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Low back pain secondary PTSD

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I have chronic back pain and I filed a ptsd claim and I was wondering if this looks like a approval for Low back pain and secondary ptsd?She mentioned The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition.

 

 

1. Diagnostic Summary --------------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?  [X] Yes [ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: Major Depressive Disorder ICD code: F33.1 b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): n/a 3. Differentiation of symptoms ------------------------------ a. Does the Veteran have more than one mental disorder diagnosed? [ ] Yes [X] No c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [ ] No [X] Not shown in records reviewed 4. Occupational and social impairment ------------------------------------- a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [ ] No [X] No other mental disorder has been diagnosed c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBI SECTION II: ----------- Clinical Findings: ------------------ 1. Evidence Review ------------------ Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 2. MENTAL STATUS: Appearance: casually dressed, adequately groomed Activity: normal, no psychomotor agitation or retardation Attitude: polite, cooperative Speech: fluent, coherent Mood: depressed Affect: appropriate, mood congruent Perception: no hallucinations Thought flow: logical, goal directed Thought content: no delusions Thoughts of harm: no suicidal/homicidal ideation Level of consciousness: alert Oriented: to all spheres Attention: good Current Suicide Risk Factors: _X____ Does not have thoughts of suicide or self harm at this time _X____ Does not express feelings of hopelessness or helplessness at this time Current Suicide Assessment: _X____ Low: Patient judged NOT to be at significant risk for self-harm d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran has been arrested twice for domestic violence. He denied recent or pending charges. e. Relevant Substance abuse history (pre-military, military, and post-military): denied  f. Other, if any: n/a 3. Stressors ------------ Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: As an MP, Veteran was among those who responded to a suicide. The EMT's were already there and had taken him down and had him on the stretcher. His job was to interview the family. Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [ ] Yes [X] No Is the stressor related to the Veteran's fear of hostile military or terrorist activity? [ ] Yes [X] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No 4. PTSD Diagnostic Criteria --------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criterion A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criterion A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Criterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violence, in one or more of the following ways: [X] No criterion in this section met. Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:  Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] No criterion in this section met. Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] No criterion in this section met. Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] No criterion in this section met. Criterion F: [X] Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. Criterion G: [X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: [X] The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?: No response provided. 5. Symptoms ----------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses: [X] Depressed mood [X] Chronic sleep impairment [X] Mild memory loss, such as forgetting names, directions or recent  [X] Disturbances of motivation and mood [X] Difficulty in establishing and maintaining effective work and social relationships [X] Difficulty in adapting to stressful circumstances, including work or a worklike setting [X] Inability to establish and maintain effective relationships [X] Suicidal ideation [X] Impaired impulse control, such as unprovoked irritability with periods of violence 6. Behavioral Observations -------------------------- depressed, low energy 7. Other symptoms ----------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [X] Yes [ ] No If yes, describe: irritability, reduced concentration, low energy and fatigue, reduced interest in activities, tearfulness, feeilngs of worthlessness, limited coping and isolativeness; "I try to stay away from people if I can...Sometimes when I am really angry I bite my hand. I do that a lot." 8. Competency ------------- Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks, (including any testing results) if any -------------------------------------------------- The CAPS-5 for the assessment of ptsd was utilized in this evaluation. NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. ****************************************************************************---------------------- Indicate method used to obtain medical information to complete this document: [X] Examination via approved video telehealth Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: 1. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Direct service connection OPINION: Direct service connection Does the Veteran have a diagnosis of (a) PTSD, DEPRESSION, ANXIETY that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) MILITARY POLICE DUTIES during service? Rationale must be provided in the appropriate section. Additional remarks for the examiner: DD214 MOS MILITARY POLICE CAPRI ADJUSTMENT DISORDER ******************************************************************** 2. MEDICAL OPINION REQUEST TYPE OF MEDICAL OPINION REQUESTED: Secondary Service connection.  Secondary Service Connection. Is the Veteran's PTSD, DEPRESSION, ANXIETY at least as likely as not (50 percent or greater probability) proximately due to or the result of low back pain? Rationale must be provided in the appropriate section. If more than one mental disorder is diagnosed please comment on their relationship to one another and, if possible, please state which symptoms are attributed to each disorder. 3. If your examination determines that the Veteran does not have diagnosis of PTSD and you diagnose another mental disorder, please provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed mental disorder is a result of an in-service stressor related event. Additional remarks for the examiner: CAPRI ADJUSTMENT DISORDER b. Indicate type of exam for which opinion has been requested: DBQ PSYCH PTSD Initial TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: 1.& 3. There is no information to make a link or suggeat that the veteran's major depressive disorder was incurred in or caused by the MILITARY POLICE DUTIES during service or that it is a result of an in-service stressor related event. TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR SECONDARY SERVICE CONNECTION ]  a. The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: 2.Veteran describes his back pain as having played a role in his depression while in the military and now. Hence, there is some suggestion by the veteran's statement only that his depressive disorder is linked to or a partial result of his low back pain. ************************************************************************* 

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This is a very unusual C & P exam.

PTSD was diagnosed but no response for criterion # 1. ?

There are 4 specific MH disabilities suggested  and mentioned in the C & P ( That is often  good thing) but-

"There is no information to make a link or suggeat that the veteran's major depressive disorder was incurred in or caused by the MILITARY POLICE DUTIES during service or that it is a result of an in-service stressor related event. "

Also it appears that the examiner did diagnose PTSD but not attribute your PTSD to your service, or as cause of the back problem.

And this does not quite make sense to me:

 "The condition claimed is at least as likely as not (50% or greater probability) proximately due to or the result of the Veteran's service connected condition. c. Rationale: 2.Veteran describes his back pain as having played a role in his depression while in the military and now. Hence, there is some suggestion by the veteran's statement only that his depressive disorder is linked to or a partial result of his low back pain. "

Also this:

 Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation?  [X] Yes [ ] No 2. Current Diagnoses -------------------- a. Mental Disorder Diagnosis #1: M Major Depressive Disorder ICD code: F33.1 

Have you already been formally service connected for Major Depressive disorder?

In that case it would make sense but I am not sure that would prompt a secondary SC award for the back condition. Do your SMRs reveal any back problems and treatment?

I dont know if "low back pain" is even ratable. I assume you have not had  a C & P for the back pain condition?

I hope the C & P exam has a signature and that you google the name to make sure this was a real MH professional who did the C & P.

Others might have a different opinion than mine and they will chime in.

Can you tell us what the 60% SC is for?

 

 

 

 

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I have 40 percent for frequent urination. And 10 percent lumbar straine and 10 percent for pes planus. I complain about pain a lot during my mental health appointments. I have been rated for low back pain for about 8 years now. Think their trying to make it service connection by saying my back pain is related to ptsd. 

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I am not familiar with the lumbar strain ratings (they are here in the VA Schedule of Ratings link below)

but wonder if the back pain was included in that rating and maybe the 10% is way too low, since they first made it.

It is odd -----that I was going to ask you if you had pes planus because severe pes planus and pronation can definitely cause lower back pain.

I attributed my chronic lower back pain to all the work I did in my lifetime, particularly when I raised livestock but the very first morning after I woke up, and had just worn custom orthotics the night before, for the first time, my chronic  back pains disappeared !!!!!!!!!!

When I first saw my podiatrist the first question on the medical Hx form was Do you have chronic back pain.?

Severe foot conditions can completely through off the alignment of our spine.

But I am not a doc , and also I am not a veteran, so I will try to find the rating info in the VA SRD and post it here.

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These two BVA decisions contain rating info from the VA SRD that might help you:

"Under 38 C.F.R. § 4.71a, Diagnostic Code 5295, the maximum 40

percent evaluation is warranted for lumbosacral strain that

is severe with listing of the whole spine to opposite side,

positive Goldthwait's sign, marked limitation of forward

bending in standing position, loss of lateral motion with

osteo-arthritic changes, or narrowing or irregularity of

joint space, or some of the above with abnormal mobility on

forced motion.  A 20 percent evaluation is appropriate when

lumbosacral strain is accompanied by muscle spasm on extreme

forward bending, loss of lateral spine motion, unilateral, in

standing position.  A 10 percent evaluation is warranted when

there is characteristic pain on motion, and a zero percent

evaluation is assigned when lumbosacral strain is manifested

by slight subjective symptoms only.  38 C.F.R. § 4.71a,

Diagnostic Code 5295 (2001).

Under Diagnostic Code 5292, a 10 percent rating is assigned

for limitation of motion of the lumbar spine when limitation

is slight, 20 percent when moderate and 40 percent when

severe.  38 C.F.R. § 4.71a, Diagnostic Code 5292 (2001).

 

The Court has held that functional loss, supported by

adequate pathology and evidenced by visible behavior of the

veteran undertaking the motion, is recognized as resulting in

disability.  See DeLuca v. Brown, 8 Vet. App. 202 (1995); 

see also 38 C.F.R. §§ 4.10, 4.40, 4.45 (2001)."

What Diagnostic code are they using for your lumbar strain and when was the 10% award made?

This BVA  decision also shows the Pes Planus ratings, higher with severe pronation.

"B.  Bilateral Pes Planus

 

The Veteran's service-connected bilateral pes planus is currently assigned a 30 percent rating under Diagnostic Code 5276.  Under this diagnostic code, acquired flatfoot which is mild, with symptoms relieved by built-up shoe or arch support, warrants a noncompensable rating.  When it is moderate, with weight-bearing line over or medial to great toe, inward bowing of the tendo Achilles, pain on manipulation and use of the feet, a 10 percent rating is warranted for bilateral or unilateral disability.  When it is severe, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities, a 30 percent rating is warranted for a bilateral disability.  When it is pronounced, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on mancipation, not improved by orthopedic shoes or appliances, a 50 percent rating is warranted for bilateral disability.  38 C.F.R. § 4.71a, Diagnostic Code 5276.

 

Is that same DC they used for your pes planus rating? And how long  ago was that rating made?"

https://www.va.gov/vetapp02/files03/0214345.txt

I think your ratings for these separate disabilities might be way to low. Hard to tell.

Severe pronation and pes planus does not get better, it gets worse. I need new orthotics almost every year.

 "Had kidney problems in the military too. Also had a recent exam for arthritis of the back. "

Your SC for urination is surely due to the kidney problems in service. Have the affects of that SC gotten worse?

What diagnostic code are they using for the urination disability?

 

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And, it appears you do not have any rating at all for any MH issues nor formally claimed them ?

 

The arthritis back exam will tell more but it looks to me like you could get higher ratings for the Pes Planus, the lumbar condition and even the kidney disorder......depending on if your medical evidence warrants a higher rating..that is wh6y I asked how long ago those above ratings were made.

Would you be able to scan and attach here their decision based on the above C & P exam when you get it?

(Cover C file # , name prior to scanning it)

 

 

Edited by Berta
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