RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01789
BRANCH OF SERVICE:  Army	BOARD DATE:  20140630
SEPARATION DATE:  20041208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty SPC/E-4 (42L10/Administrative Specialist) medically separated for a chronic abdominal pain and migraine condition.  She had a history of migraine headaches dating to 2001 and suffered recurrent attacks despite a protracted attempt to control them with multiple treatment regimens.  She began to have right abdominal pain in 2001 and an examination discovered a left ovarian cyst.  Surgery was performed but pain continued in her right abdomen.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The abdominal pain and migraine conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic post-operative abdominal pain and  migraine headaches, responsive to fioricet” as unfitting, rated 10% and 0% respectively, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy for the abdominal pain condition.  The CI did not agree with findings, waived a formal hearing and submitted a written appeal to the USAPDA which affirmed the PEB findings and ratings.  The CI made no further appeals and was medically separated.

CI CONTENTION:  “1. The 10% rating for abdominal pain was considerably low and later special compensation was granted for the loss of my ovary, but the rating didn’t increase.  2.  Migraine received a 0%; however, the condition was not maintained but increasingly worsening. 3.  My bladder incontinence was not rated during medical board.  4.  My feet were not rated during medical board and orthotics were prescribed while on active duty.   Most of the last year and half I was in tennis shoe profiles.  Currently, my walking is severely impaired due to progressive arthritis.  5. Surgery was performed on my left foot; however, a rating was not given.”

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 ratings for the unfitting abdominal pain and migraine conditions are addressed below; the bladder incontinence and foot conditions are not within the DoDI 6040.44 defined Board purview.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040903	VA - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Abdominal Pain	5099-5003	10%	Differential Nerve Block & Abdominal Nerve Distraction	7699-7615	NSC*	20050225	
Migraine Headaches	8100	0%	Migraine Headaches	8100	50%	20050603	
Other Additional MEB/PEB Entries x 0	Other x 12	20050225	
Combined:  10%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20050603 (most proximate to date of separation [DOS]).
*NSC VARD 20061218 (no condition was associated w/pain and therefore not rated)

ANALYSIS SUMMARY:

Chronic Abdominal Pain Condition.  The narrative summary (NARSUM) dated 10 August 2004 notes the CI had three cesarean sections (one on active duty per VA Compensation and Pension [C&P] exam) for childbirth and a hysterectomy while not on active duty in 1999.  In 2002, service treatment records (STR) indicated she began to experience right lower quadrant abdominal pain that was described as similar to the pain she experienced before her hysterectomy.  Abdominal ultrasound showed a left ovarian mass that was thought to be possibly causing the pain and the CI had the left ovary removed on 15 November 2002, but the right side abdominal pain continued.  During the surgery a right side hernia was sought but was not found, but dense adhesions were noted that involved the intestines and the left pelvic sidewall.  At a pain management evaluation on 6 January 2003, the CI described the pain as a “ripping, tearing pain” sensation on the right side, rated seven out of ten severity, increased by walking or standing and improved by rest.  In other notes, the pain was indicated to be in the midline abdominal area (suprapubic), associated with painful intercourse, unrelieved by urination and associated with urinary urgency, leakage and frequent urination at night.  Throughout the course of evaluation by multiple specialists (including gynecology, surgery, gastroenterology and pain management); attempts were made to treat the pain as nerve entrapment or irritation, but despite some partial and/or temporary relief the right lower abdominal pain continued.  During a discussion regarding the inadvisability of repeated abdominal/pelvic surgery for a transient right ovarian cyst noted on abdominal computer tomography (CT) scan and ultrasound, the gynecologist noted that lysis of adhesions (cutting scar tissue within the body) could cause more adhesions.  The CI also received treatment for possible gynecologic causes of her pain including endometriosis without improvement, as well as a gastroenterology evaluation which did not indicate any cause for the pain.  Notes in the STR indicated that the CI’s bladder problems began in childhood and she continued to report urinary symptoms and issues with constipation.  The urologic specialist treated the CI with medications for an overactive bladder condition.  A final surgical attempt at severing the sensory nerves in the area (neurolysis) on 12 May 2004 was unable to identify any specific involved nerves and general blind lysis in the surrounding tissue was unsuccessful.

At the MEB exam on 10 August 2004, approximately 4 months prior to separation, the CI reported right lower abdominal pain that was constant, rated four out of ten, with “very intermittent” sharp exacerbations and she was taking about two narcotic pain pills per week.  The MEB physical exam noted a normal neurological examination and the abdomen was tender only to palpation at the junction of vertical and horizontal abdominal surgical scars, but was otherwise normal without noted organ enlargement, masses or rebound tenderness.

At the VA C&P General exam on 25 February 2005, approximately 3 months after separation, the CI reported right lower abdominal pain that began in 2000 to 2001, but worsened in 2002, which interfered with her daily activities, but had not caused lost work time in the last 12 months.  The CI reported the pain as a rip and tearing sensation in the right lower abdomen that radiated across her abdomen and was severe enough, due to daily activities, to require her to lie down with a heating pad three or four times per week.  Pain increased with abdominal straining and would cause an increase in her pain for a few hours.  She reported no problems with urination except frequency.  The VA examination showed a normal gait and posture with a normal neurological examination.  Abdominal examination noted multiple surgical scars and the right edge of one scar was tender in a small “quarter sized” area; the right lower quadrant was tender to palpation “in all aspects.”  The VA examiner noted elsewhere during the examination that lumbar spine range-of-motion did not cause back pain, but did increase abdominal pain.  At a VA C&P gynecologic examination on 3 March 2005, the CI reported the same symptoms as at the General C&P exam, but also noted ongoing problems with constipation and urinary urgency, frequency and leakage.  There was no gynecologic or urinary tenderness.  Pelvic ultrasound showed the post-surgical changes with a normal right ovary and no other abnormality.  The examiner’s impression was that the pelvic adhesions were the likely cause of her chronic abdominal pain, and “she has had C-sections and a hysterectomy, which all could have contributed to the formation of the scar tissue.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic post-operative pain as unfitting, rated 10%, coded 5099-5003 and cited the USAPDA pain policy, with a pain rating of slight/constant.  The VA did not service-connect claims for differential nerve block and abdominal distraction and noted that they were procedures and not chronic disabling medical conditions.  The later VARD dated 18 December 2006 did not service-connect right lower quadrant pain noting that “pain, in and of itself is not a disability for which compensation may be paid” and that despite the separation with severance pay for chronic abdominal pain, no etiology of the pain was ever provided.

The Board first discussed rating the abdominal pain condition analogously to 7629 (endometriosis) as supported by VASRD §4.9 (analogous ratings) and DoD guidance on analogous codes.  The CI had pelvic pain (right lower abdominal pain that radiated across the abdomen) that was constant with regular exacerbations that did not respond to surgical treatment and required narcotic pain medications as needed.  However, no endometrial lesions were noted at surgery and medical treatment for endometriosis was not beneficial.  Other rating criteria of 7629 include bowel and bladder problems and the CI did report bladder symptoms but a thorough urologic history in service indicated that she had bladder symptoms of urgency, leakage and nighttime voiding (nocturia) since childhood.  During the gynecologic surgery in November 2002 adhesions to the bowel were noted, but there were no bladder adhesions noted.  The Board opined that it was overly speculative to relate the CI’s bladder problems to the adhesions.  The CI was also evaluated by gastroenterology and no bowel strictures or partial obstructions were identified by full evaluation of the large and small intestines (colonoscopy, upper endoscopy and small bowel follow through).  The Board concluded that rating with code 7629 criteria was not the most appropriate for the CI’s disability and therefore considered rating the chronic abdominal pain as secondary to dense post-operative adhesions, noted during the gynecologic surgery in November 2002.  No other cause was found despite a thorough medical evaluation.  The VA C&P gynecologic examiner assessed the most likely cause of the CI’s abdominal pain was the abdominal and pelvic adhesions.  Adhesions are a known medical cause of chronic abdominal pain, occurring after any type of abdominal surgery, but at a high rate following gynecologic or lower abdominal surgery.  The Board first deliberated coding IAW VASRD §4.114 (digestive system) utilizing 7301 (adhesions of the peritoneum).  The Board agreed that the CI exceeded the 0% rating specified as “mild” and did not meet the higher evaluations of 30% or 50% which both require evidence of partial bowel obstruction.  Therefore the Board agreed CI’s disability due to the abdominal pain met the 10% rating criteria, specified as “moderate pulling pain when attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or diarrhea.”  The Board next reviewed to see if a higher evaluation was achieved coding IAW §4.116 (gynecologic conditions and disorders of the breast) according to the General Rating Formula for Disease, Injury, or Adhesions of Female Reproductive Organs.  Members agreed that the General Rating criteria were a good match for the CI’s symptoms and disability characterization specified as “require continuous treatment,” or rated 0%, 10%, and 30%, respectively.  All Members agreed that the disability due to the chronic abdominal pain exceeded the 0% rating and the Board majority concluded that it met the 30% rating criteria (symptoms “not controlled by continuous treatment”) because symptoms were constant with exacerbations despite many failed procedures and treatment attempts.  The minority voter concluded the condition was best described by the 10% criteria (symptoms that “do not require continuous treatment”).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.9, the Board majority recommends a disability rating of 30%, coded 7699-7615 (analogous to ovary disease, injury or adhesions) for the chronic abdominal pain condition.

Migraine Headache Condition.  The NARSUM dated 10 August 2004 noted the CI began with headaches about 3 years earlier; the CI was diagnosed with chronic daily/migraine headaches by both civilian and service neurologists.  Magnetic resonance imaging of the brain in April 2001 (ordered for other symptoms) was normal.  Notes in the STR indicate that the CI was treated with abortive medications for the migraine headaches, as well as narcotic pain medications.  The chronic daily headaches were thought to be rebound headaches related to heavy over the counter use of anti-inflammatory medications which the CI was advised to stop.  The civilian neurology evaluation on 18 February 2004 noted the CI was using Fioricet (sedative migraine medication) and Imitrex (abortive migraine medication) with minimal, occasional relief.  The CI was prescribed a preventive migraine medication (Topomax), to be titrated to an effective dose over a few weeks.  At the MEB neurology evaluation on 17 March 2004, there was not yet an indication of improvement in the frequency of the migraine headaches.  At an emergency room visit on 13 September 2004 for a migraine, it was noted the CI was out of her preventive migraine medication.  Neurological examinations were normal.  The NARSUM indicated the CI was at maximal medical improvement and that according to the neurologist the migraine symptoms “may be worse in the last year.”  However, the CI provided a rebuttal letter to the PEB and indicated that she was prescribed Topomax in March 2004 and was to increase the dose by two pills daily on a weekly basis to achieve control of her headaches.  At a dose of three pills twice a day the CI indicated that her migraines were controlled for 3 months, but then had broken through and her dose was increased to four pills twice daily at that time and indicated that she was still at that dosage, but could increase the dosage one more time to five pills twice daily if necessary.

At the MEB exam on 10 August 2004, 4 months prior to separation, the CI reported prostrating headaches three to four times per week despite preventive medication use that resulted in lost work time of two to three days per month.  The neurological examination was normal.  The MEB examiner described the CI’s current functional status as “required to miss fairly frequent work duties due to the migraine headaches.”  The MEB examiner provided a pain rating of slight/intermittent.  The commander’s statement noted that “at various times” the CI had to “leave work due to migraines or abdominal pains that incapacitates her to work.”

The VA C&P exam on 25 February 2005, performed 2 months after separation, did not address the migraine condition, but listed 12 conditions reported by the CI and migraine headaches was not among them.  However, the VARD dated 3 June 2005 rated the migraine condition based upon the STR, noting that the CI did not “specifically claim this condition, so an exam was not ordered for this condition.”  The VARD noted that the MEB examiner “describes them [migraine headaches] as prostrating one to four times per month and that you have to miss work frequently due to your headaches.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the migraine headaches coded 8100 as unfitting and rated them 0%, citing they were “responsive to Fioricet.”  The VA rated the migraine headaches based on the STR at 50%, also coded 8100.  The Board noted that the CI’s medical management, with significant changes in her treatment that occurred in the 9 months prior to separation, made application of the 8100 rating criteria difficult.  At the MEB and the MEB neurology examinations the CI reported “prostrating headaches” one to four times per month despite use of multiple medications.  However, as noted, the CI was still titrating the dose of preventive migraine medication at the time.  The commander’s statement in June 2004 provided evidence that the CI did have severe migraines headaches that caused her to leave work at “various times,” but did not specify the frequency.  The Board noted the CI indicated in her statement to the PEB in September 2004 that she was having success with the preventive medication, though she was concerned she only had one more medication increase available.  The Board also considered that the CI did not claim migraine headaches at the VA, or mention migraine headaches at the general VA C&P examination, suggesting that the headaches were reasonably well controlled.  The Board opined that the medication adjustments over the 9 months prior to separation, including the cessation of daily use of over the counter medications and the addition of a preventive migraine medication, appeared to have brought the CI’s migraine condition under improved control as the date of separation neared.  In the period of time when the dose of preventive medication was being increased, the record supports a 3-month period of good control with a break through period when the CI increased from three to four pills twice daily, with good control implied following the increase per the CI’s statement.  The Board agreed the evidence was possibly consistent with less frequent prostrating attacks than “averaging one in 2 months in the last several months,” as required by the 8100 code 10% rating criteria, but it was not possible to be certain based on the available evidence.  However, the Board agreed that the record supported that the migraine condition was improving with treatment changes.  The Board concluded that based on the totality of evidence, the CI’s migraine condition at the time of separation most closely met the 10% rating criteria of code 8100 and did not achieve the next higher evaluation of 30% which requires “characteristic prostrating attacks occurring on average once a month over last several months.”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously recommends a disability rating of 10%, coded 8100 for the migraine condition.

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 the USAPDA pain policy for rating chronic abdominal pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic abdominal pain condition, by a 2:1 vote, the Board recommends a disability rating of 30%, coded 7699-7615 IAW VASRD §4.116.  The single voter for dissent (who voted for a 10% rating, coded 7699-7615) submitted the attached minority opinion.  In the matter of the migraine headaches condition, the Board unanimously recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Abdominal Pain	7699-7615	30%	
Migraine Headaches 	8100	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130930, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				

MINORITY OPINION:  

The CI was found unfit for constant, slight chronic post-operative abdominal pain (coded 5099-5003, rated 10%) and migraine headaches responsive to treatment (coded 8100, rated 0%).  The USAPDA pain policy was inappropriately cited with respect to the abdominal pain condition.  The Board ‘s charge is to judge the fairness of PEB fitness adjudications based on the functional impairment consequences of conditions as they existed at the time of separation, and IAW VASRD principles, coding and rating options.

After due deliberation, in consideration of the totality of the evidence, and IAW §4.3 (reasonable doubt), the Board unanimously concluded the headache condition was more appropriately rated 10%.  My disagreement concern’s the Board majority conclusion that there was sufficient cause to recommend a change from the PEB rating for the abdominal pain condition.  We unanimously agreed the condition was more accurately coded 7699-7615 as the better clinical fit, but the majority rated it 30% for “symptoms not controlled by continuous medication.”  I concluded; however, the CI’s abdominal pain due to symptoms which prior to the time of separation required “continuous treatment” is most fairly and accurately rated 10%.

The only finding related to the abdominal condition by the NARSUM examiner was tenderness in the CI’s right lower quadrant near her post-surgical scars.  He noted that while her abdominal pain was “quite aggravating, she could work through it.”  He considered the pain “slight/constant” per the AMA pain rating scale.  This was supported by the commander’s statement that the CI was an “excellent” performer.  After multiple medical procedures resulting in little to no benefit, the examiner concluded the CI had reached maximum medical benefit; her condition was stable and prognosis good.  He diagnosed it as “neurogenic abdominal pain status-post multiple abdominal surgeries.”  I agree with his conclusions.

The VA approach considered two post-surgical scars, coded 7804 and 7805, rated 10% (for pain) and 0% (due to no functional impact), respectively.  They also rated uterine fibroids, coded 7628 and rated 0% (due to no significant disabling impairment).  They concluded that abdominal nerve distraction (code 7699-7615, the same coding we the PDBR recommend) was not service-connected and not rated; right lower quadrant pain was subsequently also not service-connected or rated by the VA.  The VA Gynecologic C&P examiner concluded that pelvic adhesions, lysis of some adhesions, and multiple surgeries contributing to the formation of scar tissue, most likely caused the CI’s abdominal pain.  I also concur with this conclusion.

The totality of objective evidence does not achieve a reasonable threshold for overturning the Informal PEB’s rating adjudication of the abdominal condition at 10%, and a combined rating of 20% (due to the increase to 10% for the headache) is an accurate and fair representation of the CI’s disability picture at the time of separation.  The CI had a history of abdominal pain dating back to 1999 (due to pre-service hysterectomy and two earlier pre-service C-sections).  She enlisted in 2000 at age 31; she was first seen for abdominal pain in 2002, and noted her pre-service history.  Despite an extremely thorough work-up, multiples evaluations by different specialists and surgical and non-surgical treatments over an almost 2-year period, there was little to no conclusive evidence of the cause of the CI’s continuing pain, or that it had a functional impact on her ability to work, other than her inability to deploy and periodic exacerbations which caused her to leave work.  Also, the CI was only taking about two Tylenol #3 per week for this pain by her own report, which is insignificant.  She was on no other medications or undergoing no other treatments for the abdominal pain at the time of separation.  So, while her condition was unfitting for military duty, it would not likely impact her ability to find civilian work.  And it certainly did not meet the rating criteria for the 30% recommended by the majority.

RECOMMENDATION:  The minority voter therefore recommends the abdominal condition is best coded 7699-7615, rated at 10%, and the headache condition also be rated 10%.  I respectfully submit that a fair combined disability separation rating is 20%.

SAMR-RB			

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20150000633 (PD201301789)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

						
CF: 
(  ) DoD PDBR
(  ) DVA