In July 2011, I received my results from a two year long VA claim for a list of problems that were denied or remained the same. I need help in understanding why the C&P examiner used the higher of two ROM measurements in determining my rating decision:
Higher ROM: "C&P examiner noted forward flexion of the thoracolumbar spine was 70 of 90 degrees (normal 0 to 90 degrees), with pain noted at 60 degrees; extension was 10 of 30 degrees (normal 0 to 30 degrees), with pain noted at 5 degrees; left and right lateral flexion was 15 of 30 degrees (normal 0 to 30 degrees), with pain noted at 10 degrees; and, left and right lateral rotation was 30 of 30 degrees, for a combined range of motion of 170 degrees."
Lower ROM: "C&P examiner noted positive tenderness of bilateral paravertebral muscles. Negative left straight leg raise and negative right leg raise; forward flexion of the thoracolumbar spine was 0 to 45 degrees with discomfort; extension 0 to 15 degrees with discomfort; left and right lateral flexion was 0 to 10 degrees with discomfort, and left and right lateral rotation was 0 to 27 degrees with discomfort. These are initially and with repetition and they are limited because of pain."
Here's the original rating decision:
Evaluation of low back pain with mild degenerative changes currently evaluated
as 10 percent disabling (now claimed as back pain; and, degenerative disc disease).
The evaluation of low back pain with mild degenerative changes currently evaluated as
10 percent disabling is confirmed and continued based on the range of motion reported on
VA examination.
VA treatment records document ongoing evaluation and treatment for your low back
condition, and include magnetic imaging results from 2007, which show central disc
protrusion at L5 through S1, with bilateral S1 nerve root impingement. Records also
noted your pain has been so bad at times that you have sought emergent care from outside
providers.
On VA examinations, you related the history of your back condition and the treatment
you have received. You reported constant pain, with associated weakness, fatigue, a lack
of endurance, and incoordination. You also reported flare-ups of pain that occur daily
and last an hour or more each time. You use Lyrica to treat your pain, and a cane to
assist with ambulation. You receive additional pain management treatment which has
included epidural steroid injections, and also use a transcutaneous electrical nerve
stimulation (TENS) unit. You denied any incapacitating episodes in the prior 12 months,
but have had to call in and miss approximately 20 days of work in the past year.
The VA examiner noted forward flexion of the thoracolumbar spine was 70 of90 degrees
(normal is 0 to 90 degrees), with pain noted at 60 degrees; extension was 10 of 30
degrees (normal is 0 to 30 degrees), with pain noted at 5 degrees; left and right lateral
flexion was 15 of30 degrees (normal is 0 to 30 degrees), with pain noted at 10 degrees;
and, left and right lateral rotation was 30 of30 degrees, for a combined range of motion
of 170 degrees. There was no further limitation or decrease in joint function following
repetition due to pain, fatigue, weakness, lack of endurance, or incoordination of the
thoracolumbar spine, but pain was noted. The lumbar spine was negative for any
evidence of edema, ecchymosis, erythema, or ankylosis; but there was evidence of
tenderness over the bilateral paravertebral muscles. Prior x-rays and magnetic resonance
imaging studies were reviewed, and the VA examiner's final diagnosis was degenerative
disc disease of the lumbar spine with herniated disc at L5-S 1.
Based on the range of motion evidence in the most recent VA examination, no change in
the current evaluation of your low back pain with mild degenerative changes is warranted
at this time. A 10 percent evaluation is assigned for forward flexion of the thoracolumbar
spine greater than 60 degrees but not greater than 85 degrees; or, combined range of
motion of the thoracolumbar spine greater than 120 degrees but not greater than 235
degrees; or, or muscle spasm, guarding, or localized tenderness not resulting in abnormal
gait or abnormal spinal contour; or, for intervertebral disc syndrome with incapacitating
episodes having a total duration of at least one week but less than 2 weeks during the past
12 months. A higher evaluation of 20 percent is not warranted unless there is forward
flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60
degrees; or, the combined range of motion of the thoracolumbar spine is not greater than
120 degrees; or, unless there is muscle spasm or guarding severe enough to result in an
abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or
abnormal kyphosis; or, unless there are incapacitating episodes of intervertebral disc
syndrome having a total duration of at least 2 weeks but less than 4 weeks during the past
Question
chiefhouse00
Greetings
In July 2011, I received my results from a two year long VA claim for a list of problems that were denied or remained the same. I need help in understanding why the C&P examiner used the higher of two ROM measurements in determining my rating decision:
Higher ROM: "C&P examiner noted forward flexion of the thoracolumbar spine was 70 of 90 degrees (normal 0 to 90 degrees), with pain noted at 60 degrees; extension was 10 of 30 degrees (normal 0 to 30 degrees), with pain noted at 5 degrees; left and right lateral flexion was 15 of 30 degrees (normal 0 to 30 degrees), with pain noted at 10 degrees; and, left and right lateral rotation was 30 of 30 degrees, for a combined range of motion of 170 degrees."
Lower ROM: "C&P examiner noted positive tenderness of bilateral paravertebral muscles. Negative left straight leg raise and negative right leg raise; forward flexion of the thoracolumbar spine was 0 to 45 degrees with discomfort; extension 0 to 15 degrees with discomfort; left and right lateral flexion was 0 to 10 degrees with discomfort, and left and right lateral rotation was 0 to 27 degrees with discomfort. These are initially and with repetition and they are limited because of pain."
Here's the original rating decision:
Evaluation of low back pain with mild degenerative changes currently evaluated
as 10 percent disabling (now claimed as back pain; and, degenerative disc disease).
The evaluation of low back pain with mild degenerative changes currently evaluated as
10 percent disabling is confirmed and continued based on the range of motion reported on
VA examination.
VA treatment records document ongoing evaluation and treatment for your low back
condition, and include magnetic imaging results from 2007, which show central disc
protrusion at L5 through S1, with bilateral S1 nerve root impingement. Records also
noted your pain has been so bad at times that you have sought emergent care from outside
providers.
On VA examinations, you related the history of your back condition and the treatment
you have received. You reported constant pain, with associated weakness, fatigue, a lack
of endurance, and incoordination. You also reported flare-ups of pain that occur daily
and last an hour or more each time. You use Lyrica to treat your pain, and a cane to
assist with ambulation. You receive additional pain management treatment which has
included epidural steroid injections, and also use a transcutaneous electrical nerve
stimulation (TENS) unit. You denied any incapacitating episodes in the prior 12 months,
but have had to call in and miss approximately 20 days of work in the past year.
The VA examiner noted forward flexion of the thoracolumbar spine was 70 of90 degrees
(normal is 0 to 90 degrees), with pain noted at 60 degrees; extension was 10 of 30
degrees (normal is 0 to 30 degrees), with pain noted at 5 degrees; left and right lateral
flexion was 15 of30 degrees (normal is 0 to 30 degrees), with pain noted at 10 degrees;
and, left and right lateral rotation was 30 of30 degrees, for a combined range of motion
of 170 degrees. There was no further limitation or decrease in joint function following
repetition due to pain, fatigue, weakness, lack of endurance, or incoordination of the
thoracolumbar spine, but pain was noted. The lumbar spine was negative for any
evidence of edema, ecchymosis, erythema, or ankylosis; but there was evidence of
tenderness over the bilateral paravertebral muscles. Prior x-rays and magnetic resonance
imaging studies were reviewed, and the VA examiner's final diagnosis was degenerative
disc disease of the lumbar spine with herniated disc at L5-S 1.
Based on the range of motion evidence in the most recent VA examination, no change in
the current evaluation of your low back pain with mild degenerative changes is warranted
at this time. A 10 percent evaluation is assigned for forward flexion of the thoracolumbar
spine greater than 60 degrees but not greater than 85 degrees; or, combined range of
motion of the thoracolumbar spine greater than 120 degrees but not greater than 235
degrees; or, or muscle spasm, guarding, or localized tenderness not resulting in abnormal
gait or abnormal spinal contour; or, for intervertebral disc syndrome with incapacitating
episodes having a total duration of at least one week but less than 2 weeks during the past
12 months. A higher evaluation of 20 percent is not warranted unless there is forward
flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60
degrees; or, the combined range of motion of the thoracolumbar spine is not greater than
120 degrees; or, unless there is muscle spasm or guarding severe enough to result in an
abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or
abnormal kyphosis; or, unless there are incapacitating episodes of intervertebral disc
syndrome having a total duration of at least 2 weeks but less than 4 weeks during the past
12 months.
Best Regards
ChiefHouse
Best Regards
Chiefhouse
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