RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xxxxxxxxxxxxxxxxxxxx	 CASE:  PD 13-00545	
BRANCH OF SERVICE:  AIR FORCE	 BOARD DATE:  20131114
SEPARATION DATE:  20031128		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3C251, Communications Computer Systems Control) medically separated for fibromyalgia.  The CI began to have neck and back pain in 1998 that became constant by 2000.  Additionally, frequent headaches and episodes of light-headedness, along with gastrointestinal issues, and a mood disorder secondary to pain led to a 2003 diagnosis of fibromyalgia with secondary irritable bowel syndrome (IBS).  Counseling and an array of conservative treatments to relieve the variety of symptoms were pursued.  The fibromyalgia could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty Code (AFSC) or to satisfy physical fitness standards.  She was issued a temporary P4 profile and referred for a Medical Evaluation Board.  The chronic neck pain, headaches, and chronic light-headedness and mood disorder secondary to pain were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The informal PEB adjudicated “fibromyalgia” as unfitting, rated 20%, in accordance with Department of Defense Instruction (DoDI) 1332.39 and Veteran’s Affairs Schedule for Rating Disabilities (VASRD) guidelines.  History of tobacco abuse and obesity were adjudicated as Category III – conditions that are not unfitting and not compensable or ratable.  The CI made no appeals, and was medically separated. 

CI CONTENTION:  “The combined medical conditions of Fibromyalgia, severe headaches, severe depression, chronic fatigue, and the discovery that my depression is linked to Bipolar Disorder, have caused me to be fully disabled.  After discharge I attempted to work but was unable to hold a job.  I now draw SSA disability and VA compensation (rated 70% but receive 100% due to inability to work).  In early 2009, I had a psychotic episode that caused me to be hospitalized and led to the discovery of Bipolar.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The Service rating for the unfitting fibromyalgia condition, with its associated symptoms including headaches, mood disorder and fatigue, is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records. 

RATING COMPARISON:  
   
Service IPEB – Dated 20030924	VA - (9 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia with associated Fatigue, IBS, Mood Disorder and HAs	5025	20%	Fibromyalgia with Polyarthritis of the Hips, Shoulders, Wrists, and Knee, and Chronic Fatigue	5025	10%	20040826	
			DJD C-Spine	5242	20%	20040826	
			DJD L-Spine	5242	10%	20040826	
			Depressive Disorder with Generalized Anxiety Disorder	9434	30%	20040826	
			IBS	7319	10%	20040826	
			Tension HA	8199-8100	0%	20040826	
History of Tobacco Use	Not Unfitting	No VA Entry	
Obesity	Not Unfitting		
No Additional MEB/PEB Entries	Other x 10	20040826	
Combined:  20%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20041108 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  The Military Disability Evaluation System (MDES) is responsible for maintaining a fit and vital fighting force.  While the MDES considers all of the service member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member’s career, and then only to the degree of severity present at the time of final disposition.  The MDES has neither the role nor the authority to compensate service members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service connected by the VA but not determined to be unfitting by the PEB.  However the Department of Veteran Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the veteran’s disability rating should his degree of impairment vary over time.  The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation.  The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Military Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation.  The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence.  Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Fibromyalgia Condition.  The CI first noted musculoskeletal symptoms early in her Air Force career, with leg pain during basic training in 1997 and neck pain following a whiplash injury in 1998.  She later noted that her “widespread muscle pain and fatigue” began in 1999.  Also in 1999, she was evaluated for chronic lower abdominal pain with diarrhea.  Evaluation of these diverse symptoms included consultation with numerous specialists, including cardiology for lightheadedness, gastroenterology for abdominal pain and diarrhea, pain management and neurology for chronic pain.  In 2003, she was evaluated by behavioral health and was found to have a mood disorder secondary to her chronic pain.  Radiology studies, twelve months prior to separation, revealed normal cervical and lumbar spine X-rays, without evidence of degenerative joint disease.  Magnetic resonance imagery (MRI), ten months prior to separation, revealed an “unremarkable” cervical spine with “mild disc degeneration …no focal abnormalities” of the lumbar spine, but noted some “early degenerative changes.”  Profiles (AF Form 422) from 2003, six months prior to separation, note that the CI was non-deployable for back, head and neck pain, with duty restrictions of “no running, jumping, marching, prolonged standing or walking >30 minutes,” and no pushing, pulling, lifting or carrying greater than twenty pounds.  Service treatment records (STRs) dated 12 Feb 2003 noted her Axis I diagnosis of adjustment disorder with depressed mood, secondary to her chronic pain, and listed her profile as S1.  An initial narrative summary (NARSUM) physical examination, dated 11 April, 2003, seven months prior to separation, reported that monthly injections gave her a 25% reduction in pain.  Examination noted limited cervical and lumbar motion due to pain, with “moderate myofascial spasm in the paralumbar spine.”  The NARSUM’s diagnoses were (1) chronic neck and back pain, (2) chronic headaches, (3) chronic lightheadedness secondary to pain and (4) mood disorder secondary to pain.  On 23 Apr 2003, a mental health clinic note documented that the CI had been recently informed that she had fibromyalgia (FM), and that her MEB was being rewritten.  STRs noted a consultation with rheumatology on 03 June 2003, six months prior to separation, which described a “constellation of symptoms compatible with fibromyalgia with chronic generalized pain, complications of fatigue, sleep disturbance and chronic depression.”  Physical examination noted “typical trigger pointing noted in the cervical, scapular and lumbar regions of the spine.”  An outpatient note on 24 July 2003 reported “widespread muscle pain and fatigue,” back pain and neck pain, “hip knee ankle shoulder pain [sic],” forgetfulness, feeling lightheaded and dizzy, with “concentration difficulty,” headache, and “IBS” (irritable bowel syndrome).  At this occasion, the CI noted that she “misses work due to IBS” or “if [she] has a flare with muscle pain.”  The psychiatric NARSUM addendum, on 25 July 2003, four months prior to separation, noted a five month history of “mood symptoms which corresponded with her lower back pain.”  The CI noted that she felt “depressed, had trouble falling asleep and didn’t feel well rested.”  The mental status examination (MSE) noted only mild dysphoria but noted that the CI “appeared depressed.”  The MSE also noted poor concentration, “poor motivation and distractibility.”  The CI’s symptoms of poor concentration and fatigue had responded well to Zoloft (an antidepressant).  She stated that she was able to sleep well, noting “good appetite and interests” and was “overall 80% better with Zoloft.”  The examiner stated that the CI exhibited “significant response to antidepressant despite…poor pain control.”  Noting a “mild” degree of impairment for civilian and industrial adaptability, the mental health addendum added that the CI was “unqualified for worldwide service;” but also stated “Anticipate she could return to functioning if her pain could be resolved [sic].”  A formal psychiatric diagnosis was not assigned, but the same examiner three days previously had recorded a diagnosis of “mood disorder due to pain disorder.”  The final addendum and update to the MEB NARSUM, on 3 September 2003, three months prior to separation, noted that the CI was not qualified for worldwide assignment, listing the following final diagnoses:  (1) chronic neck and back pain, (2) chronic headaches, (3) fibromyalgia, (4) chronic lightheadedness due to pain, (5) mood disorder secondary to pain, (6) irritable bowel syndrome and (7) obesity.  The CI informed a psychiatric provider on 03 October 2003, two months prior to separation, that she was “doing well in terms of anxiety and depression…”  A global assessment of functioning (GAF) score of 70 was assigned, connoting mild psychiatric symptoms or difficulty.  At a separation examination, one month before separation, the CI reported that her ability to work was limited by “fibromyalgia, chronic fatigue and chronic headaches,” which, she noted, had caused her only to “miss several days” of work.  The commander’s undated memorandum to the PEB summarized that the CI’s condition affects her “ability to satisfy in-garrison and deployment duty requirements,” and her ability to work full shifts.  Noting “significant mobility restrictions due to her profile,” her commander recommended medical retirement.  At the VA Compensation and Pension (C&P) exam performed nine months after separation, the CI reported that she was unable to obtain work “because of her fibromyalgia with depression.”  The CI noted irritable bowel syndrome since 1999, with “frequent diarrhea with occasional constipation” associated with abdominal cramps, which aggravated but did not interfere with her daily activities.  The CI also noted “no specific food intolerance,” yet her enlistment medical history Form SF 93 in 1997 had documented that “milk causes diarrhea,” and STRs had noted a “history of lactose intolerance.”  At the C&P examination, the CI also noted fibromyalgia with “generalized weakness and muscle aches with depression and anxiety, polyarthritis and GI symptomatology…precipitated by any physical exertion.”  The CI noted that her musculoskeletal pain and stiffness with weakness interfered with her daily activities.  At the C&P examination, the only medication that she was taking was Tylenol.  Physical examination revealed “multiple trigger points” in the upper back, shoulders, neck, elbows and knees, “typical of fibromyalgia.”  Muscle strength was normal.  A second C&P examiner on the same day reported that her headaches were “relieved by taking over-the-counter preparations sometimes.”  A psychiatric C&P examiner reported that her medications (which she stopped) had “helped a great deal” with respect to her daily functioning.

The Board directs attention to its rating recommendation based on the above evidence.  In accordance with (IAW) VASRD code 5025, fibromyalgia includes “widespread musculoskeletal pain with tender points,” with or without fatigue, sleep disturbance, headache, IBS and depression, all of which had been noted in the NARSUM.  The IPEB found only one condition unfitting; namely, the fibromyalgia, since the other musculoskeletal symptoms, the IBS and the mood disorder were subsumed within that diagnosis.  On the other hand, the VA, eleven months after separation, rated the neck pain, lumbar pain, IBS, tension headaches and depression with anxiety each as separate conditions.  The VA rated the fibromyalgia condition at 10%, including within that condition the symptoms of fatigue with “polyarthritis of the hips, shoulders, wrists and knees.”  Although it was acknowledged in the VARD that the “widespread pain” characteristic of fibromyalgia includes “pain that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine or low back) and the extremities,” the VA elected to rate axial conditions separately.  The fibromyalgia symptoms of depression, IBS and headaches were likewise rated separately by the VA.  However, by subsuming all of those symptoms under the 5025 code, Board members agreed that the PEB appropriately avoided the considerable risk of pyramiding; that is, the evaluation of the same disability under various diagnoses, which is prohibited under VASRD §4.14.  Furthermore, the Board concluded that a recommendation for separate ratings can only be made if individual conditions were independently unfitting.  Board members agreed that the PEB properly subsumed all of the fibromyalgia symptoms under the 5025 code, but then debated if the higher 40% rating might be justified.  Under the 5025 code, a 20% rating is appropriate when symptoms are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but are present more than one third of the time.  A 40% rating, the maximum rating available under this code, is warranted when fibromyalgia is constant, or nearly so, and refractory to therapy.  The psychiatric addendum noted that the CI’s “breakthrough symptoms of poor concentration and fatigue responded well” to Zoloft.  At the time of the MEB, it was noted that the CI “sleeps well,” has “good appetite and interests” and is “overall 80% better with Zoloft.”  Injections were noted to be partially helpful for pain.  Having noted that she had missed “several days,” but not “consecutive days”, due to her FM, IBS and chronic fatigue, the CI also reported that she had “missed very little work,” and that she “misses work due to IBS” or “if [she] has a flare with muscle pain.”  The psychiatrist’s note two months prior to separation reported that the fibromyalgia-related mood condition was “doing well.”  The fibromyalgia condition clearly required medication, as further evidenced by the exacerbation of her symptoms when, after separation, she stopped taking the medications which she had been prescribed and switched to Tylenol only.  Medication was also reported to be helpful for headaches.  Board members concluded therefore that the “constant, or nearly so” and “refractory to therapy” stipulations of the 40% rating were not met; and agreed that the condition most closely approximated the 20% rating at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the unfitting condition of “fibromyalgia with associated fatigue, irritable bowel syndrome, mood disorder and headaches.”  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on DoDI guidelines for rating fibromyalgia was operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

UNFITTING CONDITION	VASRD CODE	RATING	
Fibromyalgia, with associated fatigue, irritable bowel syndrome, mood disorder and headaches	5025	20%	
COMBINED	20%	

The following documentary evidence was considered:	

Exhibit A.  DD Form 294, dated 20130501, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Recor

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-00545.

	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.

							Sincerely,

Attachment:
Record of Proceedings