RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04813
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Multiple Launch Rocket System (MLRS) Crewmember, medically separated for “posttraumatic stress disorder (PTSD) with major depressive disorder MDD),” and “chronic low 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 - 20050419	VARD - 20050616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD with MDD	9411	10%	PTSD	9411	30%	20050421	
Chronic Low Back Pain	5299-5237	10%	Degenerative Joint Disease, Thoracolumbar Spine 	5242	10%	20050422	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

PTSD with MDD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI first presented to the mental health (MH) clinic on 12 July 2004 which was 3 months after his redeployment.  He reported combat exposure with nightmares and suspiciousness.  After rejoining his family, sleep deteriorated and nightmares increased.  He exhibited intolerance of crowds, flashbacks, irritability, auditory hallucinations, avoidance of military related themes and general numbness.  He developed symptoms of depression, including lack of energy, fatigue, sadness and isolation from friends.  During his initial presentation to MH, he reported an inexplicable deterioration of his marriage with frequent arguments and talk of divorce.  He was diagnosed with PTSD and treated with medications and individual/group therapy.  He reported additional symptoms of paranoia and the sighting of a ghost and shadows from October 2004 to March 2005.  He was increasingly stressed at work and experienced episodes of anxiety.  He reported suicidal ideation and was placed on quarters for 24 hours at least twice to control aggressive impulses and stabilize sleep.

During the 10 March 2005 MEB NARSUM examination, 2 months prior to separation, the CI reported hating everybody he was close to and had days when he felt worthless with thoughts of suicide but no pressure to act on them.  His sleep pattern had improved and his mood was better since being stabilized on medications.  He no longer exploded or went crazy.  He was working at a vehicle wash facility and felt considerably less stressed away from military triggers.  His last episode of rage which necessitated quarters was 10 February 2005.  His marriage and home life had improved.  He was taking Celexa (anti-depression), Zyprexa (anti-psychosis) and Trazodone (sleep) daily.  The mental status examination (MSE) showed less agitation than previously but he remained worried and embittered.  His mood was dysphoric, affect was blunted or subdued, his overall demeanor was serious and he was impatient and annoyed by the lengthy MEB process, but his impulse control was intact.  His thoughts of suicide were free of impulses to act.    Diagnoses of PTSD and MDD were rendered with a Global Assessment of Functioning (GAF) of 42 (serious symptoms, impairment).  

At the 21 April 2005 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported nightly nightmares, recurring distressing thoughts of war, avoidance of war related topics, limited sleep, easy anger and estrangement from others.  He also reported anxiety at times, depression, 2-4 hours of sleep at night, and the ability to establish and maintain only very limited social relationships with his family.  He worked 50-to 60 hours per week.  He planned to go to Germany to live with his wife and possibly go to school and look for work.  He helped around the house cleaning, mowing the lawn and helping with his daughter’s care.  He used the computer, watched television and payed bills himself.  He saw a therapist weekly and continued with medications as described above.  The MSE showed an anxious affect but no suicidal ideation.  The examiner rendered a diagnosis of PTSD with a GAF score of 80 (transient symptoms, slight impairment)

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorder 10%, coded 9411 (PTSD), citing the condition required “psychotropic medication and outpatient treatment.”  The VA rated the MH disorder 30%, also coded 9411, based on the C&P examination, 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), due to such symptoms as:  depressed mood, anxiety and a chronic sleep impairment.” 

Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 (general rating formula for MH disorders).  The panel noted the provisions of VASRD §4.129 (mental disorders due to traumatic stress) automatically applied to this case because PTSD was 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 considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  The §4.130 criteria for a 70% rating requires evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.  A 50% rating requires evidence of occupational and social impairment with reduced reliability and productivity.  The NARSUM examination noted the CI was working, symptoms were improving and he remained in treatment.  Therefore, the panel agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.

The most proximate source of comprehensive evidence on which to base the permanent rating was the VA C&P examination and STRs from July-December 2005.  The CI continued to report anxiety, depression, nightmares, sleep problems and limited social relationships.  He remained in treatment with therapy and medications.  However, he worked 50-60 hours per week and assisted with the care of his infant daughter and household chores.  Panel members concluded the CI’s symptoms were most consistent with the criteria for a 10% disability rating at TDRL removal.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a TDRL placement rating of 50% and permanent disability rating, after removal from the TDRL, of 10% for the PTSD.

Chronic Low Back Pain (LBP).  According to the STR and MEB NARSUM, the CI’s back condition began in June 2003 after heavy lifting.  After redeployment, he reported mild to moderate persistent LBP for more than 12 months which periodically radiated to his right or left leg.  He also experienced numbness, tingling and weakness in his right leg.  

The 2 March 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, showed spinal stenosis and lower extremity weakness.  The 24 March 2005 goniometric physical therapy evaluation showed flexion of 100 degrees (normal 90) and extension of 10 degrees (normal 30) with limitations due to pain shooting across the low back.  He could sit to stand, fully squat and toe walk six feet without difficulty.  During the 31 March 2005 MEB NARSUM examination, 2 months prior to separation, the CI reported persistent LBP aggravated by activity and occasional right leg weakness.  Physical examination showed no deformity, but there were spasms.  Straight leg raise testing (SLR) showed pain at 30 degrees on the right and 60 degrees on the left, but there was no obvious sensory or motor deficits.  Neuroimaging showed a disc protrusion at L5-S1 with canal stenosis, and degenerative disk disease at T9-10.  

At the 22 April 2005 VA C&P examination, 1 month before separation, the CI reported constant pain that travelled down both legs, but did not cause incapacitation.  Physical examination showed normal posture and gait.  There was positive SLR on the right and left, but no complaints of radiating pain on movement.  There was no muscle spasm or tenderness noted.  The ROM evaluation showed flexion of 65 degrees and extension of 15 degrees with pain.  

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 pain limited motion and muscle spasm.  The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not  greater than 85 degrees with pain on motion.  

Due to the constructional TDRL requirements outlined above, the panel must determine a rating recommendation for the back condition at TDRL placement and removal.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) as reported on the C&P examination proximate to separation.  The NARSUM examination noted the presence of painful motion, which also met the criteria for a 10% rating.  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 which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD 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 at TDRL placement.  The panel then determined the rating recommendation for the back condition at TDRL removal.  However, the most proximate source of evidence was the 1-month pre-separation VA examination.  Therefore, the panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a TDRL placement rating of 10% and permanent disability rating after removal from TDRL of 10% for the back condition.

BOARD FINDINGS:  In the matter of the PTSD, the panel recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 10% IAW VASRD §4.130.  In the matter of the back condition, the panel recommends an initial TDRL rating of 10% in retroactive compliance with VASRD §4.129, as DOD directed, and §4.71a; and a 10% permanent rating at 6 months.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Posttraumatic Stress Disorder 	9411	50%	10%	
Chronic Low Back Pain	5299-5237	10%	10%	
COMBINED	60%	20%	

The following documentary evidence was considered:

 [AR NUMBER], XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear  XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 60% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period no re-characterization of your separation or modification of the permanent disability rating of 20%. Enclosed is a copy of the Board’s recommendation and record of proceedings for your information. The constructive TDRL period will result in an adjustment to your pay providing you 60% retired pay for six months from the date of your original medical separation and then no re-characterization of your separation or modification of the permanent disability rating of 20% following the constructive six month TDRL period. 
The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances. These agencies will provide you with official notification by mail as soon as the directed corrections have been made. Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted. Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557.
A copy of this decision has also been provided to the Department of Veterans Affairs.

Enclosure