RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01697
BRANCH OF SERVICE:  Army	BOARD DATE:  20141007
SEPARATION DATE:  20090601

SUMMARY OF CASE: The available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (52D/Power Generation Equipment Repairer) medically separated for an autoimmune disorder and cognitive disorder.  The conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards.  He was issued a permanent P3/S3 profile and referred for a Medical Evaluation Board (MEB).  Anti-phospholipid syndrome and cognitive disorder, characterized as medically unacceptable, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded left hemisphere stroke secondary to anti-phospholipid antibody syndrome (APLS) as medically acceptable.  The Informal PEB adjudicated “cognitive disorder and APLS as a single unfitting condition, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition (left hemisphere stroke) was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 combined unfitting autoimmune and cognitive and the contended not-unfitting left hemisphere stroke condition are addressed below.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any condition 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 20090206	VA* - (28 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cognitive Disorder…	9399-9305	10%	Residuals, Stroke Due to APLS with Mild Cognitive Changes	7099-8009	10%	20120927	
Left Hemisphere Stroke Secondary to APLS	Not Unfitting					
Other x 0 (Not in Scope)	Other x 2	
Rating:  10%	Combined:  10%	
*Derived from VA Rating Decision (VARD) dated 20121013 (most proximate to the date of separation (DOS))

ANALYSIS SUMMARY:

Cognitive Disorder Resulting from Left Hemispheric Stroke due to Anti-phospholipid Antibody Syndrome (APLS).  The CI suffered an ischemic stroke on 30 May 2008 and was found to have APLS during the evaluation for the etiology of the stroke.  He also had mild persistent cognitive disorder as a result of the stroke.  Due to the overlap of these conditions, all three are presented in one narrative and then adjudicated separately.  As noted, the CI presented on 30 May 2008 with stroke symptoms which included the history of vision loss and numbness of the right side of his face and right arm.  During the course of a week’s admission, he was found to have APLS.  Other potential causes for the stroke were excluded.  He was placed on an anti-coagulant (to decrease the risk of a blood clot and another stroke.)  At a follow-up appointment in neurology on 3 November 2008, he was noted to have slight decreased sensation of the right side of his face (a deficit of the trigeminal nerve, the fifth cranial nerve), diminished sensation of the right arm and leg, and right pronator drift (indicative of some weakness), but with normal muscle bulk and tone.  The gait was normal.  The neurologist observed that the APLS was the most likely cause of the stroke and would require lifelong anti-coagulation.  However, the residual effects from the stroke were not disabling and met retention standards.  The next day, the CI underwent neuropsychological testing as part of the MEB evaluation.  The CI reported that he now needed to use reference books more often (than previously).  He still drove, but had been in an accident.  It is not clear if this was related to residual effects from the stroke.  However, he was able to drive from Atlanta to Augusta, Georgia for the appointment (approximately 150 miles.)  He had disagreements with his co-workers, but otherwise no problems at work.  On the mental status examination, his attitude was guarded, mood frustrated and attention span decreased.  Thought processes and content were intact.  On testing, his memory showed mild overall impairment as did executive functioning.  The attention, concentration and information processing measurements showed significant impairment.  The Board noted that the specific areas of testing showed mild to moderate impairments in memory and executive function, and moderate to severe for attention span (it was noted that he had previously been diagnosed with attention deficit disorder).  The overall assessment was that he was functioning within the average range of intelligence and revealed little evidence of a generalized decline in cognitive functioning.  However, he was thought to have a mild to moderate cognitive deficit and to be disqualified for continued military service (the Board recognized the inconsistency of these two sentences from the report.)  

An ophthalmological examination 3 days later was unremarkable and showed resolution of the previous visual deficit.  The mental health narrative summary (NARSUM) was dated 12 November 2008, over 6 months prior to separation.  He was noted to have a cognitive disorder with “occasional decrease in work efficiency and inability to perform occupational tasks.”  This meets the criteria for a 30% rating IAW VASRD §4.130.  He denied speech or language problems, but endorsed ongoing memory problems.  The general NARSUM was a day later on 13 November 2008.  He was noted to fail retention standards for both the APLS and the cognitive disorder.  He reported that his tempo at work was “much more slow and deliberate” and noted “subtle right sided weakness.”  He complained of poor short-term memory and decreased intellectual function which impacted his work efficiency.  However, he put in a full duty day, wore his uniform, attended all formations, did physical training and was working in his MOS.  The Board noted that he did not display an inability to perform his job, but rather a reduced efficiency in the work place performance.  The examination referenced the above neurological examination.  It was noted that he was anxious to separate from the military.  He was frustrated that he needed to take the anti-coagulant (Coumadin) every day and wanted to move to another profession.  He was thought to be stable, non-deployable, and to have a good prognosis.  It was stated that he could “do all soldiering activities except deploy.”  The supervisor noted on the 24 November 2008 assessment that he had a “slight memory problem in which it effects his job performance a little he still gets everything he needs to do done it just takes a bit longer.”
At the VA Compensation and Pension (C&P) neurological examination performed 2 years after separation, the CI was noted to have a normal neurological examination and probable cognitive impairment, but the latter was not further specified.  At the mental health examination 2 weeks after the neurological examination, the CI reported that he was going to an automotive school and was half way through it.  He had held two part time jobs since separation and had been told that memory problems were an issue in his performance.  However, an inability to perform his job was not noted.  He reported long standing attention and concentration difficulties originating in childhood.  He was diagnosed with “R/O cognitive disorder NOS, secondary to CVA; anxiety disorder NOS, ADHD by hx.”  (R/O = rule out; NOS = not otherwise specified; CVA = cerebrovascular accident [stroke]; ADHD = attention deficit hyperactivity disorder; hx = history.)  A Global Assessment of Function of 70 was assigned, indicative of some mild symptoms or impairment, but generally functioning pretty well.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB used the codes 9399-9305 (vascular dementia) while the VA used code 7099-8009 (hemorrhage of the blood vessels) to rate the conditions at 10%.  The Board noted that there were three separate issues for consideration.  These were the APLS which was treated with Coumadin; the second the cognitive disorder secondary to the stroke (a residual effect); and the sensory and motor changes secondary to the stroke (also “residua”).  The Board first considered the APLS.  It was determined to be both unacceptable medically by the MEB and unfitting by the PEB, but not separately rated by the PEB.  The Board observed that while the use of Coumadin was required to treat the APLS, this only limited the CI in the ability to deploy.  No occupational or social impairment resulted in garrison or in civilian employment.  The single blood clot incident which lead to the stroke was over a year prior to separation.  Accordingly, the Board determined while the condition could be determined to be separately unfitting, no compensable rating was supportable.  The Board then considered the unfitting cognitive disorder.  Both the military and VA examiners (well after the time of separation) noted a mild deficit which impaired duty.  One PEB examiner noted the description for a 30% rating “occasional decrease in work efficiency and inability to perform occupational tasks,” but the residual symptoms from the cognitive disorder were overall considered to be mild to moderate for several criteria and moderate to severe for one.  He was able to perform his job albeit at reduced efficiency.  The overall level of function remained relatively intact in that he continued to perform in his MOS, but with more frequent use of reference material.  The supervisor noted that he took “a bit longer” do perform his duties, but also noted that he was able to get “everything he needs to do done…”  The Board also observed that the VA C&P, while remote from separation, indicated continued improvement after separation and is consistent with continued improvement after the MEB NARSUMs and up to separation.  The Board considered if the evidence supported a 30% rating or the 10% rating adjudicated by both the PEB proximate to separation and by the VA remote from separation.  The Board majority determined that the evidence better supported the description of the 10% rating (occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication) rather than the 30% rating (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 Board also considered the residual sensory and motor changes.  The neurologist determined that these met standards.  The MEB found them to be medically acceptable and the PEB found them not unfitting.  The Board considered both and did not find a preponderance of evidence to support a change in the PEB determination that these were “not unfitting” conditions.  Therefore, no additional rating can be recommended for these residual.  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 cognitive impairment, left hemispheric stroke, and APLS conditions.
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 cognitive disorder secondary to left hemispheric stroke due to an APLS condition and IAW VASRD §4.124a and §4.130, the Board, by majority vote, recommends no change in the PEB adjudication.  In the matter of the contended left hemispheric stroke with residua mild hemiparesis (weakness) and hemi-sensory disturbance conditions secondary to APLS, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 201400416, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150006302 (PD201401697)

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