RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01451
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20061205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O3, Clinical Nurse, medically separated for “upper extremity dysesthesias” with a 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:  

SAFPC – 20061023 	VARD - 20070321	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Upper Extremity Dysesthesias 	8799-8712	20%	Right Upper Extremity Peripheral Neuropathy	5237-8515	30%	20061009	
Adjustment Disorder… 	Category III	Depression and Adj Disorder…	9434	50%	20061023	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Upper Extremity Dysesthesias.  According to the service treatment record and MEB narrative summary (NARSUM), the CI was first seen for right arm weakness on 23 September 2005 and noted to have slight right hand weakness.  An evaluation was begun, but, prior to completion, she presented to the emergency room (ER) on 13 October 2005.  She was evaluated by neurology and admitted from the ER to expedite the evaluation.  Laboratory studies were essentially normal as were a head CT scan and a brain MRI.  A cervical spine MRI showed degenerative disc disease (DDD) at C5-6 and C6-7.  Sensory changes were present on admission but resolved by discharge the next day.  She also had right greater than left motor loss of the arms which was subjectively and objectively improved by the time of discharge.  It was recorded that the motor examination was complicated by give way weakness (often a sign of less than maximal effort).  

On follow-up in neurology 26 October 2005, the motor examination was marked by a variable and unsustained effort.  Her strength and reflexes were assessed to be normal.  Two weeks later in neurosurgery the examiner found that the give way weakness improved to normal with encouragement and he did not see a relationship between the DDD and weakness.  The CI was referred to physical and occupational therapy (PT and OT) for rehabilitation.  Electrodiagnostic studies of the right upper extremity (RUE) were “essentially normal.”  The decreased recruitment seen on one study might have reflected “lack of full effort” or a possible upper motor neuron lesion (above the nerve root).  It was also noted that specific treatment in PT designed to help with a radiculopathy had not been beneficial.  Formal neuropsychological testing on 30 December 2005 raised the possibility of a somatoform disorder.  In neurology on 15 March 2006, she was noted to have decreased cold sensation and pinprick sensitivity over the entire RUE.  She had 4/5 give way weakness of the RUE on initial testing, but it was normal when both arms were tested simultaneously.  In a phone call on 27 April 2006 she advised the neurologist that she had similar sensory changes in the left arm.  

The 18 May 2006 MEB NARSUM neurology examination, 7 months prior to separation, noted complaints of sensory changes and weakness of the upper extremities had plateaued.  Physical examination showed that she cradled the right arm.  The reflexes were normal as was strength when the both arms were tested simultaneously.  Sensory changes were noted over the entire RUE and left hand in a glove-like distribution.  Atrophy was absent.  It was noted that the neurological deficit was not typical for any specific etiology.  All testing had been normal other than the cervical spine MRI; the pathology present on that examination did not correlate with the symptoms though.  In physical medicine on 26 June 2006, 7 months after separation, the CI reported progressive RUE weakness since trauma (not defined) prior to symptom onset in October 2005.  Sensation was grossly intact.  There was motor loss, right greater than left, of the arms, but it “fluctuated throughout the exam.”  The MRI was repeated and showed some degenerative arthritis at C5-6, but without cord or nerve root impingement.  

At the 9 October 2006 VA Compensation and Pension (C&P) general examination, 11 months after separation, the CI reported right greater than left sensory and motor loss due to cervical spine disease.  She denied current treatment and limitations in the activities of daily living including gardening and pushing a lawnmower.  Physical examination showed a sensory and motor deficit of the right C6, C7, C8, and T1 nerve roots with normal reflexes.  It was also noted that the median nerve was the most likely peripheral nerve involved.  Degenerative arthritis was present on X-ray.  Intervertebral disc syndrome was diagnosed.  Atrophy was not recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the upper extremity dysesthesias 20%, analogously coded 8799-8712 (lower radicular group neuralgia).  The VA rated the RUE peripheral neuropathy 30%, dual coded 5237-8515 (cervical strain-paralysis of the median nerve), based on the C&P general examination, citing incomplete paralysis hand movements at the moderate level.

The panel noted the cervical spine MRI prior to separation was near normal and that the one after separation did not show nerve impingement.  The motor examination was shown to fluctuate on multiple examinations and was normal when distracted (testing both arms simultaneously).  The electrodiagnostic studies did not show an RUE radiculopathy or peripheral neuropathy.  Multiple examinations noted a normal examination of the left upper extremity and the pathology found on others varied between examinations.  A finding that the left upper extremity was separately unfitting was not supported by the evidence.  The evidence does not support a rating higher than the mild 20% rating adjudicated by the PEB.  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 (bilateral) upper extremity condition.  

Contended PEB Condition:  Adjustment Disorder with Anxiety and Depressed Mood.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement.  The MEB mental health assessment noted that she met retention standards.  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 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 upper extremity dysesthesia condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with anxiety and depressed mood, the panel recommends no change from the PEB determination as not unfitting (Category III).  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 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01451.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings