J Basser: 0:03

Welcome folks to the Exposed Vet Radio Show. The Exposed Vet Radio Show is brought to you by Exposed Vet Productions. It's now a production show instead of a radio show, and in cooperation with Valor for Vet. My co-host today is Mr Ray Cobb. I'm looking at him right here. How are you doing?

Ray Cobb: 0:18

Ray, I'm doing great. How are you this evening?

J Basser: 0:21

I'm doing really well Before a guy has no teeth and still talks right. Hey, great, how are you this evening? I'm doing really well before guys have no teeth and still talk right. But, uh, hey, we got a treat, we've got valor for vets, bethany spangenberg, and, uh, this is an education. Only show guys, uh, if you want to, you know, if you want to get in a good education of how the va works and how they do is, uh, you need to listen to this show and others like it. This show will be posted up on youtube and some other places, uh, probably by tomorrow, but I want to introduce everybody to Bethy Spangenberg. She is the owner of a company called Valor for Vet and that's valorforvetcom, and she is a physician's assistant and she does independent medical opinions for veterans seeking their disability. And, without further ado, bethy, how are you?

Bethanie Spangenberg: 1:04

I'm doing great. I'm excited for this new production and see how things go. You sound great for not having any teeth.

J Basser: 1:13

Yeah, well, I went for Christmas and it didn't work out, I guess. But I've got temporary sanguinary but I talk better without them. I can't whistle At least I don't whistle as much, right? But we're going to talk about neurology. We started this on a couple of shows ago. Last month we discussed some of the neurological issues. Of course, there's some proposed changes in the mix, and then the election happened and everything got turned up on its head. So we don't know what's going to happen now. But we're going to basically go off on what we've got and that's the Title 38, part 4. And we're going to discuss the DBQ for neurologic conditions and we're going to focus on things like ALS today. Is that right, bethany?

Bethanie Spangenberg: 1:53

That's right, yes, Well, you go ahead and take off young lady kind of what prompted this particular show and maybe the next year of our show, is the VA had proposed changes to the neurologic conditions and the time frame for comment was getting ready to close and I felt that it was important that we had a discussion about, you know, valor for Vet as a company, me as a physician assistant and accredited agent kind of putting comment out there to voice our concerns with what was being proposed. That they were proposing weren't, in my opinion, they were not going to benefit the veteran, they were going to hurt the veteran and I felt that it was important to comment on that. And after the show that we had, which is, you know, if they want to listen to it, we've got it up on Audible and Spotify and on our website. But after that show, I sat down and I wrote a 12-page letter to the VA outlining the things that I was concerned with. And in order to continue the discussion, I wanted to continue with neurologic conditions and the VA has like 11 DBQs for neurologic conditions and I just felt it appropriate to start at the top and work our way down the list. For ALS or Lou Gehrig's disease, the DBQ itself is 12 pages. We're not going to go through every question and break it down because it is very comprehensive, but the key takeaway for this particular show is that this DBQ sets the stage for veterans who have significant diseases and that may need or meet additional benefits, such as special monthly compensation, such as housebound or aid and attendance, and that's primarily going to be the emphasis as we go through this DBQ.

Bethanie Spangenberg: 4:08

Now, one thing I do want to mention I'm going to post, you know, the full response from like the 12 page response. I'm going to post it somewhere. It's not going to be ideal to read it here. Nobody wants to. You guys won't have to wake you up. But I do want to take a second and preface today's show with one of the sections that I talked about in my letter. All right, sounds good, okay. So on page 10 of the 12 pages, the section is DBQ structure, and let me jump to the front here because I want I want it to be clear that the VA is proposing these changes because they want to. Their goal is to provide Clear evaluation criteria, improve rating quality and consistency and ensure the evaluations are accurate, and I don't think that their theme or purpose was really clear in their proposed changes. And so part of my feedback is that. So this section talks about DBQ structure. Section talks about DBQ structure, ensuring consistency across neurologic motor conditions such as ALS or Lou Gehrig's disease. So word for word, for my final recommendation, I would like to discuss the structure of disability benefits questionnaires.

Bethanie Spangenberg: 5:39

When comparing DBQs for amyotrophic lateral sclerosis or ALS, multiple sclerosis, parkinson's disease and other neurologic motor conditions, it becomes clear that there are significant discrepancies in their design, despite these conditions often leading to substantial dependence as the disease progresses. Given that these conditions can result in the need for aid and attendance with activities of daily living, housebound status or even bedridden care, it is concerning that DBQs for neurologic motor conditions like Parkinson's disease do not include the same comprehensive section as those for ALS or multiple sclerosis. For example, the ALS DBQ includes specific sections for documenting housebound status, aid and attendance, higher level aid and attendance, the use of assistive devices and the remaining effective function of the extremities. These sections provide information that helps identify a veteran's need for higher levels of care and entitlement to special monthly compensation. In contrast, the Parkinson's disease DBQ lacks these important sections, creating a significant gap in assessing the veteran's true level of disability and care needs.

Bethanie Spangenberg: 6:55

While proposing changes to the DBQ structure may extend beyond the scope of the current rule changes. This discrepancy highlights the need for broader revisions to meet the purpose of the proposed rule changes. This discrepancy highlights the need for broader revisions to meet the purpose of the proposed rule changes. Aligning the structure of DBQs for neurologic motor conditions, such as Parkinson's disease, with those for ALS and MS would provide a more accurate, consistent and clear framework for evaluating veterans' conditions. And so again, all over that proposed rule change, we saw, you know, them beat the words for accuracy, consistency and yada, yada, yada. But I think if that's truly their goal, we need to have a deeper discussion what these DBQs entail. So I just wanted to let you guys you know that's part of what I came up with from our last discussion. So thank you. I know the whole letter is lengthy, so it can be a lot, but any questions about the letter or that section?

J Basser: 7:59

I don't like to comment about it. I mean, als is probably the only disability in the VA system that anybody who's served and comes down with ALS I guess I don't think there's a time period that actually will be service-connected for it. That's a disability to where you're going to get maximum of R2 one day and that's the only good thing about it, because when you get your R2, you won't have it long.

Bethanie Spangenberg: 8:23

Yeah, unfortunately, yeah, unfortunately. So when we look at ALS, it's amyotrophic lateral sclerosis. A lot of people reference it as Lou Gehrig's disease. Lou Gehrig was a baseball player in the 1920s, I believe, and he developed the disease. And's where it's. The awareness really spread and so that's how it kind of Lou Gehrig's disease becomes synonymous with ALS.

Bethanie Spangenberg: 9:02

But what happens with that disease is there are some dysfunction of the proteins with the brain and the spinal cord and it shuts down the communication of the nerves from the brain to the body. What's sad about ALS is that the individual that develops the disease, they stay cognitively intact, meaning they're aware of the changes. They're aware that they're losing feeling in their feet or losing strength in their feet, they're aware that they're struggling to swallow or struggling to breathe, and so they actually start to suffocate in their own bodies and they're fully aware of what's happening because the disease as it progresses, it causes respiratory failure, it causes the lungs to stop moving and functioning like they're supposed to. So that's what's really impactful about ALS is because it's really emotionally and physically devastating for the individual that develops it. So there is no cure. There are some medications to kind of delay the progression of the disease, but typically these patients will die between two and five years after diagnosis, so their life expectancy is pretty short or limited after diagnosis.

J Basser: 10:18

Unless you're Stephen Hawking.

Bethanie Spangenberg: 10:21

Oh, did he have ALS? Did he have something?

Bethanie Spangenberg: 10:25

he had something else well maybe I was gonna say maybe his brain, he came up with something, because they're actually you know, what's interesting is, every time we we have a show, there's something that comes up beforehand that kind of prefaces the show without me even trying to.

Bethanie Spangenberg: 10:44

So I was reading a book on mitochondrial function and it's a medical book and it has to do with how medicine is actually transitioning to the cellular level rather than looking at just the individual system.

Bethanie Spangenberg: 11:01

So instead of looking at the cardiovascular system by itself and just of looking at the cardiovascular system by itself and just like the endocrine system by itself, they're really starting to look down at the cellular level and realizing that these systems truly are integrated and they function together. But in that book it was talking about ALS and how the problem is the proteins within the brain. So we have all these proteins that communicate and tell our body what to do, and part of the problem with the protein is that it's folded. And they have actually shown that sauna if you go in the sauna on a regular basis that the sauna will help to unfold that protein that is incorrectly folded. It will unfold it and correctly fold it back. So I don't know if Stephen Hawking tapped into some of that cellular level brilliance that he has. I don't think he advocated for the sauna, but it sounds like that we're really trying to look a little bit deeper at some of these conditions. So who knows?

J Basser: 12:07

Anyways, I can see the claims filed tomorrow.

Bethanie Spangenberg: 12:10

We need a sauna. Right, right, it's out there, so that's actually. Yeah, I'm starting to advocate for that because I'll get my husband one. I can't give you a sauna, how? About a shoehorn, because I get my husband, one and all, can't give you a thought about a shoehorn. Yeah, hey, let's. Oh, I'm not going to make any political comments right now. Two million dollars to what country, for what surgeries, I don't know. Anyways, all right, als. Any questions so far about what we talked about?

J Basser: 12:49

That's pretty much it. I like the studies on the cells because you know you are your body's nothing but cells. I think if they can figure that out, they can maybe cure a lot of stuff. They can cure the cells. Diabetes is one of them. Cure it, hurry up. We all three would like that, that's true.

Bethanie Spangenberg: 13:11

Are we all three on insulin pumps?

J Basser: 13:14

No.

Bethanie Spangenberg: 13:14

I don't think so.

Ray Cobb: 13:16

Am I not on here?

Bethanie Spangenberg: 13:18

Not yet. You're on there. I'm talking about an insulin pump. Insulin pump.

J Basser: 13:24

You're still taking a shot, aren't you Ray?

Bethanie Spangenberg: 13:29

You're muted.

J Basser: 13:30

Muted. Yeah, you're muted, Ray. He's still taking a shot. I'm pretty sure of it, because I think Pam has to give him to him because of the situation.

Ray Cobb: 13:43

Can you hear me now. Yeah, okay, I lost you for a while there.

J Basser: 13:47

Okay, don't know why You're still taking shots right.

Ray Cobb: 13:52

Yeah, yeah, I still take. I take four shots a day, okay. Okay, so and I'm on the U500, which is extremely you know, extremely powerful. It's five times stronger than R Mm-hmm. Yes, has some interesting. For me it's pretty interesting. Even though I'm on U500, taking 65 units, my blood sugar will go on any given day. Very seldom comes under 170. And most of the time stays around the 200 to 225 level and they're scared to give me any higher dose. So what do you do?

Bethanie Spangenberg: 14:47

Body's so insulin resistant is what they tell me you would probably benefit for a pump, but I don't know if that's something you want to tackle With your situation or levels.

J Basser: 15:03

You'd have to get a high-dose pump, because I don't think you'd be. I think you'd go through 150 in a hurry.

Ray Cobb: 15:07

Yeah, I would.

J Basser: 15:08

How are you liking yours so?

Bethanie Spangenberg: 15:09

far John.

J Basser: 15:11

I like it, I love it, I love it to death. I mean it's, you know it doesn't let diabetes control your life, like you know, stopping and pulling the needle out and doing this and that you know, sitting in a car waiting before you go eat, give yourself a shot, and embarrassment and things like that. So it's pretty good for the psyche and the only thing that hurts is when that automatic cannula gets inserted. Yeah, yeah, mm-hmm.

Bethanie Spangenberg: 15:51

So I'm going to kind of go on to the next section here. Um for als, als is presumptive. You have to have 90 days of active duty and with that diagnosis you actually get a priority processing through the va. So they they try to get you through the system pretty quick and you jump the line there.

Bethanie Spangenberg: 16:04

What's also interesting about ALS and why it's presumptive is that the medical studies that have come out, funded by the VA, has shown that veterans are twice as likely than the general population to develop ALS. So they don't know exactly why people develop ALS. But they're trying to correlate the difference between the general population and what veterans are exposed to. So they believe there's some type of toxin in the military during their time that is causing these folded proteins to develop into ALS develop into ALS Specifically I have the medical article says risk factors include environmental exposure such as toxins, and physical stress associated with military service. So that's kind of how that came about for it to be presumptive for all veterans that have served 90 days or more Before I get a little bit right go ahead.

J Basser: 17:08

Yes, go ahead. I just uh, I just talked, I said that to myself oh, okay, um, I got medical notes here.

Bethanie Spangenberg: 17:15

Typically with als is the individual will develop symptoms and they really have to go through a workup of exclusion. So they're going to have mris, they're going to have nerve, they're going to have all kinds of testing done before they finally get down to the ALS diagnosis. So from the time of symptom onset until you actually get a diagnosis could be a few years Sometimes. There's another condition that is very similar to ALS. It's called PLS and it's primary lateral sclerosis. Um, I believe don't quote me on that, but I believe it's primary lateral sclerosis. The only difference between the two is that PLS actually develops at a slower progression. Right now the VA rates PLS and ALS the same.

Bethanie Spangenberg: 18:07

In the proposed changes they were looking at significantly reducing the PLS compensation and give. My understanding is that they were going to give it its own rating schedule. In fact, I have it in front of me they were going to give it its own rating. Um, I'm not going to get too fast stuff, but I believe it was like 10%. So, and then you would compound all the other limitations as a separate disability percentage.

Bethanie Spangenberg: 18:35

So where ALS gets a hundred percent, automatically presumptive, pls is not presumptive. It is not. Uh, they're trying to change it to where it's not 100%. So again, in the long run the diseases end the same. Maybe PLS has a little bit of life extension in comparison to ALS, but the disease progression itself is very similar, just one's quicker than the other. So I was disappointed to see that and I know when I looked through the comments for the proposed changes there was like 10 or 11 plus neurologists or specialists that commented on that. They're like no, this is terrible for these veterans. You can't you know the, the need and the, the disease progression is terrible. Like you shouldn't be doing that.

J Basser: 19:27

That guy needs to be unemployed.

Ray Cobb: 19:33

Yeah.

Bethanie Spangenberg: 19:37

ALS can lead to several secondary health issues, including respiratory failure. That's because what I talked about Malnutrition, because they can't swallow, so they have troubles with consuming food towards the end as the disease progresses. Pneumonia, because with the swallowing they can aspirate and get some of that food down into their lungs and then develop bacteria. And then one primary or predominant secondary condition is those mental health conditions that I talked about, because the person's trapped in their body. So it's sad, but those are the medical myths that I have before we dive into this TVQ, anything you guys want to add.

J Basser: 20:17

Diagnostic paralysis. I know all about that. So if you lose both of them, you're in trouble.

Bethanie Spangenberg: 20:30

All right, let's jump right into the DBQ. Like I said before, it's 12 pages. I'm not going to go through each section, I just want to kind of lay out the format for each each section here. So, as we start off with all DBQs, it's the veteran's information, the relationship the examiner has to the veteran and the health did I say that right? The medical examiner's relationship to the veteran and the role that the medical examiner plays to that veteran, such as being their provider if they're seen in the clinic. The next section is evidence review. That's standard in all the DBQs.

Bethanie Spangenberg: 21:11

Often for this one the veteran is going to submit their medical records and, like I said previously, that workup is going to be extensive for the medical examiner and that has a lot of value when they go to complete these disability exams. Section one is the diagnosis. Section two is the medical history. Section three question, first question does the veteran report any muscle weakness in the upper and or lower extremities attributable to ALS? Primary symptoms when they first start is going to be weakness in the upper or lower extremities. This is a question that also prompts they need to consider SMC for ALS patients. The Federal Register does not prompt the Rater to consider SMC for any other comparable neurologic condition like Parkinson's disease. It does not prompt them for SMC, which I find disappointing.

Bethanie Spangenberg: 22:30

Next question is does the veteran have any pharynx or larynx or swallowing conditions attributable to ALS, which we talked about? The difficulty swallowing which can cause them to develop pneumonia or malnutrition, that typically develops later in the disease. It's not one of the primary symptoms that arises. That's as the disease progresses that the individual may develop those difficulties. Question 3C on page three says does the veteran report any respiratory conditions attributable to ALS? The very next question which I find interesting is does the veteran report signs or symptoms of sleep apnea or sleep apnea-like conditions attributable to ALS? That is a secondary condition that they're specifically asking about for ALS. Why aren't they doing it for the other conditions? The next question here talks about complete or partial loss of sphincter control as it relates to stool and the bowels. That is a special monthly compensation question. They're 3F, 3g, question 3I and question 3J all prompt special monthly compensation as it relates to the bladder and bowel. They don't do that for the other ones.

Ray Cobb: 24:02

Any questions so far no, there's a lot of carryover on those smcs how strong or how likely, but you may not know. The answer to this is an end. Is a veteran given an smc, um, for example, an r1, or even standard aid and attendance based on what they're recommending there or what they're referring to there under their special monthly compensation? Does it help the veteran? Or is it like it is with some of the other, like diabetes, where they've got to go and prove it and fight for it and it takes a while to get it?

Bethanie Spangenberg: 24:55

So that's why I feel that it should be different, because this DBQ is laying it out for the veteran to get their maximum rating and it does not do the same for diabetes or other medical conditions. And I have not had direct experience with ALS specifically, but I have seen claims for, like former prisoner of war, I used to be certified in those exams they do whatever they can to get that FPOW at the max rating percentage that they can. That is what tone is set for this ALS DBQ is. They are trying to capture everything they possibly can to support this veteran that has developed ALS, which I appreciate. But why aren't we doing it for the other conditions? Why aren't we doing it for our other?

J Basser: 25:46

veterans. Actually, this is on the VA, basically on them, because the court has and we're talking the federal, not the Veterans Court, but the one above it has said I forget the case right now, but it has said that the VA, it is the VA's responsibility to maximize the benefit for the veteran, depending on circumstances.

Bethanie Spangenberg: 26:08

Yes, that's for every veteran yes, that's for every veteran.

J Basser: 26:15

Yes, so they're not playing ball with the court, you know. They're just doing what they can do.

Bethanie Spangenberg: 26:26

So if we move along this DBQ here, one I forgot to mention that also does. Smc for bladder and bowel is 3L. I mean we have two and a half pages just focusing on hey, what SMC does this veteran qualify for? The other thing that is interesting with ALS is in the M21, I believe it's M21, with ALS is in the M21, I believe it's M21, but I know that there are standard periodic assessments that the veteran has for ALS because of the progression of the disease. If they do an exam, the very next exam is already timed out, it's already scheduled, because they know that that veteran's disease is going to progress. So they're doing what they can to capture those benefits in a timely fashion, which they don't do for other.

J Basser: 27:19

You know, when you first started the DBQ, we started asking about extremities and loss of balance and gait and things like that. If your first symptoms and first signs are loss of use of your hands and your feet, you've got to automatically go to R2. So any other SMC that they talk about or give you is a moot point, because once you get to R2, you're not going no higher, right, that's true.

Bethanie Spangenberg: 27:43

We're going to jump to page six. Page six top question is does the veteran report erectile dysfunction or female sexual arousal disorder attributable to ALS? So again prompting SMC. Section four jumps into the neurologic exam. For these exams they are going to be pretty comprehensive. The examiner is going to document the speech, the cognition, their gait, how they walk, strength of the upper and lower extremities, the reflexes in the upper and lower extremities. They're going to want to have the examiner look at muscle tone and atrophy and then document the severity of the muscle conditions. Section five is just an open section about the other physical findings that were not previously discussed. Section six says mental health manifestations due to ALS or its treatment. Does the veteran have depression, cognitive impairment or dementia or any other mental disorder attributable to ALS? They are prompting the examiner to trigger a possible secondary condition that has developed. They don't do that in the other DDQs. Section 7 is specifically dedicated to housebound status Due to ALS. Is the veteran substantially confined to his or her dwelling in the immediate premises or, if institutionalized, to the ward, or they confined to the ward or the clinical area. So they are prompting the benefit for housebound status.

Bethanie Spangenberg: 29:34

If we go on to page nine, section eight has questions dedicated specifically for aid and attendance. I'm going to read through these questions because I think veterans that are also seeking may not have ALS but they're also seeking aid and attendance. I think they need to be aware of what questions may be asked or what the expectation is if you're seeking that benefit. So question 8A is the veteran able to dress or undress him or herself without assistance? 8b does the veteran have sufficient upper extremity coordination and strength to be able to feed him or herself without assistance?

Bethanie Spangenberg: 30:15

8c is the veteran able to attend to the wants of nature, such as toileting, without assistance? 8d is the veteran able to bathe him or herself without assistance? 8e is the veteran able to keep him or herself ordinarily clean and or herself without assistance? A E Is the veteran able to keep him or herself ordinarily clean and presentable without assistance? A F Does the veteran need frequent assistance for adjustment of any special prosthetic or orthopedic appliance? So those questions if you're ever applying for aid and attendance, those are the types of questions that you should expect to hear and have an answer for so you can express your need. Any questions for that.

J Basser: 31:07

I think that would automatically qualify for the caregiver program too. Somebody's going to stay at home and work Well yeah, I mean what you just said.

Ray Cobb: 31:14

It's the answer to those daily activities as it stands today. I know that's going to be changing and going to affect next October some changes there as well. But right now you know one of those if you're pre-9-11, is going to get you aid and attendance level one which is over $1,500 for your spouse and it goes to her in whatever account she chooses to go for, chooses to go for. And if you have three of those, if you're pre-9-11 and only need two, if you're post-9-11, that's going to put you up to level two in the caregiver and that's going to give you an additional $3,004. And that is based on, you know, an E4 in your area. So it could be higher in some areas and lower in others, but that sounds to me like it's going to be an additional funds that a spouse will be able to receive on top of the because of the ALS and what it does.

J Basser: 32:35

It seems like it would just be automatic for the caregiver program Should be, because there's no way a spouse can work and take care of an ALS patient.

Ray Cobb: 32:43

Well, that's pretty obvious if you're listening to it. Yeah, yeah.

J Basser: 32:49

One of my son's teachers. He died from it or her husband died from it. She had to take off like three years or stay with him.

Ray Cobb: 32:57

Well, that was another thing, too, that comes into play there. When you have those conditions, you cannot be left alone.

Bethanie Spangenberg: 33:15

The aid and attendance section actually has two other questions to it that I didn't read. It mainly has to do with bedridden uh, the veteran being bedridden, so ask if they're bedridden or not. And they always define this, which I find their definition interesting says, for VA purposes, being bedridden will be that the condition which actually requires that the claimant remain in bed, the fact that the claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. The day to promote convalescence or cure will not suffice. So I don't I don't understand their definition of being required if the physician is prescribing the bed rest.

J Basser: 34:01

It's a condition puts you in the bed and you can't get out. Basically, that's what bedridden status? Lsd one. If you can't move your extremities or your arms and you can't ambulate or move around, you got to stay in bed.

Ray Cobb: 34:15

There's a couple I've seen with it and actually when they got them up in a wheelchair they actually had to take a sheet or a large towel and tie under their arms and in the back of the chair to keep them sitting up or from slumping over, and that's usually pretty close to the final days.

Bethanie Spangenberg: 34:37

Unfortunately. I just find it interesting that they don't say that like hey, like if the doctor tells you that you're required to be in bed, that doesn't count. It has to be like you're involuntary bedridden. Just use the word involuntary. I don't understand anyways. Um, this is where the caregiver is prompted in this section. Does the veteran require care and or assistance on a regular basis due to his or her physical and or mental disabilities, in order to protect him or herself from the hazards and or dangers in his or her daily environment? So that's when you said they can't be left alone. That's where they're prompting that question. So the next section, section nine, is specifically dedicated to the need for higher level, a more skilled aid and attendance. So they're saying that for VA purposes, this skilled, higher level of care includes, but is not limited to, healthcare services such as physical therapy, administration of injections, placement of indwelling catheters, changing of sterile dressings and or like functions which require professional health care training or the greater supervision of a trained health care professional to perform. In the absence of this higher level of care provided in the home, the veteran would require hospitalization, nursing home care or other residential institutional care. I don't know of another DBQ that prompts this next step for aid and attendance. The higher level Section 10 talks about assistive devices. That's pretty standard in all the DBQs.

Bethanie Spangenberg: 36:27

Section 11 is prompting loss of use and they have added a better understanding of what that means to the neurologic changes. Is they wanted to remove from the federal register the definitions of what the the functions were for the muscles, like where they what they call innervate, so like internal rotation of the shoulder, external rotation, like range of motion. So the federal register defines that. Well, in their proposed changes they said that the, oh, the examiners already know what those functions are. We don't need to have them defined in the Federal Register. Wait a minute, wait a minute. We should not be removing any resources that are there to help the medical examiner. Those resources are valuable to those examiners because they're not legally trained individuals. So that actually helps to provide that consistency that they say that they're trying to instill. So part of the emphasis I'm putting on the need for education of the medical examiner or the need to really define these things, is this section right here.

Bethanie Spangenberg: 37:55

So they in the past have not had the definition of what it means to have no effective function remaining other than that would be served as an amputation with a prosthesis remaining, other than that would be served as an amputation with a prosthesis. That is a very common question that gets asked because they try to define loss of use saying if we would chop the veteran's leg off and give him a prosthetic, would he have been better off? And, honestly, when I would do the DBQs back at the VA, that's what I would ask. I would say, okay, so we're looking at your ankle today. If I would cut your ankle off and I gave you a fake one, would you be better off today? And I would listen to their response and mark you know based off their response. And so the understanding of that question was not provided to me in any type of clinician training or any type of handbook, and so it was a really vague question for an examiner to be asking, if you don't have any context of why that question is there, what it really means. So I see that they have added additional information regarding that and I think it's valuable that I read that out here.

Bethanie Spangenberg: 39:17

For remaining effective function of the extremities. Looking at loss of use. It says the intention of this section is to permit the examiner to quantify the level of remaining function. It is not intended to inquire whether the veteran should undergo an amputation with fitting of a prosthesis. For example, if the functions of grasping with the hand or propulsion of the feet are as limited as if the veteran had an amputation and prosthesis, the examiner should check, yes, and describe the diminishing function. The question simply asks whether the functional loss is to the same degree as if there were an amputation of the affected limb. That definition is not perfect, but it is much better than what we were previously given Any questions regarding that section no.

Bethanie Spangenberg: 40:25

Pretty much cut and dry. So let me read to you what it used to just be, and I want you to try to wrap your head around what this means, because even from a medical standpoint I don't really understand how they proposed it so traditionally this is the only thing that was in the DBQ. Due to the ALS condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? So that's why I would ask OK, so if we would cut your ankle off, give you a fake one, would it be better? So I'm glad they added that definition in there.

Bethanie Spangenberg: 41:09

Section 12 on page 11 of 12, asks about financial responsibility. Basically, in the medical examiner's opinion, are they able to manage their benefit payments in their best interest, or at least direct someone else to do so? Section 13 talks about diagnostic testing pulmonary function test, any imaging. Section 14 talks about functional impact, which is pretty standard in all the DBQs. Section 15 is the remarks standard in all the DBQs. Section 16 is the examiner's certification and their signature. So examiner's name, title, area of practice, their contact information, their npi, their medical license and their state. So again, that's a lengthy dbq. I didn't touch each question, um you know word for word, but I I know that als is a devastating disease and I see the effort and appreciate the effort that the va is doing. However, I feel like we need to make it consistent for for many of the conditions that end up causing the limitations of of loss, use of loss of bowel and bladder control. I think there's a lot more there that we need to address.

J Basser: 42:36

You know the former CMP examiner yourself. I don't know if you've ever done this. Have you ever done a CMP for a person with an injury, a spinal injury or a paralyzed diaphragm? You ever done one of?

Bethanie Spangenberg: 42:50

those. I've had what they call hemiparesis, so it's just one side versus the other, but not on both. But I know that the pulmonary function testing is not good.

J Basser: 43:02

No, here's the deal I mean. What you've got to realize is that even as an independent medical examiner yourself, you can be forceful in this. Now, if they do an examination and require a pulmonary function test that the patient's got it's already been diagnosed with a paralyzed diaphragm. They need to do the test while the person's lying down, not sitting up.

Bethanie Spangenberg: 43:23

I've never heard of that. What's the difference?

J Basser: 43:26

If you're sitting up, you've got gravity helping you a little bit and you'll have a little bit, you know, and you blow, and you'll have a little bit of function. But if you're lying down, that puts you in an actual condition, to where you're talking, at least a 23% drop. That's what they need to be rated on. Not standing up you should be. Laying down, make sense.

J Basser: 43:46

That makes sense, but they're going to do what they want to do, you know. So that makes sense, but they're going to do it there. They're going to do what they want to do, you know. So then they give you a little juice at the end when you go in the box, and that little catch you with the albuterol because they can improve your reading before they get you out the door. Laughter, laughter, laughter. No, there's certain things and certain points that you catch on to over time. You know, because if you live it, you know what was done wrong and you know what needs to be done right.

Bethanie Spangenberg: 44:30

So I don't know if we've talked about this before, but at least on a recording anyway. But I feel like to really appreciate where we're at now. You have to understand how this process has progressed. So I'm in the process of writing the history of compensation and pension and the programs that have been built for our veterans, starting way from the very beginning.

Bethanie Spangenberg: 45:03

From the very beginning it is interesting to see you know how the government has appreciated the injuries associated with war and I think you know the history will talk about. You know the economy at that time and what the income was like at that time, what kind of compensation was given, what was considered. And it was really prompted because I came across a legal advertisement for an attorney group out of Cleveland from the 1800s and it outlined how much veterans would get if they lost a horse during the war or if they had other, you know, an amputation, like the $6 that they would get a month for having an amputation. So I think it'll be interesting for those that enjoy history and kind of want to understand you know how we've gotten to, where we're at and the direction we're heading, and I'm hoping to have it's going to be about 200, 300 pages, hopefully having it done in August, so it'll be a good one.

Ray Cobb: 46:12

I'll be interested in that. Were you aware that back during the Civil War, if an attorney represented you before the VA, the maximum he could charge was $20 of your back pay?

Bethanie Spangenberg: 46:26

I did not know that. I haven't you know, it's not even honestly, it's not even in that advertisement. I'll have to go through it. It's got the old paper stench and so I have to delicately like flip those pages.

J Basser: 46:38

Oh yeah yeah, that's a bad stench. Kind of reminds me of driving down through I-40 in Tennessee in between Knoxville and Chattanooga. They've got a bunch of paper mills and the whole damn place has been right. Yeah as you go across the Owassee River.

Ray Cobb: 47:00

Oh yeah, oh, my God, whole damn place smells that.

J Basser: 47:01

It right, yeah, you don't actually go across the uh oasis river yeah exactly what you're talking about oh my god, you gotta roll your windows up and put you put it on the restart because you do not want to smell that stuff. You ever go down 75 going toward florida, bethany driving that way. When you get there make sure you got your windows up you know what's crazy.

Bethanie Spangenberg: 47:20

You say that and I drive to chill coffee which is 23 minutes up the road almost every day and they have mead paper mill. It's not mead now, but the the paper mill has ran chill a coffee for the last 50 years, so it is on a cloudy day that that smell is it burns.

J Basser: 47:41

It makes you sick, your stomach.

Ray Cobb: 47:43

Well, you know, right there beside that paper mill, like you said, on a cloudy day it's been several years ago now, probably 25 years ago the worst automobile collisions took place right there in that area.

J Basser: 47:59

Foggy day right there in that area, a foggy day and there was 128 car pileup and I think 33 or 34 people lost their lives. I heard about that. I've been stuck in traffic in that. I mean we used to go into Georgia because Michael was shooting TV shows and stuff and we had to go from here to Georgia several times and I got stuck in that one. It was raining and bad wreck and we sat there for about three hours, isn't that correct?

Ray Cobb: 48:25

Wow, they actually have gates up to shut the interstate. Mm-hmm.

J Basser: 48:32

Oh, they got signs, big flashing signs up too, you know, and it tells you, you know certain times. That's why you need rain. It's always been bad.

J Basser: 48:45

These new vehicles are handy now because they got the front radar. That will save your life, because the radar will cut through that fog but nothing else will. You can't see much but the radar. If the car stops in front of you, your car is going to stop you. It does stop you. Get off the road as fast as you can, because the guy behind you might be a tractor, trailer and not have radar.

Bethanie Spangenberg: 49:15

You know, if I transition back to that whole proposal for neurologic conditions, there was over and I was impressed with the number of comments that were submitted. I was trying to pull it up before we got on here. I can't find it now, but there was over 50 comments from people about the proposed changes and all but one all but one opposed the changes because they did not feel that it was going to benefit the veteran. And the one comment that gave the proposed changes a complete stamp of approval was one of the largest advocacy groups in our country and I am disappointed. So I'm not going to say who they are.

J Basser: 50:07

but You've got to realize. The guy that probably wrote it was probably sitting at his computer at the bar. He probably had seven right already. I don't know.

Bethanie Spangenberg: 50:19

I'd like to Not the leader.

J Basser: 50:47

I don't know, I'm actually surprised we haven't. Can I give you some advice as to get there? Go ahead and look and go on their websites and look at these organizations and start reading their bylaws and look where their true allegiance actually lies within. Then your eyes will open and you'll be enlightened to the new universe.

Bethanie Spangenberg: 51:07

Our small town supports this major advocacy group these small towns.

J Basser: 51:16

Have you got that post and the Legion post in the same town? Yeah, it's down the street. Do the sheriffs come by and raid each other because they keep bootlegging? It happened a lot in Eastern Kentucky.

Ray Cobb: 51:32

Oh goodness, it happens a lot in Tennessee too. I mean, you know Now you said the largest group, if I remember correctly. Okay, go ahead, okay, go ahead, no, go ahead. I was going to say, if I remember correctly the numbers that I've seen, if you're talking about largest membership, the American Legion is the largest membership and I disagree with a lot of our bylaws and I argue with them. I mean, you know, with this show, along with my show, I get a lot of attention from our state commander and my national commander has come and visited me personally to be on the show and I have no problem challenging them and telling them how wrong they are. It is not the American Legion.

Bethanie Spangenberg: 52:23

Oh okay, it's not the largest, but it is a large.

Ray Cobb: 52:28

Okay, so it's the second largest, so I know who you're talking about now. And that goes along with what he says about the bar. I can relate with that one too. Private club yeah, private organization.

Ray Cobb: 52:44

Private, military organization. And you know the kind of interesting thing when they go to all three of them, all three of your majors, when they go to Congress and talk about how many votes they have to get changes like this made, they don't tell Congress that they hadn't cleaned up their death row in seven years. And they're still counting guys that have been dead for five to seven years on their roll and they're not very quick to take them off. I've experienced that taking two or three years and widows calling me saying would you please tell them to quit sending my husband mail. He's been dead for two years.

J Basser: 53:30

You know, I bet you still voted.

Ray Cobb: 53:39

Is he from Johnson County down in Texas?

J Basser: 53:47

Johnson County, the famous county, no matter what state you're in.

Ray Cobb: 53:50

Yeah, Now we'll get a bunch of calls from some of these guys from Texas now, since I made that comment.

J Basser: 54:01

No, yeah, I doubt it. You might, but don't worry, I got your back. We'll send some detective boys down there. You used to send a bunch of boys to Texas, but after the Alamo they quit doing that. What's your take on it, beth? What do you think?

Bethanie Spangenberg: 54:32

uh, I mean if these changes go through, there's gonna be a lot of veterans screwed. Yeah, big time big time um maybe you know as we. You know, I don't know the best way to really kind of incorporate the letter and some of the things that we discussed and how I followed up with those in my request, but I think the biggest deficit or harm to the veteran is going to come to these, these, uh, peripheral neuropathies that they're proposing to change.

Bethanie Spangenberg: 54:58

Yes, Um we have a DBQ. I was actually trying to look up you know the order of the DBQ, so then that way I could kind of talk about the game plan. But I know they're coming up probably towards the end of the year. But I think that's actually the biggest change that's proposed. That's going to negatively impact the veterans is the peripheral neuropathy.

J Basser: 55:22

My best advice if you're listening or watching the show, if you've got a claim, even an initial claim, for any neurological condition either it's radiculopathy or whatever based on a neck injury or diabetes, diabetic neuropathy I would strongly recommend you go ahead and get this claim in now, before any change takes effect, because you can be rated on today's criteria, because there's a cutoff date when it happens. If it happens, of course, don't ever be reactive, always be proactive and get it in, because you know if they make changes like this, it's going to screw the pooch one of these days. You know the vascular ones really got me, yeah, the changes. The same guy wrote it.

Bethanie Spangenberg: 56:08

Looking at the neurological conditions order, the next one is going to be central nervous system and neuromuscular diseases, which is like not specifically multiple sclerosis, but similar. Maybe we can combine those two or the next two, but then it's cranial nerves and then diabetic peripheral neuropathy, then fibromyalgia. So we're not. Peripheral nerves don't come until almost the last one. So I don't know, maybe we don't have to go in order. We can kind of combine and move things around. But if you want, john, we can jump to that one next. That way I can get content ready.

J Basser: 56:49

We can do personal neuropathy next. That'd be fine. I have no problem with that, because I think mainly that's probably going to be your biggest hitter when it comes to the disability, because you know diabetes and injuries, I mean, it's still the same, isn't it for real nerves.

Bethanie Spangenberg: 57:13

Let's do that then.

J Basser: 57:15

Okay, I have no problem with that. Well, we've got three minutes left. Beth, I think everybody your email address and how to contact you if they want to contact Valor for Vet and utilize your all's wonderful services.

Bethanie Spangenberg: 57:30

So our website is wwwvalor4vetcom. That's Valor V-A-L-O-R. The number four, vet, v-a-l-o-r. The number four vet, v-e-t dot com. Our phone number is 888-448-1011.

Bethanie Spangenberg: 57:48

We're looking out for a few things on our website that is coming as a change. We're we're slowly trying to add all the diagnostic codes, kind of like similar to military disability made easy, but we're focusing mainly on more of the medical aspect. Where I'm a physician assistant and patient education when it comes to diseases is really my passion, so we're going to be adding a lot of those articles and veterans can look the each blog post up by their diagnostic code and and learn stuff about, you know, secondary conditions, prognosis, things like that. So big things coming in 2025. I'm looking forward to it. The book like I mentioned, we're going to be putting out an interest list where people can sign up if they're interested and at the book's release we'll send out an email if they're interested in in picking up a copy. Yeah, out an email if they're interested in picking up a copy. Yeah, give us a call. We have disabled veterans on our team and so they love to talk just as much as you do, so give us a call, okay.

J Basser: 58:51

Yes, we do appreciate everybody watching and we'll do this again next week. This is John John Stacey. I am the owner of the ExposedNet production group now I guess we'll call it. And thanks to Betsy Spangenberg for coming on and being our guest and she'll do it again next month. She's a monthly guest and we work hand-in-hand with Valid for Vet. And I want to thank Mr Ray Cobb down in Tennessee. How you doing, ray? Thank you for coming on, buddy and sitting with us, and with that we'll be signing off for now, thank you.