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Goniometer Usage


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#1 hollywoodnc

 
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Posted 12 December 2008 - 08:00 PM

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?

#2 rentalguy1

 
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Posted 12 December 2008 - 08:38 PM

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.

#3 jbasser

 
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Posted 12 December 2008 - 09:07 PM

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:

Edited by jbasser, 12 December 2008 - 09:08 PM.


#4 Rockhound

 
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Posted 13 December 2008 - 04:30 AM

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:


#5 vaf

 
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Posted 13 December 2008 - 09:15 AM

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.

#6 Ricky

 
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Posted 14 December 2008 - 02:56 AM

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.

#7 71M10

 
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Posted 15 December 2008 - 01:17 PM

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

#8 hollywoodnc

 
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Posted 16 December 2008 - 06:20 AM

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