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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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  • Most Common VA Disabilities Claimed for Compensation:   

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  • Can a 100 percent Disabled Veteran Work and Earn an Income?

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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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rhdawgs

C&P Completed what's your thoughts?

Question

Hello everyone, newbie here, so I apologize if I have WAY to much info or posted in wrong place. First, I would like to thank everyone for their service or their family members service to this great country. I also want to give props to this site, WOW, just by reading many threads I have learned SO MUCH, so THANK YOU ALL!

I just my results back from my C&P's for my Neck (Cervical Spine) and Back (Thoracolumbar Spine). If the rater goes off of the ROM alone and if it is deemed SC then I think I should get at least 10% SC for Neck/Spine and 10% SC for lower back. (I have evidence in my files confirming the fall and going to TMC because of Neck & Back Pains while in Iraq etc.) I read on here where someone mentioned to pay attention to things like "Arthritis", I noticed in both my reports that the Arthritis question is answered as YES.  

CERVICAL:
a. Have imaging studies of the cervical spine been performed and are the
       results available?
       [X] Yes   [ ] No
           If yes, is arthritis (degenerative joint disease) documented?
           [X] Yes   [ ] No

BACK:
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

 

Here's my questions:

1. Does having Arthritis with images possibly increase the percentage of disability, decrease the percentage or they simply just stick with ROM when determining SC disability percentage?

2. My forward Flexion in Spine and Back are 30 or less and 50 or less, should that put me @ 20%, if these are given SC status?

3. Do they normally just rate ALL of these conditions as 1 and basically just give either the 10%-20% SC?

Also, anyone with knowledge of general ratings care to let me know what they think about the report, SC, Possible percentages etc. would be greatly appreciated.

Thank you.

Posting both full C&P's for reference below. 

*** C&P GENERAL MEDICAL Has ADDENDA ***
         Neck (Cervical Spine) Conditions
         Disability Benefits Questionnaire
    Name of patient/Veteran:  XXXXXXXXXXXXXX
    Is this DBQ being completed in conjunction with a VA 21-2507, C&P Examination [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 cervical
    spine (neck) condition?
    [X] Yes   [ ] No
       [ ] Ankylosing spondylitis
       [X] Cervical strain
       [X] Degenerative arthritis of the spine
       [ ] Intervertebral disc syndrome
       [ ] Segmental instability
       [ ] Spinal fusion
       [ ] Spinal stenosis
       [ ] Spondylolisthesis
       [ ] Vertebral dislocation
       [ ] Vertebral fracture
       Diagnosis #1:  Strain
       ICD code:  S13.8XXA
       Date of diagnosis:  2004
       Diagnosis #2:  Multilevel uncovertebral arthritis
       ICD code:  M50.30
       Date of diagnosis:  2017
    2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
       cervical spine (neck) condition (brief summary):

       Does the Veteran have a diagnosis of (a) Neck pain that is at least as
       likely as not (50 percent or greater probability) incurred in or caused by
       (the) injury during service?

       There is a LOD dated 07/13/2004 where the veteran
       was seen and treated for an injury to his neck and back while in service.
       The veteran reports that since the time of his fall, he has experienced neck and back pain that
       increases with activity.
---------------------------------------------------------------------------------------------------------------------------

       ===========================================================
       Note Text
         LOCAL TITLE: 1010M MEDICAL CERTIFICATE                          
        STANDARD TITLE: ADMISSION EVALUATION NOTE                       
        DATE OF NOTE: JUL 22, 2005@12:34    
        ==========================================================
        TRIAGE
        HISTORY
        ---------------------------------------------------------
       ----CHIEF COMPLAINT:back pain that started over 1 yr ago while deployed
       in Iraq, onset in assoc with wearing the gear required,  body armor,  weapon,
       helmet, etc.  back pain is across low back ,  does not radiate.  Has stiffness in
       am, pain worsens as day progresses and varies according to activity,
       increased pain at night, interferes with sleep.  Has records from visit while on active
       duty 9/04, indicates  rx was naprosyn and robaxin,  patient says he was given
       light duty consisting of no additional lifting,  but had to continue usual
       carrying of pack and vest.  rx was ineffective.
        ---------------------------------------------------------
        ---------------------------------------------------------
       ----HX. OF PRESENT ILLNESS:  as above,  he initially also had neck pain
       but this has improved and is minor.  back pain however,  is daily ,  constant,
       with associated stiffness.  saw family doctor who prescribed toradol,  it did
       not help. has taken vicodin that belonged to family member,  it did help,
       just took a couple. currently taking tylenol or alleve intermittently.
       xray result unknown to patient. denies numbness or weakness in legs.
       sometimes limps but this is due to his back pain and guarding.
       Is not exercising regularly,  occasional golf.  does stretching at times
       but not regularly. swims occasionally.
--------------------------------------------------------------------------------------------
    b. Dominant hand:
       No response provided
    c. Does the Veteran report flare-ups of the cervical spine (neck)?
       [X] Yes   [ ] No
           If yes, document the Veteran's description of the flare-ups in his or
           her own words:
              The veteran reports neck pain with prolonged sitting erect or when
              turning his head from side to side.
    d. Does the Veteran report having any functional loss or functional
       impairment of the cervical spine (neck) (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:
              The veteran reports neck pain with prolonged sitting erect or when
              turning his head from side to side.
    3. Range of motion (ROM) and functional limitations
    ---------------------------------------------------
    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 (0-45):           0 to 30 degrees
           Extension (0-45):                 0 to 40 degrees
           Right Lateral Flexion (0-45):     0 to 35 degrees
           Left Lateral Flexion (0-45):      0 to 35 degrees
           Right Lateral Rotation (0-80):    0 to 60 degrees
           Left Lateral Rotation (0-80):     0 to 60 degrees
           If abnormal, does the range of motion itself contribute to a
           functional loss? [X] Yes, (please explain)   [ ] No
              If yes, please explain:
              Decreased ROM interferes with the veteran turning his head from
              side to side, interferes with driving when needing to look side too
              side when changing lanes.
       Description of pain (select best response):
         Pain noted on examination and causes functional loss
         If noted on examination, 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 joint or associated soft tissue of the cervical spine (neck)?
       [X] Yes   [ ] No
          If yes, describe including location, severity and relationship to
          condition(s):
          Pain at posterior neck on palpation.
 
    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 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 nor 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   [X] No   [ ] Unable to say w/o mere speculation
    d. Flare-ups
       Is the examination being conducted during a flare-up? [ ] Yes   [X] No
           If the examination is not being conducted during a flare-up:

           [X] 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.
           [ ] The examination is neither medically consistent nor 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   [X] No   [ ] Unable to say w/o mere speculation
    e. Guarding and muscle spasm
       Does the Veteran have guarding, or muscle spasm of the cervical spine?
       [ ] Yes   [X] No
    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:
         Less movement than normal due to ankylosis, adhesions, etc.,
         Interference with sitting, Interference with standing
    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
       Elbow 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
       Elbow 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
       Wrist 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
       Wrist 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
       Finger 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
       Finger Abduction
         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
       Biceps:
         Right: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
       Triceps:
         Right: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
       Brachioradialis:
         Right: [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
         Left:  [ ] 0   [ ] 1+   [X] 2+   [ ] 3+   [ ] 4+
    6. Sensory exam
    ---------------
    Provide results for sensation to light touch (dermatomes) testing:
       Shoulder area (C5):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
       Inner/outer forearm (C6/T1):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
       Hand/fingers (C6-8):
         Right: [X] Normal   [ ] Decreased   [ ] Absent
         Left:  [X] Normal   [ ] Decreased   [ ] Absent
    7. Radiculopathy
    -----------------
    Does the Veteran have radicular pain or any other signs or symptoms due to
    radiculopathy?
    [ ] Yes   [X] No
    8. Ankylosis
    ------------
    Is there ankylosis of the spine? [ ] Yes   [X] No
    9. Other neurologic abnormalities
    ---------------------------------
    Does the Veteran have any other neurologic abnormalities related to a
    cervical spine (neck) condition (such as bowel or bladder problems due to
    cervical myelopathy)?
    [ ] Yes   [X] No
    10. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
    -----------------------------------------------------------------------
    a. Does the Veteran have IVDS of the cervical spine?
       [ ] Yes   [X] No
    11. 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
    b. If the Veteran uses any assistive devices, specify the condition and
       identify the assistive device used for each condition:
       No response provided.
    12. Remaining effective function of the extremities
    ----------------------------------------------------
    Due to a cervical spine (neck) 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.)
    [ ] Yes, functioning is so diminished that amputation with prosthesis would
        equally serve the Veteran.
    [X] No
    13. 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.
    14. Diagnostic testing
    ----------------------
    a. Have imaging studies of the cervical spine been performed and are the
       results available?
       [X] Yes   [ ] No
           If yes, is arthritis (degenerative joint disease) documented?
           [X] Yes   [ ] No
    b. Does the Veteran have a 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):
              SPINE CERVICAL MIN 4 VIEWS   
              Exm Date: OCT 02, 2017@11:55
                   Reason for Study: C&P Exam
                  Clinical History:
                    Pain fall from truck
                  Report:
              Findings: There is straightening of the cervical spine
              compatible
                    muscle spasm. No fracture or dislocation. No focal lytic or
              sclerotic osseous lesion. No degenerative disc disease. There
              is C5-6 uncovertebral arthritis with bilateral neuroforaminal
              narrowing. There is also left-sided foraminal stenosis at
              C3-4 and C4-5.  
                  Impression:
              1. Straightening of the cervical spine due to muscle spasm.
              2. Multilevel uncovertebral arthritis with bilateral
              neuroforaminal

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

Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
Name of patient/Veteran:
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:
        No response provided.
          Diagnosis #1:  Multilevel annular bulging
          ICD code:  M51.36
          Date of diagnosis:  2005
    2. Medical history
    ------------------
    a. Describe the history (including onset and course) of the Veteran's
    thoracolumbar spine (back) condition (brief summary):
       Does the Veteran have a diagnosis of (a) Back pain that is at least as
       likely as not (50 percent or greater probability) incurred in or caused by
       (the) injury during service?
       
       There is a LOD dated 07/13/2004 where the veteran was seen and treated for
       an injury to his neck and back while in service.  The veteran reports that
       since the time of his fall, he has experienced neck and back pain that
       increases with activity.

    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:

           The veteran reports constant lower back pain  that increases with
           prolonged sitting, standing, walking, bending, lifting, pushing and
           pulling motions.  He reports increased pain when exposed to cold damp
           weather.
    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.
           The veteran reports constant lower back pain  that increases with
           prolonged sitting, standing, walking, bending, lifting, pushing and
           pulling motions.  He reports increased pain when exposed to cold damp
           weather.
    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 50 degrees
           Extension (0 to 30):                 0 to 25 degrees
           Right Lateral Flexion (0 to 30):     0 to 25 degrees
           Left Lateral Flexion (0 to 30):      0 to 25 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? [X] Yes (please explain)   [ ] No
              If yes, please explain:
              Decreased ROM interferes with stair climbing, lifting and bending.
       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
       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):
           Pain at mid lumbar region on palpation.
    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 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?
       [ ] Yes   [X] No   [ ] 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:
           [X] 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.
           [ ] 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   [X] No   [ ] 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:
       Guarding:
          [ ] None
          [ ] Resulting in abnormal gait or abnormal spinal contour
          [X] 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:
         Less movement than normal due to ankylosis, adhesions, etc.,Disturbance
         of locomotion, Interference with sitting, Interference with standing
    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

    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
    b. If the Veteran uses any assistive devices, specify the condition and
       identify the assistive device used for each condition:
       No response provided.
    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?
       [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):
              SPINE LUMBOSACRAL 2 OR 3 VIEWS
              Exm Date: OCT 02, 2017@11:55
                   Reason for Study: C&P Exam
                  Clinical History:
                    Multiple bulging disc, Fall from truck
                  Report:
              Findings: 5 lumbar-type vertebral bodies are seen. No
              fracture or
              dislocation. No compression fracture. No focal lytic or
              stenotic
              osseous lesion is seen. There is no significant facet
              arthritis.  
                 Mild L5-S1 degenerative disc disease is noted. The sacroiliac
                    joints are normal.  
                  Impression:
                     1. Mild L5-S1 degenerative disc disease.  
===================================================================
              ===========
              Exam Date/Time   09/29/2005 13:00
              Procedure Name   MRI LUMBAR W/O CONTRAST
              Clinical History pain in the back
              Report
              T1 and fast spine echo t2 weighted sagittal imaging was performed
              through the
              lumbar spine.  this was augmented by thin section axial imaging
              through the
               lower three lumbar levels.  
              The vertebral bodies are normal in heighth and signal intensity.
              the
              intervrebral disk spaces are maintained. minimal desiccative
              changes are
              present at the level of l5-s1.  thin section axial imaging reveals
              a normal
              l3-l4 disk.  minimal annular bulging is seen at the level of l4-l5
              without
              encroachment upon the thecal sac or exiting nerve roots.  similar
              change is
              seen at the level of l5-s1, again without encroachment upon the
              thecal sac or
              exiting nerve roots.  the conus medullaris is well seen and is of
              normal
               contour and signal intensity.
              Impression
               Multilevel annular bulging without significant canal stenosis.  
    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 reports constant lower back pain that increases with
              prolonged sitting, standing, walking, bending, lifting, pushing and
              pulling motions.  He reports increased pain when exposed to cold
              damp weather.
    17. Remarks, if any:
    --------------------
    No remarks provided.
****************************************************************************
                                 Medical Opinion
                        Disability Benefits Questionnaire
    Name of patient/Veteran:  XXXXXXXXXXXXXXXXXXXXX
    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
    MEDICAL OPINION SUMMARY
    -----------------------
    RESTATEMENT OF REQUESTED OPINION:
 a. Opinion from general remarks: Does the Veteran have a diagnosis of (a)
    Back pain that is at least as likely as not (50 percent or greater
    probability) incurred in or caused by (the) injury during service?
   
 b. Indicate type of exam for which opinion has been requested: Back
    TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE
    CONNECTION ]
   
 a. The condition claimed was at least as likely as not (50% or greater
    probability) incurred in or caused by the claimed in-service injury, event or
    illness.   
   
 c. Rationale: Conclusion/Raationale:  The claim file has been reviewed. Does
    the Veteran have a diagnosis of (a) Back pain that is at least as likely as
    not (50 percent or greater probability) incurred in or caused by (the) injury
    during service?
    
    Based on the claim file review, there is evidence that the veteran suffered
    injuries to his neck and back as the result of a fall from a truck.  MRI
    findings revealed multilevel annular bulging without significant canal
    stenosis.
    Based on the claim file review as well as the veteran's current diagnosis and
    symptoms, it is my opinion that the veteran's  multilevel annular bulging
    without significant canal stenosis is at as least as likely as not (50
    percent or greater probability) incurred in or caused by (the) injury during
    service.
    *************************************************************************

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Don’t have any experience with the back injuries but my guess is 20% for the Spine ROM..455CB4EC-8BB2-4298-8A4B-C97FB3DC4E28.thumb.png.4da6e72159e15f8ff715d1c01c637ce8.png

Edited by jfrei

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First of all, welcome aboard and happy to see another fellow Vet seeking help. I see atleast 10% for your neck, and back both granted SC. The VA is weird, sometimes they will grant them together as 1 rating, and other times divide up like mine, for back and the nerve damage to both the legs, due to the pressing of Spine against the nerves. Good luck and keep us posted. I currently put in a new claim for an increase, as I just had Back surgery a few weeks ago. God Bless

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Thank you and good luck on your increase request.. thanks also to both of you for answering my questions... I’m thinking it can go anywhere between 0-20%, I guess we’ll have to wait and see.

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Arthritis gets you 10%, and only  10%.  Range of Motion gets you more.  Presribed bed rest gets you the most.  Surguries get you more temporarily.

Also, adjecent joints can get affected (first arthritis then ROM) via you currently service connected joint.  File for them secondary.  Its not like arthritis spreads, but it does make your other joints work harder.  And don't forget bilateral, i.e., a bad foot can cause problems in your other foot.  Claim as secondary.

I got my thorasic/lumbar secondary to my neck, and I got my left foot secondary to my right foot, and I got my left shoulder secondary to my right shoulder.  See a pattern.

I takes time though, as your new problems develop over time and use (overuse).

Good luck with your claims,

Hamslice

 

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Thanks Hamslice, I appreciate the comment.. It's weird, my journey started in 2005 when I returned from Iraq, but I was very ignorant and naive concerning the entire process. After looking through my records, it appears at though I missed a C&P for eother PTSD or my neck and back..(Can't remember), only after strong recommendations from my family doctor (who is a DR in the Army reserves) and discussions woth several buddies I met with at a reunion earlier this year did I even know what I needed to do, what this ringing in my ears was etc... This site and a few others have been nothing but AWESOME in gathering needed information.
So like I said in my first post, if they rate the cervical and back separately, there is a chance that I could get 20% SC for both, but I also know there is a chance I could get 0%, so time with tell. 

Thanks again.

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