DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374

IN   REPLY   REFER  TO:
1850
CORB:003
20 Feb 20

From: To:

Director, Secretary of the Navy Council of Review Boards 
PD-2017-01700

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 17 Feb 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy.

2.	On 12 February 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX		CASE: PD-2017-01700 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20090909

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Surface Ship Nuclear Propulsion Plant Operator, medically separated for “major depressive disorder” and “chronic back pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  Review all conditions. 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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20090609	VARD - 20100316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	
Major Depressive Disorder	
9434	
30%	
20091016	
Cluster B Personality Features	Cat II					
Occupational Problem	Cat II					
Chronic Low Back Pain	5237	10%	Thoracolumbar Strain With Scoliosis	5237	20%	20091016	
Lumbago	Cat II					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 70%	
	
ANALYSIS SUMMARY:

Major Depressive Disorder (MDD). According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported a 1-year history of depression with symptoms of depressed mood, decreased appetite, insomnia, decreased energy, feelings of worthlessness, loss of interest and pleasure and anxiety in October 2008.        She reported thinking it might be

better if she died in a car accident, but denied any plan or suicidal intent. She denied symptoms of mania/hypomania or psychosis. She reported physical abuse by her father, but no history of sexual abuse. Her parents divorced when she was 13 years old and lived with her mother. She reported being diagnosed with attention deficit and hyperactivity disorder in childhood for which she was prescribed psychostimulant medication. During high school she reported being sent to a psychiatrist because of an “attitude problem” and was prescribed an antidepressant medication for 3 months. There was no history of psychiatric hospitalization or suicide attempts. The CI was divorced, but currently engaged. There was no history of substance abuse, legal problems or disciplinary problems in the military. The CI did not like her job and strongly desired to be discharged from the Navy. She attributed her depression to chronic back pain, fiancé being deployed, family issues and a strong dislike of her job. She was treated by a therapist on a regular basis.

At the 10 December 2008 MEB NARSUM examination, 9 months prior to separation, the CI reported persistent depressive symptoms despite treatment. The mental status examination (MSE) noted a depressed mood and affect with the CI being tearful at times during the interview. There was no suicidal ideation, evidence of delusions or hallucinations (or other symptoms suggestive of psychosis), speech disturbance, cognitive impairment or other abnormalities. The Axis 1 diagnoses were MDD, single episode, moderate and occupational problem. Cluster B personality traits (dramatic, overly emotional, or unpredictable thoughts or behaviors) were noted on Axis II. The global assessment of functioning (GAF) assignment was 60, which is on the cusp of moderate to mild impairment on this scale. The non-medical assessment dated 9 January 2009, 8 months prior to separation, stated the CI’s job performance was satisfactory but she was missing approximately 5 hours per week for medical appointments and treatments.

At the 16 October 2009 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported not liking her job. She reported she was not accepted by the men in her Rate. She alleged she was not trained properly or treated courteously. She denied being sexually harassed. She reported her work performance had always been good, but she became depressed due to her work situation and personal considerations, including physical conditions. She reported use of an antidepressant (Cymbalta) with resolution of most of her symptoms. She noted that when she tried to stop medication on several occasions her symptoms returned. She denied any history of difficulty getting along with others. The CI had remarried in September 2009. She was not working, but was in the process of completing massage therapy training. The MSE noted mood and affect were anxious and sad. The CI was described as open and forthcoming in the interview. She was pleasant and cooperative. There was no active suicidal ideation, delusional or hallucinatory symptoms, or other symptoms suggestive of psychosis, speech disturbance or objective cognitive impairment. Her judgment and insight were considered good. The Axis I diagnoses were MDD, single episode, without full recovery, without psychotic features, primary insomnia, and occupational problem. The GAF assignment was 55, which is in the moderate range of impairment on this scale. The VA psychiatrist indicated the CI’s work performance had always been good in the Navy and provided the opinion that she was able to comprehend simple and complex commands, process information normally, and able to establish and maintain personal and work relationships.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MDD 10%, coded 9434 (MDD), citing single episode, moderate. The Navy PEB listed the “cluster B personality features” and “occupational problem” as related diagnoses (Category
II) that contributed to the disability in this case. The panel agreed that the cluster B personality features and occupational problem were diagnoses related to the MDD condition and were not separately ratable since such ratings would be based on the same occupational and social impairment IAW VASRD §4.130 and are prohibited by VASRD §4.14 (avoidance of pyramiding). The VA rated the MDD 30%, coded 9434, based on the C&P examination, citing occasional decrease in work efficiency and intermittent periods of inability to perform occupational  tasks.

The panel noted that there was no traumatic event causing the unfitting mental health disorder and therefore concluded that application of VASRD §4.129 was not appropriate in this case.

A 10% rating was supported for occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. The higher rating of 30% requires evidence of “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) which were not present in this case. After due deliberation, considering all 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 MDD.

Chronic Low Back Pain (LBP). According to the STR and MEB NARSUM, the CI’s back condition began in April 2007 after a motor vehicle accident (MVA). The CI had onset of LBP at the time and subsequently had been involved in multiple other MVAs that aggravated her back (November 2007 and two between March and May 2008). She was treated with medications, epidural steroid injections, radiofrequency ablation, physical therapy and chiropractic care, none of which provided permanent improvement. Eight treatment visits (between April 2007 and 22 July 2008) in the STR described the CI’s back range of motion (ROM) as full ROM, within functional limits or within normal limits. However, at a visit on 19 November 2007, 2 days after her second MVA, ROM was “decreased” and on 4 December 2007 the CI could reach her hands to her knees (approximately 45 to 60 degrees).

The 10 December 2008 MEB orthopedic examination, 9 months prior to separation, noted complaints of LBP without radiation or neurological symptoms. Physical examination showed a normal gait and spinal alignment. Back range of motion (ROM) was measured as “approximately” 50 degrees flexion (normal 90) and combined ROM of 185 degrees (normal 240). The CI was neurovascularly intact with normal strength throughout.

The 11 February 2009 MEB pain medicine addendum, 7 months prior to separation, indicated the CI reported LBP with no radiation, but with occasional numbness to the bilateral lower extremities since November 2007 (MVA). A lumbar spine MRI in March 2008 was unremarkable, except for normal variant of the S1 vertebrae and subtle osteoarthritic changes at L5-S1. An MRI in May 2008 showed a transverse process fracture at L1. She returned in July 2008 for re- evaluation and she was treated with L2-L5 medial branch blocks with complete relief of her pain and she was scheduled for radiofrequency ablation (RFA) of the medial branches. However, when she returned on 8 October 2008, she reported the new onset of radiating pain to the lower extremities, without bowel or bladder issues. Repeat MRI on 8 October 2008 was unchanged. She was treated with epidural steroid injection, which helped the radicular symptoms. She then underwent the RFA procedure on 3 December 2008. At a follow-up visit on 8 January 2009, 8 months prior to separation, she reported marked improvement of her pain. No further interventions were recommended.

At the 16 October 2009 VA C&P examination, 1 month after separation, the CI reported localized low back pain, decreased ROM, spasms, fatigue and numbness, but could function with medication. She reported that she did not experience functional impairment or limitation of motion during flare-ups and the condition had not resulted in any incapacitation. Physical examination showed normal posture and gait. Spinal contours were normal and there was no muscle spasm. There was tenderness of the lumbar spine and right sacroiliac joint, but no radiating pain with movement. Straight leg raise testing to elicit radicular symptoms was negative.           Thoracolumbar spine ROM after three repetitions was flexion of 90 degrees and

combined ROM of 240 degrees, with painful motion noted. There was no additional loss of motion with repetitive use.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5237 (lumbar spine strain). The PEB listed lumbago as a related diagnosis (Category II) that contributed to the disability in this case. The panel agreed the lumbago was a diagnosis related to the back condition and was not a separate condition which could be separately rated without pyramiding (§4.14). The VA rated the back condition 20%, coded 5237.

Although the MEB orthopedic addendum showed greater limitation of motion than the VA examination, the CI had undergone significant interventions for recently worsened symptoms around the same time as the MEB NARSUM examination and 2 months later pain medicine indicated these interventions resulted in significant improvement in the CI’s LBP and radicular symptoms. Therefore the panel placed greater probative value on the VA examination, which was the most proximate examination to separation. Members agreed there was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine, however the VA examiner noted the presence of painful motion and a 10% rating was therefore 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 documentation of intervertebral disc syndrome with incapacitating episodes, which would provide for a higher rating under that formula. After due deliberation, considering all 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 condition.

BOARD FINDINGS: In the matter of the MDD and IAW VASRD §4.130 the panel recommends no change in the PEB adjudication. In the matter of the back condition and IAW VASRD §4.71a the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.