RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01108
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Tactical Unmanned Aerial Vehicle Operator, medically separated for “chronic low back pain (LBP)” with a disability rating of 10%.  

CI CONTENTION:  He was not evaluated thoroughly for all his conditions. Some of his conditions continue to negatively impact his daily activities. The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based on 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 - 20070822 	VARD - 20080107	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP secondary to Degenerative Disc Disease (DDD)	5243	10%	DDD, Thoracolumbar Spine with Sciatica…	5243-5242	10%	20071205	
Cervical Pain	Not Unfitting	C5-6 Disc Herniation/Herniated Nucleus Pulposus, Cervical Spine…	5235	10%	20071205	
Posttraumatic Stress Disorder (PTSD)	Not Unfitting	Posttraumatic Stress Disorder (also claimed as
Cyclothymic Disorder, Depression and Bipolar Disorder)	9411	30%	20071205	
Cyclothymic Disorder…	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:  

Chronic LBP.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic LBP condition began in July 2002 after lifting and moving heavy military equipment.  He developed shooting LBP radiating down the left leg.  While deployed from March 2003 to March 2004, he reported three episodes of back pain and spasm.  He reinjured the back in August 2004 in a motor vehicle accident.  During his fitness test in February 2006 he had severe LBP that radiated down the left leg to the toes with tingling.  Magnetic resonance imaging showed L5 DDD and a mildly bulging disk at L5-S1.  Continued conservative treatment to include physical therapy was recommended.  There was overall improvement with a combination of treatments but LBP and left side sciatica continued causing monthly spasm.  

At the MEB examination (recorded on DD Form 2808) dated July 2007, 3 months prior to separation, a slight right limp and normal toe to heel walking were noted along with a goniometer-measured range of motion (ROM) of forward flexion to 85-90 degrees from three measurements (normal is 90 degrees).  Pain limited motion and he used his hands on his knees to stand straight.  There was localized tenderness at L5-S1 but no spasm, guarding or abnormal spinal contour although he leaned forward in slight flexion.  Straight leg raising (SLR) on the left was to 75 degrees and to the right 80 degrees with pain.  He moved slowly and deliberately getting on and off the examination table and rising from chair.  The examiner noted the CI had LBP with radiculopathy that prevented performance of duties and was unresponsive to conservative therapy but the condition did not yet require surgery.  

During the NARSUM examination he reported daily constant 6/10 LBP with a pulling, shooting sensation in the low back across the buttocks and down the left leg.  The pain increased to 9/10 with spasms which awakened him from sleep and required emergency room visits.  The pain prevented all activities, and caused decreased movement of the left leg.  Duties were non-physical and administrative and he could not perform any physical training, sit for long periods, or wear full combat equipment.   

At the VA Compensation and Pension (C&P) examination performed approximately 2 months after separation, the CI reported LBP and stiffness with intermittent radiation down the left posterior thigh to the posterior left knee.  Stretching exercises improved symptoms.  He reported no significant effects on occupation but reported in the past 12 months there were 6 to 8 flare ups which lasted 23-48 hours and required emergency room visits.  There were no surgeries.  An examination showed normal gait and no assistive devices; ROM showed flexion to 70 degrees (normal 90 degrees) with pain.  There was flattening of normal lumbar lordosis, para spinal tension, and normal strength and reflexes.  SLR on the right was positive and para spinal tenderness was absent.   X-rays showed minimal degenerative changes of the lumbar spine.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the 5243 code (intervertebral disc syndrome) due to DDD with tenderness but no muscle spasm, guarding, or deformity.   The VA assigned a 10% rating using the 5243-5242 code (degenerative arthritis of the spine due to intervertebral disc syndrome) based on the VA C&P examination 2 months after separation, citing forward flexion greater than 60 degrees but not greater than 85 degrees.  The MEB examination and the C&P examination documented either painful motion (IAW §4.59), tenderness or ROM measurements that are consistent with a 10% rating.  There is no evidence-based alternative coding/rating scheme that would result in a rating greater than 10%.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the LBP condition was appropriately recommended in this case.

The Board finally deliberated if additional disability was justified for peripheral nerve impairment due to radiculopathy.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  Pain (whether or not it radiates), stiffness, or aching is rated under the general formula for the spine and was considered in the 5243 rating above.  There was insufficient evidence in this case of functional impairment attributable to peripheral neuropathy that adversely impacted duty performance.  The Board therefore concluded that no peripheral nerve (radiculopathy) condition could be recommended for additional disability rating.  

Contended PEB Conditions:  PTSD, Cyclothymic Disorder, Cervical Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting. 
 
PTSD and Cyclothymic Disorder.  The CI had his first mental health contact in January 2007 as a self-referral due to issues related to loss of anger control at work and at home.  Symptoms had worsened after his return from Iraq in 2004.  He was exposed to traumatic combat experiences while deployed and reported “uncontrollable” mood swings, “up periods”, depression, re-experiencing, avoidance and arousal symptoms, and increased libido. The NARSUM examination, performed 2 months pre-separation rendered diagnoses of PTSD and cyclothymic disorder and he received a Global Assessment of Functioning score of 65 (mild symptoms, impairment).  He was treated with medications and the examiner noted he had significantly improved his mood as well as his anxiety and was much less irritable.  He reported doing well at work and there was improvement at home.  

The C&P examination, performed 3 months after discharge, noted he was working as an instructor with the military and had not missed considerable time from work due to a mental disorder.  He endorsed symptoms of PTSD but had some friends and leisure activities outside of the home he shared with his family.  He interacted with others, participated in activities of daily living and met family responsibilities.  A mental status examination was unremarkable. He had a functional score of 63 (mild symptoms, impairment.) He was taking a mood stabilizing medication.  

The PTSD and cyclothymic disorder were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the either of these contended conditions and so no additional disability ratings are recommended.

Cervical Pain. The CI awoke with a stiff neck in October 2006.  Neurology consultation noted the CI reported neck pain radiating into the left arm.  He had 7/10 pain with occasional left shoulder pain with stiffness, left arm numbness and weakness.  Pain decreased with massage, hot pads and rest but increased with prolonged standing.  Examination showed flexion 45 degrees (normal 45 degrees), decreased range on extension and left lateral rotation with intact cranial nerves, normal muscle bulk and tone. There was no tenderness, muscle spasm or guarding.  Neurosensory was intact.   Neuroimaging showed marked extrusion of C5-C6 intervertebral discs.  There was a mildly abnormal left arm electro-myelogram study, suggesting an old C7 radiculopathy but a review suggested findings were unclear and might be unrelated to the herniated disc.  By May 2007 the overall problem appeared improved with three epidural steroid injections and physical therapies so he no longer had radiating left arm pain.   He reported almost complete resolution of symptoms after injections.   His profile changed from U3 to U2 for cervical pain.  

At the December 2007 C&P examination, performed 3 months post-separation, the CI reported stiffness and pain aggravated by overuse and cold weather with intermittent radiating pain down the left arm becoming progressively worse over time. This was treated with daily stretching exercises and home cervical spine traction three times weekly with improvement in symptoms.  He had two flare ups with reported severe pain, stiffness and muscle spasm, lasting 4-5 days in the past 12 months and requiring emergency room visits and use of narcotic pain medication.  Examination showed flexion 35 degrees (normal 45 degrees), no radiation or tenderness, strength 5/5 and normal sensation.  Cervical spine x-rays showed no significant abnormality.  There was no incapacitation the past 12 months. 

The Board directed attention to its fitness recommendation based on the above evidence.  The Board noted the commander’s reference to the presence of neck spasms and pain and its impact on his duties.   The Board also noted a history of treated cervical pain throughout 2007 and 2008, the presence of right-sided cervical pain on flexion to 35 degrees and thrice weekly in-home cervical spine traction with flare-ups and spasms requiring narcotic pain medication which precludes occupational proficiency.  The Board determined the CI’s cervical neck condition interfered with the satisfactory duty performance and soldiering physical requirements.  After due deliberation, members agreed by majority that the preponderance of the evidence with regard to the functional impairment of the cervical neck condition favors its recommendation as an additionally unfitting for disability rating.  It is appropriately coded 5235 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD and cyclothymic disorder conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended cervical pain condition, the Board by majority agrees that it was unfitting and by majority recommends a disability rating of 10%, coded 5235 IAW VASRD §4.71a, citing forward flexion to 35 degrees.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Low Back Pain	5243	10%	
Cervical Pain 	5235	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140128, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX AR20160013051 (PD201401108)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA