2018 AANEM

ELECTRODIAGNOSTIC MEDICINE
SELF-ASSESSMENT EXAMINATION

Electrodiagnostic Medicine
Self-Assessment Examination Committee
Kevin F. Fitzpatrick, MD, Chair McLean, Virginia
Joshua P. Alpers, MD Signal Mountain, Tennessee
Kogulavadanan Arumaithurai, MD Rochester, Minnesota
Jennifer A. Baima, MD Worcester, Massachusetts
Miguel Chuquilin, MD Gainesville, Florida
Karissa Gable, MD Hillsborough, North Carolina
Matthew E. Hoffman, DO, PhD Rochester, Minnesota
Scott Homer, MD Brookline, Massachusetts
Bashar Katirji, MD Cleveland, Ohio
Chafic Karam, MD Portland, Oregon
Yuebing Li, MD, PhD Cleveland, Ohio
Masato Nagao, MD, PhD San Francisco, California
Laura Nist, MD Loma Linda, California
John W. Norbury, MD Greenville, North Carolina
Kamakshi Patel, MD, MPH Galveston, Texas
Katalin Scherer, MD Tucson, Arizona
Seneca A. Storm, MD Reno, Nevada
Rebecca Traub, MD Chapel Hill, North Carolina

CME available 5/2018 - 5/2021

Dr. Chafic Karam is a speaker for Soleo Health and Nufactor. Any conflicts of interest have been resolved
according to ACCME standards. All other authors and planners of this activity had nothing to disclose.

Copyright © May 2018

AMERICAN ASSOCIATION OF NEUROMUSCULAR &
ELECTRODIAGNOSTIC MEDICINE
2621 Superior Drive NW
Rochester, MN 55901

1 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

 2018 AMERICAN ASSOCIATION OF NEUROMUSCULAR & ELECTRODIAGNOSTIC
MEDICINE
ELECTRODIAGNOSTIC MEDICINE SELF-ASSESSMENT EXAMINATION

SPONSOR

The mission of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) is to
improve the quality of patient care and advance the science of neuromuscular diseases and
electrodiagnostic medicine by serving physicians and allied health professionals who care for those with
muscle and nerve disorders. This mission is accomplished through programs in education, research, and
quality assurance. The association offers printed educational material, CDs and DVDs, internet education,
as well as practice guidelines and educational guidelines for electrodiagnostic and neuromuscular medicine
training programs. The AANEM also sponsors courses, workshops, demonstration sessions, and other live
educational programs. Its official journal is Muscle & Nerve.

As President of the AANEM in 1988, Dr. Joel A. DeLisa envisioned the creation of an AANEM-sponsored
self-assessment examination in electrodiagnostic medicine. As a result, he charged the Electrodiagnostic
Self-Assessment Examination Committee and its Chair, Dr. William S. Pease, to begin developing the
examination. The work of the ensuing 4 years culminated in the first Electrodiagnostic Medicine Self-
Assessment Examination (EDXSAE) being given in 1992.

DESCRIPTION

The self-assessment examinations (SAEs) are offered as a teaching tool to both individuals and training
institutions. Institutions proctoring the SAEs or an individual completing the SAEs as an enduring material
have sole rights to the SAE results, respectively. The AANEM does not offer a pass/fail grade for SAEs.
AANEM does offer SAE National Average Results for both individuals and training institutions annually.
The National Average Results by Training Level can be found on the website at www.aanem.org or will be
shared with institutions that proctor the SAEs.

Part I of the examination contains 50 multiple-choice video clip questions on DVD and should be
completed in 1 hour. It tests the ability to identify electrical potentials recorded with needle electrodes
and displayed on a monitor. Physicians are asked to describe and identify characteristics of motor unit
action potentials, spontaneous activity, and abnormal potentials, and interpret their significance, as well
as to analyze electrodiagnostic techniques and anatomy.

Part II of the examination contains 100 multiple-choice questions and should be completed in 2 hours. It
tests background knowledge and the application of neurophysiologic techniques to the diagnosis,
evaluation, and treatment of patients with impairments and/or disabilities of musculoskeletal, neurologic,
or other body systems. The examination covers anatomy, the autonomic nervous system, ethics, needle
electromyography (EMG), nerve conduction studies, clinical applications, muscle and nerve pathology and
physiology, somatosensory evoked potentials, and technical considerations.

2 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

Part III of the examination is a review session. The maximum time available for continuing medical
education (CME) credit to complete the Part III in a non-proctored setting is 10 hours.

All three parts must be completed to receive CME. Part I and Part II by themselves are not eligible for CME
credit. Review session materials include the correct answers and question analysis, along with reference
citations, indicating why the answers and distractors are correct and incorrect.

FUTURE RECOMMENDATIONS

To assist in planning, developing, and refining future EDXSAEs and for giving feedback to the AANEM
Electrodiagnostic Self-Assessment Examination Committee, please fill out the online evaluation form
immediately following the examination. Each candidate and program director will be emailed the link to
the evaluation the week following the examination. Candidate input is particularly critical in determining
the evolution of the examination.

EDUCATIONAL OBJECTIVES

The EDXSAE is designed as a self-assessment tool to assist physicians in identifying their strengths and
weaknesses in the area of electrodiagnostic medicine, as a study guide, as a teaching tool in residency
programs, and to meet maintenance of certification requirements for board certification. During the DVD
portion of the examination, physicians are asked to describe and identify characteristics of motor unit
action potentials, spontaneous activity, and abnormal potentials and interpret their significance (medical
knowledge). The written portion of the examination covers physicians’ background knowledge and the
application of neurophysiologic techniques to the diagnosis, evaluation, and treatment of patients with
impairments and/or disabilities of musculoskeletal, neurologic, or other body systems (medical
knowledge, practice-based learning). The examination covers anatomy, the autonomic nervous system,
clinical applications, needle EMG, ethics, nerve conduction studies, muscle and nerve pathology and
physiology, somatosensory evoked potentials, and technical considerations (medical knowledge, practice-
based learning, interpersonal and communication skills, professionalism, and systems-based practice).

STUDY GUIDE

Physicians should refer to the AANEM Suggested Reference List which was developed by an AANEM
Education Committee as a study aid, as well as monographs and course books available on the AANEM
website at www.aanem.org. The materials, as well as the EDXSAE, also may help in preparing for the
American Board of Electrodiagnostic Medicine (ABEM) examination. However, there is no exchange of
information permitted between the ABEM and the AANEM EDXSAE Committees regarding content to be
covered, level of difficulty, or specific examination questions.

Candidates may keep their copies of the examination and review session booklets along with their results
to use for study following completion of the examination. The NMSAE is a good study tool for those taking
the board certification examination in neuromuscular medicine.

3 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

ACCREDITATION STATEMENT

The AANEM is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to
provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT

The AANEM designates this enduring material for a maximum of 13 AMA PRA Category 1 Credits™.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY APPROVAL

The American Board of Psychiatry and Neurology has reviewed the AANEM EDXSAE and has approved this
program as part of a comprehensive self-assessment program, which is mandated by the American Board
of Medical Specialties as a necessary component of maintenance of certification.

AMERICAN BOARD OF PHYSICAL MEDICINE AND REHABILITATION APPROVAL

The American Board of Physical Medicine and Rehabilitation (ABPMR) has reviewed the AANEM EDXSAE
and approved this program as an option for the ABPMR Maintenance of Certification (MOC) program.
ABPMR diplomates who complete the AANEM EDXSAE will receive credit for 1 self-assessment.

4 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

TRAINING PROGRAM LIAISONS

Participating institutions proctor the AANEM EDXSAE for their own residents and fellows and for other
interested physicians who live in the area. Training Program Liaisons are appointed from each cooperating
institution and are recognized through formal written appointments, suitable for placing on curriculum
vitae, and are included on the list below. Interested individuals and institutions are urged to contact the
AANEM Executive Office if they wish to participate. Training Program Liaisons should:

1. Keep their Department Chairs informed about the AANEM EDXSAE, its schedule, content, and
cost.
2. Assist in arrangements for proctoring the AANEM EDXSAE when administered.
3. Hold a review session led by a competent electrodiagnostic medicine consultant, preferably
an American Board of Electrodiagnostic Medicine (ABEM) Diplomate.
4. Act as contacts for AANEM surveys of teaching practices, research activities, and relevant
issues.
5. Encourage active participation in the AANEM and its annual meeting by all interested house
staff, fellows, and faculty members in their departments.
6. Act as a resource person for communicating AANEM information to members of their
departments.
Electrodiagnostic Medicine Training Program Liaisons by State/Province
Eroboghene E. University of Alabama at Birmingham AL John W Norbury, MD East Carolina University Greenville NC
Ubogu, MD Birmingham
Juan G. Ochoa, University of South Alabama Mobile AL James B Caress MD Wake Forest University School Winston- NC
MD Hospitals of Medicine Salem
Matthew T Mayo Clinic College of Phoenix AZ Erik J Kobylarz MD, PhD Dartmouth-Hitchcock Medical Lebanon NH
Hoerth MD Medicine Center
Holli Horak, MD University of Arizona Health Tucson AZ Sara J. Cuccurullo, MD JFK Medical Center Edison NJ
Sciences Center
Mary I. Kim, MD Loma Linda Univ Medical Loma Linda CA Wei W. Ma, MD, MS Seton Hall University School of Edison NJ
Center Health and Medical Sciences
Laura D. Nist, MD Loma Linda University Loma Linda CA Monifa Brooks, MD Rutgers New Jersey Medical Newark NJ
School
Perry B. Shieh, UCLA Medical Center Los Angeles CA Andrew H. Dubin, MD, Albany Medical Center Albany NY
MD, PhD MS
Marc R. Nuwer, UCLA Medical Center Los Angeles CA Steven Herskovitz, MD Albert Einstein College of Bronx NY
MD, PhD Medicine
Said R. Beydoun, USC Medical Center/LAC Los Angeles CA Mark A. Thomas, MD Montefiore Medical Bronx NY
MD Center/Albert Einstein College
of Medicine
Namita A Goyal University of California Orange CA Todd R Lefkowitz DO Kingsbrook Jewish Medical Brooklyn NY
MD (Irvine) Center
Jay J Han MD University of California Orange CA Geetha Chari, MD SUNY Health Science Center at Brooklyn NY
(Irvine) Brooklyn
John W. Day, Stanford School of Medicine Palo Alto CA Ping Li, MD University at Buffalo School of Buffalo NY
MD, PhD Medicine
Margaret Adler, Los Angeles County Harbor- Redondo CA Matthew M. Shatzer, Hofstra Northwell School of Manhasset NY
MD UCLA Medical Center Beach DO Medicine
Carol University of California Sacramento CA Suryanarayan Murthy North Shore University Hospital Manhasset NY
Vandenakker (Davis) Medical Center Vishnubhakat MD,
Albanese, MD MBBS
Chamindra UCSD Medical Center San Diego CA Miguel X. Escalon, MD, Icahn School of Medicine at New York NY
Konersman, MD MPH Mount Sinai
Jeffrey W. Ralph, University of California (San San CA Paul F. Kent, MD, PhD New York and Presbyterian New York NY
MD Francisco) Francisco Hospital (Columbia Campus)
Dianna Quan, University of Colorado Aurora CO Eric L. Altschuler, MD, New York Medical College New York NY
MD PhD (Metropolitan)
William Sullivan University of Colorado Aurora CO Deana Gazzola, MD New York University School of New York NY
MD Medicine
Agnes Jani- University of Connecticut Farmington CT Alex Moroz, MD New York University School of New York NY
Acsadi MD School of Medicine Medicine

5 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

 Perry K. George Washington Washington DC Emma Ciafaloni, MD University of Rochester Rochester NY
Richardson, MD University School of
Medicine
Devon I. Rubin, Mayo Clinic College of Jacksonville FL Jennifer H Paul MD University of Rochester Program Rochester NY
MD Medicine (Jacksonville)
Andrew L. Jackson Memorial Miami FL Cara Harth, MD SUNY at Stony Brook Health Stony Brook NY
Sherman, MD, Hospital/Jackson Health Sciences Center
MS System
Doraiswami R. University of Miami Miami FL Robert J. Weber, MD SUNY Upstate Medical Syracuse NY
Ayyar, MD University
Tuan H Vu MD University of S Florida Tampa FL Shahram Izadyar, MD SUNY Upstate Medical Syracuse NY
University
Hassan H. Emory University Atlanta GA Anne Felicia Ambrose Burke Rehabilitation Hospital White Plains NY
Monfared, MD MD, MS
Taylor B Harrison Emory University School of Atlanta GA Lester S. Duplechan, MD University of CIncinnati College Cincinnati OH
MD Medicine of Medicine
Andrea J. University of Iowa Hospitals Iowa City IA Gary S. Clark, MD, Case Western Reserve Cleveland OH
Swenson, MD and Clinics MMM, BS University (MetroHealth)
Monica E. Rho, McGaw Medical Center of Chicago IL Bashar Katirji, MD Case Western Reserve Cleveland OH
MD Northwestern University University Hospitals
Senda Ajroud- Northwestern University Chicago IL John A Morren MD Cleveland Clinic Cleveland OH
Driss, MD Feinberg School of Medicine
Rabia Malik, MD Rush University Medical Chicago IL Bakri H. Elsheikh, MBBS, Ohio State University Hospital Columbus OH
Center MRCP
Lawrence A University of Illinois at Chicago IL Sam Colachis, MD Ohio State University Hospital Columbus OH
Zeidman MD Chicago
Prempreet S Loyola University School of Maywood IL Michael J Valle DO Kettering Health Network Dayton OH
Bajaj, DO Medicine
Anjum Sayyad Marianjoy Rehabilitation Wheaton IL Christopher E. Parnell, University Hospitals Osteopathic Sandusky OH
MD Hospital DO Consortium
Nathan D. Indiana University School of Indianapolis IN David R. Gater, MD, PhD Penn State Hershey Medical Hershey PA
Prahlow, MD Medicine Center
Dragos Sabau, Indiana University School of Indianapolis IN Sankar Bandyopadhyay, Penn State Milton S Hershey Hershey PA
MD Medicine MD Medical Center
Mazen M University of Kansas School Kansas City KS Jyoti Pillai, MD Drexel University College of Philadelphia PA
Dimachkie MD of Medicine Medicine
Sarah Eickmeyer, University of Kansas School Kansas City KS Michael Mallow MD Thomas Jefferson University Philadelphia PA
MD of Medicine Hospital
Jessica Colyer, University of Kentucky Lexington KY David A. Lenrow, MD, JD University of Pennsylvania Philadelphia PA
MD College of Medicine Health System
Darryl L. Kaelin, University of Louisville Louisville KY Alexandra Urban, MD UPMC Medical Education Pittsburgh PA
MD
Stephen Kishner Louisiana State University New LA Wendy M. Helkowski, UPMC Medical Education Pittsburgh PA
MD, MHA Orleans MD
Brian J Copeland Louisiana State University New LA Carmen E. Lopez- University of Puerto Rico San Juan PR
MD School of Medicine Orleans Acevedo, MD
Elizabeth M. Beth Israel Deaconess Boston MA David A. Soto-Quijano, VA Caribbean Healthcare San Juan PR
Raynor, MD Medical Center MD System
Anthony A. Brigham and Women's Boston MA Andrew S. Blum, MD, Brown University Providence RI
Amato, MD Hospital PhD
Rina M. Bloch, Tufts Medical Center Boston MA Tulio E. Bertorini, MD University of Tennessee College Memphis TN
MD of Medicine
Melanie C. Sinai Hospital of Baltimore Baltimore MD Christopher J Garrison University of Texas at Austin Austin TX
Brown, MD MD, MBA Dell Medical School
James W. Russell, University of Maryland Baltimore MD Rita G. Hamilton, DO Baylor University Medical Dallas TX
MBChB Program Center Program
Matthew E. National Capital Consortium Bethesda MD Kim Barker, MD UT Southwestern at Dallas Dallas TX
Miller, MD
Tanya J. Lehky, National Capital Consortium Bethesda MD John S. Harrell, MD Baylor College of Medicine Houston TX
MD (Bethesda)
Gary W. University of Michigan Ann Arbor MI Joel E. Frontera, MD University of Texas Health Houston TX
Gallagher, MD Science Center at Houston
Mary C. Spires, University of Michigan Ann Arbor MI Jeffrey C. McClean, MD San Antonio Uniformed Services JBSA Fort Sam TX
MD Health Education Consortium Houston
Lawrence Horn Detroit Medical Detroit MI Nicolas E. Walsh, MD UTHSCSA San Antonio TX
MD, MS Center/Wayne State
University
Kavita M. Grover, Henry Ford Hospital/Wayne Detroit MI Jose E. Cavazos, MD, UTHSCSA San Antonio TX
MD State University PhD
Deepti Zutshi, Wayne State University Detroit MI Jeffrey G. Jenkins, MD University of Virginia Medical Charlotesville VA
MD Center
Michael T. Michigan State University East Lansing MI Kelly Gwathmey, MD University of Virginia Charlottesville VA
Andary, MD, MS
Justin C. Riutta, William Beaumont Hospital Royal Oak MI Beverly Roberts- Eastern Virginia Medical School Norfolk VA
MD Atwater, DO, PhD
Michael Leffler- University of Minnesota Minneapolis MN Scott A. Vota, DO Virginia Commonwealth Richmond VA
McCabe MD University Health System
Margherita Mayo Graduate School of Rochester MN Jennifer M Zumsteg MD University of Washington Seattle WA
Milone MD, PhD Medicine
Joseph Burris, University of Missouri- Columbia MO Bonnie J. Weigert, MD University of Wisconsin Madison WI
MD Columbia Hospitals and Clinics
Ghazala R. Hayat, St Louis University School of Saint Louis MO Chad Carlson, MD Medical College of Wisconsin Milwaukee WI
MD Medicine
Muhammad T. Washington University Saint Louis MO Nick Ketchum, MD Medical College of Wisconsin Milwaukee WI
Al-Lozi, MBBS School of Medicine

6 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

 William Filer, MD University of North Carolina Chapel Hill NC Sara Khan, MD Aga Khan University Karachi Sindh
Hospital
James F Howard University of North Carolina Chapel Hill NC Sameer Chhibber, MD University of Calgary Calgary AB
MD Hospitals
Karissa Gable, Duke University Medical Durham NC Ian A. Grant, MD Dalhousie University Halifax NS
MD Center

7 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

2018 AANEM ELECTRODIAGNOSTIC MEDICINE SELF-ASSESSMENT EXAMINATION

PART I
DVD VIDEO CLIP EXAMINATION

DO NOT BEGIN THE EXAMINATION UNTIL YOU HAVE READ THE

INSTRUCTIONS AND ANSWERED THE SAMPLE QUESTIONS

The DVD video clip portion of the examination contains 50 questions and will take 1 hour. All questions
are multiple choice with one best answer. You are to select the one best answer. If a question is left
unanswered or is given more than one answer, it will be marked wrong.

The DVD begins with two sample items to familiarize you with the format of the examination. There then
will be a marked spot on the DVD to stop so that you will have the opportunity to ask any questions you
might have about the examination. Once the examination begins, the DVD will run continuously and does
not need to be stopped.

The first portion of the examination consists of 50 video clips corresponding to the first 50 questions in
your test booklet. Each video clip will last from 45 to 60 seconds each with repeating segments often
shown during this time period. The amplitude and the sweep speed are indicated in the lower left-hand
corner of the screen. The values listed refer to the marked divisions on the screen. The screen has 10
vertical and 10 horizontal divisions. Thus, if the sweep is listed as 10 ms, the entire screen sweep is 100
ms (10 x 10 ms). Amplitude and sweep may change to demonstrate findings in different ways.

A pause will introduce each question. Because the DVD does not stop between questions, each question
should be completed in the allotted time. An alert will sound for each question indicating that
approximately 10 seconds remain. Signals may be triggered, sometimes in raster or superimposed form.

All questions must be answered on the Scantron answer form provided. Use a #2 pencil and make your
marks heavy and black. The box corresponding with the letter answer you have selected must be filled in
completely without having marks outside the box. If you erase, you must do so completely. Please note:
any stray marks on the form may be counted as errors, so please be neat.

8 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

Sample Question Instructions

1. Read this section before the DVD starts.

2. When ready, review the sample video clips which are the first 2 items on the DVD.
3. After the samples have been shown, the DVD will be stopped and the opportunity to ask questions
will be permitted.

Sample question A. What type of study is shown?

A. Needle electromyography.
B. Sensory nerve conduction studies.
C. Motor nerve conduction studies.
D. H-reflex testing.
E. Repetitive nerve stimulation.

The correct answer is A, needle electromyography.

Sample question B. The waveforms displayed are:

A. Complex repetitive discharges.

B. Motor unit action potentials.
C. Fasciculation potentials.
D. Myotonic discharges.
E. Positive sharp waves.

The correct answer is B, motor unit action potentials.

9 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

10 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination
 DO NOT LOOK AHEAD
AT THE FOLLOWING QUESTIONS
UNTIL YOU ARE INSTRUCTED
TO BEGIN

11 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

1. Which of the following statements is true about this tracing?

A. It confirms the placement of the needle into subcutaneous tissue.

B. It is reflective of muscle fiber depolarization.
C. It is indicative of a neuropathy.
D. It is representative of fatty infiltration of the muscle.
E. It is representative of muscle atrophy.

2. The motor unit shown is most likely to be seen in which of the following clinical settings?

A. Acute denervation.
B. Chronic denervation and reinnervation.
C. Neuromuscular junction disorder.
D. Demyelinating neuropathy.
E. A normal patient.

3. The discharge seen is which of the following?

A. Representative of motor unit action potentials.

B. Reliable in differentiating a neuropathy from a myopathy.
C. Highly sensitive for a neuromuscular junction disorder.
D. Highly specific for a neuromuscular junction disorder.
E. Only recordable using a special nondisposable concentric needle electrode.

4. The waveforms shown in the video:

A. Are produced by voluntary muscle contraction.

B. Are secondary to denervation of the muscles.
C. Can be a characteristic finding in irritable myopathies.
D. Are involuntary.
E. Represent electrical artifact from an uninsulated room.

5. Which of the following answers best describes the waveform shown in the video?

A. Fibrillation potential.
B. Motor unit.
C. Pacemaker artifact.
D. Electrical interference.
E. Endplate spike.

12 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

6. If the waveform seen in the video were observed in the extensor indicis, which diagnosis is most
likely?

A. Acute lateral cord brachial plexopathy.

B. Chronic lateral cord brachial plexopathy.
C. Acute posterior cord brachial plexopathy.
D. Chronic posterior cord brachial plexopathy.
E. Acute medial cord brachial plexopathy.

7. The waveform seen in the video would LEAST likely be expected in which of the following
diagnoses?

A. Acid maltase deficiency.

B. Paramyotonia congenita.
C. Duchenne muscular dystrophy.
D. Myotonic dystrophy type 1.
E. Myotonia congenita.

8. The observed waveforms are best described as:

A. Spontaneous, regular firing pattern, slow firing rate.

B. Spontaneous, regular firing pattern, fast firing rate.
C. Spontaneous, irregular firing pattern, slow firing rate.
D. Spontaneous, irregular firing pattern, fast firing rate.
E. Voluntarily activated, regular firing pattern, slow firing rate.

9. The pattern in the video is generated with minimal voluntary activation and minimal force
generated and best described as:

A. Reduced recruitment.
B. Decreased recruitment.
C. Delayed recruitment.
D. Normal recruitment.
E. Early recruitment.

13 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

10. Which of the following answers best describes the waveforms seen in the video?

A. Complex repetitive discharges.

B. Myokymia.
C. Neuropathic motor units.
D. Myopathic motor units.
E. Electrical interference.

11. The pattern in the video, recorded from the biceps brachii, may be seen in:

A. Normal physiology.
B. Motor neuron disease.
C. Polymyositis.
D. Medial cord brachial plexopathy.
E. C7 radiculopathy.

12. How many phases are present in the motor unit shown in the video?

A. 7.
B. 4.
C. 2.
D. 5.
E. 6.

13. What is the approximate firing frequency of the waveforms shown in the video?

A. 1 Hz.
B. 5 Hz.
C. 10 Hz.
D. 15 Hz.
E. 20 Hz.

14. The waveform shown indicates:

A. Muscle endplate activity.

B. Muscle spikes.
C. 60 Hz artifact.
D. Subcutaneous tissue.
E. Active denervation.

14 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

15. Which of the following is/are seen in the video?

A. Complex repetitive discharges.

B. Myokymia.
C. Myotonic discharges.
D. Myopathic motor units.
E. Electrical interference.

16. What measurement technique is being shown in the video?

A. Single-fiber electromyography.
B. Quantitative sudomotor axon reflex testing.
C. Heart rate variability.
D. Somatosensory evoked potentials.
E. Quantitative motor unit analysis.

17. Which of the following is true for the waveform in this video?

A. It can range from 1 to 50 mV in amplitude.

B. It represents a group of muscle fibers firing repetitively.
C. It is usually in the range of 100-500 impulses/second.
D. It does not begin or end suddenly.
E. It demonstrates waxing and waning.

18. The waveform shown in the video is most likely to be seen in which clinical diagnosis?

A. Myopathy.
B. Neuromuscular junction disorder.
C. Motor neuron disease.
D. Chronic polyneuropathy.
E. A normal patient.

15 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

19. This video was recorded during a needle electrode examination of the rhomboid muscle. Which
waveform is shown?

A. Electrocardiogram artifact.
B. Fibrillation potential.
C. Motor unit potential.
D. Endplate spike.
E. 60-Hz interference.

20. A patient has this abnormality in the flexor digitorum profundus IV, first dorsal interosseous, and
abductor digiti minimi. The abductor pollicis brevis and extensor indicis are normal. What is the
most likely diagnosis?

A. Ulnar neuropathy at the elbow.

B. Ulnar neuropathy at the carpal tunnel.
C. Ulnar neuropathy at the hook of the hamate.
D. Lower trunk brachial plexopathy.
E. Medial cord brachial plexopathy.

21. The predominant waveform in this video is most frequently seen in which of the following
conditions?

A. Facioscapulohumeral dystrophy.
B. Central core disease.
C. Lumbosacral radiculopathy.
D. Parathyroid disease.
E. Hyperkalemic periodic paralysis.

22. Which of the following provides innervation to this muscle?

A. Posterior interosseous nerve.

B. Anterior interosseous nerve.
C. Superficial radial nerve.
D. Ulnar nerve.
E. Lateral cord of the brachial plexus.

16 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

23. If fibrillations are seen in the muscle being studied secondary to injury to a peripheral nerve,
which sensory nerve conduction study may be abnormal?

A. Ulnar nerve to the little finger.

B. Medial antebrachial cutaneous nerve.
C. Ulnar nerve to the ring finger.
D. Radial nerve to the thumb.
E. Median nerve to the middle finger.

24. With a complete ulnar lesion in the arm, the muscle undergoing testing substitutes for the
adductor pollicis, generating which of the following “so-called” signs?

A. Flick.
B. Wartenburg.
C. Froment.
D. Palmaris brevis.
E. "OK."

25. The muscle shown can be affected by a nerve lesion at the level of:

A. The ligament of Struthers.

B. The arcade of Frohse.
C. The transverse carpal ligament.
D. The pisohamate hiatus.
E. The arcade of Struthers.

26. A patient has an abnormality only in the muscle being tested. Where is the associated clinical
sensory abnormality?

A. Dorsal aspect of the foot and ankle.

B. Between the big and long toes.
C. Plantar aspect of the foot.
D. Medial ankle into the foot.
E. Lateral ankle into the foot.

17 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

27. A patient has fibrillations in this muscle after a biopsy procedure. Where was the biopsy?

A. Anterior triangle of the neck.

B. Posterior triangle of the shoulder.
C. Quadrilateral space of the shoulder.
D. Posterior facet of the cervical spine.
E. Posterior triangle of the neck.

28. The muscle being studied in the video shares a myotome with which of the following?

A. Upper trapezius.
B. Biceps.
C. First dorsal interosseous.
D. Abductor pollicis brevis.
E. Flexor pollicis longus.

29. Which of the following is true about the muscle being examined?

A. It is the flexor digitorum longus.

B. It is innervated by the L5 nerve root.
C. It is innervated by the superficial fibular (superficial peroneal) nerve.
D. It is more easily activated by flexing the knee first then plantar flexing the ankle.
E. It is the most commonly used recording muscle for the H reflex.

30. The muscle studied in the video is innervated by which of the following nerves?

A. Musculocutaneous.
B. Radial.
C. Median.
D. Ulnar.
E. Lateral antebrachial.

18 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

31. Positive sharp waves in the muscle shown could result from which of the following nerve
lesions?

A. Radial neuropathy in the axilla.

B. Radial neuropathy at the spiral groove.
C. Posterior interosseous neuropathy.
D. Any of the above.
E. None of the above.

32. The muscle being studied:

A. Would be spared in medial cord of brachial plexus lesions.

B. Would be spared in lower trunk of brachial plexus lesions.
C. Would be affected in lateral antebrachial nerve lesions.
D. Would be affected in anterior interosseous nerve lesions.
E. Would be affected in ulnar nerve lesions.

33. The muscle being examined is which of the following?

A. Abductor digiti quinti pedis.

B. Abductor hallucis.
C. Adductor hallucis.
D. Flexor hallucis.
E. Extensor digitorum brevis.

34. Needle electromyography of the muscle shown in the video will demonstrate:

A. Intermittent involuntary motor unit discharges.

B. Rhythmic motor unit discharges.
C. Waxing and waning discharges.
D. Normal muscle activation.
E. Silent muscle contraction.

19 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

35. The neuropathy of the nerve being examined has been associated with which of the following
etiologies?

A. Acute inflammatory demyelinating polyradiculoneuropathy.

B. Diabetes mellitus.
C. Post infectious.
D. Parsonage–Turner syndrome.
E. All of the above.

36. The muscle being examined is which of the following?

A. Rhomboid major.
B. Infraspinatus.
C. Trapezius.
D. Serratus anterior.
E. Latissimus dorsi.

37. When examining this muscle, why must the needle remain superficial?

A. To avoid damage to the carotid artery.

B. To avoid damage to the jugular plexus.
C. To avoid damage to the jugular vein.
D. A and B.
E. A and C.

38. The nerve lesion of the right hand shown is which of the following?

A. Radial nerve lesion.

B. Ulnar nerve lesion.
C. C7 radiculopathy.
D. Posterior interosseous nerve lesion.
E. Posterior cord lesion.

39. Needle electromyography of the muscle activity in the video will demonstrate:

A. Waxing and waning discharges.

B. Numerous positive sharp waves.
C. Rapidly waning motor unit discharges.
D. Cramp discharge.
E. Electrically silent muscle activity.

20 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

40. What is the innervation of this muscle?

A. Fibular (peroneal) division of the sciatic nerve.

B. Tibial division of the sciatic nerve.
C. Fibular (peroneal) nerve above the fibular neck.
D. Tibial nerve above the fibular neck.
E. Tibial nerve below the fibular neck.

41. A nerve root lesion involving the muscle examined may also involve which of the following
muscles?

A. Anconeus.
B. Extensor carpi ulnaris.
C. Brachioradialis.
D. Flexor carpi ulnaris.
E. Flexor pollicis longus.

42. Mononeuropathy of the nerve innervating this muscle may also cause abnormality of which of
the following nerves?

A. Lateral femoral cutaneous.

B. Superficial fibular.
C. Calcaneal.
D. Saphenous.
E. Medial plantar.

43. The muscle studied will be affected by a lesion of which of the following nerves?

A. Superficial fibular (superficial peroneal).

B. Deep fibular (deep peroneal).
C. Femoral.
D. Tibial.
E. Sural.

44. The muscle being examined is innervated by which of the following nerves?

A. Radial.
B. Posterior interosseous.
C. Anterior interosseous.
D. Axillary.
E. Musculocutaneous.

21 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

45. The waveform shown is indicative of:

A. A normal median motor nerve conduction study.

B. A Martin–Gruber anastomosis.
C. A Richie–Cannieu anastomosis.
D. A carpal tunnel syndrome.
E. Overstimulation.

46. The increased amplitude of the first versus the second waveform in the video is due to a:

A. Higher high frequency filter.

B. Lower high frequency filter.
C. Different motor unit potential.
D. Higher low frequency filter.
E. Lower low frequency filter.

47. What change should be made to the display settings in order to more easily demonstrate the
desired response shown?

A. Increase the gain.

B. Increase the low frequency filter.
C. Increase the sweep duration.
D. Increase the stimulus intensity.
E. Increase the stimulus duration.

48. The test being shown assesses which of the following nerve pathways?

A. Ipsilateral trigeminal nerve afferent and bilateral facial nerve efferent pathways.
B. Ipsilateral trigeminal nerve afferent and bilateral oculomotor nerve efferent pathways.
C. Ipsilateral facial nerve afferent and ipsilateral facial nerve efferent pathways.
D. Ipsilateral facial nerve afferent and bilateral facial nerve efferent pathways.
E. Ipsilateral trigeminal nerve afferent and bilateral trigeminal nerve efferent pathways.

22 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

49. If the nerve conduction study depicted in this video was abnormal, which of the following
diagnoses can be considered?

A. Lower trunk brachial plexopathy.

B. Ulnar neuropathy.
C. Median neuropathy.
D. Radial neuropathy.
E. Medial cord plexopathy.

50. What is wrong with this test?

A. Nothing, it helps diagnose myasthenia gravis.

B. There is artifact on this test.
C. The test requires stabilization of the limb.
D. There are better nerves to use for this test.
E. B, C, and D.

23 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

2018 AANEM ELECTRODIAGNOSTIC MEDICINE SELF-ASSESSMENT EXAMINATION

PART II
WRITTEN EXAMINATION

DO NOT BEGIN THE EXAMINATION UNTIL YOU HAVE READ THE INSTRUCTIONS

The written examination contains 100 questions. In a proctored setting 2 hours is allowed for the
examination. All questions are multiple choice with one best answer. You are to select the one best
answer. If a question is left unanswered or is given more than one answer, it will be marked wrong.

All questions must be answered on the Scantron answer form provided. Continue using the same answer
sheet you used for the DVD portion of the examination starting at Question #51. Use a #2 pencil and
make your marks heavy and black.

The box corresponding with the letter answer you have selected must be filled in completely without
having marks outside the box. If you erase, you must do so completely. Please note: any stray marks on
the form may be counted as errors, so please be neat.

24 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

 DO NOT LOOK AHEAD
AT THE FOLLOWING QUESTIONS
UNTIL YOU ARE INSTRUCTED

25 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

26 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination
51. The findings of an attenuated or absent ulnar sensory nerve action potential, a decreased
median compound motor action potential recorded from the abductor pollicis brevis, and
normal median and ulnar motor and sensory nerve conduction velocities are consistent with:

A. C8, T1 root lesion.

B. Ulnar compression at the elbow.
C. Neurogenic thoracic outlet syndrome.
D. All of the above.
E. None of the above.

52. The muscle biopsy illustrated in the photomicrograph above has been stained with an antibody
for a specific muscle protein (arrow). The staining pattern is most consistent with:

A. Duchenne muscular dystrophy.

B. Remote poliomyelitis.
C. Inclusion body myositis.
D. Polymyositis.
E. Dermatomyositis.

27 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

53. Among the following myopathies, which one is the most common in patients aged 50 years or
older?

A. Dermatomyositis.
B. Polymyositis.
C. Chloroquine myopathy.
D. Coxsackie virus induced myositis.
E. Inclusion body myositis.

54. A 47-year-old woman presents with numbness in the ring and little fingers and weakness of
finger abduction and ring and little finger flexion. Which of the following would be the most
likely sonographic finding in the ulnar nerve at the elbow?

A. Focal constriction of the nerve.

B. Focal enlargement of the nerve.
C. Increased nerve echogenicity.
D. Decreased nerve vascularity.
E. Reduced mobility of the nerve.

55. Polyphasic motor unit action potentials have at least how many phases?

A. 2.
B. 3.
C. 4.
D. 5.
E. 6.

56. Vacuolated fibers, mononuclear cells invading nonnecrotic fibers, and congophilic deposits are
the pathological hallmarks of:

A. Facioscapulohumeral muscular dystrophy.

B. Polymyositis.
C. Limb-girdle muscular dystrophy.
D. Inclusion body myositis.
E. Myophosphorylase deficiency.

28 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

57. Which of the following is the best statement about the Valsalva maneuver test for autonomic
dysfunction?

A. The Valsalva ratio requires specialized equipment.

B. The subject blows into a tube at maximal effort.
C. A drop in blood pressure is the primary stimulus.
D. The response is independent of medication effect.
E. The test is less sensitive than tilt table studies.

58. You examine a young man who experienced pain in the area of the shoulder followed shortly
thereafter by weakness and atrophy of the shoulder girdle musculature without history of
trauma. With the onset of the weakness, the man noted that his pain decreased significantly.
Which one of the following will you be able to tell him?

A. Epidural steroid injections will help.

B. Physical therapy would be the recommended treatment.
C. He may need surgical exploration.
D. He may develop problems with his leg.
E. Recovery should be complete in a few weeks.

59. Which of the following is the most characteristic abnormality seen on needle examination of a
patient with myasthenia gravis?

A. Fibrillation potentials.
B. Fasciculations.
C. Complex repetitive discharges.
D. Long duration motor unit action potentials (MUAPs).
E. MUAP variation.

60. In children, one would expect slowing of both motor and sensory nerve conduction velocities
with:

A. Metachromatic leukodystrophy.
B. Myotubular (centronuclear) myopathy.
C. Pompe disease (acid maltase deficiency).
D. Eulenburg disease (paramyotonia congenita).
E. Kugelberg–Welander form of spinal muscular atrophy.

29 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

61. Which of the following electrodes is best at detecting a reduced safety factor?

A. Single fiber.
B. Macro.
C. Concentric.
D. Surface.
E. Subcutaneous.

62. Reduced insertional activity may be seen in:

A. End-stage myopathies with fibrosis.

B. Subacute denervation.
C. Myotonic disorders.
D. Healthy young or muscular patients.
E. Acute inflammatory myopathies.

63. The most sensitive indicator of small-fiber sensory neuropathy is a(n):

A. Reduced sural nerve action potential amplitude.

B. Reduced recruitment on needle electromyography of the abductor hallucis muscle.
C. Significant drop in systolic blood pressure on head-up tilt studies.
D. Low quantitative sudomotor axon reflex test amplitude.
E. Increased sympathetic skin response onset latency.

64. The ion selectivity of an acetylcholine receptor is best characterized by being permeable to:

A. CI- only.
B. Na+ only.
C. K+ only.
D. Ca++ only.
E. Na+, K+, and Ca++.

65. Consider the case of a median nerve crush injury due to a fracture at the elbow. The median
nerve motor nerve conduction study with wrist stimulation can be normal how long after injury?

A. 24 hours.
B. 7 days.
C. 14 days.
D. 30 days.
E. Anytime.

30 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

66. Blocking, noted during single fiber EMG:

A. Is the intermittent disappearance of one of a pair of repetitively firing single muscle fiber
potentials.
B. Occurs when the end-plate potential for the disappearing potential exceeds the threshold
for propagation of the muscle action potential.
C. Has no relationship to clinical fatigue and weakness.
D. Is unrelated to the decremental response seen on repetitive nerve stimulation testing.
E. Occurs in pairs of single muscle fiber potentials with normal amounts of jitter.

67. Post-tetanic potentiation:

A. Is due to a reduction in the immediately available store of acetylcholine (ACh).

B. Is due to a depletion of the calcium store in the nerve terminal.
C. Is due to enhanced release of ACh.
D. Occurs only in presynaptic neuromuscular transmission disorders.
E. Occurs only in postsynaptic neuromuscular transmission disorders.

68. Which one of the following maneuvers is most helpful for reduction of stimulus artifact?

A. Decreasing the distance between the recording electrode and the stimulus.
B. Applying lotion to the skin in the study area.
C. Lowering the high-frequency filter settings.
D. Decreasing the distance between the active and reference electrodes.
E. Placing the ground electrode between the stimulator and the recording electrode.

69. Miniature end-plate potentials:

A. Represent spontaneous depolarizations of the presynaptic nerve terminal.

B. Only occur following a depolarization of the presynaptic nerve terminal in response to a
nerve action potential.
C. Are produced by quanta of acetylcholine spontaneously released from the presynaptic
nerve terminal.
D. Are reduced in amplitude in Lambert-Eaton myasthenic syndrome.
E. Are increased in amplitude in botulism.

31 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

70. In studying a healthy nerve, if you change the temperature from 26 to 34°C, the nerve
conduction velocity will change from 36 m/s to a value between the range of:

A. 38-42 m/s.
B. 42-46 m/s.
C. 48-56 m/s.
D. 58-62 m/s.
E. 30-34 m/s.

71. In single fiber needle electromyography, jitter derives from:

A. The presence of excess acetylcholine in the synaptic cleft.

B. Reduced number of voltage-gated sodium channels on the postsynaptic membrane.
C. Variable times of neuromuscular transmission from a nerve to two paired muscle fibers.
D. Impaired sodium influx across the muscle membrane.
E. Impaired calcium release into the muscle sarcoplasm.

72. The length of time required for fibrillation potentials to appear in a denervated muscle following
nerve injury is most dependent on the:

A. Extent of demyelination at the site of the injury.

B. Distance between the spinal cord and the muscle being studied.
C. Distance between the spinal cord and the site of the nerve injury.
D. Distance between the site of nerve injury and the tested muscle.
E. Extent of axonal degeneration.

73. A 50-year-old male reports difficulty walking across the beach and inability to surf-cast
successfully while fishing. A prior diagnosis of polymyositis was made at another institution, but
20 mg of prednisone daily produced no clinical effect. Neurologic examination demonstrated
diffuse proximal weakness, areflexia, and dryness of the mouth, requiring frequent sips of water
for him to talk. No sensory loss or cranial nerve signs are noted. Nerve conduction studies
demonstrate low amplitude compound muscle action potentials. Needle examination reveals no
spontaneous activity or diagnostic signs. The best subsequent study is:

A. Single-fiber electromyography.
B. Acetylcholine receptor antibody assay.
C. Quadriceps muscle biopsy.
D. Repetitive nerve stimulation studies.
E. Sural nerve biopsy.

32 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

74. Acquired demyelinating polyneuropathies can be diagnosed electrodiagnostically by the
presence of severe slowing of conduction velocity and:

A. Small amplitude, polyphasic motor unit action potentials (MUAPs).

B. Sparing of facial nerve conduction.
C. 4+ fibrillation potentials.
D. Conduction block.
E. Substantially increased MUAP amplitudes.

75. Which of the following reduces the nerve conduction velocity?

A. Increased myelin thickness.

B. Increased axon diameter.
C. Reduced axon temperature.
D. Increased distance between nodes of Ranvier.
E. Reduced number of axons.

76. The nerve terminal at the neuromuscular junction releases its neurotransmitters following a
rapid influx of:

A. Calcium.
B. Potassium.
C. Sodium.
D. Dopamine.
E. Chloride.

77. Which study is the most helpful in differentiating a problem in the brachial plexus from the
nerve root?

A. Sensory nerve action potentials.

B. Compound nerve action potentials.
C. F waves.
D. H waves.
E. Repetitive nerve stimulation.

33 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

78. A 32-year-old female with a history of ptosis is referred for repetitive nerve stimulation studies.
Stimulation of the right median nerve at 2 Hz is shown in the Figure above. Which of the
following is the most likely explanation?

A. Abnormal decremental response of 19%.

B. Lowering of the intramuscular temperature from 32°C to 28°C.
C. Supramaximal stimulation.
D. Movement induced artifact.
E. Normal response.

79. A 50-year-old woman presents with a 6-month history of numbness and tingling in both feet.
She has no focal lower extremity weakness and normal muscle stretch reflexes in both legs. She
denies any bowel or bladder incontinence. She was diagnosed with lung cancer 6 months ago
and has completed radiation and chemotherapy. She is now receiving hospice care for pain
management. After discussion with the patient, her significant other, and the referring
physician, you recommend:

A. Conducting a full electrodiagnostic evaluation, including nerve conduction studies (NCSs)

and needle electromyography (EMG), for peripheral neuropathy.
B. Performing only NCSs and avoiding painful needle EMG.
C. Magnetic resonance imaging of the spine, which is not painful.
D. Performing only the needle EMG, which will provide the most useful data in this case.
E. Considering not performing any further testing since her prognosis is poor.

80. The ligament of Struthers, when present, may entrap which nerve?

A. Ulnar.
B. Median.
C. Anterior interosseous.
D. Radial.
E. Posterior interosseous.

34 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

81. A 43-year-old gentleman is referred for electrodiagnostic evaluation of suspected thoracic outlet
syndrome versus C8 radiculopathy. The patient's hospital chart documents chronic depression,
histrionic behavior, and episodes of somatization. The nerve conduction studies are normal. As
you attempt the needle electromyography (EMG) examination of the first muscle, the patient
jumps up and screams, “You're killing me, stop it, stop it!” What should you do next?

A. Continue the needle EMG examination, as the patient is incompetent to refuse.

B. Distract the patient and continue the needle EMG examination.
C. Continue the needle EMG examination using a smaller needle.
D. Stop the needle EMG examination; report no evidence of cervical radiculopathy.
E. Stop the needle EMG examination; report needle EMG data inadequate to answer the
question.

82. The most typical finding on nerve biopsy of a patient with chronic inflammatory demyelinating
polyradiculoneuropathy is:

A. Fibrinoid necrosis of blood vessel walls.

B. Wallerian degeneration.
C. Myelin ovoids.
D. Segmental demyelination.
E. Naked axons.

83. For the past 6 weeks, a 54-year-old school teacher had difficulty climbing stairs, getting out of
the bathtub, and had mild difficulty speaking. She has a subtle periorbital, anterior thorax,
periungual, and heliotrope rash. Needle electromyography will most likely demonstrate:

A. Small motor unit action potentials (MUAPs) with increased numbers firing.
B. Small MUAPs with decreased numbers firing.
C. Large MUAPs with increased numbers firing.
D. Large MUAPs with decreased numbers firing.
E. Normal MUAPs with increased numbers firing.

35 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

84. A needle electromyography study is requested to determine the location of a median nerve
injury. Nerve conduction studies demonstrate normal ulnar and radial sensory and motor
responses. Along with no median sensory responses from the thumb and index, middle, and ring
fingers and low amplitude median motor responses to the abductor pollicis brevis (APB) with
normal latency and conduction velocity. The needle examination of the APB, flexor pollicis
longus, and flexor carpi radialis is abnormal, with fibrillation potentials and normal configuration
motor unit potentials firing with reduced recruitment. Which of the following muscles is the
most appropriate to examine next in order to most closely determine the location of axon
injury?

A. Second lumbrical.
B. Pronator quadratus.
C. Flexor digitorum profundus.
D. Pronator teres.
E. Flexor digitorum sublimis.

85. Isolated weakness of the infraspinatus muscle may result from:

A. Hypertrophy of the transverse suprascapular ligament.

B. Ganglion within the spinoglenoid notch.
C. Ganglion within the supraspinatus notch.
D. Tethering within the quadrilateral space.
E. Compression of the C5 nerve root.

86. Which muscle is supplied by the deep peroneal nerve?

A. Tibialis posterior.
B. Fibularis tertius (peroneus tertius).
C. Fibular longus (peroneus longus).
D. Plantaris.
E. Flexor digitorum longus.

87. Which of the following statements is correct regarding complex repetitive discharges?

A. They result from ephaptic activation of adjacent muscle fibers.

B. They have a gradual onset.
C. They have a highly irregular firing pattern.
D. They are never seen in otherwise normal muscles.
E. They result from repetitive axonal depolarization.

36 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

88. A patient’s heart rate changes with breathing are most affected by:

A. Age.
B. Gender.
C. Height.
D. Weight.
E. End tidal pCO2.

89. The most common characteristic of vasculitic neuropathy is:

A. Mononeuropathy or mononeuritis multiplex.

B. Symmetric distal polyneuropathy.
C. Proximal myopathy.
D. Focal entrapment neuropathy.
E. Symmetric distal sensory neuropathy.

90. A 57-year-old woman experiences a 4-week history of intermittent diplopia and ptosis. Her
neurologist suspects ocular myasthenia gravis (MG). Which of the following is the most sensitive
test in the diagnosis of ocular MG?

A. Fast (50 Hz) repetitive nerve stimulation.

B. Slow (3 Hz) repetitive nerve stimulation.
C. Single-fiber electromyography.
D. Reduced compound muscle action potential amplitudes.
E. Acetylcholine receptor antibodies.

91. A patient undergoes an electrodiagnostic study as part of the work up for arm pain. Nerve
conduction studies disclose normal ulnar motor (recording hypothenar eminence) and sensory
(recording the small finger) studies. The median sensory (recording from the index finger)
studies are normal, but the median motor studies (recording from thenar eminence) reveals a
very low response with stimulation at the wrist and elbow. The median distal motor latency is
normal. The thenar eminence appears of normal bulk and power on clinical exam, and the
needle electrode examination of the abductor pollicis brevis muscle is normal. Stimulation of the
ulnar nerve at the wrist while recording over the thenar eminence discloses a normal motor
response. This constellation of findings is most consistent with:

A. T1 motor radiculopathy.
B. Lower trunk brachial plexopathy.
C. Nerve lesion of the recurrent thenar branch of the median nerve.
D. Martin Gruber anastomosis.
E. Riche-Cannieu anomaly.

37 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

92. Which one of the following safety precautions is recommended for needle electromyography
(EMG)?

A. Attach the patient bed or examining table to a ground.

B. Ensure that the leakage current from a chassis to ground is greater than 220 µA.
C. Attach all electrodes before turning on the EMG machine.
D. Ensure that patients are doubly grounded to earth.
E. Do not use extension cords to connect the EMG machine to the outlet.

93. Which of the following is a characteristic finding in postradiation plexopathy?

A. Myotonia.
B. Fibrillations.
C. Myokymia.
D. Positive sharp waves.
E. Synkinesis.

94. The most sensitive nerve conduction study indicator of an acute inflammatory demyelinating
polyneuropathy is the:

A. Late response minimum latency.

B. Motor response amplitude.
C. Motor distal latency.
D. Motor fiber conduction velocity (CV).
E. Sensory fiber CV.

95. The earliest needle electromyography changes observed immediately after an acute nerve injury
(axonotmesis) are:

A. Fibrillation potentials.
B. Positive sharp wave potentials.
C. Complex repetitive discharges.
D. Fasciculation potentials.
E. Decreased recruitment.

38 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

96. Which finding listed is the earliest electromyographic change seen in acute radiculopathies with
axonal loss?

A. Fibrillation potentials or positive sharp waves in paraspinal muscles.

B. Fibrillation potentials or positive sharp waves in proximal limb muscles.
C. Fibrillation potentials or positive sharp waves in distal limb muscles.
D. Increased number of polyphasic motor unit action potentials (MUAPs) in paraspinal muscles.
E. Increased number of polyphasic MUAPs in distal limb muscles.

97. Pseudofacilitation seen in repetitive stimulation:

A. Shows no significant change in waveform area.

B. Reveals a decrementing response in waveform amplitude and area.
C. Shows an incrementing response in waveform amplitude and area.
D. Results from activation of increased numbers of muscle fibers.
E. Occurs due to fewer acetylcholine quanta released on successive stimuli.

98. In recording a blink reflex, unilateral electrical stimulation of the supraorbital nerve elicits which of
the following?

A. A bilateral R1 component.
B. A unilateral R1 component in all healthy subjects.
C. Shorter R1 latencies compared with glabellar tapping.
D. Unilateral R1 and contralateral R2 components only.
E. None of the above.

99. Compared to larger diameter axons, smaller diameter axons demonstrate:

A. Increased axoplasmic resistance.

B. Thicker myelin.
C. Longer internodal distances.
D. Greater blood flow.
E. Faster conduction velocity.

39 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

100. The muscle pair most likely to receive a portion of its innervation from L5 is:

A. Tibialis anterior; abductor hallucis.

B. Fibularis longus (peroneus longus); abductor digiti minimi pedis.
C. Tibialis posterior; tibialis anterior.
D. Extensor hallucis longus; vastus medialis.
E. Gluteus medius; adductor longus.

101. Which of the following potentials/discharges typically has an irregular rhythm?

A. Myokymic discharges.
B. Fasciculation potentials.
C. Positive sharp waves.
D. Complex repetitive discharges.
E. Fibrillation potentials.

102. Your associate shows you the above 3 Hz repetitive stimulation study of the abductor digiti
quinti. You would:

A. Interpret it as consistent with a neuromuscular disorder.

B. Have the study repeated after ensuring skin temperature is 32°C.
C. Repeat with adjustment of stimulator position and stimulus intensity.
D. Suggest repeating the study in other nerves to verify the findings.
E. Interpret as normal.

40 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

103. Compared to concentric needles, monopolar needles:

A. Record motor unit action potentials (MUAPs) as smaller in amplitude.

B. Generate less background noise during a needle electromyography study.
C. Induce slightly greater pain for the average patient.
D. Record from a larger territory of MUAPs.
E. Have recording characteristics that are more constant.

104. Reversal of the anode and cathode can result in:

A. No influence on latency measurements.

B. Altered latency measurement.
C. Inaccurate sensory studies only.
D. Inaccurate motor studies only.
E. No influence if supramaximal stimulus is used.

105. Axon reflexes appear in which of the following disorders?

A. Congenital myopathy.
B. Myasthenia gravis.
C. Diabetic neuropathy.
D. Dermatomyositis.
E. Duchenne muscular dystrophy.

106. Maintaining the elbow in extension while performing an ulnar motor conduction study can
result in:

A. The calculated conduction velocity (CV) being slower than the actual CV.
B. The nerve being taut as it crosses the elbow.
C. Anterior migration of the ulnar nerve.
D. Inconsistent CVs across the elbow.
E. The calculated CV being faster than the actual CV.

41 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

107. The amplitude of the largest potential in the tracing above is approximately:

A. 150 µV.
B. 200 µV.
C. 250 µV.
D. 300 µV.
E. 350 µV.

108. A muscle supplied by the posterior interosseous nerve is the:

A. Brachioradialis.
B. Triceps.
C. Extensor carpi radialis longus.
D. Supinator.
E. Anconeus.

109. Before jumping to a conclusion regarding a diagnosis based on the absence of a recorded
compound muscle action potential, which of the following should be checked when performing
nerve conduction studies?

A. There is proper placement of the recording and stimulating electrodes.

B. The stimulus duration (ms) and stimulus intensity (mA) are large enough.
C. The pre-amp is turned on.
D. The electrodes are plugged in.
E. All of the above.

42 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

110. A 71-year-old man presents with a 6-month history of progressive weakness. His symptoms are
worse when he wakes in the morning and fluctuate during the day. He has difficulty combing his
hair and climbing stairs. He denies any pain, numbness, double vision, difficulty in swallowing,
bladder abnormalities, or dark urine. However, he notes some dryness of his mouth. He has
been a heavy smoker for many years. Reflexes facilitate with exercise. Nerve conduction studies
reveal median and peroneal sensory responses to be normal. Median and peroneal motor
responses have low compound muscle action potential amplitudes (2 mV and 0.5 mV,
respectively) with normal conduction velocities and distal latencies. What condition is most
consistent with these findings?

A. Amyotrophic lateral sclerosis.

B. Myasthenia gravis.
C. Myotonic dystrophy.
D. Polyradiculopathy.
E. Lambert–Eaton myasthenic syndrome.

111. The procedure to obtain the waveform in tracing A above was modified to obtain the waveform
in tracing B above. The change resulted from:

A. Increasing the amplifier gain.

B. Increasing the high-frequency cutoff.
C. Decreasing the amplifier gain.
D. Warming the extremity being studied.
E. Decreasing the low-frequency cutoff.

43 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

112. Myotonic discharges are best characterized electrically by:

A. Reduced compound motor action potential amplitude.

B. Short-duration, polyphasic motor unit action potentials.
C. Frequent fasciculations.
D. Spontaneous potentials which wax and wane in amplitude and frequency.
E. Repetitive discharges which have an initial positive deflection and cease abruptly.

113. Which of the following enzymes is involved in mitochondrial respiratory chain function?

A. Muscle phosphorylase.
B. Phosphofructokinase.
C. Succinate dehydrogenase.
D. Phosphoglyceromutase.
E. Phosphoglycerate kinase.

44 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

114. The top figure shows results of a conventional motor conduction study of the left median (A2
and A3) and left ulnar nerve (B4, B5, and B6). The bottom figure shows a motor conduction
study of the left median nerve upon stimulation at the wrist (A1) and at the elbow (A2),
recording over the abductor digiti minimi. Which of the following is the most likely explanation
of the findings?

A. Carpal tunnel syndrome and Martin-Gruber anastomosis.

B. Ulnar neuropathy at the elbow and Martin-Gruber anastomosis.
C. An isolated ulnar neuropathy at the elbow.
D. Martin-Gruber anastomosis with the communicating branch that supplies the abductor digiti
minimi.
E. Volume-conducted potential from distant median-innervated muscles.

45 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

115. You wish to perform collision studies. Which of the following instrument features is most
helpful?

A. Signal averaging.
B. Dual stimulators with delay controls.
C. Magnetic stimulation.
D. Waveform rectification and integration.
E. Window trigger.

116. An 82-year-old man is treated chronically with prednisone for severe chronic obstructive
pulmonary disease. Over the course of 12 months, he develops mild proximal muscle weakness.
His examination discloses only mild weakness (Medical Research Council grade 4+/5 strength) in
proximal muscles in the upper and lower extremities. His physician suspects steroid-induced
myopathy and refers him for an electrodiagnostic study. Which of the following findings is most
likely to be discovered on this study?

A. Short-duration, small amplitude, polyphasic units in proximal limb muscles.

B. Fibrillation potentials and positive sharp waves in proximal limb muscles.
C. Normal study of the proximal muscles.
D. Low amplitude compound muscle action potential responses.
E. Long-duration, large amplitude polyphasic units in proximal limb muscles.

117. Which of the following is correct regarding the intrafusal muscle fibers in humans?

A. They are not innervated by any neurons.

B. They are innervated only by alpha motor neurons.
C. They respond to changes in muscle force.
D. They respond to changes in muscle length.
E. They are more sensitive to concentric contractions than eccentric contractions.

118. Polyphasic motor unit potentials are:

A. Found primarily in neuropathic processes.

B. Present in normal muscles in varying proportions.
C. Decreased in early primary muscle disease.
D. Decreased when muscle temperature is lowered.
E. Unrelated to the age of the studied patient.

46 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

119. In botulism, which mechanism is responsible for failure of neuromuscular transmission?

A. Prevention of calcium ion influx after presynaptic motor nerve terminal depolarization.
B. Increase of acetylcholine hydrolysis in the synaptic cleft.
C. Prevention of acetylcholine containing vesicles from fusing with the presynaptic membrane.
D. Prevention of cation influx across the postsynaptic membrane.
E. Hyperpolarization of the postsynaptic membrane.

120. Fasciculation potentials are best recognized during needle electromyography by their:

A. Morphology.
B. Recruitment pattern.
C. Amplitude.
D. Rise time.
E. Firing pattern.

121. Which of the following is true regarding neurapraxia?

A. Conduction block usually affects sensory greater than motor fibers.

B. It is an irreversible process.
C. Large myelinated fibers are more susceptible.
D. Axonal continuity is disrupted along the length of the lesion.
E. Remyelination does not occur.

47 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

122. For the figure above, the waveform marked with the arrow most likely represents:

A. Another motor unit firing at the same time.

B. A fibrillation potential.
C. A satellite potential.
D. A phase.
E. A turn.

123. As the temperature of a nerve is lowered, which of the following statements is true?

A. The peak sodium conductance decreases.

B. The amplitude of the action potential decreases.
C. The action potential’s rise time decreases.
D. The action potential’s fall time decreases
E. The area of the action potential increases.

48 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

124. Which is a recognized site of distal ulnar nerve entrapment?

A. Guyon's canal.
B. The ligament of Struthers.
C. The arcade of Frohse.
D. The spiral groove.
E. The transcarpal ligament.

125. When sampling a limb muscle affected by a motor neuron disorder, a second motor unit action
potential (MUAP) would be expected to start firing when the first MUAP is firing at:

A. 1 Hz.
B. 4 Hz.
C. 7 Hz.
D. 10 Hz.
E. 15 Hz.

126. All neuromuscular junction disorders have which pathophysiologic mechanism in common?

A. Decreased release of acetylcholine.

B. Increased activity of acetylcholinesterase.
C. Decreased resting potential of the muscle membrane.
D. Reduced safety factor.
E. Decreased acetylcholine reserves in the pre-synaptic terminal.

127. Compared to an adult male, a 9-year-old girl is more likely to have:

A. Slower motor nerve conduction velocity.

B. Smaller compound muscle action potential amplitude.
C. Shorter blink reflex latency.
D. Shorter F-wave response latency.
E. Shorter sensory nerve conduction latency.

49 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

128. Neurapraxia and axonotmesis are both associated with:

A. Wallerian degeneration.
B. Reduced motor unit recruitment.
C. Reduced distally evoked compound muscle action potential amplitude.
D. Irreversible conduction block.
E. Increased sensory nerve action potential amplitudes.

129. A greater/prolonged motor unit action potential (MUAP) rise time is indicative of:

A. Reduced synchrony of firing between muscle fibers contributing to the MUAP.

B. Greater muscle fiber density.
C. An axon loss lesion.
D. A distant motor unit from the recording electrode.
E. Myopathic motor units.

130. Which of the following is the minimum rate of steady firing for most human motor neurons?

A. 10-12 Hz.
B. 14-16 Hz.
C. 18-20 Hz
D. 1-2 Hz.
E. 4-5 Hz.

131. Which of the following conditions is most likely to have X-linked inheritance?

A. Dysferlin-associated myopathy.
B. Facioscapulohumeral dystrophy.
C. Bulbo-spinal muscular atrophy (Kennedy syndrome).
D. Charcot-Marie-Tooth disease types 1A and 1B.
E. Proximal myotonic myopathy.

132. Which muscle is frequently supplied by a single spinal root level?

A. The supraspinatus muscle.

B. The teres minor muscle.
C. The rhomboid major muscle.
D. The deltoid muscle.
E. The serratus anterior.

50 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

133. Which of the following muscles would be expected to be normal in a lesion of the posterior cord
of the brachial plexus?

A. The teres major muscle.

B. The anconeus muscle.
C. The abductor pollicis longus muscle.
D. The pectoralis major muscle.
E. The teres minor muscle.

134. The tracing above represents repetitive stimulation of the ulnar nerve at a frequency of 2 Hz,
recording from the abductor digiti quinti. Based on an analysis of the response amplitudes, the
findings are most consistent with:

A. Steroid myopathy.
B. Myasthenia gravis.
C. Hypomagnesemia.
D. Lambert–Eaton myasthenic syndrome.
E. Myotonia congenita.

51 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

135. The response in the figure above is recorded from the trapezius with stimulation of the spinal
accessory nerve posterior to the belly of the sternocleidomastoid. Which of the following is the
closest approximation to its baseline-to-peak amplitude, latency, and duration of the negative
peak?

A. 4.0 mV, 2.4 ms, 14.0 ms.

B. 8.0 mV, 3.0 ms, 15.0 ms.
C. 9.5 mV, 2.5 ms, 13.5 ms.
D. 10.0 mV, 2.8 ms, 50.0 ms.
E. 11.0 mV, 2.0 ms, 12.0 ms.

52 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

136. In the figure above, which pair of arrows on the x-axis most accurately reflects the total
duration of the motor unit action potential?

A. A-C.
B. A-D.
C. A-E.
D. B-C.
E. B-E.

137. The presence of normal digital sensory nerve action potentials and diffuse fibrillation potentials
2 weeks after injury in a patient with a flail arm with loss of sensation suggests which of the
following?

A. Probable root avulsion.

B. Questionable brachial plexus lesions.
C. No root avulsions or tearing of axons.
D. Damage to ventral roots, but not the dorsal root.
E. Median, ulnar, and radial neuropathy.

138. Which of the following is the normal range of motor unit discharge rates at low levels of
contraction and 2 distinct motor unit potentials firing?

A. 2-4 Hz.
B. 6-8 Hz.
C. 10-15 Hz.
D. 15-20 Hz.
E. 20-30 Hz.

53 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

139. Recordings over the abductor hallucis muscle following supramaximal stimulation delivered
posterior to the medial malleolus are pictured above. This study shows:

A. Late responses with a normal minimal latency of about 51 ms.

B. Excessive chronodispersion of the late response.
C. A late response peak latency of 53 ms, which is delayed.
D. An abnormally high amplitude of the late response.
E. Normal late responses except for the presence of A waves.

140. You perform electrodiagnostic studies on a 75-year-old male with weakness and atrophy most
prominent in the quadriceps and volar forearm muscles. You conclude that the findings support
a myopathy. Muscle biopsy will most likely demonstrate:

A. Vacuoles with positive glycogen staining.

B. Prominent fiber type grouping.
C. Perifascicular atrophy.
D. Vacuoles with positive amyloid staining.
E. Nemaline rods.

54 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

141. Which of the following is most helpful in discriminating polymyositis from dermatomyositis?

A. Serum creatine kinase levels.

B. Weakness.
C. Fibrillation potentials.
D. Small amplitude, polyphasic motor unit action potentials.
E. Skin lesions.

142. A 32-year-old man presents with a 2-year history of worsening right foot drop. He has no history
of habitual leg crossing, squatting, weight loss, or immobility. Fibular nerve conduction studies
reveal no motor or sensory response on the right side. Needle electromyography shows
fibrillations and positive sharp waves in the tibialis anterior and fibularis longus with voluntary
motor units. To further characterize the lesion, a neuromuscular ultrasound is obtained. A round
anechoic mass with no Doppler flow is visualized at the level of the fibular head. What is the
most likely cause of this patient’s fibular neuropathy?

A. Schwannoma.
B. Ganglion Cyst.
C. Adventitious bursitis.
D. Abscess.
E. Enlarged lymph node.

143. A 40-year-old male presents with muscle stiffness and proximal weakness with prominent
muscle pain. There is no facial weakness or ptosis. He has a history of cataracts,
cardiomyopathy, and hypogonadism. On examination, there is mild proximal limb weakness and
percussion of the thenar eminence produces slow sustained contraction of the thumb across the
palm. On electrodiagnostic testing, which of the following would be expected to occur to
compound muscle action potential amplitude following a short period of exercise?

A. No decrement.
B. Greater than 10% decrement immediately following exercise with a prolonged recovery
over 30 to 40 minutes.
C. A mild increase which amplifies with repetition.
D. Greater than 10% decrement immediately following exercise with recovery within 2 minutes
and a habituation of the decrement on repeated testing.
E. Dramatic facilitation of 80%.

55 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

144. A 36-year-old woman presents with a 3-year history of left hand weakness and numbness. Her
examination demonstrates weakness of all hand muscles. Her electrodiagnostic studies show
decreased ulnar sensory amplitude. Needle electromyography shows abnormal spontaneous
activity in the first dorsal interosseous, abductor pollicis brevis, and extensor indicis proprius
muscles. What is the most likely lesion at in this patient?

A. Medial cord of the brachial plexus.

B. Lower trunk of the brachial plexus.
C. Lateral cord of the brachial plexus.
D. Posterior cord of the brachial plexus.
E. C8 radiculopathy.

145. Proximal nerve segments conduct faster than distal segments because:

A. Skin impedance is lower in proximal segments.

B. Body temperature is warmer in proximal segments.
C. Distance measurements are more accurate in proximal segments.
D. Longer stimulus duration is required to excite proximal nerves.
E. Stimulus intensity is required to excite distal nerves.

146. Stimulus artifact is defined by:

A. A region of electrical potential where the isopotential voltage lines associated with a current
source change slowly over a short distance.
B. The initial sign of depolarization of the action potential.
C. A signal that commonly contaminates the desired potential.
D. The current/voltage delivered from the stimulator’s electrodes taking the path of least
resistance through the extracellular fluid and being detected by the recording electrodes.
E. The initial positive (downward) deflection of the M wave.

147. Thigh pain followed by weakness and atrophy of the quadriceps in elderly men is most
commonly seen as a complication of which one of the following?

A. Alcoholism.
B. Uremia.
C. Hemophilia.
D. Myeloma.
E. Diabetes.

56 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

148. Which of the following diagnoses share a mutated gene?

A. Miyoshi myopathy and hereditary inclusion body myopathy.

B. Duchenne muscular dystrophy and limb-girdle muscular dystrophy (LGMD).
C. Hereditary inclusion body myopathy and LGMD.
D. Multifocal motor neuropathy and hereditary motor and sensory neuropathy type 2.
E. Hereditary motor and sensory neuropathy type 1A and hereditary neuropathy with liability
to pressure palsies.

149. Gain: 100 µV/div; Sweep speed: 10 ms/div

The above potentials were recorded from 2 different muscles in the same patient during a
concentric needle electromyography (EMG) study, with similar findings noted in pelvic and
shoulder girdle muscles bilaterally. Needle EMG findings of more distal limb muscles, along with
the motor and sensory nerve conduction studies, are normal. The potentials are most likely:

A. Normal motor unit action potential variants.

B. Associated with a neuropathic process.
C. Associated with a myopathic process.
D. Due to a defective needle electrode.
E. Complex repetitive discharges.

150. Which of the following is a characteristic of monopolar needles?

A. Aluminum wire.
B. Cannula acting as a reference.
C. Beveled electrode end.
D. Teflon coated solid steel wire.
E. Nichrome wire.

57 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

151. How many months of EMG training have you completed at the time of this exam?

A. 0 - 3 FTE months of EMG training.

B. 4 - 6 FTE months of EMG training.
C. More than 7 FTE months of EMG training.
D. I am a practicing physician.

58 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination

59 2018 AANEM Electrodiagnostic Medicine Self-Assessment Examination