Dynamic Surface Electromyography (SEMG) … · Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objective diagnostic

Dynamic Surface Electromyography (SEMG) Information Sheet

Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objective diagnostic tool that allows us to visualize and objectively quantify muscle spasm in the neck and back. With this technology the muscular component of a soft tissue injury can be documented thus enabling one to go beyond subjective patient and doctor reports. Similar to an electrocardiogram (ECG) which measures heart activity, dynamic SEMG measures paraspinal muscle activity (those on either side of the spine). Utilizing adhesive surface electrodes and by having the individual move through a range of motion, normal or abnormal muscle activity can be determined. Dynamic SEMG can determine the extent of muscle hypertonicity and dysfunction. This aids the practitioner in developing an accurate course of rehabilitation. There are many documented research papers substantiating the validity of the dynamic SEMG (available upon request); it has also been extremely successful in correlating with patient symptoms. I am a licensed chiropractor and have been the head clinician of Central Chiropractic Group since my graduation from the Canadian Memorial Chiropractic College (CMCC) in 1990. I am also founder and clinical director of the Welcome Back Spinal Care Center. I have taught undergraduate courses in orthopedics at the Canadian College of Naturopathic Medicine (CCNM), and applied physiological therapeutics at both CCNM and CMCC. I am a Fellow of the Academy of Traditional Acupuncture and was selected in 2006 to serve as a peer-assessor in x-ray evaluation for the College of Chiropractors of Ontario. I am certified in surface electromyography through the National College of Chiropractic in Chicago and have been providing independent surface electromyography assessments and interpretation for other doctors and rehabilitation clinics since 1993. I have written several articles on this diagnostic modality and have aided others in their research using dynamic SEMG as an outcome measure. Dynamic SEMG is an accepted diagnostic procedure that is billable within the scope of chiropractic. If you have any questions, please do not hesitate to contact me. Sincerely, Dr. Arnie Deltoff [email protected] (see next page for patient information)

Ranges of Motion Analyzed

Cervical Spine

Lumbar Spine

Flexion

Bending the head forward, relaxing and re-extending to the neutral position - utilizes both and

paraspinal muscles evenly.

left right

Lateral Flexion (Side Bending)

Bending the head to the utilizes the paraspinal and SCM (sternocleidomastoid) muscles.

Bending the head to the utilizes the paraspinal and SCM muscles.

left left left

right right right

Rotation

Turning the head to the utilizes the paraspinal and SCM

muscles.

Turning the head to the utilizes the paraspinal and SCM muscles.

left left

left

right

right right

Lateral Flexion (Side Bending)

Bending the torso to the utilizes the paraspinal muscles.

Bending the torso to the utilizes the paraspinal muscles.

left left

right right

Rotation

Turning the torso to the utilizes the paraspinal muscles.

Turning the torso to the utilizes the paraspinal muscles.

left left

right right

Flexion

Bending the torso forward, relaxing and re-extending to the neutral position - utilizes both and

paraspinal muscles evenly.

left right

© Dr. Arnie Deltoff, 2009

Patient Name: Date of Study:Accident Date: Claim #:Tests Performed: Cervical and Lumbar Flexion/Re-extension, Lateral Bending and Rotation

Cervical Spine Study (note: PS=paraspinal, SCM=sternocleidomastoid)

Criteria Patient Values Normal Values

Flexion-Relaxation Response Left - marked loss Present - full flexion value is equal or lowerRight - marked loss than value at rest

Re-extention Peak to Flexion Peak Ratio Left - 1.27 abnormal Normal > 3.2 Abnormal < 1.8Right - 1.20 abnormal

Full Flexion Value Left - 4.86 normal Normal < 10 uV Abnormal > 15 uVRight - 7.82 normal

Irritability Left - marked jitter Graph is smooth (no jitter)Right - marked jitter

Symmetry relative symmetry <20% difference between L & RConsistency Left - consistent trials Each repetition is similar in shape and

Right - consistent trials amplitude

Activation Patterns Lt. PS - relatively normal Rt. PS - abnormal Ipsilateral paraspinal andLt. SCMs - abnormal Rt. SCMs - abnormal sternocleidomastoid activity

Co-contraction Lt. PS - no co-contraction Rt. PS - co-contraction No antagonistic muscles contractionLt. SCMs - co-contraction Rt. SCMs - mild co-contraction

Test Subject January 6, 2010December 1, 2009 abc123

Flexion / Re-extension

Lateral Bending

Dynamic Surface Electromyography (sEMG)Summarized Results

Lt. SCMs co contraction Rt. SCMs mild co contractionIrritability Lt. PS - marked jitter Rt. PS - marked jitter Graph is smooth

Lt. SCMs - marked jitter Rt. SCMs - marked jitterSymmetry Paraspinal muscles - increased left activity Relatively equal values between

Sternocleidomastoids - increased right activity left and right activity

Activation Patterns Lt. PS - normal Rt. PS - relatively normal Ipsilateral paraspinal andLt. SCMs - normal Rt. SCMs - normal contralateral SCM activity

Co-contraction Lt. PS - mild co-contraction Rt. PS - co-contraction No antagonistic muscles contractionLt. SCMs - mild co-contraction Rt. SCMs - mild co-contraction

Irritability Lt. PS - marked jitter Rt. PS - marked jitter Graph is smoothLt. SCMs - marked jitter Rt. SCMs - marked jitter

Symmetry Paraspinal muscles - increased left activity Relatively equal values betweenSternocleidomastoids - relatively symmetrical left and right activity

Based on the criteria above, the cervical spine demonstrates the following levels of dysfunction / muscle guarding:

Flexion 61% rated as moderate to marked dysfunctionLateral Bending 73% rated as moderate to marked dysfunctionRotation 50% rated as moderate dysfunction

Overall 72% rated as moderate to marked dysfunction

Rotation


Patient Name: Date of Study:

Lumbar Spine Study

Criteria Patient Values Normal Values

Flexion-Relaxation Response Left - marked loss Present - full flexion value is equal or lowerRight - complete loss than value at rest

Re-extention Peak to Flexion Peak Ratio Left - 1.04 abnormal Normal > 3.2 Abnormal < 1.8Right - 1.34 abnormal

Full Flexion Value Left - 51.63 abnormal Normal < 10 uV Abnormal > 15 uVRight - 54.05 abnormal

Irritability Left - jitter Graph is smoothRight - jitter

Symmetry relative symmetry <20% difference between L & RConsistency Left - consistent trials Each repetition is similar in shape and

Right - consistent trials amplitude

Activation Lt. PS - abnormal Rt. PS - relatively normal Ipsilateral paraspinal activityCo-contraction Lt. PS - co-contraction Rt. PS - mild co-contraction No antagonistic contractionIrritability Lt. PS - jitter Rt. PS - marked jitter Smooth graph

Flexion / Re-extension

Lateral Bending

Summarized Results - Page 2

Test Subject January 6, 2010

Irritability Lt. PS jitter Rt. PS marked jitter Smooth graphSymmetry Paraspinal muscles - increased right activity Relatively equal L/R activity

Activation Lt. PS - relatively normal Rt. PS - normal Ipsilateral paraspinal activityCo-contraction Lt. PS - co-contraction Rt. PS - co-contraction No antagonistic contractionIrritability Lt. PS - jitter Rt. PS - marked jitter Smooth graphSymmetry Paraspinal muscles - increased right activity Relatively equal L/R activity

Based on the criteria above, the lumbar spine demonstrates the following levels of dysfunction / muscle guarding:

Flexion 74% rated as moderate to marked dysfunctionLateral Bending 67% rated as moderate to marked dysfunctionRotation 60% rated as moderate to marked dysfunction

Overall 79% rated as marked dysfunction

Rotation


Patient Name: Date of Study:Accident Date: Claim #:

The cervical spine demonstrates: moderate to marked dysfunction in forward flexionmoderate to marked dysfunction in lateral flexionmoderate dysfunction in rotation

Interpretation

Analysis

Test Subject

Dynamic Surface Electromyography (sEMG)

abc123January 6, 2010

December 1, 2009

Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objectivediagnostic tool that allows us to visualize and objectively quantify muscle spasm in the neck and back. With this technology themuscular component of a soft tissue injury can be documented thus enabling one to go beyond subjective patient and doctor reports.

Muscle dysfunction may manifest as hypertonicity (increased muscle tone), spasm (little difference between rest and activity), guarding (protective muscle contraction) or fasciculations (twitches) for example. These can all be measured electrically. There is direct correlation to general pain and joint dysfunction. Muscle dysfunction may be caused by multiple factors. It isimportant to note that the absence of muscle dysfunction may not mean the absence of pain.

The information provided here will help guide the practitioner in the patient's rehabilitation by directing them to the muscles and ranges of motion that demonstrate dysfunctional patterns. As well, in the case of positive examination findings, future testing will allow the practitioner to gauge the efficacy of their treatment.

Research has indicated that the flexion test is of utmost importance and, therefore, the result of this part of the examination has slightly more 'weighting' in the overall dysfunction score. All results rated as moderate* dysfunction or above are deemed

moderate dysfunction in rotationOverall the cervical spine demonstrates a 72% dysfunction which relates to moderate to marked dysfunction

There is also indication of the following: hypertonicity spasm guarding fasciculations

With this degree of dysfuction: A combination of passive therapy and muscle strengthening is recommended.The patient may benefit from further assessment (eg. neurological, MRI, CT, US) of the cervical spine as signs and symptoms dictate

The lumbar spine demonstrates: moderate to marked dysfunction in forward flexionmoderate to marked dysfunction in lateral flexionmoderate to marked dysfunction in rotation

Overall the lumbar spine demonstrates a 79% dysfunction which relates to marked dysfunction

There is also indication of the following: hypertonicity spasm guarding fasciculations

With this degree of dysfuction: More passive therapy may be beneficial.The patient may benefit from further assessment (eg. neurological, MRI, CT, US) of the lumbar spine as signs and symptoms dictate

Dr. Arnie Deltoff, DC, FATAMyodynamics Inc.230-4915 Bathurst StreetToronto, ON M2R 1X9Phone: 416-512-2225 Fax: 416-512-2226

Note: Dysfunction levels are to be used for comparative purposes and to guide the practitioner in the rehabilitative process. All information must be correlated with clinical observations. Testing was performed according to established protocols using the Myovision dynamic multi-channel sEMG.

* ie. moderate, moderate to marked, marked and severe

Normal Studies for Comparison

Flexion / re-extension (any region) 1 2 3 4 5 6 Peak to peak ratio – the peak value of

re-extension is greater than 3.2 times the peak value of flexion

peak Full flexion value (marks 1,3,5) – is below 10

microvolts peak ratio Flexion-relaxation response – presence of this phenomenon is indicated when the full flexion value is even with or below resting value

Cervical Lateral Flexion Cervical Rotation left right left right left right left right paraspinal paraspinal muscles muscles Sternocleido- Sternocleido- mastoid mastoid muscles muscles left right left right right left right left Lumbar Lateral Flexion or Rotation Activity Pattern – in the neck, lateral bending involves left right left right activation of the same-sided paraspinals and SCM

muscles; rotation involves the activation of the same-sided paraspinals and opposite-sided SCM muscles. In the low back, however, both lateral bending and rotation involves the activation of same-sided paraspinal muscles. Co-contraction – there should be little to no activity of the opposite-sided muscles during lateral bending or rotation

General Considerations Symmetry – the right and left should be equally active for their respective motions Irritability – all graphs should be smooth; “spiky” movement indicates muscle fasciculations Consistency – all trials should be relatively equal in shape and amplitude

MyoVision Dynamic Report

Patient: Exam Date: Jan 06, 2010 02:30:15 PM

MyoVision Dynamic sEMG Flexion Study Background and Explanation

A dynamic EMG flexion study was performed utilizing the sEMG system with electrodes attached to the skin. The system utilizes 25-500 Hz filtering system which allows measurement of the muscle fibers utilized in maintaining posture.

The basic principle of the dynamic flexion study is simple. When in full flexion of the cervical or lumbar spine, normal individuals display sEMG values (in microvolts) which drop to very low levels as ligaments instead of muscles are used to maintain the full flexed position. This is known as the flexion relaxation phenomenon. In patients with low back pain, sEMG values maintain high levels in full flexion and do not relax as with normals. This is known as an absence of flexion relaxation.

A landmark study titled "Electric Behavior of Low Back Muscles During Lumbar Pelvic Rhythm in Low Back Patients and Healthy Controls" (Sihoven, Partanen, Hanninen Soimakallio; The Archives of Physical Medicine and Rehabilitation vol 72, Dec 1991) was published on the flexion relaxation phenomenon.

The following results were reported:

1. Surface EMG pattern yielded more information than needle EMG.2. There was a clearly noticeable increase in sEMG activity in LBP patients.3. There was only a partial decrease in sEMG readings in LBP patients while in full flexion, in contrast with normals which demonstrated marked decreases in sEMG activity.4. The ratio of the mean maximum sEMG level reached in flexion to the mean maximum sEMG level in re-extension was lower in LBP patients than in normal controls. The ratios were 3.2 in normals, and 1.8 in LBP patients.5. Test-retest reliability was very high (0.92 flexion, 0.97 extension)

It is important to note that the results of this test should be correlated with other exams, and should not beused on its own to determine disability.

Copyright 1998-2003 PBI MyoVision WinScan 800 969-6961 ver. 2,0,0,47 Page 2



A dynamic sEMG flexion study was performed on ******************* on Jan 06, 2010. The graph is labeled Dynamic Cervical Flexion.

PERCENT DIFFERENCE TESTsEMG activity in the Left Cervical was 2% LESS than the Right Cervical.

FLEXION/RE-EXTENSION RATIO TEST (Table 1)This test quantifies the ratio of the peak in flexion (FLEX PEAK)to the peak in re-extension (REEX PEAK).Research has found that in general, normals produce ratios greater than 3.2, with symptomatic patients less than 1.8. The results of this test should be examined in combination with the FLEXION TEST (Table 2).

The patient produced a(n) UNEXPECTED ratio of 1.27 in the Left Cervical and a(n) UNEXPECTED ratio of 1.20 in the Right Cervical.

Table 1: Peak Analysis Data (Average of three (3) trials)

SITE FLEX PEAK REEX PEAK RP/FP RATIO STD DEV RESULTS

Left Cervical 6.88 8.72 1.27 0.09 UNEXPECTEDRight Cervical 8.49 10.16 1.20 0.12 UNEXPECTED

FLEXION TEST (Table 2)

sEMG values in full flexion should be very low. The flexion test measures the averaged sEMG value of three trials of flexion. Normal readings are below 10uV, BORDERLINE between 10 and 15uV, and ABNORMAL above 15 microvolts. Normal sEMG readings in standing neutral (NEUTRAL MIN) should be below approximately 9 uV. Higher readings correlate with disorders of the spine.




The patient demonstrated averaged readings in the Left Cervical of 4.86 indicating a(n) NORMAL readingin flexion.The patient demonstrated averaged readings in the Right Cervical of 7.82 indicating a(n) NORMAL reading in flexion.

Table 2: Flexion TestSite FLEX MIN STD DEV CONDITION NEUTRAL MIN

Left Cervical 4.86 0.95 NORMAL 3.70Right Cervical 7.82 0.66 NORMAL 3.00

Results of the study should be correlated with other exams and should not be used alone to determine disability or treatment protocol

I have examined the data and the analysis performed, and agree with the reported findings.


MyoVision Dynamic ReportOffice Information: Patient Information:

Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:30:15 PMProtocol Name: Dynamic Cervical Flexion


14.7

0.0

11.8

4.9

8.8

9.8

5.9

14.6

2.9

19.50.0

24.4

1 2 3 4 5 6

Markers 1, 3, 5 -> Flexion Markers 2, 4, 6 -> NeutralProtocol Name: Dynamic Cervical Flexion Page Name: Left-Right C2 T1 Sites

Left Cervical Right Cervical


Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:33:07 PMProtocol Name: Dynamic 4 Ch Cerv Lat Flex & Rotation


18.5

0.0

14.8

6.0

11.1

11.9

7.4

17.9

3.7

23.80.0

29.8

1 2 3 4 5 6 7 8

Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Lateral Flexion


18.4

0.0

14.7

6.0

11.0

11.9

7.3

17.9

3.7

23.80.0

29.8

1 2 3 4 5 6 7 8

Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Lateral Flexion

Left SCM Right SCM


Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:33:07 PMProtocol Name: Dynamic 4 Ch Cerv Lat Flex & Rotation


16.1

0.0

12.9

5.6

9.7

11.2

6.5

16.9

3.2

22.50.0

28.1

1 2 3 4 5 6 7 8

Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Rotation


10.6

0.0

8.5

5.6

6.4

11.2

4.2

16.9

2.1

22.50.0

28.1

1 2 3 4 5 6 7 8

Protocol Name: Dynamic 4 Ch Cerv Lat Flex Rotation Page Name: L/R Rotation

Left SCM Right SCM



A dynamic sEMG flexion study was performed on ******************* on Jan 06, 2010. The graph is labeled Dynamic Lumbar Flexion.

PERCENT DIFFERENCE TESTsEMG activity in the Left Lumbar was 7% LESS than the Right Lumbar.

FLEXION/RE-EXTENSION RATIO TEST (Table 1)This test quantifies the ratio of the peak in flexion (FLEX PEAK)to the peak in re-extension (REEX PEAK).Research has found that in general, normals produce ratios greater than 3.2, with symptomatic patients less than 1.8. The results of this test should be examined in combination with the FLEXION TEST (Table 2).

The patient produced a(n) UNEXPECTED ratio of 1.04 in the Left Lumbar and a(n) UNEXPECTED ratio of 1.34 in the Right Lumbar.

Table 1: Peak Analysis Data (Average of three (3) trials)

SITE FLEX PEAK REEX PEAK RP/FP RATIO STD DEV RESULTS

Left Lumbar 71.33 74.46 1.04 0.05 UNEXPECTEDRight Lumbar 62.49 83.56 1.34 0.13 UNEXPECTED

FLEXION TEST (Table 2)

sEMG values in full flexion should be very low. The flexion test measures the averaged sEMG value of three trials of flexion. Normal readings are below 10uV, BORDERLINE between 10 and 15uV, and ABNORMAL above 15 microvolts. Normal sEMG readings in standing neutral (NEUTRAL MIN) should be below approximately 9 uV. Higher readings correlate with disorders of the spine.




The patient demonstrated averaged readings in the Left Lumbar of 51.63 indicating a(n) ABNORMAL reading in flexion.The patient demonstrated averaged readings in the Right Lumbar of 54.05 indicating a(n) ABNORMAL reading in flexion.

Table 2: Flexion TestSite FLEX MIN STD DEV CONDITION NEUTRAL MIN

Left Lumbar 51.63 10.87 ABNORMAL 17.00Right Lumbar 54.05 0.91 ABNORMAL 19.17

Results of the study should be correlated with other exams and should not be used alone to determine disability or treatment protocol

I have examined the data and the analysis performed, and agree with the reported findings.



Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:20:38 PMProtocol Name: Dynamic Lumbar Flexion


88.0

0.0

70.4

4.9

52.8

9.8

35.2

14.7

17.6

19.60.0

24.5

1 2 3 4 5 6

Markers 1, 3, 5 -> Flexion Markers 2, 4, 6 -> NeutralProtocol Name: Dynamic Lumbar Flexion Page Name: Left - Right L1 L5 Sites

Left Lumbar Right Lumbar


Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:23:04 PMProtocol Name: Dynamic Lumbar Lat Flex & Rotation


31.5

0.0

25.2

5.6

18.9

11.2

12.6

16.8

6.3

22.40.0

28.0

1 2 3 4 5 6 7 8

Protocol Name: Dynamic Lumbar Lat Flex Rotation Page Name: L/R Lateral Flexion



Patient: ID: Sept 9, 2009Exam Date: Jan 06, 2010 02:23:04 PMProtocol Name: Dynamic Lumbar Lat Flex & Rotation


32.4

0.0

25.9

5.4

19.5

10.7

13.0

16.1

6.5

21.40.0

26.8

1 2 3 4 5 6 7 8

Protocol Name: Dynamic Lumbar Lat Flex Rotation Page Name: L/R Rotation


Dynamic Surface Electromyography (SEMG) … · Dynamic surface electromyography (SEMG) measures the electrical activity that muscles exhibit when in use. It is an objective diagnostic

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