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Editors: Pease, William S.; Lew, Henry L.; Johnson, Ernest W.
Title: Johnson's Practical Electromyography, 4th Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > II - Technical Aspects of EMG > Chapter 9 - Pictorial Guide to Nerve Conduction Techniques
Chapter 9
Pictorial Guide to Nerve Conduction Techniques
Henry L. Lew
Su-Ju Tsai
Abbreviations for the electrode placement are as follows:
E1 Placement of the active electrode
E2 Placement of the reference electrode
G Placement of the ground electrode
S • Cathode Placement of the cathode for stimulation
• Anode Relation of stimulator anode to the cathode
Cranial Nerves
Table 9-1 Cranial Nerve VII to Nasalis (Fig. 9-1)
Figure 9-1 • Cranial nerve VII
Electrode placement
E1 Over nasalis (lateral side of midnose)
E2 Over contralateral nasalis
G On the cheek or chin
S Postauricular stimulation—behind the lower ear, below the mastoid
process and behind the neck of the mandible
Normal values
Mean ± SD Normal limit
Onset latency
(1)
3.5 ± 0.4 ms ≤4.2 ms
Amplitude (2) ≥1 mV
Note: Alternate recording sites from other facial muscles as needed to evaluate specific
branches of CN VII.
Table 9-2 Blink Reflex (Fig. 9-2)
Electrode placement
E1 Over bilateral orbicularis oculi muscle, lower lateral
portion
E2 Medial inferior orbit
Figure 9-2 • Blink reflex
G Chin
S Cathode At the supraorbital notch
Anode Superiorly
Normal values (3) (n = 83)
Mean ± SD (Normal
limit)
Side-to-side difference
(Normal limit)
R1 latency 10.5 ± 0.8 ms (≤13.0
ms)
0.3 ± 0.9 ms (≤1.2 ms)
Ipsilateral R2 latency 30.5 ± 3.4 ms (≤41.0
ms)
1.0 ± 3.4 ms (≤4.4 ms)
Contralateral R2
latency
30.5 ± 4.4 ms (≤44.0
ms)
Note: Amplitudes are variable.
Table 9-3 Cranial Nerve XI to Trapezius (Fig. 9-3)
Figure 9-3 • Cranial nerve XI
Electrode placement
E1 Over the upper trapezius, midway between C7 spinous process
and acromion.
E2 On acromion
G Medial clavicle
S Cathode At the posterior edge of the
sternocleidomastoid muscle
Anode Superiorly
Normal values (4,5) (n = 30)
Mean ± SD Normal limit
Onset latency 2.2 ± 0.4
ms
≤ 3.0 ms
Peak
amplitude
3.9 ± 1.6
mV
≥ 1.0 mV
Upper Body
Upper Body: Motor Nerves
Table 9-4 Phrenic Nerve (Fig. 9-4)
image
Figure 9-4 • Phrenic nerve
Electrode placement
E1 On the xiphoid process
E2 On the costal margin, at anterior axillary line
G Medial sternum
S Cathode 3 cm above the clavicle, along the posterior border
of the sternocleidomastoid muscle
Anode Superiorly
Normal values (6) (n = 50)
Mean ±
SD
Normal limit
Onset
latency
6.3 ± 0.8
ms
≤8.6 ms
Amplitude 597 ± 139
µV
≥400 µV
Table 9-5A Long Thoracic Nerve-1 to Serratus Anterior (Fig. 9-5A)
Figure 9-5 • A. Long thoracic nerve
Electrode placement (7) (Fig. 9-5A)
E1 Self-adhesive, 8.0 × 0.5-cm, ring-type electrode—cranial end at nipple level (5 cm
distal to the bipolar stimulator) in line with the bipolar stimulator contact points and
the anterior superior iliac spine
E2 Self-adhesive surface electrode over the seventh rib distal to the pectoralis muscle
G Over the ipsilateral latissimus dorsi
S In the axilla just anterior to the midaxillary line
Normal values (7) (n = 15, self-adhesive ring-type electrode recording)
Side Mean ± SD Normal limit
Onset
latency
Right 2.3 ± 0.5 ms ≤3.5 ms
Left 2.3 ± 0.4 ms ≤3.2 ms
Side-to-side difference 0.3 ± 0.2 ms ≤0.6 ms
Amplitude Right 3.8 ± 1.9 mV ≥1.6 mV
Left 3.9 ± 1.9 mV ≥1.2 mV
Side-to-side difference 0.6 ± 0.6 mV ≤2 mV
Table 9-5B Long Thoracic Nerve-2 to Serratus Anterior (Fig. 9-5B)
Figure 9-5 • B. Long thoracic nerve
Electrode placement
E1 A needle electrode is placed into the digitation of the serratus anterior muscle
over the fifth rib, along the midaxillary line.
E2 Two cm distal to the E1 (no need if a concentric needle electrode is used for
E1)
G Over the 12th rib level at the anterior axillary line
S Cathode Slightly above the upper margin of the clavicle lateral to
the clavicular head of the sternocleidomastoid muscle
Anode Superomedially
Normal values (8) (n = 16, concentric needle recording)
Age
(years)
Onset latency
Mean ± SD
Normal limit
20–35 3.6 ± 0.3 ms ≤4.2 ms
36–50 3.8 ± 0.4 ms ≤4.4 ms
51–65 4.0 ± 0.4 ms ≤4.8 ms
Table 9-6 Axillary Nerve to Deltoid (Fig. 9-6)
Figure 9-6 • Axillary nerve
Electrode placement
E1 Midway between acromion and deltoid tubercle
E2 At deltoid tubercle
G Between the stimulating point and active electrode
S Cathode Supraclavicular fossa
Anode Superomedially
Normal values (9) (n = 62)
Mean ± SD Normal limit
Onset latency 3.9 ± 0.5 ms ≤5.0 ms
Note: No information on amplitude is available (9).
Table 9-7 Musculocutaneous Nerve to Biceps (Fig. 9-7)
Figure 9-7 • Musculocutaneous nerve
Electrode placement
E1 Midpoint of the biceps brachii muscle belly
E2 Distal biceps tendon
G Over the acromion
S Cathode Supraclavicular fossa
Anode Superomedially
Normal values (9) (n = 62)
Mean ± SD Normal limit
Onset latency 4.5 ± 0.6 ms ≤5.7 ms
Note: No information on amplitude is available (9).
Table 9-8 Suprascapular Nerve (Fig. 9-8)
Figure 9-8 • Suprascapular nerve
Electrode placement
E1 A concentric recording needle (E2 = reference/outer cannular of needle)
Supraspinatus: Insert the needle just above the scapular spine at the
midpoint. Advance the needle in a downward and forward direction until
the needle touches the scapula, then withdraw it 2–3 mm. Infraspinatus:
Insert the needle 3 cm below the scapular spine and 3 cm lateral to the
medial border of the scapula.
G Over the posterolateral shoulder
S Cathode Supraclavicular fossa
Anode Superomedially
Normal values (9) (n = 62)
Onset latency Mean ± SD Normal limit
Supraspinatus
recording
2.7 ± 0.5 ms ≤3.7 ms
Infraspinatus
recording
3.3 ± 0.5 ms ≤4.2 ms
Note: No information on amplitude is available (9).
Table 9-9 Thoracodorsal Nerve to Latissimus Dorsi (Fig. 9-9)
Figure 9-9 • Thoracodorsal nerve
Electrode placement (10)
E1 Supine position with the arm abducted to 90 degrees. E1 is on the posterior
axillary line at the intersection of the line horizontally drawn from the inferior
angle of the scapula.
E2 On the posterior axillary line distal to E1
G On the chest wall, between E1 and S1
S1 Cathode In the axilla toward the lateral margin of the
scapula
Anode Superior
S2 Cathode Erb's point
Anode Superior
Normal values (10) (n = 30)
Mean ± SD Range
Axilla
(S1)
Onset latency 1.9 ± 0.4 ms ≤2.7 ms
Amplitude, right 4.1 ± 1.8 mV ≥1.4 mV
Erb's
point
(S2)
Onset latency 3.6 ± 0.4 ms ≤4.5 ms
Amplitude 6.0 ± 2.0 mV ≥2.0 mV
Table 9-10 Median Nerve to the Abductor Pollicis Brevis (Fig. 9-10)
Figure 9-10 • Median nerve to the abductor pollicis brevis
Electrode placement
E1 Midline between the first
metacarpophalangeal
joint and the first
carpometacarpal joint
E2 Distal to E1 on the first
metacarpophalangeal
joint
G On the dorsum of the
hand
S Cathode S1: 8 cm
proximal
to the E1,
measured
first to the
midpoint
of the
distal wrist
crease and
then on
the line
between
the
tendons of
the flexor
carpi
radialis
and the
palmaris
longus
S2: On the
antecubital
crease, at
the medial
border of
the biceps
brachii
tendon
Anode Proximal
Normal values (11,12) (n = 47)
Mean ±
SD
Normal
limit
Onset
latency
3.7 ±
0.3 ms
≤4.3 ms
Amplitude 13.2 ±
5.0 mV
≥5.0 mV
Nerve
conduction
velocity
56.7 ±
3.8 m/s
≥50 m/s
Normal values (13) (n = 243)
Mean ±
SD
Normal
limit
Onset
latency
3.7 ±
0.5 ms
≤4.7 ms
Amplitude 10.2 ±
3.6 mV
≥3.0 mV
Nerve
conduction
velocity
57 ± 5
m/s
≥47 m/s
Table 9-11 Median Nerve (Anterior Interosseous Branch) to the Pronator Quadratus (Fig. 9-11)
Figure 9-11 • Median nerve (anterior interosseous branch) to the pronator quadratus
Electrode placement
E1 Centrally over the dorsum of the
forearm, 3 cm proximal to the ulnar
styloid
E2 On the medial dorsum of the wrist
over the ulnar styloid process
G On the dorsal forearm, between the E1
and stimulating electrodes
S Cathode On the antecubital
crease, at the medial
border of the biceps
brachii tendon
Anode Proximally
Normal values (14) (n = 52)
Right Left
Onset
latency
3.6 ± 0.4
ms
3.5 ± 0.4 ms
Onset to
peak
amplitude
3.1 ± 0.8
mV
3.1 ± 0.8 mV
Table 9-12 Radial Nerve to the Extensor Digitorum (Fig. 9-12)
Figure 9-12 • Radial nerve to the extensor digitorum
Electrode placement
E1 Proximal third from the antecubital
crease (S1), over the belly of the
extensor digitorum
E2 On the medial dorsum of the wrist over
the ulnar styloid process
G Between the E1 and the S1
S Cathode S1: In the antecubital
fossa just lateral to the
biceps tendon as the
tendon crosses the flexor
crease
S2: In the axilla between
the coracobrachialis and
the long head of the
triceps
Anode Proximally
Normal values (15) (n = 30)
Mean ±
SD
Normal limit
Onset
latency
2.6 ± 0.4
ms
≤3.5 ms
Amplitude 11.2 ±
3.5 mV
≥4.3 mV
Conduction
velocity
68 ± 7.0
m/s
≥54 m/s
Table 9-13 Radial Nerve to the Extensor Indicis Proprius (Fig. 9-13)
Figure 9-13 • Radial nerve—to the extensor indicis proprius
Electrode placement (16)
E1 Concentric needle electrode into the extensor indicis proprius,
at the distal third of the dorsal forearm and on the dorsum of
the ulna (E2 = outer cannula of needle)
G Between E1 and S1, on the dorsum of the forearm
S Cathode S1: In pronation of the forearm; 4 cm proximal
to the needle insertion site, radial border of the
extensor carpi ulnaris muscle
S2: In pronation of the forearm; 5 cm proximal
to the lateral epicondyle, lateral border of the
triceps brachii muscle
S3: Erb Point
Anode Proximally
Normal values (n = 49)
Mean ± SD Normal limit
Distal latency
(17)
2.4 ± 0.5
ms
≤2.9 ms
Conduction
velocity (16)
S1-S2 61.6 ± 5.9
m/s
≥50 m/s
S2-S3 72.0 ± 6.3
m/s
≥60 m/s
Table 9-14 Ulnar Nerve to the Abductor Digiti Minimi (ADM) (Fig. 9-14)
Electrode placement
E1 On the border of the palm and dorsum of the hand, halfway
between the wrist crease and the base of the little finger
E2 Distal to the fifth metacarpophalangeal joint
G On the dorsum of the hand or between the stimulating and
recording electrodes
S Cathode The arm is in a 45 degrees abducted and externally
rotated position with the elbow moderately flexed
to 90–135 degrees (18).
S1: 2 cm proximal to the E1, along the radial border
of the tendon of the flexor carpi ulnaris
S2: 2 cm distal to the ulnar groove at the elbow
S3: 10 cm proximal to the S2, measured in a curve
along the ulnar groove to a point between triceps
and brachialis
S4: 10 cm proximal to S3 in the axilla
Anode Proximally
Figure 9-14 • Ulnar nerve—to the abductor digiti minimi
Normal values (n = 31)
Mean ±
SD
Normal limit
Onset latency (18) 3.2 ± 0.5
ms
≤4.2 ms
Amplitude 6.14 ±
1.90 mV
≥2.3 mV
Nerve conduction
velocity (18,19,20)
S1-S2 61.8 ± 5.0
m/s
≥53 m/s
S2-S3 62.7 ± 5.5
m/s
≥52 m/s
S3-S4 62.8 ± 6.0
m/s
≥51 m/s
Normal values (21) (n = 248)
Mean ±
SD
Normal limit
Distal latency (21) 3.0 ± 0.3
ms
≤3.6 ms
Amplitude, peak to
peak (21)
11.6 ± 2.1
mV
≥7.4 mV
Conduction velocity
(21)
S1-S2 61 ± 5 m/s ≥51 m/s
S2-S3 61 ± 9 m/s ≥43 m/s
S3-S4 61 ± 7 m/s ≥47 m/s
Table 9-15 Ulnar Nerve to the First Dorsal Interosseous (Fig. 9-15)
Electrode placement
E1 On the dorsum of the hand, the first web space, 1 cm radial to the midpoint of the second
metacarpal bone
E2 Over the first metacarpophalangeal joint
G Between E1 and S1
S Cathode At the ulnar wrist crease, along the radial border of the tendon of the flexor
carpi ulnaris
Figure 9-15 • Ulnar nerve—to the first dorsal
interosseous
Anode Proximally
Normal values (22) (n = 373)
Onset latency Amplitude
Age (years) Mean Limit Mean Limit
<20 3.3 ms ≤4.2 ms 15 mV ≥8 mV
20–29 3.4 ms ≤4.1 ms 14 mV ≥8 mV
30–39 3.3 ms ≤4.4 ms 15 mV ≥6 mV
40–49 3.2 ms ≤4.2 ms 13 mV ≥6 mV
50–59 3.4 ms ≤4.4 ms 13 mV ≥6 mV
60–69 3.6 ms ≤4.5 ms 12 mV ≥7 mV
>70 3.6 ms ≤4.2 ms 12 mV ≥8 mV
Note: No summarized values are available (22).
Mean side-to-side difference, FDI = 0.2 ms (0.0–1.3); ipsilateral difference, FDI - ADM = 0.9 ms
(0.2–2.0) (22).
Table 9-16 F Wave in the Upper Extremity (Fig. 9-16)
Figure 9-16 • F wave in the upper extremity
Electrode placement
E1 Median nerve: over the abductor pollicis brevis (see Fig. 9-10)
Ulnar nerve: over the abductor digiti minimi (see Fig. 9-14)
E2 Median nerve: slightly distal to the first metacarpophalangeal joint
Ulnar nerve: distal to the fifth metacarpophalangeal joint
G On the dorsum of the hand
S Cathode Positioned as for standard wrist stimulation (see Figs.
9-10 and 9-14)
Anode Distally with supramaximal stimulation (see Figs. 9-10
and 9-14)
Normal values (23,24) (shortest of 10 stimuli, minimal latency)
Nerve Range Side-to-side differences
Median/APB 22–31 ms ≤2.3 ms
Ulnar/ADM 21–32 ms ≤2.5 ms
Note: Ulnar F wave latency (25) = [arm length (cm) × 0.31] – [ulnar nerve forearm velocity
(m/s) × 0.123] + 11.05. A prolongation of >2.5 ms is considered abnormal.
Upper Body—Sensory Nerves
Table 9-17 Lateral Antebrachial Cutaneous Sensory Nerve (Fig. 9-17)
Figure 9-17 • Lateral antebrachial cutaneous sensory nerve
Electrode placement (26)
E1 On volar aspect of the
forearm, over the radius
bone, 10 cm distal to the
stimulating cathode
E2 3 cm distal to E1
G Between the stimulating
and recording electrodes
S Cathode Just lateral
to the
biceps
tendon on
the
antecubital
crease
Anode Proximally
Normal values (26) (10-cm distance) (n
= 213)
Mean ±
SD
Normal
limit
Peak
latency
2.2 ±
0.2 ms
≤2.6 ms
Onset to
peak
amplitude
18 ± 10
µV
≥3 µV
Normal values (27) (10-cm distance) (n
= 157)
Mean ±
SD
Normal
limit
Peak
latency
2.8 ±
0.2 ms
≤3.3 ms
Onset to
peak
amplitude
18.9 ±
9.9 µV
≥8 µV
Table 9-18 Medial Antebrachial Cutaneous Sensory Nerve (Fig. 9-18)
Figure 9-18 • Medial antebrachial cutaneous sensory nerve
Electrode placement (27)
E1 On volar aspect of the forearm,
over the ulna bone, 14 cm
distal to the stimulating point
E2 3 cm distal to E1
G Between the stimulating and
recording electrodes
S Cathode Along the medial
border of the
biceps brachii
muscle, 5 cm
proximal to the
medial
epicondyle
Anode Proximally
Normal values (27) (n = 157)
Mean ±
SD
Normal limit
Peak
latency
2.7 ±
0.2 ms
≤3.3 ms
Onset to
peak
amplitude
11.4 ±
5.2 µV
≥5 µV
Table 9-19 Median Sensory Nerve to the Second and Third Digits (Fig. 9-19)
Figure 9-19 • Median sensory nerve to the second and third
digits
Electrode placement
E1 A ring electrode is placed distal to the base of the second or third
digit.
E2 4 cm distal to the active electrode
G On the dorsum of the hand
S Cathode S1: 14 cm proximal to E1 on the line between the
tendons of the flexor carpi radialis and the palmaris
longus
S2: The midpoint of the line from E1 to S1
Anode Proximal
Digit 3: Normal values (28) (n = 50)
Mean ± SD Normal limit
Peak latency S1
S2
S2/S1
3.07 ± 0.2 ms
1.58 ± 0.15 ms
52 ± 4%
≤3.5 ms
≤1.88 ms
≥44%
Peak amplitude S1
S2
S2/S1
52 ± 13 µV
67 ± 20 µV
128 ± 29%
≥26 µV
≥37 µV
≤186 %
Digit 3: Normal values (29) (n = 258)
Mean ± SD Normal limit
Onset latency S1
S2
2.7 ± 0.3 ms
1.4 ± 0.2 ms
≤3.3 ms
≤1.8 ms
Peak latency S1
S2
3.4 ± 0.3 ms
2.0 ± 0.4 ms
≤4.1 ms
≤2.8 ms
Onset to peak
amplitude
S1
S2
41 ± 20 µV
43 ± 28 µV
≥10 µV
≥4 µV
Peak to peak
amplitude
S1
S2
63 ± 33 µV
66 ± 43 µV
≥12 µV
≥5 µV
Digit 2: Normal values (29) (n = 258)
Mean ± SD Normal limit
Onset latency S1
S2
2.6 ± 0.3 ms
1.3 ± 0.2
≤3.2 ms
≤1.7 ms
Peak latency S1
S2
3.4 ± 0.3 ms
1.9 ± 0.2 ms
≤4.1 ms
≤2.4 ms
Onset to peak
amplitude
S1
S2
37 ± 19 µV
38 ± 24 µV
≥8 µV
≥4 µV
Peak to peak
amplitude
S1
S2
56 ± 31 µV
53 ± 36 µV
≥9 µV
≥4 µV
Table 9-20 Median and Radial Sensory Nerves to the Thumb (Fig. 9-20)
Figure 9-20 • Median and radial sensory nerves to the thumb
Electrode placement (30,31)
E1 Ring electrode, on the proximal phalanx
E2 Ring electrode, on the distal phalanx
G Dorsum of the hand
S Cathode Sm: Median nerve, 10 cm proximal to E1, in a line
measured first to the midpoint of the distal wrist crease
and then on the line between the tendons of the flexor
carpi radialis and the palmaris longus
Sr: Radial nerve, over the lateral radius, 10 cm proximal to
the active electrode
Anode Proximal
Normal values (30) (n = 78)
Mean ± SD Normal limit
Peak latency Median
Radial
2.5 ± 0.2 ms
2.4 ± 0.2 ms
≤2.9 ms
≤2.8 ms
Baseline to
peak
amplitude
Median
Radial
30 ± 2 µV
12 ± 1 µV
Note: The upper limit of normal differences between the median and radial nerve is latency
difference ≤0.3 ms, and amplitude of median nerve ≥200% amplitude of radial nerve.
Table 9-21 Median and Ulnar Sensory Nerves to the Fourth Digit (Fig. 9-21)
Electrode placement
E1 Ring electrode, on the first metacarpophalangeal joint of the fourth digit
E2 Ring electrode, on the distal interphalangeal joint of the fourth digit
G Dorsum of the hand
S Cathode Sm: Median nerve, 14 cm proximal to E1, in a line measured
first to the midpoint of the distal wrist crease and then to a
point on the line between the tendons of the flexor carpi
radialis and the palmaris longus
Su: Ulnar nerve, 14 cm proximal to E1, along the radial
border of the flexor carpi ulnaris tendon
Anode Proximally
Normal values (32) (n = 37)
Distal
Latency
Side Mean ± SD Normal limit
Figure 9-21 • Median and ulnar sensory nerves to the fourth
digit
Dominant
hand
Median
Ulnar
3.14 ± 0.24 ms
3.03 ± 0.21 ms
≤3.6 ms
≤3.5 ms
Non-
dominant
hand
Median
Ulnar
3.11 ± 0.32 ms
3.01 ± 0.32 ms
≤3.7 ms
≤3.6 ms
Note: The upper limit of normal increase in latency for the median versus ulnar nerve is ≤0.5
ms. No information on amplitude is available (32).
Table 9-22 Radial Sensory Nerve to the Base of the Thumb (Fig. 9-22)
Figure 9-22 • Radial sensory nerve to the base of the thumb
Electrode placement (33)
E1 Over the extensor pollicis longus tendon at the wrist
level
E2 4 cm distal to E1, on the radial side of the second
metacarpal bone
G Between E1 and the stimulating cathode
S Cathode Over the radius, 10 cm proximal to E1
Anode Proximally
Electrode placement (34)
First web space recording
E1 Over the tendon of the extensor pollicis longus tendon
at the apex of the first web space (near the wrist)
E2 On the skin between the heads of the first and second
metacarpal bones
G Dorsal aspect of the hand
S Cathode On the radial side of the forearm, 10
cm proximal to the active electrode
Anode Proximally
Thumb recording
E1 Proximal phalanx of the thumb
E2 Distal phalanx of the thumb
G Dorsal aspect of the hand
S Cathode On the radial side of the forearm, 15–
17 cm proximal to the active
electrode
Anode Proximally
Normal values (33) (n = 49)
Mean ± SD Normal limit
Onset latency 1.8 ± 0.3
ms
≤2.4 ms
Peak latency 2.3 ± 0.4
ms
≤3.1 ms
Peak to peak
amplitude
31 ± 20 µV ≥µV
Normal values (34) (n = 20)
First web space recording (10 cm)
Mean ± SD Normal limit
Onset latency 1.6 ± 0.1
ms
≤1.9 ms
Peak to peak
amplitude
42.2 ± 14.9
µV
≥16.0 µV
Thumb recording (15–17 cm)
Mean ± SD Normal limit
Onset latency 2.8 ± 0.2
ms
≤3.3 ms
Peak to peak
amplitude
12.3 ± 4.9
µV
≥5.0 µV
Table 9-23 Ulnar Sensory Nerve to the Fifth Digit (Fig. 9-23)
Electrode placement
E1 Ring electrode, middle of proximal phalanx of the fifth digit
E2 Ring electrode, on the distal phalanx of the fifth digit, 4 cm distal to E1
Figure 9-23 • Ulnar sensory nerve to the fifth digit
G On the dorsum of the hand
S Cathode S1: 14 cm proximal to E1, along the radial border of the flexor
carpi ulnaris tendon
S2: At the midpoint of the line from E1 to S1
Anode Proximally
Normal values (35) (n = 100)
Mean ± SD Normal limit
Onset latency S1
S2
2.6 ± 0.2 ms
1.4 ± 0.2 ms
≤3.0 ms
≤1.8 ms
Peak latency S1
S2
3.4 ± 0.3 ms
2.0 ± 0.2 ms
≤4.1 ms
≤2.5 ms
Onset to peak
amplitude
S1
S2
32 ± 20 µV
33 ± 17 µV
≥6 µV
≥3 µV
Peak to peak
amplitude
S1
S2
50 ± 32 µV
55 ± 36 µV
≥4 µV
≥4 µV
Table 9-24 Ulnar Dorsal Cutaneous Sensory Nerve (Fig. 9-24)
Figure 9-24 • Ulnar dorsal cutaneous sensory nerve
Electrode placement
E1 Over the proximal point of the “V” formed by the fourth and the fifth
metacarpal bones
E2 Over the fifth metacarpophalangeal joint
G On the dorsum of the hand
S Cathode 8–10 cm proximal to E1 between the ulna and the flexor
carpi ulnaris tendon
Anode Proximally
Normal values (36) (n = 54)
Mean ± SD Normal limit
8-cm study: peak
latency
1.84 ± 0.20
ms
≤2.3 ms
10-cm study: peak
latency
2.09 ± 0.21
ms
≥2.7 ms
Baseline to peak
amplitude
23.5 ± 8.8
µV
≥5.9 µV
Lower Body
Lower Body—Motor Nerves
Table 9-25 Femoral Motor Nerve (Fig. 9-25)
Figure 9-25 • Femoral motor nerve
Electrode placement for surface recording (37)
E1 About 6 cm above from the superior and medial border of the
patella
E2 Over the quadriceps tendon just proximal to the patella
G Between E1 and stimulating cathode
S Cathode S1: Above the inguinal ligament S2: Below the
inguinal ligament The distance between
stimulation points across the inguinal ligament is
5.5 ± 1.6 cm.
Anode Proximally
Normal values (37) (n = 100)
Mean ±
SD
Normal limit
Above the inguinal
ligament latency
7.1 ± 0.7
ms
≤8.5 ms
Below the inguinal
ligament latency
6.0 ± 0.7
ms
≤7.4 ms
Delay across the
inguinal ligament
1.1 ± 0.4
ms
≤1.9 ms
Nerve conduction
velocity above the
inguinal ligament
66.7 ± 7.4
m/s
≥50 m/s
Note: No amplitude data available (37).
Normal values with needle recording (38) (n = 16)
Stimulation at the
inguinal ligament
Mean ±
SD
Normal limit
Latency ligament
latency
4.6 ± 0.5
ms
≤5.5 ms
Amplitude 12.1 ± 1.1
mV
≥2.5 mV
Note: The bipolar surface stimulation electrodes were placed lateral to the point of pulsation
over the inguinal ligament while a concentric needle electrode was inserted into the belly of
the rectus femoris.
Table 9-26 Sciatic Nerve (Fig. 9-26)
Electrode placement (37)
Figure 9-26 • Sciatic nerve
E1 On the extensor digitorum brevis (Fig. 9-27, peroneal portion),
abductor hallucis (Fig. 9-28A, tibial portion), or abductor digiti
minimi (Fig. 9-28B, tibial portion)
E2 See Figures 9-27 and 9-28.
G Between E1 and stimulating cathode
S Cathode S1: Surface stimulation in the popliteal fossa S2:
A long needle electrode in the midway below
the gluteal fold
Anode Proximally
Normal values (39) (n = 18)
Mean ± SD Normal limit
Nerve conduction
velocity to abductor
digiti minimi
51.3 ± 4.4
m/s
≥42 ms
Table 9-27 Peroneal* Motor Nerve to EDB (Fig. 9-27)
Figure 9-27 • Tibial nerve
Electrode placement (40)
E1 On the extensor digitorum brevis muscle, which is 1 cm
distal to the tubercle that is its origin. This is 2–3 cm distal
to the lateral malleolus.
E2 At the fifth metatarsophalangeal joint
G On the dorsum of the foot
S Cathode S1: 8 cm proximal to E1, lateral to the
tibialis anterior tendon S2: Posterior and
inferior to the fibular head S3:
Approximately 10 cm proximal to the S2,
and medial to the tendon of the biceps
femoris
Anode Proximally
Normal values (41) (n = 32)
Mean ±
SD
Normal limit
Onset
latency
4.5 ± 0.8
ms
≤6.0 ms
Amplitude 4.4 ± 1.2
mV
≥2.0 mV
Conduction Velocity
S1-S2 49.9 ±
5.9 m/s
≥40 m/s
S2-S3 51.1 ±
6.3 m/s
≥40 m/s
Normal values (40) (n = 242)
Mean ±
SD
Normal limit
Onset
latency
4.8 ± 0.8
ms
≤6.4 ms
Amplitude 5.9 ± 2.6
mV
≥0.7 mV
Conduction Velocity
S1-S2 47 ± 4
m/s
≥39 m/s
S2-S3 57 ± 9
m/s
≥39 m/s
*Note: No amplitude data available37.
*Peroneal nerve also known as fibular.
Table 9-28 Medial Plantar Motor to Abductor Hallucis (Fig. 9-28A)
Figure 9-28 • A. Tibial nerve (medial plantar)
Electrode placement
E1 1 cm posterior and 1 cm inferior to the navicular tubercle, at
the junction of plantar skin and dorsal foot skin
E2 On the first metatarsophalangeal joint
G Over the dorsum of the foot
S Cathode S1: 8 cm proximal to E1, right behind the
medial malleolus S2: At the popliteal fossa
Anode Proximally
Normal values (42,43) (n = 37)
Mean ± SD Normal limit
Onset latency
(42)
4.8 ± 0.8
ms
≤6.4 ms
Amplitude (43) 11.6 ± 4.3
mV
≥3.0 mV
Conduction
velocity (42)
49.8 ± 6.0
m/s
≥38 m/s
Table 9-28 Lateral Plantar Motor to Abductor Digiti Minimi (Fig. 9-28B)
Figure 9-28 • B. Tibial nerve (lateral plantar)
Electrode placement
E1 Half distance from the sole of the foot to the tip of the lateral
malleolus
E2 On the fifth toe
G Over the dorsum of the foot
S Cathode 8 cm proximal to a site 1 cm posterior and 1 cm
inferior to the navicular tubercle
Anode Proximally
Normal values (44) (n = 10)
Mean ± SD Normal limit
Onset
latency
4.4 ± 0.5
ms
≤5.4 ms
Amplitude
(43)
11.0 ± 3.9
mV
≥3.2 mV
Table 9-29 F Wave in the Lower Extremity (Fig. 9-29)
Electrode placement
E1 For peroneal nerve: over the extensor digitorum brevis (see Fig. 9-27) For tibial
nerve: over the abductor hallucis (see Fig. 9-28A)
E2 For peroneal nerve: at the fifth metatarsophalangeal joint For tibial nerve: at the
first metatarsophalangeal joint
G Dorsum of the foot
S Cathode For peroneal nerve: 8 cm proximal to E1, lateral to the tibialis
anterior tendon
For tibial nerve: 8 cm proximal to E1, and just behind the medial
malleolus
Anode Distally
Normal values (45) Peroneal nerve F wave latency in ms (shortest of 10 stimuli, n = 180)
Age Height (cm) Mean ± SD Normal limit
Figure 9-29 • F wave in the lower extremity
19–
39
<160 ≤43.6 ± 2.5 48.6
160–169 ≤47.1 ± 3.7 54.5
>170 ≤51.5 ± 4.1 59.7
40–
79
<160 ≤45.4 ± 4.8 55.0
160–169 ≤49.6 ± 4.6 58.8
>170 ≤54.6 ± 4.5 63.6
(Reprinted from Buschbacher RM. Peroneal nerve F-wave recorded from extensor digitorum
brevis. Am J Phys Med Rehabil 1999;78:S48–S52, with permission.)
Tibial nerve F wave latency to AH in ms (shortest of 10 stimuli, n = 180) (46)
Age Height (cm) Mean ± SD Normal limit
19–
39
<160 43.2 ± 2.2 ≤47.6
160–169 47.2 ± 3.0 ≤53.2
170–179 52.0 ± 4.0 ≤60.0
>180 53.1 ± 4.4 ≤61.9
40–
59
<160 45.4 ± 4.0 ≤53.4
160–169 49.3 ± 2.2 ≤53.7
170–179 53.6 ± 3.7 ≤61.0
>180 58.3 ± 5.3 ≤68.9
60–
79
<160 49.0 ± 4.8 ≤58.6
160–169 52.8 ± 4.4 ≤61.6
170–179 54.7 ± 3.2 ≤61.1
>180 57.3 ± 5.8 ≤68.9
(Modified from Buschbacher RM: Tibial nerve F-wave recorded from abductor hallucis. Am J
Phys Med Rehabil 1999;78;S43–S47, with permission.)
Table 9-30 H Reflex to the Calf (Soleus) (Fig. 9-30)
Electrode placement
E1 Halfway between the popliteal crease and the medial malleolus, with subject in prone position
E2 Over the Achilles tendon
Figure 9-30 • H reflex to the calf
G Between the stimulating and recording electrodes
S Cathode At the midpopliteal crease
Anode Distal
Stimulation duration = 1.0 ms
Normal values: onset latency (ms) (47) (n = 251)
Age Height (cm) Mean ± SD Normal limit
19–39 <160 27.1 ± 1.8 ≤30.7
160–169 28.6 ± 1.9 ≤32.4
170–179 30.3 ± 1.8 ≤33.9
>180 32.0 ± 2.1 ≤36.2
40–49 <160 27.8 ± 1.1 ≤30.0
160–169 30.2 ± 1.4 ≤33.0
170–179 31.0 ± 1.6 ≤34.2
>180 32.7 ± 2.1 ≤36.9
50–79 <160 29.3 ± 1.9 ≤33.1
160–169 31.7 ± 1.6 ≤34.9
170–179 31.9 ± 1.7 ≤35.3
>180 33.2 ± 2.5 ≤38.2
Note: The upper limit of increase in latency from one side to the other is 2.0 ms (47).
Equation to calculate: HLat at 9.1 + (0.1 × Age) + (0.46 × Length) (48)
(Reprinted from Buschbacher RM. Normal range for H-reflex recorded from the calf muscles. Am J Phys Med Rehabil
1999;78:S75–S79, with permission.)
Lower Body—Sensory Nerves
Table 9-31 Lateral Femoral Cutaneous Sensory Nerve (Fig. 9-31)
Electrode placement
E1 17–20 cm distal to the anterior superior iliac spine, on the line between the
anterior superior iliac spine and the lateral border of the patella
E2 3 cm distal to E1
G Between E1 and the stimulating cathode
S Cathode S1: below the inguinal ligament, 1 cm medial to the line between
the anterior superior iliac spine and the lateral border of the
Figure 9-31 • Lateral femoral cutaneous sensory
nerve
patella
S2: above the inguinal ligament, 1 cm medial to the anterior
superior iliac spine
Anode Proximally
Normal values (49) (n = 20)
Mean ± SD Normal limit
Onset
S1 (14–18
cm)
2.5 ± 0.2 ms ≤2.8 ms
S2 (17–20
cm)
2.8 ± 0.4 ms ≤3.6 ms
Peak to peak
amplitude
S1 7.0 ± 1.8 µV ≥3.4 µV
S2 6.0 ± 1.5 µV ≥3.0 µV
Note: No data on onset to peak amplitude available.
Table 9-32 Posterior Femoral Cutaneous Nerve (Fig. 9-32)
Figure 9-32 • Posterior femoral cutaneous nerve
Electrode placement
E1 6 cm proximal to the midpopliteal fossa
E2 3 cm distally
G 3 cm distally
S Cathode 12 cm proximal to E1 on a line between E1 and the ischia
tuberosity
Anode Proximally
Normal values (50) (n = 80)
Mean ± SD Normal limit
Peak latency 2.8 ± 0.2
ms
≤3.2 ms
Onset to peak
amplitude
6.5 ± 1.5
µV
≥3.5 µV
Table 9-33 Saphenous Sensory Nerve (Fig. 9-33)
Figure 9-33 • Saphenous sensory nerve—distal technique
Electrode placement
E1 Slightly anterior to the highest prominence of the medial
malleolus, between the malleolus and the tendon of the tibialis
anterior
E2 3 cm distal to E1, at the level of the malleolus
G Between E1 and the stimulating cathode
S Cathode 14 cm proximal to E1 deep to the medial
border of the tibia
Anode Proximally
Normal values (51) (n = 230)
Mean ± SD Normal limit
Onset latency 3.2 ± 0.3 ms ≤3.8 ms
Peak latency 3.8 ± 0.3 ms ≤4.4 ms
Onset to peak
amplitude
6.5 ± 3 µV ≥3.5 µV
Table 9-34 Superficial Peroneal* Nerve: Medial and Intermediate Dorsal Cutaneous Branches (Fig. 9-34)
Figure 9-34 • Superficial peroneal nerve: medial and intermediate dorsal
cutaneous branches
Electrode placement
E1 At the level of the ankle Medial branch: just lateral to the
tendon of the extensor hallucis longus Intermediate branch:
1–2 cm medial to the lateral malleolus
E2 3–4 cm distal to the E1s
G Between E1 and the stimulating cathode
S Cathode 14 cm proximal to E1 on the
anterolateral aspect of the lower leg
Anode Proximally
Normal values (52) (n = 80)
Branch Mean ± SD Normal limit
Peak latency Medial
Intermediate
3.4 ± 0.4 ms
3.4 ± 0.4 ms
≤2.7–4.7 ms
≤2.8–4.6 ms
Peak to peak
amplitude
Medial
Intermediate
18.3 ± 8.0 µV
15.1 ± 8.2 µV
≥2.3 µV
≥4 µV*
Onset to peak
amplitude
(53)
Intermediate 20.5 ± 6.1 µV ≥8.3 µV
Nerve
conduction
velocity
Medial
Intermediate
51.2 ± 5.7 m/s
51.3 ± 5.4 m/s
≥39.8 m/s
≥40.5 m/s
Note: The value is the smallest value of the range.
*Peroneal nerve also known as fibular.
Table 9-35 Tibial Nerve (Mixed Nerve Responses): Medial and Lateral Plantar Nerves (Fig. 9-35)
Figure 9-35 • Tibial nerve: medial and lateral plantar nerves
Electrode placement
E1 Behind the medial malleolus at the level of the ankle
E2 Proximally
G Over the dorsum of the foot
S Cathode Medial branch: 10 cm distal to E1 to the first web
space, and then 4 cm more distal along the first
web space (total 14 cm distal to E1)
1.
Lateral branch: 14 cm distal to E1, on the sole
between the fourth and fifth metatarsals
2.
Anode Distally
Normal values (54) (n = 41)
Branch Mean ± SD Normal limit
Peak Medial 3.16 ± 0.26 ms ≤3.7 ms
Latency Lateral 3.15 ± 0.25 ms ≤3.7ms
Amplitude Medial
Lateral
>10 µV
>8 µV
Table 9-36 Sural Sensory Nerve (Fig. 9-36)
Figure 9-36 • Sural sensory nerve
Electrode placement
E1 Posterior and inferior to the lateral malleolus
E2 3 cm distally
G Between E1 and the stimulating cathode
S Cathode 14 cm proximal to E1 in the midline or slightly
lateral to the midline of the posterior lower
leg, between the two heads of gastrocnemius
Anode Proximally
Normal values (55) (n = 56)
Mean ±
SD
Normal limit
Peak latency
(55)
3.5 ±
0.25
≤4.0 ms
Baseline to peak
amplitude (53)
23.7 ±
3.8 µV
≥10 µV
Nerve
conduction
velocity (54)
43.3 ±
4.3 m/s
≥34.7 m/s
Normal values (56) (n = 80)
Mean ±
SD
Normal limit
Onset latency 3.1 ± 0.3
ms
≤3.6 ms
Peak latency 3.8 ± 0.3
ms
≤4.5 ms
Onset to peak
amplitude
17 ± 10
µV
≥4 µV
Table 9-37 Sural Nerve—Lateral Dorsal Cutaneous Branch (Fig. 9-37)
Figure 9-37 • Sural nerve— lateral dorsal cutaneous branch
Electrode placement
E1 At the midpoint of the fifth metatarsal and just lateral to
the extensor digitorum brevis tendon to the fifth toe
E2 Distally
G On the dorsum of the foot
S Cathode 12 cm proximal to E1 behind the
lateral malleolus
Anode Proximally
Normal values (57) (n = 40)
Mean ± SD Normal limit
Onset latency 3.2 ± 0.4 ms ≤4.0 ms
Peak latency 3.9 ± 0.5 ms ≤4.9 ms
Baseline to peak
amplitude (57)
5.8 ± 2.1 µV ≥3 µV
Nerve conduction
velocity (onset)
37.6 ± 4.8 m/s ≥28.0 m/s
Nerve conduction
velocity (peak)
37.6 ± 4.8 m/s
30.7 ± 3.7 m/s
≥28.0 m/s
≥23.3 m/s
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