Editorial Pract Neurol: first published as 10.1136/practneurol-2021-002946 on 28 April 2021. Downloaded from Neurology and clinical neurophysiology: an artificial divide

Matthew C Kiernan ‍ 1,2

1Brain and Mind Centre, The The editors of Practical Neurology ask a suggested that neurophysiological testing University of Sydney, Sydney, reasonable question: who is best placed should be undertaken by someone who New South Wales, Australia 2Department of Neurology, to oversee the neurophysiological investi- not only understands the patient’s neuro- Royal Prince Alfred Hospital, gation of patients presenting with neuro- logical presentation, but who can deter- Sydney, New South Wales, logical symptoms? Before considering the mine what is to be studied as the test is Australia complexities of this seemingly straightfor- being performed, and who can interpret Correspondence to ward question, it is accepted at the outset the findings in situ and in relation to Professor Matthew C Kiernan, that any physician or technician could be the patient’s clinical presentation and Brain and Mind Centre, The trained to follow a testing proforma based phenotype. University of Sydney, Sydney, New South Wales, Australia; ​ on a symptom, or constellation of symp- Before considering the more complex matthew.kiernan@​ ​sydney.​ toms. So, the question does not relate to answer to the original question, we must edu.au​ an issue of capability, nor should it relate agree that whoever undertakes the testing Accepted 5 April 2021 to capacity. Rather, it would seem logical should be sufficiently trained and have Published Online First to consider how the best outcome can be appropriate experience with the testing 28 April 2021 achieved—that is, to diagnose the cause apparatus and techniques. Essentially, that that underlies a patient’s symptoms. means dedicated training (fellowship) and Clinical neurophysiology forms part supervision, followed by a period of tran- of a neurologist’s array of instruments sition from trainee to accredited service and tests that, carefully coordinated, provider. In many countries, neurophys- yields the most rewarding and sometimes iological testing is undertaken by neurol- surprising results. At its simplest level, ogists. In others, particularly in Europe, it represents a technology platform that training in clinical neurophysiology and aids the diagnosis and management of the provision of electrodiagnostic services patients with neurological disease. More has branched off to become a stand- http://pn.bmj.com/ fundamentally, however, it is indispens- alone specialty, separate to neurology. able for differentiating myopathic from The potential benefits of this approach neuropathic causes of weakness; and include a review by a second set of eyes, for determining the pattern of neuro- an increase in practice within the specific genic abnormality.1 Critically, clinical area, and the saving of time. neurophysiology can assist in the diag- In the standalone model, after a consul- on September 29, 2021 by guest. Protected copyright. nosis and localisation of a lesion, and in tation with a neurologist, the patient staging the development or recovery from presenting with limb weakness would neurological diseases. In the presence of receive a referral to a new specialist to neurogenic abnormalities, electromyog- undertake diagnostic neurophysiological raphy (EMG) studies can reveal changes testing. In such a setting, it is accepted of denervation that are not apparent or that many of the subtleties garnered not definite by means of clinical exam- through the clinical history and exam- ination.2–4 As such, the EMG machine ination (as undertaken by the now refer- can be considered akin to an electrical ring neurologist) would largely fall by stethoscope: it enables the neurologist to the wayside. Having received a referral, © Author(s) (or their detect clinical signs that often cannot be the clinical neurophysiologist would then employer(s)) 2021. No identified by clinical examination. What it develop their perspective on the presenta- commercial re-­use. See rights and permissions. Published reveals and subsequently achieves for each tion, to determine a process of testing that by BMJ. patient will vary, even when the patho- would aid the diagnosis of the patient’s To cite: Kiernan MC. logical condition is the same, depending condition. These simple acts of process Pract Neurol 2021;21:274– on that particular patient’s clinical symp- segregation serve no real purpose, other 275. toms and signs. In this setting, it could be than being service (specialty) driven, and

274 Kiernan MC. Pract Neurol 2021;21:274–275. doi:10.1136/practneurol-2021-002946 Editorial Pract Neurol: first published as 10.1136/practneurol-2021-002946 on 28 April 2021. Downloaded from certainly provide no added benefit for the patient. On Taken from a different perspective, were you to ask the contrary, there remains potential for a relatively aspiring neurologists as to their preference—undertake simple process to be subjugated, with the possibility their own neurophysiological testing, or outsource it that the clinical neurophysiologist embarks on a course to a separate craft group—I would venture to guess of testing that may not answer the question posed by that those with a relevant subspecialty interest, where the referring neurologist—namely, what is the cause neurophysiological testing forms part of standard of the patient’s weakness?—which becomes lost in patient diagnostic workup and monitoring, would ask translation. Furthermore, the clinical neurophysiol- to turn on the power, activate their electrical stetho- ogist remains separated from the process, and is not scopes and listen to the music. responsible for subsequent treatment and patient management. Twitter Matthew C Kiernan @JNNP_BMJ Of course, with any service, there are inevitable Contributors MCK is the sole author. issues related to supply and demand, and indeed Funding This study was funded by National Health and 5 Medical Research Council of Australia Programme Grant financial considerations. However, such matters (#1132524), Partnership Project (1153439) and Practitioner should not be the core consideration when asking Fellowship (1156093). who is best placed to undertake the neurophysiolog- Competing interests MCK serves as Editor-­in-­Chief of the ical testing of patients presenting with neurological Journal of Neurology, Neurosurgery & Psychiatry (BMJ, UK). problems. From an historical perspective, neurophys- Patient consent for publication Not required. iology from its inception has been intimately linked Provenance and peer review Commissioned; externally peer to neurology, and particularly neurological discovery. reviewed by Nick Kane, Bristol, UK. Over more recent decades, it has been the key pathway ORCID iD to unlock patient symptomatology and, in many cases, Matthew C Kiernan http://​orcid.​org/​0000-​0001-​9054-​026X the clinical phenotype. Perhaps this mutually depen- dent relationship was best described by EA Carmichael REFERENCES through his guiding philosophy that the best way to 1 Rubin DI. Needle electromyography: basic concepts. Handb study neurological disease was to study human phys- Clin Neurol 2019;160:243–56. iology.6 While the use of technology has permeated 2 Shefner JM, Al-Chalabi­ A, Baker MR, et al. A proposal for new diagnostic criteria for ALS. Clin Neurophysiol all subspecialty endeavours—from neurogenetics 2020;131:1975–8. through to neuroimaging—the key contributions of 3 Yeh WZ, Dyck PJ, van den Berg LH, et al. Multifocal motor clinical neurophysiology have been increasingly hard- neuropathy: controversies and priorities. J Neurol Neurosurg wired into the modern-­day practice of neurology. By Psychiatry 2020;91:140–8. analogy, one could also reasonably ask why neurolo- 4 Garg N, Park SB, Vucic S, et al. Differentiating lower gists do not report brain scans. In consort, the land- motor neuron syndromes. J Neurol Neurosurg Psychiatry scape is rapidly changing, and taking the field of stroke 2017;88:474–83. http://pn.bmj.com/ neurology and endovascular clot retrieval as cases in 5 Nuwer MR, Duncan M, Nuwer JM. A profile of Neurology practice based on Medicare services: an AAN medical economics point, this change has already occurred, with neurol- and management Committee report. American Academy of ogists reporting scans of their patients, as well as the Neurology. Neurology 2001;56:586–91. intervention. Would this report be better coming from 6 Merton PA. The first Carmichael memorial lecture. a radiologist, divorced from the patient, the clinical

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