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      How to get your questions answered. A few observations, and requests of all members. All folks who come here are volunteers who do this on their own time and their own dime.To avoid burning out our best contributors please follow these guidelinesf you are reading a post and it reminds you of a question you want to ask, start a new topic, if you place your question in someone thread it will be difficult to distinguish your question from the original poster, you will get better results posting a new topic with your question. 1. Before Posting please do a search and see if your question has already been answered. If you find the answer print it out and put it in a file to use as a reference file, I find this helpful myself. 2. If you can not find the answer and you do post a question, please print out those answers and refer to them to avoid duplicate questions. 3. Refer to the Frequently Asked Questions4. Duplicate questions will come up from time to time but the keeping them to the minimum will lighten the load on the regular volunteers.5. Respect folks privacy do not request their personal phone numbers for claims help, it is inappropriate and not why they are here.6. Keep the topics focused on veterans issues, in closing Search first Search ... Ask second.it may save a lot of time or at the very least enlighten you.
    • Listen Live Every Wed 5:30 PM CST to SVR Radio, Veterans Issues are discussed with various guests.

      Listen Live Every Wed 5:30 PM CST to SVR Radio, Veterans Issues are discussed with various guests. Please check the little home I am carving out for our SVR partners. http://www.hadit.com/svr.html
    • A bit about Tbird and HadIt.com for those who've asked...

      The following is on my About page, but some have been asking how this all happened. So here is my little story. Tbird US Navy 1983 – 1990 E-6 HadIt.com the website domain registered Jan 20, 1997 the domain is registered and paid for through Jan 21, 2023 at which time I plan to register it for another 15 years Lord willing and the creek don't rise. I guess the best place to start is Jan 1991; I had gotten out of the navy Dec 1990. At my separation seminar, there was a DAV rep Jim Milton he told us to bring our medical records in and he would look through them for us and let us know if we should file a claim with the VA. Well, bless his heart, he opened my medical file, reads the first insert, looks me straight in the eye, and says you will be 50% for the rest of your life and he would file the claim for me. 50% was for surgery I had in the service. True to his word he met with me and talked with me for a long time filled out my paper work and urged me to file for PTSD. I would not file the PTSD claim, nor even discuss it. By Feb 1991 I had moved to the San Francisco bay area and was staying at a friends apartment and pretty much I was just a puddle. In desperation one night I called suicide hot line, I had no job, no idea about going to the VA. They talked with me for a long time and explained to me that I could go to the local VA hospital even if I did not have insurance. Now, I know what you are thinking if I was 50% why didn't I just go to the VA in the first place, two reasons 1, this was Feb 1991 and the 50% didn't come till May and 2, even if it had come through it is unlikely that I would have had the mental acuity at the time to put the two together. I relate this here because it is where so many of our brothers and sisters are coming from, perhaps where you started. Fuzzy and unsure, in pain and sometimes homeless they come to the VA hospital for help. And that is where I ended up. Up to the pysch ward I went, blah, blah, blah, a few days later I was released with a promise of a call from the out patient program, which I would soon be entering. Blah, blah, blah, after many missed communications, and no call backs I was at the Day Hospital everyday M-F. And this brothers and sisters is where I began to learn and formulate my plan for HadIt.com. Veterans, veterans everywhere…I spent a year in the day hospital and about another year at a sheltered workshop before I got back on my feet. So I just talked to veterans everyday waiting for appointments, waiting for prescriptions, waiting for a vet rep and I started to learn the system. While in the navy I was data analyst and had to learn a 5 volume manual and just about anything you were suppose to do was in that manual. So I figured there must be a manual on how to do a VA claim or at the very least regulations. So I found out about the Code of Federal Regulations, United States Code, Veterans Affairs Manuals and so on and so forth. Of course this was 1991/1992 I was living in a tiny studio apartment in a particularly bad neighborhood, working in a sheltered workshop making a nickel per envelope I stuffed throw in PTSD and you will see that it was a difficult task for me to get somewhere where they had copies of these, let alone that they would let me look at. And there was so much knowledge around me, it was like the gold rush in those days, I could just sit on a bench a veteran would sit down next to me a little conversation later I had another nugget, I made copious notes. Phone numbers to call, ask for this guy or that guy he'll give you the straight scoop and they'd slip me a piece of paper with a number on it. You want to read this regulation or that one and another slip of paper into my hand. I spent a lot of time on those benches watching the squirrels they gathered their nuts and I gathered mine :) So I'm thinking I could put a little handbook together print it out and hand it out at the VA. Or perhaps fliers. Still formulating, time goes by, 1994/1995 I am being treated for PTSD regularly and doing and feeling much better and I go to work for a company as a marketing systems analyst and I discover the internet. Well let me tell you that was perhaps one of the most significant life changing events I have ever experienced. And I might add finally a positive one :) It seemed only natural to me that surely there must be a website that contained all the knowledge I wanted, well as it turned out not so much, lots of stuff but I wanted to get straight to the claims information and there was a lot of stuff to wade through to get to it. So taking my lesson from the squirrels earlier I started to gather, gather, gather…and learn HTML and work as a marketing systems analyst and work my claim. 1996/1997 major PTSD cork blows and unemployed. Working my claim, working the website. 20 Jan 1997 register HadIt.com domain name right after getting off the phone with the VA and saying I've had it with this. As fate would have it the old DAV board goes down just as mine opens up and folks start to wander in. So HadIt.com has two main components the website which supports the discussion board with links, articles, research resources etc. The website starts to grow, I can't tell you how many times I had to switch servers for space and features. I continue on a downward trend and in 1998 ended up back home in St Louis living in my sisters basement in therapy and working it, I swear I would have swung a dead chicken around my head at midnight naked if I thought it would have helped. The website continued to do great during this time, I just stayed in the basement bought new software, new books, and learned how to make things work and I continued to use this knowledge to make HadIt.com better. My 100% finally came through from the VA and I had a friend who is an advocate who helped me thru my SSDI claim, he was literally at my side thru the entire process and that came through for me. My therapist and sister continued to try and get me to leave the basement, but to no avail. At some point in 1998 or 1999 I put a counter on the website and was shocked to discover how many visitors we were getting. Time goes by my sister gets married and I move from the basement to the upstairs, there is much celebration that Aunt T is living in the light again. More time goes by and I settle into my life in St Louis and spend more time on the site trying new things, finding more information. 2003 I buy my own home VA loan. For years now I have just considered HadIt.com my job and I get up every morning go to the office and work for several hours, take an afternoon break and see where the rest of day takes me. I have a place in the office to use the computer and a comfortable to place to read journals and articles and take notes. Blah, blah, blah so that is my story and HadIt.com's intertwined.
    • HadIt.com Pass It On Cards

      Hi I've updated our HadIt.com Pass It On Cards. They are in a PDF format you can print them out cut them there are 12 to a page. If you have found HadIt.com helpful and would like to pass it on to other veterans this is an easy way to do it.I hope you find them helpful, feel free to leave a few anywhere veterans gather, veterans centers, veterans hospitals, public libraries, be creative. Please make sure though, that if you want to leave some at any business you ask permission first.Here you go http://www.hadit.com...it_on_cards.pdf
    • VA Training and Fast Letter Forum Index

      VA Training and Fast Letter Forum Index The following is the index with links to the various Training and Fast Letters plus a few miscellaneous. These letters are not necessarily in the original formatting. I have tried to present them in an easy-to-read form instead of some forms as originally presented. Some of the paragraphs were WAAAAYYY too long. lol - HadIt.com Member fanaticbooks Something to be aware.... Some of these letters may be rescinded, outdated, or otherwise no longer viable. I have still included them because sometimes they provide additional insight or just plain more information than the newest version. Use them wisely. The oldest letters will display at the bottom with the latest letters displayed at the top, all in sequential numbers. Coding of the letters... FL = Fast Letter TL = Training Letter First two numbers = last two digits of year of origin Training Letter http://www.hadit.com/forums/index.php?/topic/40694-va-tl-00-07/ http://www.hadit.com/forums/index.php?/topic/40693-va-tl-00-06/ Fast Letter Number Title http://www.hadit.com/forums/index.php?/topic/44262-va-fl-11-15/ http://www.hadit.com/forums/index.php?/topic/44260-va-fl-11-13/ http://www.hadit.com/forums/index.php?/topic/44261-va-fl-11-11/ http://www.hadit.com/forums/index.php?/topic/44310-va-fl-11-09/ http://www.hadit.com/forums/index.php?/topic/42151-va-fl-11-03/ http://www.hadit.com/forums/index.php?/topic/40957-va-fl-10-49/ http://www.hadit.com/forums/index.php?/topic/40958-va-fl-10-46/ http://www.hadit.com/forums/index.php?/topic/40959-va-fl-10-45/ http://www.hadit.com/forums/index.php?/topic/40960-va-fl-10-42/ http://www.hadit.com/forums/index.php?/topic/40961-va-fl-10-39/ http://www.hadit.com/forums/index.php?/topic/40962-va-fl-10-35/ 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Goniometer Usage

Question

Posted

Correct me if I'm wrong, but aren't ALL doctors supposed to use a Goniometer to render correct orthopedic ROM?

Are Goniometers used for specific parts on the body? If so, which?

Is there a reg that supports the use of this device, or is it Voluntary?

Last, but not least, can ROM be challenged if a doctor fails to use one?

How many of you had an Ortho exam, and a Goniometer was not used?

Same as above, but one WAS used?

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7 answers to this question

Posted

§4.46 Accurate measurement.

Accurate measurement of the length of stumps, excursion of joints, dimensions and location of scars with respect to landmarks, should be insisted on. The use of a goniometer in the measurement of limitation of motion is indispensable in examinations conducted within the Department of Veterans Affairs. Muscle atrophy must also be accurately measured and reported.

I've never had a C&P where a goniometer was used. The C&P that was used to reduce my rating had ranges of motion that weren't even written in degrees of motion, which is also against the regs. I will urge caution, though, because my last several C&P's warranted huge increases in my compensation, and goniometers were not used. Some docs have been doing this long enough that they don't need one. I have enough of a mechanical inclination that I could most likely be very accurate at measuring ROM's without a goniometer, too. I always advise to check the results of the C&P before disputing it.

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Posted

The spine exam index sheet has it spacifically written into the instructions. I actually had one used on me on 2 occasions.Go figure.

Spine Examination

Spine

Name: SSN:

Date of Exam: C-number:

Place of Exam:

A. Review of Medical Records:

B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints is unrelated to claimed disability.

Report complaints of pain (including any radiation), stiffness, weakness, etc.

Onset

Location and distribution

Duration

Characteristics, quality, description

Intensity

Describe treatment - type, dose, frequency, response, side effects.

Provide the following (per veteran) if individual reports periods of flare-up:

Severity, frequency, and duration.

Precipitating and alleviating factors.

Additional limitation of motion or functional impairment during the flare-up.

Describe associated features or symptoms (e.g., weight loss, fevers, malaise, dizziness, visual disturbances, numbness, weakness, bladder complaints, bowel complaints, erectile dysfunction).

Describe walking and assistive devices.

Does the veteran walk unaided? Does the veteran use a cane, crutches, or a walker?

Does the veteran use a brace (orthosis)?

How far and how long can the veteran walk?

Is the veteran unsteady? Does the veteran have a history of falls?

Describe details of any trauma or injury, including dates, and direction and magnitude of forces.

Describe details of any surgery, including dates.

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, recreational activities, driving.

C. Physical Examination (Objective Findings): Address each of the following as appropriate to the condition being examined and fully describe current findings:

Inspection: spine, limbs, posture and gait, position of the head, curvatures of the spine, symmetry in appearance, symmetry and rhythm of spinal motion.

Range of motion

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. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

iii. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.

v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of cervical spine musculature. In the situation where there is unfavorable ankylosis of the cervical spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation

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. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

iii. Describe presence or absence of: pain (including pain on repeated use); fatigue; weakness; lack of endurance; and incoordination.

iv. Describe objective evidence of painful motion, spasm, weakness, tenderness, 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.

v. Describe any postural abnormalities, fixed deformity (ankylosis), or abnormality of musculature of back. In the situation where there is unfavorable ankylosis of the thoracolumbar spine, indicate whether there is: difficulty walking because of a limited line of vision; restricted opening of the mouth (with limited ability to chew); breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea; dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root involvement.

Neurological examination

Please perform complete neurologic evaluation as indicated based upon disability for which the exam is being performed. Please provide brief statement if any of the following (a-e) is not included in exam. For additional neurologic effects of disability not captured by a - e, (e.g. bladder problems) please refer to appropriate worksheet for the body system affected.

Sensory examination, to include sacral segments.

Motor examination (atrophy, circumferential measurements, tone, and strength).

Reflexes (deep tendon, cutaneous, and pathologic).

Rectal examination (sensation, tone, volitional control, and reflexes).

Lasegue's sign.

For vertebral fractures, report the percentage of loss of height, if any, of the vertebral body

Non-organic physical signs (e.g., Waddell tests, others).

D. For intervertebral disc syndrome

Conduct and report a separate history and physical examination for each segment of the spine (cervical, thoracic, lumbar) affected by disc disease.

Conduct a complete history and physical examination of each affected segment of the spine (cervical, thoracic, lumbar), whether or not there has been surgery, as described above under B. Present Medical History and C. Physical Examination.

Conduct a thorough neurologic history and examination, as described in C5, of all areas innervated by each affected spinal segment. Specify the peripheral nerve(s) affected. Include an evaluation of effects, if any, on bowel or bladder functioning.

Describe as precisely as possible, in number of days, the duration of each incapacitating episode during the past 12-month period. An incapacitating episode, for disability evaluation purposes, is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.

E. Diagnostic and Clinical Tests:

Imaging studies, when indicated.

Electrodiagnostic tests, when indicated.

Clinical laboratory tests, when indicated.

Isotope scans, when indicated.

Include results of all diagnostic and clinical tests conducted in the examination report.

F. Diagnosis:

G. Additional Limitation of Joint Function:

Impairment of joint function is determined by actual range of joint motion as reported in the physical examination and additional limitation of joint function caused by the following factors:

Pain, including pain on repeated use

Fatigue

Weakness

Lack of endurance

Incoordination

Do any of the above factors additionally limit joint function? If so, express the additional limitation in degrees.

Indicate if you cannot determine, without resort to mere speculation, whether any of these factors cause additional functional loss. For example, indicate if you would need to resort to mere speculation in order to express additional limitation due to repetitive use.

Signature: Date:

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B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints is unrelated to claimed disability.

Please, anyone correct me if I am wrong, but isn't it against the regulations or USC's, that the VA is not allowed to direct the C&P examiner to make such a finding as stated above?

I thought I read someplace,, where by it stated that although the Rating Officer can request a C&P exam, if they feel the evidence or lack of it, is needed to determine SC, but they can only ask for an opinion of the condition for which SC is claimed. That their request must be neutral in form so that it does not appear that they are asking the C&P examiner to make an opinion unfavorable to the Veteran.

IMHO-It appears that the statement above is directing the C&P examiner to write an opinion, stating only those findings that he believes are not related to the Veterans SC condition and saying nothing about which ones are.

It seems to me that this statement should also include the following

B. Present Medical History (Subjective Complaints):

Please comment whether etiology for any of these subjective complaints are unrelated to and which ones are related to the claimed disability

Rockhound Rider :rolleyes:

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I agree with rentalguy, it's best to find out what the decision is on your claim before you contest the C & P exam as being inadequate because a goniometer was not used. My husband has ratings for cervical and lumbar spine problems, and in his C & P's, the examiner did in fact use a goniometer. I was there for the most recent one, and I've asked my husband to make a point of telling me whether or not one was used on the exams for which I wasn't present, just in case we don't like the rating decision.

I know that many examiners just eyeball it. I would wait to see what the rating decision is before I challenged the examination.

I want to repeat something here that I read in an earlier post. Be aware that in many cases, the veteran will be observed in the general waiting area, or in the examination room as to how he/she is sitting in a chair. Back straight up against the back of the chair indicates the veteran can sit upright at a 95 degree angle. I'm not suggesting that anyone "slouch," but I am suggesting that you will be observed for this kind of thing when you're not aware of being under observation.

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Hollywood - Shane is correct. Most doc's who comment on ROM have been doing it so long that they do not need to use a meter.

Rock - that is what the statement says in a round about way. If the do is tasked to opine on those that are not SC'ed then the results would be that those not opined on are then by their own ommission of an opinion are service connected. This statement is normally used in case of a TDIU exam - they are trying to see if any non-service connected complaints are resulting in TDIU and the precentage of effect.

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Why use a goniometer when you can just say full range of motion and never measure anything much less observe the individual.

I recently ran into this when a C&P was returned for a clarification(no second appointment) on whether my cervical spine DDD was related to my SC thoracolumbar spine issues. Examiner said more likely than not related to my SC thoracolumbar spine but than stated full range of motion. In two C&P's they have never had me complete any ROM movements for my cervical spine. Physical therapy reports (multiple) show reduced motion, the First C&P exaimner stated head position Other-cervical kyphosis - head forward.

proper way - Measure it / Lazy way - Guestimate it / VA way - Lie about it!

Best regards,

Tyler

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Thank You ALL for your responses! It is truly helpful.

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