TMA Opposes Vestibular Diagnostic Testing by Chiropractors

February 17, 2010

Glenn Parker
Executive Director
Texas Board of Chiropractic Examiners
333 Guadalupe Street
Tower III, Suite 825
Austin, Texas 78701
FAX: (512) 305-6705

Re: Proposed Rule Sec. 75.17 (c) (3) (C), Vestibular Diagnostic Testing, as published in the Texas Register on January 22, 2010 at 35 TexReg 437.

Dear Mr. Parker:

The Texas Medical Association ("TMA") is a private, voluntary, nonprofit association of Texas physicians and medical students.  TMA was founded in 1853 to serve the people of Texas in matters of medical care, prevention and cure of disease, and improvement of public health.  Today, our maxim continues in the same direction: "Physicians Caring for Texans." TMA's diverse physician members practice in all fields of medical specialization.

On behalf of the more than 45,000 member physicians of the Texas Medical Association (TMA) we appreciate this opportunity to review and offer comments on the proposed rule relating to a chiropractor performing vestibular diagnostic testing. The following comments are offered.

The vestibular system is a component of the inner ear and communicates with the central nervous system. Tests of vestibular function are diagnostic tests designed to evaluate the function and structure of the inner ear and/or brain, and they include hearing evaluations because the hearing and balance functions of the inner ear are closely related.

The eyes are closely linked to the inner ear; these organs depend on each other for good balance and clear vision. Head movement or other stimulation of the inner ear sends signals to the muscles of the eyes via the nervous system; this is called the vestibule-ocular reflex, or VOR. The VOR normally generates eye movement that maintains clear vision with head movement.

Electronystagmography (ENG) is a battery (group) of eye-movement tests that look for signs of vestibular dysfunction or neurological problem by measuring nystagmus (a type of involuntary side to side eye movement). ENG tests are the most common ones administered to people with dizziness, vertigo, and/or balance disorders.

It takes years of training and education in the intricacies of the audiovestibular system in order to perform, read and interpret ENGs and VNGs and counsel patients effectively. The additional education required by the Chiropractic Board in the proposed rule is insufficient to provide the level of education, skill and expertise necessary to perform and interpret an ENG or VNG (videonystagmograpy testing measures the movements of the eyes directly through infrared cameras, instead of measuring the mastoid muscles around the eyes with electrodes as in ENG). Incorrect performance and/or interpretation of ENG or VNG testing can result in wrong side diagnosis, wrong site diagnosis, poor and/or incorrect patient counseling, and ineffective and potentially dangerous intervention.

The ears and eyes are not part of the spine and musculoskeletal system of the human body. Further, disorders affecting the biomechanical condition of the spine and musculoskeletal system of the human body do not cause vestibular system pathology and, therefore, vestibular testing does not fall within the statutory scope of practice of chiropractors.

The Texas Medical Association respectfully requests the Board of the Texas Board of Chiropractic Examiners not to adopt the proposed rule concerning vestibular testing.

Sincerely,

William H. Fleming III, MD
President

WHF: ama


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