Nerve Conduction Studies & Evoked Potentials 1 —
Training activity: 4

Details

Perform sensory and motor nerve conduction studies on the upper limbs for carpal tunnel and ulnar nerve neuropathy including the following measurements: Limb temperature Amplitude and latency Velocity

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like? 

• Identify what is expected of you in relation to accurately performing the diagnostic tests and obtaining specific measurements (limb temperature, amplitude, latency, velocity). 

• Consider how the learning outcomes apply, specifically in relation to performing diagnostic tests, applying legislation and guidelines and managing risk, and demonstrating effective communication. 

• Discuss with your training officer to gain clarity of what is expected of you in relation to specific technical requirements, acceptable ranges for NCS measurements, and troubleshooting common issues. 

What is your prior experience of this activity? 

• Think about what you already know about performing practical clinical procedures, especially those involving medical equipment and electrical stimulation. 

• Consider possible challenges you might face during the activity, such as maintaining correct limb temperature, dealing with unwanted electrical artifact, or ensuring patient comfort during a procedure. 

• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if you cannot achieve a supramaximal stimulus despite maximal settings, potentially indicating equipment or patient resistance issues. 

• Acknowledge how you feel about performing invasive or potentially uncomfortable procedures on patients. 

What do you anticipate you will learn from the experience? 

• Consider the specific skills you want to develop, such as precise electrode placement, stimulus delivery, and obtaining reliable neurophysiological data. 

• Identify the specific insights you hope to gain into the technical nuances of obtaining reliable neurophysiological data and minimising the effects of non-pathological factors (e.g., limb temperature) on NCS results. 

What additional considerations do you need to make? 

• Consult actions identified following previous experiences of practical clinical procedures. 

• Identify important information you need to consider before embarking on the activity, such as reviewing academic content on recording and stimulus parameters, electrode placement, instrumentation, and sources of error in NCS measurements. 

In action

Is anything unexpected occurring? 

• Are you noticing anything surprising or different from what you anticipate whilst performing the sensory or motor nerve conduction studies? 

• Are you encountering situations such as:  

• • Technical difficulties arise with the equipment e.g., unable to achieve a supramaximal stimulus, excessive electrical artifact, or high impedance challenging your ability to perform diagnostic tests accurately 

• • The patient reports unexpected discomfort or movement during stimulation, compromising the quality and reproducibility of the recordings 

• • The limb temperature cannot be maintained within the optimal range, introducing potential non-pathological effects that could compromise the validity of velocity and amplitude measurements  

How are you reacting to the unexpected development? 

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to placement, stimulation, or recording technique? 

• Consider the steps you are taking in the moment, such as:  

• • Immediately pausing the stimulation to troubleshoot the technical issue e.g., checking electrode connections or skin preparation before proceeding with the measurement 

• • Adjusting the patient’s position or providing immediate reassurance to minimise movement artifact and ensure patient comfort 

• How are you feeling in that moment? For instance, are you finding it difficult to adapt your technique to overcome the technical failure? Is it affecting your confidence in obtaining reliable neurophysiological data? 

What is the conclusion or outcome? 

• Identify how you are working within your scope of practice. For example, are you successfully troubleshooting a common electrical artifact issue by adjusting the ground electrode placement? Or are you needing support because the inability to maintain limb temperature or a persistent equipment malfunction requires senior technical intervention? 

• What are you learning as a result of the unexpected development? For example, are you mastering a more effective technique for recognising and eliminating electrical noise? Or gaining insight into the critical importance of limb temperature management? 

On action

What happened? 

• Begin by summarising the key steps you took when performing the sensory and motor nerve conduction studies and obtaining the required measurements (limb temperature, amplitude, latency, velocity). 

• Consider specific events, actions, or interactions which felt important, such as how you managed electrode placement and achieved supramaximal stimulation or how you ensured limb temperature remained stable. 

• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adjusting the ground electrode placement to eliminate unexpected electrical artifact, maintaining diagnostic quality.  

• How did you feel during this experience, e.g., did you feel focused on troubleshooting the technical issue or stressed by the potential for unreliable data? 

How has this experience contributed to your developing practice? 

• Identify what learning you can take from this experience regarding technical performance. What strengths did you demonstrate, e.g., technical precision in electrode placement and stimulus delivery? What skills and/or knowledge gaps were evident, e.g., uncertainty in recognising and addressing artifact caused by patient movement? 

• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in obtaining reliable measurements and managing risk related to non-pathological effects? 

• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the need to stop the study prematurely due to persistent equipment malfunction that you could not resolve, and how you reacted to this. 

What will you take from the experience moving forward? 

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the technical reliability of your NCS performance and measurement acquisition. 

• What will you do differently next time you approach performing upper limb NCS, for instance, by proactively reviewing the correlation between stimulus intensity and evoked response amplitude to verify supramaximal stimulation more efficiently? 

• Do you need to practise any aspect of the activity further, such as advanced troubleshooting of technical artifacts or key learning outcomes related to obtaining reproducible amplitude and latency measurements? 

Beyond action

Have you revisited the experiences? 

• How have your subsequent experiences of performing sensory and motor nerve conduction studies (NCS) on the upper limbs since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent patient presented with severe edema (swelling) or anatomical variation making standard placement difficult forced you to re-evaluate the rigidity of the standard electrode placement protocol you applied during your first attempt at this training activity. 

• Considering what you understand about limb temperature management, optimal electrode placement, and troubleshooting poor signal quality now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your NCS performance technique based on further learning and experiences? For example, how you proactively implemented the use of a more precise measurement tool for calculating distances between stimulation and recording sites, demonstrating you have adapted improvements based on further learning. 

• Has discussing challenging cases requiring modified electrode placements or the impact of incorrect limb temperature measurement with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where sub-optimal NCS results were caused by cold limb temperature refined your understanding of the critical nature of pre-test temperature stabilisation and monitoring during the study. 

How have these experiences impacted upon current practice? 

• How has the learning from this initial training activity, in combination with subsequent upper limb NCS experiences, contributed to your overall confidence and competence in performing nerve conduction studies for carpal tunnel and ulnar nerve neuropathy, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in performing accurate latency and amplitude measurements now enables you to perform and mark up a sensory and motor nerve conduction test on one limb confidently during a DOPS assessment. 

• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to performing upper limb nerve conduction studies? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer immediately when unresolvable electrical noise or interference is compromising signal integrity, recognising this requires specialist technical input beyond routine troubleshooting scope. 

• Looking holistically at your training journey, how has this initial upper limb NCS performance experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to performing diagnostic tests and applying legislation and managing risk? For example, how this foundational experience has supported your development in practicing safely by providing the necessary knowledge base for the subsequent learning outcomes focused on producing factual reports based on technical data. 

Relevant learning outcomes

#	Outcome
# 5	Outcome Perform diagnostic tests including upper limb nerve conduction studies and multi-modality evoked potential studies on a range of patients.
# 7	Outcome Apply legislation and guidelines and manage risk in the performance of upper limb nerve conduction studies and multi-modality evoked potential studies.
# 9	Outcome Demonstrate effective and compassionate communication skills with all stakeholder including patients and the multidisciplinary team.