RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02531
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Supply Management Journeyman, medically separated for “asthma” and “low back pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant contends that she was given a higher rating by the VA.  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 - 20050422	VARD - 20050712	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	30%	20050408	
Low Back Pain	5243	10%	Thoracolumbar Spine, with Spondylosis	5239	0%	20050408	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Asthma.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this CI was evaluated in July 2003 for exertional shortness of breath.  A diagnosis of asthma was made, based on clinical presentation and pulmonary function tests (PFTs).  Despite treatment, the asthma condition did not improve adequately to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “asthma, moderate severe, not well controlled,” for PEB adjudication.

At the 12 January 2005 MEB NARSUM examination, 9 months prior to separation, the CI was using an Albuterol inhaler for shortness of breath only occasionally, due to pregnancy.  However, there was a clinical note from 28 December 2004, 2 weeks prior to the MEB, prescribing daily oral bronchodilator (Singulair) medication.  Review of the STR showed two clinical encounters in evidence documenting the use of an oral or parenteral steroid for asthma during the year prior to separation.  There was no evidence in the STR that asthma exacerbations were frequent enough to require monthly visits to a physician.  

At the VA Compensation and Pension (C&P) evaluation on 8 April 2005 (2 months prior to separation) the examiner noted that the CI was taking anti-inflammatory inhalation medications and oral anti-inflammatory medications on a daily basis.  The examiner did not specify what medications were being used.  The pulmonary function tests (PFTs) in evidence which the Board weighed in arriving at its recommendation, are summarized below.  

Pulmonary Exam	
PFT ~10 Mo. Pre-Sep
	MEB PFT ~9 Mo. Pre-Sep 	
VA C&P ~2 Mo. Pre-Sep
	
FEV1 (% Predicted)	99	103	82	
FEV1/FVC	89	87	82	
Meds	Daily bronchodilator / inhaled anti-inflammatory and oral anti-inflammatory	Occasional bronchodilator / inhaled anti-inflammatory	Daily bronchodilator / inhaled anti-inflammatory and oral anti-inflammatory	

The Board directed attention to its rating recommendation based on the evidence.  The PEB rated the asthma condition 10% (coded 6602).  The VA rated the asthma condition 30% (coded 6602), citing daily inhalational or oral bronchodilator therapy; or inhalational anti-inflammatory medication.  In VASRD §4.97, a 30% rating stipulates “FEV-1 of 56 to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  

The Board noted that the VA C&P exam reported use of daily oral bronchodilators.  Inhaled anti-inflammatories, which are not specified as a daily requirement under the 30% requirement, were also used, as noted by the C&P examiner.  Board members agreed that the VASRD §4.97 threshold for a 30% rating was reasonably satisfied in this case on the basis of bronchodilator and inhalational anti-inflammatory medication use.  A 60% rating was not justified in the absence of at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic corticosteroids.  There was insufficient spirometry evidence to support the next higher 60% rating.  The MEB NARSUM exam noted only occasional use of bronchodilator inhaled anti-inflammatory medication.  However, the MEB NARSUM exam was 5 months prior to separation, whereas, the VA C&P exam was 2 months prior to separation.  Therefore, the VA C&P exam is of more probative value relative to the date of separation (DOS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 30% for the asthma condition, coded 6602.

Low Back Pain (LBP).  According to service treatment records and the MEB narrative summary (NARSUM), this CI’s initial visit with complaint of back pain was 24 April 2002.  It was thought that the back pain was due to large breasts.  She had breast reduction surgery in March 2003, but this did not relieve the pain.  She had visits to chiropractic and physical therapy clinics, and was treated with pain medications and muscle relaxers.  X-ray studies in January 2004 showed a normal lumbar spine.  Despite all treatment efforts, the back pain condition did not improve adequately to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “chronic back pain” for PEB adjudication.

The MEB NARSUM examination on 12 January 2005 (5 months prior to separation) noted complaints of constant back pain aggravated by lifting, walking, and running, as well as her recent pregnancy.  Physical exam showed normal appearing thoracolumbar spine, with no pain on motion.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root involvement were negative.  Thoracolumbar ROM was normal.
      
At the VA Compensation and Pension (C&P) examination on 8 April 2005, performed 2 months before separation, the CI reported constant pain through her whole back, occasionally radiating toward her neck.  The pain was described as burning, with a sharp sensation.  The pain was aggravated by physical activity, and was better with rest.  She denied incapacitation, and had not lost any work time due to incapacitating episodes.  The CI reported that she was able to brush teeth, cook, walk, shower, climb, shop, vacuum, dress, garden, drive a car, take out the trash, and push a lawnmower.

On physical examination (PE), the CI was alert and pleasant.  Her gait and posture were normal. There was no tenderness or spasm noted anywhere throughout the musculoskeletal system.  On focused PE of the thoracolumbar spine, there was no radiation of pain on movement, no muscle spasm, and no tenderness.  Straight leg raise (a provocative maneuver to test for signs of radiculopathy, or radiating pain due to spinal nerve root involvement) was normal.  Thoracolumbar ROM was normal.  With repetitive use, there was no limitation based on pain, fatigue, weakness, lack of endurance, or incoordination.  There was no sign of intervertebral disc syndrome (IVDS).

The Board directed attention to its rating recommendation based on the evidence.  The PEB used VASRD code 5243 (IVDS), and rated the LBP condition 10%.  The VA chose VASRD code 5239 (spondylolisthesis or segmental instability) and assigned a disability rating of 0%, citing normal ROM of the thoracolumbar spine.  The Board noted that the April 2005 C&P exam was performed by a physician who was Board Certified in Occupational Medicine.  The exam was just 2 months before the DOS, and was conducted in a very thorough fashion.  Therefore, the Board determined that the April 2005 C&P exam had significant probative value.  At that exam, there was no tenderness or spasm noted anywhere throughout the musculoskeletal system, and thoracolumbar ROM was normal.  The Board concluded that there was insufficient evidence to support a 10% disability rating.  Of note, the Board may recommend a lower rating than that which was adjudicated by the service PEB, so long as the combined rating recommended is not lower than what the CI received at the time of service separation.  Given the Board’s aforementioned rating recommendation for the CI’s asthma condition, it is within the Board’s purview to recommend a 0% rating for the CI’s back condition in this case.

The Board also considered the matter of radiculopathy.  After review of all the information in the record, there was insufficient evidence of a clinically significant radiculopathy that interfered with performance of military duties.  Therefore, the Board concluded that there was no unfitting radiculopathy present at the DOS.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended, by majority decision, a disability rating of 0% for the LBP condition.      

BOARD FINDINGS:  In the matter of the asthma condition, the Board unanimously recommends a disability rating of 30%, coded 6602, IAW VASRD §4.97.  In the matter of the LBP condition, the Board majority recommends a disability rating of 0%, coded 5299-5237, IAW VASRD §4.71a.  The single voter for dissent recommended modification and did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Asthma	6602	30%	
Low Back Pain	5299-5237	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02531.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR  
DFAS-IN