RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03076
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050901

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, MLRS Crewmember, medically separated for “chronic subjective low back pain” and “major depression,” rated 10% and 10%, respectively, with a combined  disability rating of 20%.  

CI CONTENTION:  The Ci requests consideration of all conditions.  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 upon a 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 - 20050720	VARD - 20051020	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Low Back Pain	5299-5242	10%	Degenerative Disease, Thoracolumbar Spine	5242	10%	20050331	
Major Depression	9434	10%	Posttraumatic Stress Disorder	9411	30%	20050418	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in September 2004 after he turned to the left and felt an immediate sharp pain and a pop in his lower back.  Neuroimaging on 25 October 2014 showed right L5/S1 bulge, a L4-5 minor bulge, and a L3-L4 minor annular bulge. He was referred for surgical evaluation.  Neurosurgery consult noted lumbar degenerative disc disease.  He received a permanent profile given his condition had not responded to conservative therapy.  The MEB forwarded low back pain for PEB adjudication.  At the MEB examination dated 7 April 2005, 5 months prior to separation, the CI reported low back pain with intermittent numbness and tingling of bilateral legs and feet. Physical examination showed range of motion (ROM) of forward flexion at 75 degrees and combined ROM of 215 degrees.  He reported discomfort at the endpoints of the ROM in all planes.  Extremities showed no effusion, swelling or muscle atrophy, no radicular signs, and normal reflexes. He was able to heel walk and toe walk.  Sensations were normal.  Gait was normal.  He showed discomfort on arising from the seated position initially.  The MEB NARSUM examination on 15 April 2005, 5 months prior to separation, reflected the above findings on 7 April 2005.  The AMA pain rating was slight intensity and constant frequency.  A diagnosis of lumbago due to degenerative disc disease was rendered.  

At the 31 March 2005 VA Compensation and Pension (C&P) evaluation, performed 5 months before separation, the CI reported constant low back ache sometimes going from upper thigh and both legs to the mid back area with burning, sharp and aching sensation, rated 3/10.  It occurred spontaneously with stress and activity, sitting and standing.  He could function with medication when he had pain.  He reported incapacitation once or twice in the past year for 3-4 days total.  Work capacity was limited due to limited lifting, running, jumping and backpacking.  There was no lost work time at his usual occupation of ammo specialist for the past 43 months.  Physical examination showed normal gait and posture without the use of assistive devices.  There was no obvious limitation of function for standing or walking.  Examination of the spine demonstrated no radiation of pain, no muscle spasm, no tenderness, ankyloses or abnormal straight leg raise test.  ROM showed flexion to 90 degrees and combined ROM of 210 degrees.  There was no intervertebral disc syndrome.  Neurological examination of the lower extremities was normal.  Lumbar spine x-rays showed minimal degenerative disc space narrowing at L4-5 and bilateral spondylolysis of L5 without subluxation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded 5242 (lumbosacral strain), citing combined ROM of 226 degrees.  The VA also rated the degenerative disc disease condition 10% coded 5242 (lumbosacral strain), based on the VA C&P examination 5 months before separation, citing combined ROM of 210 degrees.  The Board considered that the VASRD General Rating Formula for Diseases and Injuries of the Spine and found both MEB and VA ROM met the 10% rating criteria by combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees (MEB 226 and VA 210 degrees).  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 low back pain condition.  

Major Depression.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s major depression condition began in June 2003 after deployment to Iraq in April 2003.   He threatened to shoot himself June 1 and was taken to Germany for evaluation.  According to the Post-Deployment Health Assessment he was hospitalized 4-14 June 2003.  At that time he did not report combat stressors, but noted that he had “a lot” of depression, thoughts of being better off dead and little interest in doing things for the past 2 weeks.  Major depression disorder (MDD) was diagnosed and he was treated with anti-depression medication.  While on leave in July 2003 he overdosed on his anti-depression medication and 15 tablets of a dietary supplement.  The next day he voluntarily admitted himself to the hospital.  He received outpatient treatment with the psychiatrist he initially saw from 10 July 2003 to 23 November 2003.  Diagnosis was changed to bipolar disorder and other antidepressants were tried.  He redeployed to Iraq December 2003-April 2004.  He stopped the medications and the depression returned.  He displayed physical and verbal aggression towards his wife, hitting her three times.  His diagnosis changed again and he resumed anti-depression medication he had taken previously.  He began to feel better and was progressing.  The MEB forwarded MDD for PEB adjudication.  
The MEB NARSUM examination on 22 June 2005, 2 months prior to separation, noted complaints of problems with attention span, concentration, motivation and sleep.  He continued to have episodes of depression.  He was taking an anti-depression medication and a sleep aid.  He was in regular therapy.  Mental status examination (MSE) 27 April 2005 showed mildly depressed mood.  A diagnosis of MDD was rendered with a Global Assessment of Functioning (GAF) score of 65 (mild impairment, symptoms).  Impairment for social and industrial adaptability was definite.  At the 18 April 2005 VA Compensation and Pension (C&P) evaluation, performed 4 months before separation, the CI reported he was taking an anti-depression medication and a sleep aid daily.  He was in an artillery unit and received incoming fire, had nightmares about the Iraqi War 3-4 times per week, avoidance and recurring thoughts of the war, was more distant with others and had difficulty showing love and affection. He could not sleep without medication.  He saw a psychologist once every 1-2 weeks since January 2005 and saw a psychiatrist about once per month.  He performed personal chores.  He ate out with buddies at work and had a friend with whom he occasionally went to the movies and visited.  He liked to watch television, hike, camp, and walk.  He studied programs on his computer.  He was able to work a 40 hour work week.  MSE revealed some depressed feelings.  The examiner noted his depressed feelings were related to PTSD, his primary diagnosis.  A diagnosis of PTSD was rendered with a GAF score of 85 (absent, minimal symptoms with good functioning).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD condition 10%, coded 9434 (MDD), citing psychotropic medication and outpatient treatment and performing duties in the unit.  The PEB rated the condition IAW AR 635-40, appendix B-107, paragraph citing mild impairment.  The VA rated the PTSD condition 30% coded 9411 (PTSD), based on the VA C&P examination 5 months before separation, citing poor sleep, nightmares, anger, increased startle response, problems with concentration and ability to maintain limited social relationships.  The Board first considered if application of VASRD §4.129 with a 6 month (50% minimum) period on the TDRL was indicated in this case.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for MH conditions.  All members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  

The Board then considered if there was evidence for a §4.130 rating higher than the 10% rating assigned by the PEB.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.” The NARSUM examination was most proximal to separation and noted the CI had mild symptoms of depression with a GAF score of 65.  Despite the PEB’s use of AR 635-40 for rating purposes, the Board determined that the CI’s occupational and social impairment was controlled by medication for a 10% rating at the time of separation.  The C&P examination noted he was working full-time and able to engage in leisure activities with friends.  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 MDD condition.  

BOARD FINDINGS:  In the matter of the MDD condition and IAW VASRD §4.130, the Board recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140626, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 
XXXXXXXXXXXXXXXXXX, AR20160017157 (PD201403076)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA