RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03362
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150409
SEPARATION DATE:  20080902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Munitions System Journeyman) medically separated for a neck and back condition.  The neck and back condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was placed on limited duty and referred for a Medical Evaluation Board (MEB).  “Back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded one other condition (asthma).  The Informal PEB adjudicated “chronic neck pain” and “chronic low back pain” as unfitting, rated 10% and 10% respectively.  Asthma was determined to be a Category II condition (conditions that can be unfitting but are not currently compensable or ratable), citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) IAW National Defense Authorization Act of 2008.  The PEB also noted severe obesity as a Category III condition.  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:

Service IPEB – Dated 20080703	VA - (9 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5237	10%	Cervical Strain	5237	20%	20090527	
Chronic Low Back Pain	5237	10%	Lumbar Strain and Thoracic Scoliosis…	5237	20%	20090527	
Asthma	CAT II	Asthma	6602	30%	20090527	
Other x 1 (Not in Scope)	Other x 6	
Combined:  20%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20090724 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Chronic Neck Pain.  The evidence available for review documents that the CI began complaining of neck pain in mid-2004.  The service treatment records do not document any injury or inciting event as the cause of her neck pain.  She had plain film X-rays that demonstrated “…a straightened cervical lordosis, which may be secondary to paraspinal muscle spasm vs. positioning.”  A cervical spine magnetic resonance imaging (MRI) study was normal.  The evidence strongly supports that her pain was caused by myofascial pain/cervical muscle spasms.  She was treated with non-steroidal anti-inflammatory drugs (NSAID), physical therapy (PT), chiropractic treatment and trigger point injections with some response.  There was no mention of upper extremity radicular symptoms.  The narrative summary (NARSUM) completed 5 months prior to separation noted that her back had been continuously symptomatic since 2004 and she had not responded to extensive PT and pain management.  Surgical options were not considered to be useful in her situation.  The physical exam revealed a slightly decreased range-of-motion (ROM) of the cervical spine with spasm of the cervical paraspinal muscles.  She did have multiple trigger points palpable.  At the VA Compensation and Pension (C&P) exam performed approximately 9 months after separation, the CI reported that her neck pain began due to a motor vehicle accident (MVA) and that her neck pain was worsening.  She reported that NSAIDs, trigger point injections, and chiropractic treatment helped some.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM (Degrees)	PT/MEB ~ 5 Mo. Pre-Sep	VA C&P ~ 9 Mo. Post-Sep	
Flex (45 Normal)	45	30	
Combined (340)	270	190	
Comment	Bubble Inclinometer Used
	Goniometer used; Pos. painful motion & tenderness to palpation; No spasm or Deluca criteria	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied the analogous VASRD code of 5299-5237 (cervical or lumbosacral strain) and rated at 10%.  The VA applied code 5237 and rated at 20% based on the ROM measurements documented in the C&P exam.  In assigning probative value to the somewhat conflicting PT and C&P examinations, the Board notes that: the PT measurements are consistent with corroborating prior to separation evidence e.g., gross ROM observations in outpatient notes consistently apply the descriptors “normal” or “slightly decreased”; the MEB and PT exams are consistent with the diagnostic and clinical pathology in evidence; and although there is not a reasonable accounting for progressively impaired ROM in the interval between the PT and C&P examinations, the CI stated that her condition was “worsening” on the C&P examination.  The probative value of the PT measurements was judged to be somewhat compromised by the use of a bubble inclinometer to obtain the ROM measurements.  Based on all evidence and associated conclusions just elaborated, Board members agreed that preponderant probative value should be assigned to the prior to separation MEB evaluation.  Using the General Rating Formula for Diseases and Injuries of the Spine, the PT exam’s 45 degree ROM measurement is non-compensable; however, the MEB exam’s documentation of cervical muscle spasm meets the 10% criteria under the general rating formula.  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 condition.

Chronic Low Back Pain.  In late 2004, the CI slipped while walking on stairs during a move injuring her low back.  At her next base, she began treatment with PT in October 2004, stating “I’ve always had back pain.”  The CI continued treatment by PT and her primary care physician diagnosed her with “myofasciitis” in May 2005 and treated her with NSAIDS and muscle relaxers.  Continued treatment did not resolve her pain.  The NARSUM noted that her back had been continuously symptomatic since 2004 and she had not responded to extensive PT and pain management.  The C&P exam noted that her low back pain began due to a motor vehicle accident and was worsening.  The C&P data contained the following excerpt regarding radiographic data:

“06/23/2008 X-RAY L-SPINE Reason for Order:  low back pain on and off for years.  IMPRESSION: No bone or joint abnormality.  At disk space L4-L5 show linear punctate densities could be due to artifacts.  If there is persistent clinical concern and consider MRI of the spine.”

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM (Degrees)	PT ~2 Mo. Pre-Sep	VA C&P ~ 9 Mo. After-Sep	
Flexion (90 Normal)	70	50	
Combined (240)	170	140	
Comment	Inclinometer used; Normal gait; Pos. painful motion & tenderness to palpation; Normal strength, sensation & reflexes	Pos. painful motion; No tenderness or spasm; Normal strength	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied code of 5237 and rated at 10%.  The VA applied code 5237 and rated at 20% based on the ROM measurements documented in the C&P exam.  In assigning probative value to the somewhat conflicting PT and C&P examinations, the Board notes that: the PT measurements are consistent with corroborating prior to separation evidence; the MEB and PT exams are consistent with the diagnostic and clinical pathology in evidence; and although there is not a reasonable accounting for progressively impaired ROM in the interval between the PT and C&P examinations, the CI stated that her condition was “worsening.”  Although the probative value of the PT measurements was judged to be somewhat compromised by the use of an inclinometer, based on all evidence and associated conclusions, Board members agreed that preponderant probative value should be assigned to the prior to separation PT evaluation of the CI’s thoracolumbar spine.  Using the General Rating Formula for Diseases and Injuries of the Spine, the PT exam’s 70 degree ROM measurement meets to 10% criteria under the general rating formula as assigned by the PEB.  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 low back condition.

Contended Asthma Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the asthma condition was not unfitting.  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.  There is no indication in the record that the asthma condition was ever profiled (all profiles present for review were P2 or better).  The commander’s statement specifically noted the following statement, “Her supervisors have not seen any indication that her asthma impacts her work negatively.”  All service treatment record entries were reviewed and considered by the Board.  There was no performance based evidence found in the record to support that the asthma condition significantly interfered with satisfactory duty performance.  After due deliberation 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 Asthma contended condition and so 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chronic neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended asthma 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 20140702, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03362.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings