degenerative arthritis Lower Back C&P plus backpay and neuropathy questions

OffGridGrunt · January 4, 2016

I recently finished a series of C&Ps for various conditions and I was hoping to get some input on just what exactly it all means - I was wondering what if any kind of rating might I be looking at? Is there a possibility for getting back pay? What can I do (possibly in an appeal) to do more to strengthen my case? At this point my case should be done with the gathering evidence phase (I can't check because ebenefits is being weird). All C&P's are done and everything that needed to be turned in is (I hope).

The first C&P/DBQ I'd like assistance with is my claim for "Lower Back Condition". Originally I had claimed "chronic lower back pain" only to later find out that really isn't a thing and thus I was denied. When I went in for this most recent exam the reviewing doctor first went to my C-File and saw that I had claimed "chronic lower back pain" back in 2004. He then went into my military treatment record and found considerable amounts of treatment records for several issues in my lumbar spine and beyond. "They should have connected you back in 2004" he said to me. Sufficed to say that his positive first impressions put me a little more at ease with the C&P (which normally turns me into an anxious, nervous wreck).

I've now gained access to the DBQ and would like any information that you well informed folks could provide. I've cut it down as much as I thought I could. If a question is missing and/or option is missing assume it wasn't checked. All non-pertinent information I cut out and did some heavy editing as far as formatting goes. Here it is:

Back (Thoracolumbar Spine) Conditions

Disability Benefits Questionnaire

Indicate method used to obtain medical information to complete this document:

[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

claims file:

VA medical records.

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: LS strain, chronic, with LLE radiculopathy

Date of diagnosis: 2000s

2. Medical history

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

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

During military service, the Veteran did develop chronic left lower back pain with radiation down the left buttock to the calf. On 6/10/2003, an MRI of the LS spine was performed with the following findings: Broad based posterior/central disc bulging at L4-5 without associated neural impingement.

After service discharge in 2004, the Veteran continued with intermittent lower back and LLE problems. Repeat lumbar MRi in 2009 was read as normal.

Currently he continues with chronic daily left lower back pain with LLE weakness and paresthesias. He is taking Ibuprofen and has a TENS unit as needed. He deniesbowel/bladder/sexual dysfunction related to his lower back.

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:

Increased pain and stiffness

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.

Stiffness/LLE radiculopathy

3. Range of motion (ROM) and functional limitation

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

a. Initial range of motion

[X] Abnormal or outside of normal range

Forward Flexion (0 to 90): 0 to 75 degrees

Extension (0 to 30): 0 to 20 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 30 degrees

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

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

Description of pain (select best response):

Pain noted on exam on rest/non-movement

If noted on exam, which ROM exhibited pain (select all that apply)?

Forward Flexion, Extension

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):

There is localized tenderness over the bilateral paralumbar muscles and the left SI joint and left sciatic notch.

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?

[ ] Yes [X] No

If the examination is not being conducted immediately after repetitive use over time:

[X] The examination is neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time.

Does pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time?

[ ] Yes [ ] No [X] Unable to say w/o mere speculation If unable to say w/o mere speculation, please explain:

Not currently flared up.

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 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:

Not currently flared 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] Not resulting in abnormal gait or abnormal spinal contour

Provide description and/or etiology:

Left lower back muscle spasm is noted today. Localized tenderness:

[X] Not resulting in abnormal gait or abnormal spinal contour

Guarding:

[X] None

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:

[X] 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