Nerve Conduction Studies & Evoked Potentials 2 —
Training activity: 6

Details

Interpret results of upper limb nerve conduction studies and make recommendations for further investigations/tests in line with clinical context: Carpal tunnel syndrome Ulnar neuropathy at the elbow

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 interpreting upper limb nerve conduction study results, specifically for Carpal tunnel syndrome and Ulnar neuropathy at the elbow and making recommendations for further investigations/tests based on clinical context.
• Consider how the learning outcomes apply, specifically in relation to identifying further investigations, interpreting nerve conduction studies, and demonstrating effective communication.
• Discuss with your training officer to gain clarity of what is expected of you in relation to successful interpretation and appropriate recommendations for these specific upper limb conditions.

What is your prior experience of this activity?

• Think about what you already know about interpreting nerve conduction study results, particularly for upper limbs, and understanding common entrapment neuropathies.
• Consider possible challenges you might face during the activity, such as interpreting equivocal findings, integrating findings with complex clinical history and symptoms, or knowing which further investigations are appropriate, and think about how you might handle them.
• 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 the findings are borderline or equivocal for Carpal Tunnel Syndrome and require senior review to determine diagnosis
  • When the interpretation suggests a proximal pathology (e.g., radiculopathy) that requires recommendations for tests outside routine peripheral NCS
  • If communication regarding complex differential diagnoses with the MDT is needed
• Acknowledge how you feel about interpreting the results and making recommendations for further tests in the context of this training activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as systematically reviewing study parameters, correlating findings with the known pathophysiology of Carpal tunnel syndrome and Ulnar neuropathy, and formulating evidence-based recommendations, drawing upon previous experiences.
• Identify the specific insights you hope to gain into understanding the spectrum of findings in these conditions or appreciating how interpretation directly impacts patient management.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting nerve conduction studies or making recommendations.
• Identify important information you need to consider before embarking on the activity, such as diagnostic criteria for Carpal tunnel syndrome and Ulnar neuropathy, guidelines for further investigations, and relevant patient clinical information.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting the upper limb NCS results and formulating recommendations?
• Are you encountering situations such as:
  • The findings for Ulnar neuropathy at the elbow show unexpected proximal slowing or abnormality suggesting a higher lesion (e.g., C8 radiculopathy) that conflicts with the initial request for simple entrapment?
  • The Carpal tunnel study results are borderline, making definitive diagnosis or recommendation for further investigation difficult, requiring complex clinical correlation
  • The patient’s symptoms are highly inconsistent with the physiological findings, challenging the appropriateness of the recommended next steps?

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 data analysis or differential diagnosis in the moment?
• Consider the steps you are taking in the moment, such as:
  • Immediately consulting academic or departmental guidelines to differentiate between common entrapment findings and more proximal pathologies
  • Formulating recommendations that specifically address the ambiguity (e.g., suggesting EMG confirmation or imaging)
• How are you feeling in that moment? For instance, are you finding it difficult to integrate complex physiological data with clinical context? Is it affecting your confidence in identifying appropriate further investigations?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully identifying and describing a clear pattern of severe Carpal Tunnel Syndrome? Or are you needing support because the ambiguity of the findings or the requirement to recommend complex tests beyond peripheral NCS necessitates senior clinical review?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective systematic approach to reviewing data for proximal lesions in upper limb studies? Or gaining insight into the specific investigations needed for differential diagnosis in neurology?

On action

What happened?

• Begin by summarising the key steps you took when interpreting upper limb NCS results and formulating recommendations for conditions like Carpal Tunnel Syndrome (CTS) and Ulnar Neuropathy at the elbow.
• Consider specific events, actions, or interactions which felt important, such as how you systematically checked for focal slowing across segments of the Ulnar nerve, or how you integrated the patient’s pain distribution to determine if CTS was the primary diagnosis.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, re-evaluating the possibility of a proximal lesion (e.g., radiculopathy) when findings were unexpectedly normal for severe clinical symptoms, leading to a recommendation for an EMG.
• How did you feel during this experience, e.g., were you confident in consulting external guidelines to support your differential diagnosis or challenged by the need to formulate recommendations that fell outside peripheral NCS?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding interpretation and recommendation. What strengths did you demonstrate, e.g., accurate application of diagnostic criteria for CTS? What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the most appropriate further investigation when findings were borderline or equivocal?
• Compare this experience against previous engagement with similar activities – has your practice improved in systematically analysing upper limb data to exclude proximal pathology?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding recommending complex ancillary tests or discussing findings suggesting central nervous system involvement, 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 interpreting upper limb studies and making recommendations.
• What will you do differently next time you approach interpretation of upper limb NCS, for instance, by proactively reviewing the patient’s full clinical history before analysis to anticipate potential differential diagnoses?
• Do you need to practise any aspect of the activity further, such as reviewing guidelines for appropriate further investigations for different neurological localisations or key learning outcomes related to interpreting NCS results?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences interpreting upper limb NCS, especially challenging cases requiring differentiation between entrapment and proximal lesions, 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 with suspected Carpal Tunnel Syndrome showed subtle proximal findings forced you to re-evaluate the diligence of your systematic segmental analysis you applied during your first attempt at interpretation.
• Considering what you understand about interpretation, identifying further investigations, and disease pathophysiology 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 interpretation methodology and recommendation formulation based on further learning and experiences? For example, how you proactively reviewed and integrated the standard clinical guidelines for recommending EMG follow-up when NCS findings are equivocal, demonstrating you have adapted improvements based on further learning.
• Has discussing complex differential diagnoses or the clinical impact of inappropriate recommendations 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 recommendation that overlooked key symptoms, refined your understanding of the critical nature of integrating clinical history into physiological interpretation.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent interpretation experiences, contributed to your overall confidence and competence in interpreting NCS and identifying further investigations, particularly in preparing for assessments like CBDs? For example, how your accumulated ability in analysing segmented upper limb data now enables you to confidently discuss differential diagnoses for entrapment neuropathies during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to interpretation and recommendation? 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 or Neurologist immediately when the interpretation suggests a complex pathology (e.g., motor neuron disease or severe proximal plexopathy) that falls outside routine upper limb peripheral NCS scope.
• Looking holistically at your training journey, how has this initial upper limb interpretation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to identifying further investigations and interpretation? For example, how this foundational experience has supported your development in subsequent learning outcomes focused on reviewing the evidence base for IOM, which requires advanced interpretation skills.

Relevant learning outcomes

#	Outcome
# 6	Outcome Identify further investigations in line with clinical context and the patients history and symptoms.
# 9	Outcome Interpret peripheral nerve conduction studies and evoked potential studies.
# 12	Outcome Demonstrate effective and compassionate communication skills with all stakeholders, including patients and the multidisciplinary team.