RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00142
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Counter Intelligence Specialist, medically separated for “daily headaches” and “mechanical myofascial pain in cervical area,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requests the Board consider all conditions as he 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 based upon a 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 - 20030613	VARD - 20030821	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Daily Headaches	8100	10%	Vascular Headaches with Migrainous Associated Syncopal Episodes	8100	30%	20030730	
Mechanical Myofascial Pain in Cervical Region	5099-5021	0%	Cervical Myofascial Pain with Early Degenerative Disc Disease	5003-5290	10%	20030730	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY: 

Chronic Migraine Headaches.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2003 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The Board must correlate the above clinical data with the 2003 rating schedule; applicable diagnostic codes include: 5290 (limitation of cervical spine motion) and 5293 (intervertebral disc syndrome; based on incapacitating episodes).  

According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first noted migraine headaches in 2002.  An emergency room (ER) note dated 20 October 2002 recorded that he had a 2-month history of headaches which were “off and on.”  He was evaluated in neurology on 8 November 2002 and reported daily headaches associated with sensitivity to light (photophobia) and sound (phonophobia) and nausea.  Once the headache started, it lasted the rest of the day.  He could continue to function, but preferred to lie down.  He had a normal neurological examination.  He was started on a prophylactic medication and lifestyle modifications were recommended.  He was also given an abortant medication (Imitrex).  A brain magnetic resonance imaging (MRI) study on 7 March 2003 was remarkable for a chronic maxillary sinusitis.  His headaches persisted though.  In primary care on 14 April 2003, he reported that his headaches had been associated with “blackouts” for several minutes on 5 occasions, one of which he reported had been witnessed by the battalion surgeon.  Two days later, he was seen in follow-up in neurology.  He reported that the daily headaches had resolved, but that he still had “migraines” three times a week.  MEB was recommended.  One week later he was brought to the ER by ambulance after passing out in the field.  His examination was unremarkable.  He was noted to be in no acute distress (NAD).  On 30 April 2003, he was seen in acute care and was found to be moderately uncomfortable and lying in a dark room.  An EEG (electroencephalogram) on 6 May 2003 was normal.  The next day, the CI woke up with a headache and then fainted (syncope).  His examination was unremarkable and he was given modified duty for 24 hours.  

The neurology addendum to the MEB NARSUM dated 14 May 2003, 4 months before separation, noted that on 5 occasions in the last 2 months, the CI had headaches severe enough, to the point that he “passed out.”  However, convulsions were not noted, nor was tongue biting or incontinence.  Each occurred at the peak of the headache intensity.  He had taken several prophylactic medications, but had discontinued these as he (the CI) determined that they were ineffective.  It was noted that he went to the ER every month or two.  His headaches increased with the neck and back pain from which he also suffered.  The NARSUM examiner also noted that the CI’s condition was “actually better than it was several months ago despite a decrease in the number of medications he [was] taking.”  On 19 May 2003, he was treated in the ER and reported loss of consciousness (LOC) with the headache.  He was noted to be in moderate pain.  The examination was otherwise unremarkable other than tenderness over the neck.  The NARSUM was also dated 19 May 2003.  It noted the ongoing treatment for the migraine headache condition as well as myofascial pain syndrome of the neck, upper shoulder, and thoracic muscles.  It was recorded that his headaches had improved the prior “few months due to decreased expectations of him at work.”  He was seen the next day in neurology and begun on Neurontin, a different medication for headache prophylaxis and chronic pain.  He was again seen in the ER for a headache on 28 May 2003 and noted to be “miserable, but not in severe distress.”  He was noted to be on Neurontin, which he had recently begun.  The examination remained unremarkable.  He was treated for nausea and placed on quarters for 24 hours.  Electroencephalogram (EEG) tests on 29 May and 5 June 2003 were normal.  He was next seen in neurology on 10 June 2003 and reported that he had not had a severe headache in 10 days.  The last severe headache was the day he began the Neurontin.  The PEB dated 13 June 2003, 2 months prior to separation, noted the CI had daily headaches which developed, at times, into migraines and required ER care about every 2 months.  These were aggravated by physical activity and job stress.  Recently, these had improved with a reduction in the stressors.  The CI concurred with this assessment.  On 29 June 2003, the CI was again seen in the ER.  He reported a recurrent headache.  It was not the “worst” he had had, but did not respond to Imitrex.  He stated that he used the Neurontin.  His examination was unremarkable and he was in no acute distress.  He was treated for pain and discharged to home.  There were no further clinical visits prior to separation in evidence.  
At the VA Compensation and Pension (C&P) examination on 30 July 2003, performed less than a month before separation, the CI reported incapacitating headaches occurring about once a week, lasting for about 6 hours.  It was also noted that “In the past, he had required Emergency Room visits approximately once per month.”  He was thought to have vascular headaches and migrainous headaches with syncopal episodes, the latter currently asymptomatic.  The neurological examination was unremarkable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10% (code 8100 migraine) citing the requirement for “emergent medical care about every two months.”  The VA rated the headache condition 30% (code 8100), citing “emergent medical care about every two months” and “subjective complaint of one headache per week lasing up to six hours...”  Review of STR shows that the CI experienced headaches severe enough to present to the ER or acute care 5 times in the 4 months prior to separation.  A history of prostrating headaches occurring on average once per month over last several months to support a rating of 30%.  However, the Board also noted that this includes the period immediately before the CI began taking Neurontin which the CI reported was of benefit in decreasing the severity of the headaches.  He reported to neurology, on 10 June 2003, that he had one severe headache 10 days earlier, the day he began the Neurontin.  Between this visit and the date of separation, just over 2 months later, he was seen in the ER once and reported that the headache was not his worst and was noted to be in no acute distress.  This supports a 10% rating for one prostrating headache over 2 months.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change to the separation rating of 10% for the migraine headache condition coded 8100 as adjudicated by the PEB.  

Mechanical Myofascial Pain in Cervical Region.  According to the STRs and the MEB NARSUM, the CI first reported shoulder pain in March 2002 when he was seen for a 3 month history of pain and diagnosed with myofascial pain of the shoulder region (rhomboids and trapezii).  This responded to manipulation in physical therapy (PT).  The CI continued treatment in PT over the next few months, although this was primarily for treatment of low back pain (LBP) and mid-thoracic pain.  His pain persisted despite treatment and he was referred for an evaluation in physical medicine.  He was seen on 12 August 2002 and thought to have myofascial pain syndrome and his medical regimen was changed.  He continued PT and also underwent osteopathic manipulation and acupuncture without resolution of the pain.  The CI was then entered into the MEB process.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 2 May 2003, 4 months prior to separation, the CI reported myofascial pain.  On the examination form, the neck, spine and musculo-skeletal system, and neurological examination were all checked normal.  An MRI of the cervical spine on 7 May 2003 showed degenerative disc disease (DDD) at multiple levels, but without nerve root or spinal cord impingement.  The neurological addendum for the NARSUM, dated 14 May 2003, noted paraspinal muscle tenderness about the neck.  The neurological examination was normal other than a questionable sensory loss.  At the MEB NARSUM examination, dated 19 May 2003, 3 months prior to separation, the CI reported pain with sit-ups and crunches.  He was unable to run or wear body armor.  Compression of the cervical spine (a provocative test for nerve root entrapment) was negative.  Rotation was reduced to 50 degrees bilaterally.  The other range of motion (ROM) measurements were not recorded.  Trigger points were present for the paracervical and upper shoulder muscles.  The motor examination and reflexes were normal.  

At the VA Compensation and Pension (C&P) examination in 30 July 2003, performed 1 month before separation, the CI reported weekly flare ups which could result in a 20% loss of ROM.  On examination, the ROM showed mild discomfort on rotation, but exceeded VA normal values in all measurements other than lateral bending which was reduced bilaterally to 35 degrees from the VA normal value of 45 degrees.  The neurological examination was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the analogous code 5099-5021 (myositis), citing no significant loss of motion.  The VA assigned a 10% rating using the dual code 5003-5290 (degenerative arthritis-limitation of motion of the cervical spine) based on the VA C&P examination 1 month prior to separation, citing slightly limited motion of the cervical spine.  The Board noted that the 5290 code is no longer used in the current VASRD.  A 10% rating using the code 5021 is supported by a slight limitation in motion and by painful motion, the latter IAW VASRD §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the neck condition, coded 5021.  

BOARD FINDINGS:  In the matter of the headache condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the neck condition, the Board unanimously recommends a disability rating of 10%, coded 5021 IAW VASRD §4.71a.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Migraine Headaches	8100	10%	
Mechanical Myofascial Pain in Cervical Area	5021	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150129, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170002970 (PD201500142)

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