RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-00015
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050819	

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army Reserve, E2, Basic Trainee, medically separated for “post concussive headaches” and “chronic neck pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

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

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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 20050802	VARD - 20060330	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post-Concussive Headaches	8045-9304	10%	Post-Concussion Migraine Headaches	8045-8100	30%	20060227	
Chronic Neck Pain	5237	10%	Cervical Spondylosis 
with Disc Herniation	5242	20%	20060227	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Post-Concussive Headache Condition.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an onset of recurrent headaches resulting from a head injury during basic training approximately 9 months pre-separation in December 2004.  The CI fell negotiating an obstacle course (rope swing) suffering a head contusion without loss of consciousness.  The preliminary evaluation was negative and the initial clinical course was benign. 
With the persistence of headaches, a progressive ancillary imaging work-up ensued.  A basal ganglia lesion was identified which was ultimately judged to be benign (capillary telangiectasia) and not related to the symptoms, and there were no other imaging abnormalities.  A neurology consultant for the MEB documented headaches that “come and go but are much worse with any activity” and reported a history of “several” emergency room visits, but did not elaborate any prostrating episodes.  The headaches were attributed to “cerebral concussion” (an opinion corroborated by prior specialty evaluations).  There was no STR evidence of acute management issues or emergent treatment (emergency room or otherwise) with regards to the headaches.
  
The NARSUM was conducted 18 July 2005 (1 month pre-separation) and documented “daily headaches ... mostly at night and early morning ... aggravated by any strenuous physical activity,” and specifically noted that the CI had not required any emergency room visits since the initial injury.  The NARSUM physical examination recorded normal mental status and neurological findings and the diagnosis was “post-traumatic headaches.” 

A VA general Compensation and Pension (C&P) examination was conducted 6 months post-separation on 27 February 2006 and was preceded by a VA neurologic consultation on 6 February 2006.  The VA neurologist opined that there were prostrating headaches “approximately twice a month” and made a diagnosis of “migraines,” although the recorded history linked the onset with head injury.  The General C&P examiner opined that there were prostrating headaches “three times a month,” although documenting full-time employment as a clerk without work loss due to headache.  The C&P diagnosis was, “Migranous cephalgia, it is more likely than not due to the chronic cervical spine condition.” 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under 8045-9304 (brain disease due to trauma rated as dementia) was compliant, based on the Service diagnosis, with the VASRD in effect.  The VA’s 30% rating analogous to 8100 (migraine) was based on the C&P documentation of prostrating headaches and diagnostic latitude from the VA examiners.  Members agreed, however, that the diagnosis of headaches as a component of concussion was well supported by the Service opinions and compellingly consistent with the clinical facts.  The applicable VASRD §4.124a rating language for 8045-9304 which was in effect at the time of separation is excerpted below.
Purely neurological disabilities, such as hemiplegia, epileptiform seizures, facial nerve paralysis,etc., following trauma to the brain, will be rated under the diagnostic codes specifically dealing with such disabilities, with citation of a hyphenated diagnostic code (e.g., 8045– 8207).
Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304.  This 10 percent rating will not be combined with any other rating for a disability due to brain trauma. Ratings in excess of 10 percent for brain disease due to trauma under diagnostic code 9304 are not assignable in the absence of a diagnosis of multi-infarct dementia associated with brain trauma.
The Board is obligated by DoDI 6040.44 to apply the VASRD in effect to its recommendations.  Although a 30% rating was subject to consideration for the CI’s headaches under code 8100, albeit not firmly supported by the pre-separation Service evidence; it must be recognized that the above rating language specifically subsumes headaches “recognized as symptomatic of brain trauma.”  Therefore, having concluded that the latter was clinically accurate in this case, the VASRD in effect did not permit a rating higher than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the post-concussive headache condition.  

Cervical Spine.  There was an onset of persistent neck pain with intermittent upper extremity radicular symptoms resulting from the above training injury.  Imaging (MRI) revealed degenerative changes and a “small” C6/7 disc herniation without neural encroachment.  There were numerous normal upper extremity neurological examinations in the STR and none to the contrary with the exception of a single entry noting 4/5 left grip strength.  Bilateral upper extremity electrodiagnostic (EMG) testing was normal, and neurosurgery opined that surgery was not indicated.  

The same MEB neurology consultant documented “persistent neck pain ... markedly increased with neck turning” and provided cervical range-of-motion (ROM) measurements.  Although the examiner noted “mild” spasm, the recorded ROM measurements were markedly decreased, with flexion limited to 10 degrees (normal 45) and extension to 15 degrees (normal 45).  In contrast to the reported history, the rotational measurements were only somewhat limited at 60 degrees (normal 80).  There were multiple outpatient STR entries (before and after the preceding neurology consult) documenting (or implying) grossly normal ROM, and there were none indicating significant ROM limitation.  Formal ROM measurements for the MEB were performed by physical therapy (PT) on 28 June 2005 (7 weeks pre-separation), and were reported as flexion to 35 degrees with combined ROM of 150 degrees (normal 340, bilateral rotation now decreased to 25 degrees).  Of note, a primary care entry 2 weeks prior to the PT measurements documented grossly full ROM with painful motion only.

The NARSUM documented continuing neck pain “averaging” 7/10 and with “some upper extremity tingling and numbness.”  The physical examination recorded tenderness, trapezial spasm, normal gait and spinal contour, and normal neurological findings (5/5 upper motor and grip strength, intact sensation, symmetric reflexes).  The NARSUM cited the above PT ROM measurements for the MEB, without comment regarding gross ROM observations at the time of the NARSUM.

The post-separation VA C&P examination (same as for headaches) documented “chronic neck pain ... mostly upon awakening” rated 5/10 without mention of radicular symptoms.  The only functional limitation noted was with tilting the neck for phone calls at work (“no effects on her daily activities of living”).  The VA physical examination noted that the CI held her head “tilted to the right with moderate muscle spasms,” consistent with the presence of torticollis.  The latter is an intermittent and transient condition and was well established as a periodic diagnosis in subsequent VA records.  Neurological findings were normal.  The VA ROM measurements were flexion to 35 degrees, extension 20 degrees, right lateral flexion 25 degrees (normal 45), and right rotation 30 degrees; but, the examiner reported that the CI was “unable to perform” left flexion and rotation maneuvers (logically due to the torticollis); thus, combined ROM could not be ascertained.  The examiner further reported “about 5-10 degrees” of loss of motion with repetition “due to weakness and stiffness,” without indicating any specific planes of motion or correlation with the torticollis present at the time of the examination.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s DA Form 199 cited the VASRD §4.71a 10% criteria of tenderness and spasm for its rating under 5237 (cervical strain), with no comment regarding ROM.   The VA’s 20% rating under 5242 (degenerative arthritis of the spine) was premised on ROM deduction from flexion based on the above C&P comment regarding loss of motion with repetition.  The 35 degree flexion from both the MEB PT and baseline C&P examinations yields a 10% rating.  Members agreed that the 10 degrees flexion from the MEB neurology consult was subject to too much probative value mitigation and was too much of an outlier to influence the Board’s recommendation.  Members further agreed that the C&P evidence for loss of motion with repetition was too vague and too compromised by the torticollis (a temporary condition not reflective of baseline disability) to be reasonably justified as a DeLuca deduction for rating purposes. 
It remains, however, that the combined ROM of 150 degrees from the MEB PT measurements is a §4.71a 20% criterion.  Members thus deliberated whether this evidence was sufficiently probative to support a 20% recommendation.

In this regard it was relevant that, with the exception of the MEB neurology consultation with its own probative value concerns, there was an abundance of outpatient STR evidence from the time of the injury up to and after the MEB PT evaluation indicating that there was no significant ROM limitation.  There was no reasonable clinical explanation for such marked deterioration in ROM shortly after a protracted stable period associated with little or no ROM limitation.  Although it can be conceded that the MEB PT measurements were performed on a bad day, the Board’s recommendation should be premised on baseline, not sporadic, disability.  The same reservation was applicable to the VA ROM evidence obtained during a temporary attack of torticollis.  Members ultimately agreed that the preponderance of ROM evidence was more aligned with the 10% than the 20% criteria of §4.71a.  There was no evidence for abnormal spinal contour to satisfy that 20% criterion and neither the functional link to fitness requisite for rating, nor the presence of a VASRD ratable deficit, were supported in justification of additional rating for the radicular symptoms.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the cervical spine condition. 

BOARD FINDINGS:  In the matter of the post-concussive headache condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the cervical spine condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20131119, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160005823 (PD201400015)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA