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Routine: DVBCWSP1

DVBCWSP1.m

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  1. DVBCWSP1 ;ALB/RLC - SPINE WKS TEXT - 1 ; 14 JUN 2005
  1.  ;;2.7;AMIE;**144**;DEC 2, 2003;Build 5
  1.  ;
  1. TXT ;
  1.  ;;
  1.  ;;A. Review of Medical Records:
  1.  ;;
  1.  ;;B. Present Medical History (Subjective Complaints):
  1.  ;;
  1.  ;;Please comment on whether the etiology for any of these subjective complaints
  1.  ;;is unrelated to the claimed disability.
  1.  ;;
  1.  ;;   1.  Provide date, circumstances of onset and course since onset.
  1.  ;;   2.  Report complaints of pain (including any radiation).
  1.  ;;
  1.  ;;       a.  Onset, description of pain.
  1.  ;;       b.  Location and distribution 
  1.  ;;       c.  Duration, frequency.
  1.  ;;       d.  Severity (mild, moderate, severe).     
  1.  ;;       e.  Have there been incapacitating episodes of back pain in the 
  1.  ;;           past 12 months?  Duration?  (Incapacitating episodes are episodes
  1.  ;;           that require bedrest prescribed by a physician and treatment by
  1.  ;;           a physician).
  1.  ;;
  1.  ;;   3.  Describe treatment - type, include dose for medication, frequency,
  1.  ;;       response, and side effects. 
  1.  ;;   4.  Provide the following (per veteran) if individual reports periods of
  1.  ;;       flare-up:
  1.  ;;
  1.  ;;       a.  Severity, frequency, and duration. 
  1.  ;;       b.  Precipitating and alleviating factors. 
  1.  ;;       c.  Additional limitation of motion or functional impairment during
  1.  ;;           the flare-up.
  1.  ;;
  1.  ;;   5.  Describe associated features or symptoms (e.g., stiffness, fatigue,
  1.  ;;       spasms, weakness, decreased motion, numbness, paresthesias, leg or
  1.  ;;       foot weakness, bladder complaints (i.e., urinary incontinence (how
  1.  ;;       treated, appliance, absorbent material, number of times changed per
  1.  ;;       24 hours), urgency, retention (require catheterization), frequency
  1.  ;;       (daytime voiding interval, nocturia)), bowel complaints (i.e.,
  1.  ;;       obstipation, fecal incontinence (extent of leakage, pads?), erectile
  1.  ;;       dysfunction).
  1.  ;;   6.  Describe walking and assistive devices.
  1.  ;;
  1.  ;;       a.  Does the veteran walk unaided? Does the veteran use a cane,
  1.  ;;           crutches, or a walker? 
  1.  ;;       b.  Does the veteran use a brace (orthosis)? 
  1.  ;;       c.  How far and how long can the veteran walk? 
  1.  ;;       d.  Is the veteran unsteady? Does the veteran have a history of
  1.  ;;           falls?
  1.  ;;
  1.  ;;   7.  Describe details of any trauma or injury, including dates.
  1.  ;;   8.  Describe details of any hospitalizations or surgery, including dates
  1.  ;;       and locations, if known. 
  1.  ;;   9.  Functional Assessment - Describe effects of the condition(s) on the
  1.  ;;       veteran's mobility (e.g., walking, transfers), activities of daily
  1.  ;;       living (i.e., eating, grooming, bathing, toileting, dressing), usual
  1.  ;;       occupation, driving.
  1.  ;;  10.  History of neoplasm:
  1.  ;;
  1.  ;;       a.  Date of diagnosis, diagnosis.
  1.  ;;       b.  Benign or malignant.
  1.  ;;       c.  Type and date(s) of treatment.
  1.  ;;       d.  Date of last treatment.
  1.  ;;
  1.  ;;C. Physical Examination (Objective Findings): Address each of the following as 
  1.  ;;   appropriate to the condition being examined and fully describe current
  1.  ;;   findings:
  1.  ;; 
  1.  ;;   1.  Inspection: spine, limbs, posture and gait, position of the head,
  1.  ;;       curvatures of the spine, symmetry in appearance.
  1.  ;;
  1.  ;;   2.  Range of motion
  1.  ;;
  1.  ;;       a.  Cervical Spine 
  1.  ;;
  1.  ;;           The reproducibility of an individual's range of motion is one
  1.  ;;           indicator of optimum effort. Pain, fear of injury, disuse or
  1.  ;;           neuromuscular inhibition may limit mobility by decreasing the
  1.  ;;           individual's effort. If range of motion measurements fail to
  1.  ;;           match known pathology, please repeat the measurements.
  1.  ;;           (Reference: Guides to the Evaluation of Permanent Impairment,
  1.  ;;           Fifth Edition, 2001, page 399).
  1.  ;;
  1.  ;;           i. Using a goniometer, measure and report the range of motion in
  1.  ;;              degrees of forward flexion, extension, left lateral flexion,
  1.  ;;              right lateral flexion, left lateral rotation and right lateral
  1.  ;;              rotation. Generally, the normal ranges of motion for the
  1.  ;;              cervical spine are as follows:
  1.  ;;
  1.  ;;              -Forward flexion: 0 to 45 degrees 
  1.  ;;              -Extension: 0 to 45 degrees 
  1.  ;;              -Left Lateral Flexion: 0 to 45 degrees 
  1.  ;;              -Right Lateral Flexion: 0 to 45 degrees 
  1.  ;;              -Left Lateral Rotation: 0 to 80 degrees 
  1.  ;;              -Right Lateral Rotation: 0 to 80 degrees
  1.  ;;
  1.  ;;           There may be a situation where an individual's range of motion is
  1.  ;;           reduced, but "normal" (in the examiner's opinion) based on the
  1.  ;;           individual's age, body habitus, neurologic disease, or other
  1.  ;;           factors unrelated to the disability for which the exam is being
  1.  ;;           performed. In this situation, please explain why the individual's
  1.  ;;           measured range of motion should be considered as "normal".
  1.  ;;
  1.  ;;           
  1.  ;;          ii. Describe presence or absence of objective evidence of pain.
  1.  ;;
  1.  ;;         iii. Describe objective evidence of painful motion, spasm, weakness,
  1.  ;;              tenderness, atrophy, guarding, etc.
  1.  ;; 
  1.  ;;          iv. Describe any postural abnormalities, fixed deformity
  1.  ;;              (ankylosis), or abnormality of musculature of cervical spine
  1.  ;;              musculature.
  1.  ;;
  1.  ;;       b. Thoracolumbar spine 
  1.  ;;
  1.  ;;          The reproducibility of an individual's range of motion is one
  1.  ;;          indicator of optimum effort. Pain, fear of injury, disuse or
  1.  ;;          neuromuscular inhibition may limit mobility by decreasing the
  1.  ;;          individual's effort. If range of motion measurements fail to
  1.  ;;          match known pathology, please repeat the measurements.
  1.  ;;          (Reference: Guides to the Evaluation of Permanent Impairment,
  1.  ;;          Fifth Edition, 2001, page 399).
  1.  ;; 
  1.  ;;          It is best to measure range of motion for the thoracolumbar
  1.  ;;          spine from a standing position. Measuring the range of motion
  1.  ;;          from a standing position (as opposed to from a sitting position)
  1.  ;;          will include the effects of forces generated by the distance
  1.  ;;          from the center of gravity from the axis of motion of the spine
  1.  ;;          and will include the effect of contraction of the spinal
  1.  ;;          muscles. Contraction of the spinal muscles imposes a significant
  1.  ;;          compressive force during spine movements upon the lumbar discs.
  1.  ;;
  1.  ;;          i. Provide forward flexion of the thoracolumbar spine as a unit.
  1.  ;;             Do not include hip flexion. (See Magee, Orthopedic Physical
  1.  ;;             Assessment, Third Edition, 1997, W.B. Saunders Company,
  1.  ;;             pages 374-75). Using a goniometer, measure and report the range
  1.  ;;             of motion in degrees for forward flexion, extension, left 
  1.  ;;             lateral flexion, right lateral flexion, left lateral rotation
  1.  ;;             and right lateral rotation. Generally, the normal ranges of 
  1.  ;;             motion for the thoracolumbar spine as a unit are as follows:
  1.  ;;
  1.  ;;             -Forward flexion: 0 to 90 degrees 
  1.  ;;             -Extension: 0 to 30 degrees 
  1.  ;;             -Left Lateral Flexion: 0 to 30 degrees 
  1.  ;;             -Right Lateral Flexion: 0 to 30 degrees 
  1.  ;;             -Left Lateral Rotation: 0 to 30 degrees 
  1.  ;;             -Right Lateral Rotation: 0 to 30 degrees
  1.  ;;
  1.  ;;           There may be a situation where an individual's range of motion is
  1.  ;;           reduced, but "normal" (in the examiner's opinion) based on the
  1.  ;;           individual's age, body habitus, neurologic disease, or other
  1.  ;;           factors unrelated to the disability for which the exam is being
  1.  ;;           performed. In this situation, please explain why the individual's
  1.  ;;           measured range of motion should be considered as "normal".
  1.  ;;
  1.  ;;
  1.  ;;          ii. Describe presence or absence of objective evidence of pain.
  1.  ;;
  1.  ;;         iii. Describe objective evidence of painful motion, spasm, weakness,
  1.  ;;              tenderness, atrophy, guarding, etc.
  1.  ;;
  1.  ;;
  1.  ;;              a. Indicate whether there is muscle spasm, guarding or localized
  1.  ;;                 tenderness with preserved spinal contour, and normal gait.
  1.  ;;
  1.  ;;              b. Indicate whether there is muscle spasm, or guarding severe
  1.  ;;                 enough to result in an abnormal gait, abnormal spinal contour
  1.  ;;                 such as scoliosis, reversed lordosis or abnormal kyphosis.
  1.  ;;
  1.  ;;          iv. Describe any postural abnormalities, fixed deformity (ankylosis), 
  1.  ;;                  or abnormality of musculature of back.
  1.  ;;