RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01687
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Armament Repairer) medically separated for cranial conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  Post-concussive syndrome with headaches (non-prostrating) 4-5 times per week was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated post-concussive syndrome with 4-5 headaches/week, non-prostrating 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:  Please consider all conditions.

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 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 20020618	VA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Concussive Syndrome with 4-5 Headaches, Non-Prostrating	8045-9304	10%	No VA Claim Filed	
Other MEB/PEB Conditions x 0 (Not In Scope)		
RATING:  10%	RATING:  N/A	

ANALYSIS SUMMARY:  

Post Concussive Syndrome and Headaches.  Service treatment records indicated the CI collided with a fellow player during a flag football game 1 August 2001.  He had a momentary loss of consciousness (3-5 seconds).  He reported neck pain but repeat cervical spine X-rays within a week were normal.  He received medication for muscle relaxation and pain.  He later reported multiple recurrent daily headaches as well as multiple brief losses of consciousness up to four times per week.  He was evaluated by neurology on 20 August 2001.  Computerized tomography (CT) of the head was normal.  Post-concussive syndrome was diagnosed.  Repeat CT was normal and an electroencephalogram showed no evidence of a seizure disorder.  He was evaluated in the emergency room (ER) in February 2002 and again in March 2002 due to syncope associated with dizziness.  He reported having a constant headache since the initial injury.  Despite treatment with several medications, the symptoms persisted and he was referred for neuropsychological evaluation.

On the MEB DD Form 2807, Report of Medical History, dated 30 December 2001, the CI indicated little dizziness and fainting, small memory loss, and headaches everyday all day, difficulty with sleep.  He had seen a psychiatrist for counseling for sleep disorder, blackouts and stress.  The profiling section of the DD Form 2808, Report of Medical Examination, listed no diagnoses and assigned a P4 and S1 profile.  The P4 profile noted no driving, no operating machinery, no handling of weapons or ammunition, and no strenuous physical activity.  A primary clinic note, dated March 2002, noted the CI reported two blackouts that day and the presence of a migraine headache.  The neuropsychological evaluation, May 2002, documented the CI’s test scores were consistent with his estimated level of premorbid functioning.  Personality testing was consistent with significant psychopathology, noting he was likely to be anxious, tense, irritable and frustrated with a tendency to focus on physical and somatic symptoms (the result of head injury).  He reported headaches, memory loss, a change in his mood and personality.  He did not do any physical work but was able to attend fitness training in the morning and do mostly paperwork during the day.  He was taking anti-convulsion and over the counter pain medicine.  Diagnostic impression included post concussive syndrome with a Global Assessment of Functioning (GAF) of 60-65 (mild impairment, symptoms.)

At the MEB narrative summary dated June 2002, the CI reported multiple severe headaches 4 to 5 times per week with multiple brief losses of consciousness during the week.  There were no witnesses.  Heavy physical activity and bright lights worsened the headaches.  He was not functioning in his MOS and did only administrative work and performed no physical activity.  He was unable to enjoy his usual outdoor activities.  Pain was rated constant and moderate. A diagnosis of post concussive syndrome with headaches, non-prostrating was rendered.  No VA Compensation and Pension exam was done and no VA claim was filed.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the headache condition as post-concussion syndrome with 4-5 headaches, non-prostrating coded 8045-9304 (Brain disease due to trauma and dementia due to head trauma).  This coding approach was consistent with the VASRD in effect at the time, which required that subjective symptoms of TBI be rated in this manner.  Regarding the appropriate coding option, it was agreed that the 8045-9304 code chosen by the PEB is technically accurate in this case.  The applicable 2002 VASRD for the 8045 code (TBI) states:

“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 evidence clearly shows that the CI’s ratable disability was a direct consequence of TBI.  The PEB’s rating was consistent with the above VASRD criteria.  The option of applying the 8100 coding criteria was deliberated.  Under an 8045-8100 code (Migraine headaches rated analogous to TBI), the rating is based on the frequency of “prostrating attacks” over the last several months.  Board members debated whether this approach was justified by VASRD §4.7 (Higher of two evaluations) and §4.3 (Reasonable doubt).  Due to his headache condition, the CI was unable to perform strenuous military training.  Although the CI had chronic daily headaches, clinic encounter examiners observed him to be in no acute distress.  He was able to perform non-strenuous military duties, attend daily formation and perform administrative work.  The CI indicated episodes of syncope occurred infrequently since December 2001.  Other than the two ER visits due to syncope in the presence of headache, there were no reported episodes of any events that might constitute prostrating headaches.  The Board noted that a year after separation, the neurologist concluded the CI’s headaches were likely worsened and perpetuated by analgesic rebound phenomenon.  Except for circumstances of physical exertion, there was not sufficient evidence of prostrating headaches during the several months prior to separation that would warrant rating the headache condition higher than the 10% adjudicated by the PEB.  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 post concussive syndrome and headaches 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 post-concussive syndrome and headaches condition and IAW VASRD §4.124, the Board recommends no change in the PEB adjudication.  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 20140414, w/atchs
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, AR20160003272 (PD201401687)

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