RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00158
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040423

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Motor Transport Operator, medically separated for “chronic back pain” with a disability rating of 0%.

CI CONTENTION:  “Injuries sustained during tour of duty via a vehicle accident which included back injury, traumatic brain injury with headaches, dizziness, eyesight problems and ongoing memory issues.  Continued back pain limits work options and duties.”  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 at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20040116	VARD - 20160304	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	0%	Lumbar Strain	5237	10%	20160406	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in June 2000 from two motor vehicle accidents.  Magnetic resonance imaging (MRI) of the lumbosacral spine dated 20 March 2003 revealed a normal lumbosacral spine without evidence of neural foraminal impingement.  There was no evidence of herniated disc or disc degeneration.  The osseous structures and marrow spaces maintained normal alignment and signal characteristics and the interspinous ligaments were without evidence of signal abnormalities.  The prevertebral, paraspinal and post vertebral soft tissues also appeared normal.  Bone scan done in March 2003 of the lumbosacral spine, thoracic spine and pelvis were normal.  

The 1 December 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of considerable low back pain with associated paresthesias to the right thigh, and occasional radicular pain to the right lower extremity.  Physical examination showed a normal gait and spinal contour, no paraspinal muscle spasm, normal reflexes, normal strength, and examination maneuvers for radicular signs were negative.  The NARSUM examiner reported trunk flexion with fingers reaching to mid-shin which approximates 70‐80 degrees of thoracolumbar flexion (normal 90).  

Physical therapy (PT) entry dated 3 December 2003, 1 month prior to separation recorded decreased flexion (hand to shin) with pain during flexion and extension.  

A VA Compensation and Pension (C&P) evaluation was performed 12 years after separation, and was not probative for PDBR purposes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain).  The limitation of motion recorded in both the NARSUM and PT examination were without numerical values, but both examiners indicated there was a decrease in ROM, and there was tenderness during the NARSUM and painful motion during the PT examination, therefore, panel members agreed a 10% rating was warranted.  

There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic back pain condition, coded 5237.  

BOARD FINDINGS:  In the matter of the chronic back pain condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  There are 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160328, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014084, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure