RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01833
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20081125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Pharmacy Specialist, medically separated for “cervical spine strain” and “depressive disorder,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  His conditions continue to worsen and negatively affect his ability to work.  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 - 20080811	VARD - 20090306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Spine Strain	5237	   10%	No VA Placement	
Depressive Disorder 	9435	10%	Adjustment Disorder	9440	30%	20090115	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:  

Cervical Spine Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in the summer of 2007 after he was involved in two motor vehicle accidents (MVA).  X-rays of the cervical spine showed disc space narrowing with minimal neuroforamina (the site where nerves pass through the vertebral column) compromise at C4-5 and MRI showed a disc protrusion extending into the left neural foramina.  

At a neurological visit on 11 September 2007 the CI reported numbness of the right arm and hand with some “twitching and some numbness of the left fifth digit.”  He also reported dropping objects.  Physical examination revealed tenderness, but no spasm.  Range of motion (ROM) was normal.  Spurling’s maneuver (to determine nerve root irritation) was negative as was straight leg raise testing and femoral stretch.  Gait and station were normal.  Upper and lower extremity strength was normal bilaterally and there was decreased sensation of the right arm to light touch, otherwise sensation was normal, as were deep tendon reflexes.  The CI had right-sided symptoms and a left-sided disc protrusion. 

An orthopedic examination on 5 February 2008, showed no erythema, swelling, ecchymosis, laceration, abrasion, or other soft tissue abnormality.  Pain was localized to the mid cervical region at approximately C4-5.  He had a good ROM of the cervical spine with flexion, extension and lateral rotation, although he had pain with extension.  There was no shooting pain down his arm.  Spurling’s maneuver was negative.  He had 5/5 strength of the upper extremities and reflexes were normal.  Sensation of the left upper extremity was intact; however, he complained of mildly decreased sensation over his right deltoid, the inner aspect of his forearm, and over the first three digits of his right hand.  The examiner noted it was not clear what the origin of the pain was, but thought the pain was much out of proportion to what the findings were on the MRI and examination.  A surgical option was thought not to be appropriate.  

During 18 March 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported severe neck pain.  Physical examination showed tenderness of the spine.  The 2 May 2008 MEB NARSUM examination, 6 months prior to separation, showed no tenderness.  Spurling’s test was positive.  Motor strength and reflexes were normal.  The examiner noted many lost duty days due to his neck condition.  Physical therapy ROM measurements after three repetitions were forward flexion of 40 degrees (normal 45) and combined ROM of 285 degrees (normal 340), with pain in all planes of motion.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5237 (cervical strain), citing satisfactory evidence of painful motion.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) or combined ROM (greater than 170 degrees but not greater than 335 degrees).  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 that 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 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 cervical spine pain condition.  
Depressive Disorder.  According to the STR and the MEB NARSUM, the CI was referred to psychology on 22 June 2007 since the command was concerned about his behavior which he knew could be irritating to others.  He noted increased irritability and decreased sleep, appetite, energy, and libido as well as anxiety with impending doom after the second MVA noted above.  He also reported auditory hallucinations that had been with him since early teen years and reported having psychiatric therapy for depression from age 8 to 18 due to a family stabbing.  Mental health tests (MMPI (Minnesota Multiphasic Personality Inventory) and SIMS Structured Inventory of Malingered Symptoms)) indicated chronic psychological maladjustment and the question of malingering.  The CI was diagnosed with depressive disorder, not otherwise specified (NOS) and anxiety disorder, NOS and had a Global Assessment of Function (GAF) score of 65 (some mild symptoms).  Treatment consisted of Cymbalta (duloxetine, an antidepressant) and Restoril (temazepam for insomnia) for sleep.  Multiple therapy sessions were carried out and the CI reported a significant reduction in the “the voices” with less stress.  On 29 January 2008, the CI reported difficulty sleeping, increased anxiety and depressive symptoms, which appeared to coincide with stress at work, pain, and use of opioid medication.  The dosages of Cymbalta and Restoril were increased.  On 28 May 2008 the CI reported having discontinued the Cymbalta and saw no difference except he had increased anxiety and irritability, but did not wish to restart the medication.  A note dated 11 July 2008 indicated the CI was taking Seroquel (quetiapine for depression) as needed for stress and anxiety.  On 8 August 2008 the CI had a GAF score of 70 (some mild symptoms).  During the 18 March 2008 MEB examination the CI reported anxiety, rage and massive depression.  The examiner checked normal for psychiatric on the clinical evaluation, but listed anxiety/depression in the summary of defects and diagnoses.  

The 10 June 2008 MEB NARSUM examination noted complaints of trouble sleeping and anger.  Mental status examination showed the CI was dressed in his Army combat uniform and had good hygiene.  He was cooperative and had good eye contact.  Speech was at a normal rate, rhythm, tone and quality.  Motor activity was within normal limits with no abnormal movements present.  He was quite relaxed and leaned back in a chair.  Mood was depressed and affect was mildly dysphoric, but no significant signs of depression or other noticeable problems were noted.  Thoughts were organized and goal directed.  The CI answered questions appropriately and stated he had memory problems, but was able to recall multiple dates and events from the past.  He denied delusions, ideas of reference, auditory and visual hallucinations, other than having a voice tell him what not to do.  He denied suicidal and homicidal ideations.  Cognition was intact and intelligence was average based on vocabulary.  Insight was fair and judgment and reliability appeared to be good.  The MMPI and SIMS tests were clinically significant overall and tended to focus on somatic issues likely related to chronic medical issues.  The interpretation was that the CI had difficulty adjusting due to medical issues on a chronic basis, which impaired his mood and performance.  The examiner noted the CI had a history of depression prior to enlistment, which continued and worsened likely due to medical issues.  He also developed symptoms of anxiety, which were only moderately controlled with medication and therapy.  The examiner noted impairment for military duty to be considerable and for civil and industrial adaptability to be moderate.  The condition existed prior to service and was aggravated during service.  His GAF score was 60 (moderate symptoms).

At the 15 January 2009 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported depression more days than not, with insomnia, low energy, problems with concentration, irritability, chronic pain and difficulties adjusting to physical limitations resulting from the MVA.  Mental status examination revealed the CI to be clean and appropriately dressed.  There was no psychomotor active and speech was unremarkable.  He was cooperative and relaxed.  Affect was normal and mood was depressed.  His attention was intact and he was oriented to person, time and place.  Thought process and thought content were unremarkable.  Judgment was intact; intelligence was average; and the CI had insight and understood he had a problem.  The CI reported he slept an average of 2-3 hours each night with difficulty falling and staying asleep.  He had no delusions or hallucinations.  He did not have inappropriate behavior, interpreted proverbs appropriately, had no obsessive/ritualistic behavior, had no panic attacks, and had no homicidal or suicidal thoughts.  Impulse control was good without episodes of violence.  Remote, recent and immediate memory were mildly impaired.  Psychological testing suggested the CI experienced severe symptoms of clinical depression and PTSD based on a PTSD checklist for combat and non-combat trauma.  Upon further evaluation, the CI’s responses reflected his perceived difficulties adjusting to physical limitations resulting from the July 2007 MVA rather than reflecting difficulties recovering from the traumatic nature of the event.  The Axis I diagnosis was adjustment disorder, chronic with mixed anxiety and depressed mood.  His GAF score was 60 (moderate symptoms).  The examiner noted the signs and symptoms of the mental disorder were transient and mild with decreased work efficiency and ability to perform occupations tasks only during periods of significant stress based on his being depressed most of day, more days than not, along with insomnia, low energy, problems with concentration, and irritability related to chronic pain and difficulties adjusting to physical limitations.
	
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mental health disorder 10% with an undetermined EPTS factor, coded 9435 (unspecified depressive disorder), citing a depressive mood disorder in 2002 treated with counseling and antidepressants and rated for continuous medication required to control symptoms.  The VA rated the mental health disorder 30%, coded 9440, (chronic adjustment disorder), based on the C&P examination 2 months after separation, citing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal).”

The panel considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  All panel members agreed that the evidence of record did not support application of VASRD §4.129 based on “the CI’s responses reflected his perceived difficulties adjusting to physical limitations resulting from the July 2007 accident rather than reflecting difficulties recovering from the traumatic nature of the event.”  

Panel members noted the CI had symptoms such as depressed mood, anxiety, chronic sleep impairment, but those symptoms were generally controlled with continuous medication and appeared to coincide with stress at work, pain, and use of opioid medication.   Furthermore, the CI had known depressive symptoms prior to enlistment for which he received counseling.  The VA examiner noted the signs and symptoms were transient and mild and decreased work efficiency and ability to perform occupations tasks only during periods of significant stress, which favors a 10% rating.  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 depressive disorder.

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the depressive disorder 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.  Therefore, the panel 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 20170215, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180005420, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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,					      
Enclosure