Electromyography and Nerve Conduction Studies

Updated: Aug 20, 2018
  • Author: Stephen Kishner, MD, MHA; Chief Editor: Jonathan P Miller, MD  more...
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Electrodiagnostic testing encompasses a range of specialized tests, including nerve conduction studies (NCS) and needle electromyography (EMG), that are used to evaluate the conduction of electrical impulses along peripheral nerves. These tests should be considered and performed only after a careful history and physical examination, which are sometimes sufficient to establish a diagnosis of neuromuscular dysfunction without further testing. However, in some cases, the subtlety of sensory or motor deficits necessitates further workup for a conclusive diagnosis. [1]

Nerve conduction studies and needle EMG are commonly performed by physical medicine and rehabilitation or neurology specialists to assess the ability of the nervous system to conduct electrical impulses and to evaluate nerve/muscle function to determine if neuromuscular disease is present.

Nerve conduction studies

For this test, a series of surface electrodes are placed at different locations along specific peripheral nerves. The nerve is stimulated at one site and recorded at a different site to determine if the nerve is conducting electrical impulses appropriately.

Each electrical stimulation is recorded as a waveform on a computer and analyzed by the electromyographer performing the test. [2]

Standard nerve conduction studies typically include motor nerve conduction, sensory nerve conduction, F waves, and H reflexes.

Sensory and motor nerve conduction studies involve analysis of specific parameters, including latency, conduction velocity, and amplitude. Onset latency is the time it takes for the stimulus to initiate an evoked potential and reflects the conduction along the fastest fibers. Peak latency is the latency along the majority of axons and is measured at the peak amplitude. [3] Both are affected by the state of the myelination of the nerve.

The conduction velocity along the nerve also depends on the state of myelination and is often decreased in disorders or trauma that affects nerve myelination, although it may be normal if a few myelinated axons remain intact. Reduction of amplitude of recorded responses generally indicates a loss of axons. [4]

These studies, in conjunction with the physical examination and correlation to a set of normative values, assist the electromyographer in diagnosing a multitude of nerve disorders, including entrapment neuropathies, brachial plexopathies, and polyneuropathies.

It is often important to distinguish between sensory and motor nerves, as certain disease processes can affect one or both. Radiculopathy produces motor deficits but does not affect sensory nerves since the anatomic location of the damage is proximal to the dorsal root ganglion. When a lesion is distal to the dorsal root ganglion, such as in brachial plexopathies, both motor and sensory nerves are affected.

Sensory nerve conduction studies

Sensory nerve conduction studies are performed via stimulation of a nerve (ie, sufficient to produce an action potential) at one point and measurement of the action potential at another point along the course of the nerve. [5] Peripheral sensory nerves can be used to localize a lesion in relation to the dorsal root ganglion that contains the cell body of the nerve, allowing differentiation of preganglionic disorders (eg, radiculopathies, cauda equina lesions, posterior column disease) from postganglionic disorders (eg, neuropathies, plexopathies). With a preganglionic lesion, the sensory nerve action potential is normal (although clinically abnormal) because axonal transport from the cell body to the peripheral axon remains intact. [6]

Motor nerve conduction studies

In motor nerve conduction studies, motor nerves are stimulated and the compound muscle action potential from the muscle is recorded. This corresponds to the integrity of the motor unit. Results of this study can be affected by any process that damages the anterior horn cell body or axon, Schwann cells, the neuromuscular junction, or the muscle cell itself. [7] Also analyzed are the size, shape, and morphology of the compound muscle action potential to determine the state of myelination, the number of functioning muscle fibers, and the function of the neuromuscular junction. Since the cell body of motor nerves is located in the anterior horn of the spinal cord, the motor nerve conduction is abnormal in both preganglionic and postganglionic injuries.

Late responses

Distal nerve segments are relatively easy to analyze since they can be studied directly. To study proximal nerve segments, late responses based on conduction along the proximal nerve are used. Late responses include F waves and H reflexes.

F waves

The F wave is a late response involving the motor axons that can be elicited in most upper and lower extremity muscles. A stimulus is applied to a distal motor nerve that travels antidromically from the peripheral nerve, to the anterior horn cell, and a response fires back down the motor neuron and is recorded as a muscle response that occurs after the compound muscle action potential. F waves tend to have lower sensitivity for radiculopathy but can be useful in the assessment of polyneuropathy.

H reflexes

The H reflex is basically an electrophysiologically recorded Achilles muscle stretch reflex. It is performed by stimulating the tibial nerve in the popliteal fossa. From there, the stimulus goes proximally through the reflex arc at that spinal segment, then distally from the anterior horn cell and the motor nerve. It can be recorded over the soleus or gastrocnemius muscles. The H reflex is most commonly used to evaluate for an S1 radiculopathy or to distinguish from an L5 radiculopathy.

Needle EMG is used to assess both nerve and muscle function. A small-diameter monopolar pin or coaxial needle is placed into a muscle to evaluate insertional activity, resting activity, voluntary recruitment, morphology, and size of motor units, as well as motor unit recruitment. The needle electrode examination provides valuable information about the electrical characteristics of individual muscle fibers and motor units, as well as the integrity and innervation of muscle fibers. This test can be uncomfortable for the patient.

Insertional activity

Insertional activity is the electrical activity present as the electrode is passed through muscle cells. These are discharge potentials provoked by the disruption of the cell membrane itself. Careful attention is given to the duration and amount of electrical noise after each movement of the needle. This activity is decreased in atrophied muscle or fatty tissue. Conversely, it is also increased in many abnormal conditions that cause membrane instability, such as neuropathies, radiculopathies, and inflammatory myopathies.

Spontaneous activity at rest

Resting or spontaneous activity is the electrical activity present when the muscle is at rest and the electrode is not being moved. This includes both normal and abnormal spontaneous activity.

Normal muscle should be silent after the needle is inserted; however, if the needle happens to be near the neuromuscular junction, miniature endplate potentials or endplate potentials may be heard or seen. The most common abnormal spontaneous activity is reported as a gradation of either positive sharp waves (PSWs) or fibrillation potentials on a scale of 1+ (transient but reproducible discharges) to 4+ (abundant spontaneous potentials).

Fibrillations result from motor axonal loss that is not balanced by reinnervation. Conditions that cause this include any nerve disorder that affects the motor axon, inflammatory myopathies, and direct muscle injury. Depending on the amplitude of the PSWs and/or fibrillation potentials, the electromyographer can determine how recently the injury to the nerve occurred. Low-amplitude fibrillation potentials suggest that denervation occurred in the remote past, whereas high-amplitude fibrillation potentials suggest an ongoing active denervation process.

Voluntary muscle recruitment

Recording of voluntary recruitment of motor unit action potentials can provide additional information. Reduced recruitment signifies motor axonal loss or functional dropout due to focal demyelination or conduction block. By contrast, increased recruitment with a small voluntary force can be seen with myopathy.


The information gathered from needle EMG is combined with that provided by nerve conduction studies to determine the overall interpretation. The results of the analysis of the collective studies often permits delineation of the type of underlying pathologic process, such as a polyneuropathy, mononeuropathy or entrapment neuropathy, radiculopathy, plexopathy, disordered neuromuscular transmission, or myopathic process. In many cases, one diagnosis explains the abnormalities found on the study, but, occasionally, more than one diagnosis is necessary to complete the interpretation of the electrodiagnostic findings.



EMG and nerve conduction studies are an extension of the physical examination. They can be useful in aiding in the diagnosis of peripheral nerve and muscle problems. This can include peripheral neuropathies [8] , entrapment neuropathies [9] , radiculopathies [10] , and muscle disorders.



Electrodiagnostic (EDX) studies should never be performed on patients with external wires like external pacing wires, guidewires, and so on. Central lines are not a contraindication, but the contralateral limb should be used. Patients with implanted cardiac pacemakers and cardioverter-defibrillators are not a contraindication to nerve conduction studies (NCS). Several studies have shown no pacemaker inhibition during NCS, but there has been one reported case of pacemaker failure due to peripheral nerve stimulation. There are no reported cases of implantable automatic cardioverter-defibrillators (IACDs) being triggered by NCS. For patients with IACDs, stimulation should not be performed near the implanted device and the contralateral extremity should be used when possible. Stimulation intensities should be kept under 1 Hz and pulse width under 0.2 ms duration because, theoretically, it could be confused by the device as a QRS complex/cardiac rhythm. Repetitive stimulation should also be avoided. 

Patients with bleeding disorders or who are anticoagulated are not a contraindication to EMG. However, extra care should be taken during the needle exam. There is a lack of official guidelines, but there are some general recommendations: the smallest gauge needle available should be used, study should be limited to superficial muscles, avoid deep muscles that could compress neurologic structures, and avoid muscles with large vasculature nearby. [11]


Common Nerve Conduction Study/Electromyography Findings


Radiculopathy is a pathologic process that affects nerves at the root level, often presenting as pure sensory complaints since the sensory fibers are much larger and more easily injured, but sensorimotor or pure motor complaints are also possible. [6] A pure sensory lesion will have negative EMG and sensory NCS results, even though the patient is experiencing a clinical sensory deficit. Other possible findings include normal sensory nerve action potential (SNAP) and a compound motor action potential (CMAP) that is normal to reduced.

An H reflex could be abnormal with an S1 radiculopathy, but F waves are neither sensitive nor specific for a radiculopathy. EMGs show PSWs and fibrillation potentials in at least two different muscles innervated by two separate peripheral nerves with the same root.

Chronology of radiculopathy findings

Upon injury to a nerve root, the patient may begin to report clinical symptoms immediately, but abnormalities in EMG/nerve conduction studies do not appear right away. [3] Thus, although a physician may be tempted to obtain an EMG/nerve conduction study, the electrodiagnostic evidence may be insufficient to confirm or exclude the diagnosis.

A few days after the injury, there may be decreased recruitment and prolonged late responses. After one week, there may be decreased CMAP and some abnormal spontaneous activity in the paraspinals. At 2-3 weeks, abnormal spontaneous activity may be seen in the limbs and paraspinals, and this is when an EMG/nerve conduction study is appropriate. Around 5-6 weeks, reinnervation begins, demonstrated by increased amplitude from the reinnervated motor unit.

Table 1. Findings of Nerve Conduction Studies and EMG in Carpal Tunnel Syndrome [1] (Open Table in a new window)

Severity of Carpal Tunnel

Sensory Nerve Action Potential

Compound Motor Action Potential

Needle EMG Activity


Prolonged latency




Prolonged latency and decreased amplitude

Prolonged latency




Prolonged latency and decreased amplitude

Abnormal activity

Table 2. Common Disorders [2] (Open Table in a new window)


Distal Motor Latency

Distal Sensory Latency

Conduction Velocity

Amplitude of the Evoked Response

Motor neuron disease





Axonal polyneuropathy



Slight decrease


Demyelinating polyneuropathy





Entrapment neuropathy

Normal (may be prolonged if this is a distal entrapment such as carpal tunnel syndrome)

Normal (May be prolonged if this is a distal entrapment such as carpal tunnel syndrome)

Decreased at the entrapment region

May be decreased when stimulating proximal to the site of entrapment





Motor response may be decreased





Decreased motor amplitudes


Technical Considerations

Limb temperature is a very important factor during electrodagnostic studies. Skin temperature should be between 32º C and 34º C. During nerve conduction studies cooler temperatures can lead to prolonged distal latencies, slowed nerve conduction velocities, increased amplitude, and increased duration potentials. Temperatures below 32º C can also lead to increased duration, amplitude, and phases of motor unit action potentials during the needle study. Ideal limb temperature can be maintained using warm water, heating lamp, warm packs, or hydrocollator.

Age is another important factor to consider during electrodiagnostics. Young children have slower conduction velocities because the process of myelination of peripheral nerves becomes completed between the ages of 3 and 5 years. Additionally, conduction velocities begin to decrease after the age of 60 years at a rate of 0.5 to 4.0 m/s/decade.

Electrodiagnostic testing is very sensitive and can be subject to the electrical noise in the environment.  Flourescent lights, computers, fans, and so on that generate 60 Hz are common sources of electrical disturbance. To minimize this interference, the examiner should ensure that skin is clean from dirt and oil, has sufficient electrode jelly, the electrodes are firmly in contact with the skin, and that the ground is between the stimulator and recording electrodes. [12]