RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2017-05090
BRANCH OF SERVICE:  army	SEPARATION DATE:  20060227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “generalized pain involving the head, neck, and lower back [post-concussive syndrome]” with a disability rating of 10%.

CI CONTENTION:  Review of all conditions requested.  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 - 20060120	VARD - 20060911	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Generalized Pain involving the Head, Neck, and Lower Back	5099-5003	10%	Migraine Headaches Status Post-Concussion Syndrome	8100	0%	20060725	
			Pericervical Muscle Strain and Pain	5237	20%		
			Chronic Lumbar Strain…	5237	20%		
Depression secondary to General Medical Condition	Not Unfitting	Pain Disorder associated with Psychological Factors and General Medical Condition	9499-9411	NSC	20060720	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Generalized Pain Involving The Head, Neck, and Lower Back.  The PEB combined the multiple conditions under a single disability rating, analogously coded 5099-5003 and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the multiple conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Head Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s head condition began in the April to May 2003 timeframe. While deployed to Iraq an RPG struck his building knocking him to the ground.  MRI of the brain in January 2005 showed right maxillary sinus mucous retention cysts or polyps, but was otherwise normal.  During the 13 December 2005 MEB NARSUM, 3 months prior to separation, the CI complained of back and neck pain, and headaches (HAs).  He noted the HA pain had persisted since the shrapnel incident.  The pain was isolated to the left temple and occurred without nausea, vomiting, or visual changes. Physical examination revealed a normal appearing head and intact cranial nerves function.  The diagnosis of post-concussive syndrome was recorded.  HA frequency and intensity were not documented, and impact on duty performance or functional impairment was not mentioned.  However, the examiner opined that diagnosed mental health (MH) conditions had interfered in the CI’s ability to achieve pain relief, and that there would be no significant relief until his MH conditions improved.  The MH conditions of undifferentiated somatoform disorder and depression secondary to a general medical condition were determined to have met retention standards by both the psychologist and psychiatrist after evaluations.  The CI declined MH treatment.

During the 25 July 2006 VA Compensation and Pension (C&P) general examination, 5 months after separation, the CI reported he currently had HAs once a week that could last from 2 minutes to a few hours.  He could no longer take medication for the HAs due to an acid reflux condition.  The HAs resolved on their own and there was no functional loss.  Physical examination showed tenderness to the left temple with palpation but none about the sinus area; there was no periorbital edema. The VA rated the head condition 0%, coded 8100 (migraines), based on the C&P general examination, citing a non-compensable examination.

The panel first considered if the HA condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting.  The panel noted there were no additional examinations documented in the STR related to the HA condition beyond the C&P examination.  There was no report of prostrating HAs, or interference with duty performance.  The HA condition was neither implicated in the commander’s statement nor profiled.  The STR did not demonstrate that the CI’s head pain would have caused him to be separated from service.  After due deliberation, members agreed the preponderance of the evidence does not support a conclusion that the functional impairment from the HA condition was integral to the CI’s inability to perform his military occupational specialty (MOS); and, accordingly cannot recommend a separate rating.  

Neck.  According to the STR and MEB NARSUM, the CI’s neck condition began as noted above. MRI of the cervical spine in January 2005 was normal.  X-rays performed on 11 April 2005 were also normal.  At the 22 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months before separation, the CI reported his neck pain interfered with sleep.  Physical examination was unremarkable except for left-sided tenderness.  During the MEB NARSUM, 3 months prior to separation, the CI reported neck pain with difficulty turning the head in either direction.  The pain was of a throbbing, aching quality and constant at times.  Medication or therapy did not relieve the pain.  Physical examination of the cervical spine was not conducted; however, the examiner stated, “There is no significant structural lesion to explain the degree of pain manifested by service-member at this time, as well as the failure of various secondary non-operative modalities.” Again, the examiner implicated the role of MH in relation to the neck pain.
Using a goniometer, the 10 January 2006 MEB physical therapy range of motion (ROM) examination, 2 months prior to separation, documented flexion at 65 degrees (normal 45), and combined ROM of 300 degrees (normal 340).  Painful motion was not addressed.

During the C&P general examination, the CI reported he mainly had a stiff neck.  The pain was daily, intermittent, and exacerbated by driving, increased movement, turning his head while driving, and carrying a backpack on his shoulders.  The CI gave no indication that the neck condition would interfere with employment.  Physical examination showed mild palpable muscle spasms to the left side of the neck with repetitive ROM, and pain-limiting motion.  ROM recorded flexion to 45 degrees and combined ROM of 240 degrees.  The cervical spine had no swelling, redness, or deformities.  The VA rated the neck condition 20%, coded 5237 (cervical strain), based on the C&P general examination, citing limitation of flexion.
 
The panel considered if the neck condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted the negative MRI and the absence of radiographic evidence of arthritic changes.  There were no additional examinations documented in the STR related to the neck condition beyond the C&P examination, and no evidence of focused treatment of the neck.  The NARSUM examiner made no distinction between neck and back pain.  Though the neck condition was profiled, he was allowed to participate in upper body weight training.  The STR did not demonstrate that the CI’s neck pain condition would have caused him to be separated from service.  The panel could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of neck pain with the performance of duties at the time of separation.  After due deliberation, members agreed the preponderance of evidence does not support a conclusion that the functional impairment from the neck condition was integral to the CI’s inability to perform his MOS and accordingly cannot recommend a separate rating for it.  

Low Back.  According to the STR and MEB NARSUM, the CI’s low back condition began as above.  The CI was treated with narcotic analgesics, chiropractic therapy, and was managed by pain management for both neck and back pain.  MRI in January 2005 was essentially normal with no evidence of canal stenosis, nerve impingement, or significant herniation.  During the MEB NARSUM, 3 months prior to separation, the CI reported he had not received any significant relief from his back pain.  Radiographs of the thoracolumbar spine from July 2005 were completely normal.  Laboratory studies evaluating autoimmune diseases, and metabolic conditions were all negative.  Physical examination revealed a slightly flexed posture and a mildly antalgic gait which was worse with toe walking, Motor strength was 5/5 in both upper and lower extremities, and deep tendon reflexes were intact.  The MEB PT ROM examination 2 months prior to separation, documented thoracolumbar flexion of 79 degrees (normal 90), and combined motion of 180 degrees (normal 240).  The reason for limitation of motion was not addressed.

During the C&P general examination, 5 months after separation, the CI stated that the lower back condition, and the left leg pain, would affect his ability to do his job.  He was not employed.  The CI did not use any assistive device for ambulation and noted that he could walk a mile before having back pain.  Driving more than 5 hours increased pain to the lower back.  The CI often required assistance with activities of daily living due to the intensity of back pain.  Physical examination revealed an antalgic gait.  Reflexes were normal and straight leg raises were positive in both lying and sitting positions without radiating pain.  Forward flexion was to 58 degrees, limited by pain, and the CI was able to continue to 85 degrees.  Combined ROM was 170 degrees.  Repetitive ROM was limited due to complaints of recurrent pain.

The panel first considered if the low back condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform his MOS; and, accordingly a separate rating is recommended.  The panel next directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the generalized pain involving the head, neck and low back and applied a single 20% rating, analogously coded 5099-5003 (degenerative arthritis), based on the USAPDA pain policy.  The VA rated the low back condition 20%, coded 5237 (cervical strain), based on the C&P general examination, citing limitation of flexion, and consideration of DeLuca.

The NARSUM back examination was limited.  Back tenderness, spasms, and spine alignment were not described.  The CI reportedly had a mildly antalgic gait.  Radiographs of the spine were normal.  The profile limited lifting to 25 pounds, which limited his ability to perform tasks related to his work on the ward.  The PT ROM documented measurements consistent with a 10% rating, and the C&P examiner documented the presence of muscle spasms with repetitive motion and ROM measurements in the 10% range with painful motion.  

Panel members agreed the C&P examination was more comprehensive and offered greater probative value.  Panel members also acknowledged that although the ROM measurements supported only the 10% rating, the panel could not lower the rating adjudicated by the PEB.  Therefore, the panel concluded that unbundling the head, neck and lower back conditions was of no benefit to the CI.  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 bundled generalized pain involving the head, neck, and lower back.

Contended PEB Condition:  Depression Secondary To A Generalized Medical Condition.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the generalized pain involving the head neck, and lower back and IAW VASRD §4.71a the panel recommends no change in the PEB adjudication.  In the matter of the contended depression secondary to a generalized medical condition, the panel recommends no change from the PEB determination as not unfitting.  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.  

XXXXXXXXXXXXXXXXXXX  

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.

	A copy of this letter has been provide to the counsel you listed on your application,