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    Clinical Neurophysiology section news Clinical Neurophysiology section news Document Transcript

    • Fall 2007 Clinical Neurophysiology section news The Official Newsletter of the Clinical Neurophysiology Section/Volume 13/Issue 2 CLINICAL NEUROPHYSIOLOGY EXECUTIVE COMMITTEE OFFICERS Message from the Chair By Lawrence H. Phillips, II, MD Chair Lawrence H. Phillips, II, MD, FAAN Charlottesville, VA For those of you who have attended recent annual meetings of the AAN, it should come as no surprise to you that our organization is very large. The Clinical Neurophysiology Section is, of Chair-Elect John S. Ebersole, MD course, a part of the organization, and its role is to represent the interests of those of us who prac- Chicago, IL tice in this area. A large part of that role involves communication, both from the Clinical Neuro- physiology Section membership to the AAN, and vice versa. Immediate Past Chair Elson L. So, MD, FAAN Rochester, MN There has been concern that membership in sections is viewed as being not very important or COUNCILORS helpful to the members of those sections, since other functions within the AAN also serve the interests of various subspecialties. As you may know, our input to the Academy is through the John C. Kincaid, MD, FAAN Indianapolis, IN Committee on Sections, which is composed of the chairs of all 30 of the sections within the AAN. Gloria Galloway, MD, FAAN This committee meets twice yearly, and each chair has a liaison at the Academy whose role is to Columbus, OH provide support and communication for the section. At recent COS meetings, the issue of rele- vance and involvement of the sections in the larger affairs of the AAN has been discussed at Newsletter Editor length, and one result of those discussions has been that an executive committee of the COS has Mary Kay Floeter, MD, PhD Bethesda, MD been formed to provide a more efficient way for the sections to interact with the Academy. Each member of the executive committee is charged with being a representative to several individual Newsletter Committee sections, and Dr. Gloria Galloway, who is also a member of the Clinical Neurophysiology Section M.K. Floeter, MD, PhD Executive Committee, is ours. We anticipate that this new system will help increase the impact Jerry J. Shih, MD Matthew D. Gold, MD and visibility of the sections in the affairs of the Academy. Deepak K. Lachhwani, MD Susan M. Palac, MD An issue that will likely come up soon is that the Academy is examining the participation of sec- tion members in the activities of the section. Each section has many more members than attend AAN STAFF LIAISON Travis J. Dunbar section meetings or have any other visible role in section activities. Since there is an expense in- 1080 Montreal Ave. volved in maintaining membership rolls for the sections (for example, the mailing of this newslet- St. Paul, MN 55116 ter), the AAN leadership is considering ways to pare down the size of sections to eliminate people Tel: (651) 695-2761 whose names are on the books but who really don’t participate in section activities. If you are, Fax: (651) 361-4861 tdunbar@aan.com like I am, a member of several sections, you may wish to consider how you rank your member- ship in each of those sections for their importance to you in your professional life. I hope you will IN THIS ISSUE: find that the Clinical Neurophysiology Section is of importance to you and will so indicate when • Message from the Chair you are asked by the AAN. • AAN Seeks representation on CoA-END We, along with all other sections, are being asked to prepare a strategic plan that will used to help • Courses at the 2008 Annual Meeting direct future activities of the Academy. I view this as an especially important activity for the • ABPN Update Clinical Neurophysiology Section. Several developments in clinical practice that will influence • Letter from Abroad the future of electrodiagnosis, and practice patterns and reimbursement may be very different in • Journal Article Review the future. The addition of the existing Neuromuscular subspecialty certification and the pending • Volunteers Needed for the Epilepsy certification will likely also alter our professional landscape. How these changes will be Newsletter Committee incorporated into existing professional practice and the future direction of the Clinical Neuro- physiology Section should be considered thoughtfully and proactively. The leaders of the section will be working on the strategic plan over the next year, and any members who wish to contribute will be welcomed. Just let me know of your interest. Clinical Neurophysiology Section - 1
    • Fall 2007 The Official Newsletter of the Clinical Neurophysiology Section /Volume 13/Issue 2 AAN Seeks Representation on CoA-END Epilepsy/Clinical Neurophysiology (EEG) By George R. Lee III MD Program ID Title What is the CoA-END? This is the Committee on Accreditation 2DS.002 Intractable Epilepsy: What to Do When Nothing for Education in Electroneurodiagnostic Technology Works (www.coa-end.org/) and it is one of many national accrediting 3AS.007 Epilepsy Case Studies committees that are governed by the Commission on Accredita- tion of Allied Health Education Programs (CAAHEP). 3BS.002 Special Considerations in Women's Epilepsy 3CL.002 Coding Lunch: Epilepsy The CoA-END is composed of four representatives from the American Society of Electroneurodiagnostic Technologists 3DS.005 Intraoperative Neurophysiologic Monitoring: Spinal (ASET), two from the American Clinical Neurophysiology Soci- Cord and Nerve Root Monitoring ety (ACNS), and two from the American Society of Neurophysi- 3FC.002 Clinical Epilepsy ological Monitoring (ASNM). It has two primary functions: 1. Assess the merits of applicant END education programs 4PC.002 Video-EEG Monitoring in the Neurologic Practice: for accreditation by CAAHEP Tools, Techniques, and Applications 2. Undertake periodic review of the Standards and Guidelines 5BS.004 Recognition and Management of the Many Types of of an Accredited Program for Electroneurodiagnostic Status Epilepticus Technology (Standards) 6TP.003 Epilepsy Therapy Currently 14 accredited electroneurodiagnostic technology pro- 7BS.002 Pediatric Epilepsy and Nonepileptic Events: Case- grams across the country are responsible for training technolo- Based Discussions gists to perform electroencephalography, evoked potentials, poly- somnography, nerve conduction studies, long term epilepsy 7FC.004 Clinical EEG monitoring, and intraoperative neurophysiologic monitoring. Pe- 8BS.001 EEG in Children and Adolescents: Common Pit- riodic assessment of these programs and comprehensive evalua- falls, Classic Syndromes, and Identification of Sur- tion of programs seeking initial accreditation are carried out by gical Candidates the CoA-END. Neuromuscular Disease/Clinical Neurophysiology (EMG) The standards and guidelines by which END programs must op- 1KP.006 Diagnosis and Management of Motor Neuron Dis- erate to receive and maintain accreditation are determined by the ease: Spinal Muscular Atrophy representatives of this committee with approval of the CAAHEP board. It is imperative that the AAN play a role in determining 2CL.003 Coding Lunch: Neuromuscular Disease the educational content for programs and scope of responsibility for technologists. 2FC.003 Peripheral Neuropathy 2SW.001 EMG Skills Workshop: Basic The AAN is currently seeking membership in CAAHEP in order to have board members on the CoA-END; however, approval is 3AC.002 Clinical Approach to Muscle Disease pending the next meeting of the Commission in April 2008. Until 3AS.008 How to Test the Autonomic Nervous System this time, we have been allowed two nonvoting participants. I am currently serving in this capacity, and Dr. Marc Nuwer will be 3BS.008 Small Fiber Neuropathies: Somatic, Autonomic, or rotating off this assignment. We are looking for volunteers to a Mixture of Both serve as the second nonvoting participant. Please contact Travis 3PC.005 Neuromuscular Junction Disorders Dunbar, tdunbar@aan.com, if you are interested in serving or have questions or issues regarding the CoA-END. 3SW.001 Advanced Techniques in EMG and Neuromuscular Disease 6CS.001 Unusual Diagnostic and Management Cases in Neu- Courses at the 2008 AAN annual meeting romuscular Disease By Travis Dunbar 6PC.003 Evaluation and Management of Autonomic Disor- The 60th annual meeting of the AAN will be held in Chicago ders April 12 to 19, 2008. Several courses on topics related to clinical 7AC.004 Clinical EMG I neurophysiology are listed below. The numeral of the program ID indicates the day of the meeting, beginning with April 12, the 7PC.004 Clinical EMG II first day. 7TP.003 Neuromuscular Therapy Epilepsy/Clinical Neurophysiology (EEG) 8BS.003 Rapid Quantitation in EMG: Learning Accurate and Efficient Motor Unit Potential Analysis Program ID Title 8BS.005 Autoimmune Antibody Testing in Neuropathy: Indi- 1KP.001 Epilepsy Update cations for the Practicing Neurologist 2BS.006 Critical Care Epilepsy/EEG Clinical Neurophysiology Section - 2
    • Fall 2007 The Official Newsletter of the Clinical Neurophysiology Section /Volume 13/Issue 2 ABPN Update first examination will be offered on September 8-12, 2008. Appli- cations will be available online late fall 2007 at the ABPN web- Extracted from the ABPN website www.abpn.com and the site. ACGME website www.acgme.org Through 2012, applicants can qualify by a practice pathway Clinical Neurophysiology: 182 neurologists passed the May documenting satisfactory completion of 12 months of fellowship 2007 initial certification examination in Clinical Neurophysiol- training in a non-ACGME-accredited neuromuscular medicine ogy. The next initial certification examination will be held in program after residency or by attestation of a minimum of 25% of 2009. A recertification examination is scheduled for August 18 - practice time devoted to neuromuscular medicine for a minimum 22, 2008, with an application deadline of January 2, 2008 (late of two years. After the 2012 examination, all applicants, other deadline February 1, 2008). In the 2007-8 academic year, there than those initially approved during the "grandfathering period," are 85 ACGME certified fellowship programs and 213 filled po- are required to submit documentation of successful completion of sitions. one year of ACGME-accredited fellowship training in neuromus- cular medicine. As of the 2007-8 academic year, there are 15 Sleep Medicine: The Sleep Medicine Certification Program was ACGME certified fellowship programs, with 8 filled positions. developed by the American Board of Internal Medicine, the American Board of Pediatrics, the American Board of Psychiatry Performance in practice: The Performance in Practice (PIP) and Neurology, and the American Board of Otolaryngology for component of the recertification process for the American Board diplomates in internal medicine, pediatrics, psychiatry and neu- of Psychiatry and Neurology (ABPN) was approved in March by rology, and otolaryngology. The first sleep medicine examination the American Board of Medical Specialties, and is slated for im- is scheduled to be given in November 2007. For the first 5 years plementation beginning with the 2013 examinations. PIP is aimed (2007-2011) diplomates of the four boards can qualify to take the only at Neurology diplomates with time-limited certificates certi- examination via the practice pathway. Applicants may either pro- fied after 1994. Physicians certified before 1994 are vide documentation of current certification by the American "grandfathered" into the program and are encouraged, but not Board of Sleep Medicine or attest to the equivalent of 12 months required, to participate at this point in time. PIP will evaluate of full-time post-residency or post-fellowship experience provid- whether a physician has participated in practice improvement ing clinical care to patients with sleep disorders, accumulated activities over the 10-year maintenance of certification cycle. over a maximum of five years prior to application with a mini- This will be evaluated by chart review, and second-party external mum experience of evaluating 400 patients, interpreting and re- review. Beginning in 2013, each diplomate will be required to viewing raw data of 200 polysomnograms and 25 multiple sleep complete three (3) PIP modules in a ten-year period. Further in- latency tests. After the 2011 examination, all applicants other formation is available on the ABPN website. than those initially approved during the "grandfathering period" are required to submit documentation of successful completion of one year of sleep medicine fellowship training in an ACGME Letter from Abroad certified program. By Prof. Dr. Detlef Claus Department of Neurology and Clinical Neurophysiology, The examination content follows a blueprint developed by the Darmstadt, Germany Sleep Medicine Test Committee, whose members represent the four ABMS boards sponsoring the exam. Clinical neurophysiology has a very long tradition in Germany. Sleep staging and the scoring and interpretation of sleep studies Hermann von Helmholtz achieved the first measurement of nerve are important clinical skills to be assessed in the Sleep Medicine conduction velocity in 1850. Fritsch and Hitzig carried out elec- Examination; however, the November 2007 exam will not require trical stimulation of the motor cortex in dogs as early as 1870. candidates to make distinctions based on differences between Hans Berger discovered the human electroencephalogram (EEG) former scoring rules (i.e., Rechtschaffen and Kales) and the scor- and did the first EEG recordings in 1924. The German society of ing rules in the recently released American Academy of Sleep clinical neurophysiology and functional imaging (Deutsche Ge- Medicine Manual for Scoring of Sleep and Associated Events. In sellschaft für Klinische Neurophysiologie und Funktionelle exam questions related to sleep staging, both the old and the new Bildgebung, DGKN) was founded in 1950. The society’s first nomenclatures will be used to identify sleep stages. Further infor- president was Richard Jung. The society now has 3219 members mation about the blueprint and the content of the exam can be and 36 extraordinary members. In addition there are 40 honorary found on the ABPN website, http://www.abpn.com/sleep.htm . members, 47 corresponding members, and two corporate mem- bers. Neuromuscular Medicine: The ABPN and the American Board of Physical Medicine and Rehabilitation established the Joint Neurophysiology technicians are members of the Deutscher Ver- Committee on Certification in the Subspecialty of Neuromuscular band Technischer Assistentinnen/Assistenten in der Medizin e.V., Medicine in 2005 to establish neuromuscular medicine as a area which is located at Spaldingstr. 110B, D-20097 Hamburg. There of subspecialization and to provide a means of identifying prop- are about 20,000 members. In Germany, clinical neurophysiology erly trained and experienced physicians in neuromuscular medi- is not a separate speciality as it is in some other European coun- cine. The certification examination will be offered by the ABPN tries. Here it is a subspecialty of neurology. Therefore, clinical biennially (every two years) for diplomates in Neurology and neurophysiologists could be neurologists, pediatricians, psychia- Neurology with Special Qualification in Child Neurology. The trists, neurosurgeons, or physiologists. The majority of clinical examination will be administered to candidates from the ABPN neurophysiologists are neurologists. Clinical neurophysiologists and ABPMR at the same time in the same testing centers. The are members of the DGKN. Clinical Neurophysiology Section - 3
    • Fall 2007 The Official Newsletter of the Clinical Neurophysiology Section /Volume 13/Issue 2 The German System of Qualification. despite a big demand for such services. The standard of qualification is set by the DGKN. Diplomas exist for EEG, electromyography (EMG) and nerve conduction studies The DGKN makes scientific awards such as the Hans Berger (NCS), evoked potentials and transcranial magnetic stimulation, Award for life-long scientific work in the field of clinical neuro- polysomnography, ultrasound, and functional imaging. The cur- physiology. Then there is the Richard Jung Award for fundamen- ricula to gain these diplomas are set by the DGKN, partly in co- tal scientific work in the field of clinical neurophysiology. The operation with other scientific societies. For each diploma the Alois Kornmueller Award is given to scientists younger than 35 trainee must pass an examination. As a prerequisite for all three years old who have done outstanding scientific research in clini- diplomas (i.e. EEG, evoked potentials, and EMG) the physician cal neurophysiology, and the Ultrasound Award is aimed at has to work a full day per week for one year in a certified neuro- young researchers. physiologic laboratory. The trainee must practise clinical neuro- physiology for six months in order to qualify to do the test for The German Scientific Conference of Clinical Neurophysiology each diploma. is held once per year at different venues across Germany. Fur- thermore, the DGKN offers research grants and supports relevant To become a certified instructor a neurophysiologist needs to symposia and scientific meetings. work actively in a clinical neurophysiology laboratory for at least two years after sitting the board examination. Neurophysiology Continuing education in clinical neurophysiology is also organ- instructors are approved for each of the specialities (i.e. EEG, ized by the DGKN with the help of the Richard Jung Academy. EMG and NCS, evoked potentials and transcranial magnetic CME points are offered to participants. stimulation, polysomnography, ultrasound, and functional imag- ing). Finally, the DGKN encourages the use of EEG and magneto- EEG in the diagnosis and treatment of epilepsy, critical care Neurophysiology laboratories that are qualified for teaching must monitoring, sleep monitoring, somnology, sleep medicine, neuro- perform at least 1800 EEGs per year, 750 EMGs per year, or 750 physiology of autonomic function, motor control physiology, and evoked potentials per year. The number of neurophysiology labo- functional imaging. ratories in Germany that are accredited by the DGKN is: • EEG 295 Journal Article Review • EMG 158 By Mary Kay Floeter, MD, PhD • EP 125 • Ultrasound 117 Quantitative methods for evaluating EMG signals evolved in the years following World War II, spurred by the availability of im- • Polysomnography 18 proved electronic circuits and the need for diagnosis and prognos- tication of nerve injuries. Circuitry for a voltage-level trigger and No full clinical neurophysiologists are in general practice, be- a delay line allowed the full motor unit action potential (MUAP) cause there is no adequate recompense for doing neurophysi- waveform to appear on an oscilloscope screen so that it could be ological investigations. However some neurologists in general photographed and accurately measured. By collecting and meas- practice do carry out neurophysiological tests. The majority of uring amplitude, duration, and phases in samples of MUAPs, clinical neurophysiologists work in the neurology departments of Professor Fritz Buchthal and colleagues determined which wave- general hospitals or university hospitals. Very few independent form measures differentiated between weakness caused by dis- departments for clinical neurophysiology exist in Germany. eases of muscle and diseases of the peripheral nerve. Over several Those that do exist are to be found mainly in university hospitals decades Buchthal, and the physicians he trained in his laboratory or in general hospitals in the bigger cities, for example in Göttin- in Copenhagen, dominated the field of clinical EMG, developing gen, Magdeburg, Nuremberg, and Bremen. Neurophysiological standardized procedures for MUAP analysis, collecting norma- research is mainly done in specialist university departments. tive data for individual muscles at different ages, and correlating MUAP measures with patient diagnoses obtained from clinical The extremely low fees paid for recording EEGs or EMG/NCS, examination and muscle biopsy in a wide variety of disorders. and also for interpreting the results are a big problem in Ger- Quantitative MUAP analysis became a cornerstone of diagnostic many. electromyography. For example, the current charges payable in Germany are as fol- lows: Although the utility of quantitative EMG for clinical diagnosis • Carrying out EEG’s and interpreting the results, $31 was established, the routine use of Buchthal's manual method is • Sleep EEG, $72 limited in current clinical practices, primarily because of the time • Evoked potential testing (sensory / visual / acous- required for collection and measurement of MUAPs. Thus there tic), $27 to $33 is considerable interest in computerized algorithms for automat- ing MUAP quantitation. For the most part, algorithms imple- • Needle electromyography and electroneurography mented on commercial EMG machines attempt to reproduce the tests, $18 to $22 information acquired using manual methods-measures of the • Ultrasound scans of the cerebrovascular system, $40 mean amplitude, duration, and phases of a sample of MUAPs. In order to accomplish this, computerized algorithms must accu- This means that hospitals, as well as neurologists in general prac- rately discriminate individual MUAPs and accurately measure tice, cannot earn much by performing these physiological tests, their waveform parameters. Key questions have been whether Clinical Neurophysiology Section - 4
    • Fall 2007 The Official Newsletter of the Clinical Neurophysiology Section /Volume 13/Issue 2 automated methods give comparable results to the manual are needed to determine MUAP duration in an objective way. method and whether the algorithms used by different EMG ma- chines provide the same results. Rodriguez I, Gila L, Malanda A, et al. Motor unit action poten- tial duration, I: variability of manual and automatic meas- To examine this issue, Brownell and Bromberg (2006) compared urements. J Clin Neurophysiol 2007;24(1):52-58 the measures from automated analysis of the same EMG signals with three algorithms implemented in software on two different Brownell AA, Ni O, Bromberg MB. (2006) Comparison of EMG machines. They used EMG recordings from healthy volun- three algorithms for multi-motor unit detection and wave- teers and a simulated EMG signal created by summating seven form marking. Muscle Nerve. 33:538-45. MUAP-like waveforms with defined parameters. They found that none of the three programs was perfect in extracting and classify- ing every MUAP, with different numbers of MUAPs detected by Volunteers Needed for the Newsletter Com- each. This was in part related to the length of time that each pro- mittee gram sampled the EMG signal. Nevertheless, in the simulated signal with only seven different MUAPs, all had some failures of The newsletter committee is looking for volunteers to serve on detection or misclassification of one MUAP as two different the newsletter committee. The section newsletter is published MUAPs. An issue that remains to be resolved is whether these twice each year, in the fall and spring. Members of the committee differences in the sample of MUAPs that were discriminated submit news articles and calendar items, solicit topic and journal would affect the clinical interpretation of the EMG. Brownell and reviews, and edit the material that is submitted. If you are inter- Bromberg also looked at how well the programs performed at ested, please contact Travis Dunbar at tdunbar@aan.com, or Dr. automatic marker placement on those MUAPs that were detected Floeter at floeterm@ninds.nih.gov. in common. The positions of the markers were recorded, then cleared and independently placed manually by two electromyog- raphers. They found that the programs performed well in deter- If you are not already a member mining MUAP amplitudes, with good agreement between the and would like to three programs and the manual cursor placement by electromyog- raphers. The measurement of MUAP duration was more discor- Become a Member of the dant, affecting the reliability of parameters, such as area, that American Academy of Neurology partly derive from the measurement of duration. Clinical Neurophysiology Section Determining MUAP duration hinges on the identification of the Contact the AAN Staff Liaison: initial and terminal deflections of the EMG voltage signal from Travis J. Dunbar the baseline. Rodriguez and colleagues (2007) evaluated the in- American Academy of Neurology tra- and inter-examiner reliability of MUAP duration measure- 1080 Montreal Avenue ments of two senior electromyographers and compared their best St. Paul, Minnesota 55116 performance with that of four different computer algorithms for Phone: (651) 695-2761 / Fax: (651) 361-4861 marking MUAP duration. The two senior electromyographers independently placed duration cursors manually on a set of 240 Email: tdunbar@aan.com MUAPs on three occasions separated by 2 weeks each. The com- bined inter- and intra- operator variability was found to exceed Membership is open to anyone with an 30%. The greatest contributions to variability came from the po- interest in issues pertinent to clinical neurophysiology sition of the marker indicating the end of the terminal portion in those waveforms with a shallow slope of initial and terminal de- flections. The cursor positions of the four automated algorithms for these same motor units were then compared to the "gold stan- dard" of the electromyographers - defined as the mean of the three closest manual cursor placements for each MUAP. The variability of the automatic cursor positions was similar to that of the manual placement. The two algorithms that defined the analy- sis region from the trigger point of the MUAP and progressing outward performed better than from the two algorithms that scanned the analysis window from beginning to end. The conclusions to be drawn from these studies is that automated programs can be used for the collection of MUAPs, but that the collected samples still require review and editing by the electro- myographer to remove duplicates and adjust the position of cur- sors, particularly those defining the initial and terminal portions of the waveform. In the manual method for quantitative MUAP analysis, duration is one of the most specific parameters for dis- tinguishing between neurogenic and primary muscle disorders. These studies emphasize that better methods of signal analysis Clinical Neurophysiology Section - 5
    • Fall 2007 The Official Newsletter of the Clinical Neurophysiology Section /Volume 13/Issue 2 Calendar of Meetings November 30- December 4, 2007 American Epilepsy Society October 7-10, 2007 Annual Meeting American Neurological Association Philadelphia PA Annual Meeting www.sfn.org Washington DC www.aneuroa.org February 13-17, 2008 American Clinical Neurophysiology Society October 17-20, 2007 Annual Meeting and Courses American Association of Neuromuscular Savannah, Georgia and Electrodiagnostic Medicine www.acns.org 54th Annual Meeting Phoenix Arizona April 12-19, 2008 www.aanem.org American Academy of Neurology Annual Meeting November 2-4, 2007 Chicago Illinois American Academy of Neurology www.aan.com Fall Conference Las Vegas NV www.aan.com/fall07 28 October - 2 November 2010 29th International Congress of Clinical Neurophysiology November 3-7, 2007 Kobe, Japan Society for Neuroscience www.iccn2010kobe.com Annual Meeting San Diego California www.sfn.org Clinical Neurophysiology Section - 6