RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04310
BRANCH OF SERVICE:  aRMY 	SEPARATION DATE:  20060603

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Aviation Operations Specialist, medically separated for “chronic neck pain” and “chronic post-concussive syndrome with headaches and vertigo,” rated 10% and 10% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI submitted a one page contention discussing her unfit conditions and why they should have been rated higher.  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 based on 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 - 20060223	VARD - 20080429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5237	10%	Cervical Spine Condition	5237	0%	20070227	
Chronic Post-Concussive Syndrome with Headaches, Vertigo	8045-9304	10%	Vertigo	6299-6205	30%	20070413	
			Syncope	8911	10%	20070413	
			Headaches and Memory Problems Secondary to Head Injury	9304-8100	NSC	20070413	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in February 2003 after falling backwards landing on her head and back while ice skating.  Radiological studies in October 2005 were normal.  The CI participated in physical therapy (PT) and was prescribed medication for pain.  Despite treatment, the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “non-radicular neck pain” for PEB adjudication.

The MEB NARSUM examination on 16 November 2005, 7 months prior to separation, documented the CI’s report of neck pain made worse with wearing of a Kevlar, body armor, ruck sack, or with any type of heavy lifting.  The pain was localized to the back of her neck without any radiation.  She denied any numbness or tingling of her upper extremities and denied any bladder or bowel changes.  Physical examination showed mild tenderness to palpation along the paraspinal muscles with no associated muscle spasm.  Range of motion (ROM) recorded forward flexion to 35 degrees (normal 45), extension of 15 degrees (normal 45), and combined ROM of 160 degrees (normal 340).  At the PT appointment (requested by PEB for ROM testing) on 2 February 2006, 4 months prior to separation, ROM testing documented cervical spine forward flexion to 45 degrees, with extension of 20 degrees, and combined ROM of 274 degrees.  Painful motion was recorded during ROM testing.

The VA Compensation and Pension (C&P) examination was accomplished 8 months post-separation.  The CI reported that she continued to experience neck pain since the 2003 fall.  Physical examination of the neck revealed bilateral pain on palpation of the neck muscles.  ROM documented “lateral right and left flexion of 33 and 33 degrees, right and left rotation of 70 degrees, and inclination/reclination of 35 and 30 degrees respectively.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic neck pain condition 10% coded analogous to 5237 (Cervical strain) based on the limitation of motion documented at the PT exam.  Likewise, the VA used to same code to assign a 0% rating, noting that the ROM documented “bilateral lateral flexion to 33 degrees and rotation to 65 degrees.”  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and/or combined ROM (greater than 170 degrees but not greater than 335 degrees) reported at the PT exam for the MEB, more proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The Board noted the limitation of cervical spine combined ROM recorded in the MEB NARSUM examination met the threshold for a 20% rating.  However, the Board placed greater probative value on the PT ROM since it was more proximate to separation, had greater clinical details and supported the 10% rating.  After due deliberation, and 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 chronic neck pain condition.

Chronic Post-Concussive Syndrome with Headaches, Vertigo.  According to STR and the MEB NARSUM, the CI’s post-concussive syndrome condition was the result of the fall noted above.  There was no apparent loss of consciousness, but she reported that she was diagnosed with post-concussion syndrome by a neurologist in South Korea.  Shortly thereafter, she reported onset of headaches and lightheaded with fast movement.  She had no complaint of memory loss.  CT and MRI of the head and brain showed no evidence of a mass, hemorrhage or fracture.  The CI continued to have headaches and later developed dizziness, near syncope, and problems with concentration and multi-tasking.  She also reported double vision or a heavy feeling in her eyes.  
She underwent evaluations with ENT specialist and neurologist, and there were no objective findings on any evaluation that addressed the etiology of her subjective symptoms.  Treatment did not result in improvement sufficient to allow continuation in her military specialty.  The MEB forwarded “post concussive syndrome” for PEB adjudication.

At the ENT [ear, nose and throat] 29 September 2004 visit, the CI reported she had seen a neurologist twice for the dizziness, and was provided vestibular PT and medication.  She noted that when she stood for a long time in formation, she felt as though she would pass out.  She reported headaches and was unclear where the headaches were located.  Physical/neurological examination was normal.  The examiner recorded recommendations and follow up visit.  The 7 December 2004 ENT visit documented that the CI had a normal brain MRI, and a normal hearing test (audiogram).  The examiner stated there were no additional recommendations, but noted that the CI was reassured that there was nothing seriously wrong with her.

At the MEB examination (recorded on DD Form 2807 and 2808) dated 21 October 2005, approximately 8 months prior to separation, the CI reported she was taking over the counter medications.  She endorsed frequent headaches, dizziness, and problems with vision, motion sickness, and sleeping.  The CI also reported that she had numbness or tingling in her tongue and lips when having a near syncopal event.  She sometimes had vertigo and her symptoms had been present since the fall.  Her vertigo lasts from seconds up to 10 minutes, and were not associated with falling or loss of balance.  The examiner documented that the CI had three syncopal events in 2003 but none since then.  It was noted that the CI had prescriptions to abort the headaches which she took as needed.  At the Neurology examination for the MEB on 25 October 2005, the CI reported symptoms of blurry vision but no double vision or photophobia.  She also had headaches, dizziness, vertigo, and near syncope.  She reported problems with concentration and indicated that she was unable to multi-task.  Physical examination documented normal sensory and motor examinations.  All of the cranial nerves were intact, and short term memory was noted to be “subjectively impaired.”  The neurologist assessed the diagnosis of post-concussion syndrome and recommended a change in medication for symptomatic treatment of her symptoms.  Headache frequency, quality and duration was not addressed.

The VA Compensation and Pension (C&P) neuropsychiatric examination was accomplished 9 months after separation.  The CI reported that she continued to have headaches, dizziness and syncope which occurred with less frequency and intensity, and had not caused any loss of work.  She took over the counter medication as needed.  She also reported daily vertigo attacks that lasted only for a few seconds.  She had not suffered any falls nor any loss of consciousness.  The CI noted that she experienced “blackouts sometimes having a feeling that she is about to collapse.”  The neurological examination was unremarkable.  The examiner recorded the diagnosis of chronic tension headaches, and stated there was no neurological cause of the dizziness.

The Board directed its attention to its rating recommendation based on the above evidence.  PEB rated the condition at 10% coded analogously 8045-9304 (dementia due to head trauma), citing “without objective findings.”  The VA did not service connect the headaches and memory problems; however, did rate the condition of vertigo at 30%, coded analogously 6299-6205 (Meniere’s syndrome).  The VA also rated the condition of syncope at 10% under the 8911 code (petit mal seizures).  The VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma (8045).  There are two different scenarios for rating under this code; analogously with purely neurological deficits, or purely subjective symptoms (headaches, dizziness, insomnia, etc.).  In the absence of associated neurological disabilities (seizures, nerve paralysis, etc.), rating of this condition under 8045-9304 is limited to 10%, and cannot be combined with any other rating for a disability due to brain trauma.  The Board found absence of evidence that would support any neurological disability, and therefore, only 10% was supported. 

The Board considered the 8911 code for the reported near syncopal events, and determined there was insufficient evidence to support a rating under this code.  The NARSUM documented absence of syncopal events during the 2 years prior to separation, and the C&P examiner noted the CI indicated there had been no report of loss of consciousness or loss of memory during the episodes.  There was no objective findings to explain the near syncopal events.  Board members agreed there was insufficient evidence to support a rating under this code.  There were no additional applicable codes to consider for rating the condition.  

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 adjudication of the chronic post-concussive syndrome with headaches, vertigo, condition.

BOARD FINDINGS:  In the matter of the chronic neck pain condition and IAW VASRD § 4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the chronic post-concussive syndrome with headaches and vertigo condition and IAW VASRD §4.124a, the Board recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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, 20141124, with attachments
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, AR20160018400 (PD-2014-04310)

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