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Subsection CLINICAL NEUROPHYSIOLOGY


	Clinical Neurophysiology Subsection – Indian Academy of Neurology Minutes of the meeting held on 12th September, 2009
	Clinical Neurophysiology Subsection meeting was held at Nayanar Hall 3 between 1:30-2.40 pm on 12th September, 2009. Prof. M.Gourie-Devi, President of clinical neurophysiology subsection had expressed her inability to attend the meeting as she was not attending the conference. Dr. V.G. Pradeepkumar, member of the local organization committee, was busy with organizational responsibilities. Hence, he too expressed his inability to attend the subsection meeting. In the absence of Prof. M.Gourie-Devi, the meeting was presided over by Dr. M.Veerendra Kumar, the National Delegate of the subsection.
	The following members attended the subsection meeting.
	Dr. (Col.) Narayanaswamy (Pune) Dr. (Prof.) A.K.Meena (Hyderabad) Dr. (Prof.) Sanjeev Thomas (Trivandram) Dr. (Prof.) Mathew Alexander (Vellore) Dr. Suresha Kodapala (Bangalore) Dr. B.K.Pankaj (Jharkhand) Dr. Garima Shukla (New Delhi) Dr. Manjari Tripathi (New Delhi) Dr. A.O.Saroja (Belgaum, Karnataka) Dr. Nachiketh Dixith (Madhya Pradesh) Dr. (Prof.) M.Veerendrakumar (Bangalore)
	The following issues were discussed during the meeting.
1	At the last Asian-Oeanian Congress of Clinical Neurophysiology (AOCCN) meeting held at Seoul, South Korea (April 15-18, 2009), 20 delegates from India attended the conference. This was the largest number of foreign delegates from one country attending the conference. This was made possible because the organising committee of AOCCN conference awarded 13 young investigator fellowships to delegates from India. For this generous gesture, members expressed their thanks to the AOCCN organizing committee.
2	The main conference of International Federation of Clinical Neurophysiology (IFCN) is held once in four years. The next conference — 29th International congress of clinical Neurophysiology (ICCN) — will be held at Kobbe, Japan from 28th October to 1st November, 2010. Dr. M.Veerendra Kumar informed the members about the availability of young investigator fellowships for the ICCN conference. It was suggested that availability of fellowships be published in the academy journal (Journal of Indian Academy of Neurology) for dissemination of information to wider number of delegates from India. Dr. M.Veerendra Kumar felt that a larger number of delegates could attend the conference and present scientific papers. This would help in making our presence felt at International level.
3	During the subsection meeting held last year, it was decided that the next Clinical Neurophysiology conference would be organized at CMC Vellore in the year 2010. IAN’s conference is scheduled for September, 2010 and ICCN conference is scheduled for October/November, 2010. Therefore, it may be difficult to organise the conference in the later half of 2010. Dr. Mathew Alexander, Prof. of Neurology at CMC Vellore, informed the members that the clinical neurophysiology conference would be organised in January/February 2011. Prof. Mathew Alexander has already contacted Prof. Jun Kimura, Mark Hallett, Andrew Eisen and Sanjeev Nandedkar. The main emphasis of the conference will be Electromyography and Magnetic stimulation.
4	Col. Narayanaswamy sought clarification regarding payment of annual membership fee once in 5 years (at the rate of Rs. 200/member/year) instead of every year. Dr. M.Veerendra Kumar informed the members that Indian Academy of Neurology (IAN) has to pay membership dues to IFCN every year at the rate of $ 4.0/member. This roughly amounts to Rs. 200/member every year. Further, the membership fee has to be deposited by 1st January every year. In the previous years — consequent to the member’s busy schedule and the cumbersome affaire of getting a bank draft for Rs. 200 every year — members had to be sent several E-mails/ postal letters for payment of annual membership dues. This invariably resulted in late payment of fee to IFCN. Few members also expressed the view that a lump sum amount for 5 or more years or a life time payment towards subsection membership fee could be considered. The issue was discussed during clinical neurophysiology subjection meeting held at Bangalore (year 2006). Members agreed to the suggestion of paying Rs .1000/- once in 5 years. Since then, members are being requested to pay a lump sum of Rs. 1000/- towards 5-year’s annual membership fee. Similarly, new members are required to pay Rs. 2000/- (Admission fee: Rs. 1000/-; 5-year annual membership fee: Rs. 1000/-)
5	Last year, during clinical neurophysiology subsection meeting, it was planned to publish guidelines for the evaluation of GB Syndrome, Carpal Tunnel Syndrome, and Repetitive Nerve Stimulation Test. Prof. Mathew Alexander, Dr. V.G. Pradeep Kumar, and Dr. M.Veerendra Kumar were appraised about the need to submit the guidelines early. Dr. Sanjeev Thomas, Editor of Annals of Indian Academy of Neurology agreed to publish the guidelines in the Academy of Journal. The guidelines could be 4-5 pages in length but they should be profusely illustrated.
6	Dr. Manjari Tripathi drew to member’s attention the issue of substandard EEG recordings. Many of these are recorded at centers where the personnel do not possess adequate training in recording EEG. Often they are recorded and reported by non-neurologists with inadequate or no training in clinical neurophysiology or electroencephalography. It was suggested that this issue merits greater attention and may be discussed during IAN’s general body meeting.
7	It was suggested by members that IAN is considering the possibility of extending the conference time to 2.5 days from the current 1.5 days. This is basically to add new features or to accommodate more platform/ poster presentations. The subsection discussed the need to have a full session on Clinical neurophysiology at the annual meeting of the IAN. At present the papers are all scattered around in various sessions and there is no focus. Since the IAN is increasing the duration of the annual meeting, we should have a three hour session the content of which can be decided by the subsection. We would like to include brief presentations (20 minutes each) on neurophysiological techniques, evaluation of various syndromes, and free paper session within this three hours. This issue had been discussed earlier as well during the subsection meeting at Mumbai (2007). The meeting has authorized the National Delegate (Dr. Veerendrakumar) to write to the IAN Ex. Committee with this proposal, so that the EC could ratify.
8	The issue of training facilities and the non-uniform nature of training for technologists in the country were also discussed. It was suggested first a detailed study of the syllabus and course curriculum at different centers in the country be carried out. Subsequently, guidelines for minimum standards for training may be developed. The subsection members were requested to send the syllabus and course curriculum at their centers to Dr. M.Veerendra Kumar.
9	The Electroneuromyogrphy (ENMG) systems manufactured by international companies are rather expensive. Hence, most of the practicing neurologists in India are using EMG systems manufactured in the country. Currently, three Indian companies are manufacturing EMG systems. Dr. B.K.Pankaj was interested to know about the quality of these machines and how to select a machine for purchase. This issue was discussed in detail. In the evaluation of the ENMG system, one needs to assess the hardware and the software. Software determines the display of signals, user friendliness, and manipulation of data for measurement, analysis etc. The hardware determines the robustness of the system in recording signals even in hostile environments, stimulus delivery protocols etc. The hardware also determines the software that will be used in the ENMG system. In the absence of reliable technical details from the manufacturers, it was felt that there is difficulty in grading the various Indian EMG systems. For grading the EMG systems, it is necessary to perform neurophysiological procedures using all the three or more ENMG systems in one place/lab. It has been observed that in the ENMG studies performed using Indian ENMG systems, sural sensory conduction study is often found to be missing. Even when performed, on few occasions, the sural SNAP recorded as being absent was found to be normal on repeat study (at NIMHANS, Bangalore). Therefore, recording of sural SNAP using antidromic method could be used to grade the amplifier system in the machine. If one could record a good SNAP from a 50-60 year old healthy subject, one could presume that the amplifiers of the ENMG system are fairly good. During nerve conduction studies, delivery of current stimulus of correct intensity is another important factor. For sensory conduction studies, in healthy subjects, the sensory threshold is usually around 2-3 mA (stimulus duration 0.2 ms). Therefore, in healthy subjects, a stimulus of 8-12 mA intensity most often suffices to obtain SNAPs of maximal amplitude. One could make use of this feature to asses the stimulator in an Indian ENMG system. If the sensory threshold in a healthy subject is within acceptable range, then, one can be certain that the stimulator is working satisfactorily. If the sensory threshold in a healthy subject is inordinately high eg. 10 or 12 mA, then, one cannot be certain that when the ENMG system displays 100 mA, the ENMG system is really delivering a stimulus of that intensity. This casts doubt on the stimulus delivery system in the machine. The other important component of the ENMG system is the filters. They help to remove the unwanted signals (noise) and to record signals of interest. Dr. Pankaj mentioned that the CMAPs recorded in his ENMG system (Indian make) are of very low in amplitude. It was suggested that inadequate setting of filters could be one possible explanation. In most of the ENMG systems (both national and international), the default filter settings (settings when the machine was installed) for performing nerve conduction studies or needle ENMG are incorrect. Hence, one should manually set the filters correctly and use the same settings for all subsequent studies. A lower setting of high frequency (HF) filter could be one of the reasons for low amplitude CMAPs.
10	For the last few years, local organizing committee of conference is providing separate room for holding subsection meetings. Because of the tight schedule of the conference, subsection meetings are scheduled during lunch time. If lunch is served in the subsection meeting room, then one full hour is available for conducting the subsection meeting. Otherwise, the time available gets reduced. It was suggested that the national delegate could correspond with the local organizing committee earlier so that lunch is served at the venue of subsection meeting(s). The meeting ended with thanks to all the members for actively participating in the deliberations.
	Dr. M.Veeredra Kumar National Delegate to IFCN
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