RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02649
BRANCH OF SERVICE:  Army	BOARD DATE: 20141209
SEPARATION DATE:  20060428

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (14T/Patriot Missile Launcher) medically separated for hand tremors.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “benign essential tremor,” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “benign essential tremor” as unfitting, rated at 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “The VA has rated me at 40%.”

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 rating for the unfitting benign essential tremor condition is 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 20060316	VA - (3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Benign Essential Tremor	8199-8105	10%	Bilateral Benign Essential Tremors	8004	30%	20060731	
Other x 0 (Not in Scope)	Other x 3	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20060915 (most proximate to date of separation)

ANALYSIS SUMMARY:

Benign Essential Tremor Condition.  The CI was diagnosed with essential tremor, a condition manifesting as a fine low amplitude tremor most noticeable with movement typically affecting the hands.  There are no other signs of motor dysfunction in essential tremor (such as seen in Parkinson’s disease).  Approximately 30% of adults with essential tremor report onset during childhood or adolescence.  Fine movements are affected, and handwriting is particularly troublesome.  Writing and drawing may demonstrate large, tremulous, angulated loops and examination of previous handwriting samples may be useful in determining the time of onset and assessing severity and progression.  The condition may slowly progress over the course of years or remain static (30% of patients) after initial development.  The CI’s signature on a medical form on 19 July 2003 (3 months after entry into service) showed evidence of tremor.  The CI was initially evaluated by neurology on 17 December 2004, for complaint tremor of both hands (left more than right) for more than a year that he noted when doing fine work.  The tremor also caused difficulty firing a rifle accurately.  The tremor occurred with movement and was markedly attenuated with a little alcohol consistent with essential tremor.  On examination the tremor was limited to the hands.  Gait, balance, and coordination were normal.  At the time of the initial neurology evaluation on 17 December 2004, the CI was able to draw spirals using both hands.  One spiral demonstrated a fine tremor but the circular form was well formed and the lines were reasonably well spaced, the space between lines was maintained without crossing.  Laboratory testing, electroencephalogram and magnetic resonance imaging of the brain were normal, confirming the clinical diagnosis of essential tremor.  He was treated with medication (propranolol) and a neurology follow-up on 2 August 2005 noted report of a 50% improvement by the CI.  Some difficulty using tools and aiming his weapon was again noted.  A form completed by the CI on 2 August 2005, demonstrated legible writing with a very fine tremor and the ability to form accurate circles around items on the form with a fine tremor.  Treatment with a second medication did not afford any additional improvement and MEB was initiated by neurology on 6 January 2006.  

The neurology MEB narrative summary performed on 6 January 2006, noted difficulty manipulating small tools and accurately firing a weapon due to the tremor of both hands.  On examination there was a high frequency, low amplitude tremor in both hands especially with the hands outstretched.  The remainder of the neurologic examination was normal including balance, coordination, and gait.  At the time of the MEB history and physical examination on 31 January 2006, the CI’s hand writing remained unchanged and was legible with minimal tremor evident.  The CI noted “minor tremor both hands” and “head will sometimes shake.”  

At the VA Compensation and Pension examination on 31 July 2006 (performed 3 months after separation), the CI reported the hand tremors were unchanged and aggravated by fatigue, anxiety and use of caffeine.  The tremors interfered with precise fine movements.  On examination there was a fine tremor of the hands.  The examination was otherwise normal.

The Board directed attention to its rating recommendation based on the above evidence.  The Board noted that there is no specific VASRD diagnostic code for benign essential tremor.  According to VASRD §4.20 (analogous ratings), it is permissible to rate a condition not listed in the VASRD under a closely related disease or injury in which the functions affected, and the anatomical localization and symptomatology are closely analogous.  According to VASRD §4.7 (higher of two evaluations), where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating, otherwise, the lower rating will be assigned.  The PEB rated the benign essential tremor 10% analogously using VASRD diagnostic code 8105, Sydenham’s chorea citing mild impairment based on inability to fire a weapon and perform other soldier’s common tasks but otherwise no limitation of daily activities.  The VA rated bilateral benign essential tremors 30% analogously using VASRD diagnostic code 8004, paralysis agitans (Parkinson’s disease) citing absence of symptoms supporting a higher rating under 8004.  Under diagnostic code 8004, 30% is the minimum rating.  Paralysis agitans, more commonly known as Parkinson’s disease, is a much more serious neurologic condition than essential tremor and manifests with widespread neurological impairments which are progressive (often rapidly progressive over 3 to 7 years from impairment to disability).  The onset of the disease is typically in adults over the age of 40 and is uncommon under the age of 40.  Parkinson’s disease causes a rest or postural tremor which typically decreases with movement (opposite to that of essential tremor).  In addition it causes generalized bradykinesia (generalized slowness of movement), gait disturbance (dragging legs, shuffling gait), postural instability (with imbalance and tendency to fall), rigidity (resistance to passive movement), micrographia (very small letters when writing), masked facial expressions, difficulty speaking, difficulty swallowing, autonomic nervous system disturbances, and dementia (occurs late in the course of the disease); none of which were evident in the CI.  Diseases that can cause a clinical appearance similar to Parkinson’s disease in young patients were excluded by the medical evaluation performed by the neurologist.  The CI was diagnosed with essential tremor, a condition manifesting as a fine low amplitude tremor most noticeable with movement typically affecting the hands which slowly worsens or remains static and does not manifest the widespread neurologic impairments that are seen in Parkinson’s disease.  Therefore the Board concluded that the use of the VASRD diagnostic code 8004 was not appropriate because other than tremor, the affected functions, anatomic localization and symptomatology are not closely analogous.  The Board next considered the analogous diagnostic code used by the PEB, 8105 (Sydenham’s chorea).  Sydenham’s chorea refers to a movement disorder often seen in children following a streptococcal infection.  Chorea is a movement disorder characterized by rapid and unpredictable contractions affecting mostly distal limbs, but also the face and trunk.  The movements are involuntary and non-patterned with variable speed, timing, and direction, flowing from one body part to another and giving, in less severe cases, an appearance of fidgetiness.  The unpredictable nature of chorea is a feature that distinguishes it from tremor and dystonia.  While there are many serious conditions that can cause chorea (just as there are many serious conditions that can cause tremor), chorea itself does not involve the widespread neurologic impairments seen in Parkinson’s disease.  While essential tremor and chorea are not the same movement disorder, the localization, symptomology, and impairment are analogous.  Further, the diagnostic code affords a rating based on an assessment of impairment and not specific features of chorea allowing for analogous use.  There was no disease of the peripheral nerves and no loss of sensation or muscle strength that would be similar to a peripheral nerve condition.  Therefore the Board concluded the diagnostic code (8105) selected by the PEB was the most appropriate after consideration of VASRD §4.20 and §4.7.  The Board then discussed whether the impairment from the essential tremor more nearly approximated the mild (10%) versus moderate (30%) rating under diagnostic code 8105.  The most objective evidence the Board found in the record were the samples of the CI’s handwriting, an important skill that is affected by essential tremor.  At the time of neurology evaluation in December 2004, the CI was able draw spiral shapes maintaining the spacing between lines without crossing lines and forming a circular shape.  A fine tremor was evidence in the lines.  In August 2005, the CI’s was hand writing was clearly legible and he formed small circles on forms.  A fine tremor was evident in the line of the circles but the small circles were accurately placed around the items circled and the ends of the circles were accurately connected.  In January 2006, the CI’s handwriting on an examination form was clearly legible and similar to August 2005.  In addition, the CI was able to accurately place x-marks inside the small circles on the form.  The Board concluded that the impairment from essential tremor more nearly approximated the 10% rating for mild impairment than moderate.  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 benign essential tremor 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 benign essential tremor condition and IAW VASRD §4.124a, 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 20131209, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
President
DoD 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, AR20150007064 (PD201302649)

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