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Evidence-Based Physiatry

Evidence-Based Physiatry

Learning to Choose Wisely

Paganoni, Sabrina MD, PhD

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American Journal of Physical Medicine & Rehabilitation: August 2018 - Volume 97 - Issue 8 - p 602-603
doi: 10.1097/PHM.0000000000000965
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Among the resources that are available to support the practice of evidence-based physiatry, the Choosing Wisely campaign deserves special consideration. Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation that is aimed at promoting the wise utilization of health care resources. The spirit of the initiative is to support physicians in adopting decision-making care models that are anchored in evidence, provide clinically meaningful benefit for patients, and are not duplicative.

The campaign was inspired by an article that was published by Dr. Howard Brody in 2010 in the New England Journal of Medicine entitled “Medicine's Ethical Responsibility for Health Care Reform—The Top Five List.” The article urged medical societies to identify the top 5 tests, treatments, and procedures that were overused in their field. More than 80 specialty societies have joined the campaign and contributed more than 500 lists of top 5 “Things Providers and Patients Should Question” in different fields of medicine. Several of the participating societies are relevant for physiatry including the American Academy of Physical Medicine and Rehabilitation, the American Association of Neuromuscular & Electrodiagnostic Medicine, the American Academy of Neurology, the American Medical Society for Sports Medicine, the American Academy of Orthopedic Surgeons, and the American Physical Therapy Association, to name a few. Physician resources are freely available on the Choosing Wisely application and online ( In addition, patient-friendly downloadable handouts are also available based on the recognition that the important goal of reducing overuse in medicine requires engaging patients in honest discussions about what tests and interventions are truly necessary.

Several physiatry-relevant Choosing Wisely lists exist. A notable example is the set of recommendations published by the American Association of Neuromuscular & Electrodiagnostic Medicine. A first list of five recommendations was published in 2015. An update was published in 2017 and the American Association of Neuromuscular & Electrodiagnostic Medicine Choosing Wisely list now contains “Ten Things Physicians and Patients Should Question” before deciding to proceed with a specific test or intervention ( This list of recommendations was developed by the Professional Practice Committee of the American Association of Neuromuscular & Electrodiagnostic Medicine, a committee that includes both neurologists and physiatrists. The recommendations were selected based on the greatest potential for overuse or misuse and availability of evidence-based research in the literature to support the recommendation.

Whereas we encourage the readers to review the full list of American Association of Neuromuscular & Electrodiagnostic Medicine Choosing Wisely recommendations, we selected one of the 10 recommendations as an example of the format, methods, and goals of the campaign. Recommendation #4: “Don't do nerve conduction studies without also doing a needle electromyography (EMG) for testing for radiculopathy, a pinched nerve in the neck or back.” Furthermore, recommendation #4 includes the following statement: “Needle EMG is necessary to identify and characterize the disease process.”

The evidence to support the recommendation about needle EMG is derived from two articles that were published years ago in the American Journal of Physical Medicine and Rehabilitation by Dillingham et al.1,2 The goal of these two publications was to determine prospectively the optimal electromyographic screening examinations of the upper2 and lower1 limbs that ensure identification of radiculopathies yet minimize the number of muscles studied. To answer this question, the authors performed a prospective multicenter study from May 1996 to September 1997. Patients with suspected cervical2 or lumbosacral1 radiculopathy were recruited and examined by needle electromyography using a standard set of muscles. Patients with radiculopathy confirmed by electrodiagnosis were selected for analysis. Various muscle screens were tested against this group of patients with radiculopathies to determine the frequency with which each screen identified the patient with radiculopathy. When paraspinal muscles were one of the screening muscles, six-muscle screens yielded consistently high identification rates. Studying additional muscles produced no improvements in the identification of lumbosacral radiculopathies1 and only marginal increases in the identification of cervical radiculopathies.2


Physiatrists should be aware of current evidence-based electrodiagnostic protocols that are likely to provide meaningful benefit to patients while minimizing waste and overuse. When performing an electrodiagnostic test for suspected radiculopathy, nerve conduction studies need to be accompanied by needle EMG of appropriate muscles. When paraspinal muscles are sampled, six-muscle screens yield consistently high identification rates of both cervical and lumbosacral radiculopathies.1,2


1. Dillingham TR, Lauder TD, Andary M, et al.: Identifying lumbosacral radiculopathies: an optimal electromyographic screen. Am J Phys Med Rehabil 2000;79:496–503
2. Dillingham TR, Lauder TD, Andary M, et al.: Identification of cervical radiculopathies: optimizing the electromyographic screen. Am J Phys Med Rehabil 2001;80:84–91
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