Critically re-evaluating a common technique: Accuracy, reliability, and confirmation bias of EMG

Objectives: (1) To assess the diagnostic accuracy of EMG in radiculopathy. (2) To evaluate the intrarater reliability and interrater reliability of EMG in radiculopathy. (3) To assess the presence of confirmation bias in EMG. Methods: Three experienced academic electromyographers interpreted 3 compact discs with 20 EMG videos (10 normal, 10 radiculopathy) in a blinded, standardized fashion without information regarding the nature of the study. The EMGs were interpreted 3 times (discs A, B, C) 1 month apart. Clinical information was provided only with disc C. Intrarater reliability was calculated by comparing interpretations in discs A and B, interrater reliability by comparing interpretation between reviewers. Confirmation bias was estimated by the difference in correct interpretations when clinical information was provided. Results: Sensitivity was similar to previous reports (77%, confidence interval [CI] 63%-90%); specificity was 71%, CI 56%-85%. Intrarater reliability was good (k 0.61, 95%CI 0.41-0.81); interrater reliability was lower (k 0.53, CI 0.35-0.71). There was no substantial confirmation bias when clinical information was provided (absolute difference in correct responses 2.2%, CI 213.3% to 17.7%); the study lacked precision to exclude moderate confirmation bias. Conclusions: This study supports that (1) serial EMG studies should be performed by the same electromyographer since intrarater reliability is better than interrater reliability; (2) knowledge of clinical information does not bias EMG interpretation substantially; (3) EMG has moderate diagnostic accuracy for radiculopathy with modest specificity and electromyographers should exercise caution interpreting mild abnormalities.