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C&P back any idea what this could be rated at?

seawalker

New Member
Registered Member
Back (Thoracolumbar Spine) Conditions
Disability Benefits Questionnaire
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
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
[ ] Degenerative arthritis of the spine
[X] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: lumbar degenerative disc disease
ICD code: M51.36
Date of diagnosis: 2020
2. Medical history
------------------
CLIN DOC: Progress Note
Page: 1 Printed on: Feb 07,

a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):
SM reports an initial injury to his back doing physical therapy. Reports
progression of low back pain over time with second injury in 2018 after
which he could barely walk for about 4 weeks. he reports constant low
back pain, radiation down the right leg all the way to the ankle,
radiation down the left leg to the thigh. he has numbness in the left
thigh. He reports treatment with PT, accupuncture, chiropractor. He
reports failed treatment with tramadol, gabapentin due to side effects.
He underwent epidural steroid injections and RFA without relief. He
reports best relief was with SI joint injections for about 3months.
Referred to neurosurgery, their note identifies disc dessication L2-S1 and
disc bulge L5-S1 but without evidence of stenosis or nerve root
compromise. Opinion was that he might be a candidate for SI joint fusion.
Pain mgmt also suggested that he might be a candidate for a spinal cord
stimulator if no other interventions planned. Current treatment is with
oxycodone 1-2 tabs 2x per day.
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:
he reports daily flares ups of pain so sharp and severe it makes him
nauseous
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 reports limitations to prolonged sitting, standing, walking,
bending/lifting and with almost all daily activities. He has not done
his regular MOS nor any physical training with the military for about
the last year. He can do ADL, very limited household activity, no
yardwork.
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):
Extension (0 to 30):
Right Lateral Flexion (0 to 30):
Left Lateral Flexion (0 to 30):
Right Lateral Rotation (0 to 30):
Left Lateral Rotation (0 to 30):
CLIN DOC: Progress Note
0 to 40 degrees
0 to 10 degrees
0 to 15 degrees
0 to 20 degrees
0 to 15 degrees
0 to 15 degrees
Page: 2 Printed on:

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 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):
mild tenderness to palpation over right SI joint
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?
[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: [ ] Yes
If no, please describe:
[X] No
CLIN DOC: Progress Note

Page: 3 Printed on:

based upon the veteran's report, available records and my exam I
would not expect any additional loss of ROM
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?
[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: [ ] Yes
If no, please describe:
based upon the veteran's report, available records and my exam I
would not expect any additional loss of ROM
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
[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:
There is guarding of movement to prevent pain and slow wide gait
f. Additional factors contributing to disability
CLIN DOC: Progress Note
Page: 4 Printed on:
[X] No

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+
CLIN DOC: Progress Note
Page: 5 Printed on: Feb 07, 2020 1:52:58 pm Division: 689

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: [ ] Normal [X] 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?
[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?
[]Yes [X]No
CLIN DOC: Progress Note
Page: 6 Printed on:

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? []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?
CLIN DOC: Progress Note
Page: 7 Printed on:

[X]Yes []No
If yes, provide type of test or procedure, date and results (brief
summary):
MRI 2019 degenerative disc disease L2-S1, disc bulge L5-S1 but
without evidence of stenosis or nerve root compromise
Thoracic spine xray 2018 normal
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 reports limitations to prolonged sitting, standing, walking,
bending/lifting and with almost all daily activities. He has not
done his regular MOS nor any physical training with the military
for about the last
17. Remarks, if any:
--------------------
correia
passive ROM n/a
there is objective evidence of pain with rising from seated, prolonged
sitting, change in
position from sitting to standing, standing to lying and back again.
contralateral joint n/a
ATTENDING
Signed:
CLIN DOC: Progress
 

oddpedestrian

Super Moderator
Staff Member
PEB Forum Veteran
Lifetime Supporter
Registered Member
Here is the best chart to figure out your spine rating, just off the forward flexion measurement it looks like 20% but the rest of the exam supports higher. Raters are REALLY bad just going off the one number alone.
 

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RonG

PEB Forum Regular Member
PEB Forum Veteran
Lifetime Supporter
Registered Member
where do you find you c&p exams?
Those who have been through the IDES might be able to provide guidance about how to review or receive copies of the C&P exams.


In general and not necessarily applied to IDES processes,
"You are entitled to request a copy of your C&P exam and it is highly encouraged to do so. To get a copy of the final report from your exam, you can:

  • Contact your local VA regional office;
  • Call VA at 800-827-1000 and request an appointment to view your file; or
  • Have your representative request a copy on your behalf
Regardless of how you choose to request a copy of your C&P exam, it is important to remember that VA will not provide a copy unless you do so. Again, VA decision-makers often place significant weight on C&P exams when deciding claims. Therefore, it is important for you to review the exam to determine if the results are favorable and ensure that the exam was filled out completely and thoroughly, reflecting the most accurate information possible."

Good luck,
Ron
 

Paramount

Well-Known Member
PEB Forum Veteran
Registered Member
I know this post is old. But I want to put this out for future audience.

However if you are going through IDES. Your CP exams will be sent to you from your Peblo. If you are not going through IDES and just want to obtain them you need to fax a signed copy requesting all your CP exams and/or your C-File at the VA. Which should have everything up to the date you request it.
 
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