degenerative arthritis C&P--If ROM is outside of normal range??

ShuMan · October 18, 2015

Team,

I looked at my C&P results and I saw an interesting box checked the: If ROM is outside of normal range, but is normal for the Veteran (for
reasons other than a back condition, such as age, body habitus,
neurologic disease), please describe:?

I'll post the exam below but to me it looks like she is saying that I am lying? How will this effect my rating? What do you think my Rating will be for the below exam? I'm currently rated at 0% for Lumbar strain.

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: Lumbago

ICD code: M54.5

Date of diagnosis: 04/ 2006

2. Medical history

------------------

a. Describe the history (including onset and course) of the Veteran's

thoracolumbar spine (back) condition (brief summary):

The Veteran could not initially remember a specific incident in-service

but attributes low back pain after lifting up large pieces of equipment

while in-service. He reports lumbar level back pain that is located to

the

L sided without radiation. He was evaluated by the VA ER and was treated

with PT and chiropractic services.

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:

I be doing something like pouring dog food or nothing strenuous and

it

will hurt.

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.

I get back spasms about 2 times a month. I have to change my position

with sitting and standing. I modifies my activities to minimize

things.

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 30 degrees

Right Lateral Flexion (0 to 30): 0 to 30 degrees

Left Lateral Flexion (0 to 30): 0 to 30 degrees

Right Lateral Rotation (0 to 30): 0 to 20 degrees

Left Lateral Rotation (0 to 30): 0 to 20 degrees

If ROM is outside of normal range, but is normal for the Veteran (for

reasons other than a back condition, such as age, body habitus,

neurologic disease), please describe:

Limited effort on PE. Greater ROM note on casual observation without

facial grimacing as was demonstrated at the time of the PE.

If abnormal, does the range of motion itself contribute to a

functional loss? [X] Yes (please explain) [ ] No

If yes, please explain:

It is difficult to assess the true degree of functional loss

considering the noted discrepancies at the exam versus casual

observation

Description of pain (select best response):

Pain noted on exam but does not result in/cause 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? [ ] Yes [X] 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):

L lateral lumbar area at L4-5.

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?

[X] Yes [ ] No

Does pain, weakness, fatigability or incoordination significantly limit

functional ability with repeated use over a period of time?

[ ] Yes [X] No [ ] Unable to say w/o mere speculation

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 is not currenlty in a flare-up.

========================================================

e. Guarding and muscle spasm

Does the Veteran have guarding or muscle spasm of the thoracolumbar spine

(back)? [X] Yes [ ] No

Muscle spasm:

[X] None

[ ] Resulting in abnormal gait or abnormal spinal contour

[ ] Not resulting in abnormal gait or abnormal spinal contour

[ ] Unable to evaluate, describe below:

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:

L lumbar area as described above.

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:

Provide description and/or etiology:

Anicipatory

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: