Most people walk into a specialist’s office holding their MRI like a ticket. Dr. Reed Stone sets it down. “When a patient comes in with an MRI, put it down,” he told Dave Kashuba and Mike McGann on this week’s Pain 2 Power. The patient usually looks at him and asks whether he is going to read it. His answer: “That’s the last thing.”
If you have numbness, tingling, weakness, or pain that runs down an arm or a leg, and somebody has told you that you need a nerve test, this episode is for you. Dr. Stone is a neurologist at Palm Beach Neurology who has done this work, in his words, “every day for over 40 years.” He spent the half hour on what the test feels like, what it can and can’t tell you, and why the order you do things in matters so much.
By The First Rehabilitation Team · Reviewed by Dr. Dave Kashuba, Ph.D.
A neurologist who has also been a patient at First Rehab
Dave has worked with Dr. Stone since 1990. He introduced him as a New Yorker who started out at Brooklyn College, a Yankees fan (“although we didn’t finish it the way we should have”), and the doctor a lot of people in Palm Beach County get sent to for EMG testing. Dave added that, as far as he knows, Dr. Stone is the only one who still does his own testing.
Then Dr. Stone said something that wasn’t on the run sheet. “I can say I’ve been a patient,” he said. He has lifted weights since he was a teenager and, by his own account, collected the usual injuries along the way. “Sometimes we’re not so smart about what we do. We do it anyway because we want to impress everybody.”
The shoulder that kept him out of the gym
His shoulder got bad enough that he couldn’t sleep, and he said he drove his wife and his staff crazy. It kept him out of the gym for a long time. After working with Dave’s team, here is how he described it: “No pain, no surgery, nothing. I’m back in the gym.” These days he trains alongside his son Xander, a discus and hammer thrower, and he still follows the exercise program the clinic gave him.
Mike pointed out that this is the name of the show. A doctor who sends patients to First Rehab went there himself and came out the other side. If your own shoulder pain is keeping you up at night, that page covers how we approach it.
Does an EMG hurt?
Dave asked this first because it is the question his patients ask him. A lot of people picture big needles and electric shocks. Dr. Stone started with some history. EMG and nerve conduction testing first came out, as he put it, “sort of in the 1940s,” and the early version was, in his word, a little prehistoric.
From autoclaved needles to something close to acupuncture
He likes to tell younger patients that the original needles were autoclaved, meaning sterilized and used again. Most of them have never heard the word. “They look at me, they’re caught in the headlights,” he said. Those old needles hurt.
Today’s are very fine. “It’s literally almost like acupuncture,” Dr. Stone said. He described the needles as microphones. Once one is in a muscle, it picks up that muscle’s electrical activity, and he watches and listens to it as an audio and video recording on a laptop. He didn’t pretend it is nothing. There may be some discomfort, he said, but done properly and with expertise it isn’t a terrible procedure.
The two halves of the test
The nerve conduction study comes first. A small electrical pulse goes over the arm or leg where the nerve sits, and the equipment measures how fast the message travels, how big it is, and whether it is blocked somewhere along the way. The needle part then looks at the muscles themselves. Together, Dr. Stone said, they give him the ability to make an accurate diagnosis.
Mike, who said he has “a slew of nerve issues” in his neck and back, had never heard the test explained like that. His take was simple. A little discomfort sounds worth it if it finds the source of the numbness or pain.
Why the MRI comes last
This is where Dr. Stone was firmest. Patients arrive with prescriptions from other doctors that name the test and sometimes the diagnosis too. “I put prescriptions down,” he said. The way he works hasn’t changed in four decades. “The gold standard, and it still is, is history and physical.”
The nerve test, as he explained it, is there to help corroborate the diagnosis, and sometimes it changes it. It can’t make the diagnosis on its own. You need a proper history and exam before the test, so you know what question the test is answering.
What a first visit with Dr. Stone looks like
Mike asked him to walk through a first appointment. It starts with a concise history and the right questions. Dr. Stone admitted that part is harder than it sounds, because people like to talk about a lot of things and his job is to keep them on track. Next comes a detailed exam of the muscles, nerves and sensation. Then the nerve conduction test, to see whether it backs up what he found and whether it matches the MRI. Sometimes it doesn’t.
“We’re tending to treat too much with technology,” he said. That is the moment the MRI goes on the desk.
Dave’s version: “I do not do treatment on an MRI”
Dave said he tells patients the same thing. “I do not do treatment on an MRI,” he said, and surgeons don’t operate on one either. His example was the rotator cuff. He sees people with full thickness tears who lift their arm and do fine, and people with a small tear who can’t. The picture and the person don’t always line up, which is why the exam matters. Our physical therapy page explains what a first evaluation at the clinic involves.
When the diagnosis turns out to be something else
Most of the episode circled back to one idea. A label can be wrong, and a wrong one costs people. Dave, Dr. Stone and Mike each brought a story.
| Who told it | The first label | What it turned out to be |
|---|---|---|
| Dave Kashuba | A friend diagnosed with ALS | Kennedy’s disease, and the ALS treatment stopped |
| Dr. Reed Stone | Carpal tunnel, from an earlier test | Sometimes a problem in the neck or the brachial plexus |
| Dr. Reed Stone | Spinal stenosis, headed for surgery | A peripheral neuropathy in the feet that had been overlooked |
| Mike McGann | Years of misdiagnoses for his mother | Charcot, a neurological disorder the family had never heard of |
The friend who was planning his death
Dave told the story of someone close to them who was diagnosed with ALS. After testing, the diagnosis changed to Kennedy’s disease, which Dave described as one that affects men and isn’t life threatening, and the ALS treatment stopped. “He was literally planning his death,” Dave said.
Dr. Stone didn’t take a bow for it. In neurology, he said, many different diseases can produce the same abnormalities on a test, so he leans on the history, the exam, and how a disease behaves over time. Sometimes the right call on a first visit is to wait, or to get another opinion to make sure.
Dave said the same patient had been improving, which with ALS isn’t supposed to happen, and that told him something else was going on. It led to two of Dave’s lines. “A good therapist knows what they don’t know,” he said. And one he says he always uses: “The difference between a surgeon and God is God knows he’s not a surgeon.” Mike’s verdict: “That’s really good.”
Carpal tunnel that turns out to be the neck
Dr. Stone sees a lot of carpal tunnel. He also sees patients who arrive with an earlier test and a carpal tunnel label that turns out to be wrong, because the real problem is in the neck, or in the brachial plexus, which he called a complicated circuitry in your shoulder. Careful thought and testing, he said, get the best outcome. Our pages on hand and wrist pain and neck pain show how the two can overlap, and our certified hand therapy team treats carpal tunnel once it is confirmed.
Back surgery, and the feet nobody checked
The case Dr. Stone seemed to care about most involves people already headed for the operating room. Someone has back pain, has been told it is spinal stenosis, and is having trouble walking. Then he examines them and finds a peripheral neuropathy in their feet that was missed. “They’re going to have the surgery, but they’re not going to get better,” he said. In his view, how well the surgery turns out depends on what he tells the surgeon beforehand. Our back pain page covers stenosis from the therapy side.
Mike compared it to the TV show House: rule out the wrong answers until you find the right one, even when the right one is unusual.
When you can’t feel your own feet
Mike’s mother found out something was wrong at church. Someone set a kneeler down on her foot and knelt on it. “She did not know until she saw the blood on the floor,” Mike said. It took a long time and a string of misdiagnoses before anyone named it: Charcot, a neurological disorder nobody in the family had heard of. Once there was a name, Mike said, there was finally a starting point.
Dave sees a version of this at the clinic. Some patients with peripheral neuropathy have no feeling in their feet at all and still have full strength, because the nerve problem is in sensation. And they still drive. He once asked a patient how he knew how hard he was pressing the gas. As Dave told it, the answer was that he watches the speedometer.
Balance problems are often where it shows up
A lot of people come to therapy because they are falling, or nearly falling, Dave said. One of his first questions is about medications, and in particular whether they have recently been put on a statin. He had raised statins at the top of the show too, naming a muscle condition called myositis as one possible side effect. Dr. Stone said it depends on the medication and the problem, but that muscle issues and sometimes peripheral neuropathy are what he commonly sees. His word for it was tricky.
That is a conversation for the doctor who prescribed it. Never stop a medication on your own because of something you heard on a radio show.
Vitamins B and D
Dave also brought up vitamin deficiencies, which he said can cause a lot of the same symptoms. He has seen cases where that is exactly what it turned out to be, and patients started back on vitamin B. He added that vitamin D is now being linked to neurological symptoms as well. Mike’s response: “I really need to see Dr. Stone.”
1987, a hand in water, and “I was the MRI”
Dave started practicing in 1987, and part of the show was two veterans comparing notes. Before nerve testing was routine, he said, one way to check for carpal tunnel was to put the patient’s hand in water and leave it there. Think of a kid in the bathtub whose fingers wrinkle up. With carpal tunnel, the affected part wouldn’t shrivel the same way. Mike loved it.
There were no MRIs then either. “In 1987, there was no MRIs. And I was the MRI,” Dave said. A doctor would ask him whether a problem was rehabable or needed surgery, and he would answer from the exam and from what the patient told him. That subjective history still drives how he evaluates people, and it is why he keeps telling listeners to come in before atrophy sets in.
What that means if you call us
Dave repeated an offer he makes on most episodes: he sees people for free to work out what is going on and who they should see. Sometimes that is therapy at First Rehab. Sometimes it is a referral to someone like Dr. Stone first. He said Dr. Stone does the same in reverse, sending patients over with a prescription and a message to tell Dave he said hi, including people who travel a long way. Dave said earning that trust from a doctor this respected means a great deal to him.
A string walks into a bar, and where to find the episode
Every Pain 2 Power ends with Dave’s joke. This week a string walked into a bar. The bartender recognized him as a troublemaker and threw him out. So the string tied himself into a little knot, frayed the top of his hair, and came back in. “Aren’t you that same string?” the bartender asked. “No, I’m afraid not.” Dr. Stone said the jokes are like dessert.
Listen to the full conversation on the Pain 2 Power podcast page, watch it in our video library, or read more about Dr. Reed Stone on his guest page. Palm Beach Neurology’s number, as he gave it on air, is 561-845-0500. The show airs live Saturdays at 8:30 AM on 100.3 Legends Radio.
We are a physical, occupational and hand therapy clinic on US-1 in North Palm Beach. If you have numbness, weakness, a shoulder that won’t settle, or a balance problem nobody has explained, call us at 561-624-4263 to book an evaluation. If what we find points to a nerve problem that needs testing first, we will tell you, and we will tell you who to see.
This article is general information, not medical advice. Every situation is different, so please consult a qualified professional about yours.