236 lines
14 KiB
Mathematica
236 lines
14 KiB
Mathematica
DVBCWNS5 ;VMP/JER - SPINE WKS TEXT - 1 ; 12/02/03 11:00am
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;;2.7;AMIE;**60**;DEC 2, 2003
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TXT ;
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;;A. Review of Medical Records:
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;;
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;;B. Present Medical History (Subjective Complaints):
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;;
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;;Please comment whether etiology for any of these subjective complaints is
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;;unrelated to claimed disability.
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;;
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;;1. Report complaints of pain (including any radiation), stiffness,
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;; weakness, etc.
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;; a. Onset
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;; b. Location and distribution
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;; c. Duration
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;; d. Characteristics, quality, description
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;; e. Intensity
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;;2. Describe treatment - type, dose, frequency, response, side effects.
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;;3. Report whether there are periods of flare-up. Provide the
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;; following if individual reports periods of flare-up:
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;; a. Severity, frequency, and duration.
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;; b. Precipitating and alleviating factors.
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;; c. Additional limitation of motion or functional impairment during
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;; the flare-up.
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;;4. Describe associated features or symptoms (e.g., weight loss, fevers,
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;; malaise, dizziness, visual disturbances, numbness, weakness,
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;; bladder complaints, bowel complaints, erectile dysfunction).
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;;5. Describe walking and assistive devices.
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;; a. Does the veteran walk unaided? Does the veteran use a cane,
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;; crutches, or a walker?
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;; b. Does the veteran use a brace (orthosis)?
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;; c. How far and how long can the veteran walk?
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;; d. Is the veteran unsteady? Does the veteran have a history of
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;; falls?
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;;6. Describe details of any trauma or injury, including dates, and direction
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;; and magnitude of forces.
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;;7. Describe details of any surgery, including dates.
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;;8. Functional Assessment - Describe effects of the condition(s) on the
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;; veteran's mobility (e.g., walking, transfers), activities of daily
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;; living (i.e., eating, grooming, bathing, toileting, dressing), usual
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;; occupation, recreational activities, driving.
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;;
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;;C. Physical Examination (Objective Findings): Address each of the following as
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;; appropriate to the condition being examined and fully describe current
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;; findings:
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;;
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;; 1. Inspection: spine, limbs, posture and gait, position of the
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;; head, curvatures of the spine, symmetry in appearance, symmetry
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;; and rhythm of spinal motion.
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;;
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;; 2. Range of motion
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;;
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;; a. Cervical Spine
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;;
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;; The reproducibility of an individual's range of motion is one
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;; indicator of optimum effort. Pain, fear of injury, disuse or
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;; neuromuscular inhibition may limit mobility by decreasing the
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;; individual's effort. If range of motion measurements fail to
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;; match known pathology, please repeat the measurements.
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;; (Reference: Guides to the Evaluation of Permanent Impairment,
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;; Fifth Edition, 2001, page 399).
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;;
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;; i. Using a goniometer, measure and report the range of motion in
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;; degrees of forward flexion, extension, left lateral flexion,
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;; right lateral flexion, left lateral rotation and right lateral
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;; rotation. Generally, the normal ranges of motion for the
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;; cervical spine are as follows:
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;;
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;; -Forward flexion: 0 to 45 degrees
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;; -Extension: 0 to 45 degrees
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;; -Left Lateral Flexion: 0 to 45 degrees
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;; -Right Lateral Flexion: 0 to 45 degrees
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;; -Left Lateral Rotation: 0 to 80 degrees
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;; -Right Lateral Rotation: 0 to 80 degrees
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;;
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;; There may be a situation where an individual's range of motion is
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;; reduced, but "normal" (in the examiner's opinion) based on the
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;; individual's age, body habitus, neurologic disease, or other factors
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;; unrelated to the disability for which the exam is being performed. In
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;; this situation, please explain why the individual's measured range of
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;; motion should be considered as "normal".
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;;
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;; ii. If the spine is painful on motion, state at what point in the
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;; range of motion pain begins and ends.
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;;
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;; iii. State to what extent (if any), expressed in degrees if
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;; possible, the range of motion is additionally limited by pain,
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;; fatigue, weakness, or lack of endurance following repetitive use
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;; or during flare-ups. If more than one of these is present,
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;; state, if possible, which has the major functional impact.
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;;
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;; iv. Describe objective evidence of painful motion, spasm, weakness,
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;; tenderness, etc.
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;;
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;; v. Describe any postural abnormalities, fixed deformity
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;; (ankylosis), or abnormality of musculature of cervical spine
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;; musculature. In the situation where there is unfavorable
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;; ankylosis of the cervical spine, indicate whether there is:
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;; difficulty walking because of a limited line of vision;
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;; restricted opening of the mouth (with limited ability to
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;; chew); breathing limited to diaphragmatic respiration;
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;; gastrointestinal symptoms due to pressure of the costal margin
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;; on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical
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;; subluxation or dislocation
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;;
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;;
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;; b. Thoracolumbar spine
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;;
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;; The reproducibility of an individual's range of motion is one
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;; indicator of optimum effort. Pain, fear of injury, disuse or
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;; neuromuscular inhibition may limit mobility by decreasing the
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;; individual's effort. If range of motion measurements fail to
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;; match known pathology, please repeat the measurements.
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;; (Reference: Guides to the Evaluation of Permanent Impairment,
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;; Fifth Edition, 2001, page 399).
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;;
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;; It is best to measure range of motion for the thoracolumbar
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;; spine from a standing position. Measuring the range of motion
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;; from a standing position (as opposed to from a sitting position)
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;; will include the effects of forces generated by the distance
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;; from the center of gravity from the axis of motion of the spine
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;; and will include the effect of contraction of the spinal
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;; muscles. Contraction of the spinal muscles imposes a significant
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;; compressive force during spine movements upon the lumbar discs.
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;;
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;; i. Provide forward flexion of the thoracolumbar spine as a unit.
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;; Do not include hip flexion. (See Magee, Orthopedic Physical
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;; Assessment, Third Edition, 1997, W.B. Saunders Company,
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;; pages 374-75). Using a goniometer, measure and report the range
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;; of motion in degrees for forward flexion, extension, left
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;; lateral flexion, right lateral flexion, left lateral rotation
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;; and right lateral rotation. Generally, the normal ranges of
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;; motion for the thoracolumbar spine as a unit are as follows:
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;;
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;; -Forward flexion: 0 to 90 degrees
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;; -Extension: 0 to 30 degrees
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;; -Left Lateral Flexion: 0 to 30 degrees
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;; -Right Lateral Flexion: 0 to 30 degrees
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;; -Left Lateral Rotation: 0 to 30 degrees
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;; -Right Lateral Rotation: 0 to 30 degrees
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;;
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;;There may be a situation where an individual's range of motion is reduced, but
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;;"normal" (in the examiner's opinion) based on the individual's age, body
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;;habitus, neurologic disease, or other factors unrelated to the disability for
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;;which the exam is being performed. In this situation, please explain why the
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;;individual's measured range of motion should be considered as "normal".
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;;
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;; ii. If the spine is painful on motion, state at what point in the range
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;; of motion pain begins and ends.
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;;
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;; iii. State to what extent (if any), expressed in degrees if possible,
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;; the range of motion is additionally limited by pain, fatigue,
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;; weakness, or lack of endurance following repetitive use or during
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;; flare-ups. If more than one of these is present, state, if possible,
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;; which has the major functional impact.
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;;
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;; iv. Describe objective evidence of painful motion, spasm, weakness,
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;; tenderness, etc.
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;;
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;; a. Indicate whether there is muscle spasm, guarding or localized
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;; tenderness with preserved spinal contour, and normal gait.
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;;
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;; b. Indicate whether there is muscle spasm, or guarding severe enough
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;; to result in an abnormal gait, abnormal spinal contour such as
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;; scoliosis, reversed lordosis or abnormal kyphosis.
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;;
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;; v. Describe any postural abnormalities, fixed deformity (ankylosis),
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;; or abnormality of musculature of back. In the situation where
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;; there is unfavorable ankylosis of the thoracolumbar spine,
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;; indicate whether there is: difficulty walking because of a
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;; limited line of vision; restricted opening of the mouth (with
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;; limited ability to chew); breathing limited to diaphragmatic
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;; respiration; gastrointestinal symptoms due to pressure of
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;; the costal margin on the abdomen; dyspnea; dysphagia;
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;; atlantoaxial or cervical subluxation or dislocation; or
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;; neurologic symptoms due to nerve root involvement.
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;;
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;; 3. Neurological examination
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;;
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;;Please perform complete neurologic evaluation as indicated based upon
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;;disability for which the exam is being performed. Please provide brief
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;;statement if any of the following (a-e) is not included in exam. For
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;;additional neurologic effects of disability not captured by a - e,
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;;(e.g. bladder problems) please refer to appropriate worksheet for the body
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;;system affected.
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;;
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;; a. Sensory examination, to include sacral segments.
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;; b. Motor examination (atrophy, circumferential measurements, tone,
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;; and strength).
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;; c. Reflexes (deep tendon, cutaneous, and pathologic).
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;; d. Rectal examination (sensation, tone, volitional control, and
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;; reflexes).
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;; e. Lasegue's sign.
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;;
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;; 4. For vertebral fractures, report the percentage of loss of
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;; height, if any, of the vertebral body
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;; 5. Non-organic physical signs (e.g., Waddell tests, others).
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;;
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;;D. For intervertebral disc syndrome
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;;
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;; 1. Conduct and report a separate history and physical
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;; examination for each segment of the spine (cervical,
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;; thoracic, lumbar) affected by disc disease.
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;; 2. Conduct a complete history and physical examination of each
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;; affected segment of the spine (cervical, thoracic, lumbar),
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;; whether or not there has been surgery, as described above
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;; under B. Present Medical History and C. Physical Examination.
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;; 3. Conduct a thorough neurologic history and examination, as
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;; described in C5, of all areas innervated by each affected
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;; spinal segment. Specify the peripheral nerve(s) affected.
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;; Include an evaluation of effects, if any, on bowel or bladder
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;; functioning.
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;; 4. Describe as precisely as possible, in number of days, the
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;; duration of each incapacitating episode during the past
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;; 12-month period. An incapacitating episode, for disability
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;; evaluation purposes, is a period of acute signs and symptoms
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;; due to intervertebral disc syndrome that requires bed rest
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;; prescribed by a physician and treatment by a physician.
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;;
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;;E. Diagnostic and Clinical Tests:
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;;
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;; 1. Imaging studies, when indicated.
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;; 2. Electrodiagnostic tests, when indicated.
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;; 3. Clinical laboratory tests, when indicated.
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;; 4. Isotope scans, when indicated.
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;; 5. Include results of all diagnostic and clinical tests conducted in the
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;; examination report.
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;;
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;;F. Diagnosis:
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;;
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;;
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;;Signature: Date:
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;;END
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