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Found 14 results

  1. If the V.A. is issuing you medication, let's just say it's for back pain, does that mean your about to when your claim? Sorry guys about the initial post. Thanks for those that have answered!
  2. I submitted my supplemental claim 3 days ago for the following diagnosis with evidence: - Flat Feet (Primary) - Bilateral Plantar Fasciitis (Secondary) - Bilateral Pronation to mid and rear foot (Secondary) - Intra-articular Hip Pain (Primary) - Femoroacetabular Impingement (Secondary) - Right Adductor Groin Pain (Tertiary) - Athletic Pubalgia (Tertiary) - Osteitis Pubis (Tertiary) - Right Knee Pain - Low Back Pain - Left Tennis Elbow - Bilateral Tinnitus The VA updated va.gov 2 days ago with these pending diagnosis: - Impairment of femur - Flatfoot - Limitation of leg motion (flexion) - Lumbosacral or cervical strain - Limitation of forearm motion (flexion) - Tinnitus Through my own insurance, for all of the injuries listed in the first group of injuries above, I got doctors to diagnose me with them and they added, "More than 51% probable that the injuries occurred during military service" since the same injuries got denied in the past. I used those evidences to file my supplemental claim. I called the VA today to request for them to change what they put back to how I had it. The missing items like "Pronation", I had them annotate where to find the diagnosis on the doctors notes so that they can add it. I think they overlooked it. They also left out my right adductor pain. For the hip injury, it's not just, "Impairment of femur" as they put it. Why did they do this? Are they trying to gyp me? Why didn't they annotate the secondaries and the tertiaries like I annotated it? Instead of "Right Knee Pain" they put "Limitation of leg motion (flexion)". For "Low Back Pain" they put "Lumbosacral of Cervical Strain." For "Left Tennis Elbow" they put "Limitation of forearm motion (flexion)". Are they trying to gyp me or did I make the mistake of calling them asking them to change it back to how I had it?
  3. I am a little confused, I have "psoriatic arthritis, also claimed as back condition" as my current and only rated condition 20%, which was from my initial claim 10 years ago. They were submitted as 2 different items, "back pain" & "psoriatic arthritis" but combined. Anyway, I submitted a claim in september for an increase to my P.A. and a few other new claims related to tgr P.A. and had C&Ps in November. I have been waiting ever since with no updates, denials, deferrals, granted claims etc. Last week I get a call for a contractor exam about my back. I was a bit confused, about why I was having the exam but it is what it is so I went today. The examiner said "you are not rated for a back condition, you have no official diagnosis for your back, it just says back pain." "I don't know why you had an x-ray without a diagnosis, the x-ray said there was no arthritis in your back. So I don't know why they combine these as a single rating." I am not entirely sure why I had this exam, it makes me a little nervous about all of this. 1.) Any reasons my 5(in total including P.A. increase) claims would have no decisions made at all after nearly a year? 2.) Should I be prepared for bad news? Is it likely they will just deny all of them because they have not done any grants approved? 3.) Has anyone had an issue like this they can shed some light? 4.) Assuming there are no further exams, is 4-6 weeks a good guess for a decision length from this C&P?
  4. This is my latest C&P what am I looking at? Can anyone break this down? Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No Evidence Comments: BOARD REMAND 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a cervical spine (neck) condition? [X] Yes [ ] No Cervical Spine Common Diagnoses: No diagnosis provided. Diagnosis #1: CERVICO-OCCIPITAL NEURALGIA ICD code: == Date of diagnosis: 9/28/2015 Diagnosis #2: CERVICAL RADICULOPATHY WITH BULGING DISC ICD code: == Date of diagnosis: 2016 Diagnosis #3: MECHANICAL CERVICAL PAIN SYNDROME ICD code: == Date of diagnosis: 4/29/2015 If there are additional diagnoses that pertain to cervical spine (neck) conditions, list using above format: CERVICAL VERTEBRAE(NECK MUSCLE SPASM), DATE OF DIAGNOSIS, 6/25/1996. CERVICAL HERNIATED AND BULGING DISC, MUSCLE SPASM, AND CORD CONTUSION WITH COMPRESSION MYELOMALACIA, 8/14/12 CERVICAL SPONDYLOSIS AND DEGENERATIVE DISC DISEASE, 9/25/2014. On today's C&P examination, 11/21/17, Veteran reports several incidents in 1992-1995 of blunt trauma including carrying 50 caliber machine gun barrels and ammunition. Involved in ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Also went to Bethesda for back school(approx. week). Currently, Veteran reports daily neck pain. Denies neck surgery. Denies no recent physical therapy. Uses Flexeril, Ibuprofen, Oxycodone, and Tens unit for pain relief. Last treated by chiropractor in 2016(Tampa Bay, Florida). b. Dominant hand: [ ] Right [ ] Left [X] Ambidextrous c. Does the Veteran report flare-ups of the cervical spine (neck)? [ ] Yes [X] No 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: Can't do much of any type of physical activity, that's really limited. Obviously a hindrance, job related stuff. Multiple days off from work(pain, stiffness). Can't do lawn activities. Can't wash dishes. Can't play with your kids like you want to. Sleeping is impossible-Sometimes you have to sleep sitting up in a chair. 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 46 degrees Extension (0-45): 0 to 15 degrees Right Lateral Flexion (0-45): 0 to 23 degrees Left Lateral Flexion (0-45): 0 to 14 degrees Right Lateral Rotation (0-80): 0 to 48 degrees Left Lateral Rotation (0-80): 0 to 44 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes, (please explain) [ ] No If yes, please explain: Limited bending. 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? [X] Yes [ ] 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): Tenderness on palpation of the cervical spine. b. Observed repetitive use Is the Veteran able to perform repetitive use testing with at least three repetitions? [ ] Yes [X] No If no, please provide reason: Unable to perform due to severe pain. 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 time. Please explain. [X] 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 [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: This examiner is unable to opine and would otherwise be speculating to state whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over a period of time. Therefore this examiner cannot describe any such additional limitation due to pain, weakness, fatigability or incoordination. Furthermore, such opinion is also not feasible to give degrees of additional ROM loss due to "pain on use or during flare-ups" without speculation. d. Flare-ups Not applicable e. Guarding and muscle spasm Does the Veteran have guarding, or muscle spasm of the cervical spine? [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. Please describe: Decreased ROM. 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: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Flexion: Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Finger Abduction Right: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [ ] 5/5 [X] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 b. Does the Veteran have muscle atrophy? [X] Yes [ ] No If muscle atrophy is present, indicate location: Upper Arm Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side: 37.5 cm. Atrophied side: 36 cm. 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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Inner/outer forearm (C6/T1): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent Hand/fingers (C6-8): Right: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] Decreased [ ] Absent 7. Radiculopathy ----------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? [X] Yes [ ] No If yes, complete the following section: a. Indicate location and severity of symptoms (check all that apply): Constant pain (may be excruciating at times) Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Intermittent pain (usually dull) Right upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left upper extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Numbness Right upper extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left upper 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 C8/T1 nerve roots (lower radicular group) 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 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? [X] Yes [ ] No b. If yes to question 10a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] 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): 9/25/2014,MRI Cervical spine:Visibility of the central canal of the cord at the C5 level with diameter of 2mm, not considered to reflect significant syringohydromyelia and not associated with mass or abnormal enhancement. Spondylosis and degenerative disc disease of the cervical spine. Right-sided predominant disc osteophyte complex at C6-7 causes mild right central canal and moderate right neural foraminal stenosis at this level. No other central canal stenosis with milder areas of neural foraminal encroachment detailed above. C2-3:Focal shallow central to right paracentral disc protrusion. No central canal or neural foraminal stenosis. C3-4:Mild generalized disc bulge. Mild right than left neural foraminal stenosis with central canal patent. C6-7:Mild generalized disc bulge with more focal disc osteophyte complex in the right paracentral, right subarticular, and right lateral stations. C7-T1:Negative for disc herniation. 8/14/2012, MRI Cervical spine:Herniated disk C3/4, C5/6, and C6/7 levels. Bulging disk C2/3 and C4/5 levels. Diffuse spondylitic changes. Straightened alignment suggesting muscle spasm. Focal area of cord contusion or compression myelomalacia at C5 level. 15. Functional impact ---------------------- Does the Veteran's cervical spine (neck) condition impact on his or her ability to work? [X] Yes [ ] No If yes, describe the impact of each of the Veteran's cervical spine (neck) conditions, providing one or more examples: Veteran is capable of limited lifting, carrying, and bending. 16. Remarks, if any: -------------------- NOTE:Veteran performed neck flexion repeition which reduced ROM to 32deg. Unable to perform any further repetition for other ROM maneuvers. ************************************************************************* Additional exam request information: For any joint condition, examiners should test the contralateral joint, unless medically contraindicated, and the examiner should address pain on both passive and active motion, and on both weightbearing and non- weightbearing. In addition to the questions on the DBQ, please respond to the following questions: 1. Is there evidence of pain on passive range of motion testing? YES 2. Is there evidence of pain when the joint is used in non-weight bearing? YES **************************************************************************** Medical Opinion Disability Benefits Questionnaire Name of patient/Veteran: 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 Evidence Comments: BOARD REMAND MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: (a) Please state all diagnoses as to the Veteran's cervical spine, and address all diagnoses already of record: herniated disk and bulging disk of the cervical spine and spondylitic changes, muscle spasm and contusion/compression, spondylosis and degenerative disc disease of the cervical spine, mechanical cervical pain syndrome and radiculopathy. (b) Please provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed cervical spine disability was caused by or etiologically related to active duty. Please specifically address the back injuries and complaints of back pain noted in the STRs. (c) Please specifically address the Veteran's lay statements that he has suffered cervical spine pain since service, and that in service he suffered injury to his neck while carrying heavy equipment and continuous wear of duty gear. (d) Please address the conflicting evidence of record and offer a clarifying opinion, notably the February 2013 VA examination positing a negative nexus, and the April 2016 private opinion positing a positive nexus. b. Indicate type of exam for which opinion has been requested: NECK 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: Upon review of all available medical evidence, including eVBMS, virtual VA, and Board Remand, the following pertinent information is obtained and reported in 'Evidence Comments': Prior VA Examination, 6/25/96, reports Mr. served in the Marine Corps. he was inducted in 1990 and received separation with an honorable discharge in 1996. Medical History-In 1992, he had onset of pain in the neck area diagnosed at Quantico. Xrays were negative. Impression was muscle spasm and stress. Enlistment RME/RMH for national guard, 4/13/98, reported no neck problems and normal exam of the spine. Miami VAMC, Outpatient clinic, 5/6/2005:Assessment is chronic neck and low back pain-Will get plain films and MRI, does not want any meds. 2/28/2013, VA examination opines "Unable to find SMR evidence of significant neck injury or complaint in service. No evidence to support chronicity of problem for over 10 years post-discharge." THIS OPINION IS GIVEN LOW WEIGHT BECAUSE IT IS NEITHER SUPPORTED NOR CONSISTENT WITH THE RECORDS IN FILE THAT SHOW COMPLAINTS OF NECK PAIN INDICATING A CHRONIC CONDITION. 4/29/15, DBQ neck was completed providing a diagnosis of mechanical cervical pain syndrome and radiculopathy. As received 4/8/16, VA physician, , states that the Veteran suffers from cervico-occipital neuralgia and cervical radiculopathy with bulging disc "are as likely as not a direct result of blunt trauma received during the patient's military career. His conditions are a severe occupational impairment to the veteran and has been exacerbated by many years of continuous wear of duty gear related to his profession." On today's C&P examination, 11/21/17, Veteran is a credible historian and reports several incidents in 1992-1995 of blunt trauma, involving ground defensive tactic also known as "Bull in the Ring" in which the marine is in full gear and is potentially tackled by several marines. Following this , Veteran incurred concussion-1992 or 1993). Veteran also reported chronic neck pain during service was due to carrying 50 caliber machine gun barrels and ammunition. He also went to Bethesda for back school(approx. week). In summary, the Veteran has been under chronic medical care for neck pain first reported during service(6/25/96) and the condition has progressed from cervical muscle spasm to mechanical cervical pain syndrome and radiculopathy, cervical herniated and bulging disc with muscle spasm, cord contusion/compression myelomalacia, cervical spondylosis and degenerative disc disease, cervico-occipital neuralgia, and cervical radiculopathy with bulging disc. A nexus has been established. Therefore, it is at least as likely as not that the claimed condition has direct service connection.
  5. Hi Folks Had a C&P for lower back injury related to MST in 1975. C&P examiner a PHD/PA with an impressive resume also retired Rear Admiral filed his report less likely than not a couple of weeks ago. The report was full of misspellings, information discrepancies and a lie or two! This gentleman had me on the wrong ship, took very poor notes and many of the doctors I've seen as well as dates & times totally wrong. He tried to dispute my IMO from Dr David Anaise by saying I never told Dr Anaise I had a motorcycle accident after my separation from the Navy, that was an outright lie and I had the proof in emails that in fact I did tell Dr Anaise about the motorcycle accident. It's clearly obvious this PA pencil whipped this report and hit send, does anyone think my IMO will carry more weight than this sloppy inadequate C&P report? I have uploaded a rebuttal to my ebenny case file. Thanks Rob
  6. I have a rating for Scheuermann's Kyphosis, which is basically curvature of my spine. My total ROM is very close to the next highest rating. I have a C-shapped spine, meaning I already lean forward xyz degrees. So of course, it already looks like my Flexion when I bend forward is more than it really is, because of my C-shapped spine. My question is this. How does one get around the Total ROM testing, when the shape of one's back is already curved forward? Has anyone else had experience with alternative measurements in the ROM test? Below is similar to how my current curvature looks, which increases how my forward flexion looks on the goniometer. Basically my back is screwing me out of a higher rating. LOL Thanks in advance... P.S. No physicians have made any reference to already having a forward stance, so that may be an approach?
  7. Hey everyone. Ive been in the army for 5 years and im getting out in 197 days exactly and im just down right terrified. I wana cry at night cause im scared but my body wont let me shed one tear. Im here partly to get help to understand what i should do to get va disability, personal stories and partly for emotional support. Im going to behavior health for suicidal ideation, depression and anxiety currently. Ive been speaking to my ex girlfriend shes studying to be a shrink and she thinks i have paranoid schizophrenia and i was speaking to my mother the other day she said my sister has said for the last 4 years that she thought i have it as well, they both have never met in their life. However i did abuse cough syrup a few times. And im afraid they might blame the schizophrenia on that. But i was seeing behavior health before that even. Military found out. Never got introuble for it. Dark history in my life, but i have overcome that thanks to my asap class. Thank you God. I just got a psychiatric evaluation done, but im still waiting on the tests to come back to know whats really happening i dont even know who i am and worst of all for service connection, i have no clue at all what to make of this. I just had surgery for my shoulder impingement syndrome 2 weeks ago, they removed a bursa, did clavicular excision, and bicep tenesis. And ive healed well but still have a limited range of motion. (That much is all i know of va disability) I was told i have occipital nuralgia which causes me not only to have emence neck pain but to have incredible migranges daily i just walk around the motorpool acting like im busy but the pain is so bad i massage my neck and scalp to ease the pain and take naproxen like crazy, and when im off work not only do i stay home for fear of social interaction, i stay to nurse my headaches. I drink caffeine to help it and take more pain medication. I have lower back problems that came out of no where. 4 years ago my chiropractor said its facet syndrome but i stopped going to him for the last few years cause it wasnt helping and i went to see my primary care provider again for it he said its para spinal myalgia. Gave me some muscle relaxers and said have a good day after I asked for a referal back to the chiropractor. He just blew me off i feel. But i have social anxiety im scared to be a bother..... And i know im just screwing myself over but i cant help how i am. And i have to schedule appointments for anything and hes always a month backed up. Idk what to do about anything ladies and gentleman. Im begging for your help here. Im bugging my family so much about my anxieties they are ignoring my phone calls even... I want 100% disability not because it gets me out of work. I LOVE WORKING. It makes me feel accomplished and like I deserve to live and breath Gods air. But mentally im not right in the head.... If you all ask i can even show you all a text i sent to my mother when i was having a really bad episode, and even that doesnt cover all of me. (You all dont know me so i feel a ok sharing this if it helps the advice i would be given.) i mean its 0308. My mind is just racing itself i cant sleep at all!! PLEASE HELP.
  8. Hello everyone, I am just curious at what I looking at for compensation. I am currently SC 20% for back and 10% for right radiculopathy. I am looking to get SC for left radiculopathy and an increase in my back. Thoughts please. My thoughts. I get SC for bilateral readiculopathy @ 10% each and back stays the same at 20%. my goal is to get 30-40% for back. Important sections are in bold to cut through the silt.... LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: AUG 07, 2015@08:00 ENTRY DATE: AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [ ] Other: 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 Diagnosis #1: Degenerative joint disease, lumbar spine, with bilateral sciatica ICD code: 721.3, 724.3 Date of diagnosis: 2003 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): 35 y/o male on active Marine Corps service 1998-2002 as enlisted aviation operations specialist. Currently works full-time as office manager, doing mostly desk work and sometimes teleworking from home. Gets his medical care usually via the VA, but also has a private doctor. Approx 2000 he injured his back while doing heavy lifting on his ship. Since then he has had recurrent back pain that has now become continuous. Currently while sitting at rest he says his low back pain is about 7 out of 10. If he sits for an hour, or walks or does yard work for about 45 min, then the pain gets up to 9-10 and takes several hours to return to baseline with rest. With the pain flares he describes reduced range of motion and weakness but not incoordination. The pain often radiates down the back of both legs, and also sometimes causes tingling and numbness. No bowel or bladder difficulties. No back surgery. Current meds: ibuprofen, vicodin, baclofen, gabapentin. Also uses an electrical stimulator intermittently. Has seen a chiropractor and physical therapy with modest temporary relief. Currently walks for exercise. In the past year has had to take off from work about 12 days because of back pain. 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: If he sits for an hour, or walks or does yard work for about 45 min, then the pain gets up to 9-10 and takes several hours to return to baseline with rest. With the pain flares he describes reduced range of motion and weakness but not incoordination. The pain often radiates down the back of both legs, and also sometimes causes tingling and numbness. 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. If he sits for an hour, or walks or does yard work for about 45 min, then the pain gets up to 9-10 and takes several hours to return to baseline with rest. With the pain flares he describes reduced range of motion and weakness but not incoordination. The pain often radiates down the back of both legs, and also sometimes causes tingling and numbness. 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 20 degrees Right Lateral Flexion (0 to 30): 0 to 20 degrees Left Lateral Flexion (0 to 30): 0 to 20 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: Difficulty bending forward to reach. 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? [ ] 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): Mild-moderately tender over lumbar spines and paralumbar muscles. 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 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: Per patient history, pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over time. However I am unable to quantify the degree of reduced range of motion during the flare-ups because I don't observe them, and the patient's description is a widely variable estimate and also depends on subjective factors such as individual pain tolerance. It would be speculation for me to quantify an additional range of motion loss that might occur during flare-ups or repeated use. 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: Per patient history, pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over time. However I am unable to quantify the degree of reduced range of motion during the flare-ups because I don't observe them, and the patient's description is a widely variable estimate and also depends on subjective factors such as individual pain tolerance. It would be speculation for me to quantify an additional range of motion loss that might occur during flare-ups or repeated use. 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: 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: Interference with sitting 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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] 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: [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? [X] Yes [ ] No a. Indicate symptoms' location and severity (check all that apply): Constant pain (may be excruciating at times) Right lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Left lower extremity: [X] None [ ] Mild [ ] Moderate [ ] Severe Intermittent pain (usually dull) Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Numbness Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe Left lower extremity: [ ] None [X] Mild [ ] 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 [X] Mild [ ] Moderate [ ] Severe Left: [ ] Not affected [X] Mild [ ] 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 ----------------------------------------------------------------------- a. Does the Veteran have IVDS of the thoracolumbar spine? [X] Yes [ ] No b. If yes to question 11a above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment by a physician in the past 12 months? [ ] 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? [X] Yes [ ] No If yes, describe (brief summary): Able to sit for the interview. Gait is normal. Limits his back ROM due to pain. 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): MRI,SPINE LUMBAR W/O CONT. Exm Date: MAR 20, 2015@19:14 INDICATION: Back pain radiating down the right more than left leg. COMPARISON: Lumbar spine MRI 2/11/2003. Lumbosacral spine x-rays 1/14/2014. TECHNIQUE: MRI of the lumbar spine including: sagittal and axial T1 and fast-T2. Sagittal fast-STIR. FINDINGS: This report assumes five lumbar-type vertebral bodies. Lumbar spine alignment is preserved. Vertebral body heights and disc space heights are preserved. Normal disc signal. No developmental narrowing of the spinal canal. Diffusely abnormal T1-dark marrow signal, similar to 2003. The tip of the conus medullaris is at L1; the conus medullaris and nerve root of the cauda equina have an unremarkable appearance. At L1-2, no spinal canal or neural foraminal narrowing. At L2-3, no spinal canal or neural foraminal narrowing. At L3-4, no spinal canal or neural foraminal narrowing. At L4-5, diffuse disc bulge. Minimal spinal canal narrowing. Mild bilateral facet arthropathy. Minimal bilateral neuroforaminal narrowing. At L5-S1, disc bulge with small superimposed central protrusion. Bilateral facet arthropathy with small posteriorly oriented in facet joint cyst on the right. Mild bilateral neural foraminal narrowing, left greater than right. Within the limits of this examination, no infrarenal abdominal aortic aneurysm. Impression: 1. Minimal multilevel facet arthropathy without evidence of neural impingement. 2. Persistent diffusely abnormally dark T1-marrow signal. This is nonspecific but can seen with smoking, anemia, hematopoietic or hyperplastic marrow or marrow dyscrasias; neoplastic lymphoproliferative conditions would be unlikely to remain stable in appearance since 2003. 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: Avoid heavy lifting. 17. Remarks, if any: -------------------- Veteran was informed that this evaluation is for compensation and pension purposes only, and he/she is to return to his/her treating clinician for regular medical care.
  9. Hi everyone! Hope all is well! My boyfriend has his C/P on Saturday for his increase request that he put in back in November. Can you give your opinions on the results of the C/P? VA Notes Source: VA Last Updated: 18 Mar 2015 @ 0431 Sorted By: Date/Time (Descending) VA Notes from January 1, 2013 forward are available 3 calendar days after they have been completed and signed by all required members of your VA health care team. If you have any questions about your information please visit the FAQs or contact your VA health care team. Date/Time: 14 Mar 2015 @ 0930 Note Title: COMP & PEN GENERAL MEDICAL EXAM NORTH TEXAS HEALTH CARE SYSTEM - DALLAS DIVISION KOKEL,JIM S KOKEL,JIM S Location: Signed By: Co-signed By: Date/Time Signed: 14 Mar 2015 @ 0940 LOCAL TITLE: COMP & PEN GENERAL MEDICAL EXAM STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: MAR 14, 2015@09:30 ENTRY DATE: MAR 14, 2015@09:40:43 AUTHOR: EXP COSIGNER: URGENCY: STATUS: COMPLETED Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Name of patient/Veteran: Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional CONFIDENTIAL Page 5 of 134 relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [X] Yes [ ] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: vbms 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 Diagnosis #1: lDDD and facet DJD Date of diagnosis: increase sc 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): initiall hurt l-s on patrol in afganistan in a fire fight. he has had 2 facet injections and helped x 2 weeks only. sch for ablation 3-27-15. chiropractic therapy did not help. 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: lbp every day and constant. pains are usually sharp, averages 7, can CONFIDENTIAL Page 6 of 134 go higher earlier in am and cant put on socks. agggrevated by sitting long periods, walking, standing, sex. no pains in legs, no numbnes in legs. wears a back brace. no surgery. compared to military to now it is now about 60 % worse. pains are alot more freq/worse, cant do things like he used to do. affects his sleep. c. Does the Veteran report having any functional loss or functional impairment of the thoracolumbar spine (back) (regardless of repetitive use)? [ ] Yes [X] No 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 40 degrees Extension (0 to 30): 0 to 5 degrees 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: pains with rom 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)? [ ] Yes [X] No 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 CONFIDENTIAL Page 7 of 134 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 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)? [ ] Yes [X] No f. Additional factors contributing to disability No response provided 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 CONFIDENTIAL Page 8 of 134 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: [ ] Negative [X] Positive [ ] Unable to perform Left: [ ] Negative [X] Positive [ ] Unable to perform 8. Radiculopathy ---------------- Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy? CONFIDENTIAL Page 9 of 134 [ ] 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? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Brace(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: 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, CONFIDENTIAL Page 10 of 134 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? [ ] 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? [ ] Yes [X] No 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: manual 17. Remarks, if any: -------------------- No remarks provided. Thanks!
  10. I have currently have a diagnosis for bilateral patella phemorial syndrome I am rated at 20 %for that and 20 % for bilateral Achilles tendinitis .I have in my medical files after falling off a obstical course it says add back therapy to treatment and for months after that date continuation of back pain and therapy. In my civilian records in more recent times i have been diagnosed with 2 herniated disks in my lower back. in the same area where the back pain was at in service. I have had pain in my back sense service .I was informed that the disk issue could be caused by the fall. 1) how do i connect the 2 in the VA's eyes ? 2) Other then the doctor's current notes and x rays showing the herniated disk what current medical evidence do i need? The pain has Progressively been getting worse with age and weight gain 3)Other then getting an IMO what are the KEY WORDS they are looking for in a fully developed claim ? ​During service I was basically given Motrin for all pain and told to suck it up.Now I realize there could have been a real underlying issue thank you for all you do i would appreciated any help you can be
  11. "Hi, my name is DeadPlug. I have been a long time follower of this website and this is my first post." HI DEAD PLUG! "Thanks! My problem has been in gaining timely care, or.. care in general from the V.A." *Grumbling ensues* "I know I know. They are monsters. Here we go:" January 2006 Joined U.S. Army Infantry, 11B (19 years old) – Private. May 2006 Korea, Camp Casey (Light Infantry/Bradley Operator) (A snippet of my training) http://www.liveleak.com/view?i=cd3_1407015733 May 2007 Texas (FOUO: Ops Asst.) October 2007 Hemorrhoid problems begin in military (Documented with multiple occurrences) May 2009 Discharged from Active Duty – Specialist Rank August 2009 REFRAD for Active Duty – Released with: Spondylolisthesis, Spondylosis, and Degenerative Disc Disease. Med boarded sort of. December 2009 Filed for eligibility with VA February 2010 VA Denial (The first of many) May 2011 Surgery: Hemorrhoid (Private) September 2011 Back Adjustments (Chiropractor) until October 2011 November 2011 Joined Army Reserves (Ops Asst. again) January 2012 Went to VA: Back Pain March 2012 Went to VA: Back Pain said to be “Psychosomatic” (documented). Treatment offered: MRI 6 months away. (Machines were broke they said) May 2012 Ongoing back pain - Private MRI: Degenerative Disc Disease, Moderate narrowing May 2012 Electrical stimulation, lumbar Injections & epidural fluoroscopies until July 2012 August 2012 Surgery: Lumbar Fusion, L4, L5, S1 (Private) September 2012 Physical therapy 3x a week until Oct. 2012 (Aged off insurance/Uninsured/Reliant on military). October 2012 Went to VA: Back Pain. January 2013 Difficulty walking, pain. June 2013 Surgery: Hemorrhoid (Private). Discharged from Reserves – Specialist Rank July 2013 First meet with VA Rehab August 2013 Surgery: Hemorrhoid Private) August 2013 Very first VA Rehab for back and walking problems… August 2013 Unable to receive pain management (unaffordable/uninsured) September 2013 DO Neuro-musculoskeletal (Private): Adjustments on a regular basis. September 2013 VA Outreach; Mental Health. Complaints. Intervention by Law Enforcement October 2013 Surgery: Hemorrhoid (Private) January 2014 Rehab (Private) until March 2014 (26 years old) January 2014 Appealed VA Denial (12-18 months to wait for another denial) April 2014 Surgery: Hemorrhoid (Private) ^^Some doozies I know. Let me elaborate on any that you'd like. Anything with “Private” means my parents had to pay out of pocket…. The Doctor I used will be revealed when the question is posed "Did your doc just do a surgery for the money?" He's very reputable. I have not worked any jobs other than Military since May 2009. I am UNDER weight and I eat as much as possible. I am 27 years old and I round out to 150 pounds at 6’1”. (Almost below my min. body weight again) I left the military in 2009 at 210 pounds. ______________________________________________________________________________________________________________________________________________ Definitions: Spinal Fusion: http://www.youtube.com/watch?v=WID1p_UJZIM Degenerative Disc Disease http://www.youtube.com/watch?v=Q_5U7skcQeM Spondylolisthesis http://www.youtube.com/watch?v=DlJM2kLGwUI Spondylolysis http://www.youtube.com/watch?v=du8Ch38mP54 Lumbar Pedicle Screw Surgery http://www.youtube.com/watch?v=QZ6XpGzuvg8 Sciatica http://www.spine-health.com/video/sciatica-interactive-video ______________________________________________________________________________________________________________________________________________ I understand I have made many mistakes in this process. Where people say "mistake" I hear "got reamed" so we may need to agree to disagree on the terminology throughout. I posted pictures to help substantiate my claims. I have done my very best at concealing the real sensitive data. I could care less if my name gets known. I just want this issue solved (I have a baby on the way and I am tired of going the direction of useless dead beat. I need an education but school means I need therapy first. Something that has become a burden on my entire family. It is financially and physically time consuming for everyone involved.) The military has released me for medical, re-enlisted me (*cough* high ASVAB scores *cough*) and then threw me out on my ass again. I hope they realize my back is broken, not my brain... Also, my grades in school went from "Being on probation" to "Deans List" and an A.A. thanks to one magical (illicit) medicine. Take a guess... Having an issue with images. I will figure it out soon. ______________________________________________________________________________________________________________________________________________ 2009Feb17 http://picoolio.net/images/2014/08/04/2009Feb17VADenial.png 2009Oct09 http://picoolio.net/images/2014/08/04/2009Oct09MedicalRecord.png 2009Oct15 http://picoolio.net/images/2014/08/04/2009Oct15CATscan.png 2009Oct23 http://picoolio.net/images/2014/08/04/2009Oct23MedBoard.png 2009Oct23 http://picoolio.net/images/2014/08/04/2009Oct23MedicalRecord.png 2009Oct27 http://picoolio.net/images/2014/08/04/2009Oct27Orders.png 2009Oct27 http://picoolio.net/images/2014/08/04/2009Oct27P.1.png 2009Oct27 http://picoolio.net/images/2014/08/04/2009Oct27P.2.png ______________________________________________________________________________________________________________________________________________ 2010Feb10 http://picoolio.net/images/2014/08/04/2010Feb10VADenial.png ______________________________________________________________________________________________________________________________________________ 2012December17 http://picoolio.net/images/2014/08/04/2012December17PerroneMedsVAmedsseperate.png 2012July19 http://picoolio.net/images/2014/08/04/2012July19ReservesLOD.png ______________________________________________________________________________________________________________________________________________ 2013May05 http://picoolio.net/images/2014/08/04/2013May05NeuroDoc.png 2013June26 http://picoolio.net/images/2014/08/04/2013June26JCornynvsVA.png 2013July03 http://picoolio.net/images/2014/08/04/2013July03VADenial.png 2013Aug04 http://picoolio.net/images/2014/08/04/EverettWayne_A_P_L_P_Standing.00014C19.jpg ______________________________________________________________________________________________________________________________________________ (Extra Data) Grades http://picoolio.net/images/2014/08/04/Grades.png Some of my Vaccines http://picoolio.net/images/2014/08/04/Vaccines.png Found letter by my mother, Page 1: http://picoolio.net/images/2014/08/04/MotherPg1.png Page 2 of letter: http://picoolio.net/images/2014/08/04/MotherPg2.png
  12. I began a claim in August 2013, after going to the VAMC for the past 12 years from time to time for what they now call "anxiety and depression". I initially went to the VARO and they initiated a claim for "anxiety due to physical assault in basic training" and "back condition". Only on my second visit to the VARO did they provide me with Form 21-0781 for determining PTSD. The VAMC according to my medical records have never used the term "PTSD" in my file as of yet. I have since gone to the DAV for representation, thanks in part to the great information on this website. I gave them my buddy statements to submit on my behalf since there was no documentation of the assault at the time. I am concerned that as of today by file has been moved to the "Preparing for Decision" phase on eBenefits webpage. They estimate my claim to be complete between Jan 2014 - April 2014 - moving the window up one month from last week. That means my claim could be complete in less than six months total time. I know I should be happy that it's not taking two years to complete, but this is almost too fast, maybe? They did the C&P for my back in October already (and have military documentation of a back condition on active duty), and I was not happy with the results when I read my records. I was unprepared and had not talked to the DAV yet, and didn't realize they rate your range of motion and not whether bending over causes you pain or not. I have never done a C&P for PTSD or anxiety. Could they be using my medical records and buddy statements and not require a C&P? Or could that still happen? I'm a bit naive on this whole process. I didn't even know there was such a thing as SC disability unless you got hurt in combat. Any help, thoughts, suggestions would be appreciated. Thanks.
  13. 1. Diagnosis: Does the Veteran now have or has he/she ever been diagnosed with a thoracolumbar spine (back) condition? YES If yes, provide only diagnoses that pertain to thoracolumbar spine (back) conditions: Diagnosis #1: Low back strain and degenerative disc disease Date of Diagnosis: UNKNOWN 2. Medical history: The veteran stated during his military service in the Army, he was playing football when he injured his head, low back, and his left shoulder. He was tackled and he was knocked out for about 30 min. He was transferred to the hospital. He said that his first memory was woke up in the field. He had x-rays on his back and his shoulder. Since then, he has been complaining recurrent low back pain due to suspected pinch nerve and osteoarthritis. He has been seen or ER at VAMC because of his back. He also recalled that he had Physical Therapy during his Army time. He also recalled that during his Desert Storm, he was hit in the head but had no LOC. He denies any other accident or trauma, he still having cognitive problem and memory issues. From his left shoulder, he is having pop all the time, some weakness and LOM. He is having a constant 4/10 on pain intensity but its depend on activities. Sometimes is a zero but sometimes is an 8/10. From his lower back, he is having a constant back pain about 4/10 on pain intensity. His worse pain is a 10/10 on pain intensity once a year. He is on Naproxen with fair response. 4. Initial range of motion (ROM) measurement: a. forward flexion ends: 60 Select where objective evidence of painful motion begins: 40 b. Select where extension ends: 15 Select where objective evidence of painful motion begins: 10 c. Select here right lateral flexion ends: 20 Select where objective evidence of painful motion begins: 20 d. Select where left lateral flexion ends: 20 Select where objective evidence of painful motion begins: 20 e. Select where right lateral rotation ends: 20 Select where objective evidence of painful motion begins: 20 f. Select where left lateral rotation ends: 30 Select where objective evidence of painful motion begins: <X) No objective evidence of painful motion 5. ROM measurment after repetitive use testing a. Is the Veteran able to perform repetitive-use testing with 3 repetitions? YES b. post test forward flexion ends: 60 c. post test extension ends: 15 d. post test right lateral flexion ends: 20 e. post test left lateral flexion ends: 20 f. post test right latereral rotation ends: 20 g. post test left lateral rotation ends: 30 or greater 6. Functional loss and additional limitation in ROM b. Does the Veteran h ave any funtional loss and/or functional impairment of the thoracolumbar spine (back)? YES c. If the Veteran has a functional loss, functional impairment and/or additional limitations of ROM of the thoracolumbar spine (back) after repetitive use, indicate the contributing factors of disability below: <X> Pain on movement 7. Pain and muscle spasm (pain on palpation, effect of muscle spasm on gait) a. Does the Veteran have localized tenderness or pain to palpation for joints and/or soft tissue of teh thoracolumbar spine (back)? YES If yes, describe: thoracolumbar paraspinal muscle b. Does the Veteran have guarding ofr muscle spasm of the thoracolumbar spine (back)? YES If yes, is it severe enough to result in: <X> Guarding and/or muscle spasm is present, but do not result in abnormal gait or spinal countour 10. Sensory exam Foot/toes (L5): Right and left Decreased 14. Intervertebral disc syndrome (IVDS) and incapacitating episodes a. Does the Veteran have IVDS of the thoracolumbar spine? YES b. If yes, has the veteran had any incapacitating episodes over past 12 months? NO 18. Diagnostic testing a. Have imaging studies of the thoracolumbar spine been performed and are the results available? YES If yes, is arthritis documented? YES c. Are there any other significant diagnostic test findings and/or results? YES If yes, provide type of test or procedure, date and results (brief summary): Report status: Verified Date Reported: Nov 10, 2011 Date Verified: Nov10, 2011 Impression: Frontal and Lateral Lumbar Spine 11/9/2011: No comparison lumbar spine. Preserved lumbar column alignment, vertebral body heights and disc spaces. Multilevel anterior osteophytic lipping. Normal sacroiliac joints. Posterior fusion anomaly at lumbosacral transition. Nonobstructive bowel gas pattern. Indeterminate renal outlines. No opacities to suggest biliary, pancreatic, or urinary tract stones. 19. Function Impact YES, He is on SSDI due to Mental and Physical condition. 20. Remarks, if any: C-File was reviewed. No evidence of back injury during service.
  14. I am currently in the process of my first claim. I am petitioning for an increase based on my two bulging disks, the narrowing of my spinal collumn, and the thoracic/lumbar arthritis. The migraines are something I just realized may be connected. I usually just ate my motrin 800 , drank some water, and laid down when they would come around. At my appt today, i brough it up with my new doc and explained the symptoms exactly. He said theres a good chance it has to to with my back issues. Question 1: Do I file a new claim for migraines? Question 2: Do i have to wait for my current increase to be taken care of? Question 3: I was never treated for migraines in service, will this be an issue in service connecting it? One more gripe. I closed a bank account i had and forgot to change my comp direct deposit info. A few months later i realized i wasnt getting the check (its only for 10%). I corrected the issue back in march. My last payment went out october 2012. My balance has sine grown to over 1000 dollars and i cant get any help on releasing the funds. They said all someone has to do at my regional office is turn the payment back on. My VFW rep is unreachable(detroit for ya) and when i show up in person they say that they will take care of it. Any help on handling this? Thanks in advance brothers.
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