Quantitative electrodiagnostic patterns of damage and recovery after spinal cord injury: a pilot study.

Study design: Prospective observational pilot study. Objectives: To compare quantitative electromyographic (EMG), imaging and strength data at two time points in individuals with cervical spinal cord injury (SCI). Setting: SCI center, Veterans Affairs Health Care System, Palo Alto, California, USA. Methods: Subjects without suspected peripheral nerve injury were recruited within 3 months of injury. Needle EMG examination was performed in myotomes above, at, and below the SCI level around 11- and 12-months post injury. EMG data were decomposed using custom software into constituent motor unit trains and each distinct motor unit was analyzed for firing rate and amplitude. Strength measurements were made with dynamometry and according to the International Standard of Neurologic Classification of SCI (ISNCSCI). Cervical magnetic resonance images (MRI) were evaluated by two neuroradiologists for gray and white matter damage around the SCI. Here, we compare the EMG, strength, and imaging findings of the one of the four participants who completed both 3- and 12-month EMG evaluations. Results: There was an increase in force generation in all muscles tested at 1 year. Localized findings of very fast firing motor units helped localize spinal cord damage and revealed gray matter damage in spinal segments where MRI was normal. Meanwhile, improvement in strength over time corresponded with different electrophysiologic patterns. Conclusions: Electromyographic decomposition at two time points provides valuable information about localization of spinal cord damage, integrity of motor neuron pools and may provide a unique understanding of neural recovery mechanisms.

Traumatic brain injury in U.S. Veterans with traumatic spinal cord injury.

Patients with both a spinal cord injury (SCI) and traumatic brain injury (TBI) are often very difficult to manage and can strain the resources of clinical units specialized in treating either diagnosis. However, a wide range of estimates exists on the extent of this problem. The aim of this study was to describe the scope of the problem in a well-defined population attending a comprehensive SCI unit. Electronic medical records of all patients with SCI being followed by the SCI unit in a U.S. Veterans' hospital were searched to identify those with concurrent TBI. The data were analyzed for age, sex, cause of injury, level and completeness of SCI, cognitive impairment, relationship with Active Duty military, and date of injury. Of 409 Veterans with a traumatic SCI, 99 (24.2%) were identified as having had a concurrent TBI. The occurrence did not appear to be closely related to military conflict. Reports of TBI were much more common in the last 20 yr than in previous decades. Documentation of TBI in patients with SCI was inconsistent. Improved screening and documentation could identify all patients with this dual diagnosis and facilitate appropriate management.

Myotonic discharges discriminate chloride from sodium muscle channelopathies.

Non-dystrophic myotonic syndromes represent a heterogeneous group of clinically quite similar diseases sharing the feature of myotonia. These syndromes can be separated into chloride and sodium channelopathies, with gene-defects in chloride or sodium channel proteins of the sarcolemmal membrane. Myotonia has its basis in an electrical instability of the sarcolemmal membrane. In the present study we examine the discriminative power of the resulting myotonic discharges for these disorders. Needle electromyography was performed by an electromyographer blinded for genetic diagnosis in 66 non-dystrophic myotonia patients (32 chloride and 34 sodium channelopathy). Five muscles in each patient were examined. Individual trains of myotonic discharges were extracted and analyzed with respect to firing characteristics. Myotonic discharge characteristics in the rectus femoris muscle almost perfectly discriminated chloride from sodium channelopathy patients. The first interdischarge interval as a single variable was longer than 30 ms in all but one of the chloride channelopathy patients and shorter than 30 ms in all of the sodium channelopathy patients. This resulted in a detection rate of over 95%. Myotonic discharges of a single muscle can be used to better guide toward a molecular diagnosis in non-dystrophic myotonic syndromes.

Triceps Brachii in Incomplete Tetraplegia: EMG and Dynamometer Evaluation of Residual Motor Resources and Capacity for Strengthening.

BACKGROUND: Candidates for activity-based therapy after spinal cord injury (SCI) are often selected on the basis of manual muscle test scores and the classification of the injury as complete or incomplete. However, these scores may not adequately predict which individuals have sufficient residual motor resources for the therapy to be beneficial. OBJECTIVE: We performed a preliminary study to see whether dynamometry and quantitative electromyography (EMG) can provide a more detailed assessment of residual motor resources. METHODS: We measured elbow extension strength using a hand-held dynamometer and recorded fine-wire EMG from the triceps brachii muscles of 4 individuals with C5, C6, or C7 level SCI and 2 able-bodied controls. We used EMG decomposition to measure motor unit action potential (MUAP) amplitudes and motor unit (MU) recruitment and firing-rate profiles during constant and ramp contractions. RESULTS: All 4 subjects with cervical SCI (cSCI) had increased MUAP amplitudes indicative of denervation. Two of the subjects with cSCI had very weak elbow extension strength (<4 kg), dramatically reduced recruitment, and excessive firing rates (>40 pps), suggesting profound loss of motoneurons. The other 2 subjects with cSCI had stronger elbow extension (>6 kg), more normal recruitment, and more normal firing rates, suggesting a substantial remaining motoneuron population. CONCLUSIONS: Dynamometry and quantitative EMG may provide information about the extent of gray matter loss in cSCI to help guide rehabilitation strategies.

History dependence of human muscle-fiber conduction velocity during voluntary isometric contractions.

The conduction velocity (CV) of a muscle fiber is affected by the fiber's discharge history going back ∼1 s. We investigated this dependence by measuring CV fluctuations during voluntary isometric contractions of the human brachioradialis muscle. We recorded electromyogram (EMG) signals simultaneously from multiple intramuscular electrodes, identified potentials belonging to the same motor unit using EMG decomposition, and estimated the CV of each discharge from the interpotential interval. In 12 of 14 subjects, CV increased by ∼10% during the first second after recruitment and then fluctuated by about ±2% in a way that mirrored the fluctuations in the instantaneous firing rate. The CV profile could be precisely described in terms of the discharge history by a simple mathematical model. In the other two subjects, and one subject retested after cooling the arm, the CV fluctuations were inversely correlated with instantaneous firing rate. In all subjects, CV was additionally affected by very short interdischarge intervals (<25 ms): it was increased in doublets at recruitment, but decreased in doublets during continuous firing and after short interdischarge intervals in doubly innervated fibers. CV also exhibited a slow trend of about -0.05%/s that did not depend on the immediate discharge history. We suggest that measurements of CV fluctuations during voluntary contractions, or during stimulation protocols that involve longer and more complex stimulation patterns than are currently being used, may provide a sensitive approach for estimating the dynamic characteristics of ion channels in the human muscle-fiber membrane.

The innervation and organization of motor units in a series-fibered human muscle: the brachioradialis.

We studied the innervation and organization of motor units in the brachioradialis muscle of 25 normal human subjects. We recorded intramuscular EMG signals at points separated by 15 mm along the proximodistal muscle axis during moderate isometric contractions, identified from 27 to 61 (mean 39) individual motor units per subject using EMG decomposition, and estimated the locations of the endplates and distal muscle/tendon junctions from the motor-unit action potential (MUAP) propagation patterns and terminal standing waves. In three subjects all the motor units were innervated in a single endplate zone. In the other 22 subjects, the motor units were innervated in 3-6 (mean 4) distinct endplate zones separated by 15-55 mm along the proximodistal axis. One-third of the motor units had fibers innervated in more than one zone. The more distally innervated motor units had distinct terminal waves indicating tendonous termination, while the more proximal motor units lacked terminal waves, indicating intrafascicular termination. Analysis of blocked MUAP components revealed that 19% of the motor units had at least one doubly innervated fiber, i.e., a fiber innervated in two different endplate zones by two different motoneurons, and thus belonging to two different motor units. These results are consistent with the brachioradialis muscle having a series-fibered architecture consisting of multiple, overlapping bands of muscle fibers in most individuals and a simple parallel-fibered architecture in some individuals.

Electrophysiological evidence of doubly innervated branched muscle fibers in the human brachioradialis muscle.

OBJECTIVE: Motor-unit action potentials (MUAPs) with unstable satellite (late-latency) components are found in EMG signals from the brachioradialis muscles of normal subjects. We analyzed the morphology and blocking behavior of these MUAPs to determine their anatomical origin. METHODS: EMG signals were recorded from the brachioradialis muscles of 5 normal subjects during moderate-level isometric contractions. MUAP waveforms, discharge patterns, and blocking were determined using computer-aided EMG decomposition. RESULTS: Twelve MUAPs with unstable satellite potentials were detected, always two together in the same signal. Each MUAP also had a second unstable component associated with its main spike. The blocking behavior of the unstable components depended on how close together the two MUAPs were when they discharged. CONCLUSIONS: The latencies and blocking behavior indicate that the unstable components came from branched muscle fibers innervated by two different motoneurons. The satellite potentials were due to action potentials that traveled to the branching point along one branch and back along the other. The blockings were due to action-potential collisions when both motoneurons discharged close together in time. SIGNIFICANCE: Animal studies suggest that branched muscle fibers may be a normal characteristic of series-fibered muscles. This study adds to our understanding of these muscles in humans.

EMGLAB: an interactive EMG decomposition program.

This paper describes an interactive computer program for decomposing EMG signals into their component motor-unit potential (MUP) trains and for averaging MUP waveforms. The program is able to handle single- or multi-channel signals recorded by needle or fine-wire electrodes during low and moderate levels of muscular contraction. It includes advanced algorithms for template matching, resolving superimpositions, and waveform averaging, as well as a convenient user interface for manually editing and verifying the results. The program also provides the ability to inspect the discharges of individual motor units more closely by subtracting out interfering activity from other MUP trains. Decomposition accuracy was assessed by cross-checking pairs of signals recorded by nearby electrodes during the same contraction. The results show that 100% accuracy can be achieved for MUPs with peak-to-peak amplitudes greater than 2.5 times the rms signal amplitude. Examples are presented to show how decomposition can be used to investigate motor-unit recruitment and discharge behavior, to study motor-unit architecture, and to detect action potential blocking in doubly innervated muscle fibers.

Validation of a computer-aided EMG decomposition method.

This paper presents an objective assessment of the accuracy of EMGLAB, a computer-aided EMG decomposition program that we developed. EMG signals were recorded simultaneously using monopolar needle and fine-wire electrodes from nearby sites in the tibialis anterior muscle during moderate isometric contractions. The signals were decomposed independently by an experienced operator, yielding 3-12 (mean 8.7) motor-unit action potential (MUAP) trains per signal. Decomposition accuracy was estimated by crosschecking 83 pairs of trains from different signals that corresponded to the same motor units. The results show that EMGLAB was able to decompose large MUAPs (peak amplitudes greater than 2.5 times rms signal amplitude) with 98-100% accuracy, and smaller MUAPs with 80-100% accuracy. Many of the errors involved misalignment of small MUAPs within superimpositions and amounted to less than 5 ms. These results validate the accuracy of EMGLAB for decomposing EMG signals of moderate complexity.

Increased jitter and blocking in normal muscles due to doubly innervated muscle fibers.

Increased jitter and intermittent impulse blocking in electromyographic (EMG) signals are considered evidence of transmission abnormality and are not usually associated with normal muscle. However, motor unit action potentials (MUAPs) that exhibit increased jitter and blocking have recently been shown to occur in the brachioradialis muscles of neurologically healthy subjects. The jitter and blocking result from collisions, refractoriness, and conduction-velocity variability in long muscle fibers that are innervated by two different motoneurons at widely separated endplates. We analyzed MUAPs obtained by decomposing EMG signals from the brachioradialis muscles of four normal subjects. The rate of blocking of some MUAP components was as high as 28%, the jitter between some components exceeded 300 micros (mean consecutive difference), and the mean incidence of irregular MUAPs was 14%. These values would be considered abnormal in many other muscles. Jitter from doubly innervated fibers can be distinguished from other types of pathological jitter because one component exhibits amplitude variability. Clinical neurophysiologists should be aware that increased jitter and blocking do not necessarily indicate pathology in brachioradialis and perhaps other long, parallel-fibered muscles.

Electrophysiological evidence of adult human skeletal muscle fibres with multiple endplates and polyneuronal innervation.

Electromyographic (EMG) signals were recorded using intramuscular electrodes at six different sites in the brachioradialis muscles during voluntary isometric contractions in four subjects. The potential waveforms and discharge patterns of up to 12 simultaneously active motor units were identified from each signal using computer-aided decomposition. Out of a total of 301 motor unit potentials identified, 23 potentials exhibited behaviour consistent with having been generated by muscle fibres that were innervated by two different motoneurons at widely separated endplates. These potentials discharged in association with two different motor units, but were blocked or delayed whenever the two motor units discharged within a few milliseconds of one another. The blocking was consistent with a collision or refractoriness when one motoneuron tried to excite the fibre while it was already conducting an action potential initiated by the other motoneuron. The delays were consistent with decreased conduction velocity associated with incomplete recovery of the fibre after a preceding action potential. From the temporal separation between the discharges of the two motoneurons that resulted in blocking, the spatial separation between the endplates was estimated to be between 26 and 44 mm. These findings challenge the classical concept of the motor unit as an anatomically distinct and functionally independent entity. It is suggested that the human brachioradialis muscle may contain both long, polyneuronally innervated fibres and short, serially linked, singly innervated fibres.