Back Pain / Spine MEBs

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xeno

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PEB Forum Veteran
The below criteria were forwarded to us through DoD disability channels, all the way from D.C. These are the criteria used by the Veterans Administration
(VA) to adjudicate disability on spine/back pain cases. Since the DoD Disability Evaluation System utilizes the VA Schedule for Rating Disabilities
(VASRD) in the adjudication and compensation of disability, VA criteria must be utilized by the DoD. To do so, the Informal Physical Evaluation Board
(IPEB) must have certain information included in the narrative summary. That information is below.

At first glance, it seems like the volume of info required is huge. However, upon careful reading, the info required is little more than that contained in
a reasonable history and physical, with the addition of some critical rangeof- motion figures. Spend five minutes reading the following criteria and I
think you'll agree that only a few additional questions and a minimum of additional exam are required. And if that info is already in the neurosurgeon's or orthopedist's note, then you need not reproduce it in your Narrative Summary.
Will the IPEB require ALL of this info on EVERY back pain / spine case? Probably not. Use your best judgement. If you do a good H&P (like you always do) with some range-of-motion measurements, chances are it'll be quite acceptable to the IPEB. And now, with no further ado, here are the criteria.
SPINE
B. Present Medical History (Subjective Complaints):
Please comment whether etiology for any of these subjective complaints is unrelated to claimed disability.
1. Report complaints of pain (including any radiation), stiffness,weakness, etc.
a. Onset
b. Location and distribution
c. Duration
d. Characteristics, quality, description
e. Intensity
2. Describe treatment - type, dose, frequency, response, and side effects.
3. Report whether there are periods of flare-up. Provide the following if individual reports periods of flare-up:
a. Severity, frequency, and duration.
b. Precipitating and alleviating factors.
c. Additional limitation of motion or functional impairment during flare-up.
4. Describe associated features or symptoms (e.g., weight loss, fevers, malaise, dizziness, visual disturbances, numbness, weakness, bladder complaints, bowel complaints, erectile dysfunction).
5. Describe walking and assistive devices.
a. Does the veteran walk unaided? Does the veteran use a cane, crutches, or a walker?
b. Does the veteran use a brace (orthosis)?
c. How far and how long can the veteran walk?
d. Is the veteran unsteady? Does the veteran have a history of falls?
6. Describe details of any trauma or injury, including dates, and direction and magnitude of forces.
7. Describe details of any surgery, Compensation and Pension Examination including dates.
8. Functional Assessment - Describe effects of the condition(s) on the veteran's mobility (e.g., walking, transfers, bed activities), activities of
daily living (i.e., eating, grooming, bathing, toileting, dressing), usual occupation, recreational activities, driving.
C. Physical Examination (Objective Findings):
Address each of the following as appropriate to the condition being examined and fully describe current findings.
1. Inspection: spine, limbs, posture and gait, position of the head, curvatures of the spine, symmetry in appearance, symmetry and rhythm of
spinal motion.
2. Range of motion
a. Cervical Spine
The reproducibility of an individual's range of motion is one indicator of optimum effort. Pain, fear of injury, disuse or neuromuscular inhibition may limit mobility by decreasing the individual's effort. If range of motion measurements fail to match known pathology, please repeat the measurements.
(Reference: Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, page 399).
i. Using a goniometer, measure and report the range of motion in degrees of forward flexion, extension, left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation. Generally,the normal ranges of motion for the cervical spine are as follows:
Forward flexion: 0 to 45 degrees
Extension: 0 to 45 degrees
Left Lateral Flexion: 0 to 45 degrees
Right Lateral Flexion: 0 to 45 degrees
Left Lateral Rotation: 0 to 80 degrees
Right Lateral Rotation: 0 to 80 degrees
There may be a situation where an individual's range of motion is reduced, but "normal" (in the examiner's opinion) based on the individual's age, body
habitus, neurologic disease, or other factors unrelated to the disability for which the exam is being performed. In this situation, please explain why the
individual's measured range of motion should be considered as "normal".
ii. If the spine is painful on motion, state at what point
in the range of motion pain begins and ends.
iii. State to what extent (if any), expressed in degrees if possible, the range of motion is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups.
If more than one of these is present, state, if possible, which has the major functional impact.
iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.
v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of cervical spine musculature. In the situation where there is unfavorable ankylosis of the cervical spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation
b. Thoracolumbar spine
The reproducibility of an individual's range of motion is one indicator of optimum effort. Pain, fear of injury, disuse or neuromuscular inhibition may limit mobility by decreasing the individual's effort. If range of motion measurements fail to match known pathology, please repeat the measurements.
(Reference: Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, page 399).
It is best to measure range of motion for the thoracolumbar spine from a standing position. Measuring the range of motion from a standing position
(as opposed to from a sitting position) will include the effects of forces generated by the distance from the center of gravity from the axis of motion
of the spine and will include the effect of contraction of the spinal muscles. Contraction of the spinal muscles imposes a significant compressive
force during spine movements upon the lumbar discs.
i. Provide forward flexion of the thoracolumbar spine as a unit. Do not include hip flexion. (See Magee, Orthopedic Physical
Assessment, Third Edition, 1997, W.B. Saunders Company, pages 374-75). Using a goniometer, measure and report the range of motion in degrees for forward
flexion, extension, left lateral flexion, right lateral flexion, left lateral rotation and right lateral rotation. Generally, the normal ranges of motion for the thoracolumbar spine as a unit are as follows:
Forward Flexion: 0 to 90 degrees
Extension: 0 to 30 degrees
Left lateral flexion: 0 to 30 degrees
Right lateral flexion: 0 to 30 degrees
Left lateral rotation: 0 to 45 degrees
Right lateral rotation: 0 to 45 degrees
There may be a situation where an individual's range of motion is reduced, but "normal" (in the examiner's opinion) based on the individual's age, body
habitus, neurologic disease, or other factors unrelated to the disability for which the exam is being performed. In this situation, please explain why the
individual's measured range of motion should be considered as "normal".
ii. If the spine is painful on motion, state at what point
in the range of motion pain begins and ends.
iii. State to what extent (if any), expressed in degrees if possible, the range of motion is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups.
If more than one of these is present, state, if possible, which has the major functional impact.
iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.
a. Indicate whether there is muscle spasm, guarding or localized tenderness with preserved spinal contour, and normal gait.
b. Indicate whether there is muscle spasm, or guarding severe enough to result in an abnormal gait, abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis.
v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of back. In the situation where there is unfavorable ankylosis of the thoracolumbar spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root involvement.
3. Neurological examination
Please perform complete neurologic evaluation as indicated based upon disability for which the exam is being performed. Please provide brief statement if any of the following (a-e) is not included in exam. For additional neurologic effects of disability not captured by a - e, (e.g. bladder problems) please refer to appropriate worksheet for the body system affected.
a. Sensory examination, to include sacral segments.
b. Motor examination (atrophy, circumferential measurements, tone, and strength).
c. Reflexes (deep tendon, cutaneous, and pathologic).
d. Rectal examination (sensation, tone, volitional control, and reflexes).
e. Lasegue's sign.
4. For vertebral fractures, report the percentage of loss of height, if any, of the vertebral body.
5. Non-organic physical signs (e.g., Waddell tests, others).
D. For intervertebral disc syndrome
1. Conduct and report a separate history and physical examination for each segment of the spine (cervical, thoracic, lumbar) affected by disc
disease.
2. Conduct a complete history and physical examination of each affected segment of the spine (cervical, thoracic, lumbar), whether or not there has
been surgery, as described above under
B. Present Medical History and C. Physical Examination.
3. Conduct a thorough neurologic history and examination, as described in C5, of all areas innervated by each affected spinal segment. Specify the
peripheral nerve(s) affected. Include an evaluation of effects, if any, on bowel or bladder functioning.
4. Describe as precisely as possible, in number of days, the duration of each incapacitating episode during the past 12-month period. An incapacitating episode, for disability evaluation purposes, is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.
E. Diagnostic and Clinical Tests:
1. Imaging studies, when indicated.
2. Electrodiagnostic tests, when indicated.
3. Clinical laboratory tests, when indicated.
4. Isotope scans, when indicated.
5. Include results of all diagnostic and clinical tests conducted in the
examination report.
F. Diagnosis:
 
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