basics of electrodiagnostic medicine patrick kortebein md uams department of physical medicine &...
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Basics of Electrodiagnostic Medicine
Basics of Electrodiagnostic Medicine
Patrick Kortebein MDPatrick Kortebein MDUAMS Department of Physical Medicine UAMS Department of Physical Medicine
& Rehabilitation& Rehabilitation4/10/064/10/06
Patrick Kortebein MDPatrick Kortebein MDUAMS Department of Physical Medicine UAMS Department of Physical Medicine
& Rehabilitation& Rehabilitation4/10/064/10/06
Electrodiagnostic StudiesElectrodiagnostic Studies
Nerve Conduction Studies (NCS)Nerve Conduction Studies (NCS) MotorMotor SensorySensory Other (F-wave, H-reflex)Other (F-wave, H-reflex)
Electromyography (EMG)Electromyography (EMG) ““Needle exam”Needle exam”
Nerve Conduction Studies (NCS)Nerve Conduction Studies (NCS) MotorMotor SensorySensory Other (F-wave, H-reflex)Other (F-wave, H-reflex)
Electromyography (EMG)Electromyography (EMG) ““Needle exam”Needle exam”
PurposePurpose
1. Confirm a tentative clinical diagnosis 2. Exclude other disorders3. Determine stage of disease
e.g., location, severity, rate of progression, prognosis4. Characterize disease
e.g., axonal vs demyelinating5. Identify subclinical disease
1. Confirm a tentative clinical diagnosis 2. Exclude other disorders3. Determine stage of disease
e.g., location, severity, rate of progression, prognosis4. Characterize disease
e.g., axonal vs demyelinating5. Identify subclinical disease
ExampleExample
1. NCS- Motor / Sensory1. NCS- Motor / Sensory Axonal vs Demyelinating processAxonal vs Demyelinating process
1. NCS- Motor / Sensory1. NCS- Motor / Sensory Axonal vs Demyelinating processAxonal vs Demyelinating process
NCS: Common NervesNCS: Common Nerves
Upper Extremity:Upper Extremity: MedianMedian UlnarUlnar RadialRadial
Lower Extremity:Lower Extremity: PeronealPeroneal TibialTibial Sural (sensory)Sural (sensory)
*Normal Values- Variable*Normal Values- Variable
Upper Extremity:Upper Extremity: MedianMedian UlnarUlnar RadialRadial
Lower Extremity:Lower Extremity: PeronealPeroneal TibialTibial Sural (sensory)Sural (sensory)
*Normal Values- Variable*Normal Values- Variable
Example Example
2. EMG2. EMG
Muscle Electrical ActivityMuscle Electrical Activity RestRest Volitional ActivityVolitional Activity
2. EMG2. EMG
Muscle Electrical ActivityMuscle Electrical Activity RestRest Volitional ActivityVolitional Activity
Reasons for ReferralReasons for Referral
Numbness/ParesthesiasNumbness/Paresthesias Pain; radicular Pain; radicular Weakness; generalized/facial (MG)Weakness; generalized/facial (MG) Muscle atrophyMuscle atrophy Muscle twitching/Muscle twitching/ fasciculationsfasciculations
Numbness/ParesthesiasNumbness/Paresthesias Pain; radicular Pain; radicular Weakness; generalized/facial (MG)Weakness; generalized/facial (MG) Muscle atrophyMuscle atrophy Muscle twitching/Muscle twitching/ fasciculationsfasciculations
Common ReferralsCommon Referrals
Motor Neuron: ALSMotor Neuron: ALS Radiculopathy (Cervical / Lumbar)Radiculopathy (Cervical / Lumbar) Peripheral Nerves (Motor/Sensory)Peripheral Nerves (Motor/Sensory)
Carpal Tunnel SyndromeCarpal Tunnel Syndrome Foot DropFoot Drop Polyneuropathy (*except small fiber)Polyneuropathy (*except small fiber)
AIDP (Guillain Barre’)AIDP (Guillain Barre’) NMJ: Myasthenia GravisNMJ: Myasthenia Gravis Muscle: MyopathiesMuscle: Myopathies
Motor Neuron: ALSMotor Neuron: ALS Radiculopathy (Cervical / Lumbar)Radiculopathy (Cervical / Lumbar) Peripheral Nerves (Motor/Sensory)Peripheral Nerves (Motor/Sensory)
Carpal Tunnel SyndromeCarpal Tunnel Syndrome Foot DropFoot Drop Polyneuropathy (*except small fiber)Polyneuropathy (*except small fiber)
AIDP (Guillain Barre’)AIDP (Guillain Barre’) NMJ: Myasthenia GravisNMJ: Myasthenia Gravis Muscle: MyopathiesMuscle: Myopathies
Timing of ReferralTiming of Referral
Acute vs ChronicAcute vs Chronic Acute nerve injury/damage Acute nerve injury/damage
Nerve laceration (NCS)Nerve laceration (NCS) Radiculopathy (~7-10 days to weeks)Radiculopathy (~7-10 days to weeks)
Chronic nerve injuryChronic nerve injury Radiculopathy- persistent findings distinct from Radiculopathy- persistent findings distinct from
acute process (active vs inactive)acute process (active vs inactive)
Acute vs ChronicAcute vs Chronic Acute nerve injury/damage Acute nerve injury/damage
Nerve laceration (NCS)Nerve laceration (NCS) Radiculopathy (~7-10 days to weeks)Radiculopathy (~7-10 days to weeks)
Chronic nerve injuryChronic nerve injury Radiculopathy- persistent findings distinct from Radiculopathy- persistent findings distinct from
acute process (active vs inactive)acute process (active vs inactive)
ReferralsReferrals
Axial Neck / Low Back PainAxial Neck / Low Back Pain Generally, not indicatedGenerally, not indicated
Necessary?Necessary? Will it change your treatment plan?Will it change your treatment plan? Do you need assistance with diagnosis?Do you need assistance with diagnosis?
Axial Neck / Low Back PainAxial Neck / Low Back Pain Generally, not indicatedGenerally, not indicated
Necessary?Necessary? Will it change your treatment plan?Will it change your treatment plan? Do you need assistance with diagnosis?Do you need assistance with diagnosis?
Who performs NCS/EMG?Who performs NCS/EMG?
NeurologistNeurologist Physiatrist (PM&R)- required residencyPhysiatrist (PM&R)- required residency Physical Therapist (rare)Physical Therapist (rare) Technicians (NCS only)Technicians (NCS only)Additional Training:Additional Training: FellowshipFellowship Board Certification Board Certification
AANEM (Amer Assoc Nm & EDX Med)AANEM (Amer Assoc Nm & EDX Med)
NeurologistNeurologist Physiatrist (PM&R)- required residencyPhysiatrist (PM&R)- required residency Physical Therapist (rare)Physical Therapist (rare) Technicians (NCS only)Technicians (NCS only)Additional Training:Additional Training: FellowshipFellowship Board Certification Board Certification
AANEM (Amer Assoc Nm & EDX Med)AANEM (Amer Assoc Nm & EDX Med)
What tests are performed?What tests are performed?
Depends on Depends on Referral QuestionReferral Question Evaluation by examinerEvaluation by examiner
EDX testing is an extension of the physical EDX testing is an extension of the physical exam.exam.
*Address the patients problem*Address the patients problem GeneralGeneral
NCS (e.g., CTS)NCS (e.g., CTS) EMG (e.g., cervical radiculopathy)EMG (e.g., cervical radiculopathy) NCS & EMGNCS & EMG
Depends on Depends on Referral QuestionReferral Question Evaluation by examinerEvaluation by examiner
EDX testing is an extension of the physical EDX testing is an extension of the physical exam.exam.
*Address the patients problem*Address the patients problem GeneralGeneral
NCS (e.g., CTS)NCS (e.g., CTS) EMG (e.g., cervical radiculopathy)EMG (e.g., cervical radiculopathy) NCS & EMGNCS & EMG
Cost?Cost?
Nerve Conduction StudiesNerve Conduction Studies Motor- $90/testMotor- $90/test Sensory- $80/testSensory- $80/test
EMG (minimum 5 mm per extremity)EMG (minimum 5 mm per extremity) One extremity- $250One extremity- $250
Nerve Conduction StudiesNerve Conduction Studies Motor- $90/testMotor- $90/test Sensory- $80/testSensory- $80/test
EMG (minimum 5 mm per extremity)EMG (minimum 5 mm per extremity) One extremity- $250One extremity- $250
Real world patient scenarioReal world patient scenario
46 yo RH F restaurant owner46 yo RH F restaurant owner CC: Constant “numbness/tingling” right CC: Constant “numbness/tingling” right
ulnar 2 digits for 1 monthulnar 2 digits for 1 month HPI: Carries trays at work, No clear HPI: Carries trays at work, No clear
aggravating/alleviating position/activities, aggravating/alleviating position/activities, no weaknessno weakness
Meds/Allergies: None, PMHx: NoneMeds/Allergies: None, PMHx: None UExt Neuro Exam: M/S/R normal, inc ulnar UExt Neuro Exam: M/S/R normal, inc ulnar
digits sensorydigits sensory
Tinel’s at elbow- Positive Tinel’s at elbow- Positive Dx?Dx?
46 yo RH F restaurant owner46 yo RH F restaurant owner CC: Constant “numbness/tingling” right CC: Constant “numbness/tingling” right
ulnar 2 digits for 1 monthulnar 2 digits for 1 month HPI: Carries trays at work, No clear HPI: Carries trays at work, No clear
aggravating/alleviating position/activities, aggravating/alleviating position/activities, no weaknessno weakness
Meds/Allergies: None, PMHx: NoneMeds/Allergies: None, PMHx: None UExt Neuro Exam: M/S/R normal, inc ulnar UExt Neuro Exam: M/S/R normal, inc ulnar
digits sensorydigits sensory
Tinel’s at elbow- Positive Tinel’s at elbow- Positive Dx?Dx?
Real world patient scenarioReal world patient scenario
Referral NCS:Referral NCS: Ulnar neuropathy at the elbowUlnar neuropathy at the elbow
Primary MDPrimary MD NEUROMetrix in officeNEUROMetrix in office Testing performed- InconclusiveTesting performed- Inconclusive Second study performedSecond study performed
Time Time ExpenseExpense Patient discomfort Patient discomfort
Referral NCS:Referral NCS: Ulnar neuropathy at the elbowUlnar neuropathy at the elbow
Primary MDPrimary MD NEUROMetrix in officeNEUROMetrix in office Testing performed- InconclusiveTesting performed- Inconclusive Second study performedSecond study performed
Time Time ExpenseExpense Patient discomfort Patient discomfort
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