DVBCWSP1 ;ALB/RLC - SPINE WKS TEXT - 1 ; 14 JUN 2005
;;2.7;AMIE;**144**;DEC 2, 2003;Build 5
;
TXT ;
;;
;;A. Review of Medical Records:
;;
;;B. Present Medical History (Subjective Complaints):
;;
;;Please comment on whether the etiology for any of these subjective complaints
;;is unrelated to the claimed disability.
;;
;; 1. Provide date, circumstances of onset and course since onset.
;; 2. Report complaints of pain (including any radiation).
;;
;; a. Onset, description of pain.
;; b. Location and distribution
;; c. Duration, frequency.
;; d. Severity (mild, moderate, severe).
;; e. Have there been incapacitating episodes of back pain in the
;; past 12 months? Duration? (Incapacitating episodes are episodes
;; that require bedrest prescribed by a physician and treatment by
;; a physician).
;;
;; 3. Describe treatment - type, include dose for medication, frequency,
;; response, and side effects.
;; 4. Provide the following (per veteran) 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.
;;
;; 5. Describe associated features or symptoms (e.g., stiffness, fatigue,
;; spasms, weakness, decreased motion, numbness, paresthesias, leg or
;; foot weakness, bladder complaints (i.e., urinary incontinence (how
;; treated, appliance, absorbent material, number of times changed per
;; 24 hours), urgency, retention (require catheterization), frequency
;; (daytime voiding interval, nocturia)), bowel complaints (i.e.,
;; obstipation, fecal incontinence (extent of leakage, pads?), erectile
;; dysfunction).
;; 6. 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?
;;
;; 7. Describe details of any trauma or injury, including dates.
;; 8. Describe details of any hospitalizations or surgery, including dates
;; and locations, if known.
;; 9. 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, driving.
;; 10. History of neoplasm:
;;
;; a. Date of diagnosis, diagnosis.
;; b. Benign or malignant.
;; c. Type and date(s) of treatment.
;; d. Date of last treatment.
;;
;;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.
;;
;; 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. Describe presence or absence of objective evidence of pain.
;;
;; iii. Describe objective evidence of painful motion, spasm, weakness,
;; tenderness, atrophy, guarding, etc.
;;
;; iv. Describe any postural abnormalities, fixed deformity
;; (ankylosis), or abnormality of musculature of cervical spine
;; musculature.
;;
;; 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. Describe presence or absence of objective evidence of pain.
;;
;; iii. Describe objective evidence of painful motion, spasm, weakness,
;; tenderness, atrophy, guarding, 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.
;;
;; iv. Describe any postural abnormalities, fixed deformity (ankylosis),
;; or abnormality of musculature of back.
;;
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWSP1 8894 printed Apr 09, 2024@20:44:44 Page 2
DVBCWSP1 ;ALB/RLC - SPINE WKS TEXT - 1 ; 14 JUN 2005
+1 ;;2.7;AMIE;**144**;DEC 2, 2003;Build 5
+2 ;
TXT ;
+1 ;;
+2 ;;A. Review of Medical Records:
+3 ;;
+4 ;;B. Present Medical History (Subjective Complaints):
+5 ;;
+6 ;;Please comment on whether the etiology for any of these subjective complaints
+7 ;;is unrelated to the claimed disability.
+8 ;;
+9 ;; 1. Provide date, circumstances of onset and course since onset.
+10 ;; 2. Report complaints of pain (including any radiation).
+11 ;;
+12 ;; a. Onset, description of pain.
+13 ;; b. Location and distribution
+14 ;; c. Duration, frequency.
+15 ;; d. Severity (mild, moderate, severe).
+16 ;; e. Have there been incapacitating episodes of back pain in the
+17 ;; past 12 months? Duration? (Incapacitating episodes are episodes
+18 ;; that require bedrest prescribed by a physician and treatment by
+19 ;; a physician).
+20 ;;
+21 ;; 3. Describe treatment - type, include dose for medication, frequency,
+22 ;; response, and side effects.
+23 ;; 4. Provide the following (per veteran) if individual reports periods of
+24 ;; flare-up:
+25 ;;
+26 ;; a. Severity, frequency, and duration.
+27 ;; b. Precipitating and alleviating factors.
+28 ;; c. Additional limitation of motion or functional impairment during
+29 ;; the flare-up.
+30 ;;
+31 ;; 5. Describe associated features or symptoms (e.g., stiffness, fatigue,
+32 ;; spasms, weakness, decreased motion, numbness, paresthesias, leg or
+33 ;; foot weakness, bladder complaints (i.e., urinary incontinence (how
+34 ;; treated, appliance, absorbent material, number of times changed per
+35 ;; 24 hours), urgency, retention (require catheterization), frequency
+36 ;; (daytime voiding interval, nocturia)), bowel complaints (i.e.,
+37 ;; obstipation, fecal incontinence (extent of leakage, pads?), erectile
+38 ;; dysfunction).
+39 ;; 6. Describe walking and assistive devices.
+40 ;;
+41 ;; a. Does the veteran walk unaided? Does the veteran use a cane,
+42 ;; crutches, or a walker?
+43 ;; b. Does the veteran use a brace (orthosis)?
+44 ;; c. How far and how long can the veteran walk?
+45 ;; d. Is the veteran unsteady? Does the veteran have a history of
+46 ;; falls?
+47 ;;
+48 ;; 7. Describe details of any trauma or injury, including dates.
+49 ;; 8. Describe details of any hospitalizations or surgery, including dates
+50 ;; and locations, if known.
+51 ;; 9. Functional Assessment - Describe effects of the condition(s) on the
+52 ;; veteran's mobility (e.g., walking, transfers), activities of daily
+53 ;; living (i.e., eating, grooming, bathing, toileting, dressing), usual
+54 ;; occupation, driving.
+55 ;; 10. History of neoplasm:
+56 ;;
+57 ;; a. Date of diagnosis, diagnosis.
+58 ;; b. Benign or malignant.
+59 ;; c. Type and date(s) of treatment.
+60 ;; d. Date of last treatment.
+61 ;;
+62 ;;C. Physical Examination (Objective Findings): Address each of the following as
+63 ;; appropriate to the condition being examined and fully describe current
+64 ;; findings:
+65 ;;
+66 ;; 1. Inspection: spine, limbs, posture and gait, position of the head,
+67 ;; curvatures of the spine, symmetry in appearance.
+68 ;;
+69 ;; 2. Range of motion
+70 ;;
+71 ;; a. Cervical Spine
+72 ;;
+73 ;; The reproducibility of an individual's range of motion is one
+74 ;; indicator of optimum effort. Pain, fear of injury, disuse or
+75 ;; neuromuscular inhibition may limit mobility by decreasing the
+76 ;; individual's effort. If range of motion measurements fail to
+77 ;; match known pathology, please repeat the measurements.
+78 ;; (Reference: Guides to the Evaluation of Permanent Impairment,
+79 ;; Fifth Edition, 2001, page 399).
+80 ;;
+81 ;; i. Using a goniometer, measure and report the range of motion in
+82 ;; degrees of forward flexion, extension, left lateral flexion,
+83 ;; right lateral flexion, left lateral rotation and right lateral
+84 ;; rotation. Generally, the normal ranges of motion for the
+85 ;; cervical spine are as follows:
+86 ;;
+87 ;; -Forward flexion: 0 to 45 degrees
+88 ;; -Extension: 0 to 45 degrees
+89 ;; -Left Lateral Flexion: 0 to 45 degrees
+90 ;; -Right Lateral Flexion: 0 to 45 degrees
+91 ;; -Left Lateral Rotation: 0 to 80 degrees
+92 ;; -Right Lateral Rotation: 0 to 80 degrees
+93 ;;
+94 ;; There may be a situation where an individual's range of motion is
+95 ;; reduced, but "normal" (in the examiner's opinion) based on the
+96 ;; individual's age, body habitus, neurologic disease, or other
+97 ;; factors unrelated to the disability for which the exam is being
+98 ;; performed. In this situation, please explain why the individual's
+99 ;; measured range of motion should be considered as "normal".
+100 ;;
+101 ;;
+102 ;; ii. Describe presence or absence of objective evidence of pain.
+103 ;;
+104 ;; iii. Describe objective evidence of painful motion, spasm, weakness,
+105 ;; tenderness, atrophy, guarding, etc.
+106 ;;
+107 ;; iv. Describe any postural abnormalities, fixed deformity
+108 ;; (ankylosis), or abnormality of musculature of cervical spine
+109 ;; musculature.
+110 ;;
+111 ;; b. Thoracolumbar spine
+112 ;;
+113 ;; The reproducibility of an individual's range of motion is one
+114 ;; indicator of optimum effort. Pain, fear of injury, disuse or
+115 ;; neuromuscular inhibition may limit mobility by decreasing the
+116 ;; individual's effort. If range of motion measurements fail to
+117 ;; match known pathology, please repeat the measurements.
+118 ;; (Reference: Guides to the Evaluation of Permanent Impairment,
+119 ;; Fifth Edition, 2001, page 399).
+120 ;;
+121 ;; It is best to measure range of motion for the thoracolumbar
+122 ;; spine from a standing position. Measuring the range of motion
+123 ;; from a standing position (as opposed to from a sitting position)
+124 ;; will include the effects of forces generated by the distance
+125 ;; from the center of gravity from the axis of motion of the spine
+126 ;; and will include the effect of contraction of the spinal
+127 ;; muscles. Contraction of the spinal muscles imposes a significant
+128 ;; compressive force during spine movements upon the lumbar discs.
+129 ;;
+130 ;; i. Provide forward flexion of the thoracolumbar spine as a unit.
+131 ;; Do not include hip flexion. (See Magee, Orthopedic Physical
+132 ;; Assessment, Third Edition, 1997, W.B. Saunders Company,
+133 ;; pages 374-75). Using a goniometer, measure and report the range
+134 ;; of motion in degrees for forward flexion, extension, left
+135 ;; lateral flexion, right lateral flexion, left lateral rotation
+136 ;; and right lateral rotation. Generally, the normal ranges of
+137 ;; motion for the thoracolumbar spine as a unit are as follows:
+138 ;;
+139 ;; -Forward flexion: 0 to 90 degrees
+140 ;; -Extension: 0 to 30 degrees
+141 ;; -Left Lateral Flexion: 0 to 30 degrees
+142 ;; -Right Lateral Flexion: 0 to 30 degrees
+143 ;; -Left Lateral Rotation: 0 to 30 degrees
+144 ;; -Right Lateral Rotation: 0 to 30 degrees
+145 ;;
+146 ;; There may be a situation where an individual's range of motion is
+147 ;; reduced, but "normal" (in the examiner's opinion) based on the
+148 ;; individual's age, body habitus, neurologic disease, or other
+149 ;; factors unrelated to the disability for which the exam is being
+150 ;; performed. In this situation, please explain why the individual's
+151 ;; measured range of motion should be considered as "normal".
+152 ;;
+153 ;;
+154 ;; ii. Describe presence or absence of objective evidence of pain.
+155 ;;
+156 ;; iii. Describe objective evidence of painful motion, spasm, weakness,
+157 ;; tenderness, atrophy, guarding, etc.
+158 ;;
+159 ;;
+160 ;; a. Indicate whether there is muscle spasm, guarding or localized
+161 ;; tenderness with preserved spinal contour, and normal gait.
+162 ;;
+163 ;; b. Indicate whether there is muscle spasm, or guarding severe
+164 ;; enough to result in an abnormal gait, abnormal spinal contour
+165 ;; such as scoliosis, reversed lordosis or abnormal kyphosis.
+166 ;;
+167 ;; iv. Describe any postural abnormalities, fixed deformity (ankylosis),
+168 ;; or abnormality of musculature of back.
+169 ;;
