mune is a technology developed to evaluate neuromuscular functions . as noted above , mune automation using the traditional is method needs to address the issue of motor unit alternation . the present invention provides an automation method to estimate mun more accurately and reliably by minimizing the adverse effect of alternation based on waveforms acquired with pre - configured electrode array under controlled stimulation conditions . the methodology of the preferred embodiment of the invention is illustrated in fig5 . 1 . pre - configured electrode array . a surface electrode array 50 ( fig4 ) consists of pre - arranged electrodes on a single housing . the array is placed on the surface of skin of the subject according to anatomical landmarks ( e . g ., distal wrist crest 53 in fig4 ). the electrodes are used to deliver stimuli and to acquire response waveforms . the stimulator portion of the electrode comprises two or more electrodes 64 , 65 , and 66 ( fig4 ). the stimulator electrodes are placed over or near the nerve axons which are to be stimulated ( e . g ., median nerve 54 in fig4 ). the geometric relationship between stimulator electrodes are controlled , fixed and known . through electric circuit design , each electrode is connected as a cathode and one of the remaining electrodes is connected as an anode . alternatively , more than one electrode can be connected as cathode or anode . the ability to alter anode and cathode electrode connections allows a greater diversity in electric current patterns delivered to nerve axons . this diversity , combined with fine control of varying electric current intensity , provides a greater assortment of stimulated axons . as a result , a better sampling of motor units is achieved . multiple electrodes are used to acquire response waveform ( e . g ., electrodes 61 , 62 , and 63 in fig4 ). the spatial associations of the signal acquisition electrodes with respect to each other are fixed and known ( or is controlled with accuracy ). the spatial relationship of the signal acquisition electrodes with respect to stimulator electrodes is also fixed . after the application of each stimulus , more than one response waveform can be acquired through a different pairing of detection electrodes . as an example , two response waveforms may be acquired simultaneously , one from electrode pair 61 and 63 and the other from electrode pair 62 and 63 . all electrodes are insulated from each other and held on the skin with an adhesive . from the electrode array , with known and fixed geometric associations among all electrodes , stable and more certain response waveforms are acquired during each study session as well as from study to study . 2 . automated data acquisition . an electrodiagnostic device acquires motor responses via detection electrodes of the electrode array . the motor responses are evoked by the activation of the nerve axon under the stimulus electrode when a controlled electric shock is delivered to the nerve via stimulus electrodes . the motor responses ( both smup and cmap ) are acquired with adjustable analog gain so that the response range spans the dynamic range of the data acquisition system . the responses are also optionally filtered to reduce the measurement noise outside the primary energy band of the motor responses . a significant portion of motor response energy lies in the frequency range of 30 - 800 hz . to avoid aliasing , the analog response waveform is lowpass filtered and sampled at rates in excess of twice of its nyquist frequency . as an example , if the cmap is filtered with a lowpass filter of 2500 hz , the waveform is sampled at a rate at or greater than 5000 hz . the stimulation parameters may depend upon the subject demographics . for example , higher stimulus intensity is used when the subject has an above - average body mass index . the body mass index correlates with adipose tissue volume . a higher body mass index is a good predictor of a thicker layer of adipose tissue separating skin and nerve axon , and therefore a higher stimulus intensity is needed to activate the axon . the stimulation parameters depend upon the prior electrophysiological responses . for example , a stimulus response curve 102 ( fig7 ) for the nerve under study is generally available when stimuli with a gradual increase in intensity are delivered to obtain maximum cmap response . the is method operates at the threshold region 101 ( the boxed area of the stimulus response curve shown in fig7 ). using the electrode placement arrangement identical to that for acquiring maximum cmap response , the is response waveforms are acquired . the stimulation parameters are digitally controlled with finer precision ( e . g ., 0 . 1 ma increments in stimulus intensity ). more than one stimuli of the same intensity are delivered to the nerve axon in order to elicit responses from distinct motor units with overlapping activation thresholds . the control of the stimulation parameters is tightly integrated with the subsequent waveform analysis procedures . if alternation activities are detected and cannot be separated effectively from activation activities , an even finer stimulus intensity increment is used to differentiate the motor units with overlapping activation threshold . in addition to stimulus intensity 110 ( fig6 ), other controllable and adjustable parameters include duration 111 , polarity 112 , and repetition interval 113 . for example , instead of stimulus intensity adjustment , both duration and intensity are altered simultaneously to attempt to evoke different motor units . the real - time integration of response waveform analysis and data acquisition control improves the efficiency , accuracy , and reliability of the mune . i . mus activity region determination and noise estimation . the baseline and any dc offset of the acquired response waveforms are removed . the onset 49 ( fig2 ) and the duration 46 ( fig2 ) of the maximum cmap are used to determine the response activity region 47 ( fig2 ). the response activity region 47 is searched within the maximum cmap duration . in this search , the absolute deviations of the response waveforms from their median are averaged across waveforms at each time sample so as to form an activity profile . the region of the activity profile where the value exceeds the noise level defines the response activity region . segments of the response waveform falling outside the activity region are no longer considered in the mune analysis . the waveform segment outside of the maximum cmap region is used to estimate background noise . the noise power is calculated and a multiple of the noise power is then used to screen response waveforms . any waveform having a power less than this threshold is considered a null response waveform and is removed from further analysis . ii . identical waveform measure and merging . a similarity measure is used to evaluate whether the differences between two waveforms are exclusively due to noise . the measure is based on euclidian distance and is calculated as follows : the sample - by - sample difference between the two waveforms are calculated and squared ; the squared difference values are added ; and the summation is divided by the number of samples or the length of the waveform . measures based on other metrics such as mean absolute value and correlation coefficient are also possible . the similarity of a given pair of waveforms is compared with the noise threshold . a pair of waveforms is considered as having identical responses if the similarity measure is below the noise threshold . the identical waveforms are then combined to produce a single , consolidated waveform for subsequent analysis . waveform combination is done by averaging the two waveforms . consolidated waveforms have better waveform quality and reduced noise . waveform combination also improves the efficiency of alternation pattern determination process by reducing the number of waveforms to be examined . iii . waveforms sorting . the response waveforms are sorted by waveform energy and the stimulus intensity to facilitate alternation identification . i . deferment decision level . because of the possibility of alternation , morphological differences between consolidated response waveforms cannot be automatically attributed to activation of additional motor units . a decision has to be made as to whether waveform variations are due to the activation of a new motor unit or due to alternation . previously , such a decision would generally be made sequentially , based on manual examination of each pair of waveforms . in the global search method , the decision is deferred in order to assess consequence of either possibility ( new motor unit or alternation ) by considering more than two waveforms . the level of decision deferment ( i . e ., how many additional waveforms need to be considered before a decision is made ) is controlled via automation parameter settings . when the level of deferment is set at one , then the decision process utilizes step - by - step sequential manual processing . global search with a deferment level of two will determine the best path of alternation or activation based on two new response waveforms . when the level of deferment is set to be the same as the total number of acquired waveforms , the decision is made only after all possible combinations of alternation and new motor units are considered . a higher deferment level will lead to a better discrimination of alternation activities , and thus a more accurate estimate of motor unit number . however , a greater computational complexity is associated with a higher deferment level . ii . global search paths . the global search method evaluates all possible combinations of smups at a pre - set decision deferment level . the approach is illustrated with an example below ( shown in fig8 ). if the deferment level is one , a decision is made as to whether the changes in x 2 is a result of new motor unit or alternation . the scores of the two candidate paths are calculated ( see waveform scoring section ): { x 1 , x 2 − x 1 } and { x 1 , x 2 }. the path with a higher score is selected . if the path { x 1 , x 2 − x 1 } is selected , the next step is to form candidate paths that include x 3 : { x 2 − x 1 , x 3 − x 1 } ( x 3 is a result of alternation ) and { x 2 − x 1 , x 3 − x 2 } ( x 3 is a result of new activation ). the scores for the two paths are calculated and the path with a higher score is selected . if more response waveforms are available , the process is repeated for all other waveforms . the lower half of the candidate paths shown in fig8 are not considered further by the search algorithm once the boxed x 2 node is excluded from the first segment of path . if the deferment level is greater than one ( e . g ., two ), no commitment needs to be made at the x 2 level until x 3 is observed . this will allow the evaluation of all paths shown in fig8 . when candidate paths are constructed , the path { x 1 , x 2 , x 3 − x 2 } will be one of them . a score may be higher than { x 1 , x 2 − x 1 , x 3 − x 1 }, suggesting that the path with boxed nodes is a better solution . in effect , a higher deferment level allows for a global optimization solution instead of a sequence of local optimization solutions . iii . smup waveform extracting . for each search path , a set of smups are obtained , depending upon the assumption made to form that path . for example , if it was assumed that the path consists of all new motor unit activities from one node to another , the smups will be differences between successive response waveforms associated with each node ( for the most top path in fig8 ). iv . smup waveform scoring . multiple candidate paths are formed as a result of decision deferment . the candidate smup waveform set obtained from each path is scored based on ranking criteria . all candidate paths are ranked based on the scores of the candidate smup waveforms associated with the paths . the quantitative ranking criteria capture the desired features of true smups . a set of smups receive a higher score if the individual smup waveforms meet the criteria of initial negativity ( up peak followed by down peak ) and biphasic morphology . a similar onset for all smup waveforms will yield a higher score as well . in the case that two successive response waveforms are due to alternation but the path search dictates that they are considered as new motor unit activation , the candidate smup derived from the path will be the difference between the two individual motor unit responses . thus , it will likely have smaller amplitude , irregular morphology , and perhaps a delayed onset time because of the phase cancellation . consequently , the score for the candidate smup will be low and the incorrect candidate path will be penalized with a lower score . additional scoring components for candidate smup waveforms include : the offset of a smup waveform power over the average power level of all smups ; the offset of a smup waveform onset over that of the cmap ; the offset of a smup waveform duration over that of the cmap ; the offset of a smup waveform maximum negative peak location over that of the cmap ; the offset of the waveform numbers of this smup group over the total number of consolidated mu waveforms . each feature is weighted by a weighting factor that is consistent in determining its relative importance to other features . the weighting factors are based on prior data analysis , physiological factors , and other considerations . the weighted feature scores are summed for all features and all smups to form the final ranking score for a group of smups . fig9 shows two groups of smups : the left panel shows a group of smups with a lower ranking score , and the right panel shows a group of smups with a higher ranking score . ( i ) mus alternation equation . as an example , a frequently observed alternation pattern is shown in table 1 where two motor units ( mu 3 and mu 4 ) alternate before both of them are activated together . the first column is the recording waveforms , and the second column describes the individual mus included in these recordings . direct subtraction of the mus responses would result in creating three motor units : mu 3 = x 1 − x 0 , mu 4 a = x 2 − x 1 = mu 4 − mu 3 , and mu 5 = x 3 − x 2 = mu 3 . as a result , mu 4 a will be an under - estimation of mu 4 , leading to an over - estimation of mune . to identify the alternation patterns , one first removes the common component x 0 ( mu 1 + mu 2 ) to obtain residuals r i = x i − x 0 , i = 1 , 2 , 3 . the residuals r i , i = 1 , 2 , 3 and their mus are listed in the third and fourth columns of table 1 , respectively . these residuals satisfy the following alternation equation : the above equation condition indicates that alternations are present in the recording waveforms x 1 and x 2 . subsequently , x 2 − x 1 is not a true smup . instead , the components r 1 and r 2 are considered as potential motor units for further evaluation . in general , for a set of consolidated recording waveforms x 0 , x 1 , . . . x l , ∀ l ≧ 3 , one needs to remove the common component x 0 to obtain residual signals r i = x i − x 0 ≠ φ , i = 1 , . . . , l , ∀ l ≧ 3 . if the residual components r i satisfy the alternation equation : ∑ r i i ∈ j , j ≠ i , j ∈ [ 1 , … ⁢ , l ] = r j , ( 1 ) ( here index set j is a subset of [ 1 , 2 , . . . , l ]), then these components r i , iεj , are candidates to be assessed as alternating motor units . direct subtraction between their original waveforms x i , iεj should be avoided . a . potential smups extracting . the flow chart in fig1 describes the methods of extracting potential smups by using alternation equations . in this step , all the consolidated mu response waveforms x i , are re - arranged at different positions according to their power . the large power waveforms are placed on high positions . the base waveform ( aforementioned common components among the mu responses ) is first considered as a null signal , and then each of the mu response waveforms x i is tested once as a base waveform . at each determined base waveform position , the residual components r i , are obtained by subtracting the base waveform from all those mu response waveforms which are at a higher position than that of this base waveform . this set of residual waveforms is checked using alternation equations ( 1 ). the residual waveforms that satisfy an “ alternation equation ” are identified and recorded . this procedure is repeated until all the mu response waveforms have been used as the base waveforms . those residual components of r i satisfying alternation equations indicate a fact that their corresponding original mu waveforms x i are alternating mu response waveforms . all of the alternating waveforms that have an overlap range form an alternation range . the recording waveforms from a muscle group may contain many alternation ranges . in any particular alternation range , the smaller residual waveforms on the left side of the alternation equations ( 1 ) are taken as potential smups . beyond the alternation ranges , the potential smups are extracted using traditional is method , i . e ., a potential smup is extracted by directly subtracting an mu waveform from another mu waveform that is one position above . the procedure discussed above can be further explained using the following example . table 2 shows a case involving 5 alternating motor units : mu 1 - mu 5 . the first column lists the recording mu response waveforms x i . the first ( i . e ., lowest ) waveform x 0 has the least power , and the last ( i . e ., highest ) waveform x 9 has the largest power . the second column describes their corresponding motor unit components . while waveform x 0 is determined as the base waveform , the residual waveforms are obtained by subtracting the base waveform x 0 from all the higher position waveforms from x 1 to x 9 . the resulting residual waveforms r i , i = 1 , . . . , 9 , and their corresponding components , are listed in the third column and fourth column , respectively . those residual waveforms only presenting on the left side of the above equations are extracted as potential smups . accordingly , they are : r 1 ( mu 1 ), r 2 ( mu 2 ), r 3 ( mu 3 ), and r 4 ( mu 4 ). the residual waveform r 5 ( mu 1 + mu 2 ) appears on both sides of the equations , thus it cannot be a smup . these five alternation equations relate to seven response waveforms from x 1 to x 6 , and x 8 . these seven mu response waveforms form an alternation range including waveforms from x 1 to x 8 . beyond this range , only one recording waveform exists , which is x 9 . within this alternation range , the direct subtraction among the alternating waveforms from x 1 to x 8 is avoided . beyond this alternation range , traditional is method is used . that is , the waveforms sequential subtraction result is taken as potential smups , which result in x 9 − x 8 ( mu 3 + mu 5 − mu 2 ). b . smups validation . the flow chart in fig1 describes the methods of smup validation by using self - check method . this process is explained as follows . the aforementioned smup search process has extracted a group of potential smups , and they are r 1 ( mu 1 ), r 2 ( mu 2 ), r 3 ( mu 3 ), r 4 ( mu 4 ), and x 9 − x 8 ( mu 3 + mu 5 − mu 2 ). these potential smups do not include all the true motor units ( mu 5 is missed ), and also contain potential smups that are not true motor units ( x 9 − x 8 is not a correct one ). to validate the potential smups , firstly , identical waveforms or any composite smup waveforms ( combinations of other smups ) are identified and removed from this potential smup group . in the above example , none of candidate waveforms are removed . the potential smups are r 1 ( mu 1 ), r 2 ( mu 2 ), r 3 ( mu 3 ), r 4 ( mu 4 ), and x 9 − x 8 ( mu 3 + mu 5 − mu 2 ). secondly , a self - check method is provided . that is , if the potential smup combinations with the original base waveform x 0 are used to compare with the recording waveforms x 1 , at least one subset of potential smups must exist and their summation matches a given recording waveform . otherwise , the recording waveform without a match must have a new smup component . in table 2 , a self - check can identify waveform x 7 does not meet the matching criteria . thus , it must contain new potential smups . then , the mis - matched waveforms are used to obtain additional smups . the mismatched waveform subtracts lower level waveforms sequentially to obtain new residual waveforms . if a newly obtained residual waveform can be combined with existing smup candidates to match two or more recording waveforms , the new residual waveform is added to the potential smup pool . as noted above , waveform x 7 is a mis - matched waveform . new residual waveforms are formed by subtracting lower position waveforms from waveform × 7 . two residual waveforms x 7 − x 5 ( mu 5 ) and x 7 − x 2 ( mu 1 + mu 5 ) meet the matching criteria twice for waveform x 7 and x 9 . thus , they are added to the potential smup pool . now , the potential smups group consists of r 1 ( mu 1 ), r 2 ( mu 2 ), r 3 ( mu 3 ), r 4 ( mu 4 ), x 9 − x 8 ( mu 3 + mu 5 − mu 2 ), and new potential smups x 7 − x 5 ( mu 5 ) and x 7 − x 2 ( mu 1 + mu 5 ). after this self - check process , identical waveforms and composite smup waveforms are detected and removed . in this example , x 7 − x 2 ( mu 1 + mu 5 ) is the combination of r i ( mu 1 ) and x 7 − x 5 ( mu 5 ), and thus removed . the final selection is a set of smups from the potential smup group that has a minimum number of smups , but matches all the consolidated mus responses . this last step can exclude incorrect waveforms x 9 − x 8 ( mu 3 + mu 5 − mu 2 ), and keep the true motor units which are r 1 ( mu 1 ), r 2 ( mu 2 ), r 3 ( mu 3 ), r 4 ( mu 4 ), and x 7 − x 5 ( mu 5 ) 6 . motor unit number estimation . mune is used to estimate the number of smup waveforms that will take to match the maximum cmap waveform . each smup is from an individual motor unit and the maximum cmap is the result of all motor units in the muscle group . a specific feature of the waveform is used for matching waveforms instead of the total waveform morphology . for example , if the peak - to - base amplitude of a smup is 20 uv and the amplitude for cmap is 5 mv , then the number of smup waveforms needed to match the cmap is 250 . commonly - used measures for waveform size are peak - to - base amplitude , peak - to - peak amplitude , and peak area of smup and cmap waveforms . the smup waveforms extracted from response waveforms do not have the same morphology and the size feature from each smup waveform is also different . different methods are used to obtain the average smup feature : calculating the features of each smup waveform , and then average individual features ; averaging all the smup waveforms , and then calculating the feature of the averaged smup ; calculating the size feature of the largest response waveform with a known number of motor units , and then normalizing the value of the feature by the number of motor units . global search method provides multiple sets of smups . each set of smups will lead to an estimate of mun . in addition to the mean estimate of mun , the variance of the estimates is also calculated to describe the variations of the mun estimates . a smaller variance gives a higher confidence of the robustness of the estimates . thus it will be seen that this invention describes methods and apparatus for estimating motor unit number of a muscle group . a pre - configured electrode array is used to acquire more stable and more certain response waveforms . based on intermediate waveform processing results , the experimental condition is dynamically adjusted through digitally controlled stimulation and acquisition setup for fast and repeatable motor unit number estimation . an automation algorithm enhances the response waveform quality ; determines the optimal solutions for alternation and activation patterns of the response waveforms ; derives individual single motor unit potentials ; calculates waveform features useful for motor unit number estimation ; and reports an estimated value of motor unit number as well as the confidence level of the estimation . it will be appreciated that still further embodiments of the present invention will be apparent to those skilled in the art in view of the present disclosure . it is to be understood that the present invention is by no means limited to the particular constructions and method steps herein disclosed and / or shown in the drawings , but also comprises any modifications or equivalents within the scope of the invention .
a method for the assessment of neuromuscular function by motor unit number estimation , comprising : determining and controlling stimulation and data acquisition process via pre - configured electrode array so as to acquire stable and less uncertainty mu responses ; pre - processing acquired mus responses so as to attenuate noise , determine mus activity region , and improve processing speed and accuracy ; minimizing alternation effects by globally searching and comparing smups ; eliminating alternation effects by identifying alternating mus directly ; and computing and reporting mune results , as well as the statistical description of these mun estimates to evaluate its robustness .