degenerative arthritis I was reevaluated for my back after multiple filings

[BklynVet]

Hi,
I filed for ED, testicle pain, a varicocele and hypogonadism and for some strange reason, the VA decided to check my back.  When I asked them why, they said that the Regional Office wanted my back re-evaluated.  I've been at 20% for my back since 2003 so I'm a little worried.  Why check my back?  They left me alone for over 12 years?  I've been filing alot for the past 2 years so I'm wondering if I might have triggered a reevaluation by filing too much.

LOCAL TITLE: C&P SPINE
STANDARD TITLE: ORTHOPEDIC SURGERY C & P EXAMINATION CONSULT 
DATE OF NOTE: AUG 12, 2015@15:00 ENTRY DATE:  AUG 12, 2015@17:01:28
AUTHOR: XXXXXXXXXXX      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?
[ X] Yes [] No

If yes, list any records that were reviewed but were not included in the Veteran's VA file claim:
VBMS, CPRS


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
[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


2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):

Date of service:  Mar 2000  - Mar 2003

=14pxPatient stated that he was in Officer Training School 2000, @ Maxwell AFB, Alabama.  He jumped over a log and fell into a hole.  He had immediate back pain and back spasms.  He was taken to the medical center.  He was given ibuprofin and bed rest.  The pain level went down, and he was able to return to duties.  However, the pain did not completely go away.  He was place don profile.  He stated that he would have stiffness along with the pain in the mornings.

The pattern of pain remains the same.  No furtner trauma to the back.

Currently the pain is constant pain is at 3/10.  Worsen in the mornings on awakening and with bending forward, where his pain goes up to 8/10.  Often he would get spasm in the mornings.  His pain radiates to the R>L, posterior to the calf.  There is numbness and tingling at the bilateral great toes.

*****************************************

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:
=14pxI have more pain in the mornings and when I do anything for too long.


c. Does the Veteran report having any functional loss or functional
impairment of the thoracolumbar spine (back) (regardless of repetitive use)?
[X] Yes  [ ] No
=14pxIncreased back pain in the mornings and being in prolonged positions.


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 10 degrees
Right Lateral Flexion (0 to 30): 0 to 10 degrees
Left Lateral Flexion (0 to 30): 0 to 10 degrees
Right Lateral Rotation (0 to 30): 0 to 10 degrees
Left Lateral Rotation (0 to 30): 0 to 10 degrees

If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes (please explain) [ ] No
If yes, please explain:
Pain on movement


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? [ 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):
Tender L4-515 intevertebral and lower lumbar area.


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? [ X] Yes [] No

Select all factors that cause this functional loss:
Pain

ROM after 3 repetitions:
Forward Flexion (0 to 90): 0 to 60 degrees
Extension (0 to 30): 0 to 5 degrees
Right Lateral Flexion (0 to 30): 0 to 5 degrees
Left Lateral Flexion (0 to 30): 0 to 5 degrees
Right Lateral Rotation (0 to 30): 0 to 10 degrees
Left Lateral Rotation (0 to 30): 0 to 10 degrees


c. Repeated use over time

Is the Veteran being examined immediately after repetitive use over time?
[ X] Yes [] No

Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[X ] Yes [ ] No [] Unable to say w/o mere speculation
=14pxSelect all factors that cause this functional loss:
Pain


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:
[ X] 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.
[] 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:
=14pxNo flare ups at this time.


e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [X] Yes [ ] No

Muscle spasm:
[] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[ X] Not resulting in abnormal gait or abnormal spinal contour
[ ] Unable to evaluate, describe below:
Provide description and/or etiology:
Tightness at the promixal lumbar paraspinals

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:
Provide description and/or etiology:
Tender at the lower lumbar area and interverbral L4-5

Guarding:
[ X] None
[ ] Resulting in abnormal gait or abnormal spinal contour
[] 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:
None

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 [X ] 1+ [] 2+ [ ] 3+ [ ] 4+
Left: [ X] 0 [ ] 1+ [] 2+ [ ] 3+ [ ] 4+

Ankle:
Right: [ ] 0 [ X] 1+ [] 2+ [ ] 3+ [ ] 4+
Left: [X ] 0 [ ] 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: [ ] 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: [] None [ ] Mild [ X] Moderate [ ] Severe
Left lower extremity: [] None [ X] Mild [ ] Moderate [ ] Severe

Intermittent pain (usually dull)
Right lower extremity: [ X] None [] Mild [ ] Moderate [ ] Severe
Left lower extremity: [ X] None [] Mild [ ] Moderate [ ] Severe

Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [] Mild [ X] Moderate [ ] Severe
Left lower extremity: [ ] None [] Mild [X ] Moderate [ ] Severe

Numbness
Right lower extremity: [ ] None [] Mild [X ] 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 [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?
[ X] Yes [] No

If yes, identify assistive device (s) used (check all that apply and indicative 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


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):
=14pxRight foot dorsiflexors strength decreased to 5- /5 with prolonged resistance.


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):
SPINE LUMBOSACRAL MIN 4 VIEWS
Exm Date: MAY 19, 2015@10:09
=14pxFINDINGS:
The vertebral bodies are normal in height and alignment. No fracture or subluxation is see.
Mild, multilevel degenerative changes involving the lumbar spine, most prominent at L4-5 and L5-S1 levels.  The paraspinous structures are unremarkable.
Impression:
No acute fracture or subluxation of the lumbar spine.  Mild, multilevel degenerative changes involving the lumbar spine, most prominent in the lower lumbar region.

*******************************
Lumbar Spine MRI: 3/27/2014
IMPRESSION: Mild multilevel lumbar spondylosis and degenerative disc disease resulting in multilevel bilateral forminal stenosis as detailed above.


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:
Works as a Contract Administrator.  He is usually sits for a long periods of time, which is uncomfortable.




17. Remarks, if any:
--------------------

MITCHELL V SHINSEKI:

=14pxAny further comments on flare ups or repetitive motion so far as fatigue, lack of endurance, increased pain, change in range of motion, incoordination or weakness, beyond what is listed above, would be speculation.

***********************************************
CURRENT LEVEL OF SEVERITY:
Current level of Severity of the low back: Moderate-Severe

[BklynVet]

I was rated at 20% for my back. 10% for radiculopathy in my right leg. These 2 ratings were back in 2003.

During my multiple filings, they also included my left leg for 0% radiculopathy in 2014.

Should I be worried about them decreasing my back or radiculopathy?  

I thought they were doing the C&P for my erectile dysfunction because I thought my back problems could have caused it but the examiner showed me the request from the Regional Office requesting that they reevaluate my back.

[Vync]

Unfortunately, the VA's C&P department is not always clear about what type of exam you are having. I have been a victim of expecting an exam for A, but in reality it was for B. Your back can indeed impact ED. The same nerves that control your privates travel through your entire spine. Problems anywhere along the spine can impact everything below. It is also very possible that you might get a C&P for your ED. They will probably roll it into a general medical C&P. However, if you have medical evidence proving all the requirements for SC of your ED, the VA might accept it without a new C&P.

I am including some additional information to help you understand about when the VA can/cannot reduce and/or ask for new exams:

The VA can request a new C&P at any time, but generally will not under the following conditions:

• The veteran is over age 55.
• The disability is static (such as a loss of limb).
• The disability is considered permanent and is not expected to improve (e.g. blindness, deafness).
• The disability is already at a minimum rating for that particular disability.
• Reducing an individual rating would not affect the total combined disability rating.

Below are overviews of "protection" ranges. The word "protection" is kind of a misnomer as it is not total protection.

• 5 year rule: If the rating has been in effect for 5 years, it cannot be reduced unless your condition has improved on a sustained basis (The VA must have documentation supporting this is a permanent improvement).
• 10 year rule: A service connected disability rating cannot be terminated if it has been in effect for 10 years. Compensation can be reduced if evidence exists that the condition has improved. The sole exception is if the VA can prove fraud, in which case the VA can terminate the benefits.
• 20 year rule: If the rating has been in effect for 20 years, it cannot be reduced below the lowest rating it has held for the previous 20 years. The only exception is if the VA can prove fraud.
• 100% rule: The VA must prove your medical situation has materially improved and as a result, you are able to perform substantial work.

 

[Navy04]

I have the same ratings as you do for the Back and nerve damage bud, nothing to worry about. Remember that the VA at any time can look at whatever condition. I put in my last FDC in Nov 14, claim sat at Prep for Decision for over 2 months, then the VA ordered all the C&Ps, and decided to Review most of my conditions in Feb 15, including PTSD, which were not up for Review until Feb 16. All those Reviews were brutal, especially the PTSD, but in the End it backfired in the VA's face, with most High %s continuing and my Migraines were Increased. Good luck and keep us posted.   BTW I have a current claim Supposedly for Increase, that the VA opened 2 months ago, and sent me to a Heart Surgeon to have my Scars and Tongue Nerve Damaged reviewed, and it is currently at Prep for Decision. It is always something bud