RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-02124
BRANCH OF SERVICE:  Army	BOARD DATE:  20141021
SEPARATION DATE:  20070619

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (11B/Infantryman,) medically separated for syncope.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The syncope condition, characterized as “Syncope secondary to Orthostatic Hypotension” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four additional conditions, “Post-concussive headaches (controlled with medication, not unfitting for military duty); Thrombocytopenia (acute; not unfitting for military duty); Recurrent epistaxis (EPTS) and Recurrent major depression (EPTS; not unfitting for military duty).”  The PEB adjudicated “neurocardiogenic syncope” as unfitting, rated 10% with likely application of the VA Schedule for Rating Disabilities (VASRD).  The PEB also determined MEB diagnoses 2, 3, 4 and 5 were not unfitting.  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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting syncope condition is addressed below; along with the not unfitting post-concussive headaches, thrombocytopenia, recurrent epistaxis and recurrent major depression conditions as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 2000509	VARD - ( 2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neurocardiogenic Syncope	8299-8210	10%	Migraine Headaches Including Syncope and Epistaxis	8100	30%	20070823	
Post-Concussive Headaches	Not Unfitting	No VA Entry	20070823	
Thrombocytopenia	Not Unfitting	No VA Entry	20070823	
Recurrent Epistaxis	Not Unfitting	No VA Entry	20070823	
Recurrent Major Depression	Not Unfitting	No VA Entry	20070823	
Other x 0 (Not in Scope)	Other x4 	
Combined:  10%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20080123 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

Neurocardiogenic Syncope Condition.  In mid-2006, the CI began having episodes of headache, nausea and episodes of collapse 2 to 3 days a week.  These episodes did not involve abnormal movements, incontinence or injury.  He also had episodes of epistaxis (nose bleeds) but these were present since childhood although they increased during his military service.  He was evaluated by a neurologist with two electroencephalograms, brain magnetic resonance imaging and a CT scan of the head; all were essentially normal.  Possible seizure activity was ruled out.  He also underwent a cardiac evaluation that included electrocardiogram, a Holter/event monitor, echocardiogram and a tilt table test; again essentially normal, which ruled out a cardiac cause of his episodes.  The neurologist started the CI on a pain medication for his headaches that help the headaches but not the syncopal episodes.  As his episodes continued, he was referred for a “provoked tilt table test” in January 2007 which was markedly positive, recreating all of his symptoms.  He was diagnosed with “orthostatic hypotension and syncope; and the cardiologist recommended treatment with a class of medications called Beta-blockers.”  The narrative summary prepared 3 months prior to separation contained the following passages:

“He followed up with cardiology in April 2007.  He told them that his episodes had decreased from 2-3 times per week to once per week on the Propranolol [beta-blocker - sic].  The final assessment indicated, "Orthostatic hypotension and syncope."  At present time, the Soldier still has epistaxis and headaches at least once per week.  But the headaches, felt to be related to head injury/post concussive syndrome, are well controlled with Midrin and rest, are not incapacitating or prostrating, and are not, by themselves, unfitting for military duty.  His only known trigger is stress of any kind.”

The physical exam was essentially normal.  The VA Compensation & Pension exam was performed 2 months after separation and documented a similar history to that summarized above.  The C&P examiner pointed out several times that that the CI always had the headache preceding the syncopal episodes.  Also noted was the following passage:

“He was started empirically on Midrin for migraine headaches and a few times in the past, he has been able to abort passing out with the Midrin but still by in large he still will have the headache and then pass out if he is now [not sic] able to get the Midrin in him fast enough.”

The physical exam was essentially normal and the examiner made the following conclusive statement:

“I do not concur with neurocardiogenic syncope, and in my opinion, he does not have neurocardiogenic syncope.  Again, my diagnosis is atypical migraine headache syndrome with associated epistaxis and syncope.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB applied the analogous VASRD code 8299-8210, paralysis of Tenth (pneumogastric, vagus) cranial nerve, and rated it 10% for “moderate.”  The VA applied code 8100 and rated it 30% citing “…whenever there are characteristic prostrating attacks occurring on an average of once a month over the last several months.”  The PEB adjudication makes it clear that the syncopal episodes resulted in his separation from service.  All of the symptoms the CI experienced during one of his syncopal episodes were recreated during the provocative tilt table test, indicating that the proper diagnosis was neurocardiogenic syncope.  Additionally, the headaches were related to the syncope, were well controlled and not prostrating.  Physiologically, the tenth cranial nerve (Vagus nerve) innervates the heart (among many structures) and is involved in regulating pulse and blood pressure responses when changes are required to remain conscious, i.e., assuming an upright posture.  The Board members agreed that the PEB’s use of VASRD code 8210 (copied below for the reader’s convenience) for rating this CI’s neurocardiogenic syncope was appropriate.

Tenth (pneumogastric, vagus) Cranial Nerve

8210 Paralysis of:
Complete ............................... 50
Incomplete, severe ................ 30
Incomplete, moderate ........... 10

NOTE: Dependent upon extent of sensory and motor loss to organs of voice, respiration, pharynx, stomach and heart.

Rating under code 8210 entails a judgment call regarding the severity of incomplete paralysis, especially the “moderate” vs. “severe” distinction.  Board members agreed that a fair threshold for the “severe” rating should entail functionally significant impairment encroaching on some occupational tasks.  It was concluded that there was sufficient evidence in this case, syncopal episodes at least three times a month, that this threshold was met.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the neurocardiogenic syncope condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that post-concussive headaches, thrombocytopenia, recurrent epistaxis and recurrent major depression conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations and requires a preponderance of evidence.  The post-concussive headaches, thrombocytopenia, recurrent epistaxis and recurrent major depression conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions 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 any of 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 neurocardiogenic syncope condition, the Board unanimously recommends a disability rating of 30%, coded 8299-8210 IAW VASRD §4.124a.  In the matter of the contended post-concussive headaches, thrombocytopenia, recurrent epistaxis and recurrent major depression conditions, 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.

RECOMMENDATION:  The Board 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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Neurocardiogenic Syncope	8299-8210	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX

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 XXXXXXXXXXXXXXXXX, AR20150006366 (PD201402124)

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 recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

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

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

Encl						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						
CF: 
(  ) DoD PDBR
(  ) DVA