RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   XXXXXXXXXXXXXXXXXXX 	CASE:  pd-2015-01185
BRANCH OF SERVICE:  air force 	SEPARATION DATE:  20090728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “mild intermittent asthma,” with a disability rating of 10%.  

CI CONTENTION:  CI CONTENTION:  “The asthma has limited my career choices but the back issues have hurt my neck having me see a chiropractor.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20090407	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild Intermittent Asthma	6602	10%	 No VA Examination in Evidence			
Scoliosis and Back Pain	CAT II				
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Mild Intermittent Asthma.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s asthma condition began in July 2008 with complaints of dyspnea and wheezing in the mornings and evenings starting with an upper respiratory syndrome (URI).  According to the Family Practice clinic evaluation on 4 August 2008 (12 months prior to separation) when he first complained of the wheezing, the examination did not find wheezing and the CI was prescribed Albuterol and instructed to use two puffs every 4-6 hours as needed.  On 12 August 2008 (11 months prior to separation), pulmonary function testing (PFT) showed an FEV-1 of 80% of predicted and an FEV-1/FVC of 111%, a post-bronchodilator test was not performed.  A methacholine challenge test performed on the same day revealed reactive airways.  An inhaled steroid (Pulmicort) was prescribed on 18 August 2008 without re-evaluation of the CI.  

At the 18 September 2008 Family Practice clinic visit, the CI was evaluated for URI symptoms.  He did not have dyspnea or wheezing and was no longer using the inhaled steroid or the albuterol.  On examination there were no abnormal lung sounds.  At the conclusion of the visit, the Family Physician (and writer of the MEB NARSUM) did not restart the inhaled steroid or the albuterol.  At the 31 October 2008 Family Practice clinic visit, the CI reported rare use of albuterol (2-3 times since prescribed) and denied pulmonary symptoms.  On examination no abnormal lung sounds were heard.  At the 15 December 2008 MEB NARSUM examination, 7 months prior to separation, the CI reported his asthma was controlled with his rescue inhaler which he used less than twice a month.  He had no nighttime cough, no hospitalization, emergency room visits or systemic steroids secondary to his asthma.  Current medications included Albuterol as needed.  At the 17 April 2009 Family Practice clinic visit, 3 months prior to separation, the CI said that he presented to clinic to have his profile updated because his unit wanted him to physical fitness test prior to separation.  The CI denied dyspnea and cough though he did say that running exacerbated his asthma.  The CI was able to play basketball without respiratory complaints.  On examination there were no abnormal lung sounds.  At the conclusion of the visit the Family Physician (and writer of the MEB NARSUM) updated the profile to include no running; however, did not restart the inhaled steroid.  At the 1 June 2009 Express Clinic evaluation for sore throat, fever and right earache, the CI reported he had not had to use his asthma inhaler and physical examination showed no abnormal lung sounds.  On the 15 June 2009 Report of Medical Assessment, the CI listed “Lortab” as the only medication he was taking.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma, bronchial).  The panel considered the issue of whether the requirement for daily bronchodilator and/or routine anti-inflammatory therapy was met in this case, as that is the pivotal criteria between a 10% or 30% rating IAW VASRD §4.97.  The panel considered the evidence in treatment notes and the CI’s statement of medication use.  Pulmicort (inhalational steroid) was prescribed and filled only one time by a provider who was not the primary care physician in August 2008 (over 11 months prior to separation).  In subsequent visits, the primary care physician chose not to restart the inhaled steroid.  The remaining evidence refers to Albuterol usage, described as “rare usage” (2-3 times in 3 months) on 31 October and less than twice monthly at the NARSUM examination.  The last note in evidence dated 1 June 2009, 2 months prior to separation, the CI reported he did not need to use the albuterol.  

A 10% rating stipulates “intermittent inhalational or oral bronchodilator therapy.”  Panel members agreed that the PEB’s 10% rating was justified by the intermittent use of Albuterol (inhaled bronchodilator) therapy reflected in the NARSUM examination.  A 10% rating was also justified by FEV-1 of 80% predicted by the pulmonary function examination; however, a post-bronchodilator PFT was not available for review.  Although inhaled anti-inflammatories, which are not specified as a daily requirement under the 30% rating provision, were prescribed, this medication was dispensed one time over 11 months prior to separation, was not being used at the time of separation and was not restarted by the primary care physician. The panel did not consider this one time medication a current prescription to satisfy the 30% requirement at the time of separation.  
 
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the asthma condition.  

Contended PEB Condition:  Scoliosis and Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended scoliosis and back pain, a Category II condition (can be unfitting but are not currently compensable or ratable) was unfitting but not compensable because it existed prior to service based on the CI’s statement to his primary care provider about scoliosis in high school.  According to the STR and the MEB NARSUM, the CI’s back pain caused the CI to seek treatment on 28 April 2008 (5 months after enlistment and immediately after finishing technical training school).  The CI reported he had a history of scoliosis with intermittent back pain in high school that was worsening since joining the service.  He reported that in the past he was told to wear a brace, but he did not because the brace was uncomfortable.  Upper and lower back pain reportedly started gradually and worsened with exercise, stooping, bending and lifting.  The CI denied any radicular symptoms.  On examination his thoracic spine had an abnormal appearance with noted curvature.  Range of motion (ROM) of the thoracolumbar spine was reported as full.  His gait was normal.

On 29 April 2008, a scoliosis series (X-ray) was completed which showed mild thoracolumbar dextroscoliosis with angulation of 11 degrees.  Also lower cervical levoscoliotic curve of 19 degrees, but indicated this may be partially positional.  The CI was treated with physical therapy, NSAIDs and a muscle relaxer.  At a 21 May 2008 physical therapy initial evaluation the CI complained of increased back pain over the previous 2 months that he attributed to military training.  On that day he complained of general back pain that was most prevalent in the right upper back in the shoulder area that radiated into the right neck and was associated with tingling and numbness of the right upper extremity.  Physical examination revealed normal ROM in the cervical, thoracic and lumbar spine.  There was tightness of bilateral paraspinal muscles (region is not recorded) and tenderness over the right sacroiliac joint.  Gait was recorded as “independent, without device” and slight external rotation of the right foot.  A 25 June 2008 discharge summary from physical therapy noted that therapy was discontinued because the CI had improved and his long and short term goals had been met.  No examination is available for that visit.  The October 2008 Duty Limiting Report restricted carrying a weapon (due to pain medications and subjective weakness of the right hand) and stated the CI was not world-wide qualified.  The commander’s statement indicated “his medical condition restricts his ability to carry a weapon and thus renders him unable to perform in Garrison and deployed Security Forces missions.”  On the 15 December 2008 NARSUM, the examiner stated PT was of little benefit and the CI required continuous duty restrictions which rendered him unable to perform his core military duties or deploy and was disqualified for continued military service.  On examination there was mild scoliosis with right parascapular spasm.  Motor and sensory testing were normal. The examiner referred to a PT note for ROM but this was not found in the record; however, the 4 December 2008 PT note documented “dysfunction at the lumbosacral region and mid thoracic region” implying painful motion.  

The PEB determined the scoliosis and back pain existed prior to service and was not permanently aggravated, therefore not compensable or ratable.  The CI has not received a VA disability rating.  The panel noted that scoliosis is a developmental disorder and that according to the record existed prior to entering military service; however, the CI was found acceptable for military service at his Military Entrance Processing Station physical examination and the CI was able to complete his first 5 months of service prior to initiation of limiting back pain.  Scoliosis, in and of itself is not disqualifying for enlistment provided the lumbar curve is less than 20 degrees and the thoracic curve is less than 30 degrees.  The CI's thoracolumbar scoliosis was measured at 11 degrees and so was not disqualifying for enlistment.  After the onset of daily, constant back pain the CI was treated with a variety of modalities including non-steroidal anti-inflammatory medications, brief bursts of steroids, multiple rounds of physical therapy and activity modification.  The CI continued to complain of upper and lower back pain that was accompanied by a subjective weakness and tingling of the right upper extremity.  Full neurologic evaluation of the upper extremity including two separate cervical spine MRIs, physical examination, and nerve conduction studies failed to reveal a neurological cause or even an abnormality.  The subjective weakness that caused the CI to fear he may drop his weapon and get in trouble is one of the main deciding factors the primary care provider recommended the CI be found unfit for this condition.  

The panel agreed the evidence showed the scoliosis and back pain interfered with performance of duties and was unfitting.  The panel next considered whether or not there was evidence of permanent service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  As noted above, the CI did not have back pain at the time of enlistment then participated in basic military training and technical school training for security forces prior to presentation with back pain.  The panel recommends assigning a disability rating for the scoliosis and back pain due to permanent service aggravation.  Although there was insufficient limitation of motion documentation to support a minimum rating using VASRD §4.71a General Rating Formula for Diseases and Injuries of the Spine, the panel agreed a 10% rating was justified for the presence of painful motion IAW VASRD §4.59, Painful Motion.  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.  There was no evidence of intervertebral disc syndrome with incapacitating episodes to support a rating using code 5243.  After due deliberation, the panel concluded the scoliosis and back pain was permanently aggravated by service and recommends a disability rating of 10%, coded 5299-5237 (lumbosacral strain).   

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.97, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended scoliosis with back pain condition, the panel unanimously concluded there was permanent service aggravation and recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Mild Intermittent Asthma	6602	10%	
Scoliosis and Back Pain	5299-5237	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150610, w/atchs
Exhibit B.  Service Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01185.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR