RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2015-01247
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Engineer Track Vehicle Crewman, medically separated for “chronic low back pain…” with a disability rating of 10%.

CI CONTENTION:  The CI referenced a 1997 motorcycle accident determined to be in the line of duty.  The 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 - 20040129	VARD - 20050829	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Mid and Lower Back Condition	5237	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in June 1997 after a motorcycle accident.  Radiographic studies revealed ‘minimal partial compression fractures of the lower thoracic and upper lumbar vertebra with associated degenerative disc disease (DDD).  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic LBP” and “moderate degenerative L/S disc disease” for PEB adjudication.  There was a paucity of clinical treatment documents contained in the case file and therefore, the majority of reviewed documents in determining an impairment rating were obtained from MEB-driven evaluations.  The 29 July 2003 MEB NARSUM examination, 10 months prior to separation, noted that the CI’s back pain had not changed since 1999.  He reported persistent LBP, along with occasional bilateral lower extremity numbness.  He endorsed the inability to run, lift, do push-ups, sit-ups, or carry any load because pain was aggravated with most activities.  The examiner assessed the CI’s pain as “moderate” and “constant.”  His physical examination (PE) revealed a slight antalgic gait.  His thoracic and lumbar spine were straight.  Lower lumbar spinal tenderness was present.  Thoracolumbar spine range of motion (ROM) was significantly limited and painful.  Forward flexion was measured at 30 degrees (normal 90), extension was normal, and lateral flexion was at 15 degrees bilaterally.  Rotation of the spine was not documented.  Maneuvering tests for evaluating a radiculopathy were normal and neurosensory and motor parameters were intact.  Multiple spinal-focused non-organic pain initiators were demonstrated during the examination.  

The 10 October 2003 MEB Report of Medical Examination (Standard Form 88), 7 months prior to separation, documented “limited ROM of back” and “pain with supine position.”  Additionally, vital signs of blood pressure and pulse were obtained with the CI in a “sitting” position.  There was no VA Compensation and Pension evaluation in evidence proximate to separation.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the LBP condition 10%, coded 5237 (lumbar spine strain).  The VA chose the same code for the LBP condition but denied the claim for service connection, citing the STR and the CI’s failure to attend the scheduled examination.  The Board was confronted with only a single ROM measurement that was 10 months prior to separation which, in and by itself, would rate at 40% impairment under the VASRD criteria for limited thoracolumbar flexion to 30 degrees.  However, 3 months closer to separation, when vital signs were obtained while the CI was in a sitting position, there was evidence demonstrating a much greater degree of lower spine motion than the previous measurement of 30 degrees.  In the absence of additional trauma or interim adverse pathology, members agreed that the more recent and apparent improvement in such motion (as indicated by sitting) more appropriately reflected lower spine motion to a level somewhere above 60 degrees and thus indicating support of a 10% rating.  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’s adjudication for the LBP condition. 

BOARD FINDINGS:  In the matter of the chronic LBP condition, the Board unanimously recommends no change in the PEB’s adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005975, XXXXXXXXXXXXXXXXXX. 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,