Dear Editor,
As a chiropractic neurologist and electrodiagnostician, I read with interest Dr. BenEliyahu's first part in his three part series on SEPs in chiropractic clinical practice1 (editor's note: Part II is in this issue, page 22).
While Dr. BenEliyahu never specifically suggested that chiropractors should consider performing EPs on their patients, his over simplification of EPs may mislead some doctors into believing that EPs can be easily performed in anyone's office. The fact is that EPs are a highly developed discipline that requires extensive training in a clinical setting under someone who knows what they are doing. Although Dr. BenEliyahu does not specifically suggest that EPs may be used as a stand alone diagnostic test, by not setting EPs in the context of the rest of the electrodiagnostic examination (and as an extension of the electrodiagnostic examination), some may misinterpret his discussion to imply that EPs may be used in isolation from other neurophysiological techniques.
Dr. BenEliyahu does make some statements which are not truly accurate. For instance, he states that SEPs are helpful in the diagnosis of peripheral nerve entrapments. While a SEP may inadvertently detect an advanced focal entrapment neuropathy, it would hardly be considered sensitive in this regard and certainly could not differentiate between a focal and diffuse mononeuropathy. Dr. BenEliyahu seems to suggest that there is a wealth of sensitivity research on SEPs and DSEPs in the detection of a variety of peripheral and central sensory neuropathies. This is not the case. The majority of sensitivity studies which have been conducted on SEPs and DSEPs have focused on radiculopathies. Of these, the better controlled studies have suggested sensitivity values ranging from 25-78 percent,2-6 hardly what one would consider a sensitive test. Furthermore, most of these studies showed needle EMG to be more sensitive than SEPs and DSEPs in the detection of nerve root lesions. The only exceptions appear to be in upper lumbar radiculopathies,6 which are rare, and in slowly progressive spinal stenotic lesions,3 where surgical decompression becomes necessary.
Finally, in the "oldies but goodies" section, Dr. BenEliyahu makes reference to the use of visual evoked potentials (VEPs) for detecting multiple sclerosis (MS). Since the advent of MRI, the use of VEPs in the detection of MS has become all but a clinical memory, with the exception of perhaps a few HMOs (just kidding).
Evoked potentials are useful for a variety of peripheral and central neuropathies, but under limited circumstances and within the context of the entire electrodiagnostic examination. They were never intended as a stand alone screening diagnostic test, nor will they ever perform satisfactorily under such applications. Because SEPs are so limited in their correct scope of application and require a high degree of training and sophistication to be of any clinical utility, they are best left to the specialists in this field.
As a final note, Dr. BenEliyahu would do well to reference his statements of scientific fact. This is the only acceptable means of distinguishing between an author's opinion or casual statements and those statements based upon authoritative works. In the absence of references, a wise consumer will always assume the former to be the case.
I look forward to reading the remainder of this series on EPs.
References
- BenEliyahu D. Somatosensory evoked potentials in chiropractic clinical practice, Part I. Dynamic Chiro 1994, 12(14):14,25.
- Aminoff MJ, Goodin DS, Parry GJ, Barbaro NM, Weinstein PR, Rosenblum ML. Electrophysiologic evaluation of lumbosacral radiculopathies: electromyography, late responses and somatosensory evoked potentials. Neurology 1985, 35:1514-8.
- Snowden ML, Haselkorn JK, Kraft GH, Bronstein AD, Bigos SJ, Slimp JC, Stolov WC. Dermatomal somatosensory evoked potentials in the diagnosis of lumbosacral spinal stenosis: comparison with imaging studies. Muscle Nerve 1992, 15:1036-44.
- Eisen A, Hoirch M, Moll A. Evaluation of radiculopathies by segmental stimulation and somatosensory evoked potentials. Can J Neuro Sci 1983, 10:178-82.
- Tokuhashi Y, Satohk, Funami S. A quantitative evaluation of sensory dysfunction in lumbosacral radiculopathy. Spine 1991, 16:1321-8.
- Saal JA, Firtzh W, Saal JS, Herzog RJ. The value of somatosensory evoked potential testing for upper lumbar radiculopathy. Spine 1992, 17(6 supplement):S133-7.
John J. Meyer, MS, DC, DACAN
Assistant Professor
Northwestern College of Chiropractic
Bloomington, Minnesota
Dr. BenEliyahu Replies
Dear Editor,
As a clinician, researcher and author, I'd like to assure Dr. Meyer my intentions are always to educate and never to mislead anyone as suggested in his letter. The objective of this series of monographs was to introduce SSEP/DSSEP to the general practice chiropractic doctor. It was never intended to be an exhaustive treatise on the subject directed at "chiropractic neurologists and electrodiagnosticians," such as Dr. Meyer. It is not possible to squeeze into a few paragraphs what many have written books on, so it is appropriate to provide a general, brief review for the general practice DC with no knowledge of SSEPs. While the article may be oversimplified for someone with credentials, that is a very small percentage of the readership. I don't believe a disclaimer is necessary since most DCs I've spoken to who knew little of SSEPs found the article informative, but did not think they were now capable of performing SSEPs in their office based on an introductory overview.
I don't recall anywhere in the article where I implied SSEP is a stand alone test. SSEPs are an extension of the nerve conduction studies and/or needle EMG studies. As far as VER and BAER, while Dr. Meyer may consider them "oldies but goodies," they are still performed by neurologist, protocols are still published in the Guidelines to Evoked Potentials by the American Electroencephalographic Society in 1992. I felt it was still important for the practicing DC to at least understand what they are.
In my opinion SSEPs are useful in clinical chiropractic practice because they are noninvasive, well tolerated by patients, complement traditional nerve conduction studies, and can help detect proximal lesions as well as radiculopathies. This series was intended to stimulate the reader's interest and was never intended to be an everything you wanted to know about SSEP.
David BenEliyahu, DC, DABCT, DABCSP
Selden, New York
Hats Off
My hat goes off to Curtis Turchin for his comments in the Aug. 12 issue of "DC" regarding the Consumer Reports article. He, as well as the writers of the article, has a firm grasp on what is limiting chiropractic's acceptance and clearly shows the ramifications of where we will be headed if we don't change our course. He is correct in viewing the report as an opportunity, rather than another reason for us to cry out against everyone else's misunderstanding of what we do.
Gene Desepoli, DC
Brooklyn, New York
"a crime to ... every person with a spine."
I found (Dr. Turchin's) reaction to Consumer Reports story on chiropractic unique and very puzzling.
Apparently even doctors are unable to be discriminating when reading such biased material. The general public will not be better equipped to choose chiropractic after reading the CR article. They will be less likely now to enter any chiropractor's office. That (Dr. Turchin) is a crime to you, me and every person with a spine.
Steve Wilson, DC
San Diego, California
Curtis Turchin for President
I am a member in good standing of the silent majority of the chiropractic profession. I am writing to say that I and most chiropractors completely agree with Dr. Turchin's review and comments of the Consumer Reports article. Just like in politics it is the vocal minority that gets all the publicity and the attention. They feel they need to scream louder to get heard. Well, I think that most of us in the majority are getting "mad as hell, and we're not going to take it anymore." We have sat quietly by while the straights have yelled, we watch in silence at "alternative techniques" proclaim their powerful cures, and we sit and watch as we have had almost all rights as health care providers in the insurance system stripped from us. If Curtis Turchin wants to run for president of the ACA or any other chiropractic organization, I will be first in line to vote for him, because our leaders run in fear of the vocal minority and refuse to take hard stances on important issues.
Michael Vesely, DC
Los Angeles, California
"My duty as a board examiner is to protect the public..."
Having read Dr. Timothy Mirtz' article (July 15) regarding student loans, I must take issue with one of his statements.
Dr. Mirtz suggests as his first and foremost solution that DCs who successfully negotiate the NBCE parts 1-3 be granted license in any state in the union. He feels it is "ridiculous to keep new chiropractors out of your state on the basis of fear." As a California board examiner, I can state unequivocally that nothing could be further from the truth as far as I'm concerned. My duty as a board examiner is to protect the public from a chiropractor who is not at least minimally qualified to practice chiropractic in California.
I examine candidates in chiropractic adjusting and physiotherapy, and I do not seek to fail candidates out of fear they may come to my home town and diminish my economic gain. Rather, I will fail a candidate who in my opinion does not possess the minimum qualifications which would protect the public from potential harm. In one instance, during the adjustive portion of an exam, I recall asking a question designed to test the candidates knowledge of low back adjusting. That candidate "set up" on the model's body and when asked what the candidate's contact hand was resting upon, I was told, "The transverse process of L4." I asked the question again and was again told the transverse process. I asked and was told the third time the transverse process; at that point I marked my grading sheet.
I kindly suggest that Dr. Mirtz and all chiropractors dispense with the notion that board exams are designed to delay your admission to practicing solely on the basis of some economic gating process. I encourage my colleagues to apply to their respective boards and request serving as a board examiner, not only to dispel the ugly thoughts of an adversarial board, but to gather the rewards of service back to our profession.
Bradley Wolff, DC
California Exam Commissioner
Here We Go Again!
Well, here we go again. I just can't believe my eyes.
Another national media event full of sensation lies.
First it was "20/20," then the "Crusaders" and now Consumer Reports,
I guess next it will be in Weekly Reader or on Wide World of Sports.
So many patients have asked me, "Why are they out to get you guys?"
There are many reasons, but here's just a few I want you to realize.
On top of the list, in capital letters, is Bill Clinton's health care proposals.
They can take their reforms (they will never work) and put in the garbage disposals.
The powers that be are trying their best to deny chiropractic's inclusion,
They view our successes and the money we save as a cataclysmic intrusion.
The drug companies would lose millions of dollars on pain pills and muscle relaxers,
If all low back or neck sprains and strains were sent to the chiropractors.
The hospital beds would be far less full if they sent us the disk protrusions.
While the back surgeons would have time on their hands adding to their confusion.
So you see if you were one of those folks, then chiropractic is a great threat,
And they will do their best to scare anyone who hasn't tried chiropractic yet.
Is chiropractic safe? Well, please examine these facts before making up your mind,
Chiropractic is the safest form of health care that anyone can possibly find.
Our malpractice insurance rates each year that our professionals pay,
Would be tremendously costly if chiropractic was dangerous in any way,
Less than one-third of what the average medical doctor is charged yearly,
What does that tell you about who is safer and who has to pay more dearly.
Ten years the British studied back pain and in all their research they found,
That chiropractic is safer, much more effective and cost wise, greatly more sound.
A government sponsored New Zealand study, termed chiropractic's safety "impressive"
While Utah compensation records proved medical costs are 10 times more excessive.
California and Oregon workers' compensation in comparing missing work and cost,
Said medical health care took twice the money for care with also twice the work lost.
Ontario economist found chiropractic safer, more cost effective and medically superior.
They said questionable or harmful medical treatments for back cases were inferior.
Each week, unnecessary surgery and drug reactions cause 3-5 thousand to die.
How in the world can they call chiropractic unsafe, I wish someone could explain why.
These are just a few of the studies and there are many, many more besides these,
That prove chiropractic is more effective, cost less and does more to please,
So if you hear more negative reports about how chiropractic can possibly harm you,
Just remember the source and it is health care reform that is trying hard to alarm you.
David M. Pierce, DC
Scottsboro, Alabama