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    • Full Knee Replacement
      First, if you  have newer x-rays from outside the VA, get them and the reports into your VA med file. The distance from the VA hospital initially is not as important as the distance to a local VA outpatient clinic. But, once you convince the clinic PCP then outside care (consult in VA speak) can be authorized, since the VAMC is farther away than 40 miles. 
    • Dro Review Processing Time
      I sent in an NOD requesting DRO review about two months ago.  Nothing appeared on ebenefits so I sent an ISIS message.   Took them 2 weeks to reply  (ignore their note that days reply would be sent in 5 workdays)   Return meggage said NOD was received but ebenefits is a little behind   Message said a letter was sent to me asking if I wanted DRO review.  Msg said ignore letter because I already asked for DRO in NOD. Here's  the killer.  Average time for DRO review    631 days
    • Code Sheet
      After reading my code sheet I saw I have one of those. I'm rated on my ankle as 5020-5271. It's also static.  To me the code sheet eases the Veterans MNF. I know what my codes are and I know that my contentions are either static or non-static.  This shoulf not be a secret to is at it is vital information. Nor should this be a huge issue to get. 
    • Auto Adaptive Reimbursement
      I'd try to get something in writing concerning changes/refusals, than, "run the flag up the pole" any way that I thought would help. Automatic transmissions are more or less standard these days, so I'd not be surprised about that.  Bureaucratic screw ups in budgets are not a valid reason for failing to provide benefits required by title 38. Looking at things from a different perspective, some vehicle options are often listed as options,even though they are really "standard". A/C and automatic transmissions are just two. Another possible go-around is that different trim levels of the same vehicle have different options as "standard". You could possibly buy a base version, and add options at extra cost, or an up trim version with the "options" already included as "standard". It may be that the VA is looking at what the "normal" buyer options are, and trying to avoid paying for them.  
    • CUE? Not using SMR?
      Yes, if they notice the CUE they can adjust on their own.  I just had the EED adjusted on my initial claims for asthma and left ankle, the rater looked at my entire record while processing my unadjudicated claim for diabetes.  He immediately file a cue and adjusted the EED.  I didn't have to do anything for the EED/CUE. However, my ED was actually a CU they started them in 98 vs. 97.  
    • C&P Exam Results, WTH is going on, Please Help!!!
      Agree with killemall. You got this Navy04, we can't wait for you to come back here and say DONE!    
    • Code Sheet
      Thanks Asknod My problem is finding out the code for the disability.?? PTSD Code has it at 9411&9435 Code for Unspecific Depresssive Disorder VA Notes from  PCP  has PTSD  As : SCT47505003  My Sleep Apnea Notes has the code as SCT 73430006, Some of these I get confused with Insurance Codes  for Insurance Purposes. Jbasser & Jerrel Cook had a blog talk radio show on these rating codes Last year some times Maybe I'll recheck the Archives Shows. I tried to look up the code for OSA but never found it. just the SCT #73430006..?  And I have a Boo-Coo List of NSC disability's/contentions.  with the SCT# at the end of them
    • Auto Adaptive Reimbursement
      Update. My friend talked to the head of prosthetics in Tucson(kristine) and she informed him that the VA will not cover some items like power options,automatic transmissions and a few others.(I can't remember the list of things he told me).These were all covered by the VA previously.
    • NOD / DRO or TARP?
      All, Thank you for the response's. Due to me posting all of my documents intermittently, there seems to be some confusion with the timeline and issues. I will attempt to run thru this chronologically and repost all documents including my 2015 decision which I had not previously posted and answer all questions. March 2009- Filed original Claim for the following issues and received results October 2009 (see 2009 - Rating Sheet below) I do not have the entire decision packet: TBI - 10 % SC Residuals, gallbladder removal - 0% SC Back Condition - declined SC Psoriasis - declined SC PTSD - declined SC / Stressor conceded as combat action badge. October 2010 - Filed NOD / DRO for PTSD March - 2011 - Appeal decision received. I never stated that PTSD was due to MST. The paragraph on page 2 of 2011Appeal decision below is just the last part of 10 pages that I cut out covering rules and US code that they sent in the letter. The actual decision starts at the bottom of that page. Results: PTSD declined - I did not submit any new evidence. Diagnosed as "adjustment disorder with mixed anxiety and depressed mood". Blamed on me worrying about my husband returning to Iraq, even though he had just returned??? October 2014  - Initiated following claims: (I had transferred to the North Texas VA and had finally began receiving treatment after being fed up with OKC VA. I live in southern Oklahoma, so its a drive for me to go to either one) PTSD - Re-open Claim. TBI - Request for increase. May 2015 -  I reported for C&P exams at the Dallas VA clinic for PTSD and TBI. I'm not sure if this is relevant, but I received a call while my husband and I were driving there stating that the TBI examiner had to leave early and they would have to re-schedule that exam. I protested because it is a 3 hour drive. They called me back 10 minutes later stating that he would conduct the exam. He seemed pissed the whole time. His notes stated that No TBI residuals were present.  This is also the exam where the PTSD screener stated "However, it should be pointed out that most of the symptoms the veteran described during today's MH examination certainly those common to a PTSD diagnosis- she also described during her 7/8/09 Initial PTSD examination, in Oklahoma City, three years PRIOR to her son's illness."  ( see 2015 C&P exam notes below) June 2015 - Latest decision received. Results (see 2015 - decision part 1 &2 below): TBI - Decreased to 0% SC PTSD - 50% SC May 2016 - Wondering what my best next COA should be? Would like to get PTSD effective date back to 2009 and get TBI increased to at least percentage it was before. I have about 50 days to file my NOD. Q&A: Berta: What did the C & P doc diagnose you with? 2009 - TBI (SC) and adjustment disorder with mixed anxiety and depressed mood (not SC) 2015 - No TBI residuals and PTSD w/ major depressive disorder.   Berta: Have you googled the doctor who did the C & P? I do not know the Doctor's name from 2009. But I have found several articles referring to a Dr. Gail Poyner who was conducting PTSD exams at OKC VA at the time. She was fired from the VA in 2010 for applying test to Veterans to see if they were malingering or faking. Her research paper can be found here: http://link.springer.com/article/10.1007%2Fs12207-010-9076-x?LI=true I would like to have my C-File to see if she conducted the evaluation.   Gastone: What did you claim as the PTSD Stressors in your 09 app for PTSD? Combat Action Badge   Gastone: The 1st Denial, discussed "No Evidence of Personal Assault," MST? No MST ever claimed. The paragraph that covers PTSD due to MST was just the last paragraph of 10 pages of regulations that they sent with the decision. Actual decision starts at the bottom of that page.   Gastone: Did you know anything about the DRO Process Requirement, for the N & M Evidence? I did. My fault I didn't send any. I was fed up with OKC VA and assumed they would send me for a new C&P exam. Stupid on my part.   Gastone: Did you ever get a copy of your 09 PTSD C & P DBQ? No, I did not. Blue button records do not go back that far. I have requested a copy of my C-File. EBenefits states that I will get it between NOV 2017 and NOV 2018.   Gastone:  Do you currently have a VA MH Psychiatrist/Psychologist that treats you on a regular basis? I was being seen at Bohnam, TX VA. After they kept switching Dr's a few times, I now just get my meds re-filled thru my family physician. My husband is active duty, so we are on tri-care prime remote. I also qualify for VA choice, but have not used it.   Gastone: Have they given you an official PTSD DX? I have a PTSD diagnosis and receive 50% SC in 2015.   Berta: Did they have the incident reports? I faxed in two incident reports. They do not show on the evidence list, but stressor was conceded with CAB.   Flores97: Email congressman for C-File. Thank You for the advice. I emailed my congressman today and reiterated the time crunch I am under.     2011 - Appeal decision.pdf 2015 - C&P exam Notes.pdf 2015 - decision part 1.pdf 2015 - decision part 2.pdf 2009 - Rating Sheet.pdf
    • Full Knee Replacement
      I just came back from the Ortho doctor in town he said I need a full knee replacement for my service connected injury after looking at past 11 years of x-rays from the VA and what he just took today. The Marine Corps. somehow don't keep x-rays after a certain period of time. The VA says they will not do one until I'm 60 years old, all they wanted to do was give me injections for the pain. What I have now is a Torn ACL and I'm running bone on bone, and my knee cap is just about gone so here is the question. I already receive 20% for my left knee, due to the past 3 surgery's. So after having the knee replacement what will I be looking at? for an increase? Does the VA have to pay for this since I live 178 miles from the Nearest VA hospital? because they are still telling me if you were injured on active duty you must go to the VA hospital even through the VA says They will not do a knee replacement until I'm 60? I already talked to two Veterans in town at the Vet center and they had the same problem but they paid for it out of their own pocket for the surgery then filed for an increase award. So far they are still waiting for the VA to answer them back. any ideals on the best route to take? I hate to get this done out in a local hospital then fine out the VA will not pay and give me an increase for the full knee replacement. Thank for any information on this subject.

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hollywoodnc

Goniometer Usage

8 posts in this topic

Correct me if I'm wrong, but aren't ALL doctors supposed to use a Goniometer to render correct orthopedic ROM?

Are Goniometers used for specific parts on the body? If so, which?

Is there a reg that supports the use of this device, or is it Voluntary?

Last, but not least, can ROM be challenged if a doctor fails to use one?

How many of you had an Ortho exam, and a Goniometer was not used?

Same as above, but one WAS used?

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§4.46 Accurate measurement.

Accurate measurement of the length of stumps, excursion of joints, dimensions and location of scars with respect to landmarks, should be insisted on. The use of a goniometer in the measurement of limitation of motion is indispensable in examinations conducted within the Department of Veterans Affairs. Muscle atrophy must also be accurately measured and reported.

I've never had a C&P where a goniometer was used. The C&P that was used to reduce my rating had ranges of motion that weren't even written in degrees of motion, which is also against the regs. I will urge caution, though, because my last several C&P's warranted huge increases in my compensation, and goniometers were not used. Some docs have been doing this long enough that they don't need one. I have enough of a mechanical inclination that I could most likely be very accurate at measuring ROM's without a goniometer, too. I always advise to check the results of the C&P before disputing it.

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The spine exam index sheet has it spacifically written into the instructions. I actually had one used on me on 2 occasions.Go figure.

Spine Examination

Spine

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. Review of Medical Records:

B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints is unrelated to claimed disability.

Report complaints of pain (including any radiation), stiffness, weakness, etc.

Onset

Location and distribution

Duration

Characteristics, quality, description

Intensity

Describe treatment - type, dose, frequency, response, side effects.

Provide the following (per veteran) if individual reports periods of flare-up:

Severity, frequency, and duration.

Precipitating and alleviating factors.

Additional limitation of motion or functional impairment during the flare-up.

Describe associated features or symptoms (e.g., weight loss, fevers, malaise, dizziness, visual disturbances, numbness, weakness, bladder complaints, bowel complaints, erectile dysfunction).

Describe walking and assistive devices.

Does the veteran walk unaided? Does the veteran use a cane, crutches, or a walker?

Does the veteran use a brace (orthosis)?

How far and how long can the veteran walk?

Is the veteran unsteady? Does the veteran have a history of falls?

Describe details of any trauma or injury, including dates, and direction and magnitude of forces.

Describe details of any surgery, including dates.

Functional Assessment - Describe effects of the condition(s) on the veteran's mobility (e.g., walking, transfers), activities of daily living (i.e., eating, grooming, bathing, toileting, dressing), usual occupation, recreational activities, driving.

C. Physical Examination (Objective Findings): Address each of the following as appropriate to the condition being examined and fully describe current findings:

Inspection: spine, limbs, posture and gait, position of the head, curvatures of the spine, symmetry in appearance, symmetry and rhythm of spinal motion.

Range of motion

Cervical Spine

The reproducibility of an individual's range of motion is one indicator of optimum effort. Pain, fear of injury, disuse or neuromuscular inhibition may limit mobility by decreasing the individual's effort. If range of motion measurements fail to match known pathology, please repeat the measurements. (Reference: Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, page 399).

i. Using a goniometer, measure and report the range of motion in degrees of forward flexion, extension, left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation. Generally, the normal ranges of motion for the cervical spine are as follows:

Forward flexion: 0 to 45 degrees

Extension: 0 to 45 degrees

Left Lateral Flexion: 0 to 45 degrees

Right Lateral Flexion: 0 to 45 degrees

Left Lateral Rotation: 0 to 80 degrees

Right Lateral Rotation: 0 to 80 degrees

There may be a situation where an individual's range of motion is reduced, but "normal" (in the examiner's opinion) based on the individual's age, body habitus, neurologic disease, or other factors unrelated to the disability for which the exam is being performed. In this situation, please explain why the individual's measured range of motion should be considered as "normal".

ii. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

iii. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.

v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of cervical spine musculature. In the situation where there is unfavorable ankylosis of the cervical spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation

b. Thoracolumbar spine

The reproducibility of an individual's range of motion is one indicator of optimum effort. Pain, fear of injury, disuse or neuromuscular inhibition may limit mobility by decreasing the individual's effort. If range of motion measurements fail to match known pathology, please repeat the measurements. (Reference: Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, page 399).

It is best to measure range of motion for the thoracolumbar spine from a standing position. Measuring the range of motion from a standing position (as opposed to from a sitting position) will include the effects of forces generated by the distance from the center of gravity from the axis of motion of the spine and will include the effect of contraction of the spinal muscles. Contraction of the spinal muscles imposes a significant compressive force during spine movements upon the lumbar discs.

i. Provide forward flexion of the thoracolumbar spine as a unit. Do not include hip flexion. (See Magee, Orthopedic Physical Assessment, Third Edition, 1997, W.B. Saunders Company, pages 374-75). Using a goniometer, measure and report the range of motion in degrees for forward flexion, extension, left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation. Generally, the normal ranges of motion for the thoracolumbar spine as a unit are as follows:Forward flexion: 0 to 90 degrees

Extension: 0 to 30 degrees

Left Lateral Flexion: 0 to 30 degrees

Right Lateral Flexion: 0 to 30 degrees

Left Lateral Rotation: 0 to 30 degrees

Right Lateral Rotation: 0 to 30 degrees

There may be a situation where an individual's range of motion is reduced, but "normal" (in the examiner's opinion) based on the individual's age, body habitus, neurologic disease, or other factors unrelated to the disability for which the exam is being performed. In this situation, please explain why the individual's measured range of motion should be considered as "normal".

ii. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

iii. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.

a. Indicate whether there is muscle spasm, guarding or localized tenderness with preserved spinal contour, and normal gait.

b. Indicate whether there is muscle spasm, or guarding severe enough to result in an abnormal gait, abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis.

v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of back. In the situation where there is unfavorable ankylosis of the thoracolumbar spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root involvement.

Neurological examination

Please perform complete neurologic evaluation as indicated based upon disability for which the exam is being performed. Please provide brief statement if any of the following (a-e) is not included in exam. For additional neurologic effects of disability not captured by a - e, (e.g. bladder problems) please refer to appropriate worksheet for the body system affected.

Sensory examination, to include sacral segments.

Motor examination (atrophy, circumferential measurements, tone, and strength).

Reflexes (deep tendon, cutaneous, and pathologic).

Rectal examination (sensation, tone, volitional control, and reflexes).

Lasegue's sign.

For vertebral fractures, report the percentage of loss of height, if any, of the vertebral body

Non-organic physical signs (e.g., Waddell tests, others).

D. For intervertebral disc syndrome

Conduct and report a separate history and physical examination for each segment of the spine (cervical, thoracic, lumbar) affected by disc disease.

Conduct a complete history and physical examination of each affected segment of the spine (cervical, thoracic, lumbar), whether or not there has been surgery, as described above under B. Present Medical History and C. Physical Examination.

Conduct a thorough neurologic history and examination, as described in C5, of all areas innervated by each affected spinal segment. Specify the peripheral nerve(s) affected. Include an evaluation of effects, if any, on bowel or bladder functioning.

Describe as precisely as possible, in number of days, the duration of each incapacitating episode during the past 12-month period. An incapacitating episode, for disability evaluation purposes, is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

E. Diagnostic and Clinical Tests:

Imaging studies, when indicated.

Electrodiagnostic tests, when indicated.

Clinical laboratory tests, when indicated.

Isotope scans, when indicated.

Include results of all diagnostic and clinical tests conducted in the examination report.

F. Diagnosis:

G. Additional Limitation of Joint Function:

Impairment of joint function is determined by actual range of joint motion as reported in the physical examination and additional limitation of joint function caused by the following factors:

Pain, including pain on repeated use

Fatigue

Weakness

Lack of endurance

Incoordination

Do any of the above factors additionally limit joint function? If so, express the additional limitation in degrees.

Indicate if you cannot determine, without resort to mere speculation, whether any of these factors cause additional functional loss. For example, indicate if you would need to resort to mere speculation in order to express additional limitation due to repetitive use.

Signature: Date:

Edited by jbasser

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B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints is unrelated to claimed disability.

Please, anyone correct me if I am wrong, but isn't it against the regulations or USC's, that the VA is not allowed to direct the C&P examiner to make such a finding as stated above?

I thought I read someplace,, where by it stated that although the Rating Officer can request a C&P exam, if they feel the evidence or lack of it, is needed to determine SC, but they can only ask for an opinion of the condition for which SC is claimed. That their request must be neutral in form so that it does not appear that they are asking the C&P examiner to make an opinion unfavorable to the Veteran.

IMHO-It appears that the statement above is directing the C&P examiner to write an opinion, stating only those findings that he believes are not related to the Veterans SC condition and saying nothing about which ones are.

It seems to me that this statement should also include the following

B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints are unrelated to and which ones are related to the claimed disability

Rockhound Rider :rolleyes:

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I agree with rentalguy, it's best to find out what the decision is on your claim before you contest the C & P exam as being inadequate because a goniometer was not used. My husband has ratings for cervical and lumbar spine problems, and in his C & P's, the examiner did in fact use a goniometer. I was there for the most recent one, and I've asked my husband to make a point of telling me whether or not one was used on the exams for which I wasn't present, just in case we don't like the rating decision.

I know that many examiners just eyeball it. I would wait to see what the rating decision is before I challenged the examination.

I want to repeat something here that I read in an earlier post. Be aware that in many cases, the veteran will be observed in the general waiting area, or in the examination room as to how he/she is sitting in a chair. Back straight up against the back of the chair indicates the veteran can sit upright at a 95 degree angle. I'm not suggesting that anyone "slouch," but I am suggesting that you will be observed for this kind of thing when you're not aware of being under observation.

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Hollywood - Shane is correct. Most doc's who comment on ROM have been doing it so long that they do not need to use a meter.

Rock - that is what the statement says in a round about way. If the do is tasked to opine on those that are not SC'ed then the results would be that those not opined on are then by their own ommission of an opinion are service connected. This statement is normally used in case of a TDIU exam - they are trying to see if any non-service connected complaints are resulting in TDIU and the precentage of effect.

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Why use a goniometer when you can just say full range of motion and never measure anything much less observe the individual.

I recently ran into this when a C&P was returned for a clarification(no second appointment) on whether my cervical spine DDD was related to my SC thoracolumbar spine issues. Examiner said more likely than not related to my SC thoracolumbar spine but than stated full range of motion. In two C&P's they have never had me complete any ROM movements for my cervical spine. Physical therapy reports (multiple) show reduced motion, the First C&P exaimner stated head position Other-cervical kyphosis - head forward.

proper way - Measure it / Lazy way - Guestimate it / VA way - Lie about it!

Best regards,

Tyler

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Thank You ALL for your responses! It is truly helpful.

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