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AF | PDBR | CY2013 | PD-2013-02198
Original file (PD-2013-02198.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD-2013-02198
BRANCH OF SERVICE: Army  BOARD DATE: 20141014
DATE OF PLACEMENT ON TDRL: 20040109
Date of Permanent SEPARATION: 20050822


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Medic) medically separated from the Temporary Disability Retired List (TDRL) for dementia due to head trauma. Despite attempts at rehabilitation, the CI could not meet the requirements of her Military Occupational Specialty (MOS). She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The MEB referred “post-concussion syndrome ” and “major depressive disorder (MDD)” to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “status post-concussion…with impaired speed of processing, execution function, hypersomnia, and depressed mood/personality change” as unfitting, rated 30%. The IPEB placed the CI on the TDRL. The CI was re-evaluated in April 2004, approximately 3 months after being placed on the TDRL. The IPEB determined her MH condition remained unstable and continued her on the TDRL, but changed the VASRD disability code to 9304 (dementia due to head trauma). A second TDRL re-evaluation was completed in June 2005 from which the IPEB determined her MH condition was stable. The MH condition remained unfit and the IPEB adjudicated a 0% rating, citing “no specific industrial impairment.” The CI initially demanded a Formal PEB, but eventually withdrew this demand and accepted the IPEB’s disability determination. The CI was medically separated.


CI CONTENTION: “Due to the accident, I required an artificial disc replacement with removal of the C5 disc.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’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/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board 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, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.





RATING COMPARISON :

Final Service PEB - 20050708
 VA (15 Mo. Prior to Final Service PEB Adjudication Date*) Effective 20040110
On TDRL - 20040109
 Code Rating Condition Code Rating Exam
Condition
 TDRL Sep.
S/P Closed Head Injury…with Cognitive Deficits and Depression 9399-9304 30% 0% Major Depressive Disorder Associated with Concussive Syndrome 8045-9434 70% 20040419
Post-Concussive Syndrome with Headaches and Memory Loss 8045-9304 10% 20040419
Other MEB/PEB conditions in scope x 0
 Other x 1 20040419
Combined: 30% → 0%
 Combined: 80%
*Reflects VA rating exam proximate to TDRL placement; no VA rating evidence proximate to permanent separation. VARD 20091207 increased DC 8045-9304 to 70% effective 20090710. VARD 20130221 changed DC 8045-9304 to 8045, maintaining a 70% rating, effective 20090710; and added DC 8100 ( “ Post Traumatic Migraines Associated with TBI I njury ” , formerly rated under DC 8045-9304), rated 30% effective 20101117.


ANALYSIS SUMMARY:

Dementia Due to Head Trauma. On 26 April 2003 the CI sustained a head injury while horseback riding. An emergency room evaluation revealed a bump on the base of the back of the head (occipital area) and a cut to the left forehead with contusion and bruising of the right eye. Witnesses reported a loss of consciousness of 4-5 minutes. Neuro-imaging revealed fractures of the temporal right skull base and occipital bone. Her last memory was of being on the horse and riding 1/4-1/2 mile from the stable. There were pieces of memory for the 5 days following the accident and she did not have full memory until 6 days after the accident. She was admitted to Intensive Care Unit for 2 days and treated prophylactically with Dilantin and Percocet. Magnetic resonance imaging (MRI) performed on 30 May 2003 revealed bruising of the right temporal and frontal lobes. She was limited to 4 hours of light duty. Over the next few months, she reported numerous symptoms: angry volatile temperament, spontaneous crying episodes, sadness, detachment, mood swings, irritability, easy frustration, impatience, loss of confidence in driving, slowed cognition, disorientation to place, impaired ability to think, headaches, chronic neck pain, fatigue and sleep problems. She was eventually diagnosed with adjustment disorder, unspecified and placed on Elavil. Neurosurgical consultation dated 15 July 2003 revealed the CI had sustained a cerebral concussion, cerebral contusions and basilar skull fracture, but required no neurosurgical intervention and was expected to typically resolve over time. The neurosurgeon opined that her symptoms of headache, fatigue, apathy, mood swings, and memory problems were characteristic of post-concussion syndrome (were particularly long lasting and disabling). He further stated her symptoms had led to a reactive depression that included feelings of worthlessness and loss of interest in remaining in the Army. The only objective neurological finding was related to eye muscle function. He recommended symptomatic treatment by a neurologist and suggested a P3 profile. She was placed on convalescent leave and recommended for a MEB. Progress notes revealed she developed bad mood swings, identified as “Rages” and began to spend money impulsively. During neuropsychological testing, dated 10 September 2003, the CI reported she had completed 3 years of college, had a General Technical score of 122, which correlated with a high verbal IQ. She had been diagnosed with anorexia nervosa in 1997 and had received MH care from a psychologist and psychiatrist, who treated her with daily Paxil. She was currently taking Percocet as needed for chronic headaches, Elavil for sleep as needed, and Mobic for headaches.
She reported that her primary concerns were bad mood swings, emotional dyscontrol, depression, irritation by little noises and occasional rages. She reported overeating and weight gain to an increase in two pant sizes, hypersomnia resulting in sleep up to 14 hours a day, little libido, spending money impulsively which was in contrast to her pre-injury behavior of conservative spending and increased headaches. She described panic attacks, which seemed to lead to agoraphobia symptoms. She avoided shopping malls, movie theaters and demonstrated psychomotor retardation during testing. She also reported a family history of serious mental illness in her mother and sister. The psychologist examiner opined a differential of residual effects of PCS versus a psychiatric basis for her disorder. The Minnesota Multiphasic Personality Inventory showed extremely low self-esteem and clinically significant depression. The examiner recommended a diagnosis of MDD and reassessment by cognitive tests when depressive symptoms remitted at 6 months after treatment for depression. Examiner opined CI was suffering from a combination of traumatic brain injury (TBI) and psychiatric disturbance. Psychiatric consultation dated 26 September 2003 noted CI had symptoms that qualified her for DSM-IV PCS research criteria. He raised the possibility her weight gain was the result of a head trauma induced frontal lobe syndrome. He discussed the possibility of significant genetic predisposition and opined the head injury was the major source of the depression and personality changes. The MEB narrative summary (NARSUM) dated 20 October 2003 noted that the CI had chronic headaches in the back of her head. Gabapentin treatment resulted in slight improvement. She also reported cognitive problems; problems with multi-tasking aspects of concentration, naming objects and days of the week, episodes of disorientation to location, poor attention span that was improving, short-term memory problems, forgetfulness, unprovoked anger and irritability. Crying episodes were decreasing and she was sleeping 3 to 4 hours nightly. She was working 4 hours per day in housing and performing tasks that included typing. Neurological examination revealed a mini mental status examination (MSE) of 30/30. The examiner cited the findings from neuropsychological testing as well as findings by her treating psychiatrist dated November 2003. The psychiatrist documented presenting problems of irritability, fatigue, mood liability, apathy and anxiety as consistent with post-concussional disorder based on DSM-IV-TR criteria. He treated the CI with Gabapentin with good results. The neurology examiner rendered diagnoses of PCS and MDD and opined that the cognitive deficiencies from her TBI prevented her from performing in her MOS and that she failed to meet retention standards.

On 9 January 2004 the PEB placed the CI on TDRL with a disability rating of 30%, coded 9304-9327. Electroencephalogram performed in March 2004 was mildly abnormal. The NARSUM TDRL re-evaluation occurred on 9 April 2004. The MSE revealed a 26/30 mini MSE with subtractions in short-term recall, naming and orientation. The remainder of the neurological examination revealed normal double vision. Interval MRI dated March 2004 confirmed anatomical evidence of post-traumatic encephalomalacia (softening of brain tissue) and gliosis (a process of scarring to the central nervous system) was more extensive on the right than the left frontal lobes, but there was also damage to the right anterior temporal lobe. Neurologist noted that the brain atrophy indicated a poor prognosis and those symptoms of post-concussion would remain the same or gradually improve. Diagnoses of post-concussion syndrome and MDD remained and permanent retirement was recommended given the persisting cognitive impairment and brain MRI findings.

Two separate VA Compensation and Pension (C&P) general examinations were performed by two different specialists on 19 April 2004, 6 months after separation. During the C&P examination for head injury, the physical examination was notable for her double vision, but otherwise normal. The neurologist opined that she had a substantial head injury with at least three areas of contusion; and, her headaches and short-term memory problems were post-traumatic; and, that a head injury like this could exacerbate any underlying emotional disorders. C&P examination for MDD, noted her 0% service-connection for anorexia nervosa, that she had been treated for anxiety and depression from 1996-1999 and that she reported her symptoms were worse since the accident.
Her worst symptoms were the uncontrollable anger and rage. She was attending school and majoring in computer science while working as a web support technician. She was having difficulty at work and at school. She had missed 2 weeks of work over a period of 2 months. She enjoyed miniature golf, swimming, and reading. MSE noted impaired memory, concentration and judgment, flat affect and sad and anxious mood. Diagnoses were MDD, mood disorder due to a medical condition, and impulse control disorder with a Global Assessment of Functioning (GAF) of 40 (severe). The examiner opined that as a result of the accident, some of her mental symptoms were exacerbated and other new symptoms appeared. Neuropsychological reevaluation performed on 7 May 2004 revealed a decrease in intellectual functioning, memory abilities, word finding abilities and appeared to reflect decreased cognitive functioning. Her IQ was in the high 80s. The psychologist recommended a change in medication to decrease irritability and hypomanic symptoms she had developed. Diagnoses of post-concussive disorder, mood disorder secondary to TBI, possible hypomania and organically induced personality changes were rendered with a GAF of 55 (moderate). The examiner recommended continued TDRL for additional 18 months and then reevaluation. On 7 July 2004, the PEB described her condition as post-traumatic encephalomalacia of both frontal lobes and right temporal lobe with residual dementia with a depressive disorder and impulsive personality change, coded 9304. The PEB continued TDRL until June 2005 with a recommendation for repeat neuropsychological evaluation. Neuropsychological testing performed on 19 May 2005 noted variability and inconsistency in performance and with variable effort. Her IQ was 109. A diagnosis of depression was rendered. During NARSUM TDRL examination dated 10 June 2005, CI reported many mood swings with irritability, some continued disorientation to time, impairments in multitasking and concentration with some difficulty with comprehension and word finding that have not improved in the previous year. She took Gabapentin and Effexor for the headaches and the Effexor seemed to control her violent outbursts. She was still working at Discover and had graduated with a BS in computer information systems in February 2005. She was able to drive and lived with family for extra care and support and managed her own finances. Neurological examination was normal and revealed a 30/30 MMSE. Diagnoses of PCS and MDD remained. Prognosis was poor given that symptoms had not significantly improved in the previous 2 years. Permanent retirement was recommended. The applicant was removed from TDRL on 8 July 2005 with a separation disability rating of 0% for status post (s/p) closed head injury, coded 9399-9304.

The Board directed attention to its rating recommendation based on the above evidence. The PEB initially adjudicated s/p concussion to frontal area, right skull base and occipital skull fractures, improving, but not considered stable condition as unfitting with a TDRL disability rating of 30% coded 9304-9327 (organic mental disorder). The VA rated MDD associated with concussive disorder at 70% coded 8045-9434 (TBI-MDD) and PCS with headache and memory loss 10%, coded 8045-9304 (TBI - dementia due to head trauma (TBI). TBI is a neurologic disorder that can manifest as physical and psychiatric impairment. The TBI rating criteria in effect at the time of separation rated purely neurological disabilities(under the diagnostic codes specifically dealing with such disabilities with citation of a hyphenated diagnostic code), subjective complaints (no greater than a 10% rating utilizing diagnostic code 9304) and multi-infarct dementia under VASRD §4.130, Schedule for Rating Mental Disorders. The Board deliberated and determined that VASRD§ 4.129 was not applicable in this case because the depression was secondary to TBI; and accordingly the nature of the precipitating event did not meet the requirements as set forth in VASRD§ 4.129. The Board considered whether the CI met criteria for a greater than 30% rating at the time of placement on TDRL. Criteria for a 50% rating require occupational and social impairment with reduced reliability and productivity. The CI had a normal mini MSE, was able to work and attend school and had a boyfriend with generally satisfactory functioning. The Board concluded she did not meet criteria for the higher 50% rating; and in fact met the criteria for a 30% rating.
The Board then considered whether the disability rating of 0% at separation off the TDRL was appropriate. Neuropsychological testing revealed little cognitive deficits.
She was working, had completed a BS degree and was maintaining good relationships. She remained on medication with intermittent episodes of break though rage. The Board noted that after the first TDRL review, her condition was listed as post-traumatic encephalomalacia, of both frontal lobes and right temporal lobes with decrease in intellectual memory and cognitive abilities with depressive mood disorder, coded 9304, based on the MRI findings that showed an anatomical basis for the cognitive findings. The TDRL removal NARSUM documented “2.5 months” of time lost from work in the past year and that the CI’s symptoms had not significantly improved in 2 years. A significant aspect of the VASRD §4.130 30% rating criteria state: “occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.” After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL removal rating of 30% for the dementia due to head trauma 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. In the matter of the s/p closed head injury condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication at the time of placement onto TDRL. In the matter of the s/p closed head injury condition, the Board unanimously recommends a disability rating of 30%, coded 9399-9304 IAW VASRD §4.130 at the time of removal from TDRL. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
TDRL PERMANENT
S/P closed Head Injury Condition 9399-9304 30% 30%
COMBINED 30% 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131103, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record


XXXXXXXXXXXXXXX
President
Physical Disability Board of Review


XXXXXXXXXXXXXXX
PDBR Psychiatrist


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 XXXXXXXXXXXXXXXXXX , AR20150008370 (PD201302198)

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

         a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

         b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

         d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

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

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