degenerative arthritis a little help here Please

[silverdollar22]

I went in for an increase of my back, left knee and left hip.  I was seen by a overly nice female examiner that turns out to be a nurse practitioner and the outcome of this c&p was shocking to say the least!  When we got done talking for a least a half an hour she said "oh this is only for an increase so lets take a look at your back. She never used a geinommeter or any device to measure my ROM but said to turn around and face the chair and bend over which I did to approx. 30 degree range and she said OK that's all we need. The next couple of days i read this on e-benefits  

  Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination Request? [X] Yes [ ] No ACE and Evidence Review ----------------------- Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence Review --------------- Evidence reviewed (check all that apply): [X] VA e-folder (VBMS or Virtual VA) [X] CPRS 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 [ ] Lumbosacral strain [X] Degenerative arthritis of the spine [ ] Intervertebral disc syndrome [ ] Sacroiliac injury [ ] Sacroiliac weakness [ ] Segmental instability [ ] Spinal fusion [ ] Spinal stenosis [ ] Spondylolisthesis [ ] Vertebral dislocation [ ] Vertebral fracture  Page 20 of 66 Diagnosis #1: Degenerative Disc Disease of the Lumbar Spine ICD code: M47.0 Date of diagnosis: already service connected Diagnosis #2: Lumbar radiculoapthy ICD code: M54.16 Date of diagnosis: already service connected 2. Medical history ------------------ a. Describe the history (including onset and course) of the Veteran's thoracolumbar spine (back) condition (brief summary): Since the veteran is already service connected for his condition, this exam will focus on his current status. He reports pain in his lower back that is rated a "7". He takes Hydrocodone i tab by mouth a few times per week. No surgery to his lower back. He denies that he has had steroid injections, or pain medication injections. He has lumbar radiculopathy that is constant. 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: this will occur about once per week that will last for most of the day with a pain level of a "8-9". Precipitating factors: unknown. 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. limited ROM of the lumbar spine is in itself a functional limitation of the lumbar spine. 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 65 degrees Extension (0 to 30): 0 to 20 degrees Page 21 of 66 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 20 degrees Left Lateral Rotation (0 to 30): 0 to 20 degrees If abnormal, does the range of motion itself contribute to a functional loss? [X] Yes (please explain) [ ] No If yes, please explain: limited ROM of the lumbar spine is in itself a functional limitation of the lumbar spine. 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? [ ] Yes [X] 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): he does have localized tenderness noted to the lumbar spine on the spinal cord and on either side of the spinal cord. 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: [ ] 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  Page 22 of 66 time. Please explain. [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: There was a question on the 2507 that asks whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over period of time. There really is no way to predict functional ability during a flare-up when it is not witnessed. This would be subjective, presumptive and speculative at best and an opinion is not feasible and cannot be rendered. 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 d uring 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: There was a question on the 2507 that asks whether pain, weakness, fatigability or incoordination could significantly limit functional ability during flare-ups, or when the joint is used repeatedly over period of time. There really is no way to predict functional ability during a flare-up when it is not witnessed. This would be subjective, presumptive and speculative at best and an opinion is not feasible and cannot be rendered. e. Guarding and muscle spasm  Page 23 of 66 Does the Veteran have guarding or muscle spasm of the thoracolumbar spine (back)? [X] Yes [ ] No 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: he walks with a slight forward bend to his back due to the pain 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: Disturbance of locomotion, Interference with sitting, Interference with standing Please describe additional contributing factors of disability: he cannot walk over 15-20 minutes at the time. He cannot sit for greater than 10-20 minutes and standing for over 15 minutes. 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 Page 24 of 66 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: [ ] Normal [X] Decreased [ ] Absent Left: [ ] Normal [X] 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 Page 25 of 66 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 [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] 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 [X] Moderate [ ] Severe Left lower extremity: [ ] None [ ] Mild [X] Moderate [ ] 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? [ ] 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 [ ] 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 -----------------------------------------------------------------------  Page 26 of 66 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? [X] Yes [ ] No If yes, identify assistive device(s) used (check all that apply and indicate frequency): Assistive Device: Frequency of use: ----------------- ----------------- [X] Cane(s) [ ] Occasional [X] Regular [ ] Constant b. If the Veteran uses any assistive devices, specify the condition and identify the assistive device used for each condition: for his lower back and radicular symptoms 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  Page 27 of 66 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? [X] Yes [ ] 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): MRI LUMBAR SPINE W/O (JUN 09, 2014@07:51) Report: MRI Lumbar Spine Sagittal STIR and sagittal and axial T1 weighted, T2 weighted images of the lumbosacral spine were obtained. Findings: Comparison to MRI of the lumbar spine on 8/4/11. Normal alignment of the lumbar sacral spine is visualized. Heterogenuos bone marrow signal is noted likely due to degenerative changes. L5-S1 Modic type II changes. At T12-L1, L1-2 there is disc desiccation, mild diffuse disc bulging with mild facet joint hypertrophy without significant neural foramina narrowing. Normal appearance for the patient's age. At L2 L3 there is a right paracentral and foraminal disc protrusion with extrusion and mild superior migration, producing narrowing of the right lateral recess and posterior displacement of the right L3 nerve root. Protrusion contacts and produce mild displacement of the a right L2 nerve root within the neural foramen. At L3-4 mild disc narrowing and desiccation, diffuse disc bulging without significant central spinal canal narrowing. Mild bilateral facet  Page 28 of 66 joint hypertrophy without significant neural foramen narrowing. Unchanged in comparison to prior At L4-5 there is disc narrowing, bulging and desiccation with moderate facet joint hypertrophy, ligamentum flavum hypertrophy and bilateral mild neural foramina narrowing. Unchanged in comparison to the prior. At L5-S1 severe disc narrowing and desiccation with moderate facet joint hypertrophy, ligamentum flavum hypertrophy and bilateral mild neural foramina narrowing. There is a mild degenerative retrolisthesis of L5 on S1. Unchanged in comparison to the prior. The conus medullaris ends at the lower portion of L2 body. Cauda equina demonstrated no compression. No evidence of paraspinous soft tissue abnormality. Impression: 1. L2 L3 right paracentral and foraminal disc protrusion with extrusion and mild superior migration, producing mild displacement of the right L2 nerve within the neural foramen and the right L3 nerve within the lateral recess. Please correlate clinically for right L2 and/or L3 radiculopathies. 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 pain in his lower back on a daily basis. He has missed 9 days of work over the past year due specificially to his lower back. 17. Remarks, if any: -------------------- Page 29 of 66 No medical opinion was requested for this already service connected disability.

I checked and they reduced me from 30% to 10% off of this exam!  I checked the cfr and here's what i found

The Spine

   Rating

General Rating Formula for Diseases and Injuries of the Spine

Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis20

Is it me or according to this it should be rated at at least 20% even with the bad ROM reading?

Edited September 17, 2016 by silverdollar22

[Buck52]

It looks like a Favorable exam.   its a lot better than what I've seen veterans get!

its hard to say what your rating will be...in my opinion this looks like it will be rated as Moderate 

so anything around 30/50% in my opinion.

look up the Moderate symptoms for this type disability  and see what the % should be rated!

If its lower that what is in the systems chart...Disagree with the rating decision and request it be rated to the full extent of the CFR's and quote them back in your NOD  21-0958

This examiner did ok  I think...even if she didn't use the Rom G-meter!

Also you might check out the forums here on hadit  of the veterans that have been rated for your type of condition...to give ya an Ideal

jmo

....Buck

 

[Buck52]

Note:

I don't know how bad your disability is?  but if its chronic and prevents you from working  then this exam is not what you want/ deserve &  if it keeps you from working Request TDIU  P&T be  Awarded.

you should get what your symptoms show  in my opinion.

so don't let them Low Ball ya my friend.

.............Buck

[silverdollar22]

Buck i went from 30% down to 10% off of this exam!!!  I have a very bad back and thought they could'nt reduce you like this off of one exam!  Maybe i'm wrong!

[Buck52]

I don't see how they can reduce you  when in the Exam Report  it stated this

Does the Veteran's thoracolumbar spine (back) condition impact on his or her ability to work? [X] Yes ''

Yes they should be two exams and medical evidence to show you have improved.

I'll try to find those Regs

[Buck52]

 

§3.327   Reexaminations.

(a) General. Reexaminations, including periods of hospital observation, will be requested whenever VA determines there is a need to verify either the continued existence or the current severity of a disability. Generally, reexaminations will be required if it is likely that a disability has improved, or if evidence indicates there has been a material change in a disability or that the current rating may be incorrect. Individuals for whom reexaminations have been authorized and scheduled are required to report for such reexaminations. Paragraphs (b) and (c) of this section provide general guidelines for requesting reexaminations, but shall not be construed as limiting VA's authority to request reexaminations, or periods of hospital observation, at any time in order to ensure that a disability is accurately rated.

(Authority: 38 U.S.C. 501)

(b) Compensation cases—(1) Scheduling reexaminations. Assignment of a prestabilization rating requires reexamination within the second 6 months period following separation from service. Following initial Department of Veterans Affairs examination, or any scheduled future or other examination, reexamination, if in order, will be scheduled within not less than 2 years nor more than 5 years within the judgment of the rating board, unless another time period is elsewhere specified.

(2) No periodic future examinations will be requested. In service-connected cases, no periodic reexamination will be scheduled: (i) When the disability is established as static;

(ii) When the findings and symptoms are shown by examinations scheduled in paragraph (b)(2)(i) of this section or other examinations and hospital reports to have persisted without material improvement for a period of 5 years or more;

(iii) Where the disability from disease is permanent in character and of such nature that there is no likelihood of improvement;

(iv) In cases of veterans over 55 years of age, except under unusual circumstances;

(v) When the rating is a prescribed scheduled minimum rating; or

(vi) Where a combined disability evaluation would not be affected if the future examination should result in reduced evaluation for one or more conditions.

(c) Pension cases. In nonservice-connected cases in which the permanent total disability has been confirmed by reexamination or by the history of the case, or with obviously static disabilities, further reexaminations will not generally be requested. In other cases further examination will not be requested routinely and will be accomplished only if considered necessary based upon the particular facts of the individual case. In the cases of veterans over 55 years of age, reexamination will be requested only under unusual circumstances

[Buck52]

REDUCTION

VA is authorized to require claimants to periodically report for medical examinations. Examinations are usually scheduled for awards based on conditions that could change in severity over time. As with initial C&P examinations, claimants have a duty to report for examinations when scheduled. Failure to show for an examination without an acceptable reason could cause VA to reduce or stop payments.

If VA obtains medical evidence of an improvement in the claimant's condition, VA can seek to reduce the disability rating. Before monthly payments can be reduced, VA must follow a formal process to first propose a reduction in the rating and then reduce the rating. Most importantly, a claimant who VA is seeking to reduce in rating must receive notice of the proposed reduction before any change occurs and has the right to challenge the reduction and submit evidence against the reduction. Further, some long-term ratings have "protections" from reduction. In any case, a claimant receiving notice of a proposed reduction needs to respond quickly (usually within 30 days) to prevent a change in payments before he or she can challenge the decision to reduce.

Claimants who decide to challenge a proposed reduction and request that payments not be reduced during the appeal must be aware of the possibility of having to repay money to VA if the appeal is unsuccessful. This point is often overlooked. But, if VA pays compensation at a rate later found to be incorrectly high, the claimant will "generate an overpayment" which will have to be paid back to VA. If the rating change is large, the amount owed to VA could be significant. In addition, if the claimant cannot or will not repay the overpayment, VA will withhold an amount from future compensation payments until the overpayment is resolved. Claimants who challenge reductions are strongly urged to keep the impacts of a possible overpayment in mind.

Whatever the case, VA must make several determinations before a reduction can occur. These include: ensuring that the proposed reduction is based on a proper medical examination; finding that there has been an actual change in the condition, not just a temporary improvement; and basing a decision to reduce on entire history of the condition. Each of these determinations can be challenged by a claimant and a decision to reduce can be appealed the same way as an initial denial with the same risk of generating an overpayment.