Welcome to AASEM
Leader in Functional Electrodiagnostic Medicine
Functional Electrodiagnosis
Medicare Administrative Law Judges (ALJ) have found the A-delta NCS Small Pain Fiber Nerve Conduction Study “reasonable and necessary and entitled to payment” and recognized AASEM small pain fiber nerve conduction study certification. NOTE: Since the A-delta NCS is the sole spf-NCS device on the market, A-delta NCS is interchangeably used here.
About
Functional EDX History
Standard EDX were developed between 1918 and 1944, decades before the 1963 Nobel Prize in Medicine was awarded to Hodgkins and Huxley for discovering the Voltage-Gated Channels responsible for generating nerve signals. Therefore, standard EDX cannot assess function, but instead were designed to estimate gross structural damage by measuring the speed at which an electric shock travels along large motor fibers (nerve fibers causing muscle contraction). Dr. James L Hedgecock, who in 1975 had earned his PhD for discovering the relationship between blood oxygen levels and skin electrical impedance, was the first to recognize functional EDX was possible by measuring the strength of voltage required to cause the voltage-gated channels to fire action potentials.
In 1997 Hedgecock invented the A-delta NCS prototype and immediately began studying radiculopathy. Breakthrough discoveries followed. The first was that the excellent localizing (Fast Pain) A-delta fibers, known to up-regulate during the acute Epicritic Phase of injury, down-regulate within hours leading into the Protopathic Phase (chronic stage of injury). Hedgecock then found that generally the stronger a patient’s subjective pain the greater the reduction in A-delta fiber sensitivity. This combined with poor localizing C-type (Slow Pain) fiber up-regulation explains why many patients inaccurately localize the source of spinal injury/pain leading to mismatching CT and MRI imaging to pseudo-lesions with failed interventions and failed spinal surgeries.
AASEM FOUNDING
In 2002 Dr. Cork, Robert Odell, MD, PhD and Lanny Taub, MD founded the organization which later became known as the American Association of Sensory Electrodiagnostic Medicine. Because a main goal was to insure adequate A-delta NCS training and certification, so by 2003 the AASEM Board tasked Dr. Hedgecock as Director of A-delta NCS Certification, a position he holds to this day. To date over 800 neurosurgeons, orthopedists, pain and other medical specialists have received AASEM A-delta NCS Certification. In 2021, due to the pandemic, in-person training was replaced by online training in which doctors read Hedgecock’s online textbook, watch videos, then and a written examination. Last, doctors make a video of them setting up and performing the A-delta NCS on a patient.
PEER-REVIEWED CONFIRMATION
After Hedgecock perfecting his testing protocols and a nomogram analysis, in 1999 he carried out a demonstration at Louisiana State University (Shreveport) for Randall Cork, MD, PhD, Director of the LSU Pain Management Center. In 2002 Cork’s peer-reviewed study was published in the Journal of Pain Symptom Control & Palliative Care (see studies). Cork found A-delta NCS to have 94.6% sensitivity (statistically 100% accuracy) localizing and quantifying radiculopathic lesions.
WHY FEW SPF-NCS STUDIES ARE PUBLISHED
EMG neurologists are incentivized to remain in denial concerning any technology challenging their economic position. The Editorial Board of every journal has an EMG provider, so any study dealing with EDX is vetted by an EMG neurologist who rejects A-delta NCS studies because they would be “of no interest to our readers.”
Reimbursement
Large v. Small Fiber EDX
Many A-delta NCS providers report excellent reimbursement. Some report they must appeal Medicare cases, because in spite of Medicare Administrative Law Judges (ALJs) and Qualified Independent Contractors (QICs) finding the A-delta NCS to be “reasonable, necessary and entitled to payment” regional Local Coverage Determinations (LCDs) misleadingly name the A-delta NCS as an example of a device that cannot performing large fiber EDX, ignoring that it is covered for small fiber EDX. This seems to be conspiracy in that all the contractors’ LCD have identical wording: “Examinations using portable hand-held devices which are incapable of real-time wave-form display and analysis and incapable of both (large motor fiber) NCS and needle EMG testing will be included in the E/M service. They will not be paid separately. Example include: The A-delta NCS or delta fiber analysis testing and /or similarly limited machines with other names.” Federal regulations are clear that carriers cannot repeat what ALJs have found false. However, these carriers know ALJs and QICs lack the power to stop carriers from using invalid statements, because ALJs and QICs can only rule on single cases. The answer is federal court where AASEM members may be able to recover denied payments.
FUNCTIONAL V. STRUCTURAL EDX
1918-1944 EDX Neurologists through their American Association of Neuromuscular Electro-Diagnostic Medicine perpetrate A-delta NCS falsehoods
In the early 1950s the American Association of Neuromuscular Electrodiagnostic Medicine was founded. Though leading experts warned members about understanding the limitations, these warnings were ignored and members perpetuated the misconception that EMG EDX could assess pain and measure nerve function, and today most non-neurologists believe standard EDX can assess pain and measure function. These limitations are evidenced in most radiculopathy EDX reports where the summary states; “the suspected nerve root cannot be ruled out.” Even non-neurologist aware of these limitations continue to refer patients, if for no other reason than to avoid being accused of malpractice.
Example Case
Dr. Hedgecock’s wife was suffering left foot pain that a functional A-delta NCS (motor f-EMG is possible with the A-delta NCS device), demonstrated left lateral gastrocnemius deficit (S1). The left required twice the voltage to initiate muscle twitch than the right lateral gastrocnemius. In the picture (right) atrophy of the left calf is obvious (white bars are equal length). Non-neurologists consulted for her foot pain all recommended an EDX referral, and were surprised to learn from Dr. Hedgecock that standard EDX cannot assess pain fibers and are limited to detecting gross large motor fiber structural damage. Most reported that their misconception started back during their internships when told not to waste time, “just send patients to the neurologist and read the report.”
EDX NEUROLOGICAL REPORT – IT’S HYSTERIA?
To prove the point, Hedgecock and his wife agreed to have who was reported to be the leading Southern California neurologist perform an EDX. As can be seen (right) the report notes left calf atrophy, but the EDX failed to find any problem. It comes as a surprise to many that because neurologists are trained in all areas of neurology, they are trained in psychiatry. After the EDX this top EDX neurologists explained to Hedgecock and his wife that many women have similar symptom and the symptoms are likely due to hysteria.
Note: The foot pain was finally relieved by physical therapy.
FUNCTIONAL MOTOR EDX
Since 2013 A-delta NCS has become the first and only EDX to be used in National Library of Medicine Physician Clinical Trials – Clinicaltrails.gov, a service of the National Institute of Health, it is time to unveil functional motor EDX. During the 2007 AASEM Annual Conference Dr. Hedgecock demonstrated that because A-delta fibers signing spinal cord motor fibers to cause the withdrawal reflex, the motor fibers and muscles are. Like the A-delta fibers, selectively responsive to 250 Hz voltage. As he demonstrated, when the motor unit is damaged, long before gross degeneration develops, the involved muscle requires much stronger voltage to cause twitching on the involved side.
Based on this EDX advance, by early 2024 the AASEM shall begin training and certifying in both F-NCS (A-delta NCS) and F-EMG, and change to the American Association of Functional Electrodiagnostic Medicine
AN HONEST EDX REVIEW
Journal of Neurology: James A Charles, MD, FAAN (2013)
“In the management of spine trauma with radicular symptoms (STRS), EMG and (large fiber) nerve conduction studies (NCS) often have low combined sensitivity and specificity in confirming nerve root injury. The anatomic level of injury may not correspond to the root level. Paraspinal studies are non-localizing and can be falsely positive and negative. An honest clinician neurologist or physiatrist who is treating patients with STRS should not have fears that our conclusions will lower their income. However, there are no practice parameters or established guidelines on the clinical utility of EMG/NCS in evaluation of STRS. It appears that unless there is a clinical differential diagnosis including a peripheral neuropathic lesion vs. a root lesion that cannot be resolved with the history, neurological examination, and imaging studies, there is limited evidence to support the use of EMG/NCS in the evaluation, treatment, and prognosis of patients with STRS.
NOTE: No recent spinal pain/radiculopathy textbooks mentions standard EMG as even an alternative diagnostic method. ”
Address
3333 N Calvert St #555
Baltimore, MD 21218
Phone
(410) 261-8800