Electrodiagnostic Services



Muscle and Nerve Disorders


Diagnosing nerve disorders.

As technology continues to advance, so too does modern medicine. In particular, advancements in the field of electrodiagnostic medicine have greatly improved physicians’ ability to diagnose a whole host of conditions that can affect the peripheral nervous system. Dr. Eric R. Beck is a triple-board-certified physical medicine and rehabilitation specialist who makes every effort to study the latest advances in his field and, more importantly, to offer them to you. Dr. Beck performs today’s state-of-the-art electrodiagnostic studies — electromyography (EMG) and nerve conduction (NCV) tests — in the comfort and convenience of his offices in Huntsville and Ft. Payne.

The ABCs of EMG and NCV


Your care with Dr. Beck starts with a complete health history and physical exam and discussion of your symptoms. Dr. Beck will then perform an EMG and NCV study. (EMG is performed along with NCV tests to differentiate a muscle disorder from a nerve disorder.) EMG is a test of a muscle’s electrical activity and is recommended if you are experiencing pain or weakness. With EMG, Dr. Beck will have you sit or lie down, depending on which muscle is being tested. He will then apply a special numbing spray to your skin over the selected muscle and an extremely thin needle electrode is gently inserted into the muscle. The electrode records the electrical activity while your muscle is relaxed and while you contract it with increased forcefulness under the direction of Dr. Beck.
An NCV study is performed to diagnose nerve damage or destruction and to evaluate nerve disease. With this test, Dr. Beck will place sticky electrodes — similar to those used for EKG exams — on your skin over the nerve. He then stimulates the nerve with a mild electrical impulse while the electrodes record the speed of the impulse as it travels from point A to point B. Dr. Beck will repeat this process for each nerve being tested. A normally functioning nerve will transmit a faster and stronger signal than a damaged or diseased nerve.

Nerve damage or destruction can be caused by many conditions, including carpal tunnel syndrome, diabetic neuropathy and herniated disc. Dr. Beck brings you more than 13 years of clinical experience and has performed thousands of electrodiagnostic studies. He is the trusted choice of many area physicians for their patients who need his highly specialized care.


Dr. Eric R. Beck MD - EMG and NCV Testing

Carpal Tunnel


Treating carpal tunnel in the elderly: early electrodiagnostic testing is key. Early diagnosis crucial.

Prospects for a good outcome in the treatment of carpal tunnel syndrome diminish if intervention begins late, when the condition is far along.

Therefore, a key to success in dealing with this most common of entrapment neuropathies is to catch it in its earliest stages. This is especially the case for adults over the age of 50, suggest findings from the Albert Einstein College of Medicine’s Montefiore Medical Center in New York.

The research also suggests that “greater attention needs to be paid to objective evidence of carpal tunnel syndrome severity rather than subjective complaints when evaluating elderly adults…,” the investigators wrote in the journal. Muscle & Nerve.

Other noteworthy observations by these same researchers:

Symptoms of carpel tunnel syndrome in older patients can be ambiguous; the condition appears to progress more rapidly in the elderly population; and electrophysiologic abnormalities seem to be both more common and severe in the older subjects.

In consequence to these findings, it is advisable for primary care physicians and other specialists to establish a low threshold for suspecting carpal tunnel syndrome. This is important for older adults who present complaints that their wrist, hand, palm or finger tingles, aches, feels numb or swollen. All of these symptoms can result in less gripping strength.

Risk factors

By way of reminder, carpal tunnel syndrome occurs following entrapment of the median nerve within the carpal tunnel, resulting in demyelination and then axonal degeneration.

Several theories exist to explain the cause of the syndrome, although likeliest is the existence of pressure within the carpal tunnel sufficient to obstruct venous outflow and produce back pressure, edema formation and nerve ischemia.

Risk factors include genetics, medical history, social status, vocations and avocations involving repetitive motions and demographics (whites are probably at highest risk; the female-to-male ratio is at least 3:1).

In the Montefiore study, researchers noticed that the incidence of carpal tunnel syndrome appears to peak in adults between the ages of 50 and 54, decreases after that and then climbs again to a second peak occurring between the ages of 75 and 84.

More Thenar Muscle Wasting

One of the objectives of the Montefiore study was to bolster the relatively thin understanding of the clinical and electrophysiologic characteristics of carpal tunnel syndrome in elderly adults.

“We examined age differences in clinical, functional and electrophysiologic features in elderly adults referred to a neuromusclar service for evaluation of symptoms suggestive of carpal tunnel syndrome,” the researchers wrote in the journal’s July 2006 issue. “Of 415 consecutive subjects referred over an 18 month period, 343 met clinical criteria for carpal tunnel syndrome. There were 158 young (less than 50 years), 115 middle-aged (51-64 years) and 70 elderly adults (over 65 years). Our findings are consistent with previous studies that found worsening electrophysiologic changes with increasing age.”

Carpal tunnel syndrome in older adults is reported to be associated with more thenar muscle wasting, particularly diurnal paresthesias, and more severe motor and sensory axon loss and indeed, in the Montefiore study, elderly adults demonstrated a higher prevalence of thenar weakness and thenar atrophy than younger subjects.

“There were also more patients with absent sensory potentials in the older group,” the team wrote.

Early Diagnosis is Crucial

Approximately 90% of mild-to-moderate cases of carpal tunnel syndrome respond to conservative management. However, given that the condition is progressive, the earlier it is diagnosed the more likely it is to respond to conservative intervention.

Conservative management, of course, typically includes nighttime wrist splinting, use of nonsteroidal antiinflammatory drugs (with or without diuretics), oral or injectable steroids and physical or occupational therapy. Naturally, though, before commencing conservative management of carpal tunnel syndrome, the patient’s complaint must be diagnosed as such. The “gold standard” of testing for carpal tunnel syndrome is an electrodiagnostic study performed by or under the direct supervision of a board-certified specialist adhering to testing standards and guidelines developed by the American Board of Electrodiagnostic Medicine.

The most relevant electrodiagnostic tests for diagnosing carpal tunnel syndrome are electromyography (EMG) and nerve conduction studies (NCS). In addition to identifying abnormalities associated with specific symptoms and signs of carpal tunnel syndrome, these two tests are capable of excluding other neurologic diagnoses.

Further, these tests can yield data of the sort necessary for accurately assessing the severity of nerve damage. Typically, testing that demonstrates nothing but sensory abnormalities will be found to have mild carpal tunnel syndrome, while sensory abnormalities accompanied by motor dysfunction are usually taken as evidence of moderate severity. The condition is considered truly severe when testing reveals decreased or absent sensory or motor responses distal to the carpal tunnel or neuropathic abnormalities.

These tests can be repeated at future dates to gauge the effectiveness of therapy and other interventions.

Conclusions

Carpal tunnel syndrome is a serious problem for the elderly.

It is treatable, but treatment is most effective when started while the condition is in an early stage. Carpal tunnel syndrome should be suspected when patients – old or young – present with symptoms even loosely characteristic of the condition. These patients should promptly undergo electrodiagnostic testing to establish or rule out carpal tunnel syndrome as the diagnosis.

However, a problem with electrodiagnostic testing is that often the interpretation of the raw data is reported in ambiguous terms. Worse, delivery of the unhelpfully vague report takes many long weeks, during which time the specialist who performs the interpretation is uncommunicative.

At the medical offices of Eric R. Beck, MD, PhD, FAAPMR, none of these shortcomings exists. We are very clear as to whether a study comes back normal or abnormal; if the latter, we then spell out the degree of severity so that you can confidently proceed with treatment planning. Further, we offer extremely rapid turnaround on our reports of findings:

Typically, we put a summary report in your hands within 24 hours and a full report a short time later.

We also see your patients quickly, usually seven days after we are contacted with a request to schedule an appointment.

Once your patient arrives here, he or she is treated with utmost courtesy. Moreover, we strive to make the examination as painless and stress-free as possible by offering ethyl chloride numbing of the skin prior to needle testing.

We welcome your referrals of patients suspected of carpal tunnel syndrome and other musculoskeletal-neurologic problems. We can perform comprehensive evaluations of your patients and, if you desire, initiate treatment and perform follow-up, keeping you apprised every step of the way. But no matter the way you choose to utilize us, know that your patients will be satisfied by the high-quality services and interactions delivered at each encounter and will return to you as willing as ever to continue entrusting you with their ongoing care.


Ulnar Nerve Involvement in Atypical Carpal Tunnel Presentation


The vast majority of mild-to-moderate cases of carpal tunnel syndrome respond to conservative management – meaning that the earlier this progressive entrapment neuropathy is diagnosed, the more likely it is to respond to physical or occupational therapy, along with wrist splinting, nonsteroidal anti-inflammatory drugs and steroids.

But therein lies the rub. Carpal tunnel syndrome does not always present with classic symptoms, an unfortunate habit that can prevent earliest possible detection when diagnosing by medical history and observed signs alone.

A good illustration of the problem comes from Italy’s University of Siena. Writing in the February 2008 issue of the journal Muscle & Nerve, researchers there report new evidence of a long-suspected association between carpal tunnel syndrome and impairment of ulnar sensory nerve fibers. The university contends that subclinical damage to the ulnar nerve at the wrist can cause carpal tunnel syndrome to appear as something other than what it is. Moreover, ulnar nerve damage may disguise it long enough that, by the time clinicians realize they are dealing with carpal tunnel syndrome, the infirmity may have progressed to the severe stage.

The lesson is obvious: Cases that do not appear to be carpal tunnel syndrome should nonetheless be suspected as that very thing until proven otherwise by “gold standard” tests – and, in this instance, the gold standard is electrodiagnostic testing.

Extra-median spread

An important insight emerging from the University of Siena research is that approximately 42% of carpal tunnel syndrome patients can be expected to experience sensory symptoms outside the typical median nerve distribution.

“According to previous reports, an extra-median spread of symptoms is more frequent in the mild than in the severe or extreme stage of carpal tunnel syndrome,” the investigators write.

They offer an explanation for this: “Damage to ulnar nerve axons in carpal tunnel patients may be caused indirectly by compressive forces transmitted to the ulnar nerve by high pressure in the carpal tunnel, rather than reflecting comorbidity of carpal tunnel syndrome and Guyon’s canal syndrome.”

Elaborating, the researchers assert that these transmitted forces are sufficient to obstruct venous outflow and produce back pressure, edema formation and nerve ischemia.

“It could be advanced that in early carpal tunnel syndrome, ectopic discharges from damaged ulnar sensory afferents play a dominant role in conditioning extra-median spread of symptoms.”

This leads the researchers to conclude that central mechanisms may suppress or mask symptoms. “For example, chronic stimulation of nociceptive afferents of the median nerve could exert some gating of sensory processing from low-threshold ulnar fibers,” they write. Further, peripheral factors such as indirect ulnar nerve compression acting in concert with plastic changes at a subcortical or cortical level might also contribute to the extra-median spread of symptoms, the team proposes.

What electrodiagnostics can reveal.

As you know, symptoms of carpal tunnel syndrome include numbness, swelling, achiness and/or tingling of the wrist, hand, palm and/or fingers, often accompanied by a pronounced decrease in the ability to grip objects. White females are at highest risk of developing carpal tunnel. A free informational journalr the medical com munity published by syndrome. Also prone to it are individuals whose job (or recreational activities) involve repetitive hand-wrist motions – particularly true in situations where workplace ergonomics are subpar or nonexistent.

There are a number of avenues to diagnose carpal tunnel syndrome. By far the best way is with electrodiagnostic testing.

It is demonstrably reliable and cost-efficient when administered in accordance with American Board of Electrodiagnostic Medicine standards/guidelines and is conducted or overseen by a board-certified specialist.

Electromyography and nerve conduction studies are the two most relevant such tests for identifying abnormalities associated with specific symptoms and signs of carpal tunnel syndrome. Both can also indicate entrapment neuropathy severity: A finding of sensory abnormalities by themselves usually indicates a mild stage of carpal tunnel syndrome, but sensory abnormalities present with motor dysfunction typically signifies a moderately severe stage. (Carpal tunnel syndrome is at its most advanced stage when sensory and motor responses distal to the carpal tunnel or neuropathic abnormalities are appreciably degraded or entirely absent.)

Conclusions
Carpal tunnel syndrome occurs following entrapment of the median nerve within the carpal tunnel, resulting in demyelination and then axonal degeneration. Changes in impulse transmission of ulnar motor axons have been documented in patients with carpal tunnel syndrome.

The ulnar nerve may be subject to compression in Guyon’s canal as a consequence of high pressure in the carpal tunnel, and this may help explain extra-median spread of sensory symptoms in carpal tunnel syndrome patients.

Prospects for a good outcome in the treatment of carpal tunnel syndrome are at their best if intervention begins earlier rather than later.

Carpal tunnel syndrome should be suspected when patients – with or without extra-median spread – present with symptoms even loosely characteristic of the condition. These patients should promptly undergo electrodiagnostic testing to establish or rule out carpal tunnel syndrome as the diagnosis.

Resist ambiguously reported electrodiagnostic test results or those that are not delivered in a timely manner. At the offices of Eric R. Beck, MD, PhD, FAAPMR in Huntsville, Fort Payne and Birmingham, Alabama, our standard operating procedure is to compile electrodiagnostic test reports that are clear and informative. When a study is abnormal, we articulate for you the degree of severity so that you can confidently proceed with treatment planning. Further, we report back to you in summary form within 24 hours and deliver a detailed report a short time later.

We also see your patients quickly, usually seven days after we are contacted with a request to schedule an appointment.

Once your patient arrives here, he or she is treated with utmost courtesy. Moreover, we strive to make the examination as painless and stress-free as possible by offering ethyl chloride numbing of the skin prior to needle testing.

We welcome your referrals of patients suspected of carpal tunnel syndrome and other musculoskeletal-neurologic problems. We can perform comprehensive evaluations of your patients and, if you desire, initiate treatment and perform follow-up, keeping you apprised every step of the way. But no matter the way you choose to utilize us, know that your patients will be satisfied by the high-quality services and interactions delivered at each encounter and will return to you as willing as ever to continue entrusting you with their ongoing care.

Please call Valley Center for Nerve Studies & Rehabilitation in Huntsville and Fort Payne at (256) 382-1603 for more information about our services and approaches to care or simply to schedule an electrodiagnostic test. To schedule an appointment online, please use our secure online appointment request form.