- 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 Feb 18, 2025@23:19:18 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