RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00243
BRANCH OF SERVICE: Army                                                                   SEPARATION DATE:  20090118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-7, IT Specialist, medically separated for “intervertebral disc syndrome” with a disability rating of 20%.  

CI CONTENTION:  The CI contends for all of her MEB/PEB conditions.  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 -  20081001	VARD - 20100203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intervertebral Disc Syndrome	5243	20%	Lumbar Degenerative Disc Disease With Intermittent S1 Radiculopathy	5242	20%	20091002	
Depression	Not Unfitting	Depression	9435	30%	20091002	
Reactive Airway Disease	Not Unfitting	Asthma, Exercise Induced	6602	10%	20091002	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDTIIONS:  70%	

ANALYSIS SUMMARY:  

Intervertebral Disc Syndrome.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began in approximately 2000 after lifting some relatively heavy cases.  Over time it became worse since she had to lift, move, and setup her equipment.  Physical therapy and chiropractic treatments offered marginal benefit.  Magnetic resonance imaging (MRI) in December 2006, ordered for chronic low back pain and some radiation down the leg, demonstrated mild degenerative disease at L4-L5 and L5-S1 without neural foraminal (where nerves pass from the vertebral column) narrowing or canal stenosis.  X-rays in January 2007 were unremarkable without spondylolysis (a bony defect or fracture within the pars interarticularis) or spondylolisthesis (one vertebra slips forward onto the one below it) and with normal sacroiliac joints and alignment of the vertebral bodies.  In April 2007 she noted stiffness in her back and noted weight gain secondary to in vitro fertilization (IVF) therapy.  Treatment consisted of celecoxib, a nonsteroidal anti-inflammatory drug (NSAID) and tramadol, an opioid-like medication.  Neurosurgical evaluation in July 2007 noted the CI complained of low back pain with radicular symptoms to the right lower extremity marked by numbness and tingling.  She reported pain with a severity of 7/10 (10 being the worst pain), which was aggravated by prolonged sitting and standing and alleviated with Naprosyn (naproxen, an NSAID).  Computerized tomography (CT) of the lumbar spine demonstrated degenerative disc disease at L5-S1 with a broad based posterior bulge that effaced the thecal sac.  Physical medicine evaluation in May 2008 revealed spine flexion with hands to about the knees with pain.  She had tenderness to palpation around the right side sacral base and sacroiliac area with some pain in the right lumbar paraspinals.  The physical medicine diagnosis was a herniated intervertebral disc based on a 2004 film notable for internal disk degeneration at the L4 and L5 levels and a small central herniation at the L5 level.  The examiner noted the CI could also have had facet and right sacroiliac generated pain as well.  A thoracolumbar spine series on 13 June 2008 demonstrated mild thoracolumbar dextrocurvature (curvature to the right) with mild degenerative changes and a small spur at the L4 and L5 vertebral bodies and mild narrowing of the posterior aspect of the L5-S1 disk space.  An MRI in June 2008 demonstrated mild degenerative changes at L4-L5 and L5-S1, which was similar in appearance to an initial study in 2004.  Neurosurgical evaluation in July 2008 noted an 8 year history of low back pain with no radicular pain.  Two years earlier surgery was not advised.  Examination revealed focal tenderness near the L3-L4 area.   Deep tendon reflexes were intact without motor deficit and her gait was normal.  She had no interventional treatments, but reported severe debilitating pain that prevented her from performing her MOS or physical training.  

At the MEB examination on June 2008, 7 months prior to separation, the CI reported lower back pain and “numb/tingling feet/toes” and sciatica caused by LBP (low back pain).  The examiner noted a decreased active range of motion (ROM) of the thoracolumbar spine without any step offs or deviations.  There was no spasm in the paravertebral muscles, but there was very slight tenderness in the right paravertebral muscles of the lumbosacral area.  There was negative straight leg raises (to determine nerve root irritation) and the neurological evaluation was unremarkable.  At the NARSUM examination in August 2008 the CI was noted to be 67 inches tall and weighed 215 pounds.  She had mild tenderness on the right and left paraspinal muscles without any evidence of spasm present.  She demonstrated the ability to flex forward and to do hyperextension with mild pain and no radiation of symptoms.  She had negative straight leg raises and negative Patrick testing (to determine hip pathology).  The ROM measurements are in the chart below. 

At the VA Compensation and Pension (C&P) examination on 2 October 2009, performed 9 months before separation, the CI reported constant low back pain, flaring up with spasm and temporary limitation of motion with physical exertion, bending, or repetitive motion.  Intermittently, she felt sciatica extending down one lower extremity or the other; however, she had no bowel or bladder incontinence.   She used no assistive devices and had no functional limitation of work or activities of daily living.  She had no incapacitating episodes, incoordination, weakness or fatigue.  On examination there was mild pain, moderate spasm, and mild fatigue with all movements.  There was no weakness, incoordination or tenderness.  Repetitive motion increased pain and spasm at all degrees of movement without changing the ROMs, which are in the chart below.  Straight leg raising was negative and the neurological evaluation revealed no numbness, weakness or atrophy of the lower extremities.  Deep tendon reflexes were 2+ and symmetrical in all four extremities.  The VA examiner’s assessment was lumbar degenerative disc disease with intermittent S1 radiculopathy.  

The range of motion (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 ~5 Mo. Pre-Sep
	VA C&P ~8 Mo. Post-Sep
	
Flexion (90 Normal)	(50)45, 50,50	50	
Extension (30)	(10)5,10,10	5	
R Lat Flexion (30)	(10)10,10,10	20	
L Lat Flexion (30)	(10)10,15,10	20	
R Rotation (30)	(30)30,30,30	15	
L Rotation (30)	(25)30,25,25	15	
Combined (240)	135	125	
Comment	Painful limitation of all motions 	Mild pain, moderate spasm, and mild fatigue with movement	
§4.71a Rating	PEB 20%	VA 20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5243 code (intervertebral disc syndrome), citing painful flexion to 45 degrees.  The VA also assigned a 20% rating using the 5242 code (degenerative arthritis of the spine) based on the VA C&P examination 9 months after separation, citing  reduced range of motion.  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 on the NARSUM and VA examinations.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported intermittent numbness and tingling of the lower extremities.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore, the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  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 intervertebral disc syndrome condition.  

Contended PEB Conditions-Clinical Depression and Reactive Airway Disease.  The Board’s main charge is to assess the fairness of the PEB’s determination that the clinical depression and reactive airway disease conditions were not unfitting.  The clinical depression and reactive airway disease conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   

Depression.  In November 2004 the CI complained of depression, irritability, problems with concentration, and obsessive thoughts due to an inability to conceive a child after over 5 years of marriage as well having had a history of multiple deaths in her family in the recent past.  At the mental health examination the CI had a dysthymic affect and was tearful and anxious.  Her cognition was normal and she had no homicidal or suicidal ideation.  A possible adjustment disorder was raised and her Prozac (fluoxetine, an antidepressant) dose was increased.  The CI was seen in consultation on 17 July 2008 at which time she reported a long history of feelings of depression beginning in her teenage years.  She took antidepressant medication prior to entry in the Army when she was 17.  She had close family losses and was treated with Prozac to which she responded well, but symptoms of depression worsened when she discontinued the medication.  When deployed a fellow soldier died and one was injured in a bombing of a restaurant 6 years earlier, the memory of which caused sadness whenever she was reminded of the event.  She had occasional episodes of anxiety when uncomfortable, but the episodes resolved in 10 minutes or less.  She had fertility treatments resulting in two pregnancies, both of which resulted in miscarriage.  She reported her mood as euthymic and stable with good sleep, normal interest level, good self-esteem, a fair energy level, good concentration, good appetite, and no psychomotor agitation or retardation and no suicidal or homicidal ideation.  For the mental status evaluation she was alert, cooperative, appropriately dressed and groomed, without unusual behavior or mannerisms.  Her mood was euthymic and affect broad in range and congruent with her mood.   Thought processes were linear.  She had no hallucinations, delusions, illusions, or suicidal or homicidal ideation.  Sensorium and intellect were grossly intact and insight and judgment were good.   The Axis I diagnosis was depressive disorder, not otherwise specified, which met retention criteria and her Global Assessment of Functioning was 80 (If symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning).  The psychiatrist examiner opined the CI was psychiatrically fit for duty.  No further psychiatric evaluation was required.  

Reactive Airway Disease.  The NARSUM noted the CI was diagnosed with exercise-induced asthma and she was given an albuterol inhaler.  She stated that she used the inhaler on rare occasions related to exercise.  The CI had normal spirometry .and a negative methacholine challenge test, which was not consistent with asthma on 17 July 2009.  The NARSUM indicated she was seen in the pulmonary clinic and it was determined she did not suffer from asthma and was fit for duty.  

There was no performance-based evidence from the record that the depression and reactive airway conditions significantly interfered with satisfactory duty performance at separation.  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 for the depression and reactive airway contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the intervertebral disc syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended depression and reactive airway conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20150402, 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 
XXXXXXXXXXXXXXXXXX, AR20160018552 (PD201500243)

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, I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA