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Alan E. Goodridge, MD, FRCP(C)

Applications and Limitations of Electromyography and Nerve-Conduction Studies

SUMMARY
RESUME
A

Les etudes electromyographiques et de conduction Electromyography and nerve-conduction studies are very useful tools in the evaluation nerveuse sont des outils tres utiles pour evaluer les maladies nerveuses musculaires peripheriques. On devrait of disease of peripheral nerve and muscle. les considerer comme prolongement de l'examen They should be thought of as extensions of the physique. Ces tests devraient servir a repondre a des physical examination. The tests should be used questions sp&cifiques et a arbitrer les dilemmes diagnostiques. Ces tests ont cependant des limites to answer specific questions and to help clairement definies. Les taux de faux negatifs sont eleves et arbitrate diagnostic dilemmas. The tests, resultats positifs inattendus peuvent induire en erreur. however, have very definite limitations. There les de ces examens repose beaucoup sur la La valeur are significant false-negative rates, and correlation electrophysiologique-clinique. unexpected positive results can be misleading. The tests rely heavily on careful clinicalelectrophysiological correlation. (Can Fam Physician 1988; 34:339-343.) Key words: electromyography, nerve-conduction studies, diagnosis, laboratory medicine

.Ii~ iI

Dr. Goodridge is assistant professor of Medicine at Memorial University of Newfoundland and a member of the Division of Neurology at the Health Sciences Centre in St. John's, Newfoundland. Requests for reprints to: Dr. Alan E. Goodridge, Division of Neurology, Health Science Centre, 300 Prince Philip Drive, St. John's, Nfld. AlB 3V6

To obtain the maximum benefit of sending a patient to the EMG laboratory, it is worthwhile to have a basic understanding of the various test procedures, along with their applications and limitations.

Nerve-Conduction Studies
To perform motor nerve-conduction studies, recording electrodes are placed over the belly of a muscle appropriate to the nerve being studied. The nerve is stimulated at various sites along its course to elicit the motor or "M" response. The latency to the onset of the response and its amplitude are measured. When multiple sites along the nerve are stimulated, the latency difference between any two sites can be determined. The surface distance between these two stimulation sites is then measured, allowing calculation of the motor-conduction velocity. The conduction velocity from the distal site of stimulation cannot be determined because the latency includes not only the conduction time through this portion of the nerve but also the delay at the neuromuscular junction. Therefore, for a standard site ofdistal stimulation

HE TERM 'EMG' is often used collectively, to refer to both needle

electromyography and nerve-conduction studies. While each of these tests gives different types of information, the information is often complementary. Both tests are therefore commonly applied in investigating a single problem. EMG differs from many laboratory tests in that it is interactive and serves as an extension of the physical examination. The test must be tailored carefully for each patient's problem. The study design is influenced by nuances of the history and examination, and may be further modified as the test proceeds.
CAN. FAM. PHYSICIAN Vol. 34: FEBRUARY 1988

of a motor nerve, one simply records the "distal latency". The "F" response is a late response that comes after the direct motor response. When a peripheral motor nerve is stimulated, impulses travel not only orthodromically but antidromically back to the anterior horn cells. A portion of these anterior horn cells then fire orthodromically, producing a small late response. This response therefore provides some information about conduction through proximal sites of a nerve that cannot be studied directly. The H-reflex can be thought of as the electrophysiological equivalent of a tendon reflex. Most commonly, the posterior tibial nerve is stimulated, and a late response is elicited from soleus, reflecting conduction through the SI reflex pathway. Specific sensory nerves can also be stimulated by placing recording electrodes either distal or proximal to the site of stimulation. The amplitude of the response and latency are measured. As the stimulating and recording electrodes are placed directly over the nerve, the conduction velocity can be directly calculated after a measure339

ment is taken of the distance between the two sites.

Electromyography
To perform electromyography, a needle is inserted directly into a muscle. Three types of information can be obtained by varying the degree of activity of the muscle. Initially, the muscle is kept at rest. In normal muscle, no spontaneous electrical activity is seen, except in the region of the neuromuscular junction. When muscle fibres lose their innervation, positive sharp waves and fibrillation potentials are seen. These are small diphasic and triphasic potentials that discharge spontaneously in denervated muscle. These potentials are not seen in normal muscle in a subject of any age, and their presence provides clear evidence of disease ofthe axon or ofthe muscle fibres. With the muscle at rest, other forms of spontaneous activity, too, may be seen, including myotonia, fasciculations and cramps. When the muscle is tested with light exertion, individual motor units can be examined. Each motor-unit potential reflects the sum of potentials from a number of muscle fibres near the examining electrode that are supplied by the same axon and anterior horn cell. In a normal muscle, the fibres of a single motor unit all fire synchronously and are usually characterized by a triphasic potential. In disease ofthe nerve or muscle, the muscle fibres innervated by the same axon may fire asynchronously, and the motor unit potentials become more complex with four or more phases (polyphasic). The amplitude of the response reflects the number of muscle fibres of a single motor unit close to the examining electrode. In disease of the muscle, the individual muscle fibres are damaged, and the amplitude of the motor-unit potentials is reduced. In disease of the nerve, the amplitude of the remaining motor potentials may be unaffected, but after re-innervation has taken place, a single axon may innervate many more muscle fibres, and the amplitude of the motor-unit potentials may increase greatly. At maximal voluntary effort the recruitment of motor units is examined. As one increases voluntary effort, there is a gradual increase in the number of motor units firing and a gradual increase in the firing rate of those motor
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units. In disease of muscle, the motor units remain intact, but the muscle fibres are diseased and with exertion, many motor units are recruited very quickly. This response is termed 'hyperrecruitment'. In disease of peripheral nerve, the number offunctioning motor units is reduced. To increase the degree of muscle contraction, the remaining motor units must fire much more rapidly, and although the number of motor units firing is decreased, the firing rate is increased. This response is termed 'reduced recruitment'.

tainty can often be resolved by electrophysiological testing. Electromyography is helpful in determining whether weakness is of peripheral or of central origin. After a shoulder dislocation, movement of the shoulder may be inhibited by pain or by an axillary nerve injury. A stroke
may be confused with a radial nerve

palsy, and hysterical paralysis may be thought to be of peripheral nerve origin. The presence or absence of denervation potentials and the pattern of recruitment of motor units will often sort out this type of diagnostic

Special Techniques
Single-fibre EMG is a special technique used to measure the variability in the latency of firing of two muscle fibres belonging to the same motor unit. In normal muscle there is very little variability, but in muscle affected by a disorder of neuromuscular transmission, such as myasthenia gravis, this latency variability (jitter) may be substantially increased. Repetitive stimulation techniques are also useful for examining patients with a suspected disorder of neuromuscular transmission. A peripheral nerve is stimulated repetitively at various rates, both pre- and post exercise. The amplitude of the motor responses is examined for evidence of an increment or decrement, by comparing the first response with subsequent responses.

problem. Electromyography and

nerve-con-

General Applications
As with all neurological practice, the first principle is to determine whether a problem exists in the nervous system and if so, to identify the site of disease. This same principle is applied in the EMG laboratory. Abnormal test results are particularly helpful for localization. A test might therefore be used to support a physician's clinical impression: to confirm, for instance, that an ulnar neuropathy is localized to a patient's elbow rather than the wrist. A test might also be used to resolve a differential diagnosis that cannot be resolved by standard clinical assessment: to determine, for example, if paresthesias in the first and second digits of one hand are caused by a C6 radiculopathy or by a carpal tunnel syndrome. Occasionally, it may be difficult to determine if the origin of weakness is disease of the nerve or of the muscle, and this uncer-

duction studies (EMG/NCS) also help elucidate the pathophysiology of a disease process. In disease of the peripheral nerve, it is necessary to distinguish an axonal from a demyelinating neuropathy. With an axonal neuropathy, the amplitude of the motor and sensory responses will be reduced, although the conduction velocities will be normal or near normal. Electromyography may show evidence of active denervation with positive sharp waves and fibrillation potentials. In a demyelinating neuropathy, the conduction velocities will be slow, and there may be evidence of conduction block.' In conduction block, some ofthe action potentials fail to be conducted past a particular point. As the axons are intact, there will be no denervation potentials. When a peripheral nerve injury has occurred, the studies help determine whether the injury resulted in neuropraxia, axonotemesis, or neurotmesis. Neuropraxia caused by a prolonged compression injury results in an area of demyelination. The axon is intact, and recovery can take place rapidly, as remyelination occurs over a period of weeks. Electrophysiologically, this lesion will manifest as focal-conduction slowing and conduction block. Conduction below the demyelinated region is normal. Electromyography will not demonstrate evidence of denervation, although the recruitment of motor units will be reduced. Axonotemesis may also result from a prolonged compression injury or, alternatively, from a closed crush injury. The axon is damaged, and it degenerates along its entire length, distal to the site of injury. Recovery will be delayed while the axon regenerates at a rate of
CAN. FAM. PHYSICIAN Vol. 34: FEBRUARY 1988

one to two millimetres per day. Electrophysiologically, this lesion will manifest as a reduced amplitude of the motor and sensory responses, and there will be positive sharp waves and fibrillation potentials. Reinnervation (polyphasic) potentials will initially be seen in the proximal muscles and later in the distal muscles. Neurotmesis is the most severe type of peripheral nerve injury, usually resulting from an open laceration. The supporting tissues of the nerve are damaged, and therefore reinnervation will be incomplete, and neuroma formation will commonly occur. Initially, the electrophysiological features are the same as those of axonotemesis, and the distinguishing feature will be seen in follow-up, when reinnervation is found to be incomplete. The EMG/NCS therefore provide some guidelines relating to the severity and prognosis of a problem. A radial nerve Saturday-night palsy, for example, can be easily diagnosed on clinical grounds, but the electrophysiological studies can be used to determine whether the injury has resulted in neuropraxia or axonotemesis; the distinction has clear implications for the duration of patient's disability and the rate of recovery. The clinical consultation component of the electrophysiological assessment is essential. The electromyographer must be thoroughly familiar with the clinical problem in order to design the best study for the individual patient. If the primary diagnosis considered is not supported by the electrophysiological findings, additional tests may be performed. The consultation component is also necessary to provide an adequate clinical-electrophysiological correlation. An opinion can then be given concerning the probability that an abnormality found in the test results is relevant to the patient's problem and, conversely, the probability that a certain diagnosis still exists in spite of a normal study result.

testing that is necessary. Technical factors such as inappropriate electrode placement and incorrect filter settings may be overlooked, and this may lead to erroneous results. The test results may fall in the borderline range or show non-specific abnormalities. Such findings should not be overinterpreted. The clinician's clinical judgement should be the arbiter in these situations. A normal EMG/NCS does not necessarily rule out a diagnosis of pathology. A disease process may be mild in electrophysiological terms, in spite of prominent symptoms. Therefore, if there are a sufficient number of normally functioning nerve or muscle fibres, the EMG/NCS may be normal. Alternatively, the data obtained from the study may be incomplete, if the study is ordered at an inappropriate time. After a nerve injury, it may take up to five weeks for positive sharp waves and fibrillation potentials to develop.' If the testing is performed too early, the absence of such responses may inappropriately be interpreted as suggesting that complete recovery will occur quickly. The initial electrophysiological assessment after a nerve injury is useful for estimating prognosis, and subsequent studies may be made to determine if reinnervation is taking place. Once it is established that the patient is recovering, the value of further testing diminishes, and clinical assessment of progress is usually sufficient. The studies have very limited use in following the progress of an established chronic

to treatment. For example, the symptoms of a carpal tunnel syndrome may be quite severe, even though electrophysiological abnormalities are minor, and these minor findings would not preclude surgery. Conversely, in the case of a prolapsed intervertebral disc, the presence ofactive denervation in a myotomal distribution is not necessarily an indication for surgery.

Specific Indications and Their Limitations

Mononeuropathy Nerve-conduction studies for mononeuropathies are useful to provide support for a clinical impression and to help with the localization of pathologies. This is particularly important pre-operatively. In addition, the studies can be used to identify any coexisting or contributing problems. The most common peripheral mononeuropathy is a carpal tunnel syndrome. Electrophysiological features include prolongation of the median nerve terminal latency and a reduced median sensory-conduction velocity across the carpal tunnel. Falsenegative rates may exceed 20%, but they can be kept much lower with minor modifications of the testing techniques.2 Studies that are confined to one or two standard procedures on the median nerve and do not examine other nerves, not only will have high false-negative rates but will also miss other potentially relevant problems. Ulnar neuropathies are far more commonly localized to the elbow than elsewhere. However, the motor-conduction velocity may be normal in 50% of patients with ulnar neuropathies that are localized to the elbow.3 The sensory and electromyographic studies may help to differentiate whether the neuropathy is localized to the elbow or wrist. Other mononeuropathies, including a peroneal neuropathy at the knee and posterior tibial neuropathy at the tarsal tunnel, can be assessed in a similar fashion, by identifying a focal area of conduction slowing or block. In general, the nerve-conduction studies are most useful when the peripheral nerve is superficial and can be readily stimulated. For more proximal neuropathies, such as those involving the axillary nerve or femoral nerve, electromyography is generally more helpful. The nerve-conduction studies
341

polyneuropathy. Although EMG/NCS help to determine whether weakness is of central or peripheral origin, they have no part in the grading of muscle strength. EMG/NCS are inappropriate for blind assessments, and a "survey" approach to their use is likely to be meaningless. The tests rely on, but do not replace, a careful clinical assessment.

General Limitations
A host of factors can limit the information that may be obtained by EMG/ NCS. Patient co-operation is essential to obtain accurate test results. Subop-

tenosynovitis, diabetes, hypothyroidism, or amyloidosis. Electrophysiotimal relaxation can easily hide fibrilla- logical evidence of a C6 radiculopathy tion potentials and positive sharp cannot be equated with a prolapse of a
waves in partly denervated muscle. As C5-6 intervertebral disc. Caution should be applied when the tests involve some discomfort, the patient may not permit the amount of using the results of EMG/NCS as a guide

about localization is not an end in itself. A median neuropathy at the level ofthe carpal tunnel may be the result of

The EMG/NCS cannot provide an etiological diagnosis. Information

CAN. FAM. PHYSICIAN Vol. 34: FEBRUARY 1988

should not look exclusively at the nerve in question, but should also check other nerves, to establish, for example, if there is, a co-existing polyneuropathy. The electromyography studies may reveal a radiculopathy or plexopathy that was originally thought to have been a peripheral mononeuropathy.

Plexopathy The electrophysiological assessment of a plexopathy relies largely on electromyography to delineate the extent of the plexus involvement. The presence of denervation potentials is a reliable and easily identified abnormality, but abnormalities in the pattern of recruitment and of the motor-unit configuration can also help with localization. Nerve-conduction studies have a limited use. Their major use is to help identify a more peripherally located lesion. For example, the nerve-conduction studies may demonstrate an ulnar neuropathy at the elbow or a median neuropathy at the wrist that was originally considered to be a thoracic outlet syndrome. On the other hand, the value of nerve-conduction velocities across the lower trunk of the brachial plexus is widely debated. The sensory nerve-conduction studies can also be used to distinguish a plexopathy from a radiculopathy. In a plexopathy, the axon is disrupted, and the corresponding sensory potential will be diminished. In a radiculopathy, the lesion is proximal to the dorsal root ganglia (the site of the cell bodies of the sensory nerves), and the sensory potentials remain completely normal, in spite of a peripheral sensory loss.4 Paraspinal electromyography is also mandatory to help distinguish a plexopathy from a radiculopathy. The paraspinal muscles are innervated by the posterior rami ofthe spinal nerves, and therefore one would not find evidence of paraspinal muscle denervation in disease of the plexus.4 (Unfortunately, the reverse can not be true, and the paraspinal electromyography can be normal in disease of the root.) Radiculopathy In an acute radiculopathy, electromyography approaches the yield, in terms of localization, of a myelogram. Diagnostic findings include the demonstration of active denervation and reduced recruitment of motor units in
342

a myotomal distribution. In approximately 50% of acute radiculopathies, denervation can also be demonstrated in the paraspinal muscles, which allows for very secure localization.5 In a radiculopathy resulting from a prolapsed intervertebral disc, it would also be necessary to demonstrate the absence of denervation in myotomes innervated above and below the myotome involved. Evidence of denervation in multiple myotomes indicates a polyradiculopathy, and this finding has substantial bearing on the different

when conclusions are based solely on the presence of an increased proportion of polyphasic motor units.

diagnosis. Perhaps one of the most common reasons for referral to an EMG laboratory is to assess a patient with chronic pain in one limb who is thought to have a chronic radiculopathy. Electromyography in this situation is often non-diagnostic, unlike situations in which patients show acute radicular symptoms, and may only show polyphasic motor units. Polyphasic motor units simply indicate previous nerve (or muscle-fibre) injury with subsequent reinnervation. They may develop indolently and asymptomatically, or alternatively, a discrete event may have occurred in the past, with subsequent complete recovery. In the absence of active denervation or reduced recruitment ofmotor units, little can be said about the timing of the development of polyphasic motor units. Not only is the diagnostic significance of polyphasic motor units imprecise, but the diagnostic assessment of these units can also be imprecise. A certain proportion (10%-15%) of polyphasic motor units is considered to be normal, and this proportion increases with age. To assess polyphasia reliably, the clinician must assess a large number of motor units in each muscle and check several muscles spanning at least three myotomes. This process can be very time consuming, painful, and subject to subjective interpretation by the electromyographer. Even in cases where there is clearly a significant increase of polyphasic motor units, the abnormalities are commonly widespread and therefore not helpful for localization. Computer-assisted analysis ofmotor units can circumvent some of these problems. Given the problems ofthe diagnostic assessment and significance of polyphasic motor units, the EMG reports should be interpreted with caution

Neuronopathy Electromyography is quite helpful for the diagnosis of disease involving the anterior horn cells. In amyotrophic lateral sclerosis, electrophysiological features include positive sharp waves and fibrillation potentials in the paraspinal muscles and in three limbs or in two limbs and the head. The motor units are characteristically markedly polyphasic, and some are "giant". The sensory nerve-action potentials should be normal.6 These electromyographic findings may occur in a muscle that clinically appears normal or in a limb where all the findings suggest an upper motorneuron lesion. The denervation potentials have the same diagnostic significance as a wasted fasciculating muscle, and thus the electromyography is very much an extension of the physical
exam.

Peripheral polyneuropathy The diagnosis of a peripheral neuropathy is made on clinical, not electrophysiological, grounds. EMG/NCS should be used to determine the type of
neuropathy and perhaps as a means to obtain a crude assessment of severity. Clinically, it is often difficult to distinguish a demyelinating neuropathy from an axonal neuropathy. The electrophysiological studies can usually make the distinction and therefore help narrow the differential diagnosis. The nerve-conduction studies test predominately the large motor and sensory fibres. The small fibres, such as those serving pain and temperature, are not reflected in these tests. Therefore the results of nerve-conduction studies may be normal in a neuropathy involving only the small fibres. Polyneuropathies may clinically appear to be predominately motor or sensory. The nerve-conduction studies can help to establish if there are mixed sensory and motor features. The electrophysiological studies therefore help to characterize a peripheral polyneuropathy, but do not determine the specific diagnosis.

Myopathy
For the electrophysiological assessment of muscle disease, one relies on
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electromyography rather than on nerve conduction studies. Characteristically, in a myopathy there is hyper-recruitment of small, short-duration polyphasic motor units. The abnormalities may be subtle, and a normal study result can be found in 13% of patients with a myopathy. Some electromyographic features of a myopathy will help narrow the differential diagnosis. Positive sharp waves and fibrillation potentials may be seen in some myopathies with significant inflammation or necrosis, such as polymyositis or Duchenne dystrophy. Other forms of spontaneous activity, such as myotonia, will point to one of a few specific disorders.
Disease of

with high rates of repetitive stimula- PRESCRIBING INFORMATION floctation. This is the electrophysiological fenine 200 mg tablets. THERAPEUTIC correlate ofthe improved strength with CLASSIFICATION: Analgesic. INDICAIDARAC (floctafenine) is indicated repeated muscle contraction that oc- TIONS: for short-term use in acute pain of mild and curs in such patients. moderate severity. CONTRAINDICA-

Conclusions
Electromyography and nerve-conduction studies are very useful tools in the evaluation of disease of peripheral nerve and muscle. They should be thought of as extensions ofthe physical examination. The tests should be used to answer specific questions and to help arbitrate diagnostic dilemmas. However, the tests have very definite limitations. There are significant falsenegative rates, and unexpected positive results can be misleading. The tests rely heavily on careful clinicalelectrophysiological correlation. (y)

neuromuscular transmission Standard nerve-conduction studies

are normal in a patient with myasthenia gravis. However, electromyography may show some myopathic features and variability in the size of motor units. Single-fibre electromyography will show increased jitter in the extensor digitorium communis muscle in over 90% ofpatients with generalized myasthenia gravis.8 In cases of ocular myasthenia gravis, single-fibre electromyography should also be used to evaluate the frontalis muscle, where abnormal jitter may be found in over 75% of patients.8

References

1. Wilbourn AJ. Value and limitations of electromyographic examination in the diagnosis of lumbosacral radiculopathy. In: Hardy RW, ed. Lumbar disc disease. New York: Raven Press, 1982:65-109. 2. Kimura J. Carpal tunnel syndrome: localization of conduction abnormalities within the distal segment of the median nerve. Brain 1979; 102:619-35. 3. Hallett MD. Electrophysiological approaches to the diagnosis of entrapment neuropathies. In: Aminoss MJ, ed. Neurological Clinics: Electrodiagnosis 1985; 3:531-41. Repetitive stimulation techniques 4. Wilboum AJ. Electrodiagnosis of plexare also employed, stimulating a pe- opathies. In: Aminoss MJ, ed. Neurological ripheral nerve such as the accessory Clinics: Electrodiagnosis 1985; 3:511-29. nerve or ulnar nerve. A decremental 5. Streib E, Daube JR. Electromyography of response of more than 10%, which is paraspinal muscles (abstract) Neurology considered abnormal, will be found in 1975; 25:386. 600/o-70% of patients with myasthenia 6. Kimura J. Electrodiagnosis in disease of gravis.8 The yield of stimulating a nerve and muscle: principles and practice. F.A. Davis Company, proximal nerve, such as the accessory Philadelphia: 1983:431-48. nerve, is higher than stimulation more 7. Buchthal F, Kamieniecka Z. The diagdistally, and a study should not be con- nostic yield of quantified electromyography sidered normal unless proximal stud- and quantified muscle biopsy in neuies have also been performed. romuscular disorders. Muscle Nerve 1982; In botulism and myasthenic syn- 5:265-80. drome, a marked incremental response 8. Kelly JJ, Daube JR, Lennon VA, et al. The can be demonstrated either after a laboratory diagnosis of mild myasthenia short period of sustained exercise or gravis. Ann Neurol 1982; 12:23842.

TIONS: IDARAC (floctafenine) is contraindicated in patients with peptic ulcer or any other active inflammatory disease of the gastro-intestinal tract and in patients who have demonstrated a hypersensitivity to the drug. WARNINGS: USE IN PREGNANCY: The use of IDARAC (floctafenine) in women of childbearing potential requires that the likely benefit of the drug be weighed against the possible risk to the mother and fetus. Use of the drug in women who are nursing is not recommended. USE IN CHILDREN: The safety and efficacy of IDARAC in children have not been established and therefore is not recommended. The safety and efficacy of long-term use of IDARAC have not been established. PRECAUTIONS: IDARAC (floctafenine) should be used with caution in patients with impaired renal function. In clinical trials with IDARAC, dysuria without apparent changes in renal function was reported. It has not been established whether dysuria is related to dose and/or duration of drug administration. Patients taking anticoagulant medication may be given IDARAC with caution. Alterations in prothrombin time have been observed only in clinical trials where the administration of IDARAC was extended beyond two weeks. IDARAC should be used with caution in patients with a history of peptic ulcer or other gastrointestinal lesions. ADVERSE REACTIONS: The most commonly occurring side effects reported during IDARAC (floctafenine) therapy were: CENTRAL NERVOUS SYSTEM: Drowsiness, dizziness, headache, insomnia, nervousness, irritability. GASTROINTESTINAL SYSTEM: Nausea, diarrhea, abdominal pain or discomfort, heartburn, constipation, abnormal liver function, gastrointestinal bleeding. UROGENITAL SYSTEM:

Dysuria, burning micturition, polyuria, strong smelling urine, urethritis and cystitis.
ALLERGIC-TYPE REACTIONS: Maculopapular skin rash, pruritis, urticaria, redness and itching of the face and neck. SYMPTOMS AND TREATIENT OF OVERDOSE: No cases of overdose have been reported with IDARAC (floctafenine). In a case of overdose standard procedures to evacuate gastric contents, maintain urinary output and provide general supportive care should be employed. DOSAGE AND ADMWISTRATION: The usual adult dose of IDARAC (floctafenine) is 1 to 2 tablets (200 to 400 mg), 3 to 4 times per day as required. The maximum recommended daily dose is 1200 mg. IDARAC is recommended for short-term management of acute pain. The tablets should be taken with a glass of water. IDARAC is not recommended for use in children. AVAILABILITY: Each tablet of IDARAC contains 200 mg of floctafenine. Tablets are biconvex, cylindrical, yellowish-white, scored on one side with D57 above the breakline and a distinctive logo on the reverse side. IDARAC is available in bottles of 100 tablets. Store at room temperature, protected from light. IDARAC is a Schedule F (prescription) drug. Product
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