RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04356
BRANCH OF SERVICE:  Army	
DATE PLACED ON TDRL:  20050428
DATE REMOVED FROM TDRL:  20070130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantry, medically separated from the Temporary Disability Retired List (TDRL) for “low back pain,” and “rectal incontinence,” rated 20% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  Conditions should have been unfitting, rated higher, continue to worsen and negatively impact 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 – 20050214/20070117	VARD – 20050509 & 20061026	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Neurogenic Bladder	7542	20%	Not Unfitting	Neurogenic Bladder	7542	20%	--	
Chronic Low Back Pain	5299-5243	10%	20%	Spinal Cord Injury…	5299-5243	10%	--	
Bowel Incontinence	7332	10%	0%	Neurogenic Encopresis	5243-7332	10%	--	
COMBINED RATING:  40% → 20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Neurogenic Bladder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s urinary incontinence condition began in January 2004 after sustaining a back injury from a fall with full combat gear.  The MEB forwarded “chronic urinary incontinence” for PEB adjudication.  At the 4 October 2004 urology consultation, performed 7 months prior to TDRL placement, the CI was followed-up for chronic urinary incontinence.  Urodynamics showed “a large low-pressure, fairly flaccid bladder with decrease in urethral pressure profile and sphincter EMG [electromyography] activity consistent with lower cord lesion.”  The assessment was urinary incontinence secondary to cord injury.  The urologist recommended continued timed voiding (which had helped to a degree) to keep the bladder as empty as possible.  The MEB NARSUM examination on 4 November 2004, performed 6 months prior to TDRL placement (with addendum dated 22 November 2004), noted complaints of chronic urinary incontinence.  The CI did not wear diapers.  Physical examination was not contributory.

At the 20 January 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months before TDRL placement, the CI reported urinating 8 times a day at intervals of 2 hours.  He had no night time voiding problems, and no problems starting urination.  He had urine incontinence that did not require a pad or absorbent material.  Genital examination was normal.

At the 8 March 2006 urology consultation, performed 11 months before TDRL removal, the CI reported symptoms of “occasionally leaking urine, has some urgency, but has a good stream.  He did not feel that he was retaining urine.  He complains of no fecal incontinence.”  Review of systems indicated he had some loss of urinary control with physical activity.  Genitourinary examination was normal.  Cystometrogram (assess bladder while storing urine) and uroflow (measure flow and force of urine) study from 5 January 2006 was summarized, and the urologist indicated that “bladder pressure and flow rates were acceptable.”  The CI had “some sensation bladder fullness” at 500 ml [sensation usually greater at a lower volume].  Impression was “The (CI) does not have a neurogenic bladder.  While he does have some stress incontinence, which is unusual in a man, his bladder pressures and flow rates were acceptable.  He totally empties his bladder.  He has no abnormal rectal examination findings consistent with a global nerve injury from the sacral spinal cord.”  The urologist recommended annual uroflow and cystometrogram for the next several years.

The interim TDRL examination on 21 June 2006, performed 7 months before TDRL removal, noted complaints of continued urinary incontinence which was controlled somewhat by timed voiding.  He reported small episodes of incontinence with this treatment but the large volume incontinence episodes seemed to be under control.  Examination was non-contributory and continuation on TDRL was recommended.  The TDRL examination on 3 January 2007, the month of TDRL removal, noted complaints of incontinence without the use of diapers.  He went “to the bathroom sometimes on an hourly basis to avoid issues of urinary incontinence.”  The CI stated that with dietary control, he could control his bowel movement (see below).  The physician indicated that the CI would have difficulty performing Army duties with incontinence.  Physical examination showed no focal signs.

The Board directed attention to its rating recommendation based on the above evidence.  At TDRL placement, the PEB rated the neurogenic bladder condition 20%, coded 7542 (neurogenic bladder), citing timed voiding once an hour to prevent incontinence.  The VA also rated the neurogenic bladder condition 20%, coded 7542 based on the VA C&P examination 3 months before TDRL placement, citing daytime urinary frequency interval between 1 and 2 hours.  At TDRL removal, the PEB adjudged that the neurogenic bladder had minimal to mild stress incontinence that did not require wearing a pad or appliance, and was no longer unfitting and therefore not rated.

At TDRL placement, the CI had abnormal urologic studies showing a neurogenic bladder and used timed voiding (daytime urinary frequency interval between one and two hours) to control his urinary incontinence.  There was no required use of absorbent material or awakening to void that warranted any rating higher than the 20% awarded by the PEB.  At TDRL removal, the CI used timed voiding (daytime urinary frequency interval between one and two hours) to control his urinary incontinence; however, urologic testing from 11 months prior to TDRL removal were “acceptable” and indicated the CI no longer had a neurogenic bladder, but had stress incontinence with urine leakage with activity.

The Board’s main charge is to assess the fairness of the PEB’s determination that at TDRL removal the neurogenic bladder was not unfitting.  The TDRL physician indicated that the CI went to the bathroom (urinated) on up to an hourly basis to avoid issues of urinary incontinence and “would have difficulties performing Army duties with incontinence.”

Although the clinical urology results were improved from TDRL placement, they were still abnormal although “acceptable.”  The CI still had a daytime urinary frequency interval adjudged as between 1 and 2 hours, with urine spillage with activities despite the timed voiding.

The Board deliberated if the CI’s frequent daytime voiding and stress incontinence with activity rose to the level of being unfitting for an E4 Infantry soldier.  Given the activity requirements of the CI’s MOS and the CI’s timed voiding and stress incontinence with activity, the Board adjudged that the preponderance of the evidence supported that the CI’s neurogenic bladder was unfitting at TDRL removal.  Given the frequency of daytime voiding, the CI met the 20% rating criteria under code 7542.

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 neurogenic bladder condition at TDRL placement.  However, there was a preponderance of evidence that the CI’s bladder condition was still unfitting at TDRL removal and the Board recommends a disability rating of 20% for the neurogenic bladder condition, coded 7542 at TDRL removal.

Chronic Low Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition began in approximate May 2003 timeframe after falling with full combat gear.  Diagnostic imaging in February 2004 showed a disk bulge at L4-5 and L5 retrolethesis (degenerative disk disease).  The CI had low back pain and his associated bowel and bladder symptoms are discussed in other sections.  There was no surgical indication.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “spinal cord injury” for PEB adjudication.

The MEB NARSUM examination on 4 November 2004, 6 months prior to TDRL placement (with addendum dated 22 November 2004), noted complaints of severe low back pain with intermittent pain down both legs and numbness and tingling down into both legs.  Physical examination showed a normal gait with lumbar spine tenderness and no muscle spasm.  The range of motion (ROM) was flexion to 90 degrees (normal) and combined 235 degrees (normal 240).  Provocative testing for radicular symptoms was negative.  Rectal examination revealed markedly decreased sphincter tone and anal reflex was absent.  Lower extremity reflexes were normal and symmetric.  Electrodiagnostic studies (EMG/NCV) performed on 15 November 2004 were negative for radiculopathy or other peripheral neuropathy.

At the 20 January 2005 VA C&P evaluation, performed 3 months before TDRL placement, the CI reported suffering from L4-5 degenerative disc disease and T12-L1 decreased in height, with symptoms of headaches.  X-rays were negative.  Physical examination showed normal gait and posture.  Provocative testing for radicular symptoms was negative, and there was no tenderness, spasm or painful motion.  ROM was normal with flexion of 90 degrees and combined 240 degrees, with no decrease on repetition.  Lower extremity strength, sensation and reflex testing was normal.  The TDRL examination on 3 January 2007 (the month before TDRL removal) noted complaints of back pain with incontinence.  Physical examination showed the CI could walk on heels and toes.  There was no tenderness.  ROM was flexion to 40 degrees due to mechanical limit, and combined ROM of 190 degrees.  Strength and reflex testing in the legs was normal.  There was diminished sensation to light touch in the first web space of the left foot compared to the right.  Provocative testing for radicular symptoms was negative.

The Board directed attention to its rating recommendation based on the above evidence.  At TDRL placement, the PEB rated the chronic low back pain condition 10%, analogously coded 5299-5243 (intervertebral disc syndrome), citing limited motion.  The VA also rated the spinal cord injury condition 10%, also analogously coded 5299-5243 based on the MEB NARSUM examination, citing tenderness and slight limitation of motion.  At TDRL removal, the PEB rated the chronic low back pain condition 20%, analogously coded 5299-5243, citing limitation of motion.  The Board agreed that at TDRL placement a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB NARSUM.  The Board agreed that that at TDRL removal a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the TDRL examination.  There was no evidence of incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for intervertebral disc syndrome.  There was no evidence of an associated unfitting lower extremity radiculopathy for consideration of a separate peripheral nerve rating.  The associated bowel and bladder dysfunctions are described separately.

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 pain condition.

Bowel Incontinence.  According to the STR and MEB NARSUM, the CI’s bowel incontinence condition began in January 2004 after sustaining a 2003 back injury from a fall with full combat gear.  The bowel incontinence was related to the back injury and gastroenterology evaluation found no intrinsic colon disease.  The MEB forwarded “encopresis, neurogenic” for PEB adjudication.  The MEB NARSUM examination on 4 November 2004, 6 months prior to TDRL placement (with addendum dated 22 November 2004) noted complaints of fecal incontinence at least once every two days.  He had some voluntary control of bowel movements, and did not wear diapers.  Rectal manometry was performed and showed abnormal sensation and urge.  Physical examination showed markedly decreased rectal sphincter tone and absent anal reflex.

At the 20 January 2005 VA C&P evaluation, performed 3 months before TDRL placement, the CI did not relate any gastrointestinal symptoms.  Physical examination showed decreased rectal sphincter tone.  The TDRL examination on 3 January 2007, the month of TDRL removal, noted the CI stated that due to dietary considerations he did not have problems with unplanned defecation.  “He states that with dietary control, he can control his bowel movement.”  Physical examination showed “no focal signs noted.”

The Board directed attention to its rating recommendation based on the above evidence.  At TDRL placement, the PEB rated the bowel incontinence condition 10%, coded 7332 (rectum and anus, impairment of sphincter control), citing occasional incontinence episodes with decreased sphincter tone and absent anal reflex.  The VA also rated the neurogenic encopresis condition 10%, analogously coded 5243-7332 based on the VA C&P examination 3 months before TDRL placement, citing decreased sphincter tone the VA examination and evidence of occasional leakage of stool from the MEB NARSUM summary.  At TDRL removal, the PEB rated the bowel incontinence condition 0%, coded 7332, citing the condition was well controlled by keeping solid stools and the CI did not wear a pad and did not have problems with unplanned defecation.  The Board agreed that at TDRL placement a 10% rating was justified for occasional moderate leakage.  There was no requirement for use of a pad or excessive leakage to warrant any higher rating.  The Board agreed that at TDRL removal a 0% rating was justified as there was no indication of leakage, involuntary bowel movement, or requirement for wearing a pad.

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 bowel incontinence condition.

BOARD FINDINGS:  In the matter of the neurogenic bladder condition, the Board unanimously recommends no change in the PEB adjudication for TDRL placement and a finding of unfit with a disability rating of 20%, coded 7542, for TDRL removal IAW VASRD §4.115b.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bowel incontinence condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Neurogenic Bladder	7542	20%	20%	
Chronic Low Back Pain	5299-5243	10%	20%	
Bowel Incontinence	7332	10%	0%	
COMBINED	40%	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 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 AR20160018422 (PD201404356)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			       
						      Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA