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Dr. Miller: EMG. It's easier than you think. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists," with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Daniel Cushman. He's a sports medicine physician who uses electromyelography, or EMG. And, Dan, it's easier than people might think it is. I think there's some news out there from the past experiences of folks who say that it's painful. You hear about this on blogs and websites that you read. And I think that some patients come in and they're very nervous about having this procedure because they think it's pretty onerous, from what they've read. Talk about that. It's a lot different now.

Dr. Cushman: Definitely. I think this is one thing that I do where every day, when someone comes in, I have to talk them down before we even get started.

Dr. Miller: Really? Because they've looked it up online?

Dr. Cushman: They hear from their friends is the most common thing. Their friend will say, "Oh, I had this done to me. It was the worst thing ever."

Dr. Miller: And they're usually talking about an experience that was some time ago?

Dr. Cushman: Correct. Exactly.

Dr. Miller: So what is EMG? Let's talk about that first and then go into how you do it and why it's less painful or stressful?

Dr. Cushman: So EMG talks about electromyography, which is looking at the electrical signals from the muscle. And the point of that is really to examine how well the muscles are working, how well the nerves are working, that go to those muscles. And there are two parts to the test. One is called the nerve conduction study. And what happens there is a small probe is placed on the nerve, on the surface of the skin, and a small shock is sent down the nerve. Just like in a wire, we can see how well that nerve is working by sending a signal down it. That's the first part.

Dr. Miller: Now, that sounds . . . you know, when somebody hears they're going to get shocked, they obviously think, "Uh-oh, this might be incredibly uncomfortable."

Dr. Cushman: Exactly. And so the way it works is that we just basically go up slowly on the electricity until they start even feeling it. They don't even feel it at the beginning. And then after they get . . . usually, the first one is the worst one. Then after that, they get used to it. It's kind of like when you rub your feet on carpeting, you touch something metal, nobody likes that sensation. But if you were to do that to yourself four times, by the fourth time, you'd be like, "Oh, I'm used to this."

Dr. Miller: It's like a little static shock.

Dr. Cushman: That's exactly it. Yeah.

Dr. Miller: So it's not like touching something coming out of a wall socket.

Dr. Cushman: Not at all.

Dr. Miller: Not at all.

Dr. Cushman: No.

Dr. Miller: Okay. Now, what about the needles? You use needles occasionally . . .

Dr. Cushman: Exactly.

Dr. Miller: . . . when you're doing EMGs.

Dr. Cushman: So the second part of the test is the actual EMG portion. And that's using a small needle about the size of an acupuncture needle, so really thin. And all we do is, we don't use any electricity, we just put it into different muscles along, in the body, depending on the test. So when we put that needle into the muscle, we can hear how the nerves are talking to the muscle. This part, on average, the pain level for people is somewhere in the range 3 out of 10. That's the most people will say it is. It doesn't really hurt. It feels more like a crampy sensation.

And when we do this, this gives us a lot of information. It can help us find if there's a pinched nerve, even though we're not really doing anything with the nerves. We're only doing the muscles. It can tell us a lot of information. It can tell us how old the problem is, if there's a new problem, if there's damage to the nerve, or if there's not damage to the nerve, and if things are getting better or have not started healing yet.

Dr. Miller: Talk about some of the common conditions where you use EMG to back up your clinical diagnosis.

Dr. Cushman: The most common that I do is probably carpal tunnel syndrome in the wrist. That's probably the most common. And then I would say the second most common would be a pinched nerve either in the neck or in the back.

Dr. Miller: So, basically, if you have . . . I mean, most of your patients are probably referred. Is that right?

Dr. Cushman: Yeah, most are.

Dr. Miller: And so you're getting patients from their referring providers who think they might have the right diagnosis, but they come to you to back up that diagnosis.

Dr. Cushman: That's correct. A good example would be a hand surgeon who . . . somebody might come in and say, "My fingers hurt," or, "My wrist hurts," or, "My hand hurts." And the surgeon can't particularly tell if that's coming from a pinched nerve in the neck or a pinched nerve in the wrist. And so, this test would help differentiate those.

Dr. Miller: So, obviously, not all patients need an EMG, but perhaps just a percentage of patients where the diagnosis is unclear.

Dr. Cushman: Correct.

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Dr. Miller: Ultrasound guided procedures in orthopedics. We're going to talk about that next on The Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm here with Dr. Daniel Cushman and he's a nonoperative sports medicine physician using ultrasound guided techniques to deliver therapy to patients. Daniel, can you tell me a little bit about how ultrasound made its way into sports medicine? I mean, I think most people are aware that ultrasound is used to look at little babies in utero and to diagnose other things, but this is kind of new in sports medicine, kind of interesting and cool.

Dr. Cushman: Definitely.

Dr. Miller: Tell me a little bit about that.

Dr. Cushman: The most common joke I hear when I'm ultrasounding a patient is they say, "Is that a boy?" And I think that's what everybody knows ultrasound from is it's from babies.

Dr. Miller: You haven't found any head?

Dr. Cushman: No, fortunately not yet.

Dr. Miller: Okay, they haven't asked you just check out the probe over the area where the baby might be.

Dr. Cushman: I had a pregnant woman do that and it's kind of fun actually. But originally, the thought was you do an x-ray, you get radiation. You do a CT scan, you get radiation. But a lot of the time with ultrasound, we get the same amount of information without having to do radiation.

The other advantage that we found nowadays is that you can actually have somebody move while you're doing it. So if you're doing an x-ray, the person is standing still. If you're doing an ultrasound, you could have them move their shoulder and actually see if something is pinching up on something else or something like that. So that's kind of where it came from and it's really developed a lot over the last ten years especially.

Dr. Miller: So expand on that a little bit. The great news is that when you use ultrasound, when does the patient doesn't receive radiation nor does anyone else using the probe, what is ultrasound? Is it a sound wave?

Dr. Cushman: Yeah, good question. That's it exactly, it's a sound wave. I think about it like putting a speaker on your hand. If you think about doing that you can kind of feel those vibrations and those vibrations are what you get with an ultrasound but they're so small you don't feel them. So the machine can send out sound waves and then pick them back up. Based off of that, it can tell how tissues are looking like underneath the skin.

Dr. Miller: How long ago did the ultrasound make an appearance in the use of musculoskeletal?

Dr. Cushman: Yeah, I think it was originally in the '50s is when ultrasound was originally made and that was one of the original thoughts is that you could use it for something like this, but it never really caught on until probably the last 20 years or so is when it's really caught on.

Dr. Miller: How many doctors now are able to do this?

Dr. Cushman: So it's getting more and more common. There are two areas that it's used probably the most commonly. The rheumatologist use it a lot looking at joints and then additionally, the orthopedics specialist like myself tend to use it a lot for these sorts of things.

Dr. Miller: Now for this little podcast, I wanted to talk a bit about how you use ultrasound to deliver medication or therapy into areas that you're interested in treating.

Dr. Cushman: We do that very commonly and there are a couple of advantages we find. Number one is kind of the way we're taught in medical school is to take a needle and put it into the area based off of landmarks on the body.

Dr. Miller: That's what I used to do in injecting the shoulders, and I don't do that anymore because people like you have an ultrasound probe and do it probably a lot better than I ever did.

Dr. Cushman: Yeah, and there's been a lot of studies on this and in some places, it honestly doesn't matter. You can do for example, the knee, somewhere around 93% accurate if you just do it by landmarks. If you do it with the ultrasound, it's closer to 100%. So most of the time, you really don't need to. But in some places like the hip where only about 40% accurate, if we just put a needle down to the hip, while it's 100% accurate with an ultrasound machine.

Dr. Miller: How about shoulders?

Dr. Cushman: Shoulders, so if we're talking about the shoulder joint, it's probably in somewhere in the range of 80% accuracy without it. So a lot of the times, we'll have doctors who have done the injection and they're just not 100% sure it was in the right spot and the person didn't get better. So they will do an injection with ultrasound to make sure it's in the right spot and see if that's really helping.

Dr. Miller: How about spine? I know that some people with back pain ultimately get injections to try to get by the need for surgery. Do you use ultrasound in delivering injections into the spine?

Dr. Cushman: So for the spine, that's still what I would call in the experimental phase. So there are some people who do it, but for the most part, we still rely on x-rays to do those.

Dr. Miller: So for folks who might need some type of injection and I guess typically, you're injecting medications to reduce pain or inflammation, what would be the reason for them to seek out someone with your skills?

Dr. Cushman: I find that a lot of the times, it's more of the doctors they work with are the ones who kind of send them over to us to help out with that. But a lot of the times, I find that just from my own patients, when I see them I use these a lot of the times to help diagnose the problem. So a good example would be if somebody's shoulder hurt. Sometimes that pain is coming from their neck, not from their shoulder. So when we do an injection and it doesn't help, we know we were in the right spot so it really could be coming from somewhere else.

Dr. Miller: So it helps with diagnoses as well?

Dr. Cushman: Yeah, exactly.

Dr. Miller: So the bottom line is, if you're interested in having one of your joint pains evaluated, you could have this done under ultrasound guidance. If there's therapy that's needed, it could be injected via an ultrasound guided

Dr. Cushman: Definitely.

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Dr. Miller: Diagnostic ultrasound. We're going to talk about that next on Scope radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Daniel Cushman. He's a sports medicine physician in the Department of Orthopedics at the Orthopedic Center here at the University of Utah. Daniel, welcome. Tell me a little bit about ultrasound-guided diagnosis of musculoskeletal disorders. I know this is a new technique, relatively new. It's been around for a long time but it's finding more applications these days.

Dr. Cushman: Definitely. Ultrasound is kind of a non-invasive way of looking at structures underneath the skin. It doesn't do a great job for things like bones which we have X-rays for, but if you're talking about something above the bone like a tendon or a muscle or those kinds of things, we can see those very well with ultrasound.

Dr. Miller: Does it assist you in your clinical diagnosis?

Dr. Cushman: All the time. For example, somebody hurts their shoulder, we can get a good look at those tendons, the rotator cuff tendons with ultrasound or if somebody's wrist is hurting we can look at the tendons there. Sometimes we can look at nerves particularly to see if they're being pinched somewhere.

Dr. Miller: It would help you, let's say, looking at a shoulder with an ultrasound, that might help you determine whether there was a full thickness tear or partial tear or even no tear.

Dr. Cushman: Exactly, and that's something that on exam when we're examining patients it's not something that's as obvious as it seems it should be. A lot of the time we can have patients who have completely torn their rotator cuff and they don't really have too many problems and then the opposite is true where somebody has done almost no damage to rotator cuff but they're in severe pain.

Dr. Miller: This would also help you decide on the guidance of treatment, right? Whether they go to physical therapy or whether you rest the shoulder for time.

Dr. Cushman: Exactly.

Dr. Miller: It just gives you a better sense of your diagnosis I suppose.

Dr. Cushman: All the time.

Dr. Miller: The other thing that's interesting is you're doing this right at the clinic visit, so this sort of obviates the need for having an MRI.

Dr. Cushman: Yeah. Definitely. A lot of the time I'll just simply grab the ultrasound machine with my patient in the room and it just takes a little bit of gel and that's pretty much it.

Dr. Miller: So this also maybe has a lower cost than the standard sort of other imaging techniques that we have.

Dr. Cushman: It's significantly lower and I don't know the exact numbers but probably somewhere in the range of a tenth the price of an MRI if you're looking at a shoulder for example.

Dr. Miller: Is it as good as good as an MRI for looking at, let's say again, a shoulder?

Dr. Cushman: Yes. That's really dependent more on the person doing the exam. If somebody has had a lot of experience with ultrasound, studies show they're about as good as an MRI. If somebody is not as experienced, then it's really only as good as the person who's doing the exam.

Dr. Miller: What other areas of the musculoskeletal system do you use this on? How about Achilles tendons or . . .?

Dr. Cushman: A lot of the time we can tell without having to use the ultrasound machine what the problem is but other times it's very helpful and so Achilles tendons, we do use it on occasion. There are there are some times where we think we know the diagnosis and this really either confirms it or shows us that something else is causing the problem and so it's helpful in that regard.

Dr. Miller: How about in the hip?

Dr. Cushman: In the hip joint there's a couple of uses for that pretty commonly. People who have had hip replacements where they can't really do an MRI afterwards and they still have some pain, a lot of times some of the hip replacement surgeons will have us take a look at the tendons that are going over the the prosthesis.

Dr. Miller: Sometimes patients will come in with pain and you've told me previously that you can use the ultrasound to sort of find out where that pain arises from or is there a structure along the nerve that is actually causing the pain. So for instance you might think it's . . . the patient may tell you that they have pain at the wrist or the end of the arm but actually the generation of that pain is higher up and you've learned that from the ultrasound.

Dr. Cushman: Yes, exactly. One of the one of the disadvantages of something like an MRI is you can really only do one segment at a time so you can only look at the neck or you can only look at the shoulder. You can't really do both at the same time. With an ultrasound, if you're thinking maybe a nerve is causing this, you can trace it all the way from the finger, all the way up the arm to the shoulder, to the neck and get a pretty full view of the entire nerve or whatever structure you're really looking for.

Dr. Miller: How many specialists like yourself are versed in using ultrasound as a diagnostic tool nowadays?

Dr. Cushman: Here at the U, there's probably about four or five of us at least in our department and it's getting more and more popular because it's such an easy test for patients. Patients generally love it by comparison to having to do an MRI or going back and additionally it's so much cheaper for the patient.

Dr. Miller: It also gives you real time feedback so that you don't have to wait for test results coming back from radiology.

Dr. Cushman: Definitely. A lot of the time, one other thing I was going to mention was that when patients say, "It hurts when I do this," and they move their arm or they move their leg, we can actually look at it while it's moving as opposed to an MRI or an X-ray, which only shows a static picture.

Dr. Miller: Do you think in the future that more orthopedic surgeons and sports specialists will be trained in this technique so that it's pretty common throughout the specialty?

Dr. Cushman: I think so. I think it's becoming kind of a second set of eyes for people to look under the skin.

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