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What to Expect in a Low Back Pain C&P Exam

Low Back Pain C&P Exam

Veterans who have served in the military and are experiencing low back pain often seek compensation and pension examinations (C&P exams) from the Department of Veterans Affairs (VA). These exams are essential for determining the eligibility and extent of disability benefits for veterans. Leah Bucholz explores what to expect during a lumbar spine or low back pain C&P exam, helping veterans prepare for this crucial evaluation.

Understanding the C&P Exam

A C&P exam, or Compensation and Pension examination, is a comprehensive medical evaluation conducted by a qualified healthcare provider. The goal is to assess a veteran’s medical condition and provide adjudicators information to help determine their eligibility for VA disability benefits. The examination includes a thorough assessment of the veteran’s medical history, physical condition, and any functional limitations related to their low back pain or lumbar spine issues.

The Process

The C&P exam process begins after a veteran has filed a claim for their low back condition or after the VA has determined that there is a need for a reevaluation. Once the need for an exam has been determined, the veteran will receive a packet in the mail, containing information about the scheduled examination. This packet typically includes details such as the date, time, location, and the name of the examining physician.

One essential document to be aware of during this process is the Disability Benefit Questionnaire (DBQ). This questionnaire provides the examining physician with a structured format for documenting the veteran’s medical history, physical examination, and any associated conditions.

The DBQ and VA’s Website

The Disability Benefit Questionnaire, or DBQ, is a critical document used by the examining physician to gather specific information during the C&P exam. Veterans can access these forms on the VA’s official website, making it essential for veterans to understand and be familiar with its components.

To find the appropriate DBQ for their condition, veterans can visit the VA’s website and search for the specific form related to their low back pain or lumbar spine condition. The DBQ is divided into various categories, covering different medical conditions, including gastrointestinal, genitourinary, gynecologic, infectious disease, and the one of interest here, muscular-skeletal.

Filling Out the DBQ

The DBQ is a comprehensive document with sections for the examining physician to complete. Here is an overview of the sections and the information they cover:

  1. Administrative Data: This section collects basic information such as the veteran’s name, social security number, date of the exam, and whether the DBQ is being completed at the request of the veteran. It also confirms whether the veteran was examined in person and the type of records reviewed.
  2. Claim Condition: This section identifies the specific condition related to the C&P exam. It may include conditions such as low back pain, degenerative disc disease, arthritis, or facet arthropathy. The DBQ also asks for the date of diagnosis for the condition.
  3. Medical History: Here, the veteran is asked to describe the history of the condition, such as when and how it started and any relevant events. This section may also address whether the veteran experiences flare-ups of the condition and details about the frequency, duration, characteristics, and precipitating and alleviating factors.
  4. Functional Loss: The DBQ inquires about functional loss or impairment related to the joint or extremity being evaluated. Veterans need to indicate whether they have functional loss and explain its impact.
  5. Range of Motion: This part of the DBQ assesses the range of motion of the affected area. It examines flexion, extension, lateral flexion, and rotation. The examining physician will document whether the range of motion is normal, abnormal, not indicated, or unable to test and provide measurements if applicable.
  6. Pain and Limitation: If there is pain during range of motion testing or limitations due to pain, the DBQ asks the physician to document the affected angles and explain the pain’s impact on functional loss.
  7. Passive Range of Motion: In cases where passive range of motion is tested, the physician will provide similar measurements and descriptions as in the active range of motion section.
  8. Other Physical Findings: The DBQ covers other physical findings like pain with weightbearing, non-weightbearing, and muscle strength testing. It also considers crepitus, tenderness to palpation, guarding, muscle spasms, and any additional factors contributing to disability.
  9. Specific Tests: The DBQ includes sections on reflexes, sensory testing, straight leg tests, and radiculopathy. It addresses the presence and severity of these symptoms and their impact on functional loss.
  10. Other Conditions: The document explores related conditions like ankylosis, neurologic abnormalities, and invertebral disc syndrome. Physicians will provide details about their findings in these areas.
  11. Assistive Devices: Veterans are asked whether they use assistive devices like wheelchairs, braces, crutches, canes, or walkers.
  12. Scars: If applicable, physicians will document any scars related to the condition.
  13. Diagnostic Testing: The DBQ asks whether the veteran has undergone diagnostic tests like MRI, CT scans, x-rays, or EMGs.
  14. Posttraumatic Arthritis: Physicians will indicate whether posttraumatic arthritis is present and how it affects the veteran.
  15. Functional Impact: This section focuses on the impact of the condition on the veteran’s ability to work or engage in daily activities.
  16. Additional Remarks: Physicians may include any additional comments or information relevant to the examination.

Once all sections are completed, the examining physician will sign the DBQ and provide their contact information.

Preparing for Your C&P Exam

To ensure a successful C&P exam for your low back pain or lumbar spine condition, follow these key tips:

  1. Familiarize Yourself with the DBQ: Visit the VA’s website and review the DBQ related to your condition. This will help you understand the information that will be documented during the examination.
  2. Gather Relevant Medical Records: Compile your medical records, including any test results, treatment history, and relevant documentation related to your low back pain. Providing this information to the examining physician can support your case.
  3. Be Honest and Thorough: During the exam, be honest about your symptoms, pain, and limitations. Describe your condition as accurately as possible to ensure an accurate evaluation.
  4. Communicate Effectively: If you experience pain or discomfort during the examination, be sure to express it to the physician. Clear communication is essential in documenting the severity of your condition.
  5. Know Your Rights: Familiarize yourself with the VA’s guidelines and procedures for disability evaluations. Understanding your rights and the examination process can help you navigate the system more effectively.

Conclusion

The C&P exam is a critical step in the process of obtaining disability benefits for low back pain or lumbar spine conditions as a veteran. By understanding the components of the Disability Benefit Questionnaire and preparing for the examination, you can increase your chances of receiving a fair and accurate evaluation. Remember to be honest, thorough, and communicative during the exam. Consult with veterans’ advocates or legal experts if you have any questions or concerns about the process. Your health and well-being are of utmost importance, and the C&P exam is a crucial part of ensuring you receive the support you deserve.

Also read: Who Can Assist With Filing A Claim For VA Benefits?

At Prestige Veteran Medical Consulting, a veteran-owned company, we specialize in Independent Medical Opinions (IMOs) known as Nexus letters.

Our purpose is to empower YOU, the veteran, to take charge of your medical evidence and provide you with valuable educational tools and research to guide you on your journey.

Understanding the unique challenges veterans face, our commitment lies in delivering exceptional service and support.

Leveraging an extensive network of licensed independent medical professionals, all well-versed in the medical professional aspects of the VA claims process, we review the necessary medical evidence to incorporate in our reports related to your VA Disability Claim.

Prestige Veteran Medical Consulting is not a law firm, accredited claims agent, or affiliated with the Veterans Administration or Veterans Services Organizations. However, we are happy to discuss your case with your accredited VA legal professional.

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Leticia has been in the medical field for nearly 14 years. She has always had a passion for medicine and caring for her community. Leticia has spent the last 4 years caring for veterans and first responders with alcohol and substance abuse in a medical rehabilitation setting whilst continuing her education working towards a degree in software development.

Someday she hopes to develop medical software that further enhances the patient’s experience in medical care. Leticia has a deep respect and love for those who have served as she comes from a family of law enforcement and military veterans.

Alan Bucholz

ALAN BUCHOLZ, PA-C:

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Alan enlisted in the US Army as a combat medic, where he deployed in support of Operation Iraqi Freedom.
Influenced by his time as a combat medic, he attended the Interservice Physician Assistant program while on
active duty, was commissioned as an officer, and subsequently deployed to Afghanistan.  

Alan’s military and medical background inspired him to form Prestige Veteran Medical Consulting with his
wife, Leah Bucholz, a Physician Assistant and Army Combat Veteran.  He has devoted himself to using his
knowledge gained in the military as a medical professional to serve the Veteran community.

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ALAN BUCHOLZ, PA-C:

U.S ARMY VETERAN, CHIEF FINANCIAL OFFICER

Alan enlisted in the US Army as a combat medic, where he deployed in support of Operation Iraqi Freedom.
Influenced by his time as a combat medic, he attended the Interservice Physician Assistant program while on
active duty, was commissioned as an officer, and subsequently deployed to Afghanistan.  

Alan’s military and medical background inspired him to form Prestige Veteran Medical Consulting with his
wife, Leah Bucholz, a Physician Assistant and Army Combat Veteran.  He has devoted himself to using his
knowledge gained in the military as a medical professional to serve the Veteran community.

Julie Pereira

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ADMINISTRATIVE ASSISTANT

During her Active-Duty time in the US Navy as a Hospital Corpsman, Julie provided medical administration
and patient care services in the field, the hospital, and base medical office settings.  This military medical and
administrative background has given Julie the hands-on experience and extensive knowledge necessary to
provide unparalleled service to her fellow Veterans through the Prestige Veteran Medical Consulting team.

Julie’s educational achievements include a Bachelor of Arts with a minor in Human Services and a pre-nursing associate in arts and science.

Julie has been inspired by her firsthand knowledge of navigating the VA Benefits process. She has dedicated
most of her adult life to serving Veterans through her knowledge derived from her military and civilian medical
education and training.

Jennifer Januta

JENNIFER JANUTA, PA-C:

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During her Active-Duty service in the Army, Jennifer supported various research efforts centered on combat casualty care and Soldier performance. Her military background gave her unique insights into veterans’ distinct challenges, ultimately inspiring her to join the Prestige Veteran Medical Consulting team.

Jennifer’s educational achievements include a master’s in molecular biology from George Washington University and a master’s in data science from Texas Tech University. Jennifer wholeheartedly dedicates herself to utilizing her knowledge and expertise gained from 15 years of healthcare experience to impact the well-being of those who have served positively.

Alan Bucholz

ALAN BUCHOLZ, PA-C:

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Alan enlisted in the US Army as a combat medic, where he deployed in support of Operation Iraqi Freedom.
Influenced by his time as a combat medic, he attended the Interservice Physician Assistant program while on
active duty, was commissioned as an officer, and subsequently deployed to Afghanistan.  

Alan’s military and medical background inspired him to form Prestige Veteran Medical Consulting with his
wife, Leah Bucholz, a Physician Assistant and Army Combat Veteran.  He has devoted himself to using his
knowledge gained in the military as a medical professional to serve the Veteran community.

Leah - Meet the Team

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​“It is essential to remember that there is no greater honor than caring for service members on the battlefield. Continuing to care for Veterans after separation is an opportunity that I have been afforded to extend that care in this new battlefield related to service-incurred disabilities.”

Her inspiration comes from years of military experience working alongside her fellow servicemembers, particularly key leaders who have influenced her journey, applying their wisdom to her path. She values her team deeply, most of whom are also disabled combat veterans, each member a trusted individual sharing her vision.

 “Driven by passion and purpose, I aim to create a sustainable change that empowers veterans and future generations.”

Leah’s journey hasn’t been without challenges. From overcoming and living with her service-related disabilities to navigating work-life balance, she’s learned to face each hurdle head-on with resilience.  Like many of her veteran brothers and sisters, her early background consisted of limited resources and opportunities. Her military service has helped shape her into a steadfast leader, offering relatable inspiration to others.

Join us in celebrating Leah, a compassionate leader, and resilient veteran, driving our mission to serve those who served our nation.