The threshold tracking nerve conduction study technique: Experience of clinical users unfamiliar with a research-grade neuronal excitability system.

Objective: To 1) explore if clinical electrophysiologists with different degrees of experience performing standard nerve conduction studies could run a threshold tracking nerve conduction study (TTNCS) protocol and 2) learn how clinical users view a research-grade TTNCSs neuronal excitability system. Methods: Five clinical electrophysiologists conducted a TTNCS session using QTracS and then completed a questionnaire describing their impressions. Results: All of the electrophysiologists completed the QTracS protocol on an initial attempt. Perceived strengths comprised the ease of preparatory steps and quick protocol speed. Identified drawbacks included an unwieldly user-interface. The electrophysiologists indicated that knowledge of TTNCS principles and applications would be critical for incorporation of the method into clinical use. Conclusions: This pilot study suggests that clinical electrophysiologists can carry out TTNCSs with a research-grade system. The development of a more user-friendly program, along with dedicated education and training, could lead to wider application of the TTNCS technique. Significance: Considered together with clinical presentation and other biomarkers, increased use of TTNCSs could provide improved assessment of neuromuscular disease and treatment response.

Quantitative ultrasound of the tongue: Echo intensity is a potential biomarker of bulbar dysfunction in amyotrophic lateral sclerosis.

OBJECTIVES: To learn if quantitative ultrasound (QUS) distinguishes the tongues of healthy participants and amyotrophic lateral sclerosis (ALS) patients by echo intensity (EI) and to evaluate if EI correlates with measures of bulbar function. METHODS: Ultrasound was performed along the midline of the anterior tongue surface in 16 ALS patients and 16 age-matched controls using a linear hockey stick 16-7 MHz transducer. A region of interest was manually drawn and then EI was determined for the upper 1/3 of the muscle. For patients, the ALS functional rating scale - revised (ALSFRS-R) was used to calculate bulbar sub-scores and the Iowa Oral Performance Instrument (IOPI) was used to measure tongue strength. RESULTS: EI was significantly higher in ALS patients than in healthy participants (49.8 versus 37.8 arbitrary units, p < 0.01). In the patient group, EI was negatively correlated with ALSFRS-R bulbar sub-score (RS = -0.65, p < 0.01). An inverse correlation between EI and tongue strength did not reach significance (RS = -0.34, p = 0.28). CONCLUSIONS: This study suggests that EI can differentiate healthy from diseased tongue muscle, and correlates with a standard functional measure in ALS patients. SIGNIFICANCE: Tongue EI may represent a novel biomarker for bulbar dysfunction in ALS.

Approximate complex electrical potential distribution in the monodomain model with unequal conductivity and relative permittivity anisotropy ratios.

OBJECTIVE: Electrical conductivity and relative permittivity are properties that indicate muscle health and they have different values parallel and perpendicular to the direction of the myofiber, a concept known as anisotropy. When the intrinsic electrical properties of muscle have ratios of anisotropy that are different then there is no analytical solution that can describe the electrical potential distribution in the tissue. APPROACH: Here, we present approximate analytical solutions to monodomain equations with unequal anisotropy ratios. For this, we base our analysis on perturbation theory where the electrical potential is approximated by the sum of the zeroth- and first-order terms of an infinite series. MAIN RESULTS: The validity of the approach is confirmed using experimental data for healthy and diseased muscle available online. SIGNIFICANCE: A better understanding of electrical potential distribution in anisotropic skeletal muscle tissue will allow the development of improved diagnostic tools for neuromuscular diseases.

Three-harmonic optimal multisine input power spectrum for bioimpedance identification.

OBJECTIVE: The attention towards optimal signals for measuring electrical bioimpedance (EBI) has increased recently due to the many advantages they offer such as, for example, reduced measuring time. Here, the design of a three-harmonic optimized multisine input power spectrum for measuring bioimpedance is considered. APPROACH: The approach is based on designing the input power spectrum multisine excitation by optimizing a scalar function of the information matrix using the Fricke-Morse model. MAIN RESULTS: Simple analytical equations are provided that can be adopted by the reader to optimize the multisine input power spectrum to satisfy any specific application-related EBI measurement. SIGNIFICANCE: The presented signal may be a good choice of excitation signal in EBI applications where optimal excitation power spectrum is desired.

Permittivity of ex vivo healthy and diseased murine skeletal muscle from 10 kHz to 1 MHz.

A better understanding of the permittivity property of skeletal muscle is essential for the development of new diagnostic tools and approaches for neuromuscular evaluation. However, there remain important knowledge gaps in our understanding of this property in healthy and diseased skeletal muscle, which hinder its translation into clinical application. Here, we report the permittivity of gastrocnemius muscle in healthy wild type mice and murine models of spinal muscular atrophy, muscular dystrophy, diabetes, amyotrophic lateral sclerosis and in a model of myofiber hypertrophy. Data were measured ex vivo from 10 kHz to 1 MHz using the four-electrode impedance technique. Additional quantitative histology information were obtained. Ultimately, the normative data reported will offer the scientific community the opportunity to develop more accurate models for the validation and prediction of experimental observations in both pre-clinical and clinical neuromuscular disease research.

New electrical impedance methods for the in situ measurement of the complex permittivity of anisotropic skeletal muscle using multipolar needles.

This paper provides a rigorous analysis on the measurement of the permittivity of two-dimensional anisotropic biological tissues such as skeletal muscle using the four-electrode impedance technique. The state-of-the-art technique requires individual electrodes placed at the same depth in contact with the anisotropic material, e.g. using monopolar needles. In this case, the minimum of measurements in different directions needed to estimate the complex permittivity and its anisotropy direction is 3, which translates into 12 monopolar needle insertions (i.e. 3 directions × 4 electrodes in each direction). Here, we extend our previous work and equip the reader with 8 new methods for multipolar needles, where 2 or more electrodes are spaced along the needle's shaft in contact with the tissue at different depths. Using multipolar needles, the new methods presented reduce the number of needle insertions by a factor of 2 with respect to the available methods. We illustrate the methods with numerical simulations and new experiments on ex vivo ovine skeletal muscle (n = 3). Multi-frequency longitudinal and transverse permittivity data from 30 kHz to 1 MHz is made publicly available in the supplementary material. The methods presented here for multipolar needles bring closer the application of needle electrical impedance to patients with neuromuscular diseases.

Recording characteristics of electrical impedance-electromyography needle electrodes.

OBJECTIVE: Needle EMG remains the standard clinical test for neuromuscular disease (NMD) assessment, but it only characterizes myofiber membrane depolarization. On the other hand, electrical impedance provides non-electrically active structural and compositional data of tissues. Here, we designed a prototype of needle electrode integrating electrical impedance and EMG measurement capabilities, the so-called I-EMG needle electrode. APPROACH: We use finite element method models to study the impedance recording characteristics of I-EMG needle electrodes. The simulated electrical and mechanical design specifications are then manufactured to create a prototype of an I-EMG needle electrode. We pilot these new needle electrodes by conducting in vivo impedance measurements with muscle at rest on healthy wild-type (wt, n = 5) and muscular dystrophy (mdx, n = 5) mice. Comparisons between wt and mdx mice are performed using Mann-Whitney test, two-tailed, p < 0.05. The electrical characterization of the EMG electrode in the developed I-EMG needles was performed in vitro on saline solution and through EMG detection in wt animal at rest and during voluntary contractions. RESULTS: Muscle impedance demonstrate good repeatability (p < 0.05 and p < 0.005 for resistance and reactance at 50 kHz, respectively) and agreement between different I-EMG needles. Impedance data allows us to discriminate between mdx and wt muscle (p < 0.05 and p < 0.005 for resistance and reactance at 10 kHz, respectively). EMG broadband noise power and peak amplitude using the I-EMG needle were similar to that of a commercial monopolar EMG needle. EMG recordings using the I-EMG needle measured electrical activity similar to a standard monopolar needle with muscle at rest and during voluntary contraction. SIGNIFICANCE: Needle I-EMG technology may offer the opportunity to enhance the diagnostic capability and quantification of NMD beyond that possible with either impedance or EMG techniques separately. Ultimately, needle I-EMG could serve as a new bedside tool to assess NMD without increasing the complexity or duration of the EMG test.

New electrical impedance methods for the in situ measurement of the complex permittivity of anisotropic biological tissues.

The capability of measuring the complex permittivity of tissues has the potential to provide valuable new insights to inform medical assessment and diagnosis. However, existing electrical impedance approaches have practical limitations when aiming to measure tissues' anisotropy with accuracy. Here we present new methods that overcome the limitations of previous approaches by modeling the anisotropy in both the resistivity and reactivity of tissues measured in three or more different directions. These new methods are validated with numerical simulations and in situ experiments on healthy ovine skeletal muscle. The obtained data between 3 kHz and 1 MHz are also made publicly available in the supplementary information.

Recording characteristics of electrical impedance myography needle electrodes.

OBJECTIVE: Neurologists and physiatrists need improved tools for the evaluation of skeletal muscle condition. Here we evaluate needle electrical impedance myography (EIM), a new minimally invasive approach to determine muscle status that could ultimately become a bedside tool for the assessment of neuromuscular disorders. APPROACH: We design and study the recording characteristics of tetrapolar EIM needle electrodes combining theory and finite-element model simulations. We then use these results to build and pilot in vivo an EIM needle electrode in the rat gastrocnemius muscle ([Formula: see text]). The dielectric properties of muscle are reported (mean ± standard deviation). RESULTS: The numerical simulations show that the contribution of subcutaneous fat and muscle tissues to needle EIM data is <3% and >97%, respectively, and the sensed volume is [Formula: see text] cm3. Apparent resistivity [Formula: see text] [Formula: see text] cm and relative permittivity [Formula: see text] (dimensionless) measured at 10 kHz are in good agreement with in vivo dielectric properties reported in the literature. SIGNIFICANCE: The results presented show the feasibility of measuring muscle impedivity in vivo using a needle electrode from 10 kHz to 1 MHz. The development of needle EIM technology can open up a new field of study in electrodiagnostic medicine, with potential applications to both disease diagnosis and biomarker assessment of therapy.

Circular motion analysis of time-varying bioimpedance.

This paper presents a step forward towards the analysis of a linear periodically time-varying (PTV) bioimpedance ZPTV(jw, t), which is an important subclass of a linear time-varying (LTV) bioimpedance. Similarly to the Fourier coefficients of a periodic signal, a PTV impedance can be decomposed into frequency dependent impedance phasors, [Formula: see text], that are rotating with an angular speed of wr = 2πr/TZ. The vector length of these impedance phasors corresponds to the amplitude of the rth-order harmonic impedance |Zr( jw)| and the initial phase is given by Φr(w, t0) = [Symbol: see text]Zr( jw) + 2πrt0/TZ, with t0∈[0, T] being a time instant within the measurement time T. The impedance period TZ stands for the cycle length of the bio-system under investigation; for example, the elapsed time between two consecutive R-waves in the electrocardiogram or the breathing periodicity in case of the heart or lungs, respectively. First, it is demonstrated that the harmonic impedance phasor [Formula: see text], at a particular measured frequency k, can be represented by a rotating phasor, leading to the so-called circular motion analysis technique. Next, the two dimensional (2D) representation of the harmonic impedance phasors is then extended to a three-dimensional (3D) coordinate system by taking into account the frequency dependence. Finally, we introduce a new visualizing tool to summarize the frequency response behavior of ZPTV( jw, t) into a single 3D plot using the local Frenet-Serret frame. This novel 3D impedance representation is then compared with the 3D Nyquist representation of a PTV impedance. The concepts are illustrated through real measurements conducted on a PTV RC-circuit.

Differentiation of the intracellular structure of slow- versus fast-twitch muscle fibers through evaluation of the dielectric properties of tissue.

Slow-twitch (type 1) skeletal muscle fibers have markedly greater mitochondrial content than fast-twitch (type 2) fibers. Accordingly, we sought to determine whether the dielectric properties of these two fiber types differed, consistent with their distinct intracellular morphologies. The longitudinal and transverse dielectric spectrum of the ex vivo rat soleus (a predominantly type 1 muscle) and the superficial layers of rat gastrocnemius (predominantly type 2) (n = 15) were measured in the 1 kHz-10 MHz frequency range and modeled to a resistivity Cole-Cole function. Major differences were especially apparent in the dielectric spectrum in the 1 to 10 MHz range. Specifically, the gastrocnemius demonstrated a well-defined, higher center frequency than the soleus muscle, whereas the soleus muscle showed a greater difference in the modeled zero and infinite resistivities than the gastrocnemius. These findings are consistent with the fact that soleus tissue has larger and more numerous mitochondria than gastrocnemius. Evaluation of tissue at high frequency could provide a novel approach for assessing intracellular structure in health and disease.

Spaceflight and hind limb unloading induce similar changes in electrical impedance characteristics of mouse gastrocnemius muscle.

OBJECTIVE: To assess the potential of electrical impedance myography (EIM) to serve as a marker of muscle fiber atrophy and secondarily as an indicator of bone deterioration by assessing the effects of spaceflight or hind limb unloading. METHODS: In the first experiment, 6 mice were flown aboard the space shuttle (STS-135) for 13 days and 8 earthbound mice served as controls. In the second experiment, 14 mice underwent hind limb unloading (HLU) for 13 days; 13 additional mice served as controls. EIM measurements were made on ex vivo gastrocnemius muscle. Quantitative microscopy and areal bone mineral density (aBMD) measurements of the hindlimb were also performed. RESULTS: Reductions in the multifrequency phase-slope parameter were observed for both the space flight and HLU cohorts compared to their respective controls. For ground control and spaceflight groups, the values were 24.7±1.3°/MHz and 14.1±1.6°/MHz, respectively (p=0.0013); for control and HLU groups, the values were 23.9±1.6°/MHz and 19.0±1.0°/MHz, respectively (p=0.014). This parameter also correlated with muscle fiber size (ρ=0.65, p=0.011) for spaceflight and hind limb aBMD (ρ=0.65, p=0.0063) for both groups. CONCLUSIONS: These data support the concept that EIM may serve as a useful tool for assessment of muscle disuse secondary to immobilization or microgravity.

Electrical impedance myography for the assessment of children with muscular dystrophy: a preliminary study.

Electrical impedance myography (EIM) provides a non-invasive approach for quantifying the severity of neuromuscular disease. Here we determine how well EIM data correlates to functional and ultrasound (US) measures of disease in children with Duchenne muscular dystrophy (DMD) and healthy subjects. Thirteen healthy boys, aged 2-12 years and 14 boys with DMD aged 4-12 years underwent both EIM and US measurements of deltoid, biceps, wrist flexors, quadriceps, tibialis anterior, and medial gastrocnemius. EIM measurements were performed with a custom-designed probe using a commercial multifrequency bioimpedance device. US luminosity data were quantified using a gray-scale analysis approach. Children also underwent the 6-minute walk test, timed tests and strength measurements. EIM and US data were combined across muscles. EIM 50 kHz phase was able to discriminate DMD children from healthy subjects with 98% accuracy. In the DMD patients, average EIM phase measurements also correlated well with standard functional measures. For example the 50 kHz phase correlated with the Northstar Ambulatory Assessment test (R = 0.83, p = 0.02). EIM 50 kHz phase and US correlated as well, with R = -0.79 (p < 0.001). These results show that EIM provides valuable objective measures Duchenne muscular dystrophy severity.

Electrical impedance alterations in the rat hind limb with unloading.

OBJECTIVES: Methods are needed for quantifying muscle deconditioning due to immobilization, aging, or spaceflight. Electrical impedance myography (EIM) is one technique that may offer easy-to-follow metrics. Here, we evaluate the time course and character of the change in single- and multi-frequency EIM parameters in the hind-limb suspension model of muscle deconditioning in rats. METHODS: Sixty-two rats were studied with EIM during a two-week period of hind limb unloading followed by a two-week recovery period. Random subsets of animals were sacrificed at one-week time intervals to measure muscle fiber size. RESULTS: Significant alterations were observed in nearly all impedance parameters. The 50 kHz phase and multi-frequency phase-slope, created by taking the slope of a line fitted to the impedance values between 100-500 kHz, appeared most sensitive to disuse atrophy, the latter decreasing by over 33.0±6.6% (p<0.001), a change similar to the maximum reduction in muscle fiber size. Impedance alterations, however, lagged changes in muscle fiber size. CONCLUSIONS: EIM is sensitive to disuse change in the rat, albeit with a delay relative to alterations in muscle fiber size. Given the rapidity and simplicity of EIM measurements, the technique could prove useful in providing a non-invasive approach to measuring disuse change in animal models and human subjects.

Circuit modeling of the electrical impedance: I. Neuromuscular disease.

Multifrequency electrical impedance myography (MFEIM) in the 3-300 kHz range was applied to 68 subjects representing 19 different neuromuscular diseases, and the impedances analyzed using the 5-element circuit model. Depending on severity, the 'cellular' parameters r(2), r(3), 1/c(1) and 1/c(2) were found to be as much as 10- to 20-fold larger than for normal subjects (taking age and girth into account), but in almost every case the extracellular fluid parameter r(1) was at most only marginally affected. Strong correlations are found between r(2) and 1/c(1,) but in the case of ALS that breaks down when c(1) (representing the muscle fiber membrane capacitance) falls below half the normal value. Also, c(2) (tentatively associated with intracellular organelle membranes) was found to be the most sensitive to disease progress in ALS, about three times more so than the 50 kHz phase, already suggested for use in clinical drug testing. We conclude that following parameters obtained using the combined MFEIM/5-element circuit analysis scheme offer a reliable, non-invasive and objective way of characterizing muscle in neuromuscular disease or during clinical drug testing.

Circuit modeling of the electrical impedance: II. Normal subjects and system reproducibility.

Part I of this series showed that the five-element circuit model accurately mimics impedances measured using multi-frequency electrical impedance myography (MFEIM), focusing on changes brought on by disease. This paper addresses two requirements which must be met if the method is to qualify for clinical use. First, the extracted parameters must be reproducible over long time periods such as those involved in the treatment of muscular disease, and second, differences amongst normal subjects should be attributable to known differences in the properties of healthy muscle. It applies the method to five muscle groups in 62 healthy subjects, closely following the procedure used earlier for the diseased subjects. Test-retest comparisons show that parameters are reproducible at levels from 6 to 16% (depending on the parameter) over time spans of up to 267 days, levels far below the changes occurring in serious disease. Also, variations with age, gender and muscle location are found to be consistent with established expectations for healthy muscle tissue. We conclude that the combination of MFEIM measurements and five-element circuit analysis genuinely reflects properties of muscle and is reliable enough to recommend its use in following neuromuscular disease.

Multipoint incremental motor unit number estimation as an outcome measure in ALS.

BACKGROUND: Improved outcome measures are necessary to reduce sample size and increase power in amyotrophic lateral sclerosis (ALS) clinical trials. Motor unit number estimation (MUNE) is a potentially attractive tool. MUNE methods previously employed in multicenter trials exhibited excessive variability and were prone to artifact. OBJECTIVE: To evaluate a modification of standard incremental MUNE in a multicenter natural history study of subjects with ALS. METHODS: Fifty healthy subjects were evaluated twice and 71 subjects with ALS were studied repeatedly for up to 500 days. Side and nerve studied was based on clinical examination findings. Nerves were stimulated at 3 specified locations and 3 increments were obtained at each location. Average single motor unit action potential (SMUP) amplitude was calculated by adding the amplitude of the third increment at each location and dividing by 9; SMUP was divided into maximum CMAP amplitude to determine the MUNE. RESULTS: Test-retest variability was 9% in normal subjects. Average MUNE for normal subjects was 225 (±87), and was 41.9 (±39) among subjects with ALS at baseline. Subjects with ALS showed clear decrements over time, with an overage rate of decline of approximately 9% per month. SMUP amplitude increased with time in a fashion consistent with the known pathophysiology of ALS. CONCLUSION: Multipoint incremental MUNE has a number of attributes that make it attractive as an outcome measure in ALS and other diseases characterized by motor unit loss. It can be rapidly performed on any EMG machine and has repeatability and rates of decline that favorably compare to other previously described methods.

Correlation between muscle electrical impedance data and standard neurophysiologic parameters after experimental neurogenic injury.

Previous work has shown that electrical impedance measurements of muscle can assist in quantifying the degree of muscle atrophy resulting from neuronal injury, with impedance values correlating strongly with standard clinical parameters. However, the relationship between such data and neurophysiologic measurements is unexplored. In this study, 24 Wistar rats underwent sciatic crush, with measurement of the 2-1000 kHz impedance spectrum, standard electrophysiological measures, including nerve conduction studies, needle electromyography, and motor unit number estimation (MUNE) before and after sciatic crush, with animals assessed weekly for 4 weeks post-injury. All electrical impedance values, including a group of 'collapsed' variables, in which the spectral characteristics were reduced to single values, showed reductions as high as 47.2% after sciatic crush, paralleling and correlating with changes in compound motor action potential amplitude, conduction velocity and most closely to MUNE, but not to the presence of fibrillation potentials observed on needle electromyography. These results support the concept that localized impedance measurements can serve as surrogate makers of nerve injury; these measurements may be especially useful in assessing nerve injury impacting proximal or axial muscles where standard quantitative neurophysiologic methods such as nerve conduction or MUNE cannot be readily performed.

A portable system for the assessment of neuromuscular diseases with electrical impedance myography.

PRIMARY OBJECTIVE: To create a system for the acquisition of multi-angle, multifrequency muscle impedance data. RESEARCH DESIGN: Device development and preliminary testing. METHODS AND PROCEDURES: The system presented here employs an interrogating signal composed of multiple tones with frequencies between 10 kHz and 300 kHz. The use of a composite signal makes possible measurement of impedance at multiple frequencies simultaneously. In addition, this system takes impedance measurements at multiple orientations with respect to the muscle fibres by means of an electronically reconfigurable electrode array. The required measurement time is reduced by taking advantage of muscle's linearity with respect to the flow of electrical current. MAIN OUTCOMES AND RESULTS: The system was tested in normal subjects, a patient with amyotrophic lateral sclerosis, and one with inclusion body myositis; unique impedance signatures were identified the two patients. CONCLUSIONS: Early data suggest that this system is capable of high-quality data collection and may detect changes in neuromuscular disease; study of additional normal subjects and patients with a variety of neuromuscular diseases is warranted.