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Scheduled clinics

Neuromuscular faculty work at clinic on different days depending the day of the week and the week of the month. Above is the schedule you should follow on the rotation. It is a good idea to check ahead in EPIC to see when patients are scheduled (use the “neuromuscular fre” EPIC context). It is also a good idea to email or message the attending you will be working with ahead of time to let them know you are planning to join them.

If an attending does not have patients scheduled for the day, see if there is another neuromuscular attending has patients scheduled in EPIC and ask them if you can join them.

SYLLABUS 

Purpose: The goal of the neuromuscular rotation is to learn essential approaches to the evaluation, diagnosis, and management of a broad range of neuromuscular disorders.

Faculty Supervisors: Dr. Lindsay Zilliox (Interim Division Director), Dr. Charlene Hafer-Macko, Dr. Neil Porter, Dr. Peter Jin

Responsibilities: Before the first day of the rotation please contact Dr. Zilliox via DocHalo to let her know you are on the rotation. You will be expected to attend clinics and evaluate patients with the attending physicians. You will be expected to gain some familiarity with NCS/EMG and may have the chance to practice with supervision, but you are not expected to perform these independently.

  • This rotation takes place in the Frankel clinic. Please report to the Frenkil clinic immediately following morning report.  Patients are scheduled starting at 8am.

  • You can view the schedule by changing your EPIC context to “Neuromuscular Fre”

  • ***Due to COVID, please make sure you touch base with the attending the day prior to their clinic to ensure they have in person appointments for you to see***

  • Many of the patients are scheduled in two slots for the day; one is for the initial history/physical, and the second is for their nerve conduction studies/EMG. Typically this happens back-to-back in the same room.

  • The patients are booked under the attending. The fellows or techs will take from the pool of patients; if there is a nerve conduction study to be done, they will do it. This is a good opportunity to ask questions on how the study is performed.

  • Portions of this rotation may be mostly shadowing, however, you will be expected to see follow ups who do not need electrodiagnostics. You may also be asked to briefly evaluate patients prior to electrodiagnostic studies. You should discuss which patients the attending wants you to see at the start of clinic.

  • Residents are expected to learn the basics of performing a nerve conduction study and EMG. Depending on how busy clinic is, you should have the opportunity to practice this at least once.

  • Most neuromuscular clinics include a combination of follow ups, new patients and visits for electrodiagnostics. The resident is expected to see follow ups/new patients as determined by the attending and watch electrodiagnostic studies.

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GOALS/OBJECTIVES

At the end of the rotation, residents will be expected achieve the following competencies and milestones.

Neuromuscular Medicine

  • Motor neuron disease

  • radiculopathy

  • brachial/lumbosacral plexopathy

  • mononeuropathies (cranial, median, ulnar, peroneal, sciatic)

  • mononeuropathy multiplex

  • axonal neuropathy

  • demyelinating neuropathy

  • autonomic neuropathy

  • neuromuscular junction disorders

  • myopathies (muscular dystrophies, inflammatory, metabolic/endocrine, toxic, critical illness, congenital, mitochondrial, channelopathies, rhabdomyolysis hyerCKemia)

NCS/EMG

  • repetitive stimulation

  • facial nerve

  • blink reflexes

  • physiology (potentials, transmission, temperature effects)

  • peripheral nerve anatomy

  • artifacts and variants

  • basic patterns (axonal, demyelinating, focal, multifocal)

  • motor neuropathy

  • radiculopathy

  • NMJ (MG, LEMS, botulism), myopathy (inflammatory, dystrophy, channelopathies, toxic)

Key readings

Please see neurology resident handbook on Google Drive for readings

1.  AAN Practice Parameters: International consensus guidance for management of myasthenia gravis

2.  Evidence-based guideline: Intravenous immunoglobulin in the treatment of neuromuscular disorders

3.  Evidence-based guideline: Treatment of painful diabetic neuropathy

4. Evidence-based guideline update: Plasmapheresis in neurologic disorders

5.  Assessment: Symptomatic treatment for muscle cramps (an evidence-based review)

6.  Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review) 



SUGGESTED READINGS

The following two books are designed to be easily read by residents:

1.  Atlas of Neuromuscular Diseases. A Practical Guideline.  2nd edition. Feldman EL, Grisold W, Russell JW, Löscher W. eds., Springer-Verlag Wien, New York, 2014.

The pdf can be downloaded from the Springer-Verlag website for minimal cost.

2.  Electromyography and Neuromuscular Disorders. Preston DC, Shapiro BE



OTHER MUSCLE DISEASE REFERENCE SOURCES

  1. Myology. Engel AG & Franzini-Armstrong

  2. Evaluation and treatment of myopathies. Contemporary neurology series, No 44, Griggs RC, Mendell JR, Miller RG

  3. Muscle biopsy: a laboratory investigation, 2nd edition. Loughlin M.

  4. Muscle biopsy: a practical approach, 2nd edition. Dubowitz V, Sewry CA, Fitzsimons RB

  5. A color atlas of muscle pathology. Cumming WJK, Fulthorpe J, Hudgson P, Mahon M



NEURO-MUSCULAR JUNCTION AND MYASTHENIA GRAVIS

  1. Myasthenia gravis and myasthenic disorders. Engel AG



PERIPHERAL NERVE DISORDERS

  1. Peripheral Neuropathy. Dyck PJ, Thomas, Griffin, Low, Poduslo

  2. Peripheral Neuropathy Companion: Illustrated Case Studies. edited by Peter J. Dyck, P. James B. Dyck, Christopher J. Klein, Phillip Low, Kimberly K. Amrami, JaNean Engelstad, and Robert J. Spinner.

  3. Peripheral Neuropathy in Childhood. Ouvrier RA, McLeod JG, Pollard JD

  4. Focal Peripheral Neuropathies. Stewart JD

  5. Clinical Autonomic Disorders: Evaluation and Management. Low PA



EMG

  1. Principles of Clinical Electromyography: case studies. Oh SJ

  2. Anatomical guide for the electromyographyer. Perotto A

  3. Peripheral Neurology: case studies. Liveson JA

  4. Electromyography in Clinical Practice: a case study approach. Katirji B

  5. Electrodiagnosis in disease of nerve and muscle: principles and practice. Kirmura J



Last Updated: May 13, 2022