EMG efficiency tips

[JFS]

First year in practice in an ortho/pain practice. I do up to 10 EMGs per week and trying to figure out how to become more efficient at them without adding on a tech. Currently booking 20 minutes for single limb and 40 minutes for two limb EMGs. A rare complicated EMG will slow me down but generally sticking well within those numbers. Does anyone have advice on how to get faster than this without sacrificing quality, specially for lower extremity studies?

Some basics that helped me with speed have been disposable leads, concentric needles, doing upper extremities sitting upright (surprisingly no issues so far getting good elbow angle and positioning for ulnar studies). Lower extremities remain the bane of my existence, I have patients lay on one side and then turn over to other side, overall due to multiple factors seems like I do these at 50% of the speed of upper extremity studies.

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[JBM16BYU]

PM&R/Neuromuscular: In my honest (and probably blunt, sorry) opinion, I think going any faster than that is going to sacrifice quality of the study. You are already doing things to optimize efficiency (disposable leads, concentric needles, etc.). There is a reason that a certain number of NCS are suggested for evaluation of certain conditions. There is also a reason that certain needle EMG protocols are suggested to help rule in or rule out particular conditions with particular presentations. This would be including a short history and physical. Going any faster will likely decrease the quality of your EMGs. I’m assuming, in that 20 minutes for a single limb, you’re also not performing neuromuscular ultrasound in conjunction with the NCS and EMG, which would take up more time, yes, but adds benefit to particular diagnoses.

 

[JFS]

PM&R/Neuromuscular: In my honest (and probably blunt, sorry) opinion, I think going any faster than that is going to sacrifice quality of the study. You are already doing things to optimize efficiency (disposable leads, concentric needles, etc.). There is a reason that a certain number of NCS are suggested for evaluation of certain conditions. There is also a reason that certain needle EMG protocols are suggested to help rule in or rule out particular conditions with particular presentations. This would be including a short history and physical. Going any faster will likely decrease the quality of your EMGs. I’m assuming, in that 20 minutes for a single limb, you’re also not performing neuromuscular ultrasound in conjunction with the NCS and EMG, which would take up more time, yes, but adds benefit to particular diagnoses.

I appreciate honest opinions! I’ve seen others do garbage 15 minute two limb EMGs and that’s not my plan. I do more than average number of studies for upper extremities (I like comparatives, 2 channel FDI/ADM) and follow standard AANEM guidelines with (quick) H&P, appropriate limb positioning and such, so I’m not trying to cut on that. Most of my referrals are for CTS/CuTS/radiculopathy/peripheral polyneuropathy, and if neuropathy or radiculopathy I’ll end up managing them myself majority of the time.

I’ve been curious about NMUS and following literature for it, but I’d be nervous to integrate it for now. Hard enough to get paid in full for NCS/EMG, so adding an extra charge would make me paranoid.

Anyone do lowers with patient supine or sitting?

 

[j4pac]

What does your root screen look like?

 

[TheGreatestTrochanter]

Little thing that can speed things up for UE EMG -measure everything out before you start, better than stopping and grabbing the tape multiple times.

I know of someone (highly respect this person) that also has high confidence in measuring 8 and 14cm with his hand and does that. If he is getting even borderline results he goes back with official measurements. I don't do that but in all honesty if you are off by a cm it doesn't change the latency much at all. So I see the merits but it feels wrong. He does save a ton of time like that.

 

[JFS]

What does your root screen look like?

Biceps, Triceps, extensor digitorum, FDI, APB. Cervical paraspinals <5% if only 1 muscle positive.

Vastus lateralis, tib anterior, peroneus longus, lateral gastroc, short head biceps. Paraspinals <5% if only 1 muscle positive.

If bilateral upper or bilateral lower generally only screening the most symptomatic side and moving to other side only if initial screen positive. If slam dunk CTS or CuTS then just needling APB and FDI.

The screens don’t generally take me more than 2 minutes per limb unless there’s a lot going on

 

[JFS]

Little thing that can speed things up for UE EMG -measure everything out before you start, better than stopping and grabbing the tape multiple times.

I know of someone (highly respect this person) that also has high confidence in measuring 8 and 14cm with his hand and does that. If he is getting even borderline results he goes back with official measurements. I don't do that but in all honesty if you are off by a cm it doesn't change the latency much at all. So I see the merits but it feels wrong. He does save a ton of time like that.

That’s hilarious to think of doing but makes a ton of sense. I’m too anal about my measurements so I think I’d end up measuring anyways. I do measurements at the beginning and only takes me 15-30 seconds so I feel ok with that use of time.

 

[JFS]

How does everyone position their patients for lower extremity studies?

 

[JBM16BYU]

A few things to help:
1. Upper limb root screen: I would suggest taking out APB (painful and doesn’t add a lot to the carpal tunnel diagnosis since you can grade it’s severity based on NCS) and replacing with pronator teres. It’s a great muscle that is also median nerve but its roots are C6-7, so it can help you with radiculopathy level.
2. Upper limb root screen: Given you are already checking triceps, I also would switch the extensor digitorum (since you already have a radial-innervated muscle with triceps) and instead needle deltoid. Needling deltoid will give you an axillary innervated muscle, complete the 5 major terminal nerves, and gives you another posterior cord muscle for your plexus cases.
3. Lower limb root screen: I would suggest switching short head of biceps femoris (which I only personally use if trying to determine common fibular neuropathy localization) and instead add in either TFL (my preference since you can perform supine still) or Gluteus medius. Both of these are L5 predominant nerve root and superior gluteal nerve, which does not come off of sciatic. Your current screen, besides vastus lateralis, are all technically sciatically-derivative muscles. You need muscles that are different peripheral nerves but same root to confirm radiculopathy, which means something before sciatic.
4. You are performing the entire root screen in the limb in 2 minutes? I would argue that is way too quick to do it justice.
5. Positioning for lower limbs: NCS for fibular motor and tibial motor supine, side lying for sural sensory. EMG: I personally do as many as I can supine, then go sidelying for lumbar paraspinals, gluteus medius, gluteus Maximus, or any hamstring muscle.
6. Unless the patient has had recent (within the last few years) posterior-approach lumbar or cervical spine surgery, you should probably be doing paraspinal muscles.

 

[JFS]

A few things to help:
1. Upper limb root screen: I would suggest taking out APB (painful and doesn’t add a lot to the carpal tunnel diagnosis since you can grade it’s severity based on NCS) and replacing with pronator teres. It’s a great muscle that is also median nerve but its roots are C6-7, so it can help you with radiculopathy level.
2. Upper limb root screen: Given you are already checking triceps, I also would switch the extensor digitorum (since you already have a radial-innervated muscle with triceps) and instead needle deltoid. Needling deltoid will give you an axillary innervated muscle, complete the 5 major terminal nerves, and gives you another posterior cord muscle for your plexus cases.
3. Lower limb root screen: I would suggest switching short head of biceps femoris (which I only personally use if trying to determine common fibular neuropathy localization) and instead add in either TFL (my preference since you can perform supine still) or Gluteus medius. Both of these are L5 predominant nerve root and superior gluteal nerve, which does not come off of sciatic. Your current screen, besides vastus lateralis, are all technically sciatically-derivative muscles. You need muscles that are different peripheral nerves but same root to confirm radiculopathy, which means something before sciatic.
4. You are performing the entire root screen in the limb in 2 minutes? I would argue that is way too quick to do it justice.
5. Positioning for lower limbs: NCS for fibular motor and tibial motor supine, side lying for sural sensory. EMG: I personally do as many as I can supine, then go sidelying for lumbar paraspinals, gluteus medius, gluteus Maximus, or any hamstring muscle.
6. Unless the patient has had recent (within the last few years) posterior-approach lumbar or cervical spine surgery, you should probably be doing paraspinal muscles.

This was awesome, thank you for all the detail!

1. I agree I prefer to not do the APB but my local hand surgeons prefer it, my technique is similar enough in pain to FDI that I don’t mind too much. I used to do PT instead but EDC was frankly faster.
2. Good thought, I’ll mull that one over. I will say I do expand significantly if thinking plexopathy.
3. Great points, I’ll make that change.
4. All fair. I disagree but value your perspective. On the pain forums we are having conversations on efficiency while staying true to good patient care so I think it will be valuable to others here to get these perspectives. I’ve seen different physicians doing 30 second 5-6 muscle screens to 10 minute 5-6 screens for the same muscles, so I understand if some consider 2 minutes too fast. 1 minute is my personal “too fast” cutoff.
5. May try full supine with bend at the knees to capture sural based on part of your response
6. I agree there’s good data supporting the use of paraspinals and I’m a big proponent. Having said that, the time required to appropriately position and ensure no baseline activity isn’t worth it to me in the context of my practice (it would add 2 more minutes per screen). I do utilize it when the clinical picture is less clear or when only one peripheral muscle is positive on testing. I have the luxury that I’m doing interventional spine and communicate closely with referral sources. This means that patients are being sent with targeted questions with spine MRIs already completed, and I discourage hunting expeditions that I used to see PCPs sending in training.

 

[TheGreatestTrochanter]

I find if the rest of the root screen is normal, paraspinal muscles are not all that helpful except in select cases. Often once the root screen is done, especially if you have an MRI and a good H/P, you already know and I find those just add pain and no useful info. I know thats not academically as sound and some of my EMG attendings I had in training would object, but life outside academia I don't think i've missed much with mostly not performing paraspinals.

 

[sdnuser001]

I do lower extremity with patient supine but have to switch them prone halfway though to do sural and h reflex which can sometimes be annoying.

Still, I have 30 minutes slots for all EMGs and tend to almost always do bilateral

How does everyone position their patients for lower extremity studies?

 

[MusicalMed]

Hi all, appreciate this thread! I unfortunately feel as a new attending (just started a few weeks ago) I’m WAY slower and would love to be fast enough to crank out a single limb in 20 minutes and two in 40, but I have a hard time finishing most 2 limbs in under 60 minutes. Also I feel my documentation adds challenges, as where I have to enter in all my numbers manually into a separate computer. I know I need cut history time, need to be better at politely cutting people off. Any other tips you all have for someone like myself?