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The Median Nerve

Giuliano Gentili • Mario Di Napoli

The Median Nerve

Motor Conduction Studies

Giuliano Gentili Neurological Service S. Camillo de’ Lellis General Hospital Rieti Italy

Mario Di Napoli Neurological Service S. Camillo de’ Lellis General Hospital Rieti Italy

ISBN 978-3-319-10472-0 ISBN 978-3-319-10473-7 (eBook) DOI 10.1007/978-3-319-10473-7 Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014957639

© Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

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To my mother, who taught me to love and to wait. To my wife Maria Carla, inspiring muse and model for this book and my life. To my little son Giulio, with the hope that he knows to wait the wonderful things that life will reserve for him.

Giuliano

“Well, I must endure the presence of two or three caterpillars if I wish to become acquainted with the butterfl ies. It seems that they are very beautiful…”

The little prince , Antoine de Saint-Exupéry

To all persons that are in my heart… They know where they are, so it is not necessary to remember and thank them here for their love, patience, devotion, help, support… and to a lasting friendship that permitted to complete this work overcoming diffi culties, exertions, troubles, and many days without sleeping… all over the years of this long and hard work. Thank you Giuliano; without your efforts, this work would not have come to light.

Mario

vii

Contents

List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Synoptic Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Motor Conduction Studies Index (by Practical Criteria) . . . . . . . . . . . . . . . . . . . . . . xvii

Part I Motor Conduction Studies: Median Nerve

M1 Elbow, Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

M2 Wrist, Elbow – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

M3 Wrist, Elbow – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

M4 Wrist, Elbow, Axilla – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

M5 Axilla, Elbow, Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24


M7 Wrist, Below Elbow, Elbow, Above Elbow, Erb’s Point – Hand . . . . . . . . . . . . 29 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32



M10 Wrist, Elbow, Axilla – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55



M13 Wrist – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

viii

M14 Wrist, Elbow, Axilla, Erb’s Point – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

M15 Elbow, Wrist, Palm – Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

M16 Elbow, Wrist, Palm – Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

M17 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110





M22 Wrist, Palm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135









M31 Wrist, Elbow, Midarm, Axilla – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

M32 Palm, Wrist, Elbow – Hand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

M33 Wrist, Forearm – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212


Contents

ix


M36 Wrist, Forearm, Elbow – Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Part II Motor Conduction Studies: Anterior Interosseous Nerve (motor branch of the median nerve)

A1 Above Elbow, Below Elbow – Distal Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

A2 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

A3 Elbow – Distal Forearm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

A4 Elbow – Distal Forearm, Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

A5 Elbow – Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Contents

xi

BMI Body mass index CTS Carpal tunnel syndrome CMT Charcot-Marie-Tooth disease CIDP Chronic infl ammatory demyelinating polyradiculoneuropathy CMAP Compound muscle action potential DML Distal motor latency EMG Electromyography ENG Electroneurography GBS Guillain-Barré syndrome MNCV Motor nerve conduction velocity PML Proximal motor latency SNAP Sensory nerve action potential SNCV Sensory nerve conduction velocity Unit Description cm Centimetre Hz Hertz kHz Kilohertz m/s Meter per second μs Microsecond μV Microvolt mA Milliampere ms Millisecond mV Millivolt

List of Abbreviations

xiii

The median nerve is the most studied nerve during the daily routine activities in each clinical neurophysiopathological laboratory not only for the frequency of the pathologies of which it is affected like the carpal tunnel syndrome (CTS) but also for the simplicity to investigate that makes it a preferred nerve in multiple disease studies. With the fi rst studies of Dawson and Scott (1949) and Dawson (1956) through the propagation of electrical impulses along the median and ulnar nerves and the recording of the peripheral nervous responses by means of electrodes applied to the skin, the knowledge process about nerve conduction in man kicked off in the following years a number of validation studies of the electroneurographic method allowing to determine normal and pathological ranges. The electroneurography (ENG) was born in those years as a diagnostic method. It was initially used in the diagnosis of compressive diseases such as the CTS or in the defi nition of the diabetic neuropathy, and its utility was gradually extended to diagnose many other diseases.

This volume represents a chronological path that allows the reader to move from pilot stud-ies on the peripheral nerve conduction in humans during the 1950s to the most recent scientifi c evidence, a journey through the fi rst conduction motor studies of the 1960s, the techniques of motor nerve conduction to the abductor pollicis brevis (APB) muscle with added palm stimu-lation fi rstly described in the second half of the 1970s, the studies of the fl exor carpi radialis (FCR) muscle introduced in the 1980s, the median-ulnar nerve motor comparative techniques proposed in the 1990s, and the more recent conduction studies described since the early 2000s to today.

The main attention has been given to techniques that have shown higher sensitivity and specifi city in the diagnosis of CTS and for this reason are widely used in clinical practice like the comparison of latencies of motor responses from the second lumbrical (2 L) and interosse-ous (INT) muscles by stimulation at the wrist.

More than 40 techniques are described in this text-atlas including methods from the original rationale and variants and organized according to practical criteria for easy reference; all of the tests are presented by facilitated pictures in order to make it easy to understand and follow a reproduction of every method. There have been reports of the parameters and settings used by the authors and the normative and pathological values cited in the entries and present in subse-quent articles in order to enrich and update the evidence. With particular attention, it has been reproduced in every test in the laboratory so as to present iconographically the signals acquired in the normal subject; an effective diagnostic utility of each test was then evaluated in several diseases and in varying degrees of the same pathology as in the CTS. All traces acquired, both in normal and pathological subjects, are shown with different settings to adapt easily and be more accessible to the different situations that may arise in clinical practice.

The execution of the techniques described in the manuals of electroneurography on the market is not always able to provide a complete answer to the many clinical questions. The nonuse of the correct technique because it is not known, incorrect use of a technique, and the absence of normative and pathological values represent all factors that can alter the diag-nostic power of the electroneurographic examination.

From this premise volume was born a systematic monograph of motor electroneurographic techniques focusing on the median nerve with the aim to validate the various methods described

Introduc tion

xiv

in the literature since the early articles of the 1950s to the present in order to defi ne the feasibil-ity, reproducibility, and actual usefulness in the diagnostic fi eld. Some of these techniques, abandoned over the years, still show their worth and deserve to be known in the clinical setting, still not having found the right recognition in any of the manuals on the market. This text-atlas, which is the result of over 5 years of hard work, comes from our daily neurophysiopathological experience; we have described in detail the technique, standardization, and normal and patho-logical values derived from the original articles and the subsequent literature as never seen in any other work before.

We therefore hope that this text, which is useful to both the novice and the experienced specialist, is always in a laboratory of electromyography as a valid means of ease of reference for the study on the fi eld.

Introduction

xv

Synoptic Table

–

A

R

G

+

Active electrode

Reference electrode

Ground electrode

Cathode

Anode

Recording site

Stimulating site

R

S

Digit I

Digit V

S2(palm)

S1(wrist)

C 8T 1

Lower trunk

Medial cordMediannerve

RAbductor pollicis brevis (APB)

R

A

8 cmG–

+– +

Fig. 1 Motor conduction study to the abductor pollicis brevis (APB) muscle, stimulation of the wrist (S1) and on the palm (S2)

xvi

Muscle Branch Cord Trunk Root

PT Pronator teres Median Lateral Upper/middle C6-C7

FCR Flexor carpi radialis Median Lateral Upper/middle C6-C7-C8

FDP Flexor digitorum profundus Anterior interosseous Lateral/medial Middle/lower C7-C8

FPL Flexor pollicis longus Anterior interosseous Lateral/medial Middle/lower

PQ Pronator quadratus Anterior interosseous Lateral/medial Middle/lower

PL Palmaris longus Median Lateral/medial Middle/lower

FDS Flexor digitorum sublimis Median Lateral/medial Middle/lower C7-C8-T1

C7-C8-T1

C7-C8-T1

C7-C8-T1

APB Abductor pollicis brevis Median Medial Lower

OP Opponens pollicis Median Medial Lower

FPB Flexor pollicis brevis Median Medial Lower

1L First lumbrical Median Medial Lower

2L Second lumbrical Median Medial Lower C8-T1

C8-T1

C8-T1

C8-T1

C8-T1

Anterior interosseous nerve(AIN)

FDP

FDS

FPL

FPB

PQPQ

APB

PT

PL

FCROP

1L

Digit I

Digit I

C 5

C 6

T 1

Middle trunk

Lower trunk

Upper trunk

Lateral cord

Medial cord

Mediannerve

C 7C 8

Digit V 2L

•

•

••

•

• •

••

•

•

•

Fig. 2 Muscles innervated by the median nerve (forearm and hand)

Synoptic Table

xvii

Median Nerve

Distal latency studies

M1 - Technique from median thenar muscle; stimulation of the elbow and of the wrist M2 - Technique from abductor pollicis brevis and opponens pollicis muscles; stimulation

of the wrist and of the elbow M3 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow M4 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow and

of the axilla M5 - Technique from abductor pollicis brevis muscle; stimulation of the axilla, elbow

and of the wrist M6 - Technique from opponens pollicis muscle; stimulation of the wrist and of the elbow M7 - Technique from abductor pollicis brevis muscle; from abductor pollicis brevis and

opponens pollicis muscles; stimulation of the wrist, below elbow, elbow, above elbow and of the Erb’s point

M8 - Technique from median thenar muscle; stimulation of the wrist and of the elbow M9 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow M10 - Technique from median thenar muscles; stimulation of the wrist, elbow and of the

axilla M11 - Technique from opponens pollicis muscle; stimulation of the wrist and of the

elbow M12 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow M13 - Technique from abductor pollicis brevis and abductor digiti minimi muscles; stim-

ulation of the wrist M14 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow,

axilla and of the Erb’s point M16 - Technique from abductor pollicis brevis muscle; stimulation of the elbow, wrist

and on the palm M18 - Technique from median thenar muscle; stimulation of the wrist and of the elbow M20 - Technique from second lumbrical and the abductor pollicis brevis muscles; stimu-

lation of the wrist M23 - Technique from abductor pollicis brevis and fi rst dorsal interosseous muscles;

stimulation of the wrist M24 - Technique from abductor pollicis brevis and abductor digiti minimi muscles;

stimulation of the wrist M25 - Technique from fi rst lumbrical and the abductor pollicis brevis muscles; stimulation

of the wrist

Motor Conduction Studies I ndex (by Practical Criteria)

xviii

M27 - Technique from second lumbrical and interosseous muscles; stimulation of the wrist

M29 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the elbow

M30 - Technique from median thenar and ulnar thenar muscles; stimulation of the wrist

M34 - Technique from medial thenar motor muscle; stimulation of the wrist M35 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and on

the palm M36 - Technique from second lumbrical muscle; stimulation of the palm, distal forearm

and of the elbow

Wrist-palm studies

M15 - Technique from opponens pollicis muscle; stimulation of the elbow, wrist and on the palm

M16 - Technique from abductor pollicis brevis muscle; stimulation of the elbow, wrist and on the palm

M22 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and on the palm


M36 - Technique from second lumbrical muscle; stimulation of the palm, distal forearm and of the elbow

Forearm velocity studies

M31 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow, mid-arm and of the axilla

M32 - Technique from abductor pollicis brevis muscle; stimulation on the palm, wrist and of the elbow

Amplitude ratio studies



Median-median comparative studies

M20 - Technique from second lumbrical and the abductor pollicis brevis muscles; stimu-lation of the wrist

M25 - Technique from fi rst lumbrical and the abductor pollicis brevis muscles; stimula-tion of the wrist

Median-ulnar comparative studies

M13 - Technique from abductor pollicis brevis and abductor digiti minimi muscles; stim-ulation of the wrist

Motor Conduction Studies Index (by Practical Criteria)

xix

M23 - Technique from abductor pollicis brevis and fi rst dorsal interosseous muscles; stimulation of the wrist

M24 - Technique from abductor pollicis brevis and abductor digiti minimi muscles; stim-ulation of the wrist


M30 - Technique from median thenar and ulnar thenar muscles; stimulation of the wrist M34 - Technique from medial thenar motor muscle; stimulation of the wrist

F-wave studies

M10 - Technique from median thenar muscles; stimulation of the wrist, elbow and of the axilla

M12 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the elbow M21 - Technique from abductor pollicis brevis muscle; stimulation of the wrist

Residual latency (RL), sensory-motor index (SMI) and terminal latency index (TLI) studies

M5 - Technique from abductor pollicis brevis muscle; stimulation of the axilla, elbow and of the wrist

M11 - Technique from opponens pollicis muscle; stimulation of the wrist and of the elbow


M18 - Technique from median thenar muscle; stimulation of the wrist and of the elbow M29 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow M33 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow

Needle recording studies

M2 - Technique from abductor pollicis brevis and opponens pollicis muscles; stimulation of the wrist and of the elbow


M4 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow and of the axilla


M19 - Technique from fl exor carpi radialis muscle; stimulation of the elbow M24 - Technique from abductor pollicis brevis and abductor digiti minimi muscles;

stimulation of the wrist

Forearm: fl exor carpi radialis (FCR) muscle studies

M17 - Technique from fl exor carpi radialis muscle; stimulation of the elbow M19 - Technique from fl exor carpi radialis muscle; stimulation of the elbow M26 - Technique from fl exor carpi radialis muscle; stimulation of the elbow


xx

Hand: abductor pollicis brevis (APB) muscle studies



M4 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow and of the axilla

M5 - Technique from abductor pollicis brevis muscle; stimulation of the axilla, elbow and of the wrist

M7 - Technique from abductor pollicis brevis and opponens pollicis muscles; stimulation of the wrist, below elbow, elbow, above elbow and of the Erb’s point



M14 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow, axilla and of the Erb’s point


M16 - Technique from abductor pollicis brevis muscle; stimulation of the elbow, wrist and on the palm

M21 - Technique from abductor pollicis brevis muscle; stimulation of the wrist M22 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and on

the palm M23 - Technique from abductor pollicis brevis and fi rst dorsal interosseous muscles;

stimulation of the wrist M24 - Technique from abductor pollicis brevis and abductor digiti minimi muscles; stim-

ulation of the wrist M28 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and on

the palm M29 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow M31 - Technique from abductor pollicis brevis muscle; stimulation of the wrist, elbow,

mid-arm and of the axilla M32 - Technique from abductor pollicis brevis muscle; stimulation of the palm, wrist and

of the elbow M33 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and of the

elbow M35 - Technique from abductor pollicis brevis muscle; stimulation of the wrist and on

the palm

Hand: median thenar (MT) muscle studies

M1 - Technique from median thenar muscle; stimulation of the elbow and of the wrist M8 - Technique from median thenar muscle; stimulation of the wrist and of the elbow M10 - Technique from median thenar muscles; stimulation of the wrist, elbow and of the

axilla M13 - Technique from median thenar and ulnar hypothenar muscles; stimulation of the

wrist M18 - Technique from median thenar muscle; stimulation of the wrist and of the elbow M30 - Technique from median thenar and ulnar thenar muscles; stimulation of the wrist


xxi

Hand: opponens pollicis (OP) muscle studies


M6 - Technique from opponens pollicis muscle; stimulation of the wrist and of the elbow M11 - Technique from opponens pollicis muscle; stimulation of the wrist and of the

elbow

Hand: fi rst lumbrical (1L) muscle studies

M25 - Technique from fi rst lumbrical and the abductor pollicis brevis muscles; stimula-tion of the wrist

Hand: second lumbrical (2L) muscle studies

M20 - Technique from second lumbrical and the abductor pollicis brevis muscles; stimu-lation of the wrist


M36 - Technique from second lumbrical muscle; stimulation of the palm, distal forearm and of the elbow

Anterior interosseous nerve (motor branch of the median nerve):

Forearm: fl exor pollicis longus (FPL) muscle studies

A2 - Technique from fl exor pollicis longus muscle; stimulation of the elbow A5 - Technique from fl exor pollicis longus muscle; stimulation of the elbow

Forearm: pronator quadratus (PQ) muscle studies

A1 - Technique from pronator quadratus muscle; stimulation above the elbow and below the elbow

A3 - Technique from pronator quadratus muscle; stimulation of the elbow A4 - Technique from pronator quadratus and from abductor pollicis brevis muscles;

stimulation of the elbow


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