ELECTRODIAGNOSTIC MEDICINE
OBJECTIVES BEGINNER
Patient Care
Residents are expected to:
Perform a comprehensive electrodiagnostic evaluation of each patient and to provide a
concise diagnosis and plan for further treatment
Describe the variety of conditions frequently encountered in electrodiagnostic medicine
Determine a logical approach of testing for each individual condition
Discuss the electrophysiology of common normal and abnormal findings encountered in
Electromyography and Nerve conduction studies (EMG/NCS)
Develop an extensive knowledge base of neuromuscular anatomy
Familiarize oneself with the EMG/NCS machine and be able to troubleshoot common
errors and problems encountered in EMG/NCS testing
Identify patient and family concerns associated with the testing process as well as the
results
Define the patient safety issues with EMG/NCS including proper maintenance, inspection
of the machine, and risk of blood borne pathogen exposure
Obtain appropriate informed consent for the procedure
Respect that the patient is experiencing an uncomfortable procedure
Complete an Electrodiagnostic Medicine Proctored Clinical Exam (CEX)
Medical Knowledge
Residents are expected to:
Anatomy & Physiology:
Define the components of the motor unit
Draw the Brachial Plexus, including the terminal nerves
List the nerve root level and peripheral nerve innervation of upper and lower extremity
muscles
Describe the nerve root and peripheral nerve innervation of the skin in both the upper and
lower extremity
Describe microanatomy of the axon-membrane and supporting structure
Compare the structure of myelinated and unmyelinated nerves
Identify the microanatomy of muscle, i.e., sarcomere, T-tubules, action, myosin, etc
Describe nerve and muscle membrane physiology such as potential and permeability
Compare impulse propagation in myelinated and unmyelinated nerves
Describe muscle contraction in microscopic terms, i.e., actin-myosin binding, ratcheting
effect, sarcomere shortening
Describe the response of the peripheral nervous system to injury
Instrumentation:
Describe the purpose of the EMG/NCV recording device
Identify the relative contraindications to electrodiagnosis
Identify the complications of electrodiagnosis
List the components of the EMG machine and their purpose
Discuss the concept of differential amplification and the purpose of G1 and G2 electrodes
Define sensitivity and gain
Describe the differences between monopolar and concentric needles in terms of recording
area, noise and wave form characteristics
List at least three ways to reduce stimulus artifact
Give examples of high and low frequency responses commonly seen during
Electrodiagnostic studies
Discuss the effects of inadequate or excessive stimulus intensity
List five causes of electrical interference and how to minimize them
Nerve conduction Studies (NCS):
Adjust various Parameters to record sensory, motor nerve conductions and motor unit
potentials
Demonstrate the proper placement of recording, reference and ground electrodes;
recognize proper stimulation sites; measure the latencies and calculate conduction
velocities
State the various physiological factors, which can influence the electrodiagnostic results,
e.g., age, body temperature, volume conduction, electrical interferences, and
measurement error
Memorize normal values for distal latencies evoked response amplitudes and conduction
velocities of different nerves
Measure sensory latencies and amplitudes of median, ulnar, radial, superficial peroneal,
dorsal ulnar cutaneous nerve, and medial antebrachial cutaneous nerves.
Measure motor latencies, amplitude and conduction velocities of median, ulnar, radial,
peroneal, tibial nerves, and musculocutaneous nerves
Distinguish between the late responses (H, F, A) waves, their etiology and clinical
significance
Demonstrate the ability to perform H reflex and F wave studies and interpret the results.
Differentiate between axon loss and conduction block
Demonstrate the ability to perform and diagnose upper and lower extremity nerve
entrapments and radiculopathies
Differentiate axonal versus demyelinating type of peripheral neuropathies
Demonstrate the ability to diagnose neuropraxia versus axonotmetic and neurotmetic
nerve lesion in mononeuropathies
Needle Electromyography (EMG):
Analyze a normal motor unit potentials morphology (shape, size, and phases) and
recruitment pattern on needle EMG exam
Define the initial deflection, duration, amplitude, rate, rhythm, origin, and diagnostic
significance of these potentials: miniature endplate potentials, end plate potentials,
fibrillations, positive waves, fasciculations, myotonia, myokymia, complex repetitive
discharges, pseudomyotonia, tremor and cramp discharges, 60 cycle interference and
artifacts
Explain the reason why fibrillations and positive sharp waves are commonly seen in
myopathy
Describe typical electromyographic findings in muscle disease
Describe the electromyographic findings in neuropraxia, axonotmesis, and neuronotmesis
over time in terms of spontaneous activity, recruitment, and motor unit action potential
morphology
Know key muscles for cervical and lumbar radiculopathy
Practice-Based Learning and Improvement
Residents are expected to:
Review the literature for electrodiagnostic medicine Best Practices for neuromuscular
disorders
Disseminate these Best Practices to patients, consultants, and staff
Interpersonal and Communication Skills
Residents are expected to:
Interact with patients in a sensitive manner
Communicate on a given patients intellectual/educational level
Produce concise, accurate documentation of the consultation, electrodiagnostic findings,
and recommendations
Complete all chart notes in a timely manner
Participate in teaching discussions
Professionalism
Residents are expected to:
Promote respect, dignity, and compassion for patients
Accept responsibility for their own actions and decisions
Demonstrate reliability and punctuality
Understand and adhere to HIPPA regulations
System-Based Practice
Residents are expected to:
Appreciate when electrodiagnostic medicine procedures are most appropriately rendered
to maximize information gain and patient outcome
Appreciate when electrodiagnostic medicine procedures are/are not cost-effective for the
patient and health care system
Understand where electrodiagnostic medicine testing fits in the continuum-of-care for
persons with neurologic disorders
OBJECTIVES ADVANCED
Patient Care
Residents are expected to:
Review the objectives for the beginning rotation and to master what they have not learned
Perform 4 to 6 Electrodiagnostic medicine evaluations per day with limited faculty
supervision
Determine a logical approach of testing for each individual condition
Characterize the electrophysiology of common normal and abnormal findings
encountered in EMG/NCS
Build on their knowledge base of neuromuscular anatomy
Troubleshoot common errors and problems encountered in EMG/NCS testing
Identify patient and family concerns associated with the testing process as well as the
results
Learn the patient safety issues with EMG/NCS including proper maintenance, inspection
of the machine, and risk of blood borne pathogen exposure
Obtain appropriate informed consent for the procedure
Respect that the patient is experiencing an uncomfortable procedure
Communicate with tech support personnel when a machine is not functioning
Review inpatient and outpatient Electrodiagnostic medicine consults to determine
medical necessity, and the best time frame to perform the exam
Develop enough speed to complete the exam in the allotted time frame
Medical Knowledge
Residents are expected to:
Anatomy & Physiology:
Outline the events occurring at the neuromuscular junction
Review the course and muscles supplied by the facial, phrenic, suprascapular, axillary,
and spinal accessory nerves
Review the anatomy of the lumbar and brachial plexus
Discuss myopathic and neuropathic biopsy findings
Describe anomalous innervation including the Martin-Gruber anastomosis and accessory
deep peroneal nerve
List the most common forms of muscular dystrophy, motor neuron diseases (e.g.,
Amyotrophic Lateral Sclerosis (ALS), Spinal Muscular Atropthy (SMA), hereditary
motor/sensory neuropathies(HMSN), and myopathies and be familiar with their genetics,
incidences, ages of onset, evaluation (to include electrodiagnostic studies), treatment
options, and recommendations and prognosis
Differentiate muscular dystrophy/congenital myopathy from kalemic and metabolic
myopathies
Describe the findings of stiff man syndrome and other diseases of continuous muscle
activity
Understand the anatomy of the blink reflex
Instrumentation:
Describe the effect of changes in the high and low frequency filters on the sensory nerve
action potential (SNAP) and compound muscle action potential (CMAP) latencies and
amplitudes
Describe the effect of changes in the high and low frequency filters on the motor unit
action potential (MUAP)
Describe the technical difficulties of performing Electrodiagnostic testing in the ICU
setting
Nerve Conduction studies (NCS):
Perform lateral femoral cutaneous, plantar, saphenous, spinal accessory, and
suprascapular nerve studies
Demonstrate the ability to evaluate Neuromuscular junction disorders with repetitive
stimulation testing
Evaluate and perform testing to diagnose patients with lumbar and brachial plexopathy
Evaluate an inpatient with generalized weakness or difficulty weaning off the ventilator
List the disease categories associated with axonal and demyelinating neuropathies
Identify common reasons for utilizing Somatosensory Evoked Potentials (SSEP). State
the limitations and the pathophysiology behind their generation. Have a basic
understanding of interpretation.
Interpret the blink reflex in a normal patient, and in a patient with trigeminal and facial
nerve involvement
Describe the sensitivity and specificity of the various studies to diagnose median
neuropathy
Describe the combined sensory index (CSI) for diagnosing median neuropathy
Electromyography(EMG):
List the common forms of voluntary and spontaneous activity seen with muscle disease
Be familiar with and apply the grading systems available for documenting the extent of
spontaneous activity
Describe the effects of muscle disease on MUAP morphology
Give the differential diagnosis of an abnormal interference pattern
Discuss single fiber electromyography (SFEMG) and its possible uses
Define jitter and fiber density based on SFEMG usage
Discuss when not to perform electromyography as part of the testing
State the indications for anal sphincter EMG and how to perform the exam
Practice-Based Learning and Improvement
Residents are expected to:
Review the American Association of Neuromuscular and Electrodiagnostic Medicines
(AANEM) Recommended Policy for Electrodiagnostic Medicine
Review AANEM practice parameters for Electrodiagnsotic studies in carpal tunnel
syndrome, ulnar neuropathy at the elbow, and peroneal neuropathy
Perform the minimum number of tests to establish an accurate diagnosis
Interpersonal and Communication Skills
Residents are expected to:
Interact with patients in a sensitive manner
Communicate on a given patients intellectual/educational level
Produce concise, accurate documentation of the consultation, electrodiagnostic findings,
and recommendations
Complete all chart notes in a timely manner
Participate in teaching discussions
Professionalism
Residents are expected to:
Promote respect, dignity, and compassion for patients
Accept responsibility for own actions and decisions
Demonstrate reliability and punctuality
Understand and adhere to HIPPA regulations
Serve as a role model for the more junior residents
Supervise and teach residents who are just learning electrodiagnosis
System-Based Practice
Residents are expected to:
Appreciate when electrodiagnostic medicine procedures are most appropriately rendered
to maximize information gain and patient outcome
Appreciate when electrodiagnostic medicine procedures are/are not cost-effective for the
patient and health care system
Understand where electrodiagnostic medicine testing fits in the continuum-of-care for
persons with neurologic disorders