RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00106
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Track Vehicle Repairer, medically separated for “chronic mechanical low back pain without neurologic abnormality” and “major depression,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Further evaluation determined it was nerve damage.  Unconfirmed diagnosis present at the time of service and separation.  Took years to confirm.”  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 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 - 20030317	VARD - 20030917	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain without Neurologic Abnormality	5299-5295	10%	Low Back Strain	5295	10%	20030404	
			Disc Protrusions, Thoracic Spine, T5-6, T6-7	5293-5291	0%	20030404	
Major Depression	9434	10%	Adjustment Disorder with Depressed Mood	9440	10%	20030429	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Mechanical Low Back Pain without Neurologic Abnormality.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in February 2001 of non-specific etiology.  MRI performed in August 2001 showed a small herniated disk at T5-T6 without neurological involvement, and a normal lumbar spine.  There was no surgical indication.

At the June 2002 MEB examination (recorded on DD Forms 2807 and 2808) 11 months prior to separation, the CI reported he had “musculoskeletal back pain.”  Physical examination showed tenderness to palpation at L4-5 paralumbar muscles, and non-tender spine.  He had normal muscle strength and full range of motion (ROM) of the thoracolumbar spine with the exception of decreased extension of 15 degrees (normal 30).

During the13 December 2002 MEB NARSUM examination, 4 months prior to separation, the CI complained “my back hurts and impairs me from performing most duties.”  The CI reported that he was unable to perform any military activities requiring physical activity.  The examiner noted the CI’s mental health condition impacted his ability to rehabilitate his back condition.

Physical examination was performed by another physician 9 months prior to separation and showed normal muscle strength in lower extremities and normal sensory function.  The spine was not tender but tenderness was noted to palpation at L4-5 paralumbar muscles.  ROM recorded flexion to 90 degrees (normal) and 15 degrees of extension (normal 30).  

At the 4 April 2003 VA Compensation and Pension (C&P) evaluation, 1 month prior to separation, the CI reported his pain medication was helpful.  He was able to perform all the activities of daily living, and he did not require the use of assistive device for ambulation.  He had no incapacitating episodes requiring bedrest.  Physical examination showed ROM flexion to 90 degrees and extension of 30 degrees, with painful motion.  

The panel directed its attention to its rating recommendation based on the above evidence.  The 2003 Veterans’ Administration Schedule for Rating Disabilities (VASRD) was in effect at the time of separation (DOS).  The 2003 standards for rating based on range of motion (ROM) impairment were subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment.  The PEB rated the back condition 10%, coded 5299-5295 (analogous to lumbosacral strain), for painful motion.

The VA rated the low back strain condition 10% coded 5295, based on the VA C&P examination 1 month before separation, citing painful motion.  A 0% rating under the 5295 code represents slight subjective symptoms only, while a 10% rating is for “characteristic pain on motion.”  

The panel agreed that a 10% rating, but no higher, was justified based on the evidence.  There was no path to a higher rating under any applicable code (5292 or 5393) since ROM documented in the NARSUM and C&P examinations were not compensable and spasms were not recorded in any of the STR, nor was there evidence of weakness with loss of neurological functioning.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

Major Depression.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) Mental health (MH) addendum, the CI’s major depression began in October 2000 after his father died.  He sought help from a therapist and later treated by a psychiatrist due to his symptoms of depressed mood, irritability, poor sleep, feelings of hopelessness and helplessness and loss of interest in usual activities.  In August 2001, the CI was hospitalized for 5 days after a suicide attempt.  He took an overdose of his medications.  He had no other hospital admissions, but continued to have transient feelings of suicidality.  

During the 10 December 2002 MEB NARSUM addendum examination, 5 months prior to separation, the CI complained of frequent irritability towards others and difficulty controlling his feelings of anger connected with his father’s death.  
After he was discharged from the hospital he was stable with slight improvement in mood and no suicidal or homicidal thinking or intent.  However, in December 2001 and January 2002 he had transient feelings of suicidality but was able to calm himself and contract for safety.  The CI remained stable and his symptoms reportedly were mild to moderate but chronic.

Mental status examination (MSE) recorded a depressed mood and constricted affect, and no other abnormality.  The examiner noted the presence of mild to moderate depressive symptoms most reflective of dysthymia.  A Global Assessment of Functioning (GAF) score of 65 for mild symptoms and or impairment was recorded.

At the 29 April 2003 VA Compensation and Pension (C&P) MH evaluation, performed 1 week before separation, the CI reported he had problems with irritability, isolation and his temper.  He could go for a full week without sleep or sleep for a full week.  He acknowledged periods of remission but believed treatment had been ineffective.

MSE recorded depressed mood and anxious and angry affect, although it was noted he was pleasant and cooperative.  The remaining of the MSE was unremarkable.  The CI noted that his depressed mood was primarily due to his physical issues and to his grief over his father’s death.  The examiner opined that the CI did not meet diagnostic criteria for major depressive disorder nor for dysthymic disorder, and that the evidence supported an adjustment disorder with depressed mood.  A GAF score in the mild range was assessed.

The panel directed attention to its rating recommendation based on the above evidence. 

The PEB rated the major depression 10%, coded 9434 (major depressive disorder), citing mild social and industrial impairment IAW AR 635-40, appendix B-107.  

The VA rated the adjustment disorder claimed as major depression 10% coded 9440 (adjustment disorder), based on the VA C&P examination 1 week before separation.

The panel members first agreed that the provision of VASRD§ 4.129 for a “mental disorder that develops in service as a result of a highly stressful event” were not applicable.

The panel next proceeded to the rating recommendation.  The panel considered the single inpatient admissions 19 months prior to separation, and the absence of documented visits to the emergency room, and the absence of suicidal ideation in the 6 months prior to separation.  The panel also noted the mild GAF score recorded at the MH addendum and C&P examinations.  

Panel members concluded, the CI’s condition at separation was most reflective of the 10% level of disability for “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.”

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the major depression condition.  

BOARD FINDINGS:  In the matter of the chronic mechanical low back pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  

In the matter of the major depression condition and IAW VASRD §4.130, the panel 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 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 20160303, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013356, XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure