RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-02994
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was active duty E4, Light Wheeled Vehicle Mechanic, medically separated for “cognitive disorder, not otherwise specified (NOS), secondary to traumatic brain injury (TBI)” with a disability rating of 10%.   

CI CONTENTION:  No specific contention was made.  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 - 20050606	VARD - 20051025	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cognitive Disorder, NOS	8045-9304	10%	Cognitive Disorder & Chronic Headaches due to Traumatic Brain Injury	9304	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Cognitive Disorder, NOS.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s cognitive disorder began in September 2003 after he fell into a motor pool pit (about 7 feet).  He had no recollection of falling.  The CI’s last memory was from 2 days prior to the accident and his first memory after the accident was calling his wife the day after the accident. A CT brain scan found predominately right frontal and left parietal contusions/hematoma at that time.  The CI subsequently developed headaches, mood lability, depression, abulia, memory problems, and sleep changes, which improved over time.  
The 4 January 2005 MEB NARSUM examination, 7 months prior to separation, noted complaints of daily morning headaches that responded to Benadryl.   The CI reported his symptoms and headaches improved over the previous 4 months, and he rated his pain level as 3/10.  For more severe headaches he took phenergan with some relief.  The CI reported prostrating headaches approximately once a week that limited physical activities but improved with medication.   The prostrating headaches were induced by physical activities.  The CI also reported his memory had improved, but he continued to have mood lability with easy agitation and irritability.  Physical examination was unremarkable.  There was no skull defect and neurological examination was normal.  The examiner summarized the findings of a neuropsychological (NP) test from November 2004 and noted that his performance indicated possible cognitive deficits in areas including memory, verbal fluency, attention/concentration, slowed processing, executive functioning, and visual-spatial perception.   The impression written by the psychologist was, “While the cognitive difficulties noted on the examination are somewhat consistent with brain injury, the poor effort noted on some of the testing brings into question motivational issues and possible secondary gains.”

At the 11 May 2005 psychiatric MEB examination, the CI reported he currently worked in the Medical Hold Company doing computer work as he could no longer do physical activity because it “gives me headaches.”  He denied depression, but endorsed irritability.  He denied significant sleep or memory issues and denied symptoms suggestive of PTSD.  The mental status examination was unremarkable.  The CI stated his mood was “good.” The examiner referenced the NP follow-up examination of December 2004, that stated that the CI “may have cognitive deficits resulting from his head injury, the exact nature and severity of those deficits cannot be determined.”  Additional comments were the same as recorded above during the NARSUM examination.  The examiner indicated the CI was unable to perform his normal duties due to his physical and cognitive limitations and it was likely that he would have difficulty securing and maintaining employment because of his lack of initiative and poor motivation.  The CI did not attend the scheduled VA Compensation and Pension examination so STRs were used for a rating decision.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cognitive disorder 10%, analogously coded 8045-9304 (residuals of TBI - dementia due to head trauma).  The VA also rated the cognitive disorder 10%, coded 9304, based on the STR, citing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by continuous medication.  

The VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma coded 8045.  There are two different scenarios for rating under this code; analogously with purely neurological deficits, or based on purely subjective symptoms, such as headaches, dizziness, insomnia, etc.   In the absence of associated neurological disabilities (seizures, nerve paralysis, etc.), rating of this condition under 8045-9304 is limited to 10%, and cannot be combined with any other rating for a disability due to brain trauma.  The panel found an absence of evidence that would support any neurological deficit. The rating options under code 8100 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 panel noted that the headaches responded to antihistamine-based medication and with limitation of physical activity.  Although the CI reported that these headaches occurred one to two times a week and caused him to miss 2-3 days a week of work, the STR was silent in this regard. There was no corroboration that the CI’s headaches caused him to miss work or seek treatment in the emergency room. The panel members agreed evidence of prostrating headaches was not apparent in the STR. The commander’s statement offered no insight regarding headaches at work or manipulation of the environment to accommodate the CI.  Panel members agreed, a rating under the 8100 code was not justified, and his condition was most consistent with a rating under the 8045-9304 code.  

The rating option under VASRD §4.130 is based on social or occupational impairment.  A consideration of rating is appropriate based on the diagnosis of cognitive disorder.  The psychiatric MEB examination noted that all of the CI’s cognitive symptoms had largely resolved with the exception of headaches.  Panel members concluded, a rating higher than the 10% was not justified based on the evidence at separation.  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 cognitive disorder, NOS, secondary to TBI condition.  

BOARD FINDINGS: In the matter of the cognitive disorder not otherwise specified and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  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 20170328, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190008734, XXXXXXXXXXXXXXXXXX 

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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.