NEUROMUSCULAR/EMG SECTION

RESIDENT EDUCATION CURRICULUM

Description of Rotation

The Neuromuscular/EMG Section of the Department of Neurology has redefined its educational programs for Neurology residents. The following rotations are offered:

  1. One-month “observer rotation” required for all Adult Neurology residents and an elective for Pediatric Neurology residents.
  2. Additional two-month rotation (total of three consecutive months in the EMG Laboratory) for residents interested in learning to perform nerve conduction studies and needle electromyography, and those who have a potential interest in fellowship training in neuromuscular disease.
  3. Advanced EMG elective rotation of three consecutive months in the EMG Laboratory. Participation in this elective requires prior successful completion of the introductory 3 month EMG rotation and requires permission from the Neuromuscular Section head, based on specific request by the interested resident.
  4. Elective in clinical neuromuscular disease. This elective requires permission from the Neuromuscular Section head, based on specific request by the interested resident.

Educational Purpose

  1. To provide an experience that will allow the resident to increase their knowledge of anatomy of the peripheral nervous system and the clinical presentation and pathophysiology of neuromuscular disorders.
  2. To provide an experience that will allow the resident to achieve understanding of electrodiagnostic studies correlating it with the basic science of neurophysiology.
  3. To learn the indications for ordering, diagnostic evaluationand interpretation of EMGs and autonomic studies.
  4. To provide training and supervision that allows development of skills necessary to perform accurate electrodiagnostic studies.

Assessment Summary

The resident will work one-on-one with staff, and get immediate feedback about his/her performance after every patient encounter/work-up. It is expected that the resident will improve their performance based on the feedback they receive and as the rotation progresses.

Resident performance will be assessed in the six core competencies:

  1. Patient Care (PC)
  2. Medical Knowledge (MK)
  3. Interpersonal and Communication Skills (ICS)
  4. Practice Based Learning and Improvement (PBLI)
  5. Professionalism (P)
  6. Systems Based Practice (SBP)

By the end of the rotation, the resident should receive and/or complete the following assessments:

  1. Verbal feedback from preceptors
  2. Global written assessments (METS)
  3. Procedure Logs
  4. Written examination
  5. Testing of residents performance through direct observation and record review

Expectations

Basic Rotation in EMG

The curriculum will include lectures in clinical neurophysiology as applied to nerve conduction studies and needle electromyography. Residents will observe nerve conduction studies and needle electrode examinations and will participate in the analysis and interpretation of data leading to electrodiagnostic impressions. Residents will participate in a daily EMG Case Conference with a neuromuscular staff or fellow, during which classic EMG studies will be reviewed, with additional exposure to autonomic studies. Residents are expected to read two articles supplied by email ‘Electromyography ‘ & ‘ Nerve Conduction Studies’ by Mark Ross.

Expectations (cont.)

Additional Two-Month Rotation in EMG

In addition to the curriculum in the Basic Rotation, the additional two-month rotation is directed toward developing technical skills in NCS and needle EMG. This two-month rotation must directly follow the Basic Rotation. Extended time away during this rotation is discouraged. There will be more concentration on EMG design to answer the clinical question being asked by the referring physician. There will be more emphasis on electrodiagnostic impression writing and interpretation of abnormal results. There will be continued EMG case sessions with staff and fellows, as well as an EMG unknowns quiz at the end of the rotation. Resident is required to read David Preston’s book.

Three-Month Advanced Elective in EMG

This rotation must be approved by the Neuromuscular Section head, and requires successful completion of the basic three-month rotation. The three-month rotation requires a commitment of three consecutive modules in the EMG Laboratory. For those interested in completing 200 studies for ABEM certification requirements, extended time away during the rotation is discouraged, and must be approved in advance. During this rotation the focus will be on improving needle EMG skills and electrodiagnostic interpretation skills.

Clinical Neuromuscular Disease Elective

This one-month elective must be approved in advance by the Neuromuscular Section head. The resident will see patients every half day with members of the Section. Depending on the staff physician, the experience may be as an observer during staff encounters with patients. The resident may elect to observe in the multidisciplinary ALS Clinic and in the Peripheral Nerve Clinic. There is an opportunity to observe and learn skin biopsy techniques and observe nerve and muscle biopsy procedures. Attendance at biweekly Tuesday noon neuromuscular conferences is required.

Orientation

This occurs on the first day of the rotation by the staff attending assigned to the clinic/lab. Orientation to the EMG machine will evolve over the first month of the clinical rotation.

Supervision

Residents will actively participate in the clinics/lab supervised both by neuromuscular staff physicians as well as neuromuscular fellows.

Mix of Diseases

  • Muscular Disoders /myopathies/ muscular dystrophy
  • Disorders of neuromuscular junction
  • Polyneuropathy
  • Axonal
  • Demyelinating
  • Sensory, motor, autonomic
  • Mononeuritis multiplex
  • Entrapment neuropathy
  • Plexopathy
  • Radiculopathy
  • Anterior horn cell disorders/ Motor neuron disease/SMA

Patient Characteristics

Patients will be referred to the EMG laboratory from either physicians in the outpatient department or from the inpatient hospital services for further diagnosis of a wide variety of neuromuscular disorders. Children and adult, of various ethnic backgrounds and socioeconomic backgrounds with acute and chronic neurological disorders will be encountered during the EMG rotation. Adults over the age of 18 will be encountered in the neuromuscular clinic.

Procedural Skill Acquisition

Basic Rotation in EMG

  1. Interpretation of NCS and EMG data
  2. Reading an EMG report

Additional Two-Month Rotation in EMG/Three-Month Advanced Elective in EMG

  1. Normal and abnormal findings in NCS and needle EMG
  2. Interpretation of NCS and EMG findings
  3. NCS techniques on 10 volunteers, then on patients
  4. Needle EMG techniques with staff supervision
  5. Writing electrodiagnosis interpretations

Conferences

The residents should continue to attend the mandatory Neurology conferences including Neurology Grand Rounds. In addition, the residents are required to attend the biweekly Neuromuscular conference (1st and 3rdThursday of the month). This conference is located in MEB. Residents are expected to attend the Thursday morning Fellows EMG Case Conference as well. This conference is held for advanced residents to review prior cases.

References:

Resources are available in the EMG Laboratory for learning skills.

  • Electromyography in Clinical Practice: Clinical and Electrodiagnostic Aspects of Neuromuscular Disease by Michael J. Aminoff. Churchill Livingstone; 1998.
  • Neuromuscular Function and Disease: Basic, Clinical, and Electrodiagnostic Aspects by William F. Brown, Charles F. Bolton, Michael J. Aminoff. Saunders; 2002
  • Electromyography and Neuromuscular Disorders: Clinical-Electrophysiologic Correlations by David C. Preston, Barbara E. Shapiro. Butterworth-Heinemann; 1998.
  • Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice
    by Jun KimuraOxfordUniversity Press, 2001
  • Comprehensive Clinical Neurophysiology by Kerry Levin, Hans O. Luders, Saunders; 2000.
  • AAN Practice Guidelines:

SUB-SPECIALTY: Neuromuscular Disease/EMG

ROTATION EXPERIENCE: Basic Rotation in EMG/ Additional Two-Month Rotation in EMG/ Three-Month Advanced Elective in EMG / Clinical Neuromuscular Disease Elective

PATIENT CARE

Neuromuscular/ EMG Rotation (PGY3 or 4) Patient Care
Objectives

Basic Rotation in EMG

/ Teaching Methods / Assessment Strategy
Learn basic technical and procedural skills through observation of NCS and needle examination studies, including at least 2 lower extremity studies, 2 upper extremity studies, 2 polyneuropathy studies, 2 motor neuron disease studies, and 2 studies involving neuromuscular junction studies / Clinical Teaching
Direct patient care / Global ratings
Case Logs
Gather essential patient history pertinent to their examination as well as screen for potential contraindications to performing either the NCS or NEE. / Direct Patient Care
Performance Feedback
Clinical Case Conference / Global ratings
Focused Record Review
Communicate effectively with patients regarding the testing procedure and be able to provide appropriate discharge instructions / Clinical Teaching
Clinical Experience
Performance Feedback
Clinical Case Conference / Global ratings
Demonstrate awareness of patient’s concerns regarding pain and modesty during the EMG procedure. / Clinical Teaching
Direct Patient Care
Clinical Case Conference / Global ratings
Self and peer assessment
360 degree evaluation
Identify and describe abnormalities seen in common neuromuscular disorders (carpal tunnel syndrome, cervical and lumbar radiculopathy, peripheral neuropathy, myasthenia gravis and motor neuron disease) on EMG / Clinical Teaching
Performance Feedback
EMG case conference
Reading list / Global rating of live performance
In-training service examination
Objectives

Additional Two-Month Rotation in EMG

/ Teaching Methods / Assessment Strategy
Demonstrate basic technical and procedural skills of NCS; this will include performing NCS on 10 volunteers prior to conducting studies on patients / Direct Patient Care
EMG case conference
Didactic Lectures
Staff and resident instruction and supervision
Observed performance on volunteers / Global rating
Checklist evaluation of live performance
Record review
Case logs
Demonstrate basic technical and procedural skills of NCS; this should include completion of at least 5 studies on patients referred to the EMG laboratory. / EMG case conference
Didactic Lectures
Staff and resident instruction and supervision
Observed performance on patients with tech supervision / Global ratings
Checklist evaluation of live performance
Record review
Case logs
Demonstrate the basic technique of needle electrode examination with performance of 10 needle electrode examinations of both the upper and lower extremities. / EMG case conference
Didactic Lectures
Staff and resident instruction and supervision
Review of previously recorded NEE abnormalities / Global ratings
Checklist evaluation of live performance
Record review
Case Logs
Objectives

Three-Month Advanced Elective in EMG

/ Teaching Methods / Assessment Strategy
Perform competently NCS on at least 10 studies / Direct Patient Care
EMG case conference
Didactic Lectures
Staff instruction and supervision
Observed performance on patients with tech supervision / Checklist evaluation of live performance
Record review
Case Logs
Daily performance of at least one needle electrode examination per day / Direct Patient Care
EMG case conference
Didactic Lectures
Staff instruction and supervision / Checklist evaluation of live performance
Record review
Case Logs
Objectives

Clinical Neuromuscular Disease Elective

/ Teaching Methods / Assessment Strategy
Through direct observation and instruction, the resident will gain knowledge of advanced skills in examination of the muscular and peripheral nervous system in context of the neurological examination / Direct patient care
Recommended readings
Staff instruction / NEX examination (observation of live performance)
Global ratings
As the schedule permits, perform initial history and examination, present to precepting staff, follow through with work up and follow up during time on the neuromuscular rotation / Direct patient care
Recommended readings
Performance feedback / NEX examination (observation of live performance)
Global ratings
Perform interval history and examination on selected established patients / Direct patient care
Recommended readings
Performance Feedback / NEX examination (observation of live performance)
Global ratings

MEDICAL KNOWLEDGE

Neuromuscular/ EMG Rotation (PGY3 or 4) Medical Knowledge
Objectives
Basic Rotation in EMG / Teaching Methods / Assessment Strategy
Describe the basic neurophysiology of EMG including elements of a nerve conduction study and needle electrode examination / Didactic Teaching
Reading list
Clinical teaching / Global ratings
In-training examination
End of rotation quiz
Develop an approach to investigating major neuromuscular diagnoses and describe their electrodiagnostic characteristics: CTS, ulnar neuropathy, radial neuropathy, brachial plexopathy, neuralgic amyotrophy, sciatic neuropathy, peroneal neuropathy, tibial neuropathy, lumbar plexopathy, radiculopathy, polyneuropathy, myopathy / Didactic Teaching
Reading list
Clinical teaching / Global ratings
In-training examination
End of rotation quiz
Neuromuscular/ EMG Rotation (PGY3 or 4) Medical Knowledge
Objectives
Basic Rotation in EMG / Teaching Methods / Assessment Strategy
Demonstrate the approach to assessing an acute cervical motor or lumbar radiculopathy and the findings that would be associated with such a lesion. / Reading list
Clinical teaching
Departmental conferences / Global ratings
In-training examination
Describe the underlying pathophysiology, diagnostic criteria for assessing level of severity of carpal tunnel syndrome. / Didactic lectures / Global ratings
In-training examination
Objectives

Additional Two-Month Rotation in EMG

/ Teaching Methods / Assessment Strategy

Apply knowledge of nerve conduction studies and develop a study that accurately diagnoses the patient’s symptoms.

/ Didactic lecture
Clinical teaching / Global ratings
Case Logs
Record review
Characterize the main features of the needle electrode examination as being normal or abnormal. / Clinical teaching
Departmental Conferences / Global ratings
In-training examination
Analyze abnormalities seen on needle electrode exam and determine underlying pathology (neurogenic, neuromuscular junction defect or myopathic) / Didactic lecture
Case conferences
Clinical teaching / Global ratings
In-training examination
End of course quiz
Correlate findings on NCS with NEE and write an electrodiagnostic impression (for 5 patients), demonstrating comprehension of the etiology of the patient’s symptoms / Didactic lecture
Case conferences
Clinical teaching / Global ratings
In-training examination
End of course quiz
Objectives

Three-Month Advanced Elective in EMG Additional

/ Teaching Methods / Assessment Strategy
Synthesize an impression of the findings of the EMG independent of Staff’s input / Didactic Lecture
Case Conference
Clinical Teaching / Global ratings
In-training examination
End of course quiz
Localize a lesion of the brachial plexus / Didactic Lecture
Case Conference
Clinical Teaching / Global ratings
In-training examination
End of course quiz
Describe the findings of a neuromuscular junction defect and be able to discuss the differences from myasthenia gravis and Lambert Eaton syndrome / Didactic Lecture
Case Conference
Clinical Teaching / Global ratings
In-training examination
End of course quiz
Objectives

Clinical Neuromuscular Disease Elective

/ Teaching Methods / Assessment Strategy
Describe the pathophysiology neuromuscular disorders such as polyneuropathy , ALS, myasthenia gravis, and myopathy. / Didactic Lecture
NM Conference (Tues)
Neurology Case Conference (Thurs)
Clinical Teaching / Global ratings
In-training examination
Describe the fundamental principles of the neuromuscular examination and apply this knowledge in completing a thorough history and neurological examination / Didactic Lecture
NM Conference (Tues)
Neurology Case Conference (Thurs)
Clinical Teaching / Global ratings
In-training examination
Explain peripheral nerve and muscle anatomical concepts / Didactic Lecture
NM Conference (Tues)
Neurology Case Conference (Thurs)
Clinical Teaching / Global ratings
In-training examination
Discuss the various treatment and management options for neuromuscular disorders and apply the latest knowledge to care of patients / Didactic Lecture
NM Conference (Tues)
Neurology Case Conference (Thurs)
Clinical Teaching / Global ratings
In-training examination
Research a patient’s problem and provide a expanded neuromuscular differential diagnoses / Didactic Lecture
NM Conference (Tues)
Neurology Case Conference (Thurs)
Clinical Teaching / Global ratings
In-training examination
Compare and contrast different management strategies for patients with neuromuscular disorders / Didactic Lecture
NM Conference (Tues)
Neurology Case Conference (Thurs)
Clinical Teaching / Global ratings
In-training examination

INTERPERSONAL AND COMMUNICATION

Neuromuscular/ EMG Rotation (PGY3 or 4) Interpersonal and Communication
Objectives
Basic Rotation in EMG/ Additional Two-Month Rotation in EMG/ Three-Month Advanced Elective in EMG /Clinical Neuromuscular Disease Elective / Teaching Methods / Assessment Strategy
Establish excellent rapport and communication with their patients and their families / Clinical practice
Modeling / Global ratings
360 degree evaluation
Work as an integrated member of the NeuromuscularCenter and EMG Lab / Clinical practice
Modeling / Global ratings
360 degree evaluation
Present case presentations in an organized and detailed manner / Clinical practice
Modeling / Global ratings
360 degree evaluation
Educate their patients and their families as appropriate to the clinical situation in a manner that is geared to the patients educational level / Direct patient care
Modeling / Global rating
Demonstrate the ability to provide consultants with a report that can be easily interpreted. / Clinical rounds
Modeling / Global ratings

PRACTICE BASED LEARNING AND IMPROVEMENT

Neuromuscular/ EMG Rotation (PGY3 or 4) Practice Based Learning and Improvement
Objectives
Basic Rotation in EMG/ Additional Two-Month Rotation in EMG/ Three-Month Advanced Elective in EMG/Clinical Neuromuscular Disease Elective / Teaching Methods / Assessment Strategy
Research clinical questions regarding their patient’s health problems using information technology to access on-line medical information to support their own education and to improve patient care and education / Electronic medical record
Medline/OVID searches- patient centered
Case presentations / Self assessment
Global ratings
Evaluate the clinical literature applying knowledge of epidemiology, biostatistics, and research study design / Teaching conferences
Journal Clubs / Global ratings of Journal club performance
Integrate the feedback they receive from Staff physicians such that their performance will improve as the rotation progresses. / Modeling / Global ratings (METS)

PROFESSIONALISM

Neuromuscular/ EMG Rotation (PGY3 or 4) Professionalism
Objectives
Basic Rotation in EMG/ Additional Two-Month Rotation in EMG/ Three-Month Advanced Elective in EMG/Clinical Neuromuscular Disease Elective / Teaching Methods / Assessment Strategy
Demonstrate respect, compassion, integrity, and honesty / Direct patient care
Modeling / Global ratings
Interact responsibly with patients and families taking into consideration age, disability, culture and gender issues / Modeling / Global ratings
Demonstrate exemplary interaction with their colleagues / Modeling / Global ratings
Demonstrate appropriate use of the EMR in regards to patient respect and confidentiality / Direct patient care
Modeling / Global ratings
Self-assess their performance and the means for improvement / Modeling / Global ratings
Recognize mistakes that occur and take measures to learn from them so that the do not recur / Direct patient care
Modeling / Global rating
Self assessment

SYSTEM BASED PRACTICE