AANEM’s Scientific Impact Award recognizes mid-career members for serving as a first author, second author, or last (senior) author on a published paper in a national or international peer-reviewed, indexed journal within the past 2 years.
Michael C. Munin, MD, was awarded one of AANEM’s 2022 Scientific Impact Awards, for his work as the senior author on Reliability and Validity of the Modified Heckmatt Scale in Evaluating Muscle Changes With Ultrasound in Spasticity, published in Archives of Rehabilitation Research and Clinical Translation.
Munin’s research has been inspired by his clinical practice, which involves ultrasound (US) guidance techniques to improve outcomes for patients receiving botulinum toxin and phenol neurolysis injections to treat muscle spasticity and cervical dystonia. “I noticed that many patients had changes in the echotexture of the muscles that were injected. When present, these muscles had such an abnormal appearance that I wondered if they would respond to ongoing botulinum toxin treatment,” said Munin. “I also noted that muscles had either global or patchy changes and there was no way to quantitate this appearance. I had discussed my observations at a meeting with a colleague, Dr. Reebye, and we both wanted to study this further.”
Munin’s team, which included Marisa C. Moreta, DO; Alana Fleet, MD; Rajiv Reebye, MD; Gina McKernan, PhD; Michael Berger, MD, PhD; and Jordan Farag, MD; collected muscle images from 50 patients in a prospective, blinded fashion, and graded the muscles’ echotexture using the Modified Heckmatt scale. “The original Heckmatt scale is an ordinal 4-point grading system of muscle echotexture used in Duchenne muscular dystrophy. We modified the scale to describe the patchy changes seen in spastic muscles and applied standardized windows to obtain images. Moreover, to measure the accuracy of this modified clinical grading scale, we correlated the modified Heckmatt physician scores to quantitative grey scale analysis using Image J software.”
The authors found that inter- and intra-rater ICCs indicated good to excellent reliability, and there was a significant relationship between Modified Heckmatt scores and quantitative grayscale scores. “We also examined subject level characteristics that might predict Modified Heckmatt scores, but the model was nonsignificant for the effects of age, BMI, Modified Ashworth scale, duration of disease, and duration of prior botulinum toxin treatment,” added Munin.
This research is important to physicians who perform US evaluations of spastic muscle and who implement US guidance for placement of botulinum toxin injections to treat spasticity. The modified Heckmatt scale can ultimately help improve patient outcomes by selecting muscles more likely to benefit from neurotoxin injections. “I think this research is challenging the paradigm that you can inject botulinum toxin into any spastic or dystonic muscle and expect results,” said Munin. “After upper motor neuron injury or disease, muscle tissue appears to be dynamic and changes over time in a non-homogenous fashion. By injecting spastic muscles that show more normal echotexture, this approach may allow neurotoxin treatments to be more effective.”
He hopes to continue research that provides further understanding of which muscles are more likely to change in appearance and to document the frequency of this transition. “Since we have developed and validated a clinical tool to examine spastic muscle echotexture, our goal is to perform randomized trials to definitively prove this clinical concept,” he said.
Throughout his career, Munin has been involved in many areas of clinical research. He’s been active in clinical trials that evaluate botulinum toxin medications for upper and lower limb spasticity, performed studies investigating the use of diagnostic US for spastic muscle identification, and investigated causes of pain after lower limb amputation caused by heterotopic ossification. His main research interest is the application of laryngeal EMG to help diagnose and treat voice disorders. He’s collaborated with laryngologists at UPMC for more than 2 decades to advance this line of research, and his group has been productive with 15 peer-reviewed publications including several in Muscle & Nerve.
Munin currently serves as vice chair for strategic planning and program development for PM&R and holds secondary appointments in the departments of rehabilitation science and technology and otolaryngology. In addition, he is director of the spasticity clinic and co-director of the EMG labs at UPMC.
Munin said his interest in PM&R came “serendipitously” during his sophomore year of medical school, when he was assigned to a rehabilitation hospital on the spinal cord injury medicine service for a 4-week clinical experience. “I found the catastrophic nature of the injury and psychological and physical challenges faced by patients very engaging. I also liked that PM&R used a foundational knowledge base that included MSK and NM medicine.”
Munin graduated from Jefferson Medical College of Thomas Jefferson University and completed his residency in PM&R at Thomas Jefferson University Hospital. “As part of my PM&R residency, there was a strong focus on EDX medicine, and I really enjoyed the process of evaluating and diagnosing peripheral nerve pathology and NM diseases.”
Munin feels fortunate to have many mentors in residency training and early in his academic career to provide guidance. “There are too many names to list but I am grateful for the mentorship and education that I received, and I try to ‘pay it forward’ by assisting our current residents, fellows, and new attending physicians to develop their careers.”
After reflecting on his own career, Munin offered two valuable pieces of advice to early-career physicians. “First, examine areas of clinical practice where there are gaps in knowledge or treatment paradigms that are continued without supporting evidence. These clinical observations can transform into wonderful research ideas that are feasible to accomplish since you are working with the patient population who would directly benefit from the line of inquiry.”
“Second, find mentors and collaborators within your scope of research because a multi-disciplinary approach adds depth and improves the methodology. If possible, work with others outside of your specialty or institution. These concepts have been very rewarding in my career.”
Munin will be recognized at the upcoming AANEM Annual Meeting in Nashville. He’s yet to visit Nashville, and is excited to explore a new city. “I also look forward to seeing my friends and colleagues within the AANEM at the annual meeting. Our organization provides a great opportunity to learn, network, and socialize with others who have the same passion for EDX and NM.”