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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.
Patients with peripheral nerve pathology are clinically evaluated in a variety of ways in real-world practice. This leads to varied reporting of outcomes. We are conducting this study to better understand how patients with peripheral nerve pathology are assessed by clinicians across nonsurgical and surgical disciplines. The investigators for this multidisciplinary study are listed at the end of this message.
We would appreciate your participation in the study by completing the survey. The survey should take no more than 10-15 minutes to complete. Your response is highly valued and appreciated.
hi
As absence of sural response in elder NORMAL peoples doesn't carry a significance, what is EDX cause beyond that ?? is there a subclinical axonal loss ??
The AANEM guidelines for resuming practice lists everything we should do in a perfect world. Perhaps an institutional based practice could comply, but it seems almost impossible in a single physician practice. I saw my first patient yesterday on an emergent basis after being closed since March 13. Luckily I had been able to obtain n95 respirators, face shields, etc over the past 2 months, but no gowns. The patient had no Covid symptoms and her temp was normal, but no pcr was available. We followed the guidelines as best we could,but it was difficuult, slow and uncomfortable to work in full ppe. I believe we all should have a test run before full reopening because it is not easy to get everything done. The AANEM survey of what physicians are actually doing shows that many are not even using masks, let alone following the list. Many may just not reopen because of the difficulties, loss of income and fear of being sued for not following the guidelines. I wonder how many are able to be 100% compliant.
Have individual and group practitioners attested to the automatic HHS stimulus payment that was direct deposited in April 2020? I've read that no response to return the payment is defacto acceptance of terms and conditions. There is some concern that HHS keeps changing the terms and conditons. They are publishing the names of all that have attested and the amount given. Any thoughts?
Is there any significant difference in the brand/ type of infrared thermometer used for screening patients for elevated temp prior to emg other than price? Most measure forehead temp. Some say not for use on humans, but all appear the same.
My EMG/NCS exclusive practice in Northern CA has been closed since mid-March 2020 when non-essential medical procedures were temporarily banned by local public health officials during the early phase of the covid crisis. Now that some elective procedures, including surgeries, are being performed in my community in CA, I am considering re-opening slowly. I am curious to hear how other EMG practitioners feel about re-opening and what they have done to insure safety for staff and patients.
Rapidly evolving but worsening statistics and the uncertainty with Covid 19 pandemic has taken a significant toll on the financial, professional, and emotional well-being of all health care workers. Lack of appropriate PPE is the most devastating, risking lives of our friends and colleagues. Making difficult medical decisions of patient care in a virtual setting could be a frightening experience. How is one going to be confident with limited remote neuromuscular exam? How are we going to decide whether home infusion setting is better than an infusion center for our patients receiving IVIG and/or other immunosuppressants/modulators?
How are you all coping with this situation? Are you taking breaks to nourish in between and check-in with yourselves? How are you taking care of your loved ones? Are you connecting with your colleagues? Are you limiting exposure to social media or do you think it helps build connectivity in our isolated worlds and a sense of community? To our international members, are there unique approaches your governments or communities have taken to coping that you can you share?
It has been said that EMG/NCS is a mature specialty, but many of the things we see every day are not adequately explained ,as Dr Albers' post shows. Fairly common but incompletely explained phenonema arise every day. We may be so used to seeing them that they are ignored ! During the open sessions of EMG talk at our annual meetings many of these have been brought up and an explanation sought, in a " Have you ever seen this " format. Surprisingly some "pearls" were well recognized by the audience,but a few of our experts had never heard of them. One that comes to mind is the patient with symptoms confined to the ulnar distribution of his hands, but the nerve conduction studies show only unequivocal , classical carpal tunnel syndrome. After convincing the surgeon to do CTS release, the patient's symptoms completely clear.Many theories are expressed, but no hard evidence given.
Perhaps we could compile a list of these "gems", both for showing trainees that these things do occur, and as a list of research projects...... something for us to do while we're sitting around.
My practice is 100% office based and 100% EMG/NCS. I have cancelled all patients until March 30, but have not decided about after that. I am over 65 and could just retire,but I love my work and feel like I would be abandoning my patients and employees. I have read the AANEM statement,which like most others, is equivocal. Unfortunately,my referral sources all seem to have difficulty telling me how urgent are their patients problems. How are the rest of you planning for the future?
Hi all, I am planning to purchase a new EMG machine in the next few months since my old VIking Quest is >12 years old and can't be updated. I am thinking of replacing it with a newer Viking Quest ( since I am used to it ) but am also looking at the Viking Edx. Does anyone have advice on choosing one of these or other machines to consider? I do standard NCS/EMG, no single fiber. Thank you.
I was trained using nautus concentric 30 guage needles and used them the last 7 years of practice. At my new location they are purchasing concentric 30 guage needles from AMBU. I have noticed that patients seem to be complaining more about pain during EMG testing than in the past. I have not changed my technique.
Have others noted improved patient comfort with a particular brand of EMG needle?
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.
