RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00069
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060726

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E3, Food Service Specialist, medically separated for chronic low back pain (LBP) rated at 10% and chronic neck pain rated at 0% with a combined disability rating of 10%.  

CI CONTENTION:  The CI lists TBI, C2-C7 disc problems, cervicogenic headaches, C4-5 fusion, L4-L5 and S1-2 disc problems, MDD with pain disorder and anxiety disorder as conditions that should have the service ratings changed.  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 on 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 - 20060523	VARD - 20050831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	10%	Chronic Disease…Thoracolumbar Spine	5237	NSC	20050613	
			Chronic Disease…Left Leg	8599-8520	NSC		
			Chronic Disease…Bowel Control	7399-7319	NSC		
Chronic Neck Pain	5237	0%	Chronic Cervical …	5237	10%		
MDD	9434	EPTS	Acquired Psychiatric Disorder Diagnosed as Somatoform Disorder	9423	0%	20050620	
Pain Disorder…	Not Unfitting					
…Schizoid Traits						
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic LBP.  On 24 August 2004 in primary care, the CI was noted to be having a “horrible time with neck and low back pain.”  She was noted to have chronic lower back strain although no examination was documented.  In physical therapy (PT) on 1 October 2004, she reported an exacerbation of her LBP after helping some people move.  A CT discogram of the lumbar spine (a test to look for disc disease by injecting dye into the disc and observing the pain pattern and looking for a leak of the dye) was significant only for “very subtle facet degenerative change) and “very subtle early degenerative change at the L5-S1 disc without any evidence of epidural leak of contrast.”  The medical officer noted these were early findings of degenerative joint disease (DJD) and degenerative disc disease (DDD).  On 7 February 2005, an injection of the right SIJ provided relief of the LBP.  X-rays on 30 March 2005 were normal other than a slight bend (scoliosis) in the lumbar spine.  The CI was referred to a multi-specialty clinic on 11 May 2005 and was evaluated by a neurologist.  She was able to walk on her toes and heels and had normal (5/5) strength in both legs.  At the Medical Evaluation Board (MEB) examination (recorded on DD Forms 2807 and 2808) dated 23 May 2005, 14 months prior to separation, the CI reported ongoing LBP.  On examination, flexion was slightly reduced, but other ROM measurements met or exceeded VA normal values.  There were 3/5 signs of pain from maneuvers not expected to produce pain.  The neurological examination and gait were normal.  Electrodiagnostic studies on 25 May 2005 were consistent with a mild chronic L5-S1 radiculopathy on the right, but normal otherwise.  Sensation and reflexes were normal.  The gait was wide based and cautious.  

A VA Compensation and Pension (C&P) evaluation, performed on 13 June 2005, recorded she had an antalgic gait (abnormal due to pain) at the onset of the examination, but it was much smoother after the examination.  She favored the right hip.  The range of motion (ROM) was slightly reduced as charted below.  The neurological examination showed decreased sensation to vibration in both lower extremities (BLE) with no detection of a monofilament in either lower extremity.  Muscle tone was normal and atrophy absent.  Strength was recorded as 4/5 in BLE.  The reflexes were normal.  Heel, toe, and tandem gait were normal.  She could stand on one leg and do shallow deep knee bends (consistent with better than 4/5 strength).  Lumbar spine X-rays the same day were normal.  

An orthopedic consultation for the MEB was performed on 28 June 2005.  The CI reported she used a walker for ambulation of any distance, but could walk up to a mile per day.  Her back pain radiated to her right thigh.  On examination, her heel and toe walk were painful and the tandem walk appeared unsteady.  Motor function appeared to be 5/5, but of questionable effort, possibly limited by pain.  She reported reduced sensation of the left thigh, calves, and right foot.  Reflexes were normal.  Referral to a PEB was recommended.  

An addendum to the C&P evaluation was dated 7 July 2005, 13 months before separation, and was discussed with orthopedics.  The examiner noted there no record of any LBP following a motor vehicle accident (MVA) until the CI was injured at her civilian job.  The findings on the EDX studies were not explainable, but were not thought to be due to the LBP condition.  There was no evidence of a lumbar spine or thoracic spine condition nor did the evidence support that one was caused by/aggravated by the MVA.  The examiner also noted that the gait and presentation were incongruent with the diagnostic (testing) and examination results (objective findings).  

The CI reported continued pain of the neck and back and underwent a second discogram with CT scan on 29 November 2005.  This showed an increase in pain with the infusion at L5-S1; however, there was no leakage of dye and the pain did not radiate to her right leg.  It was thought to be equivocal.  The CT portion of the examination showed minor DJD in the lower thoracic and upper lumbar spine, but without DDD.  She was seen in follow up in the pain clinic on 20 December 2005.  The examiner noted that she was better than she was after the accident.  At a follow up on 26 January 2006, the examiner opined some of her complaints might stem from physical abuse in her first marriage.  The CI was again evaluated by orthopedics on 15 March 2006 for the MEB.  It was noted that her complaints and examination were unchanged.  She was noted to have a normal gait at a pain clinic evaluation on 31 March 2006.  

The MEB NARSUM examination was dated 27 April 2006, 3 months prior to separation.  She reported a prolonged course of PT for her back and that she was under consideration for surgery.  She noted that in August 2004, she had barely been touched (on the back) by a boy at work, but fell from the pain.  She reported ongoing constant pain, but denied incontinence.  On examination, flexion was limited to 87 degrees (rounds to 85).  Motion was painful in all planes.  The neurological examination was normal.  The gait was normal, but slow.  A walker was used.  The CI reported pain with 2/5 maneuvers which were not expected to be painful.  Spasm was absent.  

The CI was seen in neurology at the VA on 30 November 2006, 4 months after separation.  The neurologist reviewed the records and noted that “there are no significant structural or neurological abnormalities noted on films or on EMG.”  Repeat EDX studies of the right lower extremity on 20 April 2007, 9 months after separation, were normal.  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 ~14 Mo. Pre-Sep	VA C&P ~13 Mo. Pre-Sep	MEB ~2 Mo. Pre-Sep	
Flexion (90 Normal)	85	85	85	
Combined (240)	235	215	230	
Comment	3/5 Non-organic signs of pain positive		2/5 Non-organic signs of pain positive	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain) for localized tenderness.  It noted a normal neurological examination and that the mild radiculopathy was not separately ratable.  The VA initially determined that the back condition was not service connected (NSC) and coded it 5237 as well.  The CI filed a notice of disagreement and the VA rating decision dated 16 August 2007 rated the back at 10%, retroactive to 5 January 2005, based on a review of the evidence including post-separation treatment records.  A 10% rating for right lower extremity radiculopathy was also granted on this VA rating decision, also retroactive to 5 January 2005, based on the MEB determination that the back condition was secondary to the MVA and the June 2005 VA C&P examination.  The back rating was subsequently raised to 20% on the 19 November 2008 VA rating decision based on an evaluation dated 2 April 2008.  

The Board considered if an unfitting radiculopathy was present at separation from the Army National Guard.  The MEB NARSUM examination 3 months prior to separation documented a normal neurological examination.  The Board did note that EDX studies had shown a right lower extremity radiculopathy at L5-S1.  This was over 1 year prior to separation though and not supported by multiple imaging studies nor by the examinations which were proximate to and bracketed separation.  When repeated 9 months after separation, the EDX studies were normal.  The evidence does not support the presence of an unfitting radiculopathy at separation.  The Board then considered the rating for the back.  Tenderness, limitation in motion, and painful motion support a 10% rating.  The NARSUM 3 months prior to separation noted that spasm was absent and the gait normal but slow.  The evidence does not support a higher 20% rating for the back at separation.  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 back condition.  

Chronic Neck Pain.  According to medical records, the CI’s neck condition began in November 2003 after an MVA.  In addition, the CI reported left shoulder area pain at the time of the MVA.  On 22 December 2004, an MRI of the cervical spine was normal; however, on 10 March 2005 a discogram was positive for the C4-5 disc while the CI noted a tear of the C5-6 disc.  Subsequent clinical notes indicate the tear was of the C4-5 disc.  At the 11 May 2005 neurology evaluation for the MEB, the CI was noted to have normal sensation and gait.  Strength was normal bilaterally except for the grip which was 4/5 bilaterally.  The neurologist ordered EDX studies due to the weakened grip.  The EDX studies of the cervical spine were normal on 25 May 2005.  At the VA C&P evaluation performed on 13 June 2005, 13 months before separation, the CI reported ongoing neck pain aggravated by working on the computer and driving.  The neurological examination showed diminished sensation bilaterally, with normal motor function and reflexes.  The ROM was slightly limited due to pain although no grimacing was present.  A supplement to the evaluation dated 7 July 2005 documented a chronic strain of the cervical spine without neurological component.  She continued to report pain and was noted to have the positive discogram at C4-5 on a neuro-surgery evaluation on 23 August 2005.  She was noted to have a normal neurological examination, but the decision was made to proceed to surgery due to chronic pain.  On 29 August 2005, the CI had an anterior cervical discectomy with fusion (ACDF) at the C4-5 level.  The CI had a follow up appointment in the pain clinic on 6 October 2005 and reported an improvement in her neck pain although it persisted.  She then underwent injections of the facet joints with an improvement in her pain.  The MEB NARSUM examination on 27 April 2006 recorded that she had almost complete relief from the facet injections and she commented that she did not think that she had actually needed the surgery.  The neurological examination was normal.  The ROM was painful, but exceeded VA normal values except for rotation to the left and right.  She underwent an ablation of the facet nerves bilaterally from C4-7 on 2 June 2006.  At a pain clinic follow up on 7 June 2006, she reported good results from the ablation procedure.  

At the 29 June 2006 C&P evaluation, performed 1 month before separation, the CI reported constant pain and upper extremity weakness.  On examination, she had slight straightening of the cervical spine with tenderness.  Neither spasm nor guarding were recorded.  The ROM was reduced and painful as charted below.  The neurological examination was normal (note: the strength was recorded as 5/5, but also as slightly decreased albeit symmetrically).  Post-separation EDX studies on 31 August 2006 were normal for both upper extremities.  On 11 September 2006, she reported increased neck pain in the pain clinic.  Facet injections were accomplished on 29 September 2006 with relief of her pain.  The CI was seen in neurology at the VA on 30 November 2006, 4 months after separation.  The neurologist reviewed the records and noted that “there are no significant structural or neurological abnormalities noted on films or on EMG.”  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.  

Cervical ROM
(Degrees)	MEB ~13 Mo. Pre-Sep	MEB ~2 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flex (45 Normal)	45	45	35	
Combined (340)	285	315	235	
Comment				
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 0%, coded 5237 (cervical strain), citing painful motion with secondary limitation in motion.  The VA rated the neck condition 10%, also coded 5237, based on the VA C&P examinations citing painful and limited motion.  The limitation in motion, painful motion, and tenderness all support a 10% rating.  The evidence did not support a higher 20% rating.  The Board noted that the VA upheld this rating on future VA evaluations.  The Board also considered if an unfitting radiculopathy was present at separation.  The neurological examinations proximate to separation were essentially normal other than one which noted slight but symmetric weakness.  An EDX study was normal though.  The evidence does not support the addition of an unfitting radiculopathy at separation.  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 neck condition, coded 5237.  

Major Depressive Disorder.  According to medical records, the CI’s mental health was compromised by pre-service physical and sexual abuse including rape.  Prior to accession, she was in marital counseling and on an anti-depressant.  She also complained of insomnia which was not further addressed until after basic training and prior to the MVA.  On 21 October 2003, 1 month before the MVA, she was begun on Trazadone, an anti-depressant which is also used for insomnia.  There were no further entries regarding mental health until months after the MVA.  On 30 March 2004, it was noted by PT that the CI was a student, single mother, and an apartment manager.  On an annual medical statement for the Guard on 4 June 2004, she noted left shoulder, neck, and back pain since the MVA, but made no comment on a mental health problem.  She was seen in primary care 3 days later and noted to be depressed.  She reported she was having difficulties with both the Guard and her fiancé due to problems subsequent to the MVA.  One month later on 7 July 2004, she was noted to have an adjustment disorder which was improved on Lexapro (a different anti-depressant than she had taken previously).  The CI was seen in pain management on 10 August 2004.  She was a full-time student, working at the apartments (manager), a group therapist, and in the Guard.  She was a single mother as well.  No comment was made on a mental health condition other than non-restorative sleep attributed to pain.  On 24 August 2004 in primary care, the CI was noted to have an improved mood on Lexapro.  On 10 December 2004, the CI presented in a near hysterical manner, but calmed down during the interview with coaching.  It was recorded that she was now on Cymbalta (a different anti-depressant).  This was continued over the next few visits.  No functional limitations were present.  A psychiatric assessment for the Social Security Administration (SSA) dated 25 February 2005 noted that the impairment was not severe.  

The first psychiatric addendum for the MEB NARSUM was dated 7 April 2005.  She reported depression “off and on” since 1999 which had worsened since the MVA.  She stated that the depression was due to her chronic pain.  A metal status examination was normal other than a moderately depressed mood and consistent affect.  Neuro-psychological testing was consistent with somatization (physical symptoms from a mental health problem) with prominent features of hypochondriasis and some indication of depression.  She was thought to have a major depressive disorder (MDD) with a pain disorder.  She was also noted to have mixed personality features although a formal diagnosis of a personality disorder was not make.  Her mental health condition was thought to be EPTS but aggravated by the MVA.  She was not thought to be disqualified medically from a mental health diagnosis.  

The initial VA mental health C&P was on 20 June 2005, 13 months prior to separation.  She reported that she had left her husband as he was abusive and unfaithful.  She had a good relationship with her 8-year-old daughter.  She reported that her grades had dropped, but that she had missed a lot of classes due to pain issues.  She denied significant mental health issues prior to the MVA.  She noted that she had worked three jobs, but had left the Group Home due to physical limitations.  She still worked as an assistant (property) manager, but planned to end this job due to difficulty performing her job duties (these were not specified in this report, but elsewhere were noted to be both physical and mental).  She reported that since the MVA she was more withdrawn socially, but did have a boyfriend (since the MVA).  She was noted to have depression, anxiety, and a pain disorder.  Most of her limitations appeared to be secondary to pain and physical issues rather than psychological issues.  It was specifically noted that she was attending college and had a boyfriend.  There was not sufficient evidence to support a diagnosis of a somatoform disorder.  

The mental health addendum was updated on 15 March 2006.  She reported taking an anti-depressant (Wellbutrin).  This was the second visit to the mental health clinic, the first being the prior addendum.  The CI reported that she was in an abusive marriage from the age of 19 to 27.  Her worst period was from September 2004 to April 2005.  She had a “panic attack” in December 2004 after being threatened by a neighbor.  She was determined to finish her Masters and start her own business.  The examiner spoke with the therapist (civilian) for the CI.  He reported she was highly motivated for treatment.  She had depression on and off since prior to the MVA.  Testing was significant for both depression and a tendency towards somatization.  She was diagnosed with MDD, recurrent and moderate.  She was thought to also have histrionic, obsessive, and schizoid traits.  She was not thought to be fit for retention.  She was given an S3 profile.  

The MEB NARSUM was dated 27 April 2006.  It was recorded that the CI had not been hospitalized for a mental health condition.  The Board found no records of emergency room visits for a mental health condition either.  She reported that she no longer hated life and had hope.  She denied current suicidal or homicidal thoughts.  She had been awarded her Bachelor of Science degree in May 2006.  The CI was seen by VA vocational counseling on 16 November 2006 and was in her first semester of a Master's Program.  She was only taking 4 hours due to the pain from her disabilities.  It also noted that she had not sought a job using her recent college degree as it would exceed her physical capabilities.  It was also recorded that her somatoform disorder symptoms impacted her activities of daily living.  The CI was seen by psychiatry at the VA on 30 November 2006.  She reported that she continued to take Wellbutrin.  She stated “I am tired of the system…do not want to be disabled…fight doctors…have made me worse…the counselor and psychiatrist telling me not in my head…I am getting a lawyer...”  She was diagnosed with depression and somatoform disorder.  She endorsed a history of childhood sexual abuse and domestic violence in her marriage (divorced).  She reported that she was in her first year of a Master’s Program and having a tough time.  However, on 3 January 2007, the CI reported that she had gotten a 4.0 the (previous) semester.  Per the 19 November 2008 VA rating decision, a treatment record from July 2007 documented that she had maintained the 4.0 GPA.  At a 15 February 2007 SSA evaluation, the CI stated that she had not worked since 29 August 2004 and that her employer had covered for her.  She claimed to onset of disability as 15 February 2004. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined the major depressive disorder was not ratable as it was a worsening of a pre-existing condition (EPTS) secondary to a physical disability and considered to be a normal reaction.  It was coded 9434 (major depressive disorder).  The VA assigned a 0% rating using the code 9423 (undifferentiated somatoform disorder) for a somatoform disorder.  This was subsequently increased on the 16 August 2007 VA rating decision to 20% retroactive to 5 January 2005 using post-separation evidence and a 10% EPTS deduction.  The rating was then increased to 40% (50% - 10%) on the 19 November 2008 rating decision based on post-separation evidence.  The 10% EPTS deduction was applied in each case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% (10% - 10%) for the MDD condition, coded 9434.  

Contended Conditions:  Pain Disorder and Historic, Obsessive, Schizoid Traits.  The Pain and schizoid traits disorders was subsumed under the MDD by the PEB.  The Board noted that a single rating is adjudicated IAW VASRD §4.130 and that the impairment from the pain disorder and schizoid traits are included in the rating for the MDD.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the neck condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the major depressive disorder condition, the Board unanimously recommends a disability rating of 0%, coded 9434 IAW VASRD §4.130.  In the matter of the contended pain disorder and historic, obsessive, schizoid traits, the Board unanimously recommends no change from the PEB determination as not separately 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	10%	
Chronic Neck Pain	5237	10%	
Major Depressive Disorder	9434	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141213, 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

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002963 (PD201500069)

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