Well, we will get started here. So thank you for joining. So this is our first lecture of Restarting the Lecture series. So we had a little bit of a hiatus while our PM&R community leadership switched over. So first, I am going to go through a couple of updates from the community quickly, and then we will get into the talk from Dr. McLaughlin. So we talked as a community, and we did that survey to get a little more information from all of you on how we can best serve you. So we have switched our educational opportunities into three different buckets. So we'll continue to have the lecture series that we've had since March of 2020. That will now be at a standing time. So that will be every second Tuesday of the month at 1 PM Eastern Standard Time. While I am the Vice Chair of Education, I will be organizing that. And the next Vice Chair of Education will continue to organize this. So this is really targeting trainees, but also attendings and faculty. So looking at some didactics, cases, higher-level evidence-based reviews of topics. And then we're also going to start a set, which we have started last month, a separate trainee series. So as a lot of our fellowships only have one fellow a year, or sometimes one fellow every two years, a lot of, in recent years, a lot of those fellows have joined forces amongst themselves to create study groups and continue their education together. So we wanted to help facilitate that. So Debbie Cassidy, our Vice Chair of Trainees, is spearheading this. So that will be every third Thursday, and that will be at 7 PM Eastern Standard Time. And that will include board-level reviews and question reviews. And then thirdly, the Journal Club. So this will be every three or so months in the evenings. And this will be the same format as the Journal Club that was started by Simran Javid, and Kelly Schiavo, and Lauren Fetzko back in March of 2020. And so Jeremy Roberts and Dinesh Radnaskindam had expressed interest in restarting this. So this will probably follow a pretty similar format, and we will have more information on that scheduling soon. And then we did send out that survey. We got 53 responses. So just to review some of the results with you all. So one of the big requests we got, especially from the academic programs, was for the lecture series to try to have more consistent timing so that those programs can protect time for their trainees ahead of time. When we looked at the times, evening times were highly requested. We didn't want to keep the lecture series just to evening times because we didn't want to ask everyone to carve time out of their personal time. Although we are keeping the trainee series and the Journal Club during the evening hours, we wanted to have the lecture series stay during working hours and do that consistent timing so that people can plan ahead a little bit better. Of course, there's no time that's going to be perfect for everyone. But during work hours, 1 PM Eastern Standard Time was the highest response. So that's the time that we went with. And in terms of days, Tuesday was the highest requested day, which is what we'll do for the lecture series, followed by Thursday, which is when we will do the trainee series. And then please, we are just starting this. We are happy to change to serve everyone's needs. So please give us feedback as to how this is going for everyone. Just to go over quickly, some of the most requested topics that were reported were dystonia, which we have scheduled in a few months, gait analysis, transitions and aging, CP, FND. So as you can see, pretty cookie cutter PM&R diagnoses. So hopefully, we'll get some good talks on those in future months. Some upcoming events. So it's the second Tuesday, but on Thursday, it will be the third Thursday. So this is the same week this month. So the trainee series will actually be just in two days in the evening. And that will be a hypertonia board review. And then our lecture series, we don't have anyone for April. So if anyone wants to volunteer, I will probably be emailing a few people to request volunteers. But we do have the few months after that. We have FND, dystonia, and charcot-marie-tooth coming up. This is my personal email, or you can reach out to anyone if you have any interest in giving a lecture. Just so everyone knows, some of the feedback we got on that survey showed that some of the things that people value in these lectures are interactive sessions, cases, and emphasis on the evidence, including trying to cite some of that research, and an emphasis on that higher level pathophysiology and anatomy. We also, to allow for more interaction, switched to Zoom. It used to be just a webinar where we couldn't communicate with each other as easily. So now we'll have Zoom, so we'll have the chat and have the ability for people to unmute themselves and ask their own questions and discuss things. I also opened a ongoing open survey for either anonymous feedback or to volunteer to give a lecture or to volunteer someone else to give a lecture. So this is the link. And we'll continue to enter this link in our future communications for everyone as well. So those are just our quick updates. And we can move on to the actual lecture. So Dr. McLaughlin has volunteered to give us our first lecture of this series, which we're very excited about. Dr. McLaughlin is an Associate Director of Pediatric Rehab Medicine Program. He is an Associate Professor of Pediatrics and a Clinical Assistant Professor of Rehabilitation Medicine at the University of Missouri Kansas City School of Medicine. And we are very excited to hear from him today. So thank you. Yeah, well, thank you, AAPMNR member communities for such a great introduction. Of course, I'm only teasing you, Ibley. But hopefully, everybody can see my slides and hear me at an appropriate volume, which is always a big challenge for people to actually hear me at a real, truly appropriate volume. Oh, man. Do you guys, did a folder pop up there saying something's not responding? Oh. OK. We can see the slides. Here we go. All right. So let's buckle up. We'll talk about pediatric diseases and specific EMGs that I've done, as well as reviewing some of the basics as we go through. I've had a fair number of fortunate grants that people have allowed me to do a lot of research during my time as a pediatric rehab physician, have also done a fair amount of volunteering. And that's a picture of us on the one hill in Kansas City that you can actually ski on. I'm only teasing. There's a pretty big adaptive ski program here in Kansas City, as well as a fair number of other adaptive sports programs. But this is obviously the beginner hill, for lack of better words, where I tend to stick with a lot of my patients that want to do some kind of adaptive sports. So none of the grants or any of the donations that I've received are really specific to this type of a lecture, as you will find going into pediatric EMG is not something that people will throw a lot of money at you to do. But it is one of those things that still remains extremely needed. Our own EMG lab, and this is one of those big sources of pride, for lack of better words, for myself, is that we only have physicians who have been board certified by the American Board of Electrodiagnostic Medicine. So I sat and took that test, I think, a year or two out of my fellowship training. I think it was two years out of my fellowship training now, actually, which is just sadly now one of the four boards that I have to maintain certification for. And so always be careful what you wish for, and knowing that when you do become board certified, you do have MOC to do, obviously. So I pretty much block a fair amount of time for my MOC. We are a lab that is accredited with exemplary status by the AANEM. And so you can have a lab that's accredited by the AANEM, which means you meet certain criterion standards. And then above that standard is a lab that's accredited with exemplary status. And I think we were the first, if not one of the first, pediatric only labs to obtain that kind of level of accreditation. So a big thing for us at Children's Mercy that we're quite proud of. We perform about 150 to 200 EMGs per year at two different locations, and we're doing both inpatient and outpatient EMGs. We are the only specialty at our hospital that performs EMGs, which also allows us, like many of our clinical programs, to maintain the administrative control over some of those programs, which is a huge thing for us to be able to make sure that we are operating a lot of those clinics in the ways that we want to. Why, in parentheses, still study EMG instrumentation and still study EMGs? As I know, so many of our neuromuscular clinics have started to rely incredibly heavily on genetic testing. But genetic testing is just one portion of a toolbox that you will need to know how to interpret whenever you are looking at a clinical picture of a child with either a neuromuscular disease or actually some kind of trauma that needs your evaluation. And so we obviously are looking at these types of studies because of damage to sometimes peripheral nerves or muscles. There's some evaluation that you can do on CNS on the CNS area that we'll get into later as you start to get deeper into electrodiagnostic medicine. And obviously, one of my biggest quotes that I just said today is a picture is worth 1,000 words, but an EMG is worth 1,000 pictures. And hopefully, I will not then spend time performing 100,000 or providing 100,000 or 1 million words on EMGs today. That may lead us to having a little bit too long of a presentation. But I think EMGs themselves are incredibly valuable because they're still one of the only tests that we have that we can look at a nerve or muscles actual function. As we're getting a lot more, and my own clinic is starting to get into doing some nerve ultrasounds, just like a lot of outpatient MSK practices have been getting into. Even though we're looking at things with an ultrasound, it's still a part of the clinical picture. It is not the entirety of the aspect of seeing how nerves and muscles actually work. One of my absolute favorite quotes is that the expert is the person who knows the basics the best. And for me, that quote has always kind of stuck with me because there's a lot of people who believe that the expert's the person that knows all the deepest material and all the little nuances of everything. But a lot of times what happens is when you're the expert, you understand all of the basics of a test or of a study. But you're able to then either extrapolate or the secondary portions of the more deep portions of a test make sense because you understand everything that's going on physiologically and also with the test itself. And so obviously, remember all of these kind of things that we probably had glossed over in a short one hour session are all the things that we take advantage of whenever we're performing complex motor unit action potentials. We are looking at how those nerves travel, how we can depolarize a cell by stimulating with a stimulator, and how that actual current changes when you switch the cathode to anode when you're doing an F-wave study versus an H-reflex versus just whenever you're doing an orthodromic versus antidromic type of stimulation. All those things come into play from a physiologic basis when you're looking at things. And so one thing that I always like to do is show a photo like this or if a family asks to figure out, well, tell me and explain to me what's going on with your nerves. I always tell them that I come from an entire family of electricians. My dad is a structural engineer, so understands electrical things much more than a lot of people do. His two brothers are certified electricians. His dad was an electrician. And then on the other side of the family is a lot of farmers. So as you can imagine, I relate fairly well to some people from rural Kansas and rural Missouri when I'm trying to explain what's going on. But I always like to tell them that myelin itself is like the insulation around a wire, and the wire itself is the nerve. And if you have issues with the myelin itself, then you're having issues with that nerve shorting out. And they understand that. A lot of people from rural Kansas or rural Missouri understand that, even though I will tell you that we're a pretty big metro population of about 2 million people. And I do the same kind of explanation for people from some of the suburbs, and they have no clue what I'm talking about. So I have to think of my different explanation for how to explain those things for people who are from Kansas City proper as opposed to rural Kansas or rural Missouri. But showing this picture sometimes helps them understand what's going on and what I'm checking for in the actual test. When we're looking at CMAPs, remember, this is a thing that we are looking at the amplitude and the latency and sometimes the duration of that CMAP waveform. And so for those people who are at programs, and I know that there are some that are not doing a whole lot of EMGs, maybe the last EMG many of the fellows have done or even attendings might have done might have been actually during the time that they were in residency. And sometimes that's even the last several months of residency. Sometimes that was the January before you graduated. So I just wanted to show this and review it because we will be looking at a few different studies as we're talking through this. This is just a picture of me that somebody took of me stimulating my own media nerve. And I think it's actually, as you'll find out, these pictures that I'm sharing on here have now been put into Google. And now my face and me stimulating my median motor nerve has now proliferated itself across the internet. So be careful what picture people take of you. If I can provide any kind of advice outside of this lecture today, that might be one of those ones. So this was just a picture, like I said, that we used for an illustrative purpose of what happens during the study itself. As far as interesting things that I think we get into when you're starting to talk about deeper level things, remember that a notch filter essentially removes signals from a certain frequency from that actual waveform you're able to see. The most common notch filter that we use is that 60 hertz aspect of it, which is used during lots of our studies to remove electrical interference. I've been very fortunate to design two different EMG labs. And at both of those EMG labs, I have the ability to have one singular grounded plug that goes all the way back to the switch where you're able to control what it is. And I think the building designers that have set up these EMG labs for me think that I'm the craziest person in the world to request one outlet that goes all the way back to the control box that essentially says, why do you want one outlet for? But it really has helped improved our EMG studies in general. And so at our institution, and I don't know if many of you have seen this before, at your own institutions, but pretty much every outlet comes with a label or a number on it. And it's very helpful when you're doing studies at your own institution to look at what other numbers are on other outlets throughout your room. And so one of the things that I do when I first have to do an EMG in the ICU or something like that is I actually go around to all the outlets. And I read the numbers. And I think, which one is the one that would be the best for us to do a study with? You'll still get some electrical interference from the bed and from a ventilator and from SEDs that you obviously need to take off and sometimes take off the bed even to get a great waveform. But one of the things that people don't understand is that now there's many institutions building requirements for each of those outlets to be labeled that are in series or wired series together. So that you can understand, even though you may not have anything plugged into that same outlet, there may actually be other electrical devices plugged into that same circuit. And so I actually look at that sometimes, which is kind of a nerdy thing to do. I understand that I'm kind of in that way, guys. So nobody needs to comment in the chat about how nerdy I am. I know that I am. But getting back to the fact of looking at these notch filters is sometimes when you think about it, when you take out a signal at a certain frequency, sometimes that filters out everything at that frequency. And so sometimes abnormalities that you may be trying to see may actually be filtered out. So I don't always throw on notch filters just for the sake of throwing on notch filters. But I do have a great mnemonic for those people who do have a significant interest in taking to ABIM boards, because there are a lot of questions that I remember having about notch filters and what happens if you decrease this portion of it. What, how's that change your amplitude of a CMAP or SNAP signal? And so you guys probably will just sit back and enjoy laughing at me during this time, but it has helped me remember so many things about notch filters. So this table is something that I had found as a great mnemonic, that if you set it up on the left-hand side, you see what happens with the filter. So HF is the high filters, LF is the low filters. So if you decrease it or increase it or decrease it or increase it, how's that change the amplitude in the area of the signal itself? How's that change the latency and duration of the signal itself? So as silly as it is to say, I have done this during tests and it has significantly helped me. So they give you, I believe, one piece of paper to write something down on during your ABIM test. And this was the first thing that I wrote down straight from memory. And so as you see, it says, do it and do it and do it and indeed and indeed and indeed, right? And you see the way that the arrows are pointed, the way that you say the do it or indeeds helps you to remember which way the arrows actually point. So if you sing the song, it says, Indeed, indeed, indeed. And if you sing that song, right? The arrows, the way that you put your vocal inflections, you pretty much have the ability to reproduce this table at any point in time and answer any question anytime anybody has any chance of wanting to ask you a question about what happens with filters, which now I'm sure I'll see all of you at the AAPM and our annual assembly and you'll ask me these questions and we'll get to sing the song together, obviously. But this is a really good way for you to remember exactly what happens when you change a filter. So we have a few different cases for us to go through. This was first one was a 17-year-old female who actually, why do we have a picture of Wendy's next to it? The 17-year-old worked at Wendy's. And as one of my former attendings used to say, now the real purpose of an EMG study is to hear Dr. McLaughlin talk to all the patients. The secondary benefit is that sometimes we figure out what's wrong with them. And so this was one of those funny things that I have random conversations a lot of times with my patients, as a lot of my fellows will attest, just getting to know them or understand what their life is like. And sometimes there's actually some pieces that come out of that puzzle that are clinically meaningful. The fact that this person worked at Wendy's was not a clinically meaningful thing. However, it was one of those things that was a significant memory I had of her. But this girl had an 11-month history of essentially increasing fatigue, weakness, dysphagia, weight loss due to aversion of having certain foods. So she, I think, still weighed somewhere in the neighborhood of 160 pounds, but had about an 80-pound weight loss. So a pretty significant amount of weight loss. Fatigue, really bad in the morning. She actually had such significant weight loss that there were stretch marks in her upper extremities, weakness pretty much everywhere, and still maintained her reflexes. The first thing that I did was just starting out with sensories and motor studies of an upper and lower extremity. I know that if I were to choose an upper and lower extremity study to do, it always seems like an ulnar is a reasonable study or a median study. A lot of times in pediatrics, we're not so focused on entrapment neuropathies like we would be in the adult population. So as long as you're able to find one of those two in the upper extremity, an ulnar and motor study, usually that, and you feel like you're going to get it, that's usually a good way to start in an upper study. The lower study, I actually used a peroneal motor nerve in this one. A lot of times I'll actually use a tibial nerve. The tibial nerve is really good because it has the highest level of obtaining F waves. So if I was seriously thinking that this was some kind of a demyelinating polyneuropathy, an F wave from a tibial nerve would be extremely valuable. In this case, I went ahead and did a peroneal motor nerve. So as you can see, all of those were actually pretty good. And then I ended up, and here are the waveforms from those studies. Note that if you can see my arrow in the top middle, I actually have a third waveform that's above elbow. That's actually me double checking that when I set up the REP nerve stem study that I was consistent and reliable before we moved on to the REP nerve stem. So as you can then imagine, what I did next was REP nerve stem studies. And so in our lab, we look at the first versus fourth waveforms. And this is about a textbook chapter publication kind of image that you could write or show for somebody who has a neuromuscular disjunction disorder, specifically myasthenia gravis. And so as you see on the top one where we're actually looking at amplitudes, and that's probably the best one to look at. I also included the areas down there below. But the amplitudes in that first series of waveforms, remember you're stimulating at a higher frequency. And essentially looking at it and saying, what does the first versus the fourth or fifth, depending on your lab amplitude look like? A decrement of 10% essentially shows that there's some aspect of a neuromuscular disjunction disorder problem. So that first one, and I apologize for my color blindness, but I will try the best I can with illustrating colors. Either the blue or purple is the first one that I'm talking about. As we move on, it looks like there's a green and a red, but I'm just guessing. So that green or red one is actually immediately after she performs exercise for 30 seconds. And remember that facilitation or pseudo-facilitation occurs, you actually get increase of those amplitudes during the time right after exercise. And the reason why is because you really flooded that whole neuromuscular junction with acetylcholine. And that really allows you to have more normal looking amplitudes as you do that stimulation. But then as you see, as time goes on at one minute, two minute, and three minute post-exercise, I think represented by red, blue, or purple, and then I think yellow or green, something like that on the fifth series of stimulations. It looks like, as you can see, an increasing amount of decrement comes back after that time because we have really exhausted the ability for that nerve to send a signal to the muscle itself. So on the right-hand side is what gets put out when you look at all the CMAP amplitudes itself. So sometimes I actually rely a little bit more on the picture on the left-hand side for showing what that looks like. Again, pretty much everything I had said, but just in graphical form. And so this was just kind of our protocol looking at the first versus fifth stimulation. It's more sensitive from even more proximal muscle groups. So sometimes people prefer to use something like trapezius to do this. This was a girl who I could tell from the way that we were getting along would probably prefer me to do something in the hand. Great kid, but I think anytime you're stimulating close to somebody's neck, they're not as excited about things as if you're fine and sticking to somewhere down in the lower part of their extremities. She was obviously significant enough affected that we were able to actually use a more distal muscle as well. Infants need EMGs too. And I think this is, if I were to say an area where a lot of people start to feel a little uneasy, it's in this population. One, because our instrumentation is obviously significantly larger, but the other part of it is just handling and dealing with a newborn or young infant in the ICU is a little bit more challenging. So this was on a three-month-old who was able to be extubated actually, but still had generalized weakness, and she still had to have positive pressure ventilation. So people were hanging, she was essentially in the ICU and remained in the ICU solely from an aspect of needing positive pressure ventilation. And no one had called me at that point in time while she was intubated to say this young girl remains hypotonic and cannot move. So we performed a repetitive neurostimulation study on her. It was, I would say, as positive as it would be in a young infant. As you can see, there's something on there called simulated exercise. And so this is one of the challenges of doing something like this, or there are several challenges that I can talk about in doing this type of study on an infant. The first is obviously you're utilizing what is typically very large pieces of equipment on a very small arm. And so the ways that I have gotten around doing that is sometimes as essentially restricting the entirety of that arm motion. I have little arm boards that we made a long time ago that are essentially just pieces of a foam padding that are quite firm that you essentially put the infant's hand in. I wrap the entire arm up pretty much that the entire arm kind of looks very mummified. I hate to say that that way. I also have a stimulator that I use. And sometimes we even actually tape those electrodes that we're going to stimulate with on the skin so that we're ensuring that that does not move. As you can imagine, just a one centimeter movement in a child of that size changes you from stimulating like an ulnar nerve versus you're stimulating more of a median nerve. Or even if that child is not as hypotonic as this one is, muscle movement, and even it did occur in this one, muscle movement may significantly change the way that your waveforms look. And so I did this study several different times, unfortunately, for this child, as we tried to do two different stimulations with this kid using rep nerve stem, and then even tried to do intranasal versed to kind of provide some level of sedation because she continued to move a little bit or enough that I thought it influenced the study. One of the challenges with doing this kind of thing is obviously she needed positive pressure ventilation. There are some times that we actually do sedate kids to go bring them back to the operating room or a procedure area where we then do the procedure. This is a situation where if we did something like that, I think there was a significant enough concern that they felt like the child was not going to be able to be extubated. So this was a really good example of what happens when you kind of have a young child and you're trying to do this study. And then also how are you going to get a child to abduct their fingers? For instance, I did this study on an ADM, again, just like we did on the prior one, just because of the level of hypotonia that was being exhibited. How are we going to get a child to abduct their finger for 30 seconds so we can exercise them, right? So what we actually end up doing in that situation is that I increase the frequency of stimulation somewhere in the neighborhood of 25 to 50 hertz. So that's a fair number per second of stimulations. We do that for several seconds, essentially trying to create a decrement at that neuromuscular junction by essentially exercising that muscle using stimulations. There's no way that you'd be able to do the rep nerve study on any kind of child under a certain age that's not able to follow directions. I know that my daughter is four and a half and we have a hard enough time getting her to follow directions sometimes. So you're essentially eliminating a fair number of kids that would be needing an EMG, much less those who obviously are going through a pretty significant procedure during all that time. We have a new study, which is a 13-year-old who pretty much had increasing weakness and then ended up with loss of patellar and Achilles tendon reflexes. They did an MRI, which is naturally the first step a lot of times, it seems like, in looking for any kind of issues. Let's do an MRI of the entire brain and spine and nothing had come back positive at that point. So I was called to do an EMG that next day on this patient and we ended up actually seeing kind of a very cool finding, which is always one of my favorite things to talk about is temporal dispersion. And so this child actually ended up having a Guillain-Barre or an acute inflammatory demyelinating polyneuropathy, to use the fancy term for that. And what happens in that situation is that the area of the entire CMAP amplitude gets completely pulled apart or spread out. And so your amplitudes are much smaller, but kind of falsely so in some ways, for lack of better words, and your F-wave studies are absent. Remember your F-wave studies are an antedromic motor and orthodromic motor study at a supra-maximal stimulation. And so we didn't get F-waves from either of the lower legs on both sides. And even still, it was kind of an interesting thing to look at and essentially say, this is almost definitively, when you do a study like that, you can almost definitively say that this is a demyelinating polyneuropathy, almost solely based on how those initial CMAP amplitudes look. We've had those occur in kids that are even, and I've done EMGs on those kids as young as two or three. And sometimes you have to say, well, how are you able to look at it and confirm with F-wave studies and CMAP amplitudes that that's exactly what's going on? As I'll get into some pearls in pediatrics later, sometimes you have to know which one study you're going to do, if you're going to choose one study to do, because that may be all that the parents or the child may allow you to actually do. So just helpful to kind of think about it a little bit differently than in the adult world, that you're going to do two upper extremity motor studies and a lower extremity motor nerve study, and then two upper extremity sensory studies and a lower extremity sensory study to rule out like a polyneuropathy. Sometimes you have to say, which one study am I going to choose that I think, if positive, would lead us down the route of saying this is likely what's going on. And this 13-year-old allowed me to do all these things. I'll tell you, she was not happy about it. But in a two-year-old that we recently did this on at the beginning of July, both my fellows, Dr. Green and Lyndon Burke, helped me out an awful lot with this too. And actually, I think Dr. Green did the study. We had that discussion of what one nerve are you going to check, if you have the ability to do just one nerve. And a two-year-old obviously only allowed us to do one stimulation and then was pretty much done with the whole thing. But Dr. Green chose the right nerve, was able to do the right amount of stimulation for us to see that temporal dispersion was present. And then we were able to actually confirm an AIDP in a case that they had not yet called me for an EMG for, but had just treated and presumed was AIDP. Getting a little bit into EMGs themselves. And so remember that motor unit recruitment is very important. And this is one of those things that you're really able to look at to differentiate, is there some kind of chronic muscle issue or muscular dystrophy or myopathy versus this is more of a neuropathy aspect of things. And I think this was one of the things that I didn't quite understand or appreciate as well, whenever we were going through training, because like many of you, I did most of my EMGs at the VA where that was less of an issue. And there was not as many studies that were myopathies or new myopathies, I guess, for lack of better words, but in the pediatric population, sometimes those new myopathies are the ones that we see. So remember that firing rate, firing amplitude, polyphasicity, all of those things kind of are qualifications or I should say quantifications that you should look at whenever you're trying to do a motor unit study. Remember the regular firing rate's about five hertz, so five times a second. At about 10 hertz, you'll expect that another motor unit to come in. In neuropathic processes, remember some motor units will be unable or unavailable to fire, so that's when you'll get a motor unit that is trying to make up for the inability of other motor units to fire by then firing at a higher frequency, right? The motor unit, therefore, the motor unit will have increased firing frequency before another motor unit is recruited, which is obviously referred to as then decreased recruitment. And I always have to think about this myself whenever I'm writing my reports, and sometimes even I'll leave a needle in a little longer than usual than if I'm just looking at whether or not there's spontaneous activity like a positive wave or fibrillation. For me, this is kind of the most nuanced aspect of doing needle EMGs is sometimes looking at the motor unit levels of recruitment. Insertional activity, as we've talked a little bit about, when you put that needle in, you're you kind of leave that at rest and you're able to see if there's continued electrical activity. Each of those kind of advancements should be very crisp, which is obviously depolarization of those neuromuscular junctions and the muscle itself causing some of those signs. And so once that needle is really inserted in the muscle, wait several seconds to assess for that spontaneous activity. Any spontaneous activity is really typically abnormal, right? And occurs rhythmically. Pardon? Oh, sorry. I thought someone was asking a question there. Examples of all those abnormal spontaneous potentials are all the ones that you get tested on and are really cool to talk about. And you may go a full day without seeing them. And then you may go a full day and see one on every single patient that you have. So it's really fascinating. I don't see too many complex repetitive discharges. I've seen a couple myotonic discharges on a regular basis, just because of the population we encounter. As you can imagine, in the adult population, a lot of times people go and see lots of CRDs, but very few myotonic discharges in an entire career. So it's obviously very skewed when we're talking about pediatric specific EMGs, what types of discharges we may see relative to adult populations. Um, there are different types of spontaneous activity, some of which are generated by the muscle, some of which are generated by the nerve. And sometimes that's helpful for you to kind of think about, um, from where that abnormality might be coming from. Positive sharp waves, um, really kind of a, a classic thing. If you've never seen a positive sharp wave, you may not have ever gone through residency, I guess, for lack of better words. Uh, but remember positive sharp waves are initially downward. Um, and that's always the thing that I think people, um, forget. And that goes back to the long time ago when you were looking at things with an oscilloscope and all those things, and we have not decided to flip, to flip those screens, um, and look at them and actually call positive waves that way. So anyway, they tend to fire at a rate of, uh, half to 15 hertz. So that's, uh, fairly frequently. Um, but again, note that sometimes, um, if you're seeing a spontaneous activity and filtering that out because of some kind of notch filter, you may not see those things. Um, and then this is obviously a great look of one versus a large train of them. Usually if we're seeing an abnormality or a significantly abnormal muscle, we're seeing a large train of them or multiple positive sharp waves in addition to having, um, you know, a fibrillation included in there sometimes as well. Um, and so looking at it and things like that are always great when you see one, but I, I never try to call a study positive if I've just seen one or two, I want to see kind of more than that. And sometimes in different sampled areas of a muscle, uh, fibrillation potentials are very kind of similar to positive sharp waves. And some of those things that they are spontaneous activity, spontaneous muscle fibers that are firing. Um, sorry to keep going here fairly quickly through some of this, but I think most people are aware of these kinds of different things. And I wanted to get through some of the more advanced stuff later on. Um, some other conditions that are the ones that we see in pediatrics, um, that are associated sometimes with positive sharp waves and fibrillations are all those different myopathies and muscular dystrophies. Um, and then even, uh, from a neurogenic perspective, sometimes I do see a radiation plexopathy, um, that occurs. And so, um, that's one of those things that's kind of an oddity, um, that we see in, in pediatrics just because of, um, the amount of onch, onch rehab, I guess we're doing now. Um, CRDs, uh, we talked a little bit about those. They're a longer run of a complex spike patterns. They kind of are much more regular. Um, those are things that are associated with CRDs or are these specific ones, specific conditions. Um, myotonic discharges are always those when you hear it, you'll know exactly what it is. Um, usually associated with, uh, percussion myotonia, um, and myotonic dystrophy, uh, specifically. Um, there's a few other ones that may be positive or you may have positive findings in those, um, conditions. Um, but this is kind of what they look like on the screen and they've always been referred to as a dive bomber, um, with a waxing and waning type of pattern. Um, we do do some single fiber, um, electrode or single fiber EMG studies at our institution. Um, it is one of the most sensitive studies to look at neuromuscular junction disorder problems. The issue with that is having to have somebody have a sustained contraction for a significant period of time that you're able to look at multiple different waveforms. The challenge to that in the pediatric space is obviously explaining that to a family and explaining that to a child so that they're able to understand what it is that you're doing and why you're asking them to continually contract while having a needle, um, in their muscle. And so from a single fiber electrode perspective, I don't know that a lot of places throughout the country are doing some of those things, but it is a modified concentric needle. We have, um, one specific needle that we utilize to do this study. It costs about $450 or so. Um, and as a result, um, they're actually not for single use only as you could imagine. So they go through central processing and sterilization in between each patient use and kind of a little more complex type of thing than any rectal nerve stem that would be done. So this is a great example on the left-hand side of what your what repetitive stimulator repetitive motor units would look like compared to one that may be abnormal on the right-hand side. This is one of the slides I wanted to get to here guys. So pediatric specific lessons is take what you can when you can and I love this study or I love that quote which was from one of my attendings in residency. He said please take what you can when you can. That's a great piece of advice in pediatric EMG not always a great piece of advice for the rest of the world and your interactions with the rest of the world. So that essentially means that what you need to do is make sure that when you're doing specific studies know that at certain times you may have to do a study or two pause and let the child regroup or reposition or change or sing a Miley Cyrus song and then retry a different portion of that study later. Know that you may only get one part of a study right and so as I mentioned the true peripheral neuropathy workup includes two upper extremities and a lower extremity a lot of times to really truly look at a true neuropathy study but you may only get one part of it especially depending upon how that cooperation and a child's anxiety or fear may go into that. So know that when you're doing that study sometimes it's better to go where the money is that's why people rob banks is because that's where the money is. Sometimes I go to the most affected area or an area that I think is very affected because I may only get that one study. You try to utilize others to help your study so I will say most of the time unless the kid is a football player and about 16 or 17 years old I usually do have a parent sitting with the child laying with the child in bed the child's sitting on that patient or on that parent's lap just because anything that you can do to kind of make that seem easier or go by easier for that child try to do it you know it's all about doing as much as you can to help those kids get through this study as best as you can. A lot of times we'll have child life involved with it or even my terrible jokes got a lot of times get told during part of this as you saw the Wendy's picture before a lot of times I'll end up talking about all sorts of random things with patients while I try to do the study any kind of conversation you can make is kind of a distraction and helps out with lots of that. You can set up multiple parts of a study at one time and this was something that I never did whenever I was in residency but something that I've figured out to be an extremely important and valuable and fast way to do things in the pediatric space especially if you've got a kid who you may not think will get multiple parts of a study done right so if you're really looking at doing an ulnar and a motor nerve study one of the things I'll do is I'll put a ground on the back of their hand I'll then set up my electrodes my active and recording electrodes over their ADM and then I may set the other one over the APB and then in between studies all I'm doing is just unplugging and plugging in different electrodes instead of taking tape off and then repositioning it on a different area and so I found actually that sometimes setting up multiple parts of one study at a certain time allows you to get through a pediatric study much more quickly because you're the one that's been adjusting and modifying what you get plugged in and out of what we call my little dongle which is the thing that comes off of my EMG port so that you're able to extend the link between where your computer is and where those electrodes actually are so I'd say don't make waste and move with haste and so that's kind of part of the the bullet point above is that you really want to try to set up multiple parts of that one time and move quickly between those things so sometimes I'll set up those studies I'll measure what I want to measure and then I'll stimulate at those specific areas so then I'm not having to stimulate stimulate and then remeasure and measure again it's like I try to try to get everything measured sometimes even beforehand both where I'm going to stimulate for site one and sometimes where I'm going to stimulate for site two realize that parents also have muscles and so sometimes we when we think that there's some kind of hereditary condition going on I'll also do an EMG study on the adult sometimes instead of just doing it on the child obviously that has a little bit of registration and insurance related things that go related to that but if we're able to do the study on an adult that we may think is positive it may come back and we're able to figure something out without having to stick the child and usually that's a much better and well-received thing at least by the by the patient not always by the adult but at least by the younger patient itself I always try to meet patients where they are too so depending on what they're able to do that's where I try to do the study as I said it sometimes I've done them in wheelchairs sometimes I've done them in hospital beds sometimes I've done them with them just sitting in the corner of the room on a chair instead of bringing them over to a bed themselves know that your use of word really matters so it's calling something a pen versus a needle significant difference in doing that referring to something like static electricity versus a shock sometimes helps out an awful lot referring to things like you know if you can equate what what the feeling feels like to kids or even if I do it on my own hand or arm first before I do it on a kid it shows them a lot of times that nothing significantly bad is going to happen to them as a part of this study so as I tell a lot of parents I've done several hundred of these studies on myself both in teaching fellows and residents how to do these but also obviously one of the reasons why I've done several hundred of these on myself is because I show kids that oh look how my thumb moves when I push this button and sometimes it just decreases the level anxiety that they have in doing some parts of the study age isn't in everything so just that's something I keep trying to tell myself as I get older is that age isn't everything but I've had four-year-olds get through rep nerve stem studies perfectly fine by themselves without much of a issue I've had those say I've had 14 year olds swear that I was the devil reincarnated after doing a rep nerve studies stimulation study to them so realizing sometimes even because people want to sedate everybody under a certain age and I think that that's one of this is one of those studies that is almost better looked at and attempted and talked about in a setting in a clinical setting before you go ahead and sedate everybody and so one of the challenges of what people continually ask me and I get this from other other referring docs like usually the neurology group or an orthopedic group is asking what do we need to do should we set up sedation for this kid and I usually say let's just try it let's see what we're if we can answer the question you're asking without it because it's just one of those things that's significantly better if we're not having to do sedation on everything and my institution or at least in Kansas City if you google pediatric EMG I said be careful what pictures people take of you it's it used to be the first picture that showed up whenever somebody googled pediatric EMG and so that was kind of a big shock to me because now I guess I'm the face of pediatric EMG although recently right before this lecture I googled pediatric EMG in as well and however the algorithm works now the latest EMG webinar pediatric EMG YouTube video took over my top spot as the number one person on the face of Google uh images for pediatric EMG so I'm really disappointed um that I'm no longer the face of pediatric EMG um at least whenever you google from Kansas City um in Children's Mercy Hospital and so obviously however the algorithm works uh must think that I care more about the latest EMG webinar than a picture of myself so I don't know how that happened but I lost my top spot and I'm a little disappointed about it guys um real quick to talk about some higher level stuff this is interoperative monitoring which is something I do for a week um during a week a month each month where we're looking at SSEPs and MEPs um and a free run EMG signal for kids who are going through spinal scoliosis surgeries and so the reason why we monitor these with SSEPs and MEPs is because whenever you have a child's spine that grows abnormally uh meaning the bones in that spine it's not like the spinal cord itself is completely uh normal the spinal cord itself um is curved along with the spine and usually whenever they perform a large um a large um spinal fusion what they're doing is creating traction on the spinal cord itself so when you create traction on that spinal cord itself sometimes you have changes to the vasculature affecting the alpha motor neurons sometimes you have changes to the actual nerves itself because you are pulling um and creating enough traction on that spinal cord that you are almost injuring that spinal cord or actually fully injuring that spinal cord and so whenever we're looking at this itself the MEPs are obviously stimulated in the brain and picked up in the muscles themselves which is a really great um proxy for the health of the anterior portion of the spinal cord the SSEPs actually relate much more to the dorsal columns um and so that's a really good proxy for what is the distal or the posterior aspect of those spinal cords the free run EMG we look at if there's nerve root irritation whenever they're either putting in a screw or whenever they're um manipulating something um or or dissecting down to that area that if we notice some kind of abnormality or um sometimes if there's a hematoma or a bleeding area around that sometimes it'll be picked up because it'll cause some nerve root compression so this is much more um I call it EMG on steroids and one of the things I really love to do it's allowed me a lot of of clinical opportunities um that didn't exist previously and one of the things that I love the most about um kind of the next level EMG that I do here's just an example of what we're doing when we're doing those MEP studies we have um the BL stands for the baseline and then the the trace above it is the most recently stimulated trace and so when you see the BL it'll tell you how how high the stimulation intensity we utilize so 80 volts on the left and 100 volts on the right and um and then the hand is is monitored because that's your control uh for the rest of the case um and the lower extremities themselves are obviously if they change or um go to base or go flat um then that's a signal that that there has been some kind of spinal cord injury that has occurred during a scoliosis surgery. Same kind of thing with the SSEPs that we actually have an upper extremity um trace so that's the two boxes above a right and left upper extremity lower extremities a left and right lower SSEP um and we're monitoring um as you can see on the top we start at the bottom part of the top picture for something called EP which is Erb's point CSP is our cervical spine where we have needles and then we have uh cortical leads and the two the two lead traces above at the very bottom we um at the very bottom images and the bottom of those images we see CSP which is late um which is um stimulating at like the tibial nerve and we're still picking that up at the cervical spine and then also picking that up in the cortical leads themselves so we're kind of getting both a subcortical and cortical response and the reason why that's important is sometimes with the anesthetic that's utilized we may have blunting or decreases in our cortical responses but may still get good subcortical responses essentially showing that while the brain itself is load our the health of our spinal cord still looks intact so it's kind of a really cool thing to to do and utilize when they put in the screws themselves we actually run a triggered EMG and we stimulate the screw to make sure the screw has not breached the pedicle wall and if it does at certain intensities we know that that screw is too close to the spinal cord if it's usually eight or above when we're stimulating then it's one of those things that we think that the screw is safe and only in the bones and so this is one of those examples where it was at seven when we were stimulating so they actually looked at this screw changed where it was routed and took it out a little bit and then we re-stimulated and it looked a lot better this is a great example of a case that actually did have positive changes this is a waterfall view so if you to look on the left hand side of the screen the flat lines are at our baseline as we start to increase the stimulation intensity you start to see how the MEPs come into vision and then as we go on the right hand side of the screen at 1405 we lose the signal from the left adductor and subsequently kind of lose some of the signals on the or the left foot sorry we lose the left foot and then you actually see a decrease in the tibia gastroc lead and a decrease in the adductor quad lead and essentially this was a case where during correction they tried to over correct the spine and you see how quickly that contained from 1402 being okay to 1405 not being okay and then you see how many different times we stimulated after that as we are trying to re-correct what happened in the OR so usually that's adjusting whatever rod was in there taking that out immediately increasing the MAP trying to get perfusion back to the spinal cord this kid ended up actually being okay and so this is why we actually do all of that type of work with intraoperative monitoring this is kind of just a unique and interesting case of a kid that we knew that had a hereditary neuropathy that underwent spinal scoliosis surgery and you could see that we had to change the sweep speeds which is usually 10 milliseconds per division to 25 milliseconds per division to even see this and then his whole waveform is stretched down and abnormal. I was going to talk briefly about SDRs as I know some institutions here do monitor those or the physiatrists do monitor those what we do is a train of 50 stimulations and we look at the waveforms of those stimulations which muscles are activated versus not activated when stimulating those there's a grading criteria one through four which grade one means it's only activating the muscles that are stimulated at that level grade two may mean activating those muscles at that level and maybe one adjacent level grade three means that you're activating lots of additional muscles on the ipsilateral side so even if you're stimulating like an L3 nerve rootlet you're getting things at L5 and S1 and L4 versus a grade four which is when you get ipsilateral and contralateral types of waveforms so I think that's all I have other than showing this beautiful picture of Kansas City so there's our hospital on the top left there on our new research institute that was just completed last year and so I do have some of my spit samples in there and blood samples and CSS samples so I'm sure they built that specifically for me to house that stuff a picture of our plaza on the top right which is a great high-end shopping area downtown skyline on the bottom right there lit up for when the royals won the world series which now it's a little outdated since now we've had the Kansas Jayhawks win the NCAA tournament last year and two Super Bowls parades since that time so a little outdated picture bottom left is a picture of our most famous cuisine Kansas City barbecue and then in the bottom middle there's a picture of our most famous Kansas City and somebody who is inducted into the into her college athletics hall of fame one and only our Kim Hartman who is our fellowship director so we're very proud of our pediatric rehab medicine fellowship program here we usually match one fellow per year as a part of that program and then our other most famous Kansas City and Patrick Mahomes there so just a brief summary of what Kansas City looks like and very close our hospital is very close to this picture that's taken on the bottom right so kind of a nice location and sit in the city so we're very proud of all the work that we're able to do here in Kansas City very proud of all of our fellows that we've trained in the past and still also have two openings for clinical positions as I know many places throughout the country do but if anybody has any kind of person that would like to interview with me please just go ahead and pass on that info but otherwise thank you Emily for the invitation to present today and I hope that I've done well by staying under the hour allotted so if there's any kind of questions I'm happy to go over those otherwise I'll just kind of stop sharing my screen thanks Matt this is Becky from Boston Children's I think one of the places that we get a lot of questions are from the brachial plexus population and the spina bifida population so a lot are like now it's coming up of like oh should we be doing serial and EMGs for tethering and I'm like I don't know why we're thinking this because I think we since we do so here at our institution we're doing serial CMGs from a neurological perspective and they're using that but I think that like in our institution the orthopedics that are doing upper extremity brachial plexus stuff and then the spina bifida center is where we're getting a lot of these like EMG questions coming from thoughts yeah yeah so Becky that's a good first of all always happy to hear from you good I wish I was seeing you too but sorry that we're just on a virtual situation but that's a great point and so one of the things that has been very fascinating as I said doing IOM and doing EMG I have had the opportunity to do something much more than median nerve studies because of carpal tunnel syndrome right and I think you're bringing up potential utilizations or places in the hospital that we could have that utilize much more though the most recent or most recent examples I have about that is always the question about should we be doing H reflexes on kids who have baclofen pumps to measure for are they getting a super therapeutic or toxic level baclofen because if we're getting if if a child has an H reflex and then doesn't have it after we've increased that baclofen amount have we maximally I should say have we maximally decreased the tone because and that reflex that occurs there I think that there are some challenges just technically from an H reflex perspective another interesting one has now been that they have me doing during laryngoscopes I'm sticking a needle down and we're looking at different muscles that are innervated in the throat so kind of some really interesting ones like the crico retinoid muscle which I've never understood or knew anything about past what we had that short lecture on in medical school and now we're doing kind of some of those studies so I'm I think that when you're talking about to answer your question then Becky when you're talking about BPI studies it's very fascinating that that's not an area that our own hospital utilizes much because I think for both that and maybe the mild meningocele population it's still also kind of a functional decision as to whether or not something occurs intervention wise when you're talking about the tethering part of it I think that would be maybe one portion of the whole picture remember you also have your dynamics you also have imaging which of course I think every neurosurgeon I've ever talked to will always say every kid that was tethered looks like they're tethered still right and so I think that there's kind of that back and forth of is that enough does that provide enough clinical picture to you to help make that decision I don't know if I would make it solely based on one thing but I think if you're looking at it at multiple things that might be a helpful helpful thing. All right, well thank you everybody for attending. I always appreciate getting to see everybody's names and stuff. I'm excited for APMNR annual assembly and stuff this year when I get to see a lot of you. And Amy Zimmerman, I'll probably see you at some triathlon in the middle of Missouri here sometime soon here too. But happy to see so many wonderful names and appreciate all that you all do for Pete's Rehab. It's always one of those things that reinvigorates me in seeing a lot of you and knowing a lot of you of what you actually do on a daily basis that keeps me going. So thank you guys. That was great. Thank you so much. We really appreciate it. Thank you. Bye all.

EMG studies

diagnosing conditions

motor studies

sensory studies

myopathy

neuropathy

demyelinating polyneuropathy

intraoperative monitoring

pediatric patients

comfort