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AF | PDBR | CY2013 | PD-2013-02593
Original file (PD-2013-02593.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02593    
BRANCH OF SERVICE: Army          BOARD DATE: 20150729
SEPARATION DATE: 20050328                


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Wire Equipment System Repairer) medically separated for psychomotor epilepsy. This condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS) or physical fitness standards, so she was issued a permanent P3/S2 profile and referred for a Medical Evaluation Board (MEB). The epilepsy condition characterized as “seizure disorders, syncopal episodes…” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also forwarded post-concussive syndrome for PEB adjudication. The PEB adjudicated “psychomotor epilepsy…” as unfitting, rated 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD); t he post-concussive syndrome w as determined to be not unfitting. The CI made no appeals and was medically separated.


CI CONTENTION: “The Wounded Warrior Act”


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 :

Service PEB – Dated 20050121
 VA - (based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Psychomotor Epilepsy… 8914 10% Seizure Disorder 8045-8910 10% STR
Post-concussive syndrome Not unfitting Residuals, Post-concussive syndrome 8045-9304 10% STR
No Additional MEB/PEB Entries in Scope
 No Other VA Entries in Scope
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 70517 .




ANALYSIS SUMMARY:

Epilepsy. The neurology evaluation for the MEB dated 2 August 2004 recorded the CI’s history of recurrent seizures that began in 2001 after she reportedly ran into a tree, tripped and struck her head against the tree. Computerized tomography (CT) of the head performed on 16 October 2001 was normal and she was diagnosed with a mild concussion. The CI began having headaches and abnormal body movements that raised the question of possible psuedoseizures. She was started on anti-epileptic medication and referred to neurology. The CI presented to the emergency room (ER) twice in January 2002 for episodes of dizziness, muscle spasm, upper body shaking, and blacking out; physical examinations were normal and episodes were not witnessed. Magnetic resonance imaging of the brain performed on 18 January 2002 was unremarkable (no evidence of a mass or vascular injury). Electroencephalogram (EEG) result dated 31 January 2002 was normal. The CI underwent her first neurological examination on 31 January 2002. She reported that on 15 October 2001 after running into a tree, she was knocked unconscious and found 90 minutes later wandering around, dazed and confused and unable to respond sensibly. The following day she had a bad headache and started to shake; she could not recall anything else but woke up in the hospital. The neurologist opined that the episodes were possibly not epileptic seizures given the atypical nature of the presentation and the preserved cognitive functioning despite generalized movements. Follow-up neurology clinic visit in February 2002 documented the CI’s report of four episodes since her January visit. The CI described the episodes as starting with a left retro-orbital headache that builds to maximum intensity over a couple of minutes and then she begins to feel bad all over for a minute and this is followed by uncontrollable shaking of all extremities and the head. Witnesses have said that her eyes are open but she does not respond; the shaking episode lasts for 10-15 minutes and when it is over, she either is normal or “looks a little tired,” but is awake. The CI’s second EEG was normal. The examiner opined that her episodes were not epileptic and may represent panic attack or psuedoseizures. She was referred to psychiatry for evaluation and a third EEG was ordered (normal). Records noted that the CI continued to take anti-convulsant (Dilantin) medication, and continued to report episodes of uncontrollable abnormal body movement. In May 2002, she was admitted to the hospital for diagnostic clarification and underwent video EEG monitor. After 14 days on the neurology inpatient unit, the CI was discharged with diagnoses of psuedoseizures, posttraumatic stress disorder (PTSD) and conversion disorder; and her anti-convulsant medication was discontinued. However, the CI began treatment with a civilian neurologist and was prescribed an anti-convulsant (Trileptal) medication in April 2003. On 7 July 2003, the civilian neurologist, in a written letter, recorded that the CI had not experienced further seizure-like episodes since the initiation of Trileptal medication in April 2003. The neurologist noted that the CI would likely need to remain on the medication for at least 2 years. Primary care clinic entry dated 4 November 2003, assessed “partial seizure this AM” secondary to missed dose of her Trileptal medication. Three weeks later she presented to the ER with report of having had a seizure, and was discharged with the instruction to continue her medication and follow-up with neurology. At the neurology evaluation for the MEB examination dated 2 August 2004, the examiner noted that the video EEG recorded no epileptic activity during her episodes and she was subsequently diagnosed with psuedoseizures. However, the CI’s civilian neurologist reportedly wrote that it was possible to have true seizures despite the normal video EEG and three normal EEGs and started her on Trileptal. The CI reported that she has had one seizure since starting Trileptal in 2003. Physical and neurological examinations were unremarkable and the neurologist assessed epilepsy partial (complex-psychomotor), conversion disorder with pseudoseizures and migraine headaches. The examiner stated. “True epileptic seizures and pseudoseizures are well-reported to occur concomitantly,” and noted that since she had a good response to Trileptal, it was believed that a diagnosis of epilepsy was appropriate and treatment needed to continue. Neuropsychological in August 2004 documented average intelligence, and the diagnosis of post-concussion syndrome, slowly resolving. Psychiatry narrative summary (NARSUM) dated 23 September 2004 documented the diagnosis of post-concussion syndrome, slowly resolving, and noted that the CI did not meet “The US Army requirements per AR40-501, CH. 3-34” (dementia, cognitive disorder due to GMC). The diagnosis of pseudoseizure was absent. On the same day, the CI underwent a second neurological for MEB (23 September 2004) with the same examiner reportedly because her MEB was delayed due to need for diagnostic clarification (seizure versus psuedoseizures). The examiner documented that the initial MEB had a diagnosis of seizure disorder and migraines, and the MEB questioned the seizure diagnosis since the CI was evaluated for 14 days in an inpatient unit and was discharged with diagnoses of psuedoseizures, PTSD and conversion. It was noted that the CI began seeing a civilian neurologist post-hospitalization that suggested the CI had both psuedoseizures and true seizures. The examiner noted that the CI currently reports that she has had recurring episodes of people speaking to her but she is not aware of it; this occurred four times in the past 5 months. Her last episode of loss of consciousness (LOC) was 3 months ago, and she was unable to recall having any symptoms prior to the LOC. The CI noted that since starting Trileptal she had one seizure (April 2003-September 2004). The neurologist concluded that the CI did not meet retention standards due to seizures and migraines and formally assessed the CI with seizure disorders, syncopal episodes, and light sensitivity to anti-convulsing medications.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the condition at 10%, coded 8914 (psychomotor seizures), and the VA coded the condition analogously 8045-8910 (grand mal) to assign a 10% evaluation. The PEB assigned a 10% rating, noting the CI had only one seizure in 20 months that involved a brief loss of consciousness. A 10% evaluation requires a confirmed diagnosis of epilepsy with the requirement of medication for control. The Board agreed the 10% rating was met. The higher rating of 20% requires the presence of at least one major seizure in the last 2 years or at least two minor seizures in the last 6 months. The Board noted that the neurology NARSUM in August 2004 diagnosed psychomotor seizures and conversion disorder with seizures (psuedoseizures) and was asked to clarify the diagnoses. In September, in response to the request for clarification, the neurologist did not classify the type of seizures, simply wrote “seizure disorders, syncopal episodes.” The neurologist documented, “Her last spell with LOC was three months ago while in a locker room in which she awoke when a person was shaking her asking if she was all right. All Board members agreed that this description appeared to reflect a major seizure. The PEB acknowledged there was one recorded seizure with LOC within two years of separation, and found the CI unfit due to psychomotor seizures. In addition, the CI’s Commander stated she experienced “chronic episodes of unconsciousness (seizures).” The Board noted that psychomotor seizures are rated as major seizures under the general formula when characterized by automatic states and or generalized convulsions with unconsciousness. All Board members agreed the 20% criteria were met. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the epilepsy condition.

Contended PEB Condition. The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition of post-concussion syndrome was not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Board reviewed the available evidence and noted that the neuropsychological in August 2004 documented average intelligence; scores in the general memory index were within the high average range opined to be better than expected on the basis of her overall ability. The psychologist assessed post-concussion syndrome, slowly resolving. Psychiatry NARSUM dated 23 September 2004 documented the diagnosis of post-concussion syndrome, slowly resolving. The condition was listed on the CI’s profile as a S2 condition. The Board noted the absence of documentation of cognitive or behavioral symptoms attributed to post-concussive syndrome to support the S2 profile. Both psychologist and psychiatrist made the diagnosis and indicated the condition was resolving; however, symptoms of post-concussive syndrome were not documented, at the time, and the record did not reflect a treatment focus for cognitive or behavior issues secondary to a brain injury. There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance; the condition was not implicated in the Commander’s Statement, and was not judged to fail retention standards. 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 post-concussion syndrome conditions and so no additional disability rating is 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 surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised. In the matter of the psychomotor epilepsy condition, the Board unanimously recommends a disability rating of 20%, coded 8914 IAW VASRD §4.124a In the matter of the contended post-concussion syndrome condition, 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 recommends modifying the case determination as follows, effective the date of medical separation:

UNFITTING CONDITION VASRD CODE RATING
Psychomotor Epilepsy 8914 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131213, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150013251 (PD201302593)


1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

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.

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              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA          

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