autonomic testing
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MANUEL ZWECKER, MD
Department of Neurological Rehabilitation,
Sheba Medical Center, Tel Hashomer
Email: [email protected]
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Autonomic testing
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Sympathetic Skin Response (SSR)
reflects the activity of the sympatheticnervous system
is affected by cognitive thinking anddecision making
does not depend on residual motor function
SSR
Sound
EmotionRespiration
Light Temperature
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Sympathetic Skin Response
It is a measure of skin voltage, which, like skinresistance (galvanic skin response) isdependent on sudomotor activity.
Correlated best with unmyelinated axons Polysynaptic response
Hypothalamic, brainstem, spinal circuits,postganglionic sympathetic sudomotor axons
Generated in deep layer of skin bysympathetically mediated activation of sweatglands
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Clinical Use of SSR
Stimulation
On median or tibial nerve afferants
Intensity: 3threshold
Acoustic stimulation
Easy to measure with EMG equipments
Controversial clinical criteria
Lack of SSR -> abnormal
50% of healthy over 60 -> no SSR from lowerextremities
Little correlation with severity of autonomic dysfunction
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Factors affecting SSR Temperature
Attention
Fatigue
Predictability
Consecutive yes generation
Training? (not proven yet)
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Sympathetic skin response
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Thermal detection threshold
Cold-detection threshold
Warmth-detection threshold
Method of limits
Method of levels (forced choice)
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Thermal detection threshold
Hand
Warmth detection threshold 2.4,
Cool detection threshold 1.9,
Difference 4.3 Foot
Warmth detection threshold 5.9,
Cool detection threshold 3.0,
Difference 7.2
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Thermal detection threshold
Body parts, age
Semi-quantitative, subjective reporting
Not specific for small fibers
Reaction time (method of limits)
Heat-induced pain 46
Cold-induced pain
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Quantitative sensory testing (QST)
Thermal detection and pain threshold (WDT, CDT, HPT, CPS, PHS)
- warm (C-warm-fiber);cold (A-cold-fiber)
-heat pain (C-nociceptors), cold pain (C- or A-nociceptors)
-paradoxical heat sensation during cold (C-nociceptors)
Mechanical detection threshold (MDT, A-low threshold mechanoreceptors, v. Frey hairs)
Mechanical pain threshold (MPT, A-fiber)
Mechanical pain sensitivity/MPS for pinprick (A-mechanonociceptors)
Mechanical pain sensitivity/MPS for light touch (A-low threshold mechanoreceptors)
Wind-up ratio (WUR, trains of single pinprick stimuli)
Vibration detection threshold (VDT) (A-fiber)
Pressure pain threshold (PPT, deep pain, deep (muscle) nociceptors)
* Protocol of the German Research Network on Neuropathic Pain
TSA
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Evaluation of organic neurogenic
erectile dysfunction
The bulbocavernosus reflex (BCR)
Pudendal nerve Somatosensory evokedpotentials (SSEPs)
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Bulbocavernosus reflex (BCR)
The electrophysiologically inducedBCR measures the somatic reflexpathway from the dorsal nerve ofthe penis by means of the sensorypudendal afferent limb, the spinal
sacral segment S2 through S4,and the motor pudendal efferentlimb.
There will be no response whenthe BCR arcs are interrupted, and
the BCR will be prolonged whenafferent and efferent limbs are notcompletely destroyed.
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Pudendal Somatosensory Evoked
Potentials
Pudendal SSEPprovides an objectivemean of testing the
afferent pathways fromthe dorsal nerve of thepenis to the sensorycortex
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Pudendal Somatosensory Evoked
Potentials
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Evaluation of fecal incontinence
Anal sphincter EMG
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Evaluation of the respiratory
system
Phrenic nerve conduction study
EMG of the diaphragma
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Phrenic nerve conduction study
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EMG of the diaphragma
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Needle
EMG
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Diaphragmatic studies
Diaphragm EMG
Phrenic nerve stimulation
DML
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Evaluation of the larynx
Vocalis muscle EMG
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Unilateral vocal cord paralysis
Stridor
Laryngospasm
Dyspnoea
Cause by abnormal innervation of nervebranches into adductor fibers
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Anatomy
Recurrentlaryngeal nerve
0.5% right non-recurrent
laryngeal nerve Muscles
Lateralcricoarytenoid
Posterior
cricoarytenoid Thyroarytenoid
Interarytenoid
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Etiology
Dysfunction at
Brain and
brainstem nuclei
Vagus nerve
Recurrent laryngeal
nerve
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Causes
Post Thyroid surgery
Post cervical disc surgery
After Herpes simplex virus with cranial nerve
involvement
Fibre optic laryngoscopy showed affected
vocal cord immobile
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Etiology: Traumatic
Iatrogenic: Surgical Thyroidectomy
Anterior cervical spineprocedures
Esophagectomy
Thymectomy Carotid endarterectomy
Cardiothoracic surgery
Aortic surgery Coronary artery
bypass grafting Pulmonary lobar
resection Mediastinoscopy
Iatrogenic: Non-surgical
Endotrachealintubation Arytenoid
dislocation,subluxation
Tapias syndrome
Nasogastric tubeplacement1
Non-iatrogenic
Blunt or penetratingtrauma to the neck
Brousseau et al. A rare but serious entity: nasogastric tube syndrome. Otolaryngol HeadNeck Surg. 2006 Nov;135(5): 677-679.
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Evaluation Laryngeal
electromyography (LEMG)
Needle electrodeplacement intothyroarytenoid and
cricothyoid muscle Assess
Muscle at rest
Voluntary motor unitrecruitment
May not be useful indiagnosis
.1Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000Aug;33(4):759-70.
.2Sataloff et al. Practice parameter: laryngeal electromyography (an evidence-based review). Otolaryngol HeadNeck Sur 2004; 130: 770-779.
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Demystifying Electrodiagnostic
Studies
I.D.#: 2797
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History/Comments:
Left upper extremity pain and parethesias.
Motor Nerve Study
Left Median NerveRec Site: APB Lat (ms) Norm Lat Dur (ms) Amp (mV) Area (mVms) Dist (mm) C.V. (m/s)STIM SITEWrist 4.7
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Thank You