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Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain

Policy Number: MP-362

Latest Review Date: June 2019

Category: Medicine

Policy Grade: C

Description of Procedure or Service:

Surface electromyography, a noninvasive procedure that records the summation of muscle electrical activity, has been investigated as a technique to evaluate the physiological functioning of the back. In addition, this procedure has been studied 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.

Back Pain

Back pain is an extremely common condition, affecting most individuals at some point in their lives. Identifying the pathogenesis of back pain is a challenging task, in part due to the complex anatomy of the back, which includes vertebrae, intervertebral discs, facet joints, spinal nerve roots, and numerous muscles. Back pain may be related to osteoarthritis, disc disease, subluxation, or muscular pathology, such as muscle strain or spasm. Moreover, due to referred pain patterns, the location of the pain may not be anatomically related to the pathogenesis of the pain. For example, buttock or leg pain may be related to pathology in the spine. In addition to the diagnostic challenges of back pain is the natural history of acute back pain.

Diagnosis

Aside from the physical exam, diagnostic tests include imaging technologies, such as magnetic resonance imaging (MRI), designed to identify pathology (e.g., bulging discs), or tests such as discography to localize the abnormality by reproducing the pain syndrome. However, these tests lack specificity, and must be carefully interpreted in the context of the clinical picture. For example, magnetic resonance imaging identifies 5% of asymptomatic patients as having bulging discs. However, the presence of a bulging disc may only be clinically significant if correlated with other symptoms. Assessment of the musculature may focus on range of motion or strength exercises.

In contrast to anatomic imaging, surface electromyography (SEMG), which records the summation of muscle activity from groups of muscles, has been investigated as a technique to evaluate the physiological functioning of the back. A noninvasive procedure, SEMG is contrasted with needle electromyography, an invasive procedure in which the electrical activity of individual muscles is recorded. Paraspinal SEMG has been explored 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 is 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

  • evaluation of pain management treatment techniques

    Treatment

    Most cases of acute low back pain resolve with conservative therapy (e.g., physical therapy) while continuing normal activities within limits permitted by the pain. Therefore, initial imaging or other diagnostic testing is generally not recommended unless “red flag” warning signs are present or the pain persists for more than four to six weeks. Red flag findings include significant trauma, history of cancer, unrelenting night pain, fevers or chills, and progressive motor or sensory deficits.

    Policy:

    Paraspinal surface electromyography (SEMG) is considered not medically necessary and investigational as a technique to diagnose or monitor back pain.

    See Policy #228 for Neuromuscular and Electrodiagnostic: Nerve Conduction Studies and Electromyography Studies

    Key Points:

    The most recent literature review was updated through April 01, 2019.

Evidence reviews assess whether a medical test is clinically useful. In order to determine if a test is clinically useful, the test must provide information to make a clinical management decision that improves the net health outcome. The balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The formulation of the clinical context and purpose of the test is the first step in assessing a medical test. The test must be technically reliable, clinically valid, and clinically useful for that purpose.

Surface Electromyography

Surface electromyography (SEMG) has been used as a research tool to further evaluate the performance of paraspinal muscles in patients with back pain and to further understand the etiology of low back pain. Preliminary research has also been performed to determine which SEMG parameters best differentiate patients with and without back pain.

Clinical Context and Test Purpose

The purpose of paraspinal SEMG in patients who have back pain is to identify the pathogenesis of the pain (that is, muscle, joint, or disc disease), which will inform a decision on treatment plan.

The question addressed in this evidence review is: Does paraspinal SEMG improve net health outcomes in individuals with back pain?

The following PICOTS were used to select literature to inform this review.

Patients

The patient populations of interest are individuals with back pain.

Interventions

Paraspinal SEMG is a noninvasive technique that records the summation of 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 an individual with back pain include clinical examination and imaging.

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, more appropriate therapy will be delayed.

Timing

Prior to determining the treatment plan.

Setting

Paraspinal SEMG can be performed in an office setting.

Technically Reliable

Assessment of technical reliability focuses on specific tests and operators and requires review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this evidence review, and alternative sources exist. This evidence review focuses on the clinical validity and clinical utility.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

No articles that directly 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. In some instances, asymmetrical electrical activity may have been used to define abnormality; results may be compared with normative data. However, we no published literature defining what degree of asymmetry would constitute abnormality.

A 2016 study by du Rose and Breen looked into the relationship between lumbar intervertebral range of motion and paraspinal muscle activity in healthy adults, as measured by SEMG and quantitative fluoroscopy, in order to establish “normal” measurements. Fluoroscopic images and SEMG measurements were taken on 20 males with no history of low back pain. 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 low back pain are needed to establish standard criterion.

In the absence of a criterion standard diagnostic test, correlation with the clinical symptoms and physical exam is critical. De Luca (1993) 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. Using physical exam and clinical history as a criterion standard, De Luca 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. (Accuracy is 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 (2010, 2014) in Hong Kong published two articles on dynamic topography, an approach to analyzing SEMG findings. Both studies 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 (a more symmetric pattern in healthy controls). After physical therapy, the dynamic topography images of back pain patients were more similar to the healthy controls on some of the parameters assessed. In the second study, following rehabilitation, back pain patients were classified as responders or nonresponders based on changes in back pain severity. Some associations were found between baseline SEMG parameters and response to rehabilitation. SEMG was not repeated after 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.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from randomized controlled trials.

A number of studies describe the use of SEMG as an aid in classifying low back pain. Much of this research has focused on the use of SEMG to assess muscle fatigability rather than on how information from test findings 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, as noted in the Background section, 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) by Kienbacher et al (2016), SEMG showed potential to discriminate between impaired and unimpaired neuromuscular regulation of back extensors, which would provide useful information for designing individualized exercise programs.

In a 2015 study of patients with LBP (n=27) and pain-free controls (n=23) by Schabrun et al (2017), SEMG detected a loss of discrete motor cortical organization of the paraspinal muscles among those with LBP. The invasive technique of needle electromyography is usually performed to detect this pathology. Patients with cortical reorganization may benefit from motor skill training.

In two 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.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility. Current evidence on clinical validity does not permit construction of a chain of evidence to support the use of SEMG as a diagnostic tool for evaluating and monitoring back pain.

Summary of Evidence

For individuals who have back pain who receive paraspinal surface electromyography (SEMG) for evaluation and monitoring, the evidence includes several nonrandomized studies on using findings to classify back pain. The relevant outcomes are test accuracy and validity, symptoms, functional outcomes, quality of life, and resource utilization. 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. 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. The evidence is insufficient to determine the effects of the technology on health outcomes.

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.

American Pain Society

In 2009, the American Pain Society issued guidelines on the evaluation and management of low back pain. When discussing the diagnostic accuracy of nonimaging tests, the guidelines stated that “There is.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Key Words:

EMG, Surface, Paraspinal, Paraspinal Surface EMG, Surface EMG, Paraspinal, low back pain, low back disorders, SEMG

Approved by Governing Bodies:

Not applicable

Benefit Application:

Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

Current Coding:

CPT Codes:

There is no specific CPT code, but may be reported using the codes below. Some plans have reported that this technology has been billed using CPT code 95860-95872 and 95885-95887 which is an incorrect code range that addresses the use of needle, not surface EMG.

96002

Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles

96004

Review and interpretation by physician or other qualified health care professional of comprehensive computer-based motion analysis, dynamic plantar pressure measurement, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report.

HCPCS: S3900 Surface electromyography

References:

  1. Ahern DK, Follick MJ, Council JR et al. Reliability of lumbar paravertebral EMG assessment in chronic low back pain. Arch Phys Med Rehabil 1986; 67(10):762-5.

  2. 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 online at www.guideline.gov.

  3. American College of Occupational and Environmental Medicine. Low back disorders, evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village, IL: ACOEM; 2011.

  4. Arena JG, Sherman RA, Bruno GM, et al. Electromyographic recordings of low back pain subjects and non-pain controls in six different positions: Effect of pain levels. Pain 1991; 45(1):23-8.

  5. Bittman B, Cram JR. Surface electromyography: an electrophysiological alternative in pain management. Paper presented at: Presented at the American Pain Society; Oct 22-25 1992; San Diego, CA.

  6. Cheung J, Halbertsma JP, Veldhuizen AG, et al. A preliminary study on electromyographic analysis of paraspinal musculature in idiopathic scoliosis. Eur Spine J 2005; 14(2):130-7.

  7. Cram JR, Lloyd J and Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom 1994; 41(1-4):41-5.

  8. De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve 1993; 16(2):210-216.

  9. Demoulin C, Crielaard JM and Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine 2007; 74(1):9-13.

  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).

  11. 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):991-7.

  12. Falkenberg J, Podein RJ, Pardo X, et al. Surface EMG activity of the back musculature during axial spinal unloading using an LTX 3000 Lumbar Rehabilitation System. Electromyogr Clin Neurophysiol 2001; 41(7):419-27.

  13. Gentempo P and Kent C. Establishing medical necessity for paraspinal EMG scanning. Chiropractic: J Chiropractic Res Clin Invest 1990; 3(1):22-5.

  14. Gentempo P, Kent C. Establishing medical necessity for paraspinal EMG scanning. Chiropractic: J Chiropractic Res Clin Invest. 1990; 3(1):22-25.

  15. Greenough CG, Oliver CW and Jones AP. Assessment of spinal musculature using surface electromyographic spectral color mapping. Spine 1998; 23(16):1768-74.

  16. 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 2011; 3(10):920-8.

  17. 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.

  18. Hu Y, Siu SH, Mak JN, et al. Lumbar muscle electromyographic dynamic topography during flexion-extension. J Electromyogr Kinesiol. 2010; 20(2):246-255.

  19. 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):175-84.

  20. Hung CC, Shen TW, Liang CC, et al. Using surface electromyography (SEMG) to classify low back pain based on lifting capacity evaluation with principal component analysis neural network method. Conf Proc IEEE Eng Med Biol Soc. 2014; 2014:18-21.

  21. 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 2012; 22(14):413-26.

  22. 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.

  23. Meyer JJ. The validity of thoracolumbar paraspinal scanning EMG as a diagnostic test: an examination of the current literature. J Manipulative Physiol Ther 1994; 17(8):539-51.

  24. 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.

  25. 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 Pain 2013; 29(4):334-40.

  26. Peach JP and McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine 1998; 23(10): 1117-23.

  27. Roy SH and Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther 1998; 78(8):838-51.

  28. Roy SH, De Luca CJ, Emley M, et al. Spectral electromyographic assessment of back muscles in patients with low back pain undergoing rehabilitation. Spine 1995; 20(1):38-48.

  29. 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). Aug 1 2017; 42(15):1172-1178.

  30. 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. Spin (Phila Pa 1976) 2012; 37(8):E486-95.

  31. 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 flexion related movement control impairment. J Electromyogr Kinesiol. Dec 2014; 24(6):954-964.

  32. 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.

Policy History:

Medical Policy Group, July 2009 (3)

Medical Policy Administration Committee, August 2009

Available for comment August 10-September 23, 2009

Medical Policy Group, August 2010 (1): Description updated and no change in policy statement

Medical Policy Group, November 2011 (1): Update to Key Points; no change in policy statement

Medical Policy Group, December 2011 (3): Added statement for new 2012 Codes – 95885, 95886, 95887

Medical Policy Panel, November 2012

Medical Policy Group, November 2012 (2): No changes to policy statement. Key Points and References updated.

Medical Policy Group, December 2012 (3): 2013 Coding Updates: Verbiage change to Code 96004-added “or other qualified health care professional”.

Medical Policy Panel, September 2013

Medical Policy Group, October 2013 (2): No change to policy. ACOEM statement updated with 2011 change.

Medical Policy Panel, September 2014

Medical Policy Group, September 2014 (3): 2014 Updates to Key Points & References; no change in policy statement

Medical Policy Panel, September 2015

Medical Policy Group, September 2015 (6): Updates to Key Points and References; no change to policy statement.

Medical Policy Panel, June 2017

Medical Policy Group, June 2017 (6): Updates to Key Points, Practice Guidelines, and References; no change to policy statement.

Medical Policy Panel, June 2018

Medical Policy Group, June 2018 (6): Updates to Key Points and References.

Medical Policy Panel, June 2019

Medical Policy Group, June 2019 (3):2019 Updates to Key Points, References and Key Words: added: low back pain, low back disorder and SEMG. No changes to policy statement or intent.

 

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.