CLINICAL NEUROPHYSIOLOGY EXPERIENCE

General Goals and Objectives

1. Introduction

Clinical Neurophysiology (CN) is an area of medicine in which special emphasis is given to the assessment, monitoring and treatment of neurologic disorders involving central, peripheral and autonomic nervous systems and the neuromuscular junction and muscles. This is accomplished by a combination of clinical evaluation and electrophysiological testing.

The one year fellowship training in clinical neurophysiology at the University of Oklahoma will begin after completion of an accredited residency training in neurology, child neurology, general psychiatry or physical medicine and rehabilitation. The program will cover the broad area of clinical neurophysiology with opportunity for more extensive experience in EEG & epilepsy. Although the main emphasis will be EEG & epilepsy, the fellow will have the opportunity to learn techniques of motor and sensory nerve conduction studies, evoked potential studies, diagnostic electromyography with single fiber electromyography, electrodiagnostic assessment of movement disorders, and treating patients with Botox, testing of motor and sensory reflexes, polysomnography, testing of autonomic function and intraoperative monitoring during carotid endarterectomies, spinal surgeries and cortical resections. In addition, the fellow will have the opportunity to observe and learn techniques of cortical mapping of motor and sensory function by direct cortical stimulation.

2. Program Outline: Clinical

1. EEG, Epilepsy Training. During this assignment the fellow will have extensive training in all aspects of electroencephalography including the electronic basis and review of routine EEG performed in the three affiliated hospitals. In addition, the CN fellow will spend time learning to evaluate and manage patients with seizure disorders, which will include participation in review of video EEG of patients admitted to the epilepsy monitoring unit. The fellow will spend three and one-half days a week in this part of his training. This will include two half day clinics where the fellow will be seeing patients in the epilepsy clinic
2. Neuromuscular and EMG/NCV Training. The fellow will spend one-half day twice a week in this part of his training. During the neuromuscular/EMG assignment the fellow will rotate through a neuromuscular clinic once a week and an EMG/NCV laboratory once a week. The CN fellow will be instructed on the clinical management of neuromuscular diseases and learn the principles of nerve conduction and electromyography and autonomic testing. The CN fellow will have one half day of Neuromuscular clinic rotation per week and one half day of EMG, NCV, autonomic testing laboratory experience per week
3. Evoked Potentials. The CN fellow will spend half a day every other week learning the principles of evoked potentials, and intra-operative spinal cord monitoring during the evoked potential rotation.
4. Sleep Disorders. The Presbyterian Hospital Sleep Disorders Laboratory is an active sleep disorders center. The fellow will also obtain training in management of sleep disorders one-half day every other week. The location will be the Presbyterian Hospital Sleep Disorders Laboratory

1. Program Outline: Research

The CN fellow will take part in ongoing clinical research projects. The fellow will have a choice of participating in the ongoing new anti-epileptic drug trials, basic science research projects currently in the neurosurgery basic science laboratory, as well as the clinical studies in relation to management of patients in the epilepsy monitoring unit. The CN fellow will be required to plan and execute a project on his own in the area of EEG and Epilepsy. Any research in other areas, (EMG, NCV, EP) will be optional based on the CN fellow’s time availability and interest.

2. Program Outline: Teaching

Under the supervision of faculty members, the CN fellow will read and interpret routine EEG’s in the laboratories at the University, VA, and Presbyterian Hospitals, intra-operative EEG monitoring done during carotid endarterectomies, and evoked potentials performed pre-operatively and during surgery. In addition, the CN fellow will participate in interpretation of video EEG’s from scalp monitored studies as well as intracranially implanted electrodes. The fellow will also have the opportunities to be involved in cortical mapping as well as intraoperative electrocorticography performed at Presbyterian Hospital, under Dr. Oommen’s supervision. The fellow will actively participate in the epilepsy conferences on Fridays.

During the neuromuscular experience the CN fellow will receive instruction on the evaluation and principles of management of patients with neuromuscular disorders and on the electronic principles as well as practical aspects of motor and sensory nerve conduction studies, needle electromyography, single fiber electromyography, electrodiagnostic assessment of movement disorders, treatment of neuromuscular disorders, and other movement disorders using Botox injections and testing of motor and sensory reflexes and autonomic function. In addition, there will be a monthly session of neuropathology review of muscle and nerve biopsies once a month on Mondays at noon.

During the evoked potential training, the fellow will be instructed on the principles of data acquisition in evoked potentials as well as clinical interpretation of routine evoked potential studies. The fellow will also learn the principles of presurgical evaluation of patients by evoked potentials as well as intra-operative monitoring. There will be a CN conference three times a month on Mondays at noon, to address these areas.

During the polysomnography experience, the fellow will receive instructions on the principles of management of sleep disorders and will gain instruction on interpretation of sleep studies and other sleep related neurological disorders.

 

3. The total time commitment is based on a 5 day, 40 hour work week. The essential clinical rotations for the CN fellow will be as follows:

1. The CN fellow will spend a total of three and one-half days a week performing the EEG/epilepsy responsibilities which will include two half day clinics, one to see new patients and the other for follow-ups; the equivalent of two half days in participating in the management of patients admitted to the epilepsy monitoring unit; the equivalent of two half days in learning the principles and interpretations of EEG’s; and one half day in research related activities. (Total 3.5 days per week).
2. The CN fellow will attend one neuromuscular specialty clinic for the equivalent of half a day per week. Research in this field is optional. (Total 0.5 days per week).
3. The CN fellow will perform EMG’s and NCV’s and will gain hands-on experience in the performance of motor and sensory nerve conduction studies, needle electromyography, single fiber electromyography, electrodiagnostic assessment of movement disorders, testing of motor and sensory reflexes and autonomic function, for the equivalent of one half day per week. (Total 0.5 days per week).
4. The CN fellow will participate in evoked potential studies for the equivalent of one-half day every other week. During this time the fellow will have the opportunities to learn about routine as well as pre-operative and operative monitoring of evoked potentials. Research in this field is optional.
5. The CN fellow will participate in management of patients with sleep disorders for the equivalent of one-half day every other week. Research in this field is not required. (Total for A and B is 0.5 days per week).

Basic neurophysiology training.

Clinical responsibilities.

The program as it is envisioned will be weighted towards EEG, epilepsy and epileptology. The program will provide adequate electromyographic experience to fulfill the requirements for training in EMG and neuromuscular disease. While the fellow is on particular rotations the responsibilities will be outlined as below.

1. EEG/Epilepsy Service: This will include both inpatient and outpatient responsibilities as well as responsibility with a satellite clinic at the Southern Oklahoma Resources Center (Pauls Valley School for Retarded).

1. The epilepsy service admits two to four patients per week. The fellow will be responsible for carrying out a history and physical on patients admitted for intensive neuro-video monitoring and reviewing the patient’s situation with the attending epileptologist. The epilepsy patients are considered part of the larger Presbyterian Hospital inpatient service. The official attending is the attending on the inpatient service. The epileptologist serves as a consultant in this situation. The fellow will be working with the epileptologist. The fellow will review the video neuro-monitoring records each day by himself and then will review the records again with the attending epileptologist. Recommendations for management are made and are transmitted to the attending and residents on the inpatient service. The fellow will work with the inpatient service to optimize the care of patients admitted to the epilepsy service. Patients may also be admitted for Wada testing, subdural strip and/or grid placement, cortical mapping, or for surgical procedures. The clinical neurophysiology fellow will work with the epileptologist in these areas.
2. The fellow will read EEG’s at University Hospital, Presbyterian Hospital and at the VA Medical Center with the faculty electrophysiologist assigned to these services. It is anticipated that the fellow will have an opportunity to interpret approximately 1,500 EEG’s each year between the three institutions.
3. The fellow will see patients with epilepsy in the outpatient setting under the supervision of the epileptology staff. He/she will work directly in the clinic with an attending.
4. The epilepsy service maintain a satellite clinic at the Southern Oklahoma Resources Center, helping to manage the individuals in this population who have epilepsy. Typically these are chronic patients who are difficult to manage. The faculty attending goes to Pauls Valley one to two times per month. It is anticipated the fellow will attend this clinic with the faculty on a regular basis.

1. Neuromuscular Disease Service: While on the neuromuscular disease service the fellow will participate in carrying out of electromyographic studies at University Hospital, Presbyterian Hospital or the VA Medical Center. Currently the major laboratories are at University Hospital and the VA Medical Center. He will work under the direction of the neuromuscular disease specialists.

1. The fellow will attend the Muscular Dystrophy Association clinic while on the neuromuscular disease rotation. This clinic occurs every Monday.
2. The fellow will follow any neuromuscular disease inpatients when admitted to the hospital on either a formal or informal basis. Progress will be reviewed with the neuromuscular disease attending.

1. Sleep Neurophysiology: While involved in the sleep area, the fellow will evaluate patients who are brought in for sleep studies and then will read the sleep studies with the attending polysomno-grapher.

Title Day/Time Location

Nerve & Muscle Biopsy

Mondays, 12:00 – 1:00 Pathology Section, 3^rd Floor, UH Monthly, 1^st Monday

CN Teaching Conference

Mondays, 12:00 – 1:00 EMG Lab, UH Weekly, 2^nd, 3^rd, 4^th Mondays

Grand Rounds

Tuesdays, 12:00 – 1:00 Alternates between Chase Auditorium, VAMC and Vose Auditorium, PH

EEG/Epilepsy Conference

Fridays, 8:00 – 9:00 Vose Auditorium, PH Weekly

BIRD MEMORIAL LIBRARY

Number of journals subscribed to: 2100

Number of volumes in the library: 242,850

Number of Data Bases the library has access to: 6

This library covers all the major journals in virtually all medical sub-specialties and includes a wide variety of neurologically related journals. With the assistance of the library personnel, residents have access to the National Library of Medicine, BRS and Dialog. They also have access to MEDLINE, Nursing & Allied Health, GRANTS, and On-Line Catalogue.

VAMC LIBRARY

Number of journals subscribed to: 287

Number of volumes in the library: 1,853

Number of Data Bases the library has access to: 2

With the assistance of library personnel, residents have access to BRS and they may access MEDLINE without assistance.

CHO LIBRARY

Number of journals subscribed to: 107

Number of volumes in the library: 450

Number of Data Bases the library has access to: 4

PRESBYTERIAN HOSPITAL

Number of journals subscribed to: 150

Number of volumes in the library: 5,000

Number of Data Bases the library has access to: 3

CARPENTER NEUROSCIENCE LIBRARY (in PPB offices, UPNI Library)

Number of journals subscribed to: 18

Number of volumes in the library: 345

Number of Data Bases the library has access to: 6
[through modem connections to the Bird Library]

There is a computer in the Resident/Fellow room with internet access through which any of the online medical services may be reached and utilized by the residents and fellows.

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