J Basser: 0:03

Welcome, ladies and gentlemen, to an episode of the Exposed Vet Production. My name is John Stacy. I'm the host of this enormous show. The co-host is Mr Ray Cobb. He's with us in the audio only tonight. You won't see his pretty face, but I'm sure he's here. How you doing, Ray?

Ray Cobb: 0:20

I'm doing great. How are you Trying to get over this? Whatever this virus is that's been going around for a week or two.

J Basser: 0:31

Well, I've had some dental work down today so I want to talk a little bit. I've got a guest host tonight. Her name is Bethany Spangenberg. Bethany is the CEO of a company called Valor for Vet, which is a very good veterans company. They do a lot of veteran independent medical opinion examinations and they help veterans with their VA claims. Beth is an accredited VA claims agent or appeals agent, excuse me and she does a lot for vets. She didn't really practice the claim side, you know as far as that, but she knows the VA and knows the system because she used to work for the VA. Bethany, how are you doing?

Bethanie Spangenberg: 1:10

I'm doing well. I'm excited for tonight's show. I think there's a lot of good information that we'll talk about.

J Basser: 1:17

Okay, and we've been doing a series here last couple months on neurological stuff. I think we're going to focus and continue on that. You had an idea that you were going to touch on. Was it migraines or was it something different?

Bethanie Spangenberg: 1:35

For tonight's show. Yeah, still neurological right Peripheral neuropathies.

J Basser: 1:42

Oh, I'm sorry, I was wrong. Well, I'd much rather enjoy this section here, anyways. Peripheral neuropathies. Oh, I'm sorry, I was wrong. Well, I'd much rather enjoy this section here, anyways. Peripheral neuropathies.

Bethanie Spangenberg: 1:50

Hey. What's funny is the last time we were together you said, hey, I want to do this one.

J Basser: 1:55

I know, but that was a week ago. And with the emits the flow of information that goes in my ear and through my computer system, and with my data science and AI stuff, you know it mumbles and bounces around in there and sometimes it gets a little bit lost.

Bethanie Spangenberg: 2:19

Yeah, we skipped the order just to make you happy.

J Basser: 2:23

So we're on pro-drop. You go right ahead, girl.

Bethanie Spangenberg: 2:28

All right. Well, I just kind of want to introduce the fact that we started on this series mainly because of the proposed changes to the rating schedule and we've spent the last couple months talking about that and that kind of opened up the door with targeting or focusing on the neurologic conditions in their DBQs. Last month we talked about ALS and the kind of the discrepancies between you know that particular DBQ and how the other DBQs really don't provide the information, the information. There's more information in the ALS DBQ or the Lou Gehrig's DBQ that really helps to support the veteran in their disability and giving them all the benefits that they truly need, and the other DBQs aren't aligned that way. So that was for those.

Bethanie Spangenberg: 3:19

Maybe ALS doesn't pertain to you or the disability that you're seeking, but knowing that information that's inside that DBQ will help you understand what benefits that you may be entitled to as well. So if you have other conditions that affect you, you know a lot of those are special monthly compensation information. So take a look at it and see what kind of questions they're asking, or listen to that podcast. Oh, hi Ray.

Ray Cobb: 3:42

Hello, how are you? I got to try to get focused in now.

J Basser: 3:46

I finally figured out what was going wrong, so now, hey there, guys well so the wiggling pit did come loose in the wobbling shaft yeah it.

Ray Cobb: 3:58

Uh, that is loose. The wiring was loose up there and also kind of the way that the I guess it was the way the filters were. So I think you might have a little bit of a better view of me now.

J Basser: 4:16

Once.

Ray Cobb: 4:16

I sit back. How's that? Is that okay? Yeah, good, I'm glad you could join us. Yeah, glad to be here. I'm glad you could join us.

J Basser: 4:25

Yeah, glad to be here.

Bethanie Spangenberg: 4:27

So with that discussion, you know, we've went back to talk about the letter that we put together and I'm saying we because we had specifically a conversation of things related to the changes that we didn't like. We had that conversation and I put together a 12-page letter that I sent to the VA and I'll actually reference a little bit about that today whenever we talk about these DBQs. But today's focus is the peripheral nerve conditions. A lot of people think of this when they're thinking of radiculopathy, if they're thinking of any type of nerve damage involving the feet or the hands. This is what this DBQ is for.

Bethanie Spangenberg: 5:17

The neck DBQ has a component in there that specifically addresses radiculopathy, the same for the lumbar spine condition. It has a section in there specifically for radiculopathy. In there, specifically for radiculopathy, the diabetic peripheral neuropathy it has a DBQ dedicated for itself. So this DBQ is dedicated for nerve conditions that do not include diabetic neuropathy or the neuropathies associated with the neck and the back. So let's say, for example, associated with the neck and the back. So let's say, for example, a veteran is wanting an increase for their lower extremity radiculopathy or their sciatica is a common term that some veterans are familiar with. Instead of getting a nerve condition, dbq or exam they will actually have their whole lower back re-examined and the information regarding the radiculopathy will be documented in the back DBQ. So this is something if you have a surgery and the surgery damages the nerve, they would do this. If you have carpal tunnel, this would be something that they would do this DBQ for. So that's kind of where this DBQ is dedicated for Any questions. Before I start rambling stuff off, no.

Bethanie Spangenberg: 6:36

Okay, so just starting on page one. This is 14-page DBQ. We're looking at page one and it starts with your standard information. You're documenting the examiner's, documenting the veteran's name and information, their relationship to the veteran, whether they're a VA health care provider, if they're regularly seen in that clinician's clinic. The evidence review is on page one. We always talk about the evidence and that evidence is what is contained in your claims file and what? Um, mainly what's contained in your claims file. I was going to say in the VA record, but if you have a contract examiner, they don't have access to the VA record unless it's scanned into the uh claims file by the rater. So they've done a better job with that, you know, as years have gone on. So evidence.

Ray Cobb: 7:29

Reviews the claims file information.

Bethanie Spangenberg: 7:32

Section one is the diagnosis that the examiner is focusing on for this DVQ. We look at page two and this is the section where we look at page two and this is the section where section two, page two, is the section where the examiner will document the medical history. They'll talk about the history of the condition, how it started or what their current symptoms are. They also document the hand dominance. So for some conditions that affect the dominant hand you get a different rating for that because it's based off of your hand dominance. So they always document that. If it affects, you know the dominant hand, so it's, and sometimes the rating schedules don't always compensate for dominance, but there is specific sections for that in the rating schedule. Section three is the symptoms related to the peripheral nerve conditions. It specifically asks about the right upper extremity, the left upper extremity, the right lower extremity, the left lower extremity and the examiner is to focus on each extremity and they are supposed to document the symptoms and ask the veteran if they don't have, like if they have none, do you have any symptoms? They can say yes and the examiner is supposed to ask whether it's mild, moderate or severe. Now, just because the veteran is documenting their symptoms. That doesn't necessarily mean that that's the rating that they're getting. It's not based on their symptoms. Typically what happens during an exam or any condition affecting the nerves is the examiner is to, or clinician is supposed to, gather the symptoms, the types of symptoms and how frequently they're coming, and then they collect data from their exam, from sensation to reflexes to muscle strength. They take all of those and they put it into a category to determine clinically if it's mild, moderate or severe. And for this dbq way it's currently designed, that's what they're trying to do is they're trying to collect data from the veteran and then they'll go on later in the exam to get all those other components to really determine how severe their nerve condition is. Dbqs I would straight out ask you know, let's say, for the sake of this particular session, we're going to focus on carpal tunnel affecting the right hand. So I would ask the veteran you know we're focusing on the right upper extremity today, so then I would go through here and I would put you know the left upper extremity, those other components I would not report on those. I'm reporting specifically on the right upper extremity, carpal tunnel, and I would say is your? I'm going to ask you specifically about constant pain. That's the first question in the DBQ symptoms Are your, do you have constant pain? And the veteran would tell me yes or no. And if they have constant pain, I would say, okay, how would you consider it? Would you consider it mild, moderate or severe? This is completely documented, based off of what the veteran tells me. The next symptom that's listed here is intermittent pain, pain that comes and goes or wax and wanes. And I say do you experience intermittent pain, pain that comes and goes, pain that wax and wanes, like it's still there but it gets a little bit worse and it gets a little bit better. And if they tell me they do experience that, then I ask is it mild, moderate, severe? Whatever they tell me is what I put. Then we move on to page three, we're continuing with the symptom collection and they're asking.

Bethanie Spangenberg: 11:28

The next question asks about symptoms related to tingling or like a funny sensation in their hand. I would ask if they experience it and if they do, then I would say is it mild, moderate, severe? And I would document based on what they told me. Last question when it comes to the symptoms is numbness. Do you experience numbness? Yes, is it mild, moderate or severe and I would document it. And if they told me it was severe, I would document it severe. They told me it was mild, I would document it mild. Those symptoms are recording what the veteran is experiencing directly and you know, one person's severe, maybe another person's mild, I don't really clinically, it is just a component of understanding the impact upon the individual. It is not necessarily used to say this individual is saying their symptoms are severe. It doesn't correlate to that their condition is severe. When you have sudden flare-ups of carpal tunnel, their symptoms could be or feel severe and it may be a mild carpal tunnel on testing for the nerves. So any questions regarding subjective reports of symptoms from the veteran.

Ray Cobb: 12:54

Now, do you? Well, of course, I think you just mentioned that, but a lot of questions that I've been asked has to give it a number rating, like one through 10. Did you do that, or does a lot of them do that, or do they do something different?

Bethanie Spangenberg: 13:10

I think that's not listed anywhere in the DBQ. I think that's the way that in the clinic we are asked or taught how to identify pain. I would not ask that for this particular DBQ because it's not relevant to what they're asking or what I'm tasked with doing.

J Basser: 13:33

Maybe that's a clearer way for the examiner to communicate the mild, moderate or severe, but I would take what the veteran told me, what if you had the veteran in front of you and examine the veteran and you ask him a question and you look at his extremity the left hand, right hand, it doesn't matter but you notice there's two nerves that control your hand and you notice the pinky finger and the other finger are drawn in against the palm and he has a hard time straightening it out. And if he said it was numb, that would probably classify it as a barrier, wouldn't it?

Bethanie Spangenberg: 14:16

Not necessarily, because not every and I'm glad you asked this, because not every nerve condition presents the same in everyone. There are individuals that experience the numbness and the tingling, like almost as if your hand has fallen asleep. That's what I try to relate, that what we call paresthesias or the tingling. It affects people differently, so some people will have the paresthesias and still have their sensation intact. Some people will have numbness and never experience the tingling or paresthesias. Some people will experience pain and never experience numbness. So I'm glad you asked. Nerve symptoms do not always present the same and that is why there is multiple components in understanding the severity of a nerve condition. So you don't just take, you know, one factor. In order to clinically rate a nerve condition, you really have to take all the data that's made available to you and make a clinical decision on the severity of the condition. Makes sense, makes sense. Okay, section four still on page or. We are on page three now. Section four is muscle strength testing and I want to emphasize this section. The reason why I want to emphasize this section is, with the new proposed changes, this is the only section that will determine the rating from what is being proposed. So they plan on taking out the symptoms and the section on reflexes and the section on sensation testing and the section on skin changes. They only are wanting to rate the veteran off of muscle strength testing and I don't agree with that and we'll talk a little bit more about that later. But just wanted to emphasize you know this section and understanding of this section.

Bethanie Spangenberg: 16:28

So section four, muscle strength testing, rate the strength according to the following scale. So they get a zero out of five. We rate strength testing on five out of five points, or zero to five. Zero is there's no muscle movement. One out of five is that means that you can see the muscle move but there's no joint movement. So you can see the muscle contract, you can feel it contract, but there's no movement of the joint. Two out of five means that there's active movement without gravity. So if an individual is sitting and they decide to lift their leg up, they're lifting that leg against a gravity. When you're looking at removing the gravity, you have to position the joint where gravity is not involved. So that's more of a clinical positioning component. So in order to do that testing, three out of five is the active movement against gravity. That's where I was talking about you lifting your knee up towards the ceiling, lifting your leg up? That would be active movement against gravity. Four out of five is active movement against some resistance. So if you've been in an exam, typically for strength testing, the examiner will place their hand on your knee and have you push up, or they'll do different positions and have you kind of resist them. Four out of five means that there's active movement against some resistance, so the examiner is not pushing as hard.

Bethanie Spangenberg: 18:10

Five out of five is normal strength testing. That means that the individual is able to move the joint against a normal amount of resistance, which I think that's where muscle strength testing gets tricky. Amount of resistance which I think that's where muscle strength testing gets tricky is because I may push against the individual with 10 pounds of force and the next examiner may push against the individual with 20 pounds of force, and so when we look at strength testing you know it can be kind of tricky. What one clinician says is normal and the other clinician says is normal. So for this section the examiner is supposed to look at the joints affecting the nerve condition, whether it's the elbow or the wrist. So for carpal tunnel it would be wrist. The general rule is that if you're examining for CNP, if you're examining a joint like the wrist at carpal tunnel, you're going to actually just examine all the strength testing in the entire arm. So that's just a good rule to follow. That way you can identify if there's other contributing factors to the carpal tunnel.

Bethanie Spangenberg: 19:19

They're supposed to document on both, are supposed to document on both. If you're examining the right arm or right hand, you should always, both clinically and for comp and pen purposes, document the left side. That allows the examiner to really appreciate the comparison. So, like for grip strength, you can really appreciate if one is reduced versus one being normal when you have them to compare to. So if you have an examiner that's doing the exam, the good rule of thumb is to test both strength of both sides at the same time. So both hands at the same time, both flexion at the same time, both wrists at the same time. Gets a little tricky with the legs, but you should be doing one right after the other on the same one. You don't want to go do a strength testing on the hip and then jump down to the ankle and then go to the other side. So it's just a way for that examiner to really have a good way to measure the balance between those two sides.

Bethanie Spangenberg: 20:19

Going to page four, the examiner is to document any muscle atrophy or thinning of the muscles. When it comes to the upper extremities, you can get atrophy or the loss of muscle tone in the forearm and in the bicep is typically how we are taught to look and to measure, and then the same for the lower legs. We were taught to measure around the thigh and around the calf and it's supposed to be the same distance on each side. So they should be taking a measuring tape and measuring both of those areas. If we go to section five, we're looking at the, the reflex exam. This is where they tap to check your reflexes. Reflexes are based on a zero to four scale. Zero is absent, four is hypoactive, meaning that they're not as responsive. Two is normal, so and reflexes two is normal, so in reflexes two is normal. Three is hyperactive, without what they call clonus, which is like the muscle bouncing, and four plus means that it's hyperactive and then you get like a muscle bounce with it. That just means that that nerve is really triggered or really responsive, almost too responsive.

Bethanie Spangenberg: 21:42

So section six is the sensory exam. For sensory when it comes to the peripheral nerves, it only asks specifically about light touch sensation. They're only looking at taking a tissue or a cotton ball and touching the skin area and the examiner is to document whether it's normal, decreased or absent. And again you're doing a left to right comparison for the examination. Section seven trophic changes. This is on page five. Does the veteran have any skin changes characterized by loss of hair on the extremity, smooth or shiny skin? And you're supposed to document that? Page six looking at page, excuse me. Section eight is the individual's gait, how they're walking, and does the nerve condition affect how they walk? For carpal tunnel that we're using for this example, we wouldn't necessarily need to document the gait. I still would, just for consistency purposes to. Really, if the individual files for something later and they want a historical timeline of how things have progressed, it just contributes to you know the veteran's current status. So some examiners may not do that. I do that Specifically for carpal tunnel is section nine.

Bethanie Spangenberg: 23:14

It talks about what they call a phalanx test or a tendrils test.

Bethanie Spangenberg: 23:17

So a phalanx test is where you hold your wrists together for a minute and if you develop numbness or tingling, that's supposed to be an indication of carpal tunnel, you would get tingling into the fingers.

Bethanie Spangenberg: 23:29

Tunnel's test is where the examiner taps right at the carpal tunnel and if you get symptoms, that's supposed to be a positive test. So that's sections dedicated specifically to carpal tunnel and then section 10, after doing all those components, the examiner is now supposed to determine the severity of the nerve condition. So we take the clinician is to take the history, the symptoms, the strength testing, the reflex exam, the sensory exam, any skin changes, into consideration of how severe this nerve condition is, before they determine if it's mild, moderate or severe or if it's a complete nerve paralysis. I emphasize that because if they go down to just muscle strength testing, they're going to rate you rate the veteran based on the number zero through five, which presents a lot of challenges and I think a lot of things are missing really taking out the clinical component. I understand that they're trying to tie these ratings down to objective you know objective things but I think there's still a lot of room for error there. Any questions before I talk about the severity of the nerve?

Ray Cobb: 25:02

Yeah, I think it's pretty well having corporal tunnel myself and having surgery for it. A lot of these tests were ones they did prior to me having the surgery.

Bethanie Spangenberg: 25:16

All right. Well, if we look at the severity, section 10 is where the examiner is to document the severity of the upper extremity conditions. Now they have all the nerves listed out. I'm not going to go through every one of them, but what the examiner is supposed to determine is if a particular nerve so let's go with the ulnar nerve, that's what's affect the median nerve, excuse me, the median nerve is what is affected in carpal tunnel and they're supposed to decide if the nerve is normal, if it has complete paralysis or if it's incomplete. If it is complete, they move on. They don't have to mark anything else. If it's normal, they don't have to complete anything else. But if it's incomplete, the examiner is supposed to determine if it's mild, moderate or severe. And again, we take all those components, we make the clinical application to determine whether it's mild, moderate or severe. Section 11 focuses on the severity of the lower extremities. Again, you go to each nerve I'm not going to list them out and the examiner is supposed to determine if it's normal, incomplete or complete paralysis. If it's incomplete paralysis, they'd have to determine if it's mild, moderate or severe.

Bethanie Spangenberg: 26:44

Looking at section 12, this is standard in most of your DBQs. We're looking at assistive devices brace cane, crutch, walker, wheelchair If they use any of those for their carpal tunnel or their nerve condition, the examiner just documents it. Section 13 looks or asks about amputation. We've talked about this before. This amputation rule comes in for loss of use and it's considered the special monthly compensation. So if the examiner determines that the functioning is so diminished that amputation with prosthesis would equally serve the veteran, they would mark that and that qualifies the veteran for special monthly compensation.

Bethanie Spangenberg: 27:32

Going to page 12, section 14, just any other physical exam findings that the examiner wants to document any scars that may have come from the carpal tunnel surgery or surgery related to the nerve condition. Section 15 looks at diagnostic testing with your nerve symptoms or conditions. A lot of times you will get referred for a nerve conduction study or an emg. It's where they stick needles into the muscles and they they send electricity through and they make you jump. It's not fun. Mine wasn't fun, I had one before I. They could be painful at times. Normally they warn you beforehand but they start low and they kind of move up. Have you guys had an EMG?

J Basser: 28:30

Yeah, I tried doing one with your diaphragm.

Bethanie Spangenberg: 28:34

No, oh my gosh, does it make you cough? Tell me about that.

J Basser: 28:41

Well, they went in and they had to ultrasound to find the right location. They found the location and they took the needle and stuck it, because probably five or six inches away, they stuck the needle in there and put it two or three places and played with it and turned the amplitude machine up trying to see if it does anything. He pulled it back out and he said that's a zero. You know what zero means, right?

Bethanie Spangenberg: 29:12

Not a respond.

J Basser: 29:14

That is nothing.

Bethanie Spangenberg: 29:19

I find, when it comes to any nerve condition, whether it's even the small fibers, which we'll talk about that here in a few minutes I feel like the EMGs, or the nerve conduction studies, are highly valuable and really understanding you know what's happening with the nerve condition. So if you're a veteran that experiences that it's not. If you can get the EMG done, I would encourage you to do so because it gives it a good picture of what's happening.

J Basser: 29:48

But you got to realize too that you know when you have it done and examined it too. You know, because neurologists actually do it right, you have to realize that their test is only as good as their equipment is, and sometimes the equipment is not, you know, very good it's like it's like echocardiograms. You know it's only as good as the equipment is too. So I think a lot of a lot of ultrasound with the cardiac ultrasound, I think a lot of the stuff is basically worthless in certain areas.

Bethanie Spangenberg: 30:18

So and there's a lot that plays a part. You know who's doing the test and who's interpreting the tests and things like that. I, if I would have an individual in the clinic that complained of numbness, tingling, weakness, I would look at the EMGs, because the EMGs not only tell you the nerve, the extent of the nerve damage, but they're also able to tell you how recent it is. If they pick up on something that's what they call acute or something that's recent, those numbers from the nerve conduction study will tell them that if it's something that's chronic, it it's the. The test picks up on that too. If they have something, for example, for diabetics, there's a particular nerve that they can target and try to get data from that particular nerve, because they know that nerve is affected first in diabetes. And if they see a delay in that particular nerve, then they can say well, this is consistent with diabetic peripheral neuropathy. So there's a lot that comes, a lot of data that can come from those that's valuable in the clinic. Now, based off their what they want to propose, that's not going to have any value. So so right now I think the examiner can use that test to actually document the severity of the nerve condition. I think that makes the examiner more confident in making the determination if a condition is moderate or is severe. Maybe they're like, well, maybe it's moderate or you know they're really don't know which way to put it. And then they have that nerve conduction study can help sway their decision or can help make them a more confident decision. I should say so I like them.

Bethanie Spangenberg: 32:13

So, looking at page 14, the next section, section 16 talks about the functional impact of the peripheral neuropathy condition. I emphasize putting any functional impact into your statement in support of claim. With every single condition you're claiming we beat that with a dead horse for a good reason. Section 17 is open for remarks for the examiner. Section 18 is the last section and that's the examiner's information and signature. So it's a long DBQ.

Bethanie Spangenberg: 32:51

The time that is spent with the veteran gathering the history and doing the exam is about 45 minutes, so it's typically not in and out. They're gathering a lot of information to determine the nerve stuff. So the one thing I want to talk about or emphasize with this these conditions that we're talking about are what we consider to be large nerve fiber diseases. So those are the bigger nerves that are affected in compression at the wrist or in a pinched nerve in the back. This exam and the rating schedule does not appreciate or capture small nerve fiber diseases.

Bethanie Spangenberg: 33:48

Small nerve fiber diseases are your diabetic peripheral neuropathy. They're your chemical neuropathies, they're your vascular neuropathies. They affect the smaller nerves at the end points of an extremity, so in the fingers and the toes. With your large nerve fiber diseases you can feel, or the individual may experience, numbness and tingling higher in the arm or higher up towards the hip and the legs. When an individual only experiences the numbness, tingling sensations in the distal points or at the end points of their extremities, in their fingers and toes, then it's concerning for a small fiber nerve disease.

Bethanie Spangenberg: 34:31

The EMGs can typically differentiate between what is a large fiber disease. It does not capture the small nerve fiber diseases well at all. So an individual with a diabetic peripheral neuropathy may have a normal nerve conduction study. The only time when they look at that it's called the, the sural nerve. There is one nerve that they target to check the speed of how well it conducts and if it's decreased then they know that it's consistent with a peripheral diabetic peripheral neuropathy. They and that's typically if the sural nerve is affected. We're talking about moderate to severe diabetic peripheral neuropathy disease. If there's an individual with mild to moderate or even moderate diabetic peripheral neuropathy or small nerve fiber neuropathy, it may never change on a nerve conduction study or an EMG conditions. The VA rating schedule currently does not capture the appropriate rating or the appropriate severity of the condition. Any questions about that.

Ray Cobb: 35:56

Since it gets in on the small nerve endings, which, being the diabetic that I am, Small nerve endings, which being the diabetic that I am. That is where most of my problems presently are.

Bethanie Spangenberg: 36:18

And how is that going to affect future veterans? On diabetic peripheral neuropathy, there are clear indications where we can differentiate between a large nerve fiber versus the diabetic peripheral neuropathy In the diabetic peripheral neuropathy DBQ. It is very similar to this DBQ DBQ but there's additional testing that is done on the examination that helps that clinician put all those components together to determine if it's mild, moderate, severe. If the VA and they have proposed taking away all those little components except for the shrink testing, if a veteran with a diabetic peripheral neuropathy or a small nerve fiber neuropathy is going to be rated strictly on muscle strength, they will get the excuse, my French, they'll get the shit into the deal because it is not appropriately capturing the severity of the condition Individuals with diabetic peripheral neuropathy and moving forward. I'm going to call it DPN to save my voice. But DPN can be moderate to severe and you still have function of the large nerve fibers. You can still have good strength in the large nerve fibers even though the small nerve fibers are dead. So in the letter that we came up with it talks about that. I talk about that. I talk about how the VA needs to come up with something that is specifically dedicated to those with small fiber, small nerve fiber disease In the diabetic peripheral neuropathy or DPN, dbq. I have it here with me and I highlighted the differences. And so for this DBQ, they talk about the symptoms, they do the strength testing, they do the reflexes, but then there's a section or several questions that focus the clinical component just on the small fibers. Right here is light touch or the monofilament testing where they take the little test on your toes and they poke your toes and they do the, the feet checks. That's for diabetic peripheral neuropathy. Um, there's a question here about position sense. When you develop a small nerve fiber disease you lose position sense. So when your your thumb is in a certain position or your hands in a certain position, you lose the, the communication factor factor where your body's telling your brain. You know what the body's doing. So you lose position sense.

Bethanie Spangenberg: 39:12

The first thing to go in DPN is vibratory sensation. So they take a tuning fork and they stick it on the end of your thumb or the end of your toe and they ask you know, tell me when the vibration stops. And then they do the vibration. They'll hold the tuning fork or they'll just let it dissipate and then they can feel the vibration and if you say that the vibration stops before it actually stops, that is a sign of small nerve fiber disease. And in the clinic if I had a patient who was diabetic, they took their shoes off every single time. I saw them and I would do the vibration test every single time. You can still have a normal monofilament test where they poke your toe and have decreased vibration or vibratory sensation, and that's not normal. That is a sign of diabetic peripheral neuropathy and that's a that's not normal. That is a sign of diabetic peripheral neuropathy. Another question dedicated to the dbq for dpn is cold sensation. You put something cold or the side of the tuning fork against their hand or their foot and if they're not able to tell you whether it's hot or cold, you know that's a sign of dpn.

Bethanie Spangenberg: 40:19

Now, or, interestingly, when that examiner goes to document about the DPN, they have to take the small nerve fiber disease. This is currently. They have to take the small nerve fiber disease and put it into a large nerve fiber category, so that C&p examiner is like uh okay, so is this the radial nerve? Do I put this as the radial nerve or the median nerve or the ulnar nerve because it's really affecting them all, but it's really not. You know their, their tenos test was negative, so the median nerve can't be affected too bad. So they have to somehow document the severity of the small nerve fiber disease based on a large nerve fiber scale, and it's. It causes inconsistency and terrible ratings. And so if we take the clinical component out of even the DPN for them to try to determine the severity and we look at just strength testing that they're proposing the veteran's not going to get an appropriate rating. They're going to. They're not going to, they're getting the bad end of the deal.

J Basser: 41:41

Low ball.

Bethanie Spangenberg: 41:42

Yeah, big time.

J Basser: 41:44

Yeah, I can see that I'm about to issue myself a small fiber drop and it's just, it sucks.

Ray Cobb: 41:54

Now, I know we did this. What a month ago that we all got together and talked about this and, bethany, you wrote up a lengthy report to them. When is that going to be? When do they anticipate this is going to be implemented, or denied or not implemented? Do we know yet, or is there any idea?

J Basser: 42:19

John that might be a question for you.

J Basser: 42:22

The issue is with all regulatory items that were issued after January 20th have been put on hold and they're going through everything now to take a rake and weed out the leaves and the bull crap and for certain people haven't got their hands on it yet. So actually I don't expect it to carry much weight. I don't think it may not make it, bethany, because there's a lot of. You know your reply and a bunch of others reply to it. Of course we've had some replies that I read and Bethany showed me one with complete force, from a veterans organization. I guess they need to change the name of that organization to yes, men R Us Disappointing, it's pathetic.

J Basser: 43:12

I don't think it'll fly this year. I think if it does fly, it'll be two years from now, because it took them forever just to sleep at me. It's not finished yet. You're right. Right, they need a different system in order to uh, to test and to uh rate small, proper neuropathy. Whether it be diabetic neuropathy or whether it be autonomic neuropathy, it doesn't matter, it's basically the same thing, you know, and uh, last time I had an emg down was last year. I went to the spinal cord stuff and we did emgs on the legs, arms, everything, and, uh, I did it on the legs and the big nerves of the legs. That basically were okay, but they couldn't rule out small fiber neuropathy. That's how you see it.

Bethanie Spangenberg: 43:59

So um, I'm hoping that. Yes, I think that the system needs improved. I think they said like 1945 or maybe 51, I don't know. Somewhere around there was the last time it was updated or implemented. I I don't remember the date, but, um, I'm hoping that they're taking, you know, some information from the 51 comments that were submitted and really thinking about you know what they've forgotten about or what they've proposed Because it needs to be updated. But I think the way that they're trying to do it is they're trying to keep it at minimum and to make it to where veterans are getting minimum.

Bethanie Spangenberg: 44:44

And even though that they're trying to update them, I don't necessarily think they cap appropriately capture functional loss as it relates to disability.

Bethanie Spangenberg: 44:57

They want to try to put this muscle strength testing thing out there and if and let me read it exactly so then that way you can kind of get where my thinking is. If you have a muscle strength, that is, a muscle three out of five, that means that they can move the joint without gravity. Okay, what kind of function is there for that joint? Nothing, because the moment gravity gets involved, the moment you try to walk, move, turn over in bed, you can't move, that you can't use, or that limb becomes not functioning. And how is that any different from a zero, where there's no muscle movement? So I think, if we're looking at functional loss, I think functional loss is potentially just as bad at a three out of five as it is for a zero out of five, because the muscle movement that is required to truly function isn't adequate enough to do anything. So I think I don't think they've done the right approach on it at all.

J Basser: 46:21

I think it's by design. I think the approach being used is see, there's a federal court case that came out years ago and they got their hands slapped because there is a statute in the Title 38 that says the VA ratings itself and the raiders itself adjudicating claims must do whatever is necessary, whatever they can do, to maximize the benefit for the veteran. So this situation here with the cutting, you know, taking all the neurological stuff away and just going on strength testing, is not maximizing nothing for nobody and, uh, basically minimizing it because you got vets with a small fiber neuropathy and they can't compare it to one of the big nerves, then he's out of luck, you know. So what? He can pick the box up, but the small fiber neuropathy you're not going to hang on that long. If you got it in your hands right, you're going to drop it it's going to to slip out Yep.

J Basser: 47:21

That's right. And you know I mean personally I can't pick. I mean I can't hold nothing in my left hand. You know, and it's just. You know, if I pick something up, I guarantee you to drop it. If my wife sees me carrying a glass in my left hand across the house, she'll throw something at me Because that gets expensive. I'm serious.

J Basser: 47:42

I can see that you can see it, but it's not fun, it's not good and whoever's doing these changes I mean they need an education, because there's a system out there and it was written by Congress and Congress gave the VA permission to go ahead and make some step up and do it to implement Congress's rule.

Bethanie Spangenberg: 48:07

But they're overstepping. I don't like the way that they're going about it either. To me it's not in front of enough people to really support a change, and I think they're trying to do it in a sneaky manner.

J Basser: 48:18

They need a committee. They don't need one person doing it. Okay, they need a committee. They don't need one person doing it. Okay, you need a committee.

Bethanie Spangenberg: 48:26

You need somebody with cooler heads, and even I wouldn't doubt that there's more than one person related, let's say that there is more than one person. If there is more than one person, put them out there. Tell us who they are, what they're doing, what their role is, and not one person who got detailed because they're worried about patient safety, so now they have to reinvent the wheel. So I just uh well, or I guess, reorganize them, so to speak in today's world.

J Basser: 48:52

You know, you said the statute came out in 1940, in the 40s 45, I think okay, it's in the world war ii right now.

J Basser: 49:00

Yeah, technology has advanced so much since then that we have the computer sitting on our table here, our workstation. That one computer itself has enough computing power to handle everything we did in World War II. We've got these young geniuses out there like that can write code with their eyes shut and do anything they want to do. You know, and they can. They can AI this stuff, they can get it done and they can make it the easiest process ever. You know, all it takes is a little ingenuity, and that's what they need to be focused on is bringing them, you know, bring it into the 22nd, 21st century and getting everything situated. You know, if you got a cmp exam, that's great, you know.

J Basser: 49:48

But you know you need to take out some of the um, take out some of the roadblocks, some of the bottlenecks that are involved with the whole thing. You know, get the system right. Have a rating system for small fiber neuropathy based on diabetes, because you know, have the system right. Have a rating system for small fiber neuropathy based on diabetes, because you know, have a system for autonomic neuropathy, because that's one of the biggest fights I've ever had in my life, you know, and because it carries more. I mean it's autonomic neuropathy, you know you can't control it because you know that's an automatic nerve, so Makes it rough, but still, I mean going around the line. But it needs to be fixed and what they're doing now is not fixing anything.

Bethanie Spangenberg: 50:33

Now I would, if you don't mind. I'd like to read the little bit of the letter that I think is applicable to what we talked about tonight. If that's OK, you go right ahead. All right. So the letter that I wrote in response to the proposed changes dated January 13th 2025.

Bethanie Spangenberg: 50:56

Page three I open up about cranial and peripheral nerves. Can I say I will begin with the proposed changes to neuralgia and neuritis. While many of the proposed rule changes align with the VA stated purpose which I think I beat with the dead horse the last one, so I won't go there. But I said I believe there are significant oversights concerning the evaluation of peripheral neuropathies. One issue is the proposed reliance on muscle strength testing as the sole determinant for rating motor neuropathy of the peripheral nerves, eliminating other essential clinical factors that contribute to an accurate assessment of nerve disease severity. These factors, such as the patient's symptoms, their age, their activity level, their reflexes and the sensation testing, have been excluded under the proposed rule changes. And the sensation testing have been excluded under the proposed rule changes.

Bethanie Spangenberg: 51:43

If the VA intends to focus on a single factor to determine disease severity, it is imperative that the methodology and tools used, such as the muscle strength scale are explicitly defined. So I go on to propose something based off of the research, what the scale should look like. Next paragraph says the importance of incorporating multiple clinical factors is supported by the Merck Manual and an article titled how to Assess Muscle Strength. And I bring this up and I want to go to something that they referenced in their proposed changes. They said that the VA proposes to evaluate disability by replacing the current rating criteria current rating criteria which referred to complete and incomplete paralysis at the severe, moderate and mild incomplete paralysis level. They want to replace it with criteria that align with the Medical Research Council scale for muscle strength testing and they cite the same article that I'm getting ready to use against them. So I say that the importance of incorporating multiple clinical factors is supported by the Merck manual and an article titled how to Assess Muscle Strength. So I'm using the same article that they put in there saying well, we should only use this. And it says the article emphasizes that an examiner must quote define the precise character of symptoms, including exact location, time of occurrence, precipitate, precipitating and ameliorating factors, which makes it better, which make it worse, and associated symptoms and signs to accurately interpret a patient's report of weakness. So this article contradicts what they're trying to propose. This highlights that muscle strength testing alone is insufficient without the context provided by additional clinical factors.

Bethanie Spangenberg: 53:39

If I jump to page five of the letter, I specifically address small nerve nerve fiber neuropathies. A second oversight in the proposed rule changes is their failure to accurately assess disabilities caused by small nerve fibers, small nerve fiber neuropathies. While the proposed muscle strength testing criteria may capture disabilities associated with large nerve fibers, they are not suitable for evaluating small nerve fiber neuropathy, such as diabetic, peripheral neuropathy, chemically induced neuropathy such as like we get some, like you know chemical exposures or alcohol induced neuropathies or vascular neuropathies. The proposed rating schedule lacks clarity regarding how these conditions should be rated and will lead to inconsistent disability ratings. Currently, the DBQ for DPN fails to promote medical accuracy, as it directs medical examiners to assess small nerve fibers but ultimately requires them to indicate which large nerve fibers are affected, ignoring the unique clinical presentation of small nerve fiber neuropathies. Clinically, small nerve fiber neuropathies present with distinct patterns, typically affecting both lower extremities or both upper extremities, symmetrically, distally and progressively advancing towards the body over time. This differs significantly from the presentation of large nerve fiber neuropathies. Under the proposed criteria, veterans with severe DPN may receive inaccurate ratings due to the preservation of near normal large nerve fiber motor function, despite having an incomplete sensory impairment.

Bethanie Spangenberg: 55:17

And then the last one. I want to emphasize our last couple paragraphs here. And then the last one I want to emphasize our last couple paragraphs here. It says to ensure accurate assessment, the rating criteria must include additional provisions specifically for small nerve fiber disease.

Bethanie Spangenberg: 55:31

Due to the stark contrast to large nerve fiber disease, with the growing number of Agent Orange veterans who are service-connected for diabetes mellitus and subsequently develop small nerve fiber disease, the VA should propose a separate rating schedule tailored to these conditions. Such a formula would establish clear evaluation criteria to promote rating accuracy, quality, consistency and clarity. The accuracy, quality, consistency and clarity I kind of really pushed in this letter because that was what the VA had proposed was their whole reason for doing this. And then the last paragraph that I want to emphasize specifically discusses autonomic neuropathy. Continuing the discussion of veterans with diabetes mellitus, research on diabetic peripheral neuropathy highlights the prevalence of autonomic neuropathy, which impacts the GI system, the cardiovascular system and the genitourinary systems. Currently, the VA rating schedule lacks clear evaluation criteria to address these conditions in a way that assures rating accuracy, quality, consistency and clarity. So those are the big takeaways for that as it relates to what we've talked about tonight for that, as it relates to what we've talked about tonight.

J Basser: 56:43

Basically, whoever wrote the changes and whoever did this does not have any common sense whatsoever.

Ray Cobb: 56:51

And probably no medical background.

J Basser: 56:54

No, he's a doctor, he's an MD.

Ray Cobb: 56:56

Oh, he is.

J Basser: 56:58

Yes, he's an. Md, I don't know. I don't know if it's something that's come out of the OCG or out of the CBO. You know trying to do drastic cuts, but I don't understand this at all. But this has been in the works for a while, even before any political changes that took care of DC, you know. So this is just it's another end around. You know, and they're it's what do you call it? A trick, play a Hail Mary. I mean, if they had their way, the veterans would get nothing.

Bethanie Spangenberg: 57:44

I mean, if they had their way, the veterans would get nothing, I think. So. There's a couple of people that I've been watching over the last several years and they're still present. They're not political appointees, they're not involved in politics at all, but they are involved in leadership at the VA and they have a budget of what they want to stay under and they are trying to do what they can to to make that budget look better for the VA and for their job and for their positions. So, um, I I know that's what they're trying to do. They're trying to keep the numbers lower, uh, especially because there is such an increase in VA disability I mean, how long were we in a war recently? So there's more veterans that are applying for the disability and that's more money that goes out for our country. But the laws are there for a reason.

J Basser: 58:38

Then you add the PACT Act, then you add the Caregiver Act and you had the other things situated inside. You've got to have enough people to adjudicate these claims because everybody's following PACT Act claims and there's a lot of folks that need caregivers and things like that and there's a lot of folks that need the other things and so they have to hire. And folks need the other things, you know, and so you know they have to hire and do things, you know, with that in order to process those claims. The Congress actually passed, you know, with the Blue Water Navy that's another one you know, and so they realize that. You know well, va's doubled inside or they got so many thousand employees.

J Basser: 59:17

Now, you know, and most of them did it, you know, just because of the changes, and that's not even being looked at. So, plus, you know the PACT Act itself. I mean, a lot of stuff is geared for post-9-11 vets anyways, you know there's a lot more vets that are not post-9, that are older than post-9-11, you know that are going through stuff. Even you know you get some. But the military is a dangerous place. You don't have to be in combat to get killed. So do your race.

Ray Cobb: 59:51

Well, it's my understanding that when I went through basic training and it happened to my company, at least one person is killed or dies during basic training every time that a new company starts a basic training thing. We actually had, well, we had two. One was from a disease he picked up up and the other was from an accident that uh happened, uh out in the range. So you know, and I remember at the time, now this is, you know, we're talking back in the 60s.

Ray Cobb: 1:00:38

Uh, how, what is it like today? Because the equipment is much more advanced and, uh, I do understand that the background is, uh, more intelligent individuals. What we had back in the 60s that if you could breathe and walk and didn't stumble over your two feet, then you got in the military yeah, back then. So, uh, I don't know that we would be able to operate with the same if we had the same type of mental individuals today in the military, with the new updated equipment, like you were saying, the new ai and all the things that are coming down, uh, well, the military is totally different today. My, my wondering is has that decreased that number of injuries or has it increased the number of injuries?

J Basser: 1:01:28

Yeah, I guess it all depends on the situation and what you know, because training accidents are always going to happen. You know, people you know, and me, as a guy fell over in our boot camp graduation. He fell over dead from walking pneumonia at the graduation.

Ray Cobb: 1:01:44

So wow, yeah you know, when you look at some of these, you know the percentages that I you know, that I know they're not gonna. If they've even ever looked at it is the. Let's take the last 20 years and the number of veterans that actually came out of the military with a disability, compared to the number of veterans that came out of Vietnam with the disabilities. Now, vietnam was definitely different because some of our toxic exposures, even though you were exposed when you were in your late teens, early 20s, it didn't show up to your 40, 45, or 50. So that's going to be, you know, that's a totally different outlook of what they need to think about when you start talking about going into a conflict. That's not just going to end when you sign a peace agreement or a ceasefire.

J Basser: 1:02:45

Depends on the conflict. Like World War II, we spent a lot of time in Japan and Germany after the fact. Then we started doing nuke testing out in the Bikini Islands and we did the first test and the first bomb missed and went off. Then the people go back on board the ships to clean them off. That killed a lot of sailors right there. Yeah, so I guess we learned by our mistakes. Well, listen, we're totally out of time. I want to thank Betsy for coming on. She should be back on person next month and we'll be discussing another topic. Maybe we'll finish up this one and we'll see.

J Basser: 1:03:20

We skipped around a little bit, gotten some stuff that, especially with the peripheral nerves a lot of vets out there that's got diabetes actually including all three of us. We have it. But if you guys need an independent medical opinion, if you've got a VA claim and you need some evidence and you've got the issues, you've got some records go to wwwvalidforvetcom, register for the portal and use the phone number listed on the spot and call these folks up. They'll do an intake on you and talk to you and see what's going on and maybe they'll do a DBQ or maybe even do an IMO or independent medical examination or opinion and they'll help strengthen the claim. They do it a lot and they're good at it, but Beth is really good at it, but I have no problem putting her out there. She wants me to.

Bethanie Spangenberg: 1:04:18

Sounds like I need to start paying you, that's for sure.

J Basser: 1:04:21

No, you can pay me nothing. Well, I'll take money. Never have, never will, so other than that I'm serious, and ray, thanks for helping out. Buddy, we appreciate you, man.

Ray Cobb: 1:04:34

I'm glad you finally got a video situated yeah, I think it think we might have it worked out now. Hopefully we'll see how next week goes.

J Basser: 1:04:43

Yeah, we'll be on next week with another topic, another show, and for that this is John John Stacy. They call me Basher For Ray Cobb and Bethany Spangenberg. We'll see you next week.