NY PA CT emg ncv testing who does it

[DRJJ1]

I currently perform emg/ncv/ep testing. I would like to know how many of you do it, getting into it, or currently use it. This way we can discuss it in a civil way. I currently also besides test my own patients but how also go to other docs on a select basis to test their patients as well. How many do this too. Lets chat. Thanks

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[C Fiber]

I love EMG/NCS too. I plan to take the AAEM certification soon just for fun. Being this is a pain website. I think most of the chronic pain, ie low back/neck pain patients usually don't require EMG to diagnose their pain. EMG can be very fun and challenging in diagnosing other neurologic conditions - peripheral nerve neuropathies, entrapement neuropathies, brachial plexopathy, avulsion neuropathies from trauma, myopathies, ALS, GB, even rarely myasthenia gravis. What other syndromes do you think EMG is really indicated?

Have you heard of Neural-Scan? For small fiber neuropathy/pain nerve conduction study? What do you think about this?

www.nervepathology.com

 

[sherif807]

HI , I perform the test at my office, I do the emg portion , But i hired a company to do the ncv portion for me , Its really great .. my practice is around the ny area, I used a company called fwaves , They are very reliable , There website is "website removed" , Belive me if you enjoy NCV/EMG testing and need a legitimate help , Then call them , They are the way to go ..

 

[lobelsteve]

This ain't about pain, and it ain't legitimate.

Please lock it or remove the thread.

 

[SSdoc33]

uggghhhh. you guys are scary. i am assuming that you have been properly TRAINED in performing EMGs/NCS using legitimate equipment. it takes over a year of performing these studies day in and day out to get good at it. sometimes even longer. if you have legitimate questions about equipment or techniques, there is an EMG case sub-discussion forum under the PM&R forum. if not, run and hide from the auditors.....

 

[Ludicolo]

A small, 2+ year old thread, resurrected by a new “non-student” member, advertising a company “website removed” (thanks axm)…come on now…

I just finished reading a nice little article in today’s NYT Health Section, “The Scan That Didn’t Scan”, discussing the perils and pitfalls of relying too heavily on outside MRIs and reports. The public doesn’t realize that all MRI machines and that all radiology centers/techs/radiologists are not created equal and some doctors put too much stock in the findings on the reports (without checking out the imaging, or correlating with the history and physical exam).

The same can be held true for NCS/EMGs (or any diagnostic/therapeutic procedure for that matter). Patients and referring physicians deserve a quality electrodiagnostic examination performed by someone with proper training and experience. Please to all the future EMGers out there, work hard to become competent and proficient. Maintain your knowledge base. Don't cut corners.



PS – who takes the ABEM certification exam for fun?

 

[drusso]

PS – who takes the ABEM certification exam for fun? [/QUOTE]

That was my thought too...

 

[DOctorJay]

apparently PTs are doing it in NY
http://news.todayinpt.com/apps/pbcs.dll/article?AID=/20080915/TODAYINPT0104/80912009

 

[Ludicolo]

apparently PTs are doing it in NY
http://news.todayinpt.com/apps/pbcs.dll/article?AID=/20080915/TODAYINPT0104/80912009

Sigh.

My favorite quote: “the vast majority of PTs who perform electrodiagnostic testing have an advanced degree or very expensive training”

It may be semantics, but I strongly believe in the following wording: As a physician I practice electrodiagnostic medicine. MEDICINE. Others can say they perform electrodiagnostic testing. My personal and professional standards are higher than that.

Knowledge is power:
From the American Congress of Electroneuromyography:
http://www.emgcongress.com/healthcare.asp
http://www.emgcongress.com/whypt.asp

From the American Association of Neuromuscular and Electrodiagnostic Medicine: http://www.aanem.org/practiceissues/positionstatements/Who%27s_Qualified.cfm

 

[neglect]

Sigh indeed. A bad study is just a waste of money. The ability to put the numbers into proper clinical context, to know when to order, when not to order, is not taught to PTs anymore than it is taught to STs.

 

[Hilly12]

An EMG is never fun, how can you say so?
Please, read what it feels like to undergo this procedure
http://badgerbag.typepad.com/badgerbag/2007/10/an-emg-is-extre.html
I have done a few NCS and EMG myself, under supervision, and I have watched a lot performed by doctors and medical staff. Every time it was extremely painful for the patient! We shouldn't call this discomfort, it is REAL pain. Even men cry out with pain.
The worst is when it is done on children. I once watched NCS and EMG performed on a 3-year-old girl. She cried, again and again begging her Mum to stop it. 'Pleas, please, make them stop it!' She had learned that when she said 'please' it would be alright. But it didn't stop. She finally was exhausted from crying and only wept with little faint sobs. That was even worse. I had tears in my eyes. When it was finished, the little girl was still in pain and said it hurts, it hurts.
I am sure this was such a traumatic experience that she will never in her life see a doctor again.
So, never say EMG is fun! It means pain and agony.
Hilly

 

[SSdoc33]

An EMG is never fun, how can you say so?
Please, read what it feels like to undergo this procedure
http://badgerbag.typepad.com/badgerbag/2007/10/an-emg-is-extre.html
I have done a few NCS and EMG myself, under supervision, and I have watched a lot performed by doctors and medical staff. Every time it was extremely painful for the patient! We shouldn't call this discomfort, it is REAL pain. Even men cry out with pain.
The worst is when it is done on children. I once watched NCS and EMG performed on a 3-year-old girl. She cried, again and again begging her Mum to stop it. 'Pleas, please, make them stop it!' She had learned that when she said 'please' it would be alright. But it didn't stop. She finally was exhausted from crying and only wept with little faint sobs. That was even worse. I had tears in my eyes. When it was finished, the little girl was still in pain and said it hurts, it hurts.
I am sure this was such a traumatic experience that she will never in her life see a doctor again.
So, never say EMG is fun! It means pain and agony.
Hilly

hey, hilly12, im assuming you're not healthcare, so ill be gentle. which would you rather have: the "agony" of a 45 minute procedure or the "agony" of dying in pain from a disease that could be prevented with a EMG diagnosis?

grow up

 

[Hilly12]

hey, hilly12, im assuming you're not healthcare, so ill be gentle. which would you rather have: the "agony" of a 45 minute procedure or the "agony" of dying in pain from a disease that could be prevented with a EMG diagnosis?

grow up

SSdoc33,

I am grown-up and I am healthcare, and I will be gentle, too.

Please, give me the name of one single fatal disease that could be prevented with a EMG diagnosis.
Most diseases, if not all, that are diagnosed by EMG can be diagnosed by other means.
If a diagnosis does not lead to treatment or change in treatment, it is useless.
Absolutely no diagnostical procedure justifies a 45-minute (often it takes even 90 minutes) agony.
If a diagnostical procedure involves excruciating pain, the patient must be sedated. If this isn't possible, the procedure shouldn't be done.
Would you like to have all your teeth extracted without any anesthesia? This would also take about 45 minutes.
The main goal of people working in healthcare should be to care for the health and the well-being of their patients.
Do you know that each severe pain a person suffers is stored in the so-called 'pain memory' and can easily lead to chronic pain?

Growing up does not mean being insensitive to the pain and agony of other people. On the contrary!

Hilly

 

[SSdoc33]

SSdoc33,

I am grown-up and I am healthcare, and I will be gentle, too.

Please, give me the name of one single fatal disease that could be prevented with a EMG diagnosis.
Most diseases, if not all, that are diagnosed by EMG can be diagnosed by other means.
If a diagnosis does not lead to treatment or change in treatment, it is useless.
Absolutely no diagnostical procedure justifies a 45-minute (often it takes even 90 minutes) agony.
If a diagnostical procedure involves excruciating pain, the patient must be sedated. If this isn't possible, the procedure shouldn't be done.
Would you like to have all your teeth extracted without any anesthesia? This would also take about 45 minutes.
The main goal of people working in healthcare should be to care for the health and the well-being of their patients.
Do you know that each severe pain a person suffers is stored in the so-called 'pain memory' and can easily lead to chronic pain?

Growing up does not mean being insensitive to the pain and agony of other people. On the contrary!

Hilly

oy

i can name several, by the way, but im not going to get into with you after that inane response.

if going thru this test easily leads to "chronic pain" then there's a boatload of other things going on, most of which would be better treated by a psychiatrist

and, if appropriately done, electrodiagnosis does "care for the health and the well-being of their patients" as you put it.

 

[Hilly12]

SSdoc33,

so, according to you, when someone has excruciating pain when undergoing EMG (most people have), he needs a psychiatrist. In other words, he is imagining the pain or he is more pain sensitive than normal people. Right?
Well, that is the normal response of doctors when a patient says he is in pain. There is nothing to add. I can only say if doctors underwent the procedures they are inflicting on their patients they would not talk in this way.
Some neurologists, indeed, have a EMG done to them and afterwards say it isn't too bad. What they don't take into consideration, though, is the fact that they have healthy nerves which must only be stimulated mildly and only once to give a response. People with nerve damage must have their nerves stimulated up to 50 or even more times with the maximum stimulation of 100mA, and sometimes doctors even go beyond that. To know what it feels like, I had that done to my legs, and I can assure you, I am not pain sensitive, but after 40 stimulations with 100mA I was crying and sobbing.When they stopped I had to vomit.
As for the needles, I had them inserted and had them moved around in my legs, some needles were only slightly painful, but others just made me cry out with pain.
When the two procedures were finished, I had to go home and to lie down. My legs were sore and painful for more than a week and I had difficulties walking.
Have you had this procedure done to your legs or arms? With maximum stimulation and maximum number of needles? If yes, we can go on 'talking', if no, let's just stop. In that case you wouldn't know what you were talking about.
By the way, stick to the rules of this forum and don't insult people.
I am not insane.

 

[Ludicolo]

Hilly12

The overwhelming majority of people who undergo NCS/EMG tolerate it fine. There have actually been a few studies looking at perception of pain before, during, and after EMG. On average, the pain was ranked as moderate, 3-4/10. I’ll take a double blind study over your histrionic, anecdotal blog entry any day. But if you wish, I can link you to other patient blogs/forums that state that EMGs aren’t so bad, since that seems to be your gold standard.

We can all agree that NCS/EMG is an inherently uncomfortable test, involving the administration of electrical shocks and insertion of needles through skin into muscles. In the hands of a skilled examiner however, it should be no more uncomfortable than a flu shot. But that is the key. The EMG must be approached with empathy, communication, reassurance, good technique, and efficiency. All of which is gained with proper training and experience. Sorry you had a bad time of it, but for you to come out, and for YOUR VERY FIRST POST IN AN OLD THREAD state that EMGs mean nothing but “extreme” “excruciating” “pain and agony” “every time” is a bit over-the-top, don’t ya think?

But I will agree with you on one point – if somebody performed an EMG on a 3 year old without conscious sedation – I find that inexcusable. This goes back to who’s qualified to do EMGs, who doesn’t know their limitations. In the hands of a poorly trained health care practitioner, any procedure can be tortuous. Ever had someone fumble with venipuncture?

To answer one of your other questions, I’ve diagnosed Lambert Eaton Myasthenic Syndrome on EMG a couple times in my career. Testing eventually led to a diagnosis of lung cancer. Patients ultimately underwent surgery. Patients are currently without evidence of disease. I’ve also seen a few people diagnosed on the outside with ALS, and ended up based on my EMG having something different, and treatable. So, yes - EMGs can lead to treatment or can change treatment. EMGs can save lives if they lead to a timely, accurate diagnosis.

And, as part of my training, I have had NCS/EMG performed on myself. I know full well what it feels like. Which is why I am comfortable performing the procedure, and why defend it wholeheartedly.

 

[SSdoc33]

SSdoc33,

so, according to you, when someone has excruciating pain when undergoing EMG (most people have), he needs a psychiatrist. In other words, he is imagining the pain or he is more pain sensitive than normal people. Right?
Well, that is the normal response of doctors when a patient says he is in pain. There is nothing to add. I can only say if doctors underwent the procedures they are inflicting on their patients they would not talk in this way.
Some neurologists, indeed, have a EMG done to them and afterwards say it isn't too bad. What they don't take into consideration, though, is the fact that they have healthy nerves which must only be stimulated mildly and only once to give a response. People with nerve damage must have their nerves stimulated up to 50 or even more times with the maximum stimulation of 100mA, and sometimes doctors even go beyond that. To know what it feels like, I had that done to my legs, and I can assure you, I am not pain sensitive, but after 40 stimulations with 100mA I was crying and sobbing.When they stopped I had to vomit.
As for the needles, I had them inserted and had them moved around in my legs, some needles were only slightly painful, but others just made me cry out with pain.
When the two procedures were finished, I had to go home and to lie down. My legs were sore and painful for more than a week and I had difficulties walking.
Have you had this procedure done to your legs or arms? With maximum stimulation and maximum number of needles? If yes, we can go on 'talking', if no, let's just stop. In that case you wouldn't know what you were talking about.
By the way, stick to the rules of this forum and don't insult people.
I am not insane.

yeah, ive had it done. in fact, ive tested myself MANY TIMES with both the needle and the shocks so i know what it feels like and can be as gentle as possible. it doesnt feel great, i agree, but it is a small price to pay for an accurate diagnosis which can lead to pain relief and increased function down the road. i dont see how there is a difference between neurologists and physiatrists in terms of the discomfort of the test itself. and no one called you insane, you seem to have inferred that from somewhere.

 

[Hilly12]

Ludicolo, SSDoc33,

thanks very much for your answers and for taking my messages seriously.

I have done 10 EMGs under supervision so far, and 8 of those 10 people told me they had great pain. I felt so sorry for them. I was especially shocked when watching that 3-year-old girl undergo that procedure without any sedation. I will never forget it, it just made me feel sick.

I have seen several health care practitioners who were poorly trained and neither efficient nor compassionate, and if done by such people EMGs can mean pain and even agony.

There are a few diseases which can only be diagnosed with EMG, but on the whole I think far too many EMGs are done on patients whose diseases could be diagnosed by other, less painful, means.

I have not yet decided whether I will continue my training doing EMGs or whether I will work in a different department of the hospital where I will have to inflict less pain on patients. That is why I try to gather as much information as possible about how EMGs and NCVs are felt by patients.
My own painful experience made me think that EMGs on the whole are very painful, and what I read on the net (see the link I posted) seemed to
show that I was right.
When I read on this forum that some of you spoke about EMGs being fun, I became really angry. So I might have overreacted.

Ludicolo,
I woud be very interested if you could tell me where to find the studies looking at perception of pain before, during, and after EMG. I would also like you to link me to other patient blogs/forums that state that EMGs aren’t so bad.
Thanks in advance!
Hilly

 

[RUOkie]

Ludicolo, SSDoc33,

thanks very much for your answers and for taking my messages seriously.

I have done 10 EMGs under supervision so far, and 8 of those 10 people told me they had great pain. I felt so sorry for them. I was especially shocked when watching that 3-year-old girl undergo that procedure without any sedation. I will never forget it, it just made me feel sick.

I have seen several health care practitioners who were poorly trained and neither efficient nor compassionate, and if done by such people EMGs can mean pain and even agony.

There are a few diseases which can only be diagnosed with EMG, but on the whole I think far too many EMGs are done on patients whose diseases could be diagnosed by other, less painful, means.

I have not yet decided whether I will continue my training doing EMGs or whether I will work in a different department of the hospital where I will have to inflict less pain on patients. That is why I try to gather as much information as possible about how EMGs and NCVs are felt by patients.
My own painful experience made me think that EMGs on the whole are very painful, and what I read on the net (see the link I posted) seemed to
show that I was right.
When I read on this forum that some of you spoke about EMGs being fun, I became really angry. So I might have overreacted.

Ludicolo,
I woud be very interested if you could tell me where to find the studies looking at perception of pain before, during, and after EMG. I would also like you to link me to other patient blogs/forums that state that EMGs aren’t so bad.
Thanks in advance!
Hilly

Hilly,
I am in solo practice and while I recognise your concerns, I think they are somewhat overblown. Yes, EMG/NCS is uncomfortable, especially when they are large, detailed studies looking for neuromuscular junction disorders or other neuromuscular disease. That said, I have personally done more than 7500 studies, and have only had a handfull terminate the study prematurely. I recently did a study on a 9 y/o girl with a radial neuopathy after a humerus fx. I warned Mom & Dad that she would likely cry, and made sure the waiting room was empty. Her only response to the NCS and >15 needle sticks was "This is SO COOL!" She thanked me after the exam.

Over the past 10 years, this test has gotten MUCH LESS PAINFULL. I use 26G concentric needles, which are teflon coated. They are more expensive, but do not hurt nearly what a monopolar felt like 15 years ago (the argument for using monopolars is less pain). In 5 years, not one patient has left a study uncompleted in my lab. Compare that with MRI or myelograms! I certainly do feel that some of the pain is related to testing anxiety, and more experienced physicians put patients at ease. I never tell people it won't hurt. In fact, I tell them it will hurt a lot, and >95% tell me "it wasn't so bad".

I am curious as to what part of healthcare you are involved in. Pain is created in almost every part of a hospital. It is a necessary evil in the practice of medicine.

 

[RUOkie]

Hilly, one more thing.

Guillian-Barre syndrome is a common diagnosis. It is diagnosed by EMG and can be fatal if left untreated. It (and other acute neuropathies) will put me in the EMG lab in the hospital on Sat or Sun or late at night.

 

[Ludicolo]

Ludicolo,
I woud be very interested if you could tell me where to find the studies looking at perception of pain before, during, and after EMG. I would also like you to link me to other patient blogs/forums that state that EMGs aren’t so bad.
Thanks in advance!
Hilly

Balbierz JM, et al. Differences in pain perception in women using concentric and monopolar needles. Arch Phys Med Rehabil 2006;87:1403-6.

Objective

To examine pain perception using concentric needle electrodes and monopolar needle electrodes in an all-female study group without underlying hand or arm pain complaints, using study subjects as their own controls.

Design

Prospective randomized study. Two muscles—the biceps and abductor pollicis brevis (APB)—were examined using both a concentric needle electrode and a monopolar needle electrode.

Setting

University community.

Participants

Eighty healthy female employees at the University of Utah and Primary Children’s Hospital were enrolled. All completed the study.

Interventions

Not applicable.

Main Outcome Measures

Pain scores. Posttest verbal analog pain scale (0−10) measures were obtained after each muscle was studied. A subset of subjects (n=51) was asked to identify needle preference after completion of the study.

Results

There was no significant difference in mean pain scores between the concentric needle electrode and the monopolar needle electrode (3.06 and 3.10, respectively; P=.803). The APB muscle was significantly more painful than the biceps muscle with both needle types (mean pain scores, 3.92 and 2.24, respectively; P<.001). In the subset of subjects asked to identify needle preference after completion of the study, 21 chose a concentric needle electrode and 30 a monopolar needle electrode. This difference was not statistically significant. However, verbal analog pain scores were lower with the needle preferred by each subject (P<.20).

Conclusions

There is no significant difference in mean pain scores reported between a concentric needle electrode and a monopolar needle electrode. Subjects were clear on the needle they preferred, and the pain scores reported for the less painful needle were lower than those for the other needle.

 

[Ludicolo]

Finsterer J. Effect of needle-EMG on blood pressure and heart rate. J Electromyogr Kinesiol 2004;14:283-6.

Though immediate pain is reported by nearly all patients undergoing needle-EMG, little is known about its cardiovascular risk from changes in blood-pressure or heart-rate. This study was thus conducted to investigate if, and to which degree, blood-pressure and heart-rate are influenced by needle-EMG. In 50 patients, 24 women, 26 men, aged 26-78 years, conventional needle-EMGs from 54 muscles were recorded. Pain was assessed on a verbal analogue pain-scale (1-10) and blood-pressure and heart-rate were measured before, during and after EMG. Mean pain-ratings before, during and after EMG were 0.8, 4.1 and 1.0, respectively. Mean systolic/diastolic blood-pressure was 144/87 mmHg before, 145/86 mmHg during and 144/87 mmHg after EMG. Mean heart-rate before, during and after EMG was 77, 77 and 78 beats/min, respectively. Systolic/diastolic blood-pressure increased above 145/85 mmHg in only 2/6 patients during EMG. The weak affection of blood-pressure and heart-rate by pain from needle-EMG was found in patients with and without hypertension. Mean blood-pressure, heart-rate and pain-ratings before, during and after EMG were independent of age, sex and muscle. The correlation between pain-ratings and blood-pressure and heart-rate was not significant. This study shows that needle-EMG moderately hurts but does not increase blood-pressure or heart-rate, irrespective of known arterial hypertension. Based upon these findings, the cardiovascular risk of needle-EMG from changes in blood-pressure or heart-rate is regarded negligibly low.

 

[Ludicolo]

After much internal debate, I won’t post the links to these other forums. You can search/read for yourself.

Because here’s my unsolicited, final $0.02 on this topic: don’t believe everything you read. Approach everything with a healthy dose of skepticism. Everyone’s got an opinion, and that’s all it is – an opinion. There will always be a few very vocal outliers that shout out that NCS/EMG is the Worst. Thing. Ever. I’ve had patients who cried simply when I taped the electrodes to them. But I’ve also had patients fall asleep on me, and had others actually request more shocks and needles. I had a patient last week (before she underwent the test, mind you) use the terms “waterboarding” and “Guantanamo”, based solely on what she had read on the Internet. She did fine. There is a wide range of responses to the test, depending on the patient, examiner, and pathology being examined. Bottom line - a skilled, well-trained physiatrist or neurologist will do their best to make the test as comfortable as possible.

 

[Hilly12]

Ludicolo,

thanks very much for the links. Both show that people rate the pain during EMG at about 4 on a scale of 1 - 10. This is not very high. But mind you, these tests were done on well-informed and special patients with no severe nerve dammage (so they were not tested to the maximum) by health care practicioners who were very well trained and did their best to make the tests as painless as possible.And of course the patients knowing they were participating in a study did not want to be cowards and rated their pain much much lower than it actually was.
If I imagine I would have been asked officially to rate the pain I experienced during the EMG/NCS studies which I underwent, I would probably not have put 9,5 (that's what I experienced), but would have put 4 or 5 at the maximum. Nobody who takes part in a study wants to be called a sissy.
At the moment I am being trained as Medical Assistant in the Department of Neurology of a large clinic, but am considering working somewhere else. I suppose there are departments where Medical Assistants don't have to do painful tests all the time.
Thanks, Ludicolo and RUOkie for your answers and for letting me share my anxieties with you. It was good to write about this problem which has been worrying me ever since I started being trained in the neurology department.
It was good to 'talk' to you.
Hilly

 

[PMR 4 MSK]

Having performed a few thousand EMGs, I can tell you, your response, and those of the others in the blog are one extreme end or the continuum. Like Ludicolo, I've had patients fall asleep, and I've had patients quit before the test was finished. Most do ok, somewhere in the middle.

In residency, we practiced on each other all the time. I'd estimate I've had several hundred EMGs. I'm a needle-phobe and I survived. I still test it out all the time on myself, and my nurse, when changing settings or setting up new protocols, or just to make sure it's working properly. My nurse laughs every time she gets shocked - they way her limb and body jumps she finds amusing.

The one constant I find is that if someone comes in quite anxious, deer-in-the-headlights eyes and first thing they ask is "Is this going to hurt?" or say "I heard this was going to hurt like hell", then hands down, yes, it's going to hurt. Anxiety level plays a huge role in the amount of pain one perceives from a given stimulus. THere is a direct relationship between anxiety and percieved pain levels from acute pain through chronic pain.

So when people come in and ask "Is this going to hurt?" I guess you and others in the blog are saying I should tell them, "Yes, this is quite possibly going to be the worst thing you will have ever experienced in your life, and carries significant risk or physicially and/or psychologically damaging you for life. In addition, it is unlikely it will make a difference in your healthcare and only serves the purpose of helping me make another BMW payment. The doctor who referred you for this test is either an uninformed idiot or a sadistic bastard. Now lets get started."

The answer to your career dilemma is clear, you are not cut out to do EMG.

I will add in another 2 cents that I believe the use of techs in NCS is doing a grave disservice to the patient and referring physician in all but the simplest patients. If the doc can't do them his/herself, they should not be doing the needle portion.

 

[Xardas]

I do EMG all the time on a lot of patients orthopedics sends to me because they need to figure out where nerve lesions in the arm are and if muscles are working or not. This makes a big difference if they are going to do reconstructive work or other types of procedures like tendon releases, etc. I doubt any other test can really give my referring docs the type of real time info that they need.

Like all procedures it has its pros and cons.

I will tell you technique counts a great deal towards patient comfort. Also, talking to the patient and being reassuring makes a huge difference. I talk my patients through the procedure constantly; it helps a lot with gaining their trust.

Nobody finds it comfortable (who would?) but I've never had a patient leave or stop the procedure from pain, and most thank me afterwards for the time to explain the procedure. I don't do the kid thing though; I can' timagine any kid liking it.

Most medical procedures are uncomfortable unfortunately, even blood draws. Actually I've had blood draws that were much more painful than an EMG needle being stuck in me.

 

[Hilly12]

PMR 4 MSK,

thanks for your reply. Neither me nor anyone else here has ever scared patients by telling them the procedure would be the worst they had ever had.
Perhaps you are right, I am not cut out to do EMG tests. But perhaps you are wrong and I should go on doing these tests, because I am compassionate, which so many people working in health care are not.
I am still undecided.

Xardas,

thanks as well for your reply. You are of course right that most medical procedures are uncomfortable. But don't compare EMGs to blood-darwing. For blood drawing the needle is inserted only once (provided you know how to do it), for EMG the needles are inserted 10, 20 or even 40 times. For blood drawing the needle is just inserted a few millimeters and withdrawn, for EMG it is inserted deep and moved around. Besides, the patient has to contract the muscle, which is the part when most patients cry out with pain.
And as to falling asleep, I saw that once. But it was an old very sick man who was under heavy sedation and who was almost unconscious when he was wheeled into the room. So many people on whom EMGs are done in a hospital get so many drugs that most of the time they are under sedation. You can't compare them to those who come on an outpatient basis. They are wide awake and none of them will fall asleep.

I have one more question to all of you:
Have any studies been done as to the percentage of EMD/NCS that were necessary? I mean, what would you say, how many of the tests you have done led to treatment or a change in treatment?
Most patients that were tested here were supposed to have polyneuropathy. Many were diabetic, so their sugar level was monitored anyway and the additional knowledge that they really had polyneuropathy didn't probably change anything in their treatment.
Would you agree with me that perhaps 70% or 80% of the EMD/NCS are unnecessary? Should doctors be advised to think twice before sending a patient to a neurologist to have these tests done? Shouldn't they ask themselves what would change if they didn't do the test? If the answer is 'nothing' shouldn't they refrain from having the patient undergo this 'uncomfortable' test?
I get the impression that too many doctors just send their patients here because they think the test, though uncomfortable, is harmless?
Is it really that harmless? Lasting pain, numbness, inflammation, does occur. Has anyone ever done studies on the long term effects of these procedures? I wonder how many polyneuropathies have been induced by these procedures, especially when a great many electric 'shocks' were applied and a great many needles were inserted?

Thanks for your answers.
Hilly

 

[RUOkie]

PMR 4 MSK,

thanks for your reply. Neither me nor anyone else here has ever scared patients by telling them the procedure would be the worst they had ever had.
Perhaps you are right, I am not cut out to do EMG tests. But perhaps you are wrong and I should go on doing these tests, because I am compassionate, which so many people working in health care are not.
I am still undecided.

Xardas,

thanks as well for your reply. You are of course right that most medical procedures are uncomfortable. But don't compare EMGs to blood-darwing. For blood drawing the needle is inserted only once (provided you know how to do it), for EMG the needles are inserted 10, 20 or even 40 times. For blood drawing the needle is just inserted a few millimeters and withdrawn, for EMG it is inserted deep and moved around. Besides, the patient has to contract the muscle, which is the part when most patients cry out with pain.
And as to falling asleep, I saw that once. But it was an old very sick man who was under heavy sedation and who was almost unconscious when he was wheeled into the room. So many people on whom EMGs are done in a hospital get so many drugs that most of the time they are under sedation. You can't compare them to those who come on an outpatient basis. They are wide awake and none of them will fall asleep.

I have one more question to all of you:
Have any studies been done as to the percentage of EMD/NCS that were necessary? I mean, what would you say, how many of the tests you have done led to treatment or a change in treatment?
Most patients that were tested here were supposed to have polyneuropathy. Many were diabetic, so their sugar level was monitored anyway and the additional knowledge that they really had polyneuropathy didn't probably change anything in their treatment. Medicare does NOT pay for Electrodiagnostics with a diagnosis of Diabetic Polyneuropathy.
Would you agree with me that perhaps 70% or 80% of the EMD/NCS are unnecessary? NO, I would NOT say that I do an UNNECESSARY test 70-80% of the time. Should doctors be advised to think twice before sending a patient to a neurologist to have these tests done? Shouldn't they ask themselves what would change if they didn't do the test? Yes, this should ALWAYS be asked when ordering ANY test. That is the basis of good medicine.If the answer is 'nothing' shouldn't they refrain from having the patient undergo this 'uncomfortable' test?
I get the impression that too many doctors just send their patients here because they think the test, though uncomfortable, is harmless?
Is it really that harmless? Lasting pain, numbness, inflammation, does occur. Has anyone ever done studies on the long term effects of these procedures? I wonder how many polyneuropathies have been induced by these procedures, especially when a great many electric 'shocks' were applied and a great many needles were inserted? NONE- Low voltage/amp current is very safe, and does not cause nerve damage in any way. There are numerous studies about this. There is an excellent position statement at the AANEM website regarding this.

Thanks for your answers.
Hilly

Hilly,

I have tried very hard to be civil in these responses. Physicians who do this type of medicine for a living take the responsibilties very seriously. We truly are ethical beings and do NOT do tests merely to make a new house or car payment. I had a patient sent to me just yesterday by a neurosurgeon for "non operative back pain and EMG if needed". I do NOT think the EMG was needed so it was not scheduled. I easily could have if I wanted to plan to buy a boat. When you make comments like those, you insult the members of this forum. I understand that was not (I hope) your intention. Others may not be so kind.

 

[Ludicolo]

Wait...I found another $0.02.

You are of course right that most medical procedures are uncomfortable. But don't compare EMGs to blood-darwing. For blood drawing the needle is inserted only once (provided you know how to do it), for EMG the needles are inserted 10, 20 or even 40 times. For blood drawing the needle is just inserted a few millimeters and withdrawn, for EMG it is inserted deep and moved around. Besides, the patient has to contract the muscle, which is the part when most patients cry out with pain.

There is your qualifying statement. Procedures are quick and can be relatively painless if someone is well trained and proficient. Patients are coached during the procedure on how to contract the muscle in order to minimize discomfort. 40 EMG sticks? Really? Can’t tell if you’re exaggerating or serious.

And as to falling asleep, I saw that once. But it was an old very sick man who was under heavy sedation and who was almost unconscious when he was wheeled into the room. So many people on whom EMGs are done in a hospital get so many drugs that most of the time they are under sedation. You can't compare them to those who come on an outpatient basis. They are wide awake and none of them will fall asleep.

The patients (plural) who fell asleep on me were all outpatients. Not necessarily doped up on pain meds either. I suspect that PMR 4 MSK’s patient was an outpatient as well.

I had a patient yesterday who thought the NCS part “tickled”.

I have one more question to all of you:

You actually ask several.

Have any studies been done as to the percentage of EMD/NCS that were necessary? I mean, what would you say, how many of the tests you have done led to treatment or a change in treatment?

None that I am aware of. However there are many examples (I gave you two earlier, and others have chimed in) where an EMG has confirmed a diagnosis, ruled out other potential causes of a problem, better localized a disease process, aids in prognosis of recovery or progression, and helps guide treatment. The classic EMG board question is that of a patient with polymyositis on steroids who is getting weaker. Is his myositis progressing or is he developing a steroid myopathy? His muscle enzyme levels are still elevated. What do you do next, doctor?

Most patients that were tested here were supposed to have polyneuropathy. Many were diabetic, so their sugar level was monitored anyway and the additional knowledge that they really had polyneuropathy didn't probably change anything in their treatment.

If their sugars are stable, and they have signs/symptoms of worsening neuropathy, can you truly chalk it up to diabetes? There are hundreds of different causes for neuropathy. EMG can define extent and pathophysiology of the neuropathy, which can help guide further appropriate diagnostic testing. And treatment.

Would you agree with me that perhaps 70% or 80% of the EMD/NCS are unnecessary?

No. And to come up with an arbitrary statistic like that is very dangerous and misleading.

Should doctors be advised to think twice before sending a patient to a neurologist to have these tests done? Shouldn't they ask themselves what would change if they didn't do the test? If the answer is 'nothing' shouldn't they refrain from having the patient undergo this 'uncomfortable' test?

Agree with you here, except doctors should think before sending patients to a neurologist or physiatrist to have these tests done.

I get the impression that too many doctors just send their patients here because they think the test, though uncomfortable, is harmless?
Is it really that harmless? Lasting pain, numbness, inflammation, does occur. Has anyone ever done studies on the long term effects of these procedures?

I refer you to the following review article: Al–Shekhlee A, et al. Iatrogenic complications and risks of nerve conduction studies and needle electromyography. Muscle Nerve 27;2003:517-26. You will find that risks and complications are quite minimal. Nevertheless they do exist, and we need to be aware of them. All procedures have risks and possible complications.

Doctors have been performing NCS/EMGs for decades. It is a proven, safe, well tolerated procedure. Move on.

I wonder how many polyneuropathies have been induced by these procedures, especially when a great many electric 'shocks' were applied and a great many needles were inserted?

You, my friend, have just stepped over into irrationality. You demonstrate a clear lack of understanding of neuropathophysiology that I cannot overcome (nor should I) on an internet forum for health care professionals. You say you are training to be a medical assistant. You are in health care, but by no stretch of the imagination are you a health care professional. You need to step back, overcome your own personal fears and biases, and approach things more objectively.

And the risk of nerve injury following venipuncture is higher than that following EMG. There have been no reported cases of nerve injury following EMG. There are several following venipuncture. Do a search.

 

[PMR 4 MSK]

In my experience, about 50% or EMGs are of the sort "Patient compains of numbness/weakness/pain. EMG to R/O nerve damage" meaning I have a patient with vague complaints or inconsistent exam and I cannot rule a nerve problem in or out and need help with the diagnosis. Most of these are from PCPs and orthos with less neuro training then I. I could likely give a clinical diagnosis, and the EMG serves to confirm it, but sometimes we are surprised. A presumed CTS is really a C6 or 7 radiculopathy. A cbital tunnel syndrome is really a Guyon's canal syndrome. There are numerous examples.

The other 50% are pure CYA. The referring doc knows the pt has CTS, wants to operate, but wants objective evidence prior to surgery. Or the spine surgeon is sure that the HNP @ 4-5 is causing the radicular symptoms, but wants further objective evidence before operating. Don't blame the electromyographer, blame our litigous society. Doctors CYA, and until lawsuit reform happens, we will continue to oblige them and perform these tests as requested.

 

[Xardas]

PMR 4 MSK,

Xardas,

thanks as well for your reply. You are of course right that most medical procedures are uncomfortable. But don't compare EMGs to blood-darwing. For blood drawing the needle is inserted only once (provided you know how to do it), for EMG the needles are inserted 10, 20 or even 40 times. For blood drawing the needle is just inserted a few millimeters and withdrawn, for EMG it is inserted deep and moved around. Besides, the patient has to contract the muscle, which is the part when most patients cry out with pain.
Hilly

Standard billing for 1 limb EMG is 5 muscles. That is 5 sticks. Most of my referrals are for 1 limb or 2 limbs. That's 5-10 sticks. Its not as painful for most patients that see me as you may think - I always ask them too.

If you are seeing someone get 40 sticks there is something wrong.

There are things I can try to convince you and things I cannot.

For me, my referral sources AND my patients appreciate the service that is done. At the end of the day there is little else I can ask for.