I wanted to get some feedback on my C&P exam due to a claim. The claim went forward because my previous C&P for my DDD was full of lies about my ROM. Below is my ROM during the exam also complete redacted exam.
Anyway, any idea of what the possible increase would be?
forward flexion----0 to 15 degrees
extension---- 0 to 10 degrees
right lat flexion-- 0 to 10 degrees
left lat flexion-- 0 to 10 degrees
right lat rotation----0 to 20 degrees
left lat rotation-- 0 to 20 degrees
Here is my full exam:
CURRENT STATUS BACK CONDITION: He has a baseline pain of 7/10 that flares
up to 8-10/10 a couple times a month. If it flares up and he can't go
to work he calls in sick. He missed over 100+hrs over the past year for his
back. The pain is across the lower back and goes into both buttocks. A
couple times a week the pain can go down into both calves. He does a lot
of stretching which seems to help. He feels like there have been about 5-6 weeks total over the past year where he has been totally incapacitated and needed to have family members help him get dressed and out of bed. He is in the middle of a flare up now. Care has included chiropractic care, medications, TENS unit and physical therapy. No surgery on the back or injections in the 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:
Its like a burning shooting pain in the back down shoots down back of
legs.
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.
He can't go to work. he has a stand up desk at work when he needs
it. He has to take a lot of time off from work. When he feels totally
incapacitated he will need family members to help with daily
activities.
3. Range of motion (ROM) and functional limitation
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):
walks with slow stiff back gait slightly huched forward after exam
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?
[ ] 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
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:
He has missed over 100+ hrs of work over the past year due to his
back. He will sometimes have to go home after a half day of work
if back flares. He has a sit/stand desk at work which helps.
17. Remarks, if any: -------------------veteran now has sciatica type symptoms bilateral lower extremities. his subjective descriptions are documented in the radiculopathy section. It is likely that these symptoms are secondary to his SC low back condition as
they often represent the natural progression of such conditions.
Question
fmfdoc
Hi,
I wanted to get some feedback on my C&P exam due to a claim. The claim went forward because my previous C&P for my DDD was full of lies about my ROM. Below is my ROM during the exam also complete redacted exam.
Anyway, any idea of what the possible increase would be?
forward flexion----0 to 15 degrees
extension---- 0 to 10 degrees
right lat flexion-- 0 to 10 degrees
left lat flexion-- 0 to 10 degrees
right lat rotation----0 to 20 degrees
left lat rotation-- 0 to 20 degrees
Here is my full exam:
CURRENT STATUS BACK CONDITION: He has a baseline pain of 7/10 that flares
up to 8-10/10 a couple times a month. If it flares up and he can't go
to work he calls in sick. He missed over 100+hrs over the past year for his
back. The pain is across the lower back and goes into both buttocks. A
couple times a week the pain can go down into both calves. He does a lot
of stretching which seems to help. He feels like there have been about 5-6 weeks total over the past year where he has been totally incapacitated and needed to have family members help him get dressed and out of bed. He is in the middle of a flare up now. Care has included chiropractic care, medications, TENS unit and physical therapy. No surgery on the back or injections in the 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:
Its like a burning shooting pain in the back down shoots down back of
legs.
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.
He can't go to work. he has a stand up desk at work when he needs
it. He has to take a lot of time off from work. When he feels totally
incapacitated he will need family members to help with daily
activities.
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 15 degrees
Extension (0 to 30): 0 to 0 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 20 degrees
Left Lateral Rotation (0 to 30): 0 to 5 degrees
If abnormal, does the range of motion itself contribute to a
functional loss? [X] Yes (please explain) [ ] No
If yes, please explain:
can't sit comfortably. stands for most of history and exam
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, Right Lateral Rotation, Left Lateral Rotation
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 lumbar paraspinal muscles
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 10 degrees
Extension (0 to 30): 0 to 0 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 5 degrees
Left Lateral Rotation (0 to 30): 0 to 5 degrees
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 medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time. Please explain.
[ ] 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?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [X] Yes [ ] No
Forward Flexion (0 to 90): 0 to 10 degrees
Extension (0 to 30): 0 to 0 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 5 degrees
Left Lateral Rotation (0 to 30): 0 to 5 degrees
d. Flare-ups
Is the exam being conducted during a flare-up? [X] Yes [ ] No
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with flare-ups?
[X] Yes [ ] No [ ] Unable to say w/o mere speculation
Select all factors that cause this functional loss:
Pain
Able to describe in terms of range of motion: [X] Yes [ ] No
Forward Flexion (0 to 90): 0 to 10 degrees
Extension (0 to 30): 0 to 0 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 5 degrees
Left Lateral Rotation (0 to 30): 0 to 5 degrees
e. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [X] Yes [ ] No
Muscle spasm:
[ ] None
[X] 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:
walks slightly hunched forward
Localized tenderness:
[ ] None
[X] 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:
walks slightly hunched forward
Guarding:
[ ] None
[X] 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: walks slightly hunched forward
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:
Interference with sitting
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 [ ] 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: [ ] Normal [X] Decreased [ ] Absent
Left: [ ] Normal [X] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
7. Straight leg raising test
------Provide
straight leg raising test results:
Right: [ ] Negative [X] 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: [ ] None [ ] Mild [ ] Moderate [X] Severe
Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Intermittent pain (usually dull)
Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Paresthesias and/or dysesthesias
Right lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Left lower extremity: [ ] None [ ] Mild [ ] Moderate [X] Severe
Numbness
Right lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] Severe
b. Does the Veteran have any other signs or symptoms of radiculopathy?
[X] Yes [ ] 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 [ ] Mild [X] 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?
[X] Yes [ ] No
If yes, select the total duration over the past 12 months:
With episodes of bed rest having a total duration of at least four
weeks but less than six weeks during the past 12 months
c. If yes to question 11b above, provide the following documentation that
supports the Yes response:
[X] Medical history as described by the Veteran only, without
documentation:
see history above. Does not go to doctor everytime it flares. Was
told
by PCP that he would not prescribe bedrest.
[ ] Medical history as shown and documented in the Veteran's file:
[ ] Other, describe:
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?
[ ] Yes [X] No
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
4. 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):
walks with slow stiff back gait slightly huched forward after exam
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?
[ ] 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
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:
He has missed over 100+ hrs of work over the past year due to his
back. He will sometimes have to go home after a half day of work
if back flares. He has a sit/stand desk at work which helps.
17. Remarks, if any: -------------------veteran now has sciatica type symptoms bilateral lower extremities. his subjective descriptions are documented in the radiculopathy section. It is likely that these symptoms are secondary to his SC low back condition as
they often represent the natural progression of such conditions.
added redacted exam
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Andyman73
Just be for warned, if you didn't file for the radiculapathy or for increase of same, VA almost never gives anything away for free. So you may have to file for that, specifically. I had to, and it's
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