RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-00806
BRANCH OF SERVICE:  NAVY                                                                   SEPARATION DATE:  20090704 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Hospital Corpsman, medically separated for “thoracic back pain, common migraine without aura, bipolar disorder not otherwise specified, and  panic disorder without agoraphobia” with a combined overall effect disability rating of 0%. 

CI CONTENTION:  The CI’s conditions continue to worsen and negatively impact daily activities.  The CI’s 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:  

SERVICE PEB - 20091009	VARD - 20091118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Back Pain	Overall Effect	0%	Muscular Ligamentous Inflammation	5237	10%	20100205	
Common Migraine			Migraine Headaches	8100	10%	20100205	
Bipolar Disorder			Bipolar Disorder, Type II	9432	30%	20080619	
Panic Disorder			No VA Placement	
Attention Deficit Hyperactivity Disorder	Cat IV	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Thoracic Back Pain Condition.  The PEB determined the thoracic back pain condition alone was not independently unfitting but when combined with the other listed conditions, contributed to overall unfitness.  The Board considered whether the back considered alone was unfitting for continued military service.  If the Board determines the condition was unfitting for military service, it must then consider applicable codes and rating recommendation.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported she had back pain that begun in March 2005 secondary to motor vehicle accident (MVA).  She underwent an extensive workup with the orthopedic spine surgery without any significant findings.  The NARSUM examiner noted that as of January 2008 no restrictions to activities were placed related to this condition.  The orthopedic surgeon documented in his note dated 10 January 2008, that the bone scan was negative and all labs tests were normal.  It was opined that her back pain was “muscular” in nature and that any physical restrictions would be related to her subjective level of pain, but there was no role for any surgical intervention.  The NARSUM was conducted in May 2008, approximately 14 months before separation.  The examiner noted that the CI presented to the examination with headache complaints, but that the general examination was unremarkable.  The diagnoses of migraine and back pain were recorded, and the examiner noted that the condition of migraine be referred to the PEB as the primary diagnosis and that the migraine condition was medically disqualifying.  According to the STR, the CI was issued a LIMDU related to her back pain beginning in 2006; however, there was no evidence that she had a LIMDU post-examination by the spine surgeon who determined no limitation of duties were required.  

The Board first considered whether the back condition was unfitting for continued military service.  The sole symptom recorded in the NARSUM related to the back was back pain.  The orthopedic surgeon did not impose any restrictions to activities, all radiographic studies were negative for arthritis, inflammation, and disk disease, and all laboratory studies were negative ruling out the likelihood of any underlying occult infectious, neoplastic or inflammatory arthritic process.  She had a normal neurological examination that included sensorimotor testing, reflexes, coordination, gait and stance.

At the time of a VA Compensation and Pension (C&P) examination on 5 February 2010, 7 months after separation, physical examination of the back documented absence of radiating pain, muscle spasm, muscle weakness and sensory deficits.  There was tenderness to palpation in the lower back, and ROM recorded forward flexion to 90 degrees (normal) and combined ROM of 210 degrees (240 normal).  The commander commented that her medical condition interfered with her ability to complete many of the responsibilities expected of general corpsmen such as serving on a deployable platform, participating in mass casualty drills, live scenarios, or performing the physical readiness test, and therefore, separation was recommended.  It was noted that her condition had limited her from performing any running, heavy lifting, prolonged walking, standing, crawling, or entering into any area where her unsteady gait may pose a danger to her or others.  This would suggest primary limitations were related to her back condition at that time.  However, there were no additional LIMDUs among the service treatment records (STR) that documented restrictions related to any of the adjudicated conditions.

Board members concluded at the time of separation, the CI’s back condition was stable, and despite the complaint of back pain, she remained capable of performing many of the duties required of her position as a psych tech.  There was no indication that she had a LIMDU effective beyond 2006 related to the back.  One year prior to separation, her commander recommended that she be retained on active duty in a permanent limited duty status, if found unfit, but noted her profile significantly interfered with the ability to perform all of her required duties.  Again, the last recorded profile was a year before separation.  However, this profile preceded the specialist recommendation that she had no limitation of activities related to the back.  Board members agreed there was insufficient evidence to support that the back condition cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of thoracic back pain as an unfitting condition for separation rating.

Common Migraine Condition.  The STR noted that the CI’s headaches began in 2005.  In May 2005, a brain CT was negative for any pathology productive of persistent headaches.  Psychiatry entry dated 7 March 2008 noted the CI reported she had headaches that were at times associated with blurred vision and tingling in the fingers of the left hand.  The psychiatrist noted that the CI had been referred to psychiatry due to suspected psychosomatic origin of her headache and back pain complaints.  The CI was evaluated by the headache clinic in April 2008 and was diagnosed with migraine without aura.  

The NARSUM dated 5 June 2008, 13 months prior to separation, noted that the headaches lasted for 1-3 days and that they were sharp or stabbing in character.  The examiner documented that her headaches began in 2005 after her first pregnancy.  At the NARSUM, the CI reported “feeling tired all the time.”  Neurological examination was unremarkable.  The CI had multiple trials of medication to address her headache condition with minimal improvement.  The last treatment entry related to the headache condition was dated 14 January 2009, 6 months prior to separation.  At the time, the CI presented to the clinic for a refill of her benzodiazepine medication, once prescribed for muscle spasm.  She noted that she had taken this medication at the onset of a migraine and that the medication aborted the headaches.  The examiner stated “She reports today with the early symptoms of one of her migraines, requesting a refill.”  The provider indicated the medication was refilled.  There were no additional reports of headaches going forward.  The VA C&P examination 7 months after separation noted the CI indicated she was able to go to work but required medication for her migraines which she experienced on average of 2 times per week, lasting an hour.  She indicated that she was taking Vicodin.  

There was no indication from the record that the headache condition was profiled or that any duty limitations were recommended based on headaches.  As noted above, STRs in the 6 months prior to separation were silent.  The Board noted that the CI reported at the C&P examination that her headaches when present, lasted for about an hour in contrast to the duration of the headaches reported at the NARSUM.  The record also indicated that the CI had found a medication that was effective in aborting her headaches at headache onset. 

Board members agreed there was insufficient evidence to support that the migraine headache condition cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of migraine headache as an unfitting condition for separation rating.

Bipolar and Panic Disorder Conditions.  According to the service treatment records the CI was first evaluated in psychiatry for pain syndrome in March 2008 and was assessed with cervicalgia. It appears that she was already in the MEB process.  The examiner noted that she had completed extensive workup for her back pain and results were all negative.  It was opined that her chronic disability was the result of persistent somatic symptoms, however, no mental health diagnosis was rendered.  She was prescribed an antidepressant medication to address pain complaint.  

On 28 July 2008 the CI was diagnosed with attention deficit hyperactive disorder (ADHD) and depression after she reported symptoms of dysphoria, loss of pleasure, disturbed sleep, low energy, low motivation, poor appetite and longstanding problems with attention, poor organization, forgetfulness, and low frustration tolerance.  The psychologist referred her to psychiatry for medication management.  The record indicated that the CI was seen in psychiatry on 29 July and was prescribed a stimulant medication.  

The psychiatric addendum was accomplished on 1 October 2008.  The psychiatrist examiner for the addendum was also her treating psychiatrist.  It was noted that the CI had initially been assessed with ADHD, panic disorder with agoraphobia and depression.  She had reported ongoing marital problems with pending divorce, some depression, insomnia, loss of appetite, and lack of interest, and vague panic attacks.  The CI also reportedly described having lived in an abusive marriage for several years.  She was prescribed medication for the panic attacks and noted some benefit, and prescribed a stimulant medication for the ADHD diagnosis.  The stimulant increased her anxiety, however, the medication dose was increased and an antidepressant medication was added.  A few days later, on 31 July 2008, after increasing the stimulant dose, she became hyperactive and disorganized and irritable, and was diagnosed with bipolar disorder NOS.  She was treated with lithium and Seroquel for sleep.  The CI reportedly had not provided clear evidence of sustained hypomania, but reported a history of brief periods of hypomania lasting 2-3 days.  The examiner documented a treatment history with various medication combination trials directed at addressing her anxiety and mood symptoms.  The psychiatrist noted that her response to medication was inconsistent.  

It was noted that the CI was last seen by the addendum examiner on 1 October and at that time she reported that she was doing “reasonably well” on her medications, which consisted of lithium, and a stimulant.  She also was prescribed medication as needed for agitation and sleep, and for panic attacks.  It was noted that she reported panic attacks with a sudden onset of shortness of breath and a sense of loss of control associated with rapid heart rate, chest pain, dizziness, and nausea.  She took Xanax which was beneficial.  Frequency of attacks were not recorded. 

The addendum’s mental status examination (MSE) revealed an anxious, mildly agitated but pleasant and cooperative CI with no other abnormality.  She denied suicidal and homicidal ideation.  The psychiatrist noted that her prognosis was fair “if the patient continues to take psychotropic medication, resolves her marital problems, and resolves her medical board issues”.  The examiner noted that she was able to perform the duties of her rate but recorded “moderate” impairment for military service and “moderate” for civilian employment.  A Global Assessment of Functioning (GAF) score of 65 for mild symptoms/impairment was recorded.

There were two VA Compensation and Pension (C&P) mental examinations.  The first examination was accomplished 4 months prior to the psychiatric addendum and more than a year before separation.  The MSE was essentially normal except for down mood and constricted affect; she was tearful when asked about the future of her marriage.  The psychologist recorded diagnoses of major depressive disorder (MDD), anxiety disorder NOS and insomnia related to MDD, and noted that “while her symptoms did emerge during her military service, they appeared to stem from the considerable emotional consequence of loss as well as conflicts related to her interpersonal life as opposed to direct military experiences.”  The second examination on which the VA based its rating, was conducted 7 months after separation.  That examination documented the CI’s report that she had discontinued all of her psychotropic medications a month after separation due to pregnancy and had not resumed taking them since she was breast-feeding.  She noted brief periods of depression, and reported that she had no problems with sleep.  She reported brief episodes of mood swings which she noted had been well controlled in the past with medication.  The CI was not working but was attending college and performing well.  She also was caring for her children.  MSE was unremarkable with the exception of constricted affect and depressed mood.  The psychiatrist assessed bipolar disorder, type II as the only diagnosis, and recorded a GAF score of 70 for mild symptoms/impairment.

The last treatment entry dated 6 February 2007, 5 months prior to separation, noted the CI presented to sick call.  She reported that she had done well, had stopped her psychotropic medications 3 weeks prior, but on 5 February she had some conflict at work and became anxious and agitated.  She had ran out of her anxiety medication so she went to the VA, but by that time her symptoms had resolved, so she received no medication.  On the day of the visit she noted that her mood was “okay”.  The examiner indicated that in the review of her psychiatric history, she had multiple diagnoses and she related all of her symptoms to the beginning of the spousal abuse from her ex-husband.  It was noted that historically, her symptoms had not fully met the criteria for mania, and in this examiner’s opinion, her symptoms were more reflective of PTSD secondary to abuse issues or adjustment disorder with mixed emotional features.  The examiner noted a single medication regimen for anxiety was likely the best medication treatment approach opposed to polypharmacy.  The CI was also on a weight reduction medication. 

There was no indication from the record that any mental health (MH) condition was profiled and no MH condition was implicated in the non-medical assessment.  There was no indication from the psychiatry addendum that any MH condition failed retention standards.  The record clearly documented the challenges of formulating a treatment diagnosis, as well as the transient nature of her symptoms.  However, there was minimal evidence in the STR that any MH condition significantly interfered with the CI’s ability to perform her duties.  The last documented MH visit in February 2009, 5 months prior to separation, documented that she was “doing well”, had stopped all of her psychotropic medications, but had a recent episode of anxiety after she engaged in conflict at work.  The psychiatrist noted that her anxiety was “now rare”.  The CI was never treated in the emergency room for her condition, and there was no report of suicidal or homicidal ideation.  She was never hospitalized.  Board members concluded at the time of separation, her MH conditions were stable.  

The first VA C&P examination occurred more than a year prior to separation and had limited probative value. However, the second exam, 7 months after separation, recorded that the CI was stable, not taking any medication, was in college and caring for her children, but lacked motivation to work, and had intermittent brief periods of depressed mood.  Her GAF score was 70.  Although she was not in any type of MH treatment, there were no evidence of decompensation prompting visits to the ER, no recorded panic attacks severe enough to cause impairment, and no disturbance in sleep.  In fact, the CI indicated she had better sleep while off medication.  Board members agreed there was insufficient evidence to support that any MH condition cut short the CI’s military career.  

After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of bipolar disorder and panic disorder without agoraphobia as unfitting conditions for separation rating.  Therefore, the Board concluded there were no separately unfit conditions that rendered the CI unfit, however, the overall effect of these conditions contributed to the unfit finding.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the ADHD was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  IAW DoDI 1332.38.E.5.1.3.4, ADHD does not constitute a physical disability, and therefore, is not ratable or compensable.  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 contended conditions and so no additional disability ratings are 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 thoracic back pain, common migraine without aura, bipolar disorder, and panic disorder without agoraphobia conditions and IAW VASRD §4.71a, §4.124a, and §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended ADHD condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140218, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 31 May 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC

				
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