RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02133
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080926

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Motor Transport Operator, medically separated for “chronic low back pain” and “migraine headache with aura,” rated 20% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Joints hurt...and cannot lift things over 7 to 8 LBS…get mad easy after being in Iraq.”  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 - 20080822	VARD - 20090310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	20%	Degenerative Joint of Lumbar Spine with Disc Bulge at L4-L5	5242	20%	20090211	
Migraine Headache with Aura 	8100	0%	Migraines 	8100	10%	20090211	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in June 2005 after jumping up and down out of trucks while deployed in Iraq.  MRI studies on 22 January 2008 showed L4-L5 intraforaminal disc protrusion with mild neuroforaminal narrowing.  The protrusion may have contacted the exiting nerve root.  Examiner noted no significant findings that explained radicular pain.  

At the physical therapy (PT) appointment on 3 March 2008, 6 months prior to separation, Range of motion (ROM) measurements taken with a goniometer after multiple repetitions was flexion to 45 degrees (normal 90) with complaints of pain.  Combined ROM was 160 degrees (normal 240).  A 26 June 2008 nerve conduction study of the nerves supplying the muscles of the upper extremities was normal.  There was no electrophysiologic evidence of a left cervical radiculopathy, focal neuropathy, lumbosacral plexopathy, or generalized polyneuropathy.  The 22 July 2008 MEB NARSUM examination, 2 months prior to separation, noted complaints of progressively increased back pain.  Physical examination showed there was tenderness between L2 through S 1 with para vertebral muscle spasms present.  His gait was normal and there was no scoliosis.  Straight leg raise testing and deep tendon reflexes were normal.  Muscle strength was normal in the bilateral lower extremities and sensations were intact.  ROM from the previous PT examination was used.

At the 11 February 2009 VA Compensation and Pension (C&P) examination, 5 months after separation, the examiner noted the CI had difficulty getting out of his chair.  His posture was poor.  Physical examination showed his muscles at L3-5 were extremely tight with spasms.  ROM was flexion to 40 degrees with pain.  Combined ROM was 170 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 20%, coded 5237 (lumbosacral strain), citing loss of spinal ROM to 45 degrees flexion and normal electrodiagnostic studies of the lumbar and lower extremities. The VA rated the low back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing “forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.”  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 the MEB NARSUM and VA examinations.  The panel next considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The panel therefore concluded that an additional disability rating was not justified on this basis.  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 low back condition.  

Migraine Headache with Aura.  According to the STR and MEB NARSUM, the CI’s migraine condition began in 2005 with no history of head trauma or concussion.  The 12 March 2008 MEB neurological consult examination, 6 months prior to separation, noted complaints of pressure sensation 10/10 and associated photophobia, phonophobia, and nausea/vomiting with the headache.  The CI denied any focal numbness, tingling, weakness, or slurred speech.  The examiner recorded no history of seizures, no gait difficulties, and no coordination problems.  His headaches were episodic; then increased to approximately two times per week.  They began in the vertex or bilateral occipital regions of the head, then spread to the front, and settled behind his eyes.  Physical examination showed all cranial nerves were intact, and motor strength was normal.  The examiner confirmed criteria of migraine with aura.  The CI was prescribed migraine headache medication for the first time.

At the C&P neurology examination, 5 months after separation, the CI reported headache pain that was both steady and throbbing and occurred about three times a week.  The CI noted he had incapacitating headaches about twice a week.  He was required to go and lay down with a cool cloth on his head and the headaches would eventually ease off in 4-5 hours.  He experienced these headaches 3-4 times per week and he only took Aleve for them.  The examiner reported the CI had not worked since his medical discharge.  Physical examination was unremarkable.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and the VA each rated the migraine condition 0%, coded 8100 (migraine). The PEB cited headache frequency as twice a week and not prostrating in nature as defined by being so severe that the CI sought medical treatment by a physician and was placed on bed rest.  The VA based its rating on the C&P examination, citing characteristic prostrating attacks averaging one in 2 months over the last several months.  

The panel considered the results of the MEB and VA examinations along with the evidence of the treatment records to accurately assess the overall disability picture (§4.2) at the time of separation.  The rating options under 8100 for migraine headaches rely on the frequency of ‘prostrating’ attacks, and VASRD §4.124a does not define ‘prostrating’.  The panel’s precedence 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. The 10% rating under this code requires one prostrating headaches in 2 months over several months.  Review of the record did not support the conclusion that during the several months prior to separation, the CI experienced prostrating attacks.  However, the CI’s migraine headaches were at least weekly.  Therefore, the panel determined that a 10% rating is consistent and most closely matched with the frequency and severity of the CI’s headaches prior to separation.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the migraine condition, coded 8100.

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.17a, the panel recommends no change in the PEB adjudication.  In the matter of the migraine headache condition, the panel recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a.  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	
Chronic Low Back Pain	5237	20%	
Migraine Headache with Aura	8100	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170307, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190007280, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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.
 
	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.  Inquiries concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure