RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: HELM, KENNE E.	CASE: PD-2015-01419
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20020107

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Trainee, medically separated for “back pain” with a disability rating of 10%.

CI CONTENTION: “Still suffer from short term memory loss. Have challenges picking out fast moving objects traveling at high rate of speed. Intermittent back pain.” The complete submission is at Exhibit A.

SCOPE OF REVIEW: The panel’s scope of review is defined in DoDI 6040.44. It is limited to review of disability ratings assigned 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 or non-compensable. Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The panel’s assessment of the PEB rating determination 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(s) at the time of separation. The panel 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 panel 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 - 20011115		VARD - 20020730	
Condition	Code	Rating		Condition	Code	Rating	Exam	
Back Pain…Cervical Region…Encephalitis	5299-5295	10%		Residuals of Viral Encephalitis with Headaches, Dizziness and Back Pain	8000	10%	20020722	
COMBINED RATING: 10%		COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Back Pain (to include the cervical region due to encephalitis). According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain began in March 2001 following an episode of encephalitis. Initially he complained of upper respiratory tract infection symptoms, fever, and mental status changes. He was hospitalized for over a month in an intensive care unit where he was comatose and required intubation with ventilation. He eventually recovered and was diagnosed with encephalitis.

On a 5 June 2001 pain survey, the CI stated that he developed residual low back pain due to prolonged bedrest after a brainstem injury. He reported the pain was 5/10 in intensity and radiated to the right leg where there was also numbness. The CI used muscle relaxants and pain medication daily and complained of pain at night; he was able to work. Physical examination showed normal gait, posture, strength, reflexes, sensation and no tenderness. In September 2001, during a neuropsychological evaluation, the CI reported that since his illness, he had severe daily back pain that travelled the length of his spinal column. The pain was exacerbated by high impact exercise and frequently disrupted his sleep. He was working in an administrative position.

At the 22 July 2002 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported that he developed back pain after his 1-month hospitalization. He experienced aching, numbness and spasms once he began walking and doing daily activities. The CI was employed as a detention officer and had not sought medical care with either the VA or a private physician. He reported occasional dizziness and memory loss. Physical examination showed no stiffness in the cervical area and no decreased ranged of motion. He had a normal gait and could heel-to-toe walk. The examiner diagnosed low back strain.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5299-5295 (lumbosacral strain), citing tenderness through the entire spine with normal neurological examination. The VA considered the back pain to be a residual condition stemming from encephalitis and rated it 10%, coded 8000 (encephalitis, residuals, minimum), based on the C&P examination 6 months after separation, citing residuals of encephalitis.

The panel noted that the 2003 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004. The panel must correlate the above clinical data with the 2003 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome; based on incapacitating episodes); and 5295 (lumbosacral strain). Members agreed that criteria supporting a rating higher than 0% under code 5295 were not in evidence (muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position) and debated whether a higher rating was supported under the other codes. A 20% rating is justified for “moderate” limitation of lumbar motion, but based on the evidence, panel members concluded this degree of limitation was not present. Likewise, there was no evidence of incapacitating episodes to warrant a minimal rating.

The panel finally considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy. Although there was a report of radiating pain and occasional numbness in the right leg, there was no evidence of loss of muscle strength that could be linked to any functional deficit or limitation of specific physical requirements. The panel therefore concluded that additional disability rating for radiculopathy was not justified. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back pain condition.

BOARD FINDINGS: In the matter of the back pain (including the cervical region due to encephalitis) condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. The panel, therefore, recommends 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 20150618, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

AR20170012106, 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