How to Conquer Your C&P Exam for Back Pain

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If you’ve filed a VA claim for Back Pain, chances are you’re going to be scheduled for a C&P exam for Back Pain.

In this article, you’ll learn “what” to expect and “how” to prepare for the big day so you can get the VA rating and compensation you deserve.

Back Pain is a major problem for military veterans, often caused by the physical demands of active duty service.

In fact, Back Pain (Lumbosacral or Cervical Strain) is the #5 most common VA disability claim.

Pro Tip: VA ratings for back pain range from 10% to 100% with breaks at 20%, 30%, 40%, and 50%. Your final rating depends on the severity of symptoms as well as your limitation of range of motion as measured by a goniometer during the C&P exam. If you have no limitation of range of motion, but pain upon any movement, the minimum compensable rating of 10% should be awarded.

Summary of Key Points

• Types of Exams: There are three main types of VA exams for back pain: initial exams for new claims, increase exams if you already have a rating but are pursuing a higher rating, and secondary exams for back pain linked to other service-connected conditions.

• Exam Purpose: A back pain C&P exam evaluates three main areas: (#1) confirming a diagnosis of a back condition, (#2) determining the “nexus” for service connection, and (#3) assessing the severity of symptoms in terms of frequency, severity, and duration.

• VA Ratings for Back Pain: The VA assigns disability ratings for back pain based on symptom severity and limitation of range of motion, with ratings ranging from 10% to 100% with breaks at 20%, 30%, 40%, and 50%. Your final rating depends on the severity of symptoms and range of motion limitations measured during the exam.

• Preparation Tips: Prepare by gathering relevant medical records, keeping a detailed symptom diary, listing functional impacts, and reviewing the Back Pain Disability Benefits Questionnaire (DBQ). This will help you effectively articulate the severity and impact of your condition during the exam.

What to Expect at a VA C&P Exam for Back Pain

A VA C&P exam for Back Pain is designed to evaluate three main areas: (#1) confirming a diagnosis of a back condition, (#2) determining the “nexus” for service connection, and (#3) assessing the severity of symptoms in terms of frequency, severity, and duration.

You will get scheduled for an in-person exam because accurate range of motion measurements are a critical part of the VA’s exam process for the back and spine.

Here’s six things you can expect during a VA Back Pain C&P exam:

1. Review of Medical History

The C&P examiner should start by reviewing your medical records, including any previous diagnoses, treatments, or evaluations related to Back Pain. Note: The examiner has access to the medical records and documents you submitted to the VA. You can bring documents with you to the exam although you’re not required to.

2. Discussion of Symptoms

The examiner will ask you about your Back Pain symptoms, including when you first noticed them, how often you experience them, the intensity of the pain, and whether it affects specific areas of your back. Remember, your VA rating for Back Pain depends on the Frequency, Severity, and Duration of symptoms and how those symptoms negatively affect your work, life, and social functioning.

3. Physical Examination

The examiner should conduct a physical examination of your back to check for any visible signs of conditions that could contribute to Back Pain, such as muscle spasms, tenderness, range of motion limitations, or structural abnormalities.

4. Functional Assessment

You’ll be asked about how Back Pain affects your daily activities, such as sleeping, concentrating, working, socializing, and overall quality of life. Be honest and provide specific examples of how Back Pain interferes with your ability to function normally. For example, “My Back Pain is so severe that I have trouble sitting for long periods and it affects my job performance.”

5. Range of Motion Testing

The examiner may perform a series of tests to assess your range of motion. These tests help determine the extent of movement limitations in your back, which are crucial for evaluating the severity of your Back Pain. Do not let the C&P examiner move you to or beyond pain! As soon as you feel any discomfort, make them stop. If you can’t move, don’t do it.

6. Completion of VA DBQ for Back Pain

The examiner will document their findings on the VA DBQ for Back Pain, which is then submitted to the VA Rater for further processing. Eventually, the VA Rater will either approve, deny, or defer your VA claim for your back condition.

What Questions Will I Get Asked at a C&P Exam for Back Pain?

Here’s a list of questions the examiner is likely to ask and document on the DBQ for Back Pain at the conclusion of your exam:

List of Questions to Expect at a Back Pain C&P Exam:

Section I – Diagnosis

1. What are the claimed conditions related to your thoracolumbar spine?
2. Do you have a current diagnosis associated with any of these conditions? If yes, specify the diagnosis and date.
3. Are there additional diagnoses pertaining to your thoracolumbar spine conditions? If yes, list them.

Section II – Medical History

4. Describe the history of your thoracolumbar spine condition, including onset and course.
5. Do you experience flare-ups of your thoracolumbar spine condition? If yes, describe the frequency, duration, characteristics, precipitating and alleviating factors, severity, and extent of functional impairment during flare-ups.
6. Do you have any functional loss or impairment of the joint or extremity being evaluated? If yes, describe the functional loss or impairment in your own words.

Section III – Range of Motion (ROM) and Functional Limitation

7. Are your initial range of motion (ROM) measurements normal or abnormal?
8. Does the range of motion itself contribute to functional loss? If yes, explain how.
9. Is there pain on both passive and active motion, and on both weight-bearing and nonweight-bearing? Describe the characteristics of pain observed.
10. Can repetitive use testing be performed? If yes, is there additional loss of function or range of motion after three repetitions? Specify the factors causing this functional loss.
11. Are you being examined immediately after repeated use over time? If yes, describe any additional functional loss.
12. Are you being examined during a flare-up? If yes, describe the additional functional loss during flare-ups.
13. Do you have localized tenderness, guarding, or muscle spasm of the thoracolumbar spine? Describe the severity and location.
14. Are there additional contributing factors of disability? If yes, describe them.

Section IV – Muscle Strength Testing

15. Rate your muscle strength for various movements such as hip flexion, knee extension, and ankle dorsiflexion.
16. Do you have muscle atrophy? If yes, specify the location and measurements of normal and atrophied sides.

Section V – Reflex Exam

17. Rate your deep tendon reflexes (DTRs) for areas such as the knee and ankle.

Section VI – Sensory Exam

18. Provide results for sensation to light touch testing in areas like the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes.

Section VII – Straight Leg Raising Test

19. Provide the results of the straight leg raising test for both legs.

Section VIII – Radiculopathy

20. Do you have radicular pain or other signs of radiculopathy? If yes, indicate symptoms’ location and severity.
21. Describe any other signs or symptoms of radiculopathy.
22. Indicate the nerve roots involved and specify the side affected.

Section IX – Ankylosis

23. Do you have ankylosis of the spine? If yes, indicate the severity.

Section X – Other Neurologic Abnormalities

24. Do you have any other neurologic abnormalities or findings related to your thoracolumbar spine condition? If yes, describe them.

Section XI – Intervertebral Disc Syndrome (IVDS) and Episodes Requiring Bed Rest

25. Do you have IVDS of the thoracolumbar spine? If yes, have you had any episodes requiring bed rest prescribed by a physician in the past 12 months? Specify the duration of these episodes.

Section XII – Assistive Devices

26. Do you use any assistive devices for locomotion? If yes, identify the devices and their frequency of use.

Section XIII – Remaining Effective Function of the Extremities

27. Due to your thoracolumbar spine condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? If yes, describe the loss of effective function.

Section XIV – Other Pertinent Physical Findings, Complications, Conditions, Signs, Symptoms, and Scars

28. Do you have any other pertinent physical findings, complications, conditions, signs, or symptoms related to your thoracolumbar spine condition? If yes, describe them.
29. Do you have any scars or disfigurement related to your thoracolumbar spine condition or its treatment? If yes, describe them.

Section XV – Diagnostic Testing

30. Have imaging studies been performed in conjunction with this examination? If yes, provide details.
31. Does the imaging show evidence of degenerative or post-traumatic arthritis? If yes, provide details.
32. Do you have imaging evidence of a thoracolumbar vertebral fracture with a loss of 50% or more of height? If yes, provide details.

Section XVI – Functional Impact

33. Regardless of your current employment status, do your thoracolumbar spine conditions impact your ability to perform occupational tasks such as standing, walking, lifting, or sitting? If yes, describe the functional impact with examples.

Section XVII – Remarks

34. Do you have any additional remarks or comments related to your thoracolumbar spine condition and its impact?

These questions will help the examiner understand the severity of your back pain and its impact on your daily life and functioning.

Be prepared to provide detailed and honest responses to ensure an accurate assessment.

How to Prepare for Your VA Back Pain C&P Exam

Here are some steps to help you prepare for your Back Pain exam:

• Gather Records and Documents: Collect all relevant medical records, including diagnosis reports, treatment history, and any correspondence related to your Back Pain. This documentation will provide essential evidence to support your claim during the examination. Review the documents in detail and feel free to bring hard copies with you to the C&P exam for reference.

• Create a Symptom Diary: Keep a detailed log of your Back Pain symptoms, noting the frequency, severity, and duration of episodes. Document any factors that exacerbate or alleviate your symptoms, such as physical activity or rest. This diary will help you articulate the impact of Back Pain on your work, life, and social functioning during the exam.

• List Functional Impacts: Make a list of specific ways in which Back Pain affects your ability to perform daily tasks and activities. This may include difficulties with concentration, sleep disturbances, or challenges in social or work environments. Providing concrete examples of how Back Pain negatively impacts your daily functioning will strengthen your case during the exam.

• Review the DBQ for Back Pain: It’s a good idea to review the Back Pain DBQ. Be prepared to describe the onset and progression of your Back Pain symptoms over time, as well as any treatments you have pursued and their effectiveness (if any). Additionally, be prepared to discuss how Back Pain impacts your work, life, and social functioning.

• Review the C&P Examiners Guide to Spine Examinations: It’s also a good idea to review the guide to VA spine exams.

VA DBQ for Back Pain [Download]

The C&P examiner will complete the electronic version of the Back Conditions DBQ at the conclusion of your exam.

We’ve made a copy available for download below:

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