(cell phone 240-506-1556)

To: All veterans

Date: Dec 2014
Topic: Amyotropic Lateral sclerosis
(ALS)
Independent Veteran Medical Opinion (IMO)
Veteran Medical Nexus Opinion (VMNO)
Pages: 3

From:
Craig N. Bash, M.D.
Neuro-Radiologist
www.veteransmedadvisor.com

NPI or UPIN-1225123318- lic #--D43471

4938 Hampden lane, Bethesda, MD 20814
Phone: (301) 767-9525 Fax: (301) 365-2589
E-Mail: drbash@doctor.com

ALS = Lou Gehrigs disease

Although the exact cause of ALS is not known many associations with certain conditions have
been supported in the literature.
For example, according to the ALS foundation
The Institute of Medicine (IOM) has issued a new report (Amyotrophic Lateral Sclerosis in
Veterans: Review of the Scientific Literature, are available from the National Academies Press;
tel. 202-334-3313 or 1-800-624-6242) from experts supporting an association between military
service and later development of ALS. Published reports reviewed by the experts show up to a
two fold increased risk of developing amyotrophic lateral sclerosis (ALS, also known as Lou
Gehrigs disease) among veterans deployed in the Persian Gulf War of 1991. Veterans from
other eras, dating from World War II to post Vietnam, also appear to be at greater risk of
developing ALS.
AND Former Secretary Anthony Principis policy to aid Gulf War veterans with ALS. Under
that policy, ALS is considered a service-connected disease for those veterans who served in the
Gulf War between August 2, 1990 and July 31, 1991.
ANDHowever, ALS is not presumed to be a service-connected disease for the thousands of
other veterans diagnosed with ALS even though research has demonstrated elevated rates of
ALS in all veterans, regardless of whether they served in the 1991 Gulf War.
These patients often fall into the medical diagnostic codes/categories of ratings that are similar
to spinal cord injuries (SCI) and Multiple Sclerosis (MS) and thus the Physician doing a veteran
medial opinion should be familiar with the VA rating schedule of illnesses.

A real patients medical exam and opinion sample of some of the medical opinion identified
issues of ALS that could occur is as follows:
Upper extremities
3-4/5 strength except 3+ / left interosseii and apponens (see new 3-14-09 physical therapy note
which documents the same)
Decreased sharp dull sensation both hands and forearms.
Atrophy hypothenal muscle left hand.
Decreased sharp dull sensation both hands.
(weakness also noted by Dr. T in his neurologic exam of Sept 2007)
Pain on motion and palpation of his left wrist. Symptoms are consistent with carpal tunnel and
this is likely secondary to her overuse of this joint due to his ALS.
Legs 1-3/5 strength unable to stand unaided and uses an electric scooter.
reflexes lower extremities(see new 3-14-09 physical therapy note which documents the
same).
Diapers with stool and he wet his diapers during travel to my exam
Pt descries essentially wetting diapers continuously day and night with voiding q 1-2 hours all of
which is consistent with her neurogenic bladder.
Diaper examination revealed firm stool consistent with neurogenic bowel. She has constant
constipation with intermittent diarrhea consistent with neurogenic bowel stool
Lower extremities
4/5 strength left leg
left foot drop and he has increased shoe toe wear secondary to dragging of his toes.
decrease performance in rapid alternating movements left leg.
Decreased sensory (pinprick light touch) left lower extremity
4/2 reflexes left lower extremity.
Not able to heel or toe walk
Not able to run
Rhomberg positive
Incontinent of urine urgency and hesitancy and frequency
Neurogenic bladder--bowel. The patient is having persistent problems with incontinence of
both urine and stool since he had his ALS diagnosis. His records do not contain another more
likely cause for his urine/stool incontinence (leaks both every night soils sheets and bed
clothes.mostly leaks urine during the day 3-4 times) and he should therefore be assigned a
service connected MDC (medical diagnosis code) for these problems because ALS is known to
cause incontinence of both the GU and GI systems.
Gait, coordination, and balance problems. The patient is having persistent problems with
gait, coordination, and balance problems ever since his ALS diagnosis. For example, his
rhomberg test is positive and he cannot walk a night without a light. He occasionally falls do to

lose of balance. He has a slow broad base gait. His records do not contain another more likely
cause for his balance/gait problems and he should therefore be assigned a service connected
MDC for these problems because ALS is known to cause gait/balance problems.
Erectile Dysfunction (ED). The patient is having persistent problems with penile erections and
ejaculation ever since his AS diagnosis. His records do not contain another more likely cause
for his ED and he should therefore be assigned a service connected MDC for these problems
because ALS is known to cause ED problems.
Autonomic dysfunctions; Pt. has cold and hot intolerance which is consistent with atonomic
dysfunction secondary to his ALS diagnosis. For example, during my exam he was cold to
touch.
Need for aid and attendance The patient is having persistent problems with hygiene and home
care. His wife does helps with his activities of daily living and he could not live by himself
without assistance. He is unsafe in cooking and cleaning. His records do not contain another
more likely cause for his need for aid and attendance and he should be assigned a service
connected MDC for A and A because ALS is known to cause a need for A and A.
Summary:
Since the literature shows associations between military service and ALS (according to the
Amyotrophic Lateral Sclerosis in Veterans: Review of the Scientific Literature study) this disease
can only be service connected to a veterans service with the use of a expert veteran medical
opinion (depending of course on each veterans specific set of medical circumstances) because the
presumptive time window period for automatic service connection is very narrow.
Recommendation:
1. Since ALS is a complex diagnosis and service connection is not presumptive for most veterans it
is essential to obtain a high quality medical opinion (Independent Veteran Medical Opinion =
IMO) from an expert to establish the diagnosis. Without a veteran medical opinion it is likely that
VA will deny all claims that do not fall into the presumptive period as this disease is complex and
presents with many subtle signs and symptoms and since the VA raters are not physicians they
will not be able to connect the diagnostic dots and make a diagnosis. Once your ALS has been
diagnosed then a veteran medical opinion is also needed to identify all primary/secondary
problems as noted in the example above so that the correct medical diagnostic codes can be
assigned with the correct effective dates (Retro-active date).
2. Thus is a complex disease subject and most raters are not experienced enough to correctly
assign all of the secondary codes and the case will linger in the VA que of cases. Thus if you
have been waiting an excessive amount of time send your congressman a concise medical
opinion and ask them to ask the VA to decide the claim in two weeks (see abash bulletin on how
to speed up the case).
Craig Bash M.D. Associate Professor drbash@doctor.com cell 240-506-1556
Independent Veteran Medical Opinion (IMO)
Veteran Medical Nexus Opinion (VMNO)
based on Veterans medical records