RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01944
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150415
SEPARATION DATE:  20050701

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Visual Information Production) medically separated for cervical dystonia (movement disorder).  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued a temporary P4 profile and referred for a Medical Evaluation Board (MEB).  The “cervical dystonia,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “cervical dystonia unresponsive to maximal dose of Botox” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Correct DD 214 form item 23 released from Active Duty to released [sic] due to physical disability with disability severance pay--which I received.”

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:

IPEB – Dated 20050527	VA* - (~4 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Dystonia	5237-5299	10%	Cervical Dystonia/Torticollis	5399-5323	10%**	20050311	
Other x 0 (Not In Scope)	Other x 2	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20050427 (most proximate to date of separation). **VARD dated 20061016 increased to 30% effective 20050909 and then 60% effective 20060614.

ANALYSIS SUMMARY:

Cervical Dystonia.  The earliest note in the service treatment record, dated 6 November 2002, indicated the CI had neck pain with worsening spasm.  Apparently, he had been treated with Motrin (Ibuprofen, a nonsteroidal anti-inflammatory medication), which did not help nor did physical therapy or Flexeril (cyclobenzaprine, a muscle relaxant).  A cervical spine series revealed fusion of the C3-4 vertebral bodies and facets and narrowing of the neural foramina (where the nerves exit the spine) at C3-4.  At an emergency room visit on 17 November 2002, the diagnosis of torticollis (wryneck) was made for the CI’s muscle spasms of the neck.  A magnetic resonance imaging (MRI) revealed a left paracentral disk protrusion at C6-7, a disk bulge at C5-6 and degenerative disk and joint changes at C4-5 along with a developmental anomaly at C3-4.  Evaluation in January 2003 noted the onset of muscle spasm and neck pain in August 2002 during basic training.  When the CI’s head was turned to the right, he needed his arms to rotate his head back forward.  In February 2003, a profile was issued and Ultram (toradol, an opioid medication) and Naprosyn (naproxen, a nonsteroidal anti-inflammatory medication) were prescribed.  In May 2003, cervical spine ranges-of-motion (ROMs) were reported by physical therapy (in percentages of normal, which were rounded to the nearest 5%) to be flexion 75% (35 degrees), extension 10% (5 degrees), side bending right 0% (0 degrees) and the left 35% (15 degrees), and rotation left 50% (40 degrees) and right 35% (30 degrees).  

Neurologic evaluation in May 2003 confirmed the diagnosis of rotational torticollis (an abnormal, asymmetrical head or neck position) to the right with mild left laterocollis (head tilt toward the shoulder) most likely idiopathic and instituted Botox (onabotulinumtoxinA, to paralyze muscles) treatment.  In November 2003, Mobic (meloxicam, a nonsteroidal anti-inflammatory medication) and Lexapro (escitalopram, to treat depression and generalized anxiety disorder) were prescribed in addition to Botox, physical therapy and massages.  An undated psychiatric evaluation in 2004 raised the possibility of a conversion disorder (symptoms resemble those of a nervous system disorder) or a coping style exacerbating a possible idiopathic neuromuscular disorder.  Active ROMs were normal, but left rotation needed assistance in January 2004.  Imaging studies in May 2005 revealed dextroscoliosis (twisting of the spine to the right) of the cervical spine on X-rays, multiple lymph nodes of the neck on CT scan, and a nine millimeter focal abnormality in the right temporal lobe with bilateral maxillary sinusitis.  Surgical evaluation did not feel the cervical node was suspicious; and no biopsy was performed.  Review of the MRI findings of the brain was compatible with bilateral choroid plexus cysts and a left arachnoid cyst, incidental findings not related to torticollis.  A revised temporary P4 profile was issued on 19 August 2004 with restrictions of no lifting over 20 pounds, no deep knee bends, no standing exercises and no deployment.  The commander’s statement, dated 1 February 2005, indicated the CI was able to work at his home station only; he was non-deployable and was limited to lifting not more than 20 pounds; and his condition caused constant episodes of neck pain.

The MEB narrative summary, dated 7 February 2005, indicated the CI had a history of cervical dystonia for about 2 years marked by head turning to the right and leaning to the left associated with an irregular tremor in the head from side to side.  Movement was suppressed by leaning against a wall or touching his face.  There was no head injury, and the CI never took neuroleptic (antipsychotic or major tranquilizer) medications.  Evaluation for copper excess (normal urine copper excretion and ceruloplasmin) was normal.  An MRI of the brain in May 2004 showed non-enhancing lesions in the left and right temporal lobes respectively that were reported as non-specific and chronic.  Botox injections, Diazepam (to treat muscle spasms), Artane (trihexyphenidyl, to treat stiffness, tremors, and spasms), and Baclofen (a muscle relaxer) failed to diminish the involuntary movements.  The CI had no family history of dystonia, denied onset during childhood, and had the dystonia while asleep.  He denied other neurologic symptoms, although he noted intermittent numbness of the hands.  Neurologic examination was essentially normal except his head position at rest was turned to the right and tilted to the left and he had an irregular tremor.  The muscles of the neck (sternocleidomastoid) did not appear to be hypertrophied (enlarged).  The examiner recommended the CI be referred to a movement disorders center for evaluation since the cervical dystonia was not responsive to maximum doses of botulinum toxin.

At a VA Compensation and Pension (C&P) neurological evaluation on 11 March 2005, less than 4 months prior to separation, the CI complained of pain in the neck and movement of the head and neck for the prior 3 years.  He felt various situations contributed to development of his condition including stress during basic training, lying in a bed that was not long enough for him, and cold air blowing over his head and neck.  Symptoms became worse with underlying stress, anxiety, and nervousness and he had two treatments by a pain management specialist, who was also a psychiatrist.  At the time of the examination, he took no medication, but had used muscle relaxants without relief and had acupuncture treatment once.  His neck movements were performed in all directions and he was able to bend and touch his toes without difficulty.  There were involuntary movements of his head with a tendency to turn his head towards the right side with flexion resulting in contraction of the left sternomastoid muscle.  There were no hand tremors; and the neurological examination was unremarkable.  In the examiner’s opinion, there were underlying psychological factors as well as hyperventilation almost bordering on panic attacks.  A psychological approach to control the anxiety and depression was recommended.  At a neurology evaluation in November 2005, approximately 4 months after separation, the examiner opined that the abnormal head movements appeared to be psychogenic since there was no muscle hypertrophy, the movements were not really stereotyped as one would see with dystonia, and there was no benefit from Botox.  An MRI of the brain revealed a likely neuroepithelial cyst in the left uncus, the innermost portion of the temporal lobe.  A specialist felt the movements were consistent with dystonia and Botox treatment was resumed.  A note in April 2006 indicated there was no response to Botox; a trial of Myobloc (rimabotulinumtoxinB, a muscle paralyzing medication) and carbamazepine, an anticonvulsant medication), were instituted; and Celexa (citalopram hydrobromide, an antidepressant) was prescribed for anxiety/depression.  The CI did not notice much of a response to the Myobloc injections.

At the VA C&P examination, dated 11 July 2006 and performed 13 months after separation, the CI reported that he could not do much of anything.  His head was constantly moving with some facial grimacing.  Treatment with Myobloc seemed ineffective.  On examination, the CI had severe cervical dystonia with laterocollis and frequent head turning to the right with flexion of the neck and some secondary movement of the arms.  He could not keep his head still.  Neurological examination was unremarkable except the CI looked to be in quite a bit of distress with constant head movement and his chin tucked into his chest.  Genetic testing was discussed, but not carried out.  The examiner opined that the CI was severely disabled.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5237-5299 (cervical strain) for cervical dystonia unresponsive to maximal dose of Botox.  The VA assigned an initial rating of 10% using code 8103-8104 (tic, convulsive-paramyoclonus multiplex) from 24 August 2004 to 28 February 2005 and 10% from 28 June 2005.  The rating was increased to 30% from 9 September 2005 and then to 60% from 14 June 2006 for cervical dystonia/torticollis.  The Board noted the PEB used a code for cervical strain; however, the General Rating Formula for Diseases and Injuries of the Spine Note (1) states:  “Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately under an appropriate diagnostic code.”  The CI had a full active ROM except left rotation, which needed assistance due to muscle spasm resulting in a dextroscoliosis (curvature of the spine to the right).  Therefore, at minimum, a 20% rating is warranted especially since degenerative changes were present in the cervical spine.

The Board then directed its attention to the neurologic component, which was the basis of the dextroscoliosis as well as the CI’s overall condition.  The VA used analogous code 8103-8104 encompassing a tic (a sudden, repetitive, non-rhythmic motor movement) and paramyoclonus multiplex, which is a form of myoclonus (sudden, involuntary jerking of a muscle or group of muscles) starting in the muscles of the upper arms and spreading to other muscles of the body.  However, the CI’s condition was limited to the neck and secondary to the arms.  Both the PEB and the VA noted the CI’s condition had not been amenable to treatment, although deep nerve stimulation had not been performed.  The Board members concurred with the fact that the condition was severe.  VASRD code 8104 uses code 8103 for rating purposes; however, code 8104 states: “Rate as tic; convulsive; severe cases...60[%]” whereas code 8103 rates “severe” at 30%.  The Board discussed whether code 8103 for “severe” at 30% or 8104 for “severe” at 60% was more applicable.  A close reading of the VASRD suggests that code 8104 “severe” would be more applicable in a convulsive state.  This was not raised in the CI’s case nor was there an electroencephalogram study in the record which would normally have been performed in a convulsive disorder evaluation.  In addition, paramyoclonus multiplex usually involves many more muscle groups than just those of the neck and the arms.  Therefore, the Board favored a using code 8103 at 30% rating for the cervical dystonia since the CI’s muscles movements of the head and neck were continuous and were of a severity that he could not perform the duties of his AFS or work within a year after separation.

The question of whether pyramiding IAW VASRD §4.14 was then discussed especially noting “the evaluation of the same manifestation under different diagnoses are to be avoided.”  As noted previously, the PEB used analogous code 5299-5237 for cervical strain.  The Board recognized that to rate for cervical strain and cervical dystonia could constitute pyramiding, but that VASRD §4.71a Note (1) permits separate ratings.  Therefore, the Board considered the additional rating of 30% as reasonable.  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 cervical strain with dextroscoliosis and an additional disability rating of 30% for the neurological cervical dystonia 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.  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 cervical strain with dextroscoliosis, the Board unanimously recommends a disability rating of 20%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the cervical dystonia condition, the Board unanimously recommends a disability rating of 30%, coded 8103 IAW VASRD §4.124a.  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 re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Cervical Strain with Dextroscoliosis	5299-5237	20%	
Cervical Dystonia 	8103	30%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140617, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXXXXXXXXXXXX:

	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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN