RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXX	CASE:  PD-2017-04249
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20060123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Security Forces Journeyman, medically separated for “hypokalemic periodic paralysis” with a disability rating of 10%.  

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 - 20051207	VARD - 20070606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Hypokalemic Periodic Paralysis	8099-8023	10%	Idiopathic Hypokalemia (Also Claimed as Hypokalemic Periodic Paralysis and Acute Musculoskeletal Strain)	5099-5025	10%	20061003	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Hypokalemic Periodic Paralysis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI presented with left-sided weakness at a family practice visit on 2 June 2005 after complaining of body aches for a week.  Laboratory results revealed normal potassium levels, but elevated liver enzymes, and he was prescribed Prednisone (corticosteroid).  However, later that day, the weakness progressed to the point that he was unable to lift a pen.  He was seen in the ER and admitted to the ICU with a potassium level of 1.9 mmol/l (normal 3.5-5.1) without EKG changes.  Treatment consisted of large doses of potassium, which resolved the paralysis, and he was subsequently diagnosed with hypokalemic periodic paralysis.  During a neurology follow-up on 27 June 2005, the provider noted the CI’s successful inpatient treatment with potassium, and that laboratory results also showed low thyroid stimulating hormone (TSH) levels and elevated liver function tests (LFTs) while in the hospital.  Neurological examination showed normal muscle bulk and tone, but depressed knee reflexes.  The remainder of the examination was within normal limits, and follow-up of the elevated TSH and LFTs was recommended.  The CI stabilized until 4 August 2005 when he had another mild occurrence of weakness and pain.  A neuromuscular specialist noted the symptoms were precipitated by exertion and could result in episodic periods of paralysis.  

The MEB NARSUM examination noted CI reports of a history of weakness and low potassium.  Physical examination showed blood pressure of 112/72, pulse of 72 beats/minute, respirations of 16 breaths/minute, temperature of 97.9 degrees, height of 72 inches, and weight of 185 pounds.  Examinations of the head, eyes, ears, and throat were within normal limits without lymphadenopathy.  The lungs were clear to auscultation bilaterally, and the heart had a regular rate and rhythm without murmurs, gallops, or rubs.  The abdomen was soft, non-tender, and without masses, and bowel sounds were present.  Extremities showed no clubbing, cyanosis, or edema.  Neurologically, he was intact with no focal deficits.  

At the 3 October 2006 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported intermittent fatigue and weakness, which was treated with potassium supplementation.  Physical examination showed blood pressure of 118/78 (twice) and 116/76, and a pulse of 62 beats/minute.  He was well-developed, well-nourished and in no acute distress.  The remainder of the examination, including the musculoskeletal and neurological systems, was essentially normal. Radiograph imaging of the cervical spine, thoracic spine, and lumbosacral spine on 3 October 2006 were all negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the muscle weakness condition 10%, analogously coded 8023 (progressive muscular atrophy), citing new onset, periodic hypokalemic paralysis with no evidence of the condition before June 2005.  The PEB elaborated that “this condition can be inherited, but occasionally has secondary causes,” and ruled in favor of the CI, assigning a service connection for “thyrotoxic periodic paralysis manifested by hypokalemia with profound muscle weakness.” The VA also rated the muscle weakness condition 10%, but analogously coded 5025 (fibromyalgia), based on the C&P examination, citing the need for continuous medication to control the condition.  Panel members noted that the PEB and the VA both rated the hypokalemic periodic paralysis 10%, however, the minimum rating under code 8023 is 30% for progressive muscular atrophy, which the CI did not have.  Furthermore, he did not have fibromyalgia, which tends to be chronic and associated with widespread pain and tender points.  Although he had two episodes of weakness, they were not present more than one third of the time for a higher rating under code 5025.  

The CI’s condition presented acutely and was treated rapidly with replacement potassium, and neurologic evaluation.  The panel noted that hypokalemic periodic paralysis is marked by low potassium brought on by exertion, but there is no VASRD code that addresses electrolyte abnormalities.   Thus, panel members considered analogous code 7999-7911 (Addison’s disease) which requires “one or two crises during the past year, or; two to four episodes during the past year, or; weakness and fatigability, or; corticosteroid therapy required for control” for a 20% rating.  The VASRD defines a crisis and an episode as follows:  

Note (1): An Addisonian “crisis” consists of the rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include: anorexia; nausea; vomiting; dehydration; profound weakness; pain in abdomen, legs, and back; fever; apathy, and depressed mentation with possible progression to coma, renal shutdown, and death.  Note (2): An Addisonian “episode,” for VA purposes, is a less acute and less severe event than an Addisonian crisis and may consist of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension, or hypoglycemia, but no peripheral vascular collapse.  

A hallmark of Addison’s disease is low sodium, but low potassium can also occur as well.  Although the CI’s clinical course was consistent with the aforementioned symptoms, he did not require cortisone for treatment, but instead needed potassium replacement for the acute episodes and potassium supplementation thereafter.  The panel also noted that periodic paralysis can also be associated with hyperthyroidism, and considered rating under code 7900.  However, although the CI had low TSH levels in the hospital, there was no evidence in the record of whether it was followed up, normalized, or required treatment; and there was also no evidence of thyroid enlargement, tachycardia, muscular weakness, tremor, or elevated pulse pressure or blood pressure once potassium replacement was accomplished.  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 hypokalemic periodic paralysis, coded 7999-7911.  

BOARD FINDINGS:  In the matter of the muscle weakness condition, the panel recommends a disability rating of 20%, coded 7999-7911 IAW VASRD §4.119.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Hypokalemic Periodic Paralysis	7999-7911	20%	

The following documentary evidence was considered:  

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04249.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.