|Year : 2022 | Volume
| Issue : 1 | Page : 43-48
Normative data for ulnar nerve conduction and the influence of gender and height on ulnar nerve conduction velocity in healthy Nigerians
Lukman Femi Owolabi1, Abubakar Mohammed Jibo2, Aliyu Ibrahim3, Shakirah Desola Owolabi4, Baffa Adamu Gwaram3, Gerald Onwuegbuzie5
1 Department of Medicine, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Community Medicine, Bayero University, Kano, Nigeria
3 Department of Medicine, Bayero University, Kano, Nigeria
4 Department of Psychiatry, Bayero University, Kano, Nigeria
5 Department of Medicine, University of Abuja, Abuja, Nigeria
|Date of Submission||19-Jul-2020|
|Date of Acceptance||29-Sep-2020|
|Date of Web Publication||18-Mar-2022|
Abubakar Mohammed Jibo
Department of Community Medicine, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Despite the usefulness of ulnar nerve conduction studies in identifying disorders of ulnar nerves, there is a lack of normative values for the ulnar nerve in Nigerian population. Objective: The objective of the study was to generate normative values for motor and sensory ulnar nerve conduction studies (NCSs) in Nigerian population and to determine the influence of gender and height on ulnar nerve conduction velocity (NCV). Materials and Methods: A total of 200 healthy volunteers were selected after clinical evaluation to exclude common causes of ulnar neuropathy. We carried out NCS of ulnar nerves on all the healthy volunteers according to a standardized protocol. The NCS parameters included in the final analysis were amplitude, latency, NCV, and f-wave latency. Ethical approval was obtained for the study. Results: The mean ulnar nerve sensory velocity was 55.22 ± 5.67 with 2.5 and 97.5 percentile of 46.9 and 70.1, respectively. The mean latency of the ulnar nerve (sensory) was 2.97 ± 0.62 with 2.5 and 97.5 percentile of 2.00 and 4.52, respectively. The mean amplitude of the ulnar nerve (sensory) was 35.56 ± 9.97 with 2.5 and 97.5 percentile of 15.9 and 57.7, respectively). The ulnar NCV was significantly (P = 0.0202) higher in male. Mild inverse correlation (r = 0.2) was found between ulnar NCV and height of the participants (P = 0.0089). Conclusion: In the Nigerian population, normative values of motor and sensory ulnar nerve conduction parameters are similar to the existing values in the literature. The ulnar NCV appeared to be influenced by height and gender.
| Abstract in French|| |
Contexte: Malgré l'utilité des études de conduction du nerf ulnaire pour identifier les troubles des nerfs ulnaire, il y a un manque de normative valeurs pour le nerf ulnaire dans la population nigériane. Objectif: L'objectif de l'étude était de générer des valeurs normatives pour les moteurs et études de conduction sensorielle du nerf ulnaire (NCS) dans la population nigériane et pour déterminer l'influence du sexe et de la taille sur le nerf ulnaire vitesse de conduction (NCV). Matériel et méthodes: Un total de 200 volontaires sains ont été sélectionnés après évaluation clinique pour exclure causes courantes de neuropathie ulnaire. Nous avons réalisé une NCS des nerfs ulnaire sur tous les volontaires sains selon un protocole standardisé.Les paramètres NCS inclus dans l'analyse finale étaient l'amplitude, la latence, la NCV et la latence de l'onde f. L'approbation éthique a été obtenue pour le étude. Résultats: La vitesse sensorielle moyenne du nerf ulnaire était de 55,22 ± 5,67 avec 2,5 et 97,5 percentile de 46,9 et 70,1, respectivement. La moyenne la latence du nerf ulnaire (sensoriel) était de 2,97 ± 0,62 avec 2,5 et 97,5 percentile de 2,00 et 4,52, respectivement. L'amplitude moyenne de l'ulnaire nerf (sensoriel) était de 35,56 ± 9,97 avec 2,5 et 97,5 percentile de 15,9 et 57,7, respectivement). Le NCV ulnaire était significativement (P = 0,0202)plus élevé chez les hommes. Une légère corrélation inverse (r = 0,2) a été trouvée entre la NCV ulnaire et la taille des participants (P = 0,0089). Conclusion: dans la population nigériane, les valeurs normatives des paramètres de conduction du nerf ulnaire moteur et sensoriel sont similaires aux valeurs existantes dans le Littérature. Le NCV ulnaire semble être influencé par la taille et le sexe.
Mots-clés: Électromyographie, test de conduction nerveuse, Nigérians, normatif, nerf cubital
Keywords: Electromyography, nerve conduction test, Nigerians, normative, ulnar nerve
|How to cite this article:|
Owolabi LF, Jibo AM, Ibrahim A, Owolabi SD, Gwaram BA, Onwuegbuzie G. Normative data for ulnar nerve conduction and the influence of gender and height on ulnar nerve conduction velocity in healthy Nigerians. Ann Afr Med 2022;21:43-8
|How to cite this URL:|
Owolabi LF, Jibo AM, Ibrahim A, Owolabi SD, Gwaram BA, Onwuegbuzie G. Normative data for ulnar nerve conduction and the influence of gender and height on ulnar nerve conduction velocity in healthy Nigerians. Ann Afr Med [serial online] 2022 [cited 2022 May 17];21:43-8. Available from: https://www.annalsafrmed.org/text.asp?2022/21/1/43/339933
| Introduction|| |
The role of nerve conduction studies (NCSs) in the diagnosis of diseases of the peripheral nervous system (PNS) cannot be overemphasized. Central to the diagnosis of any PNS disease is the ability to distinguish between healthy individuals and those with the disease. NCS is used to assess the function of the conduction of the motor and the sensory nerves. It is often used in the diagnosis of polyneuropathies, mononeuropathies, radiculopathies, compressive neuropathies, and other common diseases of the PNS.
Ulnar neuropathy is a commonly encountered peripheral neuropathy either in acute diseases such as after elbow trauma or in chronic diseases such as in diabetic neuropathy and chronic compression neuropathy. In any case, meticulous clinical assessment and discerning evaluation of neurophysiologic assessment are veritable means of diagnosing and finding out the extent and distribution of peripheral nerve injury as well as in determining the prognosis of recovery of ulnar nerve disorder with management. Consequently, for diagnostic purposes, definitions of the upper and lower limits of the routinely recorded NCS parameters such as latency, amplitude, and velocity is imperative.
The relevance NCS in evaluation of peripheral nerve abnormality is becoming increasingly recognized in Nigeria. The neurophysiology laboratories available in Nigeria adopted the reference values generated outside the country to diagnose different ulnar nerve abnormalities. To identify the abnormality of ulnar nerve, there is a need for reference data from the local population. Literatures on nerve conduction parameter normative values for different nerves including ulnar nerves are enormous worldwide.,,,, It is often most desirable and encouraged in a clinical setting to have reference values that are derived from the same population or from a sample population that approximates, as closely as possible, the demographic characteristics of the patient being tested. The few reports available on NCS normative values from Nigeria were focused on median and sural nerves, but there is no published account on ulnar nerves in the country.
Nerve conduction velocity (NCV) is affected by many fact1ors such as temperature, height, age, and gender, which in turn may vary in the different geographic region and ethnic groups. Quite ironically, NCV is very rarely correlated with these physiological variables.
This study was designed to obtain reference values for ulnar motor and sensory nerve conduction from healthy Nigerians and evaluate the relationship of the nerve conduction parameters with the demographic and anthropometric parameters.
| Materials and Methods|| |
The data were collected over a 6-month period at the neurodiagnostic laboratory of the Aminu Kano Teaching Hospital (AKTH), Bayero University, Kano, Nigeria. The hospital is the reference hospital in the region, serving the residents of Kano and the neighboring northwestern states of Nigeria. The hospital has a neurophysiology center with electromyography (EMG) and electroencephalography machines.
Study design and participants
The study was a cross-sectional study with a total sample of 200 healthy volunteers, calculated using Cochran's sample size formula for continuous data. The volunteers were selected using simple random sampling technique.
All individuals that volunteered to participate in the study were screened for inclusion criteria that comprised apparently healthy volunteers with normal neurological physical examination, absence of symptoms of neuropathy from any cause, and nonuse of alcohol.
We used a standardized questionnaire to exclude those with a history of systemic or neuromuscular diseases. Individuals that were excluded included those with a history of alcohol abuse or medications that might affect the results of NCS and those with a history of diabetes, hypothyroidism, and systemic diseases. None of the individuals was taking any medication at the time of conducting the EMG study. We performed a basic neurological examination to assess muscle power, stretch reflexes, and sensations. The clinical parameters obtained from the participants were age, gender, dominant hand, and temperature. Anthropometric parameters obtained from the participants included height, second digit (2D) and fourth digit (4D) length with 2D/4D ratio, weight, and body mass index (BMI). Anthropometric measurements of participants were carried out while they stood in light clothing without shoes, and digital caliper was used to measure the second digit length (2D) and fourth digit length (4D) using a standard protocol.
Nerve conduction study
NCS was carried out using a four-channel EMG machine (Nihoen Kohden Inc., Tokyo, Japan). The procedure was performed with the participants lying comfortably in the supine position. A standardized technique was used to obtain and record action potentials for motor and sensory functions. The protocol adopted in the current was like that elsewhere, with minor alteration.
The setting used in the study was as follows: for ulnar motor nerve conduction, the low cut filter was 3 Hz and the high cut was 10 KHz, the sweep was at 2–5 ms/division, and a stimulus duration of 50 μs–1000 μs and current 0–50 mA were used for effective nerve stimulation. Supramaximal stimulation (20%–30% more than the current required for maximal action potential) was used. For sensory ulnar nerve conduction, low cut was set at 10 Hz, high cut was set at 2 KHz; the amplification between 20,000 and 100,000 times; electrode impedance was kept below 5 kΩ, and the sweep speed for sensory nerve conduction was maintained at 1–2 ms/division.
We collected data for proximal and distal latency measured from the onset of the action potential, conduction velocity, amplitude, and minimum f-wave latency of compound muscle action potential (CMAP) and sensory nerve action potential measured from positive peak to the negative peak. All the studies were performed with surface recordings and stimulations.
Ulnar motor nerve study
We performed distal stimulation of the ulnar (orthodromic) nerve at the wrist 3–4 cm proximal to distal wrist crease just medial to the flexor carpi ulnaris tendon to activate the CMAP at the center of abductor digiti minimi recorded with an active electrode (G1) and reference recording electrode (G2) placed at the fifth metacarpophalangeal joint. The proximal stimulation point was at elbow 3–4 cm distal to the medial epicondyle, with the wrist and the elbow in 90° of flexion. The ground electrode was placed between the stimulator and the active electrode. Motor amplitude, distal latency, proximal latency, and motor conduction velocity (MCV) were the parameters measured.
Ulnar nerve F-wave
The F-waves were acquired using standard electrode locations for routine motor studies. It was done with the gain changed to 200 V per division, and the sweep speed increased to 5 ms per division. At least ten supramaximal stimuli were delivered. The minimum latency (F-min), maximum latency (F-max), and range of F-wave latencies (F-range) were acquired.
Ulnar sensory study
The ulnar sensory stimulation (antidromic) was at the wrist 14 cm from the active recording electrode. Active recording electrode of the ulnar sensory nerve was placed on proximal phalanx (G1) of digit 5 and reference electrode distal to G1. The ground electrode was placed between the stimulator and the active electrode.
Sensory peak to peak amplitude, distal latency, and MCV were the parameters measured.
Statistical analysis was performed using STATA version 12 (Stata Corp, Texas, USA). For both motor and sensory (median and ulnar) nerves, the following parameters were analyzed: the distal motor latency, CMAP amplitude, MCV, and minimum latency of the motor nerves. Descriptive statistics including means with standard deviation for continuous variables and proportions for categorical variables such as gender were computed. The normal reference range of nerve conduction values was set by the 2½ (lower limit) and 97½ (upper limit) percentiles, so that reference ranges contain the central 95% of the distribution. The differences in means of parametric variables such as latency, amplitude, and velocity by gender were assessed using student t-tests numerical variables. The strength of correlation of the nerve conduction parameters with height was calculated with Pearson correlation coefficients (r). The value of the correlation coefficient varies from −1 to +1 with a value near −1 indicates a strong negative correlation, and a value near +1 indicates a strong positive correlation. All statistical tests of hypotheses were two sided at 5% significance level.
Informed consent was taken from each of the participants, and ethical approval was obtained from the ethics review committee of the AKTH, Kano.
| Results|| |
Sociodemographic and clinical characteristics
A total of 200 participants were seen during the study period. Their age ranged between 11 and 91 years, with a mean age of 44.95 ± 20.7 years. [Table 1] shows the distribution of their age by gender. They comprised 84 (42%) females with a mean age of 44.9 ± 16.9 and 116 (58%) males with a mean age of 44.8 ± 21 years. There was no significant difference in their age (P = 0.9593). About two-third (64%) of the participants were civil servants. The mean height, weight, and BMI of the participants were 167.6 ± 11 cm (M = 167 ± 11, F = 167.6 ± 10), 68.8 ± 17 kg (M = 64.3 ± 16, F = 75.1 ± 16), and 24.8 ± 6.7 (M = 23.3 ± 7, F = 26.9 ± 7). There was a statistically significant difference in weight (P < 0,001) and BMI (P = 0.0001) but not height (P = 0.7115) by gender of the participants.
Normative values for ulnar motor nerve conduction parameters
The mean ulnar nerve motor velocity in the healthy volunteers was 57.9 ± 3.2 with 2.5 and 97.5 percentile of 49.9 and 61.7, respectively. The mean latency of ulnar nerve was 2.7 ± 0.9 with 2.5 and 97.5 percentile of 1.5 and 4.6, respectively. The mean amplitude of ulnar nerve was 7.2 ± 1.4 with 2.5 and 97.5 percentile of 4.9 and 10.6, respectively. The minimum median f-wave latency of ulnar nerve (motor) was 26.5 ± 5.2 with 2.5 and 97.5 percentile of 17.5 and 36.5, respectively [Table 2].
|Table 2: Velocity, latency, and amplitude of median nerve (Motor) in healthy volunteers|
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Normative values for ulnar sensory nerve conduction parameters
The mean ulnar nerve sensory velocity was 55.22 ± 5.67 with 2.5 and 97.5 percentile of 46.9 and 70.1, respectively. The mean latency of ulnar nerve (sensory) was 2.97 ± 0.62 with 2.5 and 97.5 percentile of 2.00 and 4.52, respectively. The mean amplitude of median nerve (sensory) was 35.56 ± 9.97 with 2.5 and 97.5 percentile of 15.9 and 57.7, respectively [Table 3]. [Table 4] shows a comparison between the reference values for ulnar nerve from the current study and elsewhere.
|Table 3: Velocity, latency, and amplitude of ulnar nerve (sensory) in healthy volunteers|
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|Table 4: Comparison of ulnar motor nerve conduction study parameters to studies elsewhere|
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Relationship between ulnar nerve parameters, demographic, and anthropometric variables
The mean value of ulnar conduction velocity was significantly (P = 0.0202) higher in male volunteers (58.27 m/s) than their female counterparts (57.33 m/s). [Figure 1] shows the distribution of ulnar nerve conduction parameters by the gender of the participants. Mild inverse correlation (r = 0.2) was found between ulnar NCV and height of the participants (P = 0.0089) [Table 5]. [Figure 2] shows the best line of fit with 95% confidence interval of the relationship between ulnar MCV and height. No significant relationship was found between ulnar NCV, age, and D2/D4 ratio. [Table 5] displays the correlation matrix among ulnar motor NCV, the demographic and anthropometric variables. No significant relationship was found between ulnar sensory NCV and height (r = 0.006, P = 0.9296) [Figure 3] and [Table 5]. Similarly, no significant correlation was found between ulnar sensory conduction velocity, the demographic and anthropometric variables [Table 5].
|Figure 1: The distribution of ulnar nerve conduction parameters by gender|
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|Figure 2: The best line of fit with 95% confidence interval of the relationship between ulnar motor conduction velocity and height|
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|Figure 3: The best line of fit with 95% confidence interval of the relationship between ulnar sensory conduction velocity and height|
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|Table 5: The correlation matrix between ulnar nerve conduction velocity, age, height, and average D2/D4 ratio|
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| Discussion|| |
Reliable and locally generated normative data are fundamentally important for everyday interpretation of diagnostic evaluation and the practice of neurology. Our study examined the nerve conduction parameters of ulnar of young and old healthy individuals. We drew a comparison between the results of our study and existing studies published data in the literature. Our results for the motor parameters of the ulnar NCS agree generally with Kimura et al., Mistra and Kalita, Shehab et al., and Hennessey and Falco et al. Similarly, the data in the current study for the sensory parameters of the ulnar NCS conform largely, with little difference, with those of Kimura et al., Mistra and Kalita, and Shehab et al.
The little variation observed among the studies could be attributed to differences in demography, anthropometry, and race of the different population in the different studies underscoring the need for the necessity of reference values for every neurophysiology laboratory. In addition, differences in the methodology adopted in these various studies ranging from heterogeneous sample sizes, sample selection, and nerve conduction techniques to method of data analysis could also have contributed to the observed differences in the reference values.,,,
The current study found significantly higher ulnar conduction velocity in male than their female counterparts. The effect of gender on nerve conduction parameters is shrouded in controversy. Varying data exists in the literature on influence of gender on nerve conduction latencies, amplitudes, and velocities with some reports in favor of greater parameter values in males than females,, while the others showed the reverse.,
Our study did not find a strong correlation between ulnar nerve conduction parameters and age. Evidence from the literature, however, showed that the influence of age is most remarkable at the extremes of age. Because of incomplete myelination at birth, the nerve conduction velocities are about a half of what obtains in adulthood reaching approximately 75% by the end of 1st year of life and attains adult level by 3–5 years of age when full myelination has been achieved. This trend could not have been captured in the current study as the minimum age of the participants was 11 years. On the order hand, NCV decreases with age on account of decreasing number of nerve fiber, a continuously diminishing fiber diameter, and some molecular changes in the nerve membrane that occurs with age.
We found an inverse relationship between height and conduction velocity. This observation is in agreement with reports from other studies in the literature.,,, The influence of height on nerve conduction parameters has long been ascribed to distal tapering of axons in taller individuals, shorter intermodal distance, and progressive reduction in axonal diameter in taller individuals. The same reasons the lower limb nerves generally are slower than the nerves in the upper limbs.
Strength and limitations of the study
The decision as to whether the value derived from the assessment of ulnar nerve, in a patient from a particular population, is normal or abnormal is hinged on what is considered normal for that particular population. The normative values in the current study were derived from one of the largest sample size on normative data derivation studies. Our study also explored the influence of demographical variables that could impact the outcome of a NCS in an electrophysiology laboratory such as age, gender, and height. To the best of our knowledge, this study is the first of its kind to emanate from Nigeria.
It is worthy of note that there are many sources of error that should be taken into consideration while interpreting NCS parameter from any nerve. Temperature affects NCS parameters. In the current study, temperature control beyond ambient and participant body temperature was not focused on; thus, these results might be more applicable to patients seen in routine neurophysiology laboratories in a poor-resource setting where there is a dearth of facilities for temperature control.
| Conclusion|| |
Normative values of ulnar nerve were established for the Nigerian population. Overall, sensory and motor nerve conduction parameters for the ulnar nerve compared favorably with the existing literature data. Ulnar conduction velocity appeared to be influenced by height and gender.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Benatar M, Wuu J, Peng L. Reference data for commonly used sensory and motor nerve conduction studies. Muscle Nerve 2009;40:772-94.
Dy CJ, Mackinnon SE. Ulnar neuropathy: Evaluation and management. Curr Rev Musculoskelet Med 2016;9:178-84.
Shivji Z, Jabeen A, Awan S, Khan S. Developing normative reference values for nerve conduction studies of commonly tested nerves among a sample Pakistani population. J Neurosci Rural Pract 2019;10:178-84.
] [Full text]
Hennessey WJ, Falco FJ, Braddom RL. Median and ulnar nerve conduction studies: Normative data for young adults. Arch Phys Med Rehabil 1994;75:259-64.
Falco FJ, Hennessey WJ, Braddom RL, Goldberg G. Standardized nerve conduction studies in the upper limb of the healthy elderly. Am J Phys Med Rehabil 1992;71:263-71.
Buschbacher RM. Mixed nerve conduction studies of the median and ulnar nerves. Am J Phys Med Rehabil 1999;78 Suppl 6:S69-74.
Owolabi L, Adebisi S, Danborno B, Buraimoh A. Median nerve conduction in healthy Nigerians: Normative data. Ann Med Health Sci Res 2016;6:85-9.
] [Full text]
Owolabi LF, Adebisi S, Danborno B, Buraimoh AA. Sural nerve conduction in healthy Nigerians: Reference values and impact of age. Indian J Clin Anat Physiol 2015;2:185-9.
Cochran WG. Sampling Techniques. 3rd
ed.. New York: John Willey and Sons; 1977.
Hamdan FB. Nerve conduction studies in healthy Iraqis: Normative data. Iraqi J Med Sci 2009;7:75-92.
Misra UK, Kalita J. Clinical Neuophysiology: Nerve conduction. In: Electromyography, Evoked Potentials. 2nd
ed. India: Elsevier; 2011. p. 39-41.
Shehab DK. Normative data of nerve conduction studies in the upper limb in Kuwait: Are they different from the Western data? Med Princ Pract 1998;7:203-8.
Huang CR, Chang WN, Chang HW, Tsai NW, Lu CH. Effects of age, gender, height, and weight on late responses and nerve conduction study parameters. Acta Neurol Taiwan 2009;18:242-9.
Pawar SM, Taksande AB, Singh R. Normative data of upper limb nerve conduction in Central India. Indian J Physiol Pharmacol 2011;55:241-5.
Karnain WO, Surjit S, Bimal KA, Monika K, Sangeeta G. Gender effect on upper limb nerve conduction study in healthy individuals of North India. J Pharm Biomed Sci 2013;33:1589-93.
Fujimaki Y, Kuwabara S, Sato Y, Isose S, Shibuya K, Sekiguchi Y, et al
. The effects of age, gender, and body mass index on amplitude of sensory nerve action potentials: Multivariate analyses. Clin Neurophysiol 2009;120:1683-6.
Ahammed Naseem HV, Govindan R, Zubaida AP, Jose J. Normative data of upper limb motor nerve conduction in Northern Kerala population and effect of height on motor nerve conduction velocity. Natl J Physiol Pharm Pharmacol 2016;6:340-4.
Vashisht D, Das AL, Vaishampayan SS, Vashisht S, Joshi R. Nerve conduction studies in early tuberculoid leprosy. Indian Dermatol Online J 2014;5 Suppl 2:S71-5.
Campbell WW, Ward LC, Swift TR. Nerve conduction velocity varies inversely with height. Muscle Nerve 1981;4:520-3.
Bodofsky E, Tomaio A, Campellone J. The mathematical relationship between height and nerve conduction velocity. Electromyogr Clin Neurophysiol 2009;49:155-60.
Thakur D, Jha S, Pandey NK, Jha CB, Bajaj BK. Height, nerve conduction study, compound muscle action potential, sensory nerve action potential. J Clin Diagn Res 2011;5:260-3.
Awang MS, Abdullah JM, Abdullah MR, Tharakan J, Prasad A, Husin ZA, et al
. Nerve conduction study among healthy Malays. The influence of age, height and body mass index on median, ulnar, common peroneal and sural nerves. Malays J Med Sci 2006;13:19-23.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]