RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04904
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Military Policeman, medically separated for “posttraumatic stress disorder (PTSD)” and “posttraumatic headaches,” rated 10% each, with a combined 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:  

SERVICE PEB - 20061003	VARD - 20070330	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD with Major Depressive Disorder	9434-9411	50%	20070202	
Posttraumatic Headaches	8045-9304	10%	Post Concussive Syndrome	8045	10%	20070131	
Low Back Pain	Not Unfitting	Degenerative Disc Disease, Lumbosacral Spine	5010-5243	10%	20070131	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s PTSD began in February 2005 after an IED explosion.  The CI reported numbing, avoidance, hyper-arousal, irritability, anger, poor concentration, hypervigilance and nightmares as related to the trauma.  He also described social isolation, guilt, fear of public places and daily anxiety and panic symptoms.  He underwent intensive psychotherapy and many symptoms improved.  

The 10 March 2006 MEB NARSUM psychiatric addendum, 8 months prior to separation, noted complaints of frequent daily severe anxiety, panic attacks, memories of trauma, avoidance of stressors, easy startle and hypervigilance.  At times memory was poor and organization at work difficult.  He had withdrawn from family and friends.  Mental status examination (MSE) showed slow speech and response time, depressed mood with anxious affect.  Diagnoses of PTSD, major depressive disorder (MDD), panic disorder without agoraphobia and cognitive disorder, NOS, were rendered with a Global Assessment of Functioning (GAF) score of 65 (mild impairment).  

At the 8 December 2007 VA PTSD C&P examination, 12 months after separation, the CI reported ongoing treatment effort helped, but he felt things were getting worse due to increased suicidal thoughts related to his inability to work, increased feelings of uselessness and increased feelings of failure.  He had just been placed on anti-psychotic and anti-depression medication.  The CI had had six jobs since February 2007.  He quit all of them due to suicidal thoughts at work.  He denied suicide attempts or violence.  He had been married for 7 years, had three kids, reported his wife was supportive and he was ok around her and the kids.  Any stress triggered depression, guilt and irritability.  He reported no interest in activities or leisure pursuits.  The MSE showed a lethargic constricted affect, depressed mood, a paucity of ideas and a feeling of failure.  Sleep was variable.  There were no problems with activities of daily living and hygiene was good.  Memory was mildly impaired and PTSD symptoms persisted. Diagnosis of PTSD was rendered with a GAF score of 35 (impairment in several areas.)  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mental health (MH) disorder 10%, citing mild industrial impairment.  The VA rated the MH disorder 50%, dual coded 9434-9411 (MDD and PTSD), based on the C&P examination, citing reduced reliability and productivity.  The panel noted that IAW DoD guidance VASRD section §4.129 (mental disorders due to traumatic stress) will be applied when PTSD is an unfitting condition.  Therefore, as a matter of policy, the PDBR must recommend placement of the CI on the Temporary Disability Retired List (TDRL) for a constructive period of 6 months with a minimum rating of 50% IAW §4.129.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single MH rating using the same criteria IAW VASRD §4.130, the general rating formula for MH conditions.  The panel next considered the §4.130 rating at TDLR placement.  The §4.130 criteria for a 70% rating is evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.  A 50% rating requires evidence of occupational and social impairment with reduced reliability and productivity.  The panel agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of TDRL placement, and therefore the minimum 50% initial TDRL rating is applicable.

The most probative source of comprehensive evidence on which to base the permanent rating is the C&P examination 7 months after TDRL placement.  The §4.130 criteria for a 10% rating requires evidence of symptoms being controlled by continuous medication and a 30% rating requires evidence of occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.  The CI reported persisting symptoms of PTSD and remained in treatment with the support of therapy and the recent addition of medication.  He was unemployed but had been pursing jobs and was handling money and paying bills.  The CI continued to maintain good family relationships and was responsive to family support.  After deliberations, the panel majority concluded the symptoms most closely approximated the criteria for a 30% disability rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for 6 months of constructive TDRL for the PTSD and a permanent 30% disability thereafter.

Posttraumatic Headaches.  According to the STR and MEB NARSUM, the CI’s post-traumatic headaches began after the IED explosion described above.  The CI was thrown 15-30 feet, lost consciousness and awoke minutes later without his Kevlar.  Neuropsychological testing in June 2005 showed slowed cognition and sensory motor functions and a diagnosis of post-concussion headaches was rendered.  The 7 August 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of headaches five to seven times per month with a prostrating headache about once a month despite medical treatment.  He was prescribed medication to abort headaches, but removing him from the stress of his MOS and assigning him administrative duties proved more beneficial.  Headaches were exacerbated by stressful mental or physical situations.  Physical examination, lab tests and imaging studies were essentially unremarkable.  

At the 31 January 2007 VA Compensation and Pension (C&P) general medical examination, 2 months after separation, the CI reported the headaches moderately effected chores, exercise, sports and travel but not the activities of daily living.  Physical examination was essentially unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the posttraumatic headache condition 10%, dual coded 8045-9304 (residuals of traumatic brain injury (TBI) and dementia due to trauma) citing headaches with rating limitations.  The VA rated the posttraumatic headache condition 10%, coded 8045 (residuals of TBI) based on the C&P general medical examination, citing subjective complaints of pain and decreased concentration recognized as symptomatic of brain trauma.  

Based on the constructional TDRL requirements outlined above, the panel determined rating recommendations for the headache condition at TDRL placement and removal as follows.  Diagnostic code 8045, per the VASRD in effect, stipulates, “Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304.”  The panel considered the option of recommending a rating under 8100.  The C&P examination noted no loss of earning power due to headaches.  Members noted there was no evidence of “prostrating” attacks, meaning the CI had to stop what he was doing and seek medical attention.  There was no evidence of frequent visits to the emergency room or to the neurology clinic for headaches, thus there was insufficient evidence to justify a conclusion that a higher rating under 8100 was warranted at TDRL placement.  However, panel members agreed that a 10% rating was readily supported under the PEB code and, compliant with the rating language of the VASRD in effect for that code (see above).  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 headache condition at TDRL placement.  

The panel next considered the rating recommendation for the headache condition at TDRL removal.  The panel determined the most proximate source of comprehensive evidence, to evaluate the CI at TDLR removal was the C&P general examination performed 2 months post-separation.  The panel noted the headaches continued to only moderately impact some activities.  The panel agreed that a 10% rating, but no higher, was justified per post-traumatic coding as described above.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a TDRL placement rating of 10% and permanent disability rating after removal from TDRL of 10% for the posttraumatic headache condition.

Contended PEB Condition:  Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  Although the contended condition was implicated in the commander’s statement, it was not profiled or judged to fail 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 PTSD, the panel recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 30% IAW VASRD §4.130. The single voter for dissent recommends modification to 50% at permanent separation but does not elect to submit a minority opinion.  In the matter of the posttraumatic headache condition, the panel recommends an initial TDRL rating of 10% in retroactive compliance with VASRD §4.129, as DOD directed, and §4.130 and a 10% permanent rating at 6 months.  In the matter of the back 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 the date of medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Posttraumatic Stress Disorder	9411	50%	30%	
Posttraumatic Headaches	8034-9304	10%	10%	
COMBINED	60%	40%	

XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 60% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period recharacterize your separation as a disability retirement with a combined disability rating of 40%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period and the recharacterization of your separation as a disability retirement will result in an adjustment to your pay providing you 60% retired pay for six months from the date of your original medical separation and then 40% disability retired pay effective the date following the constructive six month TDRL period 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 wll 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