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I recently saw a lady very early on (11 days) from onset of neck pain, arm pain, paresthesias and subjective weakness of the hand. I saw her for EMG at the request of her PCP due to travel and timing issues. Clearly this is not the ideal time from for EDX evaluation of radiculopathy. Her ulnar CMAP to ADM/FDI was reduced (~3.5 mv) with normal median CMAP, normal median, ulnar, radial and MABC/LABC sensory responses. No conduction block or slowing at the elbow. Needle examination showed mildly reduced recruitment in Extensor Indicis, triceps and maybe ADM. Normal paraspinals. I suspect cervical radiculopathy, possibly in C8 distribution. Has anyone seen this presentation and type of finding before? Any thoughts about the process involved?
We need a ground electrode to provide a safe path for leakage current away from our patients. But why, given that we are using differential amplifiers with very high CMRR's, is the 60 hz artifact so overwhelming when the ground electrode is disconnected. You would think that the effects of extraneous 60 hz interference would be equal to the two pre amplifier inputs and thus cancel.
I had a patient present the other day with back and buttocks pain for EMG. The patient was in her 30's. symptoms had been going on for almost a year. no weakness. no complaints of numbness or tingling in her toes or feet. NO radiating symptoms intot the leg. normal examination for strenth and sensation (light touch and vibration). no family hx of neuropathy.
Her nerve conduction studies and needle exam were normal with exception of inability to otbain sural responses bilaterally. I moved the electrode 3 times on each side. I rolled across the calf with changes ,in stimulator alignement for several minutes and could not find anything that appeared consistant.
Can this ever be a normal varient or is this signsof neuropathy that is not symptomsatic yet?
Dear Colleagues, I was hoping for some advice on this one...
I was referred a 70 yo non-diabetic man by a neuro-ophthalmologist for vertical diplopia who in the course of his workup was found to have positive AChR antibodies. The patient woke-up with isolated fixed binocular diplopia, has had no fluctuation since onset, and has no ptosis, fatiguability, or generalized weakness on exam. MRI of the brain was normal. Repeat MRI and AChR antibodies two months later were unchanged (normal and positive, respectively). No response to pyridostigmine. Interestingly, his brother has symptomatic MG with positive antibodies, diagnosed >20 years ago.
Given the history and exam, the working diagnosis is an MRI-negative posterior circulation stroke. But what to do about the antibodies? Pre-symptomatic MG? Epiphenomenon of underlying autoimmunity?
In a patient with a severe inherited peripheral neuropathy- if the distal CMAPs (and SNAPs) are absent from the lower and upper limb nerves - how do we define whether it is predominantly demyelinating or only pure axon degenerative?
We could think of the following :
1.Recording over the FCR /FCU muscle and stimulating the Median/Ulnar nerve at the elbow and mid arm : any data available for defining when it should be called demyelinating?
2. R1 & R2 components of blink reflex if prolonged is it demyelinating ?
Could not find any defined criteria for this -would appreciate inputs please
Second question from the same patient （brachial plexopathy)
say, the thumb is in C6 dermatome. Does it mean all C6 sensory fibers go to this dermatomes and only C6 fibers go to this dermatomes?
this patient has completely normal median SNAP amplitude from the thumb ( comparable to the normal side) but completely unobtainable from the long finger ( including mid palm stim).
This is a real question. When there are two roots innervating a muscle and there is complete axonopathy to one of the two roots but not the other, do the axons from the unaffected root reinnervate (via collateral sprouting) the muscle fibers originally innervated by the other root? This question arose from seeing a patient with brachial plexopathy today.
Every patient scheduled for an elective surgical procedure in Baltimore area hospitals is required to have a COVID-19 pcr study done preoperatively, and if negative, quarantine themselves until admitted. Since reopening my EMG practice,I have adopted this procedure and also required a pcr study, mainly because of my age, my wife's age ,and her comorbidities. I have not insisted on the quarantine. Virtually all patients have understood and complied with this request. We are now able to obtain the nasal swab in our office with results returned from Quest within 3 days. This allows the patient to choose where they would like to have the swab done. A very few rare patients have refused to be tested, but for no consistent reason, other than for fear.
i wonder how others feel about pre procedure pcr testing. It is certainly not as good without quarantines,but if someone becomes ill, at least we will have some record of the patient's status and it should be of help in contact tracing.
This is a waveform that a member recorded last week from the APB in a 66 year old woman. We are sharing it as an 'unknown' waveform to see what others think. More information and the 'answer' will be shared later.
Is there evidence based literature that supports this offered diagnosis in a 55 yo with normal clinical and edX exams of an upper limb with diffuse pain?
I can recall being told by Neil Spielholtz, PhD, when I was a resident/fellow in neuromuscular medicine in 1970, that facilitation of peripheral motor nerve conduction can be seen, especially when performing proneal/fibular motor studies. Stimulating the peroneal nerve at the ankle,will occasionall cause no response from the Edb .However, stimulating at the fibular head produces a response, and after this is done, stimulating at the ankle now produces a response. I recall being told that this was "facilitation." No further explanation was given, as much as I can recall. I recently have looked this up in the literature, since I have been doing this for 40 years, and have never given it much thought. If any of the basic scientists out there can explain this to me, I would be very appreciative
I am seeking the opinion of fellow neurologists/neurophysiologists as to whether you consider clinical examination, history taking and explanation of results and discussion of management as part of the neurophysiology study or is it considered as a separate consultation? In my clinic I (as a Neurologist) personally exam the patient and take their history and based on this, set a test protocol which a neuroscientist then performs. I then see the patient in my office after the study is completed for discussion of the results and management recommendations, and I provide a detailed report back to the referring physician.
I would appreciate a simple yes or no response to the question: does the above process allow billing of an EDX study and a consultation?
In various Maryland medical institutions, the degree of testing for Covid 19 before surgeries and diagnostic procedures varies greatly from one institution to another. With most surgical procedures patients are required to have a PCR test done during the week prior to their surgery, and they are asked to isolate themselves after their test until their surgery is done. Patients having MRI or other imaging procedures are not usually required to have any testing done, and are simply asked basic questions about Covid exposure, and their temperature is measured on arrival at the facility. Inside the facility, no procedures seem to be taken other than everyone wearing facemasks. In our office we perform only electromyography and nerve conduction studies. All patients are required to have a PCR 19 study done prior to being seen, but we do not require the patient to isolate themselves after this is done. We have turned away patients who arrived without having been tested. During the procedure I wear gown, mask, shield, head cover and gloves on each patient and even though the COVID-19 test is negative, I assume that the patient could have been infected after the test was done.I suppose I am halfway between the surgical procedure and the imaging studies with regard to precautions. I wonder how others are handling safety precautions now that we are much further into the pandemic then earlier this year. Patients wonder why I am being so strict, but since we spend so much time in close quarters with the patients, I believe our degree of caution is appropriate.
What policies does your lab follow in regard to archiving raw data from EMGs/waveforms? Do you archive for a certain length of time? Any recommendations are welcome.
I have what may be a stupid question for many of you, but I do not see much motor neuron disease in my practice, so I wanted to ask the general question. I know that denervation and re-innervation are seen together in the same muscles in motor neuron disease, but are polyphasics a necessary component to the re-innervation, or would chronic neuropathic motor units also be considered enough? How often do you see polyphasia in motor neuron disease? Thanks so much for your help in advance!
Dear colleagues,
Report cases to the International Neuromuscular COVID-19 Database and become a member of the International Neuromuscular COVID-19 Consortium!
Over the last couple of months an international group of neuromuscular health care professionals have been working on creating an International Neuromuscular COVID-19 database to monitor and report the outcomes of COVID-19 occurring in patients with Neuromuscular Diseases. The database already includes almost 100 cases from various countries worldwide, including the UK, Spain, South Africa, The Netherlands and India.
There is an urgent need to understand outcomes of patients who acquire SARS-CoV‐2 infection and are receiving immunosuppressants and/or have disease features (e.g. cardiac or respiratory involvement) that may affect the outcome of COVID-19. This will help guide neuromuscular specialists in advising and caring for their patients.
The database it hosted by University College London (UCL) in the UK, at uses a secure RedCap platform; the database website can be found below: https://www.ucl.ac.uk/centre-for-neuromuscular-diseases/news/2020/may/neuromuscular-covid-19-database
We encourage colleagues to report ALL cases of COVID-19 in their neuromuscular patients, regardless of severity (including asymptomatic patients). Understanding less severe cases or even mild cases will help us understand further those who develop the most severe form. The contribution of contributions of colleagues reporting cases to the database will be duly acknowledged in publications arising from this international effort.
Target users are neuromuscular consultants / fellows / nurses / allied health professionals that become aware of NMD patients with COVID-19. We ask colleagues to report after a minimum of 7 days and sufficient time has passed to observe the disease course through resolution of acute illness and/or death. It is also possible for the reporter to return to the same case and update/complete the questionnaire.
We hope you will actively contribute to this voluntary reporting system. Through broad scale participation and collaboration, we will be able to answer these very pressing questions for our neuromuscular patients and their caregivers.
The UK Health Research Authority (HRA) was consulted and advised that this project is considered to be a research database and that it does NOT require review by an NHS Research Ethics Committee (REC). It is a database involving previously collected and available, non-identifiable information. There is NO requirement for patient consent. Although this does not cover all nations in Europe and worldwide we believe this will be the position likely taken by many authorities across Europe/the world. Please check with your local authority if you are unsure. Please contact us if you require any additional details in order to obtain regulatory approval to submit cases in your country.
The University of Kansas Medical Center IRB / REC also considers this to be retrospective data collection, therefore not requiring patient consent. But as indicated above please check with your local IRB.
With thanks and best wishes,
Mazen Dimachkie and Pedro Machado mdimachkie@kumc.edu p.machado@ucl.ac.uk
I am wondering if there is any formal guidelines or studies that give guidanc eon rating the severity of a peripheral polyneuropathy like there is for crpal tunnel? in my searchs I have not been able to find anything. retesting neuropathy for changes ins everity seems to be a common refferal from non neurologist.
According to the medical literature I have been able to review, gowns, are only secondary to gloves as the most commonly used PPE. The ANEM guidance for reopening practice suggests use of gowns for Covid positive patients, but I wonder how many of our members are now routinely using gowns during all of our studies regardless of Covid status. With all gowns, there it's a classification of ability to protect the wearer. There are several different classifications, but the most common seems to be AAMI (Association of advanced medical instrumentation. )This ranges from level one for minimal protection up to level four. There is quite a bit written about these levels of protection, but most of them were written before the Covid epidemic and seem to apply mainly to Ebola when considering viruses. There are some nicely written summaries from CDC and NiOSH which can be found by checking with Siri or Google. These are much more easy to read than the full articles. While these are very informative, they do not specifically speak to our concerns over what level of PPE we should consider when performing electrodiagnostic studies. Again, I wonder how many of us are using gowns, what level of protection we are using, and what type of gown we have been able to obtain. Level one gowns are fairly easy to find, but higher levels are extremely hard to find. I could go on for sometime discussing this, but I am afraid I am boring everyone.
It is a shame that only a small handful of members seem to use this service. If more joined in, much more could be done to get the attention of our leadership in addressing our concerns.While our organization does a superb job with education, I believe a lot more could be done helping with managing our practices. We have been given excellent suggestions for handling our practices during the Covid pandemic. However, we have not been given assistance in implementing these suggestions. We all have had difficulty obtaining PPE on an individual basis. Couldn't our organization help to find suppliers to obtain this equipment. Discounted group prices would be nice, but even help with just finding the supplies would be very helpful. It has been suggested that all our patients undergo testing for COVID-19 prior to EMG.However, it is very difficult and cumbersome to obtain testing on an individual basis. Many laboratories insist that the patient be symptomatic before testing.Couldn't our organization find a laboratory who would do this for us "on demand." As our organization grows, we should be using our buying power to assist our membership, not just now, but after things return towards " normal".
Our practice is having difficulty getting phenol covered for spasticity management. Specifically our North Carolina Medicaid contact is saying
"I cannot find Phenol in any reference. Do you have proof it is a drug? Our policy would not allow us to cover any product other than an FDA approved drug. Can proof be provided that I can pass along to see if we can get this drug added to the coverage list?"
Any thoughts on a best response to this? I would think that Medicaid would "want" phenol used for spasticity rather than botox since it is cheaper and lasts longer.
I have a single physician outpatient electrodiagnostic practice which has been closed since March 13 of this year. Our waiting list is now longer than three months, and patients are getting very restless. We just began a trial reopening, following all of the AANEM suggested guidelines. We were lucky enough to obtain all of the PPE suggested over the past three months, although much of it is of a very low quality. Gowns are nearly impossible to find,but disposable sleeves work very well and are very inexpensive.
In the past, patients were scheduled one per hour, regardless of symptoms.We began our reopening with one every two hours. For the young patients with/ hand paresthesias, this turned out to be much too long, including the time for sanitizing the exam room. However, for the elderly diabetic patient with complaints in all four extremities , neck and back, two hours was barely enough. Working with full ppe is very cumbersome and slow. The face shield tends to fog, breathing becomes hard,and the gloves make electrode handling slow..All of which must be taken into account when scheduling.
Since the referring physician's office is frequently not very clear about the patient's symptoms, it may be difficult to determine the time needed for an exam. I have found that talking to the patient a day or two before they are seen to obtain a detailed history helps me to save time in the office and better plan how much time will be needed for each patient. I highly recommend that a "telemedicine visit"be done with each patient before they come in, both for screening for Covid and for prioritizing the time that will be needed to see each patient. While a physical exam is certainly also needed, talking with the patient before hand speeds things up considerably.
With a virus spread by aerosolized droplets, N95 masks and face shields seem absolutely necessary while examining a patient, even if they have no signs of COVID-19. However, gloves may seem to slow down the performance of nerve conduction testing more than they provide increased safety. I have spoken to surgical colleagues working in an ICU who feel that they are usually not necessary and slow down the procedure being performed. I have not seen any scientific studies which show that gloves are of benefit when performing nerve conduction studies, or any other patient contact with COVID-19. I have just begun opening my practice and do use every possible PPE including gloves, but these measures do greatly slow down the testing and increase my contact with the patient at least 50%. Gloves make it very difficult to handle the adhesive on electrodes, especially tape. I wonder how others feel about gloves and whether they actually expose us to the virus more than they protect us.
I enjoy participating in the AANEM Connect Forum for a number of reasons. There are very fundamental questions posed on a frequent basis that cause me to pause and ask myself, ‘Why didn’t I think of that?’ Also, I continue to learn
new things when others contribute their thoughts and experiences. Connect is an excellent opportunity for members to interact and to address any topic, including those that may not be discussed
at an annual meeting or journal article.
