RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-00466
BRANCH OF SERVICE:  Army
DATE PLACED ON TDRL:  20041204
DATE REMOVED FROM TDRL:  20060526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Infantryman, medically separated from the Temporary Disability Retired List (TDRL) for “bipolar disorder type I,” with a disability rating of 10%.

CI CONTENTION:  His conditions continues to worsen.  His 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 based upon a 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:

SERVICE PEB – 20041204/20060526	VARD - 20050307	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Bipolar Disorder I	9432	30%	10%	Bipolar Disorder	9432	70%	50%	
Pronator Syndrome [Bilateral]	Not Unfitting	Pronator Syndrome, Right Upper Extremity (Major)	8599-8515	30%	0%	
		Pronator Syndrome, Left Upper Extremity (Minor)	8599-8515	20%	0%	
Hypertension	Not Unfitting 	Hypertension	7101	0%	0%	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Bipolar Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bipolar condition was first recorded when his command referred him for inpatient mental health hospitalization in June 2004 for “manic symptoms.”  Command reported he had been historically “slightly off” without citing specifics.  He had been able to perform his duties until 2 weeks prior to admission.  He began to display increased grandiosity and delusions and spent money excessively.  He was a vague and rambling historian.  Examination showed him to have mildly pressured speech with flight of ideas, tangential and circumstantial thought processes, and marginal to poor insight and judgment.  He was hyperactive and distractible.  He reported his mood was “outstanding.”  He was treated with psychotropic medications.  A diagnosis of bipolar disorder I was rendered with a Global Assessment of Functioning (GAF) score of 45 (serious symptoms, impairment.)  He was discharged and remained compliant with medications, gradually developing insight.  He was noted to be moderately stable with symptoms of depressed mood, poor interest/energy and diminished sense of pleasure.  The examiner noted a marked impact on duty.  His outpatient provider noted depressed mood, poor interest/energy and diminished sense of pleasure.  

At the VA Compensation and Pension (C&P) mental health examination dated February 2005, approximately 2 months after separation, the CI denied a diagnosis of bipolar disorder and requested that his military records be changed to reflect no mental health problems.  He would not address any further symptoms but admitted that at times he could not sleep well and showed grandiosity about his 30-60 inventions.  He stated he was a pastor and denied a desire to hurt self or others. He denied current treatment.  On the mental status examination (MSE) he showed circumstantial thinking and racing thoughts that interfered with sleep.  He sat inappropriately close to the examiner to witness the documentation.  He had difficulty understanding cause-effect relationships. He showed little insight/compliance.  The diagnosis and GAF score mirrored that of the NARSUM examination.  The examiner noted that as long as his mental problems were unresolved he should not be trusted with financial affairs, given his history of spending.  

At the C&P general medical examination, performed 5 months prior to TDRL removal, the CI reported he had stopped taking his two psychotropic medications about a year prior but was able to function, though he had trouble getting along with people, was frequently very irritable and bothered by loud noises and speech.  He was unmarried but had girlfriends.  He could become quite angry if people looked at him the wrong way.  Sometimes he played basketball.  He was unemployed but planned to attend college and study psychology.  The diagnosis of bipolar disorder was rendered.  

The first psychiatric TDRL NARSUM examination, performed 1 month prior to TDRL removal, noted the CI was living in his own apartment and anticipating taking college courses.  He reported he had been unemployed since TDRL placement but made a little money playing pool, commenting that he was “a tournament level pool player.”  He was not receiving treatment and had not taken medication for about a year.  He was living a socially isolated and constricted lifestyle with few friends and limited family support.  He had moved to live where “I had my friends” and spent most of his time playing pool.  He reported mild episodes with his mood and episodes of extreme irritability which lasted about 2 days.  MSE was essentially unremarkable.  A diagnosis of bipolar disorder in remission was rendered with a GAF score of 70 (mild symptoms, impairment.)

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 30% rating at TDRL placement under a 9432 code (bipolar disorder), citing mild improvement and reduction of manic symptoms with little insight and borderline compliance.  The PEB then assigned a 10% rating at TDRL removal, citing CI report of mild mood episodes and mild social and industrial impairment.  
The VA assigned a 70% rating at TDRL placement also using a 9432 code based on the VA C&P examination 8 months after separation, citing occupational and social impairment with deficiencies in most areas.  The VA then assigned a 50% rating at TDRL removal citing the absence of current outpatient records supporting treatment.  

Application of VASRD §4.129 is considered by the Board for all cases of Service connected psychiatric conditions resulting in separation; but, all members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  The PEB assigned a 30% rating but the Board must consider whether the §4.130 criteria for a higher rating is reasonably satisfied at TDRL placement.  The 50% rating is for “reduced reliability and productivity” and the 70% rating is for deficiencies in most areas.  The Board noted the proximity of the manic episode and hospitalization to discharge and the NARSUM GAF score of 45, repeated in the C&P examination 2 months after discharge.  The NARSUM examiner noted he was moderately stable.  The Board agreed that the §4.130 criteria for a rating higher than 30% were not met near the time of separation.

The Board next considered whether the §4.130 criteria for a rating higher than 10% is reasonably satisfied at TDRL removal.  The CI reported mild, short term symptoms related to mood and irritability.  He was living independently near friends, playing pool almost daily and remained unemployed.  He was no longer receiving treatment.  Board members agreed that he did not meet criteria for a higher level of disability.  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 for the bipolar condition.  

Contended PEB Conditions: Hypertension, Bilateral Pronator Syndrome.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral pronator syndrome and hypertension were not unfitting.  The hypertension condition was not profiled or implicated in the commander’s statement and hypertension and the bilateral pronator syndrome were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that this 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 hypertension contended condition and so no additional disability rating are recommended.

Bilateral Pronator Syndrome.  The CI is right-hand dominant with a long history of pain in his forearms and “dropping things.”  Mild electro diagnostic studies and weak physical examination findings resulted in a diagnosis of bilateral upper extremity pronator syndrome.  The CI underwent median nerve decompression surgery for a left upper pronator syndrome in November 2003 and for a right upper extremity pronator syndrome in March 2004.  Symptoms improved drastically and he denied any numbness or tingling, noted good strength and pain relief.  Several months prior to TDRL placement he reported the acute return of symptoms in both hands and forearms without any known etiology.  Physical examination showed exaggerated giving way and weakness with palpable pulses.  He received a P2 profile to aid in his discomfort, stating he could not do pushups, pull-ups or that he could do them at his own pace, as well as lift no more than 40 pounds in either arm.  His hand surgeon noted that his symptoms did not follow an anatomic distribution and pulses were palpable.  Subjective complaints did not necessarily follow objective findings.  He was to continue conservative therapy, including an over the counter medication for pain.  Unbundling the bilateral pronator syndrome reveals similar pathology, clinical findings and treatment of each hand, indicating each hand would be separately unfit.  The commander noted the CI was limited in performance of tasks due to pain while performing simple tasks requiring the use of his hands and forearms.  Two months after TDRL placement, the C&P examination for the peripheral nerves documented weakness, excessive fatigability of both hands and incoordination in writing with decreased range of motion with mild discomfort, right greater than left without numbness or tingling.  At the time of the TDRL psychiatric NARSUM examination in April 2006, the CI reported he spent most of his free time playing pool.  The VA C&P examination showed no evidence of follow up treatment.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of bilateral pronator condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 8599-8515 and meets the VASRD §4.124a criteria for a 10% rating for the right and the left hand separately at the time of TDRL placement and 0% rating for each hand at the time of TDRL removal. 

BOARD FINDINGS:  In the matter of the bipolar condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended bilateral pronator syndrome condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10% for the left and 10% for the right pronator condition, coded 8599-8515 IAW VASRD §4.71a at TDRL placement and 0% for each hand at TDRL removal.  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 his prior medical separation:  
  
CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Bipolar Disorder Type I	9432	30%	10%	
Left Hand Pronator Syndrome	8599-8515	10%	0%	
Right Hand Pronator Syndrome	8599-8515	10%	0%	
RATING	40%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131230, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

 
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 XXXXXXXXXXXXXXXXXXXXX AR20160016221 (PD201400466)

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  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
40% disability rather than 30% for the period 4 December 2004 to 25 May 2006 and then following this period no recharacterization of the individual’s separation or modification of the permanent disability rating of 10%.

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 as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 10% effective the day following the TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 40% retired pay for the constructive temporary disability retired period effective the date of the individual’s original medical separation and adjusting severance pay as necessary to account for the additional TDRL time in service.

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:

 
CF: 
(  ) DoD PDBR
(  ) DVA