RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02310
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20060820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E4, Master at Arms, medically separated for “post-traumatic stress disorder (PTSD)” and “lumbago,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “I don’t remember everything.”  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 – 20060712 3	VARD - 20080102	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	NSC	STR	
Depression	Cat II					
Lumbago	5299-5237	10%	Lumbago	5242	NSC	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0% NA	

ANALYSIS SUMMARY:

Post-Traumatic Stress Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s PTSD condition began in August 2005 after experiencing emotional trauma due to Hurricane Katrina.  She felt her life was in jeopardy as approximately 300 yelling civilians with weapons tried to get onto the base seeking higher ground but were denied entry.  During this same period, she witnessed the death of a 14 year old girl who had been raped.  The CI reports rubbing the girl’s forehead prior to her death.  She had daily nightmares of the girl, intrusive thoughts of Hurricane Katrina as well as hypervigilance, avoidance and hyperarousal.  She reported she saw a psychiatrist once in September 2004.  The panel did not find this examination in evidence.

The 23 April 2004 limited duty (LIMDU) was approved through 22 December 2004, 20 months before separation.  A subsequent LIMDU was not found in evidence.  The available LIMDU only diagnosed spine issues but included a psychologist referral.  The limitations included:  no prolonged standing, no running, and no carrying a weapon.

The 6 December 2005 MEB NARSUM examination, 9 months prior to separation, noted complaints of less frequent nightmares occurring 4-5 times per week.  The nightmares always involved seeing the little girl.  She reported depression and increased social isolation.  The examiner opined she did not meet criteria for major depressive episode.  She reported taking 6 to 7 hours to fall asleep because she thought about Hurricane Katrina and had nightmares.  She denied having suicide and homicide thoughts, now or ever.  She was separated but the decision to divorce was mutual and imminent.  She enjoyed reading. Her energy was average and she had a varying appetite.  She stated “that for her sadness to resolve she would have to be out of the Navy…away from New Orleans”.  During the mental status examination the CI reported taking Benadryl the night before to sleep.  She was tearful when speaking about her experiences during Hurricane Katrina.  She denied thoughts of suicide or homicide, and auditory and visual hallucinations.  The remainder of the examination was unremarkable.

The 31 March 2006 non-medical assessment, 5 months before separation, stated the CI “made positive and significant contributions to the Security Department despite her limited duty status. She is reliable and committed to the command mission and performs all assigned duties in an exemplary manner.  However, due to her medical limitations and her inability to fully contribute to the Security Department or to compete in the MA [master of arms] rating, I cannot recommend her for retention.”

There were no other STR mental health records in evidence.  Similarly, there was no VA examination in evidence for the panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 (PTSD).  The PEB also determined depression as a category II condition (contributing to the unfitting condition).  The examiner noted she did not meet criteria for a depression disorder.  Depression will be discussed below under “Contended PEB Condition.”  The VA did not service connect the PTSD because of limited medical evidence.

The panel first agreed that disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses (PTSD and depression in this case), is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for mental health conditions.

The panel next determined IAW DoD guidance, VASRD section §4.129 (mental disorders due to traumatic stress) will be applied when PTSD is an unfitting condition.  Therefore, as a matter of policy, the PDBR must recommend placement of the CI on a period of constructive TDRL with a minimum rating of 50% IAW §4.129 with reassessment after six months.

The panel next considered the §4.130 rating at TDLR placement.  The §4.130 criteria for a 70% rating is “Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood,” for a 50% rating, “Occupational and social impairment with reduced reliability and productivity”.  Evidence prior to separation, consisting of the MEB NARSUM and non-medical assessment, does not support a rating greater than 50%, therefore a rating of 50% is assigned for entry into the reconstructed TDRL period IAW with VASRD §4.129.
The panel then considered the most appropriate §4.130 rating at six months after the TDRL placement for its permanent rating recommendation.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  The most proximate sources of comprehensive evidence was the 6 December 2005 MEB NARSUM examination and non-medical assessment.  During the examination, the CI reported some PTSD symptoms but was also undergoing a divorce to which she agreed.  She enjoyed reading and was not taking psychotropic medications.  Although she was tearful when speaking about her experiences during Hurricane Katrina, she denied thoughts of suicide or homicide, and auditory and visual hallucinations.  She said in order for her sadness to be resolved she would “have to be out of the Navy…away from New Orleans”.  The non-medical assessment, most proximate to TDRL removal, did not directly implicate her mental health condition but did reference the LIMDU which had a psychologist referral.  The commander stated, “She is reliable and committed to the command mission and performs all assigned duties in an exemplary manner.”

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for 6-months of constructive TDRL and a 10% permanent rating thereafter for the PTSD condition.

Lumbago.  According to STR and the MEB NARSUM, the CI’s back condition began in October 2003 that she attributed to wearing a gun belt.  A thoracic-spine MRI showed a small T-4 fluid-filled cavity (syrinx) but otherwise a normal study.

During the 01 July 2005 family practice visit, 13 months before separation, the CI reported increased back pain after she increased her work over the past 4 days.  Physical examination revealed a negative straight leg raising test (for radiculopathy) and full range of motion; was not addressed.  

The 6 December 2005 MEB Neurology NARSUM, 9 months prior to separation, noted complaints of back pain despite multiple medication trials.  The CI noted constant tightness and aching pain in lower back that worsened with repetitive movement, exertion or prolonged sitting.  She noted occasional numbness and tingling in her hands and numbness in her finger tips.  She also reported a “pins and needles” sensation that occasionally awoke her at night.  Physical examination showed a normal gait, the ability to toe and heal walk, normal lower extremity strength, and range of motion without pain (measurements were not cited).  The examiner recommended continued physical therapy and preventative pain management.  A diagnosis of lumbago was rendered.

There was no VA examination in evidence for the panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing chronic severe refractory back pain.  The VA did not service connect the back condition because of limited clinical evidence.

Based on the unfitting PTSD condition and §4.129 constructional TDRL requirements outlined above, the panel must also determine a rating recommendation for the lumbago condition at TDRL placement and removal.

The 6 December 2005 MEB NARSUM examination is the only comprehensive and proximate examination to base a rating recommendation at TDRL placement and removal.  The panel agreed there was no limitation of thoracolumbar spine motion to support a rating higher than the PEB’s 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, and the MEB NARSUM examination did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  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 lumbago condition at the time of TDRL placement, and 10% at TDRL removal.

Contended PEB Condition:  Depression. The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  As addressed in the PTSD condition above, the panel agreed that disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses (PTSD and depression in this case), is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for mental health conditions.  Therefore, after due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the PTSD condition, the panel unanimously recommends a disability rating of 50% at the time of placement on the TDRL and a rating of 10% at the time of removal from TDRL and permanent disability disposition, coded 9411 IAW VASRD §4.129 and §4.130.  In the matter of the lumbago condition, the panel unanimously recommends a disability rating of 10% at the time of placement on the TDRL and a rating of 10% at the time of removal from TDRL and permanent disability disposition, coded 5299-5337 IAW VASRD §4.129 and §4.71a.  In the matter of the contended depression condition, the panel unanimously recommends no change from the PEB determinations as a category II condition.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD Disorder	9411	50%	10%	
Lumbago	5299-5237	10%	10%	
COMBINED	60%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150904, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 12 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 02 Aug 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 07 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 14 Jul 17 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.      

     c. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Temporary Disability Retired List for six months beginning date of discharge with a 60 percent combined disability rating and a final rating after six months of 20 percent.  

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 60 percent rating (increased from 20 percent) effective date of discharge.       

     e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Acting