RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00980
BRANCH OF SERVICE:  Army	BOARD DATE:  20141029
SEPARATION DATE:  20041113

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an activated Reserve E-4 (Light Wheel Vehicle Mechanic) medically separated for abdominal and neck pain.  These conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “abdominal pain, secondary to irritable bowel syndrome (IBS) and gastritis” and “neck pain, status post (s/p) neurosurgical discectomy and fusion,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two mental health conditions for PEB adjudication.  The PEB adjudicated “abdominal pain, due to irritable bowel syndrome, with gastritis” and “chronic subjective neck pain status post fusion, without neurologic abnormality, cervical range of motion limited by pain” as unfitting, rated 10% and 10%, respectively, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I wasn’t rated fairly for my conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Service PEB – Dated 20040930	VA* – (5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Abdominal Pain, due to Irritable Bowel Syndrome, with Gastritis	7319	10%	IBS with Diarrhea	7319	10%	20050419	
Chronic…Neck Pain…	5241	10%	S/P…Cervical Decompression and Fusion 	5237	10%	20050416	
Other x 2 (Not in Scope)	Other x 9	
Combined:  20%	Combined:  50%	
*Derived from VA Rating Decision (VARD) dated 20050525 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Abdominal Pain due to IBS with Gastritis.  Treatment records recorded the CI was activated to duty in mid-February 2003.  On 17 February 2003, 10 days after activation notice, he was diagnosed with gastroenteritis (acute) after presenting to the emergency room (ER) on base, with a 4-day history of nausea, vomiting and diarrhea.  In March 2003, the CI returned to the ER with report of blood-coated stool and pain.  The diagnosis of hemorrhoids was assessed.  On 4 April 2003, the CI deployed to Kuwait.  The narrative summary (NARSUM) recorded the CI was evacuated in July 2003 secondary to headaches and multiple sick call visits.  He was referred to gastroenterology (GI) in August for comprehensive evaluation.  In September 2003, he underwent extensive medical evaluations including biopsies and stool cultures, all were negative.  Endoscopy identified healing peptic ulcers and gastritis (irritation/inflammation of stomach lining).  Colonoscopy noted the presence of internal hemorrhoids and normal small and large bowel mucosa.  Treatment records were scarce and although the CI had several recorded GI visits, there were no recorded physical examinations prior to the MEB NARSUM.  His abdominal symptoms persisted with pain, fatigue and diarrhea despite medications, lifestyle and dietary modification.  Internal medicine clinic entry dated 3 October 2003 noted the CI had lost ten pounds in the previous 2 weeks; however, the cause was not detailed.  He had frequent bowel movements (number not recorded) and had been diagnosed with IBS.  A GI encounter note dated October 2003, recorded the CI had a good appetite; weight was stable and noted the CI may have been gaining weight.  Frequency of bowel movements (BM) was noted to be four a day.  In December 2003 the CI underwent an upper GI radiograph series that was normal.  The CI took nutritional supplements to address weight loss and improve nutrition and was under the care of a dietician.  There were no reports of fevers, chills or mucus in the stool recorded in any of the service treatment records (STR) prior to separation.  There was no indication of blood in his stool independent of hemorrhoids.  The CI had a history of gastroesophageal reflux that was controlled with medication.  An April 2004 GI clinic entry noted the CI’s diarrhea was stable and much improved.  There was no documentation in the STR of dehydration or electrolyte imbalances nor were there episodes necessitating ER visits or hospitalization.  Treatment entries recorded stable weight, no signs of anemia, no episodes of fever, and no significant decrease in blood pressure in the year prior to separation. During the MEB NARSUM performed on 21 April 2004 the CI reported he had a history of frequent diarrhea, headaches and dizziness up to 4-5 times a day and occasional blood in his stool.  Current status was not recorded.  However, the CI’s chief complaint was recorded as abdominal pain secondary to gastritis and IBS.  Physical examination of the abdomen recorded generalized tenderness, no guarding, no rebound, no mass, no enlarged organs and normal bowel sounds.  The physician diagnosed abdominal pain secondary to IBS, which was recorded as existing prior to service and gastritis recorded as service-related.  The report of medical examination (DD Form 2808, conducted by the same MEB physician) recorded that the CI reported BM frequency of 4-5 loose stools daily, and a 20-pound weight loss in 6 months during deployment.  He had no further loss and had regained three pounds.  The examiner noted the CI had not had bloody stools since his diagnosis of peptic ulcer disease.  
Physical examination revealed a weight of 126 pounds, height of 5 feet, 7 inches and blood pressure 130/82.  The physician recorded a maximum weight of 174 pounds with no indication if this was pre-active duty weight.

At the VA Compensation and Pension (C&P) general examination performed on 19 April 2005, approximately 5 months after separation, the CI noted a 2- to 3-year history of “dumping” and irritable bowel, accompanied by lower abdominal cramping pain and intermittent diarrhea.  The physician recorded that in addition to the report of the history of gastric ulcers the CI had a positive finding of H. Pylori (likely the cause of the ulcers).  The CI reported he had some mucus in his stool and he had a colonoscopy; however, colitis was not a definitive finding.  The examiner noted the absence of access to the colonoscopy report.  The CI reported his diarrhea symptoms occurred in cycles of 2- or 3-day periods and then flared for 2 or 3 days causing some more symptoms.  The cycle took on the pattern of 2 or 3 days of symptoms followed by 2 to 3 days of no symptoms.  Frequency of BM was not recorded.  The CI noted intermittent bleeding secondary to hemorrhoids and reported fatigue and sleep disturbance but noted he also experienced posttraumatic stress disorder nightmares and flashbacks that had interfered with sleep.  Physical examination recorded weight of 122 pounds, height of 67 inches and blood pressure was 128/82.  The CI noted his weight had decreased by eight pounds in a 3-month period secondary to lack of appetite attributed to gastroesophageal reflux disease, stomach discomfort and dumping syndrome that resulted when he ate large meals.  There was diffuse discomfort in the right and left lower quadrant and across the transverse colon, no rebound tenderness and no evidence of rectal hemorrhoid.  The physician diagnosed irritable bowel disorder with intermittent diarrhea.

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the condition at 10% for moderate severity coded 7319 (irritable colon syndrome).  The Board deliberated whether the CI’s IBS met the 10% or the 30% 7319 rating.  A 30% rating (severe) requires diarrhea documented as severe or alternating diarrhea and constipation in a severe pattern, with constant or near constant abdominal distress.  The Board undertook a careful review of the treatment records and noted the absence of the report of constant abdominal pain.  Clinical examinations noted no distress during physical exams, and examination of the abdomen was generally reported as normal.  The Board noted the record to document no malnutrition, anemia, no significant weight loss directly attributable to the IBS condition, no serious complications, or ER visits, and that the intermittent frequency of four to six times a day only during flare ups was most consistent with a moderate degree of disease burden.  The Board opined that the evidence in the record did not approach the 30% rating criteria of 7319.  The Board unanimously agreed the evidence supported a moderate condition consistent with a 10% rating under code 7319.  The Board adjudged that the CI’s condition did not support a higher than 10% disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the IBS condition.

Neck Pain.  The CI reported his neck pain began as the result of two motor vehicle accidents in Iraq.  He noted he was knocked unconscious when his head hit the roof of a wrecker.  Three weeks later, the CI was riding in the same wrecker and was rear-ended.  He began to have persistent neck pain and headaches.  He was treated conservatively with medication and physical therapy with unsustained improvement.  A magnetic resonance imaging (MRI) dated 18 November 2003, revealed moderate posterior disk osteophyte complex at C5-C6 and C6-C7 with mild narrowing of the spinal canal and moderate to severe bilateral neural foraminal narrowing.  The cervical spine was in normal alignment without evidence of fracture or subluxation.  In December 2003, physical therapy (PT) recorded cervical range-of-motion (ROM) flexion of 30 degrees (45 normal) and extension of 35 (45 normal).  ROM recorded at PT in January 2004 noted flexion and extension of 40 degrees.  

A clinic treatment note dated 8 January 2004 recorded that the neck pain was constant and non-radiating and that it worsened with prolonged standing.  Surgical procedural notes were not available for review; however, clinic entry dated 6 April 2004 recorded the CI underwent cervical disk fusion per the CI’s report on 18 February 2004.  A neurology visit dated 7 April 2004 recorded motor weakness of the upper extremities (bilateral hands 4/5) since surgery.  A neurology examination dated 26 April 2004 documented the CI’s report of severe neck pain since cervical spine surgery in February 2004.  The CI reported his pain starts in the neck and radiates down into the lower back and medication had not improved his pain.  The neurologist noted the CI was visibly in pain.  On examination, sensory and motor functions were recorded as normal.  Gait and stance were normal.  The neurologist diagnosed cervical radiculopathy.  The examiner recorded the results of cervical spine radiographs that demonstrated intact anterior fusion at C5-C6 and early degenerative changes at the level below the fusion, C6-C7.  The MEB NARSUM physical examination of the neck noted an anterior cervical scar and recorded cervical ROM flexion of 23 (25 when rounded) degrees with pain, extension of 15 degrees with pain, and a total combined ROM of 160 degrees.  The diagnosis of neck pain was assessed.

At the C&P examination performed on 16 April 2005, 5 months after separation, the CI reported his symptoms of nerve compression had slightly improved after surgery but he had continued to have neck pain, which at times radiated into his arms.  The April 2005 MRI of the cervical spine demonstrated cord edema.  Physical examination revealed mild paraspinal tenderness, and ROM of 35 degree flexion, 20 on extension with pain, and a total combined ROM of 195 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10% coded 5241 (spinal fusion) and noted cervical ROM was limited by pain.  The VA rated the condition at 10% coded 5237 (cervical strain) based on limitation of motion.  The higher rating under any of the spine codes requires ROM flexion measurement greater than 15 but not greater than 30 degrees.  The Board noted the ROM flexion of 23 (25 when rounded) degrees at the NARSUM, approximately 7 months prior to separation and acknowledged the ROM would qualify for the 20% rating.  However, the Board considered the cervical ROM recorded at the C&P, 5 months prior to separation had the most probative value since that examination was most proximal to separation and was consistent with the other two ROM recorded in the STR.  There was no evidence of ratable peripheral nerve impairment in this case, since there was no clear evidence of motor weakness or sensory symptoms with functional implication.  There was no evidence of incapacitating episodes for a higher rating under 5243 (intervertebral disc syndrome).  Given the record of evidence, the Board could not find other applicable VARSD codes for consideration.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic neck pain condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the abdominal pain due to IBS condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the Board by consensus recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends no re-characterization of the disability and separation determination.
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

			

SAMR-RB									

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20150008699 (PD201400980)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA