The Neurotransmitters: Clinical Neurology Education

Demystifying Neuromuscular Medicine with Dr. Anishee Undavia

• Michael Kentris • Episode 28

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Do you often forget that the peripheral nervous system is a part of neurology? Our guest, Dr. Anishee Undavia, a seasoned neuromuscular neurologist, shines a spotlight on this enigmatic field, unraveling the complexities of diseases affecting these nerves, by dividing them into "neuromuscular buckets". 

Tune in to hear how her personal journey through the fellowship program peeled back the layers of neuromuscular medicine, exposing a field teeming with breadth and depth.

Together, we navigate the labyrinth of teaching the peripheral nervous system and brainstorm original ways to dismantle educational barriers for medical students and residents.

You can find Dr. Undavia at @AnisheeShah on X/Twitter. 

https://x.com/AnisheeShah?s=20 

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Michael Kentris:

Hello everyone and welcome back to the NeuroTransmitters. So glad to have you here and I'm very happy to be joined today by Anishee Undavia, a neuromuscular neurologist from Penn State Valley Forge. Please introduce yourself. Tell us a little bit about what your deal is.

Anishee Undavia :

Hi Michael, thank you so much. I'm really, really excited to be here. Believe it or not, it's my first podcast, so this is new to me, but I'm really enthusiastic about just the opportunity to talk to you and maybe even an audience that is full of med students that might be interested in neurology, or junior residents that are kind of figuring out what their next step would be within the specialty and referring doctors or any kind of audience that has curiosity about the field of neuromuscular medicine and what it's all about. I am currently faculty at Penn Medicine at one of their suburban sites called Valley Forge, but I recently switched over from a more of an academic position.

Anishee Undavia :

I was in the Einstein-Jefferson system and I had a great time there, especially because I was very, very involved in teaching, specifically with the neurology clerkship. I was involved in that, but also in hands-on training with the residency, recruitment and that sort of thing. So because I'm no longer in that environment, I'm just so grateful for this platform, whether it's Neuro Twitter or podcasting, and, having met you, just because I would love to continue to stay engaged, continue some form of teaching and if it's in this space, I think that's a really creative way to keep going with that. So thank you again for inviting me.

Michael Kentris:

Oh, I'm so happy to have you actually, so I definitely sympathize with that story. Similar right. I went from a more neurology academic department and now I'm a little bit kind of in my little insular silo in a community teaching program. So I have trainees, but not neurology trainees, and it just makes you appreciate all the more how important it is to teach neurology, and the clinical neurology in particular, to not just neurology residents but to all commerce right, medical students, internal medicine residents and everyone who's willing to listen to us talk on at length about minutia. But why I'm particularly glad you agreed to join me today is neuromuscular neurology is such a challenging area of even just neurology in general and I was hoping you could, for those who might be less familiar with the subspecialties, just give a little definition of what you would consider neuromuscular neurology.

Anishee Undavia :

Yeah, that's a great question and a good place to start, and I often have to explain this to medical students who think of neurology as the brain and the spinal cord, but also we have to remind them that the peripheral nerves are a part of that.

Anishee Undavia :

And I guess I'll start by saying when I talk to patients, I tell them about the outside nerves or the peripheral nerves and specifically, when I'm in the EMG lab, I tell them, you know, this test isn't really going to give me information about Parkinson's disease or multiple sclerosis, but it really tells me anatomical information of any damage to the nerve, starting from the nerve root and all the way out to the muscle. And so that's really what we cover in neuromuscular medicine. Of course there's overlap with, you know, some central nervous system findings, but really when I think of neuromuscular, it's really traditionally diseases that affects the nerves after they exit the brain and spinal cord or beyond, and it includes such a vast number of conditions. And what I'll say is it can be as simple as a nerve compression, like what we see in carpal tunnel syndrome or ulnar nerve entrapment, but it also includes a whole host of autoimmune conditions, neurodegenerative problems and hereditary conditions that we can certainly talk about more in detail. So that's kind of how I explain neuromuscular to folks.

Michael Kentris:

Excellent and you know I think it's very important. I talk a lot about this as well, right? I mean, I think in frameworks, right, a lot of medicine is pattern recognition, but building those frameworks for the peripheral nervous system specifically, I think, is a little more challenging. There's not as much emphasis put on it. And again, when you're teaching, like junior trainees and things like that, what do you see as like the main barriers for people picking this up as easily as, say, like, identifying stroke syndromes versus, say, different neuropathic patterns?

Anishee Undavia :

That's a very, very good question and I think one of something we should talk about more when we think about training students and residents. I think from my experience one of the biggest barriers is for medical students and residents alike. They the emphasis is in the hospital, which is great and very, very important, because acute neurology is something we have to all be familiar with as neurologists and recognize and treat in a rapid and appropriate manner. But I think because there is so much volume these days and so much to cover in the hospital with whether it's strokes or seizures, neuro ICU cases, subarachnoid hemorrhage, et cetera there just isn't as much time and space to even think about the peripheral nervous system. So I think that's one of the big barriers. I don't know if you've experienced that, but it's that not only do we not have time to think about it, but then when we want to open that door, there's so much that we want to turn away. And one funny thing I think is that because, from med school, when you think of the peripheral nervous system, I feel like many of our minds go to the brachial plexus, which is like ugh, I don't want to think about it. I failed that test, you know. I memorized those branches a hundred times. I can't keep going back and it's obviously so much more than that and it doesn't have to be as complex as what we think about. So I think that one of the barriers is just not opening that can of worms and maybe we can overcome that by talking about it in a bit of a different way, what I have tried to do, because I went in my last position. I was both involved in neuromuscular teaching but also general comprehensive neurology in the hospital and in resident clinic. So I would try to.

Anishee Undavia :

I'll give you an example. So let's say it was Saturday and we're rounding on our inpatient service and we have a stroke follow up. Somebody who had a right internal capsule stroke came in with left sided weakness and the resident has done a great job seeing the patient following up. And then we go to the bedside for routine rounding and you know things are kind of tucked away. The patient's doing well, waiting for rehab, but I'll notice like some of them have atrophy. So I'll look down and I'll see that patient looks fine. The exam is stable.

Anishee Undavia :

The resident has said oh, the patient has three out of five strength in the left upper limb. And then I'll look at the hand and I'll see that the first dorsal enterosia is completely wasted away. We've seen this before, right? And I'll tell the resident hey, I'll just kind of look at my with my eyes and kind of make eyes with them and have them look at the hand and I'll say what's that? And it throws them off guard a little bit and I try to be non, you know, not scary about it and I'll say, especially if it's like a PGY2 resident, I'll be like you might not know why that hand is weak, but try to take a guess. Do you think it's about the stroke?

Anishee Undavia :

And you know most of them will know, well, no, atrophy doesn't happen that acutely and so it's probably not related to stroke. But they didn't kind of push further. They said, okay, the stroke is fine and they're ready for rehab. And then they'll say I don't know what that's from. I think it's one of the phenar or hypothenar muscles. You know, they're not even sure which muscle it is.

Anishee Undavia :

And now I'll kind of start asking questions in a non-confrontational way and if they're wrong, I often say well, I'm glad you said the wrong answer, because now that I'm going to correct you you might never get it wrong again and I'll say, okay, well, that's the first dorsal enterosus. What nerve do you think innervates that muscle? And they'll think about it and many of them get it right. They'll say the ulnar nerve, but some of them might say median and you know, depending on their level of training, they might have no clue at all. And okay, so we get to the ulnar nerve and then I'll say, well, what branch of the plexus do you think that supplies the ulnar nerve? And then they'll think about that. And then I'll keep working my way back and that, like three minutes, is a lesson in and of itself.

Anishee Undavia :

And I feel like that approach where it's not interrupting them too much, but hey, they had a minute to think about something that they might have not had on their mind. That patient has now taught them so much more than just that right lacunar stroke. You know what I mean. And so I kind of try to just catch them when I can and just fill their neuromuscular bucket with a little bit of information, and then the next time we see each other it might be in resident clinic and we'll take it a step further from there. That's kind of my approach. Another example is sometimes an inpatient will need an EMG and I'll really just try to encourage the resident to come down with the patient and observe the EMG and see. You know that that puts it puts the EMG in the context of their patient that they're looking after and really it gives them a sense of ownership about the case and pushes them a little bit. So that's, those are a few of my approaches.

Michael Kentris:

That's excellent, yeah, it's, it really emphasizes that, that extra step. When there is a piece that doesn't fit right, we have to ask ourselves why and then unpack that a little bit. And I know, right, we've, we've all been in the hospital and things get busy. And you right, it's, it's not a quote, unquote hospital problem and it's easy to certainly to brush that aside. And right, there's, there's not a huge number of neuromuscular emergencies, although there are some. And certainly you know, I can see why a resident, especially if they're rushing through their pre rounds, would would miss a little bit of intrinsic hand atrophy in their stroke patient. Yeah, but Exactly, you know. But you bring up a good point, right.

Michael Kentris:

I remember myself as a, as a third year medical student, right I was, I was on a PM and R rotation, right. So we're doing a lot of EMGs and things like that and I must have drawn the brachyoplexus like a hundred times and a month later I couldn't have done it at all. Right, it's. It is one of those things where it's like it's so abstract when you first learn it without clinically applying it. And you know, the instructor I had was okay, but he didn't. Let's just say he wasn't up to your standards perhaps. So you're not applying it Like why am I, why am I looking at this muscle, why am I looking at that muscle, why this nerve, and kind of painting the picture right. That that you know neurologist, obviously, localization, that would kind of unwrapped the entire problem. And it does seem like there there is, especially in the preclinical and even, to a degree, the clinical years, this lack of emphasis on the clinical applicability of a lot of the knowledge that we put ourselves through in in medical training.

Anishee Undavia :

I totally agree with you and it goes back to the the idea of neurophobia versus neurophilia, and some of the things that we deal with have a very complex neuroanatomy or you know, a broad range of differentials that can be overwhelming, and I think it really depends on who's teaching it to you and how much they like what they're doing and how much they teach you rather than shame you.

Anishee Undavia :

That that happened to all of us right At some point in our training.

Anishee Undavia :

I might have shyed I don't even know but maybe I shied away from certain fields because of that shaming, versus leading myself into one, because I saw an attending who loved what they did and wanted me to love it just as much as they did.

Anishee Undavia :

So I do think that's a big part of it. In any, in any subspecialty, but specifically neuromuscular, which you know, you can easily turn someone away and say I never want to think about the peripheral nervous system again. So I think that's very true and in fact I remember in that one specific case with the FDI atrophy, I think by Sunday the resident was like oh, by the way, I talked to the patient's wife and she said that he has had a long history of neck pain and had some, you know, surgical considerations for cervical radiculopathy and that kind of put it all into context for them and I think that wraps it up. They don't have to do much more. It's not like it's going to change the patient's course, but at least that bucket is filled with that knowledge and they can come back to that if it happens again, and I think that's really important.

Michael Kentris:

That's excellent. So you know, you brought up a good point, right? So not not everyone goes into neurology, obviously from medical school, and then even amongst neurologists, you know, there I would say it's a minority of people who go into neuromuscular subspecialty. So what was it in your training and your experiences that brought you down that pathway?

Anishee Undavia :

Yeah, that's, that's actually. It wasn't a little bit of an interesting journey. I guess when we, when I was in residency and everyone was thinking about their stroke fellowship or movement disorders, I actually didn't really know. I loved the whole breadth of neurologies but you know a lot of people went for fellowship so I decided to do neurofizz, thinking it would give me some added skills and procedural base to do EEG and EMG, which so I went on to do that.

Anishee Undavia :

But it wasn't till I was in that fellowship where I was exposed to the breadth of neuromuscular. I actually didn't really even know that we're the ones who you know diagnose and treat these rare muscular dystrophies or genetic conditions. I kind of knew but I didn't know that there are these places all over the country that collect very interesting, you know, like MDA clinic or ALS clinic. I guess maybe I was when I was in training it was the beginning of a lot of that stuff. But I got exposure as a neurofizz fellow when I was on the EMG half of things to see these specialized clinics where I saw more, you know Duchenne, muscular dystrophy or congenital myopathy such as you know Bethlehem and Ulrich's myopathy that you would never see in your career unless you were specifically attending in these clinics or rotating on these clinics. So that really interested me. I didn't. I didn't even know that it existed. So when I was in neurofizz I was also, I guess, kind of not ready to grow up and get a real job. So I talked to the neuromuscular people there and I said, hey, I'd really like to stay and do more of neuromuscular training.

Anishee Undavia :

Neurofizz is really focused on EMG and that's another misconception that maybe residents and students might think neuromuscular means EMG, but it is really so much more than that. One of my neuromuscular tendings used to say EMG has its limitations, it's not an end, all be all and there's so much more now. So I ended up doing two years of fellowship one year in neurofizz where I did EEG training and EMG training, and then a special year in neuromuscular where I got to really get a lot of experience with muscular dystrophy. A lot of my specific fellowship was focused on muscle, so I got a lot of muscular dystrophy, inflammatory myopathies. I know other centers are focused on neuropathy and so even that is getting more and more specialized and separated. But yeah, that was kind of my journey. Is that? I don't think. Unless you see it, you don't know what exists, and it opened up my eyes to what's out there and what you can do for people.

Michael Kentris:

Yeah, I was a neurofizz fellow as well, but I was more on the epilepsy side of things and. But I spent some time with the neuromuscular tendings and you're absolutely right, especially like the child neurology, neuromuscular tendings, just all these disorders that you know, you maybe you read like a paragraph about as you're studying for boards, but you may never have seen in your entire career. And yeah, it's one of those things where, like the entire breadth of neurology is so vast it feels like the body of knowledge is nearly impossible to stay on top of anymore and this accelerating at such a fast pace.

Anishee Undavia :

It is, and so much so that you might not even have access to it in your particular program. So one of my pointers to students and residents specifically residents, before they're thinking about applying, is if there's an area that you're peaked by and they just don't have the breadth of it For example, if you're for someone like you who's who's might be might have been curious about epilepsy if you don't have surgical epilepsy in your specific center, seek out that rotation, because I know there's visiting rotations and things like that, just so you can know what the potential is for you if you're interested in academics or if you're interested in going into that specific area. Unless you see it, you really won't know what it's all about and what the day to day of those providers is like.

Michael Kentris:

Very true. And yeah, it's high cutie, low cutie, big center, small centers, and they're different needs, different resources, all across the map it's. It is interesting, right, we have all these like ACG and me certifications for programs, but in reality there's still quite a lot of variability from place to place and even region to region. But definitely, but I think there's still some commonalities when we get kind of down to the fun fundamentals. So you know, I know you went through like a lot of the things that like a neuromuscular specialist kind of focuses on, like neuropathy, different musculoskeletal disorders, what would you say are kind of the most bread and butter sorts of things that kind of wind up coming to you as either a first or second opinion.

Anishee Undavia :

Yeah, so there actually isn't that side. I was thinking about that and I think I'll tell you my favorite is gate dysfunction. Two favorites gate dysfunction and weakness. We get a lot of those and you can imagine there's some overlap with movement disorders so we get to kind of think through even some central nervous system conditions when we get those cases. Other things are numbness or tingling in one or more limbs, weakness, proximal weakness, trouble climbing stairs, falls, burning, tingling. I don't know if I'm missing anything major, but I think those are the big ones.

Anishee Undavia :

And a lot of my referrals come from other neurologists. Sometimes if you have a primary doctor that knows you and knows your interests, they'll come directly from the primary doctor. But a lot of the time I'm getting referrals to start by doing an EMG for that other neurologist because they think it's neuromuscular but they're not sure what part of the neuromuscular system is involved. And then, if it is something relevant, I will kind of talk to the referring doc and say, hey, I think this is something it could be, you know, motor neuron disease or maybe something mimicking it, and I'll carry over the workup if that's okay with you. And usually they're like, yes, please, I'm glad they saw you. So that's usually the scenario. Where I'm getting my neuromuscular cases is through my colleagues within the department.

Michael Kentris:

Got you. Now, something I always remember my instructors saying to me when I was learning EMGs and I imagine it's probably a universal sentiment is that your EMGs and your nerve conduction studies are essentially an extension of your physical exam. And I think you see this more in community centers, where and tell me if this is as big of a pet peeve for you as it is for me right, you get a referral for an EMG nerve conduction studies for, like you know, neuropathy and it's for the bilateral lower extremities. If you see that referral and they're 90 or 95 and I'm like, oh God, what's your first thoughts After? Oh God.

Anishee Undavia :

What's my first thought after I get a referral for neuropathy Is that yeah, like.

Michael Kentris:

So let's say, like you said, numbness or gait, whichever you prefer, okay.

Anishee Undavia :

That's a great question. So I like to, if I know that it's a classic clinical presentation. So if they have this classic, I've been burning in my feet for the last few years. Now it's getting a little bit worse. It's very equal and symmetric. I feel it in my fingers.

Anishee Undavia :

If it's a classic story for a length dependent external neuropathy, then I, you know, I proceed with the EMG of the lower limbs and I try to find that pattern where there's, you know, sensory more than motor, distal more than proximal, and make sense of it that way. But many times with burning or weakness, I have this algorithm in my own head that I try to share with students, where I go through some very basic anatomical buckets, like I said, and I have these prefilled diagnoses in those buckets that help me decide what to ask and what to examine. So I always start with the motor neuron as the most proximal place that I go with with neuromuscular cases and I think about anterior horn cell and I think about things like ALS, which obviously we don't want to jump to ALS with these simple cases, straightforward cases, but just to be organized about it. I start with that and then I move to the nerve root, which is very common. We think about nerve root compression from lateral bulging discs. But in the in the radiculopathy bucket I also have things like AIDP, cidp or infectious causes like cytomegalovirus or Lyme polyradiculopathy, and then I go.

Anishee Undavia :

So I go anterior horn nerve root and then I go to the plexus. Plexus is honestly not that common unless there's trauma involved, but we do see cases like radiation plexopathy or indolent malignancies that infiltrate the nerve roots like lymphoma. And then I move from the plexus to the next bucket, which is the peripheral nerve, which is obviously a very big bucket, but that includes all of my nerve entrapments, like carpal tunnel, ulnar neuropathy, perineal nerve entrapment, sciatic neuropathy. But it also includes polyneuropathy, which is your classic length dependent neuropathy from diabetes or B12 deficiency or inflammatory causes such as para protein with magneuropathy. So I that's a very big bucket and certainly you know, on another talk we can dive into the different types. But I I like to stop at that bucket and think, is my patient fitting into any of those?

Anishee Undavia :

And then from the peripheral nerve I go to the neuromuscular junction which has your common condition, common things that we think about, like myasthenia gravis, also Lambert Eaton syndrome or botulism, and then finally I end with the muscle, which also a very broad and interesting bucket, which can be simple things like a statin myopathy or thyroid induced myopathy, or something complex like a necrotizing myopathy, which is an autoimmune sequelae of statin use, or hereditary things like muscular dystrophy, congenital myopathy, et cetera.

Anishee Undavia :

So it's, it's a lot and hopefully that's not overwhelming. But I always encourage students and residents to go back to motor neuron, root plexus, nerve, neuromuscular junction and muscle and I, whenever I'm in resident clinic and a resident comes and says they take this fantastic history because they're great at that. And then we get to the exam and they're like I don't know what it is, and so then I always go through this exercise and I have them fill in the buckets themselves and that's them building their own knowledge framework, whether it's for their boards or for their future practice. Where do these conditions fit in and what can I ask or examine, to kind of hone in on it. And then we move on to what diagnostics will serve that, that differential Right one phrase.

Michael Kentris:

One of my attendants in residency. She was always full of pithy phrases and she would always say like yes like what's what's? What company does it keep? Right, Referring to the symptoms like what else is there? What's around it? They write everything in medicine, and neurology in particular, very contextual. So so, like right, someone comes in, like you were saying with with burning the feet, people like is there that atrophy? Is there evidence of motor involvement? Are there autonomic symptoms as well?

Anishee Undavia :

Right, yeah or associated weakness.

Michael Kentris:

Exactly so like and that that helps refine which buckets you're going to focus your attention on right.

Anishee Undavia :

Absolutely, and then that then further helps you. You might still not know what they have, but then you can start thinking of your investigations and what makes more sense. You know as the first step, whether it's labs or EMG, or sometimes you jump right to just you know genetic testing because you have all these clinical features that are very clear and a family history to go with it. Another very important part of neuromuscular medicine is asking about parents. If you think, I'll give you an. I just had a patient the other day who I did an EMG on and I was worried about motor neuron disease and I said, well, come to my clinic, I need to examine you and kind of think through things further. And I examined him and he had gynecomastia. And then I asked him about his childhood history and he said I could never do. He's kind of a big guy. And I was like so were you athletic? No, not at all. I was like did you do pushups or squats as a kid? No, never. I said why I couldn't do them, why not?

Anishee Undavia :

I just couldn't you know, like there was really no good explanation. And then you, then I said well, did anyone in your family? And, and you know, with the gynecomastia and motor weakness I was thinking about Kennedy's disease and that's an X-link disease.

Anishee Undavia :

And you know that then you know to not just ask about mom and dad but mom's brothers. Turns out he had like six uncles on his mom's side. Many of them were estranged so we couldn't get information. But, you know, you wonder where they. You know wheelchair for unexplained reasons, or did they need a walker in their forties? All that ancillary information can really be helpful in pinpointing the next diagnostic test. You do and and avoid calling things ALS that are not ALS, you know.

Michael Kentris:

Right, and I remember when I was a fellow I had a consult for muscular dystrophy. It was in an older gentleman, like in his, you know, late late sixties, early seventies. And you know you go in and, like you said, right, you're examining, he's got diffuse atrophy, you know, arms and legs. Obviously this is very late, late stage in his life and you know you, but you you examine, he has sensory changes, right. So obviously that doesn't really doesn't really fit. But he'd been told all his life for decades that he had muscular dystrophy. And then, fortunately, his kids and his grandkids are all visiting him in the hospital at the time I'm doing this consult. So I look at his feet right, he has Charcot feet and so I asked hey, can I look at all your guys's feet?

Anishee Undavia :

Yeah, that's the best.

Michael Kentris:

And you know they all, like they had like it was like looking at over time, they all had very high arches. You know some of the middle aged folks had hammer toes. I was like, oh, you guys probably have like some variation of Charcot Marie tooth and it was one of those things, right, where it's like it's not a fancy test, it's not anything beyond just asking questions and talking to people and just putting the pieces together. It's one of those things where you're just like, oh, the light just shines over your head.

Anishee Undavia :

The moments we all live for in neurology.

Michael Kentris:

Right Cause I mean that's. That's been a few years now, but that experience will live with me forever, definitely.

Anishee Undavia :

I had something similar with FSHD which you know many students and residents don't ever see. But I think the guy, if I remember correctly, the the guy came in for pain. He had back pain and symptoms of lumbar radiculopathy, but then we examined him and he clearly had facial weakness. He had scapular winging and you know this proximal atrophy, this double hump that we see with deltoid sparing and the, the rising of the trapezius from the scapular winging. Anyway, he was with his mother and his mother had, no, no health issues, but she was sitting there with this like downturned smile and you might not notice it, but then when we asked her, we she also had some mild facial weakness. And it's so funny. How, like those little encounters, can you know, when you lean in as an neurologist, because what we're supposed to observe and ask these questions and you you can elicit so much information without doing a single lab, lab test or you know, nerve test or whatever it is.

Michael Kentris:

I know I always. I always feel slightly I haven't shaken it yet slightly awkward when I have to ask someone's like. You know, with, like, some sort of facial let's I hesitate to use the word abnormality, but it's like does your, does your face always look like that? You know, it's one of those things where you try and find the polite way to say it.

Anishee Undavia :

I don't know, have you come across any phrases that work particularly well for I would never say it, but I've had patients say I've always had RBF, and I'm not going to spell out what that means.

Anishee Undavia :

Yes, but they will tell me that straight up, but that's just how my face is. No, I think if you show that you're trying to help them and understand, no one's really gotten offended. I'll just say you know, as neurologists we pay attention to these things, and I noticed that yours is down. Has it always been like that? Do you have, or do you have, a license photo that I can look at, you know? Obviously that sometimes we do that for hemiparesis, but you could also do facial diplegia.

Michael Kentris:

Excellent.

Anishee Undavia :

Yeah.

Michael Kentris:

So so obviously you know we're a couple neurologists shooting the breeze. We we like to talk about the esoterica of neurology, but you know, a lot of times you know there are people out there maybe 50, 100 miles away from the nearest neurology, even here in the US, and for the primary care docs in the audience, how, how should they approach let's say, neuropathy? Like someone comes in, they got the numbness and the tingling EMGs labs. Where do we go?

Anishee Undavia :

Yeah, that is a very, very good question and, I think, a hard question, because we neurologists bark when too much is done and we bark when not enough is done. You don't go both ways, I don't know. I kind of am in the boat of I'll see anyone that you're not sure, I'll just see them, and, and I'd rather if they're not sure. I hate recommending tests without having seen the patient myself. I just I don't know. It just feels wasteful sometimes. But of course, for the the run of the mill length dependent neuropathies, we almost always screen for B12 and it's very valuable. A lot of the times it's low, low, normal and just supplementing it can make a big difference in the symptoms. Tsh is controversial. I've never seen it actually help me or pick up you know a treatable case. So I think a lot of people are putting that one out the door, unless they're they have metabolic syndrome and it might be relevant to their case. A1c can be helpful if they haven't been going to a PCP regularly as a first time. Definitely, I see neuropathy symptoms even with early and mild diabetes, so it doesn't have to be like an A1c of 13 to see the symptoms of a neuropathy, at least the burning pain. Interestingly, people who are newly on insulin. There's a condition called insulin neuronitis which can be very, very painful and mimic a neuropathy, and so if they recently were treated for diabetes and they got rapid control, sometimes you see patients present with symptoms of neuropathy and that should be something that a primary care could potentially deal with. So just that, that education about insulin neuronitis. They also don't always need an EMG, so I guess a referral sometimes might be better, because if it's very clear that it's in the context of their diabetes or B12 deficiency, they don't really have motor weakness or obvious sensory deficits on their exam. Maybe you could hold off on the EMG.

Anishee Undavia :

Some people want a baseline. It's very subjective. I do it based on how I think the patient will tolerate it. I want them to trust me and if I don't think an EMG is really going to make a big, big picture change in their treatment, I don't jump to it right away for every run of the millenuropathy. Of course, if there's any red flag. So if there's a profound amount of weakness, if they show up with burning pain but also they're tripping and falling, that's a red flag and they should probably see neurology and get an EMG to look for something like something that's not as common or run of the mill, because motor weakness usually comes much later, if at all. So I don't know if that answers your question, but it's kind of person to person. The bottom line is if a primary doctor sees something in neuropathy that's not classic, then they should probably be seen by a neurologist or get an EMG.

Michael Kentris:

Yeah, no, I think that's totally reasonable. Personally, when I was doing EMGs more often in my practice, I was basically doing a miniature consult every time I saw them, because and maybe I'm more guilty of this than other people but I would get a request for a certain you know, like you know, both legs or maybe all four extremities, and I'm just like this is unnecessary. Here's what we're actually going to do and this is why yeah, that's all that's going on.

Anishee Undavia :

How often? Or a limb EMG? No, I don't think so.

Michael Kentris:

Right, we're not doing a CIDP or an ALS evaluation today, right, we're not doing it yet? Yes, question, and this may be a hot take moment, so you can beg off if you. If you'd rather not answer what is your opinion in general? Right, because you're you're an academic neurologist, academic neuromuscular sub specialist, emgs in the community. What? What is going on?

Anishee Undavia :

I don't know. I don't want to make assumptions. I don't think everybody should be doing EMGs without the proper training. Definitely, I collaborate a lot with my PM and our colleagues who do a good amount of them and I think that's really great. But I don't know. I've seen. I don't want to get in trouble with what I have to say about it.

Michael Kentris:

actually, I've seen, I'll say something. I mean there's a lot of garbage EMGs out there. So, and you know, I remember I think I was a second or third year medical student around the time, but I was. I was talking with a doctor and right, emg reimbursement got got slashed by a significant margin. Oh God, I'm going to age myself 20, 13.

Anishee Undavia :

I was a fellow a couple years before that. Yeah.

Michael Kentris:

Well, I probably got cut again, but the big one was a little bit before that and I'm just like, well, yeah, right, it's, it's obvious when you think about it in the context of the greater you know system, you know for our international listeners, right, this is a US thing where, like your Medicare, Medicaid services to determine how much you get paid for a service, and basically said, too many EMGs are being done, which suggests that they're likely being done inappropriately. And you see that for a number of procedures over the years, it's not always the case. Sometimes it's just the government being the government, but in this case I think they were probably in the right in as much as we have too many doctors doing too many low quality studies. And I remember in my former practice there was a guy in the area who would do like like 15 EMGs in a day, Sometimes more than that, and I would get these reports and I'm like this is because I would get a referral for like a myopathy.

Michael Kentris:

And well, no, I would. I would get the patient referred to me as a consult first. But you are correct, Right? So I didn't see. The person is like you don't have any clinical science of a myopathy and and so it is right there there is a certain subjectivity to to EMG Quote, unquote very much.

Anishee Undavia :

Yeah, it does matter who's doing it and who's. I totally agree with you. I didn't want to say it and I'm thankful that you said that. There are a lot of garbage EMGs out there being done by people who really don't know how to. You can't just take one nerve that's a little slow and say the patient has a IDP or CIDP. You just can't. There's a demyelinating range. There's a clinical phenotype that goes with it. That would make sense.

Anishee Undavia :

There's a lot of technical pitfalls, so you need the person doing it to take the patient into consideration when you're making an interpretation. I mean the median nerve, for example, in carpal tunnel. It could be so bad looking with a normal muscle and it's just because they have anatomical variation and it's like a some kind of Martin Gruber or Rish Kanu and Astimosis and you you get them to say, oh well, they have a severe carpal tunnel. They go get carpal tunnel surgery, you know, for minimal symptoms or other symptoms that they're having and and you get in a lot of trouble. We see a lot of or spine surgery, for example. We've seen cases like that and so, yes, I think that training matters and what you're doing, the test for matters and appropriate referral makes sense. It's also a painful test, so to have to go through it two or three times before you get on the right track kind of that's unfortunate.

Michael Kentris:

Right Especially and I'm sure you've encountered this right as the second opinion neurologist is that you know it's like well, why do I need to repeat that study? I already had that study done and you know, like you said, right, you don't want to be the person who says like well, the other one was kind of not good, but I mean, that's that's. That is the reason sometimes, many, many times.

Michael Kentris:

I mean sometimes, and I always remember there are certain things to look for, like in the raw data, right, Like is the temperature documented, right? If there's no temperature documented, you can just throw that thing in the trash.

Anishee Undavia :

Yeah, I mean I don't know if that's true, but I think you really have to think about the under. Whoever's doing it has to kind of be familiar with things like Charcot-Marie tooth or, you know, demyelinating neuropathy or myositis, and if they've only trained to do them, to look for carpal tunnel or lumbar radiculopathy. That's a limited scope. And EMG, although it has its own limitations, it can be very helpful to separate some of those conditions and you have to have the clinical understanding and the EMG understanding to piece it together. It really is a subjective test. I don't know the solution for that. I guess cutting the reimbursements might have helped. I think entire practices had to close when that happened because they were just doing EMGs. Yeah, and a lot of the time I'll get the referral for the EMG from a primary doctor or a podiatrist and it's either straightforward it's much more complex than I bring them into the clinic as like a formal evaluation and then they become a neurology patient.

Michael Kentris:

Yeah, oh man. So you bring up another. I'm just remembering a conversation I had with a podiatrist a friend, not in the last few years and it was about tarstle tunnel syndrome.

Anishee Undavia :

Oh, another hot topic.

Michael Kentris:

Sorry, I'll stop bringing up controversial topics. No, please it's great, and it's one of those things where it's like I remember one of my attendings. You know he was an older gentleman and I believe his exact words were I've never diagnosed tarstle tunnel syndrome.

Anishee Undavia :

Yeah, I have gotten those referrals and you know people have pain on the medial side of their ankle sometimes and so I'll kind of open up my ship here, my precedent ship here, which is the kind of neuromuscular Bible or at least EMG Bible, I should say and needle some of the muscles that they recommend. I'll do all the appropriate tests. The problem is there's a lot of wear and tear. So when you put a, put the needle in some of those intrinsic foot muscles, you're listening for denervation or chronic re-innovation, and it can be obscured by the fact that, especially if they're older, there's so much wear and tear from walking and stomping that it might be a very nonspecific finding and it might not get you the answer. I that's where I'm starting to lean on neuromuscular ultrasound or imaging of other kinds to, really, because there was one time that only one time that we picked up an Ewing sarcoma in the ankle.

Anishee Undavia :

After someone was referred for tarstle tunnel evaluation and there were some abnormalities but I didn't make any conclusions from the EMG, I said please do direct imaging, and that's how that came about. So you can certainly have compression at that site. I just don't know if the EMG is very diagnostic necessarily in that.

Michael Kentris:

That's a fair, that's a more equitable statement than mine. Now you bring up something very interesting and something I unfortunately don't have very much experience with, which is neuromuscular ultrasound, which I know has been like kind of like the hot field for several years now. What's what's that looking like, how's it being used in practice, and what do you think kind of future directions are looking like for it?

Anishee Undavia :

Okay, so I will. I will preface it by saying I actually I don't do neuromuscular ultrasound, nor do I have much training in it, but more than, like you know, a few workshops at the national meetings when they're available, I'll go in and try to localize the nerve. But as I've said many times just in our conversation, emg can be limited and it's especially limited when people have more than one thing going on. For example, if they have a cervical radiculopathy at C8t1, but also a carpal tunnel and you don't know which one. Is that the culprit at that time for their actual symptoms. That's just an example. Or if they have an ulnar compression but you can't quite localize it because it's so severe, meaning there's like no responses on the EMG and they could have a double crush syndrome.

Anishee Undavia :

So I think I think that ultrasound can be really useful for the mononuropathies because you can measure their circumference of the nerve, typically when it is enlarged or swollen over a certain size. You can. It can be quite specific. I that's kind of where I have referred patients for ultrasound is for those circumstances when I can't tell, because they have multiple neuromuscular things or multiple areas of compression, how to localize it. I think it has a place, for sure, and I hope that it becomes more, you know, more readily available in the community. But yeah, that's kind of my take on neuromuscular ultrasound.

Michael Kentris:

No, that's excellent. Yeah, I've been. It's definitely on my my bucket list to see if I can get into some of those workshops as well. It certainly I mean certainly less painful than an EMG, right.

Anishee Undavia :

Yeah, it is less. I think you often need both. I'm rarely seeing that an ultrasound alone can make the treatment you know, get us to the treatment versus an EMG alone, usually in conjunction, kind of like a CTA and a carotid ultrasound. You kind of need both, for the one for the velocity and one for the actual 2D or 3D images.

Michael Kentris:

Fair enough. So for people, because now I remember and I don't know if this is typical or not there was a PM&R resident who had actually started a neuromuscular fellowship at the time that I was. I was an outgoing fellow, they were an incoming fellow, and is neuromuscular open to neurology and PM&R? Are there any other specialties that that do neuromuscular medicine?

Anishee Undavia :

Yeah, when I was a fellow in neuromuscular medicine at UCLA, we had a very, very strong PM&R resident who wanted to then ultimately be focused on muscular dystrophy and rehabilitation. So definitely I think it is open to multiple areas. I don't I've never seen like a pain specialist or or someone who has an interest in pain coming through. Mostly I've seen other PM&R in combination with neurology. I haven't seen any other specialties, but I'm sure there could be a space for it. Yeah, I don't have you, I don't have. Have you seen that? Have you seen?

Michael Kentris:

those are the only two that I've seen as well Only two I've seen, yeah, and then the A&M.

Anishee Undavia :

I haven't gone to one of their meetings yet, but they're heavily a combination of two and their talks are very much focused on both specialties.

Michael Kentris:

That makes sense Because I think pretty much they're the the main two specialties doing EMGs these days.

Michael Kentris:

Yes, so. So what's your, your pitch for for neuromuscular medicine? If you're going to talk to the junior neurology residents out there, what's the draw? Why should you pick that as the specialty, the subspecialty of choice?

Anishee Undavia :

That is a very good question. I one, I love it. And I think I love it because I saw other people who love it doing it. I think that it is really fun to think through those buckets that we talked about, anywhere from the root to the muscle, and I had a lot of those aha moments at the bedside.

Anishee Undavia :

And so my message to students for students I would say, when you're on your clerkship, try to seek out the neurodiagnostics lab and catch a couple of EMGs because it's not always built into the curriculum, just to know what it is, even for your shelf exam. They, you know, they almost always ask about lumbar radiculopathy or cervical radiculopathy, and so that can really give a visual to what you know what looking for those cases means. And for junior residents I would say try to fit it in. I think the PGY2s are so focused on stroke and epilepsy because that's what we see mostly in the hospital. But the Blumenfeld book has some great neuromuscular cases and if you just stop to read on a case-based level based on what you come across, you'll start making that framework early on.

Anishee Undavia :

And then, of course, pgy2 and 3, when you're in your specialty clinics, you can start filling those buckets as you prepare for the boards. But if you're interested that you might want to do it, I would definitely go and rotate. If your institution doesn't have an ALS clinic or a myasthenia clinic or a muscular dystrophy clinic, try to get some experience so you can really see what that's all about, because that nothing replaces the visual of seeing those patients, examining them, coming to an anatomical diagnosis and then discussing some of their rehab needs. We didn't really talk about genetics today, but we are scratching the surface. Now there are treatments for conditions like SMA, duchenne, muscular dystrophy, and so it's going to be more important, more and more important for residents to actually learn about them and be able to pick out those cases, to at least refer appropriately for neuromuscular so they can get the benefit of those treatments.

Michael Kentris:

Yeah, absolutely, and hopefully the cost of some of those will come down a little bit, like the Neusin medicine and ABYPARVOVIC.

Anishee Undavia :

Absolutely yeah, it is ungodly expensive, but you know.

Michael Kentris:

I believe the are the single most expensive medications in existence right now.

Anishee Undavia :

Yeah, I think you had another a really good podcast about the cost of medicine. I think it was on neurotransmitters. I was listening to you.

Michael Kentris:

Yeah, yeah, one of my friends and I were talking about MS medications.

Anishee Undavia :

Yeah, that was really helpful. I think, that's important too for perspective for when we treat these patients Especially rare disease.

Michael Kentris:

Yes, yeah, no, like rare disease, and you probably. Well, I know I'm veering slightly, that's what I do, but I remember one of my attendings had probably like six to 10 Lambert-Ethan patients, and this was before there was any FDA approved medications, and so she had them on the God, I'm a rush. I think it's the three, four DAP, if I remember correct. Right, and she would have it like synthesized and like shipped up, and but after the medication was FDA approved she couldn't get them this, this cheap old medication anymore, and so then they're like on the hook for this, like stupidly expensive medication, because there's no other options that are even being made anymore.

Anishee Undavia :

Yeah, so what they had to like get on a phone with the insurance company and yeah, like they had to go into this like prescription brand name.

Anishee Undavia :

Yeah, that's a bummer. My experience with that with I just get on the phone, I do whatever I need to do to get on the phone to the struggle I've had. It's not exactly in that realm, but in people with necrotizing myopathy from HMGCR antibodies. You'll come across so much literature that says IVIG helps, ivig helps, ivig helps, you know, and it's it's not technically approved for that, but all the experts around the country are using it and that's what they recommend first line. And so I will get on the phone with whoever I have to and share whatever observational studies have been done to explain this. Is, you know, so treatable. The more you wait, the worse it gets and more irreversible. This you know they're going to be left with disabilities. So I think part of the problem is the people who are approving it don't really know the disease and are far removed from that, and so it's our job to kind of explain the dire need for them if they're available, especially if it can be, you know, preventing handicap and things like that.

Michael Kentris:

So are you saying your peer to peers aren't with another neurologist?

Anishee Undavia :

It's often like with a radiation oncologist or something like that.

Michael Kentris:

Right, it is pretty random, sorry. Sorry for veering so far.

Anishee Undavia :

Which is very real life and very, very relatable.

Michael Kentris:

So yeah, yes, Any final thoughts? Anything you want to plug?

Anishee Undavia :

Hopefully this was a, you know, a simplified way of kind of introducing neuromuscular.

Anishee Undavia :

Obviously it's very vast and there's a lot of things we haven't talked about.

Anishee Undavia :

But I think, starting with that barrier to just opening people's eyes to neuromuscular, what it is about, even if you're not going to go into it, just knowing that it exists and that it is a part of our job as neurologists to recognize some of these things, I think, just as trainees do as much as you can to see some of these cases, or to, you know, figure out which attendings you like and are approachable and be like hey, show me that case.

Anishee Undavia :

If you ever get one, or you know, feel free to pull me in so I can kind of take a look, because some of these cases, like you know, even myotonic dystrophy it's the most common muscular dystrophy, but you might never see it if you don't seek it out. So just kind of saying hey to your attendings that are willing I'd love to see more if you have stuff to show me in and I think that that enough is motivation for the attending to be like hey, this is exciting. I want to show them this because you know I can point out these things and it can really make a difference in their, their knowledge, or fill their buckets, so to speak.

Michael Kentris:

Absolutely.

Anishee Undavia :

Yeah, and.

Michael Kentris:

I know I had a medical student just this week, you know she expressed just the barest interest in neurology, and so I'm automatically trying to convince her, like you, should become a neurologist.

Anishee Undavia :

We're such leeches in that way.

Michael Kentris:

Like I hear something I'm like oh you belong in this field, that's right, you would be good. You're good for the field.

Anishee Undavia :

We need you.

Michael Kentris:

Right, but I and I like to think that's a welcoming kind of mindset, but or even like I think we spoke about this before is like when you're meeting.

Anishee Undavia :

When you're meeting trainees, like finding out where their interests are and seeing if it relates it often does relate to neurology and you know, showing them how. For example, ophthalmology obviously we have neuro ophthalmology, which is such a great field, but they might not think about it or know about that, but interested in the pathways, but not really linking the two. And so it's it's nice to hear from a neurologist about how your interests can be linked into our field early on.

Michael Kentris:

So very much, so where can people find you online if they're going to seek you out?

Anishee Undavia :

Oh yeah, I am on Twitter. I actually really like, or I guess X is what I should say.

Michael Kentris:

Yeah.

Anishee Undavia :

I am very much enjoying the community building on X or Twitter and meeting people like you and others who are clinically focused and love what we do but also commiserate a little bit. So I am at gosh, I forgot my handle.

Michael Kentris:

Sorry, we'll edit this out in post. What's?

Anishee Undavia :

my handle at Anishisha A-N-I-S-H-E-E-S-H-A-H. Please feel free to give me feedback or, you know, just say hi or chat about neuromuscular or anything. Really, I'm available.

Michael Kentris:

We'll be looking for high quality, bite sized neuromuscular content.

Anishee Undavia :

There you go, I'll work on it. I'm starting to kind of get around to posting my first tutorial. Hasn't happened yet, but hopefully soon you inspire me, I'm going to get there. Oh, you're two kinds.

Michael Kentris:

Well, thank you again so much. I really appreciate you taking the time to come on, share your love for neuromuscular neurology and, you know, schedule and desire permitting, perhaps we can get you back on to talk more in depth about specific complaints and kind of your diagnostic treatment approach.

Anishee Undavia :

I would love that. I really, really appreciate the opportunity to be on here and talk with you, and I like this kind of casual approach. It makes it more fun and yeah, so hopefully we can do it again.

Michael Kentris:

I hope so too. Thank you again for listening. This episode was edited and produced by Rita Farhan. If you enjoyed this podcast, please leave a five-star review for us on Apple or Spotify or wherever else you might get your podcasts. This really helps with giving a show noticed and spreading the word. You can find me on X, formerly Twitter at Dr Kentress, dr KENTRIS, and you can find the official Neurotransmitters feed at Neuro Underscore Podcast. Lastly, you can find a lot of our content online and keep in touch with us through our website at theneurotransmitterscom. Thank you again for listening and we'll see you next time.

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