DVBCWNS5 ;VMP/JER - SPINE WKS TEXT - 1 ; 12/02/03 11:00am
;;2.7;AMIE;**60**;DEC 2, 2003
;
TXT ;
;;
;;A. Review of Medical Records:
;;
;;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, 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
;; the 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, including dates.
;;8. Functional Assessment - Describe effects of the condition(s) on the
;; veteran's mobility (e.g., walking, transfers), 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 30 degrees
;; -Right Lateral Rotation: 0 to 30 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:
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWNS5 14514 printed Dec 13, 2024@01:52:52 Page 2
DVBCWNS5 ;VMP/JER - SPINE WKS TEXT - 1 ; 12/02/03 11:00am
+1 ;;2.7;AMIE;**60**;DEC 2, 2003
+2 ;
TXT ;
+1 ;;
+2 ;;A. Review of Medical Records:
+3 ;;
+4 ;;B. Present Medical History (Subjective Complaints):
+5 ;;
+6 ;;Please comment whether etiology for any of these subjective complaints is
+7 ;;unrelated to claimed disability.
+8 ;;
+9 ;;1. Report complaints of pain (including any radiation), stiffness,
+10 ;; weakness, etc.
+11 ;; a. Onset
+12 ;; b. Location and distribution
+13 ;; c. Duration
+14 ;; d. Characteristics, quality, description
+15 ;; e. Intensity
+16 ;;2. Describe treatment - type, dose, frequency, response, side effects.
+17 ;;3. Report whether there are periods of flare-up. Provide the
+18 ;; following if individual reports periods of flare-up:
+19 ;; a. Severity, frequency, and duration.
+20 ;; b. Precipitating and alleviating factors.
+21 ;; c. Additional limitation of motion or functional impairment during
+22 ;; the flare-up.
+23 ;;4. Describe associated features or symptoms (e.g., weight loss, fevers,
+24 ;; malaise, dizziness, visual disturbances, numbness, weakness,
+25 ;; bladder complaints, bowel complaints, erectile dysfunction).
+26 ;;5. Describe walking and assistive devices.
+27 ;; a. Does the veteran walk unaided? Does the veteran use a cane,
+28 ;; crutches, or a walker?
+29 ;; b. Does the veteran use a brace (orthosis)?
+30 ;; c. How far and how long can the veteran walk?
+31 ;; d. Is the veteran unsteady? Does the veteran have a history of
+32 ;; falls?
+33 ;;6. Describe details of any trauma or injury, including dates, and direction
+34 ;; and magnitude of forces.
+35 ;;7. Describe details of any surgery, including dates.
+36 ;;8. Functional Assessment - Describe effects of the condition(s) on the
+37 ;; veteran's mobility (e.g., walking, transfers), activities of daily
+38 ;; living (i.e., eating, grooming, bathing, toileting, dressing), usual
+39 ;; occupation, recreational activities, driving.
+40 ;;
+41 ;;C. Physical Examination (Objective Findings): Address each of the following as
+42 ;; appropriate to the condition being examined and fully describe current
+43 ;; findings:
+44 ;;
+45 ;; 1. Inspection: spine, limbs, posture and gait, position of the
+46 ;; head, curvatures of the spine, symmetry in appearance, symmetry
+47 ;; and rhythm of spinal motion.
+48 ;;
+49 ;; 2. Range of motion
+50 ;;
+51 ;; a. Cervical Spine
+52 ;;
+53 ;; The reproducibility of an individual's range of motion is one
+54 ;; indicator of optimum effort. Pain, fear of injury, disuse or
+55 ;; neuromuscular inhibition may limit mobility by decreasing the
+56 ;; individual's effort. If range of motion measurements fail to
+57 ;; match known pathology, please repeat the measurements.
+58 ;; (Reference: Guides to the Evaluation of Permanent Impairment,
+59 ;; Fifth Edition, 2001, page 399).
+60 ;;
+61 ;; i. Using a goniometer, measure and report the range of motion in
+62 ;; degrees of forward flexion, extension, left lateral flexion,
+63 ;; right lateral flexion, left lateral rotation and right lateral
+64 ;; rotation. Generally, the normal ranges of motion for the
+65 ;; cervical spine are as follows:
+66 ;;
+67 ;; -Forward flexion: 0 to 45 degrees
+68 ;; -Extension: 0 to 45 degrees
+69 ;; -Left Lateral Flexion: 0 to 45 degrees
+70 ;; -Right Lateral Flexion: 0 to 45 degrees
+71 ;; -Left Lateral Rotation: 0 to 80 degrees
+72 ;; -Right Lateral Rotation: 0 to 80 degrees
+73 ;;
+74 ;; There may be a situation where an individual's range of motion is
+75 ;; reduced, but "normal" (in the examiner's opinion) based on the
+76 ;; individual's age, body habitus, neurologic disease, or other factors
+77 ;; unrelated to the disability for which the exam is being performed. In
+78 ;; this situation, please explain why the individual's measured range of
+79 ;; motion should be considered as "normal".
+80 ;;
+81 ;; ii. If the spine is painful on motion, state at what point in the
+82 ;; range of motion pain begins and ends.
+83 ;;
+84 ;; iii. State to what extent (if any), expressed in degrees if
+85 ;; possible, the range of motion is additionally limited by pain,
+86 ;; fatigue, weakness, or lack of endurance following repetitive use
+87 ;; or during flare-ups. If more than one of these is present,
+88 ;; state, if possible, which has the major functional impact.
+89 ;;
+90 ;; iv. Describe objective evidence of painful motion, spasm, weakness,
+91 ;; tenderness, etc.
+92 ;;
+93 ;; v. Describe any postural abnormalities, fixed deformity
+94 ;; (ankylosis), or abnormality of musculature of cervical spine
+95 ;; musculature. In the situation where there is unfavorable
+96 ;; ankylosis of the cervical spine, indicate whether there is:
+97 ;; difficulty walking because of a limited line of vision;
+98 ;; restricted opening of the mouth (with limited ability to
+99 ;; chew); breathing limited to diaphragmatic respiration;
+100 ;; gastrointestinal symptoms due to pressure of the costal margin
+101 ;; on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical
+102 ;; subluxation or dislocation
+103 ;;
+104 ;;
+105 ;; b. Thoracolumbar spine
+106 ;;
+107 ;; The reproducibility of an individual's range of motion is one
+108 ;; indicator of optimum effort. Pain, fear of injury, disuse or
+109 ;; neuromuscular inhibition may limit mobility by decreasing the
+110 ;; individual's effort. If range of motion measurements fail to
+111 ;; match known pathology, please repeat the measurements.
+112 ;; (Reference: Guides to the Evaluation of Permanent Impairment,
+113 ;; Fifth Edition, 2001, page 399).
+114 ;;
+115 ;; It is best to measure range of motion for the thoracolumbar
+116 ;; spine from a standing position. Measuring the range of motion
+117 ;; from a standing position (as opposed to from a sitting position)
+118 ;; will include the effects of forces generated by the distance
+119 ;; from the center of gravity from the axis of motion of the spine
+120 ;; and will include the effect of contraction of the spinal
+121 ;; muscles. Contraction of the spinal muscles imposes a significant
+122 ;; compressive force during spine movements upon the lumbar discs.
+123 ;;
+124 ;; i. Provide forward flexion of the thoracolumbar spine as a unit.
+125 ;; Do not include hip flexion. (See Magee, Orthopedic Physical
+126 ;; Assessment, Third Edition, 1997, W.B. Saunders Company,
+127 ;; pages 374-75). Using a goniometer, measure and report the range
+128 ;; of motion in degrees for forward flexion, extension, left
+129 ;; lateral flexion, right lateral flexion, left lateral rotation
+130 ;; and right lateral rotation. Generally, the normal ranges of
+131 ;; motion for the thoracolumbar spine as a unit are as follows:
+132 ;;
+133 ;; -Forward flexion: 0 to 90 degrees
+134 ;; -Extension: 0 to 30 degrees
+135 ;; -Left Lateral Flexion: 0 to 30 degrees
+136 ;; -Right Lateral Flexion: 0 to 30 degrees
+137 ;; -Left Lateral Rotation: 0 to 30 degrees
+138 ;; -Right Lateral Rotation: 0 to 30 degrees
+139 ;;
+140 ;;There may be a situation where an individual's range of motion is reduced, but
+141 ;;"normal" (in the examiner's opinion) based on the individual's age, body
+142 ;;habitus, neurologic disease, or other factors unrelated to the disability for
+143 ;;which the exam is being performed. In this situation, please explain why the
+144 ;;individual's measured range of motion should be considered as "normal".
+145 ;;
+146 ;; ii. If the spine is painful on motion, state at what point in the range
+147 ;; of motion pain begins and ends.
+148 ;;
+149 ;; iii. State to what extent (if any), expressed in degrees if possible,
+150 ;; the range of motion is additionally limited by pain, fatigue,
+151 ;; weakness, or lack of endurance following repetitive use or during
+152 ;; flare-ups. If more than one of these is present, state, if possible,
+153 ;; which has the major functional impact.
+154 ;;
+155 ;; iv. Describe objective evidence of painful motion, spasm, weakness,
+156 ;; tenderness, etc.
+157 ;;
+158 ;; a. Indicate whether there is muscle spasm, guarding or localized
+159 ;; tenderness with preserved spinal contour, and normal gait.
+160 ;;
+161 ;; b. Indicate whether there is muscle spasm, or guarding severe enough
+162 ;; to result in an abnormal gait, abnormal spinal contour such as
+163 ;; scoliosis, reversed lordosis or abnormal kyphosis.
+164 ;;
+165 ;; v. Describe any postural abnormalities, fixed deformity (ankylosis),
+166 ;; or abnormality of musculature of back. In the situation where
+167 ;; there is unfavorable ankylosis of the thoracolumbar spine,
+168 ;; indicate whether there is: difficulty walking because of a
+169 ;; limited line of vision; restricted opening of the mouth (with
+170 ;; limited ability to chew); breathing limited to diaphragmatic
+171 ;; respiration; gastrointestinal symptoms due to pressure of
+172 ;; the costal margin on the abdomen; dyspnea; dysphagia;
+173 ;; atlantoaxial or cervical subluxation or dislocation; or
+174 ;; neurologic symptoms due to nerve root involvement.
+175 ;;
+176 ;; 3. Neurological examination
+177 ;;
+178 ;;Please perform complete neurologic evaluation as indicated based upon
+179 ;;disability for which the exam is being performed. Please provide brief
+180 ;;statement if any of the following (a-e) is not included in exam. For
+181 ;;additional neurologic effects of disability not captured by a - e,
+182 ;;(e.g. bladder problems) please refer to appropriate worksheet for the body
+183 ;;system affected.
+184 ;;
+185 ;; a. Sensory examination, to include sacral segments.
+186 ;; b. Motor examination (atrophy, circumferential measurements, tone,
+187 ;; and strength).
+188 ;; c. Reflexes (deep tendon, cutaneous, and pathologic).
+189 ;; d. Rectal examination (sensation, tone, volitional control, and
+190 ;; reflexes).
+191 ;; e. Lasegue's sign.
+192 ;;
+193 ;; 4. For vertebral fractures, report the percentage of loss of
+194 ;; height, if any, of the vertebral body
+195 ;; 5. Non-organic physical signs (e.g., Waddell tests, others).
+196 ;;
+197 ;;D. For intervertebral disc syndrome
+198 ;;
+199 ;; 1. Conduct and report a separate history and physical
+200 ;; examination for each segment of the spine (cervical,
+201 ;; thoracic, lumbar) affected by disc disease.
+202 ;; 2. Conduct a complete history and physical examination of each
+203 ;; affected segment of the spine (cervical, thoracic, lumbar),
+204 ;; whether or not there has been surgery, as described above
+205 ;; under B. Present Medical History and C. Physical Examination.
+206 ;; 3. Conduct a thorough neurologic history and examination, as
+207 ;; described in C5, of all areas innervated by each affected
+208 ;; spinal segment. Specify the peripheral nerve(s) affected.
+209 ;; Include an evaluation of effects, if any, on bowel or bladder
+210 ;; functioning.
+211 ;; 4. Describe as precisely as possible, in number of days, the
+212 ;; duration of each incapacitating episode during the past
+213 ;; 12-month period. An incapacitating episode, for disability
+214 ;; evaluation purposes, is a period of acute signs and symptoms
+215 ;; due to intervertebral disc syndrome that requires bed rest
+216 ;; prescribed by a physician and treatment by a physician.
+217 ;;
+218 ;;E. Diagnostic and Clinical Tests:
+219 ;;
+220 ;; 1. Imaging studies, when indicated.
+221 ;; 2. Electrodiagnostic tests, when indicated.
+222 ;; 3. Clinical laboratory tests, when indicated.
+223 ;; 4. Isotope scans, when indicated.
+224 ;; 5. Include results of all diagnostic and clinical tests conducted in the
+225 ;; examination report.
+226 ;;
+227 ;;F. Diagnosis:
+228 ;;
+229 ;;
+230 ;;Signature: Date:
+231 ;;END
