degenerative arthritis a little help here Please

[silverdollar22]

I went in for an increase of my back, left knee and left hip.  I was seen by a overly nice female examiner that turns out to be a nurse practitioner and the outcome of this c&p was shocking to say the least!  When we got done talking for a least a half an hour she said "oh this is only for an increase so lets take a look at your back. She never used a geinommeter or any device to measure my ROM but said to turn around and face the chair and bend over which I did to approx. 30 degree range and she said OK that's all we need. The next couple of days i read this on e-benefits  

  Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 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 [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture  Page 20 of 66 Diagnosis #1: Degenerative Disc Disease of the Lumbar Spine ICD code: M47.0 Date of diagnosis: already service connected Diagnosis #2: Lumbar radiculoapthy ICD code: M54.16 Date of diagnosis: already service connected 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Since the veteran is already service connected for his condition, this exam will focus on his current status. He reports pain in his lower back that is rated a "7". He takes Hydrocodone i tab by mouth a few times per week. No surgery to his lower back. He denies that he has had steroid injections, or pain medication injections. He has lumbar radiculopathy that is constant. 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: this will occur about once per week that will last for most of the day with a pain level of a "8-9". Precipitating factors: unknown. 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. limited ROM of the lumbar spine is in itself a functional limitation of the lumbar spine. 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 65 degrees Extension (0 to 30): 0 to 20 degrees Page 21 of 66 Right Lateral Flexion (0 to 30): 0 to 15 degrees Left Lateral Flexion (0 to 30): 0 to 15 degrees Right Lateral Rotation (0 to 30): 0 to 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: limited ROM of the lumbar spine is in itself a functional limitation of the lumbar spine. Description of pain (select best response): Pain noted on exam and causes 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): he does have localized tenderness noted to the lumbar spine on the spinal cord and on either side of the spinal cord. 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? [ ] Yes [X] No If the examination is not being conducted immediately after repetitive use over time: [ ] The examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss with repetitive use over  Page 22 of 66 time. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time. Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: There was a question on the 2507 that asks whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over period of time. There really is no way to predict functional ability during a flare-up when it is not witnessed. This would be subjective, presumptive and speculative at best and an opinion is not feasible and cannot be rendered. 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 d uring 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: There was a question on the 2507 that asks whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over period of time. There really is no way to predict functional ability during a flare-up when it is not witnessed. This would be subjective, presumptive and speculative at best and an opinion is not feasible and cannot be rendered. e. Guarding and muscle spasm  Page 23 of 66 Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No Localized tenderness: [ ] None [X] 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: he walks with a slight forward bend to his back due to the pain 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: Disturbance of locomotion, Interference with sitting, Interference with standing Please describe additional contributing factors of disability: he cannot walk over 15-20 minutes at the time. He cannot sit for greater than 10-20 minutes and standing for over 15 minutes. 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 Page 24 of 66 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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Straight leg raising test ---------------------------- Provide straight leg raising test results: Right: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform Page 25 of 66 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe b. Does the Veteran have any other signs or symptoms of radiculopathy? [ ] Yes [X] No c. Indicate nerve roots involved: (check all that apply) [X] Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) If checked, indicate: [ ] Right [ ] Left [X] Both d. Indicate severity of radiculopathy and side affected: Right: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 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 -----------------------------------------------------------------------  Page 26 of 66 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? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Cane(s) [ ] Occasional [X] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: for his lower back and radicular symptoms 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: No response provided  Page 27 of 66 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? [X] Yes [ ] 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): MRI LUMBAR SPINE W/O (JUN 09, 2014@07:51) Report: MRI Lumbar Spine Sagittal STIR and sagittal and axial T1 weighted, T2 weighted images of the lumbosacral spine were obtained. Findings: Comparison to MRI of the lumbar spine on 8/4/11. Normal alignment of the lumbar sacral spine is visualized. Heterogenuos bone marrow signal is noted likely due to degenerative changes. L5-S1 Modic type II changes. At T12-L1, L1-2 there is disc desiccation, mild diffuse disc bulging with mild facet joint hypertrophy without significant neural foramina narrowing. Normal appearance for the patient's age. At L2 L3 there is a right paracentral and foraminal disc protrusion with extrusion and mild superior migration, producing narrowing of the right lateral recess and posterior displacement of the right L3 nerve root. Protrusion contacts and produce mild displacement of the a right L2 nerve root within the neural foramen. At L3-4 mild disc narrowing and desiccation, diffuse disc bulging without significant central spinal canal narrowing. Mild bilateral facet  Page 28 of 66 joint hypertrophy without significant neural foramen narrowing. Unchanged in comparison to prior At L4-5 there is disc narrowing, bulging and desiccation with moderate facet joint hypertrophy, ligamentum flavum hypertrophy and bilateral mild neural foramina narrowing. Unchanged in comparison to the prior. At L5-S1 severe disc narrowing and desiccation with moderate facet joint hypertrophy, ligamentum flavum hypertrophy and bilateral mild neural foramina narrowing. There is a mild degenerative retrolisthesis of L5 on S1. Unchanged in comparison to the prior. The conus medullaris ends at the lower portion of L2 body. Cauda equina demonstrated no compression. No evidence of paraspinous soft tissue abnormality. Impression: 1. L2 L3 right paracentral and foraminal disc protrusion with extrusion and mild superior migration, producing mild displacement of the right L2 nerve within the neural foramen and the right L3 nerve within the lateral recess. Please correlate clinically for right L2 and/or L3 radiculopathies. 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 has pain in his lower back on a daily basis. He has missed 9 days of work over the past year due specificially to his lower back. 17. Remarks, if any: -------------------- Page 29 of 66 No medical opinion was requested for this already service connected disability.

I checked and they reduced me from 30% to 10% off of this exam!  I checked the cfr and here's what i found

The Spine

   Rating

General Rating Formula for Diseases and Injuries of the Spine

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 kyphosis20

Is it me or according to this it should be rated at at least 20% even with the bad ROM reading?

Edited September 17, 2016 by silverdollar22

[broncovet]

You dont "Nod" an exam, but you can dispute a faulty exam several ways.  First, if there are errors of fact, then the procedure is to file to amend (correct your records).  

You can also challenge the competency of the examiner, if she or he has inadequate medical training or experience.  An examiner is an "expert" witness, and should have expert qualifications.  A nursing degree, and an internet connection is hardly expert qualifications.  BVA remands often require board certified or a signifcant degree of expertise in the applicable field.  Otherwise, you could have your college friend, who has a Phd degree in Information technology, opine that your knee injury is at least as likely as not related to service.  

1.579 Amendment of records.

(a) Any individual may request amendment of any Department of Veterans Affairs recordpertaining to him or her. Not later than 10 days (excluding Saturdays, Sundays, and legal public holidays) after the date or receipt of such request, the Department of Veterans Affairs will acknowledge in writing such receipt. The Department of Veterans Affairs will complete the review to amend or correct a record as soon as reasonably possible, normally within 30 days from the receipt of the request (excluding Saturdays, Sundays, and legal public holidays) unless unusual circumstances preclude completing action within that time. The Department of Veterans Affairs will promptly either:

(1) Correct any part thereof which the individual believes is not accurate, relevant, timely or complete; or

(2) Inform the individual of the Department of Veterans Affairs refusal to amend therecord in accordance with his or her request, the reason for the refusal, the procedures by which the individual may request a review of that refusal by the Secretary or designee, and the name and address of such official.

(Authority: 5 U.S.C. 552a(d)(2))

(b) The administration or staff office having jurisdiction over the records involved will establish procedures for reviewing a request from an individual concerning the amendment of any record or information pertaining to the individual, for making a determination on therequest, for an appeal within the Department of Veterans Affairs of an initial adverse Department of Veterans Affairs determination, and for whatever additional means may be necessary for each individual to be able to exercise fully, his or her right under 5 U.S.C. 552a.

(1) Headquarters officials designated as responsible for the amendment of records or information located in Central Office and under their jurisdiction include, but are not limited to: Secretary; Deputy Secretary, as well as other appropriate individualsresponsible for the conduct of business within the various Department of Veterans Affairs administrations and staff offices. These officials will determine and advise the requesterof the identifying information required to relate the request to the appropriate record, evaluate and grant or deny requests to amend, review initial adverse determinations upon request, and assist requesters desiring to amend or appeal initial adverse determinations or learn further of the provisions for judicial review.

(2) The following field officials are designated as responsible for the amendment ofrecords or information located in facilities under their jurisdiction, as appropriate: The Director of each Center, Domiciliary, Medical Center, Outpatient Clinic, Regional Office, Supply Depot, and Regional Counsels. These officials will function in the same manner at field facilities as that specified in the preceding subparagraph for headquarters officials in Central Office.

(Authority: 5 U.S.C. 552a(f)(4))

(c) Any individual who disagrees with the Department of Veterans Affairs refusal to amend his or her record may request a review of such refusal. The Department of Veterans Affairs will complete such review not later than 30 days (excluding Saturdays, Sundays, and legal public holidays) from the date on which the individual request such review and make a final determination unless, for good cause shown, the Secretary extends such 30-day period. If, after review, the Secretary or designee also refuses to amend the record in accordance with the request the individual will be advised of the right to file with the Department of Veterans Affairs a concise statement setting forth the reasons for his or her disagreement with the Department of Veterans Affairs refusal and also advise of the provisions for judicial review of the reviewing official's determination. (5 U.S.C. 552a(g)(1)(A))

(d) In any disclosure, containing information about which the individual has filed a statement of disagreement, occurring after the filing of the statement under paragraph (c)of this section, the Department of Veterans Affairs will clearly note any part of the recordwhich is disputed and provide copies of the statement (and, if the Department of Veterans Affairs deems it appropriate, copies of a concise statement of the Department of Veterans Affairs reasons for not making the amendments requested) to persons or other agencies to whom the disputed record has been disclosed. (5 U.S.C. 552a(d)(4)) (38 U.S.C. 501)

[Buck52]

Lotz

The best way to add merit to your hubby's claim is go get a private IMO specialist  and let him look at the C&P Exam this Dr did & you can get this Dr to use the G-Meter at his exam for your hubby to show a more through exam.

That will trump this VA Dr Opine 

Add this as your evidence  & try to get it submitted ASAP!

B/C in my opinion it would be hard for the veteran to challenge a C&P simply because were not Medical Dr's and it would just be considered speculative. 

jmo

..................Buck

[silverdollar22]

got my BWE it's white now and they said that they lowered me because of ROM and no pain in location and normal gait which is the opposite of what my C&P said!!  Here's what the C&P said

  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): he does have localized tenderness noted to the lumbar spine on the spinal cord and on either side of the spinal cord.

Localized tenderness: [ ] None [X] 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: he walks with a slight forward bend to his back due to the pain

So i guess they didn't even read my C&P correctly or they would have at least given me 20% for the gait!!  Another thing is that they denied service connection for my knee without a C&P even though my PCP wrote this letter to them:   to whom it may concern vetern , is under ,my care since June 2011. Review of record shows , vet had a MVA in 1984, while in service, that affected his left side, left knee, left side of back , & hip, His hip pain has increased since themn x ray shows degerative arthritis, which in my opinion is as likely as not is a result of trauma to his left side includinghip in 2008 while in service if you have any question or concern, please feel free to contact me /es/ SAROJ B SHARMA MD STAFF PHYSICIAN  

What about this ?  Shouldn't they take this as evidence for my claim of hip pain?

Edited September 20, 2016 by silverdollar22

[Buck52]

silver d

Yes they should use it as evidence...my advice is wait and see?

Did you happen to check this VA Examiner Medical Credentials?

If you feel you should get a higher rating or this is not the correct rating...Appeal the decision!

Then you need to get a IMO from a SPECIALIST! to rebut this VA C&P Examiner.

JMO

......................Buck

 

[silverdollar22]

Buck I did wait and see.  The RN that did my exam also has these as designation APRN, BC  whatever that means? Why would i need a specialist when the facts are in my C&P?  Also isn't my PCP's letter good enough for a nexis to my hip and auto accident in the army?  

 

                                                                     Thanks for all the help by the way!!!

[Buck52]

Silverdollar22

I think APRN.BC

Means that the Nurse has had Advance training and certified in a particular nursing skill.

APRN,BC (Advanced Practice Registered Nurse , Board Certified)

The reason you need a specialist  is  when the VA deny's your claim  even though you have medical Records   obviously they didn't take this Dr's word and disagreed with him/her or the C&P Dr don't opine in your favor such as your case....Now IF YOU HAVE A Specialist in this Field of Medicine ,that Dr can be more through in his exam and his credentials  will trump the other Dr's Opinion.

Most of the time!

That's just the way VA is....we don't know why?