PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
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Edited by :
Dr.Suganthi Chinnasami
1
, Dr. Mooi Chin Leong
1
, Dr. Santhi Datuk Puvanarajah
1
, Dato’ Dr. Hj. Md. Hanip Raia
1
.
With contributions from :
Neurophysiology Unit HKL
1 Hospital Kuala Lumpur.
NEUROPHYSIOLOGY SERVICES IN PUbLIC SECTOR IN MALAYSIA
The irst Neurophysiology unit in Malaysia was set up in 1964 at Kuala Lumpur Hospital with only one staff in charge of the unit. Over the years there has been a gradual increase in the total number of
neurophysiology units in various states in Malaysia. Currently, there are about 19 units with 67 trained Medical Assistants. The Clinical Neurophysiology Unit provides standard electroencephalography
EEG and video-telemetry VT; nerve conduction studies NCS and electromyography EMG; evoked potentials EP which include visual, somatosensory and brainstem auditory evoked response;
Transcranial Doppler TCD; and sleep studies. The unit in HKL also runs a 6 months training programme every year for technologists working in the various neurophysiology units in other major hospitals
nationwide since.
Epilepsy is one of the most common neurological conditions affecting at any given time between 0.5 and 1 of the general population in developed country. Most studies of the prevalence of active
epilepsy have estimated the igure to be 4 and 10 per 1000. The diagnosis of epilepsy is clinical and rests on the description of the seizure provided by the patient and eyewitnesses. Electroencephalogram
EEG is the study used to record the electrical activity of the brain and should only be carried out in
those patients in whom the symptoms suspicious of epilepsy. In such patients the indings of epileptic abnormalities in the EEG lends weight to the diagnosis and the seizure type may also be clariied.
EEGs are often insensitive as more than 50 of patients with epilepsy will have a normal tracing.
Portable EEG recording is done in cases where better detection of the interictal and ictal events may be achieved with prolonged recording using portable equipment and this allows recording to take
place in the patient’s usual environment.
Behavioral correlation can be achieved in inpatients by video monitoring during EEG and this is called as Video-EEG telemetry. This investigation is mandatory in the evaluation for Epilepsy Surgery and
may be the only way to distinguish epileptic seizures from the nonepileptic events.
Electrodiagnostic EDX studies play a key role in the evaluation of patients with neuromuscular disorders. Nerve conduction study and needle electromyography form the core of the EDX study and
are often used to diagnose disorders of the nerve and muscles. Performed and interpreted correctly, EDX studies yield critical information about the underlying neuromuscular disorder and allow use of
other laboratory tests in an appropriate and eficient manner. The principal goals of every EDX study are to localize the disorder and assess its severity. If the disorder localizes the peripheral nerves i.e.
neuropathic, EDX studies often yield further key information, including the iber types involving the underlying pathophysiology and the temporal course of the disorder.
Polysomnography PSG is a diagnostic test during which a number of physiological variables are measured and recorded during sleep. Information is gathered from all leads and fed into a computer
and results in a series of waveform tracings, which enable the technician to visualize the various waveforms, assign a score for the test, and assist in the diagnostic process. The PSG monitors many
body functions including brainEEG, eye movements EOG, muscle activity or skeletal activation EMG heart rhythm ECG, and breathing function or respiratory effort during sleep. PSG is useful
in identifying the abnormality in sleep disorders such as dyssomnias and parasomnias.
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Transcranial Doppler ultrasound TCD is used in the management of ischemic stroke and subarachnoid haemorrhage. In ischemic stroke, TCD can detect any stenosis in the intracranial arteries anterior
and posterior circulation and also the degree of stenosis. It can indirectly detect internal carotid artery stenosis too. Microemboli in the cerebral arteries can also be detected and this may help in
the medical management of the patients. In subarachnoid haemorrhage, TCD is used to evaluate the degree of vasospasm, and this will help the neurosurgeons in determining the subsequent management
either medically or surgically. TCD can be used to look for cerebral vasoreactivity and can be used as a supplementary investigation in brain death. It is also used as a screening tool for PFO looking for
emboli during bubble contrast injection in the peripheral vein. A possible new indication for TCD is sonothrombolysis, increasing the recanalisation rate of thrombosed arteries in acute stroke when used
together with rtPA. This is still being researched.
The data collected from the previous MOH and private survey regarding the neuromedical devices are not complete and under reported. This is most likely secondary to poor response from the concerned
units. The data for the Selangor state should be separated from the Federal Territory as there are 3 federal states currently which are Kuala Lumpur, Labuan and Putrajaya. This will show a better
picture of the current statistics. The Nerve Conduction Velocity measurement system and EMG machine should be tabulated as a single medical device in the statistics instead of reporting it as two
separate devices because both tests are done in the same machine. Till today there are no Ambulatory EEG services in Malaysia, which will enable patient to continue with their daily living activities.
There should be data survey for DBS deep brain stimulation for Parkinson’s disease management, PETSPECT imaging services in Malaysia, Depth Electrode monitoring for epilepsy, availability of
Genetic studies for hereditary Neurological diseases as well as HLA B 1502 allele testing for all patients started on Carbamazepine as well as Aquaporine a-4 testing for NMO patients.
The public sector data is corrected up to date. However the private sector data is dependant on voluntary and accurate submission of the statistics reported and therefore its dificult to verify and
comment. In summary this chapter shows the importance of the neurophysiology units in providing diagnostic studies for the increasing work-up demand in the discipline of Neurology.
The tables below show the number of neurophysiology units and the diagnostic equipments available in Malaysia in year 2007.
Table 1: Available Therapeutic and Diagnostic Facilities in Neurology
Neurophysiology Unit No in million
No pmp
Malaysia 26.64
24 100
1
Sector Public
- 21
87 Private
- 3
13
State Johor
3.17 1
4 Kedah Perlis
2.11 1
4 Kelantan
1.53 1
4 1
Melaka 0.73
1 4
1 N. Sembilan
0.96 1
4 1
Pahang 1.45
2 8
1 Perak
2.28 1
4 Terengganu
1.04 1
4 1
Pulau Pinang 1.49
3 13
2 Sabah
3 3
13 1
Sarawak 2.36
3 13
1 Selangor W.P Kuala Lumpur
6.43 6
25 1
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Table 2: Available Medical Devices in Neurology.
Population Electro-
encephalography EEG machine
Ambulatory Electro- encephalography
EEG machine Evoked
Potential EP system
Video Telemetry Recording
System No in million
No pmp
No pmp
No pmp
No pmp
Malaysia 26.64
51 100
2 21
100 1
29 100
1 11
100
Sector
Public -
28 55
14 67
18 62
8 73
Private -
23 45
7 33
11 38
3 27
State
Johor 3.17
2 4
1 1
5 1
3 Kedah Perlis
2.11 3
6 1
1 5
1 3
1 9
Kelantan 1.53
1 2
1 1
5 1
7 24
5 2
18 1
Melaka 0.73
3 6
4 2
10 3
N. Sembilan 0.96
1 2
1 1
5 1
1 3
1 Pahang
1.45 2
4 1
1 3
1 1
9 1
Perak 2.28
5 10
2 1
5 2
7 1
Terengganu 1.04
1 2
1 1
5 1
1 3
1 P. Pinang
1.49 9
18 6
3 14
2 5
17 4
1 9
1 Sabah
3 4
8 1
1 5
1 3
1 9
Sarawak 2.36
3 6
1 1
5 1
9 Selangor W.P
Kuala Lumpur 6.43
17 33
3 8
38 1
9 31
1 4
36 1
Population Electromyography
EMG machine Nerve Conduction Velocity NCV Measurement System
NMDS Data EMGNCS
Sourced from Expert Panel
EPEMGNCS Sourced from
Expert Panel No in million
No pmp
No pmp
No pmp
No pmp
Malaysia 26.64
36 100
1 27
100 1
4 -
- 17
- -
Sector
Public -
20 56
18 67
- 4
- 17
- Private
- 16
44 9
33 -
ND -
ND -
State
Johor 3.17
2 6
1 1
4 1
6 Kedah
Perlis 2.11
1 25
Kelantan 1.53
7 19
5 7
26 5
1 6
1 Melaka
0.73 2
6 3
1 6
1 N. Sembilan
0.96 1
3 1
1 4
1 1
6 1
Pahang 1.45
1 3
1 1
4 1
2 12
1 Perak
2.28 2
6 1
2 7
1 1
6 Terengganu
1.04 1
3 1
1 4
1 1
6 1
P. Pinang 1.49
5 14
3 4
15 3
1 6
1 Sabah
3 2
6 1
1 4
1 25
3 18
1 Sarawak
2.36 1
3 Selangor W.P
Kuala Lumpur 6.43
12 33
2 9
33 1
2 50
5 29
1
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Population Transcranial Doppler
NMDS Data No in million
No pmp
Malaysia 26.64
7 100
Sector
Public -
4 57
Private -
3 43
State
Johor 3.17
Kedah Perlis 2.11
Kelantan 1.53
Melaka 0.73
Negeri Sembilan 0.96
Pahang 1.45
Perak 2.28
Terengganu 1.04
Pulau Pinang 1.49
1 14
1 Sabah
3 1
14 1
Sarawak 2.36
Selangor W.P Kuala Lumpur 6.43
5 71
1
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