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July 8, 2025 62 mins

The cervical spine DBQ process has undergone significant improvements, providing clearer guidelines for examiners and potentially better outcomes for veterans with neck conditions.

• Cervical spine anatomy includes vertebrae, discs, and nerve roots that can be compressed through injury or degeneration
• Recent improvements to the DBQ require examiners to document when pain begins during range of motion testing, not just maximum movement
• Veterans should be rated based on where pain starts—verbalize when you feel pain during the exam by saying "ouch"
• Physical therapy records during flare-ups provide valuable evidence for claims and appeals
• Bring your own imaging (X-rays, MRIs, CT scans) and nerve conduction studies to C&P exams
• Submit a separate statement in support of claim for each condition being evaluated
• Radiculopathy (nerve involvement) symptoms should be documented including location, severity, and quality of pain, numbness, or tingling
• Examiners are now instructed to use clinical judgment and consider veterans' subjective reports

For assistance with independent medical opinions or disability evaluations, contact Valor 4 Vet or text our team at 888-448-1011. 


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Visit J Basser's Exposed Vet Productions (Formerly Exposed Vet Radioshow) YouTube page by clicking here.

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Transcript

Episode Transcript

Available transcripts are automatically generated. Complete accuracy is not guaranteed.
J Basser (00:00):
This is an episode of J-Blast Exposed Vet Productions
On this special day.
This is Tuesday, august the 8th, 2025.
This is kind of a make-up, forlast week we had some technical
issues and so we decided that wecan redo this show on Tuesday.
We've got my co-host here today.

(00:20):
Her name is Bethany Spangenberg.
She's the owner of Violet Revet, which is a company that does
veterans basically disabilityevaluations, independent medical
opinion examinations, and she'sgood at what she does.
She is a PA and she's also anaccredited VA appeals agent, and
tonight we're going to discussthe cervical spine, we're going

(00:40):
to cover the DBQ and some otherstuff.
Bethany, how are you doing?

Bethanie Spangenberg (00:45):
I'm doing well Trying to stay hydrated in
this heat wave that we'regetting.
I'm currently traveling withfamily Closer to the sun makes
it even worse.
Hopefully we have time for that, even though it's a family trip

(01:08):
.
We've got stuff to do.
We're covering the cervicalspine and we've covered these
DBQs for a while and I don'tknow why I didn't think of it
sooner.
But we need to talk about theregular forms for disability
applications, what those looklike and when you should submit
them.

(01:28):
More specifically, how we breakdown these DBQs.
We should be breaking downthose forms, and I bring that up
because I'm actually helping aPurple Heart recipient who
passed away.
I've talked about this casebefore.
I am helping his widow receivean attendance benefit, so it

(01:50):
starts to get a little bit hairywhenever you've got a widow who
also needs help, and so weshould start really breaking
down those benefits and whatthose forms look like.
So I'm also excited because I'ma visual person and I put a
presentation together for theshow to help any visual learners
out there.
If you're listening to it onthe podcast, I'm going to try to

(02:14):
describe the pictures andwhat's on my screen the best
that I can, so then that way youcan get some idea, but I'm
looking forward to thepresentation portion of it.

J Basser (02:24):
So Good.
That's really good and that wayyou can get some idea, but I'm
looking forward to thepresentation portion of it.
Good, that's pretty good.
Anything before we get started.
No, we need some colder weatherto hit Right.

Bethanie Spangenberg (02:45):
Let me go.
Let's see if I can share myscreen.

J Basser (03:05):
Let's see.
Let's see.
Thanks for the leave button.
There you go, yes.

Bethanie Spangenberg (03:21):
Let me see if it can give me the
presentation, can you?

J Basser (03:27):
see that, mm-hmm, you can see the whole presentation.

Bethanie Spangenberg (03:32):
It's not, I mean okay.

J Basser (03:35):
I see this and you get the left side presentation.
Can you see me still?
Yes, I see you still at thebottom, okay, on your laptop,
because the only thing I yeah,so the only thing that I can see
, yeah.
If you press the control plusbutton, control plus it might
make that bigger.

Bethanie Spangenberg (04:00):
You know what I think, on your end, on
the controls end, you canactually change the viewer, and
so then that way, thepresentation, you can see it
more predominantly.

J Basser (04:12):
Yeah.

Bethanie Spangenberg (04:23):
Let me see , okay, well, huh.

J Basser (04:46):
So are you still?
Seeing, I see you, I see you.
Right, you don't see?
The it's up.
Yeah, it's up.
It's a pretty good size.
I mean it's a lot bigger thanthe last time we looked.

Bethanie Spangenberg (04:58):
I'm trying to pull up our live feed so we
can.
Anyways, so can you, Gosh.
I don't understand why I can'tsee that you can see the whole
presentation.

J Basser (05:16):
I can see just the first page.
Then on the left side of thepresentation it's like your
computer.
I just see an image of yourlaptop.

Bethanie Spangenberg (05:24):
Okay, okay , see, I can't see that.
That's funny, all right, so letme, I see what you're saying.
I can't see Because, see if Ihit from the beginning.

(05:45):
All you see now is my.
There you go.
Let's just do it this way yougotta scroll down oh.

J Basser (05:58):
Let me see if I can open it up a little bit.

Bethanie Spangenberg (06:05):
There.
We're getting somewhere.

J Basser (06:07):
Yeah.

Bethanie Spangenberg (06:17):
There.
I think that's good Okay.
It's not the way I normallypresent it, but this is the best
I can do with this program, andthen I can actually see what's
going on other than just theslideshow, so that's good.
All right so yes, this is aPowerPoint.

(06:39):
Next, cervical spine conditionsfor the disability benefits
questionnaire.
These disability ratings comefrom the 38 CFR section 4.71A
and we'll talk about that aswell.
Let's see Next slide.
Okay, so we are going to lookfirst at the anatomy of the

(07:02):
cervical spine.
I want to lay someunderstanding out there about
how the cervical spine works andthat way you have an idea of
each of these topics as we gothrough there and what the
examiner is looking for.
So if we look at the spine here, let's see my need to zoom out

(07:23):
a little bit.
Okay, this is, the cervicalvertebrae goes down into the
thoracic vertebrae and then tothe lumbar and the sacrum.
The sacrum is cut off, but ifwe zoom in to one little segment
of the spine, we can see thewhite material which is
represented for bone.
The blue is discs.

(07:44):
That's your.
They're like jelly-like filledsacks that help to give
flexibility, mobility andprotection in that area.
Then the red, the one in thecenter, is the spinal cord and
the ones branching off are thecervical nerve roots.

(08:04):
Okay, so if we say if we'retalking about C1 or C2, we're
referencing cervical spinenumber one, cervical spine
number two and so on and soforth and then, when it gets
down to the thoracic, ittransitions to T1, t2, and so on
.
Okay, to T1, t2, and so on.
Okay, if we look at the spinalcolumn on the left, this is a

(08:29):
healthy spinal column.
In this you can appreciate asmooth bone border and this is
the disc here.
Okay, this space as well isgood.
There's no loss of the space ordisc height.
There's no herniation.
The spinal cord again goes downthe middle of these bones and

(08:53):
these nerve roots branch off.
If we look at the picture onthe right which I think it's on
your right, if it's on my rightright, it's on the right, which
I think it's on your right, ifit's on my right right the
vertebrae, the border of thevertebrae is not smooth like the
other one.
It is wavy and it's starting todeteriorate.

(09:16):
Okay, the beginning ofarthritis, osteoarthritis Osteo
for bone arthritis is for joints, so we're starting to see wear
and tear on the spine.
The disc space is starting toget smaller and, if you can
imagine, it actually starts toput pressure on the space in
these nerve roots, and so we'lltake a look at that in a

(09:36):
different angle as well.
Let me take this out.
Let me take this out.
This view is, if we're lookingat the top of your head, down
that bony vertebrae Okay, so youcan see the bony spinous
process here.
This is actually when you pushon the back of your neck.

(09:57):
That is bone that you'refeeling is that spinous process.
The spinous process isprotective.
Okay, people can actuallyfracture these with falls or
motor vehicle accident.
Same for the transverseprocesses.

(10:36):
These are to the side Again,these are protective.
That's just how the bone hasdeveloped to protect the
structures along the spine.
Because right here is veryimportant this is your spinal
cord.
The spinal cord goes rightthrough the middle.
Now, that hole in the bone iscalled the vertebral foramen.

(10:58):
So sometimes, whenever you getyour MRIs or your CT scan
reports back, you'll talk aboutnarrowing of the vertebral
foramen or you'll seehypertrophy of what they call
the ligamentum flavum.
Okay, the ligamentum flavum isa ligament that starts at the

(11:19):
top of your head and goes rightdown the middle of your spinal
cord and attaches it.
It's the fibrous tissue thatkeeps that all together and if
you get thickening of thatligament, it narrows the area
for the spinal cord even furtherand can cause troubles, create

(11:41):
problems Now when you stackthese vertebrae on top of each
other, they create a little holefor these nerve roots to come
out.
Okay, so that's why, if we lookback at this, we stack them on
top there creates a little bitof space there for this nerve
root to come out.
So if we look at diseases inthe cervical spine and this is

(12:07):
important to understand so thenthat way when you see medical
terminology, you can get anunderstanding of what's
happening.
In this picture, obviously theblue is going to represent the
bone.
You can appreciate now, whenthey're stacked on top, that it
creates holes for the nerves tocome through.
Just looking at the discs andthe different types of disc

(12:31):
disease okay, this top one isnormal.
It's nice and smooth.
It is full of fluid, it is whatI like to say, juicy, and I
actually think of these likedried apricot, because they're
kind of fibrous, like that, andsometimes you get apricots.
I don't know if you ever haveeaten dried apricots.
Have you eaten dried apricots.

(12:52):
So, there, you can go ahead.

J Basser (12:58):
When you have nothing else, sorry.

Bethanie Spangenberg (13:16):
I love dried apricots.
Sorry, I love dry, I'm justkidding, but anyways they're
really juicy.
They can be juicy if they'renot dried all the way.
And so I feel like, oh, this is, this is a healthy disc, like
just because that's the way mybrain works, okay, um, and it's
constantly, constantly medical,so it's just.
Anyways, next time you eat anapricot, think about your disc.
So as this juicy apricot startsto lose its juice, it gets the
tissue around, it is more mobileand any movement you have in a

(13:39):
joint space as far as, like whenit's supposed to be relatively
stable, any type of movementwithin that space starts to
cause arthritis in the wear andtear.
So now you have thisdegeneration of the disc that
allows more movement, and ifyou're doing lifting something,

(14:00):
pushing, pulling, you're in acar accident and you have
degenerative disc disease,you're able to get a herniated
or bulging disc more readily.
Okay, and so the bulging disc,you can see, starts to narrow
this pathway for those nerveroots to come out.

(14:20):
So as we age, degeneration andit can cause the bulging disc
and then irritate the nerve root.
The nerve root, when it'sirritated, can cause numbness,
tingling in the hands, weaknessin the hands, numbness, and
we'll talk about that as welllater on in the presentation.
Here we have thinning of thedisc.

(14:41):
Okay, that also comes withdegeneration over time.
This is essentially progressivethat we're seeing.
Now.
When it loses the juice, youhave more mobility in that sac
because it's a sac filled withjuice.
So you lose the juice and itbecomes more movable.
Well then, let's say youdecided to sleep on the couch

(15:04):
and you wake up and you sleptwrong and you put pressure on
your neck wrong.
You can actually herniate thatdisc.
You can see that the outercovering is torn and that jelly
fluid is coming out.
Now the jelly fluid isn'tabsorbable.
It's still a fibrous, gel-likematerial, but that will also
irritate the nerve roots Moreoften.

(15:26):
It's posterior towards the backhere, so then it narrows the
nerve root coming off the spinalcord.
The last one here is the againmore progressive disease that we
see with arthritis, uh,degeneration.

(15:46):
We now have the loss of thedisc height and the bone
structure is starting to get umosteophytes is what they're
called.
So they get little like um andthese are weak.
They're like little spursalmost, and weak so they're not
strong and they're not goodstructure.
It's basically the body's justtrying to protect that space.

(16:08):
So, all right, so enough aboutthis disease.
When we look at the nerve root,oops, when we look at the nerve
roots, the nerve roots, this isthe spinal cord here.
These are the nerve roots thatcome out of those holes on the
side.
These nerves come down into theshoulder, to the biceps elbow,

(16:33):
down into your fingertips overhere.
This is called radiculopathy,okay.
And when that nerve is irritatedit can be from inflammation,
from a strain where that muscleis tight and now it's causing

(16:53):
pressure down around that areaand compresses the nerve.
You can, with arthritis,bulging disc herniation, you can
get irritation.
It can be chronic, okay.
Typically your chronic nerveinjuries are something that
develops very, very slowly.
Maybe one day you'll wake upand you're like man this, this

(17:16):
area on my, my thumb, isbothering me, it's numb and I
don't know what's going on.
And then you know, a year lateryou notice that patch is bigger
and it may be something that'svery slow, and then you may
start to notice that you'regetting weak or you're dropping
something.
Sometimes it can happen moreprogressive or much quicker, but
I wanted you to see visuallythat this is the spinal cord

(17:39):
coming off the brain.
These are the cervical nerveroots that come out and come
into the hands.
These nerves control skinsensation, they control
temperature sensation, theycontrol your muscles and it also
controls your reflexes.
So you have a reflex down inyour forearm, one at your elbow,

(18:02):
one at your biceps that we teston a regular basis in the
clinic.
Any questions so far?

J Basser (18:14):
I mean you have all the nerves.

Bethanie Spangenberg (18:21):
So in the clinic, when we do our exam,
which is also what we do in theDBQ we document where you're
experiencing your symptoms spineit's either narrowing for the
nerve root or you have a discbulge or herniation that's

(18:49):
irritating the nerve root.
But we know where we can expectto see one imaging.
Now, x-rays are not good forseeing any type of fluid
material.
When it comes to the spine, youcan see disc space, but you
don't really appreciate discherniation, disc bulging, unless

(19:10):
you know.
I mean, there's certaincircumstances.
But we like to get MRIs or CTscans depending on what's going
on, and most of the time withcontrast is ideal.
But a lot of times kidneyfunction will prevent us from
getting that additional imagingwith the oh my gosh, what am I

(19:34):
thinking of With contrast?
I was looking for the wordcontrast, so anyways.
So when we do the exam and wesay, okay, well, you're, thank
you, you're the person, you'rethe correct person for me to
forget that on.
But, like for this, if you tellme that you're having numbness

(19:58):
along the top of your back thatgoes down into your arm and
involves your thumb, into yourarm and involves your thumb and
other physical exam findingsthat suspect it, I can say, okay

(20:18):
, well, I'm thinking it's likeC6 or something that involves
these two fingers, the firstfinger and second finger.
Then I can suspect that it'ssomething coming from the neck.
Now what's interesting and it'ssomething that I think is
actually valuable for people ingeneral to know, is that if you
go into the clinic and you'relike, hey, my fingers are numb,
and it's like, okay, well, whichfingers are numb?
And so, depending on whichfingers are numb, I can see if

(20:42):
the nerve entrapment is at thewrist, at the elbow or at the
neck.
Okay, so these dermatomes helpus put a clinical picture
together of what we suspect,what disease is occurring.

J Basser (21:02):
Okay, that's a good guy, good guy.

Bethanie Spangenberg (21:13):
All right, I'm going to actually speed
through this one because, sinceit's not a presentation, it
won't have the visual effect.
This is part of the DBQ.
Now we're going to jump intothe DBQ.
Okay, the DBQ is 14 pages 14pages.

(21:41):
This DBQ, the one that iscurrently out, is much better
than previous DBQs and I'mactually very impressed with the
improvements that they've made.
And I have to actually give theVA kudos on this, because when
I was going through this,there's definitions in here that
should have been in here 15years ago, believe it or not.
You know, I'm reviewing theFederal Register from 1964.
I'm writing some history aboutit or whatnot, and the Federal

(22:03):
Register from 1964 actuallycontains more clinical
information for the examinerthan the current Federal
Register does for veterans,federal Register does for

(22:27):
today's veterans, and so thereis a gap in time where veterans
got very, very poor exams andI'm hoping that that exam
quality is improving as theseDBQs improve and I'll talk
specifically about that as we gothrough here.
So this DBQ is an hour to anhour and a half.
Once you go face-to-face it's14 pages long.

(22:47):
Like I said, the first section,as with all DBQ, that's the
section where the providerdiscusses the relationship that
they have to the veteran.
Okay.
Next section is evidence review.
Always, always, always.
Statement in support of claimOkay, you can see the VA form
number there.

(23:08):
Look it up, fill it out foryour claim.
Anytime you submit a claim, youshould have a statement for
each condition.
Anytime you submit a claim, youshould have a statement for
each condition that tells thestory for that condition and the
examiner can focus theirattention to that statement and
they don't have to weed throughand say, okay, this one's for
the neck, this one's for GERD,this one's for sleep apnea.

(23:29):
One statement per form for eachcondition Okay, statement per
form for each condition.
Okay, the other thing that youneed to provide to the VA don't
depend on them to get it youneed to provide any x-rays, mris
or CT scans.
Like I said before, there'slimitations with x-rays and

(23:50):
we'll actually take a minute tolook at some x-rays.
Mris and CT scans tell a betterstory than what an x-ray is
going to tell us.
Eyes and CT scans tell a betterstory than what an x-ray is
going to tell us.
The other thing is a nerveconduction study or an EMG.
They're not fun to get, but ifyou're concerned that you have
nerve involvement irritatingthose nerve roots, then you

(24:10):
should be getting a nerveconduction study, emg that tells
a lot about the nerve status.
That doesn't always pick up onthe small fibers which the

(24:36):
cervical nerve roots at the atthe spine are large fibers so
this is not necessarily going topick up diabetic neuropathy or
small nerve fiber disease.
This is mainly for those largenerve fibers.
Okay.
When you get a nerve conductionstudy it will also tell you, or
can also tell you, if theinjury is recent or if the

(24:58):
injury has been chronic,depending on the type of waves
that are in that EMG.
A CMP examiner doesn't have toorder a nerve conduction study
for you.
So if you have one that tells astory and in the clinic, to be
honest, if we have a patientthat we're concerned has
radiculopathy, we're going toorder an EMG.
So bring one to your CMP, okay.

(25:21):
The last thing that I want torecommend is that you provide
them with your medical recordsand you need to grab your
physical therapy records.
So a lot of times you may seeyour doctor and then go to a
different clinic or differenthospital physical therapy for
your flare-ups or for yourmaintenance, or even

(25:42):
chiropractor.
But physical therapy is a bigone, because the person that
touches a goniometer the most intheir career is going to be a
physical therapist.
Okay, in the clinic, in generalpractice, in occupational
medicine, me picking up agoniometer to treat a patient is
few and far between.

(26:03):
Okay, the people that mess thismost is your orthopedic
specialist.
They are orthopedists, I guess,in general, and physical
therapists.
So a physical therapist willknow how to use this goniometer
better than anybody.
So when you go to physicaltherapy, they will document your
range of motion, and so youwant to provide that information

(26:25):
to the VA, especially if it'sduring a flare-up.
Okay, all right.
So I'm going to back up just asecond.
We talked about the evidence.
The next question that asks isit asks about dominant hand, if
you're left or right handed, andthat's because hand dominance
can get you a little bit morepercentage according to the

(26:47):
rating schedule.
So that's important for them todocument.
Section one is the diagnosis.
Section one is the diagnosis.
Okay, there's a whole list ofdiagnoses here and I've
presented to you the anatomy.
So we're going to talk aboutthe exam and then at the end
we'll talk about specificdiseases related to this DBQ and

(27:09):
the rating schedule.
Okay, section two is themedical history Part of section
two, 2b b.
It says does the veteran reportflare cervical spine?
Now when I do these cmp exams,veterans would.
It's a flare-up.
What's a flare-up?
I'm like, ah, I wish you camehere knowing what a flare-up is,

(27:33):
because I need you to describea flare-up is because I need you
to describe a flare-upno-transcript.

(28:04):
A lot of times the CMPexaminers will mark no if you
don't describe a flare-up.
When they ask you about yourback, if you don't mention a
flare-up, they'll put no, okay.
So you need to talk about thesethings.
You need to be aware of whatcauses a flare-up.
You need to know that thisquestion is going to be there
and you should be including itin your statement, okay.

(28:27):
So if they don't ask you, youhave it in your statement and
you've already showed the VAthat you do have flare-ups.
Okay, and you need to know whatcauses a flare-up before you
even walk into the exam.
For the C&P exam you can sayprolonged driving, prolonged

(28:54):
sitting, yard work, things likethat.
Okay, all right.
Question 2C talks aboutfunctional limitations.
You need to give specificexamples.
So when I am doing my, afterI've been driving for a
prolonged period, I can nolonger turn my head to the left
and look over my shoulder, soprovide a specific example.

(29:23):
Section three is range ofmotion.
Now I was.
This is one of them that I wasimpressed with.
Okay, section three range offunctional limitations, is in.
It says in here if there is painnoted on examination, it is

(29:43):
important to understand whetheror not that pain itself
contributes to functional loss.
Ideally, a claimant would beseen immediately after
repetitive use over time orduring a flare-up.
However, this is not alwaysfeasible.
That was not previouslyclarified.
It goes on to say this takesinformation regarding joint

(30:06):
function on repetitive use isbroken up into two subsets.
And then it says it takes intoaccount not only the objective
findings on the examination butalso the subjective history
provided by the claimant, aswell as review of available
medical evidence.
So they are telling theexaminer listen to the veteran,

(30:29):
listen to their history and whatthey tell you is causing pain.
Before they didn't state that.
And a lot of times still, theexaminer does not believe the
veteran.
Okay, and then it goes on to sayoptimally, a description of any

(30:52):
additional loss of functionshould be provided.
Optimally, a description of anyadditional loss of function
should be provided, such as whatthe degrees of range of motion
would be opined to look likeafter repetitive use over time.
However, this is not feasible.
A as clear as possibledescription of that loss should
be provided.
So what they're saying is useyour clinical judgment.

(31:13):
They're saying this is what therecords show, this is what the
x-rays show, this is what theMRIs show, this is what the
veteran says.
Take all that information anduse your clinical judgment.
To give them a number.
I have been talking about thisfor years.
The clinicians don't do that.
They don't want to apply theirbrain.

(31:35):
That's why that wholespeculation thing they started
doing actually it's probably not10 years ago, but I can't
resort or can't opine do resort,I can't remember it anymore
resorts to mere speculation thatthe term they would use, that's
crap.
What that says that they're notusing their clinical
applications or clinical skills.

(31:56):
So any CMP examiner thatdoesn't work in ortho, that
doesn't use a goniometer on aregular basis, that doesn't have
any occupational healthexperience, or if you're a fresh
new provider, you're reallylimited on your understanding of
clinical application on theseissues.
So okay, any questions so far,and I keep asking that.

J Basser (32:24):
But no, not really.
I mean, fortunately, I've beenthrough all of it myself.
Yeah, more and more.

Bethanie Spangenberg (32:41):
So if we look at this section three of
the DBQ, this is the range ofmotion.
This is what they're lookingfor.
Okay, this is that Goni onwhere I keep flashing.
You're supposed to put it atthe ear, at the ear hole, and
measure.
Let's see, you're supposed toput it at the ear, at the ear
hole, and measure.
Let's see you go up up and thenstart at the nose and then

(33:08):
forward and then backward thisup.
There's different ways, but myunderstanding is that's the most
efficient way.
It's actually pretty easy.
The patient or veteran has tosit to do it.
The VA considers 45 degreesnormal, okay.
45 degree flexion forward, 45degree extension is normal.
These pictures that theyprovide, this is a similar

(33:30):
picture, but the pictures thatthey use in the current rating
schedule were in there in 1964.
So that hasn't changed yourlateral flexion.
This is bending your ear toyour shoulder and that's what I
say.
So when I do the flexionextension, I'll say drop your
chin to your chest and then lookall the way up towards the

(33:50):
ceiling.
And then for lateral flexion, Isay have your right ear touch
your shoulder, have your leftear touch your shoulder, okay,
and that in those cases forlateral flexion you actually put
the goniometer behind the headand measure it from behind.
Rotation you actually put thegoniometer right on top of the

(34:12):
head, okay, and then they rotate, rotate left, rotate right.

J Basser (34:21):
Okay.

Bethanie Spangenberg (34:25):
So after each range of motion is
collected, the examiner is todocument.
Now, before this DBQ came outand they had all those generic
crappy DBQs, I would documentwhere pain starts, because the
VA should be rating a veteran onwhere pain starts during range

(34:46):
of motion.
Okay, and in this new DBQ,listen to what it says If any
limitation of motion isspecifically attributable to
pain, weakness, fatigability,incoordination or other, please
note the degrees in whichlimitation of motion is
specifically attributable tothose factors identified.

(35:09):
So they are saying if they'resaying they have pain, put the
number down.
Put the number down where thatpain starts.
And that was not previously inthere before.
So if you're looking at yourexamination and you're trying to
see what they rated you on, itis under section three, on page

(35:30):
four, Anything where it talksabout where your limitation is
not the first range of motion oreven the fatigability.
They should be looking at yourpain.
Okay, and for you as theveteran, your pain starts when
you say ouch.
Okay, you don't go.
Oh, that kind of hurts, maybe alittle bit there, or that's

(35:54):
tender, you go ouch.
You have to verbalize your pain.
They want you to do each, eachplane a single time and then

(36:18):
multiple times for fatigueability.
The three times is supposed tobasically show that your muscle
structures, your bone structuresare not able to continue at
that current flexibility due tofatigue, which, whatever I guess
I don't understand how they doit, let's see.

(36:42):
Question 3C is repeated use overtime.
This is how they're trying tocapture the fatigue and weakness
of the cervical spine andthere's three little segments in
here that they've added that Ithought were fabulous.
Does procured evidence?
So that means statements fromthe veteran and it says that
suggest pain, fatigability,weakness, lack of endurance or

(37:06):
incoordination whichsignificantly limits functional
ability with a repeated use overtime.
So they are asking what doesthe veteran's testimony say?
And they have to answer thatwas never there before it
actually.
And it goes on to say you know,use your clinical judgment

(37:29):
based on the information thatthey've given you and your
relevant sources, what degree doyou suspect would be caused
from fatigue and weakness of thecervical spine?
And then it does the same thingfor flare-ups.
Okay, they want them to usetheir clinical application, and
it states it in there.
And I've been saying thatforever.
You're supposed to listen tothe veteran.
Use your clinical judgment,come up with something.

(37:51):
You have to understand thedisease, to make the clinical
applications is if for somereason you go to your C&P exam
and it's a fabulous day, okay,and you're not really getting

(38:16):
the good measurements that theyshould be, you can actually
submit records from yourphysical therapist when you were
treated during a flare-up.
So if you get a flare-up you gosee your doctor or the urgent
care and you're like, hey, can Iget a referral to the physical
therapist?
And during that flare-up you goin the clinic and they test

(38:38):
your ranges of motion and ifduring that flare-up, while
you're seeing the physicaltherapist, it shows by
goniometer testing that you have10 degrees of motion, you could
submit that as evidence foryour rating.
So I highly suggest thatveterans start utilizing the

(38:59):
physical therapy programs thatare available to them at the VA
and when you go to appeal it sayno, I deserve a higher rating.
Here's why.
Here's the evidence they canreference those physical therapy
records in their appeal.
Page 7, 3e it talks about let mesee where we're at.

(39:25):
Not quite there yet.
Page 7, still on Section 3,talks about muscle structure.
The examiner is supposed to bepushing on their neck, pushing
on their muscles, seeing how themuscle structure is stabilizing
the cervical spine.
Muscle strength testing Section, I think where are we at

(39:55):
Section four?
Okay, so muscle strengthtesting identifies nerve
involvement of the cervicalnerve roots Okay, and if there's
some compression of the spinalcord it will pick up on some of
this.
So they want the musclestrength of the upper body okay,
the shoulders, the elbows, thewrists.

(40:16):
And from a clinical applicationwe can say, okay, well, based
off of their weakness, we knowthat this nerve root might be
involved.
And then we go further on andwe do our reflex exam Okay, that
also looks at nerve involvement.
It looks at that radiculopathywe're trying to investigate.

(40:37):
Then we do a sensory exam, okay, and then we put all that data
in our head and we say, okay,based on my clinical experience,
this is the type ofradiculopathy that they have
dermatomes.
We take those reflexes and wecan come up with what nerve root
we think is involved.
Okay, and the examiner issupposed to put that in their

(41:24):
report.
Put that in their report.
Now the new rating schedule onlywants the examiner to look at
motor function.
They want everything to berating-wise based off of
strength testing only.
So you're completely removing,taking out half of the story

(41:46):
when an examiner is trying toinvestigate her radiculopathy.
Okay, one thing I do want tohighlight in the in section
seven, is that 7A on page 9wants the examiner to ask the

(42:08):
veteran about their symptoms ofconstant pain, intermittent pain
, numbness and tingling.
If the examiner does notsuspect that you have cervical
radiculopathy, they may go onhere and say you have none of
that.
If you are experiencing any ofthat, that should be in your
statement and supportive claim.

(42:29):
You want to detail if thatconstant pain is mild, moderate
or severe.
If that numbness is mild,moderate or severe, you should
be describing the quality andthe type and where it's
occurring.
Okay, okay.

(42:55):
So now we're going to look atspecific diseases because these
are relevant in the ratingschedule.
If we look at section eight,this is ankylosing spondylitis.
Okay, so we saw the normalcervical spine structure.
If we look on the left, whatthis picture represents is that
there starts to developinflammation of the joints.
Okay, so this can be fromarthritis.

(43:17):
This can be from aninflammatory disease.
Basically, it's an autoimmunedisease where the body starts to
attack the joints.
Okay, basically it's anautoimmune disease where the
body starts to attack the jointsand what happens is the bone
regrowth becomes significant,that disc space is lost and

(43:39):
these bones start to fusetogether.
So you can see here, the discspace is lost, the bones have
these spurs, they're starting tofuse together.
Now I have seen severalpatients with this and most of
the patients I have seen havehad ankylosing spondylitis
because of inflammatoryconditions rather than severe

(44:02):
arthritis.
But I've seen both severearthritis, but I've seen both.
This is in the rating schedulebecause they want to know where
the ankylosing spondylitis is.
Is it in the neck, the thoracicspine, the lumbar spine?
And how is it fixed?
Is it fixed in what they callfavorable, so is it in an

(44:24):
anatomically correct position?
Or do they have a little bit oftorsion in their fusion,
because people can fuse with acrooked neck?
What makes it even crazier isthese bone regrowths are not
strong.
So you could have ankylosingspondylitis, have a fall and

(44:47):
break these little bone spursoff and then get refused into a
new position.
And it's often not in yourfavor because we spend eight
hours plus sleeping or reclinedin a position.
So ankylosing spondylitis isnot fun.
It actually can be verydisabling.

(45:09):
It happens in young youth too,with inflammatory conditions.
So, moving on to section oh,other neurologic abnormalities.
Oh, this is the one that, john,you want me to talk about.
I want to jump up to this oneright here for a second here.

(45:37):
So this is the spinal cord.
If you compress the spinal cordup in the cervical spine area,
that spinal cord communicatesfrom the brain and travels all
the way down and spreads outinto the feet.
So if you have compression uphigh in this central canal you

(46:00):
can affect the nerve functionall the way to your toes.
So those with a cervical spinefracture I had one from a
they're a pole vaulter for themilitary.
He broke his neck and he becameparalyzed from the neck down
from that pole vault accidentand that strictly has to do from
those diseases or even afracture that compresses that

(46:24):
spinal cord.
I've had a few patients wherethey would get an infection
around the bone and thatpressure on the spinal cord was
too great and they neverrecovered and became
quadriplegic.
I had an older gentleman falland break his neck and he
actually got a blood pocket inthat area from the fall and it

(46:45):
compressed the spinal cord andhe's now quadriplegic.
So anything that compressesthat spinal nerve or that spinal
cord, that central down, that,that central hole there, can
affect lower.
If somebody would have a spinalcord injury, like at their
belly button.
It's going to affect lower andthey're going to still be.
Typically, they still maintaintheir upper body strength.

(47:07):
Okay, so I wanted to make surethat, because some people were
like, well, they hurt their neck, why are they having feet
issues?
And it simply has to do withthe amount of pressure at the
central canal of the spinal cord.
Okay, all right, this is a bigone.

(47:28):
Section 10.
Ivds intervertebral discsyndrome.
Okay, this is a term that is nolonger routinely used in
medicine.
It is a legal classificationfor rating purposes.
Classification for ratingpurposes.

(47:51):
The VA previously did notclearly define this for
examiners.
When I was there in 2011 to2013,.
If it asked me if the veteranhad IVDS and they weren't
already service-connected for it, I put no, because I don't know
what that is.
They didn't teach me.
We don't use that term.
So the VA has actually done agood job at now explaining it,

(48:13):
and I will actually read thedefinition here to you, and this
is the.
Then the clinician has to applythis to the veteran's case in
order to determine if they haveit.
So IVDS is the group of signsand symptoms due to disc
herniation with compression.
So here we talked about thesediscs.
Okay, here's the discherniation.

(48:34):
I think a disc bulge or evensome they'll have, like what
they call protrusions, discprotrusion, believe it or not.
The protrusion versus bulge hasto do with how many millimeters
it extends beyond the vertebral, the base there, which that's.
You didn't need to know that.
So, anyways, a group of signsand symptoms due to disc

(48:58):
herniation with compression orirritation of the adjacent nerve
root.
That commonly includes backpain and sciatica In this in the
case of lumbar disc disease,and neck and arm pain in the
case of cervical disc disease.
Imaging studies are notrequired to make the diagnosis
of IVDS.

(49:19):
Okay, now here's what'sinteresting about IVDS is the
rating schedule has to do withincapacitating episodes with
required physician bed rest.
We no longer recommend bed restfor 95% of injuries, including

(49:40):
back injuries.
So if you are rated under IVDS,good luck.

J Basser (49:48):
All right.

Bethanie Spangenberg (49:50):
I'm going to try to see where we're at.
What is it?

J Basser (49:57):
The back of the writing, that was 60% back in
the day.

Bethanie Spangenberg (50:01):
Yeah, I don't know how they would do it
now because, like I said, theydon't do it that way anymore,
not in the clinic.
Page 11 talks about assistivedevices.
You should put that in yourstatement in support of claim.
I always like to document itbecause if you're documenting,

(50:25):
you know when you're age 50 thatyou use a cane well whenever
you need a walker, a wheelchairor a caregiver.
We can now document theprogression.
So I always like to put that inthe statement.
Section 12, I'm going to move alittle bit faster.

(50:46):
We're almost done.
Section 12 talks aboutremaining effective function of
the extremities.
They did a fantastic job aboutadding details into the
clinician.
They added here because ittalks about whether or not the
veteran would be equally servedwith a prosthesis, would be

(51:07):
equally served with a prosthesis.
So they clarified that thequestion simply asks whether the
functional loss is to the samedegree as if there were an
amputation of the affected limb,and so often, if you have an
ankle fusion, this should be yes, if you have an ankle fusion,
you would be just equally servedwith an amputation and a
prosthesis Okay.
Fusion you would be justequally served with an
amputation and a prosthesis Okay.

(51:34):
A lot of clinicians didn'tquite understand that section in
the past, but they did openthat up and provide better
understanding.
Section yes, it is that soundslike a very wealthy use of a
limb.
Yes, it is.
Next section is diagnostictesting.
We covered that Functionalimpact.

(51:56):
The way they've written it nowis improved.
Let me read it to you.
Regardless of the veteran'scurrent employment status, do
the conditions listed in thediagnosis section impact his or
her ability to perform any typeof occupational task, such as
sitting, standing, walking,lifting?
I've been advocating that foryears and I'm glad they finally

(52:18):
did it.
The last page is remarks in theexaminer certification.
Marks in the examinercertification.
The last thing I want to coverhere is clinical applications.

(52:39):
So you can see in this x-rayhere this is actually a
relatively healthy spine.
Okay, the the position is good.
The disc space is pretty good.
We don't have a lot ofovergrowth around the base of
the vertebrae.
Okay, If we look at this onehere, we can see there's a big
difference.
Okay, We've lost a little bitof that spinal curvature.

(53:02):
We can see here that we've gotthat osteophyte formation.
Watch it not be calledosteophytes.
Watch it be called somethingelse in the cervical spine,
because I haven't done spine forages but I still read my own
x-rays.

J Basser (53:15):
It is.

Bethanie Spangenberg (53:16):
So I'm like oh, that's arthritis, Okay.
And then the disc space here isgone, okay, you can see that
we're.
Maybe I have a disc herniationhere, okay.
So that's what I'm saying is,you can kind of see it, but an
MRI or a CT scan is going to bemore um show details of that.

(53:39):
What's also impressive of thisis that we can see here that
this individual has a chroniccalcification due to
inflammation of the thyroidgland, so that's an incidental
finding on these.
Okay, now we are talking aboutthis x-ray, but your CMP
examiners don't look at x-rays.
They copy and paste what theradiologist is saying about it.

(54:00):
I in the clinic that I was yepand the clinic that I was in, I
always looked at my own x-raysbecause there's times where I
had the radiologist's thingsfractures Plus.
That's a clinical skill I neverwanted to lose and I don't plan
on losing it.
All right, there's one morehere.
Let me see if I lost it.

(54:24):
Let me see if I lost it.
I had an actual one ofankylosing spondylitis.
I don't see it in here anymore.
Must have taken it out.
So, looking at the ratingschedule, I have about three
minutes and I'm done here, john,so I don't know if we'll go
over, but I'll try to getthrough it.

(54:44):
Looking at the rating scheduleitself, these are your
diagnostic codes.
Your lumbosacral or cervicalstrain is common.
Your degenerative arthritis,degenerative disc disease other
than intervertebral discsyndrome, is common.
The other ones, like the spinalfusion, the ankylosing

(55:05):
sinusoidal we talked about those.
Yeah, that's my rating code.

J Basser (55:07):
This is the pardon, like the spinal fusion, the
ankylosing we talked about those.

Bethanie Spangenberg (55:09):
Yeah, that's my rating.
This is the pardon.

J Basser (55:13):
Mine's 52, 41.

Bethanie Spangenberg (55:17):
52, 41.
Yeah, yeah, yep, there you go.
Okay, this is the rating,general rating schedule formula
for it as we speak.
Okay, and this has to dospecifically related to the
spine itself.
It is not related toradiculopathy, okay, so I'm not
going to go over this.

(55:37):
I just want it there forreference.
People can pause the video,they can come back to it so they
can read it.
You can see what degrees.
I'm not going to talk abouteach degree, but there's a range
for percentages and degreesthere.
This is the rate schedule forthe IBDS and it is separate and

(56:00):
it has a separate rating andthis is the rating formula for
that.
So, as you can see, 60% withincapacitating episodes having a
total duration of at least sixweeks during the past 12 months.
And the note at the bottom saysfor purposes of evaluations
under this diagnostic code, anincapacitating episode is a

(56:21):
period of acute signs andsymptoms due to IVDS that
requires bed rest prescribed bya physician and treatment by a
physician.
So and I'm sure there's somelegalities to get around that,
especially because that is nottoday's medicine and so you
really can't apply that bed restportion of it.

J Basser (56:45):
So yeah yeah.
I agree maybe we can ask thefolks in DC to do something
there's somebody I won't ask no,I got a couple I can't know.
Here's our information I got acouple.

Bethanie Spangenberg (57:06):
I can't know.
Here's our information.
You can visit our website.
Here's our phone number.
We always talk about calling.
If you're a texter, because I'mnot a caller, you can text us
too.
We implemented basically an AIrobot to answer the phone calls,
primarily because we're tryingto capture those after-hour

(57:30):
calls and those who want theinformation over the phone.
Because you can talk to therobot, they give you the
information.
Anytime you want an actual liveperson, you can say live agent
or transfer to agent and it'lltransfer you to a live person.
If we're open, if you get usafter hours, you can text this

(57:51):
phone number.
Anytime we get text messages,it goes to the whole team and we
all can get it in that moment.
So let's say that Tyler, that'sin the front office, he's
trying to help a veteran getregistered and he's waiting on
the veteran's computer to load.
He had to restart his computer.
Well, he's waiting to help thatveteran.
Well, you could be texting youat the same time.

(58:11):
He's waiting on that veteran.
So feel free to text thatnumber as well, okay, so any
questions?
I know it's a lot, it's alwaysa lot.

J Basser (58:24):
This is an enormous section because you've got a lot
of spine issues and there's alot of the disability that's
paid.
You know, because of theseissues, you know, I mean,
basically the military is adangerous place and you know
there's recreation sportsactivities football, soccer,
baseball, you're running andthings like that People fall,

(58:46):
people get hit, you know, andyou know people fall, people get
hit.
You know, and, uh, you know,especially in the navy, you know
, you get these aircraftcarriers that are big ships,
they got a lot of ladders onthem and, uh, there's nothing
worse than going at a ladderhead first.
So, but, um, the v8, of courseI was on the old old system, the

(59:09):
old school and how they did it.
My CMP exam was like three anda half hours long.
But any type of spinal cordinjury, I like that guys, the VA
should take care of it.
And if you have a neck injurywhile you're in service, let me
explain something.
You might be okay, you mightinjure your neck, but 15 years

(59:34):
after you get out wherearthritis sits in, you're not
going to be okay.
That's when you got to worryabout to be a clinic, and that's
true.
I will say one last thing.

Bethanie Spangenberg (59:49):
I think, and that's true, I will say one
last thing, I think.

J Basser (59:53):
Go ahead.

Bethanie Spangenberg (59:57):
Yeah, I will say that you know, my
clinical experience inoccupational health has made a
world of difference inunderstanding musculoskeletal
diseases and their progression.
Because you can have somebodythat's, you know, spent a lot of
their young years in themilitary and then they go on to
do something sedentary and youcan see the difference in that

(01:00:21):
story versus somebody who'sworked in construction for 50
years or I know I say 50, but Idon't think you could last 50,
but for 30 years you can reallysee like a story and their
health conditions that progress.
And so I think that there needsto be more education, both in

(01:00:42):
private practice, for the VA,when it comes to occupational
health and not only diseases butlimitations that diseases can
cause.
A lot of primary care providersstart to scratch their head
when they're trying to like,okay, well, they hurt this, what
should their weightliftinglimitation be at work?
And so with that practice andtaking injuries and diseases,

(01:01:05):
and I can say, you know, in outof time, like no pushing more
than five, no pulling more than10 pounds, no lifting more than
X, y and Z, and that has reallyhelped me with these veterans'
claims, and when I look at therecords and the story that they
tell, I can really kind ofpinpoint when things really
started to get bad.

(01:01:26):
Pinpoint when things reallystarted to get bad, and so I
think that's been a wonderfultool that I have developed that
we use at Valor for Vets.

J Basser (01:01:36):
Good Well, bethany, I want to thank you for coming on
and doing this.
It's a little form to show andI'm sure we'll get a lot of
feedback from you and I'llforward you whatever we get.
So you know, if you guys need agood IMO, give these folks a
call.
Can't go wrong with it Withthat.
This is John Tony J Baxter.

(01:01:58):
Baxter Exposed Improductions.
Don't be half of Bethany.
I'm Val Prevett.
We'll be shutting her down.
Thank you, bethany.

Bethanie Spangenberg (01:02:07):
Thank you, bethany, thank you.
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