rhdawgs

Starting in Jan 2020 any vet with a SC Disability will have access to MWR facilities thanks to the H.R.5515 - John S. McCain National Defense Authorization Act for Fiscal Year 2019." Subtitle C—Other Matters SEC. 621. EXTENSION OF CERTAIN MORALE, WELFARE, AND RECREATION PRIVILEGES TO CERTAIN VETERANS AND THEIR CAREGIVERS. (a) SHORT TITLE.—This section may be cited as the ‘‘Purple Heart and Disabled Veterans Equal Access Act of 2018’’. (b) COMMISSARY STORES AND MWR FACILITIES PRIVILEGES FOR CERTAIN VETERANS AND VETERAN CAREGIVERS.— (1) EXTENSION OF PRIVILEGES.—Chapter 54 of title 10, United States Code, is amended by adding at the end the following new section: ‘‘§ 1065. Use of commissary stores and MWR facilities: certain veterans and caregivers for veterans ‘‘(a) ELIGIBILITY OF VETERANS AWARDED THE PURPLE HEART.— A veteran who was awarded the Purple Heart shall be permitted to use commissary stores and MWR facilities on the same basis as a member of the armed forces entitled to retired or retainer pay. ‘‘(b) ELIGIBILITY OF VETERANS WHO ARE MEDAL OF HONOR RECIPIENTS.—A veteran who is a Medal of Honor recipient shall be permitted to use commissary stores and MWR facilities on the same basis as a member of the armed forces entitled to retired or retainer pay. ‘‘(c) ELIGIBILITY OF VETERANS WHO ARE FORMER PRISONERS OF WAR.—A veteran who is a former prisoner of war shall be permitted to use commissary stores and MWR facilities on the same basis as a member of the armed forces entitled to retired or retainer pay. ‘‘(d) ELIGIBILITY OF VETERANS WITH SERVICE-CONNECTED DISABILITIES.—A veteran with a service-connected disability shall be permitted to use commissary stores and MWR facilities on the same basis as a member of the armed forces entitled to retired or retainer pay" ‘‘1065. Use of commissary stores and MWR facilities: certain veterans and caregivers for veterans.’’. (3) EFFECTIVE DATE.—Section 1065 of title 10, United States Code, as added by paragraph (1), shall take effect on January 1, 2020.

Actaully 60&, 10% & 10% ='s 70% in the VA Math World...

Buck52, Thank you for your service and and especially the comments. I was recently granted 80% SC 70% for PTSD, 20% lower back, 20% spine/Neck and Tinnitus is deferred.. I have my 1st scheduled post SC appointments for back/neck and PTSD on Nov 14th, I will be very cautious while I am there. Sorry if that's offends anyone, but I'm not taking any chances.

Navy04, sorry I haven't responded before now but my Dr advised me to "Live with the pain" since my bulging disc is going away from my spine instead of into it, which I am grateful for that. However, my pain is still there every single day, hurting now as I sit on the couch typing this...Hopeing to hear something in the next few weeks about ALL of my C&P's etc. Good luck, I hope that you are healing up!

So here's a couple of more questions and like I said, terribly sorry I don't have a soft copy of the DBQ, done by QTC and only have hard copy. The Evaluater listed symptoms from the 70% down to 30% and under section 4 "Occupational and Social Impairment section", Dr checked diagnosis that would qualify for a rating of 50% "Occupational and social impairment with reduced reliability and productivity". I personally think that a rating of 50% would be fair and would be extremely surprised if I received 70% (even though I have several in the 70%) but I WOULD NOT BE SURPRISED if I received 30%, or 0% rating, guess that's just me and my pessimism. I don't want to put the cart before the Horse because even though the examiner states that he believes my PTSD is a direct result of my Military stressors from my time in Iraq, it sounds like they could still disagree and not award me SC or say it is SC and give me 0%, so who the FREAK knows I guess. But this is what he selected in my symptoms, I have some in the 70% and some as low as 30% From the General Rating Formula for Post-Traumatic Stress Disorder my symptoms are BOLDED. From the DSM-5 Criteria Diagnostic Critieria sheet, I had several in everyone of the Options from A-E and 1 through F-G on each and in I: 2 Stressors that met Criteria A. In the Symptoms section, BOLD is what he checked...Just confused since they are all over the board. Also, is it really that subjective and unknown depending on the rater that this could go anywhere from 0%-70%? Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. = 100% Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. = 70% Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. =50% Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). = 30% I think the Dr simply selected the 50% option since I had several fall in both the 70% and 30% with 1 in the 50%, just from past experiences what do you guys think about a possible rating? I appreciate any all thoughts and comments.

Broncovet, Thank you very much for responding. So in my report yes, he states that both of my stressor's meet the criteria A for PTSD....Sorry, only have a hard copy of the Results at this point...

Hello, I recently had my C&P exam for PTSD. The Dr did diagnose me with PTSD and I certainly met ALL the requirements according to the DSM-5 Criteria. When I filed my claim with DAV, I had made a claim for the following mental disabilities: PTSD, Panic disorder and /or/ agoraphobia, social anxiety disorder, & unspecified depressive disorder. The QTC Dr made a strong case for PTSD and certainly diagnosed me with PTSD and checked the box "Occupational and Social Impairment with Reduced Reliability and Productivity" He never did list any of the other disorders in my claim, although he states that due to my PHQ-9 score of 23 reflects I have severe depression and he also states that my PTSD checklist score(PCL-5) was 68. In the report he does check the box "The claimed condition was at least as likely as not(50% or greater probability) incurred in or caused by the claimed in-service injury, event, illness." He sighted my 2 stressors as evidence of the diagnosis for PTSD. Also, no sign of a GAF score, did they discontinue using it? The only one that is in my report was from 2005 when I originally went to VA but had NO CLUE what I was doing except I knew I needed help, WAY BACK THEN. When my VRO looked at the report he stated that it was good he didn't diagnose me with anything other than PTSD, why would that be? I hear of people stating they have a SC for PTSD with a secondary of Anxiety disorder. Just a little confused.... Sorry so long, I tried to list some things in the report without throwing the entire thing in here, but can do it if needed. Thank you. I can post the DBQ and the "short" report of his findings if needed, just figured it may be to much....

I apologize for this rant, but this post sickens me.... This is the kind of stuff that make ALL of us Vets weary of the VA. Are you kidding me? This Vet made it home from Nam, obviously has already proved his SC disability years ago an the VA wants to strip this SMALL stipend from am American Warrior. I understand that that we vets need to make certain we are 100% honest when attending a C&P exams, but lets be clear on 1 thing...The VA rep is certainly looking for signs, triggers or certain words used to "apply" what they believe is the correct rating or diagnosis... For those of you who disagree with me, here's a perfect example...You go into a C&P for PTSD, you state you have been having bad "dreams" the details of these "Dreams" are already being scrutinized because you didn't use the word "NIGHTMARES"!!!!! WOW. The other is more obvious and has been stated many times on this site and that is "How are you doing today?" Answer that question honestly, if you feel like a ball of nervousness that wants to freakin run away, tell then that. PLEASE VA, leave this Vet alone and let him enjoy the rest of his life....

Hamslice, no sir was in the Army. Thank you for responding, maybe I can call the VA today. I will post if I find anything out.

Hello everyone, I have now completed 2 of my 3 C&P's, took a look at Ebenefits and noticed that for Request 3 it simply has the following after it "Request 3 DBQ ADMIN CLCW" My C&P's that I have completed were for Back/Cervical and Hearing Tinnitus. Does anyone know what that means? When doing my own research I keep seeing Camp Lejune Contaminated Water claims....I've never been to Camp Lejune and obviously none of my claims has anything to do with Contaminated water... Thank you

Navy04, I agree. Hopefully with the medical documentation and the stressor statements I submitted, that's good enough. Thank you.

Thanks Hamslice, I appreciate the comment.. It's weird, my journey started in 2005 when I returned from Iraq, but I was very ignorant and naive concerning the entire process. After looking through my records, it appears at though I missed a C&P for eother PTSD or my neck and back..(Can't remember), only after strong recommendations from my family doctor (who is a DR in the Army reserves) and discussions woth several buddies I met with at a reunion earlier this year did I even know what I needed to do, what this ringing in my ears was etc... This site and a few others have been nothing but AWESOME in gathering needed information. So like I said in my first post, if they rate the cervical and back separately, there is a chance that I could get 20% SC for both, but I also know there is a chance I could get 0%, so time with tell. Thanks again.

Thank you and good luck on your increase request.. thanks also to both of you for answering my questions... I’m thinking it can go anywhere between 0-20%, I guess we’ll have to wait and see.

Hello everyone, newbie here, so I apologize if I have WAY to much info or posted in wrong place. First, I would like to thank everyone for their service or their family members service to this great country. I also want to give props to this site, WOW, just by reading many threads I have learned SO MUCH, so THANK YOU ALL! I just my results back from my C&P's for my Neck (Cervical Spine) and Back (Thoracolumbar Spine). If the rater goes off of the ROM alone and if it is deemed SC then I think I should get at least 10% SC for Neck/Spine and 10% SC for lower back. (I have evidence in my files confirming the fall and going to TMC because of Neck & Back Pains while in Iraq etc.) I read on here where someone mentioned to pay attention to things like "Arthritis", I noticed in both my reports that the Arthritis question is answered as YES. CERVICAL: a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No BACK: 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 Here's my questions: 1. Does having Arthritis with images possibly increase the percentage of disability, decrease the percentage or they simply just stick with ROM when determining SC disability percentage? 2. My forward Flexion in Spine and Back are 30 or less and 50 or less, should that put me @ 20%, if these are given SC status? 3. Do they normally just rate ALL of these conditions as 1 and basically just give either the 10%-20% SC? Also, anyone with knowledge of general ratings care to let me know what they think about the report, SC, Possible percentages etc. would be greatly appreciated. Thank you. Posting both full C&P's for reference below. *** C&P GENERAL MEDICAL Has ADDENDA *** Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXXXXXXXX Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination [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 cervical spine (neck) condition? [X] Yes [ ] No [ ] Ankylosing spondylitis [X] Cervical strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: Strain ICD code: S13.8XXA Date of diagnosis: 2004 Diagnosis #2: Multilevel uncovertebral arthritis ICD code: M50.30 Date of diagnosis: 2017 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's cervical spine (neck) condition (brief summary): Does the Veteran have a diagnosis of (a) Neck pain that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) injury during service? There is a LOD dated 07/13/2004 where the veteran was seen and treated for an injury to his neck and back while in service. The veteran reports that since the time of his fall, he has experienced neck and back pain that increases with activity. --------------------------------------------------------------------------------------------------------------------------- =========================================================== Note Text LOCAL TITLE: 1010M MEDICAL CERTIFICATE STANDARD TITLE: ADMISSION EVALUATION NOTE DATE OF NOTE: JUL 22, 2005@12:34 ========================================================== TRIAGE HISTORY --------------------------------------------------------- ----CHIEF COMPLAINT:back pain that started over 1 yr ago while deployed in Iraq, onset in assoc with wearing the gear required, body armor, weapon, helmet, etc. back pain is across low back , does not radiate. Has stiffness in am, pain worsens as day progresses and varies according to activity, increased pain at night, interferes with sleep. Has records from visit while on active duty 9/04, indicates rx was naprosyn and robaxin, patient says he was given light duty consisting of no additional lifting, but had to continue usual carrying of pack and vest. rx was ineffective. --------------------------------------------------------- --------------------------------------------------------- ----HX. OF PRESENT ILLNESS: as above, he initially also had neck pain but this has improved and is minor. back pain however, is daily , constant, with associated stiffness. saw family doctor who prescribed toradol, it did not help. has taken vicodin that belonged to family member, it did help, just took a couple. currently taking tylenol or alleve intermittently. xray result unknown to patient. denies numbness or weakness in legs. sometimes limps but this is due to his back pain and guarding. Is not exercising regularly, occasional golf. does stretching at times but not regularly. swims occasionally. -------------------------------------------------------------------------------------------- b. Dominant hand: No response provided c. Does the Veteran report flare-ups of the cervical spine (neck)? [X] Yes [ ] No If yes, document the Veteran's description of the flare-ups in his or her own words: The veteran reports neck pain with prolonged sitting erect or when turning his head from side to side. d. Does the Veteran report having any functional loss or functional impairment of the cervical spine (neck) (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: The veteran reports neck pain with prolonged sitting erect or when turning his head from side to side. 3. Range of motion (ROM) and functional limitations --------------------------------------------------- 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 (0-45): 0 to 30 degrees Extension (0-45): 0 to 40 degrees Right Lateral Flexion (0-45): 0 to 35 degrees Left Lateral Flexion (0-45): 0 to 35 degrees Right Lateral Rotation (0-80): 0 to 60 degrees Left Lateral Rotation (0-80): 0 to 60 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Decreased ROM interferes with the veteran turning his head from side to side, interferes with driving when needing to look side too side when changing lanes. Description of pain (select best response): Pain noted on examination and causes functional loss If noted on examination, 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 joint or associated soft tissue of the cervical spine (neck)? [X] Yes [ ] No If yes, describe including location, severity and relationship to condition(s): Pain at posterior neck on palpation. 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: [X] 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 time. Please explain. [ ] The examination is neither medically consistent nor 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 [X] No [ ] Unable to say w/o mere speculation d. Flare-ups Is the examination being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [X] 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. [ ] The examination is neither medically consistent nor 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 [X] No [ ] Unable to say w/o mere speculation e. Guarding and muscle spasm Does the Veteran have guarding, or muscle spasm of the cervical spine? [ ] Yes [X] No 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: Less movement than normal due to ankylosis, adhesions, etc., Interference with sitting, Interference with standing 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 Elbow 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 Elbow 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 Wrist 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 Wrist 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 Finger 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 Finger Abduction 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 Biceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Triceps: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Brachioradialis: Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+ 6. Sensory exam --------------- Provide results for sensation to light touch (dermatomes) testing: Shoulder area (C5): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent Hand/fingers (C6-8): Right: [X] Normal [ ] Decreased [ ] Absent Left: [X] Normal [ ] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [ ] Yes [X] No 8. Ankylosis ------------ Is there ankylosis of the spine? [ ] Yes [X] No 9. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities related to a cervical spine (neck) condition (such as bowel or bladder problems due to cervical myelopathy)? [ ] Yes [X] No 10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the cervical spine? [ ] Yes [X] No 11. 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 b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 12. Remaining effective function of the extremities ---------------------------------------------------- Due to a cervical spine (neck) 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.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 13. 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. 14. Diagnostic testing ---------------------- a. Have imaging studies of the cervical spine been performed and are the results available? [X] Yes [ ] No If yes, is arthritis (degenerative joint disease) documented? [X] Yes [ ] No b. Does the Veteran have a 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): SPINE CERVICAL MIN 4 VIEWS Exm Date: OCT 02, 2017@11:55 Reason for Study: C&P Exam Clinical History: Pain fall from truck Report: Findings: There is straightening of the cervical spine compatible muscle spasm. No fracture or dislocation. No focal lytic or sclerotic osseous lesion. No degenerative disc disease. There is C5-6 uncovertebral arthritis with bilateral neuroforaminal narrowing. There is also left-sided foraminal stenosis at C3-4 and C4-5. Impression: 1. Straightening of the cervical spine due to muscle spasm. 2. Multilevel uncovertebral arthritis with bilateral neuroforaminal -------------------------------------------------------------------------------------------------------------------------------------------------------------- Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: 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: No response provided. Diagnosis #1: Multilevel annular bulging ICD code: M51.36 Date of diagnosis: 2005 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Does the Veteran have a diagnosis of (a) Back pain that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) injury during service? There is a LOD dated 07/13/2004 where the veteran was seen and treated for an injury to his neck and back while in service. The veteran reports that since the time of his fall, he has experienced neck and back pain that increases with activity. 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: The veteran reports constant lower back pain that increases with prolonged sitting, standing, walking, bending, lifting, pushing and pulling motions. He reports increased pain when exposed to cold damp weather. 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. The veteran reports constant lower back pain that increases with prolonged sitting, standing, walking, bending, lifting, pushing and pulling motions. He reports increased pain when exposed to cold damp weather. 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 50 degrees Extension (0 to 30): 0 to 25 degrees Right Lateral Flexion (0 to 30): 0 to 25 degrees Left Lateral Flexion (0 to 30): 0 to 25 degrees Right Lateral Rotation (0 to 30): 0 to 30 degrees Left Lateral Rotation (0 to 30): 0 to 30 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: Decreased ROM interferes with stair climbing, lifting and bending. 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 Is there evidence of pain with weight bearing? [X] Yes [ ] 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): Pain at mid lumbar region on palpation. 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: [X] 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 time. Please explain. [ ] 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 [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: [X] 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. [ ] 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 [X] No [ ] Unable to say w/o mere speculation 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: Guarding: [ ] None [ ] Resulting in abnormal gait or abnormal spinal contour [X] Not resulting in abnormal gait or abnormal spinal contour [ ] Unable to evaluate, describe below: 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: Less movement than normal due to ankylosis, adhesions, etc.,Disturbance of locomotion, Interference with sitting, Interference with standing 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 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 b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: No response provided. 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 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): SPINE LUMBOSACRAL 2 OR 3 VIEWS Exm Date: OCT 02, 2017@11:55 Reason for Study: C&P Exam Clinical History: Multiple bulging disc, Fall from truck Report: Findings: 5 lumbar-type vertebral bodies are seen. No fracture or dislocation. No compression fracture. No focal lytic or stenotic osseous lesion is seen. There is no significant facet arthritis. Mild L5-S1 degenerative disc disease is noted. The sacroiliac joints are normal. Impression: 1. Mild L5-S1 degenerative disc disease. =================================================================== =========== Exam Date/Time 09/29/2005 13:00 Procedure Name MRI LUMBAR W/O CONTRAST Clinical History pain in the back Report T1 and fast spine echo t2 weighted sagittal imaging was performed through the lumbar spine. this was augmented by thin section axial imaging through the lower three lumbar levels. The vertebral bodies are normal in heighth and signal intensity. the intervrebral disk spaces are maintained. minimal desiccative changes are present at the level of l5-s1. thin section axial imaging reveals a normal l3-l4 disk. minimal annular bulging is seen at the level of l4-l5 without encroachment upon the thecal sac or exiting nerve roots. similar change is seen at the level of l5-s1, again without encroachment upon the thecal sac or exiting nerve roots. the conus medullaris is well seen and is of normal contour and signal intensity. Impression Multilevel annular bulging without significant canal stenosis. 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: The veteran reports constant lower back pain that increases with prolonged sitting, standing, walking, bending, lifting, pushing and pulling motions. He reports increased pain when exposed to cold damp weather. 17. Remarks, if any: -------------------- No remarks provided. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: XXXXXXXXXXXXXXXXXXXXX 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 MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: Does the Veteran have a diagnosis of (a) Back pain that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) injury during service? b. Indicate type of exam for which opinion has been requested: Back TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] a. The condition claimed was at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: Conclusion/Raationale: The claim file has been reviewed. Does the Veteran have a diagnosis of (a) Back pain that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) injury during service? Based on the claim file review, there is evidence that the veteran suffered injuries to his neck and back as the result of a fall from a truck. MRI findings revealed multilevel annular bulging without significant canal stenosis. Based on the claim file review as well as the veteran's current diagnosis and symptoms, it is my opinion that the veteran's multilevel annular bulging without significant canal stenosis is at as least as likely as not (50 percent or greater probability) incurred in or caused by (the) injury during service. *************************************************************************