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C&P Exam Prep: Amyotrophic Lateral Sclerosis (ALS)

DC 8017 neurological 38 CFR 4.124a

DBQ Overview

Interview + Physical
Form Name
Central_Nervous_System_and_Neuromuscular_Diseases
Form Code
Central_Nervous_System_and_Neuromuscular_Diseases
Page Count
13
Examiner Type
Physician or Psychologist
Estimated Duration
60-90 minutes
Exam Format
Interview + Physical

What to Expect During Your Exam

Exam Overview

To document the full extent of your ALS diagnosis and all associated complications for VA rating purposes. Under 38 CFR 4.124a DC 8017, a confirmed diagnosis of ALS is itself sufficient to warrant a 100% rating. The exam also documents every complication-such as limb paralysis, bulbar dysfunction, respiratory failure, dysphagia, bowel/bladder involvement, and speech impairment-so the VA can correctly assign Special Monthly Compensation (SMC) and ancillary benefits including Specially Adapted Housing (SAH), automobile allowance, and Dependents' Educational Assistance (DEA).

What the examiner evaluates:

  • Confirmed ALS diagnosis and date of onset
  • Upper motor neuron signs: spasticity, hyperreflexia, pathological reflexes (Babinski), pseudobulbar affect
  • Lower motor neuron signs: progressive muscle weakness, fasciculations, muscle atrophy with circumferential measurements
  • Bulbar involvement: dysarthria, dysphagia, aspiration risk, soft palate paralysis
  • Respiratory compromise: FVC%, FEV1, need for BiPAP/CPAP/ventilator support
  • Limb function: grip strength, pinch strength, elbow/wrist/knee/ankle ROM and muscle strength testing in all extremities
  • Gait and mobility: ambulatory status, need for cane, crutches, walker, wheelchair, or braces
  • Assistive devices currently in use and frequency of use
  • Bladder dysfunction: retention, incontinence, catheterization needs, UTI history
  • Bowel dysfunction: incontinence, constipation, need for bowel program or medications
  • Speech: intelligibility, aphonia, need for augmentative/alternative communication
  • Nutrition: weight loss, need for PEG tube or enteral feeding
  • Sleep disturbances: insomnia, hypersomnia, sleep apnea requiring CPAP/BiPAP/tracheostomy
  • Cognitive and emotional status: pseudobulbar affect, dementia (ALS-FTD spectrum)
  • Environmental/toxic exposure history: herbicide/Agent Orange exposure, heavy metals, solvents, pesticides, nerve agents
  • All current medications for ALS symptom management
  • Impact of condition on occupational and daily functioning

The exam will include both a structured clinical interview and a full neurological physical examination. If you require a wheelchair, transport assistance, or augmentative communication device, notify the scheduling office in advance. You have the right to have a caregiver or support person present. In most states, you have the right to record the examination with a handheld device-notify the examiner at the start of the appointment.

Typical duration: 60-90 minutes

Forced Vital Capacity (FVC%) and FEV1

Respiratory muscle strength and lung capacity, which decline progressively in ALS due to diaphragm and intercostal muscle weakness

What to expect:

You will breathe into a spirometer. The examiner will record your FVC percentage of predicted normal, FEV1, and FEV1/FVC ratio. Results directly inform the need for respiratory assistance devices and SMC levels.

Key thresholds:

  • FVC < 50% predicted — Strong indicator for BiPAP initiation; supports SMC aid-and-attendance level needs
  • FVC < 30% predicted — Severe respiratory failure; may support SMC housebound or higher-level SMC
  • Requires mechanical ventilation or tracheostomy — Supports SMC at the highest levels under 38 CFR 3.350

Tips:

  • Bring copies of your most recent pulmonology or neurology spirometry results to the exam
  • Inform the examiner if you already use BiPAP, CPAP, or a ventilator at night or continuously
  • Accurately report if your breathing is worse when lying flat (orthopnea), during exertion, or at night
  • Do not try to perform better than your actual capacity-accurate results are essential for SMC determination

Pain considerations: Respiratory effort during spirometry may cause fatigue or dyspnea. Inform the examiner if the testing worsens your symptoms.

Manual Muscle Testing (MMT) - Upper and Lower Extremities

Motor strength in individual muscle groups bilaterally (biceps, triceps, brachioradialis, wrist flexors/extensors, grip, pinch, knee extensors, ankle dorsiflexors/plantarflexors) using the Medical Research Council (MRC) 0-5 scale

What to expect:

The examiner will ask you to push, pull, and resist force with each arm and leg. Results are graded 0 (no contraction) through 5 (normal strength). Asymmetric weakness is highly characteristic of ALS and will be carefully documented.

Key thresholds:

  • MRC Grade 0-1 in any extremity — Complete or near-complete paralysis; supports SMC loss-of-use determination for that extremity
  • MRC Grade 2-3 in both lower extremities — Significant functional loss; supports SMC aid-and-attendance and wheelchair dependency
  • Loss of use of both feet or both hands — Qualifies for SMC under 38 CFR 3.350(a) and Specially Adapted Housing under 38 CFR 3.809

Tips:

  • Do not brace, compensate, or use your stronger side to assist during testing of the weaker side
  • Tell the examiner which side is dominant (right/left/ambidextrous) as this affects SMC calculations
  • Report any fasciculations (muscle twitching) you experience at rest or with exertion
  • Describe your weakest functional state, not your best performance on a good day-this is your 'worst day' representation

Pain considerations: Muscle fatigue following MMT is common in ALS. Inform the examiner if testing causes disproportionate exhaustion, cramping, or increased weakness afterward.

Grip Strength and Pinch Strength Testing

Fine motor and gross hand strength bilaterally; critical for determining loss of use of hands for VA SMC purposes

What to expect:

You will squeeze a dynamometer or resist the examiner's grip pressure. Pinch testing assesses lateral and tip pinch. Results are compared bilaterally and against normal values.

Key thresholds:

  • Minimal to no functional grip (unable to perform activities of daily living independently) — Supports loss-of-use-of-hand SMC determination under 38 CFR 3.350
  • Inability to hold utensils, writing instruments, or perform hygiene tasks — Functional loss documented for SMC purposes

Tips:

  • Bring any adaptive equipment you use (button hooks, utensil grips, stylus) to demonstrate your level of impairment
  • Report if you drop objects, cannot open containers, or require assistance with dressing, hygiene, or eating
  • Describe difficulty with fine motor tasks such as typing, buttoning, or writing

Pain considerations: Cramping during grip testing is a recognized ALS symptom. Report it to the examiner immediately.

Range of Motion (ROM) Testing - All Major Joints

Active and passive ROM in elbows (flexion/extension), wrists (flexion/extension), knees (extension), and ankles (dorsiflexion/plantarflexion) bilaterally; spasticity-related ROM restrictions are common in ALS

What to expect:

The examiner will move your joints both actively (you move them) and passively (examiner moves them). In ALS, spasticity from upper motor neuron involvement often limits passive ROM, while lower motor neuron loss limits active ROM.

Key thresholds:

  • Active ROM severely limited due to weakness/spasticity — Supports functional loss and SMC determinations
  • Contractures present — Documented muscle atrophy with contractures supports higher SMC levels

Tips:

  • Inform the examiner if you experience spasticity, stiffness, or painful muscle spasms during ROM testing
  • Do not force movement beyond your comfortable limit-accurate passive ROM is more important than demonstrating maximum effort
  • Describe how spasticity or weakness affects your ability to walk, climb stairs, dress, or transfer from bed to chair

Pain considerations: Pain during ROM testing should be reported immediately. Spasticity in ALS can cause significant discomfort during passive stretching.

Muscle Atrophy Assessment

Circumferential limb measurements at standardized anatomical points to quantify muscle wasting bilaterally; a hallmark finding in ALS lower motor neuron degeneration

What to expect:

The examiner will measure the circumference of your arms and legs using a tape measure, comparing dominant versus non-dominant limbs and recording the difference in centimeters.

Key thresholds:

  • Measurable asymmetric atrophy (>2 cm circumference difference) — Objective evidence of lower motor neuron loss; documented in DBQ field for atrophy with specific measurements
  • Diffuse bilateral atrophy — Supports advanced ALS staging and high SMC need

Tips:

  • Do not wear bulky clothing or compression garments that may obscure atrophy
  • Point out areas where you have noticed visible muscle wasting, such as the thenar eminence, forearms, or calves
  • Bring photos if you have documented visible atrophy over time, as progression is meaningful

Pain considerations: Atrophy measurement is non-painful but the examiner should be informed of fasciculations (visible or felt twitching) in the muscles being examined.

Gait and Mobility Assessment

Ambulatory ability, need for assistive devices, fall risk, and degree of lower extremity functional loss

What to expect:

You will be observed walking, if able. The examiner will document whether you use a cane, walker, crutches, wheelchair, or braces, and how frequently. The DBQ specifically asks whether these are your normal mode of locomotion.

Key thresholds:

  • Requires wheelchair as normal mode of locomotion — Meets 38 CFR 3.808/3.809 criteria for automobile allowance, adaptive equipment, and SAH
  • Requires braces/AFOs as normal mode of locomotion — Supports SMC determinations and assistive device documentation

Tips:

  • Use your actual assistive device during the examination-do not attempt to walk without it to appear more capable
  • State clearly and honestly how often you use each device and whether you could safely ambulate without it
  • If you have fallen due to ALS-related weakness, report the number of falls and circumstances

Pain considerations: Foot drop, spasticity, and leg weakness can cause pain and trip hazards during gait testing. Inform the examiner of any discomfort.

Speech and Bulbar Function Assessment

Dysarthria severity, aphonia, palatal function, swallowing ability (dysphagia), and aspiration risk

What to expect:

The examiner will listen to your speech quality, ask you to perform palatal movements, assess your swallowing history, and document any nasal regurgitation or choking episodes.

Key thresholds:

  • Speech not intelligible or individual is aphonic — Directly rated in DBQ and supports maximum SMC level; constant inability to communicate by speech is a separately ratable complication
  • Dysphagia requiring daily medication, PEG tube, or esophageal stent — Separately rated ALS complication supporting higher SMC and ancillary benefits
  • Aspiration events documented — Supports respiratory complications and aspiration pneumonia risk

Tips:

  • Bring your augmentative/alternative communication (AAC) device if you use one, and demonstrate its use
  • Report the progression of your speech impairment-when it started, how quickly it has worsened
  • Describe specific functional losses: cannot make phone calls, family cannot understand you, require text-to-speech software
  • Report all episodes of choking, aspiration, or pneumonia related to swallowing difficulties

Pain considerations: Fatigue during speech testing is expected in ALS with bulbar involvement. Inform the examiner if speaking during the exam causes significant exhaustion.

Estimate

Rating Criteria Breakdown

100% ALS is rated at 100% under 38 CFR 4.124a, DC 8017 for all se ...

ALS is rated at 100% under 38 CFR 4.124a, DC 8017 for all service-connected cases. A confirmed diagnosis of ALS alone is sufficient to support a 100% evaluation effective January 19, 2012. No functional threshold must be met beyond the diagnosis itself. The examiner must document all compensable complications-including limb paralysis, bulbar dysfunction, respiratory failure, dysphagia, bowel/bladder impairment, and speech loss-because these complications drive Special Monthly Compensation (SMC) levels above 100%, not the basic percentage rating. VA must also consider entitlement to DEA, automobile allowance and adaptive equipment, and Specially Adapted Housing (SAH) for all ALS veterans.

Key Symptoms

  • Progressive upper and lower motor neuron degeneration
  • Muscle weakness and atrophy in limbs, trunk, and bulbar musculature
  • Fasciculations at rest
  • Spasticity and hyperreflexia (UMN signs)
  • Dysarthria progressing to aphonia
  • Dysphagia with aspiration risk
  • Respiratory muscle weakness with declining FVC
  • Bowel and bladder dysfunction
  • Loss of use of one or more extremities
  • Wheelchair or assistive device dependence
  • Weight loss and malnutrition
  • Sleep-disordered breathing requiring CPAP/BiPAP/ventilator
  • Pseudobulbar affect
  • Cognitive changes (ALS-FTD spectrum)

CFR: 8017 Amyotrophic lateral sclerosis - 100 percent. Note: Consider the need for special monthly compensation. Per M21-1, Part V, Subpart iii, 12.C.2.c, a diagnosis of ALS alone is sufficient to support an evaluation of 100 percent. Per M21-1, Part V, Subpart iii, 12.C.2.d, if a complication of ALS independently warrants 100%, assign that as the primary DC using a hyphenated code (e.g., 8017-5110), and separately evaluate additional complications. All ALS awards must be assigned at least a 100% evaluation. SMC and ancillary benefits (SAH, automobile allowance, DEA) must be evaluated in every ALS case.

How to Describe Your Symptoms

Limb Weakness and Muscle Atrophy

How to describe:

Describe specific functional losses in concrete, daily-life terms. State which limb was affected first and how the weakness has progressed. Quantify your limitations: how many steps you can walk before needing to rest, whether you can lift objects, whether you drop things, and whether you can transfer independently.

Worst-day example:

“On my worst days, I cannot lift my right arm above shoulder height, I drop objects without warning, and I cannot take more than 10 steps without using my walker. My left hand cramps painfully when I try to grip anything, and I can no longer button my shirt or hold a fork independently.”

What the examiner listens for:

Specific muscle groups affected, bilateral versus unilateral involvement, rate of progression, functional tasks that are impaired (grooming, dressing, eating, writing), and whether weakness is worse with fatigue or repetitive activity.

Understatements to avoid:

Do not say 'I manage okay' or 'I get by.' Do not demonstrate your best performance during testing. Do not minimize weakness because you have adapted with assistive devices-describe what you cannot do without those devices.

Respiratory Symptoms

How to describe:

Describe shortness of breath at rest and with exertion, orthopnea (worsening when lying flat), morning headaches from CO2 retention, and disrupted sleep due to respiratory insufficiency. State whether you currently use BiPAP, CPAP, or supplemental oxygen, and how many hours per day.

Worst-day example:

“I cannot lie flat without my BiPAP-without it I wake up gasping. I have significant shortness of breath walking from my bedroom to the kitchen. I wake up with headaches most mornings, and my spouse says I stop breathing during sleep. I am fatigued constantly from poor sleep quality.”

What the examiner listens for:

FVC trend over time, current respiratory support requirements, orthopnea severity, frequency of respiratory infections, and any hospitalizations for respiratory failure.

Understatements to avoid:

Do not minimize breathing difficulties as just 'being out of shape.' If you use BiPAP only at night, still report it clearly. Report every respiratory hospitalization and every ER visit for breathing.

Bulbar Symptoms - Speech and Swallowing

How to describe:

Describe when your speech first changed, how quickly it has progressed, and the practical impact: people cannot understand you on the phone, in noisy environments, or after short conversations. For swallowing, describe specific foods you have had to eliminate, coughing or choking episodes, and any weight loss attributable to eating difficulty.

Worst-day example:

“On my worst days, my speech is completely unintelligible to strangers and even family members misunderstand me after a few minutes of conversation. I have stopped eating solid foods because I choked three times in the past month. I have lost 18 pounds in the past six months because eating takes so long and is exhausting.”

What the examiner listens for:

Rate of progression of dysarthria, whether aphonia has occurred, use of AAC devices, documented aspiration events, pneumonia episodes from aspiration, weight loss trajectory, and whether PEG tube placement has been discussed or performed.

Understatements to avoid:

Do not speak in your clearest, most effortful voice during the exam while downplaying how you typically sound when fatigued. Report aspiration events even if they did not require hospitalization.

Bladder and Bowel Dysfunction

How to describe:

Describe the specific type of dysfunction: urinary urgency, incontinence episodes per day, need for catheterization, recurrent UTIs, bowel incontinence, constipation requiring a bowel program, and use of absorbent materials. Quantify how many times per day/night these symptoms interfere with function.

Worst-day example:

“I have urinary urgency that gives me less than a minute of warning, and I have urinary incontinence episodes at least twice daily. I use absorbent pads that I change more than four times per day. I have had three UTIs in the past year requiring antibiotics. For bowel function, I require daily medications and a prescribed bowel program to prevent impaction.”

What the examiner listens for:

Frequency and severity of incontinence, catheter use, UTI frequency, bowel program requirements, need for absorbent materials and how frequently they are changed, and any hospitalizations for these complications.

Understatements to avoid:

Do not omit bladder or bowel symptoms out of embarrassment-these are rated complications that affect SMC. Do not understate the frequency of incontinence episodes.

Fatigue and Functional Capacity

How to describe:

In ALS, fatigue is both primary (neurological) and secondary (from respiratory insufficiency, malnutrition, poor sleep). Describe how quickly you fatigue, how long recovery takes, and how fatigue limits your ability to complete activities of daily living independently.

Worst-day example:

“After showering and dressing-with assistance-I am exhausted and need to rest for 30 to 45 minutes before I can do anything else. Any physical activity, including a short conversation, significantly worsens my fatigue. By mid-afternoon I have no functional reserve and require full assistance for all remaining daily activities.”

What the examiner listens for:

Time to fatigue onset, recovery time required, impact on ADLs, need for caregiver assistance, and whether fatigue has led to loss of employment or community participation.

Understatements to avoid:

Do not describe your energy level on a good day or after rest. Report your functional capacity at its worst, which is your typical baseline per M21-1 'worst day' guidance.

Mobility and Assistive Device Use

How to describe:

Clearly state which devices you use, how often, and whether they are your normal mode of locomotion. The VA specifically needs to know if a wheelchair, walker, cane, or braces are required for your typical daily ambulation-not just occasional use.

Worst-day example:

“I use my power wheelchair as my primary means of getting around. I cannot safely walk more than a few feet even with my walker because of foot drop and leg weakness, and I have fallen three times in the past two months. Without the wheelchair I would be confined to bed or a chair.”

What the examiner listens for:

Whether the device is required for routine daily locomotion versus occasional use, fall history, distance limitations, and whether ambulation without the device is unsafe.

Understatements to avoid:

Do not leave your wheelchair or walker in the car to appear more independent. The VA rates you on your actual functional needs, and using your device is not a sign of weakness-it is medical evidence.

Environmental and Toxic Exposure History

How to describe:

ALS is presumptively service-connected under 38 CFR 3.318 for veterans who served 90 or more days. The examiner will document exposure history including herbicide/Agent Orange, heavy metals, solvents, pesticides, insecticides, and nerve gas agents. Provide complete and accurate deployment and occupational history.

Worst-day example:

“N/A - this is a factual history section, not a symptom description. Provide dates, locations, and nature of exposures as accurately as possible.”

What the examiner listens for:

Service dates (must be 90+ days to qualify for presumptive), deployment locations with known herbicide exposure (Vietnam, certain bases), MOS involving chemical exposure, and any documented exposure incidents.

Understatements to avoid:

Do not omit deployments or duty stations. Even if you were not in a combat role, the examiner needs your full service history. If you are unsure about specific chemical exposures, say so rather than guessing.

Common Mistakes to Avoid

Prep Checklist

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Before Your Exam

Day Of

During the Exam

After the Exam

Your Rights During a C&P Exam

  • You have the right to a thorough and accurate C&P examination. If the examination is inadequate-meaning the examiner did not test the relevant functions, did not review your records, or the report contains clear errors-you have the right to request a new examination.
  • You have the right to have a caregiver, family member, or support person present during your C&P examination. They may observe but should not answer questions on your behalf unless invited to do so by the examiner.
  • In most states, you have the right to record your C&P examination using a personal recording device. Verify your state's recording consent laws before your appointment.
  • You have the right to request a copy of the completed DBQ/C&P examination report. Submit your request through MyHealtheVet, your VSO, or a written FOIA request after the exam is finalized.
  • ALS is presumptively service-connected under 38 CFR 3.318 for veterans who served 90 or more days on active duty. You do not need to prove the disease was caused by military service-qualifying service alone establishes the presumption.
  • A diagnosis of ALS is sufficient to support a 100% disability rating under 38 CFR 4.124a DC 8017. You do not need to meet any symptom threshold beyond the confirmed diagnosis.
  • You are entitled to Special Monthly Compensation (SMC) above the 100% rating if ALS complications result in loss of use of limbs, need for Aid and Attendance, housebound status, or other qualifying disabilities. VA must evaluate SMC in every ALS case.
  • You are entitled to Specially Adapted Housing (SAH) under 38 CFR 3.809 based solely on a service-connected ALS diagnosis rated 100% disabling-without meeting the typical locomotion-preclusion threshold.
  • You are entitled to an automobile allowance and adaptive equipment under 38 CFR 3.808 if ALS has caused loss of use of one or both feet, one or both hands, or permanent impairment of vision.
  • You may be entitled to Dependents' Educational Assistance (DEA) under Chapter 35 based on a permanent and total disability rating. VA must evaluate DEA eligibility in every ALS case.
  • You have the right to submit a written statement (VA Form 21-10210) correcting or supplementing information from your C&P examination if the report contains errors or omissions.
  • You have the right to appeal any unfavorable rating decision through the Supplemental Claim, Board of Veterans' Appeals Direct Review, or Higher-Level Review lanes under the Appeals Modernization Act (AMA).
  • If you are terminally ill, you have the right to expedited processing of your claim. Notify the VA that your claim involves a terminal diagnosis-ALS qualifies-and request Priority Processing.
  • VA must provide benefits at the highest level supported by the evidence. VA cannot assign a rating below 100% for a confirmed service-connected ALS diagnosis. If the rating decision assigns anything less than 100%, it is legally erroneous and must be appealed immediately.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.