RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01817
BRANCH OF SERVICE:  Army	BOARD DATE:  20150217
DATE OF PLACEMENT ON TDRL:  20051210
DATE REMOVED FROM TDRL:  20070605

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, (Motor Vehicle Operator) medically separated for vocal cord dysfunction, initially described as mild persistent asthma.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The asthma, moderate persistent and allergic rhinitis conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB (IPEB) adjudicated “asthma, mild persistent” as unfitting, rated 30% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI was placed on the Temporary Disability Retired List (TDRL) on 9 December 2005 for the asthma condition.  In May of 2007, the diagnosis was changed to probable vocal cord disorder after the TDRL re-evaluation exam.  The CI contested the change in diagnosis, but it was upheld by the IPEB.  The CI made no further appeals and was subsequently removed from TDRL and permanently.

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/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 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 – 20070523	VA 3 Mo. Prior to Adjudication Date* - Effective 20060607	
On TDRL - 20051210	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
Asthma, Mild Persistent	6602	30%	---	Asthma	6602	30%	20060317	
Vocal Cord Dysfunction	6599-6520	NA	0%					
Allergic Rhinitis	Medically Unacceptable; Not adjudicated by the PEB	Allergic Rhinitis	6522	0%	20060317	
Other x 0	Other x 6	20060317	
Combined:  30% → 0%	Combined: 40%	
*Reflects VA rating exam proximate to TDRL placement; no VA rating evidence proximate to permanent separation.

ANALYSIS SUMMARY:

Pulmonary Condition.  The service treatment record documents that the CI presented to the emergency department in June 2001 for symptoms of chest discomfort.  The aching left chest pain followed exertion and was concerning for a cardiac etiology.  Over the next year, the CI received comprehensive evaluations by cardiology and internal medicine which were normal.  The cardiologist recommended that the CI follow-up with his primary care doctor for further work-up of his persistent, non-cardiac chest pain.  A follow-up internal medicine encounter on 21 January 2003 listed a new diagnosis of mild intermittent asthma.  The CI was started on a daily inhalational anti-inflammatory and bronchodilator medications, but had persistent symptoms.  On 3 August 2004 the CI was referred to an MEB for the diagnoses of moderate persistent asthma and allergic rhinitis, which was controlled with medications.  He was able to meet all duty requirements except passing the physical fitness test.  On 3 September 2004, the IPEB found the CI fit for duty.  However, the CI’s symptoms persisted and increased to the point that he was unable to wear a gas mask.  Accordingly, he was again referred for another MEB.  On 18 July 2005 (4 months prior to TDRL placement), the MEB narrative summary was accomplished by internal medicine.  The CI complained of intermittent chest tightness, congestion, coughing, and wheezing.  He had shortness of breath with rest and activity limiting exercise.  He reported persistent symptoms despite medication use.  His pulmonary function tests (PFTs) showed improvement after a bronchodilator consistent with obstructive airway disease (conditions that impede exhaling air from the lungs; these include asthma and vocal cord dysfunction).  His PFTs with exercise were consistent with exercise-induced bronchospasm (constriction of muscles in airway walls producing narrowing).  The CI reported he could not tolerate the protective mask secondary to shortness of breath and chest tightness.  On exam, the lungs showed good air entry and were clear to auscultation.  The 21 June 2005 baseline PFTs were normal with a FEV-1 of 86% predicted and a FEV-1/FVC of 96%.  The diagnosis listed moderate persistent asthma treated with daily medications.  The VA Compensation and Pension (C&P) examination on 17 March 2006 (4 months after TDRL removal) noted the CI complained of chronic, non-productive cough, wheezing, and dyspnea on exertion.  His symptoms were worse in the spring and autumn.  Asthma triggers were exertion, various chemicals, dust, and smoke.  He did not require oxygen and had not been hospitalized for asthma.  The examiner documented no evidence of breathing difficulty throughout the examination and the CI’s lungs were clear to auscultation.  There signs of labored breathing or respiratory compromise.  The CI did not show up for his scheduled PFT appointment.  The diagnosis was listed as asthma with a normal pulmonary exam.  The CI reported taking a daily anti-inflammatory and bronchodilator medications.

The TDRL (removal) evaluation on 26 April 2007 and accomplished by an allergist.  The CI reported symptoms from company runs and diesel exhaust.  Following separation from active duty, he denied wheezing or other asthma symptoms at any time, other than when he forgot to use his inhalational bronchodilator medication prior to hard exercise.  He reported occasional nocturnal awakenings while on active duty, but had none in recent years.  The exam showed normal air exchange, with the lungs clear to auscultation.  The 26 April 2007 comprehensive PFTs, with an inhalational irritant (Methacholine), were characteristic of vocal cord dysfunction (a clinical phenomenon of paradoxical motion and inappropriate closing of the vocal folds).  Vocal cord dysfunction is frequently caused by inhalational irritants and often concomitant with, or misdiagnosed as, asthma.  The allergist reported that the vocal cord dysfunction was noticeable in the baseline PFTs, and clearly aggravated during the Methacholine challenge.  The 26 April 2007 baseline PFTs were normal and showed a FEV-1 of 95% predicted and a FEV-1/FVC of 104%.  The examiner diagnosed mild persistent asthma which was very much exaggerated by vocal cord dysfunction and further noted that the onset of asthma, with a history of no risk factors, coincided with heavy prolonged diesel exhaust exposure.  The mild degree of asthma was not expected to interfere with military duties if managed properly.  A reduction in the medication usage was begun.  The examiner recommended that the CI receive a new MOS that did not involve heavy exposure to vehicle exhaust fumes.  The allergist opined that vocal cord dysfunction represented more of a hindrance to running and wearing a protective mask.  The plan was to encourage a regular exercise program, physical reconditioning, weight control, and to work on relaxing his throat during running.  He informed the CI that his vocal cord problem could possibly require some definitive rehabilitation by otolaryngology (Long-term management combines speech therapy, avoidance of perceived laryngeal irritants, and psychological counseling).  The allergist recommended the CI be kept on TDRL, and once reconditioned, and able to meet the Army physical fitness, height, and weight standards, be highly encouraged to reenlist.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first considered its rating recommendation at the time of placement on TDRL.  The 17 October 2005 (2 months prior to separation) IPEB rated the asthma condition (VA code 6602) at 30% citing increasing severity of symptoms requiring multiple medications and inability to wear a gas mask.  The VA used the same code and assigned the same 30% rating.  All members agreed the pulmonary condition did not approach the 60% rating based upon history of exacerbations, intermittent (at least three per year) courses of systemic corticosteroids, or PFTs.  A rating higher than the 30% adjudicated by the PEB and VA is not supported by the evidence.

The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The sole basis for the Board’s permanent disability recommendation is the optimal VASRD rating for disability at the time the CI is permanently separated at removal from TDRL.  The TDRL removal IPEB changed the diagnosis of the unfitting pulmonary condition to vocal cord dysfunction, coded 6599-6520 (stenosis of the larynx) and rated it at 0%, citing the predominant pulmonary impairment being vocal cord dysfunction with mild persistent asthma based upon characteristic diagnostic PFTs.  The mild asthma condition was determined to be not unfitting.  The Board first considered if the diagnosis change was appropriate at TDRL removal and recognized that a 30% rating would be warranted if the unfitting diagnosis remained asthma vice vocal cord dysfunction.  Nonetheless, the Board concurred with the PEB adjudication as follows.  As noted, vocal cord dysfunction is frequently misdiagnosed as asthma as well as concomitant with asthma.  The findings support the presence of both diagnoses.  In response to the changed pulmonary diagnosis, the allergist initiated correction of the medical management.  The examiner, in fact, opined that the CI could return to duty in a different MOS after weight loss and physical conditioning as well as vocal cord rehabilitation.  The Board then looked at the rating and noted that the PFTs at TDRL removal support a 0% rating.  The use of medications is not a rating criterion for this condition as it is in asthma.  The Board found no route to a rating higher than the 0% rating adjudicated by the PEB.  It next considered if asthma was separately unfitting at TDRL removal.  The CI had experienced near symptom resolution with only intermittent inhalational bronchodilator use per the medication profile.  The asthma was very much exaggerated by the predominant pulmonary condition of vocal cord dysfunction.  The PFTs documented a FVC of 91%, FEV1 of 95%, and FEV1/FVC of 104%.  The evidence does not support a finding that the asthma condition was separately unfitting at TDRL removal.  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 adjudications for the pulmonary condition at either TDRL placement or TDRL removal.

Contended conditions.  The contended allergic rhinitis condition was determined to be medically unacceptable by the MEB, but not adjudicated by the PEB, implying a not unfitting determination.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The allergic rhinitis was profiled along with the asthma condition as part of the P3 profile; it was not implicated in the commander’s statement though.  Review of the medical records shows that while the CI was on medications for the allergic rhinitis, it was only mentioned incidentally to the primary concern, the “asthma” condition, and no separate visits for allergic rhinitis were in evidence.  The Board observed that even if it were unfitting, the findings would only support a 0% rating; neither the nasal polyps nor nasal obstruction was annotated.  The allergic rhinitis condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that it 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 contended allergic rhinitis condition; and, therefore, no additional disability ratings can be 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 vocal cord dysfunction/mild persistent asthma condition and IAW VASRD §4.97 and 4.100, the Board unanimously recommends no change in the PEB adjudication at either TDRL entry or exit.  In the matter of the allergic rhinitis condition, the Board unanimously recommends that it cannot be added as an additional unfitting condition and, therefore, 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 20140416, 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, AR20150019012 (PD201401817)

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