RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-01387
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20050822

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Aerospace Ground Equipment Apprentice, medically separated for “exercise induced asthma” and “chronic low back pain,” rated 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 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 - 20050705	VARD - 20060518	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Exercise Induced Asthma	6602	10%	Exercise Induced Asthma	6602	10%	20060411	
Chronic Low Back Pain	5237	10%	Spina Bifida Occulta	5239	NSC	20060411	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Exercise Induced Asthma.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s asthma condition began in August 2004 with shortness of breath and syncope during the run portion of a fitness test, with other evidence of dyspnea on exertion at lower exercise levels.  Methacholine challenge test was positive (for asthma) and pulmonary function tests (PFTs) documented responsiveness to bronchodilators.  

The 18 February 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of shortness of breath diagnosed as exercise induced asthma.  Asthma medication was albuterol (inhalational bronchodilator) prior to activity.  Physical examination showed lungs clear to auscultation bilaterally with no wheezes, rales or crackles and good air movement.  Results from the following PFTs showed the following results after bronchodilator use:  

22 October 2004 - FEV1 was 93% of predicted, FEV1/ FVC was a ratio of 85%
25 October 2004 - FEV1 was 94% of predicted, FEV1/ FVC was a ratio of 85%
18 August 2004 - FEV1 was 92% of predicted, FEV1/ FVC was a ratio of 79%
1 February 2005 - Methacholine challenge positive

There was a PFT evaluation performed on 7 February 2006, 6 months after separation, which showed FEV1 of 67% and FEV1/FVC of 78%; however, the examiner indicated the test did not meet standards and may have been effort dependent.  

At the 11 April 2006 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported severe shortness of breath with exertion.  He had shortness of breath with wheezing with any strenuous activity or exercise and the symptoms were worsened by cold weather.  The CI reported that he used his albuterol inhaler approximately three to five times per week, but had never used a steroid inhaler or systemic oral steroids.  He had no medical visits for asthma since leaving the military.  Physical examination showed head, eyes, ears, nose and throat were normal.  Lungs were clear.  The final diagnosis was “reactive airway disease.  Fairly generally associated with exercise. Findings confirmed on multiple PFT.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (bronchial asthma), citing numerous PFTs.  The VA also rated the asthma condition 10%, coded 6602, based on the C&P examination, citing “forced expiratory volume in one second (FEV1) of 71 to 80 percent of predicted value; or the ratio of FEV1 to forced vital capacity (FEV1/FVC) of 71 to 80 percent; or intermittent inhalational or oral bronchodilator therapy.”  

The VA rater noted PFTs from the military that reported FEV1 of 67% predicted and FEV1/FVC ratio of 84% predicted.  However, these were pre-treatment values from the Methacholine challenge; post-bronchodilators (albuterol and Atrovent) PFT values improved after Methacholine administration to 69% and 86% respectively which demonstrated good response.  
Panel members agreed that the PEB’s 10% rating was justified by the intermittent use of inhaled bronchodilator therapy reflected in the STR.  There was no PFT evidence to support the next higher 30% rating, as pre-bronchodilator values or values following recovery from a Methacholine challenge are not ratable, and the post-separation PFT evaluation was adjudged to have lowered probative value due to its being 6 months after separation, not meeting standards, and being an outlier to all PFTs in the STR.  Likewise, a 30% rating was not justified in the absence of daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication.  After due deliberation, considering all 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 asthma condition.  

Low Back Pain.  According to the STR and MEB NARSUM, the CI first had back pain in November 2002 without history of acute trauma, but he suffered a lifting injury in May 2003 which led to chronic back pain.  X-ray of his lumbar spine revealed mild L5-S1 joint space narrowing, spina bifida occulta (congenital condition) at S1 representing a normal variant, and mild right sacroiliac joint narrowing.  An MRI performed in November 2004 was normal.  

The 18 February 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of low back pain.  Physical examination showed tenderness and “decreased range of motion (ROM) in all directions.”  However, no measurements were provided.  There was no neurologic or motor deficits noted.  The 18 April 2005 physical therapy (PT) MEB ROM evaluation of the lumbar spine (not thoracolumbar), performed with a bubble inclinometer (not goniometric), recorded forward flexion of 35 degrees, extension of 10 degrees, side bending of 15 degrees each side, and no rotation measurements.  The 20 July 2005 pain clinic evaluation, 1 month prior to separation, noted complaints of back pain with radiation.  Physical examination showed back tenderness.  The ROM evaluation showed flexion of 45 degrees (normal 90) and extension of 20 degrees (normal 30).  The examiner performed a discogram that revealed degenerative disc disease.  The CI was seen in the emergency department for radiating back pain on 19 August 2008 (the week of separation).  Physical examination showed a normal gait, but there was back tenderness and decreased (unmeasured) forward flexion with full extension.  

At the 11 April 2006 C&P examination, 8 months after separation, the CI reported chronic low back pain.  Physical examination showed tenderness and a very slow gait without a limp.  He was very slow getting up from and sitting down into the chair due to back pain.  ROM testing showed forward flexion of 60 degrees and combined ROM of 170 degrees (normal 240).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain).  The VA determined the back condition was not service-connected, coded 5239 (spondylolisthesis or segmental instability), based on the STR and VA examination.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) as reported on all examinations.  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 the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5237.  

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.97, the panel recommends no change in the PEB adjudication.  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Exercise Induced Asthma	6602	10%	
Chronic Low Back Pain	5237	20%	
COMBINED	30%	

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01387.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.