C&P Exam Guide

Back/Spine C&P Exam

The examiner will perform range of motion testing with a goniometer, assess pain levels, check for neurological symptoms, and evaluate functional impact.

DBQ: Back (Thoracolumbar Spine) Conditions DBQ
Exam type: In-person (required for ROM testing)
Typical duration: 30-45 minutes

What the Examiner Looks For

Range of motion measurements (flexion, extension, lateral bending, rotation), pain on motion, muscle spasm, guarding, neurological symptoms, functional limitations, and flare-ups.

Related Diagnostic Codes

DC 5237
Lumbosacral or cervical strain
DC 5242
Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010)
DC 5243
Intervertebral disc syndrome

General Tips for Every C&P Exam

📝Be honest — do not exaggerate or minimize.
📝Describe your WORST days, not your best.
📝Focus on how the condition impacts your daily life and ability to work.
📝Keep a symptom journal or diary before your exam.
📝Review the DBQ for your condition beforehand.
📝Arrive early and bring all relevant records.
📝You can bring a support person (spouse, friend).
📝The exam is for evaluation, not treatment — do not expect prescriptions.
📝The examiner is not your doctor — they report findings to the VA.
📝If you disagree with the exam results, you can request a new exam.

✅ DO

⚠️ Critical tip
STOP at the point of pain during range of motion testing — do NOT push through pain. The examiner measures where pain begins, not your maximum range.
⚠️ Critical tip
Describe your flare-ups in detail — frequency, duration, triggers, and how they limit you beyond your baseline
Mention any radiating pain down your legs (radiculopathy)
Describe how back pain affects daily activities: sitting, standing, driving, sleeping
Mention any assistive devices (brace, cane, TENS unit)
Report incapacitating episodes where you were prescribed bed rest

❌ DON'T

⚠️ Critical tip
Don't push through pain to show toughness — this will result in better ROM measurements and a LOWER rating
Don't go on a 'good day' if possible — the exam should reflect your typical condition
Don't forget to mention flare-ups — the examiner MUST document these

📋 BRING

MRI/X-ray results
Records of physical therapy
List of medications (especially pain meds and muscle relaxers)
Documentation of any bed rest prescribed by a doctor

🔍 EXPECT

Goniometer range of motion testing
Repetitive motion testing (bending 3+ times)
Neurological tests (reflexes, sensation, strength in legs)
Questions about flare-ups and their impact

This information is for educational purposes only. It is not legal or medical advice. Every veteran's situation is unique. Consider consulting with a Veterans Service Organization (VSO) or VA-accredited attorney for personalized guidance.