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AF | PDBR | CY2013 | PD-2013-02345
Original file (PD-2013-02345.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02345
BRANCH OF SERVICE: Army  BOARD DATE: 20140801
SEPARATION DATE: 20050630


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV1/E-1 (42L/Administrative Specialist) medically separated for a back problem and microcytic anemia. The back condition and anemia could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB). The back condition and anemia, characterized as “mechanical low back pain (LBP)” and “anemia,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “chronic mechanical LBP with degenerative disc disease L4/L5 and L5/S1 disc protrusion” [sic] and “microcytic anemia” as unfitting, rated 10% and 0% respectively, with application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: The CI’s contention was largely illegible.


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for the unfitting back condition and anemia are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20050329
 VA - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Mechanical LBP 5237 10% Residuals of Low Back Injury 5237 20% STR
Microcytic Anemia 7700 0% Iron-Deficiency Anemia 7700 30% STR
Other x 0 (Not in Scope)
 Other x 3 STR
Combined: 10%
 Combined: 50%*
Derived from VA Rating Decision (VA RD ) dated 200 50728 ( most proximate to date of separation [ DOS ] ). *VARD of 20060206 added migraine headaches, 8100, 30%, increasing combined to 70%, backdated to day after separation.


ANALYSIS SUMMARY: IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.
Chronic Mechanical Low Back Pain Condition. Service treatment records (STR) showed that the CI complained of chronic LBP since she fell during training in 1997. The pain worsened in 2003 and did not respond sufficiently to physical therapy, medications or injections. A lumbar spine X-ray showed “transitional anatomy” (a minor congenital anomaly which may cause pain). A bone scan showed only mild reactive changes in the right sacroiliac joint, probably secondary to scoliosis. A magnetic resonance imaging study showed a broad disk bulge at L5-S1 with mild-to-moderate bilateral neural foraminal narrowing.

A neurosurgical examination on 23 August 2004 (10 months prior to separation) showed normal spine contour and normal gait. The examiner concluded there was no surgical indication. A primary care clinic examiner on 21 December 2004 (6 months prior to separation) documented observations inconsistent with the severity of reported pain. For example, despite “slow and cautious” exertion and “pained facial expressions,” she “sprang rapidly onto the exam table” to tie her shoes when informed they were untied. Lumbar flexion was described as “can flex nearly to touch toes” (normal to 90 degrees). Extension was approximately 10 degrees (normal 30 degrees). Although pain appeared to limit the ability to perform straight leg raise (SLR) testing in the supine position, the testing was negative in the seated position. Non-dermatomal sensory loss was also observed. At a follow-up visit with the same primary care examiner on 20 January 2005 (5 months prior to separation) the CI was complaining of severe lower back pain. The examination noted that she could remove her shoes and perform other movements in the exam room despite her complaints of severe pain. The examiner reported that range-of-motion (ROM) testing was “essentially unchanged” from the prior visit, and concluded that the degree of pain and activity impairment was embellished.

At the MEB narrative summary (NARSUM) on 8 February 2005 the CI complained of chronic LBP 6/10 (0-10 severity scale), activity-related exacerbations of 10/10 pain and pain radiating down the right leg. She reported giving up many activities she previously enjoyed, like walking. Physical examination showed tenderness in the mid lumbosacral area. Thoracolumbar spine repetitive active ROM measured with an inclinometer was as follows: flexion of 60/60/60; extension of 20/20/20; right lateral bend of 35/35/35 (normal to 30 degrees); left lateral bend of 30/35/35 (normal to 30 degrees); right rotation of 25/25/25 (normal to 30 degrees) and left rotation of 20/20/20 (normal to 30 degrees). Combined ROM was 185 degrees. Flexion was measured passively at 80 degrees. Painful motion was present. At a VA Compensation and Pension (C&P) evaluation on 2 November 2005 (4 months after separation), the CI stated her asthma symptoms were well controlled “though she does experience some mild shortness of breath (SOB) with a lengthy walk during cold weather.” The examination noted lower extremity strength testing that was inconsistent, as well as SLR testing that was completely normal in the seated position, but produced severe back pain in the supine position. The examiner concluded that these findings were “mutually inconsistent and suggest some degree of symptom exaggeration.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated chronic mechanical LBP at 10% under the 5237 code (lumbosacral strain) and cited decreased passive ROM and pain with motion. The VA used the same code, but assigned a 20% rating based on the limitation of active motion as reported by the NARSUM examiner. It was agreed that a 10% rating was supported by application of §4.59 (painful motion) and that the next higher 20% rating was not justified on the basis of combined ROM, or abnormal spinal contour or gait due to muscle spasm or guarding. However, the Board acknowledged that active ROM is the primary consideration in a rating determination and that in this case a 20% rating could be justified for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. In this regard, it was considered that inclinometer measurements may not correlate with VASRD-mandated goniometric measurements and the flexion reported by the primary care provider in December 2004 (“flex nearly to touch the toes”) was well beyond 60 degrees. Board members were further challenged by different examiners observations that questioned the reliability of examination findings and by conflicting statements by the CI regarding the ability to take lengthy walks. The Board ultimately concluded that the evidence presented above could not be reconciled with the 20% rating description and that the condition was most accurately depicted by the 10% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic mechanical LBP condition.

Microcytic (Iron Deficiency) Anemia. The STR showed that from the earliest available lab data (1999), there was evidence of anemia. Serial labs revealed low levels of hemoglobin (the iron-containing pigment in red blood cells that transports oxygen) and low iron stores. Anemia can cause symptoms such as fatigue, SOB with exertion, dizziness, chest pain and headaches. The CI complained of severe fatigue and symptoms of pica (persistent craving and compulsive eating of nonfood substances that can be associated with low blood levels of iron and other minerals) by consuming ice and cornstarch. A hematology evaluation in 2003 concluded the CI had iron deficiency anemia, likely due to multiparity (multiple births) and ongoing menses with inadequate oral replacement. Iron supplementation was accompanied by increase in hemoglobin levels and symptomatic improvement, although side effects from the oral iron (constipation and indigestion) led to non-compliance.

The CI followed-up with a hematologist in August 2004 (10 months prior to separation) after stopping her iron supplements 6 months previously. Oral iron was re-instituted and hemoglobin levels responded. Of the six available lab tests in evidence during the year prior to separation, the lowest hemoglobin value was 8.5 mg/100 ml (in August 2004, prior to re-starting iron supplementation). There were three other values between 9 and 10 mg/100 and two values greater than 10 mg/100 ml. The highest level was 11.7 mg/100 ml (8 months prior to separation). A hemoglobin measurement on 21 December 2004 (6 months prior to separation) was 9.0 mg/100 ml, but the following day was 10.4 mg/100 ml.

At the NARSUM exam on 8 February 2005 (5 months prior to separation) the CI complained of excessive fatigue and tiredness. The examiner noted the CI was taking anti-depressant medication, but did not consider if fatigue and tiredness could be a consequence of a specific psychiatric condition. At a psychiatric visit on 3 May 2005 (2 months prior to separation), the psychiatrist identified complaints of fatigue and insomnia among a list of psychological symptoms. At a VA C&P exam on 2 November 2005 (4 months after separation), the CI stated her asthma symptoms were well controlled “though she does experience some mild shortness of breath with a lengthy walk during cold weather.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating under the appropriate 7700 code (anemia, iron deficiency), while the VA rated the condition at 30% under the same code. A 30% rating requires “Hemoglobin 8gm/100ml or less, with findings such as weakness, easy fatigability, headaches, lightheadedness, or shortness of breath.” Hemoglobin levels below 10 mg/100 ml support a 10% rating if findings such as weakness, easy fatigability or headaches are present and a 0% rating if there are no symptoms. The Board debated if there were any symptoms directly attributable to anemia near the time of separation, given the fact that the hemoglobin values most proximal to separation were at levels unlikely to be associated with symptoms; that symptoms previously ascribed to anemia were now considered related to a psychiatric condition or to asthma; and that the CI engaged in “lengthy” walks. Regardless of the presence of symptoms however, Board members agreed that the hemoglobin values in evidence most proximal to the time of separation were not consistent with the “hemoglobin 10 gm/100ml or less” stipulation of a compensable rating and therefore a rating higher than 0% was not supported. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the microcytic anemia condition.
BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the chronic mechanical LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the microcytic anemia condition and IAW VASRD §4.117, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131024, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record









                                   
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150002562 (PD201302345)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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