RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00012
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20041213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Motor Transport Operator, medically separated for “chronic back pain, without neurologic abnormality” with a disability rating of 10%.  “Migraine headaches” were determined to have existed prior to service (EPTS) and were not rated.  

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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20041117	VARD - 20050610	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain…	5299-5237	10%	Degenerative Disc Disease	5243	10%	20050422	
Migraine Headaches	EPTS	Migraine Headaches	8100	30%	20050422	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in July 2004 with a gradual onset of symptoms after lifting.  Lumbar spine imaging showed no specific abnormality.  

During the 7 September 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported low back pain (LBP) with occasional numbness, but the examiner recorded a normal spinal evaluation.  The 24 September 2004 MEB NARSUM examination documented complaints of constant, non-radiating LBP aggravated by all types of activities and physical exertion.  The provider noted signs of overreaction during the examination, with positive, diffuse tenderness to superficial palpation over the lumbar paraspinal muscles.  There was no muscle spasm or atrophy, and straight leg raise testing and facet loading were negative.  “Trunk mobility” was limited in all planes of motion secondary to pain/poor effort.  Flexion was 52 degrees (normal 90)” and combined ROM was 136 degrees (normal 240).  Muscle strength was normal, but limited by give-way weakness/poor effort; sensation was decreased “in no particular dermatomal pattern.”  

At the 22 April 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI complained of continuous LBP without radiation.  The ROM evaluation showed flexion of 90 degrees and a combined ROM of 240 degrees.  There was no additional functional impairment on the basis of fatigue, incoordination, pain, or weakness; and no mention of painful motion, tenderness or spasm of the lower back.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing ROM limited by pain with localized tenderness.  The VA rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the C&P examination, citing limited painful motion.  Members assigned little probative value to the NARSUM examination because the provider indicated it was unreliable due to poor effort during ROM and muscle strength testing, overreaction to examination maneuvers, and non-organic responses to sensation testing.  The VA examination showed full ROM without evidence of painful motion and no tenderness or muscle spasm.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD 4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.

Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition existed prior to service and was not permanently service-aggravated.  The PEB determined the migraine headaches to be an EPTS condition based on the history by the CI at a neurological evaluation in 2004.  In accordance with DoDI 1332.38 (E3.P4.5.2.3.), the presumption of service aggravation (SA) may only be overcome by a preponderance of medical evidence that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  On a medical examination in March 2004, prior to activation in May 2004, the CI reported no history of frequent headaches or use of any medications.  The panel concluded that the DoDI threshold to overcome the presumption of SA was not met, and therefore considered a rating recommendation for the migraine headaches.  

According to the STR, MEB NARSUM, and MEB neurology consult, the CI had a “several year history” of recurrent vascular headaches/migraine headaches.  After being activated on 15 May 2004, he described nearly daily headaches that became incapacitating; a brain CT performed on 24 July 2004 was negative.  At a primary care visit on 27 July 2004, the CI reported a migraine that occurred 3 days earlier and did not respond to abortive medication, which usually helped.  He was then started on propranolol (prophylactic medication for migraines).  

The 27 August 2004 MEB neurology examination, 3 months prior to separation, noted CI complaints of migraine headaches from "working outdoors a lot" after activation, with resultant severe, nearly daily vascular headaches that had become incapacitating.  The headaches began with flashes of light, visual disturbances, and sensitivity to light, and were followed by dizziness and a severe bifrontal headache associated with nausea and vomiting.  He also stated noxious odors, such as the smell of gasoline or diesel fuel, would precipitate a headache.  He averaged 4 headaches a week lasting several hours unless he used an abortive Imitrex injection, which ended the headaches in approximately 2 hours.  However, the side effects of the medication made him weak and dizzy and unable to work.  The prophylactic propranolol had been stopped due to lack of efficacy.  The neurologist recorded a normal examination and indicated it could take many months for the CI to achieve control of the headaches, if at all, with any deployments greatly exacerbating his condition.  Additionally, the headaches would be aggravated by environmental factors in the military, and thus MEB was initiated.

During the 7 September 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported dizzy spells when having migraine headaches approximately 4 times a week.  At a 22 November 2004 evaluation by a second neurologist, 1 month before separation, the CI reported headaches 3-4 times a week, and that while Imitrex made them less severe, it did not decrease their frequency.  He stated he would rather suffer with the headache than the medication side effects, which included chest tightness.  He had tried other prophylactic medications in the past which did not help.  The neurological evaluation was normal and medications were changed to Pamelor (prophylactic) and Cafergot (abortive). 

At the 22 April 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported migraine headaches approximately once a month, usually in the late evening or at night and frequently  associated with nausea.  Treatment consisted of Pamelor every day, and Percocet whenever the headaches occurred, with good response and no side effects.  The provider noted the headaches did “not cause a functional loss at work,” and the neurological examination was normal.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the migraine headaches as an EPTS condition, coded 8100 (migraine headaches), and not permanently aggravated by military service.  The VA rated the migraine headaches 30%, coded 8100, based on the C&P examination, citing prostrating migraines which occurred once a month. Members noted that rating guidance for code 8100 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 CI developed prostrating headaches after activation in May 2004.  The first neurologist indicated it would take several months to find the right medications and bring the headaches under control.  In November 2004, he was prescribed new medication, and at the C&P examination, he was still on the same medication and described much less frequent headaches that responded well to a pain medication without side effects.  He also indicated the headaches did not result in any work loss.   The panel concluded the CI no longer suffered from prostrating headaches, and therefore no higher than a 0% rating was supported under 8100 for “less frequent attacks” than one every 2 months. After due deliberation, the panel agreed the preponderance of evidence with regard to the functional impairment of migraine headaches favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 8100 and meets the VASRD §4.124a criteria for a 0% rating at separation. 

 

BOARD FINDINGS:  In the matter of the chronic back pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended EPTS migraine headaches, the panel recommends the condition be considered permanently service aggravated and recommends a disability rating of 0%, coded 8100, IAW VASRD §4.124a.  As the proposed new combined disability ratings result in no change to the combined disability rating previously assigned, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180011257, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure