RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02953
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Patient Administration Specialist, medically separated for “asthma” and “chronic low back pain,” each rated 10%, with a combined disability rating of 20%.

CI CONTENTION:  She should have received higher ratings for her asthma, back and migraine headache 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 - 20050426	VARD - 20060111	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	30%	STR	
Chronic Low Back Pain	5237	10%	Low Back Strain	5237	10%	STR	
Migraine Headaches	Not Unfitting 	Migraine Headache	8100	10%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Asthma.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was diagnosed with asthma in 2003 (methacholine challenge).  A treatment note in October 2004 documented that she had been started on Advair (inhaled steroid with bronchodilator), twice daily, with some improvement, and numerous STR entries documented continued use of Advair, along with frequent use of albuterol (inhaled bronchodilator).  This medication use was also corroborated by the pharmacy medication profile.  There was no STR evidence of respiratory failure, hospital admissions, continuous requirement for systemic corticosteroids, or monthly exacerbations requiring physician visits.

The 13 April 2005 MEB NARSUM examination, 3 months prior to separation, documented the CI’s “symptoms are not well controlled despite adequate therapy.”  The examiner referenced poor exertional tolerance and multiple triggers.  The single pulmonary function test (PFT) in evidence was performed on the same day as the NARSUM.  This yielded an FEV1 of 79% predicted and an FEV1/FVC ratio of 84%.  The physical examination recorded expiratory wheezes.  The MEB NARSUM orthopedic examination, the next day, provided the following corroboration, “She currently uses an albuterol inhaler once daily and Advair twice daily with incomplete control of her symptoms.”  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma, bronchial), citing the NARSUM PFT results; although, the DA Form 199 specifically acknowledged the CI’s use of albuterol, Advair, and Singulair.  The VA rated the asthma condition 30%, coded 6602, also referencing the STR evidence from the NARSUM as well as the medication criteria elaborated below.  Members noted that VASRD §4.97 defines both PFT-derived and clinical treatment criteria for rating under code 6602, with a 10% stipulating “FEV-1 of [71-80%] predicted, or; FEV-1/FVC of [71-80%], or; intermittent inhalational or oral bronchodilator therapy.”  A 30% rating requires “FEV-1 of [56-70%] predicted, or; FEV-1/FVC of [56-70%], or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  Although the PFT criteria in evidence only satisfied a 10% rating, it is clear that the use of Advair was amply supported by the evidence and warrants a 30% rating.  The panel also noted it would not be unreasonable to concede daily use of albuterol and/or Singulair, either of which would also satisfy the 30% criterion for daily inhalational or oral bronchodilator.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 30% rating for the asthma condition, coded 6602.

Chronic Low Back Pain (LBP).  The STR and MEB NARSUM orthopedic examination documented a back injury from a fall in October 2003.  The CI subsequently suffered chronic LBP, although there was a paucity of treatment notes for it.  The NARSUM stated that a November 2004 MRI (not in evidence) precluded surgical intervention.  There was STR documentation of a normal gait, and grossly normal to modestly limited range of motion (ROM), but no mention of severe ROM limitation or abnormal spinal contour.  

The orthopedic NARSUM, 3 months prior to separation, documented “constant” pain rated 5-9/10, and “aggravated by sitting and walking for more than 2 hours.”  The physical examination recorded “no local tenderness” and normal neurological findings, with no mention of spasm, gait disturbance, or abnormal contour.  Measured ROM was flexion to 75 degrees (normal 90) with a combined ROM of 215 degrees (normal 240), without specifying painful motion.  As above, there was no temporally probative VA evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5237 (lumbosacral strain), citing tenderness and the NARSUM ROM findings.  The VA also rated the condition 10%, coded 5237, referencing the same STR evidence and citing applicable VASRD §4.71a criterion.  Members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees), as reported in the orthopedic NARSUM which recorded the only ROM measurements proximate to separation.  There was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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 low back condition.
Contended PEB Condition:  Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the condition was not unfitting.  It appears from the record that this condition was added during late MEB proceedings, although details are unclear.  A 13 April 2005 MEB neurology consult documented a 2-year history of headaches that had recently escalated when the CI moved to night shift work.  They occurred about twice weekly, lasted 3-5 hours, and treatment was being titrated. While she reported multiple emergency visits for treatment, the STR contained only one such encounter in November 2004.  The neurologist diagnosed “migraine headaches without aura” and opined that the condition was medically acceptable.  The condition was not profiled, and although the commander’s statement implicated “chronic migraines,” it did not specify any duty limitations or identify any work loss due to headaches.  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 migraine condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the asthma condition, the panel recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended migraine headache condition, the panel recommends no change from the PEB determination as not unfitting.  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 as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Asthma	6602	30%	
Chronic Low Back Pain	5237	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170317, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008808, 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 40% 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 minus the amount of severance pay you were previously paid at 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.  Inquiry 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