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AF | PDBR | CY2014 | PD-2014-01776
Original file (PD-2014-01776.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-01776    
BRANCH OF SERVICE: Army         BOARD DATE: 20150514
SEPARATION DATE: 20030617                


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Technical Engineer Supervisor) medically separated for chronic neck pain, with cervicogenic headaches, with components of migraine headaches superimposed. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent P3/U3 profile and referred for a Medical Evaluation Board (MEB). “Migraine headaches” and “chronic neck pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also forwarded low back pain as medically acceptable. The Informal PEB adjudicated “chronic neck pain with…cervicogenic headaches with components of migraine headaches superimposed” as a single unfitting condition, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The low back pain was found to be not unfitting. An Administrative Correction was completed by the US Army Physical Disability Agency (USAPDA) noting “headaches are not independently unfitting…”, however this correction had no effect on the rating. The CI made no appeals and was medically separated.


CI CONTENTION: “Please consider all conditions.”


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 :

USAPDA Admin Corr – Dated 20030506
 VA – (8 mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Neck Pain,
with Headaches 		5399-5323 10% Chronic Neck Pain 5399-5323 10% 20021017
Tension Headaches 8199-8100 30% 20021017
Low Back Pain Not Unfitting Lumbar Strain 5295 10% 20021017
Other x 0 (Not in Scope)
 Other x 1
Rating: 10%
 Combined Rating: 40%
Derived from VA Rating Decision (VA RD ) dated 20030630 ( most proximate to date of separation [ DOS ] )


ANALYSIS SUMMARY: As noted above, the PEB combined the neck pain with the headaches, and treated them as a single unfitting condition. The Board evaluated whether or not it was appropriate for these two pain problems to be “bundled” together. The Board must determine if the PEB’s approach of combining the two problems under a single rating was reasonably justified in lieu of separate ratings. The Board must apply separate ratings in its recommendation if compensable ratings for each pain problem are achieved IAW the VASRD. If the Board judges that two or more separate ratings are warranted, however, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting. After due deliberation, the Board determined (by majority decision) that the evidence supports a conclusion that each of the chronic pain problems, separately, would have rendered the CI unable to perform his required military duties. Specifically, the Board finds the headaches to be separately unfitting. The Board noted that migraines were listed on the February 2003 Physical Profile (DA Form 3349). Severe headaches were also very prominently addressed in the written statement by his commander. Therefore, because headaches were separately unfitting, the Board recommends a separate disability coding and rating for each of the chronic pain problems. It was not appropriate for the chronic neck pain to be bundled with the chronic headaches and treated as a single unfitting condition.

Chronic Neck Pain. In August 2001, this CI was injured in a parachute landing fall (PLF). Following the injury, he developed pain in his neck and back. He was seen by Orthopedics and the pain was diagnosed as myofascial. X-rays of the cervical and thoracic spine were normal. Magnetic resonance imaging (MRI) showed some straightening of the cervical spine, but no evidence of underlying pathology. On 16 October 2002, the CI was seen by a neurologist. The examiner’s diagnostic impression was: refractory cervical pain and paraspinal spasm, with cervicogenic headaches. Many different therapeutic modalities were tried; including physical therapy, chiropractic manipulation, ultrasound treatment, biofeedback, trigger point injections, Botox injections, and steroid injections. In spite of all treatment efforts, his symptoms persisted.

In October 2002, 8 months before separation, the CI had a VA Compensation and Pension (C&P) exam. He reported dull, moderate pain in the neck and back which intensified with activity. The pain would become severe about 2-3 times per month and could last for hours to days. He also reported head pain (the headaches are discussed below). On physical examination (PE), he was in no acute distress. There was tenderness to palpation (TTP) of the paraspinal muscles, the trapezius muscles, and the cervical vertebra. The superior aspect of the trapezius muscles was noted to be in spasm. Both hands showed normal muscle strength with no atrophy. Range-of-motion (ROM) of the cervical spine was normal, but was painful. The ROM measurements are summarized in the chart below. Cervical ROM was not affected by weakness, instability, fatigue, incoordination, or lack of endurance.

A focused MEB PE was done by Neurology on 28 January 2003. The CI was alert and oriented, with normal speech and language. Cervical ROM was significantly impaired due to paraspinal spasm and pain. There was significant tenderness on both sides of his neck, as well as the occipital area (back of the head). There was no tenderness to percussion of his entire spine. Gait was normal, and neurological exam (motor and sensory) was normal. For diagnostic impression, the examining neurologist wrote: “Two year history of significant musculoskeletal pain syndrome, without significant abnormalities on physical examination or imaging.”

The MEB narrative summary (NARSUM) was dictated on 20 March 2003. The CI reported that he could perform most of his activities of daily living without any significant disability. On PE of the neck, the spine was in line without step-off or deviation. There was some TTP of the paracervical muscles bilaterally, at the base of the skull. Neurological exam (motor and sensory) was normal. The cervical ROM evaluations in evidence, which the Board weighed in arriving at its recommendation, are summarized in the chart below.

Cervical ROM
 (Degrees)
 VA C &P ~ 8 mos . Pre-Sep
MEB ~ 3 mos . Pre -Sep
Flex ion
 65 65
Extension
 50 35
R Lat Flexion
 40 35
L Lat Flexion
 40 40
R Rotation
 80 60
L Rotation
 80 45
Comment
 pain with motion n o mention of painful motion

The Board directed attention to its rating recommendation based on the above evidence. The Board determined that, since the chronic neck pain was largely due to muscle spasm, use of a muscle diagnostic code (DC) was appropriate. IAW VASRD §4.73, the muscle group involved was Group XXIII. At the time of separation, the CI’s disability from chronic neck pain was best described as “moderate.” There was insufficient evidence to support classifying his neck pain as “moderately severe” or “severe.” Therefore, the Board determined that a 10% rating was appropriate. The Board tried to find a path to a higher rating, using other VASRD codes that could be applied to the chronic neck pain, but there was insufficient evidence to justify a higher rating using other VASRD codes. The Board also considered the matter of radiculopathy. After review of all the information in the record, there was insufficient evidence of a clinically significant radiculopathy that interfered with performance of military duties. Therefore, the Board concluded that there was no unfitting radiculopathy present at the time of separation. Considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 10% disability rating for the unfitting chronic neck pain, coded 5399-5323.

Headaches. In addition to chronic neck pain, the CI also suffered from headaches. At the October 2002 C&P exam, he reported that his pain began in the neck and moved up to the scalp, causing a throbbing, stabbing pain behind the eyes, and causing blurred vision. This occurred about 3-4 times per month, and required him to stop and rest. He was unable to work when a headache developed. Two days prior to that C&P examination, he was seen at the emergency room (ER) for severe neck pain and headache. He was treated with intravenous Valium and Toradol, which gave him some relief of the pain. In fact, the CI has been seen in the ER on multiple occasions for severe neck pain, headache, and vomiting.

At the January 2003 Neurology evaluation, the examining neurologist wrote “The headaches were consistent with migraine, and were characterized by a unilateral throbbing pain severe in intensity, with nausea, vomiting, and photophobia, which increased with exercise. Treating his headaches with Maxalt, Indocin, and Midrin was not particularly effective.” In March 2003, the NARSUM examiner wrote that the CI was having headaches 3-4 times per week which limited his abilities, but did not prevent his functioning. However, about once per week, he was having a severe headache which prevented his functioning for approximately 1-day. The Board carefully reviewed all evidentiary information available. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends (by majority decision) a disability rating of 30% for the chronic, severe headaches.

Other PEB condition. In addition to chronic neck pain and headaches, the CI also suffered from low back pain (LBP). This condition was adjudicated by the PEB as “Not disqualifying.” The Board’s main charge with respect to the LBP condition is to assess 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. This condition was thoroughly reviewed and considered by the Board. The LBP was not specifically profiled, nor was it judged to fail retention standards. There was no indication from the record that the LBP significantly interfered with satisfactory duty performance. After due deliberation, and in consideration of the preponderance of the evidence, the Board found insufficient cause to recommend a change in the PEB fitness determination for the LBP. Therefore, 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 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 chronic neck pain, and IAW VASRD §4.73, the Board unanimously recommends a disability rating of 10%, coded 5399-5323. In the matter of the chronic headaches, and IAW VASRD §4.124a, the Board recommends (by majority decision) a disability rating of 30%, coded 8199-8100. The single voter for dissent did not elect to submit a minority opinion. In the matter of the low back pain, the Board unanimously recommends no change from the PEB determination as not disqualifying. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, 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 his prior medical separation:

CONDITION
 VASRD CODE RATING
Chronic neck pain 5399-5323 10%
Cervicogenic headaches, with components of migraine headache 8199-8100 30%
COMBINED
 40%















The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140421, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record
        



XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXXX , AR20150014378 (PD201401776)


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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

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