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2 Specialties Clinical neurophysiologyClinical neurophysiologyDr Robin Kennett Consultant clinical neurophysiologistDr Rosalind Kandler Consultant clinical neurophysiologist1 Description of the specialtyClinical neurophysiology uses measurement of electricalactivity from the central and peripheral nervous systemto help in the diagnosis and management of a widerange of neurological conditions in all age groups. Mostconsultants work within neuroscience centres, althoughsome services are delivered in district general hospitals(DGHs), and all departments are supported byhealthcare scientists (HCS). The core investigations areelectroencephalography (EEG) and nerve conductionstudies (NCS) with electromyography (EMG), whichare mostly performed on outpatients and constitute thelargest part of clinical neurophysiology workload. EEGis used to investigate children and adults with epilepsy,the most common serious neurological condition, 1 andnerve conduction is required for the management ofperipheral nerve disorders such as entrapmentneuropathy (carpal tunnel syndrome, ulnar neuropathy,etc) and generalised peripheral neuropathy (eg diabeticneuropathy). Clinical neurophysiology is used toinvestigate a wide range of less common neurologicaldiseases, and most departments also perform long-termEEG monitoring to record episodic disorders(ambulatory EEG and video-telemetry), evokedpotentials for multiple sclerosis, and EMG forradiculopathy, muscle disease, myasthenia gravis andmotor neuron disease. Some departments offer highlyspecialised investigations that may not be available in allneuroscience centres, including EEG monitoring onintensive therapy unit (ITU) for coma, intracranial EEGandevokedpotentialrecordingduringneurosurgeryforepilepsy, brain tumours, Parkinson’s disease and spinalsurgery, polysomnography to investigate sleepdisorders, and evoked potentials for retinal disease andhearing loss.The scope of clinical neurophysiology brings it intocontact with many other specialties including neurologyand neurosurgery, paediatrics, rheumatology andorthopaedics, plastic surgery, ophthalmology, generalmedicine and general practice.2 Organisation of the service and patternsof referralNeurophysiology testing requires specialised recordingapparatus, an appropriate environment and trainedmedical and scientifc personnel. Consequently, servicesare hospital based and usually only available inneuroscience centres or larger DGHs. Smaller DGHsmay provide outpatient EEG and nerve conductionstudies, but patients needing more specialisedinvestigation or inpatient studies will be treated intertiary centres, on a hub-and-spoke model. DGHswithout clinical neurophysiology services are at adisadvantage for managing patients with acuteneurological conditions and further plans to strengthenneurology support to these hospitals 2 should includeprovision for neurophysiology. Sources of referral areusually from secondary or tertiary care but somedepartments allow limited direct access from primarycare.3 Working with patientsPatients referred for a neurophysiological opinion willusually be under the care of hospital consultants whowill explain the need for investigation. The results aresent to the referring physicians, but because of thecomplexity and technical nature of neurophysiologyreports, it is unusual for a copy being sent directly to thepatient. Where appropriate, the results may be discussedwith the patient by a consultant clinicalneurophysiologist: HCSs are not usually in a position toprovide a tailored clinical opinion or discuss furtherC○ Royal College of Physicians 2013 67
Consultant physicians working with patientsmedical management. It is good practice to provideinformation to the patients in advance of anyinvestigation which explains the procedures as well aspossible risks and consent issues. The British Society forClinical Neurophysiology (BSCN) has producedrecommendations on patient information documentsthat, after local modifcation, are sent by mostdepartments with appointment letters. 3 Manyconditions investigated by clinical neurophysiology arelong-term illnesses and have excellent patient groupsand charities.4 Interspecialty and interdisciplinary liaisonConsultant neurophysiologists are dependent on highlytrained and skilled scientifc support staff who typicallyperform all EEG and evoked potential studies and assistwith nerve conduction recordings. Although clinicalreports are usually produced by medical personnel,scientifc staff are increasingly asked to provideprovisional reports, requiring close cooperation toensure limits of competence and standards aremaintained.There should be regular meetings and reviews betweenusers of neurophysiological services and the medicaland scientist staff who perform the studies. Althoughinformal discussion with referring clinicians to explainthe signifcance of results is a normal part of aconsultant’s work, more formal multidisciplinary teams(MDTs) may be required for EMG with neurologistsand pathologists, EEG with neurologists andpaediatricians and for sleep disorders with neurologistsand chest physicians. Large MDT meetings to includeneurologists, neurosurgeons, neuroradiologists andneuropsychologists are usual in centres undertakingcomplex surgical treatment of patients with intractableepilepsy. Liaison with many other physicians who referpatients to neurophysiology is via a written report,which must therefore be clear and capable of beingunderstood by non-specialists.The complexity and relative rarity of neurophysiologyinvestigation, and its dependence on equipment andsupport staff mean that there is limited opportunity forthe specialty to be delivered in the community.5 Delivering a high-quality serviceA high-quality neurophysiology service requiresappropriate facilities, equipment and trained staff.FacilitiesThe minimum requirements would include: a self-contained department in a quiet location a suffcient number of rooms large enough toaccommodate equipment, couches, patients,relatives and staff access for beds and disabled patients shielding from electrical interference ease of access for outpatients, and proximity toneurological inpatient wards when video-telemetryis performed secretarial and staff offces for the analysis of data,preparation of reports and clinical management ofthe service.EquipmentThe following equipment would be required: digital EEG recording apparatus with simultaneousvideo, preferably linked to a central server for dataanalysis and storage EMG and evoked potential recording systems more specialist equipment according to the servicesoffered (eg portable apparatus for operativemonitoring, video-telemetry, polysomnography) number and different types of machines to matchthe service demand regular maintenance contract to ensure safety andaccuracy.Education, training, mentoring and appraisalConsultants in clinical neurophysiology will havetrained in the specialty following the curricularrequirements laid out by the Joint Royal Colleges ofPhysicians Training Board (JRCPTB) and regulated bythe General Medical Council (GMC). Occasionally,limited neurophysiological services are delivered byconsultants not trained in the specialty (although a fewneurologists have dual certifcation withneurophysiology), but the BSCN recommends that alldepartments offering a comprehensive service aresupervised by a consultant in neurophysiology tomaintain standards. 4 The supervising consultant worksalongside the scientifc service manager to providedepartmental leadership and to ensure that local clinicalgovernance is in place, including in-house training andeducation, health and safety, appraisal and audit. TheBSCN, in conjunction with the Department of Healthand the Association of Neurophysiological Scientists(ANS), has developed quality standards for departments68 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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