RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00419
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E7, Intelligence Analyst, medically separated for “fibromyalgia,” with a disability rating of 20%.

CI CONTENTION:  The CI’s conditions continue to be chronic.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 PEB, but determined to be not unfitting.  Any conditions outside the Board’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.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

SERVICE PEB – 20041105	VARD – 20060705	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia	5025	40%	20060513	
Homozygosis (CC) Hemoglobin C Disease, Associated with Nausea, Vomiting, Cramps, Non-Alcoholic Steatophepatitis,
Iron Anemia, and Left Lower Extremity Pain	Cat II	Hemoglobin C Disease	7799-7700	NSC		
		Status Post Cholecystectomy with Chronic Diarrhea;
Status Post Resection of Duodenal Hamartoma; Status
Post Antrectomy; Gastroesophageal Reflux Disease; Hiatal Hernia	7346-7318	30%		
Hypertension	Cat II	Hypertension	7170	10%		
Left Knee Pain	Cat II	Medial Meniscus Tear, Left Knee	5299-5258	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Fibromyalgia.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported diffuse musculoskeletal pain since approximately June 2002 and was given a diagnosis of fibromyalgia (FM) in approximately October 2003 at a Deployment Health Clinic evaluation.  

The CI was also evaluated for intractable nausea, vomiting, and chronic diarrhea, following deployment in 2002.  The evaluations noted gastroesophageal reflux disease (GERD) but were otherwise negative.  The CI was hospitalized in May of 2003 for full evaluation of her symptoms.  The evaluation was negative and while hospitalized the CI was not observed to have nausea, vomiting, or diarrhea.  One week after discharge she presented to an emergency room with nausea and vomiting and was admitted again.  Endoscopic and radiologic studies showed a nearly obstructing mass in the duodenum.  The CI underwent surgery on 30 July 2003 for removal of the mass, found to be a benign tumor (hamartoma).  A surgical note indicated that incision and dilation of the pylorus (connects stomach to duodenum), lysis of adhesions, and gallbladder removal were also performed at the same time.  Initially the CI reported doing well after surgery, but an evaluation at a Deployment Health Clinic on 31 October 2003 noted the CI reported abdominal pain, nausea and diarrhea along with muscle and joint pain.  The examination noted 14/18 FM tender points.  A rheumatology consult was recommended and at the initial rheumatology evaluation at her duty station in November 2003, the CI reported diffuse musculoskeletal pain and a history of chronic diarrhea.  The CI reported she could perform all normal daily activities.  The examiner noted that gastrointestinal evaluation had not identified inflammatory bowel disease, infection, or any other cause for the persistent gastrointestinal symptoms.  The CI was on multiple medications for chronic pain including pain medication and an antidepressant medication, as well as an antidepressant prescribed for a mood disorder.  A complete examination was normal except for 18/18 FM tender points and the rheumatologist indicated the diagnosis was most likely FM.  At a follow-up rheumatology visit on 4 December 2003 the CI reported that she was doing well except for slightly increased joint pain due to changes in her physical therapy, without other joint symptoms.  No abdominal pain or other gastrointestinal symptoms were noted.  Medications included daily and weekly medications for nausea.  (Phenergan and Zofran).  Examination of all joints was normal, with 18 of 18 FM tender points present.  The rheumatologist’s assessment was the CI’s FM was stable and no change in medications was recommended.  The CI was encouraged to participate in low impact exercise.  

A psychiatric evaluation was performed on 9 and 18 December 2003 to determine if there was a psychiatric component to the CI’s symptoms.  No Axis I or Axis II diagnosis was determined.  A rule out diagnosis of somatization disorder was noted on Axis I and a rule out diagnosis of mixed cluster B personality traits was noted on Axis II.  The psychiatrist concluded that there was no evidence of a mental defect, emotional illness, or psychiatric disorder as defined by AFI 48-123 of sufficient severity to warrant disposition through medical channels.  Despite treatment, the FM condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “fibromyalgia” for PEB adjudication

The MEB rheumatology NARSUM written on 24 November 2003, appears to cite the initial rheumatology evaluation in November 2003 noted above.  Examination of the neck, low back, hands wrists, elbows, shoulders, hips, knees, and ankle and feet was normal.  There were 18/18 FM tender points present.  An addendum to the MEB rheumatology evaluation dated 21 June 2004 indicated that the CI had been seen in April 2004 with bilateral hand and ankle symptoms, but had been out of her antidepressant medication (for FM symptoms) for over a week.  The examination noted 12/18 tender points and paraspinal muscle spasm.  Bilateral hand and right ankle X-rays performed on 22 April 2004 were normal and right ankle X-rays showed “minimal” degenerative changes in the foot.  There was no evidence of changes due to inflammatory arthritis.  The CI’s antidepressant medication was restarted and a muscle relaxant was prescribed.  At the last follow-up visit in June 2004, the CI reported she was doing well.  The examination was remarkable only for mild left biceps tendinitis, thought to be related to recent increased exercise.  Her medications were continued without change.

At the VA C&P examination in June 2005, 4 months after separation, the CI reported neck, low back, bilateral hip and shoulder pain, without neurological symptoms.  She also reported gastrointestinal symptoms of nausea, diarrhea and GERD.  Physical examination showed a normal gait.  There was no muscle spasm or weakness.  There was no joint swelling, tenderness, or laxity.  Strength, sensation, and reflexes of all extremities were normal.  The abdominal examination was normal except for TTP over the surgical scar.  The CI’s mood and affect were normal.  Bilateral knee and hip X-rays were normal.  In a deferred rating decision, the VA indicated the examination was insufficient for rating FM.  An upper gastrointestinal series noted a small hiatal hernia with demonstrated reflux, and was otherwise normal.  

A VA C&P gastroenterology examination on 12 May 2006, 16 months after separation, noted that the CI had resumption of diarrhea after her general surgery in 2003.  After the surgery her diarrhea continued, but there was less nausea and vomiting.  The diarrhea was described as several small volume episodes after eating and unrelated to abdominal tenderness, which was located mainly over her surgical scar.  She reported no bowel incontinence or bloody diarrhea.  The CI’s weight was noted to be high and stable.  The examination noted diffuse abdominal tenderness.  The VA gastrointestinal specialist assessment was that the continuing gastrointestinal symptoms were more likely than not due to post-cholecystectomy effects with “bile-salt diarrhea.”  He specifically stated he did not think the CI had irritable bowel syndrome based on diagnostic criteria and did not think the gastrointestinal symptoms were related to her FM diagnosis.

At a VA C&P examination on 13 May 2006, 16 months after separation, the CI reported daily stable widespread pain of the neck, back, shoulders, arms, legs and right knee and muscular aching, with a poor response to narcotic pain medication, but improvement with rest.  No other medications for FM were reported.  She reported symptoms of musculoskeletal pain, sleep disturbance, abdominal pain and diarrhea, and depression with exacerbating factors of emotional stress, insufficient sleep, and overexertion.  The examination noted 14/18 FM tender points and normal muscle strength and noted “no other significant findings.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5025 code (Fibromyalgia).  The PEB associated the gastrointestinal symptoms with the Hgb C disease and adjudicated a mix of conditions as a single condition and as not unfitting.  The CI appealed the Informal PEB (IPEB) findings up to the Secretary of the Air Force Personnel Council (SAFPC) which concurred with the findings of the IPEB and Formal PEB.  The original VA Rating Decision deferred the rating of the FM condition noting that the initial C&P examination provided insufficient information.  The VARD dated 5 July 2006 rated the FM condition 40%, coded 5025, (Fibromyalgia) based on the VA C&P examination 16 months after separation.  

There was evidence of widespread musculoskeletal pain, tender points, that were “present more than one third of the time” for the 20% rating.  There was no evidence that the FM symptoms were “constant, or nearly so, and refractive to therapy” proximate to the date of separation for the next higher rating.  The C&P examination 16 months after separation at which the CI reported that her FM symptoms were refractory to treatment, was outside the 12 month period defined by DoDI 6040.44 for special consideration of post-separation VA evidence in the Board’s rating recommendation at the time of separation.  Additionally, the CI reported her symptoms were refractory to therapy, however, the examination noted only use of opioid pain medications at that time and there was no corroborating evidence in record that the FM symptoms were constant and refractory to treatment.  The gastrointestinal symptoms were not thought to be predominately related to the FM condition by Service medical specialists and post-separation, the VA gastrointestinal C&P provided a strongly stated opinion that the gastrointestinal conditions were not related to the FM diagnosis.  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 FM condition.  

Contended PEB Conditions.  Homozygosis (cc) Hemoglobin C disease, associated with nausea, vomiting, cramps, non-alcoholic steatohepatitis, anemia, left knee pain, and hypertension.  The contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance-based evidence from the record that any of the above conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the above conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the FM condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended homozygosis (cc) Hemoglobin C disease, associated with nausea, vomiting, cramps, non-alcoholic steatohepatitis, anemia, left knee pain, and hypertension conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131113, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
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-2014-00419.

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