uk practice for the electrodiagnosis of mnd · electrodiagnosis of mnd results mark baker stephan...
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UK Practice for the Electrodiagnosis of MND
Results
Mark Baker
Stephan Jaiser
Design
• Form A• Practice parameters for individual doctors
• One per doctor, potentially multiple per centre
• Form B• Individual clinical cases
Form AIndividual Practice
General
• Number of doctors 45
• Number of centres 28
0
5
10
15
20
1 2 3 4 5 6
Nu
mb
er o
f ce
ntr
es
Number of responses per centre
Number of referrals
0
5
10
15
Nu
mb
er
of
resp
on
ses
Number of referrals
Number of referrals
• Centres with multiple responses
Responses per centre Number of referrals
2 10-120
2 30
2 30
2 36-75
2 40-45
3 96
3 170-350
6 30
Appointment length
0
5
10
15
30 35 40 45 50 55 60 65 70 75 80 85 90
Nu
mb
er
of
resp
on
ses
Appointment length (min)
Appointment length
• Centres with multiple responses
Responses per centre Appointment length (min)
2 30
2 30-45
2 40-60
2 80-90
2 90
3 40-45
3 45
6 30-45
Guidelines
• In use?
• Which ones?
0
5
10
15
20
25
Yes No
Nu
mb
er o
f ce
ntr
es
0
5
10
15
Awaji Revised El Escorial El Escorial El Escorial/Awaji Revised ElEscorial/Awaji
Other
Nu
mb
er o
f ce
ntr
es
Local protocol
0
5
10
15
20
25
30
Yes No
Nu
mb
er o
f ce
ntr
es
Local audit
0
5
10
15
20
25
0 1 2 3
Nu
mb
er o
f ce
ntr
es
Number of audits per centre
EMG study
• Four regions studied?
0
5
10
15
20
25
30
35
Yes 3 or 4 No
Nu
mb
er o
f re
spo
nse
s
EMG study
• Two muscles per region?
0
5
10
15
20
25
30
35
Yes One in bulbar and thoracic One in thoracic One in bulbar No
Nu
mb
er o
f re
spo
nse
s
EMG study
• One or two sides?
0
5
10
15
20
One side Two sides Depends No or conflicting data
Nu
mb
er o
f re
spo
nse
s
EMG study vs appointment length
0
2
4
6
8
10
12
30 35 40 45 50 55 60 65 70 75 80 85 90
Nu
mb
er
of
resp
on
ses
Appointment length (min)
4 regions - yes
4 regions - no
0
2
4
6
8
10
12
30 35 40 45 50 55 60 65 70 75 80 85 90
Nu
mb
er
of
resp
on
ses
Appointment length (min)
2 muscles - yes
2 muscles - no
p=0.63 (Mann-Whitney U)
p=0.45 (Mann-Whitney U)
• Four regions studied?
• Two muscles per region?
EMG study
• Muscles – bulbar
0
5
10
15
20
25
30
35
40
45
Tongue Trapezius SCM Masseter Orbicularis oris Mentalis Orbicularis oculi Frontalis
EMG study
• Muscles – cervical
0
5
10
15
20
25
30
35
40
45
EMG study
• Muscles – thoracic
0
5
10
15
20
25
30
35
40
Paraspinals Rectus abdominis Erector spinae External oblique Pectoralis Not done
EMG study
• Muscles – lumbosacral
0
10
20
30
40
50
60
Quadriceps TA Gastrocnemius Paraspinals Iliopsoas FHB TFL AH
EMG on anticoagulation
0
5
10
15
20
25
30
Yes No Discussion ofrisks/limited
INR NOS INR<3/discussion INR<2.5/discussion No data
Nu
mb
er o
f re
spo
nse
s
• Warfarin
EMG on anticoagulation
0
5
10
15
20
25
30
35
40
Yes No Caution/caveats Stop>24h No data
Nu
mb
er o
f re
spo
nse
s
• NOACs
Other tests
• NCS
0
5
10
15
20
25
30
35
40
45
Yes If clinical suspicion If requested If clinical suspicion orrequested
No No data
Nu
mb
er o
f re
spo
nse
s
Other tests
• Segmental/proximal studies
0
5
10
15
20
Yes If clinical suspicion If requested If clinical suspicion orrequested
No No data
Nu
mb
er o
f re
spo
nse
s
Other tests
• Repetitive nerve stimulation
0
5
10
15
20
Yes If clinical suspicion If requested If clinical suspicion orrequested
No No data
Nu
mb
er o
f re
spo
nse
s
Other tests
• MUNE
0
5
10
15
20
25
30
35
40
45
Yes If clinical suspicion If requested If clinical suspicion orrequested
No No data
Nu
mb
er o
f re
spo
nse
s
Other tests
• TMS
0
5
10
15
20
25
30
35
40
Yes If clinical suspicion If requested If clinical suspicion orrequested
No No data
Nu
mb
er o
f re
spo
nse
s
Other tests
• Other• Turns/amplitude and MUP 1
• USS for fascics/MMN 2
Form BIndividual Referrals
General
• Number of centres 31
• Time from referral (days)• Range 0-150
• Mean 23.2
• Median 20
Referring speciality
0
20
40
60
80
100
120
140
160
180
Referral indication
0
20
40
60
80
100
120
140
160
180
200
ALS/MND/AHCD/PMS/etc Other
Diagnosis made
0
20
40
60
80
100
120
ALS/MND/AHCD/PMS/etc Other
Accuracy of initial clinical diagnosis
0%
10%
20%
30%
40%
50%
60%
164 18 8 2 21 1 1 1 1 1n
Repeat EMG recommended
• 26%
• Example reasons• “Assess progression”
• “If clinical deterioration”
• For alternative test e.g. sfEMG
Comments
Variation in practice across UK
• Appointment length for EMG for ?MND
• EMG on anticoagulation
Appointment length
• What factors determine appointment length?• Number of muscles sampled? – No.
• Local protocols? – No.
• Published guidelines?
• Survey of UK practice?• Justification for appointment length for ?MND
• Do we need a national standard?
EMG on anticoagulation
• Review of evidence• E.g. Dodd et al.
• Survey of UK practice?
• Focus on NOACs?
• Rolling database?
UK Practice for the Electrodiagnosis of MND
Results
Mark Baker
Stephan Jaiser