RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03856
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Cable Systems Installer-Maintainer, medically separated for “chronic low back pain” with a disability rating of 10%.

CI CONTENTION:  The CI simply stated: “Back injuries” and “Major Depressive Disorder.”  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 – 20060228	VARD - 20060922	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Degenerative Disc Disease (DDD) Lumbar Spine	5243	20%	20060727	
			Radiculopathy Right Lower Extremity Associated with DDD Lumbar Spine	8599-8521	10%		
Adjustment Disorder with Mixed Emotional Features	Not Unfitting	Adjustment Disorder with Depressed Mood	9440	30%	20060720	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in May 2004 when she attempted to lift a cable while deployed to Iraq.  She was placed on quarters.  Diagnostic imaging of the CI’s lumbar spine in July 2005 noted no significant abnormalities.  Electro-diagnostic studies (EMG/NCV) were not accomplished secondary to the CI’s needle phobia.  There was no surgical indication and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The CI was referred for MEB which forwarded “chronic low back pain (moderate/constant)” for PEB adjudication.

At the physical therapy (PT) clinic examination on 23 Aug 2005, 8 months prior to separation, the CI had low back pain, 6/10 in intensity.  Prolonged sitting, physical training and sleeping exacerbated the pain while hot baths relieved it.  Range of motion (ROM) measurements were recorded per the chart below.  Physical examination showed the CI walking with a forward-flexed posture.  Painful motion was noted over L4-S2 vertebrae.  Neurologic examination was without referred pain, increased tone, numbness or tingling into the lower extremities.

At the time of the Troop Medical Clinic appointment on 30 August 2005, the CI reported no improvement with an epidural steroid injection (administered 5 days prior).  She described her back pain as unrelenting, not relieved by either rest or medication.  Bowel and bladder function were not affected.  Physical examination showed tenderness of the lumbosacral spine.  Lumbosacral spine motion was “normal.”  There was evidence of non-organic pain.  There was no spine deformity noted.  Motor and reflex testing was normal. The CI’s standing posture was erect and normal but her gait and stance were abnormal, with limping observed.  ROM was observed as “normal.” 

At the MEB examination (recorded on DD Forms 2807 and 2808) dated September 2005, 7 months prior to separation, the CI reported pain, numbness, and tingling in both legs because of her back problem.  Physical examination recorded decreased ROM in the lumbosacral spine, with positive straight leg raise testing bilaterally (possible sign of neurologic abnormality as related to the low back condition).

The MEB NARSUM examination on 12 September 2005 (7 months prior to separation) noted complaints of back pain 6-10/10 in intensity, aggravated with prolonged standing or bending. The pain radiated into her left leg and she reported right leg weakness.  She said she had fallen several times secondary to the leg weakness.  Physical examination showed normal gait and stance. There was tenderness in the lower lumbar area and left paraspinous muscles.  Straight leg raise testing was positive.  Muscle strength was 5/5 in all extremities.  Reflex testing was normal.  ROM measurements were recorded per the chart above. The CI had normal muscle bulk and tone but showed decreased sensation of the left lower extremity (as compared with the right).  The examiner documented functional limitations per her profile.

A PT examination on 17 October 2005 (6 months prior to separation) showed ROM measurements per chart below.  The examiner observed the CI with a slow labored gait and pained expression, but stated her active ROM measurements were inconsistent with observed functional mobility (specifically trunk rotation, and flexion with transitional movements (e.g. sitting to standing)).

At the VA Compensation and Pension (C&P) examination on 27 July 2006, performed 3 months after separation, the CI reported frequent moderate-to-severe back pain and spasms with associated weakness, and numbness and tingling in her lower extremities. Bending, twisting, lifting, prolonged sitting, standing, or walking precipitated the pain.  Pain was relieved with medication.  Flare-ups occurred 2-4 times per month and were relieved with bedrest and medication.  She was limited in her ability to do chores around the house and could not drive for more than 15-20 minutes without experiencing pain.  The CI did not use any assistive devices for her condition.   Physical examination showed a normal posture and gait.  ROM measurements were recorded per chart below.  There were no paravertebral spasms.  Moderate pain was noted with bilateral leg raise.  Repetitive motion testing elicited additional pain but did not cause additional fatigue, lack of endurance, weakness or incoordination (negative DeLuca).  Neurologic and sensory testing showed diminished results bilaterally.  Muscle strength testing was adequate bilaterally.

The ROM examinations 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)	MEB ~7 Mo. 
Pre-Sep	PT ~6 Mo. 
Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Flexion (90 Normal)	45	45	60	
Extension (30)	5	5	20	
R Lat Flex (30)	35 (30)	35 (30)	20	
L Lat Flex (30)	90 (30)	40 (30)	20	
R Rotation (30)	39 (30)	29 (30)	20	
L Rotation (30)	35 (30)	35 (30)	20	
Combined (240)	170	170	160	
Comments	Painful motion; tenderness, Altered gait prob not due to spasm or spine contour	Goniometer and Inclinometer used.  Physician states “AROM inconsistent with observed functional mobility.”	Neg. DeLuca. Thorough exam most proximate to DOS. Ratable ROM.	
§4.71a Rating	20%	20%	20%	

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral strain), citing thoracolumbar ROM limited by pain, and positive tenderness without neurologic abnormality.    The VA assigned a 20% rating using the 5243 code (intervertebral disc syndrome [IVDS]) based on the VA C&P examination 3 months after separation, citing the CI’s flexion limited to 60 degrees.  Additionally, the VA assigned a 10% rating using an analogous 8521 code (incomplete paralysis of the external popliteal nerve), citing diminished bilateral deep tendon reflexes of the lower extremities.  

The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported by a preponderance of the examinations proximate to separation.  There was no evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There was no associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  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: Adjustment Disorder with Mixed Emotional Features.  Adjustment disorder is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending it as unfitting.  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 the contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended adjustment disorder with mixed emotional features 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.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140826, 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 (PD201403856)

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