Welcome everyone, thank you for coming. This is our first Neuromuscular Medicine and Electrodiagnostic Member Community Day session. First of many, we hope. I'm Shawn Jordanson and I'm the chair. I am in private practice in upstate New York and a clinical professor at Albany Medical College and adjunct professor at University of Vermont. And I am very lucky and happy to be joined by Sandra Hearn, who is our vice chair. And she is a assistant professor and residency program director at University of Michigan and has many leadership positions in the AANEM and AAPNR, including being part of the program planning committee that helped plan this first virtual meeting. So definitely gotta give her props for that. So we're very excited to have you all here. And I have to say in all this election drama, I am reminded that this is, I've spent a year as the chair of this member community. It was a very exciting election. Now that my critics of my administration may tell you that I nominated myself for the position and that I ran unopposed. And even then they had to do a recount because I got so few votes. But having said all that, to be honest, I am in the position that I've wanted to be in ever since I've joined the academy, which is being a part of a community within the academy that is specifically designed for people who have academic, clinical, or research interests, primarily in electrodiagnostics and neuromuscular medicine. So this is, I think, a very exciting time for us. My hope is today you're gonna learn some things, you're gonna have some fun, you're going to put some faces to names that you may not have known before. But more than anything, I hope you're gonna get a sense of the promise that this group has for people who are interested in this part of our field and all the potential it has going forward for when we can actually meet in person and really do some serious networking and just get a lot out of this. So with that, I'm going to bring us to our first offering, which is gonna be a crossfire on a somewhat controversial topic, which is gonna be, should you bill a consult routinely for an electrodiagnostic evaluation? So arguing the pro is going to be Mike Andery, who is a professor and residency program director at Michigan State, past president of the AANEM and author of articles too numerous to count. Going to and taking the con position is gonna be Kevin Fitzpatrick, who is in private practice with Mount Vernon Rehabilitation Associates in Northern Virginia and also in many leadership positions in the AANEM and AAPNR. So with that, take it away, Mike. All right, well, thanks. Hopefully this will be okay. It's kind of a weird thing to be doing, but it's a weird time. And I don't know how we got stuck with Sean, but we could do a recount, eh? All right, so this debate, Kevin and I are gonna talk about it. This came from an article that we wrote in PMNR in 2013. At that time, Douglas, Dr. Wayne went against me, and this is a picture of the article. So I'm gonna start with, we're gonna try to go through this pretty quickly. It's a case of a 62 year old who came from a family physician for Rudolph Lumbosacral radiculopathy. And there's history in there with diabetes, and there's an MRI and the physical exam that shows loss of ankle reflexes and normal knee reflexes and mild intrinsic foot atrophy. So I'm gonna go through this pretty quickly, sorry guys, but the differential of left and right lumbosacral radiculopathy for lumbar stenosis, a generalized polyneuropathy, and then much less likely mononeuropathy is a tibial nerve, like bilateral tarsal tunnel, tibular nerve, and then everybody has carpal tunnel syndrome as far as I'm concerned. The EMG and nerve conduction showed a distal symmetric sensory greater than motor, primarily demyelinating peripheral neuropathy. And we're not really gonna go through the numbers, no findings for lumbosacral radiculopathy. At the end of the report, the physiatrist suggested that the nocturnal symptoms in the feet may benefit from a trial of gabapentin, and that she would be happy to treat the patient for these problems with the consent of the primary care physician. And so the debate we're gonna have is should we be billing for a consultation or evaluation and management, E&M is what I'm gonna call those, in addition to the charges for the electrodiagnostic study. So should they be billed, are they always appropriate, and when should we do that? So that's the debate we're gonna have. My view is that yes, Dr. Wayne and Dr. Fitzpatrick are doing a great job, and I think not. And so going through this, I would make the case that before recommending a medication, physicians shouldn't just say, give them a med, that we should spend extra time to talk to the patient and consider many things beyond the testing itself. Have they taken it in the past? Do they wanna try gabapentin? Did we talk about adverse effects and how much it's gonna cost and what their insurance is gonna say? Did they consider the gabapentin risks and benefits to other medicines? There's lots of medicines for polyneuropathy or no medicines. All of these things are considered to ensure the optimal treatment of the patient. If you're gonna make a recommendation in my view, you don't just say everybody with polyneuropathy should get gabapentin, because I would make the case that's not good. Uh-oh. Sorry about that. I don't know why these move. And so that is behavior for a management that's over and above the E&M. And so when you're gonna go and talk about neuropathy, also the etiology of the neuropathy could warrant a E&M code. So for this case, the cause of the polyneuropathy were not really addressed. And that could be, it looks obvious that it's due to diabetes, but is it really that obvious? And in order to say that it's diabetic neuropathy and it's not a rapidly progressive neuropathy that you shouldn't need further workup, we should and could talk to the patients about other medications, hereditary issues, autoimmune, alcohol, nutrition, and other medical problems. And just assume that it's diabetes is, I would say, too quick and not necessarily in the patient's best interest. And to sort out and ask all those questions, those are further evaluation questions that should be asked. And I don't think that those are necessarily part of the electrodiagnostic history and physical. So if it's more typical for CIDP, then they should recognize that and point it out, but they would need to ask more questions almost always. So I would say almost always warrants more E&M if you're gonna try to look at the full clinical picture and if we're gonna accept the EMG and electrodiagnostic testing as extension of history and physical. So Hague showed an article in 99 that if you integrate the HNP with the electrodiagnostic testing, it's complicated and that the testing frequently changes the diagnoses considered clinically. And therefore, a limited HNP to reach a conclusion may not suffice. And that the E&M in my hands, I almost always do it. And I think that we as physicians and physiatrists should usually do it. And that when the patient's referred to the electromyographer there's gonna be symptoms and there's gonna be a medical question. And so not all symptoms, as you know, are not due to neuromuscular problems. If you look for them, we were part of this study with Dillingham and the Hopkins group and the odds. And we found pushing 30% of people who came in for neuromuscular testing had other problems. And surely that has biased me when I look now at patients to find other things. And that if they have a normal EMG, then you're more likely to find other problems like bursitis, tendonitis, arthritis, myofascial pain. And I would argue that's not part of the HNP for electrodiagnosis. So should we provide input to the management of these diagnoses? And I'm, you know, to me, it's of course. And I know it takes extra time. But, and then I guess the other thing if there's not really a management question, should the EMG be ordered? And then the answer is no, to me. If you already know what they got and the referring physician knows for sure, they've already decided they're gonna do surgery, they're gonna do whatever they're gonna do. And there's not really a medical question and leave it alone. So if there's not a management question, don't do the testing. But that's not what we're in the position of. So I would say if you stopped after the EMG and nerve conductions and don't do more than that, then don't bill the E&M. But honestly, when I'm with a patient, I'm gonna, I'm thinking about the next step and I can't really live with that. So I'm not, I don't practice like that and I hate to practice like that, so I don't. So I routinely will get the E&M. All right, Kevin, you're up. All right, well, thank you. I wanted to say thank you to Dr. Andrew. He did a great job. I think what you'll see here is that we're gonna agree on probably more things than we're gonna disagree on. I'm not gonna say thank you to Dr. Jorgensen because he's the one that gave me the unpopular side of this argument. As an example of that, you can see that perhaps Dr. Andrew has some other motivation when it comes to billing for both codes during a study. Just as an example, this is actually a live view of where Dr. Andrew's joining us from tonight. From what I've been told, this is one of his two yachts that he owns and he's actually in the cabin there tonight. You can see it, so just poking a little fun. But obviously I got the unpopular side of this, so I'll try to take you through that. I think one of the things we wanna think about as we go through this is we wanna understand the CPT codes that we're using. If we could just go to the next slide. Thank you. So firstly, I have to understand what CPT codes are. This is probably not gonna be a surprise to everyone, but AMA assigns all procedures and work that physicians perform a CPT code, and those are each assigned an RVU by the ROC committee of the AMA. And those CPT codes are, excuse me, the RVUs are divided into practice expense RVUs, physician work RVUs, and then malpractice. We're gonna be talking about the physician work component of the RVUs. The CPT codes that are pertinent to our discussion tonight will be the electrodiagnostic codes consisting for the vast majority of studies of one of the codes between 95907 and 95913 to constitute the nerve conduction studies, and then the add-on EMG codes, most commonly 958856 and seven. The important thing to remember about these is that those nerve conduction study codes include a portion of that code that's dedicated to E and M time. And for most of the codes that we're gonna use, that's gonna be estimated to be about 10 to 15 minutes of E and M time. So what you have to remember if you're considering using both of these codes is that you have to meet criteria for both. So you've already got 10 to 15 minutes in the NCS codes to do your E and M, so you're gonna have to do work above and beyond that to meet criteria for both. The other codes would be the E and M codes, 99201 through five, which I'm sure everyone is familiar with. And those are divided into history, physical examination, and medical decision-making. Those can be calculated using time or using kind of a component-based calculation. And probably many of us have seen some sort of cheat sheet that looks something like this that has the codes listed along the top there, and then the different criteria that must be met. So how many components of an HPI or how many elements were involved and how many systems were covered in our review of systems in addition to how many body systems were examined in a physical examination, and then how complex was the medical decision-making. So I think what I want you all to remember is that as you consider using both of the codes, you've got to check all these boxes on top of what you've already done for the NCS portion of the code. So, you know, Dr. Andrea might argue that he did some management, so he qualifies for both codes, but you can see that there's no E&M code that just covers management, right? It has to be the history, it has to be the physical examination. So I don't think there's gonna be any argument from anyone about what is necessary for EDX. So I don't think that there's any confusion about the fact that an H&P is a critical component of the electrodiagnostic consultation. It's on the first page of President Shapiro, that's from this article in Occupational Medicine. Dimitri describes it in his textbook that any electrodiagnostic consultation requires a history and focus physical examination. So there's no doubt that it's part of what we're billing for when we bill nerve conduction study codes. So that can be summed up very quickly in a one-word slide there. Okay, and then the other part is management. And I think this is something where we could disagree with a little bit. I think you could certainly make an argument that nerve conduction study and EMG codes do not necessarily include components of management. But I would argue that, and this is I think where Dr. Andrew and I agree that the management is a critical and necessary component of the electrodiagnostic examination, although you can envision a scenario where an electrodiagnostic study could be performed without any direct input into management. But like Dr. Andrew said, if you're not answering the management question, then why are you doing this study to begin with? So just to kind of get into a little bit more practical components as you're trying to make decisions about what to do, whether to use both of these codes or just one, you wanna remember that the interview and examination is an expected component of the EDX code, and it is accounted for in the calculation of the RBUs for the EDX codes. Some criteria that I try to consider as I'm trying to decide whether this is just an EDX visit or this is a visit that includes a consultation as well would be if I have provided services that are clearly outside the scope of a typical EDX visit. And I'm all for billing both of these codes when you've done the appropriate amount of work and you've documented appropriately the criteria for both of those codes. I don't think they should be used routinely or as part of an EDX code just because you've done an electrodiagnostic visit. That doesn't necessarily mean that you've met criteria for both of those. So some of the things that I try to think about is consider the referral source. If the referral is from a primary care physician who's referred the patient for numbness in their feet with no additional workup, then you're probably gonna have to do more work to manage the patient. And so that would be a good indication to use both codes. When I do it, I write two separate notes. I write my consultation report and I write my EMG report. So that's where I justify to myself that I've proven that I've checked all the boxes for both of the codes. I'm not suggesting that that's necessary, but I think you should be able to clearly point out, here's where I did the work for the nerve conduction EMG, and here's where I did the work for the consultation. If you make a management decision that is not outside the scope of the EMG visit, if you do an EMG and someone is diagnosed with carpal tunnel syndrome and on the way out their door, you tell them, oh yeah, pick up a splint. I don't think you've gone above and beyond what's expected for a typical EDX study. And I think Dr. Ender laid out a nice case where he's physical examination and he's done that. So those are some of the criteria that I use. I'm gonna turn it over. All right, so thank you, Kevin. That was good. To me, we agree on almost everything and he's right. I have two yachts. So, and so I think we agree on virtually everything except the management issue. So is suggesting simple treatment for splints management for EM. And if you casually say it on the way out the door and you don't write it down and you didn't ask the questions, then I think you're probably right. But I would never do that. I would just say, if you're gonna suggest a splint for somebody, in my view requires a lot of other activities, like what can't you do? What's good and the argument would be, and there's a long discussion here theoretically, but that's a quality of life decision that I think requires multiple activities. And then you gotta decide why a splint? Why not injections? Why not one of the surgeries? Why not exercises? Why not rest? Why not work restrictions? Why not yoga or cold laser or whatever else people are into? So I think those are questions that you don't really need to answer in your electrodiagnostic history and physical, and I would argue our additional history and possibly physical exam if you do things differently. So I guess, and then from a documentation point of view, Kevin made a point, I've gotten audited by Medicare and I didn't have problems. I integrate my report into it. And then I usually put a clinical evaluation and management recommendations. I'm actually changing this, but clinical evaluation and management recommendations at the end, that puts things in there that are not the electrodiagnostic impressions. The electrodiagnostic impressions are above it. So if you're not going to do any management recommendations, then don't bill for it. I absolutely agree. I kind of schedule my practice so I have slower, you know, an hour for EMG, and I have residents with me all the time, and, you know, not being a doctor just drives me nuts, so I think we're done. I mean, I got no chance here. Kevin is a soldier, and he's looking at me, he's got a gun and he's got weapons, and, you know, I'm only down there shooting at a target range. I got no chance, however, I'm open for questions. So we got, you know, what do we got, five minutes for questions? Three minutes for questions? You got eight minutes for questions, you're good. Oh, okay. I thought we had until 825. Well, we went, Kelly and I had to cut out about 100 slides, so I'll just say that, you know, for me, and I'll just babble until I get questions. You have a couple questions in the chat. All right, I can't see the chat because of the share, so I'll stop my share. There we go. First question is, will insurance companies pay for the E&M charges? Okay, now that is a problem, for sure, a lot of insurance companies won't. You guys will know the answers better than me. In our state, if we document it right, 90, I've had very little trouble with it. I mean, it's clearly legal, and it's clearly, you know, you know, I'm going to use the ethics part of billing is just, to me, almost comical. There's little or no ethics in billing. There's, you know, insurance companies, in my opinion, do many unethical things that are very clearly legal. So I'm going at this from a legal point of view. So I've not had a lot of problems. And then Debra asked, how much time do we do for each study? You know, I have residents. So for depending on in four hours, I will do between four and six studies. And we're dragging over every time. So I'm a solid hour for an EMG. Some of mine are pretty complicated. You know, if it's straightforward carpal tunnel, it's a different, you know, those go quicker. Mike and Kevin, I'm going to throw an extra variable in there for you guys to consider. To what degree should the referring providers question the reason for the consult sway our decision to address and bill for a separate problem? So, for example, you know, scenario A, you have ortho hand has referred for carpal tunnel syndrome evaluation prior to surgery that they're going to perform. They're already managing the splints, they're already managing the injections. They don't really have a separate question. And maybe the patient complains of neck pain or shoulder pain, but that's not what the referral was for. No EM for that. That's very unusual in my practice, but I would have, you know, Kevin and I talked about that this afternoon and like, yeah, if they're scheduled for surgery on Thursday and it's Tuesday and you're doing it, you know, no. Yeah, I totally agree. If you find something else as you're working them up, like Mike talked about this afternoon, if they finally have day for vein or you find out they've got tennis elbow and you're doing some treatment and evaluating them for that, that's a different story. But if that's where your evaluation starts and ends, then I don't think you've got room for both in that case. If they've got a positive Babinski, that will sway me. So, yeah, like for me, that would be one that wouldn't go. Single fiber, I don't bill E&Ms mostly for that because I'm not adding much. Does anyone add on a CTS steroid injection and an EMG appointment without checking with the referrer? Not me. No, I wouldn't do it without some kind of prior discussion with the referral. Do you do that, Eric? You're muted. I do not. But, you know, there are patients, I see a lot of patients from the Oregon coast who come a long way and it'll be a long time before they can get back. You know, they might drive five hours for the appointment. So it's just, it's come to mind, but I haven't thought it was a good practice to get, good habit to get into. So. Okay. Somebody said for 10 minute HMP is assumed in the NCV. Is it required to document this? Ooh, we do, you, I think we're required to put a brief HMP in there. It doesn't have to be a 10 minute and Kevin was using the 10 minutes as the time. You don't need to have a 10 minute, you know, that's if you bill by time, if you bill by time over half your time, I think needs to be counseling and coordination of care. Right? That's it. Yeah. That would apply for the E&M. 10 to 15 minutes is just kind of, you know, it's not something that needs to be proven. It's kind of how they calculate what, what the RVU is assigned to that NCS. Right. It's kind of a rough guy. Yeah. With my regular patients, not EMG patients, I, I, I code on time, like 80 or 90% because I'm doing management of rehab patients. Ultrasound, incorporate an ultrasound to adjust the time. Incorporate an ultrasound to adjust to the EMG. I have not been good at that. There are people on this call, like Sean, who I think does this and other many other people have done that. I don't do that. Yeah. I do do that. The circumstances that it's appropriate and useful are, are kind of complicated. But when appropriate, I, I do. But whether you get paid for that is a state by state thing. I just saw, for the first time. Parker, you need to shut up. That's one of my residents saying the residents want to incorporate ultrasound. They do. And rarely I do, you know, sometimes I'll pull out an ultrasound if I'm looking for a, you know, the Terry's minor or something like that. So Patel has them come in separately. How are you doing, Atul? And then I don't know, Eric, about the new E&M codes. I saw they are coming out, but I haven't read them yet. So you're thinking they come out, you don't have to counsel for half the time. Is that right? Yeah, I think it's, I'm not 100% sure, but I think it's pretty similar to what goes on now for virtual visits, where you can count for your total time, including time, you know, reviewing imaging studies and so on. Right. And it doesn't have to be face to face? The total time spent on the appointment does not have to be face to face. It doesn't have to be face to face for virtuals. Right, for the virtuals, I know. It's good for a boomer like me because I type slow, takes me a long time. Hey, Mike, let me ask you. So in a typical, you know, morning in the EDX lab, like how, what percentage of the patients are you billing for E&M? 95. Wow. Almost all. And you've been audited and that's never really been an issue? Yeah, I bill a two and a three. Threes mostly, but sometimes twos. But I, I mean, if I don't send somebody out with a management suggestion, it's unusual or a workup suggestion. Like, like if it's a neuropathy, I'm going to ask them questions about why they have neuropathy, what do I think the causes are, and I'll suggest workup. But if it's coming from neurology, I don't tell them how to work up a neuropathy. They may miss other musculoskeletal stuff. I'll tell you what, the telemedicine and the nurse practitioners or PAs were getting referrals. They're missing obvious stuff. And I've had neurologists who are phenomenal doctors miss upper motor neuron problems because they can't do it on telemedicine. So stepping back now and really examining the patients, I, you know, like I will tell my residents that you've got to do Babinski's on everybody, even if you have an amputation. I want all of us to think of upper motor neuron problems because neck pain and cervical myelopathy in the elderly, you know how common that is. And it gets missed a lot in my, you know, once or twice a month, we find that. Great. Thank you, Mike and Kevin, both for this, this engaging discussion with the group. If others have questions or thoughts on this, please feel free to share them in our neuromuscular medicine and electrodiagnostic forum here with AAPMNR. I'm going to drop one more thing in the chat as we wrap up this particular section, which is a link to AANEM's position statement on this. If others are curious on another group's line of thinking there. Meanwhile, we're going to switch gears and move to the next session of our evening. Let me drop in the chat a repost of our schedule for those who have joined us more recently. So you can see where we're at. So we just finished a terrific debate between Dr. Anderi and Dr. Fitzpatrick about billing for AANEM and EDX on the same day. Now we're going to switch gears and go to a Q&A with our panelists. Our panelists are Dr. David Arnold, Dr. Nassim Raad, and Dr. Bob Rinaldi. Dr. Arnold is an associate professor at the Ohio State University. I got it. In the departments of neurology, PM&R, neuroscience and physiology, and cell biology. And is a lead researcher in this area. Dr. Nassim Raad is an assistant professor at University of Washington Medicine. She is rehab director of the MDA and ALS center and the EMG center there. And Dr. Bob Rinaldi is professor of pediatrics and physical medicine and rehabilitation at Children's Medical Center at UT Southwestern, where he serves as chief of pediatric rehabilitation medicine. So now is your time, all of us in the community, to feel free to pepper the chat with questions for these three. And I will call on one or two of the panelists for each question and get different ideas out there. If there's ever something you wanted to know, whether others practice it similarly to you, whether others use different or similar techniques, now's the time to ask. And some of our panelists will pick that up. So we will do that for the next half hour or so. I'm going to start us out with a question that probably many of us have encountered because it's a common condition. I'm going to ask the panelists, when you're evaluating for carpal tunnel syndrome, under what circumstances do you do needle EMG of the thenar eminence? And under what circumstances might you skip that piece? Any of our panelists want to take that one? I'm going to throw it out to Dr. Rad. So I think that's a great question, and it comes up a lot. I tend to perform, well, twofold to this answer. I think that it's useful to perform needle EMG to the thenar eminence if you see demyelination changes in your motor conduction studies to the median nerve, because needle EMG is much more sensitive for axonal changes. So even if you don't see any amplitude drop in the motor median nerve near conduction studies. I'm going to open this up also to a second thought, and maybe this will go back to some billing stuff. I know recently there's been talk on whether or not you need to incorporate needle EMG to bill. So can you just bill for nerve conduction studies without needle EMG? And I know my colleagues at UW have various opinions on this, and we struggle to find an answer. So I know more and more people are needling even without any changes on the median motor studies because of this. So I open that up to any panelists or anybody who has additional billing thoughts on that. But otherwise, I practice by needling when I see demyelinating changes. I generally don't needle the APB unless there is amplitude change on the CMAP. I know there's less sensitivity on the needle, but I just don't find that it changes the management strategy that much. So the one muscle that I do would be pronator teres or FCR to look for mimics, and then I can kind of, my rationale is I'm like doing a more complete study. I know that's limited, but that's generally what I do. And honestly, that has changed the impression of the study more than needling the APB. I'm not normally surprised. Like I just kept needling the APB for a long time, and I was like, this is not changing my impression very often, unless there's borderline CMAP amplitude or something like that. I generally don't. But that is something that I talk with fellows and residents almost every day about. So I'm not convinced that that's the right strategy. That's just my strategy. Great. Do either of you or any of you ever use features from the history and physical to sway you there? I definitely so. I think acute median neuropathy is an entirely different situation. So if you look at focal neuropathies, I like to think about it as a continuum. And so with acute compression, oftentimes the motor axons are affected more. So if you look at like, setter-knight palsy, proximal radial neuropathy, oftentimes the motor axons look more abnormal in those cases. Prognosis is still pretty good. But I think there's more likelihood of having active spontaneous activity when you have acute onset. And I think that it has different management implications potentially. That makes a lot of sense. Thank you. Let's flip topics. Question from Dr. Kiyoto. Do you always do EMG study in a patient with suspected statin-associated proximal weakness? I'm going to ask Dr. Arnold, do you want to take that one first? Yeah, I mean, I think with proximal weakness, I probably would. There's diverse types of statin-related myopathies. But I think if you see active spontaneous activity, you might be concerned for necrotizing myopathy, which would be immune-mediated. Of course, there are antibodies for that. But the yield of that's not perfect. The needle EMG not only will tell you if there's active spontaneous activity, it may help guide a biopsy. So choose the right muscle. So you want a muscle that is abnormal, but not too abnormal. So it would be nice to like, we generally like to do the biceps muscle for a biopsy. So if the biopsy looks a little abnormal, then that's the better muscle to biopsy if possible. So I probably would, but I'd be interested to hear other ideas or thoughts. I would say we perform the exact same way. So typically any proximal weakness, even if there's a high suspicion for statin as being the cause, really looking again for acute denervation muscle membrane changes, guiding muscle biopsy. We even see them referred to us even if they have positive HMG, clenzyme antibodies. So I still think that EMG is part of the management. And we've seen a few patients who were complaining of pain, didn't have any weakness that we could really appreciate on exam. And surprisingly, their EMG showed florid proximal muscle changes. So I think it's also very helpful for the subtle weakness cases as well. Great. A related question. Do you always order HMG-CoA reductase antibodies in a patient with suspected statin-associated proximal weakness? I think even if it's not statin-related, you can have necrotizing myopathy without a statin exposure. So if you're thinking necrotizing myopathy, you should order it. Agreed. It's part of our panel. Yeah, with or without statin use, because you can see it without statin use. I'm going to spin the question a little differently to you guys and actually ask, if you were to put yourselves in the seat of the primary care physician, if the top of the differential is a statin-associated myopathy, would you advocate to have the patient sent to electrodiagnostic testing? Or would you advocate for trial of med changes first? I would advocate for an evaluation. I think that whether or not you include your evaluation with the EMG, or whether you refer them to EMG and then have them separately have an evaluation, if you're truly suspecting a myopathy, then it doesn't always potentially resolve with just medication changes. And I think that some of them have lasting consequences, and the patient's going to need more management. Certainly, if they thought this was a statin-induced myalgia, they didn't see any elevated CK levels, there weren't a lot of concerns, I think they can change medications and see what that does. But if they're truly concerned about a myopathy presentation, I would suggest that they defer for EMG and evaluation. Great, thank you. We're going to switch lanes to pediatrics. Here's a question. In working up pediatric patients with suspected neuromuscular diseases, has the role of electrodiagnosis been diminished and replaced in part by genetic testing or by muscle and nerve ultrasound? And I'll put this out to Dr. Rinaldi. Yeah, I think it largely has. Genetic testing nowadays, we can check for so many different diagnoses with that, and the turnaround time on the testing is actually fairly quick now. And this is practice-based, but I think most people are now opting to do the genetic testing first. Now, I'm going to put a caveat in that and say that in conditions where you aren't quite sure you're dealing with a neuromuscular condition, then an EMG can be beneficial to define whether you're actually working with a neuromuscular condition or not. And certainly there are many mimics in pediatrics, particularly kids less than four or five years of age, conditions that can mimic neuromuscular conditions, but they're not. So in those cases, I tend to opt for an EMG neuroconduction study first to kind of define the ballpark I'm working in. If it comes back suspect for a neuromuscular condition, then I'll order the gene panel. So I'll use it kind of as a screening tool in many cases. The other downside to EMG neuroconduction studies in pediatrics, just like on the adult side in many cases, can tend to be very nonspecific and non-diagnostic. So even if we get it, we're still probably going to do the gene panel. Many cases like SMA, we don't even think about EMG and SMA anymore. We just go straight to the gene panel. Turnaround times are one to two weeks on those studies. And within the context of the diagnostic workup, it's just a lot easier to do that. You remember, back in the day when I trained, I'm not gonna age myself here. When the turnaround time on the SMA deletion studies was four to six weeks, we would do EMG nerve conduction studies because we were wanting answers at that point. We had the plan at that point. And so we would do them back then. But it's gotten a lot easier not to use them now. Great, thank you. A question on when the patient is your own patient and an electrodiagnostic study is needed, do you do it yourself? And are there any issues with self-referral in that situation? For me? Sure. I'd love to do them. Where I practice, we don't do them. Neurology does them. We make plenty of referrals for EMG nerve conduction studies in neurologists. Where I practiced previously, we did them. So that was my practice was to, if I was suspecting something, then I would just do the EMG and add it in. I think in general, if we're building the electrodiagnostic codes, it is okay to do that on one's own patient. And if it's in the same exact encounter, then that's exactly back to the initial debate. So under very specific circumstances where you're adding beyond the EDX. If I'm doing it on the same day, I'm definitely billing a separate code. Unfortunately, my practice isn't built right now to accommodate EMG on the same day. But yes, I usually self-refer to myself. And usually if they're gonna need follow-up care, then do like a shadow E&M visit already scheduled after their EMG to discuss next steps. Great. Next question has to do with evaluation of the Guillain-Barre syndrome or GBS studies. This person has done quite a few GBS studies and clinically they seem to have GBS, but they've been consistently axonal to the point where it seems unusual to see a demyelinating one lately. We recognize GBS has an axonal variant, but are others seeing this more than they have in the past? More axonal GBS in the past. I see Dr. Anderi nodding. Dr. Anderi, you wanna chime in? Yeah, I mean, I see that too. I don't know. I don't have any good reason why or any good data whether we're seeing them a little bit later so that the demyelination turned into axon loss. But the neurologist, we're not doing the treatment, but the neurologists are frequently treating what appear to be primarily axonal or purely axonal acute neuropathies and they're treating them with IVIG. So I have no idea why. I'm certainly seeing axonal variants. I don't know if I can comment on more than the past though. I don't have a good answer for that. We're still seeing a handful of clearly demyelinating with secondary axonal changes. Yeah, I would say at our center we mostly see demyelinating. There are some pretty nice studies showing that even with the same ganglioside antibodies, different phenotypes can be related to different genetic backgrounds. And so there are regional variables. And so it's possible that that's related to the population. I don't know where the person that asked this question is, but there could be population genetic based differences that could be driving that. But I haven't seen, as far as just changes in general, we still primarily see AIDP variants. I'm gonna toss one back for Dr. Rinaldi. Do you run into any problems with getting genetic testing done when you need it? Yeah, in fact, I just texted Atul back on that. Hey, Atul. Yeah, we occasionally get pushback on that, but in my experience, it's not been secondary to lack of prior EMG nerve conduction studies. We're typically getting pushback because something in the entire diagnostic workup is missing according to the insurer. Something in the history, something in the lab we've not done to date, something ruling out other diagnoses first. So occasionally we get pushback. Actually, it's gotten a lot better though, in my experience over the past few years. Good news. Next question is about tarsal tunnel syndrome and peripheral neuropathy. This person's been recently referred some patients in their 70s and 80s, decade of life, with foot numbness and a clinical question of whether they have tarsal tunnel syndrome. How accurate is our nerve conduction studies to differentiate peripheral polyneuropathy from aging versus tarsal tunnel syndrome in that age group? And do we have a recommended approach? Any takers on that one? Can I go to Dr. Arad? Sure, and I'm smiling. I will self-admit, tarsal tunnel is one of my least favorite referral questions. So I don't know how others feel about that. So I think to kind of hone in on the question, so I feel like this is kind of two parts. So for peripheral neuropathy differentiated from aging, I'm sure many EMGers have different opinions on this, whether or not you can say that it absent, thorough, do you always blame it on age, being age-related, if it's symmetric? Do you say that it's an early polyneuropathy if there aren't any other motor changes on your nerve conduction studies? And now differentiating that from tarsal tunnel. So I know from my experience in an aging population, we tend in tarsal tunnels to get absent responses bilaterally. And so we're not really able to distinguish if it's tarsal tunnel versus age-related changes. We also tend to see needle changes pretty frequently, again, in both neuropathy in the intrinsic foot versus tarsal tunnel. I would suggest that certainly if you're looking at tarsal tunnel and you're seeing perineal nerve conduction studies, then again, this certainly argues against just an isolated tarsal tunnel syndrome. But I think both of these in an aging population can be challenging. Dr. Anderage, would you like to chime in on that one too? Yeah, I agree with everything you said. I would just say I like to see normal needle to the EDB and abnormal tibial needle EMG and I want to see planar and tibial motor responses that are worse than the EDB motor response, superficial fibular and serral. So the thing I hate about the tarsal total, there's 400 nerves you have to do, you know what I mean? It's just like, it takes a long time and they're hard, especially in the elderly and I think it's really, really difficult and I'm really, really confident I can't tell the difference. It's hard. It's really good input. I think I agree and I think looking at orders of magnitude of changes makes a big difference. It's not just looking for mild abnormalities, but by comparison, is there a big difference between proximal and distal for neuropathy? Is there a big difference between perineal and tibial for tarsal tendon syndrome or amorphocal lesion? All right. Let's throw out another question. Let's go to neuropathy again. To the panelists, under what circumstances when you're working up for peripheral polyneuropathy do you check the other side? Do you establish symmetry? Almost always. Almost always. Same. Unless it's completely normal on one side and the patient has symmetric symptoms, then I usually, and if I don't have any differential concerns for something that would present in isolated, but if I'm looking for a polyneuropathy, I always tell residents, if something's abnormal on one side, you have to compare it to the other side and you have to give me normal somewhere, if possible, so go to the arms. I would say from a pediatric perspective too, in kids less than four or five years of age before peripheral nerve maturation is complete, the normative data can be all over the place. There are charts that we utilize for normative nerve conduction, velocities, amplitudes, but because of the variation, we typically recommend doing both sides. Excellent. I'm glad to hear that. I fully agree with you all. Let's go to motor neuron disease. Would love to hear from the panelists, any particular approach to muscle selection? Do you have favorite muscles to pick? And does the clinical pattern of the patient's weakness presentation sway your choice of how you approach the muscle selections? Let's go to Dr. Arnold. It depends on the presentation, of course. I think the best thing is to go to where the patient's weak and then just find two muscles in each region by different nerves and myotomal innervations, and then for thoracic, I do like rectus abdominis pretty well because it's a little bit easier to activate, but I do thoracic paraspinals most of the time. For cranial, I like to do trapezius spinal accessory because it's easy and it's less kind of intimidating. I just tell the patient I'm going to check his shoulder muscle, you know, so it's just you can flow right through it. In the lower limb, if there's not a clear pattern on clinical exam, I'll generally do medial gastroc and vasolateralis just to make sure I'm separating the myotomes. And then in the upper limb, normally the split hand phenomenon, normally the FDI or APB are going to be higher yield. I do find that generally APB is more affected in general. I don't like to test that muscle if I can help it, but sometimes if that's really obviously affected, I will. And then I'll go proximal arm, just trying to make sure I separate the myotomes. Thank you. Anything to add from the other panelists? I'm, I was going to say pretty similar. I usually, I'll do at least three, I mean, I'll start in the limb that's affected. And then I typically do three muscles, you know, provided that each one's a different nerve root and different peripheral nerve. So I typically, you know, I typically will do deltoid and either the triceps or the pronator and then either the FDI or APB to cover that. And in the lower extremity, vastus medialis or lateralis, and then the TA and the medial gastroc. Now, certainly if I have a high suspicion and those three muscles aren't giving me the two, you know, two positive muscles that I need, I'll continue to add on. And then similarly, you know, the tongue is, you know, challenging. So in addition to the trap, I like doing the sternocleidomastoid because they can, you know, it's easier for them to kind of activate. I tend to do thoracic paraspinals over rectus, but again, it's probably easier for placement. So I agree with Dr. Arnold. Based on their presentation that certainly, you know, if they have no bulbar symptoms, I'm going to lean towards thoracic versus, you know, doing cranial nerves. If they have bulbar symptoms, in my experience, I'm more likely to get like distal hand muscles that are involved before, you know, leg segments, if it's an early presentation. There's also a really nice taper in muscle and nerve. Don't quote me on the year, but I think it's 2017 where they go through like optimal muscle acute de-nervation and chronic re-nervation changes in ALS patients, and they actually kind of break down. Like if you just did the deltoid and this muscle, like what percentage would you see? For the most part, I think it's pretty much in alignment with what myself and Dr. Arnold said. But if anyone wants to see that specific paper, they can. Oh, and somebody... I put it in the chat. Is that the one? Yes, that is. Okay. Yeah. And so there's certainly muscles that I think we all have preferences to, but yeah, that's a really nice paper and one that hadn't been done in the past, so yeah. I found that paper very useful also. I'll just comment about one of the things I found on the PMNR side is a lot of the referrals that we get from motor neurons or where motor neuron disease ends up coming to the top of the differential are often surprises in that they're referred for, you know, they think it's plexopathy or they think it's their back pain and that's why the foot doesn't move anymore. And I found that that muddies the waters a little bit with muscle selections because it's oftentimes that we're not just trying to confirm motor neuron disease, but also that it's not something else instead. Great. We have a couple more minutes. I just want to make sure if any of our audience or any of our participants have additional questions, you guys have time to put some of those in there. Meantime, let me ask... I'm going to ask Dr. Rinaldi, one of the things that I struggle with with EMG of babies is getting them to activate triceps. Do you have any particular tricks for that muscle or others? No, but that brings up a really good, I think, teaching point that we talk about with our trainees. When we're doing infants, we take advantage of natural reflexive flexion patterns. So one of the caveats we use or one of the rules we typically use is if you're doing needle studies on a baby and you want to look at recruitment, we go for a flexor muscle group. So upper extremities, bicep, lower extremity, antib, hamstring. If you want to check spontaneous activity, insertional activity, then we go for an extensor group. Upper extremity would be tricep because when you put the needle in, the kid's going to do this. You're going to have a nice, quiet muscle for about three milliseconds. We typically look at the muscle activation patterns in the kids to decide which muscle to put the needle in based upon what we're looking for with the needle. Something else in the chat there. Let's talk about something ulnar. We haven't done ulnar. I'm going to ask the group, under what circumstances do you tend to perform a dorsal ulnar cutaneous study? What are the clinical or electrophysiological things that would push you to get that test? Let's go to Dr. Rad, if you can. Yeah. So certainly, if based on history or exam, I have a high suspicion for an ulnar neuropathy at the wrist, I tend to add the duck in if I already see abnormal snaps or C-maps, and I can't localize. So that's the most common time. So if they didn't ask me about a wrist, but I see abnormal snaps and C-maps, and it doesn't localize across the elbow, and I think there's a good chance it might be the wrist, adding a duck and getting that normal response, I feel like that's the most useful. Because if you do it and there isn't any other changes on NCS, then the question becomes, have you found a normal duck? Has that added anything to the differential? Thank you. Anyone else on that? All right, let's take another question. For patients with a suspected inherited neuropathy, any easy way to get genetic testing outside of an MDA clinic that is reasonably inexpensive and covers most of the likely causes? Inherited neuropathy genetic testing. I can take that. Yeah, go ahead, Dr. Rad. Don't you get it for free now? I think there's some routes right now that you can actually get it for free. We have a genetics counselor in our clinic, but I think I just heard about there's some routes to get it either very inexpensively or free. The problem is the yield of that sometimes is once you get past the first couple big ones, so CMT1A, that's most patients, I think over 70%, then your yield dramatically drops down, especially if it's axonal. The yield is crazy low. If this is a question, if somebody sees a ton of inherited neuropathy, I encourage you to reach out to some of the genetic companies like Invitae. So in the MDA centers, most of us have access to free clinical panel testing. And how that works is the genetic company has partnered with some pharmaceutical company who will cover the cost in agreement for being able to access the results. So this is available for our inherited neuropathies panel, our SMA panel. Invitae's kind of expanded it to include a whole entire neuromusculars panel, but there are specific panels for just inherited neuropathies. And there is free partnership codes that you can input. So if you're seeing a lot of these patient populations, and I encourage you to just reach out to the company for free testing kits and that free partner code. Alternatively, with the panel testing, you can run prior auth on patients. And so a lot of times, there'll be a max out of pocket cost. That's typically $100 to $200, depending on the genetic company that you use. But genetic testing has become much more affordable. I do caution that if you don't routinely do it, be a little careful because we have genetic counselors, but those of us that perform it ourselves are versed and have been trained in some of the aspects of genetic counseling. And you'll get a lot of variance of unknown significance. And if you aren't aware about how to speak to your patient about that, going back to that rule of thumb, don't order anything that you don't know how to explain later on to them. But there are free things available if you see this often and would like that opportunity. Excellent. Thank you. That wraps up our panel discussion. Thank you again to Dr. Rad, Dr. Bernaldi, and Dr. Arnold for being with us tonight. I learned lots of little things that I'm going to incorporate already the next time I'm in the lab. This brings us to intermission. So I'm going to post the schedule one more time. We are right at 8 o'clock CT. So please, everyone, go ahead and take a 10-minute break and rejoin us in 10 minutes to hear from Dr. Kyoto. Feel free to turn your video and microphone off. In other words, go to mute. And that will allow you to take a break without having to leave the entire Zoom room. All right, see you soon. This is Mia, so just give me a holler when you're ready to get started and I can take my slide down and get Tony's up. Tony, are you ready to go? I am. Okay. We have 57 on the line, so I think we are ready. Thank you, Mia. So I am going to welcome everyone back for our final session. Let me get back in my groove here. There we go. This is where we're at. We're wrapping up intermission and welcoming everyone back for our mini plenary session. It is my honor and privilege to introduce Dr. Tony Kiyoto. He is someone I am very proud to have as a colleague. I'm lucky enough to work directly with him here at Michigan Medicine. Dr. Kiyoto is a professor of PM&R here at Michigan Medicine. He is our service chief and our associate chair of clinical affairs. He's also a past president of the AANEM. It's great to have his perspective to share here with the group, and he's going to give us an update, a 2020 update on PM&R and neuromuscular disease. Thank you, Dr. Kiyoto. You're welcome. Hi, everyone. It's really nice to have such a big audience for this first community session, and really my hats off to Sean and Sandra for their coordination and efforts on doing this, so really, really job well done. I want to just talk a little bit about things that are happening in the world of neuromuscular disease in 2020. It's been a very bizarre year, and there are things that I just thought that we shouldn't ignore that are just a part of our everyday life, and just to share that as part of this session. I have no conflicts of interest to disclose, but nobody can talk about 2020 without talking about COVID, and obviously, COVID has changed everything that we do, and certainly in the areas of neuromuscular medicine and EDX, it certainly has changed our lives significantly. Certainly telemedicine has played a huge role in neuromuscular medicine care, and I'm going to show some slides in the upcoming on how that's changed. Just a couple of questions. We know we've heard a lot in the press about how cancer care and heart disease care, that there has clearly been delay in diagnosis and care for patients with those problems, but I suspect that we're also seeing that in the area of neuromuscular medicine. Certainly we've seen some patients with COVID-related neuromuscular disorders who have not been hospitalized, who have been rather slow to get to us for diagnosis and evaluation, and I suspect that there are other areas where we are seeing delays in care. This is important to us because we know that there are some conditions like TBS and ALS where a delay in care really can have a significant impact on the patient's function and prognosis. I think that these are issues that are important that we're dealing with in our home communities in terms of engaging with primary care on making sure that those patients are getting the care that they need. The other thing that we're seeing is a big disruption in rehabilitation care. We certainly have seen that, and there's really good documentation in the PM&R literature on how that's impacted spinal cord injury and stroke care, but certainly it's true with our patients with neuromuscular disorders. A lot of those patients have not been, during the months of March through the summer, been not really interested in participating in face-to-face visits for physical and occupational therapy. And I don't think we've been able to document yet the impact of that disruption, but I suspect over the next six to 12 months, we're going to see more information coming out that the disruption of rehabilitation care has had a huge impact on our patients, and that it's more than just the phenomenon that we're seeing in our home institution with the patients that we care for. Obviously, we're seeing a lot of patients with neuromuscular diagnoses related to COVID. Probably the overwhelming most common is critical illness myopathy and neuropathy, but there are certainly other conditions that have been documented in the literature. Certainly, patients with myositis, the schemata on the right shows that the coronavirus does have a direct attachment to the ACE2 receptor on the muscle and can cause myositis that has been documented to be worse in patients with sarcopenia, who are elderly, and also in patients with pre-existing conditions of neuromuscular disorders, specifically in the literature, patients with dystrophies who have worsening symptoms because of myositis from SARS. Cranial neuropathies, the olfactory gets most of the press, but certainly facial, oculomotor, and trochlear are not unusual. There have been, I'll show a study that's out on AIBP. These patients tend to be more demyelinating and tend to be in patients more likely who are hospitalized rather than patients who are still in the community with less severe presentations of COVID. There have been some literature reports on exacerbations of underlying neuromuscular disorders, specifically myosinia gravis, and those patients typically respond to prednisone and IVIG. And there have been a couple of case reports on prone positioning resulting in neuralgia parasitica in patients after COVID presentation. So there's a lot of places where these patients are going to interact with our folks. I tend to find if our institution is one example of what's happening out there in the general community, we tend to see that a lot of these disorders take a back seat to respiratory and other general health conditions, but all of these disorders are ones that really significantly impact patients' functionality, and these are patients we are going to see. I think these are important awarenesses from the first phase of this disease, because as most of us are seeing in our communities, we're seeing a ramp-up of cases, and so being aware of these presentations is going to be important through the winter months. There's a study of muscle and nerve on AIDP and COVID-19. Thirty-seven cases tend to be older patients, onset from time of first COVID symptom approximately 11 days. Clinical presentation and severity of these cases is similar to those with non-COVID GBS, but again these tend to be patients who are hospitalized. Demyelinating form was seen in about half of the cases. About 14 percent was sensory and motor axonal, and about 13 to 14 percent were Miller-Fisher variant. You'll see CSF abnormalities in 76 percent, and anti-ganglioside antibodies were absent for the most part in when they were tested, so this is kind of the presentation that we're seeing at least in the first wave as reported. A lot of discussion in the literature about chronic pain after COVID. Obviously we're seeing a lot of patients who are survivors from time in the ICU, and for lots of reasons some of those neuromuscular, but for lots of other reasons these patients have a real high risk of chronic pain. In the situation where some of the pain clinics, and certainly ours is one example, kind of take a backseat to the acute care issues, the healthcare systems seem relatively overwhelmed to be able to manage these issues as well, and we see the burden of chronic pain is in lots of different issues. You see patients who are relatively deconditioned, you see patients with neuromuscular disorders, you see patients with CNS disorders, you see patients with significant pulmonary and cardiovascular complications, and then you see all the mental health burden, PTSD, social isolation, long time being isolated in the ICU if they're sick, and all of those things come together to really increase the risk of chronic pain. So again, preaching to the choir because I'm talking to a group of podiatrists who really follow that biopsychosocial model of pain, your services are going to be really important and really necessary for managing what's going to be a real epidemic of patients with chronic pain issues from 2021 and beyond. Well, some people say, you know, you don't let a good pandemic go to waste, and certainly one way in which we did not do that is that we finally, most of our centers were really not very well prepared for telemedicine in March and April, but we got there pretty quickly. And did the pandemic drive telemedicine? And I think in our example at our health center, the answer is definitely yes, and it was on the side of the physicians. The physicians really hadn't bought into it, but when they saw their practices disappeared, they bought into it pretty quickly. Patients bought into it because they knew that they didn't want to come in, and obviously the payers really helped as well, so that's really helped as well. Certainly in the future, we may see more doctor call centers as telemedicine takes a bigger, bigger chunk of our work. I know our current health center is targeting that 30 percent of E&M visits will be telemedicine ongoing into the future. One of the issues that I see is an issue with the increased use of telemedicine and the increased use of the EMR for communication is that there's this expectation that there is real-time, on-demand access to physicians, and that puts a lot of additional burden on physicians. I don't know what you have noticed, but my experience has been that my patients will look at a message to me through the portal, like an email, and they expect to have almost an immediate reply, like you're sitting there looking at your phone, waiting for them to contact you. There are certainly reimbursement strategies for managing this, and so it's something that's worthwhile getting educated about. If you spend more than five minutes with the portal message, there are E&M codes that would allow you to bill for that time, but that does add a lot of complication to your ongoing practice. One of the positive things about this real-time, on-demand perspective is that it might actually mitigate the delay in care. I think that this is the beginning of us seeing this. I think we're going to see a lot more of this, and I think it's really going to impact our practice. This is our health care system, starting at fiscal year first quarter of 2019 through a fiscal year of 2020. And you see the rapid climb in e-visits, 258% increase in eight quarters. And every other aspect of E&M except for electronic consults has really seen an exponential growth during this period of time. And I'm sure your health system has data that's pretty similar to this. The future of telemedicine, we're gonna see a lot more wearable and sensors being connected to the health system. We already have direct access to our ventilators and our CPAP and BiPAP machines with downloaded data. We certainly have the same in terms of downloaded data from pacemakers, but we're gonna be able to track health variables, vital signs and functional mobility and activity levels at a real time basis, a lot more regularly with our patients and that data will be regularly available to us. And it's gonna be part of our ongoing visit and evaluation of our patients. So I think that that's what we should expect. I think that's what's coming. You know, I think we always saw physiatrists as being a natural for neuromuscular diseases, excellent physical assessment skills, understanding disease processes. But one of the things I think that we're really seeing in our trainees now is that ultrasonography is really pushing a lot of positions towards neuromuscular disease. And I think that we as neuromuscular providers really need to be prepared that we will have trainees who are going to use ultrasound as kind of the awakening to the idea of having a neuromuscular career and be prepared to be able to mentor them in this regard. We've been very fortunate. We have a great relationship with Dr. Jorgensen who's taken under his wing some of our trainees and has done a really nice job of doing this. But I think that this is gonna be something that our trainees are going to be demanding of us and we are going to have to be able to deliver that to them. Obviously, we are in a lot of ways primary care physicians as physiatrists for patients with brain injury and for patients with spinal cord injury. And the same is true with a lot of our patients with neuromuscular disorders. Not only do we manage their rehab therapies, their orthotics, their equipment, but we tend to be the go-to person for their musculoskeletal and pain management. And then we handle all sorts of system management issues from neuromuscular respiratory weakness and sleep apnea, the bone health, nutritional management, cardiovascular risk factors, metabolic syndrome, and so on and so forth. So physiatrists are gonna have a more and more engagement with physicians who are doing more the disease management aspect of neuromuscular care. And these are areas that really are going to be go-to areas for physiatrists to really be involved in the management of these patients. And so it's a real opportunity for us. These are areas that we're really strong in and we need to continue to advocate. And we also need to be sure that our trainees are getting this training. I think the other area that I think that is really important for us is to be advocates for technology. Technology is really important for a lot of our neuromuscular patients. Patients who are severely impaired, like some of our adults with Duchenne muscular dystrophy, they come to clinic and they spend all their time on access to the internet and gaming. And they wanna know how they're gonna be able to manage those interfaces, and they wanna be able to access technology. But also, we need to be looking at how we're using technology to enhance patients' function. And that's something that is our secret sauce. It's what we're good at is, it's not just whether or not this device would work for a patient, but what would this piece of equipment do in terms of improving patients' quality of life? And then, of course, an area that we're good at, sometimes we're very frustrated that it falls in our lap, but the whole issue of advocating with insurance companies. We know that as technology becomes available for patients, that the insurance companies are going to be behind the curve, and that we're going to be the ones who are gonna be providing them the education to advocate for our patients, to get the devices that they need that really will change their lives. And that's the job we've been doing for a long time. That is not going away. I think it's gonna get bigger as more technology is gonna be available to our patients. And yes, we do need to do the genetics and all the genetic evaluation and all the genetic treatments. But again, in terms of genetics, you get one cure for one disease. But when you look at applying technology, you get a single functional adaptation that can affect all diseases that affect that area. So if you have a device that works on improving proximal muscle strength, it doesn't matter whether you have FSH dystrophy or ALS. If you have weakness in that area, that technology will help you. So it's an area in which both the genetics, the cure and the technology are complementary. And I think that we are well-equipped to be able to live in that space and to be able to provide that guidance to our patients. Obviously, some of the technology might be used in ways that they weren't attended. The hand on the left, if it looks familiar, that's Luke Skywalker replacing his hand after his fight with Darth Vader. But certainly on the right, a lot of controversy about whether you provide prosthetics for patients that actually make them better than they would have been previously. And so, I mean, there are some controversies that we're gonna have to address in terms of the ethics of the use of technology. And again, I think we're well-versed to be able to address those issues. There are lots of issues with regard to areas of technology that are being utilized. I'm gonna provide you with my presentation because I have some videos in here that you can take a look at. I don't have enough time to show them all because of time, but there's a lot out there already in terms of upper extremity robotics to improve ADL ability, lower extremity robotics to improve patients' functionality, brain-computer interface has got some challenges but has been utilized, and certainly the use of autonomous equipment. So I'm gonna go forward a little bit just so I can get to the end because I am already past time on some of the things that I just talked about. Let's see, things that I wanted to talk about. The last thing I wanted to talk about is I did wanna talk a little bit to you about artificial intelligence because I think that that's gonna be in our future. We're already seeing some of that in our environment now. Certainly people use EchoDot and environmental control to turn on the lights or open the door and whatnot. In the future, we might see virtual assistants being able to provide patients with reminders on what time do they take their medication or that they need to do their ADLs. But in the future, there may actually be robotic assistants and attendants that actually can do the work of a nursing assistant. And so wouldn't that change the formula in terms of what we can do for our patients? We can send a robot up to the moon to drive around, collect samples, do all sorts of stuff. Why can't we invent a robot that actually can dress a patient? And the answer is we can. And I think that that's gonna be in our future and it'll be very exciting when we can do that. There's gonna be artificial intelligence in your office. Now there already is. I mean, Dragon certainly is a primitive form of artificial intelligence. But we know that we're going to have artificial intelligence at our elbow to help us to improve our ability to diagnose and manage patients. It's already happening now. There's a VA system that is being utilized now to help physicians at the bedside to diagnose cancers and to come up with the correct treatment for a specific patient. There are NIH cancer treatment algorithms in AI that are being utilized today. And what that will result in is more personalized treatment and more personalized treatment planning. If you look at the years 2013 through 2016 and look at deep learning articles in PubMed, the vast majority of them are on diagnostic imaging, but it's interesting what the next two are. Electrodiagnosis and genetic diagnosis. Isn't that interesting? And doesn't that sound like neuromuscular medicine? And so we could certainly envision us having tools in the clinic that will help us to identify the pattern we're seeing in a patient and be able to make a correct diagnosis and then to be able to come up with a treatment plan that will be the best treatment plan for that patient. You know, I laugh all the time when we're in the EMG lab and somebody thinks about something and they go, oh, I'm gonna look at an article or I'm gonna look at a book. If you have artificial intelligence, you won't need that. It'll already be there. It'll be at your elbow. There is AI in EMG already using rules and probabilistic theory and knowledge base to be able to create an EMG support system. Some of that is being used to help make diagnosis, but some of it actually is already in a rudimentary sense already being used to come up with unbiased grading for needle EMG results. And this is certainly an area we've talked about in crossfires in the past in terms of grading needle EMG studies wouldn't be interesting if we had AI at our elbow side where we had a objective way of consistently measuring the results of a needle exam. And so that's something that's being worked on and something that we may have in our near future. Certainly use of AI to aggregate patient information, aggregate laboratory and imaging information, genetic information, functional data, and to then use it to forecast functional outcome, use of bionics and robotics for the right patient is something that we will see in most of our careers life. Thank you for your attention. I really appreciate it. Wherever you are, have a great week at the AAPMNR 2020. I'll hand it back over to Sandra. Thank you so much, Tony. That was great. I'm gonna hand it over to Sean. Well, we are out of time, but this was everything I hoped it was gonna be and more. Thank you everyone for attending. Thank you faculty and staff for being here. Thank you faculty for adjusting to this. Thank you to the academy for making all these incredible changes in short notice and all the work that went into it. And I hope to see everybody next year. We have more sessions on neuromuscular and EDX, and I hope to be in the audience with you there as well. Good night, everybody. Thank you. Good night.

electrodiagnostic evaluation

neuromuscular medicine

comprehensive evaluation

consultation code

needle EMG

carpal tunnel syndrome

genetic testing

ultrasound

pediatric neuromuscular diseases

telemedicine

wearable devices

artificial intelligence

EMG support systems