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AF | PDBR | CY2013 | PD-2013-02350
Original file (PD-2013-02350.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02350
BRANCH OF SERVICE: AIR FORCE    BOARD DATE: 20150731
SEPARATION DATE: 20040901


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Jet Engines Journeyman) medically separated for asthma and chronic low back pain (LBP). The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty. She was issued a temporary P4L4 profile and referred for a Medical Evaluation Board (MEB). The asthma and LBP condition, characterized as “chronic LBP s/p L4-L5 microdiskectomy and asthma,” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB adjudicated the same as unfitting, rated 10% and 10% respectively citing criteria of DoD and Veterans Affairs Schedule for Rating Disabilities (VASRD). The PEB also adjudicated “tobacco use” as a Category III condition, (not separately unfit & compensable/ratable). The CI appealed to the Formal PEB (FPEB), which affirmed the PEB findings and ratings, and was medically separated.


CI CONTENTION: Her conditions continue to worsen and negatively impact her daily activities and should have been rated higher. Her complete submission is at Exhibit A.


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 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

FPEB - Dated 20040630
 VA* - (~5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Asthma 6602 10% Asthma 6602 0% 20050216
Chronic LBP S/P L4-L5 Discectomy 5243 10% Herniated Disc L4-L5 Level S/P L4-L5 Discectomy 5243 20% 20050216
Other Conditions x 1 (Not In Scope)
 Other x 3
RATING: 20%
 RATING: 20%
*Derived from VA Rating Decision (VARD) dated 20 050618 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Asthma. The narrative summary (NARSUM) noted the CI was seen for acute symptoms of fever, chills, coughing and shortness of breath (SOB) in early October 2003. She was treated with antibiotics, a bronchodilator (BD) inhaler, and a course of oral steroids. Notes in the service treatment record (STR) indicated the SOB resolved but the CI continued to have a persistent productive cough. Pulmonary function tests (PFT) 24 October 2003 showed post-BD results of reduced forced vital capacity (FVC) and a forced expiratory volume in one second (FEV1) of 51% of normal and an FEV1/FVC ratio of 84% of normal. After the CI completed the antibiotics and oral steroids, primary care (PC) notes indicated continued prescription of BD medication. Pulmonary evaluation performed on 15 January 2004 noted that the CI was currently not using any inhalers and had symptoms limited to a productive cough, without SOB, and she was able to do physical training three to five times a week on a bicycle or elliptical trainer. The PFT was repeated and was somewhat improved with a post-BD results of reduced FVC and an FEV1 of 67% of normal and an FEV1/FVC ratio of 81% of normal. The pulmonary specialist noted the PFT results indicated a mixed pattern not suggestive of asthma. The CI was scheduled for full PFT testing and advised to stop smoking. Primary care notes in the interim indicated the CI continued without asthma symptoms and was exercising regularly. No regular use of asthma medications was noted. Full PFT and a methacholine challenge test were performed and noted a mild degree of airway hyper-reactivity, with some of the noted obstruction possibly due to upper airway obstruction (according to the NARSUM the CI was treated for allergies with nasal symptoms.) At a follow-up visit 23 March 2004, the pulmonary specialist diagnosed moderate obstructive asthma. The CI was prescribed a combined steroid (Advair) and BD inhaler twice daily and follow-up PFT in three months was recommended. A follow up PC visit 29 March 2004 noted that the CI had no symptoms and was not using the BD inhaler “at all.” At the MEB exam 29 March 2004, the CI reported asthma, denied any SOB or chest tightness, but still had occasional coughing spells. The medications list included Advair twice daily “started today.” The MEB physical exam noted a normal lung exam. A PC note after the MEB exam 23 August 2004 noted the CI had “mild, intermittent asthma. Uses Proventil [BD inhaler] < [less than] 1X/month.”

The VA Compensation and Pension (C&P) General exam performed on 16 February 2005, 7 months after separation, noted a history of smoking and environmental allergies with asthma, nasal, and sinus symptoms. The CI reported that after 3 months of “bronchodilator” use she currently had symptoms limited to a mildly productive cough. A PFT completed on 7 September 2005 showed post-BD test results of normal FVC, FEV1 of 71% of normal and FEV1/FVC of 91% normal. At the C&P Respiratory exam performed on 12 September 2005, 12 months after separation, the CI reported no current treatment of the asthma condition and reported treatment with a BD inhaler when she was diagnosed in 2003. She reported asthma attacks once or twice per year with treatment visits for exacerbations less than once per year, and symptoms limited to intermittent non-productive cough, less than daily. The lung exam was normal.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB and VA both rated the asthma condition 10%, coded 6602 (Asthma). The Board noted that the evidence in record supports that the CI had an acute upper respiratory illness in October 2003 that triggered SOB. The SOB resolved readily with treatment with antibiotics, a limited course of oral steroids, and use of a BD inhaler. At the post-separation VA C&P exams the CI reported only occasional productive cough ever since “three months of bronchodilator use”, but indicated no current asthma treatment and infrequent episodes of asthma, and even less frequent need for medical treatment (less than once per year). The initial PFT in record, performed a few weeks after the acute URI, met the 6602 60% rating for an “FEV1 of 40 to 51 percent predicted”. The next PFT 15 January 2004 was improved (despite no reported asthma medication use) and met a 30% rating for “FEV1 of 56 to 70 percent predicted.” At the C&P exams the asthma condition met a 10% 6602 rating based on the PFT results of “FEV1 of 71 to 80 percent predicted”, or based on “intermittent…bronchodilator therapy.” The Board noted that in service the pulmonary specialist had prescribed use of an anti-inflammatory inhaler, to be re-evaluated in 3 months and the NARSUM noted the CI had started an anti-inflammatory inhaler that day. However, a PC note the same day as the MEB exam indicated no asthma symptoms and no use of the BD inhaler at all. There was no documentation of a pulmonary follow-up 3 months later in record, but the PC note 5 months later (August 2004) noted only use of a BD inhaler intermittently. Whether the CI used the anti-inflammatory inhaler, or for how long, is not clear from the available evidence. However, it appeared to have been at most a trial of medication that the CI did not continue to use or require for management of asthma symptoms. The Board considered that the evidence in record supports that following the acute URI with asthma symptoms the CI slowly, but steadily improved with residual infrequent asthma episodes that required intermittent use of a BD inhaler. Therefore, the Board concluded that the disability due to the asthma condition met a 10% rating and no higher. After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the asthma condition.

Chronic Low Back Pain (LBP). The NARSUM noted the CI developed LBP in November 2002 after she felt a “pop” in her back during a coughing spell. Physical therapy (PT) helped somewhat, but the LBP with left lower extremity (LLE) radiation persisted and a magnetic resonance imaging scan completed on 30 January 2003 showed an L4-5 disc herniation with nerve impingement on the left. The CI had microdiskectomy surgery 10 March 2003. The CI was treated with PT, but the LBP continued. At a PT visit 11 June 2003, the exam noted a non-antalgic gait and trunk range-of-motion (ROM) was noted as “FF [forward flexion] limited by 20%”, with no reproduction of symptoms. A PC visit 13 August 2003 noted full back flexion, with “limited” extension and left lateral flexion, and at a PC visit 28 October 2003, all back ROM was noted to be “limited”. The CI had an exacerbation of LBP 18 November 2003 with flexion of 30 degrees noted with no LE symptoms, and a PC visit 5 January 2004, eight months before separation, noted pain with “full flexion.” At a neurosurgery (NS) follow-up visit 24 February 2004, 6 months prior to separation, the CI reported she was 70% improved, but continued to have constant, low grade LBP, without radiating pain, numbness, or tingling (N/T) of either LE. The exam noted there was tenderness of the lumbar surgical area with normal strength, sensation, and reflexes of both LEs. No further surgery was recommended and an MEB was initiated. At the MEB exam 29 March 2004, the CI reported LBP. The MEB physical exam cited the 24 February 2004 NS exam noted above, which was normal except for tenderness of the lumbar area and did not document thoracolumbar (TL) ROM.

The CI appealed the Informal PEB and requested evaluation by PT for additional documentation for the FPEB. At the PT evaluation 24 June 2004, the CI reported LBP and pain and N/T that radiated into the left thigh, anteriorly and posteriorly, above the knee. The exam noted “mild restriction” of flexion, “severe restriction” of extension, with radiating pain to the left thigh, and lateral flexion and rotation within normal bilaterally, with painful motion. The therapist recommended continuation of a home exercise program and indicated no further treatment was necessary. A PC note 23 August 2004, a week prior to separation, noted mild lumbar tenderness and full ROM.

At the VA Compensation and Pension (C&P) exam 16 February 2005, 6 months after separation, the CI reported LBP, rated 2-3/10. The exam noted a normal gait. She was able to heel and toe walk, get out of a chair, and get on and off the exam table without difficulty. There was no muscle spasm present and ROM was flexion of 60 degrees (normal 90) and combined ROM of 150 degrees (normal 240). No additional limitation of ROM was noted with repetition. Lower extremity strength, sensation, and reflexes were normal

The Board directed its attention to its rating recommendation based on the above evidence. The PEB and the VA coded the back condition 5243 (intervertebral disc syndrome). The PEB rated it 10% and the VA 20%. The Board noted that the evidence at the MEB exam supports a 10% rating according to the current VARSD rules for rating the spine in effect at the time of separation IAW VASRD §4.59 (painful motion) and the only support for the 20% rating at the C&P exam was the ROM of flexion of 60 degrees based on flexion of “greater than 30 degrees but not greater than 60 degrees.” At the C&P exam the CI reported mild LBP and the exam noted a normal gait and was otherwise benign, with the examiner noting that the CI was able to move throughout the exam without difficulty. The Board considered that the evidence proximate to separation in the STR noted full flexion with pain, but at the C&P exam the CI appeared to be in no distress, yet paradoxically had more limited flexion ROM. VASRD §4.7 (Higher of two evaluations) states that “where there is a question as to which of two evaluations shall be applied, the higher evaluation will be applied if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating will be assigned.” Members did not consider that the lone finding of limited flexion on the cusp of the 10% and 20% ratings at the C&P exam provided sufficient support to recommend the higher rating. Members thus agreed that at separation the disability due to the low back condition met the 10% rating and no higher and there was no evidence at the MEB or C&P exam to support a higher rating based on considerations of functional loss IAW VASRD §4.40 (Functional loss). The Board also noted that there were no incapacitating episodes documented in record to provide a higher rating alternatively based upon the total duration of incapacitating episodes in the last 12 months. After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.

The Board also considered if there was evidence in record to support recommending the LLE symptoms as separately unfitting peripheral nerve impairment due to the low back condition and therefore eligible for additional disability rating. Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation. Following surgery the CI intermittently reported LLE pain, numbness, and tingling but strength, sensation, and reflexes were normal in the STR and at the C&P exam. The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a and since no evidence of a motor or sensory deficit associated with functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment.


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 asthma condition and IAW VASRD §4.97, the Board unanimously recommends no change in the PEB adjudication. In the matter of the low back condition and IAW VASRD §4.71a, 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 20131114, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762
Dear XXXXXXXXXXXXXXXXXXXX :

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02350 .

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.


Sincerely,




XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings
cc:
SAF/MRBR

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