Results of the selection of the same waveform.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"61560",title:"Vascular Injury in Total Hip Replacement: Management and Prevention",doi:"10.5772/intechopen.77256",slug:"vascular-injury-in-total-hip-replacement-management-and-prevention",body:'This chapter gives an etiology, management, and prevention of common injuries that occur at the time of total hip replacement surgeries or postoperative period. A total hip replacement has become one of the most successful procedures with minimal complications and long-term result [1]. According to the data published by various major national and international joint registries, an increasing number of total hip replacements are performed each year. The incidence of vascular injury occurs at the time of hip surgery or immediate postoperatively or in the late postoperative period, which is quite rare (0.2–0.3%), but the inevitable and serious issue may cause morbidity and even mortality [1, 2]. The most common pattern of vessel injuries include lacerations, pseudoaneurysms, thromboembolic and arteriovenous fistula [3, 4, 5].
Contiguous arteries to the acetabulum that are susceptible to be injured during total hip replacement are mostly branches of common iliac vessels; external iliac vessels, obturator vessels, superior and inferior gluteal artery, and internal pudendal arteries and veins as shown in Figure 1 [6, 7, 8, 9, 10, 11, 12]. Indeed, many vascular structures surrounding the acetabulum may be injured by direct and indirect trauma have been reported [12, 13]. In particular, the primitive cause of injuries includes reaming during acetabular preparation, and retractor induced injury, drilling holes for fixation of screws in cementless acetabular cups, excessive traction in surgery, postoperative cup migration (Figure 2a and b). Also, cement erosion, excessive local heating by methyl methacrylate in cemented total hip replacement are further reasons of occurrence of arterial injuries during total hip replacement [4, 14, 15, 16, 17, 18, 19, 20]. However, there are many reported reasons in which symptoms of vessel injury were not evident. The possible reasons might be bone fragments or contamination caused due to soft tissue defect, result in infections [21].
Three-dimensional construction of pelvis and vessel structures using computed tomographic images.
Vessel injury. (a) Photograph illustrating inserted acetabular screw close to external iliac artery and vein (arrow) (reprinted with permission from Hwang [25]). (b) Postoperative false aneurysm of superior gluteal artery (circled lines) by protruding cement to fix acetabular component (horizontal arrow) (reprinted with permission from Bakker and Gast [10]).
Vessel injuries giving immediate symptoms of total hip replacement are the severe hemorrhage. The most common ischemic symptoms in the delayed postoperative period include pain, the decrease of hemoglobin, swelling, reduced blood pressure and hypovolemic shock [1, 2, 4, 6, 10, 11, 22, 23]. Other presenting signs and symptoms of vessel injury in revision surgeries include excessive bleeding, loss of pulse and instability during extraction of hip prosthesis [19].
In some reports, gender biasing has also been observed as one of the causes of vessel injury. In several retrospective studies, the female dominance of vessel injury as compared to male (3:2) has been confirmed [1, 4, 5, 16, 24].
At present, the participating physicians in total hip replacement are increasing, and indeed, vessel injury is a credit to those who are engaged in these types of surgeries. The relationship of pelvic vascular structures surrounding the acetabulum has been described in several studies [7, 9, 25]. Currently, substantial work by researchers has been carried out to visualize the detailed vascular structures surrounding the acetabulum with the use of three-dimensional computed tomographic angiography (3DCT-A) [26, 27, 28, 29, 30]. These studies identified the actual distance of vessel structures to the osseous surface of the acetabulum to prevent the injuries caused by fixation of screws in cementless total hip replacement.
Earlier, in continuation to prevent these injuries during fixation of acetabular screws, a simple method of acetabular quadrant system was described by Wasielewski et al. and accepted widely till date [9]. Various anatomical studies have shown the fixation of screws in cementless primary total hip replacement, particularly in revision surgeries being most prominent reason for vascular injuries.
Wasielewski et al. defined the acetabular-quadrant system for managing safe placement of screws during primary and revision total hip replacement surgeries. The quadrant system is proposed to explain the relationship between the osseous structure of acetabulum and surrounding vascular structures to prevent the vascular structures.
Acetabular quadrant system consists of four parts of acetabulum by dividing acetabulum with two mutually perpendicular lines. The first line A originates from the anterior superior iliac spine (ASIS) and passes straight to the center of the acetabulum, dividing the acetabulum into two halves and named collectively as anterior and posterior quadrants. The second line B originates from center of acetabulum and perpendicular to the first line, resulting in the two superior and inferior halves (Figure 3). To this end, these two perpendicular lines together form four quadrants by intersecting each other at the center of acetabulum, which is collectively named as an anterior superior quadrant, anterior inferior quadrant, posterior superior quadrant and posterior inferior quadrant. Most of the work published on vascular injury has been carried out on the cadaveric bone; the authors tried to give a clear picture of quadrant system by developing the three dimensional computational model of the pelvis and surrounding vascular structure with the help of angiographic computed tomography (A-CT). In the development of three-dimensional models of vascular structures, some of the arteries and veins are not visible because of imaging limitations of computed tomographic machine.
Demonstration of quadrant system used for placement of screws in total hip surgery.
Quadrant system specifies the safe zones to fix the proper sized acetabular screws that are carefully considered at the time of total hip replacement surgery. The relationship between vascular structures and four quadrants with lines passing and center of acetabulum respectively mimic the safe and dangerous zones, which are as follows:
This quadrant contains the external iliac artery and vein. The acetabular screws fixed in this quadrant will be directed towards these vessels. However, it was found that external iliac vein is lying down in more medial position than an artery and therefore is in more risky as compared to the artery.
Obturator artery is present in this quadrant, and the bone stock is thin in respect of other quadrants. This order will increases the possibility of vessel injury during screw placement.
From the previous literature of dissection and a considerable amount of three-dimensional studies, it is evident that superior posterior quadrant has good bone stock. This quadrant contains the superior gluteal artery and vein, as they pass to the pelvis through the greater sciatic notch. The proper sized screw may be considered for safe placement as the bone stock in the central zone of this quadrant is more than 25 mm.
Screws that are fixed in this quadrant are directed towards inferior gluteal and pudendal vessels. The quadrant is considered safe for screw placement as the central zone has a good bone purchase, and therefore a proper size of a screw may not touch the vessel structure thereby preventing the vessels from injury.
Line A and line B intersect each other at the center of the acetabulum. This position is very close to the obturator artery and is always avoided for placement of screws.
However, screws placed along line A in the superior portion of the acetabulum are directed towards the external iliac artery and may not be appreciated. Screws placed along line A in the inferior portion of acetabulum lie close to obturator vessel.
From the above discussion on quadrant system, it must be pointed out that external iliac vessels, obturator vessel and superior gluteal artery seem to have the most frequent injury. The anterior quadrant must be avoided for the placement of screw during total hip procedures, as these vessels mostly lie in this quadrant. In the exposure of posterior quadrants, the superior posterior quadrant is typically safer for proper sized screw placement as it has good bone purchase regardless of the presence of vessel structures.
In view of above, to give a clear picture of the quadrant system to prevent vascular structures from injury, the acetabular cups with 12 holes and additional central screw fixation is demonstrated along with vessel structures in Figure 4.
Visualization of vessels surrounding the pelvis which are prone to injury from screw placement.
In cases of high hip center, the quadrant system serves as in normal hips but it is constructed in different ways. In the high hip, posterior superior and inferior posterior quadrants are found safe for screw placement with good bone stock at the periphery of the acetabulum as shown in Figure 5 [31].
Illustration of screw placement zones in the high hip center.
Besides, a rare case of the aberrant anatomy of vessels was found, in such cases, care must be taken during fixation of screws as they are more susceptible to injury [9, 32, 33, 34].
In the cases of revision surgeries where there is a bone loss in posterior quadrants, placement of screws is necessary in anterior quadrant. To place proper sized screws in the anterior columns, Lewallen proposed a technique in which screws and drill bits may be passed by visual perception and palpation of the careful dissection of soft tissues in anterior quadrant [7].
The quadrant system described by Wasielewski et al. is prevalent among total hip arthroplasty surgeons, until the normal hips are taken into account. In the technical demand for total hip replacement of Crowe type-IV developmental dysplasia, the posterior superior quadrant system is condemned. The reason behind this is that center of the acetabulum is shifted anteroinferiorly in the hip with a high, complete dislocation (Figure 6). Screws lying in the safe quadrant (proposed by Wasielewski et al. for normal hips) may frequently injure the obturator blood vessels. In such type of cases, modified quadrant system must be used on surgeon recommendations [26].
Illustration of shifted quadrant system anteroinferiorly in Crowe type-IV developmental dysplasia.
Retractors are placed around the acetabulum for proper exposure of acetabulum during total hip arthroplasty. It has been found that surgical approaches adopted by surgeons, are not only the appropriate causes of injury. Consequently, appropriate retractor positioning and compression is critical to minimizing the vascular injury during total hip arthroplasty. Placing the anterior acetabular retractor at anterior inferior iliac spine and inferior acetabular retractor to the anterior wall is the safest position to avoid vascular injury during total hip arthroplasty.
Acetabular reinforcement ring and antiprotrusio cages are generally used in traumatic hips and revision surgeries [35]. These prosthesis enable to fix the screws to actualize the pre-existing anatomical conditions of acetabulum. Avoiding the risk of vascular injuries, screw positioning in ventral and dorsal type of prosthesis is generally avoided. However, in such critical anatomical situations, radiological interventions must be required during surgery.
During cemented total hip replacement surgeries, cement must be allowed to reach lesser pelvis. Postoperative vascular complications occur due to cement extrusion in defect of acetabular wall can put external iliac vessels at risk. Excessive use of cement (methyl-methacrylate) can cause exothermic reaction, resulting in vessel thrombosis. Cement spiculae can erode through the artery and result in perforation and pseudoaneurysm formation in postoperative duration. The vessels are susceptible to avulsion if a revision surgery becomes necessary and intrapelvic cement is unwisely extracted.
The preoperative clinical examination of vessels must be carefully performed. Knowledge and local anatomy of vessel status surrounding the pelvis before surgery is essential and if necessary, surgeons must use the easier method like Doppler scan to measure the arterial occlusion pressure. Few arteries like femoral artery defects are easily identified in these examinations, while artery defects for the arteries like obturator and superior gluteal artery are often difficult to diagnose in early preoperative period.
In case of revision total hip surgeries and traumatized hip, an appropriate vascular surgeon must be intimated prior to performing total hip replacement surgeries.
A high index of disbelief and careful intraoperative inspection are fundamental to immediate diagnosis and treatment of most intraoperative vessel injuries, both in primary and revision total hip surgeries. Sudden vascular injury at the time of surgery may be caused my many means for example instrumentation, broken bone edges, implants etc. Prompt recognition of vessel injury is important. In these injuries, the essential step is of course bleeding control. Surgeon must not underestimate the urgency of vessel injury even in slight signs of bleeding. There are many steps that must be followed in such types of situation, which are listed below
In open massive bleeding or slight signs of bleeding, immediate bleeding sights must be identified visually, and operated to stop the hemorrhage. Additionally, ultrasonography is the easiest and immediate way to recognize the site of bleeding in closed or open cases.
In acute hemorrhage at first site, surgeons must put pressure for local control at either end of injured vessels.
Additional supplies of blood and fresh frozen plasma must be done.
Coagulation and legation technique for smaller vessels can be useful for temporary control of bleeding.
Compression technique if unsuccessful at first attempt must be followed by surgical legation, endovascular stenting, and bypass as the next step for sites of vessel injury.
Without time delay, vascular surgeons must be intervened to take the operative actions and stop the bleeding immediately.
The operating orthopedic surgeon must be familiar with the advanced operative techniques like ilioinguinal and Stoppa approach for intrapelvic exposure, generally used in major injured vessel repair.
Postoperative insult of vessel injury by surgeons, which is the slightly lesser common cause of unexplained pathological complications, might even result in death. Immediate after surgery to few days of recovery, careful monitoring of vessel status is essential to avoid postoperative vessel complications. After surgery and in the late postoperative period there are many sign and symptoms, the surgeons, and even individual must not circumvent, of course, it may be the sign of late vascular injury. Unexplained hypotension, tachycardia, nerve palsy, hypovolemic shock and decreased hemoglobin and blood pressure are the signs of vascular injury, postoperatively. In postoperative cases with the above signs and symptoms, immediate axial imaging or radiography, contrast-angiography, color ultrasonography are the more natural way to diagnose the bleeding source. Monitoring of these signs wisely is better and can be treated with open repair, stenting, bypass, coiling, or chemoembolization without any delay (Figure 7) [37, 38, 39]. The late symptoms from false aneurysm formation might be in the broad range of spectrum and very confusing and can be treated by surgical intervention, once the vascular injury is determined by diagnosis [13, 19].
Photograph showing postoperative vessel injury. (A) Arterial injury between the distal external iliac artery and the femoral artery to the origin of deep femoral artery. (B) Arterial bypass (reprinted with permission from Barbier et al. [36]).
Total hip replacement surgery is largely performed in aged patients and possibility of arteriosclerosis vessel must be taken into account, as these vessels are more vulnerable to injury [29].
Conclusively, vascular injuries are rare in hip replacement surgeries. Careful preoperative planning, better instrumentation, knowledge of anatomical structures and meticulous surgical technique are necessary to avoid vascular injury. In advent screw penetration leading to vascular injuries can present early as hemorrhage during surgery, in the intermediate term as postoperative bleeding, hypotension, etc., and late as pseudoaneurysms. Further, management of these complications is beyond the scope of this chapter which focuses on prevention of these injuries rather than its management.
The authors would thank Professor P.P. Bansod, Head of Department, Department of Biomedical Engineering, SGSITS, Indore, India, for facilitating in preparation of this chapter.
The authors declare no conflict of interest.
When we move, the electrical signals are generated in the brain through the spinal cord, and muscles contract, which causes movement. In the electrical signal transmission, although the function of the spinal cord is important, there is no consensus on the function (i.e., spinal cord excitability). The F wave which is an evoked electromyogram is one of the means to reflect the excitability of the spinal cord. Although the generation mechanism of the F wave will be described later, the F wave is characterized by various waveform shapes that can be usually recorded. On the one hand, in cases of spinal cord disease and cerebral infarction, the F wave with same shape may be recorded. Recently, due to these characteristics of the F wave, the excitability of the spinal cord has been utilized for grasping the pathological condition of neurological disorders. On the other hand, the analysis for the waveform of the F wave varies depending of the researcher, and the F wave appears in various ways; it has not yet been established as one evaluation. Hence, the ultimate objective is to establish an analysis method of waveform with low cost and effort and to improve the versatility of the analysis method in clinical setting. I will explain the F waves in terms of neurophysiology and investigated whether the averaging method can be applied to F-wave waveform analysis. In this article, we will explain with a brief reference to the physiological aspects of the F-wave generation mechanism in order to understand waveform analysis more deeply. The same waveform appears in motor nerve demyelinating diseases and diseases involving degeneration of spinal anterior horn cells. However, the same criterion for waveforms may differ from each researcher. Therefore, we found the same criterion using the correlation coefficient. The usefulness of the addition averaging method in waveform analysis was examined using the reference value of the same waveform and will be introduced here.
\nF waves conduct retrogradely toward the center when a certain electrical stimulus is afforded to the α motor neuron (hereinafter αMN). Originally, the axon does not reach the cell body due to impedance mismatch (resistance Ω = V/I) at the axion hillock. Therefore, the spinal cord anterior horn cells do not refire and do not generate F waves. However, when spikes cross the axion hillock and reach the anterior horn cells of the spinal cord due to some effect, they propagate to the dendrites and generate SD (soma-dendritic) spikes there. This spike reaches the axion hillock that has escaped from the absolute refractory period and conducts the axon antegrade from there, resulting in compound muscle action potential (CMAP) evoked from the governing muscle [1]. Nerve fibers have an absolute refractory period of 1 ms, and if the spike returns during the period corresponding to the refractory period of the axion hillock, no F waves can be generated because they cannot be conducted antegrade. Also, αMN has a structure of antidromic inhibition via Renshaw cells. Antidromic inhibition takes 2 ms, and it takes 1 ms to return from the axion hillock to the spinal cord anterior horn cells. In other words, in order to generate the F wave, the spinal cord anterior horn cells must reignite and conduct to the periphery between 1 ms after the absolute refractory period of the axion hillock has ended and 2 ms before antidromic inhibition of Renshaw cells. Whether or not the axion hillock is out of the absolute refractory period is determined by slight timing differences, and this is thought to significantly affect the incidence of F waves [1, 2]. In addition, the following three conditions are considered in which the F wave is likely to occur: (1) the hyperpolarized state in the cells increases the time required for conduction to the dendrites, which makes it easier to avoid the absolute refractory period of the axion hillock; (2) reduction of the absolute refractory period; and (3) excessive depolarization of the axon lowers the threshold level, making spikes more likely to occur with small stimuli [1] (Figure 1).
\nF-wave generation mechanism.
Although the F wave is conducted antegrade by refiring of the spinal cord horn cells and can be recorded, refiring does not occur in all neurons. Furthermore, the probability of firing the same cell with each electrical stimulation is usually low, and re-excitation occurs only once every 10–100 times [1]. Komori et al. reported that 1406 F waves were evoked by a total of 1957 electrical stimuli in 10 cases, which consisted of 1160 waveforms, of which 1033 (89.1%) had only 1 occurrence [3]. F waves can be evoked from most motor nerves, but the nerves used mainly for examination are the median nerve, ulnar nerve, and tibial nerve. Among these nerves, the ulnar and tibial nerves have a persistence close to 100%. In addition, the normal value of the F-wave persistence varies among researchers. For the median nerve, Komori and Suzuki et al. reported more than 40%, and Fisher et al. reported 79–100%, but if too high, they may suspect spasticity, a disorder of upper motor neurons. There are reports of peroneal nerves in the nerves targeted for F-wave tests, but it is said that there are cases of difficulties in Japanese people even in healthy subjects [4, 5]. In the background, Japanese people are suspected of having a potential peroneal neuropathy due to the unique Japanese culture such as sitting straight custom. Hirashima et al. reported that CMAP (M-wave) amplitude increased by peroneal nerve stimulation since 1995 [6] and examination of the peroneal nerve is now being examined.
\nIn the anterior horn of the spinal cord, there are neurons of various motor units (motor neuron pool). A motor unit is a unit composed of motor neurons, and the muscle fibers are governed by the neurons. One F wave appears due to the combination of refiring motor units. The F-wave waveforms are different due to the combination of the motor units and the timing shift; therefore, the F wave has a feature in which its waveforms appear in a variety. There are three types of motor units. The S type (slow-twitch type) is small in size and slow in contraction speed. The FF type (fast-twitch fatigable type) is large in size and fast in contraction speed but is easily fatigued. The FR type has characteristic between S type and FF type. When a person exerts, it depends on the number of motor units activated (recruitment) and the frequency of firing of motor neurons (rate coding) [7].
\nHenneman reports that there is a strong correlation between motor neuron size and recruitment order [8]. When exercising, there are rules that are mobilized in order from smaller motor units to larger motor units (size principle) [1, 2, 7]. Small motor neurons have a low stimulus threshold and are easy to fire even with weak input. The percentage of motor units varies from muscle to muscle. Enoka reported that 92.5% of S-type motor neurons and 7.5% of FR-type motor neurons dominated in gastrocnemius muscles. Similarly, the musculus interossei dorsales pedis and triceps brachii muscle were dominated mostly by small motor neurons [9].
\nWhen humans exert their power, fluctuations in rate coding, in addition to recruitment of motor units, have a great effect, too [10, 11]. For example, in a study by Moritz et al., as the muscle contraction strength of the musculus interossei dorsales pedis of the hand was gradually increased, the rate coding of firing and the number of motor units increased, and the contraction strength reached 60% or more (against maximum contraction strength). At 60% or more contraction, most of the work was done only by increasing the rate coding. In the case of F wave, it has no effect on one waveform, but F wave treats the average value of the waveform obtained by 16 or more stimuli. At that time, the rate coding of the same motor unit with respect to the number of stimulations is reflected [12].
\nFrom the above, it is necessary to adjust the rate coding of firing of units of various sizes according to the scene. When various units fire, they appear in the waveform of the F wave, and the rate coding is directly reflected in the persistence of the F wave. In other words, it can be said that the waveform and appearance persistence of the F wave reflect the motor unit. However, it has been reported that when the number of anterior horn cells decreases or degenerates due to spinal cord anterior horn cell disease or motor neuron damage, the firing of the same unit is biased and the F wave shows the same waveform. Evaluation the F wave reflecting the unit this way has the potential to lead to an objective evaluation of muscle output and voluntary motion.
\nLatency is the time taken of an electrical stimulation conduction to reach the spinal cord anterior horn cells and return to the dominant muscle. This parameter is most commonly used in clinical practice and is a highly reproducible index. In addition, the shortest rise latency in the recorded F wave is called the minimum latency, which reflects motor fibers with fast conduction time. Conversely, the longest rise latency is called the maximum latency, which reflects motor fibers with slow conduction times (Figure 2). The speed of conduction is said to be affected by height, limb length, and skin temperature. Speed of conduction is particularly reduced in diseases that affect the myelin of peripheral nerves (e.g., Guillain-Barre syndrome, Charcot-Marie-Tooth disease, etc.) [1].
\nLatency type.
Amplitude represents the magnitude of the waveform. There are two types of measurement methods. The first is the baseline to peak amplitude. The second is the peak-to-peak amplitude of the negative and positive vertices (Figure 3). We used the second peak-to-peak amplitude this time to analyze the waveform, including the positive wave. To normalize the amplitude of the F wave, the amplitude F/M ratio is expressed by the ratio divided by the peak-to-peak amplitude of the M wave when the maximal stimulation is given to the motor nerve. It is said that if the amplitude F/M ratio shows a value of 5% or more, the possibility of upper motor neuropathy is suspected [13].
\nA way to measure amplitude value.
Duration indicates the time from the rise of the amplitude of the F wave to its return to the baseline. However, depending on the waveform, the position to return to the baseline is unclear, and care must be taken when using this index because it may be affected by the experience value of the measurer. In the case of the median nerve, the location where the F wave is generated is on the baseline after the generation of the M wave, so it is difficult to define the baseline (Figure 4).
\nCases where it is difficult to measure the duration of the median nerve.
Persistence indicates the ratio of the appearance of the F wave to the total number of stimulations. Analysis of only one waveform is not sufficient because the F wave has different waveforms at each stimulus. Komori et al. reported that sufficient reproducibility was obtained with more than 50 stimuli [14]. Currently, Kimura et al. have generally analyzed using the average value of F waves obtained at least 16–30 times or more stimuli.
\nOthers analyze the number of negative vertices of the waveform. There is also an index called Fchronodispersion which indicates the variation of latency from the difference between the minimum latency and the maximum latency.
\nAmong peripheral neuropathies (neuropathies), abnormalities of F-wave waveform due to motor nerve disorders have been reported mainly by Kimura et al. [1, 15, 16, 17, 18, 19]. There are reports of Guillain-Barre syndrome [15, 16, 17], Charcot-Marie-Tooth disease [19], and diabetic neuropathy [20, 21], which are diseases in which motor nerves are predominantly impaired. There are reports related to spasticity, one of the pyramidal tract disorders [22, 23, 24, 25]. In recent years, there have been many reports of amyotrophic lateral sclerosis that is an intractable disease in which both upper and lower motor neurons are degenerated [1, 2]. In neuropathy, demyelination of axon myelin sheaths inhibits jump conduction and slows the conduction speed. As a result, it is easy to obtain a result such as a delay in the rise latency and a decrease in the persistence of the F wave. These diagnoses can be determined by latency which has high reproducibility among F-wave parameters.
\nThe authors focused on abnormal F waveforms in disorders involving upper motor neuron disorders and spinal cord anterior horn cell degeneration. In cases of spasticity among stroke, Suzuki et al. report that as the electrical stimulation intensity is increased, the waveform of the F wave appears more like the H wave as the degree of muscle tone and tendon reflex increases [26]. In addition, Suzuki et al. measured F waves obtained from the abductor of the thumb by median nerve stimulation in one case of cerebrovascular disease and compared the disease duration at 9 months, 52 months, and 70 months later. Meanwhile, physical therapy was given. As a result, they reported that as the duration of physiotherapy increased, the amplitude of F waves decreased, and the waveforms varied. In addition, improved hand muscle tone and voluntary motion. Komori et al. also reported that the amplitude of F waves increased with spasticity [25]. However, other researchers measured F waves when median nerve stimulation was applied to 14 stroke patients, and the latency and persistence were not significantly different between the non-paralyzed side and the paralyzed side. The persistence of motor unit has been reported to decrease significantly on the paralyzed side regardless of the degree of muscle tone [23, 27]. In the case of amyotrophic lateral sclerosis, atrophy of the anterior horn cells of the spinal cord reduces the number of motor units and the number of firing anterior horn cells, so the persistence decreases significantly, and the same waveform begins to appear [27]. Similarly, spinal and bulbar muscular atrophy (SBMA) has been reported to produce F-wave waveform with similar characteristics [28, 29, 30].
\nF waves with matching latency and amplitude values may appear when spasticity due to stroke or when atrophy of the spinal cord horn cells occurs, such as in ALS and SBMA. This is known as “repeater F.” This repeater F is reported to significantly appear more in patients with diabetic polyneuropathy, ALS, carpal tunnel syndrome, ulnar neuropathy, and L5 radiculopathy than in healthy subjects [1, 2, 31, 32].
\nThe authors wondered how it is difficult to determine the consistency of the waveforms using only the amplitude value or the latency and how to judge the waveforms to be the same. Some studies report the same waveform as an analysis item, but few describe the judgment method in detail. Some of the methods described for determining the same waveform include the following: (1) a method of visual judging by superimposing recorded waveforms [3, 33], (2) a method of determining the correlation coefficient between waveforms at a value of 1.00 [34, 35], and (3) in recent years, some researchers have decided to develop their own analysis software [36]. There is a risk that the evaluation method can be used only by those who are familiar with F waves when using the visual observation to determine the same waveform, because the degree of match defined as the same waveform includes individual differences.
\nThe authors examined the relationship between the results that three researchers familiar with F waves judged visually the same waveform and the results of the correlation coefficient calculated from the data [37]. The target waveform is a waveform of 30 shots derived from the musculus abductor pollicis brevis by median nerve stimulation of a healthy person for 5 trials. A total of 150 waveforms were prepared. We asked each researcher to select the same waveform in a separate room to avoid interference. The data processing method of the F wave was a moving average of three terms using Microsoft Excel. The correlation between the waveform after the moving average and the raw waveform was an extremely high value of R = 0.9963, which sufficiently reflects the raw waveform. Next, the correlation coefficients of all combinations of waveforms evoked by applying 30 electrical stimuli per trial were calculated. The waveforms visually judged the same waveforms selected by two or more out of three people.
\nThe results showed that the same waveform was selected by the 2 individuals as 10 waveforms, of which 9 (90%) showed a correlation coefficient of 0.95 or more. Next, the waveforms selected by the three persons had two waveforms, and both waveforms showed a correlation coefficient of 0.95 or more. It was suggested that the number of correlation coefficients R = 0.95 may be one index of the same waveform when analyzing the waveform of the F wave (Table 1).
\nResults of the selection of the same waveform.
However, one waveform judged to be the same waveform was recognized, although the correlation coefficient was 0.71. They were similar in waveform but slightly different in latency when the actual raw waveforms were checked. Therefore, the latency was shifted by 0.625 ms until the negative peak matches with the visual confirmation; as a result the waveform showing a correlation coefficient of 0.71 showed a correlation coefficient of 0.96.
\nAlthough the waveforms were the same in this study, the different latencies suggested that the correlation coefficient was low. We thought that the slight shift in the rise latency was affected the time it took for the spike to occur in the spinal cord anterior horn excitation threshold. This time the evoked musculus abductor pollicis brevis is composed of 115–171 motor units, considering the possibility that the rise latency could be shifted due to the spatial relationship of the cell bodies when cells are similar in size during refiring. Komori et al. allow for differences in negative peak latencies up to 1 ms when comparing the reproducibility of F waves [38]. It may be necessary to consider such differences in latency when analyzing the same waveform.
\nAn analysis method that takes into account the F wave, in which various waveforms appear, has not yet been established. In addition, there is a report on the F-wave method (F-MUNE) for estimating motor units using F waves. However, analysis requires time and effort, and versatility is poor at present [27, 39, 40]. Therefore, as stated in this introduction, we examined whether the averaging method is applicable to F waves to increase versatility by establishing simple analysis methods. The averaging method approaches 0 by averaging the waveforms that appeared in diversity with repeated stimuli. On the other hand, a waveform that appears at a fixed latency also appears as a waveform after overlapping and addition averaging [1]. In the case F wave appears in the diversification, the value become close to 0 when the addition averaging process is performed. The wave remains after the addition averaging process when the same waveform appears repeatedly. It may be possible to distinguish the same or similar waveforms if the addition averaging method is used to analyze the waveform of the F wave. However, there is a risk that the waveform may disappear due to a slight difference in latency when applying this addition averaging method to the analysis of the waveform of the F wave. Furthermore, meaning is still unclear what waveform is calculated by the addition averaging method, so we first examined the relationship between the averaging waveform and the raw waveform.
\nEisen et al. [13] first studied F waves using the addition averaging method. They addition averaged the F waves obtained by giving 32 electrical stimulations into the tibial nerve of cerebrovascular patients and compared them with that of the healthy subjects. The waveform after addition averaging reported that the duration and amplitude could be reproduced in both cerebrovascular and healthy subjects [13]. In Japan, Komori et al. focused on the latency of the negative peak in order to pursue an evaluation method that combines reproducibility and simplicity in order to promote clinical application of F wave. The waveform after adding the negative peaks manually (addition method) showed that the reproducibility of the waveform was 86.7% for the median nerve and 73.3% for the tibial nerve, even when measured on another day [38]. Next, they reported that the waveform obtained by the addition averaging method sufficiently reflected the waveform of the proven addition method [41]. Sakamaki et al. point out that such as F waves, when negative waves and positive waves appear at the same latency, may be offset when the addition averaging method is used for waveforms that appear in diversity [42]. Hiratsuka et al.’s research also tried to use the addition averaging method, but the amplitude was significantly reduced, making analysis difficult [43]. There have been fewer studies using the addition averaging method for F-wave analysis since the first half of 1988 from this background. There are other reports that use the addition averaging method for the F-wave analysis items [44, 45, 46], but only the latency and duration reflect the raw waveform, and it is a difficult situation to establish these as parameters.
\nWe reexamined the usefulness of the addition averaging method, taking into contents what Sakamaki pointed out. First, we examined whether the persistence of F waves needs to be considered for the median nerve since the persistence of F waves differs for each nerve to be affected.
\nThe method measured the F wave at rest and calculated the coincidence rate between addition averaging waveform for all waveforms and averaging waveform reflecting only F-wave appearance waveform. Subjects were 99 healthy volunteers (55 males and 45 females) who agreed to the study with an average age of 23.3 ± 5.3 years. The F wave was obtained by electrically stimulating the median nerve of the non-dominant upper limb. From the measured F waves, the waveform after addition average of the “waveform data of 1 trial (30 shots) (thereafter, TW)” and “waveform data of only the F-wave appearance waveform (thereafter, AW)” was obtained using Microsoft Excel. Next, the correlation coefficient between the two waveforms after addition average values was calculated using CORREL function. This correlation coefficient indicates the coincidence rate. The reference value of the same waveform used the correlation coefficient of 0.95 from previous studies. Next, a scatter diagram from the data of the F-wave persistence of each subject is created, and the coincidence rate is calculated using single regression analysis. The coefficient of determination (R2) is calculated, and the variation is obtained. It is examined whether the coincidence rate depends on the persistence of F wave. 80/99 subjects had a correlation coefficient between TW and AW of 0.95 or more, accounting for 80% of the total. Among them 38 subjects showed a correlation coefficient of 1.00, representing 38% of the total. 19/99 subjects showed a correlation coefficient of 0.95 or less, accounting for 20% of the total (Figure 5). A scatter plot showing the persistence of F wave and the coincidence rate is presented in Figure 6.
\nA circle graph showing the correlation coefficient of two addition averaging waveforms.
A scatter plot showing the persistence of F wave and the coincidence rate.
The coefficient determination (R) was 0.53, indicating “somewhat correlated.” The highest F-wave persistence was 60%, and the lowest value was 10% in the group that showed a concordance rate of 0.95 or less (thereafter, group A). The highest F-wave persistence was 100%, and the lowest value was 23% in the group that showed a concordance rate of 0.95 or higher (thereafter, group B) (Figure 6). The result we expected was that the higher the persistence of F waves, the higher the coincidence rate. However, those with a high coincidence rate and those with a low coincidence rate were recognized despite low persistence of F wave in group A and group B. Therefore, we confirmed the raw waveform of those with low persistence of F wave in both groups. Then, there were two factors that reduced the coincidence rate in Group A.
\nThe first factor is that the persistence of F waves is significantly lower. The amplitude could be confirmed visually because the fewer the number of waveforms that appeared, the smaller the value to be divided. On the other hand, the amplitude value was lost because the denominator to be divided was large. From the above, it is considered that the coincidence rate of the two waveforms has a low value. This result is similar to the reported study of Hiratsuka et al. [43].
\nThe second factor is that high-amplitude waveforms appear localized. It was considered that the addition averaging waveform of AW had a higher amplitude value and a lower coincidence rate because of appearing several high-amplitude waveforms. In group B, there were also two possible factors for the high coincidence rate despite the low persistence of F-wave appearance as in group A. The first factor is that the persistence of the F wave is around 50%, and the appearing waveform shows almost a similar waveform. The second factor is, even though the number of appearing waveforms was few, they were canceled out by the appearance of diversity which is also a characteristic of the F wave. As a result, we thought that the matching rate approached the baseline and showed a high value. We think that the tasks of making the persistence of F waves approach 100% using muscle contraction or evoked from tibial nerve are suitable when using addition averaging method to analyze F-wave waveform.
\nCompared with the commonly used amplitude F/M ratio, the amplitude value of after addition averaging waveform showed about 1/2 of the value [41]. It is considered to be the result of the overlap between the negative and positive waves as reported by Sakamaki and Takasu [42]. To avoid the reverse winding proposal, averaging was performed in three ways, and the ratio of amplitudes of addition averaging and the average of the values obtained for each stimulus were compared. The three ways of performing the averaging method are described below:
A method of addition averaging the recorded F wave as it is (normal).
A method of addition averaging after the match of negative peak.
A method of addition averaging after the match of rise latency.
Subjects picked up and analyzed one subject who showed 100% persistence of F wave. The results are shown inTable 2. The error amplitude F/M ratio was 2.0%, and the measured value was 25.79 μV during normal addition averaging. Next, the error when matching the negative peak was 0.43%, and the measured value was 39.59 μV. Finally, the error when the rise latency was matched was 0.67%, and the measured value was 62.05 μV. From the above, in the case of one subject this time, the average is usually the closest to the raw data, but it is necessary to increase the number of subjects and pursue it because it is the result of only one subject.
\nComparison of three addition averaging methods and average data.
At the present time, when using the addition averaging method for the F-wave waveform analysis, (1) the constant criterion of the same waveform using the correlation coefficient should be 0.95, (2) the persistence of F waves when using the addition averaging method is at least 60% or more and (3) the normal addition averaging method has less error in the amplitude value compared to the raw data.
\nHowever, all the contents described this time are the analysis results of F waves evoked by electrically stimulating “median nerve.” Therefore, we will analyze the ulnar nerve, the tibial nerve, and the peroneal nerve in the same way as described at the beginning and examine the innervated nerves to which the addition averaging method is applicable. In addition, “cluster analysis” will be introduced to avoid pointing out the content of Sakamaki et al. In this analysis method, similar waveforms are collected to create a cluster. By carrying out the cluster analysis before the addition averaging, the similar waveforms can be classified, and the cancelation of the positive wave and the negative wave due to the variation in the latency can be avoided. In addition, you can see how many F-wave clusters make up one trial during a case characteristic of F-wave waveform such as stroke with spasticity or ALS with atrophy of spinal cord horn cells.
\nWe are grateful to Dr. Suzuki and laboratory members for their helpful discussions.
\nNothing.
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\n\nIntechOpen requires:
\n\nCONFLICT OF INTEREST - AUTHOR
\n\nAll Authors are obliged to declare every existing or potential Conflict of Interest, including financial or personal factors, as well as any relationship which could influence their scientific work. Authors must declare Conflicts of Interest at the time of manuscript submission, although they may exceptionally do so at any point during manuscript review. For jointly prepared manuscripts, the corresponding Author is obliged to declare potential Conflicts of Interest of any other Authors who have contributed to the manuscript.
\n\nCONFLICT OF INTEREST – ACADEMIC EDITOR
\n\nEditors can also have Conflicts of Interest. Editors are expected to maintain the highest standards of conduct, which are outlined in our Best Practice Guidelines (templates for Best Practice Guidelines). Among other obligations, it is essential that Editors make transparent declarations of any possible Conflicts of Interest that they might have.
\n\nAvoidance Measures for Academic Editors of Conflicts of Interest:
\n\nFor manuscripts submitted by the Academic Editor (or a scientific advisor), an appropriate person will be appointed to handle and evaluate the manuscript. The appointed handling Editor's identity will not be disclosed to the Author in order to maintain impartiality and anonymity of the review.
\n\nIf a manuscript is submitted by an Author who is a member of an Academic Editor's family or is personally or professionally related to the Academic Editor in any way, either as a friend, colleague, student or mentor, the work will be handled by a different Academic Editor who is not in any way connected to the Author.
\n\nCONFLICT OF INTEREST - REVIEWER
\n\nAll Reviewers are required to declare possible Conflicts of Interest at the beginning of the evaluation process. If a Reviewer feels he or she might have any material, financial or any other conflict of interest with regards to the manuscript being reviewed, he or she is required to declare such concern and, if necessary, request exclusion from any further involvement in the evaluation process. A Reviewer's potential Conflicts of Interest are declared in the review report and presented to the Academic Editor, who then assesses whether or not the declared potential or actual Conflicts of Interest had, or could be perceived to have had, any significant impact on the review itself.
\n\nEXAMPLES OF CONFLICTS OF INTEREST:
\n\nFINANCIAL AND MATERIAL
\n\nNON-FINANCIAL
\n\nAuthors are required to declare all potentially relevant non-financial, financial and material Conflicts of Interest that may have had an influence on their scientific work.
\n\nAcademic Editors and Reviewers are required to declare any non-financial, financial and material Conflicts of Interest that could influence their fair and balanced evaluation of manuscripts. If such conflict exists with regards to a submitted manuscript, Academic Editors and Reviewers should exclude themselves from handling it.
\n\nAll Authors, Academic Editors, and Reviewers are required to declare all possible financial and material Conflicts of Interest in the last five years, although it is advisable to declare less recent Conflicts of Interest as well.
\n\nEXAMPLES:
\n\nAuthors should declare if they were or they still are Academic Editors of the publications in which they wish to publish their work.
\n\nAuthors should declare if they are board members of an organization that could benefit financially or materially from the publication of their work.
\n\nAcademic Editors should declare if they were coauthors or they have worked on the research project with the Author who has submitted a manuscript.
\n\nAcademic Editors should declare if the Author of a submitted manuscript is affiliated with the same department, faculty, institute, or company as they are.
\n\nPolicy last updated: 2016-06-09
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