RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02739
BRANCH OF SERVICE:  Army	BOARD DATE:  20150416
SEPARATION DATE:  20080327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Tracked Vehicle Mechanic) medically separated for a back condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty, but he was authorized to perform an alternate physical fitness test.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded two other conditions (adjustment disorder and hyperlipidemia) for PEB adjudication.  The Informal PEB adjudicated “chronic low back pain” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining adjustment disorder found as not unfitting, not compensable, although it may be administratively unfitting.  The hyperlipidemia condition was found as not unfitting.  An Administrative Correction PEB increased the unfitting “chronic low back pain” rating to 20%; the remaining findings were affirmed.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all 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 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:

Admin. Correction PEB – dated 20080304	VA* – (~1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	20%	Lumbosacral Spine Degenerative Disc Disease (DDD)	5243	20%	20080221	
Adjustment Disorder	Not Unfitting /
Not Compensable	Anxiety Disorder	9413	10%	20080304	
		Adjustment Disorder	9440	NSC	20080304	
Hyperlipidemia	Not Unfitting	No VA Placement	
Other x 0 (Not In Scope)	Other x 3 	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20080722 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Low Back Pain (LBP).  In 2004, this CI started having LBP.  There was no specific trauma or injury associated with the onset of his LBP.  Magnetic resonance imaging in May 2006 showed degenerative disc disease (DDD) at L4-L5, but no foraminal or spinal canal compromise.  There was DDD at L5-S1 with no definite evidence of disc herniation, but subtle foraminal compromise was seen, related to a bulging disc annulus.  He was treated with physical therapy (PT), chiropractic manipulation, and epidural steroids.  In spite of all treatment efforts, his LBP persisted and a MEB was initiated.

The MEB narrative summary (NARSUM) physical examination (PE) of his back was performed on 20 December 2007, approximately 3 months prior to separation.  The CI reported that he was in pain 75% of the time, while he was awake.  The average pain level was 7/8 of 10 with medication.  PE of the lower back showed mild tenderness in the right lumbar region.  There was no spasm, deformity, masses, or redness.  Neurological exam (motor and sensory) was normal.  Range-of-motion (ROM) was measured and is summarized in the chart below.  In the MEB NARSUM examiner diagnosed chronic LBP, with DDD at L4-L5 and L5-S1.

The CI was medically separated from service on 27 March 2008.  A month prior to separation, on 21 February 2008, he had a VA Compensation and Pension (C&P) exam.  He reported that he was continuing to have lumbar pain on a daily basis.  The pain radiated to the left leg, and was associated with a numb sensation in the left leg.  He was unable to walk more than ¼ mile at a time, and was unable to engage in sports or gymnasium work outs.  On PE, he did not appear to be in pain and his gait was normal.  He was not using any assistive devices.  PE of the thoracolumbar spine revealed no focal tenderness, no spasm or guarding, no abnormal spinal contour.  Neurological exam was normal.  During repetitive ROM measures, forward bending had pain at the limit of flexion, but no fatigability, no incoordination, and no reduction in ROM.  The C&P examiner diagnosed DDD, lumbar spine, with associated chronic pain syndrome, and left lower extremity radiculopathy.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	MEB ~3 Mos. Pre-Sep
(20071220)	VA C&P ~1 Mo. Pre-Sep
(20080221)	
Flexion (90 Normal)	55	55	
Extension (30)	30	25	
R Lat Flexion (30)	30	25	
L Lat Flexion (30)	(30) 35	25	
R Rotation (30)	(30) 45	20	
L Rotation (30)	(30) 45	20	
Combined (240)	205	170	
§4.71a Rating	20%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The Army PEB and the VA chose different coding options for the LBP condition, but both assigned a 20% disability rating.  The Board carefully reviewed the clinical data from the back examinations noted above.  At both the MEB and C&P exams, thoracolumbar forward flexion was greater than 30 degrees, but not greater than 60 degrees.  IAW the VASRD §4.71a General Rating Formula for Diseases and Injuries of the Spine, a 20% rating is warranted for thoracolumbar forward flexion greater than 30 degrees, but not greater than 60 degrees.  Therefore, the Board determined that a rating of 20% was appropriate for the LBP condition.  The Board tried to find a path to a higher rating, using other 4.71a (Schedule of ratings—musculoskeletal system) codes which could be applied to the LBP condition.  After Board consideration, none of the other 4.71a VASRD codes resulted in a higher rating since the record did not show sufficient evidence of a seriously disabling spine abnormality which would justify a higher rating.

The Board also considered the matter of peripheral neuropathy.  After reviewing all the information in the record, there was insufficient evidence of a clinically significant neuropathy that interfered with performance of military duties.  The CI did have neurological symptoms; however, there was no performance-based evidence resulting from the neurological condition which impacted his military duties.  Therefore, the Board concluded that there was no unfitting radiculopathy present at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the unfitting LBP condition.

Mental Health (MH) Condition.  On 4 September 2007, the CI self-referred to the MH clinic, due to problems with anger.  He was diagnosed with anxiety disorder, not otherwise specified (NOS).  He was started on Celexa (an anti-depressant), and Restoril (a benzodiazepine that is frequently used to treat insomnia).  The medications did improve his MH symptoms.  However, the Restoril was causing a “hangover” effect, so he was switched to Halcion (another benzodiazepine often used as a sleep-aid).  The CI was seen for follow-up on 17 October 2007, and he was much improved.  He told the examiner: “I feel normal.”  At this point, his MH diagnosis was changed to adjustment disorder, with anxiety.  Adjustment disorder was forwarded by the MEB as a diagnosis that did not cause the CI to fall below Army retention standards.  This MH condition was adjudicated by the PEB as “not compensable, although it may be administratively unfitting.”

The CI’s DOS was 27 March 2008.  Three weeks prior, on 4 March 2008, he had a VA C&P exam.  At that exam, his clothing and hygiene were appropriate.  His attitude was calm and cooperative.  No unusual movements or psychomotor changes were observed.  Speech was normal for rate, tone, and volume.  His affect was slightly flat, but generally within the normal range.  His mood was slightly anxious.  Thought processes were goal directed, and logical.  No evidence of hallucinations, delusions, obsessions, compulsions, or phobias was observed.  Memory and concentration were intact.  His insight was poor, and judgment was fair.  The Axis I diagnosis was anxiety disorder NOS.  The Global Assessment of Functioning score was 56 (indicating moderate symptoms or moderate difficulty in functioning).  With regard to impairment, the examiner wrote: “Thought processes and communication are not impaired.  Social functioning is mildly impaired.  Employment is not impaired.  Other mental conditions were not found.”

The CI’s MH condition was thoroughly reviewed by the action officer, and considered by the Board.  The MH condition was not profiled, was not implicated in the commander’s statement, and was not judged to fall below retention standards.  There was no indication from the record that his MH condition significantly interfered with satisfactory duty performance.  Although there was some disagreement among the CI’s MH care providers, the Board determined that the PEB adjudication of the MH condition was correct, and was IAW the DoDI 1332.38 which was in effect at that time.  After due deliberation, the Board found insufficient cause to recommend a change in the PEB adjudication of the MH condition.

Other PEB condition.  Hyperlipidemia (high level of lipid in the blood) was adjudicated by the PEB as not unfitting, and therefore not ratable.  The Board’s main charge with respect to this condition is to assess the appropriateness of the PEB’s fitness adjudication.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

The hyperlipidemia condition was thoroughly reviewed by the action officer and considered by the Board.  The Board determined that this condition was not specifically profiled, was not implicated in the commander’s statement, nor was it judged to fail retention standards.  There was no indication from the record that this condition 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 hyperlipidemia condition and therefore no additional disability rating is recommended.

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.  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the MH condition (adjustment disorder), the Board unanimously recommends no change from the PEB determination as not compensable.  In the matter of the hyperlipidemia condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140529, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

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 XXXXXXXXXXXXXXX, AR20150015571 (PD201402739)

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						    XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA