RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00546
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150220
SEPARATION DATE:  20060620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Fuel Systems) medically separated for vertigo.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  “Vertigo” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “vertigo, possibly related to Vestibular Dysfunction VS EPTS Migraine Headaches” as unfitting, rated 10%, referencing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and DoD guidelines.  The IPEB also adjudicated two other conditions, migraine headaches and seasonal allergic rhinitis, as Category II (conditions that can be unfitting but are not currently compensable or ratable).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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 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 IPEB – Dated 20060426	VA - (5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Vertigo … , possibly related to Vestibular Dysfunction VS EPTS Migraine Headaches	6299-6204	10%	Vertigo	6299-6204	30%	20061108	
Other x 2 (Not in Scope)	Other x 13 	
Rating:  10%	Combined Rating:  80%	
Derived from VA Rating Decision (VARD) dated 20070417(most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Vertigo Condition.  The narrative summary and service treatment record (STR) documented a long-standing history of migraine headaches and sinusitis.  She had onset of vertigo (sensation of motion) with dizziness beginning in November 2004 with an initial week of quarters for severe dizziness.  In 2005, she had a week on quarters for headache and dizziness.  Dizziness was sometimes associated with vomiting.  Formal evaluation for vertigo in June 2005 documented abnormalities with vestibular and visual dysfunction pattern on testing with normal electronystagmography and rotary chair testing was not completed due to “extreme nausea.”  However, rotary chair testing in January 2006 was reported to be within normal limits.  Medication and vestibular rehabilitation through December 2005 showed “balance improvement, no improvement in daily vertigo which occurs on stairs ascension, driving in car, or with sudden movements.”  A thorough review of the STR documented multiple exam entries regarding observed gait, specifically noting normal gait and stance; gait is slow, but otherwise normal; and normal tandem gait.  Specialist (ENT) assessment was vestibular neuritis with incomplete compensation.  ENT continued vestibular rehabilitation and in March 2006 (3 months prior to separation) noted “now usually unsteady, with vertigo 2-3 times a week usually when going upstairs or driving/riding in car.  Perceives improvement in dysequilibrium.”  Testing of balance was abnormal (Romberg +/-, Sharpened Romburg +) and the physician recommended continued vestibular rehabilitation.  Of note, hearing (audiometric testing) was normal and the CI had tinnitus (ringing in the ears) bilaterally and mostly at night without background noise.

At the VA Compensation and Pension exam performed 5 months after separation, the CI reported sudden onset of vertigo in November 2004.  The history indicated:  “She describes her dizziness as lightheadedness, feeling like she might faint, unsteady.  The vertigo occurs as follows:  feels like the room is spinning.  She has difficulty balancing as follows:  unsteady, prone to falls.”  Vertigo occurred 4 times per day lasting for 20 minutes.  Treatment was home exercises “which seem to keep it from becoming more severe.”  Medication (Antivert) did not help and “vestibular rehabilitation for 8 months which made her dizzy and nauseous, and seemed to improve things to about 65% of normal.”  The exam stated:  “There is disturbance of balance on the right and disturbance of balance on the left.  There is no finding of staggering gait or and cerebellar gait. … The examination findings are clinical exam shows disturbance of balance consisting of she was unable to walk toe to heel.”  The examiner indicated functional impairment as “she is more prone to falling, sensitive to motion, has headaches and visual motion disturbances, and anxiety, as a result of the episodes of dizziness and/or migraines.”  Tinnitus was noted as being for almost 2 years and constant in the right ear.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the vertigo using analogous coding to 6299-6204 (Peripheral vestibular disorders), but at different rating levels.  The VA also rated the CI for tinnitus (6260 at 10%).  The Board first adjudged that the CI’s vertigo did not meet the criteria for analogous rating as 6205 [Meniere’s syndrome (endolymphatic hydrops)] –There was no diagnosis of the condition in the record, and although the CI’s tinnitus may speculatively have been associated with the vertigo, there was no associated significant hearing impairment.  The Board deliberated on rating levels under 6299-6204 between the 30% criteria of “Dizziness and occasional staggering” and the 10% criteria of “Occasional dizziness.”

Both the Service and VA exams indicated a history of dizziness and occasional subjective symptoms of vertigo and imbalance not being completely resolved.  The VA quantified the balance symptoms (65%) as well describing the symptoms as “being unsteady and prone to falls.”  However, there was no objective evidence in the record of abnormal gait, staggering, falls, or use of any assistive device.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the vertigo 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 vertigo condition and IAW VASRD §4.87, the Board by a majority vote recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140124, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

MINORITY OPINION.  The minority voter recommends that 30% is the fair and equitable vertigo rating as there was sufficient evidence of imbalance symptoms to provide reasonable doubt in favor of the “occasional staggering” criteria at the time of separation.

There were objective findings supporting the diagnosis of vertigo with vestibular disequilibrium, and the diagnosis and “unfitting” nature of the condition were not at issue.  The CI had undergone prolonged and repeated treatment that did not resolve her vertigo symptoms.  My judgment is that the Board majority placed too much emphasis on the lack of objective exam findings of “staggering.”  Given the episodic nature of the CI’s dizziness and imbalance symptoms it is exceptionally reasonable to have no staggering documented at specific exam times.  A number of exams documented some balance deficits (positive Romberg tests and the VA exam’s “unable to walk toe to heel”).  The CI did not state that she was having her episodes during those exam timeframes.  Both the Service and VA examiners indicated a history of episodic dizziness and balance symptoms not being completely resolved.  The VA quantified the balance symptoms (65%) as well as describing the symptoms as “being unsteady and prone to falls.”

There was a consistent history of reported symptoms of imbalance and the CI’s report of being “prone to falling” at the VA exam meshed with service treatment note descriptions of her symptoms.  There was no indication in the record that the CI was embellishing her symptoms and I would consider her reported symptoms as being “competent, consistent lay testimony.”  The record of her imbalance symptoms more nearly approached the description of “dizziness and occasional staggering” (30%) rather than the 10% “occasional dizziness,” especially when considering VASRD §4.3 (resolution of reasonable doubt) and §4.7 (higher of two evaluations).

The minority voter 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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Vertigo	6299-6204	30%	
COMBINED	30%	

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2014-00546.

	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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

Attachment:
Record of Proceedings