RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00789
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Aviation Operations Specialist, medically separated for “residuals of traumatic brain injury” with a disability rating of 10%.  

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 - 20090116	VARD - 20091029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Residuals of Traumatic Brain Injury	8045	10%	Post-Concussion Syndrome	8045	10%	20090923	
			Tension Headaches, S/P TBI	8199-8100	50%	20090923	
Parasomnias (Sleep-Walking)	Not Unfitting	PTSD with Sleepwalking, Nightmares, and Parasomnias	9411	30%	20090921	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Residuals of Traumatic Brain Injury (TBI).  According to the service treatment record and MEB narrative summary (NARSUM), the CI fell on his head from a 7-foot bunk bed while sleepwalking in August 2007.  At the time of the injury he was disoriented and had a bad headache for several days.  He developed cognitive complaints of short-term memory troubles and word finding difficulty.  Neuropsychological evaluation on 5 August 2008, found “no consistent impairment…in any neurocognitive domain.”  His performance was generally in the average or above average range in all domains assessed.  During the evaluation, the CI reported very mild problems with long-term memory, and moderate problems with short-term memory.  Objective findings noted average intelligence with full scale IQ consistent with estimated premorbid IQ, average performance on working memory and attention tasks, average range for processing speed tasks, and average range on tests of learning and memory.  The CI scored in the superior range on nonverbal reasoning and problem solving and in the high average to normal range on tasks that measure complex problem solving skills.  The 6 August 2008 psychiatric addendum noted complaints of sleep disturbance, headaches, and irritability.  Part of his sleep disturbance had been his sleep walking, which he stated began in basic training.  His headaches occurred suddenly and were accompanied by irritable mood.  The headaches were sharp and located in the bilateral upper posterior temporal/lower parietal area of the head.  Some of them lasted 10-20 minutes and resolved with medication, while those lasting for several hours were relieved by resting in a quiet room.  The mental status examination was unremarkable.  Long-term, short-term, and immediate memory were grossly intact, and there was no evidence of problems with attention or concentration.  Sleepwalking disorder was the only Axis I diagnosis recorded.  The neurology addendum dated 11 August 2008 documented a normal examination and noted a CT scan which showed no evidence of intracranial pathology.  However, it did show a 2 mm foreign body in the soft tissue of the forehead.  

During the 13 September 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI complained of memory loss, difficulty sleeping, problems with concentration, dizziness, and headaches.  The examiner recorded post-concussion syndrome with subjective cognitive sequela, muscle tension headaches, and parasomnias.  The physical examination was unremarkable.  At the 13 September 2008 MEB NARSUM examination, the CI reported the headaches were his most concerning problem and that most of them were tension-type and required him to lay down in a quiet dark room.  Light and loud noises exacerbated his headaches and caused him to lose time from work.  Medical therapy helped control the headaches but had not relieved them completely.  He also reported mild memory impairment.  The physical examination was unremarkable.  The examiner cited the neurology MEB evaluation that opined the CI had no obvious cognitive impairment secondary to TBI.  

At the 23 September 2009 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported problems with attention and concentration, slowness of thought, and mild memory problems.  He also complained that hypersensitivity to light and sound aggravated his headaches.  He stated that he had dizziness three times per day.  He reported no other symptoms associated with the TBI injury.  The physical examination was unremarkable in relation to the TBI.  The examiner diagnosed post-concussion syndrome and tension headaches.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the residuals of TBI 10%, coded 8045 (residuals of TBI), citing level 1 impairment in the memory, attention, concentration, and executive function facet, noting the only subjective symptom facet item was the headache.  The VA rated the residuals of TBI 10%, coded 8045, based on the C&P examination, citing a level of severity of “1” under the memory, attention, concentration, executive functions facet for complaint of mild memory loss.  The VA also rated tension headaches 50%, analogously coded 8199-8100 (migraine headaches), citing very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability.  

The panel is required to evaluate cognitive impairment and subjective symptoms IAW VASRD 4.124a.  The rating is based on the highest level of severity for any facet of cognitive impairment or other residuals identified as associated with the condition.  The panel undertook a careful review of the record in evidence for support of a rating higher than 10% under the 8045 code.  Although the neurology addendum indicated the headaches caused the CI to lose work at least once per week, the commander’s statement noted the CI worked a 4-6 hour duty day “due to the medications he takes to treat his condition,” with no indication that the CI’s headaches required rest periods during most days, or interfered significantly with duty performance.  Under the subjective symptoms facet, a “1” is consistent with mild impairment and a “2” represents moderate impairment.  Examples of mild impairment include daily mild to moderate headaches or hypersensitivity to sound or light.  Examples of moderate impairment are headaches that require rest periods during most days, blurred or double vision, and marked fatigability.  The record documented headaches that occurred weekly and sometimes daily.  The CI reported headaches that lasted for hours at a time and he had to rest in a dark room.  There were no complaints of vertigo, dizziness, sleep disturbance, or fatigue.  There was no indication that he had to leave work to seek medical attention for his headaches. 

Panel members agreed the CI’s headaches were no more than mild under the subjective symptoms facet.  Therefore, the CI’s subjective symptoms were most consistent with the level “1” impairment.  The panel also considered rating the headaches under code 8100 (migraines).  The rating options under 8100 for migraine headaches rely on the frequency of prostrating attacks, but VASRD §4.124a does not define prostrating.  The Board has relied on the English definition of prostrating (extreme exhaustion or powerlessness, reduced to extreme weakness).  The panel carefully considered the frequency and nature of the CI’s headaches including objective and corroborating subjective evidence, and found insufficient evidence to support a rating under this code.  The panel noted there had been no visits to the emergency room for headaches and no evidence of incapacitating episodes and prescribed quarters.  Panel members concluded the 8100 code offered no benefit to the CI, and that taken in totality, the condition was better represented under the 8045 code since there were also cognitive complaints.  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 residuals of TBI.  

Contended PEB Condition:  Parasomnias (Sleep-Walking).  The panel notes that IAW DoDI 1332.38, enclosure 5, sleep-walking is a condition not constituting a physical disability and is not compensable.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS: In the matter of the residuals of TBI and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended parasomnias, the panel recommends no change from the PEB determination as not ratable or compensable.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, 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 20170217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007231, 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