VOLUME 29, ISSUE 4 • DECEMBER 2025.
Clinical neurophysiology sits at the intersection of science and clinical practice, offering a powerful way to support the clinical diagnosis and understand and quantify abnormal movement. Yet for many early-career neurologists, the path into this field can seem unclear. To explore how to get started, Dr. Elie Matar from the University of Sydney spoke with Professor Marina de Koning Tijssen, Chair of the Èxpertise Center of Movement Disorders, Department of Neurology at the University Medical Center Groningen, The Netherlands.
Prof de Koning Tijssen has been a leading voice in applying neurophysiology to movement disorders, particularly in myoclonus, tremor, and functional disorders. She shared her insights on training, mentorship, and the evolving role of electrophysiology in modern neurology.
Q: How did you first become interested in neurophysiology in movement disorders?
In the Netherlands, electrophysiology is an integral part of neurology training, with six years in total and one year fully dedicated to electrophysiology. During that period, I discovered I really enjoyed the process of measuring, since there is something deeply satisfying about being able to quantify what you see.
My PhD was on hyperekplexia, and even though we did not use the term “biomarker” then, that was essentially our goal: to find objective measures in patients. We studied startle reflexes using auditory stimuli, and I performed both genetic and electrophysiological analyses to assess severity and compare patients with controls. That experience convinced me that neurophysiology could truly bridge the gap between mechanism and clinical expression.
Q: Where do you think neurophysiology most influences diagnosis and management in movement disorders?
It is particularly valuable for hyperkinetic movement disorders, especially tremor and jerky movements such as myoclonus, and also for functional movement disorders. In conditions like parkinsonism or dystonia, electrophysiology plays more of a research role (at the moment!). But in clinical practice, the real diagnostic yield comes from analyzing jerky and tremulous movements. For example, when it is hard to distinguish between chorea and myoclonus, EMG can help define burst duration and pattern, clarifying whether the movement is cortical myoclonus, tremorous, or choreiform.
Q: Can you recall a case where neurophysiology changed the diagnosis or management?
Yes, several. A memorable example involves patients with ataxia who also experienced falls. These are often attributed to the ataxia itself, but when you observe jerky myoclonic movements at clinical examination and record negative myoclonus with electrophysiology, the picture changes completely. Their falls can result from transient lapses in muscle tone rather than imbalance, which makes them treatable.
I have also seen cases where EMG reveals a coexistence of non-functional myoclonus and functional overlay. Electrophysiology helps differentiate the two, or confirm they are both present. One such example is a case where a patient with DYT11 (dystonia myoclonus) who had been stable for some time began to deteriorate with more jerky movements in older adulthood, which is highly atypical of this condition. Using electrophysiology, we were able to highlight that the worsening was due to functional movement disorders. That kind of clarity can be invaluable, both for clinicians and for helping patients understand and accept their diagnosis.
Q: For trainees interested in movement disorders, what core neurophysiology skills should they learn?
It is important to understand the basics of EMG, including what muscle activity looks like on needle and surface recordings across different neurological conditions. But for movement disorders, the key skill is polymyography (multi-channel EMG). If you only learn one technique, learn that. Recording from a few muscles simultaneously allows you to evaluate burst duration, synchrony versus alternation, and proximal versus distal involvement. Furthermore, the pattern of activation, like the startle reflex in hyperekplexia, can be studied. Multi-channel EMG is the foundation for studying tremor and myoclonus, but also for functional movement disorders, for example by identifying features of entrainment. Polymyography is also useful in dystonia to identify the most active muscles before botulinum toxin treatment. In addition to EMG, accelerometry can be used not only for diagnosis in the clinic, but also for long-term home monitoring. The EMG and accelerometry measurements also help you get better at phenomenology, as you’re able to calibrate what you see with the neurophysiology.
Of course, EEG is also a valuable tool, and combining it with polymyography can help identify cortical correlates such as cortical spikes in cortical myoclonus or the Bereitschaftspotential in functional movement disorders. But, if you had to choose only one technique, polymyography remains the essential core skill for anyone interested in movement disorders.
Q: What options exist for additional training?
For those where it is possible, it would be ideal to pursue a 6- to 12-month fellowship at a center where clinical neurophysiology and movement disorders are integrated. The best learning occurs when you can see patients, generate hypotheses, and immediately test them using polymyography and EEG. Therefore, try to make sure you don’t just spend all day with the electrophysiologists, but also see the clinical side where you can direct the questions.
If you are not in such an environment, short hands-on MDS courses are an excellent start. Martje van Egomond, Francesca Morgante, and I organised one in the Netherlands through the MDS-ES, which was overbooked almost fourfold, and similar workshops in the Pan American and Asia-Oceanic section have had huge demand. They are typically two to three days long, focusing on tremor, jerky movements, functional disorders, and practical applications like EMG in cervical dystonia. Many attendees went home and set up their own labs afterwards.
Mentorship is also critical. A supportive clinical neurophysiologist can help you with protocols, analysis software, and troubleshooting.
Q: Are there formal training resources coming?
Yes, the MDS Clinical Neurophysiology in Movement Disorders Study Group is currently developing a structured curriculum. The first phase will include six foundational lectures on techniques such as tremor and myoclonus recording, followed by case-based demonstrations showing how to plan and interpret polymyography in real patients.
The goal is to build confidence: To know what you are looking for and why. Neurophysiology should be seen as an extension of the neurological examination, guided by clinical reasoning rather than performed in isolation.
Q: Are there common misconceptions about neurophysiology?
Definitely. For a time, as imaging and genetics advanced, many viewed electrophysiology as old-fashioned. But that is changing. Imaging and molecular diagnostics are invaluable, yet they do not always inform function or clinical mechanisms.
In contrast, electrophysiology can reveal what the nervous system is doing in real time, and that is irreplaceable. It is having a revival, and rightly so.
Q: Where do you see the field heading over the next decade?
I see two exciting directions:
First, machine learning and quantitative analysis: Pairing good clinical phenotyping with electrophysiological data can support diagnosis and training, especially for clinicians less experienced in movement analysis. Tools like simplified EMG or accelerometry could help confirm tremor or myoclonus remotely (even in the home setting), guiding referrals more efficiently. One day you could see such a process becoming more automated, and helping clinicians (with a directed clinical question) to confirm or disprove their clinical suspicions.
Second, deep brain stimulation: Closed-loop DBS systems and local field potential recordings are bringing electrophysiology back to the forefront of therapy. Coupling these with surface EMG provides insight into motor output, offering a new level of precision. This is a very exciting time for neurophysiology.
Q: Finally, what advice would you give to early-career clinicians considering neurophysiology?
If you love phenotyping, really observing and understanding movement, then neurophysiology will enrich your clinical life. It provides direct feedback between what you think you see and what is objectively happening.
Do not be intimidated by the equipment. After a few sessions it becomes intuitive. Focus on the signals, seek feedback from experienced neurophysiologists, and gain hands-on experience. The more you do it, the more you learn. And if you enjoy it, pursue it actively. There are now clear training pathways emerging and mentors willing to help.
Closing note
Prof. de Koning Tijssen’s reflections highlight how electrophysiology continues to evolve from a traditional diagnostic tool to a dynamic partner in clinical reasoning, education, and technology. For trainees and established clinicians alike, neurophysiology offers a unique way to see the nervous system in action and to deepen understanding of movement itself. Excitingly, there are several opportunities to get hands on and foundational knowledge in neurophysiology through MDS initiatives, so please keep a look out for these resources and events.
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