Candidate Handbook

Electrodiagnostics Exam

EDX Examination Policy
EDX Examination Construction/Development
EDX Application and Fees
EDX Examination Review
EDX Blueprints
EDX Complaints/Appeals of Examination

BOARD CERTIFIED EDX:  Examination Policy:  Purpose & Eligibility

The purpose of the Electrodiagnostic certification programs of the American Chiropractic Neurology Board is to conduct certification activities in a manner that upholds standards for competent practice in the health care specialty of Electrodiagnostics as a subspecialty of Chiropractic Neurology. The Board also conducts recertification designed to enhance the continued competence of the individual.

The American Chiropractic Neurology Board offers two qualification credentials in Electrodiagnostics by examination.  These are:

I.         CERTIFICATE OF QUALIFICATION IN ELECTRODIAGNOSTICS

And

II.       BOARD CERTIFIED IN ELECTRODIAGNOSTICS

I. Doctors of Chiropractic who have completed specialist level training in Electrodiagnostics from a chiropractic college, university, institution, foundation or agency whos program is approved by the continuing education committee of the Commission for the Accreditation of Graduate Education in Neurology (CAGEN) of a minimum of one hundred fifty (150) credit hours in Electrodiagnostics and who have demonstrated competency in both written and practical examinations administered by the Board in the specialty of Neurology and the subspecialty of Electrodiagnostics receive the

CERTIFICATE OF QUALIFICATION IN ELECTRODIAGNOSTICS

Eligibility:

1. The applicant must hold the degree of Doctor of Chiropractic from a CCE accredited college (USA) or its equivalent.
2. The applicant must have completed one hundred fifty (150) credit hours in the Electrodiagnosis from CAGEN accredited institution.  That institution must certify that the applicant has completed one hundred fifty (150) credit hours in Electrodiagnostics.  The applicant must be enrolled in the Diplomate program through a CAGEN approved entity.
3. The applicant must possess a license or registration to practice chiropractic and be in good standing with the respective licensing/registration agency.
4. The candidate must submit an application on a form specified by the Board within the Board designated deadline.

II. Doctors of Chiropractic who have completed post-doctoral specialist level training in Electrodiagnostics from a chiropractic college, university, institution, foundation or agency whose program is approved by the continuing education committee of the Commission for the Accreditation of Graduate Education in Neurology (CAGEN) of a minimum of four hundred fifty (450) hours in Neurology and Electrodiagnostics and who have demonstrated competency in both written and practical examinations administered by the Board in the specialty of Neurology and the subspecialty of Electrodiagnostics will be awarded

BOARD CERTIFIED IN ELECTRODIAGNOSTICS

The Board administers examinations for the purpose of evaluating the candidate's proficiency in Neurology and neurological subspecialties, including Electrodiagnostics. Candidates who are successful in all parts of the Board Examination of the ACNB shall receive a diploma certifying that they are
Eligibility:

1. The applicant must hold the degree of Doctor of Chiropractic from a CCE accredited college (USA) or its equivalent.
2. The applicant must show evidence of having successfully completed a post doctoral program in neurology and electrodiagnostics of four hundred fifty (450) credit hours from a CAGEN approved entity.  This CAGEN approved entity must certify that the has completed his/her course of study must certify to the Board that the applicant has satisfactorily completed four hundred fifty (450) credit hours of postdoctoral instruction in Neurology and Electrodiagnostics. 
3. These candidates must have successfully passed the Diplomate in American Chiropractic Neurology written and practical examinations or be registered to sit both sets of examinations during the same testing period.
4. The applicant must possess a license or registration to practice chiropractic and be in good standing with the respective licensing/registration agency.
5. The candidate must submit an application on a form specified by the Board within the Board designated deadline.

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Examination Construction:

All examination materials are copyrighted material of the ABCN. No reproduction or duplication of the material is permitted, unless authorized by ABCN. All draft materials utilized by examination development committee members are kept secured in a double locked enclosed area and inventoried regularly. All committee members sign confidentiality agreements when generating and/or reviewing examination materials. Any material considered unusable is shredded prior to disposal.
All duplication of examination materials has been done in a closed environment under secure arrangements. All test documents utilized by exam candidates have unique control numbers. Any examination materials delivered to an examination site by courier service have an inventory list that is signed off prior to delivery and upon opening. Once used and repackaged for courier shipment, the inventory list is completed and initialed again.

All candidates are examined utilizing the same form of the comprehensive written examination. No equivalent forms of the competency evaluation are needed. The ACNB has established a policy that all examinations will be generated in English. Written translations of the competency evaluation are not available. No adaptations of the evaluation material are utilized at this time. Accommodations for candidates with disabilities are dealt with on an individual basis in accordance with the Americans with Disabilities Act and upon special request and validation of the disability.  In accordance with American Psychological Association Standards for Test Administration, additional time may be provided to candidates who train in a language other than English, specifically in the practical/oral examination.  Again, this must be requested in advance.

Test items utilized in the examination have been keyed to an examination blueprint and validated by the collective judgment of the subject matter experts utilized via committees.  These committees include objective writers, case study writers, item writers and distractor writers.  They validate items utilizing source documents from the chiropractic neurology and electrodiagnostic field. All of these activities have been conducted under the direction of a consultant psychometrician subject to standards acceptable to the National Organization of Certification Agencies/National Commission for Competency Assurance (NOCA/NCCA) (USA).

A final review panel has been utilized to review the work of the committees and to monitor the validation procedures utilized by the committees, the linkages of the test items to the examination blueprint, and associated content specifications. The procedures utilized by the panel minimized content error on the part of the committees and have provided assurances that the committees followed generally accepted principles in item development. Each examination question has undergone this process and the items were entered into an item-banking computerized program, (LXR test software package, PAR score/PAR test) which allows the board to maintain all of the specifications of the test item relating to its linkage to the examination blueprint, job analysis, and content validity.

After a sufficient pool of questions was developed and banked into the software, an assessment was made of the number of test items developed for each content domain to ensure that there was a sufficient pool of items in each major/minor content area. Once satisfied that a sufficient pool of items existed, a form of the examination was generated according to the content specifications. Because this field is so recent, a pilot test was not possible given the very small number of individuals certified in electrodiagnostics and the number of these people involved in the writing of this examination.  However, this test has been administered for a period of two years with the test takers writing comments on the test and the committees reviewing these comments along with the psychometrician evaluating the overall statistics and item analysis.  This resulted in the final test that has been administered for the previous year.

A cut-score committee was assembled to establish the passing point of the examinations. The committee members selected were screened for their qualifications in the field of chiropractic neurology and electrodiagnostics. The cut-score procedure utilized was a modified Angoff procedure for determining the various passing points on both written and practical examinations. Each member of the committee rated each question that will be used in the grading of the examinations and a running mean score was calculated. When completed, the cut score for each of the examinations was determined, including the variance, standard deviation, KR 20 value, and the standard error of measurement. Each member of the multiple-choice exam Angoff cut-score committee was responsible for determining the passing point as it related to the minimally competent candidate. Prior to their initial rating, committee members were trained on cut-score methodology and provided a worksheet outlining the process with space on the worksheet to be used in describing the minimally competent candidate.

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Examination Policy:  Fees and Application

Fees:

The examination fee is set annually by the board and is non-refundable.

Application:

Applications for the Board Certification Examination are included at the end of this handbook. Candidates may also obtain applications from the Board Web site at http://www.acnb.org/application.html or from the ACNB at:

American Chiropractic Neurology Board, Inc.
8510 Hillcroft
Houston, Texas  77096

Or by telephone: (713) 772-4607 or FAX (713) 772-6015

Or via email:  Secretary@acnb.org

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EDX Study Guide

Neurological Electro-diagnosis
ACNB Subspecialty Examination Content Areas

Candidates for ACNB examination in the subspecialty of electrodiagnosis will be examined in the following knowledge areas.

Knowledge Areas:
Anatomy
Physiology
Specific conditions
NCV (Nerve conditions studies)
EMG (Electromyography)
EP’s (SSEP, AEP, VEP studies
The hands on practical portion

Anatomy:
There will be questions specific to anatomy, function and possible related pathologies of the following areas.

• Anatomy of the peripheral nerve.
• Anatomy of all nerve plexi
• Anatomy of each peripheral nerve, the muscles innervated by that nerve in order of innervation, the area of cutaneous reception of all nerves and the nerve roots that comprise that nerve. 
• Anatomy of the spinal cord and related pathways.
• Anatomy of a muscle, muscle fascicle, and fiber. 
• Anatomy of all nerve pathways including tunnels and areas of anatomy that could be related to injury or entrapment. 
• Know the major and usable muscles related to neurological diagnostics.  Know their location, innervation and how to activate each one. 
• Understand the organization of the central nervous system and longitudinal levels of the lesion.
• Understand the visual pathway system.
• Understand the auditory pathway system.
• Understand central motor and sensory pathways.

Physiology: 
EDX and Related physiology.

• Physiology related to action potentials, receptor potentials and conduction velocities.
• Calculations of conduction velocities.
• Physiology related to muscle contraction.
• Physiology related to muscle denervation.
• Synaptic related physiology and all information related to the neuromuscular junction, pathologies related to junctional disease prognosis.
• Information related to electricity and instrumentation.  This includes aspects of circuitry and information related to electromagnetic properties.  

Nerve conduction studies: 
Understand all related information applicable to the following knowledge areas.  All related testing technique, anatomy and areas of dysfunction.   Interpretation of related studies.  Normative and pathological scenarios.  

• Understand all information related to all nerves and specifically:
• Axillary motor
• Musculocutaneous motor
• Median motor and sensory (Sensory anti and orthodromic studies)
• Median F waves
• Ulnar motor and sensory (Sensory anti and orthodromic studies)
• Ulnar F waves
• Radial motor and sensory studies.
• Medial and lateral antebrachial cutaneous studies.
• Suprascapular studies
• Peroneal motor and sensory studies
• Peroneal F wave studies
• Tibial motor and sensory studies
• Tibial F wave studies and related H wave studies
• Femoral motor studies
• Saphenous sensory studies.
• Sural sensory studies
• Plantar sensory studies
• Understand information related to normative values for all studies.
• Understand information related to amplitude, latency and conduction velocity
• Understand temporal dispersion.
• Understand F and H wave physiology and axonal reflexes. 
• Understand the physiology of the neuromuscular junction.
• Understand anodal block
• Understand all anomalies
• Accessory peroneal anastomosis
• Martin Gruber anastomosis
• Blink studies
• Repetitive stimulation studies
• Understand inching techniques.
• Common mode rejection
• Information related to patient size and age.
• Information related to body temperature
• Understand exercise tests

SSEP studies:
Understand all information related to this type of testing, including but not limited to technical setup, performance and related pathologies, related physiological mechanisms, normative and pathological conditions.  

• SSEP studies to the tibial nerve
• SSEP studies to the peroneal nerve
• SSEP studies to the median nerve
• SSEP studies to the ulnar nerve
• Visual evoked studies, Including flash, pattern shift and full field
• BAER (AEP) Brainstem studies.

Electromyography:
Understand information related to the knowledge area for this type of testing including technical setup, performance and related pathologies, physiological mechanisms, normative data and pathological conditions.

Understand information related to the following knowledge areas, including physiology and developmental mechanisms. Understand the characteristics of the following knowledge areas.  Understand the knowledge areas related to the differential diagnosis and interpretation of  possible clinical scenarios.  Be able to identify the following pathologies on video and/or printed recording. 

• insertion activity
• end plate spikes
• end plate noise
• cramp discharge
• fibrillations
• positive sharp waves
• fasciculations
• complex repetitive discharge
• myotonia
• myokymia
• neuromyotonia
• polyphasic potentials
• parasite potentials
• serration
• complex motor units and unstable motor units. 
• doublets, triplets and multiplets
• recruitment
• activation
• jitter

Understand the following knowledge areas:

• EMG technique.
• Muscles tested.
• Information related to needles, sharps and sterile technique.
• Active and acute denervation verses chronic.  

Specific conditions: 
Understand the information related to the following knowledge areas. Differential diagnosis, related special studies, patterns and electro-diagnostic findings.

• Understand the differences and diagnostic criterion between acute, subacute, chronic and long term conditions.
• Understand axonal lesions.
• Understand myelin pathology
• Chronic and acute myelin illness.
• Antibody related conditions
• Inherited myelin lesions and specific information related to genetic deletion or duplication. 
• Understand all muscle diseases and associated knowledge areas.
• All congenital dystrophies.
• Congenital muscular dystrophies
• Disorders of muscle membranes
• Myotonic dystrophy
• Hypokalemic periodic paralysis
• Isaac’s disease
• Myopathies in systemic and iatrogenic disease
• Endocrine related myopathies
• Toxic and drug induced myopathies
• Myopathies related to infection and exercise
• Mitochondrial myopathies
• Basic understanding of genetic pathology related to mitochondrial dysfunction
• Inflammatory myopathies
• Idiopathic inflammatory myopathy
• Inclusion body myositis
• Polymyostitis
• Dermatomyositis
• Myotonic disorders
• Myotonic dystrophies and congenita
• Understand ventral horn cell disease
• Werdnig-Hoffman Disease
• Kugelberg-Welander Syndrome
• ALS
• Progressive muscular atrophy
• Progressive bulbar palsy
• Understand peripheral nerve disease
• Radicular injuries
• Plexus injuries
• Peripheral nerve disease
• Asymmetric verses symmetric
• Temporal course/Natural History
• Axonal
• Myelin
• AIDP
• CIDP
• Diabetic / thyroid related neuropathy
• Progression (Proximal verses distal verses global characteristics)
• Inherited conditions.  All CMT pathologies, peroneal muscular atrophies.
• Related to vasculitis
• Uremic conditions
• Autoimmune related (MAG, GM1, GALLOP, Sulfatide)
• Infection
• Paraneoplastic
• Infections / toxic (Included drug induced)
• Nutritional (B vitamin and lack of nutrition, ex: alcohol)
• Related to arthitic and inflammatory conditions
• Understand the differentials and related conditions to each of the following:
• Small fiber pathologies
• Myelin only pathologies
• Mainly motor fibers
• Mainly large sensory fibers.
• Axon pathologies
• Understand metabolic and systemic conditions
• Diabetes and thyroid conditions
• Understand neuromuscular junction illnesses
• Myasthenia Gravis
• Lambert Eaton
• Botulism
• Understand inherited diseases
• All CMT pathologies
• Understand related spinal cord conditions
• Syrinx
• Anterior spinal artery
• Hemisection
• Extrinsic cord pathologies
• Intrinsic cord pathologies
• Characteristic related to myelopathy
• Understand related vascular pathologies and conditions
• Peripheral vascular disease
• Basilar circulation
• Main cerebral circulation
• Understand related brainstem, cerebellar and cortical pathologies

Related Laboratory Studies:

• Understand basic blood chemistry and metabolic panel and how its relationship to peripheral nerve disease.  An example would be hemoglobic A1C and diabetes.
• Understand genetic markers.  An example would be PMP22 deletion or duplication testing for CMT pathologies.
• Nutritional evaluations.  An example would be B vitamin analysis
• Understand vascular studies and inflammatory markers
• Understand studies related to ultrasound and sonography.  An example would be carotid ultrasound and pathologies that can be measured on AEP and VEP testing due to stroke of vascular lesion. 
• Basic MRI information.  An example would be disc lesions, certain levels that they may be at and what nerve root might be affected. 

The practical examination:

• The practical will have a very specific didactic component.  The participant will be required to perform an NCV and an EMG test.  This will include one nerve and one muscle.  The participant will not know which nerve or which muscle before the examination and must be prepared and competent to examine all areas of the nervous system.  The participant will be graded on location, technique and troubleshooting.  The participant will not be tested on the knowledge of operation of a diagnostic machine due to differences between manufacturers.  If there is a technical problem with the operation of diagnostic machinery, including software or hardware problems, the proctor will assist and the participant will not be penalized.   
• During the NCV the participant will be graded on the following:
• Set up
• Stimulation site
• Electrode positioning
• Stimulation points.
• Reliable waveforms without artifact
• Calculating conduction velocity
• Must answer questions related to the nerve being tested
• During the EMG the participant will be graded on the following:
• Sterile technique
• Inserting into the right nerve and activating the muscle being tested appropriately.
• Must demonstrate an assessment of insertion activity.
• Must assessment spontaneous activity.
• Must do a motor unit analysis.
• Must assess recruitment
• Must assess activation
• Must do an acceptable amount of samples per muscle tested.
• Must answer questions related to each muscle tested.
• There will a section on video analysis
• There will be a video of a pathological waveforms on EMG testing.  These must be identified correctly.
• There will be questions asked related to the identified waveform.
• There will be a section on differential diagnosis
• The participant’s knowledge of differential diagnosis will be challenged during this section.  An example would be the difference in regards to subjective complaints, objective findings, EMG, NCV and SSEP findings between cervical myelopathy and ALS.  There will be detailed questions and analysis between a variety of conditions.  The participant will be tested in this section on their comprehensive knowledge of the material and the nervous system.  The strengths and weaknesses of the practitioner will be assisted during this section. 

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EDX Blueprints

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DACNB:  Complaints/Appeals of Examination

1. The Board must receive Complaints/Appeals within three (3) months of the mailing date of exam results to be considered.
2. The cost of reviewing failed parts of the examination will be non-refundable and set annually by the Board.

Disposition of Complaints: 
If a complaint or dispute arises questioning a Board action the following actions are to take place.

1. Administrative adjudication of a complaint/dispute.
2. The complainant shall specifically state the complaint in writing and submit this document to the Board Secretary for response by the Board.
3. The Board shall respond within thirty (30) days to the submitted complaint.
4. The complainant shall then have thirty (30) days to respond to the report of the Board and submit additional information supportive of his complaint.
5. The Board shall then have thirty (30) days to respond to the complaint and additional information being submitted.
6. The complainant shall then have thirty (30) days to request an Appeal for a Full Review Board.

Appeal to a full Review Board

1. Formation. If the administrative adjudication is unsuccessful and the complainant requests it in writing, then a Review Board shall be formed consisting of a person Board Certified in Electrodiagnosis in good standing who is not a member of the Board; an individual who is either an attorney or trained in law, such as an arbitrator or hearing officer, designated by the Board, an individual designated by the complainant.
2. Procedure. The Chair of the Review Board shall be the person designated by the Board. The Review Board shall remain neutral and shall act as a judicial tribunal to hear the dispute. The Review Board shall set a date for a hearing and conduct a hearing at which time the Board shall make a presentation concerning the dispute and the complainant or representative thereof shall make a presentation concerning the dispute. Witnesses, testimony and other evidence shall be presented to the Review Board for its consideration. The Review Board shall make a finding of facts and conclusions binding all parties, within sixty (60) days of the hearing.
3. Costs. All costs for the Review Board proceedings shall be borne and paid by the non-prevailing party, including but not limited to attorney's fees and per diem expenses and remuneration of Review Board members and witnesses. In order to initiate the proceedings, the complaining party shall post with the Board a bond in the amount of fifteen thousand dollars ($15,000 U.S.), unless, upon showing of good cause, the Board determines a lesser amount appropriate. If the complaining party does not prevail, the bond amount shall be applied to the Board's costs and attorneys' fees, and any balance shall be returned. Any costs and attorneys' fees exceeding the bond amount shall be paid by, and may be recovered against, the complaining party.

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