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AF | PDBR | CY2012 | PD2012 01350
Original file (PD2012 01350.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201350
BRANCH OF SERVICE: MARINE CORPS  BOARD DATE: 20130503
SEPARATION DATE: 20040115


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-5 (5811/Military Police) medically separated for a closed head injury with post concussive syndrome. The CI sustained a closed head injury without loss of consciousness in October 2001. The CI began to experience daily headaches. He was diagnosed with mixed posttraumatic headaches status post (s/p) traumatic brain injury (TBI). Subsequent to his fall the CI had changes to his emotional and cognitive functioning. The closed head injury with post concussive syndrome could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). The “s/p closed head injury w/post concussive syndrome” and “posttraumatic headaches secondary to #1,” and “affective disorder & cognitive disorder secondary to #1,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. The PEB adjudicated “status post closed head injury with post concussive syndrome” as unfitting, rated 10% and 10%, noting “affective disorder and cognitive disorder, posttraumatic headaches and post concussive syndrome” as CAT II conditions with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). Four conditions (panic disorder, generalized anxiety disor der symptoms, anxiety disorder and posttraumatic stress disorder [ PTSD ] ) were determined to be C ategory III conditions (not separately unfitting) . The CI made no appeals, and was medically separated with a 2 0% disability rating.


CI CONTENTION: The CI simply stated “Post Concussion Syndrome Headaches, Affective Disorder and cognitive disorder, posttraumatic headaches” without a specific contention on his application. Attached to the application was a two page statement from the Disabled American Veterans on behalf of the CI which was reviewed by the Board. Of the conditions determined to be not unfitting by the PEB, members judged that the panic disorder, anxiety disorder and PTSD were specified sufficiently in the statement to meet the DoDI 6040.44 scope requirements and are accordingly addressed below.


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 closed head injury with post concussive syndrome are addressed below; anxiety, panic and cognitive disorders will be discussed under the post concussive syndrome disorder. PTSD is contended indirectly by the CI through document by his agent and will be addressed by the Board. 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 respective Service Board for Correction of Naval Records.




RATING COMPARISON

Service IPEB – Dated 20031021
 VA - (5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
S/P Closed Head Injury
 8199-8100 10% No VA Entry
Post Concussive Syndrome
 8045-9304 10% No VA Entry
Affective Disorder and Cognitive Disorder
 CAT II No VA Entry
Post Traumatic Headaches
 CAT II Post Traumatic Vascular Headaches 8045-8100 10% 20040624
Post concussive Syndrome
 CAT II No VA Entry
Panic Disorder
 CAT III No VA Entry
Generalized Anxiety Disorder
 CAT III No VA Entry
Anxiety Disorder
 CAT III No VA Entry
PTSD
 CAT III PTSD w/Depression and Anxiety 9411 70% 20040823
No Additional MEB/PEB Entries
 Other x 14 20040624
Rating: 20%
 Combined: 80%
Derived from VA Rating Decision (VARD) dated 20040624 and 20040823 ( most proximate to date of separation [DOS]).
CI later rated for TBI at 100% effective 18 May 2010


ANALYSIS SUMMARY:

Closed Head Injury. The CI experienced daily headaches after falling and hitting his head during training. He underwent a brain CT scan which revealed no acute intracranial process. The CI reported onset of memory challenges. He started losing and misplacing things. Magnetic resonance imaging (MRI) of the brain dated 1 April 2003 revealed mild right maxillary sinus disease and no other findings. A 1 October 2001 neurology consult recorded daily headaches with pain of 5 out of 10 relieved by inactivity and worsened with temperature changes, activity, and exercise. The headaches occurred after the concussion. On examination, all cranial nerves were intact, reflexes were normal, motor and sensory tests were normal and gait was normal. Mixed headaches s/p concussion was diagnosed. 15 January 2002, the CI underwent vestibular testing to evaluate dizziness symptoms. The test was negative, indicating no pathology found to explain dizziness. Treatment records indicated significant decline in headache frequency for several months until 3 March 2003. He presented to the emergency room with report of a headache, 2 weeks in duration, accompanied by nausea and photophobia, no emesis. The CI was treated and discharged, after which his headaches were reported to be well controlled with medication. The CI reported attention and memory problems. Neuropsychological (NP) exam, 6 months prior to separation, indicated a decline in cognitive functioning possibly as a result of headaches. The CI’s profile recorded post concussive disorder with limitation of physical activities and no weapon handling. The MEB 19 June 2003, approximately 7 months prior to separation, recorded closed head injury without loss of consciousness, followed by severe headaches. The CI reported history of anxiety, depression, and difficulties with concentration. He continued to have daily headaches but, of lesser severity while on medications. Both physical and neurological examinations were normal. At the Compensation and Pension (C&P) examination, 24 June 2004, approximately 6 months after separation, the CI reported a history of depression, forgetting things, and headaches. The CI indicated he had episodic headaches about once a week. The examiner noted normal motor, reflexes, and sensory examinations, and intact mental status.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the condition 10% with the analogous code 8199-8100 (migraine). The VA rated the condition at 10% coded analogous 8045-8100 (posttraumatic vascular headaches). The 10% rating under this code requires one prostrating headaches in 2 months over past several months. The higher rating of 30% requires once monthly over several months of prostrating headache attacks. A prostrating headache is defined by symptoms of photophobia and phonophobia with nausea and vomiting. The record recorded one such potential headache; no other headaches met the requirement. Therefore, 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 s/p closed head injury.

Post Concussive Syndrome. After sustaining a head injury, the CI reported cognitive and mood symptoms that included memory, concentration, and irritability, crying spells, dizziness, and sleep disturbance. He was evaluated by psychiatry and psychology, and treated with medication for symptoms of anxiety and depression. A 30 July 2003 psychiatric addendum to the NARSUM recorded sad mood, full orientation, no evidence of thought disorder, good insight and fair judgment with intact impulse control. The psychiatrist diagnosed anxiety not otherwise specified with panic disorder and generalized anxiety disorder, precipitated s/p head injury in October 2001; post concussive syndrome. Neuropsychological addendum, dated
16 June 2003, recorded a normal mental status examination (MSE). The CI denied significant problems with depressed or anxious mood. The psychologist recorded difficulties with memory, attention, and information processing. The treatment records recorded one Global Assessment of Functioning (GAF) score of 60, 3 May 2003, denoting moderate impairment in functioning, at which time the CI reported problems with concentration secondary to pain. His mental status and cognition was stated as intact. The commander’s statement indicated the CI could not perform his duties due to inability to be armed (MP). There was no documented evidence of occupational or social impairment as a result of post concussive syndrome in the treatment records.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the condition 10% with the analogous code 8045-9304 (purely subjective symptoms, headaches, dizziness, insomnia, etc.). The 9304 code does not allow for higher rating. After careful review of the evidence, the Board determined that the CI was generally functioning satisfactorily, and any cognitive deficit was not recorded sufficiently in the records to support the application of VARSD §4.130 for a rating under 9326 code. Furthermore, the Board undertook a careful review of the medical literature and noted symptoms of disturbance in memory and concentration, headaches, irritability, insomnia, dizziness, and fatigue defines post concussive syndrome. The Board opined that the affective disorder, cognitive disorder, and posttraumatic headache conditions were an integral part of the post concussive syndrome which was discussed above, and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding). 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 post concussive syndrome condition.

Contended PEB Conditions. The contended condition adjudicated as not unfitting by the PEB was PTSD. The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudication. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board notes that the PEB psychiatric statement dated 30 July 2003, 5 months prior to separation, indicated the CI reported history of insomnia, nightmares, flashbacks, avoidance behaviors, startle response, and hyper vigilance with scanning since his combat tour in 1990. The psychiatrist noted this to be significant that the CI continued to experience similar symptoms, but to a significant more severe form; yet the MSE was essentially normal and the recommendation supported the recommendation of the PEB, which indicated the condition was not unfitting. The Board noted with interest, the CI was discharged from the military in November 1991 and re-enlisted in May 1995. The Board noted no PTSD symptoms were recorded on the neuropsychological addendum and PTSD was listed as a condition that had been treated in the past. Treatment record note, 12 March 2003, recorded PTSD resolving, with a normal mental status exam with “retention of sense of humor.” Treatment note,
23 October 2003, 3 months after the psychiatry NARSUM indicated PTSD stable. The CI indicated he had been employed briefly in 2004 or 2005 but quit because of long hours and low pay. The condition was never profiled. The commander noted that the CI could not work in his MOS due to the restriction of no weapons and indicated if the CI recovered from the cognitive deficits he could be retained. The PTSD condition was not implicated in commander’s statement. There was no indication from the record that the mental health condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the PTSD and, therefore, no additional disability ratings can be recommended.


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 s/p closed head injury condition and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication. In the matter of the s/p concussive syndrome condition to include cognitive, headache, anxiety and panic disorder conditions and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended PTSD condition, the Board unanimously recommends no change from the PEB determinations 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 recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Status Post Closed Head Injury
 8199-8100 10%
Post Concussive Syndrome
 8045-9304 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120710, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





        
         Director of Operations
         Physical Disability Board of Review
MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) CORB ltr dtd 12 Jun 13

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandum, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:
- former USMC
- former USN
- former USMC
- former USMC
- former USMC
- former USMC
- former USMC
- former USN



                                                     
                                            Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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