to the descending inputs. As for force generation, we have shown that expressing the twitch force of a motor unit in a dynamic fashion using the 'electrotwitch' concept of firing rate x macro area, approximates motor unit force output better and accounts for firing rate related force changes more effectively than force estimates based on the mechanical twitch.

The volitional unit: a functional concept in cortico-motoneuronal connections in humans.

We used the EMG precision decomposition technique to resolve complex EMG signals and derive information about the firing times of a family of motor units (MUs) and the force they produce. The active units shared a common behavior among their firing rates, a concept described by DeLuca et al. and termed the 'common drive'. This 'common' behavior was extracted as the average of the firing rates of MUs and found to track the subject's force trajectory. In this paper, we propose the existence of functional cortico-motoneuronal connections which provide for a large number of combinations between affector cortical motoneurons (CMNs) and effector spinal motoneurons (SMNs) for the generation of a purposeful movement. We argue that these connections provide the essential link between volition and movement and function as a 'volitional unit' which consists of the CMNs, the SMNs and the anatomical and interneuronal connections between them.

Classification of back muscle impairment based on the surface electromyographic signal.

A surface electromyographic (EMG) procedure for classifying muscle impairments in persons with low back pain (LBP) is described. The procedure was studied using a device, the Back Analysis System (BAS), to acquire and process EMG signals from six bilateral muscle sites during sustained isometric contractions designed to progressively fatigue the lower back. Back muscle impairment was determined on the basis of the different ways in which the EMG median frequency parameters change as a function of contraction duration and muscle site. The article describes a series of studies that have been useful in developing an automated procedure for identifying back muscle impairment by comparing individual test results to a normative database. To date, the research results have produced multivariate discriminant functions that have identified two muscle impairment categories associated with deconditioning and imbalances secondary to LBP. We have found that the functions can distinguish individuals with and without LBP with an accuracy of approximately 90%. Other studies are described in which the technique is applied to monitoring changes in muscle performance capability that occur following rehabilitation for LBP. Many of our findings here are also compared to the results of independent studies by others using similar procedures. The need for further research and development of the technique to improve its clinical applicability is also described.

Hazardous waste and neurobehavioral effects: a developmental perspective.

This paper summarizes the findings gleaned from detailed clinical examinations of three groups of residents who were exposed to trichloroethylene in well water. Also summarized are diagnostic findings for peripheral neuropathy. A detailed description of the neuropsychological test results is included, as well as a summary of domain-specific findings and diagnostic outcomes. A high rate of cognitive deficits of the type seen in patients with central nervous system dysfunction attributable to solvent exposure was seen. In addition, there was a clear developmental trend: subjects who were younger at the time of TCE exposure showed deficits in a larger variety of cognitive realms than did subjects who had already reached adulthood by the time of exposure. In particular, language deficits were seen in the younger, but not older, exposed subjects.

Distal, "Tinel-like" percussion paresthesiae, with proximal nerve lesions.

Can proximal nerve lesions cause a distal "Tinel-like" sign? We present the case studies of two patients with documented cervical root lesions who exhibited percussion paresthesiae distally in the absence of any clinical or nerve conduction evidence of distal pathology. The possible mechanisms underlying such manifestation, which has been previously reported in the literature, are explored, and a case is made for the phenomenon being related to the "distortion" of a normal sensory signal when it encounters an area of spatial inhomogeneity proximally along the nerve.

The demonstration of the size principle in humans using macro electromyography and precision decomposition.

We set out to study the relationship between a motor unit's size and firing rates and its recruitment threshold and recruitment order. The data were collected from the first dorsal interosseous muscle of 11 normal subjects and analyzed using the precision decomposition and macro electromyography techniques. Our study showed that the recruitment order of a motor unit varies directly with its recruitment threshold (P<0.00005) and that there is a progressive increase in the macro potential size of successively recruited motor units (P=0.002). The firing rates of motor units vary inversely with their recruitment order (P=0.006), the smaller, earlier recruited units consistently reaching higher firing rates than the larger, later recruited units. This study conforms the existence of a size principle of motor unit recruitment in humans and reveals the interactions between a motor unit's size and its firing rate properties.

Correlates of motor unit size, recruitment threshold, and H-reflex jitter.

The aim of this research was to study the neurophysiology of the anterior horn cell (AHC) using single-fiber EMG (SFEMG) study of the flexor carpi radialis (FCR) H-reflex. Twelve men and 7 women, ages 20-80 years, were studied. The mean H-jitter was 138 +/- 59 microseconds. H-jitter increased with age (while the M-jitter did not) and was greater in men than in women. There was a direct correlation between the H-jitter and H-latency which was used as an indirect measure of the AHC's size. Given that small AHCs have a higher input resistance than large ones, the H-jitter can be used as an indirect indicator of the AHC's input resistance and therefore its size. When subjects fell asleep, the H-jitter increased over tenfold the baseline value, raising the possibility of an alternative, oligosynaptic pathway. H-reflex jitter studies provide a useful clinical neurophysiological tool for the study of AHC physiology.

The use of multiple Tinel's sign in the identification of patients with peripheral neuropathy.

We have found that the presence of a Tinel's sign is often pervasive in subjects with peripheral neuropathy and/or risk factors for developing it. There is a paucity of research dealing with the usefulness of Tinel's sign as it relates to peripheral neuropathy (PN). The following investigation was carried out to determine if multiple Tinel's sign or MTS can be used to identify patients with an underlying PN or with risk factors for developing a PN. A total of 102 subjects were enrolled in the study prospectively. We found MTS to have a sensitivity of 79% with a specificity of 42% in detecting peripheral neuropathy and a sensitivity of 76% with a specificity of 44% in determining the presence of risk factors for developing a peripheral neuropathy. We conclude that MTS can be a fairly sensitive indicator of PN or risk factors.

An investigation of a workplace cluster of Bell's palsy.

We undertook a study to confirm the existence of an apparent cluster of Bell's palsy in an industrial plant ("W4"), and to test etiologic hypotheses regarding chemical exposures, immune suppression, and infectious etiologies. Cases were enumerated by questionnaire. Employees with a history of Bell's palsy ("cases") were invited to participate in a study that included medical history, T cell studies, viral and Lyme disease serologies, and blink reflex studies. Thirty-three unaffected volunteers from W4 and 32 from a comparison building were also tested. Extensive environmental studies were carried out in W4, evaluating infectious, chemical, and radiation exposures. The lifetime incidence of self-reported Bell's palsy was 11.6/10,000 person-years (P-Y) in W4 and 2.4 cases/10,000 P-Y in the comparison building (RR = 4.8, P < .05); the comparison rate was similar to that reported in previous population studies. When restricted to cases occurring after the onset of work, the W4 incidence was 29.2 cases/10,000 P-Y, compared to 4.8 cases/10,000 P-Y in the comparison building (RR = 6.1, P < .05). The cases and noncases did not differ with respect to clinical histories or infectious disease titers. The W4 noncases had small but significant decreases in T lymphocyte (1974 +/- 86 vs 2291 +/- 103) and CD4 (1083 +/- 318 vs 1459 +/- 494) counts compared to the remote noncases. The cases had significantly prolonged RR1, LR1, and LFC values compared to both groups of noncases. No medical or environmental factors were identified that could explain an excess of disease.