Healthcare Science Neurophysiology 2 and 3

Module details

Title

Healthcare Science Neurophysiology 2 and 3

Type

Specialist

Module code

SPS222

Credits

50

Requirement

Compulsory

Aim of this module

• To provide the trainees with a fundamental theoretical background in neurophysiological science, assessment and rehabilitation that is essential for clinical practice and research in neurophysiological sciences.
• To develop data analysis skills, the ability to synthesise information, their critical thinking and problem-solving skills for academic study as a Healthcare Scientist in Neurophysiology.

Electromyography and Nerve Conduction Studies and Evoked Potentials

This module will provide the trainee with detailed knowledge and understanding of electromyography, peripheral nerve conduction studies and evoked potentials, and their use in clinical assessment, diagnosis and management in various disease processes. They will have the ability to plan, prepare, perform and interpret peripheral nerve conduction studies and evoked potentials.

Paediatric EEG

This module will provide the trainee with detailed knowledge, understanding and the ability to perform resting and sleeping electroencephalograms (EEGs) and its use in the clinical assessment, diagnosis and management of children with neurological conditions. They will understand the pathophysiology, clinical presentation and electrocephalographic findings in paediatric epileptic syndromes and other clinical conditions.

EEG in the Intensive Care Setting

This module will provide the trainee with the knowledge, understanding and practical skills to record an electroencephalogram (EEG) in the intensive care setting. The trainee will appreciate the clinical use of the EEG and how it is used in patient management. The trainee will understand sources of errors, effects of sedation and non-pathological effects during EEG monitoring.

Sleep and Long term Monitoring

This module will provide the trainee with the detailed knowledge and understanding of the physiology of sleep and the practical skills required to record sleep parameters during polysomnography and multiple sleep latency recordings, as well as the clinical uses and management. It will also provide detailed understanding of the uses of long-term monitoring techniques, clinical uses and management in epileptic syndromes and sleep disorders.

Submodules

Learning outcomes

Electromyography and Nerve Conduction Studies and Evoked Potentials

1. Describe the anatomy and physiology of the peripheral nervous system.

2. Discuss and evaluate the types of electrodes, and their characteristics used in electromyography and nerve conduction studies and evoked potentials.

3. Describe the non-pathological sources of error and non-pathological effects on nerve conduction studies.

4. Describe the pathological changes in nerve conduction studies, clinical presentation and nerve conduction and electromyography changes in diseases of the peripheral nerves and skeletal muscle.

5. Describe the potentials associated with electromyography.

6 Critically evaluate the clinical uses of evoked potentials.

7. Describe the types and function of stimulators used in nerve conduction studies and evoked potentials (visual, auditory, somatosensory).

Paediatric EEG

8. Evaluate the design of a paediatric neurophysiology department.

9. Describe the normal resting and sleeping electroencephalogram of a paediatric patient.

10. Describe the pathophysiology, clinical presentation and electrocephalographic findings in paediatric epileptic syndromes.

11 Describe the pathophysiology, clinical presentation and electrocephalographic findings in paediatric conditions of the nervous system, paediatric metabolic manifestations on the central nervous system, and mental retardation syndromes and child psychiatry.

12. Critically appraise and discuss the clinical significance and interpretation of the paediatric electroencephalogram.

EEG in the Intensive Care Setting

13. Describe the anatomy and blood supply of the cerebral cortex and brainstem.

14. Describe the pathophysiology and management of the unconscious patient in the intensive care unit.

15. Critically appraise the techniques for the long-term monitoring of the electroencephalogram in patients on the intensive care unit.

16. Describe the effects that drugs and changes of other physiological variables have on the electroencephalogram.

17. Critically evaluate the clinical uses of the electroencephalogram in the unconscious patient.

Sleep and Long-term Monitoring

18. Describe the physiology of sleep and explain normal and abnormal sleep pattern.

19. Discuss and evaluate methods to assess excessive daytime sleepiness is assessed.

20. Critically evaluate the use of video telemetry and ambulatory recording in epileptic and non-epileptic seizure disorders.

21. Critically evaluate the clinical applications of ambulatory recordings in adult and childhood seizure disorders and disorders of sleep.

Indicative content

Nerve conduction studies and EMG and evoked potentials

• The generation of neural, membrane, propagation, resting potentials and refractory periods
  • Saltatory conduction
    • F waves
    • H reflex
  • Compound nerve, muscle and sensory action potentials
• Anatomy of the peripheral nerves
  • Brachial plexus
  • Median
  • Ulnar
  • Radial
  • Tibial
  • Sural and common peroneal nerve
•  Recording and stimulus parameters used in the electromyogram and motor/sensory nerve conduction studies
  • Different types of needle electrodes
    • Concentric
    • Monopolar and single fibre
  • Electrode placement for nerve conduction studies (motor and sensory)
    • Median
    • Ulnar
    • Radial
    • Tibial
    • Sural and common peroneal nerve
• Measure visual acuity; hearing threshold; sensory threshold Different types of electrodes used for recording evoked potentials
  • Surface
  • Gold foil
  • DTL needles
•   Causes   of   errors   encountered  and  non-pathological    effects  in  the recording of conduction studies and evoked potentials and their elimination
•   Nerve conduction studies
  • Errors in measurements and reproducibility of results
  • Limitation of motor conduction velocity measurements
  • Effect of age, gender, limb temperature
•   Pathophysiological changes in nerve conduction studies
  • Axonal degeneration, demyelination, re-innervation
  • Block and slowed conduction
•   The pathophysiology and clinical presentation and nerve conduction and electromyographic findings in the following conditions
  • Types of neuropathy
  • Axonal
  • Fibre-selective neuropathies
    • Large and small fibre neuropathies
  • Demyelinating diseases
  • Acute onset, hereditary, acquired, mononeuropathies
  • Entrapment neuropathies
    • Carpal tunnel syndrome
    • Ulnar nerve at the elbow
    • Tarsal tunnel
  • Radiculopathies
  • Traumatic nerve lesions
  • Myopathies
    • Inflammatory, endocrine, genetically determined myopathies
    • Plexus and root lesions
    • Neuromuscular junction disorders
    • Motor neurone disorders
•   Potentials related to electromyography
  • Motor units
  • Insertion activity
  • End-plate noise
  • Fibrillations
  • Fasciculations
  • Positive sharp waves
  • Spontaneous repetitive activity
    • Myotonic discharges
    • Complex repetitive discharges
    • Neuromyotonia
  • Reinnervation
•   Clinical uses of evoked potentials
• Visual
• Flash
  • Non-organic visual loss; cortical blindness
  • Pattern reversal visual evoked potentials
  • Optic nerve; demyelinating; systemic diseases
  • Chiasmal and retrochiasmal lesions
  • Optic tract and optic radiation disease
  • Occipital lesions
  • Non-organic visual loss
• Auditory brainstem
  • Conduction hearing loss
  • Lesions of the acoustic nerve and brainstem lesions
  • Demyelination; ataxias; degenerative disorders
  • Prognostic value in coma
• Somatosensory
  • Spinal cord; brainstem; trauma lesions
  • Tumours of the spinal cord
  • Giant SEPs
  • Central demyelination
  • Prognostic value in coma

EEG on the intensive care

• Anatomy and blood supply to the cerebral cortex and brainstem
• Management of the unconscious patient on the intensive care unit
  • Clinical neurological examination
  • Glasgow coma scale and outcome scale
  • General nursing, nursing procedures and techniques
• Intensive care environment
  • Electrical safety; patient safety; infection control; sterile fields
  • Intensive care equipment
•   The electroencephalogram in the unconscious patient  on  the  intensive care unit
•    Electrode types used in the intensive care unit for the recording of the electroencephalogram; electrode placement used; artefact and interference identification and elimination
  • Main interference; respirators; infusion pumps
  • Electrical beds; renal dialysis equipment
  • Vital signs monitors
•   Recording of other physiological variables
  • Electrocardiogram; pulse; respiration
  • Tremor; myoclonic jerks; eye movement

• Drugs used for sedation on the intensive care unit and their effect on the electroencephalogram
• Effect of other physiological variables and mechanism of effect on the electroencephalogram and evoked potentials
  • Blood pressure; heart rate; respiration rate; metabolic state
  • Liver and renal function
  • Electrolytes; temperature; raised intracranial pressure
• Uses of the electroencephalogram in the unconscious patient (adult and children)
  • Anoxic brain damage; head injury; cerebral infarct; encephalitis and meningitis
  • Metabolic disease; multi-organ failure
  • Status – clinical and subclinical
  • Locked-in syndrome
  • Renal dialysis
  • Prediction of outcome
  • Prognostic value
  • Raised intracranial pressure
  • Brain death and irreversible cerebral damage
  • Status epilepticus
• Technical requirements and instrumentation for the continuous monitoring of the electroencephalogram on the intensive care unit
• Basic signal processing and interpretation
  • Fourier and amplitude analysis
  • Display, quality control and validation requirements
  • Artefact identification
  • Cerebral function monitor, analysing monitor
  • Compressed spectral array

Paediatric EEG

• Design of a paediatric neurophysiology department
  • Layout, accessibility, waiting areas, recording suites
  • Child–parent facilities
  • Staff areas, availability and departmental structure
  • Equipment specifications and availability
  • Normal resting electroencephalogram, normal variants and the sleeping electroencephalogram in paediatric patients
  • Infants in the first year of life; child and adolescence
• Activation procedure their indications and contraindications
  • Hyperventilation, photic stimulation
  • Sleep deprivation and drug-induced sleep
• Paediatric epileptic syndromes
  • Epileptic syndromes of infancy and early childhood
    • Infantile spasms (West syndrome, Blitz-Nick-salaam Krämpfe)
    • Febrile convulsions
    • Benign myoclonic epilepsy; severe myoclonic epilepsy in infancy
    • Lennox-Gaustaut syndrome
    • Epilepsy with myoclonic-astatic seizures
  • Epileptic syndromes of childhood
    • Childhood absence epilepsy
    • Epilepsy with myoclonic absences
    • Benign partial epilepsies in children
      • Benign childhood epilepsy with centro-temporal spikes Childhood epilepsy with occipital paroxysms
      • Benign epilepsy with affective symptoms
      • Benign partial epilepsy with extreme somatosensory evoked potentials
      • Atypical benign partial epilepsy
      • Other forms of benign partial epilepsies
    • Epilepsy with continuous spike and slow wave during slow sleep (CSWS or ESES)
    • Acquired epileptic aphasia (Laudau-Kleffner syndrome)
    • Chronic progressive epilepsia continua of childhood (Kojewnikov’s syndrome)
    • Epileptic syndromes of late childhood and adolescence
    • Juvenile absence; juvenile myoclonic epilepsy
    • Epilepsy with generalised tonic-clonic seizures on awakening
    • Primary reading; photosensitive epilesy
    • Progressive myoclonic epilepsies of childhood and adolescence
  • Paediatric conditions of the nervous system
  • Infection of the nervous system
    • Meningitis; encephalitis; Herpes simplex encephalitis
    • Tuberculous meningoencephalitis; cerebral thrombophlebitis
  • Cerebral malaria
    • Slow virus infections
    • Subacute sclerosing panenceohalitis
    • Human immunodeficiency virus infections and AIDS
    • Rasmussens’s syndrome; Reye syndrome
  • Brain tumours; cerebral palsy
    • Structural abnormalities
  • Paediatric metabolic conditions
  • Peroxisomal disorders
  • Lysosomal enzyme disorders and other leucodystophies
  • Neuronal ceriod lipofuscinosis
    • Amino acid disorders and organic acidurias
  • Paediatric metabolic manifestations on the central nervous system
  • Endocrine disorders
  • Disturbances of carbohydrate metabolism
  • Disturbances of electrolyte balance
  • Learning difficulties and child psychiatry
  • Down’s; Fragile X; Angelman’s; Rett’s; Tourett’s syndrome
  • Autism and related disorders
  • Developmental dysphasia; attention deficit hyperactivity disorder
  • Behavioural/ conduct disorders/problems; anorexia nervosa
  • Batten’s

Sleep and long-term monitoring

• Clinical polysomnography
  • Electrode/Transducer placement
    • Electrooculogram
  • Submental muscle
  • Respiratory effort and movement
• The electroencephalogram
• Origin of the electroencephalogram
• Characteristics of the normal awake EEG in adults and paediatrics including normal variants
• Sleeping EEG in adults and Paediatrics
• Vertex sharp waves, sleep spindles, K complexes and positive occipital sharp transients of sleep (POSTs)
• Demonstrates an understanding of the normal  phenomena of sleep and  the different stages of sleep
• Sleep stages
  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • Rapid eye movement (REM)
• Sleep staging
  • Rechtschaffen and Kales
  • Hypnograms
  • Physiology of sleep and sleep disorders
• Parasomnias
• Insomnias
• Hypersomnias
• Assessment of excessive daytime sleepiness
• Multisleep latency test (MSLT)
• Maintenance of wakefulness test
• Stanford sleepiness scale
• Application of video-telemetry and Ambulatory Recording
• Differential diagnosis
• Differentiation between epileptic and non-epileptic attacks
• Classification of seizures (in known epilepsy)
• Focus localisation
• Evaluating clinical symptoms
  • Seizure classification by clinical criteria
  • Hard to recognise seizures
  • Transitory cognitive impairment
• Evaluating frequency of events
• Detection of precipitating factors
• Clinical utility of ambulatory recordings
• Adult seizure disorders
• Childhood seizure disorders
• Evaluation of episodes of altered awareness or behaviour
• Uses in sleep disorders
  • Hypersomnias
  • Parasomnias
  • Sleep apnoea
  • Periodic movements of sleep

Activities

 Electromyography and Nerve Conduction Studies and Evoked Potentials

• Identify a patient with a peripheral nerve or muscular problem requiring EMG and/or nerve conduction investigations and, with permission, follow the progress of the patient from the initial consultation, through investigations and follow-up appointment, and reflect on your learning from this process.
• Identify five patients with different peripheral nerve or muscular conditions (e.g. motor neuron disease, myasthenia gravis, etc.), write a case study on each patient and critically reflect on the role of EMG and nerve conduction studies in such conditions.
• Observe the application of evoked potentials in the surgical setting and describe, compare and contrast the different techniques used and the evidence base underpinning their use.
• Identify a patient with multiple sclerosis and, with permission, follow the progress of the patient from initial consultation, through investigations, including evoked potentials, and follow-up appointment, and reflect on your learning from this process.
• Attend a neurology, neurosurgery, neuromuscular or neurorehabilitation clinic and critically appraise the process of referral, diagnosis and treatment, including the range of healthcare professionals that contribute to the care of each patient and how the interprofessional team work together.
• Use your clinical experience to critically evaluate the use of evoked potentials and nerve conduction studies.

It is also recommended that trainees undertake the following clinical experiential learning:

• Observe the surgical treatment of patients with a peripheral nerve entrapment, such as carpal tunnel syndrome, and discuss the evidence base underpinning the surgical and non-surgical management of peripheral nerve entrapment.
• Attend an outpatient clinic and observe the work of the therapists in the treatment and management of peripheral nerve entrapment conditions.
• Observe paediatric EMG and reflect of the differences between assessing children and adults.
• Participate and contribute to multidisciplinary team meetings (MDTs) and case presentation sessions and discuss the role of MDTs in the diagnosis and management of patients.

Paediatric EEG

• Identify a paediatric patient with an epilepsy syndrome requiring EEG and, with permission, follow the progress of the patient from the initial consultation, through investigations and follow-up appointment and reflect on your learning from this process.
• Identify five patients with different epilepsies or neurological conditions (e.g. childhood absence epilepsy, West syndrome), write a case study on each patient, critically reflect on the role of EEG in paediatric conditions and evaluate the use of EEG in childhood.
• Observe the application of EEG in the non-dedicated environment and describe the different techniques used.
• Observe a paediatric epilepsy clinic and critically appraise the process of referral, diagnosis and treatment, including the range of healthcare professionals that contribute to the care of each patient and how the interprofessional team work together.
• Use your clinical experience to critically evaluate the range of montage derivations and recording parameters used in paediatric EEG.

 It is also recommended that trainees undertake the following clinical experiential learning:

• Observe the surgical treatment of patients with intractable epilepsy, evaluate the evidence base underpinning the surgical and medical management of intractable epilepsy, and present your findings to colleagues.
• Observe neonatal EEG and reflect of the maturation of the EEG.
• Participate and contribute to multidisciplinary team meetings (MDTs) and case presentation sessions and discuss the role of MDTs in the diagnosis and management of patients.

EEG in the Intensive Care Setting

• Identify a patient in the intensive care setting requiring EEG and, with permission, follow the progress of the patient from the initial admission, through investigations and outcome. Reflect on your learning from this process.
• Identify three intensive care patients referred for EEG for different reasons (e.g. status epilepticus, head injury, etc.), write a case study on each patient and critically reflect on the role of EEG in such conditions.
• Observe the application of cerebral function monitoring in the intensive care setting and describe the different techniques used.
• Attend an intensive care unit ward round and critically appraise the process of admission, diagnosis and treatment, including the range of healthcare professionals that contribute to the care of each patient and how the interprofessional team work together.

 It is also recommended that trainees undertake the following clinical experiential learning:

• Observe the neurosurgical treatment of intensive care patients and discuss how this experience will shape your professional practice.
• Observe neonatal intensive care cerebral function monitoring.
• Participate and contribute to multidisciplinary team meetings (MDTs) and case presentation sessions and discuss the role of MDTs in the diagnosis and management of patients.

Sleep and Long term Monitoring 

• Identify a patient undergoing a sleep study and, with permission, follow the progress of the patient from the initial consultation, through investigations and follow-up appointment, and reflect on your learning from this process.
• Identify a patient undergoing long-term monitoring and, with permission, follow the progress of the patient from the initial consultation, through investigations and follow-up appointment, and reflect on your learning from this process.
• Identify a patient referred for a multiple sleep latency test or polysomnography, write a case study on the patient and critically reflect on the role of the multiple sleep latency test in the diagnosis of narcolepsy or excessive daytime somnolence.
• Identify two patients referred for long-term monitoring for different conditions (e.g. intractable epilepsy, non-epileptic attacks), write a case study on each patient and critically reflect on the evidence base underpinning the role of long-term monitoring in the management of each condition.
• Attend a sleep disorders or specialist epilepsy clinic and critically appraise the process of admission, diagnosis and treatment, the contribution of each member of the healthcare team contributing to the care pathway and the factors that promote effective interprofessional working.
• Using your clinical experience gained in this module critically evaluate, including the underpinning evidence base, the application of videotelemetry and ambulatory recording in the diagnosis of epileptic and non-epileptic attacks and adults and children.

 It is also recommended that trainees undertake the following clinical experiential learning:

• Observe the neurosurgical treatment of patients with intractable epilepsy and discuss the advantages and disadvantages and evidence base for each treatment modality and present your findings at a departmental meeting.
• Observe a range of sleep studies undertaken within respiratory and sleep science and discuss the similarities and differences between the service provided by a neurophysiology and respiratory and sleep service.
• Participate and contribute to multidisciplinary team meetings (MDTs) and case presentation sessions and discuss the role of MDTs in the diagnosis and management of patients.