RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00007
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Personnel Service Specialist, medically separated for “chronic low back pain without neurological abnormality,” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  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 - 20031125	VARD - 20150206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Chronic Back Pain	5236-5237	NSC	20141014	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began with a motor vehicle accident in 1994 treated with chiropractic therapy.  He reinjured his back in April 2003 while moving lockers and was again treated with chiropractic and physical therapies.  Radiographic imaging was normal, but chiropractic notes documented hypolordosis (abnormal spinal contour).  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred to an MEB.  The MEB forwarded “chronic low back pain” to the PEB for adjudication.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 23 October 2003, 3 months before separation, the physical examination showed range of motion (ROM) as full with pain.  During the MEB NARSUM examination also performed on 23 October 2003, the CI reported continuous mild to moderate low back pain which woke him up 3-4 days per week.  Physical examination showed ROM flexion of 90 degrees (normal) without painful motion or other symptoms cited.  Chiropractic examinations performed in October and November 2003 documented the CI with full lumbar and thoracic ROMs and painful motion was not cited.

The CI did not submit for a VA disability claim until 22 February 2012, or complete a VA Compensation and Pension (C&P) evaluation until 14 October 2014 over 10 years after separation.  The Board gives consideration to VA evidence, particularly within 12 months of separation, evidence beyond 12 months, as in this case, has less probative value.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded 5299-5237 (lumbosacral strain), citing flexion 90 degrees, without spasm or tenderness. There was no evidence of forward flexion less than 85 degrees, combined ROM less than 235 degrees, or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50% or more for a 10% rating.  The Board agreed there was insufficient limitation of motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine; however, a 10% rating was justified for functional loss due to the painful motion documented by the MEB examination performed on the same day as the MEB NARSUM.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the low back condition, coded 5299-5237.

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  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	RATING	
Chronic Low Back Pain	5299-5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141230, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160018456 (PD201500007)

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 10% 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