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ROM during C&P exam with redacted exam results

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fmfdoc

Question

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.

 

Edited by fmfdoc
added redacted exam
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On ‎1‎/‎22‎/‎2016 at 1:23 PM, iceturkee said:

so what do your xrays show if you have no arthritis or a significant vertebral fracture? i am 40 percent for my back. i have five herniated discs, a slipped vertebrae, two torn discs, both foraminal and spinal stenosis and arthritis.

 

while your range of motion would warrant 40 percent, i am concerned that you use no assistive devices, (wheelchair for me but i also have rheumatoid arthritis) and have had no mri's. hence my question about what other diagnostic tests show.

thanks for the feedback. I currently don't use assistive devices(yet). I've done as much as I can to this point and hope the appeal results are coming back to me soon.

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On ‎1‎/‎25‎/‎2016 at 7:43 AM, iceturkee said:

i hope so too. but i would still be curious what your x-rays showed.

here are my x-ray results. My understanding is the ROM or lack of ROM will be key for an increase..

 

There is an exaggerated lordosis of the lumbosacral spine with

degenerative disc changes scattered in the lumbar spine.

 There is no evidence of spondylolisthesis.  partial

lumbarization of S1. minimal right convex curve to

the lumbar spine.

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true. but usually your xrays and ct scans or mri will show something significant to warrant the lack of range of motion. something, i am honestly not seeing. but i wish you the best! :-)

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thanks for your feedback. to each is own. From my understanding the rating is based on ROM not xrays results. I have read through dozens upon dozens of appeal results. I didn't see where xrays trumped C&P ROM.

 

 

Edited by fmfdoc
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