NERVE CONDUCTION

VELOCITY
 BASICS
 PRINCIPLES
 ACTION POTENTIAL
 AXONAL TRANSPORT
 TYPES OF CONDUCTION
 CMAP
 SNAP
 VARIABLES
 PRINCIPLES
 Proximal and distal rule

 Same nerve roots but different peripheral

nerves to localize the changes to one or the
other

 Until normal values

 TYPES OF CONDUCTION

 ORTHODROMIC:
 Normal physiological direction

 ANTIDROMIC:
 Opposite to normal physiological direction
 VARIABLES AFFCTING NCV
 PHYSIOLOGICAL  TECHNICAL :

 AGE  STIMULATION;
 TEMPARATURE  FAULTY LOCATION

 SEX OF STIMULATOR
 FAT AND OEDEMA
 DIGIT
CIRCUMFERANCE  BRIDGE

FORMATION
 UPPER VERSUS
BETWEEN ANODE
LOWER LIMB
AND CATHODE
TECH………CONTD…….
RECORDING: IN ADVRETANT
STIMULATION OF
 BREAK IN THE UNWANTED NERVE :
CABLE
 WRONGLY
CONNECTED  VOLUME
AMPLIFIER CONDUCTION
 WRONG SETTINGS  ANAMOLUS
OF GAIN CONDUCTION
,SWEEP,FILTER
 INCORRECT
POSITION OF ACTIVE
OR REFERANCE
NERVE CONDUCTION VELOCITY
 The speed at which the nerve conduct an
impulse
 TYPES OF NCV

 MNCV
 SNCV
 LATE RESPONSES
 H REFLEX
 F WAVE
 AXON REFLEX
 BLINK REFLEX
 TYPES

NCV
MNCV SNCV
LATE RESPONSES
MNCV
 PRINCIPLES OF MNCV

 Orthodromic
 Motor or mixed nerve is stimulated at least at
two points along it course
 Pulse is adjusted to get CMAP
 A Biphasic action potential should be
recorded
 Supra maximal stimulation should be used
ELECTRODE PLACEMENTS
 RECORING :
 PICK UP : Muscle belly (motor points)
 REFERENCE :Tendon(3 cm distal to pick up)
 GROUND : In between pickup and stimulating
 STIMULATING :
 Cathode – active – black - closer to pick up
 Anode – inactive - red
MACHINE SETTING
 Square wave pulse
 Duration-0.1ms
 Frequency-1 pulse /sec
 Intensity-5 – 40mA or 100 -300 V
 Diseased nerve-75mA or 500 V
 Filter setting-5HZ – 10KHZ
 Sweep speed-2 -5 ms/div
MEASUREMENTS
 Onset latency

 Duration

 Amplitude

 Conduction velocity
WAVE FORMS
LATENCY
 Time in ms from the stimulus artifact to the
first negative deflection of CMAP
 Measure of fastest conducting motor fibers
 It includes RESIDUAL LATENCY
 Measured in ms
AMPLITUDE
 Base line to negative peak
 Peak to peak
 Co relates with the number of nerve fibers
 Measured in mV
DURATION
 Initial take off from the base line to final return
to the baseline
 Co relates with the density of small nerve
fibers
 Measured in ms
CONDUCTION VELOCITY

 Conduction velocity is determined by dividing

the distance between the two cathodal
stimulation points by the difference between
the two latencies
Conduction distance
 CV =
Proximal –distal latency
 Meters / seconds
 NORMAL VALUES

 In between 45-70 m/sec

 Upper limbs-60 m/sec (average)
 Lower limbs -50 m/sec (average)
SNCV
 PRINCIPLES OF SNCV
 Orthodromic or Antidromic

 Orthodromic:
 Digital nerve is stimulated and SNAP recorded
at a proximal point along the nerve

 Antidromic:
 The nerve is stimulated at a proximal point
and SNAP recorded distally.
 ELECTRODE PLACEMENTS
ORTHODROMIC STUDY
 Ring electrodes – Stimulation
 Surface electrodes - recording
 Stimulating :
 Cathode – 1st IP joint
 Anode – 3cm distal
 Recording :
 Pick up – proximal point
 Reference – 3cm proximal
 Ground – in b/w stimulating and recording
ANTIDROMIC STUDY (REVERSE)
 Surface electrodes – stimulating
 Ring electrode – recording
 Stimulating :
 Cathode –proximal point
 Anode -3 cm proximal
 Recording :
 Pick up – 1st pip joint
 reference -3 cm distal
 Ground –in b/w stimulating and recording
 MACHINE SETTINGS

 Filter – 10 Hz – 2kHz
 Sweep speed -1-2ms/div
 Gain – 1-5 µV /div
 MEASUREMENTS

 Onset latency
 Amplitude
 Duration
 Conduction velocity
WAVE FORM
 ONSET LATENCY
 Stimulus artifact to the initial positive or
subsequent negative peak
 Measured in ms
 DURATION
 Initial take off from the baseline to final return
to the baseline
 It represents the number of slow conducting
fibers
 Measured in ms
 AMPLITUDE

 Base line to negative peak or Positive to

negative peak
 It represents the density of nerve fibers
 Measured in mV
 CONDUCTION VELOCITY
 SNCV is calculated dividing the distance
(mm) between stimulating and recording site
by the latency

Distance
 CV =
latency

 Meters / seconds
 ABNORMAL NCV
 Degeneration – amplitude reduction
 Demyelination – latency prolongation
LATE RESPONSES
 Late responses are the potentials appearing after motor
response (M wave) following a mixed nerve stimulation
 TYPES

 H reflex
 F wave
 Axon reflex
F WAVE
 F WAVE

It is a late response resulting from Antidromic

activation of alpha motor neuron involving
conduction to and from spinal cord and occurs at
the interface between the peripheral and central
nervous system
 F WAVE
 Reference to “foot” : originally recorded in
small foot muscle.
 With supramaximal stimulus elicits an F wave
in a distal muscle that follows the CMAP
 Impulse travels antidromically to the spinal
cord and the F wave is produced by
backfiring of motor neurons.
 An average of 5–10% of the motor neurons
available in the motor neuron pool backfire
after each stimulus.
 Test the integrity of the entire motor axons,
including the ventral roots.
 Need to average the around 10 stimulus
 Latency Prolonged in
 Polyneuropathies
 GBS & chronic inflammatory demyelinating
polyneuropathy (CIDP)
 Very limited use in radiculopathies.
PHYSIOLOGY OF F WAVE
WAVE FORMS
 HISTORICAL BACKGROUND

 Magladery and mc dougal – 1950 ( CMT )

 Small muscles in the foot
 De afferented man
 Not a reflex
 Proximal motor pathway
 FACTORS AFFECTING
F WAVE
 Renshaw cell inhibition

 Maximum voluntary contraction

 Tension
 METHODS

 Supra maximal stimulation ( 25 % )

 Stimulus rate more than 0.5
 Cathode should be proximal to anode
 It is recorded from any distal muscle by
stimulating appropriate nerve
 RECORDING

 Electrode placements – same as MNCV

Machine settings:
 Amplifier gain – 200 -300 microvolts /division
 Sweep speed – 5-10 ms / division
 PROCEDURE

 Relaxed
 slight voluntary contraction
 Amplitude of more than 20 micro volts
 10 – 20 responses
 persistence
 PARAMETERS

 Latency
 Chronodispersion
 Persistence
 Amplitude
 F/M ratio
 Conduction velocity
WAVE FORMS
 LATENCY

 Minimal latency
 Maximal latency
 Mean or median latency
 Age, height, limb length
 31 ms in hand, 61 ms in foot
 Right to left symmetry is more than 2 ms in
hand and 4 ms in foot – abnormal
 CHRONODISPERSION

 Difference between minimal latency and

maximal latency
 Measure of range of conduction of F wave
 ABP – 3.6 +/- 1.2
 ADM – 3.3 +/- 1.1
 EDB – 6.4 +/- 0.8
 PERSISTENCE

 Number of occurrence divided by number of

stimuli
 Measure of antidromic excitability of particular
motor neuron pool
 AMPLITUDE

 Depends on the number and size of the

motor unit
 5 % of M wave
 Mean amplitude
 Excitability of alpha motor neuron
 F/M RATIO

 Proportion of motor neuron pool activated by

antidromic stimulation
 To use mean rather than maximum F
amplitude for calculating F/M ratio
 ADM – O.8
 Ad H – 0.9
 CONDUCTION VELOCITY
 stimulus site to C7 spinous process via the
axilla and mid clavicular point
 Stimulus site to T12 spinous process via knee
and greater trochanter of the femur
( 2D )
 FWCV =
(F–M–1)
 CLINICAL APPLICATIONS

 Proximal motor pathway

 Segmental motor neuron excitability
 It is more precise for assessment of
segmental motor neuron excitability than H
and T reflex
 LMN
latency
 Changes in peripheral nerve and root lesion
F/M ratio
 Increased in both poly neuropathy and spasticity
persistence
 Absent or reduced in GBS, ALS, proximal nerve root
injury
choronodispersion
 Increased in poly neuropathy ( demyelinating )
 UMN
Amplitude and Persistence

 Initial stage – Decreased

 Chronic stage – Increased

 latency also prolonged while duration and

amplitude increased in UMN
H REFLEX
 H- REFLEX

The H - reflex is a monosynaptic reflex elicited

by sub maximal stimulation of the tibial nerve
and recorded from calf muscles

 Hoffman 1918
PHYSIOLOGY OF H REFLEX
 REFLEX ARC

 1 a fibers
 Spinal cord
 Alpha motor neuron
 It does not include muscle spindle
 H reflex is larger at submaximal stimulation
 Inhibited by stronger stimulation
Due to collision of orthodromic impulses by
antidromic conduction in motor axons
 MODIFYING FACTORS

 Renshaw cell inhibition

 Supraspinal mechanism
 Inhibition by adjacent motor neuron
 VARIATIONS

 In normal adults – other muscles except small

muscles of hand and feet
 In childrens – below 2 years
METHODS
 ELECTRODE PLACEMENTS
 Position :
Semi reclining or prone
 Recording :
Active - Distal edge of calf
Reference - Tendon
 Stimulating :
popleteal fossa
 MACHINE SETTINGS
STIMULATION
 Square wave pulse of 1 ms
 Stimuli below 0.1 ms will stimulate motor
axons
 Cathode is kept proximal to anode
 Stimulus frequency should not exceed 1 in 5
seconds
 PROCEDURE
 The stimuli is adjusted to evoke maximum H
response amplitude
 At this strength a small M response may also
present
 M response – help to monitor the strength of
stimuli
 At least 5 H response required for analysis
 By increasing the stimuli strength to supra
maximal maximum M responses can be
recorded
 3 M responses required for analysis
 PARAMETERS

 latency
 H - amplitude
 M wave
 H / M ratio
 H - Vibratory inhibition
 H – TA
 Conduction velocity
WAVE FORMS
 NORMAL VALUES

Latency 30.3 +/- 1.7

Amplitude 9.8 +/- 6.1

M wave 24.6 +/- 6.6

H/M ratio 0.4 +/- 0.2

H vib 42.9 +/- 18.2

H - TA 39.9 +/- 31.1

 LATENCY

 Measured in ms
 Soleus – 35 ms, FCR – 20 ms
 Age, height, limb length
 Right to left asymmetry up to 1.5 ms
 Latency in full term infant is 15.94 +/- 1.45
 AMPLITUDE

 Base to peak of the negative phase

 Measured in mV
 Alpha motor neuron excitability
 H / M - RATIO

 The ratio of peak to peak maximum H reflex

to maximum M amplitude
 To estimate the motor neuron pool activation
 Less than 0.7
 TONIC VIBIRATION REFLEX
VIBIRATORY INHIBITION
 Achilles tendon is vibrated for 1 minute at 100
Hz
 Normal – amplitude decreases
 UMN lesion – there is no decrease in
amplitude
 Due to the vibratory inhibition is less than
normal
VIBRATORY INHIBITION
RECIPROCAL INHIBITION
 CONDUCTION VELOCITY

 The distance between knee and T11 by the

latency difference between H reflex and M
response
 CLINICAL APPLICATIONS
PNS
To evaluate proximal sensory motor pathway
Helpful in plexopathies ,radiculopathies and
neuropathies
latency
 S1 radiculopathy – Absent
 C5 - C6 radiculopathy – Absent
 GBS - absent or delayed or dispersed
CNS
 Understanding the patho physiology
 Excitability of alpha motor neuron
 Amplitude, H/M ratio, H - vibratory inhibition,
H - reciprocal inhibition
 DIFFERENCE
BETWEEN H REFLEX AND F WAVE
 H reflex F wave

Nature Monosynaptic Not a reflex but

reflex due to antidromic
activation of alpha
motor neuron

Best elicited in Soleus, FCR,VM Any distal muscle

Stimulus Sub maximal Supra maximal

Persistence Persistent Variable
Amplitude 50 – 100 % of M 5 % M wave
wave
Useful in Neuropathy,radicul Neuropathy,radicul
opathy,spaticity opathy
BLINK REFLEX
 BLINK REFLEX

 The electrical analog of corneal reflex

 Kugelberg in 1952
 To evaluate trigeminal and facial
 Supra orbital nerve
 Orbicularis oculi
 REFLEX ARC

 Afferent – trigeminal nerve

 Centre – pons
 Efferent – facial nerve
PHYSIOLOGY OF BLINK REFLEX
METHOD
 ELECTRODE PLACEMENTS
Recording :
 Recording - bilaterally over orbicularis oculi
 Reference - side of nasal bone
 Ground - over chin
Stimulating :
 Cathode - supra orbital notch over supra
orbital nerve
 Anode - directed somewhat laterally
 MACHINE SETTINGS

 Gain - 200 – 500 mV/division

 Sweep speed - 10 ms /division
 Stimulus rate - 1 in 3 seconds
 Avoid prolonged studies - R2 Habituated
 Aberrant innervation - lower facial muscles
 RESPONSES

 Ipsilateral side - R1 and R2

 Contra lateral - R2
WAVE FORMS
 PHYSIOLOGICAL MECHANISM
 R 1 - Monosynaptic pathway
 R2 - Poly synaptic pathway
 NORMAL VALUES
Ipsilateral side
 R1 – less than 13 ms
 R2 -- less than 40 ms

Contra lateral side

 R2 – less than 41 ms
 CLINICAL APPLICATIONS

 Abnormal R1 and R2 on the paretic side with

normal contra lateral R2 - ipsi lateral facial
nerve lesion