Thanks for inviting me to speak and to both the AAP and the AANEM for the invitation. I'm happy to be representing neuromuscular and electrodiagnostic medicine. It's my clinical subspecialty as well as even before I was certified as a physiatrist, sort of the focus of my research and a lot of my interest in academic medicine. No disclosures. What I was planning on doing for structure is to go through some basics on what the field is. There's so much to cover, so I thought maybe cover a couple cases that hit on some of the really cool things that we do and ways that, you know, I think that sort of maybe more meaningfully show you what your future could be like if you pick the subspecialty. And then at the very end, talk a little bit about just career pathways and fellowship and board certification. And then we'll just remind people to keep their microphones muted, which is, I think, no problem for me if anyone wants to actually unmute and ask me a question. By the way, I don't think we're going to go for a full hour of my content alone. And so hopefully it's fairly interactive. So there's a lot of ground to cover in terms of the pathology or diseases that affect the peripheral nervous system that fall under the purview of neuromuscular medicine. Some of these same diagnoses, of course, are treated for in general physiatry practice. But, you know, in terms of what a neuromuscular specialist does, particularly in the diagnosis and in some of the disease modifying treatments, both gene therapies and immunomodulating ones that would be things that are fairly exclusive to us in terms of treating them, I'm not going to name through the list, but I'll just say that given that some of these things, say polyneuropathy, are extremely common, even outside of an academic setting, there's lots of demand for this expertise in private practice. There can be very general practice if you choose. In fact, that's fairly common at my institution with other people in the division to see a bit of everything. But there's also opportunity to really focus your practice. For example, some of my colleagues only see patients with ALS. When it comes to the balance of practice, you know, a lot of us love to see patients, but we know that that's a little lower throughput and there's a lot of work, you know, after clinic. So some of the clinics being more procedural based, particularly in my life, electrodiagnostics is a nice complement so that, so it gives you a bit more diversity in your practice, but also, yeah, sometimes it has important implications in terms of work-life balance and even billing and so forth, which we could talk about separately. There's lots of opportunities for research. Some of these are very rare diseases, so they haven't been studied intensively. And there's, so in other words, there's niches for people coming into the field that are pretty open and available for people if that's something that, you know, motivates you. And there's lots of opportunities for being involved with patient advocacy. There's a lot of patient-led research organizations and advocacy groups, and there's lots of room for physician involvement in that. A lot of our diseases are not that well understood, so, you know, there is often an important role for advocating for your patients, both with their employers, but also with government and so forth. And lots of opportunity for teaching. In fact, since, you know, physiatry is really a specialty centered around nerve, muscle, and bone, you know, we have the nerve and muscle subspecialty, so a lot of what we do is really of interest, and I often get a lot of my physiatry colleagues asking my opinions on cases for routine things that they see, but just being able to take it from a different perspective, not just the rehab perspective, but the neuromuscular perspective, which might be more molecular or might involve more diagnostics than typical physiatry practice. Neuromuscular medicine is, like I said, focused on the peripheral nervous system, so really starting here, the motor neuron, dorsal root ganglia, their axons in the peripheral nervous system, the peripheral nerve itself, neuromuscular junctions to the muscle. If you think about it, not just anatomically, but in terms of diseases, we see a lot of sporadic disease, in other words, it's not a genetic basis, but there's lots of genetic disease, and as we do more and more gene sequencing, and there's better ability to handle these large data sets, the polygenetic diseases or risk factors for disease is probably going to become a big part of our field going forward. We've already been, because of diseases like Duchenne's muscular dystrophy or familial forms of ALS, at the forefront of genetics in clinical neurosciences, and expect that to grow even more. There's both adult and pediatric patients that you would see. In my practice, I see a bit of both. You can, of course, do a pediatric-focused neuromuscular fellowship as well, if that's of interest to people, and then just like a lot of other physiatry jobs, there's multi-systems involved with our patients that require a lot of coordination with multiple professionals, and so using this interdisciplinary team model, which to a physiatrist is not that unusual, but outside of physiatry is not always as available, but neuromuscular medicine, if I have made any observations of spending part of my time in a neurology department, I would say that the neuromuscular practice, for example, our MDA, our Muscular Dystrophy Association, our ALS clinics, really are built on this interdisciplinary model of care that it almost feels like the most physiatry-like neurologists are the people practicing neuromuscular medicine. Of course, you can go into the specialty, as I'll mention later, from a physiatry background or from a neurology background. Of course, there's plenty of opportunities for research. I think that's relevant to the typical AAP crowd, so I'd mention that the research isn't all just bench stuff, although that's personally what I've been most involved with, so I'm not bashing it, but I wanted to point out some of the research. This is a great study that came out of Ireland looking at the survival of ALS patients who are cared for in a general neurological clinic versus a subspecialty interdisciplinary ALS clinic. Looking at this just based on whether they receive care in a more coordinated fashion in the ALS specialty clinic with multiple disciplines or more ad hoc, seeing a neurospecialist who then refers them on for services, you can see that there's quite a difference in survival between these two curves. One of the most potent interventions that we've had, even before some of the newer medications became available to slow ALS, has been this interdisciplinary model. There are lots of scientific breakthroughs. This is a time like no other, even from 10 years ago when I first started trying to get in the clinic, maybe a little longer than that, and spend time with neuromuscular patients to starting my practice. We've seen approvals just this year of a gene therapy for a familial form of ALS called Tofersen, which is an antisense therapy that knocks down the mutant form of SOD1's function in order to slow the disease progression and potentially do a first-of-its-kind disease modifying therapy for ALS, targeted to a gene. And then a few years ago and since then, there's been a number of gene therapy treatments become available for another disease like ALS, except in the pediatric population. It's not exactly the same disease, it's called spinal muscaratrophy. And that's been a real amazing treatment because this is a disease where ordinarily children wouldn't meet many of their key milestones in motor development, and not only were they able to accomplish those milestones, we really seem to be able to halt progression of that disease with some of the current therapies there. Although they're not perfect, it's been like night and day from a disease that was largely fatal to one being managed with this gene therapy. So being involved with research and seeing it come to leading those really important clinically relevant outcomes is very possible in this field. What is electrodiagnostic medicine? They're often very intertwined, although I will point out that even though neuromuscular medicine has only been available as a PMNR route for subspecialization since 2008, electrodiagnostic medicine in terms of being able to have a certification and practice electrodiagnostic has been available for much longer. And the nice thing about a physiatry background, although some neurologists will also do of course EMGs, but physiatry residents get exposed to a high volume of EMG that's required during their training years as residents, whereas in general for a neurologist to practice electrodiagnostics requires a fellowship. Physiatrists have the choice to do the fellowship in addition, but may have enough training just from their residency programs because that's how ingrained it is into our specialty. It concerns specifically the electrophysiological studies of nerve and muscle. And although it doesn't always give you the exact diagnosis, it's crucial to the diagnosis of many neuromuscular diseases. It doesn't always tell you why there's a problem, sometimes it does, but it often will tell you where the problem is and then allow you to focus your, and we'll see some examples of that, your investigations after you have this crucial test done. In addition to traditional electrophysiology, as you can kind of see from this illustration over here, more and more you're seeing examples of the EMG machine system here also has a built-in ultrasound, or there's a separate ultrasound available in the lab. And combining the two modalities, for example, to target muscles with a needle EMG, or to do other diagnostics with the ultrasound is becoming not just the exception, although we do it in our lab, but it's becoming very normal to see this in electrodiagnostic clinics across the country. And I actually thought, since I think the incorporation of imaging and ultrasound in our specialty as physiatrists, but also particularly in neuromuscular is so interesting. I thought it built the first case, was kind of inspired by that. And if you will, I'll walk you through it. I see that there's a chat and that there's just some housekeeping stuff that looks like in there. But if anyone has any comments of the cases, I'll keep an eye on the chat. I won't expect anyone to unmute or necessarily speak up just because of the format of it. But if anyone wants to take a stab at localization, I'll just give like a 10 second pause if anyone wanted to try. The talk isn't dependent on you guys trying to guess the answers or think through the problems. Just think through it on your own though. So Mr. B is a 60 year old male. He's got a past medical history of hypertension, diabetes, obstructive sleep apnea. He was in the outside hospital relative to our rehab center where we saw him with COVID pneumonia, COVID ARDS, acute respiratory distress syndrome. He was in the ICU intubated for three weeks and then suffered as well during that critical illness, acute kidney injury requiring hemodialysis temporarily. But fortunately he was able to come off the dialysis before he came to rehab. He came to rehab with impairment stemming from his post ICU weakness that wasn't the typical post ICU weakness in the sense that it was asymmetric. The right shoulder was weak more than the left. And there was a lot of intense right shoulder and neck pain as well as left thigh weakness much more than the right thigh, including inability to straighten his knee against gravity. He also had paresthesis in the front of his thigh. He went, he was going to, since he was in the inpatient setting and because at this time, this was in 2020 when we saw him, before he came to our hospital, getting an inpatient EMG wasn't possible at most acute centers because of the restrictions in EMG labs at the time, there was a shortage of PPE, people just weren't doing the tests. So these problems lingered on while he was at an inpatient and we decided to investigate it further in the rehab setting. And this was the case for most of our, most of our inpatients who came post COVID ICU in the early days is that a lot of the workups were incomplete because of the issues around the early in the pandemic. So when we examined him, he had two visits. The first visit was focused on the legs. And so I'm going to show you the exam of his lower extremities. You could see that his most severe motor deficits were on the left anterior thigh, as well as the lower leg here, the anterior and posterior lower leg. He also had sensation deficits including to the inside of the anterior lower leg, as well as on the right lateral thigh. So the lower extremity EMG was done. So right around here is where I typically ask one of our residents who are on rotation to give me their differential. But for you guys, I'll even give you the electrophysiological results. So when we did the femoral motor study to a quadriceps muscle, the vastus medialis, we couldn't get any response on the left and we saw a nice response on the right side. So there was something asymmetric going on here. Sometimes coming out of the ICU, there's this concept of critical illness myopathy or neuropathy, but that's usually a very symmetric process. So clearly something was different in his case. And when we did the needle electromyography and listened to the activity, I know you guys haven't seen these tables a lot, but I'll tell you that if you have changes sort of on the left side of the, towards the left columns of this table, usually means there's active muscle denervation. And that's what we're seeing here in these three muscles, the vastus lateralis rectus femoris, two quadriceps, as well as the adductor longus. And then as we see changes over here on the right, this can tell us about both chronic and active processes involving the loss of motor connections. But there's currently some ongoing changes. And then we see also the severity here that we can't get any recordings from some of these muscles, these quadriceps muscles. There's more recordings available in this other muscle. And then there's some changes down here, but not associated with active muscle denervation and some of the lower leg muscles here to the TA, the dorsiflexion. So what we concluded here is that there seemed to be a process affecting the lumbar plexus, which is the L2 to L4 nerve roots, because it involved both femoral and obturator contributions. It was the most severe problem he was having. And so localizing that, we were thinking immediately, okay, it could be in the plexus, it could be in the peripheral nerves, most likely. We didn't think it was coming from the spinal cord, and it'd be unlikely to be coming from neuromuscular juncture muscle, because those are usually symmetric processes. We went ahead and ordered an MRI, because we still weren't sure why this was happening. And in his case, we found a hematoma here. So the arrows are pointing to this hematoma within the psoas muscle. And so because of COVID patients having a risk for blood clots, he was on apixaban as a preventative, and he actually had a spontaneous bleed in the psoas that injured his femoral and his obturator nerves, just distal to the plexus. So we went on, because I told you this gentleman came back for a second study, so he came back about a week later, we wanted to figure out why his shoulder was weak. Clearly that hematoma wouldn't explain the arm weakness. We saw weakness here in the trapezius muscle. He couldn't shrug his shoulder. And he also was, and that was about four minus out of five. So he could do it, but it wasn't as strong as the other side, and he could barely handle any resistance. He couldn't really rotate his neck much either way, because of how much pain he was in. And we went ahead with this testing to sort of clarify what was going on. In this case, we did a motor response to the trapezius, which is from the spinal accessory nerve. It was much bigger on the left than it was on the right. There was a small response on the right, as opposed to the quadriceps tissue where there was no response on the affected side. This one had some partial response, and we saw signs of this active denervation as well as a loss of connections, although there were still some connections in terms of, we could record some of the motor units when the person had the needle in the muscle and tried to contract. And so this was then diagnosed as a spinal accessory neuropathy in the peripheral nerve, because it was just affecting that. And you could see it spared things like the deltoid or rotator cuff muscles were totally normal. And we went ahead and said, well, let's see if there's something like a blood clot or what could be causing this. It's a strange place to have a neuropathy. And although we didn't see anything pressing on a nerve, what we did see that with using an ultrasound here, so on the right side, the affected side, this is the spinal accessory nerve here. This is the outside of the nerve. The inside of the nerve is usually a little darker than that. It's very black, indicating that it's hypoechoic or usually associated with swelling in this case. And then this is what the other side, the left side, which was intact, looked like, where you had the outside right here, and then the inside being a little bit more gray, but full of the normal nerve constituents, axons, organized in fascicles without edema. And you can really appreciate the swelling when you look at the nerve in a short axis. So you rotate on it and you look at it instead of cutting it on the long axis, where it looks like a big long strip, but you cut it into like a little round tube. And you can see this is the normal side, and look how much bigger and how swollen the right side is. And in his case, although we didn't find anything pushing on the nerve, we think that this may have been a post-viral phenomenon, or we call sometimes this term mononeritis, or in some contexts even Parsonage-Turner syndrome or neuralgic chemotherapy, in other words, for this sort of post-viral nerve inflammation. And since that had happened a few months earlier, and it was incomplete, our plan was to bring him back and to repeat some testing on him. So he actually made very good progress with his rehabilitation, with his therapies. He discharged to home, in fact. He did have still some generalized weakness from being so ill. He had to ambulate with a rolling walker in the community, but he was able to get by with just a cane in the house. He had ankle foot orthotics for his foot drop, particularly on the left side where it was much weaker. And then he saw one of our peripheral nerve surgeons, a plastic surgeon, who, because of the fact that we try to give these people some time to recover on their own. So we wanted to take them out to about six months before we decided if we were going to try to do any nerve reconstruction or surgery for him. And what happened was, because that's sort of where we get the best outcomes, and we give people as much time to recover as possible. But we noticed with the repeat testing that he was actually doing better. Some of the connections were firing better. He was able to get a response now on each of the muscles that was a bit bigger. So we just kept rehabilitating him and saved him a surgery. And he did extremely well after this. So we've done, speaking of earlier the opportunity for innovation, you know, with COVID hitting us like a, in a way that was really couldn't have been anticipated back in 2020, there was a lot of opportunities for discovery. And I can just say that, you know, I was often lumped in as a neuromuscular person as part of a group, for example, here with a plastic surgeon, an ICU doctor and neuro immunologist, a radiologist, you know, and our teams down here as well of, of other physiatrists, intensivists who were making discoveries about some of the radial radiographic findings of nerves, particularly with neuromuscular ultrasound, things beyond nerves, including joints and tendinopathies that were being seen in some groups here with a group. And then we also found multiple nerve injury patterns in these patients that we described. This was a paper in July of 2020. So one of the first descriptions of some of these neuromuscular complications. So it wasn't so much that we were, there was a bit of sort of a misfortune in the sense that Chicago was hit pretty early in the pandemic, but also the being curious and having the skills to do the imaging and to do the electrodiagnostics in order to figure out what was going on with these problems. It just wasn't happening in the acute care. And so at the rehab center, we were in the position to sort of sort through some of these things and make some discoveries here. And of course, the nice thing is, you know, people are, a lot of people are interested in nerve and muscle problems, but as I was the neuromuscular person working on these problems with the rheumatology, with neurosurgery, with plastic surgery, with pulmonary critical care doctors, radiologists that we're all working around, but there's a sort of short supply of neuromuscular people. So it was an opportunity just by me simply being here that I was being asked to see a lot of these really unique patients with these really complex problems and helping out, which is just another kind of reason why this, I think this is one of the, if not the most interesting subspecialties, you know, for me personally, of course, I'm biased, but it is for anyone, you know, when I talk to them about what we're doing, there's often just a lot of easy conversations because most other specialties have issues where that can kind of boil down to some component of a neuromuscular issue, whether it's sports medicine, brain injury medicine, in rehabilitation, there's all kinds of overlaps. So, and very few people train with the skills that you will get if you were to focus on this as your career specialty. So think about that. I'll give you one more case here, and then we'll shift gears to talk about more how to pursue this as a career. So here's a 42, this is a different case. There's a reason I picked it just to give you a bit more. So that was the COVID case imaging peripheral nerve. So this is a 42 year old female. She's got a two year history of right hand and leg weakness, occasional flares of neck pain, no sensory loss. So she had an EMG done and we'll just get to it, right? That's, you know, that's going to be, you know, when it's a neuromuscular case, we almost always get an EMG. So and this table, you can just see the main take home here, a lot of muscles were tested. There were changes that were both this sort of on the left side here showing that there's active muscle denervation and changes. And then there was also chronic patterns of motor neurons, motor units that were large. And there was definitely fewer connections than normal, the muscle, and it was diffuse, you know, affecting the right leg, the right arm. So and even affecting movements that weren't so much clinically weak. We did the conduction studies here, and the pattern was a bit mixed. On one hand, if you look here, this is just sort of pointing you in on the size of the responses. So usually if they're small in size, it means that you have the loss of axon. If they're really slow or delayed, it could mean that you have demyelination or loss of the insulation around the axon. But in her case, she had both smallish responses, they weren't normal. So 3.1 should be 6, 4.9 it should be 7. But also when we went up and did the other points on the arm, which we call the nerve conduction velocities, we could see that there's a drop in the response. It went from here, usually like a 10 or 20% drop. Here it went almost down by half. And again, it went down by more than half, and there's other nerve conduction. So this raised the question of potential conduction block. And there's this other lab finding for this antibody, which is this can be associated with an immune-mediated disease that causes demyelination of nerve. So we don't really have a clear diagnosis, but we know what we need to start thinking about here. Because a pattern like this could be like something as severe as ALS, which is over here on the spectrum, but when someone has no sensory loss, but they have weakness. But it could also, you know, we were almost hopeful that it could be this other condition called MMN or multifocal motor neuropathy, because that is immune neuropathy that can potentially be treated, whereas ALS or even reversed. But with ALS, we generally can't, we can slow the progression, but we can't stop it. So it's a really important distinction. And so many of you may not have heard of MMN before or multifocal motor neuropathy, but it's really these GM1 antibodies go after these ganglion-side antibodies that can be associated with things like also that you may have heard of a Guillain-Barre syndrome or more chronic conditions like chronic inflammatory demyelinating polyneuropathy, or this motor only, which is a rare condition, multifocal motor, basically attack these nodes and these parts of the nerve where the, of these myelinated axons and causes the destruction of these sites and leading to demyelination. And if it's left long enough and not treated, sometimes you eventually lose axons. So it was possible that it was this disease, but it was certainly was also possible that it was something like sporadic ALS. And in the case of sporadic ALS, if people have it, they sometimes have these antibodies too. We really didn't have enough information to be certain. So how do we tease through it? And of course, I guess the theme here is we, with these two talks, and maybe it's a bit of my bias, is we took advantage of some of the imaging properties that we expect with these two diseases. So ALS versus multifocal motor neuropathy are potentially very different when you image because in ALS, the nerves are going to be normal in size, whereas in multifocal motor neuropathy, you're going to have these areas where the nerve has these patches. This is an example of enlargement. And here's an example of a nerve that's pretty healthy in one part of the nerve in the arm here of the median nerve, and then another part where it's really enlarged. And that just doesn't happen in ALS, but it can happen, and it's often pathognomonic in the context of someone with progressive weakness and no sensory loss for multifocal motor neuropathy. And the reason why ALS nerves aren't big is they're causing degeneration of these spinal motor neurons that live in the spinal cord. So you actually just lose the axon, they die back. And if anything, that shouldn't increase the size of a nerve. It may even cause the nerve to be slightly atrophic. But when you have inflammation and antibodies attacking structures in the peripheral nerve, that's where you can get these swellings. And this is some research here that was published in the Journal of Neurology showing ultrasound differences between ALS and multifocal motor neuropathy. So when that's your question, how good is this at distinguishing between them? Well, here's an example of nerve cross-sectional areas by ultrasound with these two diseases and healthy controls. And you can see ALS isn't that different, the control. But although there's variability, the MMN is quite a bit different in terms of the median nerve, in terms of the ulnar nerve, and you can go on and look at other nerves, but these are two of the most commonly studied ones. And so let me show you an example of the median nerve scan here in a healthy person, and then I'll show you one in that patient. So there's the nerve. This is, it looks like a kind of a, we call it a honeycomb appearance. You're scanning up the arm. It dives deeper here, up the forearm, but you can follow it the whole way there. And then it comes back up here and is actually a pretty healthy appearance throughout. And that's a typical size. And you need to see that so that when you see this example of a MMN patient, so we'll click on it here. Watch the nerve here. It's not looking too bad, but now look at it. It's getting quite big. And at some point we're going to pause it here. And now it's like double, tripled in size. It's huge up here. This is really abnormal. These are large fascicles within the nerve. It is very swollen, but this is up by the elbow. You can see there's the brachial artery now. And this is just something you don't see in a neurodegenerative disease. This was fairly normal distally, became very enlarged and patchy approximately. And so this patient, even though the EMG didn't show a lot, wasn't clear in terms of distinguishing between the entities, the ultrasound really strongly, strongly suggested it was this immune mediated disease. We actually treated them with a treatment called intravenous immunoglobulins or IVIG. And you can see here, so here's one of their waveforms. And this is where you have that partial conduction block. So it goes from being this size down to this size as you go up further up the arm. And then one year after treatment, we repeated the test and you can see that basically the waveform almost doesn't change at all as you go up the arm and we see normalization of the response and they were clinically much stronger. So imaging again can be very useful compliment to the electrodiagnostic studies to take care of neuromuscular patients. In this case, it led to the diagnosis of an immune mediated neuropathy, which had a very different natural history than ALS and was amenable to treatment. In the case for people who are keeping track, because if you don't treat MMM for long enough, you can have loss of axons, which is typically not the way we teach it in the textbook. But in these cases, you still need to think about it depending on the clinical situation. Ultrasound is a great test. If it's on the list of possible alternative explanations, one of my biggest jobs in taking care of patients with ALS is to make sure we've not left any stones unturned looking for ALS mimics and MMM is one that you just can't miss because you can treat it. And at this point, I'd just like to switch focuses after those two interesting cases that sort of highlighted, I think, two aspects where I think we're making a lot of progress. Of course, the COVID stuff, which is these neuromuscular conditions after COVID has been sort of new ground for us in trying to understand and treat. Of course, a lot of us have been interested in nerve injuries and peripheral nerve injury care with our field. So we're trying to get more and more outcome data on these patients and understand what their long-term prognosis are and actually have a study on that working with a summer medical student that I know that the AAP does a program as well for students. So very clinically applied research question there to see if these patients do okay in the long run. So we have that sort of thing going on. And then this immune-mediated neuropathy, these treatments now are being, I think, fairly well-established in our clinical care. And you're just not trained to offer those treatments, to sometimes make the diagnosis unless you do the subspecialty training. For the most part, most physiatrists would defer to a neuromuscular specialist in terms of supporting that level of investigation. So it has been two examples of why this is so rewarding for me, because there's just all these new things to discover and because when we see these patients, sometimes we can really change their trajectory and improve their lives. So how do you get going? So of course, you're going to see EMGs, you're going to see neuromuscular patients in your residency training, but in your third year of residency, if you're going to go down this pathway, which is earlier than some of the other PMNR fellowships, what you need to know is that most of the fellowships now are going through a portal, which is a recent thing over the last few years, didn't even exist. I think this has maybe been about five years now. So for most of us, we haven't been only on the side of the portal in terms of assessing applicants and not being one. In the old days, it was a little bit less coordinated and you're sort of doing a bunch of one-off applications. And so here's where you can get to the portal on the AM website. And if you want to do some snooping, just to see what the lay of the land is, there's lots of neat information there. So for example, a list of a bunch of programs, I just picked a section of it here and you can see that you'll pick up that some of the programs are ACGME accredited, some of them are not accredited, some of them will have matched or will have multiple fellowship positions and other ones will have just one. Or in the case of this one, one or two fellowships, sorry, it has two adult fellowships, one pediatric fellowship, I believe. And then you can see that it'll tell you if they consider applicants from a neurology background or a PM&R background or in some cases, it's just neurology. For example, this program here was just considering neurology applicants. Most of them consider both now. That wasn't always the case either. So that's a great resource. If you go to the AB PM&R, you can see that the process for getting certified is, it's only been a specialty that has PM&R certification to the AB PM&R since 2008. There's a number of people who grandfathered in, but since then you needed to complete a fellowship in order to sit for the test. You can do it every other year currently at one of the Pearson testing centers, which I'm sure you're familiar with for some of the other tests you may have written up to this point. And because it's a co-interdisciplinary specialty, so you can do neurology or PM&R background, AB PM&R co-sponsors the certification, but it's actually the content of the exam is determined by the ABPN, so the neurology board. And they're involved also with the scoring and the analysis, which is a four hour test with 220 questions, so no in-person exam. With the electrodiagnostics certification, that you go through the American Board of Electrodiagnostic Medicine. You don't need to have the certification to practice EMG or electrodiagnostics, but there are a number of reasons to consider it. One is that it's the most, I think, rigorous and comprehensive exam that's available. It's certainly indicative of for like the lab that you're working in terms of the certain speaks to the quality or like standards of the lab. And certainly if you're not, if you're at a major academic center versus if you're in private practice, if you're a private practice laboratory, I think in order to compete for referrals, it may give you a heads up. If you're often at a large academic hospital, you will probably get referrals either way, but it's even more important for the practitioner so that you feel comfortable, so that you've done and seen a lot of even the rare diseases that we see, which we might only see a few times a year and are just as up to date as possible. Students with the certification have to complete a certain number of studies, which you would complete part of it during your training and then part of it as a clinical experience after you've completed your residency, which is ordinarily less of an issue for PMNR resident to get that during the residency program. But the post-graduation experience, you'll have to figure out either with your first employer to make sure there's a mentorship or do a fellowship to meet those requirements. This test is done every year, and in the last number of years, there's become an additional bonus test to the ABEM for a neuromuscular ultrasound certificate that you can also add on. Currently, the area of incorporating more point-of-care ultrasound, I'm on the committee for our hospital system, is still a little bit of patchwork. So the ABEM is taking the leadership there to have a certification program. For me, it was really crucial to have this certificate in order to get privileges at my hospital, although that may vary quite a bit depending on where you're looking to work. But I anticipate in the future that there's going to be more rules surrounding who gets to do what with the point-of-care ultrasound. It's really a changing landscape. We do a lot. There's a small group of us. There's not as many physiatrists with this subspecialty training in neuromuscular medicine. There's lots of us with electrodiagnostic medicine. But particularly for the neuromuscular people, if you want to know more about what it is like to work in this field, most of us started off just thinking it was really interesting and the patients and the diagnostics and ability to make these big changes in terms of the management and quality of life, things that are possible with some of the new treatments and interdisciplinary care. Most of us get started for that reason. But really thinking about what it's like to have a job, I encourage you to take a look at some of the work we've done. So this was me and Dr. Rad had done for the AAPMNR meeting. I'd be happy to put on a session at their meeting if invited. And we have now, because the AAPMNR one is behind a paywall, we actually have this similar session that we did with a big group of doctors, physiatrists from across the country talking about career paths, including people who are in the midst of training, who just were early and late practice in terms of faculty. And you can access it for free from the AAMN website. And I just put a tiny URL here if you want to get there, or you can just search it. And again, you don't have to pay to access this one. And it gives you a really sort of lengthy discussion, hearing from a lot of different perspectives about how they've made this work. Not everyone there is board certified or neuromuscular. And that was intentional because neuromuscular and electrodiagnostic medicine are very intertwined. And it's becoming, I think, a growing subspecialty in physiatry. The neuromuscular had been dominated by neurology for many years. But I think we offer something really unique with our ability to lead with things like ultrasound and interdisciplinary care. So the field really benefits from having more physiatrists. And the field also embraces the use of things beyond just the ultrasound, but to gene therapies. And there's so many really amazing innovations that are changing things for our patients. So it's never been a better time, I think, to be in the field because there's so much more we can do than just make a diagnosis. And there's lots of room for the field to grow. We definitely need more physiatrists with this training. And this is a great time to think about it, I guess, from a standpoint of your training, because you're looking for fields where after you complete the subspecialty training that you get to have a great job and there's lots of jobs available to be had. And this one, I would tick both of those boxes. I'd like to acknowledge, you know, my lab does a lot of research. So I'd like to always acknowledge people who support the research I do, including some of the work I showed you on the COVID neuropathy issue. The course, the Association of Academic Physiatrists, who run this fantastic program that I think, you know, I'm really grateful to be connected to because you guys reaching out to you guys has been a real passion for me so that you don't have to work as hard to find out the information about my subspecialty. I felt like I had to do a lot of legwork because it just wasn't a good way to hear about it. Unless you have someone local who's doing it, you really need to seek out mentorship elsewhere. So it's becoming easier to find information. And of course, the AAM for putting our previous session online for you guys to hear about, but also for inviting me to represent the field at this session. So with that said, we've got a good amount of time, a little over 10 minutes for taking questions, any discussion. Oh, and I had one more slide with my contact. I'll put it up there. Sorry, everyone. All right. Yeah. So there's my email if you want to jot it down. If you're more comfortable emailing, I'm on Twitter as well. You can reach out that way if you prefer. And again, I'm happy to answer questions in the chat or have people unmute and chat a little bit more. We'll give everyone a minute here to get some questions, and maybe while we wait, Dr. Franz, you can tell us why and how you got interested in PM&R as a specialty. Sure, yeah, I'll put my, can everyone see the chat? I'll just type my email into the chat. I just saw, it's in the chat. I think everyone can see that now. So yeah, I'm happy because I know it's like, what, you have 50, 60 people here, so it's sometimes a little nerve-wracking speaking up. Why I got into interest in physiatry, so my main interest going into college was sports, like I wanted to be a sports trainer, athletics, and at some point during my undergrad, I did my undergrad in kinesiology. I sort of switched gears from wanting to work with athletes as much as being really interested in people with disabilities. I took advanced course about, you know, gait abnormalities and cerebral palsy. I worked with actually, at that time, a young boy, and he's now a young man with cerebral palsy on his home exercise programs through the summers. And yeah, that was once I realized sort of the goals and needs for someone who was working out for that reason and training for that reason, I thought that was maybe more interesting or greater motivation for me than just, you know, being a sports trainer. So I was lucky. I met a physiatrist during my last year of undergrad. He wasn't my research supervisor, but he worked with him and he gave me advice on my honors research. And that's when I started understanding, at least I knew what the specialty was. And that's often the hardest thing, even for, you know, people in medical school is to realize that the specialty exists and find a person or a contact to explore with, because it's not obvious how to get involved or how to find those opportunities. And so you can't really know what you don't know. So those were some of the key moments for me. I think I see a few questions coming in now. So regarding MMN, what is the general treatment course? Does the patient need only one course or they need maintenance? Yeah. So with MMN, usually people need to stay on maintenance therapy. There's a few options, but say with the, a lot of the patients respond well to IVIG or intravenous immunoglobulin. So the typical course would be to get a loading dose and then follow it up with about an infusion every three weeks. And there are other options to treat it as well, but I think that one is one of the more common ones out there. And occasionally, if you have someone who's not responding as well, you can, you can look into other options. Plasmaphoresis comes up and then there's other B cell mediated therapies that might be considered. Although for me, everyone I've treated with it has, there's not that most common disease has responded to IVIG. So I'm going to, there's the questions are really coming in now. So this is good. For the first patient case, if they had a unilateral accessory nerve had not improved by the six months mark, how could surgery have been utilized? Yeah, that's a great question. So, so there is this with immune mediated neuritis, things like Parsonage-Turner syndrome, if you've heard of that, which is like a form of brachial neuritis that's often triggered by virus or this modern neuritis, there's a one school of thought. Now, when you image, when we image it, it looks like one big thickened tube, but there is a school of thought, especially if it's supported by imaging that these patients can have almost like these hourglass deformities or these twists in the nerve that can form after the inflammation ends, it can kind of heal with some nerve torsion. And there's some groups that are really advocating for doing neurolysis, which means basically you go in and you dissect the outer portion of the nerve. You don't cut into the nerve to see if you can address the torsion. And then, and then actually the nerve may because you can essentially have a barrier to remyelination as well as for axon regeneration to occur through it. We didn't see that. That's one reason why we do image a lot of these patients is we do look for any sort of structural issues. The, for example, the hematoma was, was not big enough at that point when we saw this person that was chronic to be worth going after, but we've had other people where the hematoma was still having clear mass effect and you needed to go in there and address that lesion because the nerve isn't going to heal through it. I think that may answer your question. There are, there are options for nerve transfers as well, which is another thing to think about. Although we usually don't love to do a nerve transfer for certain muscles that are either really close, like, you know, if something's close to the neck, generally speaking, if there's neuritis and we um, give it time, the axons usually get there because they grow about an inch a month. But if it's something like, you know, hand or wrist weakness and that, and it's from neuritis up at the level of the neck, well, since axons only grow about an inch a month, it's going to take a really long time to go from the neck down to the wrist. So in those cases, we do look at what's available nearby to borrow axons from through, uh, for reconstructive surgeries called nerve transfers. And if the nerve injuries are severe, sometimes the nerve transfers have better outcomes. And so I will say that, uh, in general, we'll follow patients with repeat, uh, diagnostic studies, just up until the six month mark, sometimes a little after, because we just don't, we don't want to offer them a surgery. If it's not going to give them a better chance of recovering than, than managing things without surgery. But, uh, we also have sometimes missed something like, uh, something structural that could be addressed. So, yeah, we'd like to see these people back at least a few times. And if we see them two or three years later, there's usually not as much that can be done. So that that's, that's been the way that we manage things. I think that you'll see a lot of treatment algorithms that vary, but often sort of center on that principle of how you surveil it, you know, surveil people for the first, uh, six months or so, because there's a old literature saying that outcomes are really poor if you do nerve surgery after the six month mark. Okay. So that was the, from Spencer. And the first question was, what was that from Mary? Right. I think, sorry, my primary. And then, so the next question, sorry, my mouse pad's not working that well. Okay. I see a question from James. Good afternoon. Someone, someone's interested in pain medicine with genetics and diseases such as fibromyalgia. Do you see the possibility of crossover and private practice? I'd love to do both at some capacity. Yeah. You know, so for pain medicine, in particular, um, with the electrodiagnostics, I think a lot of our pain fellows, uh, have stayed really active with AADM or with the electrodiagnostic tracks of the AAP and AAPM in our meetings in part, because there's a lot of people with, uh, pain from neuropathic reasons. So like injured nerves in the neck and the spine, uh, peripheral neuropathy, CRPS, that the, that the, the diagnostic studies that we perform are very relevant. And of course, as if you come from a physiatry background, you have the skills to, to, you know, like a foundation of skills to build on if you want to pursue that. So it can be really useful, um, to both stay connected to this group of people for based on this, the topics that are relevant that overlap between the two specialties. Also, um, historically with our special, with our interest groups at one point, the electrodiagnostics and pain were actually lumped together. Um, I'm, I'm the chair of the, the AAPMNRs, uh, um, you know, neuromuscular group. And so it broke off as a, as a separate thing, but I think in the past they were, uh, connected. So they've, there's always been a strong relationship between pain medicine and electrodiagnostic medicine. And, uh, and so we, and I get a lot of referrals and vice versa, you know, for example, with small fiber neuropathies and so forth that, uh, we do a lot of business back and forth with each other. So, um, I think, uh, what I would say for you, if you're going to do the pain fellowship, uh, you can, doesn't stop you from doing also another fellowship in neuromuscular medicine, but what would be the more common thing to do is just during your pain fellowship is look for opportunities to keep going with the EMGs and, and then stay connected with the neuromuscular electrodiagnostic, uh, skillset and community that way. And then the next question is, uh, thanks for the presentation. Thank you. Oh, you're welcome. This is an interesting field. Yes, it is, but you're preaching to the choir, of course. Can you describe what a typical day? Yeah. So I think the work-life balance, so that's what I actually alluded to that a little bit, at least in my mind, but sometimes it's subtle and sometimes it's not subtle. I would say that, you know, for a lot of us, like there's the interdisciplinary clinics that a lot of us are involved with say the muscular dystrophy clinic and, or the ALS clinic. And those are really, um, hectic because, you know, you're trying to get patients who come in from further distances seen by everyone in one visit, but it's a great environment because these are patients who are so complicated. And so, you know, I think would be so intimidating to take care of all by yourself, but you've got a team and you're addressing all the issues so that you just feel so supported. And, uh, there's a lot of backup to everything you're doing. And in the end, even though these patients have often really complex needs, sometimes the after clinic work is not as much, uh, as, as I find sometimes when I just do my standalone general neuromuscular clinics, where I'm the only person there and these patients may not have as many complicated needs, but it ends up feeling a lot more, uh, like everything's on you afterwards to kind of deal with. So I definitely enjoy those clinics because I love the team atmosphere, the collegiality of it, the patients are great in all the settings, um, as well. But, uh, I encourage most of my fellows and residents to make sure they figure out in their career. Like for me, I have some research time. So that helps break up sometimes like, uh, the, the keep things just sort of variety of things, but I encourage a lot of people to look at procedures, like a clinic where you do botulinum toxin or a clinic that you do electrodiagnostic, uh, medicine, you know, mixed in with your clinics where you're just seeing new evaluations because, because the, uh, honestly, the number of hours you spend on something after, after clinic ends can be quite high for certain conditions. And, uh, uh, so the, so I think the secret is the thing that wears us down isn't so much the patient facing stuff. It's the, uh, you know, the bureaucracy, the paperwork and the, the, uh, the, um, you know, maybe the appeals for your insurance and so forth. So I think having a diverse clinic in the sense that you do a bit of clinics, you do a bit of electrodiagnostic testing, maybe you have some teaching or research, you know, research built into it. If you're, if your job permits that, that's really made a difference for me because I think I have most of my weekends, other than if it wasn't for some of my grants and research stuff that bleeds into my personal time, we pretty would actually be really good. And yeah, we deal with occasional emergencies, but, um, like, you know, someone getting admitted for pneumonia when they have ALS and having to talk to with like how to manage the patient with the medications that, and so forth, uh, or maybe how to, you know, you have to be careful about giving our patients oxygen, um, because they can, um, retain CO2 really easily if you just give them oxygen without, uh, making sure that you're doing it through the bleeding it into like their BiPAP or their bi-level support. So there's a few little things like that, that you get paged about, but generally I'm left alone. Most of the time there's, uh, most of the patients are, despite, even if they have a severe condition or aren't, you know, that there's just so much resources behind caring for their patients that it doesn't feel like it's all on you. And yeah, the hours are good. And I think the reimbursement can be really good too. Particularly that's the other part of doing those procedures is the electrodiagnostics pays pretty well. And so does some, some of these other things. So it's a nice blend of things that benefit you both from work-life balance, but also reimbursement standpoint. And then, uh, there's another that was from, uh, Kiana and then I see from Queen Denise here. Very informative. The case was interesting and the long COVID. Oh, great. Yeah. Uh, long COVID affects a neuromuscular function. So do you have any articles, case studies that you would recommend to learn more about post-COVID neuromuscular pain neuropathy and its management? Thanks. Yeah. It's there's a lot, actually, when you read a lot of the long COVID stuff, it really focuses on sometimes other topics like the cardiovascular pulmonary, even the brain fog when it comes to neurological. And what I think actually doesn't often get as much attention is the neuromuscular. So we see it for sure in the people who've had severe COVID, their neuromuscular symptoms are often some of the things that will bring the, keep bringing them back into the rehab clinic. Um, post ICU, uh, syndrome or PICS, um, is a thing even before COVID. And certainly the COVID patients with longer times in the hospital, longer times on ventilators, they have it, um, they have it worse than I think that than typical, you know, on average, but it may be proportionate to how severe their illness is. Then there's that other group. Um, so reading about post ICU syndrome and PICS and, and understanding a little bit more about critical illness, neuropathy and myopathy, a lot of the neuritis, mononeuritis, multiplex, or, uh, you know, some of these weird inflammatory myopathy, these are very much like rare cases. Um, but the post ICU new weakness from neuropathy, myopathy, or both that is pretty prevalent, you know, 10% of the patients who come out of a rehab center habit. So, or so after COVID illness. So then there's the people who weren't hospitalized and there's a lot of neuromuscular issues that can at least get considered. One of the most common things I think when you look at it, I guess the brain fog is the fatigue is the, um, or some of the pulmonary issues, but it's also the pair seizures. And so one of the areas that's been really neat and you can take a look at, I think it's, uh, out of the group in Boston, Oakland, who's done some work on immune mediated neuropathy, uh, associated with, uh, viral illnesses, including post COVID. You can take a look at that post COVID small fiber neuropathy, which can happen in people who had milder disease is a neat one, but we've, we've investigated people as well, who have those symptoms with skin biopsies and other things to look into what's the cause of it. And there's certainly a number of them that don't seem to have any detectable small fiber degeneration, but seem to have those symptoms, those pair seizures, those symptoms that might suggest that there is some sort of dysfunction in the peripheral nervous system. And, and in that area, I think, um, you know, the, some people like, uh, Igor Koralnik out of Northwestern has done a lot of reviews and stuff on neurological symptoms after COVID. But if you want to get a sense of the landscape and how common these things are, I think I encourage you to take a look at his work. Um, and there are, uh, some journals like muscle and nerve, you know, or the journal, the peripheral nervous system that, that I think would really be focusing on like, like COVID sequelae that are relevant to the peripheral nervous system. And, uh, yeah, it's been a big topic at our meetings, just like at the AP meeting or any of these, uh, meetings in rehabilitation and neuromuscular medicine. Uh, there's always good sessions on it. So, uh, there's a number of different sources to look into. Um, and yeah, there's definitely some zebras that get published because they're interesting cases, but, uh, I think start with one of those review articles and get a sense of like, what are the most common symptoms and then take it from there in terms of your thinking. And there's, I think if anything, there's a bit of COVID fatigue from the academics as well. Like we, there's a lot of papers coming out, describing some of the new things. And now the work is getting a little bit harder because the follow-through on terms of really doing the detailed investigations in terms of the why, rather than just sort of describing what happened is, uh, one, there's a lot of money going in that's available to support this research. So hopefully we can make, address some of those things. It's hard to do like my lab does preclinical models, but it's hard to do COVID research and preclinical models without dealing with live virus or something like that, which becomes a whole biosafety thing. So we've been a little hesitant to pursue it, but, uh, that's, that's probably what I would do is just start with one of those, uh, reviews. Kuralnik, I'll type his name in the chat, is a good person to take a look at in terms of just describing in both the inpatient and, uh, and outpatient setting the incidents of some of these neurological symptoms and then, and then kind of expand your search from there. Well, and then I see, uh, from Ming Dong, uh, thank you. Could you elaborate a little bit more on different roles in neurologists and physiatrists play in neuromuscular medicine? So I will emphasize that I think neurologists and in physiatrists, although we have a different background, when you've done a fellowship in neuromuscular medicine and when you're certified in, you know, realistically we should be able to all do the same stuff. Well, one of the key differences may be like terms of more practical things. Like if you're looking for a job for neuromuscular division, they're often embedded in, um, academic centers in neurology. So you will have to often, um, make those connections for me. Um, my, my division was really supportive of me taking a part of my job in the neuromuscular division, even though it was outside of PM and R it was in neurology. And that was really key for me, you know, just getting a job in a neurology department as the physiatrist can be problematic. If you have to take general neurology call, just like it would be hard for neurologists to take a job at a, you know, rehabilitation hospital and, and then cover, you know, amputee services or general rehab. So that, that can be a bit of a thing, but in theory, once you get a job, uh, yeah, you shouldn't feel like just because you have a physiatry background, there's things that, you know, in the neuromuscular discipline that you, uh, wouldn't be qualified to do you, you know, most of the programs except for, I think one, uh, are based in neurology departments. So physiatry residents go into, you know, accredited programs in the neurology division and yeah, you get the same training and it's the same exam. So the skillsets are very equivalent. Of course, there's things that just change, you know, the, from your background that, you know, you might influence the way that you handle things. I know I still get a lot of my neurology partners asking me questions about, you know, how to order, what types of therapies to order for back pain or, you know, in terms of orthotics and stuff like that, that I, uh, or technology center stuff related to, you know, the eye control devices and stuff like that, that I'll often be a bridge for them in terms of sorting out some of that stuff because of my background. So, you know, that does happen, but the, the, the way of thinking about it is that, yeah, the, the field, although there are more neurologists that have on average in the, with this certification and who fill in these slots currently, uh, if anything, there's just more of a niche because as physiatrists, when you're getting hired by a PM in our department, chances are they don't have a many people like you with this training. So it can be something you can use to sell yourself and, and set yourself apart from other people. So long answer. I love all the discussion though. And obviously I'm, uh, again, I'm biased that this is what I do. I don't regret it and I love doing it. So, uh, yeah, it's good to listen to some of the discussions. I, like I pointed to you on that panel discussion on the AAM website, you hear a lot of different perspectives, not necessarily negative ones so much because I think everyone was pretty passionate, but just about how they, you know, different ways to set yourself, uh, on your journey towards your own practice. Cause there's a lot of, uh, variation in terms of what our jobs look like, depending on what our interests are. So great. Amy, I think I may have set a world record here for, for the length of my seminar. Right. I just went over, but I love the questions. I was really grateful that there was a question from the audience and I appreciate you taking all those questions and thanks everyone for hanging around with us for a little bit extra time. Um, I will be posting this recording on the Google classroom. Um, and I'm also going to be sharing it with AAM so they can post it on their website as well. So we can get it out there, um, for everybody. And I will see you all tomorrow. We're doing a sports medicine tomorrow. So that will be the topic then. And then we have another discussion session on Thursday. So, uh, thanks everyone. Thanks again, Dr. Franz. This is great. I really appreciate it. Have a great day, everybody. Thanks everyone.

neuromuscular medicine

peripheral nervous system

diagnosing diseases

treating diseases

imaging techniques

immune-mediated neuropathies

interdisciplinary care

research opportunities

teaching opportunities

electrodiagnostic medicine