Navigating Peripheral Neuropathy

Bethanie Spangenberg, CEO of Valor 4 Vet and VA appeals agent, joins us to examine peripheral neuropathies and potential changes to the VA's rating system that could dramatically affect veterans' disability claims.

• Peripheral Nerve Conditions DBQ covers nerve damage including carpal tunnel syndrome and surgical nerve damage, but not diabetic neuropathy or radiculopathies
• VA currently rates nerve conditions using multiple factors: symptoms, muscle strength, reflexes, sensation, and skin changes
• Proposed changes would reduce assessment to muscle strength testing only, potentially under-rating veterans with small fiber neuropathy
• Small fiber neuropathies (affecting fingers/toes) present differently than large nerve fiber diseases but aren't properly captured in current or proposed systems
• Veterans with diabetic neuropathy can have severe symptoms while maintaining good muscle strength, leading to inappropriate ratings
• EMG and nerve conduction studies can differentiate between acute and chronic nerve damage but don't always capture small fiber disease
• Veterans with nerve conditions should ensure comprehensive documentation of all symptoms, not just muscle weakness

Contact Valor for Vet at www.valorforvet.com if you need assistance with independent medical opinions for your VA claim.

Tune in live every Thursday at 7 PM EST and join the conversation! Click here to listen and chat with us.

Visit J Basser's Exposed Vet Productions (Formerly Exposed Vet Radioshow) YouTube page by clicking here.

Episode Transcript

J Basser (00:03):
Welcome, ladies and gentlemen, to an episode of the
Exposed Vet Production.
My name is John Stacy.
I'm the host of this enormousshow.
The co-host is Mr Ray Cobb.
He's with us in the audio onlytonight.
You won't see his pretty face,but I'm sure he's here.
How you doing, Ray?

Ray Cobb (00:20):
I'm doing great.
How are you Trying to get overthis?
Whatever this virus is that'sbeen going around for a week or
two.

J Basser (00:31):
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 companycalled Valor for Vet, which is
a very good veterans company.
They do a lot of veteranindependent medical opinion
examinations and they helpveterans with their VA claims.

(00:52):
Beth is an accredited VA claimsagent or appeals agent, excuse
me and she does a lot for vets.
She didn't really practice theclaim side, you know as far as
that, but she knows the VA andknows the system because she
used to work for the VA.
Bethany, how are you doing?

Bethanie Spangenberg (01:10):
I'm doing well.
I'm excited for tonight's show.
I think there's a lot of goodinformation that we'll talk
about.

J Basser (01:17):
Okay, and we've been doing a series here last couple
months on neurological stuff.
I think we're going to focusand continue on that.
You had an idea that you weregoing to touch on.
Was it migraines or was itsomething different?

Bethanie Spangenberg (01:35):
For tonight's show.
Yeah, still neurological rightPeripheral neuropathies.

J Basser (01:42):
Oh, I'm sorry, I was wrong.
Well, I'd much rather enjoythis section here, anyways.
Peripheral neuropathies.
Oh, I'm sorry, I was wrong.
Well, I'd much rather enjoythis section here, anyways.
Peripheral neuropathies.

Bethanie Spangenberg (01:50):
Hey.
What's funny is the last timewe were together you said, hey,
I want to do this one.

J Basser (01:55):
I know, but that was a week ago.
And with the emits the flow ofinformation that goes in my ear
and through my computer system,and with my data science and AI
stuff, you know it mumbles andbounces around in there and

(02:16):
sometimes it gets a little bitlost.

Bethanie Spangenberg (02:19):
Yeah, we skipped the order just to make
you happy.

J Basser (02:23):
So we're on pro-drop.
You go right ahead, girl.

Bethanie Spangenberg (02:28):
All right.
Well, I just kind of want tointroduce the fact that we
started on this series mainlybecause of the proposed changes
to the rating schedule and we'vespent the last couple months
talking about that and that kindof opened up the door with
targeting or focusing on theneurologic conditions in their
DBQs.
Last month we talked about ALSand the kind of the

(02:52):
discrepancies between you knowthat particular DBQ and how the
other DBQs really don't providethe information, the information
.
There's more information in theALS DBQ or the Lou Gehrig's DBQ
that really helps to supportthe veteran in their disability

(03:13):
and giving them all the benefitsthat they truly need, and the
other DBQs aren't aligned thatway.
So that was for those.
Maybe ALS doesn't pertain to youor the disability that you're
seeking, but knowing thatinformation that's inside that
DBQ will help you understandwhat benefits that you may be
entitled to as well.
So if you have other conditionsthat affect you, you know a lot
of those are special monthlycompensation information.

(03:36):
So take a look at it and seewhat kind of questions they're
asking, or listen to thatpodcast.
Oh, hi Ray.

Ray Cobb (03:42):
Hello, how are you?
I got to try to get focused innow.

J Basser (03:46):
I finally figured out what was going wrong, so now,
hey there, guys well so thewiggling pit did come loose in
the wobbling shaft yeah it.

Ray Cobb (03:58):
Uh, that is loose.
The wiring was loose up thereand also kind of the way that
the I guess it was the way thefilters were.
So I think you might have alittle bit of a better view of
me now.

J Basser (04:16):
Once.

Ray Cobb (04:16):
I sit back.
How's that?
Is that okay?
Yeah, good, I'm glad you couldjoin us.
Yeah, glad to be here.
I'm glad you could join us.

J Basser (04:25):
Yeah, glad to be here.

Bethanie Spangenberg (04:27):
So with that discussion, you know, we've
went back to talk about theletter that we put together and
I'm saying we because we hadspecifically a conversation of
things related to the changesthat we didn't like.
We had that conversation and Iput together a 12-page letter
that I sent to the VA and I'llactually reference a little bit

(04:47):
about that today whenever wetalk about these DBQs.
But today's focus is theperipheral nerve conditions.
A lot of people think of thiswhen they're thinking of
radiculopathy, if they'rethinking of any type of nerve

(05:11):
damage involving the feet or thehands.
This is what this DBQ is for.
The neck DBQ has a component inthere that specifically
addresses radiculopathy, thesame for the lumbar spine
condition.
It has a section in therespecifically for radiculopathy.
In there, specifically forradiculopathy, the diabetic
peripheral neuropathy it has aDBQ dedicated for itself.
So this DBQ is dedicated fornerve conditions that do not

(05:35):
include diabetic neuropathy orthe 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, aveteran is wanting an increase
for their lower extremityradiculopathy or their sciatica
is a common term that someveterans are familiar with.
Instead of getting a nervecondition, dbq or exam they will

(05:59):
actually have their whole lowerback re-examined and the
information regarding theradiculopathy will be documented
in the back DBQ.
So this is something if youhave a surgery and the surgery
damages the nerve, they would dothis.

(06:19):
If you have carpal tunnel, thiswould be something that they
would do this DBQ for.
So that's kind of where thisDBQ is dedicated for Any
questions.
Before I start rambling stuffoff, no.
Okay, so just starting on pageone.

(06:39):
This is 14-page DBQ.
We're looking at page one andit starts with your standard
information.
You're documenting theexaminer's, documenting the
veteran's name and information,their relationship to the
veteran, whether they're a VAhealth care provider, if they're

(07:01):
regularly seen in thatclinician's clinic.
The evidence review is on pageone.
We always talk about theevidence and that evidence is
what is contained in your claimsfile and what?
Um, mainly what's contained inyour claims file.
I was going to say in the VArecord, but if you have a
contract examiner, they don'thave access to the VA record
unless it's scanned into the uhclaims file by the rater.

(07:23):
So they've done a better jobwith that, you know, as years
have gone on.
So evidence.

Ray Cobb (07:29):
Reviews the claims file information.

Bethanie Spangenberg (07:32):
Section one is the diagnosis that the
examiner is focusing on for thisDVQ.
We look at page two and this isthe section where we look at
page two and this is the sectionwhere section two, page two, is
the section where the examinerwill document the medical
history.
They'll talk about the historyof the condition, how it started

(07:54):
or what their current symptomsare.
They also document the handdominance.
So for some conditions thataffect the dominant hand you get
a different rating for thatbecause it's based off of your
hand dominance.
So they always document that.
If it affects, you know thedominant hand, so it's, and

(08:16):
sometimes the rating schedulesdon't always compensate for
dominance, but there is specificsections for that in the rating
schedule.
Section three is the symptomsrelated to the peripheral nerve
conditions.
It specifically asks about theright upper extremity, the left
upper extremity, the right lowerextremity, the left lower

(08:38):
extremity and the examiner is tofocus on each extremity and
they are supposed to documentthe symptoms and ask the veteran
if they don't have, like ifthey have none, do you have any
symptoms?
They can say yes and theexaminer is supposed to ask
whether it's mild, moderate orsevere.

(08:59):
Now, just because the veteranis documenting their symptoms.
That doesn't necessarily meanthat that's the rating that
they're getting.
It's not based on theirsymptoms.
Typically what happens duringan exam or any condition
affecting the nerves is theexaminer is to, or clinician is
supposed to, gather the symptoms, the types of symptoms and how

(09:24):
frequently they're coming, andthen they collect data from
their exam, from sensation toreflexes to muscle strength.
They take all of those and theyput it into a category to
determine clinically if it'smild, moderate or severe.
And for this dbq way it'scurrently designed, that's what

(09:45):
they're trying to do is they'retrying to collect data from the
veteran and then they'll go onlater in the exam to get all
those other components to reallydetermine how severe their
nerve condition is.
Dbqs I would straight out askyou know, let's say, for the

(10:08):
sake of this particular session,we're going to focus on carpal
tunnel affecting the right hand.
So I would ask the veteran youknow we're focusing on the right
upper extremity today, so thenI would go through here and I
would put you know the leftupper extremity, those other
components I would not report onthose.
I'm reporting specifically onthe right upper extremity,

(10:31):
carpal tunnel, and I would sayis your?
I'm going to ask youspecifically about constant pain
.
That's the first question inthe DBQ symptoms Are your, do
you have constant pain?
And the veteran would tell meyes 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

(10:53):
tells me.
The next symptom that's listedhere is intermittent pain, pain
that comes and goes or wax andwanes.
And I say do you experienceintermittent pain, pain that
comes and goes, pain that waxand wanes, like it's still there
but it gets a little bit worseand it gets a little bit better.

(11:14):
And if they tell me they doexperience that, then I ask is
it mild, moderate, severe?
Whatever they tell me is what Iput.
Then we move on to page three,we're continuing with the
symptom collection and they'reasking.
The next question asks aboutsymptoms related to tingling or
like a funny sensation in theirhand.
I would ask if they experienceit and if they do, then I would

(11:38):
say is it mild, moderate, severe?
And I would document based onwhat they told me.
Last question when it comes tothe symptoms is numbness.
Do you experience numbness?
Yes, is it mild, moderate orsevere and I would document it.
And if they told me it wassevere, I would document it
severe.
They told me it was mild, Iwould document it mild.
Those symptoms are recordingwhat the veteran is experiencing

(12:01):
directly and you know, oneperson's severe, maybe another
person's mild, I don't reallyclinically, it is just a
component of understanding theimpact upon the individual.
It is not necessarily used tosay this individual is saying

(12:27):
their symptoms are severe.
It doesn't correlate to thattheir condition is severe.
When you have sudden flare-upsof carpal tunnel, their symptoms
could be or feel severe and itmay be a mild carpal tunnel on
testing for the nerves.
So any questions regardingsubjective reports of symptoms

(12:51):
from the veteran.

Ray Cobb (12:54):
Now, do you?
Well, of course, I think youjust mentioned that, but a lot
of questions that I've beenasked has to give it a number
rating, like one through 10.
Did you do that, or does a lotof 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 inthe clinic we are asked or
taught how to identify pain.
I would not ask that for thisparticular DBQ because it's not
relevant to what they're askingor what I'm tasked with doing.

J Basser (13:33):
Maybe that's a clearer way for the examiner to
communicate the mild, moderateor severe, but I would take what
the veteran told me, what ifyou had the veteran in front of
you and examine the veteran andyou ask him a question and you
look at his extremity the lefthand, right hand, it doesn't

(13:54):
matter but you notice there'stwo nerves that control your
hand and you notice the pinkyfinger and the other finger are
drawn in against the palm and hehas 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 ineveryone.
There are individuals thatexperience the numbness and the
tingling, like almost as if yourhand has fallen asleep.
That's what I try to relate,that what we call paresthesias

(14:37):
or the tingling.
It affects people differently,so some people will have the
paresthesias and still havetheir sensation intact.
Some people will have numbnessand never experience the
tingling or paresthesias.
Some people will experiencepain and never experience
numbness.
So I'm glad you asked.

(14:59):
Nerve symptoms do not alwayspresent the same and that is why
there is multiple components inunderstanding the severity of a
nerve condition.
So you don't just take, youknow, one factor.
In order to clinically rate anerve condition, you really have

(15:20):
to take all the data that'smade available to you and make a
clinical decision on theseverity of the condition.
Makes sense, makes sense.
Okay, section four still onpage or.
We are on page three now.
Section four is muscle strengthtesting and I want to emphasize

(15:41):
this section.
The reason why I want toemphasize this section is, with
the new proposed changes, thisis the only section that will
determine the rating from whatis being proposed.
So they plan on taking out thesymptoms and the section on

(16:02):
reflexes and the section onsensation testing and the
section on skin changes.
They only are wanting to ratethe veteran off of muscle
strength testing and I don'tagree with that and we'll talk a
little bit more about thatlater.
But just wanted to emphasizeyou know this section and

(16:26):
understanding of this section.
So section four, muscle strengthtesting, rate the strength
according to the following scale.
So they get a zero out of five.
We rate strength testing onfive out of five points, or zero
to five.
Zero is there's no musclemovement.
One out of five is that meansthat you can see the muscle move

(16:48):
but there's no joint movement.
So you can see the musclecontract, you can feel it
contract, but there's nomovement of the joint.
Two out of five means thatthere's active movement without
gravity.
So if an individual is sittingand they decide to lift their
leg up, they're lifting that legagainst a gravity.

(17:11):
When you're looking at removingthe gravity, you have to
position the joint where gravityis not involved.
So that's more of a clinicalpositioning component.
So in order to do that testing,three out of five is the active
movement against gravity.

(17:32):
That's where I was talkingabout you lifting your knee up
towards the ceiling, liftingyour leg up?
That would be active movementagainst gravity.
Four out of five is activemovement against some resistance
.
So if you've been in an exam,typically for strength testing,

(17:55):
the examiner will place theirhand on your knee and have you
push up, or they'll do differentpositions and have you kind of
resist them.
Four out of five means thatthere's active movement against
some resistance, so the examineris not pushing as hard.
Five out of five is normalstrength testing.
That means that the individualis able to move the joint

(18:17):
against a normal amount ofresistance, which I think that's
where muscle strength testinggets tricky.
Amount of resistance which Ithink that's where muscle
strength testing gets tricky isbecause I may push against the
individual with 10 pounds offorce and the next examiner may
push against the individual with20 pounds of force, and so when
we look at strength testing youknow it can be kind of tricky.

(18:40):
What one clinician says isnormal and the other clinician
says is normal.
So for this section theexaminer is supposed to look at
the joints affecting the nervecondition, whether it's the
elbow or the wrist.
So for carpal tunnel it wouldbe wrist.
The general rule is that ifyou're examining for CNP, if

(19:01):
you're examining a joint likethe wrist at carpal tunnel,
you're going to actually justexamine all the strength testing
in the entire arm.
So that's just a good rule tofollow.
That way you can identify ifthere's other contributing
factors to the carpal tunnel.
They're supposed to document onboth, are supposed to document

(19:27):
on both.
If you're examining the rightarm or right hand, you should
always, both clinically and forcomp and pen purposes, document
the left side.
That allows the examiner toreally appreciate the comparison
.
So, like for grip strength, youcan really appreciate if one is
reduced versus one being normalwhen you have them to compare
to.
So if you have an examinerthat's doing the exam, the good
rule of thumb is to test bothstrength of both sides at the

(19:52):
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 thelegs, but you should be doing
one right after the other on thesame one.
You don't want to go do astrength testing on the hip and
then jump down to the ankle andthen go to the other side.
So it's just a way for thatexaminer to really have a good

(20:14):
way to measure the balancebetween those two sides.
Going to page four, the examineris to document any muscle
atrophy or thinning of themuscles.
When it comes to the upperextremities, you can get atrophy
or the loss of muscle tone inthe forearm and in the bicep is

(20:37):
typically how we are taught tolook and to measure, and then
the same for the lower legs.
We were taught to measurearound the thigh and around the
calf and it's supposed to be thesame distance on each side.
So they should be taking ameasuring tape and measuring
both of those areas.

(20:57):
If we go to section five, we'relooking at the, the reflex exam
.
This is where they tap to checkyour reflexes.
Reflexes are based on a zero tofour scale.
Zero is absent, four ishypoactive, meaning that they're
not as responsive.
Two is normal, so and reflexestwo is normal, so in reflexes

(21:23):
two is normal.
Three is hyperactive, withoutwhat they call clonus, which is
like the muscle bouncing, andfour plus means that it's
hyperactive and then you getlike a muscle bounce with it.
That just means that that nerveis really triggered or really
responsive, almost tooresponsive.
So section six is the sensoryexam.

(21:48):
For sensory when it comes tothe peripheral nerves, it only
asks specifically about lighttouch sensation.
They're only looking at takinga tissue or a cotton ball and
touching the skin area and theexaminer is to document whether
it's normal, decreased or absent.
And again you're doing a leftto right comparison for the

(22:10):
examination.
Section seven trophic changes.
This is on page five.
Does the veteran have any skinchanges characterized by loss of
hair on the extremity, smoothor shiny skin?
And you're supposed to documentthat?
Page six looking at page,excuse me.

(22:32):
Section eight is theindividual's gait, how they're
walking, and does the nervecondition affect how they walk?
For carpal tunnel that we'reusing for this example, we
wouldn't necessarily need todocument the gait.
I still would, just forconsistency purposes to.
Really, if the individual filesfor something later and they

(22:57):
want a historical timeline ofhow things have progressed, it
just contributes to you know theveteran's current status.
So some examiners may not dothat.
I do that Specifically forcarpal tunnel is section nine.
It talks about what they call aphalanx test or a tendrils test.
So a phalanx test is where youhold your wrists together for a

(23:21):
minute and if you developnumbness or tingling, that's
supposed to be an indication ofcarpal tunnel, you would get
tingling into the fingers.
Tunnel's test is where theexaminer taps right at the
carpal tunnel and if you getsymptoms, that's supposed to be
a positive test.
So that's sections dedicatedspecifically to carpal tunnel

(23:42):
and then section 10, after doingall those components, the
examiner is now supposed todetermine the severity of the
nerve condition.
So we take the clinician is totake the history, the symptoms,
the strength testing, the reflexexam, the sensory exam, any

(24:05):
skin changes, into considerationof how severe this nerve
condition is, before theydetermine if it's mild, moderate
or severe or if it's a completenerve paralysis.
I emphasize that because ifthey go down to just muscle
strength testing, they're goingto rate you rate the veteran

(24:28):
based on the number zero throughfive, which presents a lot of
challenges and I think a lot ofthings are missing really taking
out the clinical component.
I understand that they'retrying to tie these ratings down
to objective you know objectivethings but I think there's

(24:54):
still a lot of room for errorthere.
Any questions before I talkabout the severity of the nerve?

Ray Cobb (25:02):
Yeah, I think it's pretty well having corporal
tunnel myself and having surgeryfor it.
A lot of these tests were onesthey did prior to me having the
surgery.

Bethanie Spangenberg (25:16):
All right.
Well, if we look at theseverity, section 10 is where
the examiner is to document theseverity of the upper extremity
conditions.
Now they have all the nerveslisted out.
I'm not going to go throughevery one of them, but what the
examiner is supposed todetermine is if a particular
nerve so let's go with the ulnarnerve, that's what's affect the

(25:39):
median nerve, excuse me, themedian nerve is what is affected
in carpal tunnel and they'resupposed to decide if the nerve
is normal, if it has completeparalysis or if it's incomplete.
If it is complete, they move on.
They don't have to markanything else.
If it's normal, they don't haveto complete anything else.

(26:03):
But if it's incomplete, theexaminer is supposed to
determine if it's mild, moderateor severe.
And again, we take all thosecomponents, we make the clinical
application to determinewhether it's mild, moderate or
severe.
Section 11 focuses on theseverity of the lower

(26:25):
extremities.
Again, you go to each nerve I'mnot going to list them out and
the examiner is supposed todetermine 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.
Looking at section 12, this isstandard in most of your DBQs.

(26:49):
We're looking at assistivedevices brace cane, crutch,
walker, wheelchair If they useany of those for their carpal
tunnel or their nerve condition,the examiner just documents it.
Section 13 looks or asks aboutamputation.
We've talked about this before.

(27:10):
This amputation rule comes infor loss of use and it's
considered the special monthlycompensation.
So if the examiner determinesthat the functioning is so
diminished that amputation withprosthesis would equally serve
the veteran, they would markthat and that qualifies the
veteran for special monthlycompensation.

(27:32):
Going to page 12, section 14,just any other physical exam
findings that the examiner wantsto document any scars that may
have come from the carpal tunnelsurgery or surgery related to
the nerve condition.
Section 15 looks at diagnostictesting with your nerve symptoms

(27:59):
or conditions.
A lot of times you will getreferred for a nerve conduction
study or an emg.
It's where they stick needlesinto the muscles and they they
send electricity through andthey make you jump.
It's not fun.
Mine wasn't fun, I had onebefore I.

(28:19):
They could be painful at times.
Normally they warn youbeforehand 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 andthey took the needle and stuck
it, because probably five or sixinches away, they stuck the
needle in there and put it twoor three places and played with
it and turned the amplitudemachine up trying to see if it

(29:02):
does anything.
He pulled it back out and hesaid 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 thesmall fibers, which we'll talk
about that here in a few minutesI feel like the EMGs, or the
nerve conduction studies, arehighly valuable and really
understanding you know what'shappening with the nerve
condition.
So if you're a veteran thatexperiences that it's not.

(29:39):
If you can get the EMG done, Iwould encourage you to do so
because it gives it a goodpicture 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 neurologistsactually do it right, you have
to realize that their test isonly as good as their equipment
is, and sometimes the equipmentis not, you know, very good it's
like it's like echocardiograms.
You know it's only as good asthe equipment is too.
So I think a lot of a lot ofultrasound with the cardiac

(30:12):
ultrasound, I think a lot of thestuff 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 testand who's interpreting the tests
and things like that.
I, if I would have anindividual in the clinic that
complained of numbness, tingling, weakness, I would look at the

(30:39):
EMGs, because the EMGs not onlytell you the nerve, the extent
of the nerve damage, but they'realso able to tell you how
recent it is.
If they pick up on somethingthat's what they call acute or
something that's recent, thosenumbers from the nerve
conduction study will tell themthat if it's something that's

(30:59):
chronic, it it's the.
The test picks up on that too.
If they have something, forexample, for diabetics, there's
a particular nerve that they cantarget and try to get data from
that particular nerve, becausethey know that nerve is affected
first in diabetes.

(31:20):
And if they see a delay in thatparticular nerve, then they can
say well, this is consistentwith diabetic peripheral
neuropathy.
So there's a lot that comes, alot of data that can come from
those that's valuable in theclinic.
Now, based off their what theywant to propose, that's not

(31:40):
going to have any value.
So so right now I think theexaminer can use that test to
actually document the severityof the nerve condition.
I think that makes the examinermore confident in making the
determination if a condition ismoderate or is severe.
Maybe they're like, well, maybeit's moderate or you know

(32:01):
they're really don't know whichway to put it.
And then they have that nerveconduction study can help sway
their decision or can help makethem a more confident decision.
I should say so I like them.
So, looking at page 14, the nextsection, section 16 talks about

(32:22):
the functional impact of theperipheral neuropathy condition.
I emphasize putting anyfunctional impact into your
statement in support of claim.
With every single conditionyou're claiming we beat that
with a dead horse for a goodreason.
Section 17 is open for remarksfor the examiner.
Section 18 is the last sectionand that's the examiner's

(32:45):
information and signature.
So it's a long DBQ.
The time that is spent with theveteran gathering the history
and doing the exam is about 45minutes, so it's typically not
in and out.
They're gathering a lot ofinformation to determine the

(33:06):
nerve stuff.
So the one thing I want to talkabout or emphasize with this
these conditions that we'retalking about are what we
consider to be large nerve fiberdiseases.
So those are the bigger nervesthat are affected in compression

(33:31):
at the wrist or in a pinchednerve in the back.
This exam and the ratingschedule does not appreciate or
capture small nerve fiberdiseases.
Small nerve fiber diseases areyour diabetic peripheral
neuropathy.

(33:51):
They're your chemicalneuropathies, they're your
vascular neuropathies.
They affect the smaller nervesat the end points of an
extremity, so in the fingers andthe toes.
With your large nerve fiberdiseases you can feel, or the
individual may experience,numbness and tingling higher in
the arm or higher up towards thehip and the legs.

(34:15):
When an individual onlyexperiences the numbness,
tingling sensations in thedistal points or at the end
points of their extremities, intheir fingers and toes, then
it's concerning for a smallfiber nerve disease.
The EMGs can typicallydifferentiate between what is a

(34:38):
large fiber disease.
It does not capture the smallnerve fiber diseases well at all
.
So an individual with adiabetic peripheral neuropathy
may have a normal nerveconduction study.
The only time when they look atthat it's called the, the sural

(35:00):
nerve.
There is one nerve that theytarget to check the speed of how
well it conducts and if it'sdecreased then they know that
it's consistent with aperipheral diabetic peripheral
neuropathy.
They and that's typically ifthe sural nerve is affected.
We're talking about moderate tosevere diabetic peripheral

(35:21):
neuropathy disease.
If there's an individual withmild to moderate or even
moderate diabetic peripheralneuropathy or small nerve fiber
neuropathy, it may never changeon a nerve conduction study or
an EMG conditions.
The VA rating schedulecurrently does not capture the

(35:43):
appropriate rating or theappropriate 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 myproblems presently are.

Bethanie Spangenberg (36:18):
And how is that going to affect future
veterans?
On diabetic peripheralneuropathy, there are clear
indications where we candifferentiate between a large
nerve fiber versus the diabeticperipheral neuropathy In the
diabetic peripheral neuropathyDBQ.
It is very similar to this DBQDBQ but there's additional

(36:46):
testing that is done on theexamination that helps that
clinician put all thosecomponents together to determine
if it's mild, moderate, severe.
If the VA and they haveproposed taking away all those
little components except for theshrink testing, if a veteran
with a diabetic peripheralneuropathy or a small nerve

(37:06):
fiber neuropathy is going to berated strictly on muscle
strength, they will get theexcuse, my French, they'll get
the shit into the deal becauseit is not appropriately
capturing the severity of thecondition Individuals with

(37:27):
diabetic peripheral neuropathyand moving forward.
I'm going to call it DPN tosave my voice.
But DPN can be moderate tosevere and you still have
function of the large nervefibers.
You can still have goodstrength in the large nerve
fibers even though the smallnerve fibers are dead.

(37:50):
So in the letter that we cameup with it talks about that.
I talk about that.
I talk about how the VA needsto come up with something that
is specifically dedicated tothose with small fiber, small
nerve fiber disease In thediabetic peripheral neuropathy

(38:14):
or DPN, dbq.
I have it here with me and Ihighlighted the differences.
And so for this DBQ, they talkabout the symptoms, they do the
strength testing, they do thereflexes, but then there's a
section or several questionsthat focus the clinical
component just on the smallfibers.

(38:35):
Right here is light touch orthe monofilament testing where
they take the little test onyour toes and they poke your
toes and they do the, the feetchecks.
That's for diabetic peripheralneuropathy.
Um, there's a question hereabout position sense.
When you develop a small nervefiber disease you lose position

(38:57):
sense.
So when your your thumb is in acertain position or your hands
in a certain position, you losethe, the communication factor
factor where your body's tellingyour brain.
You know what the body's doing.
So you lose position sense.
The first thing to go in DPN isvibratory sensation.
So they take a tuning fork andthey stick it on the end of your

(39:19):
thumb or the end of your toeand they ask you know, tell me
when the vibration stops.
And then they do the vibration.
They'll hold the tuning fork orthey'll just let it dissipate
and then they can feel thevibration and if you say that
the vibration stops before itactually stops, that is a sign
of small nerve fiber disease.
And in the clinic if I had apatient who was diabetic, they

(39:43):
took their shoes off everysingle time.
I saw them and I would do thevibration test every single time
.
You can still have a normalmonofilament test where they
poke your toe and have decreasedvibration or vibratory
sensation, and that's not normal.
That is a sign of diabeticperipheral neuropathy and that's

(40:03):
a that's not normal.
That is a sign of diabeticperipheral neuropathy.
Another question dedicated tothe dbq for dpn is cold
sensation.
You put something cold or theside of the tuning fork against
their hand or their foot and ifthey're not able to tell you
whether it's hot or cold, youknow that's a sign of dpn.
Now, or, interestingly, whenthat examiner goes to document

(40:26):
about the DPN, they have to takethe small nerve fiber disease.
This is currently.
They have to take the smallnerve fiber disease and put it
into a large nerve fibercategory, so that C&p examiner
is like uh okay, so is this theradial nerve?

(40:51):
Do I put this as the radialnerve or the median nerve or the
ulnar nerve because it's reallyaffecting them all, but it's
really not.
You know their, their tenostest was negative, so the median
nerve can't be affected too bad.
So they have to somehowdocument the severity of the

(41:14):
small nerve fiber disease basedon a large nerve fiber scale,
and it's.
It causes inconsistency andterrible ratings.
And so if we take the clinicalcomponent out of even the DPN
for them to try to determine theseverity and we look at just
strength testing that they'reproposing the veteran's not

(41:36):
going to get an appropriaterating.
They're going to.
They're not going to, they'regetting 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 allgot together and talked about
this and, bethany, you wrote upa lengthy report to them.
When is that going to be?
When do they anticipate this isgoing to be implemented, or
denied or not implemented?

(42:15):
Do we know yet, or is there anyidea?

J Basser (42:19):
John that might be a question for you.
The issue is with all regulatoryitems that were issued after
January 20th have been put onhold and they're going through
everything now to take a rakeand weed out the leaves and the
bull crap and for certain peoplehaven't got their hands on it

(42:41):
yet.
So actually I don't expect itto carry much weight.
I don't think it may not makeit, bethany, because there's a
lot of.
You know your reply and a bunchof others reply to it.
Of course we've had somereplies that I read and Bethany
showed me one with completeforce, from a veterans
organization.
I guess they need to change thename of that organization to

(43:05):
yes, men R Us Disappointing,it's pathetic.
I don't think it'll fly thisyear.
I think if it does fly, it'llbe two years from now, because
it took them forever just tosleep at me.
It's not finished yet.
You're right.
Right, they need a differentsystem in order to uh, to test

(43:28):
and to uh rate small, properneuropathy.
Whether it be diabeticneuropathy or whether it be
autonomic neuropathy, it doesn'tmatter, it's basically the same
thing, you know, and uh, lasttime I had an emg down was last
year.
I went to the spinal cord stuffand we did emgs on the legs,
arms, everything, and, uh, I didit on the legs and the big

(43:50):
nerves of the legs.
That basically were okay, butthey 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 systemneeds improved.
I think they said like 1945 ormaybe 51, I don't know.
Somewhere around there was thelast time it was updated or
implemented.
I I don't remember the date,but, um, I'm hoping that they're

(44:20):
taking, you know, someinformation from the 51 comments
that were submitted and reallythinking about you know what
they've forgotten about or whatthey've proposed Because it
needs to be updated.
But I think the way thatthey're trying to do it is
they're trying to keep it atminimum and to make it to where

(44:41):
veterans are getting minimum.
And even though that they'retrying to update them, I don't
necessarily think they capappropriately capture functional
loss as it relates todisability.
They want to try to put thismuscle strength testing thing
out there and if and let me readit exactly so then that way you

(45:06):
can kind of get where mythinking is.
If you have a muscle strength,that is, a muscle three out of
five, that means that they canmove the joint without gravity.
Okay, what kind of function isthere for that joint?

(45:28):
Nothing, because the momentgravity gets involved, the
moment you try to walk, move,turn over in bed, you can't move
, that you can't use, or thatlimb becomes not functioning.
And how is that any differentfrom a zero, where there's no

(45:51):
muscle movement?
So I think, if we're looking atfunctional loss, I think
functional loss is potentiallyjust as bad at a three out of
five as it is for a zero out offive, because the muscle
movement that is required totruly function isn't adequate

(46:12):
enough to do anything.
So I think I don't thinkthey've done the right approach
on it at all.

J Basser (46:21):
I think it's by design .
I think the approach being usedis see, there's a federal court
case that came out years agoand they got their hands slapped
because there is a statute inthe Title 38 that says the VA

(46:42):
ratings itself and the raidersitself adjudicating claims must
do whatever is necessary,whatever they can do, to
maximize the benefit for theveteran.
So this situation here with thecutting, you know, taking all
the neurological stuff away andjust going on strength testing,
is not maximizing nothing fornobody and, uh, basically

(47:04):
minimizing it because you gotvets with a small fiber
neuropathy and they can'tcompare it to one of the big
nerves, then he's out of luck,you know.
So what?
He can pick the box up, but thesmall fiber neuropathy you're
not going to hang on that long.
If you got it in your handsright, you're going to drop it
it's going to to slip out Yep.
That's right.
And you know I mean personallyI can't pick.

(47:25):
I mean I can't hold nothing inmy left hand.
You know, and it's just.
You know, if I pick somethingup, I guarantee you to drop it.
If my wife sees me carrying aglass in my left hand across the
house, she'll throw somethingat me Because that gets
expensive.
I'm serious.
I can see that you can see it,but it's not fun, it's not good

(47:50):
and whoever's doing thesechanges I mean they need an
education, because there's asystem out there and it was
written by Congress and Congressgave the VA permission to go
ahead and make some step up anddo it to implement Congress's
rule.

Bethanie Spangenberg (48:07):
But they're overstepping.
I don't like the way thatthey're going about it either.
To me it's not in front ofenough people to really support
a change, and I think they'retrying to do it in a sneaky
manner.

J Basser (48:18):
They need a committee.
They don't need one persondoing it.
Okay, they need a committee.
They don't need one persondoing it.
Okay, you need a committee.

Bethanie Spangenberg (48:26):
You need somebody with cooler heads, and
even I wouldn't doubt thatthere's more than one person
related, let's say that there ismore than one person.
If there is more than oneperson, put them out there.
Tell us who they are, whatthey're doing, what their role
is, and not one person who gotdetailed because they're worried
about patient safety, so nowthey have to reinvent the wheel.

(48:47):
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'sin the world war ii right now.
Yeah, technology has advanced somuch since then that we have
the computer sitting on ourtable here, our workstation.
That one computer itself hasenough computing power to handle

(49:14):
everything we did in World WarII.
We've got these young geniusesout there like that can write
code with their eyes shut and doanything they want to do.
You know, and they can.
They can AI this stuff, theycan get it done and they can
make it the easiest process ever.
You know, all it takes is alittle ingenuity, and that's

(49:39):
what they need to be focused onis bringing them, you know,
bring it into the 22nd, 21stcentury and getting everything
situated.
You know, if you got a cmp exam, that's great, you know.
But you know you need to takeout some of the um, take out
some of the roadblocks, some ofthe bottlenecks that are
involved with the whole thing.
You know, get the system right.
Have a rating system for smallfiber neuropathy based on

(50:00):
diabetes, because you know, havethe system right.
Have a rating system for smallfiber neuropathy based on
diabetes, because you know, havea system for autonomic
neuropathy, because that's oneof the biggest fights I've ever
had in my life, you know, andbecause it carries more.
I mean it's autonomicneuropathy, you know you can't
control it because you knowthat's an automatic nerve, so

(50:22):
Makes it rough, but still, Imean going around the line.
But it needs to be fixed andwhat 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 bitof the letter that I think is
applicable to what we talkedabout tonight.
If that's OK, you go rightahead.
All right.
So the letter that I wrote inresponse to the proposed changes

(50:53):
dated January 13th 2025.
Page three I open up aboutcranial and peripheral nerves.
Can I say I will begin with theproposed changes to neuralgia
and neuritis.
While many of the proposed rulechanges align with the VA
stated purpose which I think Ibeat with the dead horse the
last one, so I won't go there.
But I said I believe there aresignificant oversights

(51:15):
concerning the evaluation ofperipheral neuropathies.
One issue is the proposedreliance on muscle strength
testing as the sole determinantfor rating motor neuropathy of
the peripheral nerves,eliminating other essential
clinical factors that contributeto an accurate assessment of
nerve disease severity.
These factors, such as thepatient's symptoms, their age,
their activity level, theirreflexes and the sensation

(51:38):
testing, have been excludedunder the proposed rule changes.
And the sensation testing havebeen excluded under the proposed
rule changes.
If the VA intends to focus on asingle factor to determine
disease severity, it isimperative that the methodology
and tools used, such as themuscle strength scale are
explicitly defined.
So I go on to propose somethingbased off of the research, what

(52:00):
the scale should look like.
Next paragraph says theimportance of incorporating
multiple clinical factors issupported by the Merck Manual
and an article titled how toAssess Muscle Strength.
And I bring this up and I wantto go to something that they
referenced in their proposedchanges.
They said that the VA proposesto evaluate disability by

(52:23):
replacing the current ratingcriteria current rating criteria
which referred to complete andincomplete paralysis at the
severe, moderate and mildincomplete paralysis level.
They want to replace it withcriteria that align with the
Medical Research Council scalefor muscle strength testing and

(52:44):
they cite the same article thatI'm getting ready to use against
them.
So I say that the importance ofincorporating multiple clinical
factors is supported by theMerck manual and an article
titled how to Assess MuscleStrength.
So I'm using the same articlethat they put in there saying
well, we should only use this.
And it says the articleemphasizes that an examiner must

(53:08):
quote define the precisecharacter of symptoms, including
exact location, time ofoccurrence, precipitate,
precipitating and amelioratingfactors, which makes it better,
which make it worse, andassociated symptoms and signs to
accurately interpret apatient's report of weakness.
So this article contradictswhat they're trying to propose.

(53:29):
This highlights that musclestrength testing alone is
insufficient without the contextprovided by additional clinical
factors.
If I jump to page five of theletter, I specifically address
small nerve nerve fiberneuropathies.
A second oversight in theproposed rule changes is their
failure to accurately assessdisabilities caused by small

(53:52):
nerve fibers, small nerve fiberneuropathies.
While the proposed musclestrength testing criteria may
capture disabilities associatedwith large nerve fibers, they
are not suitable for evaluatingsmall nerve fiber neuropathy,
such as diabetic, peripheralneuropathy, chemically induced
neuropathy such as like we getsome, like you know chemical

(54:12):
exposures or alcohol inducedneuropathies or vascular
neuropathies.
The proposed rating schedulelacks clarity regarding how
these conditions should be ratedand will lead to inconsistent
disability ratings.
Currently, the DBQ for DPNfails to promote medical
accuracy, as it directs medicalexaminers to assess small nerve

(54:34):
fibers but ultimately requiresthem to indicate which large
nerve fibers are affected,ignoring the unique clinical
presentation of small nervefiber neuropathies.
Clinically, small nerve fiberneuropathies present with
distinct patterns, typicallyaffecting both lower extremities
or both upper extremities,symmetrically, distally and

(54:55):
progressively advancing towardsthe body over time.
This differs significantly fromthe presentation of large nerve
fiber neuropathies.
Under the proposed criteria,veterans with severe DPN may
receive inaccurate ratings dueto the preservation of near
normal large nerve fiber motorfunction, despite having an
incomplete sensory impairment.

(55:17):
And then the last one.
I want to emphasize our lastcouple paragraphs here.
And then the last one I want toemphasize our last couple
paragraphs here.
It says to ensure accurateassessment, the rating criteria
must include additionalprovisions specifically for
small nerve fiber disease.
Due to the stark contrast tolarge nerve fiber disease, with
the growing number of AgentOrange veterans who are

(55:39):
service-connected for diabetesmellitus and subsequently
develop small nerve fiberdisease, the VA should propose a
separate rating scheduletailored to these conditions.
Such a formula would establishclear evaluation criteria to
promote rating accuracy, quality, consistency and clarity.
The accuracy, quality,consistency and clarity I kind
of really pushed in this letterbecause that was what the VA had

(56:01):
proposed was their whole reasonfor doing this.
And then the last paragraphthat I want to emphasize
specifically discusses autonomicneuropathy.
Continuing the discussion ofveterans with diabetes mellitus,
research on diabetic peripheralneuropathy highlights the
prevalence of autonomicneuropathy, which impacts the GI

(56:21):
system, the cardiovascularsystem and the genitourinary
systems.
Currently, the VA ratingschedule lacks clear evaluation
criteria to address theseconditions in a way that assures
rating accuracy, quality,consistency and clarity.
So those are the big takeawaysfor that as it relates to what
we've talked about tonight forthat, as it relates to what

(56:42):
we've talked about tonight.

J Basser (56:43):
Basically, whoever wrote the changes and whoever
did this does not have anycommon 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 somethingthat's come out of the OCG or
out of the CBO.
You know trying to do drasticcuts, but I don't understand

(57:18):
this at all.
But this has been in the worksfor a while, even before any
political changes that took careof DC, you know.
So this is just it's anotherend around.
You know, and they're it's whatdo 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, Ithink.
So.
There's a couple of people thatI've been watching over the
last several years and they'restill present.
They're not politicalappointees, they're not involved
in politics at all, but theyare involved in leadership at
the VA and they have a budget ofwhat they want to stay under

(58:04):
and they are trying to do whatthey can to to make that budget
look better for the VA and fortheir job and for their
positions.
So, um, I I know that's whatthey're trying to do.
They're trying to keep thenumbers lower, uh, especially
because there is such anincrease in VA disability I mean
, how long were we in a warrecently?

(58:27):
So there's more veterans thatare applying for the disability
and that's more money that goesout for our country.
But the laws are there for areason.

J Basser (58:38):
Then you add the PACT Act, then you add the Caregiver
Act and you had the other thingssituated inside.
You've got to have enoughpeople to adjudicate these
claims because everybody'sfollowing PACT Act claims and
there's a lot of folks that needcaregivers and things like that
and there's a lot of folks thatneed the other things and so
they have to hire.

(58:59):
And folks need the other things, you know, and so you know they
have to hire and do things, youknow, 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 doubledinside or they got so many
thousand employees.
Now, you know, and most of themdid it, you know, just because

(59:21):
of the changes, and that's noteven being looked at.
So, plus, you know the PACT Actitself.
I mean, a lot of stuff isgeared for post-9-11 vets
anyways, you know there's a lotmore 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 dangerousplace.

(59:41):
You don't have to be in combatto get killed.
So do your race.

Ray Cobb (59:51):
Well, it's my understanding that when I went
through basic training and ithappened to my company, at least
one person is killed or diesduring basic training every time
that a new company starts abasic training thing.

(01:00:14):
We actually had, well, we hadtwo.
One was from a disease hepicked up up and the other was
from an accident that uhhappened, uh out in the range.
So you know, and I remember atthe time, now this is, you know,

(01:00:35):
we're talking back in the 60s.
Uh, how, what is it like today?
Because the equipment is muchmore advanced and, uh, I do
understand that the backgroundis, uh, more intelligent
individuals.
What we had back in the 60sthat if you could breathe and
walk and didn't stumble overyour two feet, then you got in

(01:00:57):
the military yeah, back then.
So, uh, I don't know that wewould be able to operate with
the same if we had the same typeof mental individuals today in
the military, with the newupdated equipment, like you were
saying, the new ai and all thethings that are coming down, uh,
well, the military is totallydifferent today.

(01:01:19):
My, my wondering is has thatdecreased that number of
injuries or has it increased thenumber of injuries?

J Basser (01:01:28):
Yeah, I guess it all depends on the situation and
what you know, because trainingaccidents are always going to
happen.
You know, people you know, andme, as a guy fell over in our
boot camp graduation.
He fell over dead from walkingpneumonia at the graduation.

Ray Cobb (01:01:44):
So wow, yeah you know, when you look at some of these,
you know the percentages that Iyou know, that I know they're
not gonna.
If they've even ever looked atit is the.
Let's take the last 20 yearsand the number of veterans that
actually came out of themilitary with a disability,

(01:02:08):
compared to the number ofveterans that came out of
Vietnam with the disabilities.
Now, vietnam was definitelydifferent because some of our
toxic exposures, even though youwere exposed when you were in
your late teens, early 20s, itdidn't show up to your 40, 45,
or 50.
So that's going to be, you know, that's a totally different

(01:02:32):
outlook of what they need tothink about when you start
talking about going into aconflict.
That's not just going to endwhen you sign a peace agreement
or a ceasefire.

J Basser (01:02:45):
Depends on the conflict.
Like World War II, we spent alot of time in Japan and Germany
after the fact.
Then we started doing nuketesting out in the Bikini
Islands and we did the firsttest and the first bomb missed
and went off.
Then the people go back onboard the ships to clean them
off.
That killed a lot of sailorsright there.
Yeah, so I guess we learned byour mistakes.

(01:03:09):
Well, listen, we're totally outof time.
I want to thank Betsy forcoming on.
She should be back on personnext month and we'll be
discussing another topic.
Maybe we'll finish up this oneand we'll see.
We skipped around a little bit,gotten some stuff that,
especially with the peripheralnerves a lot of vets out there
that's got diabetes actuallyincluding all three of us.

(01:03:30):
We have it.
But if you guys need anindependent medical opinion, if
you've got a VA claim and youneed some evidence and you've
got the issues, you've got somerecords go to wwwvalidforvetcom,
register for the portal and usethe phone number listed on the

(01:03:51):
spot and call these folks up.
They'll do an intake on you andtalk to you and see what's
going on and maybe they'll do aDBQ or maybe even do an IMO or
independent medical examinationor opinion and they'll help
strengthen the claim.
They do it a lot and they'regood at it, but Beth is really
good at it, but I have noproblem putting her out there.

(01:04:15):
She wants me to.

Bethanie Spangenberg (01:04:18):
Sounds like I need to start paying you,
that's for sure.

J Basser (01:04:21):
No, you can pay me nothing.
Well, I'll take money.
Never have, never will, soother than that I'm serious, and
ray, thanks for helping out.
Buddy, we appreciate you, man.

Ray Cobb (01:04:34):
I'm glad you finally got a video situated yeah, I
think it think we might have itworked out now.
Hopefully we'll see how nextweek goes.

J Basser (01:04:43):
Yeah, we'll be on next week with another topic,
another show, and for that thisis John John Stacy.
They call me Basher For RayCobb and Bethany Spangenberg.
We'll see you next week.