RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02830
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20071120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Guard E1, Basic Trainee, medically separated for “recurrent light-headedness with syncope” and “chronic migraine headaches,” rated 10% and 0%, respectfully, with a combined disability rating of 10%.

CI CONTENTION:  “REVIEW ALL RELEVANT RECORDS”  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 - 20071024	VARD - 20081209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Light-Headedness with Syncope …	8299-8210	10%	Migraines Status Post Concussion (Subsuming dizziness and syncopal episodes)	8100	50%	20080909	
Chronic Migraine Headaches …	8045-8100	0%					
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Dizziness/Syncope.  The CI entered basic training in January 2007, and the service treatment records (STR) documented an emergency department (ED) evaluation for a brief loss of consciousness (LOC) 10 days later.  This episode was not associated with documented trauma or headache.  Three days after that the CI was evaluated in the ED for an accidental fall (table on which he was sitting collapsed) associated with a head contusion and brief LOC.  The CI subsequently reported numerous episodes of dizziness with and without syncope (e.g., LOC).  These episodes tended to be postural (when standing up); and, specialty evaluations with multiple ancillary studies did not identify any cardiovascular, neurological (including seizures) or other causes for the episodes.  After the second ED visit above, the STR documents seven more ED visits for syncope.  All were brief (“15 seconds or less” per a neurology note) and often associated with headache (separately addressed below); but, were without injury, seizure manifestations, residual confusion, or other complications.

The NARSUM was conducted 7 May 2007 (6 months pre-separation) and correlated the onset of the dizziness/syncopal episodes with the second event from above (involving head injury).   The NARSUM examiner treated the dizziness/syncope as a symptom complex with the headaches (separately adjudicated by the PEB); and, the MEB’s DA Form 3947 submission listed the single condition “post-concussion syndrome with chronic migraine headaches, dizziness and recurrent syncope.”  The NARSUM identified “recurrent episodes of lightheadedness” of which “at least three were associated with syncope or near-syncope.”  The NARSUM physical and neurologic examinations were normal.

A VA Compensation and Pension (C&P) examination was conducted 9 September 2008 (10 months post-separation).  The VA examiner also reported a history of onset of the dizziness/syncope with the head injury, and likewise treated this complaint along with headaches as a single syndrome.  The frequency of syncopal episodes was “now every 3-4 months” and “preceded by worsening of chronic headaches,” again with no associated seizure symptoms or residuals.  A VA neurological C&P examination was conducted the same day and the examiner opined that “headaches sometimes result in severe dizziness [with LOC].”

The Board directed attention to its rating recommendation based on the above evidence.  Members first assessed whether the PEB’s separate adjudications of dizziness/syncope and headaches were appropriate given the NARSUM and VA examiners’ approach; and, considered a single rating subsuming both conditions as pursued by the VA.  It was noted, however, that none of the examiners took into account the CI’s syncopal event preceding the head trauma incident.  This convincingly suggested that the dizziness/syncope symptoms were clinically distinct from the post-concussive headaches, and weakens an argument for treating all of the symptoms as a single condition.  Furthermore, as will become apparent from the evidence presented below regarding the headaches, the dizziness and syncopal episodes were less frequent and not an invariant feature of the headache episodes.  Members therefore agreed, although the dizziness/syncope and headache symptoms were intermingled, the PEB approach of separate ratings was the more logical course.

Having so decided, the Board deliberated the appropriate coding and rating recommendation for the dizziness/syncope condition.  The VASRD does not offer a code specific to syncopal episodes.  The PEB coded the condition analogously to 8210 for vasovagal nerve impairment, conferring a 10% rating for “moderate” impairment, with 8210 also offering a 30% rating for “severe” impairment.  Since the vagus nerve reflex is involved in the pathophysiology of the postural syncope in this case, 8210 was a reasonable analogous code on medical grounds.  The only additional code applicable for analogous rating in this case was 8911 (petit mal epilepsy).  This code defaults to the VASRD §4.124a general formula for major and minor seizures; and, the self-limited syncopal episodes which the CI suffered could be considered comparable to the disability attendant to minor seizures.

The latter option was deliberated, but members agreed that random seizures did not fairly equate to the disability attendant to the syncopal episodes in this case which were of decreasing frequency at separation, and which could likely be controlled by avoidance of abrupt postural changes.  Having settled on rating under criteria of 8210, members considered whether the higher 30% rating for “severe” impairment was reasonably recommended.  Based on the same features noted above relevant to coding choice, however, members agreed that the impairment was fairly characterized as moderate.  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 of the dizziness/syncope condition.

Post-Concussive Migraine Headaches.  After the fall resulting in a head contusion as above, there were some earlier STR entries documenting headache complaints; but, none were typical of those later characterized as post-concussive migraine headaches.  The first documentation specific to this complaint was a neurology consult 6 weeks after the inciting event.  This described chronic headaches which had been present “for past year or so” and were now “increased to near daily episodes” and sometimes accompanied by the dizziness/syncopal episodes.  The DD Form 2807-1 medical history preceding active duty (18 October 2006, 5 months earlier) did not report a complaint of headaches.  Subsequent STR entries documented conflicting opinions as to whether the headaches were pre-existing, but the same neurologist (as above) conducted the NARSUM and opined that the post-concussive headaches were distinct from the pre-existing ones.  The only STR documentation of emergent treatment of headache was in concert with an ER visit for a syncopal episode in April 2007 (10 days prior to the NARSUM), and there was no contemporary STR evidence of severe headache episodes.

At the time of the NARSUM the CI had “noted overall improvement in headache severity” with prophylactic medication (Topamax), but continued to report daily headaches rated 5/10 “lasting for a few hours ... [but] ... relieved by medication.”  The examiner rated the pain “slight/constant.”  A primary care entry on 25 September 2007 (4 months later and 2 months prior to separation) documented “severe” headaches “2-3 times a week ... require lying down ... unable to perform duties ....”  There was no other STR evidence corroborating this reported history, with no interim clinical visits for headache complaints or mention of worsening severity.  The commander’s performance statement did not characterize the frequency or severity of headaches and did not comment on work loss other than for medical appointments.

The 10-month post-separation general C&P examiner did not elaborate the frequency or severity of headaches, but noted that the CI was not under medical care and was taking over-the-counter (OTC) medication (Aleve) for them with a “fair” response.  To the VA neurological examiner on the same day the CI reported headaches “2-3 times a week” which caused “trouble formulating sentences because he is in too much pain ... [and] ... the need to lie down with them is the reason for his inability to work ... at this time.”   A comprehensive neurological examination was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The §4.124a rating for headaches (code 8100) rests on the presence and frequency of “characteristic prostrating attacks ... over the last several months.”  The VASRD does not provide a definition of “prostrating,” and the PEB cited the DoDI 1332.39 (E2.A1.4.1.4) definition which requires cessation of activities and seeking medical attention.  There were no such episodes in evidence, justifying the PEB’s 0% rating.  The VA’s rating referenced the reported history from the neurological C&P as satisfying the 50% criteria of “very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.”  The Board does not apply the strict definition of prostrating from DoDI 1332.39, but members agreed that ratable headaches require reasonably convincing evidence that they force the abandonment of work or current activities.  The 10% rating under 8100 is for prostrating attacks with an average frequency of “one in two months,” and 30% requires an average frequency of “once a month.”  Members agreed that the evidence from the VA neurological examiner was too remote from separation, too inconsistent with most of the pre-separation evidence, and somewhat contradicted by another examiner on the same day; and, thus, did not carry enough probative weight to support a 50% recommendation.  Deliberations next ensued for a 30% or 10% recommendation as above.

There was only one documented episode of headache requiring emergent treatment, and members agreed that it was reasonably conceded as prostrating.  Other than the uncorroborated history from the late STR entry cited above, there was no evidence from the outpatient STR, NARSUM, or commander’s statement which documented or suggested a need for abandoning duties because of the headache complaint itself.  The episodes associated with syncope, separately rated, could not be applied to headache rating without violation of VASRD §4.14 (avoidance of pyramiding).  Members considered if the reported history in the late STR entry, which described frequent headache episodes reasonably characterized as prostrating, was sufficiently probative in support of a 30% rating; but, agreed that it was not.  Multiple such episodes of work loss each week would have logically required concurrent clinical entries and titration of medications, since it would have constituted a dramatic reversal of the clinical course described in the NARSUM; and, more likely would not have been followed by a 10-month post-separation interval of treatment with only OTC medication.  Members ultimately concluded that the evidence reasonably supported the 10% criteria of 8100, in contrast to the PEB’s 0%, but that there was insufficient evidence to support the 30% or 50% criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the headache condition under code 8100.

BOARD FINDINGS:  In the matter of the dizziness/syncope condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the post-concussive migraine headache condition, the Board unanimously recommends a service disability rating of 10%, coded 8100, IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Recurrent Light-Headedness with Syncope	8299-8210	10%	
Post-Concussive Migraine Headaches	8100	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMA-RB
JUL 1 9 2016
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, AR20160007940  (PD201402830)

1.	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, accept the Board's recommendation to modify the individual's disability rating to 20% without re-characterization of the individual's separation.  This decision is final.

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.

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:
CF:
( ) DoD PDBR ( ) DVA