lumbosacral Back C&p Results Rating Expectations

[whoami?]

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 May 21, 2014 by whoami?

[NYNurse1124]

SOC date 6/18 waiting on information to arrive via snail mail. It's amazing at the extent of this process, the hoops and ladders to go through as well as the BS. I understand fully and completely any veteran's frusteration!

[john999]

Is this an original claim? The exam doctor did not review the vet's SMR's nor current medical records. He just looked you over and claims to have looked at your C-File.

[whoami?]

Sorry for not putting all the information. This C&P was for an increase for my lower back pain . I also added sciatic pain that runs down the back of my legs. From what I understand the radiculpathy is rated individually in addition to the back pain.

[whoami?]

I think before vets go for these subjective exams they should consult with Hadit.

John I have another C&P for PTSD this week. Do you have any advice for me? I am currently service connected for ptsd but it has gotten progressively worse since I was diagnosed in 2009. I am taking five medications to manage the symptoms but they really aren't working. I have failed out of school due to poor concentration and I currently don't have a job. I am currently recieving SSDI. The examiner mentioned that working will be a problem for me because of my back pain he said the same thing about my shoulder issue. How should I proceed John?

[whoami?]

Anyone have an insight for an upcoming C&P for PTSD already sc'd for increase?

[NavyWife]

Whoami--

Congratulations! you have the hard part done--Which is getting the service connection for PTSD.

That means your stressor has already been accepted and you already have your current diagnosis.

For your upcoming PTSD exam I would recommend that you write or type up a one page paper listing all your current symptoms that are due to PTSD. I would also write down the reasons your PTSD keeps you from working. In order to get to the higher ratings for PTSD you will need to show how it keeps you from working. I would make two copies of this, one to keep for yourself to refer to during the exam and the second I would try to give to the examiner. However don't be offended if they do not accept it --some will & some wont.

The next thing you need to do if you have not already is send the documentation from SSDI to the VA That shows that you cannot work. I am assuming the reasons you're getting SSDI are the same reasons you are getting VA. If you are getting SSDI for things that you're not service-connected for then that could become tricky and you would need to reevaluate whether to send that to VA or not. The whole purpose of doing this is to give more proof to VA that you CANNOT WORK SOLELY DUE TO YOUR SERVICE-CONNECTED CONDITIONS.

If both of these things end up not working for you then you will need to get an independent medical exam (IME) or an independent medical opinion (IMO). There is a ton of information on how to get these done properly here on hadit. If you have some extra money and really want to bolster your chances of getting an increase you could even get one done now and send it to VA.

Good luck!