CnP results for back lots of questions

[mskallday]

Hello all,

I recently got off active duty and had a CnP for my back. I was wondering what do you think the outcome of this exam will be? I have had back injuries all through my 6 years on active duty. A combined 11 months of No PT, no lifting profiles (dead mans profile). My range of motion is very poor in my back and continue to have issues with it. Every xray that I have gotten states disc narrowing suggesting DDD. I dont know why the examiner put it does not affect my ability to work, we discussed how it is an issue while in classes and in everyday functions. Thanks in advance everyone!

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:
        No response provided.

          Diagnosis #1:  lumbar strain
          ICD code:  ??
          Date of diagnosis:  2/27/2013
          
    2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
    thoracolumbar spine (back) condition (brief summary):
       original clam

       veteran testifies to and has documentation of being seen for lumbago
       2/27/2013, 3/15/2013 and 4/1/2013 after lifting 50# boxes.

       testfies to "got a shot in the back while I was in Germany because I
       couldn't walk, friends had to drive me to medical help.  I've tried the
       RICE and Ibuprophen route, dosen't help. The Medic gave me stretching
       excercises --sometimes, makes it feel worse.  I've even tried my Dad's
       TENS unit without relief. There has been no formal PT for back condition.
       
       
    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:
           "it's there 24/7, stiff & tight"
           

    c. Does the Veteran report having any functional loss or functional
    impairment of the thoracolumbar spine (back) (regardless of repetitive use)?
    [ ] Yes   [X] No

    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 10 degrees
           Right Lateral Flexion (0 to 30):     0 to 15 degrees
           Left Lateral Flexion (0 to 30):      0 to 15 degrees
           Right Lateral Rotation (0 to 30):    0 to 15 degrees
           Left Lateral Rotation (0 to 30):     0 to 15 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 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? [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):
           mid thoracic to lumbar subjective tenderness
           
           
    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   [ ] No   [X] 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

    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:

       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:

    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:
         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: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] 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
         
       Other sensory findings, if any:  full vibratory sensing
       
    7. Straight leg raising test
    ----------------------------
    Provide straight leg raising test results:
       Right: [X] Negative   [ ] Positive   [ ] Unable to perform
       Left:  [X] Negative   [ ] Positive   [ ] Unable to perform

    8. Radiculopathy
    ----------------
    Does the Veteran have radicular pain or any other signs or symptoms due to
    radiculopathy?
    [ ] Yes   [X] No
    
    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?
       [ ] Yes   [X] No
       

    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

    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?
       [ ] Yes   [X] No
       
    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?
       [ ] 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?
       [ ] Yes   [X] No
       
    17. Remarks, if any:
    --------------------
    remains independent with ADLS, attends classes M-TH, drove self to exam in
    own Trans Am vehicle

    -------------
    Dx: lumbar strain

[iceturkee]

just curious, ever had an mri? if so, what did it say? did the examiner opine its at least as likely as not that it is service connected?

don't have the criteria in front of me but i'm thinking 20 percent.

Edited April 12, 2016 by iceturkee

[mskallday]

Iceturkee,

the examiner agrees that it is service connected. Never had an MRI done on it. I'm very confused on how they rate back issues

[iceturkee]

either range of motion or doctor prescribed bed rest. been dealing with the va for almost 30 years. the examination criteria for back ratings is beyond ridiculous.

[mskallday]

5 hours ago, iceturkee said:

either range of motion or doctor prescribed bed rest. been dealing with the va for almost 30 years. the examination criteria for back ratings is beyond ridiculous.

That is is crazy... So far I had an excellent experience with the Milwaukee VA, but I say that without my ratings haha. I guess I'll see, I did the quick start program on active duty, all my exams are done and moved into prep for decision phase week ago.

[iceturkee]

11 hours ago, Dot09 said:

You should definitely get a mri. For years mine was just labeled as DDD and went and got one and found herniated discs. MRI are very accurate.

the only things a normal xray will show are fractures and/or arthritis. an mri will show just about everything!