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I am thinking 20, 20, 20. Anyone see anything else? 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 [X] Other (please identify other evidence reviewed): JOINT L 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 [X] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture Diagnosis #1: LUMBAR DDD Date of diagnosis: 2015 BY MRI Diagnosis #2: THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION Date of diagnosis: SERVICE CONNECTED Diagnosis #3: BILATERAL RADICULOPATHY Date of diagnosis: 2018 2. Medical history ----------------- a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): THE VETERAN IS A 42 YO MALE WHO SERVED IN THE MARINE CORP FROM 1995 TO 1999, THE MARINE CORP RESERVE FROM 1999 - 2001, AND THE NATIONAL GUARD FROM 2001 TO 2003 AND AGAIN FROM 2016 TO PRESENT DAY WITH DEPLOYMENT TO AFRICA FROM 2017 TO 2018. HE IS HERE FOR A CURRENT LEVEL OF DISABILITY EXAM FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION. HE REPORTS SINCE HIS LAST COMP AND PEN EVALUATION AROUND 2013 HE HAS WORSENING PAIN WITH ONSET OF RADICULOPATHY IN BOTH LEGS. HIS PAIN LEVEL RANGE IS FROM A 5-9/10 WITH A THROBBING CHARACTER HAVING OVERLYING SHARP JABS. HE IS STIFF AFTER SITTINIG AND IN THE MORNING. HIS MORNING STIFFNESS WILL LAST 1-2 HOURS. HE STATES IN REGARDS TO HIS RADICULOPATHY HIS LEFT IS WORSE THAN HIS RIGHT AND EXTEND TO HIS FEET BILATERALLY. HE PREVIOUS TREATMENT INCLUDES PHYSICAL THERAPY, CHIROPRACTIC CARE. HE DENIES ANY SURGERY. HE JUST ANOTHER ROUND OF PHYSICAL THERAPY. 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: HIS PAIN WILL ELEVATE TO A 9/10 TWICE A WEEK LASTING A FEW HOURS TRIGGERED BY OVERACTIVITY. HE WILL REST AND USE PAIN CONTROL. 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. HE REPORTS HE DIFFICULTY WALKING FOR LONG DISTANCES, CANNOT SIT IN A HARD CHAIR, HAS PROBLEM SOCIAL FUNCTION ACTIVITIES AND PLYAING WITH HIS CHILDREN. HE CANNOT LIFT OVER 15 POUNDS OR STAND MORE THAN 30 MINTUES. HE HAS PROBLEMS WITH ANY MOVEMENT THAT REQUIRES BENDING, LIKE PUTTING ON HIS SHOES. HE HAS DIFFICULTY CONCENTRATING WHEN HIS PAIN ELEVATES. HE HAS DIFFICULTY DRIVING OVER AN HOUR. 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 35 degrees Extension (0 to 30): 0 to 10 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: HE WOULD NOT BE ABLE TO RETREIVE AN ITEM FROM THE FLOOR Description of pain (select best response): Pain noted on exam and causes functional loss If noted on exam, which ROM exhibited pain (select all that apply)? Forward Flexion, Extension, Right Lateral Flexion, Left Lateral Flexion, Right Lateral Rotation, Left Lateral Rotation Is there evidence of pain with weight bearing? [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): TENDERNESS OVER THE LUMBAR VERTEBRAE, PARASPINOUS MUSCLES, BILATERAL SI JOINTS AND BILATERAL SCIATIC NERVES. 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: HE HAS NOT USED HIS BACK REPEATEDLY. d. Flare-ups Is the exam being conducted during a flare-up? [ ] Yes [X] No If the examination is not being conducted during a flare-up: [ ] The examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. [ ] The examination is medically inconsistent with the Veteran's statements describing functional loss during flare-ups. Please explain. [X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss during flare-ups. Does pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups? [ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain: HE WAS NOT HAVING A FLARE. 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 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, Other (please describe) Please describe additional contributing factors of disability: INTERFERENCE WITH LIFTING. 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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: [ ] 5/5 [X] 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 [X] 1+ [ ] 2+ [ ] 3+ [ ] 4+ Left: [ ] 0 [X] 1+ [ ] 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? [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 [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe Paresthesias and/or dysesthesias Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] 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 [ ] Mild [X] Moderate [ ] Severe Left: [ ] Not affected [ ] Mild [X] Moderate [ ] Severe 9. Ankylosis ----------- Is there ankylosis of the spine? [ ] Yes [X] No 10. Other neurologic abnormalities --------------------------------- Does the Veteran have any other neurologic abnormalities or findings related to a thoracolumbar spine (back) condition (such as bowel or bladder problems/pathologic reflexes)? [ ] Yes [X] No 11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest ---------------------------------------------------------------------- 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? [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) [X] Occasional [ ] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: BACK BRACE FOR SUPPORT 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): For Official Use Only Click image to open viewer Priority: MRI LUMBAR SPINE WO CONTRAST Proc Ord: MRI LUMBAR SPINE WWO CONTRAST Exm Date: NOV 07, 2015@11:21 Req Phys: Pat Loc: DAL PACT CL10-I2NURSE (Req'g L Img Loc: MRI Service: Unknown (Case 7346 COMPLETE) MRI LUMBAR SPINE WO CONTRAST (MRI Detailed) CPT:72148 Reason for Study: low back pain chronic Clinical History: as above Report Status: Verified Date Reported: NOV 07, 2015 Date Verified: NOV 07, 2015 Verifier E-Sig:/ES/LENA A OMAR, M.D. Report: MRI Lumbar Spine without contrast dated 11/7/2015 Clinical History: 38-year-old male with history of low back pain chronic Comparison: Radiograph 8/28/2015 Technique: Sagittal and axial T1 and T2, as well as axial PD sequences were obtained of the lumbar spine. Findings: Vertebral body height, alignment, and marrow signal are preserved throughout the lumbar spine. There is either focal fat or hemangioma in the L1 vertebral body. Vertebral bodies are unremarkable. The conus terminates at L1-L2. There is no significant canal or neural foraminal stenosis. No areas of abnormal signal within the cord are seen. There is a tiny central disc protrusion at L5-S1 without any significant narrowing of the thecal sac or neural foramen. Small amount of fluid is present in the facet joints in the lumbar spine. Visualized paraspinal soft tissues are unremarkable. Impression: 1. Essentially unremarkable MRI of the lumbar spine except for a tiny central disc protrusion at L5-S1 without any significant narrowing of the thecal sac or neural foramen. Primary Diagnostic Code: ABNORMAL /LAO 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 WORKS AS AN ACCOUNTANT. HE SITS FOR LONG PERIODS AT WORK WHICH ELEVATES HIS BACK PAIN AND DECREASES HIS CONCENTRATION AND WORK CAPACITY. HE WOULD NOT BE ABLE TO WORK A PHYSICALLY DEMANDING JOB REQUIRING PROLONGED WALKING, STANDING OR REPEATED HEAVY LIFTING. HE ALSO WOULD REQUIRE THE ABILITY TO MOVE FROM SITTING TO STANDING POSTIONS WITH A SEDENTARY JOB SUCH AS THE ONE HIS IS CURRENTLY WORKING. 17. Remarks, if any: ------------------- 1. Is there evidence of pain on passive range of motion testing? (Yes/No/Cannot be performed or is not medically appropriate) YES 2. Is there evidence of pain when the joint is used in non-weight bearing? (Yes/No/Cannot be performed or is not medically appropriate) YES 3. If yes, is the opposing joint undamaged (i.e. no abnormalities)? NA If yes, conduct range of motion testing for the opposing joint and provide ROM measurements. PASSIVE AND ACTIVE RANGE OF MOTION ARE THE SAME. ***************************************************************************** ********** THE VETERAN HAS A SERVICE CONNECTION FOR THORACOLUMBAR SPINE SEGMENTAL DYSFUNCTION. THIS IS A CHRIOPRACTIC DIAGNOSIS \: "segmental dysfunction, a motion theory concept that states that two articulating joint surfaces cannot interact optimally if they are misaligned. Basis of vertebral subluxation and theory of illness. SYNONUMS FOR SEGMENTAL DYSFUNCTION OF THE LUMBAR SPINE ARE: LOW BACK PAIN, LUMBAGO, LUMBALGIA. GIVEN THE SERVICE CONNECTED DIAGNOSIS IS BROAD BASED AND GENERAL BY DEFINITION, THE VETERANS CONFIRMED DIAGNOSIS OF LUBMAR DDD WITH COMPLICATIONS OF BILATERAL LEG RADICULOPATHY WOULD BE INCLUDING AND THEREFORE ALSO SERVICE CONNECTED. OF NOTE THE VETERAN COMPLAINED OF BACK PAIN, PAIN IN ARMS, LEGA NAD JOINTS DURING HIS DEPLOYMENT IN 2017 TO 2018 WHICH MORE THAN LIKELY WAS DUE TO HIS LUMBAR DDD WITH RADICULOPATHY.

Hey vets, I have been following these threads and threads on yoku.com for the past few months. So, first, I want to say thank you. These sites have helped tremendously. I filed for compensation for back problems during TAP in 2009. The whole process took about one year--I think I was one of the lucky ones because it didn't take two plus years or more--and I ended up getting 20%. Moving forward, my back problems became increasingly worse throughout 2014. However, I did not think I should ask for an increase because I thought I might lose the 20% I already had. Then, a few months ago, it got so bad that I couldn’t lift myself out of my car after driving for more than 15 minutes. I would try to get up and out using the door as leverage as usual and I would just fall back down. That is just one example--I have had some problems getting out of bed too... I’m really tolerant to pain, so, when there is pain, I could just fight through it and just get up, but this was something I couldn’t just fight with strength. So I thought this was insane. And, thus, I finally decided to ask for an increase at the beginning of January of this year. I went to the C&P exam at the end of March and the doctor asked me several questions and tested my range of motion (bending forward and turning side to side). She also did some other tests in regards to numbness and tingling I had in my right side. From that exam, I learned that my range of motion is less than 30 degrees from front to back and I have moderate to severe numbness and tingling in my right side from my hip down to my toes. When I check my benefits account now, it says “Preparation for Notification.” It has said this since Wednesday of last week. The only difference that I see is in the section of pending disability claims. This is the original claim and what I have been rated for: Lumbar Spine Disc Herniation And Degenerative Facet Changes Of L4-s1 10% Right Lower Extremity Radiculopathy 10% Now it shows this: Lumbar Spine Disc Herniation And Degenerative Facet Changes Of L4-s1 --INC Right Lower Extremity Radiculopathy --INC Radiculopathy Femoral Nerve --NEW So, from what I have said, what do yall think my new rating will be? Also, looking through the forums, I have also noticed that I could claim disability for Pseudofolliculitis barbae. I know it is in my record. This has been documented since boot camp... where my face swelled up like a melon after they made me shave with a blade when I told them I could only use an electric shaver. I also still have several of the no shave chits that they gave to me for it. So my other questions are: Should I file for this? If I do, will they do a C&P exam? If I do, will they have to re-rate my back disability, as well? (I would wait to file for this after the claim I have clears)