EMG/NCS and PTs

[fozzy40]

While I do not agree with PTs performing and interpreting EMG/NCS, I am curious and want to get your point of view. For those PTs who do use EMG/NCS in your practice, how and when do you decide to do perform EDX studies? How does it change your clinical practice?

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[Jarrodmac10]

While I do not agree with PTs performing and interpreting EMG/NCS, I am curious and want to get your point of view. For those PTs who do use EMG/NCS in your practice, how and when do you decide to do perform EDX studies? How does it change your clinical practice?

http://www.emgcongress.com/physicaltherapists.asp

If you don't mind me asking, why shouldn't PTs perform EMG/NCS? Aren't PTs trained to read and interpret EMG readings? My biomechanics professor once told me that PTs and PhDs use the same intramuscular techniques, of course further education is required.

 

[Fiveoboy11]

"The American Congress of Electroneuromyography (ACE) and the Section on Clinical Electrophysiology and Wound Management (SCEWM) have developed a position statement on the minimum standards of performance and interpretation of electromyography (EMG) and nerve conduction studies (NCS). The position statement has recently been reviewed and approved by the American Physical Therapy Association."
http://www.aptasce-wm.org/wp-conten...nimum_Standards_Policy_Edited_May_22_2012.doc

Above taken from the ECS section of the APTA
http://www.aptasce-wm.org/emg-practice-group/

 

[fozzy40]

From a research perspective, PTs have done A LOT of great work using both intramuscular and surface EMG targeting specific muscles and/or patterns of activation.

I have no doubt that collection of EMG/NCV data can be taught and done well without a medical background. The problem is electrodiagnostic studies are very sensitive but non-specific. What makes the test "more specific" is adding in the physical examination, understanding their medical and surgical history, medication history, etc. If you don't have a firm grasp on that, interpretation is nearly impossible. As far as I know, I do not believe electrodiagnosis is incorporated into the physical therapy curriculum.

 

[fozzy40]

"The American Congress of Electroneuromyography (ACE) and the Section on Clinical Electrophysiology and Wound Management (SCEWM) have developed a position statement on the minimum standards of performance and interpretation of electromyography (EMG) and nerve conduction studies (NCS). The position statement has recently been reviewed and approved by the American Physical Therapy Association."
http://www.aptasce-wm.org/wp-conten...nimum_Standards_Policy_Edited_May_22_2012.doc

Above taken from the ECS section of the APTA
http://www.aptasce-wm.org/emg-practice-group/

I've seen this but I still disagree.

A large part of the curriculum provided in the link above is learning the technical aspect of performing the test which is not the part I have a problem with. Payors from what I can tell really only care if you can perform the test not necessarily on the interpretation. They leave the clinical judgment of that you are ordering, designing, collecting data, and interpretation to the provider. Unfortunately, they don't seem to monitor appropriateness (until recently) and "correctness."

So, for those who do perform EDX, how do you incorporate it into your practice?

 

[Fiveoboy11]

From a research perspective, PTs have done A LOT of great work using both intramuscular and surface EMG targeting specific muscles and/or patterns of activation.

I have no doubt that collection of EMG/NCV data can be taught and done well without a medical background. The problem is electrodiagnostic studies are very sensitive but non-specific. What makes the test "more specific" is adding in the physical examination, understanding their medical and surgical history, medication history, etc. If you don't have a firm grasp on that, interpretation is nearly impossible. As far as I know, I do not believe electrodiagnosis is incorporated into the physical therapy curriculum.

Fair enough, at the same time I don't think it would be appropriate if a PT that was trained in EMG testing and was a ECS did the procedure and then sent that to a untrained physician in this realm. I don't recall seeing practice acts for physicians delineating this issue (PM&R vs internal medicine i.e.). I doubt a physician untrained in EMG interpretation could be more accurate than a PT that is trained with ECS even with the factors you mention above. And PT's know how to do a NMSK examination, we take medication and medical/surgical history into consideration but not with the knowledge level as someone like yourself.

It would be interesting to have a study on this to see accuracy of interpretation of say PM&R vs PT, ECS vs untrained physician specialty.

 

[Sheldon]

From a research perspective, PTs have done A LOT of great work using both intramuscular and surface EMG targeting specific muscles and/or patterns of activation.

I have no doubt that collection of EMG/NCV data can be taught and done well without a medical background. The problem is electrodiagnostic studies are very sensitive but non-specific. What makes the test "more specific" is adding in the physical examination, understanding their medical and surgical history, medication history, etc. If you don't have a firm grasp on that, interpretation is nearly impossible. As far as I know, I do not believe electrodiagnosis is incorporated into the physical therapy curriculum.

Fozzy,
I'm a bit biased here, but well-trained PT (residency, fellowship, board-certification) can definitely do an excellent physical examination, take into account the patient's medical and surgical history, and consider the medication history of the patient (and at the very least consult with a physician and/or pharmacist if there are any questions), AND then consider what the EMG/NCV results are telling them. EMG/NCV was taught in my graduate school in fact but the use of EMG/NCV is far beyond entry-level in my opinion. That being said, I'm quick to refer to the closet physiatrist when I think an electro-diagnostic study should be considered since my clinic (actually, the entire hospital) does not have the equipment to do so. Frankly, since I'm without an ECS board-certification, I personally feel I have no business even attempting (as I hope is reflected by first sentence).

I think that physicians should get to know the PTs who they interact with the most. Get to know their background, education, pursuit or completion of board-certification, residency, and/or fellowship. A PT who recognizes the need to assess a patient with EMG/NCV, let alone competently complete an electro-diagnostic study, (and can interpret and/or refer back the physician with the results) should be considered an invaluable ally (not a threat) in a patient's care and coordination of said care.

 

[Fiveoboy11]

That brings up an interesting follow-up question for you, interesting to me anyway. Why do you think MD/DO's do not traditionally put residency training after medical degree. I.e. in your case DO, PM&R?

 

[fozzy40]

well-trained PT (residency, fellowship, board-certification) can definitely do an excellent physical examination, take into account the patient's medical and surgical history, and consider the medication history of the patient (and at the very least consult with a physician and/or pharmacist if there are any questions), AND then consider what the EMG/NCV results are telling them.

I think you guys would do an excellent MSK examination for sure. I'm not as familiar with how detailed of a neurological examination most PTs do. However, taking a history is different from understanding the disease and medical course and how it relates to their diagnostic findings IMO. I was actually Pre-PT all throughout college and looked at a fair number of PT curriculum of mainly masters programs (DPTs were still rising at that point.) If that level of detail is now taught, that's definitely news to me.

EMG/NCV was taught in my graduate school in fact but the use of EMG/NCV is far beyond entry-level in my opinion. That being said, I'm quick to refer to the closet physiatrist when I think an electro-diagnostic study should be considered since my clinic (actually, the entire hospital) does not have the equipment to do so. Frankly, since I'm without an ECS board-certification, I personally feel I have no business even attempting (as I hope is reflected by first sentence).

Fascinating! How is EMG/NCV taught in PT school?

I think that physicians should get to know the PTs who they interact with the most. Get to know their background, education, pursuit or completion of board-certification, residency, and/or fellowship. A PT who recognizes the need to assess a patient with EMG/NCV, let alone competently complete an electro-diagnostic study, (and can interpret and/or refer back the physician with the results) should be considered an invaluable ally (not a threat) in a patient's care and coordination of said care.

I agree that physicians should get to know PTs and their background of training. Personally, I've been doing that for years.

I'm guessing no one here does them? From a PT perspective, I just don't see how an EMG/NCV would help them which is why I'm asking🙂

 

[fozzy40]

That brings up an interesting follow-up question for you, interesting to me anyway. Why do you think MD/DO's do not traditionally put residency training after medical degree. I.e. in your case DO, PM&R?

It does vary among providers. Some people will sign their name with their fellow or diplomate status i.e. fozzy40 DO, FABMR or whosamwhatzit MD, FACS.

 

[goyo1010]

I think you guys would do an excellent MSK examination for sure. I'm not as familiar with how detailed of a neurological examination most PTs do. However, taking a history is different from understanding the disease and medical course and how it relates to their diagnostic findings IMO. I was actually Pre-PT all throughout college and looked at a fair number of PT curriculum of mainly masters programs (DPTs were still rising at that point.) If that level of detail is now taught, that's definitely news to me.



Fascinating! How is EMG/NCV taught in PT school?


I agree that physicians should get to know PTs and their background of training. Personally, I've been doing that for years.

I'm guessing no one here does them? From a PT perspective, I just don't see how an EMG/NCV would help them which is why I'm asking🙂

If the what we learned and are currently learning concerning neuro evaluations (and for that fact, just plain neuro) in my program comes nowhere close to that of a med student's, then somebody shoot my face.

As for EMG/NCV in our program, our director explained to us why it was included in the curriculum. She said that it was not meant to train us in the technique, but simply to familiarize us with the process of performing and appreciate the complexities of reading and interpreting the data. It was in no way to try and make us competent to actually perform the technique. Our former professor (recently retired) was an ECS-certified PT, and his research revolved around electrodiagnostic studies. He also has a clinic which he also still runs where he uses EMV/NCV techniques to aid in diagnosing. He studied and uses H-reflex, multisegmental motor responses, blah blah mumbo jumbo (as of right now at least) to help in diagnosing. Honestly, when he taught neurophysiology, our class went crazy.

 

[_FNG_]

I am curious and want to get your point of view. For those PTs who do use EMG/NCS in your practice, how and when do you decide to do perform EDX studies?

All the ECS PTs that I know got their training through the military and I see this as the only practical area that PTs will get the necessary training (getting 2000+ hrs in practice area and at least 500 examinations--while observed by another trained professional). The military PTs have served a lot more roles than civilian PTs for awhile without apparent issues.

I was exposed to this area in one day of PT school which was a lost day in my opinion-I would be lost without the performing clinician's impressions. I think that time in school would have been better spent exposing students to something they are more likely to use such trigger point dry needling (in states that their practice pattern allows it). Most, if not all, require a physician referral and most times these physicians will refer to another physician for whatever reasons.

 

[atstudent]

The military PTs have served a lot more roles than civilian PTs for awhile without apparent issues.

Yes, but it was pointed out the other day that patients in the military are so much different than those in the general public...

 

[fozzy40]

Are there any military (active or former) PTs out there that can shed some light on clinical uses?

 

[atstudent]

Are there any military (active or former) PTs out there that can shed some light on clinical uses?

Fozzy, not the answer you're looking for, but I know my boss will use that information some. He'll occasionally make the recommendation to the doctor to do this or that test and it typically does get ordered if he makes the request. And he'll also look at the results and go through some of them with the patient. He doesn't perform the tests, but he'll look at the results (and probably the interpretation by the doctor) and use that to base his PT plan off of.

 

[_FNG_]

Yes, but it was pointed out the other day that patients in the military are so much different than those in the general public...

A military PT sees anybody on base from active duty to retired to family members. I think the population is more similar than different.

 

[Azimuthal]

A military PT sees anybody on base from active duty to retired to family members. I think the population is more similar than different.

+1. I don't have experience within the field (yet) but I was active and reserves. Military PT's see them all - not just "healthy" active-duty personnel.

 

[dg1984]

This is to Fozzy regarding neuro physical examination. Any PT worth anything can rattle off an upper quarter or lower quarter screen as quickly and as efficient as any physician. With a strong neuro background entering school I was astounded with the amount of neuro we got in PT school.

Our neurology professor (an MD and neurologist) reviewed the cirriculum for our entry level neuro class taken in the 1st year of PT school and was literally floored. She could not believe the amount of information we received and were held accountable for. This is a common misconception of PT school.

 

[fozzy40]

I cant speak for other physicians but there is no misconception here. Like I said, I looked at a lot of PT programs since I was Pre-PT.

If anyone does EMG or NCVs, please feel free to share your clinical experience. I truly am interested.

 

[dg1984]

Looked at isn't doing.

 

[fozzy40]

Looked at isn't doing.

Looked at means I'm aware of the type of training. The fact that I know what the curriculum looks like puts me probably ahead of 99% of my counterparts. But, yes...put me in the box of the ignorant.

 

[dg1984]

Looked at means I'm aware of the type of training.The fact that I know what the curriculum looks like puts me probably ahead of99% of my counterparts. But, yes...put me in the box of the ignorant.

Let's get to the real issue. Is your worry truly about patients receiving poor care? OR do your fear PTs practicing a critical aspect of PM&R care. I can honestly see the fear among physicians. If PTs can perform EMG/NCS (which in some states they already can) and if PTs can order x-rays and MRIs (which in many countries is the case), where does that leave PM&R? Injections (botox,intramuscular, epidurals etc) and meds? So obviously still necessary, but that could cause some problems.

We are so far from this being an issue, but I really think that a lot of PT hostility on this site stems from one of two things.

1. Physicians still view us as techs.

2. Physicians who know about PT or have been in contact with some very good PTs are a little intimidated when they realize the extent of our knowledge base.

I will end by saying that in general I agree with Fozzy. He is a much needed voice of reason on this site, but I really don't see where he is coming from in this discussion. PTs in many states (including Delaware) routinely conduct safe and effective EMG/NCV studies. It requires a good amount of training an is NOT an entry level skill, but as with most things in PT, what separates you is NOT entry level skills. There is no harm to the patient and they are fully able to make sense of the data. What is the problem?

 

[Fiveoboy11]

Let's get to the real issue. Is your worry truly about patients receiving poor care? OR do your fear PTs practicing a critical aspect of PM&R care. I can honestly see the fear among physicians. If PTs can perform EMG/NCS (which in some states they already can) and if PTs can order x-rays and MRIs (which in many countries is the case), where does that leave PM&R? Injections (botox,intramuscular, epidurals etc) and meds? So obviously still necessary, but that could cause some problems.

We are so far from this being an issue, but I really think that a lot of PT hostility on this site stems from one of two things.

1. Physicians still view us as techs.

2. Physicians who know about PT or have been in contact with some very good PTs are a little intimidated when they realize the extent of our knowledge base.

I will end by saying that in general I agree with Fozzy. He is a much needed voice of reason on this site, but I really don't see where he is coming from in this discussion. PTs in many states (including Delaware) routinely conduct safe and effective EMG/NCV studies. It requires a good amount of training an is NOT an entry level skill, but as with most things in PT, what separates you is NOT entry level skills. There is no harm to the patient and they are fully able to make sense of the data. What is the problem?

👍

The problem is the medical community, at least in the US, has an "understanding" of what a PT is/knows/does from their "training" with regard to PT by a non PT. From that, anything that doesn't fall within that realm of their understanding is out of our scope. It has everything to do with turf, lack of understanding, money, politics, ego. It has nothing to do with science, reasoning or evidence.

On a side note, PT's with extra training now have unlimited medication prescription rights in the UK, as of July of this year. It looks to me like the medical community over there is in favor of it too.

http://www.csp.org.uk/news/2012/07/...ves-uk-physios-world-first-prescribing-rights

 

[fozzy40]

Let's get to the real issue.

Here is the real issue: see below. This was my original question. This is the real issue. Not sure why everyone thinks I have a secondary motive.

how and when do you decide to do perform EDX studies? How does it change your clinical practice?

The problem is the medical community

That's about as accurate as me saying the problem is the PT community.

There is no harm to the patient and they are fully able to make sense of the data. What is the problem?

Not really the point of post but since you brought it up: http://www.ncbi.nlm.nih.gov/pubmed/15905653

where does that leave PM&R?

Well there is acute inpatient rehabilitation medical management of acute coronary artery syndromes, stroke, pulmonary embolism, acute heart failure, X-ray/MRI/CT interpretation, ACLS, neurogenic bowel/bladder care, wound care, family/patient education regarding active medical issues and prognosis, etc. So yeah, there is plenty of things for us to do.

Bottom line, as far as I'm concerned you guys can prescribe medications, perform EMG/NCVs, perform epidural injections, perform open heart surgery, colonoscopies. What ever you want.

I just to know the answer to my question.

 

[Fiveoboy11]

Here is the real issue: see below. This was my original question. This is the real issue. Not sure why everyone thinks I have a secondary motive.




That's about as accurate as me saying the problem is the PT community.

Not so much
Not really the point of post but since you brought it up: http://www.ncbi.nlm.nih.gov/pubmed/15905653
Nice reference. So, I suppose you're in favor of banning non MSK physicians from diagnosing MSK conditions since PT's are more accurate?

Well there is acute inpatient rehabilitation medical management of acute coronary artery syndromes, stroke, pulmonary embolism, acute heart failure, X-ray/MRI/CT interpretation, ACLS, neurogenic bowel/bladder care, wound care, family/patient education regarding active medical issues and prognosis, etc. So yeah, there is plenty of things for us to do.

We're aware of that

Bottom line, as far as I'm concerned you guys can prescribe medications, perform EMG/NCVs, perform epidural injections, perform open heart surgery, colonoscopies. What ever you want.

Nice extrapolation there. We're not chiropractors so we have no interest, and fully understand doing a lot of the above is inappropriate including injections, etc. We would just like to do what our training trains us to do, if that's ok with you?

By the way, a lot of your PM&R buddies think they know PT, evidenced by their billing for it.

I just to know the answer to my question.

I wanted to add something else to above bolded comments. To me, the study cited above means that PT's, and podiatrists, should not be interpreting EMG studies on patients with diabetes who have symptoms consistent with possible peripheral neuropathy.

 

[fozzy40]

To me, the study cited above means that PT's, and podiatrists, should not be interpreting EMG studies on patients with diabetes who have symptoms consistent with possible peripheral neuropathy

Gotcha. So only do studies who are completely healthy. There are plenty of times where medical diagnoses that are first discovered under EMG/NCV.

Since I'm not really getting an answer to my question, can someone suggest somewhere I can talk with therapists that do studies? I talked with some local therapists but none of them perform them. I tried the RehabEdge.com forum but I'm having a problem accessing the forum.

Any other suggestions?

 

[Fiveoboy11]

Gotcha. So only do studies who are completely healthy. There are plenty of times where medical diagnoses that are first discovered under EMG/NCV.

Are you arguing that no PT should ever do an EMG because of this one study? In the abstract it does state that the patient's in the study had been identified as having diabetes prior to testing. The test was also retrospective, from 1998. The PT profession has come a long way in just the small period of time since then.

I was trying to find the full text of this study to see what training the PT's included in this study underwent, but unable to get it right now. I'm going to request it from my alma matter and then I'll post it here so we know all the facts.

Since I'm not really getting an answer to my question, can someone suggest somewhere I can talk with therapists that do studies? I talked with some local therapists but none of them perform them. I tried the RehabEdge.com forum but I'm having a problem accessing the forum.

President of ECS section of APTA:

Robert Sellin, PT, DSc, ECS, [email protected]



Any other suggestions?

.

 

[fozzy40]

Are you arguing that no PT should ever do an EMG because of this one study? In the abstract it does state that the patient's in the study had been identified as having diabetes prior to testing. The test was also retrospective, from 1998. The PT profession has come a long way in just the small period of time since then.

Not just because of this one study but because there needs to be a medical background to interpret the findings. From the article:

"Nonphysician providers who did not recognize polyneuropathy performed almost exclusively EMG testing (>90%) at the expense of nerve conduction studies."

An EDX study is useless without both parts. This is simply just incorrect to do studies like this.

I don't doubt anybody's ability to perform the test. The interpretation needs a medical foundation in order to give meaningful recommendations to guide treatment. It's not a black and white test unfortunately. Trust me, I wish it were.

 

[Fiveoboy11]

Here is the full text.

Some issues from the study that I see right away. There is no information about the PT's who performed the studies, including what kind of training they had, and whether they were ECS certified (doubtful). Wouldn't doubt that a handful or less of PT's did all of the 423 EMG/NCS studies for the entire year of 1998, and of those I wouldn't be surprised if they were not ECS. It also needs to be taken into consideration that it is often frowned upon for a PT to make a medical diagnosis, so that in itself will skew the results. Perhaps if the study were controlled in a prospective manner it would yield different results, especially if PT's were instructed that they are allowed to diagnose medically. Many PT's have the idea that formally diagnosing a problem medically is inappropriate, not to mention illegal in some states. As far as the 90.8% of patients without polyneuropathy getting only EMG studies, are PT's in the state of WI allowed to order a NCS study? Who referred the patient's to these PT's for these studies? Also, of the patients who were diagnosed with polyneuropathy by PT's, 55.5% had EMG, and 44.5% had NCS. Of the orthopedists and chiropractors in the study, 0 patient's were diagnosed with polyneuropathy. Further, what is the gold standard to confirm the diagnoses of neuropathy were correct? The physicians have a higher rate of ICD9 code usage for neuropathies, yet in what way was the diagnoses made confirmed?

To me, it is often quite obvious from the subjective portion of an evaluation that a patient likely has diabetic neuropathy. Perhaps the patients seen by the PT's were not formally evaluated in addition to the studies performed. None of this information is contained within this study. This study was published in 2005, but as far as I'm concerned the study was performed in 1998. The PT profession is rapidly changing. All this study has is ICD9 stats as if that proves cause and effect. The fact that neuropathy was a less common ICD9 code does not mean neuropathy wasn't recognized or diagnosed. PT's typically use a limited amount of ICD9 codes. I have seen neuropathy many times, that may or may not have been diagnosed. I have never used it as a ICD9 code.

Anyone else have thoughts?

 

[fozzy40]

It also needs to be taken into consideration that it is often frowned upon for a PT to make a medical diagnosis, so that in itself will skew the results.

You bring up some good points/questions. The one in quotes is my main concern.

Thanks for the article!

 

[jesspt]

Gotcha. So only do studies who are completely healthy. There are plenty of times where medical diagnoses that are first discovered under EMG/NCV.

Since I'm not really getting an answer to my question, can someone suggest somewhere I can talk with therapists that do studies? I talked with some local therapists but none of them perform them. I tried the RehabEdge.com forum but I'm having a problem accessing the forum.

Any other suggestions?

Fozzy,

Oregon has no PTs who have board certification in Clinical Electrophysiology. So, It's not overly surprising that you don't find any local PTs who perform the test.

As noted in previous posts, it is incredibly rare for PTs outside of the military setting to do EMGs/NCV studies. In my experience, those PTs that I have encountered that do indeed perform these studies were either active military personell, or were retired from the military.

 

[Fiveoboy11]

I sent an e-mail to Robert Sellin, PT (pres of ECS section) about this article. Here is his response.

Fiveoboy11 -- This study is clearly flawed. The person who has done the best job of analyzing the Dilligham study is Elaine Armantrout. I am sending this email to her because I believe she has some data from an article she wrote that counters this article. I am pushed for time right now but would love to discuss more. Let's see if Elaine has anything handy she might send you.

bob


Robert A. Sellin, PT, DSc, ECS

---

Once I get any info from Elaine I will post it here.

 

[fozzy40]

Great! The study to me doesn't look anymore flawed than most retrospective studies. What I take away from is that there is a difference between physician and nonphysician EDxs...an important difference though in my opinion.

 

[dg1984]

Here is the full text.

Some issues from the study that I see right away. There is no information about the PT's who performed the studies, including what kind of training they had, and whether they were ECS certified (doubtful). Wouldn't doubt that a handful or less of PT's did all of the 423 EMG/NCS studies for the entire year of 1998, and of those I wouldn't be surprised if they were not ECS. It also needs to be taken into consideration that it is often frowned upon for a PT to make a medical diagnosis, so that in itself will skew the results. Perhaps if the study were controlled in a prospective manner it would yield different results, especially if PT's were instructed that they are allowed to diagnose medically. Many PT's have the idea that formally diagnosing a problem medically is inappropriate, not to mention illegal in some states. As far as the 90.8% of patients without polyneuropathy getting only EMG studies, are PT's in the state of WI allowed to order a NCS study? Who referred the patient's to these PT's for these studies? Also, of the patients who were diagnosed with polyneuropathy by PT's, 55.5% had EMG, and 44.5% had NCS. Of the orthopedists and chiropractors in the study, 0 patient's were diagnosed with polyneuropathy. Further, what is the gold standard to confirm the diagnoses of neuropathy were correct? The physicians have a higher rate of ICD9 code usage for neuropathies, yet in what way was the diagnoses made confirmed?

To me, it is often quite obvious from the subjective portion of an evaluation that a patient likely has diabetic neuropathy. Perhaps the patients seen by the PT's were not formally evaluated in addition to the studies performed. None of this information is contained within this study. This study was published in 2005, but as far as I'm concerned the study was performed in 1998. The PT profession is rapidly changing. All this study has is ICD9 stats as if that proves cause and effect. The fact that neuropathy was a less common ICD9 code does not mean neuropathy wasn't recognized or diagnosed. PT's typically use a limited amount of ICD9 codes. I have seen neuropathy many times, that may or may not have been diagnosed. I have never used it as a ICD9 code.

Anyone else have thoughts?

Very well said.

Furthermore, I don't have too much of an interest to perform these tests in the future, but I think it should be an option for PTs. Let's get back to the PE and the diabetic polyneuropathy issue. From my experience you generally see more of a stocking glove distribution of symptoms vs. symptoms that are localized in a specific nerve pattern (ulnar, median radial) or dermatome if coming from the c/s. I understand that patients don't usually present this clearly BUT UNDERSTAND THIS...

Our job in PT is to see if we can recreate the patients exact symptoms via neural tension, joint mobility or muscle work. If we can not reproduce the patients pain, and they don't improve from our treatment I am more than happy to refer them to a physician to rule out something more systemic in nature. From our stand point EMG or NVC studies do NOT tell us what the pain producing structure is. It will tell us if there is an UMN or LMN dysfunction, the overall speed of nerve conduction and any pathology concerning the nerve; however, it still by itself does not determine if a nerve is a pain producing structure. Upper limb tension tests or cervical spine compression WILL allow us to determine if the neural tension is a pain producer.

I did my last affil in an upper extremity clinic. Many patients were sent for EMG/NCV studies, but the data was of little use in the outpatient setting. Generally the findings were negative, but the patient would present with significant neural tension, often times as their primary pain generator.

The concept of neural tension (tested mainly with Slump, straight leg raise for LE and upper limb tension for UE) is why I think the PTs tend to get this stuff a little better than the rest. And we treat it safely without medication and need for further testing (i.e EMG/NCV, MRI etc.)

 

[fozzy40]

Our job in PT is to see if we can recreate the patients exact symptoms via neural tension, joint mobility or muscle work. If we can not reproduce the patients pain, and they don't improve from our treatment I am more than happy to refer them to a physician to rule out something more systemic in nature. From our stand point EMG or NVC studies do NOT tell us what the pain producing structure is. It will tell us if there is an UMN or LMN dysfunction, the overall speed of nerve conduction and any pathology concerning the nerve; however, it still by itself does not determine if a nerve is a pain producing structure. Upper limb tension tests or cervical spine compression WILL allow us to determine if the neural tension is a pain producer.

I did my last affil in an upper extremity clinic. Many patients were sent for EMG/NCV studies, but the data was of little use in the outpatient setting. Generally the findings were negative, but the patient would present with significant neural tension, often times as their primary pain generator.

The concept of neural tension (tested mainly with Slump, straight leg raise for LE and upper limb tension for UE) is why I think the PTs tend to get this stuff a little better than the rest. And we treat it safely without medication and need for further testing (i.e EMG/NCV, MRI etc.)

Absolutely agree with what you said here.

 

[fozzy40]

I wanted to update this thread after reviewing a report by a PT. Very interesting since it's been 7 years and I have a lot more experience now.

My personal experience over the years is that the reports from PTs who perform NCS/EMG are general subpar and sometimes flatly just incorrectly done or reported. I've worked in both the civilian and now the military sector where PTs are likely the main folks doing electrodiagnostic studies. Some in particular have been doing it much longer than I have and are technically proficient in performing the test. However as knowledgeable as they are, it's quite clear the medical background needed is not there to interpret the studies. Carpal tunnel and ulnar neuropathy studies I've seen are good enough but past that the reports I've seen have not been good.

I'm not trying to troll but give some real world feedback. If you are going to do these studies, make sure you know what you're doing with some degree of verification. I suspect that these folks have done many of these studies and just have never received the proper feedback during their training.

 

[Fiveoboy11]

I wanted to update this thread after reviewing a report by a PT. Very interesting since it's been 7 years and I have a lot more experience now.

My personal experience over the years is that the reports from PTs who perform NCS/EMG are general subpar and sometimes flatly just incorrectly done or reported. I've worked in both the civilian and now the military sector where PTs are likely the main folks doing electrodiagnostic studies. Some in particular have been doing it much longer than I have and are technically proficient in performing the test. However as knowledgeable as they are, it's quite clear the medical background needed is not there to interpret the studies. Carpal tunnel and ulnar neuropathy studies I've seen are good enough but past that the reports I've seen have not been good.

I'm not trying to troll but give some real world feedback. If you are going to do these studies, make sure you know what you're doing with some degree of verification. I suspect that these folks have done many of these studies and just have never received the proper feedback during their training.

After working with physicians for over 11 years I have to admit I have a strong mistrust for them with regard to what they do and say that relates in any way to physical therapy. So I guess I'll be polite for once and leave it at that.