PTs doing EMG?

[Apollyon]

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My wife just had an EMG for persistent arm pain, and ortho referred her to "Dr. Smith". I thought he was a neurologist, but, when I saw the report, he was "PT, ScD", and did introduce himself as "Dr. Smith".

Is this common, for PTs to do EMGs and such? He did diagnostic, only, though - didn't do any nerve blocking or anything.

(And it was like pulling teeth to get my wife to do anything - I'm just a "dumb ER doc", but, man, it was getting to me!)

Thanks, fellas.

 

[lobelsteve]

Yes. Emg for arm pain? you should have phoned a friend first.

 

[Apollyon]

Yes. Emg for arm pain? you should have phoned a friend first.

I wasn't going to give you the whole story. That's a lot more than the clinical I gave. It was indicated. I didn't order the studies - I DID phone a friend!

But thanks for the response.

 

[lobelsteve]

Anyone can do EMG and as long as an MD or "qualified" person signs off it is all good. Except the data obtained.

 

[SSdoc33]

i think it is state-dependent. in some places, techs to the nerve conductions and a "doc" does the needle. other states, chiros do EMGs on anything with a pulse.

ive been doing them for 10 years (PM&R), and im still learning the nuances. sufficed to say that if it wasnt a PMR doc or a fellowship-trained neurologist, the EMG isnt worth the paper it is printed on.

steer patients away from this ortho scumbag b/c you can bet he is getting a piece of the revenue from the EMG

 

[jesspt]

My wife just had an EMG for persistent arm pain, and ortho referred her to "Dr. Smith". I thought he was a neurologist, but, when I saw the report, he was "PT, ScD", and did introduce himself as "Dr. Smith".

Is this common, for PTs to do EMGs and such? He did diagnostic, only, though - didn't do any nerve blocking or anything.

(And it was like pulling teeth to get my wife to do anything - I'm just a "dumb ER doc", but, man, it was getting to me!)

Thanks, fellas.

No, it's not common. It's my understanding that the most common place for this to occur is in the military setting where physical therapists often serve as "physician extenders."

 

[lobelsteve]

No, it's not common. It's my understanding that the most common place for this to occur is in the military setting where physical therapists often serve as "physician extenders."

But it is exceedingly common and done for physicians convenience more thsn patient care. Thats what CMS decided a few years ago. The vast majority of emg/ncv have been prrformed by non pmr or fellow trained neuro.

 

[bedrock]

Pts

i think it is state-dependent. in some places, techs to the nerve conductions and a "doc" does the needle. other states, chiros do EMGs on anything with a pulse.

ive been doing them for 10 years (PM&R), and im still learning the nuances. sufficed to say that if it wasnt a PMR doc or a fellowship-trained neurologist, the EMG isnt worth the paper it is printed on.

steer patients away from this ortho scumbag b/c you can bet he is getting a piece of the revenue from the EMG

agree with this. Any EMG not performed by PMR physician or fellowship trained neurologist is useless.

I would complain directly to orthopedic surgeon as he is offering substandard care to his patients. Unless he is embarrassed by a fellow physician, he will continue to order useless EMGS.

 

[jesspt]

But it is exceedingly common and done for physicians convenience more thsn patient care. Thats what CMS decided a few years ago. The vast majority of emg/ncv have been prrformed by non pmr or fellow trained neuro.

My point was that it is uncommon for PTs to do them in my experience. I've only ever come across two PTs who did them, both came from a military background.

In my neck of the woods, I've only ever seen them interpreted by an MD/DO-don'tt know who actually carries out the test.

 

[lonelobo]

My point was that it is uncommon for PTs to do them in my experience. I've only ever come across two PTs who did them, both came from a military background.

In my neck of the woods, I've only ever seen them interpreted by an MD/DO-don'tt know who actually carries out the test.

This is part of the problem, EMG should be a Dynamic test depending on the results seen during the test

 

[freddydpt]

While not many PT's pursue extra training or certification to perform EMG's, it is within the scope of practice. There is an "ECS" certification that PT's can obtain. They can perform the exam and provide preliminary interpretation but final interpretations are performed by a supervising physician. This is not a military exclusive clinical privilege.

As you can see here: http://www.abpts.org/Certification/ClinicalElectrophysiology/
not many PT's even pursue it as this is usually done out of interest rather than for money.

 

[Gauss]

some states allow it. seen it done by a PT. not sure a tech would do a better job. some docs would do worse

 

[SSdoc33]

While not many PT's pursue extra training or certification to perform EMG's, it is within the scope of practice. There is an "ECS" certification that PT's can obtain. They can perform the exam and provide preliminary interpretation but final interpretations are performed by a supervising physician. This is not a military exclusive clinical privilege.

As you can see here: http://www.abpts.org/Certification/ClinicalElectrophysiology/
not many PT's even pursue it as this is usually done out of interest rather than for money.

it is within scope of practice according to whom? the physical therapists themselves? uhh, no thanks.

i see a lot of credentials under your name, but i dont see PM&R or a electrophysiology fellowship.

there are lots of certifications out there..... doesnt mean much if you dont have the training to back it up.

 

[RM38]

I have been listening to some podcasts from the AANEM lately and probably the most important thing I heard one neurologist say was "never doubt the likelihood that the results of your test will bring the surgeon's knife down on the patient." This is why I agree that it is so important to have someone with proper training to not just do the basic test that I can probably teach about anyone to do, but to actually understand the results and what does and doesn't make sense when you are actually doing it. I am only a PGY-4, but have already seen several basic CTS screens become rather complicated studies due to an unexpected abnormality that somebody with poor knowledge of the subject would likely not pick up on. I have seen PT's that are pretty good at doing the NCS portion, but never the EMG which is really the most important part usually. Even then the Attending will sometimes redo portions and find something different that changes the results and that person has been doing it for a long time.

 

[pmrmd]

^Uh, you can make the case that CTS can be diagnosed by stims alone. Remember EDX testing is an extension of your history and physical examination. I can't stand doing the needle study for the patient referred by the hand surgeon with normal cervical exam, negative spurlings, MMT 5/5 in all myotomes except thenar weakness with normal HI (both C8/T1) and classic CTS symptoms. Quite often I tell the patient they should refuse that part of the test before I do it because it adds absolutely nothing.

 

[Baritonebass]

I disagree NCS/EMG is a diagnostic test for a symptom. R/o CTS is not the purpose of the study giving the referring physician information to make a clinical decision is the key. Summary of the study should state positive and negative findings. Mri spine could be done with T1 and T2 only but it's nice to have those other sequences to answer questions. Bottom line test is incomplete without EMG needle exam and if everyone is dying from your exam work on your technique try different needle(Teflon coated).

 

[SSdoc33]

I disagree NCS/EMG is a diagnostic test for a symptom. R/o CTS is not the purpose of the study giving the referring physician information to make a clinical decision is the key. Summary of the study should state positive and negative findings. Mri spine could be done with T1 and T2 only but it's nice to have those other sequences to answer questions. Bottom line test is incomplete without EMG needle exam and if everyone is dying from your exam work on your technique try different needle(Teflon coated).

thread is completely off topic, but the AANEM says you are wrong. for simple CTS, NCS alone is sufficient. the literature is pretty clear on this. personally, i do the needle on just about everyone, partially because i have found a few stay radiculopathies here and there, but mainly b/c i can bill for it. and i would bet PMRMD is much better at at the needle exam then you are. word to the wise: dont go looking for trouble if you dont know what you are talking about.

the REAL bottom line is that chiros and PTs are not advanced enough to know what study to do, how to do them, and how to interpret them

 

[jonnylingo]

Everyone wants a piece. Everyone wants to put needles in patients and bill for it. Everyone wants to be called "doctor". What's next, MA's doing EMG and ESI? Neuro/MSK phisiology and anatomy, not to mention pathology involved with EMG/NCS, is beyond PT training. Like SSdoc33, I'm still learning nuances of this study after 6 yrs doing this.

 

[nvrsumr]

Chiros can perform EMGs in CO. I sent a complaint to the state medical board and contacted AANEM. Known issue and nothing they can do. Had a neurosurgeon who was having a chiro come to the office and do his EMGs. I personally called him to let him know I would never send him another patient.

 

[Polynikes]

I disagree NCS/EMG is a diagnostic test for a symptom. R/o CTS is not the purpose of the study giving the referring physician information to make a clinical decision is the key. Summary of the study should state positive and negative findings. Mri spine could be done with T1 and T2 only but it's nice to have those other sequences to answer questions. Bottom line test is incomplete without EMG needle exam and if everyone is dying from your exam work on your technique try different needle(Teflon coated).

Incorrect. NCS alone are sufficient to establish a Dx of CTS. The needle adds nothing to your study in the overwhelming majority of cases.

 

[freddydpt]

it is within scope of practice according to whom? the physical therapists themselves? uhh, no thanks.

i see a lot of credentials under your name, but i dont see PM&R or a electrophysiology fellowship.

there are lots of certifications out there..... doesnt mean much if you dont have the training to back it up.

I've met Neurologists who told me that PM&R had no business performing EMG's. I disagree, but remember, there are biases against anyone and everyone out there. Most PT's have needle phobia. The ones who perform EMG's have had significantly extra training to perform them.

I am not PM&R and I haven't pursued an electrophysiology fellowship, however, I was offered a job where I was asked to perform EMG's and turned it down because I didn't feel it would have been ethical for me to perform them without a higher level of training. I've also been behind closed doors at many seminars and workshops organized and instructed by PM&R discussing the utility, reliability and validity of EMG/NCV. It's why I don't include it as a routine part of my practice for bread and butter radiculopathy or even CTS. I find my neuro/msk history and physical exam skills get me through 99% of patients (those H&P skills were learned in PT school - not in medical school - and only reinforced in pain fellowship).

Also, remember that PT's performing EMG/NCV function at the level of an EMG tech who has had MUCH less education/training.

 

[Taus]

I've met Neurologists who told me that PM&R had no business performing EMG's. I disagree, but remember, there are biases against anyone and everyone out there. Most PT's have needle phobia. The ones who perform EMG's have had significantly extra training to perform them.

I am not PM&R and I haven't pursued an electrophysiology fellowship, however, I was offered a job where I was asked to perform EMG's and turned it down because I didn't feel it would have been ethical for me to perform them without a higher level of training. I've also been behind closed doors at many seminars and workshops organized and instructed by PM&R discussing the utility, reliability and validity of EMG/NCV. It's why I don't include it as a routine part of my practice for bread and butter radiculopathy or even CTS. I find my neuro/msk history and physical exam skills get me through 99% of patients (those H&P skills were learned in PT school - not in medical school - and only reinforced in pain fellowship).

Also, remember that PT's performing EMG/NCV function at the level of an EMG tech who has had MUCH less education/training.

Except the tech isn't making the final interpretation of data, recs and signing the report.

 

[SSdoc33]

I've met Neurologists who told me that PM&R had no business performing EMG's. I disagree, but remember, there are biases against anyone and everyone out there. Most PT's have needle phobia. The ones who perform EMG's have had significantly extra training to perform them.

I am not PM&R and I haven't pursued an electrophysiology fellowship, however, I was offered a job where I was asked to perform EMG's and turned it down because I didn't feel it would have been ethical for me to perform them without a higher level of training. I've also been behind closed doors at many seminars and workshops organized and instructed by PM&R discussing the utility, reliability and validity of EMG/NCV. It's why I don't include it as a routine part of my practice for bread and butter radiculopathy or even CTS. I find my neuro/msk history and physical exam skills get me through 99% of patients (those H&P skills were learned in PT school - not in medical school - and only reinforced in pain fellowship).

Also, remember that PT's performing EMG/NCV function at the level of an EMG tech who has had MUCH less education/training.

#1, the neurologist is flat out wrong
#2, PTs who perform EMGs do not have "significantly extra training". they dont know what they dont know. how does a PT recognize a myopathy on electrodiagnosis. or multifocal motor neuropathy, or ALS, or myasthenia gravis. by definition, therapists are not trained in making diagnoses.
#3, you shouldnt get kudos for turning down a job for which you dont have the proper training. You are a radiologist, a physical therapist, and a pain doc. impressive resume, but what busines do you have performing and interpreting EMGs?
#4, nobody is talking about the utility performing EMGs. i also think they are overused. that is not the point
#5, neither PTs nor techs should be performing EMGs, so it doesnt matter who has "more" training.


this is why reimbursement for EMGs got killed. b/c crappy providers were overutilizing and putting out crappy studies. sure, there are PMR docs and neuologists who are also scumbags, but at least they have the credentials to back it up.

 

[geauxg8rs]

Speaking of non MDs putting needles in people. I had a fluoro tech tell me that they think they can easily do what we do. I just laugh and tell them to shoot a lateral.

This same tech started b itching out loud (not to me directly) that patients should not stop plavix for just a "shot.". She also works in the cath lab and thinks cardiac stuff is important and pain stuff is a joke. Again I just tell them to shoot a lateral.

 

[geauxg8rs]

Here I was thinking this thread was about patients doing their own EMGs? I thought PT= patient. I thought maybe someone invented a kit you fed ex the patient. Oh well, my mistake!

 

[freddydpt]

#1, the neurologist is flat out wrong
#2, PTs who perform EMGs do not have "significantly extra training". they dont know what they dont know. how does a PT recognize a myopathy on electrodiagnosis. or multifocal motor neuropathy, or ALS, or myasthenia gravis. by definition, therapists are not trained in making diagnoses.
#3, you shouldnt get kudos for turning down a job for which you dont have the proper training. You are a radiologist, a physical therapist, and a pain doc. impressive resume, but what busines do you have performing and interpreting EMGs?
#4, nobody is talking about the utility performing EMGs. i also think they are overused. that is not the point
#5, neither PTs nor techs should be performing EMGs, so it doesnt matter who has "more" training.

#1 I agree
#2 I respectfully disagree on the extra training. I do agree that many PTs and also MDs don't know what they don't know. The irony in how you worded "how does the PT recognize..." is interesting to me. It's almost the exact wording the neurologist said to me about PM&R. It shows you how little neurologists know about PM&R training.
#3 Not looking for kudos. I was using it as an example of how some PM&R physicians don't feel significant extra training is necessary to perform EMG's.
#4 The point of that statement was to say that H&P is more important than EMG. PT school revolves solely on H&P as a diagnostic tool. EMG is an adjunct.
#5 That's your opinion and you certainly have a right to it.

I hope no one is taking this conversation personally. There is a lot of cross over of practice privileges in all fields. Pain happens to cross over a lot!

 

[lonelobo]

#3 PMR physicians should not require extra training, as we are the only field that devotes 6 months to it during training.
#5 PTs should not be performing EMGs bottom line as they do not having the training or medical knowledge to interpret then