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  • 14 Questions about VA Disability Compensation Benefits Claims

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    When a Veteran starts considering whether or not to file a VA Disability Claim, there are a lot of questions that he or she tends to ask. Over the last 10 years, the following are the 14 most common basic questions I am asked about ...
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    You’ve just been rated 100% disabled by the Veterans Affairs. After the excitement of finally having the rating you deserve wears off, you start asking questions. One of the first questions that you might ask is this: It’s a legitimate question – rare is the Veteran that finds themselves sitting on the couch eating bon-bons … Continue reading

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    • The 5, 10, 20 year rules...



      Five Year Rule) If you have had the same rating for five or more years, the VA cannot reduce your rating unless your condition has improved on a sustained basis. All the medical evidence, not just the reexamination report, must support the conclusion that your improvement is more than temporary.



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      ------



      Example for 2020 using the same disability rating



      1998 - Initially Service Connected @ 10%



      RESULT: Service Connection Protected in 2008



      RESULT: 10% Protected from reduction in 2018 (20 years)



      2020 - Service Connection Increased @ 30%



      RESULT: 30% is Protected from reduction in 2040 (20 years)
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OffGridGrunt

[[Template core/front/global/prefix is throwing an error. This theme may be out of date. Run the support tool in the AdminCP to restore the default theme.]] Lower Back C&P plus backpay and neuropathy questions

Question

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

        Left:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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:  [ ] 5/5   [X] 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   [ ] 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+

      

    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: [X] Normal   [ ] Decreased   [ ] Absent

        Left:  [ ] Normal   [X] Decreased   [ ] Absent

      

      Foot/toes (L5):

        Right: [X] Normal   [ ] 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:  [ ] Negative   [X] 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: [X] None   [ ] Mild   [ ] Moderate  [ ] Severe

        Left lower extremity:  [X] None   [ ] Mild   [ ] Moderate   [ ] Severe

      Intermittent pain (usually dull)

        Right lower extremity: [X] None   [ ] Mild   [ ] Moderate  [ ] Severe

        Left lower extremity:  [ ] None   [X] Mild   [ ] Moderate   [ ] Severe

      Paresthesias and/or dysesthesias

        Right lower extremity: [X] None   [ ] Mild   [ ] Moderate  [ ] Severe

        Left lower extremity:  [ ] None   [X] Mild   [ ] Moderate  [ ] Severe

      Numbness

        Right lower extremity: [X] None   [ ] Mild   [ ] 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   [X] Left   [ ] Both

          

    d. Indicate severity of radiculopathy and side affected:

   

        Right: [X] Not affected   [ ] Mild   [ ] Moderate   [ ] Severe

      

        Left:  [ ] Not affected   [X] Mild   [ ] Moderate   [ ] Severe

      

    10. Other neurologic abnormalities

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

    [ ] Yes   [X] No

    12. Assistive devices

    ---------------------

    [ ] Yes   [X] No

 

    13. Remaining effective function of the extremities

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

    [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):

Vital signs are stable; Lungs are clear; Heart is without m/g/r; Abdomen is soft, and without masses or organomegaly or     tenderness; Genitalia are normal, no hernias or testicular lesions, the testicles and epididymii are tender to touch bilaterally;

    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

    

    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?

             [ ] 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?

      [X] Yes   [ ] No

    

          If yes, provide type of test or procedure, date and results (brief summary):

             Repeat lumbar MRI has been ordered and is currently pending; when completed and reported, I will review it and add any additional comments as indicated.

           

    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:

The Veteran's current lower back condition would limit his ability to perform repetitive heavy lifting, pushing or pulling.

            17. Remarks, if any:

    --------------------

    The Veteran is claiming service connection for a lower back condition.

    Opinion: It is as least as likely as not that the Veteran's current lower back condition is proximately due to or caused by military service.     Rationale: The C file was reviewed.

    The STRs do document a two year history in 2002 of chronic lower back pain with LLE radiculopathy. This is also noted on separation exam in 2004. I was able to elicit the same symptoms ongoing today, as well as to confirm this on phyiscal examination.

 

    Repeat lumbar MRI has been ordered since the last study was in 2009; when completed and reported, I will review it and add any additional comments as indicated. Thus, the service connection is substantiated.

 

12/23/2015 ADDENDUM                      STATUS: COMPLETED

The Veteran underwent a lumbar MRI on 12/21/2015 with the following findings:

L3-4:    Mild facet arthrosis with minimal posterior disc bulge

L4-5:    Mild facet arthrosis with minimal posterior disc bulge

L5-S1:   Mild facet arthrosis with minonal posterior disc bulge

 

------END-------

 

          Any help interpreting this would be greatly appreciated. The "service connection is substantiated" is pretty straight forward. I'm curious whether or not I have a chance at getting the SC backdated to my original claim. It seems to me (a total non expert) that the evidence is there to support it. I am also curious about whether or not I can refute some of the conclusions that this doctor came to. While an awesome C&P doctor a back expert he is not. Since the writing of the C&P I had a chiropractor evaluation who found several more things than this doctor did. I'm curious if any of it will be enough to make a 10% difference when the rating comes down.

 

In addition I am curious if within my C&P as well as the most recent chiro consult if there isn't evidence for a possible future claim for nerve pain in my lower body. "Many times spinal conditions have other conditions that contribute to the severity of the spinal condition. For example, many spine conditions also cause radiculopathy. These secondary conditions can sometimes be independently ratable." In my C&P I believe I meet all these conditions. I am diagnosed with lumbosacral strain - chronic, as well as Lower Left Extremity radiculopathy. In addition the C&P also diagnosed me with LLE weakness and paresthesias.

 

The following is a list of conditions that the Chiropractor diagnosed me with just 8 days after the C&P doctor finalized his report.

 

----------Chiropractic Evaluation--------------

LOCAL TITLE: PM&R CHIROPRACTOR CONSULT RESULT                  
STANDARD TITLE: PHYSICAL MEDICINE REHAB CONSULT

DATE OF NOTE: DEC 31, 2015@11:04 

 

Midback pain: medial scapula, left worse than right

Quality: Burning (small area "about the size of a dime")

Radiating: Patient Denies

0-10: 9/10

Timing: Intermittent

Worse: working in a "hunched" or bent over position.

Better: Standing up /stretching

Low Back Pain: Thoraco-lumbar and lower L4-5-S1.

Quality: Dull/Ache/sometimes sharp/Throbbing

Radiating: buttock/thigh and foot ("tasered"), left worse than right

0-10: 6-7/10

Timing: Intermittent

Worse: Standing/coughing while bent over

Better: changing positions/activities

 

Trunk ROM:

       Flexion:Mod dec                 Pain:Severe

       Extension:Mild dec              Pain:No pain

       Rotation:Mild dec               Pain:No pain

       Lateral Flexion:Mild dec        Pain:No pain

Muscle Atrophy: No

Seated SLR:                             Positive L

Supine SLR:                             Positive R (low back pain)

Hip hyperextension test:                Positive R

Kemps test:                             Negative R L

 

Spinous Process Tenderness: T3-7, L2,3, Right SI

Myofascial Tenderness: Bilateral Rhomboids, Thoraco-lumbar paraspinals

bilaterally.

Lumbar MRI 12/21/2015

    Impression:

      1. Mild facet arthrosis and minimal disc bulges of the lower lumbar spine without thecal sac or neuroforaminal stenosis.

 

Oswestry Disability Index Questionnaire

Section 1 -- Pain Intensity:  2. The pain is moderate at the moment.

Section 2 -- Personal Care (Washing, Dressing, etc.):  2. It is painful to look after myself and I am slow and careful.

Section 3 -- Lifting:   2. Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed e.g. on a table.

Section 4 -- Walking:  1. Pain prevents me walking more than 1 mile.

Section 5 -- Sitting:   3. Pain prevents me from sitting more than one-half hour.

Section 6 -- Standing:  2. Pain prevents me from standing for more than 1 hour.

Section 7 -- Sleeping:  2. Because of pain, I have less than 6 hours sleep.

Section 8 -- Sex Life (if applicable): N/A

Section 9 -- Social Life:  3. Pain has restricted my social life, and I do not go out very often.

Section 10 -- Traveling:  2. Pain is bad but I manage journeys over two hours.

DISABILITY INDEX SCORE: 38%

 

Segmental Dysfunction: L3LP, RPIN, RAI_Sacrum, T3LP, T5LP

 

Assessment:

1. Lumbar: Segmental dysfunction

2. Lumbar: strain

3. Pelvic: Segmental dysfunction

4. Sacrum: Segmental Dysfunction

5. Thoracic: Segmental dysfunction

 

Alright. If you've made it this far thanks for taking the time to read this massive wall of text. If you have some information or experience to offer let me thank you in advance!

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I opined on the PTSD exam you posted in another thread here.

http://community.hadit.com/topic/65204-helphope-for-a-bad-cp-is-all-lost-hope-i-get-a-good-rater/

Also the examiner found you were not capable of handling your funds.

You might well get some retro back to the recent date of the back claim,but only a CUE claim, if a CUE was made in that decision,, would get you more retro back to the older denied claim.

You have 2 major problems with the PTSD C & P exam results.

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Berta,

I kind of ended up glossing over this comment my first time through as i ended up going over to the comment you made in my other thread. Let me see if i understand what you're saying. 

Whenever I  officially get  SCd for this most recent claim i made in October I will be back payed to that time (it will actually be June as that's when i submitted my intent to file). I kind of assumed that would be a given. However to get a retroactive date effective to my original claim in 2004, I would have to file a CUE. 

How difficult is it to file a cue? Are they any more difficult to win or is it generally like any other claim; as long as the evidence backs it up you should be fine. I guess what I'm wondering is do they come under a higher level of scrutiny or is it basically the same thing just a different process?

also I'm wondering about the implied/potential secondary condition. While I realize I'm likely overdosing on wishful thinking, if the evidence supports the fact that I've had this problem since I was in the military is there any possibility of getting that retroactively connected too? I realize the answer is most likely no to that but now I'm wondering if I didn't apply for sciatica problems when I got out. The truth is my sciatica nerve issues gave me twice the hell that my back did: I'd actually be surprised if I didn't file for something.

Thanks again for your input and help I do appreciate it. 

PS, I replied to the comments you made in the other thread. I'd appreciate your thoughts on my ideas to address the issues you brought up.

OGG

 

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OGG,

Since I am currently running through a sciatica secondary to back claim, let me say this, they will not back date it beyond the date of the claim for the sciatica.  If you did not file a claim for it when you were leaving the Marines, then you can't get retro to that point.

In general they go back 2 years for current active claims.  But for CUEs and EEDs and such they can and do, sometimes, go as far back as your original claim goes.

When I had my C&P for increase for my back I mentioned that I enjoy sciatica symptoms in both Lower extremities.  But it was not included on the award decision.  So then I had to file for it as secondary.  So many things I have learned on this site. 

Your retro goes back to the first full month after your filed your claim, or intent to file.  The VA pays on the first of the month for the month just ending.  If you filed intent in June, your first month for retro would be July.

Semper Fi.

Andyman

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Thanks for the info Andy. I had kind of assumed that would be the case. I too am learning a lot on this site. I really wish I had done a lot more research before filing this claim. I'm definitely getting there though. The first thing I need to do is get my case back into the evidence gathering stage. This time I know how to properly back up my case (thanks in no small part to this site and it's community). I feel so much more confident armed with the knowledge I've gained from here and all the follow up research it's lead me too. 

Now I need to get a copy of my c-file so I can see what all I have claimed in the past and then start re-claiming all I can. 

Thanks for your comments,

OGG

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OGG,

You're welcome.  Most of us didn't know what we didn't know.  And no matter what we've learned since then, it's still a snowman's chance in "Death Valley", waiting to see what the VA decides with our claims. 

Many times we have to wait to get their decision before we can make our next move.  But getting a copy of your C-file is of utmost importance!

Semper Fi.

Andyman

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