The biggest argument for using electromyography (EMG) guided injections is that it improves accuracy when introducing botulinum toxins in pain management. Improved accuracy can benefit both clinicians and patients.

Standard EMG machines, however, are a huge capital investment. Cost considerations can’t be avoided given the reimbursement issues of recent years and the struggle many practices have just to keep their doors open.

So, is it worth adding EMG guided injections to your practice?

The answer: It depends.

Dr. Heidi Schwarz, a neurologist and headache specialist in Rochester, New York, who regularly injects botox, doesn’t have a need for EMG guidance in her practice, though there may be other beneficial applications.

“Botox for headache works on blocking signals from sensory pain fibers that cannot be captured by EMG,” she said. “I feel this is totally unnecessary for Botox for migraine, but it is a different story for Botox for spasticity, where EMG is very helpful.”

As is the case with spasticity, research also supports using EMG guidance to locate specific muscles for treatment, even in the most difficult cases.

For example, a recent study in Tremor found that EMG guided injection helped increase needle depth accuracy when targeting the longus colli for patients with dystonic anterocollis. These injections are considered difficult and potentially dangerous to patients, according to the study.

This is not the first study to show that EMG guidance can improve toxin injection accuracy, even for inexperienced injectors.

A 2012 study found success rates to be similar for new and veteran injectors when using EMG guidance in injection of the gastrocnemius, a muscle that is far easier to target than the longus colli. The study noted that muscle palpation and anatomical landmarks are not enough to ensure injection accuracy even for large, superficial muscles.

However, as we noted, despite EMG guidance’s many benefits, standard EMG machines can cost thousands of dollars. Paying for them needs to be part of any clinician’s consideration for including EMG guided injection in practice.

One potential cost-effective alternative to a standard EMG machine is a handheld version. Though less sophisticated, a device like the Myoguide is more affordable, and may well serve your needs. Like standard EMG units, using the Myoguide for injection guidance also qualifies for reimbursement.

They also have the big advantage of being portable.

“Most EMG machines are cumbersome due to their size,” said Dr. Evan Friedman, president and founder of Intronix Technologies, maker of the Myoguide EMG System. “Many are stuck in a single room that may or may not be available. Moving EMG machines, while possible, is a rather inconvenient process.”

Like every other decision you make for your practice, it comes down to a cost/benefit analysis. And, Schwartz said, it’s imperative that patient needs are considered first and foremost in the equation.

Special thanks to Heidi Schwarz, MD, Professor of Clinical Neurology, University of Rochester Medical center, Rochester, NY, who specialises in headache medicine.

Special thanks to Dr. Evan Friedman, president and founder of Intronix Technologies.

For more information about the Myoguide, visit