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1DVBCWNS5 ;VMP/JER - SPINE WKS TEXT - 1 ; 12/02/03 11:00am
2 ;;2.7;AMIE;**60**;DEC 2, 2003
3 ;
4TXT ;
5 ;;
6 ;;A. Review of Medical Records:
7 ;;
8 ;;B. Present Medical History (Subjective Complaints):
9 ;;
10 ;;Please comment whether etiology for any of these subjective complaints is
11 ;;unrelated to claimed disability.
12 ;;
13 ;;1. Report complaints of pain (including any radiation), stiffness,
14 ;; weakness, etc.
15 ;; a. Onset
16 ;; b. Location and distribution
17 ;; c. Duration
18 ;; d. Characteristics, quality, description
19 ;; e. Intensity
20 ;;2. Describe treatment - type, dose, frequency, response, side effects.
21 ;;3. Report whether there are periods of flare-up. Provide the
22 ;; following if individual reports periods of flare-up:
23 ;; a. Severity, frequency, and duration.
24 ;; b. Precipitating and alleviating factors.
25 ;; c. Additional limitation of motion or functional impairment during
26 ;; the flare-up.
27 ;;4. Describe associated features or symptoms (e.g., weight loss, fevers,
28 ;; malaise, dizziness, visual disturbances, numbness, weakness,
29 ;; bladder complaints, bowel complaints, erectile dysfunction).
30 ;;5. Describe walking and assistive devices.
31 ;; a. Does the veteran walk unaided? Does the veteran use a cane,
32 ;; crutches, or a walker?
33 ;; b. Does the veteran use a brace (orthosis)?
34 ;; c. How far and how long can the veteran walk?
35 ;; d. Is the veteran unsteady? Does the veteran have a history of
36 ;; falls?
37 ;;6. Describe details of any trauma or injury, including dates, and direction
38 ;; and magnitude of forces.
39 ;;7. Describe details of any surgery, including dates.
40 ;;8. Functional Assessment - Describe effects of the condition(s) on the
41 ;; veteran's mobility (e.g., walking, transfers), activities of daily
42 ;; living (i.e., eating, grooming, bathing, toileting, dressing), usual
43 ;; occupation, recreational activities, driving.
44 ;;
45 ;;C. Physical Examination (Objective Findings): Address each of the following as
46 ;; appropriate to the condition being examined and fully describe current
47 ;; findings:
48 ;;
49 ;; 1. Inspection: spine, limbs, posture and gait, position of the
50 ;; head, curvatures of the spine, symmetry in appearance, symmetry
51 ;; and rhythm of spinal motion.
52 ;;
53 ;; 2. Range of motion
54 ;;
55 ;; a. Cervical Spine
56 ;;
57 ;; The reproducibility of an individual's range of motion is one
58 ;; indicator of optimum effort. Pain, fear of injury, disuse or
59 ;; neuromuscular inhibition may limit mobility by decreasing the
60 ;; individual's effort. If range of motion measurements fail to
61 ;; match known pathology, please repeat the measurements.
62 ;; (Reference: Guides to the Evaluation of Permanent Impairment,
63 ;; Fifth Edition, 2001, page 399).
64 ;;
65 ;; i. Using a goniometer, measure and report the range of motion in
66 ;; degrees of forward flexion, extension, left lateral flexion,
67 ;; right lateral flexion, left lateral rotation and right lateral
68 ;; rotation. Generally, the normal ranges of motion for the
69 ;; cervical spine are as follows:
70 ;;
71 ;; -Forward flexion: 0 to 45 degrees
72 ;; -Extension: 0 to 45 degrees
73 ;; -Left Lateral Flexion: 0 to 45 degrees
74 ;; -Right Lateral Flexion: 0 to 45 degrees
75 ;; -Left Lateral Rotation: 0 to 80 degrees
76 ;; -Right Lateral Rotation: 0 to 80 degrees
77 ;;
78 ;; There may be a situation where an individual's range of motion is
79 ;; reduced, but "normal" (in the examiner's opinion) based on the
80 ;; individual's age, body habitus, neurologic disease, or other factors
81 ;; unrelated to the disability for which the exam is being performed. In
82 ;; this situation, please explain why the individual's measured range of
83 ;; motion should be considered as "normal".
84 ;;
85 ;; ii. If the spine is painful on motion, state at what point in the
86 ;; range of motion pain begins and ends.
87 ;;
88 ;; iii. State to what extent (if any), expressed in degrees if
89 ;; possible, the range of motion is additionally limited by pain,
90 ;; fatigue, weakness, or lack of endurance following repetitive use
91 ;; or during flare-ups. If more than one of these is present,
92 ;; state, if possible, which has the major functional impact.
93 ;;
94 ;; iv. Describe objective evidence of painful motion, spasm, weakness,
95 ;; tenderness, etc.
96 ;;
97 ;; v. Describe any postural abnormalities, fixed deformity
98 ;; (ankylosis), or abnormality of musculature of cervical spine
99 ;; musculature. In the situation where there is unfavorable
100 ;; ankylosis of the cervical spine, indicate whether there is:
101 ;; difficulty walking because of a limited line of vision;
102 ;; restricted opening of the mouth (with limited ability to
103 ;; chew); breathing limited to diaphragmatic respiration;
104 ;; gastrointestinal symptoms due to pressure of the costal margin
105 ;; on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical
106 ;; subluxation or dislocation
107 ;;
108 ;;
109 ;; b. Thoracolumbar spine
110 ;;
111 ;; The reproducibility of an individual's range of motion is one
112 ;; indicator of optimum effort. Pain, fear of injury, disuse or
113 ;; neuromuscular inhibition may limit mobility by decreasing the
114 ;; individual's effort. If range of motion measurements fail to
115 ;; match known pathology, please repeat the measurements.
116 ;; (Reference: Guides to the Evaluation of Permanent Impairment,
117 ;; Fifth Edition, 2001, page 399).
118 ;;
119 ;; It is best to measure range of motion for the thoracolumbar
120 ;; spine from a standing position. Measuring the range of motion
121 ;; from a standing position (as opposed to from a sitting position)
122 ;; will include the effects of forces generated by the distance
123 ;; from the center of gravity from the axis of motion of the spine
124 ;; and will include the effect of contraction of the spinal
125 ;; muscles. Contraction of the spinal muscles imposes a significant
126 ;; compressive force during spine movements upon the lumbar discs.
127 ;;
128 ;; i. Provide forward flexion of the thoracolumbar spine as a unit.
129 ;; Do not include hip flexion. (See Magee, Orthopedic Physical
130 ;; Assessment, Third Edition, 1997, W.B. Saunders Company,
131 ;; pages 374-75). Using a goniometer, measure and report the range
132 ;; of motion in degrees for forward flexion, extension, left
133 ;; lateral flexion, right lateral flexion, left lateral rotation
134 ;; and right lateral rotation. Generally, the normal ranges of
135 ;; motion for the thoracolumbar spine as a unit are as follows:
136 ;;
137 ;; -Forward flexion: 0 to 90 degrees
138 ;; -Extension: 0 to 30 degrees
139 ;; -Left Lateral Flexion: 0 to 30 degrees
140 ;; -Right Lateral Flexion: 0 to 30 degrees
141 ;; -Left Lateral Rotation: 0 to 30 degrees
142 ;; -Right Lateral Rotation: 0 to 30 degrees
143 ;;
144 ;;There may be a situation where an individual's range of motion is reduced, but
145 ;;"normal" (in the examiner's opinion) based on the individual's age, body
146 ;;habitus, neurologic disease, or other factors unrelated to the disability for
147 ;;which the exam is being performed. In this situation, please explain why the
148 ;;individual's measured range of motion should be considered as "normal".
149 ;;
150 ;; ii. If the spine is painful on motion, state at what point in the range
151 ;; of motion pain begins and ends.
152 ;;
153 ;; iii. State to what extent (if any), expressed in degrees if possible,
154 ;; the range of motion is additionally limited by pain, fatigue,
155 ;; weakness, or lack of endurance following repetitive use or during
156 ;; flare-ups. If more than one of these is present, state, if possible,
157 ;; which has the major functional impact.
158 ;;
159 ;; iv. Describe objective evidence of painful motion, spasm, weakness,
160 ;; tenderness, etc.
161 ;;
162 ;; a. Indicate whether there is muscle spasm, guarding or localized
163 ;; tenderness with preserved spinal contour, and normal gait.
164 ;;
165 ;; b. Indicate whether there is muscle spasm, or guarding severe enough
166 ;; to result in an abnormal gait, abnormal spinal contour such as
167 ;; scoliosis, reversed lordosis or abnormal kyphosis.
168 ;;
169 ;; v. Describe any postural abnormalities, fixed deformity (ankylosis),
170 ;; or abnormality of musculature of back. In the situation where
171 ;; there is unfavorable ankylosis of the thoracolumbar spine,
172 ;; indicate whether there is: difficulty walking because of a
173 ;; limited line of vision; restricted opening of the mouth (with
174 ;; limited ability to chew); breathing limited to diaphragmatic
175 ;; respiration; gastrointestinal symptoms due to pressure of
176 ;; the costal margin on the abdomen; dyspnea; dysphagia;
177 ;; atlantoaxial or cervical subluxation or dislocation; or
178 ;; neurologic symptoms due to nerve root involvement.
179 ;;
180 ;; 3. Neurological examination
181 ;;
182 ;;Please perform complete neurologic evaluation as indicated based upon
183 ;;disability for which the exam is being performed. Please provide brief
184 ;;statement if any of the following (a-e) is not included in exam. For
185 ;;additional neurologic effects of disability not captured by a - e,
186 ;;(e.g. bladder problems) please refer to appropriate worksheet for the body
187 ;;system affected.
188 ;;
189 ;; a. Sensory examination, to include sacral segments.
190 ;; b. Motor examination (atrophy, circumferential measurements, tone,
191 ;; and strength).
192 ;; c. Reflexes (deep tendon, cutaneous, and pathologic).
193 ;; d. Rectal examination (sensation, tone, volitional control, and
194 ;; reflexes).
195 ;; e. Lasegue's sign.
196 ;;
197 ;; 4. For vertebral fractures, report the percentage of loss of
198 ;; height, if any, of the vertebral body
199 ;; 5. Non-organic physical signs (e.g., Waddell tests, others).
200 ;;
201 ;;D. For intervertebral disc syndrome
202 ;;
203 ;; 1. Conduct and report a separate history and physical
204 ;; examination for each segment of the spine (cervical,
205 ;; thoracic, lumbar) affected by disc disease.
206 ;; 2. Conduct a complete history and physical examination of each
207 ;; affected segment of the spine (cervical, thoracic, lumbar),
208 ;; whether or not there has been surgery, as described above
209 ;; under B. Present Medical History and C. Physical Examination.
210 ;; 3. Conduct a thorough neurologic history and examination, as
211 ;; described in C5, of all areas innervated by each affected
212 ;; spinal segment. Specify the peripheral nerve(s) affected.
213 ;; Include an evaluation of effects, if any, on bowel or bladder
214 ;; functioning.
215 ;; 4. Describe as precisely as possible, in number of days, the
216 ;; duration of each incapacitating episode during the past
217 ;; 12-month period. An incapacitating episode, for disability
218 ;; evaluation purposes, is a period of acute signs and symptoms
219 ;; due to intervertebral disc syndrome that requires bed rest
220 ;; prescribed by a physician and treatment by a physician.
221 ;;
222 ;;E. Diagnostic and Clinical Tests:
223 ;;
224 ;; 1. Imaging studies, when indicated.
225 ;; 2. Electrodiagnostic tests, when indicated.
226 ;; 3. Clinical laboratory tests, when indicated.
227 ;; 4. Isotope scans, when indicated.
228 ;; 5. Include results of all diagnostic and clinical tests conducted in the
229 ;; examination report.
230 ;;
231 ;;F. Diagnosis:
232 ;;
233 ;;
234 ;;Signature: Date:
235 ;;END
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