J Basser: 0:00

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, for last week we had some technical issues and so we decided that we can redo this show on Tuesday. We've got my co-host here today. Her name is Bethany Spangenberg. She's the owner of Violet Revet, which is a company that does veterans basically disability evaluations, independent medical opinion examinations, and she's good at what she does. She is a PA and she's also an accredited VA appeals agent, and tonight we're going to discuss the cervical spine, we're going to cover the DBQ and some other stuff. Bethany, how are you doing?

Bethanie Spangenberg: 0:45

I'm doing well Trying to stay hydrated in this heat wave that we're getting. I'm currently traveling with family Closer to the sun makes it even worse. Hopefully we have time for that, even though it's a family trip. We've got stuff to do. We're covering the cervical spine and we've covered these DBQs for a while and I don't know why I didn't think of it sooner.

Bethanie Spangenberg: 1:18

But we need to talk about the regular forms for disability applications, what those look like and when you should submit them. More specifically, how we break down these DBQs. We should be breaking down those forms, and I bring that up because I'm actually helping a Purple Heart recipient who passed away. I've talked about this case before. I am helping his widow receive an attendance benefit, so it starts to get a little bit hairy whenever you've got a widow who also needs help, and so we should start really breaking down those benefits and what those forms look like. So I'm also excited because I'm a visual person and I put a presentation together for the show to help any visual learners out there. If you're listening to it on the podcast, I'm going to try to describe the pictures and what's on my screen the best that I can, so then that way you can get some idea, but I'm looking forward to the presentation portion of it.

J Basser: 2:24

So Good. That's really good and that way you can get some idea, but I'm looking forward to the presentation portion of it. Good, that's pretty good. Anything before we get started. No, we need some colder weather to hit Right.

Bethanie Spangenberg: 2:45

Let me go. Let's see if I can share my screen.

J Basser: 3:05

Let's see. Let's see. Thanks for the leave button. There you go, yes.

Bethanie Spangenberg: 3:21

Let me see if it can give me the presentation, can you?

J Basser: 3:27

see that, mm-hmm, you can see the whole presentation.

Bethanie Spangenberg: 3:32

It's not, I mean okay.

J Basser: 3:35

I see this and you get the left side presentation. Can you see me still? Yes, I see you still at the bottom, okay, on your laptop, because the only thing I yeah, so the only thing that I can see, yeah. If you press the control plus button, control plus it might make that bigger.

Bethanie Spangenberg: 4:00

You know what I think, on your end, on the controls end, you can actually change the viewer, and so then that way, the presentation, you can see it more predominantly.

J Basser: 4:12

Yeah.

Bethanie Spangenberg: 4:23

Let me see, okay, well, huh.

J Basser: 4:46

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 than the last time we looked.

Bethanie Spangenberg: 4:58

I'm trying to pull up our live feed so we can. Anyways, so can you, Gosh. I don't understand why I can't see that you can see the whole presentation.

J Basser: 5:16

I can see just the first page. Then on the left side of the presentation it's like your computer. I just see an image of your laptop.

Bethanie Spangenberg: 5:24

Okay, okay, see, I can't see that. That's funny, all right, so let me, I see what you're saying. I can't see Because, see if I hit from the beginning. All you see now is my. There you go. Let's just do it this way you gotta scroll down oh.

J Basser: 5:58

Let me see if I can open it up a little bit.

Bethanie Spangenberg: 6:05

There. We're getting somewhere.

J Basser: 6:07

Yeah.

Bethanie Spangenberg: 6:17

There. I think that's good Okay. It's not the way I normally present it, but this is the best I can do with this program, and then I can actually see what's going on other than just the slideshow, so that's good.

Bethanie Spangenberg: 6:32

All right so yes, this is a PowerPoint. Next, cervical spine conditions for the disability benefits questionnaire. These disability ratings come from the 38 CFR section 4.71A and we'll talk about that as well. Let's see Next slide.

Bethanie Spangenberg: 6:59

Okay, so we are going to look first at the anatomy of the cervical spine. I want to lay some understanding out there about how the cervical spine works and that way you have an idea of each of these topics as we go through there and what the examiner is looking for. So if we look at the spine here, let's see my need to zoom out a little bit. Okay, this is, the cervical vertebrae goes down into the thoracic vertebrae and then to the lumbar and the sacrum. The sacrum is cut off, but if we zoom in to one little segment of the spine, we can see the white material which is represented for bone. The blue is discs. That's your. They're like jelly-like filled sacks that help to give flexibility, mobility and protection in that area. Then the red, the one in the center, is the spinal cord and the ones branching off are the cervical nerve roots. Okay, so if we say if we're talking about C1 or C2, we're referencing cervical spine number one, cervical spine number two and so on and so forth and then, when it gets down to the thoracic, it transitions to T1, t2, and so on. Okay, to T1, t2, and so on.

Bethanie Spangenberg: 8:22

Okay, if we look at the spinal column on the left, this is a healthy spinal column. In this you can appreciate a smooth bone border and this is the disc here. Okay, this space as well is good. There's no loss of the space or disc height. There's no herniation. The spinal cord again goes down the middle of these bones and these nerve roots branch off. If we look at the picture on the right which I think it's on your right, if it's on my right right, it's on the right, which I think it's on your right, if it's on my right right the vertebrae, the border of the vertebrae is not smooth like the other one. It is wavy and it's starting to deteriorate. Okay, the beginning of arthritis, 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 to get smaller and, if you can imagine, it actually starts to put pressure on the space in these nerve roots, and so we'll take a look at that in a different angle as well.

Bethanie Spangenberg: 9:40

Let me take this out. Let me take this out. This view is, if we're looking at the top of your head, down that bony vertebrae Okay, so you can see the bony spinous process here. This is actually when you push on the back of your neck. That is bone that you're feeling is that spinous process. The spinous process is protective. Okay, people can actually fracture these with falls or motor vehicle accident. Same for the transverse processes. These are to the side Again, these are protective. That's just how the bone has developed to protect the structures along the spine.

Bethanie Spangenberg: 10:45

Because right here is very important this is your spinal cord. The spinal cord goes right through the middle. Now, that hole in the bone is called the vertebral foramen. So sometimes, whenever you get your MRIs or your CT scan reports back, you'll talk about narrowing of the vertebral foramen or you'll see hypertrophy of what they call the ligamentum flavum. Okay, the ligamentum flavum is a ligament that starts at the top of your head and goes right down the middle of your spinal cord and attaches it. It's the fibrous tissue that keeps that all together and if you get thickening of that ligament, it narrows the area for the spinal cord even further and can cause troubles, create problems Now when you stack these vertebrae on top of each other, they create a little hole for these nerve roots to come out.

Bethanie Spangenberg: 11:51

Okay, so that's why, if we look back at this, we stack them on top there creates a little bit of space there for this nerve root to come out. So if we look at diseases in the cervical spine and this is important to understand so then that way when you see medical terminology, you can get an understanding of what's happening. In this picture, obviously the blue is going to represent the bone. You can appreciate now, when they're stacked on top, that it creates holes for the nerves to come through. Just looking at the discs and the different types of disc disease okay, this top one is normal. It's nice and smooth. It is full of fluid, it is what I like to say, juicy, and I actually think of these like dried apricot, because they're kind of fibrous, like that, and sometimes you get apricots. I don't know if you ever have eaten dried apricots.

Bethanie Spangenberg: 12:50

Have you eaten dried apricots. 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 just kidding, but anyways they're really juicy. They can be juicy if they're not dried all the way. And so I feel like, oh, this is, this is a healthy disc, like just because that's the way my brain works, okay, um, and it's constantly, constantly medical, so it's just.

Bethanie Spangenberg: 13:26

Anyways, next time you eat an apricot, think about your disc. So as this juicy apricot starts to lose its juice, it gets the tissue around, it is more mobile and any movement you have in a joint space as far as, like when it's supposed to be relatively stable, any type of movement within that space starts to cause arthritis in the wear and tear. So now you have this degeneration of the disc that allows more movement, and if you're doing lifting something, pushing, pulling, you're in a car 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 nerve roots to come out. So as we age, degeneration and it can cause the bulging disc and then irritate the nerve root. The nerve root, when it's irritated, can cause numbness, tingling in the hands, weakness in the hands, numbness, and we'll talk about that as well later on in the presentation. Here we have thinning of the disc. Okay, that also comes with degeneration over time. This is essentially progressive that we're seeing.

Bethanie Spangenberg: 14:49

Now. When it loses the juice, you have more mobility in that sac because it's a sac filled with juice. So you lose the juice and it becomes more movable. Well then, let's say you decided to sleep on the couch and you wake up and you slept wrong and you put pressure on your neck wrong. You can actually herniate that disc. You can see that the outer covering is torn and that jelly fluid is coming out. Now the jelly fluid isn't absorbable. It's still a fibrous, gel-like material, but that will also irritate the nerve roots More often. It's posterior towards the back here, so then it narrows the nerve root coming off the spinal cord. The last one here is the again more progressive disease that we see with arthritis, uh, degeneration. We now have the loss of the disc height and the bone structure is starting to get um osteophytes is what they're called. So they get little like um and these are weak. They're like little spurs almost, and weak so they're not strong and they're not good structure.

Bethanie Spangenberg: 16:04

It's basically the body's just trying to protect that space. So, all right, so enough about this disease. When we look at the nerve root, oops, when we look at the nerve roots, the nerve roots, this is the spinal cord here. These are the nerve roots that come out of those holes on the side. These nerves come down into the shoulder, to the biceps elbow, down into your fingertips over here. This is called radiculopathy, okay.

Bethanie Spangenberg: 16:44

And when that nerve is irritated it can be from inflammation, from a strain where that muscle is tight and now it's causing pressure down around that area and compresses the nerve. You can, with arthritis, bulging disc herniation, you can get irritation. It can be chronic, okay. Typically your chronic nerve injuries are something that develops very, very slowly. Maybe one day you'll wake up and you're like man this, this area on my, my thumb, is bothering me, it's numb and I don't know what's going on.

Bethanie Spangenberg: 17:22

And then you know, a year later you notice that patch is bigger and it may be something that's very slow, and then you may start to notice that you're getting weak or you're dropping something. Sometimes it can happen more progressive or much quicker, but I wanted you to see visually that this is the spinal cord coming off the brain. These are the cervical nerve roots that come out and come into the hands. These nerves control skin sensation, they control temperature sensation, they control your muscles and it also controls your reflexes. So you have a reflex down in your forearm, one at your elbow, one at your biceps that we test on 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 the DBQ we document where you're experiencing your symptoms spine it's either narrowing for the nerve root or you have a disc bulge or herniation that's irritating the nerve root. But we know where we can expect to see one imaging. Now, x-rays are not good for seeing any type of fluid material. When it comes to the spine, you can see disc space, but you don't really appreciate disc herniation, disc bulging, unless you know. I mean, there's certain circumstances. But we like to get MRIs or CT scans depending on what's going on, and most of the time with contrast is ideal. But a lot of times kidney function will prevent us from getting that additional imaging with the oh my gosh, what am I thinking of With contrast? I was looking for the word contrast, so anyways.

Bethanie Spangenberg: 19:40

So when we do the exam and we say, okay, well, you're, thank you, you're the person, you're the correct person for me to forget that on. But, like for this, if you tell me that you're having numbness along the top of your back that goes down into your arm and involves your thumb, into your arm and involves your thumb and other physical exam findings that suspect it, I can say, okay, well, I'm thinking it's like C6 or something that involves these two fingers, the first finger and second finger. Then I can suspect that it's something coming from the neck. Now what's interesting and it's something that I think is actually valuable for people in general to know, is that if you go into the clinic and you're like, hey, my fingers are numb, and it's like, okay, well, which fingers are numb? And so, depending on which fingers are numb, I can see if the nerve entrapment is at the wrist, at the elbow or at the neck. Okay, so these dermatomes help us 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, since it's not a presentation, it won't have the visual effect. This is part of the DBQ. Now we're going to jump into the DBQ. Okay, the DBQ is 14 pages 14 pages. This DBQ, the one that is currently out, is much better than previous DBQs and I'm actually very impressed with the improvements that they've made. And I have to actually give the VA kudos on this, because when I was going through this, there's definitions in here that should have been in here 15 years ago, believe it or not. You know, I'm reviewing the Federal Register from 1964. I'm writing some history about it or whatnot, and the Federal Register from 1964 actually contains more clinical information for the examiner than the current Federal Register does for veterans, federal Register does for today's veterans, and so there is a gap in time where veterans got very, very poor exams and I'm hoping that that exam quality is improving as these DBQs improve and I'll talk specifically about that as we go through here. So this DBQ is an hour to an hour and a half. Once you go face-to-face it's 14 pages long. Like I said, the first section, as with all DBQ, that's the section where the provider discusses the relationship that they have to the veteran. Okay. Next section is evidence review. Always, always, always.

Bethanie Spangenberg: 23:02

Statement in support of claim Okay, you can see the VA form number there. Look it up, fill it out for your claim. Anytime you submit a claim, you should have a statement for each condition. Anytime you submit a claim, you should have a statement for each condition that tells the story for that condition and the examiner can focus their attention to that statement and they don't have to weed through and say, okay, this one's for the neck, this one's for GERD, this one's for sleep apnea. One statement per form for each condition Okay, statement per form for each condition.

Bethanie Spangenberg: 23:35

Okay, the other thing that you need to provide to the VA don't depend on them to get it you need to provide any x-rays, mris or CT scans. Like I said before, there's limitations with x-rays and we'll actually take a minute to look at some x-rays. Mris and CT scans tell a better story than what an x-ray is going to tell us. Eyes and CT scans tell a better story than what an x-ray is going to tell us. The other thing is a nerve conduction study or an EMG. They're not fun to get, but if you're concerned that you have nerve involvement irritating those nerve roots, then you should be getting a nerve conduction study, emg that tells a lot about the nerve status. That doesn't always pick up on the small fibers which the cervical nerve roots at the at the spine are large fibers so this is not necessarily going to pick up diabetic neuropathy or small nerve fiber disease. This is mainly for those large nerve fibers. Okay. When you get a nerve conduction study it will also tell you, or can also tell you, if the injury is recent or if the injury has been chronic, depending on the type of waves that are in that EMG. A CMP examiner doesn't have to order a nerve conduction study for you. So if you have one that tells a story and in the clinic, to be honest, if we have a patient that we're concerned has radiculopathy, we're going to order an EMG. So bring one to your CMP, okay.

Bethanie Spangenberg: 25:21

The last thing that I want to recommend is that you provide them with your medical records and you need to grab your physical therapy records. So a lot of times you may see your doctor and then go to a different clinic or different hospital physical therapy for your flare-ups or for your maintenance, or even chiropractor. But physical therapy is a big one, because the person that touches a goniometer the most in their career is going to be a physical therapist. Okay, in the clinic, in general practice, in occupational medicine, me picking up a goniometer to treat a patient is few and far between. Okay, the people that mess this most is your orthopedic specialist. They are orthopedists, I guess, in general, and physical therapists. So a physical therapist will know how to use this goniometer better than anybody. So when you go to physical therapy, they will document your range of motion, and so you want to provide that information to the VA, especially if it's during a flare-up. Okay, all right. So I'm going to back up just a second.

Bethanie Spangenberg: 26:34

We talked about the evidence. The next question that asks is it asks about dominant hand, if you're left or right handed, and that's because hand dominance can get you a little bit more percentage according to the rating schedule. So that's important for them to document. Section one is the diagnosis. Section one is the diagnosis. Okay, there's a whole list of diagnoses here and I've presented to you the anatomy. So we're going to talk about the exam and then at the end we'll talk about specific diseases related to this DBQ and the rating schedule. Okay, section two is the medical history Part of section two, 2b b.

Bethanie Spangenberg: 27:21

It says does the veteran report flare 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 came here knowing what a flare-up is, because I need you to describe a flare-up is because I need you to describe a flare-up no-transcript. A lot of times the CMP examiners will mark no if you don't describe a flare-up. When they ask you about your back, if you don't mention a flare-up, they'll put no, okay. So you need to talk about these things. You need to be aware of what causes a flare-up. You need to know that this question is going to be there and you should be including it in your statement, okay. So if they don't ask you, you have it in your statement and you've already showed the VA that you do have flare-ups. Okay, and you need to know what causes a flare-up before you even walk into the exam. For the C&P exam you can say prolonged driving, prolonged sitting, yard work, things like that. Okay, all right.

Bethanie Spangenberg: 28:55

Question 2C talks about functional limitations. You need to give specific examples. So when I am doing my, after I've been driving for a prolonged period, I can no longer turn my head to the left and look over my shoulder, so provide a specific example. Section three is range of motion. Now I was. This is one of them that I was impressed with. Okay, section three range of functional limitations, is in.

Bethanie Spangenberg: 29:38

It says in here if there is pain noted on examination, it is important to understand whether or not that pain itself contributes to functional loss. Ideally, a claimant would be seen immediately after repetitive use over time or during a flare-up. However, this is not always feasible. That was not previously clarified. It goes on to say this takes information regarding joint function on repetitive use is broken up into two subsets. And then it says it takes into account not only the objective findings on the examination but also the subjective history provided by the claimant, as well as review of available medical evidence. So they are telling the examiner listen to the veteran, listen to their history and what they tell you is causing pain. Before they didn't state that. And a lot of times still, the examiner does not believe the veteran.

Bethanie Spangenberg: 30:43

Okay, and then it goes on to say optimally, a description of any additional loss of function should be provided. Optimally, a description of any additional loss of function should be provided, such as what the degrees of range of motion would be opined to look like after repetitive use over time. However, this is not feasible. A as clear as possible description of that loss should be provided. So what they're saying is use your clinical judgment. They're saying this is what the records show, this is what the x-rays show, this is what the MRIs show, this is what the veteran says. Take all that information and use your clinical judgment. To give them a number.

Bethanie Spangenberg: 31:28

I have been talking about this for years. The clinicians don't do that. They don't want to apply their brain. That's why that whole speculation thing they started doing actually it's probably not 10 years ago, but I can't resort or can't opine do resort, I can't remember it anymore resorts to mere speculation that the term they would use, that's crap. What that says that they're not using their clinical applications or clinical skills. So any CMP examiner that doesn't work in ortho, that doesn't use a goniometer on a regular basis, that doesn't have any occupational health experience, or if you're a fresh new provider, you're really limited on your understanding of clinical application on these issues. So okay, any questions so far, and I keep asking that.

J Basser: 32:24

But no, not really. I mean, fortunately, I've been through 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 of motion. This is what they're looking for. Okay, this is that Goni on where I keep flashing. You're supposed to put it at the ear, at the ear hole, and measure. Let's see, you're supposed to put it at the ear, at the ear hole, and measure. Let's see you go up up and then start at the nose and then forward and then backward this up.

Bethanie Spangenberg: 33:11

There's different ways, but my understanding is that's the most efficient way. It's actually pretty easy. The patient or veteran has to sit to do it. The VA considers 45 degrees normal, okay. 45 degree flexion forward, 45 degree extension is normal. These pictures that they provide, this is a similar picture, but the pictures that they use in the current rating schedule were in there in 1964. So that hasn't changed your lateral flexion. This is bending your ear to your shoulder and that's what I say. So when I do the flexion extension, I'll say drop your chin to your chest and then look all the way up towards the ceiling. And then for lateral flexion, I say have your right ear touch your shoulder, have your left ear touch your shoulder, okay, and that in those cases for lateral flexion you actually put the goniometer behind the head and measure it from behind. Rotation you actually put the goniometer right on top of the 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 to document. Now, before this DBQ came out and they had all those generic crappy DBQs, I would document where pain starts, because the VA should be rating a veteran on where pain starts during range of motion. Okay, and in this new DBQ, listen to what it says If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination or other, please note the degrees in which limitation of motion is specifically attributable to those factors identified. So they are saying if they're saying they have pain, put the number down. Put the number down where that pain starts. And that was not previously in there before. So if you're looking at your examination and you're trying to see what they rated you on, it is under section three, on page four, Anything where it talks about where your limitation is not the first range of motion or even the fatigability. They should be looking at your pain. Okay, and for you as the veteran, your pain starts when you say ouch. Okay, you don't go. Oh, that kind of hurts, maybe a little bit there, or that's tender, you go ouch. You have to verbalize your pain. They want you to do each, each plane a single time and then multiple times for fatigue ability. The three times is supposed to basically show that your muscle structures, your bone structures are not able to continue at that current flexibility due to fatigue, which, whatever I guess I don't understand how they do it, let's see.

Bethanie Spangenberg: 36:42

Question 3C is repeated use over time. This is how they're trying to capture the fatigue and weakness of the cervical spine and there's three little segments in here that they've added that I thought were fabulous. Does procured evidence? So that means statements from the veteran and it says that suggest pain, fatigability, weakness, lack of endurance or incoordination which significantly limits functional ability with a repeated use over time. So they are asking what does the veteran's testimony say? And they have to answer that was never there before it actually. And it goes on to say you know, use your clinical judgment based on the information that they've given you and your relevant sources, what degree do you suspect would be caused from fatigue and weakness of the cervical spine? And then it does the same thing for flare-ups. Okay, they want them to use their clinical application, and it states it in there. And I've been saying that forever. You're supposed to listen to the veteran. Use your clinical judgment, come up with something. You have to understand the disease, to make the clinical applications is if for some reason you go to your C&P exam and it's a fabulous day, okay, and you're not really getting the good measurements that they should be, you can actually submit records from your physical therapist when you were treated during a flare-up. So if you get a flare-up you go see your doctor or the urgent care and you're like, hey, can I get a referral to the physical therapist? And during that flare-up you go in the clinic and they test your ranges of motion and if during that flare-up, while you're seeing the physical therapist, it shows by goniometer testing that you have 10 degrees of motion, you could submit that as evidence for your rating. So I highly suggest that veterans start utilizing the physical therapy programs that are available to them at the VA and when you go to appeal it say no, I deserve a higher rating. Here's why. Here's the evidence they can reference those physical therapy records in their appeal.

Bethanie Spangenberg: 39:19

Page 7, 3e it talks about let me see where we're at. Not quite there yet. Page 7, still on Section 3, talks about muscle structure. The examiner is supposed to be pushing on their neck, pushing on their muscles, seeing how the muscle structure is stabilizing the cervical spine. Muscle strength testing Section, I think where are we at Section four? Okay, so muscle strength testing identifies nerve involvement of the cervical nerve roots Okay, and if there's some compression of the spinal cord it will pick up on some of this. So they want the muscle strength of the upper body okay, the shoulders, the elbows, the wrists. And from a clinical application we can say, okay, well, based off of their weakness, we know that this nerve root might be involved. And then we go further on and we do our reflex exam Okay, that also looks at nerve involvement. It looks at that radiculopathy we're trying to investigate. 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 of radiculopathy that they have dermatomes. We take those reflexes and we can come up with what nerve root we think is involved. Okay, and the examiner is supposed to put that in their report. Put that in their report.

Bethanie Spangenberg: 41:32

Now the new rating schedule only wants the examiner to look at motor function. They want everything to be rating-wise based off of strength testing only. So you're completely removing, taking out half of the story when an examiner is trying to investigate her radiculopathy. Okay, one thing I do want to highlight in the in section seven, is that 7A on page 9 wants the examiner to ask the veteran about their symptoms of constant pain, intermittent pain, numbness and tingling. If the examiner does not suspect that you have cervical radiculopathy, they may go on here and say you have none of that. If you are experiencing any of that, that should be in your statement and supportive claim. You want to detail if that constant pain is mild, moderate or severe. If that numbness is mild, moderate or severe, you should be describing the quality and the type and where it's occurring. Okay, okay. So now we're going to look at specific diseases because these are relevant in the rating schedule.

Bethanie Spangenberg: 42:58

If we look at section eight, this is ankylosing spondylitis. Okay, so we saw the normal cervical spine structure. If we look on the left, what this picture represents is that there starts to develop inflammation of the joints. Okay, so this can be from arthritis. This can be from an inflammatory disease. Basically, it's an autoimmune disease where the body starts to attack the joints. Okay, basically it's an autoimmune disease where the body starts to attack the joints and what happens is the bone regrowth becomes significant, that disc space is lost and these bones start to fuse together. So you can see here, the disc space is lost, the bones have these spurs, they're starting to fuse together. Now I have seen several patients with this and most of the patients I have seen have had ankylosing spondylitis because of inflammatory conditions rather than severe arthritis. But I've seen both severe arthritis, but I've seen both.

Bethanie Spangenberg: 44:11

This is in the rating schedule because they want to know where the ankylosing spondylitis is. Is it in the neck, the thoracic spine, the lumbar spine? And how is it fixed? Is it fixed in what they call favorable, so is it in an anatomically correct position? Or do they have a little bit of torsion in their fusion, because people can fuse with a crooked neck? What makes it even crazier is these bone regrowths are not strong. So you could have ankylosing spondylitis, have a fall and break these little bone spurs off and then get refused into a new position. And it's often not in your favor because we spend eight hours plus sleeping or reclined in a position. So ankylosing spondylitis is not fun. It actually can be very disabling. It happens in young youth too, with inflammatory conditions.

Bethanie Spangenberg: 45:14

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 one right here for a second here. So this is the spinal cord. If you compress the spinal cord up in the cervical spine area, that spinal cord communicates from the brain and travels all the way down and spreads out into the feet. So if you have compression up high in this central canal you can affect the nerve function all the way to your toes. So those with a cervical spine fracture I had one from a they're a pole vaulter for the military.

Bethanie Spangenberg: 46:12

He broke his neck and he became paralyzed from the neck down from that pole vault accident and that strictly has to do from those diseases or even a fracture that compresses that spinal cord. I've had a few patients where they would get an infection around the bone and that pressure on the spinal cord was too great and they never recovered and became quadriplegic. I had an older gentleman fall and break his neck and he actually got a blood pocket in that area from the fall and it compressed the spinal cord and he's now quadriplegic. So anything that compresses that spinal nerve or that spinal cord, that central down, that, that central hole there, can affect lower. If somebody would have a spinal cord injury, like at their belly button. It's going to affect lower and they're going to still be. Typically, they still maintain their upper body strength. Okay, so I wanted to make sure that, because some people were like, well, they hurt their neck, why are they having feet issues? And it simply has to do with the amount of pressure at the central canal of the spinal cord. Okay, all right, this is a big one.

Bethanie Spangenberg: 47:28

Section 10. Ivds intervertebral disc syndrome. Okay, this is a term that is no longer routinely used in medicine. It is a legal classification for rating purposes. Classification for rating purposes.

Bethanie Spangenberg: 47:51

The VA previously did not clearly define this for examiners. When I was there in 2011 to 2013,. If it asked me if the veteran had 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 a good job at now explaining it, and I will actually read the definition here to you, and this is the. Then the clinician has to apply this to the veteran's case in order to determine if they have it.

Bethanie Spangenberg: 48:24

So IVDS is the group of signs and symptoms due to disc herniation with compression. So here we talked about these discs. Okay, here's the disc herniation. I think a disc bulge or even some they'll have, like what they call protrusions, disc protrusion, believe it or not. The protrusion versus bulge has to 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 signs and symptoms due to disc herniation with compression or irritation of the adjacent nerve root. That commonly includes back pain 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 not required to make the diagnosis of IVDS. Okay, now here's what's interesting about IVDS is the rating schedule has to do with incapacitating episodes with required physician bed rest. We no longer recommend bed rest for 95% of injuries, including 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, they don't do it that way anymore, not in the clinic. Page 11 talks about assistive devices. You should put that in your statement in support of claim. I always like to document it because if you're documenting, you know when you're age 50 that you use a cane well whenever you need a walker, a wheelchair or a caregiver. We can now document the progression. So I always like to put that in the statement.

Bethanie Spangenberg: 50:43

Section 12, I'm going to move a little bit faster. We're almost done. Section 12 talks about remaining effective function of the extremities. They did a fantastic job about adding details into the clinician. They added here because it talks about whether or not the veteran would be equally served with a prosthesis, would be equally served with a prosthesis. So they clarified that the question simply asks whether the functional loss is to the same degree 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 served with an amputation and a prosthesis Okay. Fusion you would be just equally served with an amputation and a prosthesis Okay. A lot of clinicians didn't quite understand that section in the past, but they did open that up and provide better understanding.

Bethanie Spangenberg: 51:43

Section yes, it is that sounds like a very wealthy use of a limb.

Bethanie Spangenberg: 51:50

Yes, it is. Next section is diagnostic testing. We covered that Functional impact. The way they've written it now is improved. Let me read it to you. Regardless of the veteran's current employment status, do the conditions listed in the diagnosis section impact his or her ability to perform any type of occupational task, such as sitting, standing, walking, lifting? I've been advocating that for years and I'm glad they finally did it. The last page is remarks in the examiner certification. Marks in the examiner certification. The last thing I want to cover here is clinical applications.

Bethanie Spangenberg: 52:39

So you can see in this x-ray here 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 of overgrowth around the base of the vertebrae. Okay, If we look at this one here, we can see there's a big difference. Okay, We've lost a little bit of that spinal curvature. We can see here that we've got that osteophyte formation. Watch it not be called osteophytes. Watch it be called something else in the cervical spine, because I haven't done spine for ages 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 is gone, okay, you can see that we're. Maybe I have a disc herniation here, 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 be more um show details of that.

Bethanie Spangenberg: 53:39

What's also impressive of this is that we can see here that this individual has a chronic calcification due to inflammation of the thyroid gland, so that's an incidental finding on these. Okay, now we are talking about this x-ray, but your CMP examiners don't look at x-rays. They copy and paste what the radiologist is saying about it.

Bethanie Spangenberg: 54:00

I in the clinic that I was yep and the clinic that I was in, I always looked at my own x-rays because there's times where I had the radiologist's things fractures Plus. That's a clinical skill I never wanted to lose and I don't plan on losing it. All right, there's one more here. Let me see if I lost it. Let me see if I lost it. I had an actual one of ankylosing spondylitis. I don't see it in here anymore. Must have taken it out. So, looking at the rating schedule, 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 get through it. Looking at the rating schedule itself, these are your diagnostic codes. Your lumbosacral or cervical strain is common. Your degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome, is common. The other ones, like the spinal fusion, the ankylosing 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 do specifically related to the spine itself. It is not related to radiculopathy, okay, so I'm not going to go over this. I just want it there for reference. People can pause the video, they can come back to it so they can read it.

Bethanie Spangenberg: 55:43

You can see what degrees. I'm not going to talk about each degree, but there's a range for percentages and degrees there. This is the rate schedule for the IBDS and it is separate and it has a separate rating and this is the rating formula for that. So, as you can see, 60% with incapacitating episodes having a total duration of at least six weeks during the past 12 months. And the note at the bottom says for purposes of evaluations under this diagnostic code, an incapacitating episode is a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. So and I'm sure there's some legalities to get around that, especially because that is not today's medicine and so you really can't apply that bed rest portion of it.

J Basser: 56:45

So yeah yeah. I agree maybe we can ask the folks 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 a couple.

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'm not a caller, you can text us too.

Bethanie Spangenberg: 57:20

We implemented basically an AI robot to answer the phone calls, primarily because we're trying to capture those after-hour calls and those who want the information over the phone. Because you can talk to the robot, they give you the information. Anytime you want an actual live person, you can say live agent or transfer to agent and it'll transfer you to a live person. If we're open, if you get us after hours, you can text this 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's in the front office, he's trying to help a veteran get registered and he's waiting on the veteran's computer to load. He had to restart his computer. Well, he's waiting to help that veteran. Well, you could be texting you at the same time. He's waiting on that veteran. So feel free to text that number as well, okay, so any questions? I know it's a lot, it's always a lot.

J Basser: 58:24

This is an enormous section because you've got a lot of spine issues and there's a lot of the disability that's paid. You know, because of these issues, you know, I mean, basically the military is a dangerous place and you know there's recreation sports activities football, soccer, baseball, you're running and things like that People fall, people get hit, you know, and you know people fall, people get hit. You know, and, uh, you know, especially in the navy, you know, you get these aircraft carriers that are big ships, they got a lot of ladders on them and, uh, there's nothing worse than going at a ladder head first. So, but, um, the v8, of course I was on the old old system, the old school and how they did it. My CMP exam was like three and a half hours long.

J Basser: 59:17

But any type of spinal cord injury, I like that guys, the VA should take care of it. And if you have a neck injury while you're in service, let me explain something. You might be okay, you might injure your neck, but 15 years after you get out where arthritis sits in, you're not going to be okay. That's when you got to worry about 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 in occupational health has made a world of difference in understanding musculoskeletal diseases and their progression.

Bethanie Spangenberg: 1:00:13

Because you can have somebody that's, you know, spent a lot of their young years in the military and then they go on to do something sedentary and you can see the difference in that story versus somebody who's worked in construction for 50 years or I know I say 50, but I don't think you could last 50, but for 30 years you can really see like a story and their health conditions that progress.

Bethanie Spangenberg: 1:00:35

And so I think that there needs to be more education, both in private practice, for the VA, when it comes to occupational health and not only diseases but limitations that diseases can cause. A lot of primary care providers start to scratch their head when they're trying to like, okay, well, they hurt this, what should their weightlifting limitation be at work? And so with that practice and taking injuries and diseases, and I can say, you know, in out of time, like no pushing more than five, no pulling more than 10 pounds, no lifting more than X, y and Z, and that has really helped me with these veterans' claims, and when I look at the records and the story that they tell, I can really kind of pinpoint when things really started to get bad. Pinpoint when things really started to get bad, and so I think that's been a wonderful tool that I have developed that we use at Valor for Vets.

J Basser: 1:01:36

Good Well, bethany, I want to thank you for coming on and doing this. It's a little form to show and I'm sure we'll get a lot of feedback from you and I'll forward you whatever we get. So you know, if you guys need a good IMO, give these folks a call. Can't go wrong with it With that. This is John Tony J Baxter. Baxter Exposed Improductions. Don't be half of Bethany. I'm Val Prevett. We'll be shutting her down. Thank you, bethany.

Bethanie Spangenberg: 1:02:07

Thank you, bethany, thank you.