Here is my latest comp exam for my back. At 80% with a contention for IU in this is a guarantee.
Contentions: severe fatigue caused by "all the medication I am on" (Reopen), hallux valgus, unilateral bilateral foot condition (claimed as bunions) (Reopen), bilateral malunion of tarsal or metataral, foot condition (claimed as 2 heal fractures of the foot) (Increase), flatfoot, acquired (claimed as flat feet) (Increase), CUE peripheral neuropathy upper extremity secondary to cervical condition (New), CUE peripheral neuropathy lower extremity secondary to cervical condition (New), CUE cervical spine (Increase), Temp 100% (New), individual unemployability (New), Headaches (New), Bilateral tinnitus (Increase), Lumbosacral spine now claimed as back pain (Increase)
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Thoracolumbar Common Diagnoses:
[ ] Ankylosing spondylitis
[X] Lumbosacral strain
[ ] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
[X] Other Diagnosis
Diagnosis #1: DDD & DJD of the Thorocolumbosacral spine. This
Page 7 of 359is a more
accurate diagnosis and progression of LS spine, strain
ICD code: 722.0
Date of diagnosis: 1990
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Had back condition during service for several years diagnosed as
degenerative disc disease. Had helicopter crash 1990 and injured neck and back. HE fell off a ship as well that aggravated the back condition.
Over time his upper and lower back pain has progressed to chronic daily pain.
States he has chronic daily pain at the 8-9 pain level.
Has been given cymbalta 60mg daily which doe not seem to help, has
burning feet from DM neuropathy, radicular pain from his neck condition & pain meds side effects for the medication of drowsiness and fatigue of cymbalta
Has modified his bathroom and other house areas to alleviate back strain
and his cervical spine condition, s/p cervical fusion.
Has modified his bathroom and other house areas to alleviate back strain
and his cervical spine condition, s/p cervical fusion.
3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the
thoracolumbar spine (back)?
[X] Yes [ ] No
If yes, document the Veteran's description of the impact of flare-ups
in
his or her own words:
prolonged sitting or standing over 30 min
4. Initial range of motion (ROM) measurement
--------------------------------------------
a. Select where forward flexion ends (normal endpoint is 90):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
b. Select where extension ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
c. Select where right lateral flexion ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
d. Select where left lateral flexion ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
e. Select where right lateral rotation ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
f. Select where left lateral rotation ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
g. If ROM for this Veteran does not conform to the normal range of motion
identified above but is normal for this Veteran (for reasons other than a
back condition, such as age, body habitus, neurologic disease), explain:
No response provided.
ROM measurement after repetitive use testing
-----------------------------------------------
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
[X] Yes
[ ] No
b. Select where post-test forward flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [X] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
c. Select where post-test extension ends:
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or
greater
d. Select where post-test right lateral flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or
greater
e. Select where post-test left lateral flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or
greater
f. Select where post-test right lateral rotation ends:
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or
greater
g. Select where post-test left lateral rotation ends:
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or
greater
6. Functional loss and additional limitation in ROM
---------------------------------------------------
a. Does the Veteran have additional limitation in ROM of the thoracolumbar
spine (back) following repetitive-use testing?
[ ] Yes [X] No
b. Does the Veteran have any functional loss and/or functional impairment of
the thoracolumbar spine (back)?
[X] Yes [ ] No
c. If the Veteran has functional loss, functional impairment and/or
additional limitation of ROM of the thoracolumbar spine (back) after
repetitive use, indicate the contributing factors of disability below:
[X] Less movement than normal
[X] Excess fatigability
[X] Pain on movement
[X] Disturbance of locomotion
[X] Interference with sitting, standing and/or weight-bearing
[X] Lack of endurance
7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)
----------------------------------------------------------------------------
a. Does the Veteran have localized tenderness or pain to palpation for
joints
and/or soft tissue of the thoracolumbar spine (back)?
[X] Yes [ ] No
If yes, describe:
pain over paravertebral muscles of thoracic and ls spine
b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting
in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
c. Does the Veteran have muscle spasms of the thoracolumbar spine not
resulting in abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
d. Does the Veteran have guarding of the thoracolumbar spine resulting in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
e. Does the Veteran have guarding of the thoracolumbar spine not resulting
in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
8. Muscle strength testing
--------------------------
a. Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Hip flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Great toe extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
9. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
10. Sensory exam
----------------
Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
11. Straight leg raising test
-----------------------------
Provide straight leg raising test results:
Right: [ ] Negative [X] Positive [ ] Unable to perform
Page 12 of 359 Left: [ ] Negative [X] Positive [ ] Unable to perform
12. Radiculopathy
-----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No
a. Indicate symptoms' location and severity (check all that apply):
No response provided.
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[ ] Yes [X] No
c. Indicate nerve roots involved: (check all that apply)
No response provided.
d. Indicate severity of radiculopathy and side affected:
Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe
Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe
13. Ankylosis
-------------
Is there ankylosis of the spine? [ ] Yes [X] No
14. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities or findings related
to a thoracolumbar spine (back) condition (such as bowel or bladder
problems/pathologic reflexes)?
[ ] Yes [X] No
15. Intervertebral disc syndrome (IVDS) and incapacitating episodes
-------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
16. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[X] Yes [ ] No
Identify assistive device(s) used:
Assistive Device: Frequency of use:
----------------- -----------------
[X] Brace(s) [ ] Occasional [X] Regular [ ] Constant
. Remaining effective function of the extremities
---------------------------------------------------
Due to a thoracolumbar spine (back) condition, is there functional
impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.)
[X] No
18. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms?
[ ] Yes [X] No
19. Diagnostic testing
----------------------
a. Have imaging studies of the thoracolumbar spine been performed and are Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
2/14 Thoracic spine MRI:
1. Mild-to-moderate multi-level degenerative disc changes
most pronounced at T7-T8, without significant spinal canal or
neural foraminal stenosis.
2. Incidental nodular T2 hyperintense in the region of the
right upper quadrant. Precise localization is difficult due to
respiratory motion artifact, Ultrasonography of the is
suggested for further characterization.
2/14 LS Spine MRI
Findings: There is preservation of vertebral body heights and
alignment. The normal lordotic curvature of the lumbar spine
is relatively maintained. Bone marrow signal is slightly
heterogeneous without suspicious focal osseous lesions. Above
L4-L5, degenerative findings are relatively minor without
significant spinal canal compromise or neural foraminal
narrowing.
At the L4-L5 level, there is diffuse bulging of the
intervertebral disc with superimposition of a right foraminal
disc protrusion. There is resultant mild to moderate right
neural foraminal narrowing. The left neural foramen is mildly
compromised. A moderate degree of spinal canal narrowing is
evident.
At L5-S1, diffuse intervertebral disc bulge is present
without significant focal posterior disc contour abnormality. No
significant spinal canal narrowing is appreciated. There is
adequate neural foraminal patency bilaterally. Mild
degenerative facet arthropathy is noted bilaterally.
20. Functional impact
--------------------- Does the Veteran's thoracolumbar spine (back) condition impact on his or
her ability to work?
[X] Yes [ ] No
If yes describe the impact of each of the Veteran's
thoracolumbar
spine (back) conditions providing one or more examples:
Individual unemployability. DDD & DJD of the
thorocolumbosacral
spine. This condition prevents him from laborious type work,
lifting over 5 lbs,prolonged sitting or standing w/o breaks to sit
or stand every ten minutes. He should not climb as is a fall risk
with his severely limited ROM & amp; decreased mobility
w/chronic pain.
He should not operate machinery due to sedation of pain
medications. With the above limitations, he is more likely than
not unemployable & would be considered a occupational health
risk to employers.
21. REMARKS
-----------
a. Remarks, if any:
VBMS & CPRS reviewed document DDD thoracic and ls spin :
emultilevel,
chronic pain neck and back
b. Mitchell criteria:
MITCHELL FUNCTIONAL ASSESSMENT FOR BACK.
Can pain, weakness, fatigability, or incoordination significantly limit
functional ability either during flare-ups or when the joint is used
repeatedly over a period of time?
[ x ] Yes
[ ] No
[ ] It is not possible to determine without resorting to mere
speculation, because there is no conceptual or empirical basis for
making
such a determination without directly observing function under these
conditions.
If Yes:
[ ] Estimated loss of ROM due to pain and/or functional
loss during flare-ups or when the joint is used repeatedly over a period
of time, describing only the affected elements of ROM:
[ x] Any limitation of ROM cannot be estimated, but loss
of function during flare-ups or when the joint is used repeatedly over a
period of time is described as follows: increased back pain and decrease
ROM w/prlonged sitting or standing over ten minutes, lifting over 5 lbs
or operating machinery on pain meds.
I believe I need to see a back doctor ASAP as my back is getting worse, the VA never notified me of these results!
Question
COOL BREEZE
Here is my latest comp exam for my back. At 80% with a contention for IU in this is a guarantee.
Contentions: severe fatigue caused by "all the medication I am on" (Reopen), hallux valgus, unilateral bilateral foot condition (claimed as bunions) (Reopen), bilateral malunion of tarsal or metataral, foot condition (claimed as 2 heal fractures of the foot) (Increase), flatfoot, acquired (claimed as flat feet) (Increase), CUE peripheral neuropathy upper extremity secondary to cervical condition (New), CUE peripheral neuropathy lower extremity secondary to cervical condition (New), CUE cervical spine (Increase), Temp 100% (New), individual unemployability (New), Headaches (New), Bilateral tinnitus (Increase), Lumbosacral spine now claimed as back pain (Increase)
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Thoracolumbar Common Diagnoses:
[ ] Ankylosing spondylitis
[X] Lumbosacral strain
[ ] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
[X] Other Diagnosis
Diagnosis #1: DDD & DJD of the Thorocolumbosacral spine. This
Page 7 of 359is a more
accurate diagnosis and progression of LS spine, strain
ICD code: 722.0
Date of diagnosis: 1990
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
Had back condition during service for several years diagnosed as
degenerative disc disease. Had helicopter crash 1990 and injured neck and back. HE fell off a ship as well that aggravated the back condition.
Over time his upper and lower back pain has progressed to chronic daily pain.
States he has chronic daily pain at the 8-9 pain level.
Has been given cymbalta 60mg daily which doe not seem to help, has
burning feet from DM neuropathy, radicular pain from his neck condition & pain meds side effects for the medication of drowsiness and fatigue of cymbalta
Has modified his bathroom and other house areas to alleviate back strain
and his cervical spine condition, s/p cervical fusion.
Has modified his bathroom and other house areas to alleviate back strain
and his cervical spine condition, s/p cervical fusion.
3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the
thoracolumbar spine (back)?
[X] Yes [ ] No
If yes, document the Veteran's description of the impact of flare-ups
in
his or her own words:
prolonged sitting or standing over 30 min
4. Initial range of motion (ROM) measurement
--------------------------------------------
a. Select where forward flexion ends (normal endpoint is 90):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [X] 40 [ ] 45
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
b. Select where extension ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
c. Select where right lateral flexion ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
d. Select where left lateral flexion ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
e. Select where right lateral rotation ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
f. Select where left lateral rotation ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[X] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25
[ ] 30 or greater
g. If ROM for this Veteran does not conform to the normal range of motion
identified above but is normal for this Veteran (for reasons other than a
back condition, such as age, body habitus, neurologic disease), explain:
No response provided.
ROM measurement after repetitive use testing
-----------------------------------------------
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
[X] Yes
[ ] No
b. Select where post-test forward flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30
[ ] 35 [X] 40 [ ] 45 [ ] 50 [ ] 55 [ ] 60 [ ] 65
[ ] 70 [ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
c. Select where post-test extension ends:
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or
greater
d. Select where post-test right lateral flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or
greater
e. Select where post-test left lateral flexion ends:
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [X] 20 [ ] 25 [ ] 30 or
greater
f. Select where post-test right lateral rotation ends:
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or
greater
g. Select where post-test left lateral rotation ends:
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20 [ ] 25 [ ] 30 or
greater
6. Functional loss and additional limitation in ROM
---------------------------------------------------
a. Does the Veteran have additional limitation in ROM of the thoracolumbar
spine (back) following repetitive-use testing?
[ ] Yes [X] No
b. Does the Veteran have any functional loss and/or functional impairment of
the thoracolumbar spine (back)?
[X] Yes [ ] No
c. If the Veteran has functional loss, functional impairment and/or
additional limitation of ROM of the thoracolumbar spine (back) after
repetitive use, indicate the contributing factors of disability below:
[X] Less movement than normal
[X] Excess fatigability
[X] Pain on movement
[X] Disturbance of locomotion
[X] Interference with sitting, standing and/or weight-bearing
[X] Lack of endurance
7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait)
----------------------------------------------------------------------------
a. Does the Veteran have localized tenderness or pain to palpation for
joints
and/or soft tissue of the thoracolumbar spine (back)?
[X] Yes [ ] No
If yes, describe:
pain over paravertebral muscles of thoracic and ls spine
b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting
in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
c. Does the Veteran have muscle spasms of the thoracolumbar spine not
resulting in abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
d. Does the Veteran have guarding of the thoracolumbar spine resulting in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
e. Does the Veteran have guarding of the thoracolumbar spine not resulting
in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
8. Muscle strength testing
--------------------------
a. Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Hip flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Great toe extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
9. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
10. Sensory exam
----------------
Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
11. Straight leg raising test
-----------------------------
Provide straight leg raising test results:
Right: [ ] Negative [X] Positive [ ] Unable to perform
Page 12 of 359 Left: [ ] Negative [X] Positive [ ] Unable to perform
12. Radiculopathy
-----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No
a. Indicate symptoms' location and severity (check all that apply):
No response provided.
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[ ] Yes [X] No
c. Indicate nerve roots involved: (check all that apply)
No response provided.
d. Indicate severity of radiculopathy and side affected:
Right: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe
Left: [X] Not affected [ ] Mild [ ] Moderate [ ] Severe
13. Ankylosis
-------------
Is there ankylosis of the spine? [ ] Yes [X] No
14. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities or findings related
to a thoracolumbar spine (back) condition (such as bowel or bladder
problems/pathologic reflexes)?
[ ] Yes [X] No
15. Intervertebral disc syndrome (IVDS) and incapacitating episodes
-------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
16. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[X] Yes [ ] No
Identify assistive device(s) used:
Assistive Device: Frequency of use:
----------------- -----------------
[X] Brace(s) [ ] Occasional [X] Regular [ ] Constant
. Remaining effective function of the extremities
---------------------------------------------------
Due to a thoracolumbar spine (back) condition, is there functional
impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc.; functions of the lower extremity include balance and propulsion, etc.)
[X] No
18. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
section above?
[ ] Yes [X] No
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms?
[ ] Yes [X] No
19. Diagnostic testing
----------------------
a. Have imaging studies of the thoracolumbar spine been performed and are Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
2/14 Thoracic spine MRI:
1. Mild-to-moderate multi-level degenerative disc changes
most pronounced at T7-T8, without significant spinal canal or
neural foraminal stenosis.
2. Incidental nodular T2 hyperintense in the region of the
right upper quadrant. Precise localization is difficult due to
respiratory motion artifact, Ultrasonography of the is
suggested for further characterization.
2/14 LS Spine MRI
Findings: There is preservation of vertebral body heights and
alignment. The normal lordotic curvature of the lumbar spine
is relatively maintained. Bone marrow signal is slightly
heterogeneous without suspicious focal osseous lesions. Above
L4-L5, degenerative findings are relatively minor without
significant spinal canal compromise or neural foraminal
narrowing.
At the L4-L5 level, there is diffuse bulging of the
intervertebral disc with superimposition of a right foraminal
disc protrusion. There is resultant mild to moderate right
neural foraminal narrowing. The left neural foramen is mildly
compromised. A moderate degree of spinal canal narrowing is
evident.
At L5-S1, diffuse intervertebral disc bulge is present
without significant focal posterior disc contour abnormality. No
significant spinal canal narrowing is appreciated. There is
adequate neural foraminal patency bilaterally. Mild
degenerative facet arthropathy is noted bilaterally.
20. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or
her ability to work?
[X] Yes [ ] No
If yes describe the impact of each of the Veteran's
thoracolumbar
spine (back) conditions providing one or more examples:
Individual unemployability. DDD & DJD of the
thorocolumbosacral
spine. This condition prevents him from laborious type work,
lifting over 5 lbs,prolonged sitting or standing w/o breaks to sit
or stand every ten minutes. He should not climb as is a fall risk
with his severely limited ROM & amp; decreased mobility
w/chronic pain.
He should not operate machinery due to sedation of pain
medications. With the above limitations, he is more likely than
not unemployable & would be considered a occupational health
risk to employers.
21. REMARKS
-----------
a. Remarks, if any:
VBMS & CPRS reviewed document DDD thoracic and ls spin :
emultilevel,
chronic pain neck and back
b. Mitchell criteria:
Edited by COOL BREEZEMITCHELL FUNCTIONAL ASSESSMENT FOR BACK.
Can pain, weakness, fatigability, or incoordination significantly limit
functional ability either during flare-ups or when the joint is used
repeatedly over a period of time?
[ x ] Yes
[ ] No
[ ] It is not possible to determine without resorting to mere
speculation, because there is no conceptual or empirical basis for
making
such a determination without directly observing function under these
conditions.
If Yes:
[ ] Estimated loss of ROM due to pain and/or functional
loss during flare-ups or when the joint is used repeatedly over a period
of time, describing only the affected elements of ROM:
[ x] Any limitation of ROM cannot be estimated, but loss
of function during flare-ups or when the joint is used repeatedly over a
period of time is described as follows: increased back pain and decrease
ROM w/prlonged sitting or standing over ten minutes, lifting over 5 lbs
or operating machinery on pain meds.
I believe I need to see a back doctor ASAP as my back is getting worse, the VA never notified me of these results!
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COOL BREEZE
So, I'm now 100% p & t tdiu
COOL BREEZE
Here is my latest comp exam for my back. At 80% with a contention for IU in this is a guarantee. Contentions: severe fatigue caused by "all the medication I am on" (Reopen), hallux valgus, unil
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