RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03272
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080916

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E4, Human Resources Specialist, medically separated for “low back pain” and “Posttraumatic Stress Disorder (PTSD),” rated 20% and existed prior to service (EPTS) with no permanent service aggravation, respectively, with a disability rating of 20%.

CI CONTENTION:  The CI contends his conditions continue to worsen and 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 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 - 20080715	VARD - 20090714	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	20%	Lumbar Spine Bulging Disk L3-4 and L4-5 to include Radiculopathy	8515-5237	20%	20090611	
PTSD	9411-9432	EPTS	Mental to include Depression/Anxiety/PTSD/Bipolar Disorder	9411	NSC	20090610	
Pilonidial Cysts	Not Unfitting	Residuals Scar Pilonidal Cysts Removal	7805	0%	20090611	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM) addendum, the CI reported he first experienced back pain in October 2003 after performing sit-ups.  His back pain continued intermittently over the years, and he was treated with medications, physical therapy, and epidural injections without significant improvement.  MRI of the lumbar spine in November 2005 demonstrated L3-4 and L4-5 central osteo-annular bulging.  A repeat MRI in September 2007 showed L3-4 and L4-5 disk disease and mild canal stenosis at L3-4 without significant neural foraminal narrowing.  The CI was not a surgical candidate.  The CI’s condition did not result in improvement sufficient enough to allow unrestricted duty.  The MEB forwarded chronic low back pain for PEB adjudication.

The MEB NARSUM addendum examination on 21 March 2008, 6 months prior to separation, noted complaints of constant back pain which the CI rated 4/10.  His symptoms were worse with bending, exercising, and repetitive lifting.  He denied radiation of pain into the legs, but he had intermittent tingling into the left middle toe which lasted for about 1 hour.  Physical examination showed absence of tenderness to palpation, normal motor strength and normal neurological examination.  Gait was normal.

PT ROM for the MEB was conducted 2 months before separation, and documented forward flexion of 55 (pain begins) to 70 (end range) degrees (normal 90) and a combined ROM of 200 degrees (normal 240).  After repetition, flexion was to 80 degrees and the combined ROM was 220 degrees, with painful motion.

At the 11 June 2009 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported he had surgery in March 2009 “to trim vertebra,” and was now having continued pain daily.  The CI reported he also had dull, radiating pain to the left hip.  His pain was aggravated by prolonged standing or sitting, and relieved by changing position and medication.  Physical examination recorded a normal gait and a normal neuromuscular examination.  ROM documented flexion to 50 degrees and a combined ROM of 120 with pain on motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5237 (lumbosacral strain), citing, “satisfactory evidence of pain beginning at 55 degrees forward flexion.”  The VA rated the back condition 20% coded analogously 8515-5237, based on the VA C&P examination 9 months after separation and 3 months after surgery, citing limitation of flexion (greater than 30 degrees but not greater than 60 degrees) and/or combined ROM (not greater than 120 degrees).

The Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve 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 low back condition.  

Contended PEB Conditions:  Posttraumatic Stress Disorder and Bipolar Disorder.  According to the service treatment records and the MEB mental health (MH) narrative summary (NARSUM), the CI reported childhood history significant for physical, mental, and sexual abuse.  He had no combat experience.  Subsequent to his childhood experiences, the CI developed symptoms suggestive of PTSD.  Service records noted that the CI reported before he returned from Kuwait in 2007, he was interviewed by a psychologist.  He reportedly stated that he had never thought about his past history until he was being asked questions and he answered truthfully for the first time.  Since that time, he has had intrusive thoughts daily related to childhood trauma.  

At the MH NARSUM dated 19 May 2008, 4 months before separation, the CI reported he had a history of behavior health treatment beginning at age 8, and was referred to MH at age 13.  Both times he had been seen for withdrawn behavior and both times he reportedly denied abuse out of fear that he would be removed from his home if he was truthful about the abuse.  At the age of 16, he was court ordered to anger management after being arrested.  The CI currently reported insomnia, difficulty with sleep, hypervigilance related to past gang involvement, occasional panic attacks, and problems with focus and concentration.  He noted his greatest problem was managing his temper; he had inappropriate outbursts of anger that were usually out of proportion to the inciting stimuli.  The CI had received referrals to anger management classes and in the previous year he punched a hole in the wall at his reserve center out of anger.  He had medication trials with little benefit.  There was no evidence that the CI had inpatient MH treatment or treatment in the emergency room.  It was noted that he did not have a history of suicidal or homicidal ideation, plans, intent or attempt.  The mental status examination (MSE) was unremarkable.  The diagnoses of PTSD, chronic, manifested by exposure to events described above, and bipolar disorder, not otherwise specified (NOS) were listed and the examiner opined onset for both was prior to service (EPTS).  A Global Assessment of Functioning (GAF) score of 55 (moderate symptoms and or impairment) was recorded.

At the VA Compensation and Pension (C&P) MH examination performed 9 months after separation, the CI reported he was not in treatment for a MH condition and had no history of MH hospitalization.  He noted that he was not interested in further treatment.  His childhood history of abuse and his history of juvenile delinquent behavior was documented.  The CI denied significant impairment at work, or in his relationships, but noted that his PTSD symptoms impaired his comfort in crowds.  He was working full-time and had not lost anytime from work.  The examiner noted that the CI’s PTSD was the result of childhood experiences.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined the PTSD and the bipolar disorder NOS condition were not compensable, citing both were considered to have existed prior to service and there was absence of documentation substantiating that the conditions were permanently aggravated by the service.  The VA also assigned no rating for the MH conditions, citing the conditions were not service connected.  

The Board found no evidence to indicate this was not correct.  The Board next considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.

According to the NARSUM, the CI had reported an extensive history of childhood abuse that existed prior to military service as noted above.  The NARSUM and C&P examination noted that the CI had either met with, was evaluated or treated by MH professionals since 1999 (prior to service) related to abuse issues.  The examiner indicated the conditions existed prior to service, and that both MH conditions were exacerbated by service; however, documentation of a service related precipitating factor was not recorded.  The examiner recorded “chaotic upbringing during vital developmental periods in childhood” as precipitating condition for both PTSD and bipolar condition.  The C&P examiner suggested that his PTSD condition was service aggravated.  Both examiners appeared to have considered the questioning by the psychologist as a sentinel event that led to his symptoms and therefore, should be considered service aggravation.  The Board acknowledged both examiner’s opinion; however, the board considered the evidence in its totality and was unable to find any justification to support a change in the PEB’s decision in this matter.  After due deliberation, considering all of the evidence the Board concluded the EPTS PTSD and bipolar condition was not permanently aggravated by service beyond the natural progression of the condition and therefore recommends no change in the PEB’s adjudication.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the pilonidal cysts were not unfitting.  The pilonidal cysts condition was not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the low back condition and IAW §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the PTSD and Bipolar Disorder, NOS condition, the Board recommends no change in the PEB adjudication.  In the matter of the contended pilonidal cysts, 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.  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 20140715, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160017170 , XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure