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AF | PDBR | CY2013 | PD2013 02066
Original file (PD2013 02066.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1302066
BRANCH OF SERVICE: Army  BOARD DATE: 20140618
SEPARATION DATE: 20070221


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (88M/Motor Transport Operator) medically separated for chronic migraine headaches. The CI’s chronic migraine headaches could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded the chronic migraine headache condition to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also forwarded for PEB adjudication, adjustment disorder and two non-mental health (MH) conditions as not falling below retention standards. The PEB adjudicated “chronic migraine headaches” as unfitting, rated 0% with likely application of DoDI 1332.39 and the VA Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting and therefore not ratable. The CI made no appeals and was medically separated.


CI CONTENTION: “Please review all conditions with emphasis on those with a VA Disability rating.”


SCOPE OF REVIEW: 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 applicant. The ratings for conditions meeting the above criteria are addressed below. In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process. The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference. The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.


RATING COMPARISON :

Service IPEB – Dated 20070106
 VA - (9 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Migraine Headaches 8100 0% Chronic Migraines 8100 10% 20071128
Adjustment Disorder Not Unfitting Adjustment Disorder 9413-9440 10% 20071128
Parasthesias in Left Hand Not Unfitting Parasthesias of the Left Hand 8599-8615 NSC 20071128
Intrauterine Pregnancy Not Unfitting No VA Entry
Other x 0 (Not in Scope)
 Other x 1 20071128
Combined: 0%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 80123 ( claim filed most proximate to date of separation [ DOS ] ).
VARD 20130904 increased DC 8100 to 30% from 20120731; and increased DC 9413-9440 to 30% from 20120731.

ANALYSIS SUMMARY:

Chronic Migraine Headache Condition. The VASRD §4.124a rating schedule for 8100 (migraine) is excerpted below for convenience:

                  With very frequent completely prostrating and prolonged attacks
                           productive of severe economic inadaptability-------------------------------50
                  With characteristic prostrating attacks occurring on an average once
                           a month over last several months---------------------------------------------30
                  With characteristic prostrating attacks averaging one in 2 months over
                           last several months------------------------------------------------------------- 1 0
                  With less frequent attacks------------------------------------------------------------0
The VASRD §4.124a rating schedule for 8100 (migraine) rests heavily on the frequency of “characteristic prostrating attacks … over last several months.” The narrative summary (NARSUM) noted headache onset in June 2006. She was seen in the emergency room (ER) on 22 August 2006 and received IV medication for relief. A lumbar puncture and magnetic resonance imaging of the brain were both normal. Multiple medications were tried with partial symptom relief and the diagnosis of migraine was confirmed by a neurologist. Headaches were associated with nausea, photophobia, photosensitivity and sonophobia with near syncope (feeling she is going to black out) without frank loss of consciousness. There was occasional blurred vision, but no focal weakness. She had a second ER visit for headaches in late 2006. Migraine medications were changed to use of Percocet as an abortive medication (narcotic to keep headache from getting worse--stopped Elavil and Triptan) when the CI was 22 weeks pregnant. Source Neurology treatment note dated 4 December 2006 stated “I don't expect patient's headaches to improve in short-tem, especially during pregnancy; migraine headaches' intensity and frequency may increase.” Neurologic exams found no focal deficits. The NARSUM examiner stated “headaches are occurring "3 to 4 times a week" and last "2 to 3 days" … described as "throbbing," with an average pain level of "6." … When she gets a headache, she will "stay away from bright lights and I will lie down.” She only takes the Percocet “if the headaches get really bad.” When she does experience migraine headaches, she really cannot perform any duties of her job and mostly lies down. She has noted that her headaches can be aggravated by performing "fast-pace activities." When asked about how her condition affected her ability to perform she stated “having migraines really handicaps me and when I get them, I can't do anything and I need to lie down." Medication use indicated four Percocet taken since 4 December 2006 (NARSUM dated 7 December 2006). The November 2006 commander’s statement noted “headaches are recurrent 3-4 per week despite medication,” but did not characterize them further. Work was noted to be 30 hours per week with profile recommended not arriving to work before 0930 due to morning sickness.

At the VA Compensation and Pension (C&P) exam performed 9 months after separation, the CI reported continuing headaches on average twice a week with Tylenol use to decrease the pain. She was not taking the narcotic medication, but using Tylenol for pain. “She believes that as a result of not being in the military and not working she can tolerate the pain better. She states because she is no longer in the military and not currently employed she has been able to lay down when a headache occurs.” There were no objective neurologic findings noted on exam. The VA rated this exam at 10% coded 8100. Remote VA rating dated September 2013 indicated an increased the migraine rating to 30% effective July 2012 (more than 5 years after separation).

The Board directs attention to its rating recommendation based on the above evidence. The PEB disability description was “Chronic migraine headaches with onset in Jun 06. Imaging and Lumbar puncture normal. Therapy choices Limited by pregnancy. A review of HREC shows headaches are not prostrating but frequent and severe enough to interfere with duty. Rated for less than one prostrating headache in the Last several months.” The rating options under 8100 for migraine headaches, which are open to consideration in this case, rely on the frequency of “prostrating” attacks. The DoDI 1332.39 (in effect at separation, but since rescinded) required that “the Service member must stop what he or she is doing and seek medical attention.” However, VASRD §4.124a does not require seeking medical attention for an attack to be considered prostrating, and a common (court-sanctioned) approach is to apply the clear English definition of prostrating.

The Board carefully considered the frequency and nature of the CI’s headaches including objective evidence and corroborating subjective evidence. The confounding issues of pregnancy limiting the use of migraine medication options (to stop headache progression), as well as temporarily exacerbating the migraine headache condition, were discussed. The record also indicated the CI did not regularly use the narcotic medication (Percocet) as prescribed to stop headache progression, but only "if the headaches get really bad." The Board found scant evidence that the CI had to leave work due to the headache condition, but subjective complaints that she had to lie down during at least some of her headaches. The initial VA exam indicated post-separation improvement, while the remote VA exam and rating indicating an increase in migraine headaches was too remote from separation to carry a high probative value for rating at the time of separation. Members agreed that the ratable threshold was met for characteristic prostrating attacks averaging once in 2 months over last several months (10%). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the migraine condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the adjustment disorder, left hand paresthesias and intrauterine pregnancy conditions were not unfitting. 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.

Parasthesias in Left Hand: The left hand paresthesias condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. Left hand sensory complaints were described as “occasionally she had intermittent numbness and tingling of the left hand. Mainly involving the 4/5th fingers.” Neurologist evaluation demonstrated no objective sensory or motor deficits. The impression was “May be carpal tunnel syndrome,” but that nerve conduction studies could be done after her pregnancy. There was insufficient performance based evidence from the record that the left hand 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 contended left hand condition and so no additional disability ratings is recommended.

Intrauterine Pregnancy: The intrauterine pregnancy was uncomplicated. Pregnancy is a condition that is not permanent and is not considered a physical disability for compensation. Natural pregnancy and childbirth are not disabilities for rating purposes IAW VASRD §4.116, so no change in the PEB not unfitting determination is recommended.

Adjustment Disorder: Under the Terms of Reference of the MH Review Project the Board considered the appropriateness of any changes in MH diagnoses, PEB fitness determination; and if unfitting, whether the provisions of VASRD §4.129 were applicable and a disability rating recommendation in accordance with VASRD §4.130. Adjustment disorder was not profiled (S1) and was not judged to fail retention standards by the MEB and was adjudged as not unfitting by the PEB. Although there were some symptoms suggestive of anxiety disorder and of depression during the MEB process, the mental health diagnosis and treatment proximate to the MEB was for a diagnosed adjustment disorder. The commander stated “performs her current duties with no issues as long as she is constantly supervised. Her relationship with peers and superiors is professional, although she requires daily counseling and correction on the most basic of military courtesies and duty performance.” The MEB, psychiatry consult and VA C&P examinations documented a diagnosis of adjustment disorder. At the time of processing through the military DES, no change in diagnosis was made at any time, and therefore this case does not meet the inclusion criteria in the Terms of Reference of the MH Review Project. Board members agreed that there was not a preponderance of the evidence sufficient to change the diagnosis from adjustment disorder. Adjustment disorder is a condition not constituting a physical disability IAW DoDI 1332.38, E5 in effect at the time. All Board members agreed that no MH disorder rose to the level of being unfitting at the time of separation and cannot recommend adjustment disorder (a non-compensable condition) for disability rating.


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. As discussed above, PEB reliance on DoDI 1332.39 for rating the chronic migraine headaches condition was likely operant in this case and the condition was adjudicated independently of that instruction by the Board using VASRD rating criteria. In the matter of the chronic migraine headaches condition, the Board unanimously recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a. In the matter of the contended intrauterine pregnancy and left hand paresthesias conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. In the matter of the contended adjustment disorder (MH) condition, the Board unanimously agrees that it cannot recommend it (or any MH condition regardless of diagnosis) for additional disability rating. 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, effective as of the date of her prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Migraine Headaches 8100 10%
COMBINED
 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131007, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                          
XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX , AR20140018979 (PD201302066)
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 10% 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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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