SPECIAL CONTRIBUTION
Clinical electromyography and electrodiagnosis course
at Keio University Hospital – a 7-year experience
Meigen Liu,1 Kimitaka Hase,1 Tetsuya Tsuji,1 Toshiyuki Fujiwara,1 Shin Yamada,1Yoshihisa Masakado2 and Akio Kimura2
1Department of Rehabilitation Medicine, Keio University School of Medicine, Tokyo, Japan
2Department of Rehabilitation Medicine, Keio University Tsukigase Rehabilitation Center, Shizuoka, Japan(Received for publication on June 6, 2005)(Revised for publication on June 24, 2005)(Accepted for publication on July 21, 2005)

Abstract. Although electromyography and electrodiagnosis (EMG-EDX) is one of the most fundamental skills in rehabilitation medicine, the number of residency programs that can provide comprehensive postgraduate EMG-EDX training is still limited in Japan. Under these circumstances, westarted a 2-day primer course in EMG-EDX at Keio University Hospital in 1998. To review our 7-year
experience with the course, we analyzed the number and specialty of the participants, their appraisal of
the lectures and practical sessions, and the score distribution of the ﬁnal examination. The number ofparticipants totaled 288 during the past 7 years, and the mean number for each year was 41. The distribution by specialty for the whole period was 64.0% for rehabilitation medicine, 25.4% for orthopedic
surgery, 5.1% for neurology, 1.0% for pediatrics, 0.5% for gerontology and 4.1% for physical therapists and occupational therapists. The difﬁculty levels of the lectures were judged as appropriate by 81
to 95.5% of the participants, and the presentation was judged as good by 34 to 67% of them. For thepractice sessions, the difﬁculty levels were judged as appropriate by 88% of the participants, and thequality of the supervisors was judged as good by 64% of them. The mean score for the ﬁnal examination was 56.0 (SD 15.2, median 60). In conclusion, our course has played an important role to promote
EMG-EDX in our country by providing compact introductory exposure to EMG-EDX for beginners.
A follow-up system for the course graduates is planned to support their EMG-EDX practice. (Keio J
Med 54 (4): 193–196, December 2005)
Key words: neuromuscular disease, post graduate training, electrophysiology, rehabilitation medicineIntroduction
In the practice of physical medicine and rehabilitation (PMR), which specializes in the diagnosis, evaluation and treatment of ‘‘dysmobility’’ or a disturbanceof movement,1 electromyography and electrodiagnosis(EMG-EDX) is one of the most fundamental skills thatmust be mastered by everyone pursuing this specialty.2
This holds true for neurologists and to a certain extent
to orthopedic surgeons who are responsible for themanagement of persons with neuromuscular disorders.
Thus training in EMG-EDX should constitute a signiﬁcant proportion of the postgraduate training in PMR,
which is the case in several countries in the world.

In the United States, for example, most of the trainees in PMR take board certiﬁcation examination inelectrodiagnostic medicine just after ﬁnishing PMR
board certiﬁcation. The eligibility requirements for thisexamination are: 1) specialty certiﬁcation in American
Board of Psychiatry and Neurology, American Boardof Physical Medicine and Rehabilitation, American
Osteopathic Board of Neurology and Psychiatry,
American Osteopathic Board of Physical Medicine andRehabilitation, or Canadian equivalent; 2) training inelectrodiagnostic medicine that must include at least 6months fulltime preceptorship and 200 complete electrodiagnostic evaluations; 3) At least one year of independent experience following training and 200 ad-Reprint requests to: Meigen Liu, MD, PhD, Department of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi,Shinjyu-ku, Tokyo 160-8582, Japan, e-mail: QZV11742@nifty.ne.jp
193

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Table 1

Liu M, et al: EMG and electrodiagnosis course
The Electromyography and Electrodiagnosis Course for Beginners at Keio University Hospital
Day 1Day 2AM

Orientation (10 min)What is electrodiagnostic study? (45 min)Basics of neuromuscular system (60 min)Surface EMG (20 min)Needle EMG (70 min)Practical session 2: Needle EMG (75 min)PMNerve conduction studies and late responses (60 min)Wave form analysis (90 min)Questions & answers (30 min)Practical session 1: Nerve conduction studies and late responses (90 min)How to organize EMG studies (60 min)Questions & answers (30 min)Final examination (30 min)Certiﬁcate hand-out

ditional complete electrodiagnostic evaluations.3 In
Korea, which has one of the most advanced PMR postgraduate training systems in Asia, the requirements for
PMR board certiﬁcation consist of a four-year resident
training period that must include 200 cases of EMG
studies in addition to the experiences of more than 300
patients, 12 out-hospital seminar attendances, 200 inhospital seminar attendances, publication of more than
3 scientiﬁc articles and training at related departments.4
In contrast, although EMG-EDX is listed in thepostgraduate training curriculum released by the Japanese Association of Rehabilitation Medicine (JARM),5no speciﬁc criteria are given to document adequate
training in EMG-EDX, and it is not included in the eligibility requirements for specialty board examination.
The number of residency programs that can provide
comprehensive postgraduate EMG-EDX training is still
limited, and there are many residents who get board
certiﬁed without having sufﬁcient training and experience in EMG-EDX. More or less, this situation applies
to neurology and orthopedic surgery as well, and theimprovement and enrichment of a training system inEMG-EDX should therefore be given a very high priority in our country.
Under these circumstances, the Department of Rehabilitation Medicine at Keio University School ofMedicine started an annual primer course in EMGEDX in 1998. The purpose of this paper is to review our7-year experience with the course to point to future
directions.
Course Description
The course is aimed at beginners, and the 2-day
program consists of 8 lectures, 2 question-and-answer
sessions, 2 practical sessions and a ﬁnal examination(Table 1). The instructors and supervisors are department staffers with sufﬁcient EMG-EDX experience andone or two invited experts in the ﬁeld. The practicalsessions consist of 2 parts: nerve conduction studies andneedle EMG. The participants are divided into 7 to 8
groups, each consisting of one supervisor with morethan 10-year experience in EMG-EDX, one resident
that acts as an assistant and 6 to 7 participants. Basictechniques are demonstrated and practiced by all participants in turn, and some advanced techniques arealso covered at the request of the participants. At theend of the course, the participants take a-30 min test
consisting of 20 multiple-choice questions (12 related tobasic knowledge of EMD-EDX and 8 to case studies),and a brief test review is provided.
Method of Analysis
From the list of course participants for the past 7years (1998 to 2004) and the questionnaire survey performed at the end of each course, we analyzed thenumber and specialty of the participants, their evaluation of the lectures and practical sessions provided, andthe score distribution of the ﬁnal examination.
Results
The number of participants totaled 288 during thepast 7 years, and the mean number for each year was 41(range 32 to 54). The distribution by specialty for thewhole period was 64.0% for PMR, 25.4% for orthopedic surgery, 5.1% for neurology, 1.0% for pediatrics,
0.5% for gerontology and 4.1% for physical therapists
and occupational therapists.
For the lectures, the difﬁculty levels were judged as
appropriate by 81.0 to 95.5% of the participants, andthe presentation was judged as good in 34.1 to 67.4%
and as average in 32.6 to 61.4% of them (Table 2). For
the practice sessions, the difﬁculty levels were judged as
appropriate by 88.6% of the participants, and the quality of the supervisors was judged as good in 63.6% ofthem (Table 2). The mean score for the ﬁnal examination was 56.0 (SD 15.2, range 10 to 90, median 60).
Discussion
In the United States, many EMG-EDX courses areheld each year, such as Comprehensive Clinical Neuro-Keio J Med 2005; 54 (4): 193–196
Table 2195

Appraisal of the Lectures and Practical Sessions by the Course Participants (N ¼ 288)
Difﬁculty level

Quality

Too difﬁcult(%)

Appropriate(%)

Too easy(%)

Good(%)

Average(%)

Poor(%)

LecturesIntroduction
BasicsNerve conduction studies
Surface EMG
Needle EMG
How to organize EMG studies

019.0
14.0
6.8
6.8
5.1

95.5
81.0
81.4
93.2
93.2
94.9

4.5
00000

34.1
28.6
51.9
38.6
67.4
43.5

61.4
59.5
43.9
61.4
32.6
55.0

4.5
11.9
4.9
00
2.5

Practical sessions
Nerve conduction studies
Needle EMG

2.3
2.3

88.6
88.6

9.1
9.1

34.1
34.1

63.6
63.6

2.3
2.3

physiology Course (Cleveland Clinic Foundation), Update in Clinical Neurophysiology (Mayo Clinic), Super
EMG/Practical Electromyography (Ohio State University Medical Center), Annual Electrodiagnosis andClinical Neurophysiology: A High Intensity Review(Rehabilitation Institute of Chicago), Clinical Electromyography Review Course (University of Iowa), orElectrodiagnosis of Focal and Diffuse Neuropathies(University of Pittsburgh School of Medicine).6 These
courses are participated by residents preparing forboard examination and practicing electromyographersfor continuing medical education. In Japan, although
there have been lecture courses for technicians andhands-on seminars during the annual meeting of theJapanese Association of Clinical Neurophysiology, thecourse at Keio is the ﬁrst systematic one that attempted
to provide introductory lectures and practical sessions
in EMG-EDX targeted mainly toward physicians who
are novice to the ﬁeld.
Since the course was started in 1998, 288 participants,
mostly physicians, have ﬁnished the course. Their top
3 specialty backgrounds were PMR, orthopedics andneurology, and this reﬂects the need for EMG-EDX
for these disciplines. Because of the limited number ofsupervisors and EMG equipment, we have to limit thenumber of participants to less than 50, and 10 to 20applicants are rejected each year. This indicates that
there is potentially a great need for a course like thisamong practicing physicians involved in neuromuscularcare.
In 2000, our course became accredited as one ofthe postgraduate educational courses in PMR by theJARM, and it is becoming a very popular one amongresidents in PMR preparing for the board examination.
Prompted by our success, the Japanese Association ofClinical Neurophysiology also started a 2-day course

in 2004. Together with the course at Keio, the newcourse is hoped to contribute to popularize and improve EMG-EDX skills in Japan.
However, the intensity and thoroughness of thecourses in Japan are far less when compared with thosein the U.S. As an example, the course curriculum at theRehabilitation Institute of Chicago is demonstrated inTable 3.7 It is a 4-day course held from early morning toevening each day, and covers a wide range of EMGEDX. The level of participants is also high, having afair amount of EMG-EDX experience in their clinicalpractice. In the future, there will be a need for advanced
courses like this in Japan as well. There is also a movement toward a board certiﬁcation system for EMGEDX in our country as well, and the need for courses
like ours will be greater.
So far, we believe that our course, as the ﬁrst systematic one of this kind in Japan, has made an important contribution to promote EMG-EDX in our country
by providing compact introductory exposure to EMGEDX for beginners. The generally favorable appraisalof the course by the participants and the level of knowledge gained as measured with the ﬁnal examination indicate its potential usefulness, but do not convincingly
prove it. The usefulness or effectiveness of a training
course like ours should be evaluated by analyzing theability of the participants to organize, perform andinterpret EMG studies appropriately and efﬁciently.
We therefore consider it necessary to develop a followup and support system for the course graduates thatcan evaluate their competency as clinical electromyographers and at the same time assist them to set up
EMG laboratory, judge EMG results, update knowledge and skills in EMG-EDX. Our future action plansto achieve these goals are as follows: 1) Register as
many skilled electromyographers as possible who can196
Table 3
2003

Liu M, et al: EMG and electrodiagnosis course
Electrodiagnosis and Clinical Neurophysiology: A High Intensity Review. 26th Annual Course, Rehabilitation Institute of Chicago,

Day 1
Instrumentation
Anatomy and physiology of
peripheral nerve and muscle

Day 2Day 3

Less common nerve
conduction studies
Myopathy

Day 4

Peripheral neuropathy

Single ﬁber EMG

Evaluation of the pelvic ﬂoor

Group demonstration: single
ﬁber EMG/repetitivestimulation
Wave form practicum (1)AMPMFundamentals of nerve
conduction studies
Focal mononeuropathies

Somatosensory evoked
potentials (SSEP)Group demonstration: SSEP

Motor neuron disease
Pitfalls of nerve conduction
studiesWave form practicum (2)Radiculopathy
Peripheral nerve response toinjury
Electrodiagnostic evaluationof plexopathies andpolyradiculopathies
Needle electrode examination

Quantitative EMG
Assessment of autonomic
functionGroup demonstration:
autonomic & quantitative
testing
Focal mononeuropathies of
the upper extremities

Waveform evaluation
The neuromuscular junction

Test review

Late responses (blink, H, F,and A waves)Interactive casepresentation/discussion

Group demonstration: needle
EMG

provide support and advices; 2) Using an on-line system, the advisors provide assistance and advices to thecourse graduates real time while they are performing
EMG studies in their own laboratories; 3) By recording
the manner of organizing the EMG-EDX studies andinterpreting the results, the supervisors monitor progress, weakness and problems of their skills, and givethem appropriate feedbacks; 4) After a certain period,
the graduates are examined for their knowledge andskills, and when they are judged as competent enough,they are in turn registered as supervisors; 5) The
problems encountered while practicing EMG-EDX areaccumulated through this monitoring process, and analyzed and fed-back to improve the course. In this way,
we believe that we can contribute to a sound development and popularization of clinical EMG-EDX practicein Japan.

References
1. Kottke FJ: Physical medicine and rehabilitation: past, present andfuture. Jpn J Rehabil Med 1997; 34: 20–33
2. Ball RD: Electrodiagnostic evaluation of the peripheral nervoussystem. In DeLisa JA, Gans BM, Walsch NE eds. Physical medicine and rehabilitation. Principles and practice. 4 th ed, Lippincott
Williams & Wilkins, Philadelphia, 2005, pp 61–102
3. American Board of Electrodiagnostic Medicine Certiﬁcation Examination (http://www.abemexam.org/certexam/Eligibility
Requirements.cfm)
4. Park Chang-il: Education of rehabilitation medicine in Korea. Jpn
J Rehabil Med 2002; 39: 21–26
5. Izumi S: Postgraduate training and certiﬁcation of physiatrists inJapan. Jpn J Rehabil Med 2004: 41 (suppl): S154–S155 (Abstract)
6. Electrodiagnostic medicine courses by the AANEM. (http://www.
aanem.org/education/training/edx_course_list.cfm)
7. Course text: Electrodiagnosis and clinical neurophysiology: A
high intensity review. 26 th annual course, March 12–15, 2003,
Rehabilitation Institute of Chicago