RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pd-2015-01352
BRANCH OF SERVICE:  air force 	SEPARATION DATE:  20051114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Integrated Avionics Airborne Surveillance Radar System Apprentice, medically separated for “seizures,” with a disability rating of 10%.

CI CONTENTION:  The CI’s conditions continue to worsen and negatively affect daily activities.  The CI’s 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 - 20050805	VARD - 20051212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Seizures, or Pseudo-Seizures Possibly Related to Medication, Controlled	8914-8999	10%	Pseudo Seizure Disorder	8999-8910	10%	20050901	
Cephalgia (Headaches)	8100-8199	Cat II	Recurrent Muscle Tension Type Headaches (Claimed as
Migraines)	8199-8100	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Seizures or Pseudoseizures Possibly Related to Medication, Controlled.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s seizure condition began in October 2002 during technical school training when she had a fainting episode while bending over to untie her boots after working a 12 hour shift.  On 9 March 2004 the CI reported she had a syncopal episode that lasted up to 2 hours and had headaches (see below) almost daily, some of which were preceded by a scotoma (a partial loss of vision).  A prior cardiac evaluation including an EKG (electrocardiogram), 24-hour Holter monitoring, and a stress test were reported to be normal as were magnetic resonance imagining (MRI) and an EEG (electroencephalogram).  Because of stress, a BDI (Beck Depression Inventory) test was performed, which was normal; a BAI (Beck Anxiety Inventory) test was slightly elevated due to symptoms consistent with her history.  An echocardiogram dated 13 January 2003 was normal with an ejection fraction calculated at 60% with trace mitral and tricuspid insufficiency.  The CI had an acute onset of left upper chest pain worse with deep breaths, which was diagnosed as costochondritis (inflammation of the cartilage at the ribs/breastbone junction) and was treated with rofecoxib, a nonsteroidal anti-inflammatory drug (NSAID).  Neurologic evaluation on 17 May 2004 indicated the CI had spells where she would faint for the past few years.  One episode 2 weeks earlier was witnessed and she was noted to have stiffened all over and had shaking activity without biting of her tongue or bowel or bladder incontinence followed by drowsiness after the spell.  Neurologic examination was normal.  The neurologist felt that the CI may have had tonic-clonic seizures, although vasovagal syncope was in the differential diagnosis.  EEG and MRI studies were normal.  Topamax (topiramate, an anticonvulsant and for migraines) was prescribed to treat the seizure and headaches.  At a neurology follow-up on 11 November 2004, she reported frequent spells of loss of consciousness associated with shaking, feeling tired and “headachy” afterwards.  The spells consisted of falling.  When she tried to get out of bed she lost consciousness, which was witnessed.  She also had occasional twitching and jerking.  Neurology follow-up on 21 October 2005 noted the CI continued to have spells where she felt like she might pass out, although they were rarer since being on Topamax.  The neurologist did not think they were seizures, but was “not sure exactly what they were.” 

The 13 June 2005 MEB NARSUM examination, 5 months prior to separation, noted complaints of frequent episodes of loss of consciousness although no fainting episodes occurred from November 2002 until September 2003.  Thereafter she noted headaches and vertigo (dizziness) in the afternoon and evening.  X-rays of the sinuses were normal.  An otolaryngologist reported the CI’s head and neck and audiometric examinations were normal and raised the possibility of either an atypical form of migraine or perhaps a seizure disorder.  Neurology evaluation suggested the CI had seizures or vasovagal syncope.  Spells with loss of consciousness followed by prolonged drowsiness and confusion sounded like seizures, but orthostatic hypotension or postural orthostatic tachycardia syndrome were also considered.  Spells continued more frequently with stress at work, which was felt to be contributory.  A second opinion neurology evaluation indicated it was reasonable to be treated with anticonvulsants for presumed generalized seizures and the dose of Topamax was recommended to be increased. Physical examination was normal and neurologic evaluation was unremarkable.

At the 1 September 2005 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported 20 “attacks” over the prior 2 years, but she had no seizures for 5 months before the C&P evaluation.  As a result she was unable to drive for 6 months, work 6 feet above the ground or operate government vehicles or heavy equipment. Physical examination, including neurological and mental health evaluations, were normal.   The examiner opined the CI did not suffer from a seizure disorder, but noted her last seizure was February 2005 and she was still taking Topamax.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the seizure condition 10%, analogously coded 8914 (epilepsy, psychomotor), citing Department of Defense and Veterans Administration Schedule for Rating Disabilities guidelines.  The VA rated the seizure condition 10%, coded 8910 (epilepsy, grand mal), based on the C&P examination 2 months before separation, citing a confirmed diagnosis of epilepsy with a history of seizures.  Panel members discussed the VASRD General Rating Formula for Major and Minor Epileptic Seizures and noted that although the diagnosis of a seizure disorder was not rock solid, nevertheless, the CI did have observed seizure-like tonic-clonic-like activity, loss of consciousness, and post-episode passing out drowsiness suggestive of seizures and received Topamax as treatment.  On the other hand, EEG’s were negative.  Nonetheless, the rating most appropriate would be as major seizures since at least some of them were “characterized by generalized convulsions with unconsciousness” rather than minor seizures “characterized by brief transient episodes of random motor movements, hallucination, perceptual illusions, abnormalities of thinking, memory or mood, or autonomic disturbances.”  Since the VA examination noted the CI had no seizures for 5 months, rating options of 20%, which requires “at least one major seizure in the last 2 years; or at least two minor seizures in the last 6 months” and 40%, which requires “at least one major seizure in the last 6 months or two in the last year; or averaging at least five to eight minor seizures weekly,” but no greater, were considered.  The CI had at least two witnessed seizures in the prior 2 years and at least one in the year prior to separation; however, there was no other documented seizures in the STRs since that time although she reported in November 2005 that she felt like passing out, but did not since she was treated with Topamax.  Therefore, a 20% rating is warranted rather than a 40% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the seizure condition, coded 8999-8914.  

Contended PEB Condition: Cephalgia (Headache).  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended cephalgia condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  The CI reported in July 2004 she had frequent severe debilitating headaches and had taken Elavil (amitriptyline, an antidepressant and for nerve pain).  She noted she had problems with migraine and was prescribed Topamax.  In November 2004 she reported to continue to have pounding headaches.  The CI noted in December 2004 the migraine headaches improved with the Topamax.  At a neurology visit on 3 March 2005 she indicated the Topamax helped the headaches go away.  In September 2005 the CI complained of a headache for 3 days with dizziness that began that morning.  Treatment consisted of tramadol (an opioid-like medication) and meclizine (for dizziness).  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition; and so, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the seizure condition, the panel majority recommends a disability rating of 20%, coded 8999-8914 IAW VASRD §4.124a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  In the matter of the contended cephalgia condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  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	
Seizures or Pseudoseizures	8999-8914	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2015-01352.

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