RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00729
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050325

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E5, Administrative Specialist, medically separated for “chronic subjective neck pain” and “posttraumatic daily headache,” rated at 10% each, with a combined disability rating of 20%.   

CI CONTENTION:  “Review all conditions.”  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 - 20050125	VARD - 20050609	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Neck Pain…	5299-5242	10%	Degenerative Disk Disease, Cervical Spine 	5242	20%	20050427	
Posttraumatic Daily Headache	8045-9304	10%	Post Traumatic Headaches	8100	10%	20050519	
Left Carpal Tunnel Syndrome	Not Unfitting	History of Left Carpal Tunnel Syndrome and Left Ulnar Neuropathy	8515	10%		
Left Ulnar Neuropathy						
Hearing Loss with Tinnitus		Hearing Loss Right Ear	6100	0%	20050427	
		Hearing Loss Left Ear	6100	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80% 	

ANALYSIS SUMMARY:  

Chronic Subjective Neck Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain condition, which radiated down into the left arm, began in April 2004 after a motor vehicle accident while mobilized.  Magnetic resonance imaging (MRI) of the cervical spine in May 2004 demonstrated degenerative changes most pronounced at C5-6 and C6-7.  A neurosurgery note dated 14 May 2004 indicated the CI had 5/5 strength of the upper and lower extremities with a normal gait.  Phalen’s test (to determine carpal tunnel syndrome) was positive on the left and Tinel’s (to determine medial nerve irritation) and Hoffmann’s (to determine spinal cord myelopathy) tests were negative.  Sensation was decreased in the first, second, and third digits of the left hand.  Deep tendon reflexes were 2+ in the upper extremities and patella and 1+ in the ankle.  The examiner’s diagnoses were cervical degenerative disk and joint disease and left carpal tunnel syndrome (see below).  An MRI in July 2004 showed a bulging disk at C5-6 and C6-7, mild neural foramina (opening in the vertebral column where nerves pass to and from the spinal cord) narrowing at C5 and C6 on the right, more so at C5, and minimal neural foramina narrowing at C3-4 on the right.  

During the 31 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported pain and numbness in the shoulders.  Physical examination showed tenderness of the lower neck, which radiated to the head and shoulders.  Flexion of the neck was 40 degrees (normal 45), extension 20 degrees (normal 45), rotation left and right 30 degrees each (normal 80 each), and lateral bending left and right 20 degrees each (normal 45 each).  

At a physical medicine clinic visit on 17 August 2004 the examiner referred to a prior visit on 12 May 2004 where electrodiagnostic studies revealed myofascial upper back pain. Physical examination showed the CI holding his head in a restricted/protected posture and the range of motion (ROM) of the neck were very limited due to pain in all directions.  The examiner’s assessment was chronic neck pain and radicular symptoms of the left upper extremity with overlying myofascial pain, a clinical suspicion of PTSD [posttraumatic stress disorder] (see below), and electrodiagnostic findings most consistent with, but not conclusive for, left C5-7 radiculopathies with ongoing denervation. 

The 7 September 2004 MEB NARSUM, less than 7 months before separation, noted complaints of worsening neck problems with neck stiffness and an inability of the CI to extend the neck.  Trigger point injections and one epidural steroid injection did not help.  Physical examination showed an obvious stiff neck and a turtleneck-like posture.  Neck extension caused increased pain and burning in his neck and trapezius muscles and increased ulnar paresthesias to his left hand.  There may have been mild weakness of external rotation at the left shoulder on the left biceps.  The CI’s legs were strong and his gait was normal.

On 1 November 2004 the CI underwent an ACDF (anterior cervical discectomy and fusion) of C5-C7 and removal of marginal osteophytes (arthritic changes) using donor cancellous bone grafts, and anterior metal plates.  At a disability evaluation on 17 November 2004, 4 months prior to separation and 2 weeks after surgery, the CI reported constant pain, which required daily narcotics.  Physical examination showed ROM measurements with a flexion of 40 degrees and a combined ROM of 160 degrees (normal 340). 

At the 27 April 2005 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported constant pain, rated 7/10 (10 being the worst pain), but some of the time it reached 10/10.  The examiner noted “while admitting that the patient is having the pain throughout this examination he does not give evidence of pain in his demeanor, his emotions or his facial expressions.”  The CI had a normal posture and gait.  At the C&P orthopedic evaluation on 19 May 2005, 2 months after separation, the CI indicated he was “currently employed as a heavy equipment operator.”  Physical examination showed the CI ambulated without external support or assistance and had no evidence of an antalgic gait.  Tenderness to palpation and muscle spasm were noted.  ROM measurements were forward flexion of 15 degrees and a combined ROM of 170 degrees (although the VA Rating of Disability noted 220 degrees), with pain on motion at the cervical and left paraspinous musculature.  Upper extremities showed normal strength and normal reflexes.  X-rays of the cervical spine showed an anterior cervical fusion of C5-C7 in anatomic alignment.  The orthopedic examiner stated “that today’s evaluation is inadequate for determining the degree of impairment for the veteran’s neck condition due to recent surgery.  This should more appropriately be assessed 12-18 months postoperatively, to more accurately determine the ultimate postoperative degree of impairment.”  The examiner’s diagnosis was degenerative disc disease post anterior cervical decompression and fusion C5-7 “with instrumentation, with paraspinous muscle spasm, but without objective clinical evidence of residual upper extremity radiculopathy.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5299-5242 (degenerative arthritis of the spine), citing without significant motor abnormality and cervical ROM limited by pain.  The VA rated the neck condition 20%, coded 5242, citing forward flexion of 15 degrees.  The panel agreed that a 20% rating, but no higher, was justified for limitation combined ROM (not greater than 170 degrees), as reported on the disability evaluation prior to separation and limitation of flexion of 15 degrees (greater than 15 degrees but not greater than 30 degrees) and combined ROM of 170 degrees (not greater than 170 degrees) as reported on the VA examination after separation.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  Members did note that the VA measurement of 15 degrees flexion was a decrease from prior flexion measurements in the absence of objective evidence intercurrent accident, injury, or mechanical malfunction of operative instrumentation or represented a round down from 16 or 17 degrees or a round up from 13 or 14 degrees.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the neck condition, coded 5299-5242.  

Posttraumatic Daily Headache.  According to the STR and the MEB NARSUM, the CI’s headache condition began in April 2004 after a motor vehicle accident while mobilized.  A neurosurgical evaluation in May 2004 was silent in regard to headaches, but the neck pain (see above) was addressed.  Headaches were mentioned in a physical medicine evaluation on 17 August 2004, and upon examination the CI was holding his head in a restricted/protected posture.  An electrodiagnostic study was normal.  However, there was no reported severity or frequency of the headaches.   

During the 31 July 2004 MEB examination the CI reported severe headaches all the time.  The examiner listed post traumatic headache in the summary of defects and diagnoses.  The 18 August 2004 MEB NARSUM noted complaints of a constant headache, described as pounding type involving the left parietal area without radiation with a severity of 9-10/10.  The CI related having associated phonophobia (noise sensitivity), photophobia (light sensitivity), and nausea, but the CI did not report prostrating attacks per se; however, he complained of periods of agitation with severe anger and had episodes of presyncope approximately six times a month lasting 30-45 seconds, which caused him to sit down to alleviate the symptoms.  The headaches seemed to come from his neck and went up the back of his head and the sides of his head.  The CI had had been to the headache clinic, but multiple medications including those for nerve pain (gabapentin and Elavil), narcotics (Tylenol #3 and Percocet), nonsteroidal anti-inflammatory drugs (Motrin and Naprosyn), and for pain relief (Tylenol) did not help.  Physical examination showed intact cranial nerves except for decreased light touch and pinprick of the entire left side of the head.  There was no papilledema (swelling of the optic nerve); extraocular muscles were intact; and pupils were equal, round, and reactive to light.  There was normal strength, normal reflexes, and normal cerebellar movement.  Sensation was intact except for decreased light touch and pinprick of the left lateral foot and shin.  Headache prophylaxis with Depakote ER (valproic acid (divalproex sodium), an anticonvulsant to treat epilepsy, bipolar and migraines) and abortive treatment with zolmitriptan (for migraine relief) was initiated.  An orthopedic note dated 8 October 2004 indicated the CI had migraine headaches and was on Depakote and Zomig (zolmitriptan) for the headaches as well as narcotics (Percocet and methadone), Neurontin (gabapentin for nerve pain), and a muscle relaxer (Valium) for neck pain.  On 16 November 2004 the CI was seen in follow-up for the headaches.  Neither the Depakote nor the Zomig were effective. The previously prescribed amitriptyline (Elavil) dose was increased and Imitrex (sumatriptan) was prescribed for migraine abortive treatment.  The commander’s statement, on 10 November 2004, did not specifically address the headaches, their frequency, or whether they were prostrating.  However, the headache condition was profiled on 17 November 2004.

At the 27 April 2005 C&P general examination the CI reported that he had headaches since his accident and that they were painful 10/10 and occurred every day.  The examiner noted “although the patient says they are 10 out of 10, occurring daily, he did not appear to be having that kind of pain while he and I were talking.”  At the 19 May 2005 C&P neurology examination, 2 months after separation, the CI still complained of frequent post-concussion headaches. The examiner noted the CI was followed by neurology for headaches while in service, although the visit details were not in the STR.  Physical examination showed normal cranial nerves and normal strength throughout with slightly decreased hand grip on the left compared with the right and diminished sensation over the left fourth and fifth fingers as well as tenderness over the left elbow region.  Cerebellar function and gait were intact.  The examiner’s diagnosis was “post-traumatic headaches following concussion.”
 
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10%, coded 8045-9304 (residuals of traumatic brain injury (TBI)-dementia due to head trauma).  The VA also rated the headache condition 10%, coded 8100 (migraine), citing daily attacks of headaches which are reasonably equivalent to at least one prostrating attack monthly and no treatment or findings by examination to warrant a higher level evaluation.  VASRD code 8100 rating is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks; however, commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  

The panel carefully considered the frequency and nature of the CI’s headaches including objective medical evidence and/or corroborating subjective evidence.  There was no objective evidence of prostrating headaches or the severity or frequency of the headaches marked by stopping work or current activities, measures taken to alleviate the headache (time off from work or accommodations like having to go to a darkened/quiet room), evidence of self-management (sleep), treatment notes, or supervisor’s statements.
   
After reviewing the evidence, the panel unanimously agreed that the CI’s posttraumatic daily headache condition was not incongruent with the criteria for a 10% rating under VASRD code 8045-9304 for traumatic headaches, which was in force at the time of separation rather than code 8100 (migraine), albeit the CI did not have characteristic prostrating attacks, but had syncopal-like episodes that lasted for 30 to 45 seconds and were relieved by sitting.  Furthermore, there was not enough reasonable doubt in the CI’s favor to justify a panel recommendation for higher than the 10% rating assigned by the PEB especially since the commander’s statement did not address the headaches.  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 posttraumatic daily headache condition.

Contended PEB Conditions:  Left Carpal Tunnel Syndrome, Left Ulnar Neuropathy, Hearing Loss with Tinnitus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions and so no additional disability ratings are recommended.

Contended PEB Condition: PTSD.  The panel’s main charge is to assess the fairness of the PEB’s non-determination that the contended condition was rendered neither unfitting nor not unfitting despite its listing as a condition on an MEB dated 9 March 2005, and having been profiled on that date as well.  It was not implicated in the commander’s statement or judged to fail retention standards.  The 16 February 2005 Psychiatry Addendum to the MEB, 1 month prior to separation, but 22 days after the IPEB reconsideration, noted complaints of nightmares of the incident when a taxi deliberately crashed into his vehicle whereupon the CI experienced a concussion with a loss of consciousness as well as injuries to the neck and left wrist, elbow and shoulder along with post-concussion headaches.  He was diagnosed with PTSD on 3 February 2005 based on impaired sleep, hypervigilance with an exaggerated startle response.  He was depressed and felt “useless,” cried for no reason, did not want to leave his house, and had occasional flashbacks.  He also became irrationally protective of his family.  He did maintain his activities of daily living, described some difficulty concentrating, and completely avoided any situations that he thought might be stressful.  PTSD was confirmed on 16 February 2005.  Mental status examination revealed a friendly and cooperative CI with no psychomotor or speech abnormalities.  His mood was depressed and his affect was labile.  He was fully oriented with intact memory, but had some difficulty concentrating.  He had above average intellect based on his fund of knowledge, use of complex concepts, and vocabulary.  His thoughts were relevant and coherent with no formal thought disorder.  He could think abstractly and described nightmares and flashbacks of his trauma.  His insight and judgment was fair.  He was not suicidal or homicidal. His impairment for military duty was severe and impairment for social and industrial adaptability definitive 30%.  However, according to the examiner treatment had just been instituted, but no medication or course of therapy was noted.  However, fluoxetine, an antidepressant, was noted in a VA nursing assessment dated 6 April 2005 and its use was for managing his anger and irritability according to a VA mental health clinic note dated 22 April 2005, which also indicated he took quetiapine (used in conjunction with antidepressants).  There was no performance-based evidence from the record that the PTSD condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend the condition to have been unfitting; and so, no additional disability rating is recommended.   

BOARD FINDINGS:  In the matter of the chronic subjective neck pain condition, the panel unanimously recommends a disability rating of 20%, coded 5242 IAW VASRD §4.71a.  In the matter of the posttraumatic daily headache condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended left carpal tunnel syndrome, left ulnar neuropathy, and hearing loss with tinnitus conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  In the matter of the contended PTSD condition, the panel unanimously recommends the condition as not unfitting at the time of separation.  There are 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Subjective Neck Pain	5242	20%	
Posttraumatic Daily Headache	8045-9304	10%	
COMBINED	30% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160915, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015821, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure