ShuMan

C&P--If ROM is outside of normal range??

5 posts in this topic

Team,

I looked at my C&P results and I saw an interesting box checked the: If ROM is outside of normal range, but is normal for the Veteran (for
reasons other than a back condition, such as age, body habitus,
neurologic disease), please describe:?

I'll post the exam below but to me it looks like she is saying that I am lying? How will this effect my rating? What do you think my Rating will be for the below exam? I'm currently rated at 0% for Lumbar strain. 

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

Diagnosis #1: Lumbago

ICD code: M54.5

Date of diagnosis: 04/ 2006

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

The Veteran could not initially remember a specific incident in-service

but attributes low back pain after lifting up large pieces of equipment

while in-service. He reports lumbar level back pain that is located to

the

L sided without radiation. He was evaluated by the VA ER and was treated

with PT and chiropractic services.

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?

[X] Yes [ ] No

If yes, document the Veteran's description of the flare-ups in his

or her

========================================================

own words:

I be doing something like pouring dog food or nothing strenuous and

it

will hurt.

c. Does the Veteran report having any functional loss or functional

impairment of the thoracolumbar spine (back) (regardless of repetitive use)?

[X] Yes [ ] No

If yes, document the Veteran's description of functional loss or

functional impairment in his or her own words.

I get back spasms about 2 times a month. I have to change my position

with sitting and standing. I modifies my activities to minimize

things.

3. Range of motion (ROM) and functional limitation

--------------------------------------------------

a. Initial range of motion

[ ] All normal

[X] Abnormal or outside of normal range

[ ] Unable to test (please explain)

[ ] Not indicated (please explain)

Forward Flexion (0 to 90): 0 to 60 degrees

Extension (0 to 30): 0 to 30 degrees

Right Lateral Flexion (0 to 30): 0 to 30 degrees

Left Lateral Flexion (0 to 30): 0 to 30 degrees

Right Lateral Rotation (0 to 30): 0 to 20 degrees

Left Lateral Rotation (0 to 30): 0 to 20 degrees

If ROM is outside of normal range, but is normal for the Veteran (for

reasons other than a back condition, such as age, body habitus,

neurologic disease), please describe:

Limited effort on PE. Greater ROM note on casual observation without

facial grimacing as was demonstrated at the time of the PE.

If abnormal, does the range of motion itself contribute to a

functional loss? [X] Yes (please explain) [ ] No

If yes, please explain:

It is difficult to assess the true degree of functional loss

considering the noted discrepancies at the exam versus casual

observation

Description of pain (select best response):

Pain noted on exam but does not result in/cause functional loss

If noted on exam, which ROM exhibited pain (select all that apply)?

Forward Flexion, Extension, Right Lateral Flexion, Left Lateral

Flexion, Right Lateral Rotation, Left Lateral Rotation

========================================================

Is there evidence of pain with weight bearing? [ ] Yes [X] No

Is there objective evidence of localized tenderness or pain on palpation

of the joints or associated soft tissue of the thoracolumbar spine

(back)?

[X] Yes [ ] No

If yes, describe including location, severity and relationship to

condition(s):

L lateral lumbar area at L4-5.

b. Observed repetitive use

Is the Veteran able to perform repetitive use testing with at least three

repetitions? [X] Yes [ ] No

Is there additional loss of function or range of motion after three

repetitions? [ ] Yes [X] No

c. Repeated use over time

Is the Veteran being examined immediately after repetitive use over time?

[X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

d. Flare-ups

Is the exam being conducted during a flare-up? [ ] Yes [X] No

If the examination is not being conducted during a flare-up:

[ ] The examination is medically consistent with the Veteran's

statements describing functional loss during flare-ups.

[ ] The examination is medically inconsistent with the Veteran's

statements describing functional loss during flare-ups. Please

explain.

[X] The examination is neither medically consistent or inconsistent

with the Veteran's statements describing functional loss

during

flare-ups.

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with flare-ups?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation

If unable to say w/o mere speculation, please explain:

He is not currenlty in a flare-up.

========================================================

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine

(back)? [X] Yes [ ] No

Muscle spasm:

[X] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Localized tenderness:

[ ] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[X] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Provide description and/or etiology:

L lumbar area as described above.

Guarding:

[X] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

Provide description and/or etiology:

Anicipatory

f. Additional factors contributing to disability

In addition to those addressed above, are there additional contributing

factors of disability? Please select all that apply and describe: None

4. 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

5. 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+

6. 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

Other sensory findings, if any: Normal bilateral sensation to sharp,

dull, cold, vibration.

7. Straight leg raising test

----------------------------

Provide straight leg raising test results:

Right: [X] Negative [ ] Positive [ ] Unable to perform

Left: [X] Negative [ ] Positive [ ] Unable to perform

8. Radiculopathy

----------------

Does the Veteran have radicular pain or any other signs or symptoms due to

radiculopathy?

[ ] Yes [X] No

9. Ankylosis

------------

Is there ankylosis of the spine? [ ] Yes [X] No

10. 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

11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest

-----------------------------------------------------------------------

a. Does the Veteran have IVDS of the thoracolumbar spine?

[ ] Yes [X] No

12. 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?

[ ] Yes [X] No

13. 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

14. Other pertinent physical findings, complications, conditions, signs,

symptoms and scars

-----------------------------------------------------------------------

a. Does the Veteran have any other pertinent physical findings,

complications, conditions, signs or symptoms related to any conditions

listed in the Diagnosis Section above?

[ ] Yes [X] No

b. 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

c. Comments, if any:

NA

15. Diagnostic testing

----------------------

a. Have imaging studies of the thoracolumbar spine been performed and are

the

results available?

[X] Yes [ ] No

If yes, is arthritis documented?

[ ] Yes [X] No

b. Does the Veteran have a thoracic vertebral fracture with loss of 50

percent or more of height?

[ ] Yes [X] No

c. 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):

Negative SI joint films

16. 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:

He reports he has to change positions after sitting and stretch

his

back.

17. Remarks, if any:

--------------------

Vista imaging noted 5 views of lumbar back 04/23/2009 & again in 12/2011

interpreted by the radiologist as normal.

VBMS P. 1 STR's P 86/93 "back pain was seen, no more problems

06/06/2006.

VBMS P. 1. 04/10/2006 STR's P. 88/93 "Low back pain x one day

after

dead-lifting heavy weights".

CPRS note of 05/12/2015 "Pt states he is continuing to have back pain

as he

has had since being in military".

Chiropractic care by Dr. Jon Bright as noted in Ms. Liddy's note of

12/21/2011.

06/30/2011 "LBP since three weeks when he started playing basketball,

"bosue

classes" and increasing cardio activities. No B/B dysfunction. No

numbness or

tingling. icing and aspirin

helping some. Patient willing to trial PT and naproxen".

08/07/2010 At the time of his initial VA PC visit he did not report any back

pain or back problems.

C&P exam of 2/19/2010 did not report nor did he have any back conditions

or

symtpoms.

09/09/09 CBOC exam without complaints of back pain.

Limited effort on PE. Greater ROM note on casual observation without the

facial grimacing as was demonstrated at the time of the PE.

No additional remarks.

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Here's my take on your lumbar exam:

a. Initial range of motion
[ ] All normal
[X] Abnormal or outside of normal range

Forward Flexion (0 to 90): 0 to 60 degrees
Extension (0 to 30): 0 to 30 degrees
Right Lateral Flexion (0 to 30): 0 to 30 degrees
Left Lateral Flexion (0 to 30): 0 to 30 degrees
Right Lateral Rotation (0 to 30): 0 to 20 degrees
Left Lateral Rotation (0 to 30): 0 to 20 degrees

 

Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation

Is the exam being conducted during a flare-up? [ ] Yes [X] No


[X] The examination is neither medically consistent or inconsistent
with the Veteran's statements describing functional loss
during flare-ups.

Negative SI joint films

Based on these parts of your exam, it seems they have examined you on a good day. The only parts showing an ROM deficit was forward flexion and left/right lateral rotation. It looks like they probably did only X-rays, which didn't show anything. A CAT scan or MRI can show a whole lot more than an X-ray, which typically to showing bones alignment, vertebrae narrowing, and arthritis.

If you were to be SC for this, it looks like a 10% or 20% based on the bold "or's" I highlighted below. However, the examiner would need to opine that your spine condition was "at least as likely as not" or 50/50% due to documented in-service injuries.

If you can get your doctor to opine in your favor, it can help. Most doc's will be hesitant because they did not treat you in service. That's where the "at least as likely as not" or 50/50% comes in. If you can get a spine specialist (orthopedic doc, neurologist, or chiropractor), their opinion can carry more weight than a generic MD.

Here's the rating criteria: http://www.benefits.va.gov/warms/docs/regs/38CFR/BOOKC/PART4/S4_73.doc

General Rating Formula for Diseases and Injuries of the Spine

 

(For diagnostic codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating

       Intervertebral Disc Syndrome Based on Incapacitating Episodes):

 

            With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease

 

                  Unfavorable ankylosis of the entire spine............................................................... 100

 

                  Unfavorable ankylosis of the entire thoracolumbar spine......................................... 50

 

                  Unfavorable ankylosis of the entire cervical spine; or, forward flexion

                       of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of

                       the entire thoracolumbar spine............................................................................. 40

 

                  Forward flexion of the cervical spine 15 degrees or less; or, favorable

                       ankylosis of the entire cervical spine.................................................................... 30

 

                  Forward flexion of the thoracolumbar spine greater than 30 degrees but not

                       greater than 60 degrees; or, forward flexion of the cervical spine greater

                       than 15 degrees but not greater than 30 degrees; or, the combined range of

                       motion of the thoracolumbar spine not greater than 120 degrees; or, the

                       combined range of motion of the cervical spine not greater than 170 degrees;

                       or, muscle spasm or guarding severe enough to result in an abnormal gait

                       or abnormal spinal contour such as scoliosis, reversed lordosis, or

                       abnormal kyphosis................................................................................................ 20

 

                  Forward flexion of the thoracolumbar spine greater than 60 degrees but not

                       greater than 85 degrees; or, forward flexion of the cervical spine greater than

                       30 degrees but not greater than 40 degrees; or, combined range of motion of

                       the thoracolumbar spine greater than 120 degrees but not greater than 235

                       degrees; or, combined range of motion of the cervical spine greater than

                       170 degrees but not greater than 335 degrees; or, muscle spasm, guarding,

                       or localized tenderness not resulting in abnormal gait or abnormal spinal

                       contour; or, vertebral body fracture with loss of 50 percent or more of the

                       height.................................................................................................................... 10

 

Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code.

 

Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion.

 

Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted.

 

Note (4): Round each range of motion measurement to the nearest five degrees.

 

Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis.

 

Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability.

 

 

 

 

 

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Thank you,

Yep I'm currently SC for Lumbar Strain and was putting in for an increase.

In that situation which would hold more weight the combined ROM or the Forward flexion?

It seems like the 2 can overlap and there is a lot of room for interpretation.

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Ended up with 20% for this one.

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Congratulations!

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