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Back C&p Results Rating Expectations


whoami?

Question

Please let me know what you guys think my rating will be based on this C&P exam. Thanks.
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 reviewed?
[X] Yes [ ] No
If yes, list any records that were reviewed but were not included in the
Veteran's VA claims file:
VBMS
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
[ ] 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
[X] Lumbosacral strain
[ ] 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:
ICD code: 847
Date of diagnosis: Already connected
2. Medical history
------------------
Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
He states that he has constant pain in the lower back that radiates down
his legs at times. He states that he has pain with bending. He states
that
the pain is severe. He is currently on Lortab and Toradol for a knee
surgery that he had yesterday, so the pain is not as bad today.
3. Flare-ups
------------
Does the Veteran report that flare-ups impact the function of the
thoracolumbar spine (back)?
[X] Yes [ ] No
If yes, document the Veteran's description of the impact of flare-ups
in
his or her own words:
The veteran states that pain flares up with excessive use. Pain,
weakness, fatigability or incoordination could significantly limit
functional ability during flare ups of after repeated use. However to
specify to the amount of limited functional ability would be resorting
to mere speculation as I can not exam the veteran under these
conditions.
4. Initial range of motion (ROM) measurement
--------------------------------------------
a. Select where forward flexion ends (normal endpoint is 90):
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [ ] 45
[X] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 [ ] 35 [ ] 40 [X] 45
[ ] 50 [ ] 55 [ ] 60 [ ] 65 [ ] 70
[ ] 75 [ ] 80 [ ] 85 [ ] 90 or greater
b. Select where extension ends (normal endpoint is 30):
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [X] 10 [ ] 15 [ ] 20
[ ] 25 [ ] 30 or greater
c. Select where right lateral flexion ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20
[ ] 25 [ ] 30 or greater
d. Select where left lateral flexion ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20
[ ] 25 [ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20
[ ] 25 [ ] 30 or greater
e. Select where right lateral rotation ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25
[ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25
[ ] 30 or greater
f. Select where left lateral rotation ends (normal endpoint is 30):
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25
[ ] 30 or greater
Select where objective evidence of painful motion begins:
[ ] No objective evidence of painful motion
[ ] 0 [ ] 5 [ ] 10 [X] 15 [ ] 20 [ ] 25
[ ] 30 or greater
g. If ROM for this Veteran does not conform to the normal range of motion
identified above but is normal for this Veteran (for reasons other than a
back condition, such as age, body habitus, neurologic disease), explain:
No response provided.
5. ROM measurement after repetitive use testing
-----------------------------------------------
a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
[ ] Yes [X] No
If unable, provide reason:
Too painful.
6. Functional loss and additional limitation in ROM
---------------------------------------------------
a. Does the Veteran have additional limitation in ROM of the thoraco
lumbar
spine (back) following repetitive-use testing?
[ ] Yes [X] No
b. Does the Veteran have any functional loss and/or functional impairment of
the thoracolumbar spine (back)?
[X] Yes [ ] No
c. If the Veteran has functional loss, functional impairment and/or
additional limitation of ROM of the thoracolumbar spine (back) after
repetitive use, indicate the contributing factors of disability below:
[X] Less movement than normal
[X] Pain on movement
[X] Interference with sitting, standing and/or weight-bearing
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 the thoracolumbar spine (back)?
[ ] Yes [X] No
b. Does the Veteran have muscle spasm of the thoracolumbar spine resulting
in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
c. Does the Veteran have muscle spasms of the thoracolumbar spine not
resulting in abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
d. Does the Veteran have guarding of the thoracolumbar spine resulting in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
e. Does the Veteran have guarding of the thoracolumbar spine not resulting
in
abnormal gait or abnormal spinal countour?
[ ] Yes [X] No
8. 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
9. 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+
10. 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: [ ] Normal [X] Decreased [ ] Absent
Left: [ ] Normal [X] Decreased [ ] Absent
11. Straight leg raising test
-----------------------------
Provide straight leg raising test results:
Right: [ ] Negative [X] Positive [ ] Unable to perform
Left: [ ] Negative [X] Positive [ ] Unable to perform
12. 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 [ ] Mild [X] Moderate [ ] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
Numbness
Right lower extremity: [ ] None [X] Mild [ ] Moderate [ ] Severe
Left lower 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 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 [ ] Mild [X] Moderate [ ] Severe
13. Ankylosis
-------------
Is there ankylosis of the spine? [ ] Yes [X] No
14. 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
15. Intervertebral disc syndrome (IVDS) and incapacitating episodes
-------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
16. 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
Identify assistive device(s) used:
Assistive Device: Frequency of use:
----------------- -----------------
[X] Walker [ ] Occasional [ ] Regular [X] Constant
b. If the Veteran uses any assistive devices, specify the condition and
identify the assistive device used for each condition:
Walker is due to knee surgery that he had yesterday.
17. 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
18. Other pertinent physical findings, complications, conditions, signs
and/or symptoms
-----------------------------------------------------------------------
a. 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
b. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms?
[ ] Yes [X] No
19. 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
20. 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:
He would be unable to walk or stand for extended periods.
21. REMARKS
-----------
a. Remarks, if any:
No comments provided.
b. Mitchell criteria:
The veteran states that pain flares up with excessive use. Pain,
weakness, fatigability or incoordination could significantly limit
functional ability during flare ups of after repeated use. However to
specify to the amount of limited functional ability would be resorting
to
mere speculation as I can not exam the veteran under these conditions.
Edited by whoami?
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Thanks for your response NYNurse. I will keep you informed as to the findings in my case for this issue. Please keep me informed with you guys' progresss also. Thanks.

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  • HadIt.com Elder

This is my first time trying to interpret the results of a DBQ against rating criteria, so don't flame me if I get it totally wrong.

The DBQ showed you had forward flexion 45 degree range of motion with pain.

Next, look at the schedule of ratings for the spine to see what it says.

§4.71a Schedule of ratings—musculoskeletal system.

20% rating section

Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis

I bolded the section that might apply to your situation because your range of forward flexion motion was 45 degrees.

There was also some indications about mild to moderate levels of radiculopathy in each leg. I am not familiar with that rating table, but it could be worth a shot to look at it, too...

I didn't see any indications of whether they thought you could become SC or not. Hopefully someone else can follow up and verify this. It looks to me like if you do get awarded SC for your back, you could get 20%, possibly with an unknown radiculopathy rating.

Edited by Vync
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