Medical Policies - Medicine
Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy
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The following noninvasive electromyography (EMG) tests are considered experimental, investigational and/or unproven as techniques to evaluate, diagnose or monitor neck/back pain or any other neuromusculoskeletal condition:
• Surface EMG (SEMG) or surface scanning EMG, OR
• Paraspinal SEMG or paraspinal EMG, OR
Surface electromyography (SEMG), which records the summation of muscle electrical activity from groups of muscles, has been investigated as a technique to evaluate the physiological functioning of the back. SEMG, a noninvasive procedure, is contrasted with needle EMG, an invasive procedure, in which the electrical activity of individual muscles is recorded.
Paraspinal SEMG, also referred to as paraspinal EMG scanning, has been explored as a technique to evaluate abnormal patterns of electrical activity in the paraspinal muscles in patients with back pain symptoms such as spasm, tenderness, limited range of motion, or postural disorders. The technique is performed using one or an array of electrodes placed on the skin surface, with recordings made at rest, in various positions, or after a series of exercises. Recordings can also be made by using a handheld device, which is applied to the skin at different sites. Electrical activity can be assessed by computer analysis of the frequency spectrum (i.e., spectral analysis), amplitude, or root mean square of the electrical action potentials. In particular, spectral analysis focusing on the median frequency has been used to assess paraspinal muscle fatigue during isometric endurance exercises. Paraspinal SEMG has been researched as a technique to establish the etiology of back pain and has been used to monitor the response to therapy and establish physical activity limits, such as assessing capacity to lift heavy objects or ability to return to work.
Paraspinal SEMG is an office-based procedure that may be most commonly used by physiatrists or chiropractors. The following clinical applications of the paraspinal SEMG have been proposed:
• Clarification of a diagnosis (i.e., muscle, joint, or disc disease),
• Select a course of medical therapy,
• Select a type of physical therapy,
• Pre-operative evaluation,
• Postoperative rehabilitation,
• Follow-up of acute low back pain,
• Evaluation of exacerbation of chronic low back pain, and
• Evaluation of pain management treatment techniques.
Spinoscopy (Spinoscope®, Spinex Corp.) consists of SEMG with associated video-recordings that records vertebral movement and the corresponding muscular activity during movements of the back.
Surface electromyography (SEMG) devices approved by the U.S. Food and Drug Administration (FDA) include those that use a single electrode or a fixed array of multiple surface electrodes. Examples include the CMAP Pro (Medical Technologies) and Model 9200 EMG System (Myotronics-Noromed). Several FDA approved devices combine SEMG along the spine with other types of monitors. For example, in 2007, the Insight Discovery (Fasstech, Burlington, MA) was cleared for marketing through the 510(k) process. The device contains 6 sensor types, one of which is for SEMG. The indications include measuring bilateral differences in SEMG along the spine and measuring SEMG along the spine during functional tasks. (Earlier Insight models had fewer sensors.) FDA Product code: IKN.
This policy was originally created in 1994 and was updated regularly with searches of the MEDLINE database through July 2017. The following is a summary of the key literature to date.
Surface Electromyography (SEMG)
SEMG has been used as a research tool to evaluate the performance of paraspinal muscles in patients with back pain and to further understand the etiology of low back pain. (1-4) Preliminary research has also been performed on which SEMG parameters best differentiate between patients with and without back pain. (5, 6)
Clinical Context and Test Purpose
The purpose of paraspinal SEMG in patients who have back pain is to identify the pathogenesis of the pain (i.e., muscle, joint, or disc disease) to inform a decision on a treatment plan. The question addressed in this evidence review is: Does paraspinal SEMG improve the net health outcome in individuals with back pain?
The following PICOTS were used to select literature to inform this review:
• Patients - The relevant population of interest is individuals with back pain.
• Interventions- Paraspinal SEMG is a noninvasive technique that aggregates data on muscle activity from groups of muscles. One or more electrodes are placed on the skin surface, and recordings are taken at rest, in various positions, or during a series of exercises.
• Comparators - Other noninvasive techniques to assess back pain include clinical examination and imaging technologies.
• Outcomes -The general outcomes of interest are reduction in back pain and improvement in activities of daily living. Both false-positive test results and false-negative results can lead to an incorrect recommendation for the type of treatment or no treatment at all. Some treatments are long-term programs, and if individuals are incorrectly referred to the program, resources will be used inefficiently and more appropriate therapy will be delayed.
• Timing- Testing would occur before determining the treatment plan.
• Setting - Paraspinal SEMG can be performed in an office setting by physiatrists, chiropractors, or physical therapists.
Assessment of a diagnostic technology typically focuses on 3 categories of evidence: (1) its technical performance (test-retest reliability or interrater reliability); (2) diagnostic accuracy (sensitivity, specificity, and positive and negative predictive value) in relevant populations of patients; and (3) clinical utility demonstrating that the diagnostic information can be used to improve patient outcomes.
Several studies using different SEMG devices have suggested that paraspinal SEMG, in general, is a reliable technique, based on coefficients of variation or test-retest studies. (1, 7) No studies were identified that compared the performance of SEMG to a criterion standard reference test.
A systematic review by Mohseni Bandpei et al. (2014) identified 12 studies on the test-retest reliability of paraspinal SEMG. (8) Seven included only healthy individuals. The remaining 5 studies evaluated SEMG in patients with low back pain; 3 of these included a healthy control group. Overall, the studies reported that interrater reliability, as measured by an intraclass coefficient, varied widely (range, 0.26-0.91), with most of the values in the moderate to high range. Studies were heterogenous regarding methodology and SEMG parameters used. This evidence demonstrated that the reliability of SEMG would at least be moderate in the assessment of back muscle fatigue, but it did not address the accuracy or validity of the test.
A literature review of spinal muscle evaluation in low back pain patients, published in 2007, indicated that the validity of SEMG remains controversial. (9) Reviewers noted that, although many studies showed increased fatigability of the paraspinal muscles in patients with LBP, they could not determine whether these changes were causes or consequences of the LBP. Also, the utility of SEMG was found to be limited because of the inability to distinguish between normal and abnormal profiles due to factors such as a lack of normative data.
No articles that compare the results of SEMG (which tests groups of muscles) with needle electromyography (which tests individual muscles) for diagnosing any specific muscle pathology were identified in literature searches. However, the pathology of individual muscles (i.e., radiculopathy, neuropathy) may represent a different process than the pathology of muscle groups (i.e., muscle strain, spasm), and thus SEMG may be considered by its advocates as a unique test for which there is currently no criterion standard. Nevertheless, even if one accepts this premise, there are inadequate data to evaluate the diagnostic performance of SEMG. For example, no articles were identified in the published peer-reviewed literature that established definitions of normal or abnormal SEMG. In some instances, asymmetrical electrical activity may have been used to define abnormality; results may be compared with normative data. However, there was no published literature defining what degree of asymmetry would constitute abnormality.
A study by du Rose and Breen (2016) looked into the relation between lumbar intervertebral range of motion and paraspinal muscle activity in healthy adults, as measured by SEMG and quantitative fluoroscopy, to establish “normal” measurements. (10) Fluoroscopic images and SEMG measurements were taken for 20 men with no history of LBP. What would be considered normal intervertebral ranges of motion were related to a diverse set of muscle activation patterns as measured by SEMG. The authors concluded that larger sample sizes and measurements from patients with LBP are needed to established standard criterion.
In the absence of a criterion standard diagnostic test, correlation with the clinical symptoms and physical exam is critical. De Luca published a series of studies investigating a type of SEMG called the Back Analysis System (BAS), consisting of surface electrodes and other components to measure the electrical activity of muscles during isometric exercises designed to produce muscle fatigue. (2) Using physical exam and clinical history as a criterion standard, the author found that the BAS was able to accurately identify control and back pain patients 84% and 91% of the time, respectively, with the values increasing to 100% in some populations of patients. (Accuracy was defined as the sum of true positive and true negative results.) However, these studies were not designed as a clinical diagnostic tool per se but were intended to investigate the etiology of back pain and to investigate muscular fatigue patterns in patients with and without back pain.
Hu et al. in Hong Kong published 2 articles on dynamic topography, an approach to analyzing SEMG findings. (12, 13) The studies had similar protocols. Both included low back pain patients and healthy controls; all participants underwent SEMG at study enrollment and then back pain patients participated in a rehabilitation program. The first study found different dynamic topography at baseline between healthy people and people with back pain, e.g., a more symmetric pattern in healthy controls. (12) After physical therapy, the dynamic topography images of back pain patients were more similar to the healthy controls on some of the parameters that were assessed. In the second study, following rehabilitation, back pain patients were classified as responders or nonresponders based on changes in back pain severity. (13) Some associations were found between baseline SEMG parameters and response to rehabilitation. SEMG was not repeated following the rehabilitation program, and thus it is not clear whether there are any significant associations between continued symptoms and SEMG abnormalities. Moreover, it is not clear how SEMG analysis would affect treatment decisions for low back pain patients.
A number of studies have described SEMG as an aid in classifying low back pain. (11, 12, 13, 23) Most of this research has focused on the use of spectral analysis to assess muscle fatigability rather than how information from SEMG could enhance patient management. While SEMG may be used to objectively document muscle spasm or other muscular abnormalities, it is unclear how such objective documentation would supplant or enhance clinical evaluation, or how this information would be used to alter the treatment plan. In part, the difficulty in clinical interpretation is in understanding the extent to which the SEMG abnormalities are primary or secondary. In addition, no specific workup is recommended for acute low back pain without warning signs.
The following studies have proposed using SEMG results to inform treatment decisions; however, none provided data to validate whether treatment based on SEMG results improved outcomes. In a 2016 study of patients with chronic LBP (N=216), SEMG showed potential to discriminate between impaired and unimpaired neuromuscular regulation of back extensors, which would provide useful information for designing individualized exercise programs. (18)
In a 2015 study of patients with LBP (n=27) and pain-free controls (n=23), SEMG detected a loss of discrete motor cortical organization of the paraspinal muscles among those with LBP. (19) The invasive technique of needle electromyography is usually performed to detect this pathology. Patients with cortical reorganization may benefit from motor skill training.
In 2 studies (1988, 1992), SEMG was shown to differentiate muscle spasm from muscle contracture. Muscle spasm would be treated with relaxation therapy, and contracture would be treated with stretching exercises. (17, 18)
A literature review of spinal muscle evaluation in low back pain patients, published in 2007, indicated that the validity of SEMG remains controversial. (9) The authors note that although many studies show increased fatigability of the paraspinal muscles in patients with low back pain, it is not known whether these changes are causes or consequences of the low back pain. Also, the utility of SEMG is limited because of the inability to clearly define normal versus abnormal profiles due to factors such as a lack of normative data.
Summary of Evidence:
For individuals who have back pain who receive paraspinal surface electromyography (SEMG) for evaluation and monitoring, the evidence includes a systematic review of interrater reliability, a systematic review of validity and reliability, and several nonrandomized studies on using findings to classify back pain. Relevant outcomes are test accuracy and validity, symptoms, functional outcomes, quality of life, and resource utilization. Addressing the technical performance of SEMG, systematic reviews of small nonrandomized studies have concluded that the validity and reliability of SEMG have not been established. Heterogeneity on how SEMG recordings of muscle activity are taken limit generalizability.
Across studies, patients may be sitting or standing, and exercises are isometric or dynamic. Addressing diagnostic performance of SEMG, there have been no studies directly comparing SEMG with other noninvasive techniques for evaluating back pain, and standard criteria for normal and abnormal SEMG measurements have not been determined. Addressing clinical utility, SEMG has been proposed as a noninvasive technique providing objective measurements that would inform treatment decisions in patients with back pain. While the studies have shown that SEMG results have detected different pathologies in patients with back pain, none of the studies reported health outcomes. There are no data on the impact of SEMG for patient management or health outcomes. In addition, no new information found that would change the coverage position for spinoscopy. Therefore surface EMG (SEMG), paraspinal SEMG or spinoscopy for diagnosing and monitoring back pain remains experimental, investigational, and/or unproven.
Practice Guidelines and Position Statements
American College of Occupational and Environmental Medicine
In a 2011 guideline, the American College of Occupational and Environmental Medicine did not recommend SEMG as a technique for diagnosing low back disorders, based on insufficient evidence of efficacy. (21)
American Pain Society
In 2009, the American Pain Society issued guidelines on the evaluation and management of low back pain. (22) When discussing the diagnostic accuracy of nonimaging tests, the guidelines stated that “There is no evidence supporting the use of thermography or surface electromyography for diagnosis of low back pain (level of evidence: fair).”
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in July 2017 did not identify any ongoing or unpublished trials that would likely influence this medical policy.
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CPT codes 95860-95872 are not to be used to bill this technology as this code range addresses the use of needle, not surface electromyography (SEMG).
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A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Cram JR, Lloyd J, Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom. 1994; 41(4-Jan):41-45. PMID 7843866
2. De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve. 1993; 16(2):210-216. PMID 8429847
3. Jones SL, Hitt JR, Desarno MJ, et al. Individuals with non-specific low back pain in an active episode demonstrate temporally altered torque responses and direction-specific enhanced muscle activity following unexpected balance perturbations. Exp Brain Res. Sep 2012; 221(4):413-426. PMID 22875027
4. Sheeran L, Sparkes V, Caterson B, et al. Spinal position sense and trunk muscle activity during sitting and standing in nonspecific chronic low back pain: classification analysis. Spine (Phila Pa 1976). Apr 15 2012; 37(8): E486-495. PMID 22024899
5. Hanada EY, Johnson M, Hubley-Kozey C. A comparison of trunk muscle activation amplitudes during gait in older adults with and without chronic low back pain. PM R. Oct 2011; 3(10):920-928. PMID 22024323
6. Neblett R, Brede E, Mayer TG, et al. What is the best surface EMG measure of lumbar flexion-relaxation for distinguishing chronic low back pain patients from pain-free controls? Clin J Pain. Apr 2013; 29(4):334-340. PMID 23328325
7. Villafane JH, Gobbo M, Peranzoni M, et al. Validity and everyday clinical applicability of lumbar muscle fatigue assessment methods in patients with chronic non-specific low back pain: a systematic review. Disabil Rehabil. Sep 2016; 38(19):1859-1871. PMID 26732899
8. Mohseni Bandpei MA, Rahmani N, Majdoleslam B, et al. Reliability of surface electromyography in the assessment of paraspinal muscle fatigue: an updated systematic review. J Manipulative Physiol Ther. Sep 2014; 37(7):510-521. PMID 25204717
9. Demoulin C, Crielaard JM, Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine. 2007; 74(1):9-13. PMID 17174584
10. Du Rose A, Breen A. Relationships between paraspinal muscle activity and lumbar inter-vertebral range of motion. Healthcare (Basel). Jan 05 2016; 4(1). PMID 27417592
11. Gentempo P, Kent C. Establishing medical necessity for paraspinal EMG scanning. Chiropractic: J Chiropractic Res Clin Invest. 1990; 3(1):22-25.
12. Hu Y, Siu SH, Make JN, et al. Lumbar muscle electromyographic dynamic topography during flexion-extension. J Electromyogr Kinesiol. 2010; 20(2):246-255.
13. Hu Y, Kwok JW, Tse JY, et al. Time-varying surface electromyography topography as a prognostic tool for chronic low back pain rehabilitation. Spine J. Jun 1 2014; 14(6):1049-1056. PMID 24530438
14. Humphrey AR, Nargol AV, Jones AP, et al. The value of electromyography of the lumbar paraspinal muscles in discriminating between chronic-low-back-pain sufferers and normal subjects. Eur Spine J. 2005; 14(2):175-184. PMID 15549487
15. Peach JP, McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine. 1998; 23(10):1117-1123. PMID 9615362
16. Roy SH, Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther. 1998; 78(8):838-851. PMID 9711209
17. Ellestad SM, Nagle RV, Boesler DR, et al. Electromyographic and skin resistance responses to osteopathic manipulative treatment for low-back pain. J Am Osteopath Assoc. 1988; 88(8):991-997. PMID 2975645
18. Bittman B, Cram JR. Surface electromyography: an electrophysiologic alternative in pain management. Presented at the American Pain Society; 1992; Illinois.
19. Kienbacher T, Fehrmann E, Habenicht R, et al. Age and gender related neuromuscular pattern during trunk flexion-extension in chronic low back pain patients. J Neuroeng Rehabil. Feb 19 2016; 13:16. PMID 26896325
20. Schabrun SM, Elgueta-Cancino EL, Hodges PW. Smudging of the motor cortex is related to the severity of low back pain. Spine (Phila Pa 1976). Oct 22 2015. PMID 25893342
21. American College of Occupational and Environmental Medicine (ACOEM). Low back disorders. Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. Available at: <www.guideline.gov>. (accessed 2017 June).
22. American Pain Society (APS). Clinical Guideline for the Evaluation and Management of Low Back Pain. 2009. Available at: <http://americanpainsociety.org>. Accessed June 1, 2017.
23. Van Damme B, Stevens V, Perneel C, et al. A surface electromyography based objective method to identify patients with nonspecific chronic low back pain, presenting a flexion related movement control impairment. J Electromyogr Kinesiol. Dec 2014; 24(6):954-964. PMID 25304196
24. Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2017 June) 2.01.35.
|10/15/2018||Reviewed. No changes.|
|10/15/2017||Document updated with literature review. Coverage unchanged.|
|10/1/2016||Reviewed. No changes.|
|4/1/2015||Document updated with literature review. Coverage unchanged.|
|9/15/2012||Document updated with literature review. Coverage unchanged.|
|1/1/2010||Revised/Updated Entire Document, no change in experimental, investigational, and unproven coverage position.|
|5/15/2007||Revised/Updated Entire Document|
|8/15/2003||Revised/Updated Entire Document|
|1/1/1998||Revised/Updated Entire Document|
|5/1/1996||Revised/Updated Entire Document|
|1/1/1995||Revised/Updated Entire Document|
|4/1/1994||Revised/Updated Entire Document|
|Title:||Effective Date:||End Date:|
|Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy||10-15-2017||10-14-2018|
|Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy||10-01-2016||10-14-2017|
|Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy||04-01-2015||09-30-2016|
|Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy||09-15-2012||03-31-2015|
|Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy||01-01-2010||09-14-2012|
|Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy||05-15-2007||12-31-2009|
|Needle Electromyogram (EMG) and Paraspinal Surface Electromyography||08-15-2003||05-14-2007|
|Spinoscopy, Motion Analysis||05-01-1996||05-14-2007|