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  1. 1. Clinical neurophysiology END-Techniques Case studies
  2. 2. Diabetic neuropathy <ul><li>Diabetic neuropathies are a family of nerve disorders caused by diabetes </li></ul><ul><li>Symptoms are pain, tingling, or numbness, loss of feeling in the hands, arms, feet, and legs . </li></ul><ul><li>Nerve problems can occur in every organ system, including the digestive tract, heart, and sex organs </li></ul>
  3. 3. Causes of diabetic neuropathies <ul><li>High blood glucose </li></ul><ul><li>Long duration of diabetes </li></ul><ul><li>Low levels of insulin </li></ul><ul><li>Neurovascular factors </li></ul><ul><li>Autoimmune factors that cause inflammation in nerves </li></ul><ul><li>Smoking or alcohol use </li></ul>
  4. 4. symptoms <ul><li>Several times urination, especially night time </li></ul><ul><li>Numbness, tingling, or pain in the feet. </li></ul><ul><li>Numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers </li></ul><ul><li>Wasting of the muscles of the feet or hands </li></ul><ul><li>Indigestion, nausea, or vomiting </li></ul><ul><li>Diarrhea or constipation </li></ul><ul><li>Dizziness or faintness due to a drop in blood pressure after standing or sitting up </li></ul><ul><li>Problems with urination </li></ul><ul><li>Erectile dysfunction in men or vaginal dryness in women </li></ul><ul><li>Weakness </li></ul>
  5. 5. Types of diabetic neuropathy <ul><li>Peripheral : pain or loss of feeling in the toes, feet, legs, hands, and arms. </li></ul><ul><li>Autonomic : digestion, bowel and bladder function, sexual response, and perspiration, lungs, eyes </li></ul><ul><li>heart and blood pressure </li></ul><ul><li>Proximal: pain in the thighs, hips, or buttocks </li></ul><ul><li>Focal: sudden weakness of one nerve or a group of nerves, causing muscle weakness or pain </li></ul>
  6. 6. Principle of axonal degeneration:dying back hypothesis
  7. 7. Nerve conduction studies or electromyography <ul><li>Hand motor </li></ul><ul><li>median nerve:distal and proximal motor+F-response </li></ul><ul><li>Ulnar nerve:proximal and distal motor+F-response (make sure the patient does not have CTS). Look contra-lateral. </li></ul>
  8. 8. <ul><li>Leg motor: </li></ul><ul><li>Tibial nerve:distal and proximal motor+ F-response </li></ul><ul><li>Peroneal nerve: distal and proximal motor </li></ul><ul><li>Sensory </li></ul><ul><li>Hand sensory: median and ulnar nerve </li></ul><ul><li>Leg sensory: sural nerve </li></ul>
  9. 9. Ulnar nerve entrapment
  10. 10. F-response <ul><li>When a peripheral motor nerve is </li></ul><ul><li>electrically stimulated, impulses </li></ul><ul><li>travel orthodromically toward the </li></ul><ul><li>muscle and antidromically </li></ul><ul><li>toward the spinal cord. </li></ul><ul><li>The antidromic impulses are </li></ul><ul><li>capable of discharging alpha </li></ul><ul><li>motoneurons that then elicit </li></ul><ul><li>recurrent orthodromic impulses </li></ul>
  11. 11. Axonal reflex In normal conditions, they are only seen in tibial nerve. In earlier GBS,IDD can be seen. They are also called IDD(Intermediate Double Dischares) or M-satellites.
  12. 13. Fine-fibers and autonomic neuropathy testing <ul><li>Heat testing </li></ul><ul><li>Cold testing </li></ul><ul><li>SSR </li></ul><ul><li>R-R interval </li></ul><ul><li>Orthostatic </li></ul><ul><li>Q-Sweat-postganglionic sympathetic sudomotor axon </li></ul>
  13. 14. Psychophysic <ul><li>VEP </li></ul><ul><li>SSEP </li></ul><ul><li>LEP(Laser Evoked Potential) </li></ul><ul><li>BAEP </li></ul>
  14. 15. Charcot-Marie-Tooth (CMT) Hereditary Motor and Sensory Neuropathies The legs showed mild atrophy of the anterior tibialis and peroneal muscles Hypertrophic polyneuropathy. The most likely diagnosis was chronic inflammatory demyelinating polyneuropathy Her nerve conduction velocities (NCV) were 24.7m/s in both median and ulnar nerves without multifocal blocks Motor NCV of the right peroneal nerve was 14.7m/s; the motor NCV of the left ulnar nerve was 16.9m/s; and the motor NCV of the right median nerve was 21.2m/s Lack of conduction blocks argued against chronic inflammatory demyelinating polyneuropathy (CIDP) Based on the molecular studies and electrophysiological examination , the diagnosis of Charcot-Marie-Tooth type 1A polyneuropathy was made.
  15. 16. <ul><li>Pes cavus </li></ul><ul><li>Toeswalking </li></ul>
  16. 17. GBS <ul><li>Guillain-Barré syndrome is a disorder in which the body's immune system attacks part of the peripheral nervous system </li></ul><ul><li>Usually Guillain-Barré occurs a few days or weeks after the patient has had symptoms of a respiratory or gastrointestinal viral infection. </li></ul><ul><li>Nerve conduction velocity (NCV) test can give a doctor clues to aid the diagnosis </li></ul>
  17. 18. Multiple Motor Neuropathy <ul><li>Multifocal motor neuropathy (MMN) with conduction block </li></ul><ul><li>Immune-mediated demyelinating neuropathy with slowly progressive weakness, fasciculations, and cramping, without significant sensory involvement </li></ul><ul><li>It may resemble amyotrophic lateral sclerosis (ALS) with predominant lower motor neuron involvement, but muscle atrophy and more rapid progression are lacking </li></ul><ul><li>IV immunoglobulin (IVIG) or cyclophosphamide improve the patient´s condition in MMN but not in ALS patients </li></ul>
  18. 19. <ul><li>Electrodiagnostic studies demonstrate the presence of both demyelinating and axonal injury. </li></ul><ul><li>Clinical and electrodiagnostic criteria for the diagnosis of MMN include the following: </li></ul><ul><li>Definite MMN </li></ul><ul><ul><li>Weakness without objective sensory loss in the distribution of 2 or more nerves is present. </li></ul></ul><ul><ul><li>Definite conduction block is present in 2 or more motor nerves outside of common entrapment sites. </li></ul></ul>
  19. 20. <ul><ul><li>Sensory nerve conduction velocity is normal across the segments with demonstrated motor conduction block. </li></ul></ul><ul><ul><li>Results are normal for sensory nerve conduction studies on all tested nerves, with a minimum of 3 nerves tested. </li></ul></ul><ul><li>Upper motor neuron signs, including spasticity, clonus, extensor plantar response, and pseudobulbar palsy are absent </li></ul>
  20. 21. Conduction block
  21. 23. Absence of F-response
  22. 24. Conduction block outside of common entrapment sites. The conduction block should not be an entrapment
  23. 25. EMG: Normal activity Fibrilation <ul><li>Insertion activity: normal </li></ul><ul><li>Fibrilation: positive sharp waves </li></ul>
  24. 26. Muscle physiology
  25. 27. Motor neuron Degenerative motor neuron