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Recently a published editorial came across my desk which was actually conceived by a rather tenacious chiropractor regarding the recent scope of practice legislature, which was signed into law the second week of January. I found this letter alarming and as such, wanted to clarify statements made and set the record straight.  This “chiropractor” states in his letter to the editor that the new scope would be dangerous to the public as it allows “medically untrained chiropractors” to examine, diagnose and treat things not related to the spine.  He goes on to state that “Chiropractic care has always been based on the spine” and that “Chiropractors do not have the medical or educational training to perform these additional treatments”.  It becomes immediately apparent that one who fits these qualifications would clearly be incompetent to practice any type of medicine, and clearly has not earned the right, or demonstrated the criterion for using the title “Dr.”.  These are qualities one might possess as a technician, certainly not as a physician.

While I am sure that this “doctor”, is clearly as he puts it, “medically untrained”, and I am sure that there may be other “medically untrained chiropractors” lurking about, it is clearly an absurd thought.  Mainstream doctors of chiropractic medicine, chiropractic physicians if you will, are thoroughly trained to examine, diagnose and treat all aspects of humanism no different that any other medical physician.  The training to become a chiropractic physician incorporates years of specialized studies in all aspects of medicine, with particular attention to examination and diagnosis of all of the disorders that afflict mankind.  The single difference between allopathic medicine, (general medicine), and chiropractic medicine, is that the latter incorporates treatments without the use of drugs or surgery.  Naturally, some conditions require drugs or surgery, and naturally those individuals are referred as would be expected to appropriate specialists.  Further, chiropractic care has never been based on the spine.  The spine is merely “involved” when spinal manipulation is utilized as a treatment modality.  In fact, many chiropractic physicians such as myself, have gone on into specialized residency programs.  Perhaps this practitioner is indeed intimidated by the need for annual continuing medical education, now mandated within the new scope of practice here in NJ for the first time.  If the statements made by this practitioner were indeed accurate, then all patients under chiropractic care would need to be referred out, as no diagnosis could ever be rendered, and thus no treatment plan could ever be formulated, clearly an absurd thought.  I guess what is important here is that the general public in reading his letter should come to the realization that there may be chiropractors in practice, who feel “medically untrained”, yet continue to practice.  As such, the general public should be clear on choosing a doctor of any type, involving themselves on that particular doctors training, where they went to school, the modernization of their facility, their post doctoral training and credentials, etc.  Further information on mainstream chiropractic, or finding a doctor of chiropractic can be found on the ACA website at www.acatoday.com.

The American Association of Electrodiagnostic Medicine references somatosensory evoked potentials and states that radiculopathies may be difficult to evaluate electrophysiologically.  F wave and needle EMG abnormalities, including those encountered in paraspinal muscles, reflect only dysfunction of the motor root.  H reflexes on the other hand, are limited to diseases affecting the S1 root only.  However, somatosensory evoked potentials, elicited by segmental sensory stimulation may provide valuable information in a disc disease involving common cervical and lumbar levels, with predominant sensory abnormalities.  A good correlation between the dermatomal somatosensory evoked potentials and myelographic and clinical abnormalities has been demonstrated.

AAEM, October 1993, page 3; The dermatomal somatosensory evoked potential is particularly helpful in conditions which produced isolated involvement of the sensory fibers at sites that are either proximal in the peripheral nervous system i.e. at the plexus and root levels or within the central neuraxis.  In this case, peripheral nerve conduction studies and EMG may not be capable of detecting the lesion, (for example as in a primary sensory fiber radiculopathy with preganglionic root compression), whereas the dermatomal somatosensory evoked potential is more likely to do so.

Needle EMG is useful for detecting motor weakness concomitant to radiculopathy that sometimes cannot be detected by nerve conduction study alone.  However, nerve conduction and somatosensory evoked potentials can detect sensory radiculopathies that cannot be detected by needle EMG.  There are clear disadvantages with needle EMG: it is an invasive, painful procedure and it cannot detect sensory radiculopathies.

Pain of localized origin is treated differently than pain of a radicular origin.  Differential diagnosis includes radiculopathy, plexopathy neuropraxia, axonal degeneration or peripheral nerve entrapment.  Failure to diagnose may lead to erroneous treatment, diagnosis, and unnecessary extended care or inappropriately delayed referral.

In 1973, Upton and McCombs found cervical nerve root lesions in 70% of 115 patients with carpal tunnel syndrome or lesions of the ulnar nerve above the elbow.  They thought that this association was not fortuitous, but rather the result of serial constraints of axoplasmic flow in nerve fibers. They termed this combination double crush syndrome.  Yu et al found 20% of 525 patients with carpal tunnel syndrome had other neurologic disorders.  The associated disorders consisted primarily of involvement of the cervical roots, (53%), the ulnar nerve at the elbow, (28%), or both, (9%).  Nakano further stated that this responds only if treatment is directed toward both processes, and that electrodiagnostic and X ray studies should be performed in patients with entrapment neuropathy with symptoms referable to the neck.

Where needle EMG testing tests for end organ atrophy/muscle wasting associated with denervation, NCV testing tests the actual nerve itself, for neuropraxis and various compartment syndromes, i.e.: Carpal Tunnel Syndrome, etc.  Although the tests throughout history have been combined, the tests are mutually exclusive and test different things.  There is no medical logic that they must be combined and have only been done so through routine.  EMG only serves to uncover motor loss, by detecting atrophy of the innervated muscle tested.  Should the loss be sensory only, and not have progressed to the point of motor loss, the test is non-informative.  NCV testing uncovers any lesions to the peripheral nerve, as well as localizes the site of the lesion as well as the severity of the lesion.  This cannot be detected trough needle EMG testing.

DSEP is a sensory test that is non-invasive, and non-painful, (unlike EMG), which is much more useful in demonstrating a sensory radiculopathy that has not manifested itself as a motor neuropathy.  DSEP would uncover this type of lesion easily, which would be missed with EMG.

There is no clinical literature to support the statement that nerve conduction studies performed without electromyography are of little or no value.  As they are two separate and distinct tests that have been done together out of routine rather than out of medical necessity or rationale, the statement is invalid and has no place in medical determination of necessity.

NJCCN and Qualcare Inc.

Author: admin

Following long standing discussion, Qualcare Inc., associated with the Saint Barnabas Plan, has stated, ” It is appropriate to recognize Chiropractic Neurology, if proper credentialing criteria are met.” The decision was made after appropriate committees considered the issue. “These criteria were taken from documents that include State of NJ Statutes and materials from the American Chiropractic Neurology Board and the New Jersey Chiropractic Council on Neurology.” In light of this decision, procedures performed by chiropractic neurologists which were formerly denied reimbursement, will now be reimbursed appropriately, provided adequate documentation of medical necessity is met.  The company is the first insurance carrier to make such a profound declaration, although they are not the first to provide fair reimbursement practices for chiropractic neurologists.  It is however refreshing to see an insurance carrier make a statement like this volitionally, without being forced to through litigation or by any authoritative agency.  Hopefully other carriers, like Blue Cross Blue Sheild of NJ, will step up to the plate and make similar decisions.

The NJ Chiropractic Council on Neurology, in cooperation with the American Chiropractic Association (ACA) Council on Neurology, has developed and implemented fall prevention testing protocols that underscore, as recent legislature does, the need to reduce falls, particularly in the elderly population.

The text of the Elder Fall Prevention Act notes a number of sobering statistics regarding the consequences of falls, including the fact that “Falls are the leading cause of injury deaths among individuals older than age 65”. 25% of elderly individuals who sustain a hip fracture die within one year; and nearly 65,000 individuals older than age 65 sustain a traumatic brain injury annually as the result of a fall. And in a recent study evaluating disability in the elderly population, the results of which were published in the Journal of the American Medical Association, “Hospital admissions for falls were most likely to lead to disability”.

Members of the NJ Council on Neurology use a screening technology that, according to the manufacturer, allows a clinician to predict the probability of a fall with a .002% false positive. (Meaning very accurate). The testing, which takes only seconds, allows the user to provide those tested with a statistical report that they can clearly understand. According to nationwide testing results, more than 50% of seniors tested have significant risks of falling, despite showing no symptomatology whatsoever.

The current testing apparatus is designed to bring neurologists of chiropractic medicine background to the forefront of fall prevention testing and treatment protocols. Additionally, the council has received countless requests for referrals to those trained in fall prevention. The council says it does not currently have enough adequately trained clinicians to meet the demand for referral and fall prevention management.

For more information on fall prevention and testing, contact Dr. Scopelliti, President of the NJ Chiropractic Council on Neurology.