C&P Exam for Restless Leg Syndrome: Here’s What to Expect and How to Prepare

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If you’ve filed a VA claim for Restless Leg Syndrome (RLS), you’ll likely be scheduled for an in-person C&P exam with a third party company contracted by the VA.

In this article, you’ll learn what to expect and how to prepare for the most important day in the VA claim process to ensure you get the VA rating and compensation you deserve.

There is no separate Diagnostic Code (DC) for Restless Leg Syndrome under 38 CFR § 4.124a, so it’s rated by analogy under DC 8620 for Neuritis (nerve inflammation), with ratings from 10% to 80% with breaks at 20%, 40%, and 60%.

• If you have Restless Leg Syndrome with complete paralysis, including foot dangles and drops, with no active movement possible of muscles below the knee, flexion of the knee is weakened or (very rarely) lost, it is rated at 80%.

• If you have Restless Leg Syndrome with incomplete paralysis, it is rated between 10% (mild) and 60% (severe) with breaks at 20% (moderate) and 40% (moderately severe), depending on the severity of symptoms and any functional loss.

Summary of Main Points

• Restless Leg Syndrome C&P Exam: If you’ve filed a VA claim for RLS, you’ll likely be scheduled for an in-person C&P exam with a third-party company contracted by the VA to evaluate the severity of your condition and whether it’s connected to your military service or another service connected disability.

• Diagnostic Code and Rating Criteria: There is no separate Diagnostic Code for RLS under 38 CFR § 4.124a, so it’s rated by analogy under DC 8620 for Neuritis, with ratings ranging from 10% to 80% with breaks at 20%, 40%, and 60%, based on the severity of symptoms and functional loss.

• Purpose of the Exam: The C&P exam aims to confirm your diagnosis, assess whether your RLS is service-connected, and evaluate the severity, frequency, and duration of your symptoms, along with their impact on your work, life, and social functioning.

• Exam Day Tips: To prepare for your exam, gather relevant medical records, keep a detailed symptoms diary, list the functional impacts of RLS on your daily activities, and review the Disability Benefits Questionnaire (DBQ) for Peripheral Nerve Conditions to be ready to discuss the onset and progression of your condition.

The Purpose of a VA C&P Exam for Restless Leg Syndrome

An in-person C&P exam for Restless Leg Syndrome (RLS) is designed to evaluate three main areas:

• #1. Diagnosis Confirmation: Determine if you have a diagnosis of Restless Leg Syndrome that conforms to medical standards and guidelines.

• #2. “Nexus” for Service Connection: The examiner will provide their medical opinion on whether your RLS was caused or aggravated by your active-duty military service or another service-connected condition.

• #3. Symptoms Assessment: Assess the severity of your RLS symptoms in terms of frequency, severity, and duration, and their negative impacts on your work, life, and social functioning.

What to Expect at Your C&P Exam for Restless Leg Syndrome

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

1. Review of Medical History

The C&P examiner will start by reviewing your medical records, including any previous diagnoses, medical history, treatments, and evaluations related to RLS. The examiner has access to the medical records and documents you submitted to the VA, so you don’t need to bring records with you to the exam. However, bringing any additional documents you believe are important can be helpful.

2. History and Onset

The examiner will ask about your military service history and any prior diagnoses of RLS. Certain factors encountered in military environments, such as stress, physical exertion, and irregular sleep schedules, can contribute to the development or exacerbation of RLS. For example, you might explain, “My RLS symptoms began during my deployment due to the highly irregular and stressful conditions.”

3. Discussion of Symptoms

The examiner will ask you about your RLS symptoms, including when you first noticed them and how often you experience them. Common symptoms of RLS include an irresistible urge to move your legs, often accompanied by uncomfortable sensations. Remember, your final VA rating for RLS depends on the frequency, severity, and duration of symptoms and how those symptoms negatively affect your work, life, and social functioning.

4. Negative Impacts on Work, Life, and Social Functioning

You’ll be asked about how RLS affects your daily activities, such as sleeping, working, socializing, and overall quality of life. Be honest and provide specific examples of how RLS interferes with your ability to function normally. For instance, you might say, “My RLS is so severe that I have trouble sleeping, which affects my concentration and productivity at work.”

5. Physical Examination

The C&P examiner might conduct a physical exam to check for signs and symptoms of RLS. They may evaluate your leg movements and responses to certain stimuli to understand the impact of RLS on your daily functioning.

6. Completion of Disability Benefits Questionnaire (DBQ) for RLS

The examiner will document their findings on the DBQ for Restless Leg Syndrome (Peripheral Nerve Conditions), which then gets submitted to the VA Rater for further processing. Eventually, the VA Rater will either approve, deny, or defer your claim for RLS.

What Questions Will I Get Asked During a C&P Exam for Restless Leg Syndrome?

Based on the VA Disability Benefits Questionnaire (DBQ) for peripheral nerve conditions, here’s a list of questions you might expect during your C&P exam for Restless Leg Syndrome:

Evidence Review:

• Were any records reviewed before the exam? If so, what records (e.g., service treatment records, VA treatment records, private treatment records) and the date range?

Diagnosis:

• Do you have a diagnosis of Restless Leg Syndrome (RLS)?
• What is the ICD code and date of diagnosis?

Medical History:

• Describe the history (including onset and course) of your RLS.
• What is your dominant hand?

Symptoms:

• Do you have any symptoms attributable to RLS? If so, indicate the location and severity:
  • Constant pain (right/left upper/lower extremity)
  • Intermittent pain (right/left upper/lower extremity)
  • Paresthesias and/or dysesthesias (right/left upper/lower extremity)
  • Numbness (right/left upper/lower extremity)
  • Other symptoms (describe symptoms, location, and severity)

Muscle Strength Testing:

• Rate your muscle strength on a scale of 0 to 5 for various movements (e.g., elbow flexion, elbow extension, wrist flexion, wrist extension, grip, pinch, knee extension, ankle plantar flexion, ankle dorsiflexion).

Muscle Atrophy:

• Do you have muscle atrophy? If so, indicate the location and provide measurements in centimeters for the normal and atrophied sides.

Reflex Exam:

• Rate your deep tendon reflexes (DTRs) on a scale of 0 to 4+ for various locations (e.g., biceps, triceps, brachioradialis, knee, ankle).

Sensory Exam:

• Indicate the results for sensation testing for light touch at various locations (e.g., shoulder area, inner/outer forearm, hand/fingers, upper anterior thigh, thigh/knee, lower leg/ankle, foot/toes).

Trophic Changes:

• Do you have trophic changes (e.g., loss of extremity hair, smooth, shiny skin) attributable to RLS? If so, describe.

Gait:

• Is your gait normal? If not, describe the abnormal gait and provide the etiology.

Special Tests for Median Nerve:

• Were special tests indicated and performed for median nerve evaluation? If so, what were the results (Phalen’s sign, Tinel’s sign)?

Nerves Affected:

• Indicate the severity of RLS affecting various nerves (e.g., radial, median, ulnar, musculocutaneous, circumflex, long thoracic, upper/middle/lower radicular group, sciatic, common peroneal, superficial peroneal, deep peroneal, tibial, posterior tibial, femoral, saphenous, obturator, external cutaneous nerve of the thigh, ilio-inguinal nerve).

Assistive Devices:

• Do you use any assistive devices for locomotion (e.g., wheelchair, brace, crutch, cane, walker)? If so, identify the assistive device(s) used and the frequency of use.
• If you use any assistive devices, specify the condition and identify the assistive device used for each condition.

Functional Impairment:

• Is there functional impairment of an extremity due to RLS such that no effective function remains other than that which would be equally well served by an amputation with a prosthesis? If yes, indicate the extremity and describe the loss of effective function.

Other Pertinent Physical Findings:

• Do you have any other pertinent physical findings, complications, conditions, signs, or symptoms related to RLS? If so, describe.
• Do you have any scars related to RLS or its treatment? If yes, are any of these scars painful, unstable, have a total area equal to or greater than 39 square cm, or located on the head, face, or neck?

Diagnostic Testing:

• Have EMG studies been performed? If so, what were the results?
• Are there any other significant diagnostic test findings or results?

Functional Impact:

• Does your RLS impact your ability to work? If yes, describe the impact, providing one or more examples.

How to Prepare for Your Restless Leg Syndrome C&P Exam

Here’s some tips to help you prepare for a VA C&P exam for Restless Leg Syndrome:

1. Gather Records and Documents

Collect all relevant medical records, including diagnostic tests and reports, treatment history, medication lists, and any correspondence related to your RLS. This documentation will provide essential evidence to support your claim during the examination. Review the documents in detail and bring hard copies with you to the C&P exam for reference.

2. Create a Symptoms Diary

Keep a detailed log of your symptoms, noting the frequency, severity, and duration of episodes and flare-ups. Document any factors that exacerbate or alleviate your symptoms. This diary will help you explain the impact of RLS on your work, life, and social functioning during the C&P exam.

3. List Functional Impacts

Make a list of specific ways that RLS affects your ability to perform daily tasks and activities. For example:

• Difficulty sleeping due to leg discomfort and restlessness
• Challenges in staying seated for long periods, affecting work and social activities
• Increased fatigue and decreased concentration due to sleep disturbances
• Impaired ability to enjoy leisure activities or hobbies
• Emotional distress, including anxiety and depression, related to chronic symptoms

4. Review the DBQ for Peripheral Nerve Conditions

Review the Disability Benefits Questionnaire (DBQ) for Peripheral Nerve Conditions before your exam. Be prepared to describe the onset and progression of your condition and symptoms over time, as well as any treatments you have pursued and their effectiveness (if any).

Examples of Common Work, Life, and Functional Impacts of Restless Leg Syndrome

Here’s some examples of how RLS can affect your work, life, and functional movement:

Work Impacts

• Decreased Productivity: Restless Leg Syndrome can cause discomfort and an irresistible urge to move the legs, distracting individuals from their tasks and leading to decreased productivity and performance at work.

• Increased Absenteeism: The symptoms of RLS, particularly the disruption of sleep, may necessitate frequent medical appointments and days off, especially when symptoms are severe, thereby increasing absenteeism.

• Limited Job Opportunities: Individuals with severe RLS may find their ability to perform certain types of jobs, particularly those requiring prolonged sitting or standing, severely limited.

Life Impacts

• Social Withdrawal: The constant discomfort and urge to move associated with RLS can lead individuals to withdraw from social activities and hobbies, impacting their social life and personal interests.

• Emotional Health: The chronic nature of RLS and its effects on daily functioning can lead to emotional distress, including conditions such as depression and anxiety.

• Sleep Disturbances: Pain and sensations of restlessness during the night can significantly disrupt sleep patterns, leading to poor sleep quality and chronic fatigue, which affects overall health and wellbeing.

Functional Impacts

• Reduced Mobility: RLS can impair the ability to remain still, leading to difficulties in activities that require prolonged sitting or standing, such as watching a movie or attending a meeting.

• Impaired Sensation: The abnormal sensations in the legs can reduce the ability to sense touch or temperature accurately, making it challenging to gauge comfort levels and detect injuries.

• Weakness and Fatigue: The physical and mental strain from constant movement and lack of restful sleep can result in muscle weakness and general fatigue, leading to difficulties with activities that require strength and endurance, such as climbing stairs or engaging in physical exercise.

VA DBQ for Restless Leg Syndrome [Download]

The VA DBQ for Peripheral Nerve Conditions (Restless Leg Syndrome is a condition that’s part of this group of nerves) will be completed electronically by the C&P examiner at your exam.

We’ve made a copy available for review and download below:

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