November 13, 2023 • 57 mins
Do you often forget that the peripheral nervous system is a part of neurology? Our guest, Dr. Anishee Undavia, a seasoned neuromuscular neurologist, shines a spotlight on this enigmatic field, unraveling the complexities of diseases affecting these nerves, by dividing them into "neuromuscular buckets".
Tune in to hear how her personal journey through the fellowship program peeled back the layers of neuromuscular medicine, exposing a field teeming with breadth and depth.
Together, we navigate the labyrinth of teaching the peripheral nervous system and brainstorm original ways to dismantle educational barriers for medical students and residents.
You can find Dr. Undavia at @AnisheeShah on X/Twitter.
https://x.com/AnisheeShah?s=20
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Michael Kentris (00:02):
Hello everyone and welcome back to the
NeuroTransmitters.
So glad to have you here andI'm very happy to be joined
today by Anishee Undavia, aneuromuscular neurologist from
Penn State Valley Forge.
Please introduce yourself.
Tell us a little bit about whatyour deal is.
Anishee Undavia (00:20):
Hi Michael, thank you so much.
I'm really, really excited tobe here.
Believe it or not, it's myfirst podcast, so this is new to
me, but I'm really enthusiasticabout just the opportunity to
talk to you and maybe even anaudience that is full of med
students that might beinterested in neurology, or
junior residents that are kindof figuring out what their next
(00:42):
step would be within thespecialty and referring doctors
or any kind of audience that hascuriosity about the field of
neuromuscular medicine and whatit's all about.
I am currently faculty at PennMedicine at one of their
suburban sites called ValleyForge, but I recently switched
over from a more of an academicposition.
(01:03):
I was in the Einstein-Jeffersonsystem and I had a great time
there, especially because I wasvery, very involved in teaching,
specifically with the neurologyclerkship.
I was involved in that, butalso in hands-on training with
the residency, recruitment andthat sort of thing.
So because I'm no longer inthat environment, I'm just so
grateful for this platform,whether it's Neuro Twitter or
(01:26):
podcasting, and, having met you,just because I would love to
continue to stay engaged,continue some form of teaching
and if it's in this space, Ithink that's a really creative
way to keep going with that.
So thank you again for invitingme.
Michael Kentris (01:39):
Oh, I'm so happy to have you actually, so I
definitely sympathize with thatstory.
Similar right.
I went from a more neurologyacademic department and now I'm
a little bit kind of in mylittle insular silo in a
community teaching program.
So I have trainees, but notneurology trainees, and it just
makes you appreciate all themore how important it is to
(02:02):
teach neurology, and theclinical neurology in particular
, to not just neurologyresidents but to all commerce
right, medical students,internal medicine residents and
everyone who's willing to listento us talk on at length about
minutia.
But why I'm particularly gladyou agreed to join me today is
(02:23):
neuromuscular neurology is sucha challenging area of even just
neurology in general and I washoping you could, for those who
might be less familiar with thesubspecialties, just give a
little definition of what youwould consider neuromuscular
neurology.
Anishee Undavia (02:40):
Yeah, that's a great question and a good place
to start, and I often have toexplain this to medical students
who think of neurology as thebrain and the spinal cord, but
also we have to remind them thatthe peripheral nerves are a
part of that.
And I guess I'll start by sayingwhen I talk to patients, I tell
them about the outside nervesor the peripheral nerves and
(03:01):
specifically, when I'm in theEMG lab, I tell them, you know,
this test isn't really going togive me information about
Parkinson's disease or multiplesclerosis, but it really tells
me anatomical information of anydamage to the nerve, starting
from the nerve root and all theway out to the muscle.
And so that's really what wecover in neuromuscular medicine.
Of course there's overlap with,you know, some central nervous
(03:22):
system findings, but really whenI think of neuromuscular, it's
really traditionally diseasesthat affects the nerves after
they exit the brain and spinalcord or beyond, and it includes
such a vast number of conditions.
And what I'll say is it can beas simple as a nerve compression
(03:45):
, like what we see in carpaltunnel syndrome or ulnar nerve
entrapment, but it also includesa whole host of autoimmune
conditions, neurodegenerativeproblems and hereditary
conditions that we can certainlytalk about more in detail.
So that's kind of how I explainneuromuscular to folks.
Michael Kentris (04:04):
Excellent and you know I think it's very
important.
I talk a lot about this as well, right?
I mean, I think in frameworks,right, a lot of medicine is
pattern recognition, butbuilding those frameworks for
the peripheral nervous systemspecifically, I think, is a
little more challenging.
There's not as much emphasisput on it.
And again, when you're teaching, like junior trainees and
(04:27):
things like that, what do yousee as like the main barriers
for people picking this up aseasily as, say, like,
identifying stroke syndromesversus, say, different
neuropathic patterns?
Anishee Undavia (04:42):
That's a very, very good question and I think
one of something we should talkabout more when we think about
training students and residents.
I think from my experience oneof the biggest barriers is for
medical students and residentsalike.
They the emphasis is in thehospital, which is great and
very, very important, becauseacute neurology is something we
(05:05):
have to all be familiar with asneurologists and recognize and
treat in a rapid and appropriatemanner.
But I think because there is somuch volume these days and so
much to cover in the hospitalwith whether it's strokes or
seizures, neuro ICU cases,subarachnoid hemorrhage, et
cetera there just isn't as muchtime and space to even think
(05:28):
about the peripheral nervoussystem.
So I think that's one of thebig barriers.
I don't know if you'veexperienced that, but it's that
not only do we not have time tothink about it, but then when we
want to open that door, there'sso much that we want to turn
away.
And one funny thing I think isthat because, from med school,
when you think of the peripheralnervous system, I feel like
(05:50):
many of our minds go to thebrachial plexus, which is like
ugh, I don't want to think aboutit.
I failed that test, you know.
I memorized those branches ahundred times.
I can't keep going back andit's obviously so much more than
that and it doesn't have to beas complex as what we think
about.
So I think that one of thebarriers is just not opening
that can of worms and maybe wecan overcome that by talking
(06:12):
about it in a bit of a differentway, what I have tried to do,
because I went in my lastposition.
I was both involved inneuromuscular teaching but also
general comprehensive neurologyin the hospital and in resident
clinic.
So I would try to.
I'll give you an example.
So let's say it was Saturdayand we're rounding on our
inpatient service and we have astroke follow up.
(06:34):
Somebody who had a rightinternal capsule stroke came in
with left sided weakness and theresident has done a great job
seeing the patient following up.
And then we go to the bedsidefor routine rounding and you
know things are kind of tuckedaway.
The patient's doing well,waiting for rehab, but I'll
notice like some of them haveatrophy.
So I'll look down and I'll seethat patient looks fine.
(06:55):
The exam is stable.
The resident has said oh, thepatient has three out of five
strength in the left upper limb.
And then I'll look at the handand I'll see that the first
dorsal enterosia is completelywasted away.
We've seen this before, right?
And I'll tell the resident hey,I'll just kind of look at my
with my eyes and kind of makeeyes with them and have them
look at the hand and I'll saywhat's that?
And it throws them off guard alittle bit and I try to be non,
(07:22):
you know, not scary about it andI'll say, especially if it's
like a PGY2 resident, I'll belike you might not know why that
hand is weak, but try to take aguess.
Do you think it's about thestroke?
And you know most of them willknow, well, no, atrophy doesn't
happen that acutely and so it'sprobably not related to stroke.
But they didn't kind of pushfurther.
They said, okay, the stroke isfine and they're ready for rehab
(07:43):
.
And then they'll say I don'tknow what that's from.
I think it's one of the phenaror hypothenar muscles.
You know, they're not even surewhich muscle it is.
And now I'll kind of startasking questions in a
non-confrontational way and ifthey're wrong, I often say well,
I'm glad you said the wronganswer, because now that I'm
going to correct you you mightnever get it wrong again and
(08:05):
I'll say, okay, well, that's thefirst dorsal enterosus.
What nerve do you thinkinnervates that muscle?
And they'll think about it andmany of them get it right.
They'll say the ulnar nerve,but some of them might say
median and you know, dependingon their level of training, they
might have no clue at all.
And okay, so we get to theulnar nerve and then I'll say,
well, what branch of the plexusdo you think that supplies the
(08:29):
ulnar nerve?
And then they'll think aboutthat.
And then I'll keep working myway back and that, like three
minutes, is a lesson in and ofitself.
And I feel like that approachwhere it's not interrupting them
too much, but hey, they had aminute to think about something
that they might have not had ontheir mind.
That patient has now taughtthem so much more than just that
right lacunar stroke.
(08:50):
You know what I mean.
And so I kind of try to justcatch them when I can and just
fill their neuromuscular bucketwith a little bit of information
, and then the next time we seeeach other it might be in
resident clinic and we'll takeit a step further from there.
That's kind of my approach.
Another example is sometimes aninpatient will need an EMG and
(09:11):
I'll really just try toencourage the resident to come
down with the patient andobserve the EMG and see.
You know that that puts it putsthe EMG in the context of their
patient that they're lookingafter and really it gives them a
sense of ownership about thecase and pushes them a little
bit.
So that's, those are a few ofmy approaches.
Michael Kentris (09:30):
That's excellent, yeah, it's, it really
emphasizes that, that extrastep.
When there is a piece thatdoesn't fit right, we have to
ask ourselves why and thenunpack that a little bit.
And I know, right, we've, we'veall been in the hospital and
things get busy.
And you right, it's, it's not aquote, unquote hospital problem
(09:50):
and it's easy to certainly tobrush that aside.
And right, there's, there's nota huge number of neuromuscular
emergencies, although there aresome.
And certainly you know, I cansee why a resident, especially
if they're rushing through theirpre rounds, would would miss a
little bit of intrinsic handatrophy in their stroke patient.
(10:12):
Yeah, but Exactly, you know.
But you bring up a good point,right.
I remember myself as a, as athird year medical student,
right I was, I was on a PM and Rrotation, right.
So we're doing a lot of EMGsand things like that and I must
have drawn the brachyoplexuslike a hundred times and a month
(10:34):
later I couldn't have done itat all.
Right, it's.
It is one of those things whereit's like it's so abstract when
you first learn it withoutclinically applying it.
And you know, the instructor Ihad was okay, but he didn't.
Let's just say he wasn't up toyour standards perhaps.
So you're not applying it Likewhy am I, why am I looking at
(10:55):
this muscle, why am I looking atthat muscle, why this nerve,
and kind of painting the pictureright.
That that you know neurologist,obviously, localization, that
would kind of unwrapped theentire problem.
And it does seem like therethere is, especially in the
preclinical and even, to adegree, the clinical years, this
lack of emphasis on theclinical applicability of a lot
(11:18):
of the knowledge that we putourselves through in in medical
training.
Anishee Undavia (11:24):
I totally agree with you and it goes back
to the the idea of neurophobiaversus neurophilia, and some of
the things that we deal withhave a very complex neuroanatomy
or you know, a broad range ofdifferentials that can be
overwhelming, and I think itreally depends on who's teaching
it to you and how much theylike what they're doing and how
(11:46):
much they teach you rather thanshame you.
That that happened to all of usright At some point in our
training.
I might have shyed I don't evenknow but maybe I shied away from
certain fields because of thatshaming, versus leading myself
into one, because I saw anattending who loved what they
did and wanted me to love itjust as much as they did.
So I do think that's a big partof it.
(12:07):
In any, in any subspecialty,but specifically neuromuscular,
which you know, you can easilyturn someone away and say I
never want to think about theperipheral nervous system again.
So I think that's very true andin fact I remember in that one
specific case with the FDIatrophy, I think by Sunday the
resident was like oh, by the way, I talked to the patient's wife
(12:28):
and she said that he has had along history of neck pain and
had some, you know, surgicalconsiderations for cervical
radiculopathy and that kind ofput it all into context for them
and I think that wraps it up.
They don't have to do much more.
It's not like it's going tochange the patient's course, but
at least that bucket is filledwith that knowledge and they can
(12:48):
come back to that if it happensagain, and I think that's
really important.
Michael Kentris (12:52):
That's excellent.
So you know, you brought up agood point, right?
So not not everyone goes intoneurology, obviously from
medical school, and then evenamongst neurologists, you know,
there I would say it's aminority of people who go into
neuromuscular subspecialty.
So what was it in your trainingand your experiences that
(13:15):
brought you down that pathway?
Anishee Undavia (13:20):
Yeah, that's, that's actually.
It wasn't a little bit of aninteresting journey.
I guess when we, when I was inresidency and everyone was
thinking about their strokefellowship or movement disorders
, I actually didn't really know.
I loved the whole breadth ofneurologies but you know a lot
of people went for fellowship soI decided to do neurofizz,
(13:40):
thinking it would give me someadded skills and procedural base
to do EEG and EMG, which so Iwent on to do that.
But it wasn't till I was in thatfellowship where I was exposed
to the breadth of neuromuscular.
I actually didn't really evenknow that we're the ones who you
know diagnose and treat theserare muscular dystrophies or
(14:01):
genetic conditions.
I kind of knew but I didn'tknow that there are these places
all over the country thatcollect very interesting, you
know, like MDA clinic or ALSclinic.
I guess maybe I was when I wasin training it was the beginning
of a lot of that stuff.
But I got exposure as aneurofizz fellow when I was on
the EMG half of things to seethese specialized clinics where
(14:24):
I saw more, you know Duchenne,muscular dystrophy or congenital
myopathy such as you knowBethlehem and Ulrich's myopathy
that you would never see in yourcareer unless you were
specifically attending in theseclinics or rotating on these
clinics.
So that really interested me.
I didn't.
I didn't even know that itexisted.
(14:46):
So when I was in neurofizz Iwas also, I guess, kind of not
ready to grow up and get a realjob.
So I talked to theneuromuscular people there and I
said, hey, I'd really like tostay and do more of
neuromuscular training.
Neurofizz is really focused onEMG and that's another
misconception that mayberesidents and students might
think neuromuscular means EMG,but it is really so much more
(15:10):
than that.
One of my neuromusculartendings used to say EMG has its
limitations, it's not an end,all be all and there's so much
more now.
So I ended up doing two yearsof fellowship one year in
neurofizz where I did EEGtraining and EMG training, and
then a special year inneuromuscular where I got to
really get a lot of experiencewith muscular dystrophy.
(15:31):
A lot of my specific fellowshipwas focused on muscle, so I got
a lot of muscular dystrophy,inflammatory myopathies.
I know other centers arefocused on neuropathy and so
even that is getting more andmore specialized and separated.
But yeah, that was kind of myjourney.
Is that?
I don't think.
Unless you see it, you don'tknow what exists, and it opened
(15:53):
up my eyes to what's out thereand what you can do for people.
Michael Kentris (15:59):
Yeah, I was a neurofizz fellow as well, but I
was more on the epilepsy side ofthings and.
But I spent some time with theneuromuscular tendings and
you're absolutely right,especially like the child
neurology, neuromusculartendings, just all these
disorders that you know, youmaybe you read like a paragraph
about as you're studying forboards, but you may never have
(16:22):
seen in your entire career.
And yeah, it's one of thosethings where, like the entire
breadth of neurology is so vastit feels like the body of
knowledge is nearly impossibleto stay on top of anymore and
this accelerating at such a fastpace.
Anishee Undavia (16:40):
It is, and so much so that you might not even
have access to it in yourparticular program.
So one of my pointers tostudents and residents
specifically residents, beforethey're thinking about applying,
is if there's an area thatyou're peaked by and they just
don't have the breadth of it Forexample, if you're for someone
like you who's who's might bemight have been curious about
(17:02):
epilepsy if you don't havesurgical epilepsy in your
specific center, seek out thatrotation, because I know there's
visiting rotations and thingslike that, just so you can know
what the potential is for you ifyou're interested in academics
or if you're interested in goinginto that specific area.
Unless you see it, you reallywon't know what it's all about
(17:23):
and what the day to day of thoseproviders is like.
Michael Kentris (17:27):
Very true.
And yeah, it's high cutie, lowcutie, big center, small centers
, and they're different needs,different resources, all across
the map it's.
It is interesting, right, wehave all these like ACG and me
certifications for programs, butin reality there's still quite
a lot of variability from placeto place and even region to
(17:49):
region.
But definitely, but I thinkthere's still some commonalities
when we get kind of down to thefun fundamentals.
So you know, I know you wentthrough like a lot of the things
that like a neuromuscularspecialist kind of focuses on,
like neuropathy, differentmusculoskeletal disorders, what
would you say are kind of themost bread and butter sorts of
(18:12):
things that kind of wind upcoming to you as either a first
or second opinion.
Anishee Undavia (18:18):
Yeah, so there actually isn't that side.
I was thinking about that and Ithink I'll tell you my favorite
is gate dysfunction.
Two favorites gate dysfunctionand weakness.
We get a lot of those and youcan imagine there's some overlap
with movement disorders so weget to kind of think through
even some central nervous systemconditions when we get those
(18:40):
cases.
Other things are numbness ortingling in one or more limbs,
weakness, proximal weakness,trouble climbing stairs, falls,
burning, tingling.
I don't know if I'm missinganything major, but I think
those are the big ones.
And a lot of my referrals comefrom other neurologists.
(19:02):
Sometimes if you have a primarydoctor that knows you and knows
your interests, they'll comedirectly from the primary doctor
.
But a lot of the time I'mgetting referrals to start by
doing an EMG for that otherneurologist because they think
it's neuromuscular but they'renot sure what part of the
neuromuscular system is involved.
And then, if it is somethingrelevant, I will kind of talk to
(19:23):
the referring doc and say, hey,I think this is something it
could be, you know, motor neurondisease or maybe something
mimicking it, and I'll carryover the workup if that's okay
with you.
And usually they're like, yes,please, I'm glad they saw you.
So that's usually the scenario.
Where I'm getting myneuromuscular cases is through
my colleagues within thedepartment.
Michael Kentris (19:44):
Got you.
Now, something I alwaysremember my instructors saying
to me when I was learning EMGsand I imagine it's probably a
universal sentiment is that yourEMGs and your nerve conduction
studies are essentially anextension of your physical exam.
And I think you see this morein community centers, where and
(20:05):
tell me if this is as big of apet peeve for you as it is for
me right, you get a referral foran EMG nerve conduction studies
for, like you know, neuropathyand it's for the bilateral lower
extremities.
If you see that referral andthey're 90 or 95 and I'm like,
oh God, what's your firstthoughts After?
Oh God.
Anishee Undavia (20:29):
What's my first thought after I get a
referral for neuropathy Is thatyeah, like.
Michael Kentris (20:34):
So let's say, like you said, numbness or gait,
whichever you prefer, okay.
Anishee Undavia (20:42):
That's a great question.
So I like to, if I know thatit's a classic clinical
presentation.
So if they have this classic,I've been burning in my feet for
the last few years.
Now it's getting a little bitworse.
It's very equal and symmetric.
I feel it in my fingers.
If it's a classic story for alength dependent external
(21:04):
neuropathy, then I, you know, Iproceed with the EMG of the
lower limbs and I try to findthat pattern where there's, you
know, sensory more than motor,distal more than proximal, and
make sense of it that way.
But many times with burning orweakness, I have this algorithm
in my own head that I try toshare with students, where I go
(21:26):
through some very basicanatomical buckets, like I said,
and I have these prefilleddiagnoses in those buckets that
help me decide what to ask andwhat to examine.
So I always start with themotor neuron as the most
proximal place that I go withwith neuromuscular cases and I
think about anterior horn celland I think about things like
(21:50):
ALS, which obviously we don'twant to jump to ALS with these
simple cases, straightforwardcases, but just to be organized
about it.
I start with that and then Imove to the nerve root, which is
very common.
We think about nerve rootcompression from lateral bulging
discs.
But in the in the radiculopathybucket I also have things like
(22:10):
AIDP, cidp or infectious causeslike cytomegalovirus or Lyme
polyradiculopathy, and then I go.
So I go anterior horn nerve rootand then I go to the plexus.
Plexus is honestly not thatcommon unless there's trauma
involved, but we do see caseslike radiation plexopathy or
(22:31):
indolent malignancies thatinfiltrate the nerve roots like
lymphoma.
And then I move from the plexusto the next bucket, which is
the peripheral nerve, which isobviously a very big bucket, but
that includes all of my nerveentrapments, like carpal tunnel,
ulnar neuropathy, perinealnerve entrapment, sciatic
neuropathy.
But it also includespolyneuropathy, which is your
(22:54):
classic length dependentneuropathy from diabetes or B12
deficiency or inflammatorycauses such as para protein with
magneuropathy.
So I that's a very big bucketand certainly you know, on
another talk we can dive intothe different types.
But I I like to stop at thatbucket and think, is my patient
fitting into any of those?
(23:16):
And then from the peripheralnerve I go to the neuromuscular
junction which has your commoncondition, common things that we
think about, like myastheniagravis, also Lambert Eaton
syndrome or botulism, and thenfinally I end with the muscle,
which also a very broad andinteresting bucket, which can be
simple things like a statinmyopathy or thyroid induced
(23:40):
myopathy, or something complexlike a necrotizing myopathy,
which is an autoimmune sequelaeof statin use, or hereditary
things like muscular dystrophy,congenital myopathy, et cetera.
So it's, it's a lot andhopefully that's not
overwhelming.
But I always encourage studentsand residents to go back to
(24:00):
motor neuron, root plexus, nerve, neuromuscular junction and
muscle and I, whenever I'm inresident clinic and a resident
comes and says they take thisfantastic history because
they're great at that.
And then we get to the exam andthey're like I don't know what
it is, and so then I always gothrough this exercise and I have
them fill in the bucketsthemselves and that's them
(24:21):
building their own knowledgeframework, whether it's for
their boards or for their futurepractice.
Where do these conditions fitin and what can I ask or examine
, to kind of hone in on it.
And then we move on to whatdiagnostics will serve that,
that differential Right onephrase.
Michael Kentris (24:41):
One of my attendants in residency.
She was always full of pithyphrases and she would always say
like yes like what's what's?
What company does it keep?
Right, Referring to thesymptoms like what else is there
?
What's around it?
They write everything inmedicine, and neurology in
particular, very contextual.
So so, like right, someonecomes in, like you were saying
(25:02):
with with burning the feet,people like is there that
atrophy?
Is there evidence of motorinvolvement?
Are there autonomic symptoms aswell?
Anishee Undavia (25:09):
Right, yeah or associated weakness.
Michael Kentris (25:11):
Exactly so like and that that helps refine
which buckets you're going tofocus your attention on right.
Anishee Undavia (25:19):
Absolutely, and then that then further helps
you.
You might still not know whatthey have, but then you can
start thinking of yourinvestigations and what makes
more sense.
You know as the first step,whether it's labs or EMG, or
sometimes you jump right to justyou know genetic testing
because you have all theseclinical features that are very
clear and a family history to gowith it.
(25:39):
Another very important part ofneuromuscular medicine is asking
about parents.
If you think, I'll give you an.
I just had a patient the otherday who I did an EMG on and I
was worried about motor neurondisease and I said, well, come
to my clinic, I need to examineyou and kind of think through
things further.
And I examined him and he hadgynecomastia.
And then I asked him about hischildhood history and he said I
(26:02):
could never do.
He's kind of a big guy.
And I was like so were youathletic?
No, not at all.
I was like did you do pushupsor squats as a kid?
No, never.
I said why I couldn't do them,why not?
I just couldn't you know, likethere was really no good
explanation.
And then you, then I said well,did anyone in your family?
And, and you know, with thegynecomastia and motor weakness
(26:25):
I was thinking about Kennedy'sdisease and that's an X-link
disease.
And you know that then you knowto not just ask about mom and
dad but mom's brothers.
Turns out he had like sixuncles on his mom's side.
Many of them were estranged sowe couldn't get information.
But, you know, you wonder wherethey.
You know wheelchair forunexplained reasons, or did they
need a walker in their forties?
(26:46):
All that ancillary informationcan really be helpful in
pinpointing the next diagnostictest.
You do and and avoid callingthings ALS that are not ALS, you
know.
Michael Kentris (26:58):
Right, and I remember when I was a fellow I
had a consult for musculardystrophy.
It was in an older gentleman,like in his, you know, late late
sixties, early seventies.
And you know you go in and,like you said, right, you're
examining, he's got diffuseatrophy, you know, arms and legs
.
Obviously this is very late,late stage in his life and you
(27:21):
know you, but you you examine,he has sensory changes, right.
So obviously that doesn'treally doesn't really fit.
But he'd been told all his lifefor decades that he had
muscular dystrophy.
And then, fortunately, his kidsand his grandkids are all
visiting him in the hospital atthe time I'm doing this consult.
So I look at his feet right, hehas Charcot feet and so I asked
(27:46):
hey, can I look at all yourguys's feet?
Anishee Undavia (27:49):
Yeah, that's the best.
Michael Kentris (27:51):
And you know they all, like they had like it
was like looking at over time,they all had very high arches.
You know some of the middleaged folks had hammer toes.
I was like, oh, you guysprobably have like some
variation of Charcot Marie toothand it was one of those things,
right, where it's like it's nota fancy test, it's not anything
(28:11):
beyond just asking questionsand talking to people and just
putting the pieces together.
It's one of those things whereyou're just like, oh, the light
just shines over your head.
Anishee Undavia (28:21):
The moments we all live for in neurology.
Michael Kentris (28:24):
Right Cause I mean that's.
That's been a few years now,but that experience will live
with me forever, definitely.
Anishee Undavia (28:30):
I had something similar with FSHD
which you know many students andresidents don't ever see.
But I think the guy, if Iremember correctly, the the guy
came in for pain.
He had back pain and symptomsof lumbar radiculopathy, but
then we examined him and heclearly had facial weakness.
He had scapular winging and youknow this proximal atrophy,
(28:50):
this double hump that we seewith deltoid sparing and the,
the rising of the trapezius fromthe scapular winging.
Anyway, he was with his motherand his mother had, no, no
health issues, but she wassitting there with this like
downturned smile and you mightnot notice it, but then when we
asked her, we she also had somemild facial weakness.
(29:12):
And it's so funny.
How, like those littleencounters, can you know, when
you lean in as an neurologist,because what we're supposed to
observe and ask these questionsand you you can elicit so much
information without doing asingle lab, lab test or you know
, nerve test or whatever it is.
Michael Kentris (29:31):
I know I always .
I always feel slightly Ihaven't shaken it yet slightly
awkward when I have to asksomeone's like.
You know, with, like, some sortof facial let's I hesitate to
use the word abnormality, butit's like does your, does your
face always look like that?
You know, it's one of thosethings where you try and find
the polite way to say it.
Anishee Undavia (29:53):
I don't know, have you come across any phrases
that work particularly well forI would never say it, but I've
had patients say I've always hadRBF, and I'm not going to spell
out what that means.
Yes, but they will tell me thatstraight up, but that's just how
my face is.
No, I think if you show thatyou're trying to help them and
understand, no one's reallygotten offended.
(30:14):
I'll just say you know, asneurologists we pay attention to
these things, and I noticedthat yours is down.
Has it always been like that?
Do you have, or do you have, alicense photo that I can look at
, you know?
Obviously that sometimes we dothat for hemiparesis, but you
could also do facial diplegia.
Michael Kentris (30:32):
Excellent.
Anishee Undavia (30:32):
Yeah.
Michael Kentris (30:34):
So so obviously you know we're a couple
neurologists shooting the breeze.
We we like to talk about theesoterica of neurology, but you
know, a lot of times you knowthere are people out there maybe
50, 100 miles away from thenearest neurology, even here in
the US, and for the primary caredocs in the audience, how, how
(30:58):
should they approach let's say,neuropathy?
Like someone comes in, they gotthe numbness and the tingling
EMGs labs.
Where do we go?
Anishee Undavia (31:10):
Yeah, that is a very, very good question and,
I think, a hard question,because we neurologists bark
when too much is done and webark when not enough is done.
You don't go both ways, I don'tknow.
I kind of am in the boat ofI'll see anyone that you're not
sure, I'll just see them, and,and I'd rather if they're not
(31:32):
sure.
I hate recommending testswithout having seen the patient
myself.
I just I don't know.
It just feels wastefulsometimes.
But of course, for the the runof the mill length dependent
neuropathies, we almost alwaysscreen for B12 and it's very
valuable.
A lot of the times it's low,low, normal and just
supplementing it can make a bigdifference in the symptoms.
(31:55):
Tsh is controversial.
I've never seen it actuallyhelp me or pick up you know a
treatable case.
So I think a lot of people areputting that one out the door,
unless they're they havemetabolic syndrome and it might
be relevant to their case.
A1c can be helpful if theyhaven't been going to a PCP
regularly as a first time.
(32:16):
Definitely, I see neuropathysymptoms even with early and
mild diabetes, so it doesn'thave to be like an A1c of 13 to
see the symptoms of a neuropathy, at least the burning pain.
Interestingly, people who arenewly on insulin.
There's a condition calledinsulin neuronitis which can be
very, very painful and mimic aneuropathy, and so if they
(32:39):
recently were treated fordiabetes and they got rapid
control, sometimes you seepatients present with symptoms
of neuropathy and that should besomething that a primary care
could potentially deal with.
So just that, that educationabout insulin neuronitis.
They also don't always need anEMG, so I guess a referral
(33:02):
sometimes might be better,because if it's very clear that
it's in the context of theirdiabetes or B12 deficiency, they
don't really have motorweakness or obvious sensory
deficits on their exam.
Maybe you could hold off on theEMG.
Some people want a baseline.
It's very subjective.
I do it based on how I thinkthe patient will tolerate it.
I want them to trust me and ifI don't think an EMG is really
(33:24):
going to make a big, big picturechange in their treatment, I
don't jump to it right away forevery run of the millenuropathy.
Of course, if there's any redflag.
So if there's a profound amountof weakness, if they show up
with burning pain but alsothey're tripping and falling,
that's a red flag and theyshould probably see neurology
and get an EMG to look forsomething like something that's
(33:46):
not as common or run of the mill, because motor weakness usually
comes much later, if at all.
So I don't know if that answersyour question, but it's kind of
person to person.
The bottom line is if a primarydoctor sees something in
neuropathy that's not classic,then they should probably be
(34:09):
seen by a neurologist or get anEMG.
Michael Kentris (34:12):
Yeah, no, I think that's totally reasonable.
Personally, when I was doingEMGs more often in my practice,
I was basically doing aminiature consult every time I
saw them, because and maybe I'mmore guilty of this than other
people but I would get a requestfor a certain you know, like
you know, both legs or maybe allfour extremities, and I'm just
(34:37):
like this is unnecessary.
Here's what we're actuallygoing to do and this is why yeah
, that's all that's going on.
Anishee Undavia (34:43):
How often?
Or a limb EMG?
No, I don't think so.
Michael Kentris (34:46):
Right, we're not doing a CIDP or an ALS
evaluation today, right, we'renot doing it yet?
Yes, question, and this may bea hot take moment, so you can
beg off if you.
If you'd rather not answer whatis your opinion in general?
Right, because you're you're anacademic neurologist, academic
neuromuscular sub specialist,emgs in the community.
(35:10):
What?
What is going on?
Anishee Undavia (35:19):
I don't know.
I don't want to makeassumptions.
I don't think everybody shouldbe doing EMGs without the proper
training.
Definitely, I collaborate a lotwith my PM and our colleagues
who do a good amount of them andI think that's really great.
But I don't know.
(35:39):
I've seen.
I don't want to get in troublewith what I have to say about it
.
Michael Kentris (35:44):
actually, I've seen, I'll say something.
I mean there's a lot of garbageEMGs out there.
So, and you know, I remember Ithink I was a second or third
year medical student around thetime, but I was.
I was talking with a doctor andright, emg reimbursement got
(36:06):
got slashed by a significantmargin.
Oh God, I'm going to age myself20, 13.
Anishee Undavia (36:13):
I was a fellow a couple years before that.
Yeah.
Michael Kentris (36:16):
Well, I probably got cut again, but the
big one was a little bit beforethat and I'm just like, well,
yeah, right, it's, it's obviouswhen you think about it in the
context of the greater you knowsystem, you know for our
international listeners, right,this is a US thing where, like
your Medicare, Medicaid servicesto determine how much you get
paid for a service, andbasically said, too many EMGs
(36:40):
are being done, which suggeststhat they're likely being done
inappropriately.
And you see that for a numberof procedures over the years,
it's not always the case.
Sometimes it's just thegovernment being the government,
but in this case I think theywere probably in the right in as
much as we have too manydoctors doing too many low
(37:01):
quality studies.
And I remember in my formerpractice there was a guy in the
area who would do like like 15EMGs in a day, Sometimes more
than that, and I would get thesereports and I'm like this is
because I would get a referralfor like a myopathy.
(37:23):
And well, no, I would.
I would get the patientreferred to me as a consult
first.
But you are correct, Right?
So I didn't see.
The person is like you don'thave any clinical science of a
myopathy and and so it is rightthere there is a certain
subjectivity to to EMG Quote,unquote very much.
Anishee Undavia (37:46):
Yeah, it does matter who's doing it and who's.
I totally agree with you.
I didn't want to say it and I'mthankful that you said that.
There are a lot of garbage EMGsout there being done by people
who really don't know how to.
You can't just take one nervethat's a little slow and say the
patient has a IDP or CIDP.
You just can't.
There's a demyelinating range.
(38:07):
There's a clinical phenotypethat goes with it.
That would make sense.
There's a lot of technicalpitfalls, so you need the person
doing it to take the patientinto consideration when you're
making an interpretation.
I mean the median nerve, forexample, in carpal tunnel.
It could be so bad looking witha normal muscle and it's just
(38:33):
because they have anatomicalvariation and it's like a some
kind of Martin Gruber or RishKanu and Astimosis and you you
get them to say, oh well, theyhave a severe carpal tunnel.
They go get carpal tunnelsurgery, you know, for minimal
symptoms or other symptoms thatthey're having and and you get
in a lot of trouble.
We see a lot of or spinesurgery, for example.
(38:53):
We've seen cases like that andso, yes, I think that training
matters and what you're doing,the test for matters and
appropriate referral makes sense.
It's also a painful test, so tohave to go through it two or
three times before you get onthe right track kind of that's
unfortunate.
Michael Kentris (39:15):
Right Especially and I'm sure you've
encountered this right as thesecond opinion neurologist is
that you know it's like well,why do I need to repeat that
study?
I already had that study doneand you know, like you said,
right, you don't want to be theperson who says like well, the
other one was kind of not good,but I mean, that's that's.
(39:35):
That is the reason sometimes,many, many times.
I mean sometimes, and I alwaysremember there are certain
things to look for, like in theraw data, right, Like is the
temperature documented, right?
If there's no temperaturedocumented, you can just throw
that thing in the trash.
Anishee Undavia (39:53):
Yeah, I mean I don't know if that's true, but
I think you really have to thinkabout the under.
Whoever's doing it has to kindof be familiar with things like
Charcot-Marie tooth or, you know, demyelinating neuropathy or
myositis, and if they've onlytrained to do them, to look for
carpal tunnel or lumbarradiculopathy.
(40:14):
That's a limited scope.
And EMG, although it has itsown limitations, it can be very
helpful to separate some ofthose conditions and you have to
have the clinical understandingand the EMG understanding to
piece it together.
It really is a subjective test.
I don't know the solution forthat.
I guess cutting thereimbursements might have helped
(40:36):
.
I think entire practices had toclose when that happened
because they were just doingEMGs.
Yeah, and a lot of the timeI'll get the referral for the
EMG from a primary doctor or apodiatrist and it's either
straightforward it's much morecomplex than I bring them into
the clinic as like a formalevaluation and then they become
(40:58):
a neurology patient.
Michael Kentris (41:00):
Yeah, oh man.
So you bring up another.
I'm just remembering aconversation I had with a
podiatrist a friend, not in thelast few years and it was about
tarstle tunnel syndrome.
Anishee Undavia (41:14):
Oh, another hot topic.
Michael Kentris (41:15):
Sorry, I'll stop bringing up controversial
topics.
No, please it's great, and it'sone of those things where it's
like I remember one of myattendings.
You know he was an oldergentleman and I believe his
exact words were I've neverdiagnosed tarstle tunnel
syndrome.
Anishee Undavia (41:36):
Yeah, I have gotten those referrals and you
know people have pain on themedial side of their ankle
sometimes and so I'll kind ofopen up my ship here, my
precedent ship here, which isthe kind of neuromuscular Bible
or at least EMG Bible, I shouldsay and needle some of the
muscles that they recommend.
(41:56):
I'll do all the appropriatetests.
The problem is there's a lot ofwear and tear.
So when you put a, put theneedle in some of those
intrinsic foot muscles, you'relistening for denervation or
chronic re-innovation, and itcan be obscured by the fact that
, especially if they're older,there's so much wear and tear
from walking and stomping thatit might be a very nonspecific
(42:17):
finding and it might not get youthe answer.
I that's where I'm starting tolean on neuromuscular ultrasound
or imaging of other kinds to,really, because there was one
time that only one time that wepicked up an Ewing sarcoma in
the ankle.
After someone was referred fortarstle tunnel evaluation and
there were some abnormalitiesbut I didn't make any
(42:39):
conclusions from the EMG, I saidplease do direct imaging, and
that's how that came about.
So you can certainly havecompression at that site.
I just don't know if the EMG isvery diagnostic necessarily in
that.
Michael Kentris (42:55):
That's a fair, that's a more equitable
statement than mine.
Now you bring up something veryinteresting and something I
unfortunately don't have verymuch experience with, which is
neuromuscular ultrasound, whichI know has been like kind of
like the hot field for severalyears now.
What's what's that looking like, how's it being used in
(43:16):
practice, and what do you thinkkind of future directions are
looking like for it?
Anishee Undavia (43:22):
Okay, so I will.
I will preface it by saying Iactually I don't do
neuromuscular ultrasound, nor doI have much training in it, but
more than, like you know, a fewworkshops at the national
meetings when they're available,I'll go in and try to localize
the nerve.
But as I've said many timesjust in our conversation, emg
can be limited and it'sespecially limited when people
(43:42):
have more than one thing goingon.
For example, if they have acervical radiculopathy at C8t1,
but also a carpal tunnel and youdon't know which one.
Is that the culprit at thattime for their actual symptoms.
That's just an example.
Or if they have an ulnarcompression but you can't quite
localize it because it's sosevere, meaning there's like no
(44:04):
responses on the EMG and theycould have a double crush
syndrome.
So I think I think thatultrasound can be really useful
for the mononuropathies becauseyou can measure their
circumference of the nerve,typically when it is enlarged or
swollen over a certain size.
You can.
It can be quite specific.
(44:27):
I that's kind of where I havereferred patients for ultrasound
is for those circumstances whenI can't tell, because they have
multiple neuromuscular thingsor multiple areas of compression
, how to localize it.
I think it has a place, forsure, and I hope that it becomes
more, you know, more readilyavailable in the community.
(44:49):
But yeah, that's kind of mytake on neuromuscular ultrasound
.
Michael Kentris (44:56):
No, that's excellent.
Yeah, I've been.
It's definitely on my my bucketlist to see if I can get into
some of those workshops as well.
It certainly I mean certainlyless painful than an EMG, right.
Anishee Undavia (45:07):
Yeah, it is less.
I think you often need both.
I'm rarely seeing that anultrasound alone can make the
treatment you know, get us tothe treatment versus an EMG
alone, usually in conjunction,kind of like a CTA and a carotid
ultrasound.
You kind of need both, for theone for the velocity and one for
the actual 2D or 3D images.
Michael Kentris (45:27):
Fair enough.
So for people, because now Iremember and I don't know if
this is typical or not there wasa PM&R resident who had
actually started a neuromuscularfellowship at the time that I
was.
I was an outgoing fellow, theywere an incoming fellow, and is
(45:49):
neuromuscular open to neurologyand PM&R?
Are there any other specialtiesthat that do neuromuscular
medicine?
Anishee Undavia (45:55):
Yeah, when I was a fellow in neuromuscular
medicine at UCLA, we had a very,very strong PM&R resident who
wanted to then ultimately befocused on muscular dystrophy
and rehabilitation.
So definitely I think it isopen to multiple areas.
I don't I've never seen like apain specialist or or someone
(46:19):
who has an interest in paincoming through.
Mostly I've seen other PM&R incombination with neurology.
I haven't seen any otherspecialties, but I'm sure there
could be a space for it.
Yeah, I don't have you, I don'thave.
Have you seen that?
Have you seen?
Michael Kentris (46:37):
those are the only two that I've seen as well
Only two I've seen, yeah, andthen the A&M.
Anishee Undavia (46:41):
I haven't gone to one of their meetings yet,
but they're heavily acombination of two and their
talks are very much focused onboth specialties.
Michael Kentris (46:51):
That makes sense Because I think pretty
much they're the the main twospecialties doing EMGs these
days.
(47:12):
Yes, so.
So what's your, your pitch forfor neuromuscular medicine?
If you're going to talk to thejunior neurology residents out
there, what's the draw?
Why should you pick that as thespecialty, the subspecialty of
choice?
Anishee Undavia (47:32):
That is a very good question.
I one, I love it.
And I think I love it because Isaw other people who love it
doing it.
I think that it is really funto think through those buckets
that we talked about, anywherefrom the root to the muscle, and
I had a lot of those ahamoments at the bedside.
(47:53):
And so my message to studentsfor students I would say, when
you're on your clerkship, try toseek out the neurodiagnostics
lab and catch a couple of EMGsbecause it's not always built
into the curriculum, just toknow what it is, even for your
shelf exam.
They, you know, they almostalways ask about lumbar
radiculopathy or cervicalradiculopathy, and so that can
(48:15):
really give a visual to what youknow what looking for those
cases means.
And for junior residents Iwould say try to fit it in.
I think the PGY2s are sofocused on stroke and epilepsy
because that's what we seemostly in the hospital.
But the Blumenfeld book hassome great neuromuscular cases
and if you just stop to read ona case-based level based on what
(48:41):
you come across, you'll startmaking that framework early on.
And then, of course, pgy2 and 3,when you're in your specialty
clinics, you can start fillingthose buckets as you prepare for
the boards.
But if you're interested thatyou might want to do it, I would
definitely go and rotate.
If your institution doesn'thave an ALS clinic or a
myasthenia clinic or a musculardystrophy clinic, try to get
(49:05):
some experience so you canreally see what that's all about
, because that nothing replacesthe visual of seeing those
patients, examining them, comingto an anatomical diagnosis and
then discussing some of theirrehab needs.
We didn't really talk aboutgenetics today, but we are
scratching the surface.
Now there are treatments forconditions like SMA, duchenne,
(49:27):
muscular dystrophy, and so it'sgoing to be more important, more
and more important forresidents to actually learn
about them and be able to pickout those cases, to at least
refer appropriately forneuromuscular so they can get
the benefit of those treatments.
Michael Kentris (49:41):
Yeah, absolutely, and hopefully the
cost of some of those will comedown a little bit, like the
Neusin medicine and ABYPARVOVIC.
Anishee Undavia (49:49):
Absolutely yeah, it is ungodly expensive,
but you know.
Michael Kentris (49:54):
I believe the are the single most expensive
medications in existence rightnow.
Anishee Undavia (50:00):
Yeah, I think you had another a really good
podcast about the cost ofmedicine.
I think it was onneurotransmitters.
I was listening to you.
Michael Kentris (50:10):
Yeah, yeah, one of my friends and I were
talking about MS medications.
Anishee Undavia (50:15):
Yeah, that was really helpful.
I think, that's important toofor perspective for when we
treat these patients Especiallyrare disease.
Michael Kentris (50:24):
Yes, yeah, no, like rare disease, and you
probably.
Well, I know I'm veeringslightly, that's what I do, but
I remember one of my attendingshad probably like six to 10
Lambert-Ethan patients, and thiswas before there was any FDA
approved medications, and so shehad them on the God, I'm a rush
(50:47):
.
I think it's the three, fourDAP, if I remember correct.
Right, and she would have itlike synthesized and like
shipped up, and but after themedication was FDA approved she
couldn't get them this, thischeap old medication anymore,
and so then they're like on thehook for this, like stupidly
expensive medication, becausethere's no other options that
(51:08):
are even being made anymore.
Anishee Undavia (51:12):
Yeah, so what they had to like get on a phone
with the insurance company andyeah, like they had to go into
this like prescription brandname.
Yeah, that's a bummer.
My experience with that with Ijust get on the phone, I do
whatever I need to do to get onthe phone to the struggle I've
(51:33):
had.
It's not exactly in that realm,but in people with necrotizing
myopathy from HMGCR antibodies.
You'll come across so muchliterature that says IVIG helps,
ivig helps, ivig helps, youknow, and it's it's not
technically approved for that,but all the experts around the
country are using it and that'swhat they recommend first line.
(51:55):
And so I will get on the phonewith whoever I have to and share
whatever observational studieshave been done to explain this.
Is, you know, so treatable.
The more you wait, the worse itgets and more irreversible.
This you know they're going tobe left with disabilities.
So I think part of the problemis the people who are approving
(52:19):
it don't really know the diseaseand are far removed from that,
and so it's our job to kind ofexplain the dire need for them
if they're available, especiallyif it can be, you know,
preventing handicap and thingslike that.
Michael Kentris (52:34):
So are you saying your peer to peers aren't
with another neurologist?
Anishee Undavia (52:39):
It's often like with a radiation oncologist
or something like that.
Michael Kentris (52:44):
Right, it is pretty random, sorry.
Sorry for veering so far.
Anishee Undavia (52:52):
Which is very real life and very, very
relatable.
Michael Kentris (52:55):
So yeah, yes, Any final thoughts?
Anything you want to plug?
Anishee Undavia (53:04):
Hopefully this was a, you know, a simplified
way of kind of introducingneuromuscular.
Obviously it's very vast andthere's a lot of things we
haven't talked about.
But I think, starting with thatbarrier to just opening people's
eyes to neuromuscular, what itis about, even if you're not
going to go into it, justknowing that it exists and that
it is a part of our job asneurologists to recognize some
(53:27):
of these things, I think, justas trainees do as much as you
can to see some of these cases,or to, you know, figure out
which attendings you like andare approachable and be like hey
, show me that case.
If you ever get one, or you know, feel free to pull me in so I
can kind of take a look, becausesome of these cases, like you
know, even myotonic dystrophyit's the most common muscular
dystrophy, but you might neversee it if you don't seek it out.
(53:50):
So just kind of saying hey toyour attendings that are willing
I'd love to see more if youhave stuff to show me in and I
think that that enough ismotivation for the attending to
be like hey, this is exciting.
I want to show them thisbecause you know I can point out
these things and it can reallymake a difference in their,
their knowledge, or fill theirbuckets, so to speak.
Michael Kentris (54:10):
Absolutely.
Anishee Undavia (54:11):
Yeah, and.
Michael Kentris (54:12):
I know I had a medical student just this week,
you know she expressed just thebarest interest in neurology,
and so I'm automatically tryingto convince her, like you,
should become a neurologist.
Anishee Undavia (54:23):
We're such leeches in that way.
Michael Kentris (54:26):
Like I hear something I'm like oh you belong
in this field, that's right,you would be good.
You're good for the field.
Anishee Undavia (54:32):
We need you.
Michael Kentris (54:33):
Right, but I and I like to think that's a
welcoming kind of mindset, butor even like I think we spoke
about this before is like whenyou're meeting.
Anishee Undavia (54:45):
When you're meeting trainees, like finding
out where their interests areand seeing if it relates it
often does relate to neurologyand you know, showing them how.
For example, ophthalmologyobviously we have neuro
ophthalmology, which is such agreat field, but they might not
think about it or know aboutthat, but interested in the
pathways, but not really linkingthe two.
And so it's it's nice to hearfrom a neurologist about how
(55:08):
your interests can be linkedinto our field early on.
Michael Kentris (55:13):
So very much, so where can people find you
online if they're going to seekyou out?
Anishee Undavia (55:20):
Oh yeah, I am on Twitter.
I actually really like, or Iguess X is what I should say.
Michael Kentris (55:26):
Yeah.
Anishee Undavia (55:29):
I am very much enjoying the community building
on X or Twitter and meetingpeople like you and others who
are clinically focused and lovewhat we do but also commiserate
a little bit.
So I am at gosh, I forgot myhandle.
Michael Kentris (55:45):
Sorry, we'll edit this out in post.
What's?
Anishee Undavia (55:48):
my handle at Anishisha A-N-I-S-H-E-E-S-H-A-H.
Please feel free to give mefeedback or, you know, just say
hi or chat about neuromuscularor anything.
Really, I'm available.
Michael Kentris (56:03):
We'll be looking for high quality, bite
sized neuromuscular content.
Anishee Undavia (56:07):
There you go, I'll work on it.
I'm starting to kind of getaround to posting my first
tutorial.
Hasn't happened yet, buthopefully soon you inspire me,
I'm going to get there.
Oh, you're two kinds.
Michael Kentris (56:20):
Well, thank you again so much.
I really appreciate you takingthe time to come on, share your
love for neuromuscular neurologyand, you know, schedule and
desire permitting, perhaps wecan get you back on to talk more
in depth about specificcomplaints and kind of your
diagnostic treatment approach.
Anishee Undavia (56:40):
I would love that.
I really, really appreciate theopportunity to be on here and
talk with you, and I like thiskind of casual approach.
It makes it more fun and yeah,so hopefully we can do it again.
Michael Kentris (56:53):
I hope so too.
Thank you again for listening.
This episode was edited andproduced by Rita Farhan.
If you enjoyed this podcast,please leave a five-star review
for us on Apple or Spotify orwherever else you might get your
podcasts.
This really helps with giving ashow noticed and spreading the
word.
You can find me on X, formerlyTwitter at Dr Kentress, dr
KENTRIS, and you can find theofficial Neurotransmitters feed
(57:17):
at Neuro Underscore Podcast.
Lastly, you can find a lot ofour content online and keep in
touch with us through ourwebsite at
theneurotransmitterscom.
Thank you again for listeningand we'll see you next time.
Hello everyone and welcome back to the
NeuroTransmitters.
So glad to have you here andI'm very happy to be joined
today by Anishee Undavia, aneuromuscular neurologist from
Penn State Valley Forge.
Please introduce yourself.
Tell us a little bit about whatyour deal is.
Anishee Undavia (00:20):
Hi Michael, thank you so much.
I'm really, really excited tobe here.
Believe it or not, it's myfirst podcast, so this is new to
me, but I'm really enthusiasticabout just the opportunity to
talk to you and maybe even anaudience that is full of med
students that might beinterested in neurology, or
junior residents that are kindof figuring out what their next
(00:42):
step would be within thespecialty and referring doctors
or any kind of audience that hascuriosity about the field of
neuromuscular medicine and whatit's all about.
I am currently faculty at PennMedicine at one of their
suburban sites called ValleyForge, but I recently switched
over from a more of an academicposition.
(01:03):
I was in the Einstein-Jeffersonsystem and I had a great time
there, especially because I wasvery, very involved in teaching,
specifically with the neurologyclerkship.
I was involved in that, butalso in hands-on training with
the residency, recruitment andthat sort of thing.
So because I'm no longer inthat environment, I'm just so
grateful for this platform,whether it's Neuro Twitter or
(01:26):
podcasting, and, having met you,just because I would love to
continue to stay engaged,continue some form of teaching
and if it's in this space, Ithink that's a really creative
way to keep going with that.
So thank you again for invitingme.
Michael Kentris (01:39):
Oh, I'm so happy to have you actually, so I
definitely sympathize with thatstory.
Similar right.
I went from a more neurologyacademic department and now I'm
a little bit kind of in mylittle insular silo in a
community teaching program.
So I have trainees, but notneurology trainees, and it just
makes you appreciate all themore how important it is to
(02:02):
teach neurology, and theclinical neurology in particular
, to not just neurologyresidents but to all commerce
right, medical students,internal medicine residents and
everyone who's willing to listento us talk on at length about
minutia.
But why I'm particularly gladyou agreed to join me today is
(02:23):
neuromuscular neurology is sucha challenging area of even just
neurology in general and I washoping you could, for those who
might be less familiar with thesubspecialties, just give a
little definition of what youwould consider neuromuscular
neurology.
Anishee Undavia (02:40):
Yeah, that's a great question and a good place
to start, and I often have toexplain this to medical students
who think of neurology as thebrain and the spinal cord, but
also we have to remind them thatthe peripheral nerves are a
part of that.
And I guess I'll start by sayingwhen I talk to patients, I tell
them about the outside nervesor the peripheral nerves and
(03:01):
specifically, when I'm in theEMG lab, I tell them, you know,
this test isn't really going togive me information about
Parkinson's disease or multiplesclerosis, but it really tells
me anatomical information of anydamage to the nerve, starting
from the nerve root and all theway out to the muscle.
And so that's really what wecover in neuromuscular medicine.
Of course there's overlap with,you know, some central nervous
(03:22):
system findings, but really whenI think of neuromuscular, it's
really traditionally diseasesthat affects the nerves after
they exit the brain and spinalcord or beyond, and it includes
such a vast number of conditions.
And what I'll say is it can beas simple as a nerve compression
(03:45):
, like what we see in carpaltunnel syndrome or ulnar nerve
entrapment, but it also includesa whole host of autoimmune
conditions, neurodegenerativeproblems and hereditary
conditions that we can certainlytalk about more in detail.
So that's kind of how I explainneuromuscular to folks.
Michael Kentris (04:04):
Excellent and you know I think it's very
important.
I talk a lot about this as well, right?
I mean, I think in frameworks,right, a lot of medicine is
pattern recognition, butbuilding those frameworks for
the peripheral nervous systemspecifically, I think, is a
little more challenging.
There's not as much emphasisput on it.
And again, when you're teaching, like junior trainees and
(04:27):
things like that, what do yousee as like the main barriers
for people picking this up aseasily as, say, like,
identifying stroke syndromesversus, say, different
neuropathic patterns?
Anishee Undavia (04:42):
That's a very, very good question and I think
one of something we should talkabout more when we think about
training students and residents.
I think from my experience oneof the biggest barriers is for
medical students and residentsalike.
They the emphasis is in thehospital, which is great and
very, very important, becauseacute neurology is something we
(05:05):
have to all be familiar with asneurologists and recognize and
treat in a rapid and appropriatemanner.
But I think because there is somuch volume these days and so
much to cover in the hospitalwith whether it's strokes or
seizures, neuro ICU cases,subarachnoid hemorrhage, et
cetera there just isn't as muchtime and space to even think
(05:28):
about the peripheral nervoussystem.
So I think that's one of thebig barriers.
I don't know if you'veexperienced that, but it's that
not only do we not have time tothink about it, but then when we
want to open that door, there'sso much that we want to turn
away.
And one funny thing I think isthat because, from med school,
when you think of the peripheralnervous system, I feel like
(05:50):
many of our minds go to thebrachial plexus, which is like
ugh, I don't want to think aboutit.
I failed that test, you know.
I memorized those branches ahundred times.
I can't keep going back andit's obviously so much more than
that and it doesn't have to beas complex as what we think
about.
So I think that one of thebarriers is just not opening
that can of worms and maybe wecan overcome that by talking
(06:12):
about it in a bit of a differentway, what I have tried to do,
because I went in my lastposition.
I was both involved inneuromuscular teaching but also
general comprehensive neurologyin the hospital and in resident
clinic.
So I would try to.
I'll give you an example.
So let's say it was Saturdayand we're rounding on our
inpatient service and we have astroke follow up.
(06:34):
Somebody who had a rightinternal capsule stroke came in
with left sided weakness and theresident has done a great job
seeing the patient following up.
And then we go to the bedsidefor routine rounding and you
know things are kind of tuckedaway.
The patient's doing well,waiting for rehab, but I'll
notice like some of them haveatrophy.
So I'll look down and I'll seethat patient looks fine.
(06:55):
The exam is stable.
The resident has said oh, thepatient has three out of five
strength in the left upper limb.
And then I'll look at the handand I'll see that the first
dorsal enterosia is completelywasted away.
We've seen this before, right?
And I'll tell the resident hey,I'll just kind of look at my
with my eyes and kind of makeeyes with them and have them
look at the hand and I'll saywhat's that?
And it throws them off guard alittle bit and I try to be non,
(07:22):
you know, not scary about it andI'll say, especially if it's
like a PGY2 resident, I'll belike you might not know why that
hand is weak, but try to take aguess.
Do you think it's about thestroke?
And you know most of them willknow, well, no, atrophy doesn't
happen that acutely and so it'sprobably not related to stroke.
But they didn't kind of pushfurther.
They said, okay, the stroke isfine and they're ready for rehab
(07:43):
.
And then they'll say I don'tknow what that's from.
I think it's one of the phenaror hypothenar muscles.
You know, they're not even surewhich muscle it is.
And now I'll kind of startasking questions in a
non-confrontational way and ifthey're wrong, I often say well,
I'm glad you said the wronganswer, because now that I'm
going to correct you you mightnever get it wrong again and
(08:05):
I'll say, okay, well, that's thefirst dorsal enterosus.
What nerve do you thinkinnervates that muscle?
And they'll think about it andmany of them get it right.
They'll say the ulnar nerve,but some of them might say
median and you know, dependingon their level of training, they
might have no clue at all.
And okay, so we get to theulnar nerve and then I'll say,
well, what branch of the plexusdo you think that supplies the
(08:29):
ulnar nerve?
And then they'll think aboutthat.
And then I'll keep working myway back and that, like three
minutes, is a lesson in and ofitself.
And I feel like that approachwhere it's not interrupting them
too much, but hey, they had aminute to think about something
that they might have not had ontheir mind.
That patient has now taughtthem so much more than just that
right lacunar stroke.
(08:50):
You know what I mean.
And so I kind of try to justcatch them when I can and just
fill their neuromuscular bucketwith a little bit of information
, and then the next time we seeeach other it might be in
resident clinic and we'll takeit a step further from there.
That's kind of my approach.
Another example is sometimes aninpatient will need an EMG and
(09:11):
I'll really just try toencourage the resident to come
down with the patient andobserve the EMG and see.
You know that that puts it putsthe EMG in the context of their
patient that they're lookingafter and really it gives them a
sense of ownership about thecase and pushes them a little
bit.
So that's, those are a few ofmy approaches.
Michael Kentris (09:30):
That's excellent, yeah, it's, it really
emphasizes that, that extrastep.
When there is a piece thatdoesn't fit right, we have to
ask ourselves why and thenunpack that a little bit.
And I know, right, we've, we'veall been in the hospital and
things get busy.
And you right, it's, it's not aquote, unquote hospital problem
(09:50):
and it's easy to certainly tobrush that aside.
And right, there's, there's nota huge number of neuromuscular
emergencies, although there aresome.
And certainly you know, I cansee why a resident, especially
if they're rushing through theirpre rounds, would would miss a
little bit of intrinsic handatrophy in their stroke patient.
(10:12):
Yeah, but Exactly, you know.
But you bring up a good point,right.
I remember myself as a, as athird year medical student,
right I was, I was on a PM and Rrotation, right.
So we're doing a lot of EMGsand things like that and I must
have drawn the brachyoplexuslike a hundred times and a month
(10:34):
later I couldn't have done itat all.
Right, it's.
It is one of those things whereit's like it's so abstract when
you first learn it withoutclinically applying it.
And you know, the instructor Ihad was okay, but he didn't.
Let's just say he wasn't up toyour standards perhaps.
So you're not applying it Likewhy am I, why am I looking at
(10:55):
this muscle, why am I looking atthat muscle, why this nerve,
and kind of painting the pictureright.
That that you know neurologist,obviously, localization, that
would kind of unwrapped theentire problem.
And it does seem like therethere is, especially in the
preclinical and even, to adegree, the clinical years, this
lack of emphasis on theclinical applicability of a lot
(11:18):
of the knowledge that we putourselves through in in medical
training.
Anishee Undavia (11:24):
I totally agree with you and it goes back
to the the idea of neurophobiaversus neurophilia, and some of
the things that we deal withhave a very complex neuroanatomy
or you know, a broad range ofdifferentials that can be
overwhelming, and I think itreally depends on who's teaching
it to you and how much theylike what they're doing and how
(11:46):
much they teach you rather thanshame you.
That that happened to all of usright At some point in our
training.
I might have shyed I don't evenknow but maybe I shied away from
certain fields because of thatshaming, versus leading myself
into one, because I saw anattending who loved what they
did and wanted me to love itjust as much as they did.
So I do think that's a big partof it.
(12:07):
In any, in any subspecialty,but specifically neuromuscular,
which you know, you can easilyturn someone away and say I
never want to think about theperipheral nervous system again.
So I think that's very true andin fact I remember in that one
specific case with the FDIatrophy, I think by Sunday the
resident was like oh, by the way, I talked to the patient's wife
(12:28):
and she said that he has had along history of neck pain and
had some, you know, surgicalconsiderations for cervical
radiculopathy and that kind ofput it all into context for them
and I think that wraps it up.
They don't have to do much more.
It's not like it's going tochange the patient's course, but
at least that bucket is filledwith that knowledge and they can
(12:48):
come back to that if it happensagain, and I think that's
really important.
Michael Kentris (12:52):
That's excellent.
So you know, you brought up agood point, right?
So not not everyone goes intoneurology, obviously from
medical school, and then evenamongst neurologists, you know,
there I would say it's aminority of people who go into
neuromuscular subspecialty.
So what was it in your trainingand your experiences that
(13:15):
brought you down that pathway?
Anishee Undavia (13:20):
Yeah, that's, that's actually.
It wasn't a little bit of aninteresting journey.
I guess when we, when I was inresidency and everyone was
thinking about their strokefellowship or movement disorders
, I actually didn't really know.
I loved the whole breadth ofneurologies but you know a lot
of people went for fellowship soI decided to do neurofizz,
(13:40):
thinking it would give me someadded skills and procedural base
to do EEG and EMG, which so Iwent on to do that.
But it wasn't till I was in thatfellowship where I was exposed
to the breadth of neuromuscular.
I actually didn't really evenknow that we're the ones who you
know diagnose and treat theserare muscular dystrophies or
(14:01):
genetic conditions.
I kind of knew but I didn'tknow that there are these places
all over the country thatcollect very interesting, you
know, like MDA clinic or ALSclinic.
I guess maybe I was when I wasin training it was the beginning
of a lot of that stuff.
But I got exposure as aneurofizz fellow when I was on
the EMG half of things to seethese specialized clinics where
(14:24):
I saw more, you know Duchenne,muscular dystrophy or congenital
myopathy such as you knowBethlehem and Ulrich's myopathy
that you would never see in yourcareer unless you were
specifically attending in theseclinics or rotating on these
clinics.
So that really interested me.
I didn't.
I didn't even know that itexisted.
(14:46):
So when I was in neurofizz Iwas also, I guess, kind of not
ready to grow up and get a realjob.
So I talked to theneuromuscular people there and I
said, hey, I'd really like tostay and do more of
neuromuscular training.
Neurofizz is really focused onEMG and that's another
misconception that mayberesidents and students might
think neuromuscular means EMG,but it is really so much more
(15:10):
than that.
One of my neuromusculartendings used to say EMG has its
limitations, it's not an end,all be all and there's so much
more now.
So I ended up doing two yearsof fellowship one year in
neurofizz where I did EEGtraining and EMG training, and
then a special year inneuromuscular where I got to
really get a lot of experiencewith muscular dystrophy.
(15:31):
A lot of my specific fellowshipwas focused on muscle, so I got
a lot of muscular dystrophy,inflammatory myopathies.
I know other centers arefocused on neuropathy and so
even that is getting more andmore specialized and separated.
But yeah, that was kind of myjourney.
Is that?
I don't think.
Unless you see it, you don'tknow what exists, and it opened
(15:53):
up my eyes to what's out thereand what you can do for people.
Michael Kentris (15:59):
Yeah, I was a neurofizz fellow as well, but I
was more on the epilepsy side ofthings and.
But I spent some time with theneuromuscular tendings and
you're absolutely right,especially like the child
neurology, neuromusculartendings, just all these
disorders that you know, youmaybe you read like a paragraph
about as you're studying forboards, but you may never have
(16:22):
seen in your entire career.
And yeah, it's one of thosethings where, like the entire
breadth of neurology is so vastit feels like the body of
knowledge is nearly impossibleto stay on top of anymore and
this accelerating at such a fastpace.
Anishee Undavia (16:40):
It is, and so much so that you might not even
have access to it in yourparticular program.
So one of my pointers tostudents and residents
specifically residents, beforethey're thinking about applying,
is if there's an area thatyou're peaked by and they just
don't have the breadth of it Forexample, if you're for someone
like you who's who's might bemight have been curious about
(17:02):
epilepsy if you don't havesurgical epilepsy in your
specific center, seek out thatrotation, because I know there's
visiting rotations and thingslike that, just so you can know
what the potential is for you ifyou're interested in academics
or if you're interested in goinginto that specific area.
Unless you see it, you reallywon't know what it's all about
(17:23):
and what the day to day of thoseproviders is like.
Michael Kentris (17:27):
Very true.
And yeah, it's high cutie, lowcutie, big center, small centers
, and they're different needs,different resources, all across
the map it's.
It is interesting, right, wehave all these like ACG and me
certifications for programs, butin reality there's still quite
a lot of variability from placeto place and even region to
(17:49):
region.
But definitely, but I thinkthere's still some commonalities
when we get kind of down to thefun fundamentals.
So you know, I know you wentthrough like a lot of the things
that like a neuromuscularspecialist kind of focuses on,
like neuropathy, differentmusculoskeletal disorders, what
would you say are kind of themost bread and butter sorts of
(18:12):
things that kind of wind upcoming to you as either a first
or second opinion.
Anishee Undavia (18:18):
Yeah, so there actually isn't that side.
I was thinking about that and Ithink I'll tell you my favorite
is gate dysfunction.
Two favorites gate dysfunctionand weakness.
We get a lot of those and youcan imagine there's some overlap
with movement disorders so weget to kind of think through
even some central nervous systemconditions when we get those
(18:40):
cases.
Other things are numbness ortingling in one or more limbs,
weakness, proximal weakness,trouble climbing stairs, falls,
burning, tingling.
I don't know if I'm missinganything major, but I think
those are the big ones.
And a lot of my referrals comefrom other neurologists.
(19:02):
Sometimes if you have a primarydoctor that knows you and knows
your interests, they'll comedirectly from the primary doctor
.
But a lot of the time I'mgetting referrals to start by
doing an EMG for that otherneurologist because they think
it's neuromuscular but they'renot sure what part of the
neuromuscular system is involved.
And then, if it is somethingrelevant, I will kind of talk to
(19:23):
the referring doc and say, hey,I think this is something it
could be, you know, motor neurondisease or maybe something
mimicking it, and I'll carryover the workup if that's okay
with you.
And usually they're like, yes,please, I'm glad they saw you.
So that's usually the scenario.
Where I'm getting myneuromuscular cases is through
my colleagues within thedepartment.
Michael Kentris (19:44):
Got you.
Now, something I alwaysremember my instructors saying
to me when I was learning EMGsand I imagine it's probably a
universal sentiment is that yourEMGs and your nerve conduction
studies are essentially anextension of your physical exam.
And I think you see this morein community centers, where and
(20:05):
tell me if this is as big of apet peeve for you as it is for
me right, you get a referral foran EMG nerve conduction studies
for, like you know, neuropathyand it's for the bilateral lower
extremities.
If you see that referral andthey're 90 or 95 and I'm like,
oh God, what's your firstthoughts After?
Oh God.
Anishee Undavia (20:29):
What's my first thought after I get a
referral for neuropathy Is thatyeah, like.
Michael Kentris (20:34):
So let's say, like you said, numbness or gait,
whichever you prefer, okay.
Anishee Undavia (20:42):
That's a great question.
So I like to, if I know thatit's a classic clinical
presentation.
So if they have this classic,I've been burning in my feet for
the last few years.
Now it's getting a little bitworse.
It's very equal and symmetric.
I feel it in my fingers.
If it's a classic story for alength dependent external
(21:04):
neuropathy, then I, you know, Iproceed with the EMG of the
lower limbs and I try to findthat pattern where there's, you
know, sensory more than motor,distal more than proximal, and
make sense of it that way.
But many times with burning orweakness, I have this algorithm
in my own head that I try toshare with students, where I go
(21:26):
through some very basicanatomical buckets, like I said,
and I have these prefilleddiagnoses in those buckets that
help me decide what to ask andwhat to examine.
So I always start with themotor neuron as the most
proximal place that I go withwith neuromuscular cases and I
think about anterior horn celland I think about things like
(21:50):
ALS, which obviously we don'twant to jump to ALS with these
simple cases, straightforwardcases, but just to be organized
about it.
I start with that and then Imove to the nerve root, which is
very common.
We think about nerve rootcompression from lateral bulging
discs.
But in the in the radiculopathybucket I also have things like
(22:10):
AIDP, cidp or infectious causeslike cytomegalovirus or Lyme
polyradiculopathy, and then I go.
So I go anterior horn nerve rootand then I go to the plexus.
Plexus is honestly not thatcommon unless there's trauma
involved, but we do see caseslike radiation plexopathy or
(22:31):
indolent malignancies thatinfiltrate the nerve roots like
lymphoma.
And then I move from the plexusto the next bucket, which is
the peripheral nerve, which isobviously a very big bucket, but
that includes all of my nerveentrapments, like carpal tunnel,
ulnar neuropathy, perinealnerve entrapment, sciatic
neuropathy.
But it also includespolyneuropathy, which is your
(22:54):
classic length dependentneuropathy from diabetes or B12
deficiency or inflammatorycauses such as para protein with
magneuropathy.
So I that's a very big bucketand certainly you know, on
another talk we can dive intothe different types.
But I I like to stop at thatbucket and think, is my patient
fitting into any of those?
(23:16):
And then from the peripheralnerve I go to the neuromuscular
junction which has your commoncondition, common things that we
think about, like myastheniagravis, also Lambert Eaton
syndrome or botulism, and thenfinally I end with the muscle,
which also a very broad andinteresting bucket, which can be
simple things like a statinmyopathy or thyroid induced
(23:40):
myopathy, or something complexlike a necrotizing myopathy,
which is an autoimmune sequelaeof statin use, or hereditary
things like muscular dystrophy,congenital myopathy, et cetera.
So it's, it's a lot andhopefully that's not
overwhelming.
But I always encourage studentsand residents to go back to
(24:00):
motor neuron, root plexus, nerve, neuromuscular junction and
muscle and I, whenever I'm inresident clinic and a resident
comes and says they take thisfantastic history because
they're great at that.
And then we get to the exam andthey're like I don't know what
it is, and so then I always gothrough this exercise and I have
them fill in the bucketsthemselves and that's them
(24:21):
building their own knowledgeframework, whether it's for
their boards or for their futurepractice.
Where do these conditions fitin and what can I ask or examine
, to kind of hone in on it.
And then we move on to whatdiagnostics will serve that,
that differential Right onephrase.
Michael Kentris (24:41):
One of my attendants in residency.
She was always full of pithyphrases and she would always say
like yes like what's what's?
What company does it keep?
Right, Referring to thesymptoms like what else is there
?
What's around it?
They write everything inmedicine, and neurology in
particular, very contextual.
So so, like right, someonecomes in, like you were saying
(25:02):
with with burning the feet,people like is there that
atrophy?
Is there evidence of motorinvolvement?
Are there autonomic symptoms aswell?
Anishee Undavia (25:09):
Right, yeah or associated weakness.
Michael Kentris (25:11):
Exactly so like and that that helps refine
which buckets you're going tofocus your attention on right.
Anishee Undavia (25:19):
Absolutely, and then that then further helps
you.
You might still not know whatthey have, but then you can
start thinking of yourinvestigations and what makes
more sense.
You know as the first step,whether it's labs or EMG, or
sometimes you jump right to justyou know genetic testing
because you have all theseclinical features that are very
clear and a family history to gowith it.
(25:39):
Another very important part ofneuromuscular medicine is asking
about parents.
If you think, I'll give you an.
I just had a patient the otherday who I did an EMG on and I
was worried about motor neurondisease and I said, well, come
to my clinic, I need to examineyou and kind of think through
things further.
And I examined him and he hadgynecomastia.
And then I asked him about hischildhood history and he said I
(26:02):
could never do.
He's kind of a big guy.
And I was like so were youathletic?
No, not at all.
I was like did you do pushupsor squats as a kid?
No, never.
I said why I couldn't do them,why not?
I just couldn't you know, likethere was really no good
explanation.
And then you, then I said well,did anyone in your family?
And, and you know, with thegynecomastia and motor weakness
(26:25):
I was thinking about Kennedy'sdisease and that's an X-link
disease.
And you know that then you knowto not just ask about mom and
dad but mom's brothers.
Turns out he had like sixuncles on his mom's side.
Many of them were estranged sowe couldn't get information.
But, you know, you wonder wherethey.
You know wheelchair forunexplained reasons, or did they
need a walker in their forties?
(26:46):
All that ancillary informationcan really be helpful in
pinpointing the next diagnostictest.
You do and and avoid callingthings ALS that are not ALS, you
know.
Michael Kentris (26:58):
Right, and I remember when I was a fellow I
had a consult for musculardystrophy.
It was in an older gentleman,like in his, you know, late late
sixties, early seventies.
And you know you go in and,like you said, right, you're
examining, he's got diffuseatrophy, you know, arms and legs
.
Obviously this is very late,late stage in his life and you
(27:21):
know you, but you you examine,he has sensory changes, right.
So obviously that doesn'treally doesn't really fit.
But he'd been told all his lifefor decades that he had
muscular dystrophy.
And then, fortunately, his kidsand his grandkids are all
visiting him in the hospital atthe time I'm doing this consult.
So I look at his feet right, hehas Charcot feet and so I asked
(27:46):
hey, can I look at all yourguys's feet?
Anishee Undavia (27:49):
Yeah, that's the best.
Michael Kentris (27:51):
And you know they all, like they had like it
was like looking at over time,they all had very high arches.
You know some of the middleaged folks had hammer toes.
I was like, oh, you guysprobably have like some
variation of Charcot Marie toothand it was one of those things,
right, where it's like it's nota fancy test, it's not anything
(28:11):
beyond just asking questionsand talking to people and just
putting the pieces together.
It's one of those things whereyou're just like, oh, the light
just shines over your head.
Anishee Undavia (28:21):
The moments we all live for in neurology.
Michael Kentris (28:24):
Right Cause I mean that's.
That's been a few years now,but that experience will live
with me forever, definitely.
Anishee Undavia (28:30):
I had something similar with FSHD
which you know many students andresidents don't ever see.
But I think the guy, if Iremember correctly, the the guy
came in for pain.
He had back pain and symptomsof lumbar radiculopathy, but
then we examined him and heclearly had facial weakness.
He had scapular winging and youknow this proximal atrophy,
(28:50):
this double hump that we seewith deltoid sparing and the,
the rising of the trapezius fromthe scapular winging.
Anyway, he was with his motherand his mother had, no, no
health issues, but she wassitting there with this like
downturned smile and you mightnot notice it, but then when we
asked her, we she also had somemild facial weakness.
(29:12):
And it's so funny.
How, like those littleencounters, can you know, when
you lean in as an neurologist,because what we're supposed to
observe and ask these questionsand you you can elicit so much
information without doing asingle lab, lab test or you know
, nerve test or whatever it is.
Michael Kentris (29:31):
I know I always .
I always feel slightly Ihaven't shaken it yet slightly
awkward when I have to asksomeone's like.
You know, with, like, some sortof facial let's I hesitate to
use the word abnormality, butit's like does your, does your
face always look like that?
You know, it's one of thosethings where you try and find
the polite way to say it.
Anishee Undavia (29:53):
I don't know, have you come across any phrases
that work particularly well forI would never say it, but I've
had patients say I've always hadRBF, and I'm not going to spell
out what that means.
Yes, but they will tell me thatstraight up, but that's just how
my face is.
No, I think if you show thatyou're trying to help them and
understand, no one's reallygotten offended.
(30:14):
I'll just say you know, asneurologists we pay attention to
these things, and I noticedthat yours is down.
Has it always been like that?
Do you have, or do you have, alicense photo that I can look at
, you know?
Obviously that sometimes we dothat for hemiparesis, but you
could also do facial diplegia.
Michael Kentris (30:32):
Excellent.
Anishee Undavia (30:32):
Yeah.
Michael Kentris (30:34):
So so obviously you know we're a couple
neurologists shooting the breeze.
We we like to talk about theesoterica of neurology, but you
know, a lot of times you knowthere are people out there maybe
50, 100 miles away from thenearest neurology, even here in
the US, and for the primary caredocs in the audience, how, how
(30:58):
should they approach let's say,neuropathy?
Like someone comes in, they gotthe numbness and the tingling
EMGs labs.
Where do we go?
Anishee Undavia (31:10):
Yeah, that is a very, very good question and,
I think, a hard question,because we neurologists bark
when too much is done and webark when not enough is done.
You don't go both ways, I don'tknow.
I kind of am in the boat ofI'll see anyone that you're not
sure, I'll just see them, and,and I'd rather if they're not
(31:32):
sure.
I hate recommending testswithout having seen the patient
myself.
I just I don't know.
It just feels wastefulsometimes.
But of course, for the the runof the mill length dependent
neuropathies, we almost alwaysscreen for B12 and it's very
valuable.
A lot of the times it's low,low, normal and just
supplementing it can make a bigdifference in the symptoms.
(31:55):
Tsh is controversial.
I've never seen it actuallyhelp me or pick up you know a
treatable case.
So I think a lot of people areputting that one out the door,
unless they're they havemetabolic syndrome and it might
be relevant to their case.
A1c can be helpful if theyhaven't been going to a PCP
regularly as a first time.
(32:16):
Definitely, I see neuropathysymptoms even with early and
mild diabetes, so it doesn'thave to be like an A1c of 13 to
see the symptoms of a neuropathy, at least the burning pain.
Interestingly, people who arenewly on insulin.
There's a condition calledinsulin neuronitis which can be
very, very painful and mimic aneuropathy, and so if they
(32:39):
recently were treated fordiabetes and they got rapid
control, sometimes you seepatients present with symptoms
of neuropathy and that should besomething that a primary care
could potentially deal with.
So just that, that educationabout insulin neuronitis.
They also don't always need anEMG, so I guess a referral
(33:02):
sometimes might be better,because if it's very clear that
it's in the context of theirdiabetes or B12 deficiency, they
don't really have motorweakness or obvious sensory
deficits on their exam.
Maybe you could hold off on theEMG.
Some people want a baseline.
It's very subjective.
I do it based on how I thinkthe patient will tolerate it.
I want them to trust me and ifI don't think an EMG is really
(33:24):
going to make a big, big picturechange in their treatment, I
don't jump to it right away forevery run of the millenuropathy.
Of course, if there's any redflag.
So if there's a profound amountof weakness, if they show up
with burning pain but alsothey're tripping and falling,
that's a red flag and theyshould probably see neurology
and get an EMG to look forsomething like something that's
(33:46):
not as common or run of the mill, because motor weakness usually
comes much later, if at all.
So I don't know if that answersyour question, but it's kind of
person to person.
The bottom line is if a primarydoctor sees something in
neuropathy that's not classic,then they should probably be
(34:09):
seen by a neurologist or get anEMG.
Michael Kentris (34:12):
Yeah, no, I think that's totally reasonable.
Personally, when I was doingEMGs more often in my practice,
I was basically doing aminiature consult every time I
saw them, because and maybe I'mmore guilty of this than other
people but I would get a requestfor a certain you know, like
you know, both legs or maybe allfour extremities, and I'm just
(34:37):
like this is unnecessary.
Here's what we're actuallygoing to do and this is why yeah
, that's all that's going on.
Anishee Undavia (34:43):
How often?
Or a limb EMG?
No, I don't think so.
Michael Kentris (34:46):
Right, we're not doing a CIDP or an ALS
evaluation today, right, we'renot doing it yet?
Yes, question, and this may bea hot take moment, so you can
beg off if you.
If you'd rather not answer whatis your opinion in general?
Right, because you're you're anacademic neurologist, academic
neuromuscular sub specialist,emgs in the community.
(35:10):
What?
What is going on?
Anishee Undavia (35:19):
I don't know.
I don't want to makeassumptions.
I don't think everybody shouldbe doing EMGs without the proper
training.
Definitely, I collaborate a lotwith my PM and our colleagues
who do a good amount of them andI think that's really great.
But I don't know.
(35:39):
I've seen.
I don't want to get in troublewith what I have to say about it
.
Michael Kentris (35:44):
actually, I've seen, I'll say something.
I mean there's a lot of garbageEMGs out there.
So, and you know, I remember Ithink I was a second or third
year medical student around thetime, but I was.
I was talking with a doctor andright, emg reimbursement got
(36:06):
got slashed by a significantmargin.
Oh God, I'm going to age myself20, 13.
Anishee Undavia (36:13):
I was a fellow a couple years before that.
Yeah.
Michael Kentris (36:16):
Well, I probably got cut again, but the
big one was a little bit beforethat and I'm just like, well,
yeah, right, it's, it's obviouswhen you think about it in the
context of the greater you knowsystem, you know for our
international listeners, right,this is a US thing where, like
your Medicare, Medicaid servicesto determine how much you get
paid for a service, andbasically said, too many EMGs
(36:40):
are being done, which suggeststhat they're likely being done
inappropriately.
And you see that for a numberof procedures over the years,
it's not always the case.
Sometimes it's just thegovernment being the government,
but in this case I think theywere probably in the right in as
much as we have too manydoctors doing too many low
(37:01):
quality studies.
And I remember in my formerpractice there was a guy in the
area who would do like like 15EMGs in a day, Sometimes more
than that, and I would get thesereports and I'm like this is
because I would get a referralfor like a myopathy.
(37:23):
And well, no, I would.
I would get the patientreferred to me as a consult
first.
But you are correct, Right?
So I didn't see.
The person is like you don'thave any clinical science of a
myopathy and and so it is rightthere there is a certain
subjectivity to to EMG Quote,unquote very much.
Anishee Undavia (37:46):
Yeah, it does matter who's doing it and who's.
I totally agree with you.
I didn't want to say it and I'mthankful that you said that.
There are a lot of garbage EMGsout there being done by people
who really don't know how to.
You can't just take one nervethat's a little slow and say the
patient has a IDP or CIDP.
You just can't.
There's a demyelinating range.
(38:07):
There's a clinical phenotypethat goes with it.
That would make sense.
There's a lot of technicalpitfalls, so you need the person
doing it to take the patientinto consideration when you're
making an interpretation.
I mean the median nerve, forexample, in carpal tunnel.
It could be so bad looking witha normal muscle and it's just
(38:33):
because they have anatomicalvariation and it's like a some
kind of Martin Gruber or RishKanu and Astimosis and you you
get them to say, oh well, theyhave a severe carpal tunnel.
They go get carpal tunnelsurgery, you know, for minimal
symptoms or other symptoms thatthey're having and and you get
in a lot of trouble.
We see a lot of or spinesurgery, for example.
(38:53):
We've seen cases like that andso, yes, I think that training
matters and what you're doing,the test for matters and
appropriate referral makes sense.
It's also a painful test, so tohave to go through it two or
three times before you get onthe right track kind of that's
unfortunate.
Michael Kentris (39:15):
Right Especially and I'm sure you've
encountered this right as thesecond opinion neurologist is
that you know it's like well,why do I need to repeat that
study?
I already had that study doneand you know, like you said,
right, you don't want to be theperson who says like well, the
other one was kind of not good,but I mean, that's that's.
(39:35):
That is the reason sometimes,many, many times.
I mean sometimes, and I alwaysremember there are certain
things to look for, like in theraw data, right, Like is the
temperature documented, right?
If there's no temperaturedocumented, you can just throw
that thing in the trash.
Anishee Undavia (39:53):
Yeah, I mean I don't know if that's true, but
I think you really have to thinkabout the under.
Whoever's doing it has to kindof be familiar with things like
Charcot-Marie tooth or, you know, demyelinating neuropathy or
myositis, and if they've onlytrained to do them, to look for
carpal tunnel or lumbarradiculopathy.
(40:14):
That's a limited scope.
And EMG, although it has itsown limitations, it can be very
helpful to separate some ofthose conditions and you have to
have the clinical understandingand the EMG understanding to
piece it together.
It really is a subjective test.
I don't know the solution forthat.
I guess cutting thereimbursements might have helped
(40:36):
.
I think entire practices had toclose when that happened
because they were just doingEMGs.
Yeah, and a lot of the timeI'll get the referral for the
EMG from a primary doctor or apodiatrist and it's either
straightforward it's much morecomplex than I bring them into
the clinic as like a formalevaluation and then they become
(40:58):
a neurology patient.
Michael Kentris (41:00):
Yeah, oh man.
So you bring up another.
I'm just remembering aconversation I had with a
podiatrist a friend, not in thelast few years and it was about
tarstle tunnel syndrome.
Anishee Undavia (41:14):
Oh, another hot topic.
Michael Kentris (41:15):
Sorry, I'll stop bringing up controversial
topics.
No, please it's great, and it'sone of those things where it's
like I remember one of myattendings.
You know he was an oldergentleman and I believe his
exact words were I've neverdiagnosed tarstle tunnel
syndrome.
Anishee Undavia (41:36):
Yeah, I have gotten those referrals and you
know people have pain on themedial side of their ankle
sometimes and so I'll kind ofopen up my ship here, my
precedent ship here, which isthe kind of neuromuscular Bible
or at least EMG Bible, I shouldsay and needle some of the
muscles that they recommend.
(41:56):
I'll do all the appropriatetests.
The problem is there's a lot ofwear and tear.
So when you put a, put theneedle in some of those
intrinsic foot muscles, you'relistening for denervation or
chronic re-innovation, and itcan be obscured by the fact that
, especially if they're older,there's so much wear and tear
from walking and stomping thatit might be a very nonspecific
(42:17):
finding and it might not get youthe answer.
I that's where I'm starting tolean on neuromuscular ultrasound
or imaging of other kinds to,really, because there was one
time that only one time that wepicked up an Ewing sarcoma in
the ankle.
After someone was referred fortarstle tunnel evaluation and
there were some abnormalitiesbut I didn't make any
(42:39):
conclusions from the EMG, I saidplease do direct imaging, and
that's how that came about.
So you can certainly havecompression at that site.
I just don't know if the EMG isvery diagnostic necessarily in
that.
Michael Kentris (42:55):
That's a fair, that's a more equitable
statement than mine.
Now you bring up something veryinteresting and something I
unfortunately don't have verymuch experience with, which is
neuromuscular ultrasound, whichI know has been like kind of
like the hot field for severalyears now.
What's what's that looking like, how's it being used in
(43:16):
practice, and what do you thinkkind of future directions are
looking like for it?
Anishee Undavia (43:22):
Okay, so I will.
I will preface it by saying Iactually I don't do
neuromuscular ultrasound, nor doI have much training in it, but
more than, like you know, a fewworkshops at the national
meetings when they're available,I'll go in and try to localize
the nerve.
But as I've said many timesjust in our conversation, emg
can be limited and it'sespecially limited when people
(43:42):
have more than one thing goingon.
For example, if they have acervical radiculopathy at C8t1,
but also a carpal tunnel and youdon't know which one.
Is that the culprit at thattime for their actual symptoms.
That's just an example.
Or if they have an ulnarcompression but you can't quite
localize it because it's sosevere, meaning there's like no
(44:04):
responses on the EMG and theycould have a double crush
syndrome.
So I think I think thatultrasound can be really useful
for the mononuropathies becauseyou can measure their
circumference of the nerve,typically when it is enlarged or
swollen over a certain size.
You can.
It can be quite specific.
(44:27):
I that's kind of where I havereferred patients for ultrasound
is for those circumstances whenI can't tell, because they have
multiple neuromuscular thingsor multiple areas of compression
, how to localize it.
I think it has a place, forsure, and I hope that it becomes
more, you know, more readilyavailable in the community.
(44:49):
But yeah, that's kind of mytake on neuromuscular ultrasound
.
Michael Kentris (44:56):
No, that's excellent.
Yeah, I've been.
It's definitely on my my bucketlist to see if I can get into
some of those workshops as well.
It certainly I mean certainlyless painful than an EMG, right.
Anishee Undavia (45:07):
Yeah, it is less.
I think you often need both.
I'm rarely seeing that anultrasound alone can make the
treatment you know, get us tothe treatment versus an EMG
alone, usually in conjunction,kind of like a CTA and a carotid
ultrasound.
You kind of need both, for theone for the velocity and one for
the actual 2D or 3D images.
Michael Kentris (45:27):
Fair enough.
So for people, because now Iremember and I don't know if
this is typical or not there wasa PM&R resident who had
actually started a neuromuscularfellowship at the time that I
was.
I was an outgoing fellow, theywere an incoming fellow, and is
(45:49):
neuromuscular open to neurologyand PM&R?
Are there any other specialtiesthat that do neuromuscular
medicine?
Anishee Undavia (45:55):
Yeah, when I was a fellow in neuromuscular
medicine at UCLA, we had a very,very strong PM&R resident who
wanted to then ultimately befocused on muscular dystrophy
and rehabilitation.
So definitely I think it isopen to multiple areas.
I don't I've never seen like apain specialist or or someone
(46:19):
who has an interest in paincoming through.
Mostly I've seen other PM&R incombination with neurology.
I haven't seen any otherspecialties, but I'm sure there
could be a space for it.
Yeah, I don't have you, I don'thave.
Have you seen that?
Have you seen?
Michael Kentris (46:37):
those are the only two that I've seen as well
Only two I've seen, yeah, andthen the A&M.
Anishee Undavia (46:41):
I haven't gone to one of their meetings yet,
but they're heavily acombination of two and their
talks are very much focused onboth specialties.
Michael Kentris (46:51):
That makes sense Because I think pretty
much they're the the main twospecialties doing EMGs these
days.
(47:12):
Yes, so.
So what's your, your pitch forfor neuromuscular medicine?
If you're going to talk to thejunior neurology residents out
there, what's the draw?
Why should you pick that as thespecialty, the subspecialty of
choice?
Anishee Undavia (47:32):
That is a very good question.
I one, I love it.
And I think I love it because Isaw other people who love it
doing it.
I think that it is really funto think through those buckets
that we talked about, anywherefrom the root to the muscle, and
I had a lot of those ahamoments at the bedside.
(47:53):
And so my message to studentsfor students I would say, when
you're on your clerkship, try toseek out the neurodiagnostics
lab and catch a couple of EMGsbecause it's not always built
into the curriculum, just toknow what it is, even for your
shelf exam.
They, you know, they almostalways ask about lumbar
radiculopathy or cervicalradiculopathy, and so that can
(48:15):
really give a visual to what youknow what looking for those
cases means.
And for junior residents Iwould say try to fit it in.
I think the PGY2s are sofocused on stroke and epilepsy
because that's what we seemostly in the hospital.
But the Blumenfeld book hassome great neuromuscular cases
and if you just stop to read ona case-based level based on what
(48:41):
you come across, you'll startmaking that framework early on.
And then, of course, pgy2 and 3,when you're in your specialty
clinics, you can start fillingthose buckets as you prepare for
the boards.
But if you're interested thatyou might want to do it, I would
definitely go and rotate.
If your institution doesn'thave an ALS clinic or a
myasthenia clinic or a musculardystrophy clinic, try to get
(49:05):
some experience so you canreally see what that's all about
, because that nothing replacesthe visual of seeing those
patients, examining them, comingto an anatomical diagnosis and
then discussing some of theirrehab needs.
We didn't really talk aboutgenetics today, but we are
scratching the surface.
Now there are treatments forconditions like SMA, duchenne,
(49:27):
muscular dystrophy, and so it'sgoing to be more important, more
and more important forresidents to actually learn
about them and be able to pickout those cases, to at least
refer appropriately forneuromuscular so they can get
the benefit of those treatments.
Michael Kentris (49:41):
Yeah, absolutely, and hopefully the
cost of some of those will comedown a little bit, like the
Neusin medicine and ABYPARVOVIC.
Anishee Undavia (49:49):
Absolutely yeah, it is ungodly expensive,
but you know.
Michael Kentris (49:54):
I believe the are the single most expensive
medications in existence rightnow.
Anishee Undavia (50:00):
Yeah, I think you had another a really good
podcast about the cost ofmedicine.
I think it was onneurotransmitters.
I was listening to you.
Michael Kentris (50:10):
Yeah, yeah, one of my friends and I were
talking about MS medications.
Anishee Undavia (50:15):
Yeah, that was really helpful.
I think, that's important toofor perspective for when we
treat these patients Especiallyrare disease.
Michael Kentris (50:24):
Yes, yeah, no, like rare disease, and you
probably.
Well, I know I'm veeringslightly, that's what I do, but
I remember one of my attendingshad probably like six to 10
Lambert-Ethan patients, and thiswas before there was any FDA
approved medications, and so shehad them on the God, I'm a rush
(50:47):
.
I think it's the three, fourDAP, if I remember correct.
Right, and she would have itlike synthesized and like
shipped up, and but after themedication was FDA approved she
couldn't get them this, thischeap old medication anymore,
and so then they're like on thehook for this, like stupidly
expensive medication, becausethere's no other options that
(51:08):
are even being made anymore.
Anishee Undavia (51:12):
Yeah, so what they had to like get on a phone
with the insurance company andyeah, like they had to go into
this like prescription brandname.
Yeah, that's a bummer.
My experience with that with Ijust get on the phone, I do
whatever I need to do to get onthe phone to the struggle I've
(51:33):
had.
It's not exactly in that realm,but in people with necrotizing
myopathy from HMGCR antibodies.
You'll come across so muchliterature that says IVIG helps,
ivig helps, ivig helps, youknow, and it's it's not
technically approved for that,but all the experts around the
country are using it and that'swhat they recommend first line.
(51:55):
And so I will get on the phonewith whoever I have to and share
whatever observational studieshave been done to explain this.
Is, you know, so treatable.
The more you wait, the worse itgets and more irreversible.
This you know they're going tobe left with disabilities.
So I think part of the problemis the people who are approving
(52:19):
it don't really know the diseaseand are far removed from that,
and so it's our job to kind ofexplain the dire need for them
if they're available, especiallyif it can be, you know,
preventing handicap and thingslike that.
Michael Kentris (52:34):
So are you saying your peer to peers aren't
with another neurologist?
Anishee Undavia (52:39):
It's often like with a radiation oncologist
or something like that.
Michael Kentris (52:44):
Right, it is pretty random, sorry.
Sorry for veering so far.
Anishee Undavia (52:52):
Which is very real life and very, very
relatable.
Michael Kentris (52:55):
So yeah, yes, Any final thoughts?
Anything you want to plug?
Anishee Undavia (53:04):
Hopefully this was a, you know, a simplified
way of kind of introducingneuromuscular.
Obviously it's very vast andthere's a lot of things we
haven't talked about.
But I think, starting with thatbarrier to just opening people's
eyes to neuromuscular, what itis about, even if you're not
going to go into it, justknowing that it exists and that
it is a part of our job asneurologists to recognize some
(53:27):
of these things, I think, justas trainees do as much as you
can to see some of these cases,or to, you know, figure out
which attendings you like andare approachable and be like hey
, show me that case.
If you ever get one, or you know, feel free to pull me in so I
can kind of take a look, becausesome of these cases, like you
know, even myotonic dystrophyit's the most common muscular
dystrophy, but you might neversee it if you don't seek it out.
(53:50):
So just kind of saying hey toyour attendings that are willing
I'd love to see more if youhave stuff to show me in and I
think that that enough ismotivation for the attending to
be like hey, this is exciting.
I want to show them thisbecause you know I can point out
these things and it can reallymake a difference in their,
their knowledge, or fill theirbuckets, so to speak.
Michael Kentris (54:10):
Absolutely.
Anishee Undavia (54:11):
Yeah, and.
Michael Kentris (54:12):
I know I had a medical student just this week,
you know she expressed just thebarest interest in neurology,
and so I'm automatically tryingto convince her, like you,
should become a neurologist.
Anishee Undavia (54:23):
We're such leeches in that way.
Michael Kentris (54:26):
Like I hear something I'm like oh you belong
in this field, that's right,you would be good.
You're good for the field.
Anishee Undavia (54:32):
We need you.
Michael Kentris (54:33):
Right, but I and I like to think that's a
welcoming kind of mindset, butor even like I think we spoke
about this before is like whenyou're meeting.
Anishee Undavia (54:45):
When you're meeting trainees, like finding
out where their interests areand seeing if it relates it
often does relate to neurologyand you know, showing them how.
For example, ophthalmologyobviously we have neuro
ophthalmology, which is such agreat field, but they might not
think about it or know aboutthat, but interested in the
pathways, but not really linkingthe two.
And so it's it's nice to hearfrom a neurologist about how
(55:08):
your interests can be linkedinto our field early on.
Michael Kentris (55:13):
So very much, so where can people find you
online if they're going to seekyou out?
Anishee Undavia (55:20):
Oh yeah, I am on Twitter.
I actually really like, or Iguess X is what I should say.
Michael Kentris (55:26):
Yeah.
Anishee Undavia (55:29):
I am very much enjoying the community building
on X or Twitter and meetingpeople like you and others who
are clinically focused and lovewhat we do but also commiserate
a little bit.
So I am at gosh, I forgot myhandle.
Michael Kentris (55:45):
Sorry, we'll edit this out in post.
What's?
Anishee Undavia (55:48):
my handle at Anishisha A-N-I-S-H-E-E-S-H-A-H.
Please feel free to give mefeedback or, you know, just say
hi or chat about neuromuscularor anything.
Really, I'm available.
Michael Kentris (56:03):
We'll be looking for high quality, bite
sized neuromuscular content.
Anishee Undavia (56:07):
There you go, I'll work on it.
I'm starting to kind of getaround to posting my first
tutorial.
Hasn't happened yet, buthopefully soon you inspire me,
I'm going to get there.
Oh, you're two kinds.
Michael Kentris (56:20):
Well, thank you again so much.
I really appreciate you takingthe time to come on, share your
love for neuromuscular neurologyand, you know, schedule and
desire permitting, perhaps wecan get you back on to talk more
in depth about specificcomplaints and kind of your
diagnostic treatment approach.
Anishee Undavia (56:40):
I would love that.
I really, really appreciate theopportunity to be on here and
talk with you, and I like thiskind of casual approach.
It makes it more fun and yeah,so hopefully we can do it again.
Michael Kentris (56:53):
I hope so too.
Thank you again for listening.
This episode was edited andproduced by Rita Farhan.
If you enjoyed this podcast,please leave a five-star review
for us on Apple or Spotify orwherever else you might get your
podcasts.
This really helps with giving ashow noticed and spreading the
word.
You can find me on X, formerlyTwitter at Dr Kentress, dr
KENTRIS, and you can find theofficial Neurotransmitters feed
(57:17):
at Neuro Underscore Podcast.
Lastly, you can find a lot ofour content online and keep in
touch with us through ourwebsite at
theneurotransmitterscom.
Thank you again for listeningand we'll see you next time.
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