SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05603.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX		CASE: PD-2017-05603 BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE: 20090827

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Security Forces Journeyman, medically separated for “persistent headache syndrome status post traumatic brain injury” 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 - 20090507	VARD - 20100409	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Headache Syndrome Status Post Traumatic Brain Injury [TBI]	8045	10%	TBI with Daily Headaches	8045	40%	20090910	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

Persistent Headache Syndrome. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a head injury in March 2007 after being thrown headfirst into a wall during a training event. A witness reported that he lost consciousness for 10-15 seconds. An emergency room (ER) evaluation was unremarkable with a normal brain CT scan. A few days later, the CI reported a continued headache not controlled by medication, and he was evaluated again in the ER with unremarkable findings. He was discharged with Ultram for pain and was not seen again until he injured his knee on 7 August 2007.

Initial neurological evaluation in February 2008 resulted in suspicion of a somatoform disorder. Psychological testing showed changes that could be contributed to the head injury, but that were also consistent with a conversion disorder. A second neurologist did not find any clear indications of a conversion disorder and several neurological consultations opined symptoms were post- concussive as a result of a TBI. Several repeat MRI and CT scans of the brain were normal. The  CI continued to follow up with the second neurologist and the last visit was on 29 December 2008.  Propranolol  once  daily  was  prescribed  without  any  significant  improvement.   The   15 February 2009 commander’s statement noted the CI was unable to perform in his military specialty since the accident, was assigned to office duties to allow flexibility to attend medical appointments, and continued to perform at acceptable standards.

The 15 February 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of recurrent, frequent headaches, which occurred daily to every other day, and were associated with light/sound sensitivity and dizziness. There were no episodes of syncope, weakness, numbness or tingling, but the CI reported that his memory was occasionally “clouded.” Neurological examination was unremarkable and a diagnosis of “persistent headache syndrome probably post-concussive and TBI” was rendered.   The last follow-up neurology note, dated      1 September 2009, noted the CI had daily holocephalic headaches which were mild with rare photophobia and phonophobia, but without clear focal sensory or motor deficits.

At the 10 September 2009 VA Compensation and Pension (C&P) examination, less than a month after separation, the CI reported usually awakening with a headache that lasted all day, but varied in intensity. The intense portion of headaches lasted less than 2 hours per day. He described new, recent episodes of aggression, possibly triggered by the headaches, and was told this was caused by his headache medication. He also experienced hypersensitivity to sound and light with severe headaches. He saw his neurologist every 6 weeks for the past 1.5 years and was told the anesthesia administered after his head injury had aggravated it. He was treated with various medications, but because of side effects, there was no benefit and he had discontinued using them. He reported he was able to “adapt and overcome” and maintained regular exercise. He reported vertigo only with very severe headaches, which he noted occurred 3 times in the past week. Balance was improving but not yet normal, and he compensated by not bending over or standing up fast. He reported episodes of disorientation and getting lost while driving. Overall, he reported most symptoms related to TBI were improving. Executive functions were generally good and he stated he felt generally well. The examiner noted mood disorder and conversion disorder had been ruled out. Physical examination was unremarkable, and a diagnosis of chronic daily headaches was rendered.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the headache/TBI condition 10%, coded 8045 (residuals of traumatic brain injury), citing the schedule for rating disabilities in use by the VA in accordance with the National Defense Authorization Act 2008. The VA rated the headache/TBI condition 40%, coded 8045, based on the C&P examination, citing a level of severity of "2" indicating evidence of three or more subjective facets symptoms that moderately interfered with work; instrumental activities of daily living; or work, family, or other close relationships.

Panel members noted that under code 8045, physical and neurological residuals are to be evaluated individually and rated in accordance with “facets” on a scale of 0-3 with the following stipulations: Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets. If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. Accordingly, the PEB assigned a 10% rating, equal to a level of severity of “1,” reflecting daily mild to moderate headaches. Panel members agreed the C&P examination, conducted less than a month post-separation, was the most proximal, detailed and complete, and therefore the most  probative.   The  C&P  examination noted  the  headaches occurred daily and  included an

intense portion that lasted less than 2 hours per day. The CI reported he was able to “adapt and overcome,” and that most symptoms related to the TBI were improving and executive functions were generally good and he felt generally well. He was unemployed for the past year but had plans to attend law school. The last documented neurological visit in January 2009 noted mild headaches with rare symptoms of migraine headaches. There was no evidence the headaches required rest periods most days to meet criteria for the highest level of severity of “2” for a 40% disability rating. Therefore, there was no higher rating under code 8045. 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 persistent headache/TBI condition.

BOARD FINDINGS: In the matter of the persistent headache status post traumatic brain Injury and IAW VASRD §4.124, 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.