RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00788
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Unit Supply Specialist, medically separated for “chronic low back pain [LBP],” with a disability rating of 10%.

CI CONTENTION:  The Physical Evaluation Board (PEB) reviewed her back condition but did not review her mental health or hearing loss, which were not identified by the Medical Evaluation Board or the PEB.  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 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 - 20041018	VA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	10%	No VA Claim Filed	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic LBP.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s was treated for LBP in February 2003 due to heavy lifting.  Diagnostic imaging (MRI) revealed intervertebral disc disease at L4-L5 and L5-S1.  Despite treatment, the LBP condition could not be adequately treated to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “chronic LBP secondary to mild degenerative disc disease” for PEB adjudication. Orthopedic examinations performed on 29 June 2004 and 22 July 2004, 4 to 5 months prior to separation, noted complaints of LBP.  Physical examination showed spinal muscle tenderness, without spasm or abnormal contour.  Straight leg raising (radiculopathy testing) was negative with deep tendon reflexes normal.  The thoracolumbar range of motion (ROM) was full without painful motion.  The MEB NARSUM examination on 27 September 2004, 2 months prior to separation, noted complaints of LBP unrelieved with physical therapy, rest and nonsteroidal anti-inflammation medication.  The physical examination revealed a normal gait and posture.  She had mild paravertebral muscle spasm and tenderness.  Lower extremity motor strength was 5/5 and sensation was intact and symmetrical.  Deep tendon reflexes were +2 (normal) and provocative testing for nerve root irritation was negative.  The repetitive (x3) ROM testing was performed by physical therapy on 14 September 2004 which revealed forward flexion of 60 degrees (normal 90) and a combined ROM was 200 degrees (normal 240).  The CI did not file a VA disability claim.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic LBP condition 10%, coded 5237 (lumbosacral strain), citing tenderness and passive ROM of 64 degrees.  No VA rating was in evidence.  The Board determined the limitation in active flexion recorded on the MEB physical examination 2 months before separation supported a 20% rating.  The PEB specifically recognized this MEB physical therapy examination citing the CI had passive ROM flexion of 64 degrees rather than the more limited active flexion of 60 degrees.  The Board did not find evidence 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 20% for the LBP condition, coded 5237.

BOARD FINDINGS:  In the matter of the chronic LBP condition, the Board unanimously recommends a disability rating of 20%, coded 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	PERMANENT RATING	
Chronic LBP	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, 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, AR20170000097 (PD201500788)

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