All right, well thanks for including me in the series this year. I am briefly, I'm an attending physician and I also do research at the Shirley Ryan Ability Lab Rehabilitation Hospital, formerly known as the Rehabilitation Institute of Chicago. And we're academically affiliated with Northwestern University, so I'm in the Departments of Physical Medicine and Rehabilitation and Neurology at Northwestern. AANEM has co-sponsored this session last year and I assume again this year, so that's why I use their background. Yeah, Amy's giving me the thumbs up, yeah. I have a relationship with AANEM in that I do sit on some committees for research and engagement with PMNR physicians because they have been trying to keep the numbers somewhat balanced. Historically, the AANEM, the American Association of Neuromuscular Medicine and Electrodiagnostic Medicine has been 50-50, physiatry and neurology, with a little bit of other stuff mixed in there in terms of maybe some PhD scientists and people who work in the neuromuscular field or in electrodiagnostics, electrophysiology. But the last couple decades, it's drifted to being a little bit more neurology dominated, 60% maybe to 40, something like this. So there's a real priority in terms of just letting people know what the subspecialty is about and the roles for physiatry. So my agenda today, recognizing that you guys are at the stage of medical students are thinking about the specialty of PMNR, but it's not too early to start thinking about also the subspecialty options, is to tell you about neuromuscular medicine and electrodiagnostic medicine, which we marry together because they are so interdependent. But there's a little bit more training that goes on if you want to do a neuromuscular medicine fellowship and certification nowadays. So I'll tell you a little bit about that. I'm going to do the talk through cases just to sort of give you a flavor for what we do and happy to kind of run through after I just briefly discuss the pathways if you want to do fellowship versus just getting board certified for electrodiagnostic medicine, which doesn't necessarily require fellowship, et cetera. I'll run you through that briefly and then we can just sort of chat if there's any interest in doing that. So in this subspecialty of physiatry, we treat a lot of things. And so by definition, we're really focusing on disorders of the peripheral nervous system and there are many different ways of breaking that down. We often think of, I guess probably the best way to think about it is to start at the muscle and work your way back. So myopathies or muscular dystrophies, neuromuscular junction disorders, as you kind of walk your way up this column. Amy, are you able to see my pointer or should I go to the laser pointer? Yeah, I can see it a little bit. The laser pointer is kind of a pain if I want to click on things later. Yeah, I can see it now when it was okay. So then you go up from the neuromuscular junction to the peripheral nerves, like neuropathies, polyneuropathies, entrapment or mononeuropathies, et cetera. And as you go further up the nerve, you get to the prachial plexus or the lumbosacral plexus and there's disorders that affect that area. Then to the nerve roots exiting the spine, so radiculopathies, ganglionopathies or neuronopathies, like sensory neuronopathies, and then in the spinal cord, the motor neuron or anterior horn cells, so things like ALS, et cetera, polio. Along with the diverse amount of disorders, so most of us, I say in the second line, general versus focused practice, most of us I would say pick at some point a focus within this area. For example, some people would focus on ALS or some people would focus on myopathy or neuromuscular junction disorders. But many people pick a focus, but you have the option too to stay really general. And there's actually a really big job market these days for general neuromuscular physicians all over the country. They're in demand. We're just not generating enough of them, whether it's through neurology or physiatry, which are the two specialties that feed into this subspecialty. So there's opportunities to, if you're like me, also focus in on a particular area. So I do a lot of complex nerve injury stuff, so brachial plexus, and even reconstructive surgeries and using some of the principles that we use for brachial plexus to treat people with upper extremity deficits after spinal cord injury. You can do academics. Obviously a lot of the people talking in this series I suspect are academics. We tend to do a lot of talking. But there's lots of opportunities in private practice, especially in light of the fact that it is so hard sometimes to see a neuromuscular subspecialist or get an EMG scheduled. You can do a balance between procedures if you like EMGs or even ultrasounds, neuromuscular ultrasound, and there's lots of need for clinics as well. There's research opportunities, which we'll hit on a little bit just naturally as we go through some of our cases. Our patients often have, within these topics, some of the genetic or autoimmune disorders are relatively rare. So there's a lot of need for patient advocacy, whether that's with an employer for a patient who's not able to return to work, insurance for treatments that are rare, for rare diseases that may not be routinely covered by insurance plans but have big benefit for patients. And there's need, even more recently there's been an initiative that you may see on social media too for people with disabilities and neuromuscular diseases like ALS and muscular dystrophy has been big supporters of this for airline travel. So there's a lot of things happening in our field. I broke down the list of things that we address by the localization in this circuit here. So this is just, again, thinking about it from the muscle back is how we just did it. So let's do it in this order from the motor neuron out. So the spinal motor neuron here in the ventral horn or anterior horn cell. You have nerve roots, sensory, dorsal, motor, anterior, or ventral, and then dorsal root ganglion here, which tends to sit right around the foramina. At this point, you typically are exiting the spinal cord. You have spinal nerve roots that form together into a plexus and then peripheral nerves. And then as you go down, you have a neuromuscular junction and muscle. And apologies if you're interested in pain and sensory end organs, there's also some of those as well. So when you're focused on neuromuscular medicine, you also realize that not all of our diseases are acquired, for example, through trauma or acquired like a stroke. Like in general rehabilitation practice, like amputation, stroke, trauma, make up a lot of the bread and butter. In neuromuscular medicine, in neuromuscular rehab, there's a lot of genetic diseases. There's adult and pediatric, and if you're the neuromuscular specialist in your area, you may have to do a bit of pediatric practice if there's not a pediatric neuromuscular specialist present, because like I said, we are in short supply, but there are pediatric neuromuscular fellowships. So if you're in a place like me in Chicago, you have maybe other subspecialists you can lean on. And if you're practicing out in a community practice that's not linked to a big academic center, you might be the resource that you cover quite a bit of area geographically. So, and that may be fun and interesting for you. So, and the patients have a lot of other involvement. So we think about this as the thing that defines our patients, but they actually come with a lot of complex care requirement, and often multi-system involvement. Breathing, sometimes cardiac, in some cases like with mitochondrial disease, you'll have developmental delays. And really what it comes down to as you look at the field, it's like PMNR in general, it's very collaborative. And interestingly, since so many of the people in our field currently are from a neurology background, I feel like this point really makes the neuromuscular subspecialist from a neurology background the most PMNR literate neurologist that you'll encounter. And for people with a PMNR background, it's a very familiar environment when you go to these interdisciplinary clinics for myopathies or muscular dystrophies for ALS, and you work with large teams of allied health professionals, therapists, like occupational therapy, physical therapy, speech language pathology. Of course, there's opportunities for orthotics, prosthetics, engineering and technology is becoming so big for communication, eye gaze control, power wheelchairs, of course, with some of these newer implants that people are putting right into the brain through various commercial collaborations, which I'm sure some of you have seen things like Neuralink and these products coming out. There's going to be even more technology to solve mobility and communication problems that our patients encounter. And linked to some of that stuff is also the opportunity for research, particularly with rare genetic diseases, rare acquired diseases, because as a whole, our patients, there's lots of patients that need neuromuscular care, but when you start to stratify them out, they get there with a lot of different variations on, even when you start going into, say, limb girdle muscular dystrophies, and these myopathies, there's many, many different subtypes. And as we're getting to matching people with more precision medicine treatments, precision rehabilitation, you'll see that we'll come back to that in a second, but that really is changing the scope of our practice. On the point of collaboration, though, you can see, here's a study I'd like to point to, because currently we don't have, this is an ALS study, and this is time from diagnosis and the survival of patients with ALS. Patients taken care of in an ad hoc fashion through just general neurology clinics, this is in Ireland, but it's a nice illustration of team-based ALS clinics, interdisciplinary clinics, where people collaborate versus trying to sort it out in an ad hoc fashion. You can see that survival for these ALS patients is actually improved just simply by going to the team-based clinic, the ALS clinic. In fact, when you compare this to Reuzol or Daravon, two of the FDA-approved drugs that can slow ALS but don't cure it, the treatment effects of coming to interdisciplinary care for survival of these patients is about on the same magnitude as any of the drug therapies that we have for ALS. And then on the point of personalization of care, beyond just the personalization that we do when we get to know our patients as we treat them, as rehabilitation physicians and therapists, et cetera, there are gene therapies. So Tolfersen is a gene therapy specifically for SOD1 mutations that cause ALS, which was the first mutation, SOD1, that was identified that can cause this disease. It accounts for only about 2% of disease, but it was discovered in the mid-'90s and now has a specific tailored therapy that targets just the issues that are caused by that mutation. We're working, of course, there's about 10% to 15% of ALS is caused by genetic mutations, so there's other gene therapies in the works for other genes. Spinal muscular atrophy, SMA, apologies for the abbreviation, has now three different gene therapy type of treatments that have revolutionized the care of these patients, which is essentially a pediatric or early-onset form of motor neuron disease that often leads to patients who never even achieved basic milestones like sitting, standing, walking, now able to achieve those developmental milestones if they're treated early with gene therapy. So it is an exciting time to be in this field because of the impact of these new therapies that are coming out, and those, the beginning of the gene therapy for SMA was 2016. Tolfersen was approved just two years ago, so we are, things are just changing quickly and it's an interesting, like I said, interesting time to be in this subspecialty. So what is electrodiagnostic medicine? So I talked a lot about the neuromuscular part of it. The electrodiagnostic part of it is fundamentally an area of rehabilitation medicine that rehabilitation doctors were the leaders and have really been at the forefront of it for decades, and it has changed in the last few years, including more things like using modalities like ultrasound to help with identifying certain muscle targets or actually do complementary diagnostic scans of nerves and muscles. But at the basis of it, there's still a lot of electrophysiology, nerve and muscle physiology, which is at the backbone of our specialty at PM&R, and so in some ways neuromuscular medicine is really so fundamental to the specialty at PM&R if you're interested in rehab. So we train all of our residents to do electrodiagnostic medicine. At our program, you'll spend, on five different months, five different rotations, you'll be on electrodiagnostic rotations, and you'll see the similar setups with programs all across the country where it's often five, sometimes six, sometimes four months of electrodiagnostic medicine. EMGs are really neat because you're able to do a study on a patient in an hour or two. It doesn't always tell you the entire diagnosis, but by studying the nerves that go to the skin and to the muscles, it really is effective at giving you the localization or where the lesion is. So for some of my practice as a PM&R doctor, because I still cover weekends at the hospital, there's a lot of focus and centering of our practice around function, and although there is some diagnostics involved in taking care of inpatients in a rehabilitation setting, one of the things I find really rewarding about this subspecialty is the ability to do a little bit more diagnostic workups on patients, and the problem solving involved with that. Sorry, let me go to... And so here's an example of a case. So this case actually came from a consult I got on an inpatient who was admitted to the inpatient rehab unit. So Mr. B, he's a 60-year-old male. He's got hypertension, diabetes, obstructive sleep apnea. He actually came to us after he had COVID-19 pneumonia and ARDS, acute respiratory distress syndrome. He was intubated and cared for at the ICU level for about three weeks and had a pretty complicated hospital course, including kidney injury and had actually required hemodialysis before he came to us. So he was pretty debilitated when he arrived, and this was happening at the early stages of the pandemic. So prior to coming to the inpatient rehab setting, I don't think he had had really extensive physical examination of his neuromuscular system. And my colleague who admitted him under the general rehab unit, we had actually created a unit just for post-COVID patients at that time, was aware that there was some post-ICU weakness is what it was described, or sometimes you'll hear the term like critical illness acquired weakness, or yeah, ICU acquired weakness or critical illness myopathy. So this has been the category placed on this patient. But he didn't look, his actual exam didn't match that diagnosis. For example, he had very asymmetrical pain in his right shoulder that had been bothering him since he'd been in the acute care hospital and was still bothering him, and it was associated with arm weakness on the right side. But he also had a really weak left thigh. He couldn't extend his knee. He had a hard time putting weight through that leg because of the, and he also had pain and tingling in his anterior thigh. So we thought, you know, this is not making sense based on the typical post-ICU weakness patterns that we get used to seeing, which tend to be fairly symmetric. Maybe the shoulders are affected, maybe the hip flexors and proximal thigh muscles are affected more than the distal muscles and the feet and the hands, but it's usually pretty symmetric and it doesn't involve a lot of pain and loss of sensation. So when we examined him more closely, you could see, and I color-coded just for the purposes here, of the motor deficits in blue and the sensation deficits in red. And you can see that there's some weakness here in the thigh, also to some degree in dorsiflexion, so bending the ankle up on the left leg, and then on the left leg there's also a patch of loss of sensation. It's actually in the inside of the lower leg here, so the inside of the calf. There's also a little patch here over the right thigh. So definitely not the pattern you see typically as someone coming out of the ICU with. So focusing first on the leg, because that was preventing him from making progress with a lot of his therapies more than anything else, because he was there and was having a hard time with walking or the ambulation. You can see that when we here do a femoral motor study, so we basically stimulate the femoral nerve and record over a quadriceps muscle, in this case the vastus medialis, VM. On the left side where he had that weakness, there's no response obtained. And on the right side we get a pretty typical motor response here. And as we go through the needle electromyography, so we basically put needles in the different muscles, you can see that along with the two quadriceps muscles affected on the left, there was also a weak adductor muscle, which comes from a different nerve, the obturator. And it was pretty severe, like when we asked them to try to activate the muscle, some of these muscles we couldn't see any motor units. So we had diagnosed him there thinking that okay there's probably something like a lumbar plexopathy. In other words, the nerves are injured. Could be also like a lumbar radiculopathy I suppose as well. But we weren't 100% sure on what it was, so we obtained some more imaging. And so I won't ask you guys to read this study, but what we were able to see here on his MRI of the pelvis, where we did what's called a neurography protocol with and without contrast, is actually this fluid collection here, which turned out to be hematoma, and the hematoma was pushing on his femoral and obturator nerves, just outside the lumbar plexus. And so, if you recall, I also said Mr. B had some weakness in his right shoulder, but identifying that injury there really changed the prognosis and the trajectory for his inpatient rehab, because I don't know if many of you have seen a lot of nerve injuries or learned a lot about them, but when axons are injured like this, when they grow back, this whole distal part, say of the injuries here, like degenerates away, and the nerves have to grow from where they're injured all the way back down. So if you injure a nerve around the level of the pelvis, it has to go back down to the thigh, and they grow slowly, so they're about an inch a month or a millimeter a day. You're looking at recoveries that can take sometimes a year or more after that injury. So in other words, the need for like longer-term rehabilitation. Also, depending on the nerve injury, in some cases we expect that some nerve injuries won't recover very well at all, and they may even require things like surgery to help improve outcomes. But in this case, the surgery was not recommended for the leg, but we did recommend that we modify his rehab prognosis and plan for a longer course of treatment to rehabilitate that left leg. In the case of the shoulder pain, this was causing him actually a lot of distress, particularly interfering with his sleep. So his head was kind of twisted this way, and we couldn't quite figure out why he was in so much pain, and he had some trouble shrugging. Shoulder abduction was a little bit weak, but it was limited by pain, so like lifting his arm up. But he actually had a hard time shrugging up his shoulder, and his neck was always rotated to the right. And we actually identified on him, a little bit to our surprise, we were just screening him in the lab, because he was in so much pain, a physical exam was hard to assess. But we realized we couldn't get a response from his left spinal accessory muscle. So here we were recording over the trapezius on the left, and this is actually the right side which was affected. So the left leg, the right side of his neck, and you can see that the motor response here is much smaller than the one we get on the other side, and then when we looked at that, it was about a little less than 20% of the other side, 5.1 millivolts versus 0.87. And when we put the needle into the trapezius on the, I apologize here, yeah, no, it is labeled right. So the right trapezius here, you can see that we pick up these activities called fibrillation potentials and positive sharp waves. So this is abnormal spontaneous activity, indicating that the nerve has been injured and there's been an injury to the axons. But it's in the case of the, compared to the quadriceps muscle where we couldn't get any response, here we at least have partial response. So we expect this to have a much better prognosis. And so the localization here was to the spinal accessory nerve, and then we were still a little skeptical, so we actually did an ultrasound, and I'm just showing you here on the basis of the ultrasound. So we are looking at the spinal accessory nerve here on the right, and we're looking at it in long axis. So it's like this line here compared to the left, which is where you can see there's a lot more of this dark appearance, the loss of these fascicles that you can see here running like train tracks through this nerve here. It's also a little bit wider. And when you look at it, it's even easier to appreciate that in the short axis view. So when we cut it in cross section, here's the nerve. It's got a lot of increased cross-sectional area, indicative of neuritis. And the left side, it's more than double the area. So this was consistent with something called a spinal accessory neuritis. So the spinal accessory is not a nerve that typically gets compressed in positioning or in the ICU or affected by bleeds, and we didn't see any bleeding there. We do think that this was a post-viral neuritis, but it was fortunately incomplete. So he had two different totally, we think, somewhat unrelated, although people with COVID actually were, I don't know if you're familiar with it, but actually did have issues with hematoma formation and bleeding, as well as blood clot formation. So the hematoma, the lag, ended up being something we would see in other patients. The neuritis is a much less common feature of this infection, but has been described by our group and other groups. So Mr. B, in case you're wondering, discharged back to home. When he left the hospital, he was ambulating with a rolling walker. Now he no longer requires it. We actually fitted him with orthotics to help him walk a little bit better. He had a dropped foot as well. I didn't get into it, but he did have some loss of, like, distally in the feet of some of his nerve function as well, called a polyneuropathy. And so we treated that with the ankle foot orthotics. He followed up with a plastic surgeon who we worked closely with and told him about the electrical responses. So he agreed we shouldn't do a surgery here, and we followed this guy out for about six months pretty closely to make sure that he was on track. He kept improving slowly over time, and he did not require surgery in the end, just really targeted rehabilitation. After he left the hospital, the rehab focus really centered around these nerve injuries, because he was improving in almost every other way. And we've actually described some features with these patients early on. So this paper here was a paper I helped describe, because Chicago was hit fairly early in the COVID pandemic, where we described 12 different patients that were admitted out of our first 80-something patients admitted for the COVID, after severe COVID and ICU stays. And we found that 12 of them had evidence of mononeuropathies that were missed actually at the acute care hospital and are diagnosed in the rehab hospital with EMGs, and based on our physical exam and skills as physiatrists, we were able to identify these patterns. They weren't just run-of-the-mill deconditioning and debility after a long ICU stay, but rather they were focal nerve injuries that have very different recovery patterns and sometimes different management issues. We also realized that imaging was really crucial, especially when we're seeing these rare neuropathies and different combinations of neuropathies. So we've described some of our collaborative efforts with both point-of-care ultrasound that we did, as well as MRIs and things that were done with MSK radiologists. And actually we've done a lot on COVID neuromuscular complications at our group, and the point is it's not really one person, although we played a big part in terms of the electrophysiology, some of the ultrasound work, but we actually had a lot of people involved from both the research side and different clinical domains. So it's important to be collaborative and to be a good team player when you're in our subspecialty of rehabilitation in the neuromuscular subspecialty. I thought I'd do one more case just to keep the... I think they're more interesting than just running you through a bunch of background things on neuromuscular, so let's apply a little bit more of the knowledge that we use in this field. So this is a second case with a 42-year-old female with two-year history of right hand and leg weakness. She occasional flares up a midline neck pain, and there's no sensory changes. So we're seeing her in outpatient neuromuscular clinic, and you can see that she's had an issue where this weakness chronically has gotten worse at times, but it's also then stabilized at times, and it's mostly the patchy, like the right hand, the right lower leg. She did an EMG, and the EMG actually was interesting. I'm not expecting you guys to know how to read an EMG, but you can see that we did muscles here, right leg muscles, right upper extremity muscles, and we checked a lot of them. And then if you look at the tables, generally speaking there's things like motor unit action potentials and how they were recruited on the right side of the table, and then there's stuff on the left side of the table like abnormal spontaneous activity. This tends to tell us about more active, progressive processes affecting nerve and muscle, and this tells us about things that are usually more chronic and compensatory changes. So the motor unit amplitude gets bigger, that means that you're trying to heal over and compensate for the loss of axons or motor neurons. So this pattern, to make a long story short, affected a lot of muscles in the arms and legs, and it wasn't just easily identified anatomy like this nerve or that nerve. It's kind of diffuse, and it's got both active and chronic features. So this raised concerns about motor neuron disease, and furthermore when we looked at our conduction studies, we did notice this one thing, you know, that in addition to these needle tests, we noticed that when we did her studies, so we would stimulate say like the median nerve at the wrist, we would get a response at three, which is a bit smaller than you expect. And then you go up higher and then you get a response that's almost half, like 1.7, and we saw the same thing here at the ulnar, 4.9, and then it dropped to 2.1 below the elbow, so below the cubital tunnel. These were making us worry about something called a conduction block, and the reason that is so important, like partial conduction blocks and conduction blocks when it comes to people who have, who may have motor neuron disease, because the most common motor neuron disease is ALS, but ALS we don't have a cure for. Well, we checked a blood test for her called the anti-GM1 antibody or anti-ganglion site antibody, and it was positive. And that antibody is associated with a different type of motor neuron problem called multifocal motor neuropathy. And let me tell you about this one. This is one that you never want to miss, because it's an autoimmune condition, and immune-mediated neuropathies can be much more responsive to treatments than neurodegenerative diseases like ALS, Parkinson's, Alzheimer's. So when you suspect that there's one there, so this patient had a few features. Some of the stuff that we were seeing was suggestive of ALS because we were seeing the loss of, like, innervation to the muscle based on the electrodiagnostics. When you catch this condition early on, typically the EMG mostly shows conduction blocks or demyelinating features. She had some of that, but she mostly had axonal features, which would typically take us down this ALS pattern of weakness. But we suspected that this, you know, could be something else. So we did get that GM1 antibody. Basically these GM1 antibodies seem to create an autoimmune reactant, and this is showing you here a nerve, and then these are actually this purple stuff here is the myelin, and this is the node of our NVA. You can see that the nerves actually get attacked right at these sites that lead to focal demyelination or segmental demyelination, and that's the underpinning of multifocal motor neuron disease. And when you're comparing lower, like, a multifocal motor neuron disease from this condition versus something like ALS, there are a few different clinical features, but one of the really cool differencing features that we've realized in recent years is ultrasound. And I point out the ultrasound because I want to highlight that ultrasound is becoming a really big part of our field. It's been very common in sports medicine and for diagnostics of joints and treatment of, you know, with, for example, ultrasound-guided injections, but it's becoming a really critical part of being trained as a neuromuscular doctor. And quite frankly, physiatrists get exposed to ultrasound and MSK ultrasound as residents and often leave with some level of proficiency at the end of just a residency program that they can take with them, and that was really key for me because ultrasound's become one of the ways I've made myself known in our local community because I'm one of the few, there's two of us now, but I'm one of the, most of the neuromuscular people around Chicago are, have a neurology background and generally speaking haven't done much ultrasound at all. And so I point that out here because one of the things that we did for this patient, and unfortunately I didn't have the images available, but we used the fact that ALS and multifocal motor neuropathy, because we were still on the fence with this diagnosis, they have very different ultrasound findings. So generally speaking, when you have segment, like demyelinating disorders that are autoimmune related, nerves actually swell and get bigger. So for example, here's a median nerve in the forearm, and then you go up the arm and you can see it, look, it's, it's much bigger cross-sectional area. And then you go up higher and then it's actually not enlarged anymore at the brachial plexus when you follow this up. So you get these patchy segmental enlargements of the nerve that you have to do very careful scans along the whole length of the nerve to identify. And that finding is very suggestive of MMN, which opens up the possibility of treatment and stabilization or even reversal of the disease. And so here's just an example, it's not my work, but showing median nerve forearm ultrasound findings and cross-sectional area for both the median nerve and then the older nerve, and showing you that unlike ALS patients and control patients who don't differ too much, multifocal motor neuropathy patients on average have much bigger nerves. And also like that's just in terms of the cross-sectional area is quantified, but the other thing qualitatively, you'll see that it occurs in a patchy distribution. My ultrasound video isn't playing today, I think because I have a new laptop compared to last year, so I showed you the still pictures. Let's just move on and show you what happened. So here's the person, I told you about the EMG response, so here's just seeing the traces. Here's the older nerve at the wrist, and then we stimulate at the below the elbow and above the elbow, and the response is decreased, not fully decreased, but partially decreased, so a partial conduction block, which is very suggestive of a demyelinating disorder. We treated this patient with a treatment called intravenous immunoglobulin, or IVIG, and after a year we repeated the nerve conduction study, and you can see not only was the patient much stronger and reporting subjectively that they're functioning much better, but we could actually corroborate that with the physiology, so now you see the distal response that doesn't look that much different than before, but the improvement now as you go up the arm, the response maintains its amplitude and it looks much more like the distal response, and that indicating electrophysiologically and functionally this patient has been improving with treatment. So this is not ALS, and this is actually a treatable disease, it's one that you never want to miss, and I think the take-home points here is that imaging, including point-of-care ultrasound, which you can be trained to do as a physiatrist and even further hone in on those skills as a neuromuscular subspecialized physiatrist, can be used to identify an immune-mediated neuropathy such as multifocal motor neuropathy. There's others like CIDP, AIDP, like Guillain-Barré is AIDP, acute inflammatory demyelinating polyneuropathy, and these are all have very different natural histories and very different response to treatments than things that are, you know, on the differential with them, for example ALS, which we can't treat and unfortunately ultimately progresses to the point of respiratory failure and death. Motor unit loss and remodeling in this particular case doesn't necessarily prevent a diagnosis of multifocal motor neuropathy, so even though this is primarily a demyelinating disorder, if it's untreated, like this patient had it for two years, it actually led to some motor unit loss and axon loss, which is not typical of that disease, but clinically we were able to sniff it out with a few of the key features about their history as well as some of the lab testing we did. Imaging in addition to ultrasound MRIs, which I didn't show here, can be really helpful clues to the disorder and also the key thing here is once you suspect MMN is possible as a differential from ALS, the real definitive proof here was that they responded to the therapy, the IVIG, and there's other things that can be used to potentially treat it, including plasmapheresis and probably some of the newer immune modulating therapies that are being developed for other diseases may also benefit these patients. So lastly, I was going to finish on some stuff about fellowships and careers in neuromuscular and electrodiagnostic medicine. I would say that as a physiatrist, you don't have to do a fellowship if you want to work in this space, particularly in electrodiagnostic medicine. You should get adequate training in your residency and then all of us really benefit from post-graduation, ongoing education and mentoring from senior colleagues and participation in workshops and so forth to keep growing. But to do neuromuscular medicine and to diagnose things like ALS or treat things like multifocal motor neuropathy with immune modulating therapies, for that focus in your career, you'll typically want a fellowship. And so I'll chat a little bit about how we apply for fellowships. So nowadays, the neuromuscular fellowship, just for the last five years or plus or minus, have been run as a true match through a fellowship portal as opposed to individual applications to each school. I think this is a better way of running things, even though we know that matches can be themselves imperfect, it gives fair access. And it's really helped physiatrists get more opportunities here because you can see when you go into the portal, which is hosted by the AANEM, actually, is that it'll list all the programs and along with describing the basic features of the programs you can get off the website, it also indicates the, say, for example, Johns Hopkins will consider both neurology and or PMNR residents for their fellowship. And that is now defined for all the programs. Historically, some of them would say, we just don't take physiatrists. But now that the AANEM, which is a society that is run by both physiatrists and neurologists, is hosting and we've, I think, have more of us that have gone into the subspecialty and succeeding, we're seeing more opportunity for physiatrists to continue down this really, I think, fascinating and just rewarding specialty pathway with the combination of the specialty. I think it's always been interesting diagnostically, but now with there being so many new treatments, immune treatments, gene therapies, just regenerative options, the prognosis for patients is changing before our eyes. So then getting certified, so the American Board of Physical Medicine and Rehab actually do the certification for neuromuscular medicine. The exam is the same as what you would do for being certified as a neurologist, but they have it certified by their board. But the ABPM&R has been doing this since 2008. So some people were grandfathered in who have been working in this space as physiatrists, and now everyone going forward is getting, I think this exam's offered every other year, and does the certification through the ABPM&R, which does our primary certification as well. Then you basically do an online exam at one of those Pearson professional centers that's typically hosting these things, and it's a multiple-choice exam. I think the year that I did my exam, I believe there was only like five, four or five of us that wrote the exam. So it's increasing now, but there's still a real shortage of supply, particularly with the ABPM&R background. So from the standpoint of getting a job, having these skills and the things that they offer open up new areas of practice. For example, like I said, managing some of these conditions like myasthenia gravis, multipocal motor neuropathy, ALS. And actually I've personally found it to be really helpful just being better in the EMG lab, although you can certainly do EMG without the neuromuscular fellowship. And for EMGs, the American Board of Electrodiagnostic Medicine is the one that does our certification as electrodiagnosticians, and that is offered every year. And there's some requirements in terms of study numbers that you complete during your training and then some postgraduate studies. I believe 200 as a resident, 200 as an attending, and then you can be eligible for that. And then more recently, and I have this certificate, you can get the ABM, it has a neuromuscular ultrasound certificate, which for me, at my academic practice, they were asking for like credentialing purposes, like how do we know that you know how to do neuromuscular ultrasound? Well, it turns out it's really helpful to be aware of what options are available. So I get certified by the same board that certifies my EMG abilities, that they certified my ultrasound abilities, and that's allowed me to practice in my hospital system. And that'll vary depending on where you work. And then the last thing I'll point out is if you really want to learn more about pursuing the subspecialty, we have a nice little virtual webinar that was a panel discussion. So you can see some of my colleagues here that AANEM has made publicly available. If you want to take a look, you can follow them on YouTube and you can find this link. Here it is, and we'll send this to you guys as a PDF, but you can actually access this without being a member of the AANEM and just listening. It's about an hour plus, just a little over an hour, and you can hear a lot of people answering really like questions from the audience, questions that were pre-submitted, just really practical stuff about that career and different pathways. And I would say that two-thirds of the people on that panel hadn't done a fellowship. A lot of the times because the fellowship wasn't really even a track that was that available and the certification wasn't available prior to 2008 for physiatrists. And so I'll conclude here just telling you that neuromuscular medicine, electrodiagnostic medicine is a great subspecialty. It focuses on diseases of the peripheral nervous system from motor neuron and dorsal root ganglia out to the muscle and neuromuscular junction and everything in between. It embraces a lot of innovation from innovative new diagnostic modalities like ultrasound and then gene therapies that are becoming available to some of our patients, which is both exciting because it's changing. So if you get into it now, you'll probably know more than some of your senior colleagues about the very latest changes because it is hard to keep up, but in a good way. It's creating a lot of hope and optimism for our patients who previously had diseases that didn't have good treatments and good solutions. And there's a lot of room to grow. And for people who are interested either academically, research-wise, there's still so much work to do. And with that, I just thank you to the AAP for hosting us, the AANEM for, I guess, co-sponsoring this event and asking me to lead the way. Anytime I'm affiliated with either AAP or AANEM, I'm really proud that they've asked because when you start out in your career, it's hard for anyone to even really know who you are, nevermind ask you to do something like this. And I have some research funding that I, since we highlight a little bit of my research, I just thought I'd point out. And with that, I'll stop sharing and take a look at the audience. If there's any questions, you can type them in the chat. You can potentially unmute. Is that true, Amy, that they could unmute and ask a question? If they want to, or raise their hand. Yes, absolutely. No big pressure. And, you know, I think I put my email, which when we hand out the slides, if anyone wants to reach out to me, you know, rather than doing it in front of 54 of your, of your friends here online, I can understand that, you know, there'll be some people who prefer that too. So, but. There is a question in the chat box. Oh, great. Yep. Oh, I thought I had the chat open. Let me see. Why can't I see that? And I do have your contact information in the Google Classroom for everyone so they can follow up and I will post a presentation there as well. Oh, good. So I see. Yeah. What's the difference between EMG slash NCS, if any? So I think the question is referring to like the EMG versus the NCS. Is that correct? Abia? Yep. That's what I'm asking. So like my question was, when we do EMGs and nerve conduction studies, are we essentially using the same equipment or is the equipment different? And do we look at the data in a different way? Reverse. Yeah. So there, that's a great question. So EMG, electromyography, is typically referring to the part where you put a needle electrode inside of a muscle. So that recording, as well as the nerve conduction studies, which are typically surface recordings where we put surface electrodes that there's a number of different types of surface electrodes from stickers to ring electrodes for depending on where you're recording so they can be matched to the site that you want to record from. For those, you record an evoked response. So you stimulate with electricity over the nerve, you evoke a response sensory motor or mixed, and you can record things like the amplitude of the response, the latencies for when you get the response after the stimulus. And then if you do multiple steps along, for example, a motor nerve, you can actually calculate out conduction velocities. So those tell us, particularly, you know, in that case I showed, like an example of where we use that part of the test to identify the suspicion for demyelinating features. Some people call it NCS, nerve conduction study. Some people call it NCV, nerve conduction velocity. The reason that we use the word NCV is because those velocities tend to be really important diagnostic bits in a subset of cases. The EMG and the nerve conduction is done with the same machines. And there's a few different ones out there. The two that I've worked with, Natus and Cadwell, are pretty common, but there's a few other systems out there. I'm not really endorsing one over the others. You know, you typically feel most comfortable with what you trained on, I guess, but when you go into practice, you also think about how much they cost and what's the relationship with customer service. Because they inevitably, you know, usually need to call them up from time to time to troubleshoot some issues over, you know, with the equipment. All right. Thank you. Yeah, that was really, like, I was just confused because I was like, usually you see them side by side. So I wasn't sure if they were different, but it makes sense because obviously electromyography must be for the muscles and the nerve conduction studies is for the nerves. But thank you for clarifying that. No problem. And then, of course, the other, the one other thing I didn't mention was that the electromyography, you actually have the patients typically activate the muscles for you. So it's a volitional effort. Got it. Thank you. And the nerve conduction studies are evoked. All right. So there's some more questions. That's good. I'm answering that one because there was only, like, two questions when I started, but now there's a bunch. So I'll try to be less wordy. So other than diagnostics, are there any therapeutic uses of EMG? So there, I would say the most common, you can also do surface EMG, by the way. So if you do a surface electrode and record the volitional response from muscle when someone's activating for you. So we use that. For example, at our hospital, one of the very famous physiatrists who's retired now, Todd Kiken, realized that you could use electromyography recordings from muscle sensors to actually power prosthetic limbs. And this is called a myoelectric controller. And they developed not only technology for doing the signal recordings and the control algorithms that you can do from flexion versus extension, but they actually developed surgeries where they would actually move nerves around that were injured in an amputation to control different parts of muscles so that you could create even more complicated surface electrode arrays to record all the different signals controlled by all the different nerves to give people more degrees of control. And there's also biofeedback. For example, if someone is trying to go through some motor relearning after a nerve injury, for example, the brachial plexus, it's not that easy to remember how to do things when nerves are being hooked back up. So there's some ability to use real-time feedback with therapists. So those are a couple of the therapeutic uses of EMG signals. And there's probably more, for example, using EMG signals to control a device, like an external device for mobility, has been described. So those are a few of the things that come to mind. And then I see another question. How much time do you spend analyzing data from EMGs versus seeing patients? So for me, I do basically a third of my practices is doing EMG tests. About a third of it is seeing patients with nerve injuries, like doing clinical assessments, like complex nerve injuries from brachial plexus to spinal cord injury to carpal tunnel. And then about a third of it is seeing patients with motor neurone diseases, mostly ALS. And so that's, for me, I think most of my people I talk to in the field, whether it's spasticity management with botulinum toxins or performing electrodiagnostic studies, probably spend a quarter, sometimes even half their time doing some of those procedures. And you can chat with people about their motivation for sort of having that part of their practice. But I think that when you're looking at all the things you do, one, EMGs are relatively paid pretty well. And then you might miss out on some of these really personal relationships of seeing patients longitudinally. So some of us don't want to give up our clinical practices totally, because we enjoy those longitudinal relationships and watching people improve. But having a bit of a balance can be good. And there's different other reasons for that, too. So I encourage you to pick people's brain about that and how they set up their practice. And is it common to use EMGs in inpatient rehabs outside of academic-focused centers? So there's a disincentive to doing EMGs on inpatients. We do it when it helps us manage the rehabilitation. But the disincentive is that they're more and more moving towards reimbursement schemes where everything's sort of bundled together. So if you do extra testing while someone's admitted as an inpatient on a rehab unit, you don't necessarily get the bill for every single thing you do. So you're getting maybe paid the same amount that day for all the care you provide. So there's a case that's often made to delay the EMG testing for outpatient. And so the vast majority of patients I see in the EMG lab, even at my academic practice, are outpatients. But the point I make sometimes to our practice managers is that a lot of the patients we do inpatient EMGs on come back to us and see us in our complex nerve injury clinic. And we do more studies as an outpatient. So we take it case by case. But with nerve injury management, there's some urgency sometimes to start getting the data because it helps us make decisions if they need to have surgery. You don't want to have it delayed, for example, because you didn't do the studies early enough to realize that maybe they were more of an operative candidate than another patient, that you need the EMG to help figure that out. And so that was from Leah. And now I'm going down to the next question. Why did you choose neuromuscular medicine for fellowships versus other fellowships? I don't have a great case to make other than for doing the fellowship in neuromuscular medicine for the standpoint of making way more money or having a way better life. Really what it was is I just thought these were the most interesting patients. And I had always had some interest going into residency about ALS and motor neuron diseases. So I knew that this was typically the subspecialty that was in charge of diagnosing and being the primary physicians taking care of those patients. So that had it on my radar. But honestly, my perceptions of what you do, even after the fellowship, I realized, you know, the combination of ultrasound and the EMGs, the combination of, like I said, using stuff that we do to take care of brachial injury patients could be applied to spinal cord injury patients. I even have stuff I'm involved with doing with diaphragm ultrasounds and ventilator weaning in the hospital. So it's really opened up a lot of things that I didn't have enough vision or foresight to realize that I'd be able to do. But the skill set can really complement the needs of our specialty, both as your clinics but also as a consultant for some of your partners. So I've really enjoyed it. And I don't know, I probably would just say that I just really liked motor units and muscle and I just thought it was interesting. And I was like, not sure 100% where I was going to go next for my job. And the fellowship was there and I was sort of one foot in, one foot out, and I went for it and I don't regret it. But you know, in retroactively, we sometimes make everything seem like it was so linear, but a lot of the things I did have been somewhat, there's been a little bit of just taking a gut feeling or serendipity. But mostly things like that, I feel like picking PM&R over neurology, for example, or non-surgical versus surgical discipline. I've always been a little bit like kind of, I could see it going either way, but I'm really glad I did what I did. And then why would you do fellowship over EDX? Why would someone choose to do fellowship? Yeah, I don't think you have to do a fellowship over just, if your goal is to do a lot of electrodiagnostics in general physiatry, you totally can do that without a fellowship. I mean, once you do the fellowship, you'll find ways of maybe using that information and that extra training to improve your EMG skills perhaps, but it's not essential. In fact, most of the great electromyographers in history have not done the fellowship and have really made a huge impact in that part of the field as physiatrists who did electrodiagnostics without a neuromuscular fellowship. But if you want to, if it's at all on your radar to be a really primary physician for patients with a neuromuscular disease like muscular dystrophy or ALS in the adult world, a lot of that is led by neuromuscular certified physicians. What else? Some of those issues, like I said, like some of those immune modulating treatments that you get, you know, you really don't get exposed to how to dose IVIG or use plasmapheresis or some of these other newer immune modulating treatments in a general like physiatry setting. So doing that through my neuromuscular fellowship, it's just increased my comfort level and, you know, scope of practice. Not for everyone. TMR, targeted muscle re-innovation. Did I say TMR or not? There's a, yeah, targeted muscle re-innovation is that technique used to control those myoelectric prosthesis when you do the surgeries for moving nerves around. Thanks Jasmine. And then since this diagnostic modality involves needles and multiple pricks, how is it managed with dealing with the pediatric population? Yeah. So, and emerging alternatives. So emerging alternatives where ultrasound, it doesn't hurt. You do need patients sometimes to cooperate a bit, but you can do it on a wider age range of patients without being a big deal. Surface electrode arrays and high density arrays are potential alternatives to needle based studies for decomposing motor units. It's not really used a lot clinically yet, but we are using it in research and we've done some work on that as an alternative. I think that the kids are a big inspiration for coming up with less painful ways, but honestly the adults and patients who like have certain diseases that need serial studies, we really appreciate not having to always get stuck with needles too. You do have to be, I think, mindful of that. You know, like when I trained, I would needle, we practiced like during fellowship, needling each other and doing some of the tests on each other. Just be very conscious, like they're not awful, awful things for most of us, but they aren't fun either. So you need to definitely be mindful of that when you do those tests on people. And then, yeah, I don't see any more questions. Great. I actually, I'm really impressed. There's a lot of questions though that have come through and if anything else comes up, you guys have my contact information, feel free to reach out. I'm enthusiastic about the subspecialty, but there's actually lots of cool things to do, pain, sports, general physiatry, inpatient, outpatient, academic, non-academic. Yeah, so I don't mean to make it seem like this is like the only really cool thing to do in our field, but it's definitely, like if you like this sort of subject, you know, I think I like the diagnostic bit of it too, in addition to just maximizing function. And I think as a physiatrist who knows how to work in teams, how to maximize function, but also knows all the neuromuscular stuff, when you put it all together, it's a pretty powerful combination. And I think it's an advantage for a lot of my patients, I think, over just seeing, you know, maybe a general neurologist for their issue in terms of seeing what I can offer. Well, thank you so much. This has been a great presentation. And I also want to thank AANEM for bringing us together to do this and offer this as part of the program again this summer. So I think we'll wrap up for today. All the information will be on the Google Classroom. And I will see you guys tomorrow, same time, same place. Thanks, everyone. Thank you.

neuromuscular medicine

electrodiagnostic medicine

Shirley Ryan Ability Lab

Northwestern University

AANEM

Physical Medicine and Rehabilitation

myopathies

neuropathies

EMG

NCS

nerve conduction studies

nerve conduction study

nerve conduction studies

nerve conduction study

ncs

ncs

ncv

electromyography