Nerve Conduction Studies & Evoked Potentials 2 —
Training activity: 7

Details

Interpret results of lower limb nerve conduction studies and make recommendations for further investigations/tests in line with clinical context of peripheral neuropathy

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 lower limb nerve conduction study results in the context of peripheral neuropathy and making recommendations for further investigations/tests.
• 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 of lower limb studies specifically for different types and severities of peripheral neuropathy, and appropriate recommendations.

What is your prior experience of this activity?

• Think about what you already know about interpreting nerve conduction study results for lower limbs, and understanding the various presentations and pathological changes associated with different peripheral neuropathies.
• Consider possible challenges you might face during the activity, such as differentiating between types of neuropathy (e.g., demyelinating vs axonal), correlating findings with complex clinical presentation, or determining the most appropriate follow-up investigations, 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:
  • When the findings suggest a rapid-onset autoimmune neuropathy (e.g., GBS) requiring urgent clinical escalation
  • If the interpretation of a complex, hereditary neuropathy requires specialist genetic counselling recommendations.
  • If the diagnosis falls outside the expected conditions listed e.g., atypical mononeuropathy multiplex
• 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 applying knowledge of the pathophysiology of different peripheral neuropathies to interpret findings, identifying patterns indicative of specific conditions e.g., autoimmune diseases, entrapments, and recommending relevant further tests, drawing upon previous experiences.
• Identify the specific insights you hope to gain into understanding the complexities of peripheral neuropathy diagnosis through NCS, or appreciating the role of interpretation in guiding patient investigations and management.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting lower limb studies or cases of peripheral neuropathy.
• Identify important information you need to consider before embarking on the activity, such as classifications and diagnostic criteria for peripheral neuropathies, guidelines for further investigations in neurology, and the specific clinical context of the patient.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting the lower limb NCS results in the context of peripheral neuropathy and formulating recommendations?
• Are you encountering situations such as:
  • The results suggest a rapidly progressive demyelinating neuropathy e.g., Guillain-Barré Syndrome, requiring an immediate and urgent recommendation that deviates from routine follow-up?
  • The NCS findings are highly inconsistent with the clinical picture e.g., severe motor weakness but relatively normal conduction velocities, challenging your classification of the peripheral neuropathy?
  • You are trying to differentiate between specific fibre-selective neuropathies based on subtle amplitude and velocity differences, complicating the recommendation?

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 risk management and communication due to potentially urgent findings?
• Consider the steps you are taking in the moment, such as:
  • Immediately checking the urgency protocols for conditions like acute onset demyelinating diseases to determine the necessary escalation
  • Reviewing academic criteria to systematically categorise the neuropathy type (e.g., axonal vs. demyelinating) before finalising the recommendation
• How are you feeling in that moment? For instance, are you finding it difficult to assess the clinical severity and priority based on the physiological data? Is it affecting your confidence in making appropriate follow-up recommendations?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully identifying a clear pattern of hereditary neuropathy and recommending routine follow-up? Or are you needing support because the interpretation suggests an acute, life-threatening condition requiring immediate consultant clinical intervention and urgent investigation recommendations?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective systematic review technique for classifying peripheral neuropathies? Or gaining insight into the vital role of the Neurophysiologist in early escalation of acute neurological crises?

On action

What happened?

• Begin by summarising the key steps you took when interpreting lower limb NCS results and formulating recommendations in the context of peripheral neuropathy.
• Consider specific events, actions, or interactions which felt important, such as how you systematically classified the neuropathy (e.g., demyelinating vs. axonal) based on velocity, amplitude, and latency, or how you assessed the severity for the recommendation.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately consulting urgency protocols when the findings suggested an acute, rapidly progressive autoimmune condition (e.g., GBS), leading to a recommendation for immediate clinical escalation.
• How did you feel during this experience, e.g., were you confident in your rapid assessment of clinical priority or challenged by the need to differentiate subtle patterns of fibre selectivity?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding peripheral neuropathy interpretation. What strengths did you demonstrate, e.g., ability to apply specific diagnostic criteria for acquired vs. hereditary neuropathies? What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the specific genetic tests appropriate for rare hereditary neuropathies?
• Compare this experience against previous engagement with similar activities – has your practice improved in integrating technical findings with clinical context to assess urgency?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding recommending complex follow-up testing when findings were highly atypical, 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 lower limb studies and making recommendations for neuropathy.
• What will you do differently next time you approach interpretation of peripheral neuropathy cases, for instance, by proactively comparing findings against standardised criteria for demyelinating disease to ensure rapid classification?
• Do you need to practise any aspect of the activity further, such as reviewing the pathophysiology of different peripheral neuropathy subtypes or key learning outcomes related to identifying further investigations?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences interpreting lower limb NCS for peripheral neuropathy, especially cases involving rapidly progressive or hereditary neuropathies, 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 urgent case required immediate classification of a demyelinating neuropathy forced you to re-evaluate the speed and precision of your interpretation and application of urgency guidelines.
• Considering what you understand about interpreting complex neuropathies, identifying further investigations, and classification of neuropathy severity 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 classification methodology and recommendation formulation based on further learning and experiences? For example, how you proactively reviewed and integrated the academic criteria for differentiating between different fibre-selective neuropathies into your interpretation process, demonstrating you have adapted improvements based on further learning.
• Has discussing acute, life-threatening neuropathy cases or the clinical need for specific genetic testing 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 Neurologist about the urgency of reporting suspected Guillain-Barré Syndrome (GBS), refined your understanding of the critical nature of rapid interpretation and escalation.

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 lower limb NCS for neuropathy and identifying further investigations, particularly in preparing for assessments like CBDs? For example, how your accumulated ability in classifying peripheral neuropathy subtypes now enables you to confidently discuss the differential diagnosis 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 findings suggest an acute autoimmune neuropathy requiring immediate clinical intervention, recognising this falls outside routine investigation recommendation scope.
• Looking holistically at your training journey, how has this initial lower limb interpretation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to interpretation and identifying further investigations? For example, how this foundational experience has supported your development in meeting subsequent learning outcomes focused on discussing the uses of EMG, which provides complementary diagnostic information.

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.