Musculoskeletal

Lumbar Spine (Low Back) C&P Exam Guide

Associated DBQ Form: DBQ Back (Thoracolumbar Spine)

What to Expect During Your Exam

The back C&P exam typically lasts 30-45 minutes and includes both an interview and physical examination.

The exam includes:
1. Review of your medical history and service records
2. Discussion of your back injury and symptoms
3. Physical examination and range of motion testing
4. Assessment of pain, including flare-ups
5. Neurological testing if radiculopathy is claimed

Questions the Examiner May Ask

  • 1 How did you injure your back?
  • 2 When did the injury occur during service?
  • 3 Where exactly is your pain located?
  • 4 How would you rate your pain on a scale of 1-10?
  • 5 Does the pain radiate into your legs?
  • 6 Do you have numbness or tingling?
  • 7 What activities make your pain worse?
  • 8 How does your back condition affect your daily activities?
  • 9 Do you experience flare-ups? How often and how severe?
  • 10 What treatments have you tried?

Documentation to Bring

  • Service treatment records documenting back injury or treatment
  • Current medical records and imaging (X-rays, MRI)
  • Documentation of any surgeries
  • Physical therapy records
  • Buddy statements about the injury or observed limitations
  • Personal statement describing the injury and current symptoms

How to Prepare

Before your exam:

1. **Know your injury history** - Be ready to describe when and how the injury occurred

2. **Document your worst days** - VA rates based on your overall condition, including flare-ups

3. **List your limitations** - What can't you do because of your back? Bending, lifting, standing, sitting?

4. **Note flare-up frequency** - How often do they occur? How long do they last? What triggers them?

5. **Don't take extra pain medication** - You want the examiner to see your typical condition

6. **Be prepared for range of motion testing** - You'll be asked to bend forward, backward, and side to side

Helpful Tips

- Describe your pain honestly - don't minimize it
- Report your WORST days, not your best days
- During range of motion testing, stop when pain begins - don't push through
- Mention if pain increases with repetitive movement
- Describe functional loss - what CAN'T you do because of your back?
- If you have radiculopathy (leg pain/numbness), make sure to mention it
- Flare-ups matter - describe their frequency, duration, and severity
- Mention if you use assistive devices (cane, back brace)

Common Mistakes to Avoid

- Pushing through pain during range of motion testing
- Saying pain is 10/10 while appearing comfortable
- No documented in-service injury
- Inconsistency between reported symptoms and observed behavior

How VA Rates This Condition

Back conditions are rated under the General Rating Formula for Diseases and Injuries of the Spine (38 CFR § 4.71a):

**10%** - Forward flexion greater than 60° but not greater than 85°, OR combined range of motion greater than 120° but not greater than 235°

**20%** - Forward flexion greater than 30° but not greater than 60°, OR combined ROM greater than 120°, OR muscle spasm/guarding severe enough to result in abnormal gait or spinal contour

**40%** - Forward flexion 30° or less, OR favorable ankylosis

**50%** - Unfavorable ankylosis of the entire thoracolumbar spine

**100%** - Unfavorable ankylosis of the entire spine

**Note:** Radiculopathy (nerve pain) can be rated separately for each affected extremity.