CHAPTER 10

CONSENSUS CRITERIA FOR THE DIAGNOSIS OF PARTIAL

CONDUCTION BLOCK

Introduction..............................................................................................................................S225
Proposed Criteria for the Electrodiagnosis of Conduction Block ......................................S226
Comments on Partial Conduction Block...............................................................................S227
 Muscle Nerve 22: Supplement 8: S225-S229, 1999

CHAPTER 10

CONSENSUS CRITERIA FOR THE DIAGNOSIS

OF PARTIAL CONDUCTION BLOCK

INTRODUCTION After a third revision by the author, the panel met to

discuss remaining areas of concern and to finalize this
Physicians are often required to make diagnostic or thera- document. The document was then circulated to the
peutic decisions for conditions in which empiric data and AAEM Board of Directors for a fourth round of input
knowledge are incomplete or inconclusive. In such and approval.
settings, the development of a consensus from an appro-
priate group of experts is often helpful in focusing Conduction block of an intact motor axon prevents the
research on the critical questions and in providing interim transmission of its impulses from the anterior horn cell to
guidance until the questions are answered empirically. the muscle it innervates. Conduction block of an intact
Because the need for establishing consensus criteria is peripheral sensory axon prevents the transmission of its
common, clinical health research has developed consen- impulses from its sensory receptor to its cell body in the
sus methods over the past 3 decades. dorsal root ganglion. Partial conduction block of a nerve
is a pathophysiological process that produces motor or
A 4-round modified Delphi process was used to develop sensory deficits (that is, weakness or loss of sensation) if
this consensus.4 A member of the American Association a sufficient portion of its axons have conduction block.
of Electrodiagnostic Medicine (AAEM) Quality Assur- However, partial conduction block can only be reliably
ance Committee was chosen to draft the document. An assessed in the motor axons of a nerve. Partial conduc-
expert panel was then chosen from AAEM members tion block that persists for more than a week is diagnostic
who were authors of articles involving concepts relevant of focal demyelination.
to conduction block and who held divergent opinions at
the start of the consensus development process. The Temporal dispersion is a physiological or pathophysio-
author wrote an initial draft that was circulated amongst logical process that has not been established to produce
the members of the expert panel for unsolicited com- motor or sensory deficits. Physiological temporal disper-
ments. Based on these comments and areas of apparent sion occurs diffusely along the length of a nerve to a
agreement and disagreement, the document was revised minor degree in normal subjects. Pathophysiological or
by the author and circulated for a second time, together abnormal temporal dispersion is the result of an abnor-
with 11 questions that focused on areas of comment and mally increased range of conduction velocities among
concern. After a second revision by the author, the the individual axons of a nerve. It can be seen along the
document was circulated for a third round of comments length of a nerve in axonal loss and in diffuse demye-
with 7 more narrowly focused questions. linating lesions of peripheral nerve. Temporal dispersion
may occur focally along a short segment of a nerve to a
major degree, in which case it is diagnostic of focal
demyelination, but may not be relevant to the patho-
Author: Richard K. Olney, MD. physiology of motor or sensory symptoms.
The American Association of Electrodiagnostic Medicine (AAEM)
would like to acknowledge the following expert panel: James W. Although these concepts are well accepted, the various
Albers, MD, PhD; William F. Brown, MD, FRCP(C); Jasper R. practical or operational definitions are controversial. One
Daube, MD; Gerald Felsenthal, MD; Jun Kimura, MD; Richard A. major purpose of this consensus statement is the develop-
Lewis, MD; Robert G. Miller, MD; Shin J. Oh, MD; Gareth J.G. Parry,
MB, ChB; Jack Petajan, MD, PhD; and Austin J. Sumner, MD. ment of a definition for the pathophysiological findings
by which partial conduction block of a nerve can be
The AAEM would also like to thank the AAEM Quality Assurance
Committee for participating in the Delphi process: Chair: Cheryl F. diagnosed with a high level of confidence (definite partial
Weber, MD; Members: Faye Y. Chiou-Tan, MD; Sudhansu or complete conduction block), and can be inferred with a
Chokroverty, MD, FRCP; Earl R. Hackett, MD; Robert L. Harmon, moderate level of confidence (probable partial con-
MD, MS; Tim Lachman, MD; Kevin R. Nelson, MD; Atul T. Patel,
MD; Caroline A. Quartly, MD, FRCP(C); and John R. Wilson, MD. duction block).

The criteria that follow are intended to serve several

Key Words: conduction block • temporal dispersion purposes. First, they provide diagnostic guidelines for

Muscle & Nerve Supplement 8 1999 S225

Consensus Criteria: Partial Conduction Block

electrodiagnostic medicine (EDX) consultants. A strong nerves when stimulating at the axilla or Erb’s
consensus of the expert panel supports the need for such point (EP), the sensitivity is often lower with
diagnostic guidelines at present, until more empiric data these proximal stimulation sites for the median
are available. The expert panel anticipates that these cri- nerve unless collision stimulation techniques
teria will require periodic revision as such empiric data are used. This is because of the common ulnar
become available. Second, they provide proposed diag- innervation of deep thenar muscles.
nostic categories for research studies and clinical trials.
Third, they are intended to stimulate further discussion e. The criteria are more restrictive for the radial,
and research about partial conduction block and its distinc- peroneal, and tibial nerves than for the median
tion from temporal dispersion. The criteria are not meant and ulnar nerves. Even with surface recording
to exclude the diagnosis of a demyelinating neuropathy, of the CMAP, the vast majority of the expert
because such a diagnosis includes consideration of clin- panel agree that reduction of amplitude and area
ical findings and laboratory results in addition to EDX of the radial motor response is considered
abnormalities. sufficient only to support probable partial con-
duction block. A higher percentage reduction in
amplitude and area is required for the peroneal
and tibial nerves than for the median and ulnar
PROPOSED CRITERIA FOR THE nerves. Furthermore, greater care is necessary
ELECTRODIAGNOSIS OF CONDUCTION BLOCK to insure that stimulation is supramaximal at the
knee for the tibial nerve; special stimulation
1. Technical considerations: techniques may need to be utilized.

a. All measurement of amplitude, area, and duration f. Stimulation at EP and at the sciatic notch (SN)
in these criteria refers to values for the negative with surface electrical or magnetic stimulator,
peak of surface recorded compound muscle action or stimulation at SN with a needle, is not
potentials (CMAPs). The negative peak is defined accepted by many of the panel as sufficiently
as that component aspect of the waveform from reliable in producing supramaximal stimulation
the first negative deflection of the CMAP from to be included in the criteria for definite partial
the baseline to its first baseline crossing from conduction block. However, the expert panel
negative to positive. CMAPs that have more accepts that the probability of achieving supra-
than 1 negative peak are referred to as multi- maximal stimulation is high if maximal ampli-
phasic CMAPs. tude and area of the CMAP is achieved with
stimulus intensity at 70% or less of maximal
b. These criteria are intended to apply only to stimulator output (in other words, the stimulator
nerves in which the negative-peak amplitude of is able to deliver a supramaximal stimulus that
the CMAP with distal stimulation is 20% or is 30% more than maximal intensity).
more of the lower limit of normal.
g. With the commercial stimulators that are presently
c. The percent reduction in Table 1 is applicable to available in the United States, neither needle nor
ulnar nerve in the forearm only if median-to- magnetic stimulation of nerve roots is accepted
ulnar nerve crossover in the forearm (Martin- as sufficiently reliable in producing supra-
Gruber anastomosis) has been excluded by the maximal stimulation of demyelinated nerve roots
recording of an initially positive hypothenar to be included in these criteria.
CMAP with stimulation of median nerve at the
elbow. Furthermore, usage of excessive stimu- h. These criteria do not fully encompass all factors
lation intensity at the wrist that activates both that experienced EDX consultants consider be-
median and ulnar nerves may result in the fore interpreting that partial conduction block is
suggestion of partial conduction block in the present. For example, certain anatomical vari-
forearm segment of the median nerve due to ations such as body weight and limb edema are
ulnar innervation of deep thenar muscles. difficult to quantify. To insure that supra-
maximal stimulation has been achieved, greater
d. Although the specificity for determining partial caution is required in obese rather than thin
conduction block is similar for median and ulnar individuals and in limbs with edema.

S226 Guidelines in Electrodiagnostic Medicine

©1999 American Association of Electrodiagnostic Medicine
 Consensus Criteria: Partial Conduction Block

2. Criteria for partial conduction block of motor 3. Partial conduction block of sensory fibers may be
fibers: suspected, but cannot be established, with con-
ventional surface recording techniques.
a. Definite partial conduction block can be identi-
fied, and probable partial conduction block can
be suggested, when temporal dispersion is min-
imal (duration of the CMAP is increased by COMMENTS ON PARTIAL CONDUCTION
30% or less over the specified segment). The BLOCK
criteria for definite and probable partial con-
duction block are summarized by nerve and Limited empiric data are available that suggest the upper
segment in Table 1. Identifying definite or prob- limit of normal for changes in amplitude, area, and
able partial conduction block over any of the duration of the CMAP over distance in healthy control
long segments identified in Table 1 (segments subjects. For the median and ulnar nerves with com-
of 10 cm or more) requires reduction in ampli- parison of elbow to wrist stimulation, the normal range at
tude or area of the specified amount over a least extends to an increase in duration of 25%, a
segment without significant temporal dispersion. decrease in amplitude of 25%, and a decrease in area of
20%, with similar changes for more proximal seg-
b. Partial conduction block over a long segment ments.3,5,8,10 For the peroneal nerve with comparison of
can only be suggested when temporal disper- knee to ankle stimulation, the limits of normal at least
sion is moderate (duration of the CMAP is permit an increase in duration of 30%, a decrease in
increased by 31% to 60% over the segment). amplitude of 30%, and a decrease in area of 25%.7,10,11 For
Criteria for probable conduction block are the tibial nerve with comparison of knee to ankle
summarized in Table 1. Reduction in amplitude stimulation, the normal range at least extends to an
or area of the specified amount over a long increase in duration of 30%, a decrease in amplitude of
segment is required, but the expert panel 50%, and a decrease in area of 30%.7,11
strongly prefers that reduction exceed the
specified amount for amplitude and area. However, these data limits of normal do not consider the
effects of aging. In older patients the increase in duration
c. Partial conduction block over a long segment and decrease in amplitude (and, to a lesser extent,
can only be suspected when temporal disper- decrease in area) are more prominent than in young
sion is marked (duration of the CMAP is patients.10 Furthermore, these data do not address the
increased more than 60%) or if the CMAP is pathophysiology of changes that exceed these limits. In
multiphasic. particular, abnormalities that exceed these limits may be
produced by temporal dispersion from axonal lesions or
d. If the criteria are fulfilled for probable partial demyelination, or by partial conduction block from
conduction block in a long segment of a nerve demyelination. Reliable and objective techniques that
with minimal temporal dispersion (that is, clearly distinguish between prominent temporal disper-
duration is increased by 30% or less), the level sion and partial conduction block in intact human
of confidence in the presence of partial conduc- nerve(s) are not available.
tion block may be increased to definite if ampli-
tude and area are reduced by 20% or more and The degree of amplitude and area reduction that has been
duration is increased by 10% or less between required to support partial conduction block in clinical
stimulation sites that are separated by 3 cm or studies has ranged from 20% to 50% for amplitude and
less (a short segment). Identifying definite 20% to 40% for area.1,6 In a computer simulation study of
partial conduction block in a long segment of conduction block, amplitude reduction of 85% and area
nerve with moderate or marked temporal reduction of 50% was achieved with temporal dispersion
dispersion requires reduction in amplitude and as conduction distance approached 50 cm.9 However, this
area by 20% or more over a segment of 3 cm or computer simulation was based on individual motor unit
less without significant temporal dispersion action potentials (MUAPs) recorded from the surface of
(that is, duration is increased by 10% or less). To a rat’s intrinsic foot muscle, and the representative
identify probable conduction block over a seg- MUAP was biphasic. The effect of phase cancellation
ment of 3 cm or less requires reduction in among polyphasic MUAPs is difficult to determine but is
amplitude and area by 10% without significant expected to be greater. A previous consensus publication
temporal dispersion. has suggested caution in the diagnosis of conduction

Muscle & Nerve Supplement 8 1999 S227

Consensus Criteria: Partial Conduction Block

Table 1. Proposed Criteria for Partial Conduction Block.

Minimal Temporal Dispersion Moderate Temporal Dispersion

(duration increases by 30% or less) (duration increased by
31% to 60%)

Definite Partial Probable Partial Probable Partial

Nerve Conduction Block Conduction Block Conduction Block
Segment
(proximal/distal) Amplitude Area Amplitude Area Amplitude Area
Reduction Reduction Reduction Reduction Reduction Reduction

Median
Forearm (E/W) >50% >40% 40% to 49% 30% to 39% >50% >40%
Arm (AX/E) >50% >40% 40% to 49% 30% to 39% >50% >40%
Proximal (EP/AX) * * >40% >30% >50% >40%

Ulnar
Forearm (BE/W) >50% >40% 40% to 49% 30% to 39% >50% >40%
Across Elbow >50% >40% 40% to 49% 30% to 39% >50% >40%
(AE/BE)
Arm (AX/AE) >50% >40% 40% to 49% 30% to 39% >50% >40%
Proximal (EP/AX) * * >40% >30% >50% >40%

Radial
Forearm (E/DF) † † >50% >40% >60% >50%
Arm (AX/E) † † >50% >40% >60% >50%
Proximal (EP/AX) † † >50% >40% >60% >50%

Peroneal
Leg (BF/ankle) >60% >50% 50% to 59% 40% to 49% >60% >50%
Across FH >50% >40% 40% to 49% 30% to 39% >50% >40%
(AF/BF)
Thigh (SN/AF) * * >50% >40% >60% >50%

Tibial
Leg (knee/ankle) >60% >50% 50% to 59% 40% to 49% >60% >50%
Thigh (SN/knee) * * >50% >40% >60% >50%

* See technical consideration 1.f.

† See technical consideration 1.e.

AE = Above Elbow BE = Below Elbow E = Elbow FH = Fibular Head

AF = Above Fibular Head BF = Below Fibular Head EP = Erb’s Point SN = Sciatic Notch
AX = Axilla DF = Distal Forearm FA = Forearm W = Wrist

S228 Guidelines in Electrodiagnostic Medicine

©1999 American Association of Electrodiagnostic Medicine
 Consensus Criteria: Partial Conduction Block

block when stimulation sites are separated by more than

4 cm and when the stimulated nerve is deep at the prox- DISCLAIMER
imal stimulation site.2
This report is provided as an educational service
These consensus criteria have been developed because of the AAEM. It is based on an assessment of the
empiric data do not distinguish temporal dispersion from current scientific and clinical information. It is
partial conduction block, and this distinction is important not intended to include all possible methods of
clinically. Criteria for partial conduction block that are care of a particular clinical problem, or all
proposed in this consensus document are conservative. A legitimate criteria for choosing to use a specific
strong consensus supports that these criteria need to be procedure. Neither is it intended to exclude any
more conservative for lower limb nerves than for upper reasonable alternative methodologies. The
limb nerves, because lower limb stimulation sites are AAEM recognizes that specific patient care
more widely separated. Furthermore, a strong consensus decisions are the prerogative of the patient and
exists that partial conduction block cannot be reliably his/her physician and are based on all of the
recognized in the context of severe axon loss. Until circumstances involved.
empiric data becomes available to support a different
criterion for severe axon loss, the expert panel recom-
mends that an amplitude below 20% of the lower limit of
normal at the most distal stimulation site is sufficiently Approved by the American Association
small to preclude the confident recognition of partial of Electrodiagnostic Medicine: March 1999.
conduction block.

The expert panel was evenly divided on the issue of

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increase in duration over 60%) is sufficient to preclude 3. Felsenthal G, Teng CS: Changes in duration and amplitude of
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