RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01356
BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE: 20061010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Pharmacy Craftsman, medically separated for “fibromyalgia,” with a disability rating of 20%.

CI CONTENTION:  The applicant was given a higher rating for all her conditions by the VA.  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.  

RATING COMPARISON:  

SERVICE PEB - 20060713	VARD - 20070502	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia	5025	40%	20070116	
Depression not otherwise Specified, no Impairment	Not Unfitting, Cat II	Post-Traumatic Stress Disorder (Claimed as Depression)	9411	10%	20070212	
Irritable Bowel Syndrome	Not Unfitting, Cat II	Irritable Bowel Syndrome	7319	10%	20070116	
Gastroesophageal Reflux Disease	Not Unfitting, Cat II	Gastroesophageal Reflux Disorder	7399-7346	0%	20070116	
Attention Deficit Hyperactivity Disorder	Not Unfitting, Cat III	No VA Placement	
Tobacco Habituation	Not Unfitting, Cat III	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Fibromyalgia. According to service treatment records (STR), the CI was diagnosed with fibromyalgia associated with multiple co-morbidities in 1996, although it probably began in 1991.  She reported pain in the front and back, muscle spasm, soreness and joint pain in the hips, lower and upper back and both shoulders.  She had extensive evaluation and treatment for her fibromyalgia pain syndrome and was treated with medication and various therapies.  Symptoms increased in 2001 and she was referred to physical therapy (PT) and narcotic pain medication was added.  Symptoms increased with stress.  She made self-discovered mistakes while working as a pharmacy technician in June 2005 and was re-assigned to the Quality Assurance (QA) office.  She was referred to pain management who recommended a Medical Evaluation Board (MEB).

The narrative summary (NARSUM) in October 2005, noted she attended PT, took seven medications, and exercised.  She took narcotic medication on an as-needed basis.  She was limited in daily activities by chronic pain and flare ups during stress.  She had significant symptoms during work outs and in the PT program.  Physical exam revealed diffuse tenderness with 18 trigger points but no swelling of joints.  The examiner noted the CI was unable to work in her current career field.

The rheumatology (NARSUM), in January 2006, noted the CI continued to work in the QA office.  She felt her illness was reasonably controlled due to regular exercise and five medications.  She reported muscular “burning pain” in the mid-back and shoulder areas typical of fibromyalgia and she had Raynaud’s syndrome (hands turn blue in the cold) that responded to warming.  Physical examination noted 14/18 muscular tender points in the typical fibromyalgia distribution.  She was receiving a complex combination of pain medications that would require ongoing supervision by both primary care physician and a trained pain specialist.  A diagnosis of fibromyalgia pain syndrome was rendered.  The rheumatologist noted her condition was refractory to conservative measures.  

The NARSUM addendum, in April 2006, noted the CI was receiving intravenous (IV) lidocaine pain management on a monthly basis for the past 6 months in addition to a daily pain medication for chronic pain, which was 5/10.  Although the medications helped significantly, she still had chronic daily pain that limited her activities.  There was a gradual increase and occasional exacerbations immediately prior to her IV lidocaine treatments.  She continued to perform routine desk duties.  

At the VA Compensation and Pension (C&P) examination, in January 2007, performed 4 months after separation, the CI reported the fibromyalgia had become progressively worse and she was taking 4 medications daily, IV lidocaine therapy, and a narcotic medication as needed.  She reported pain in both knees, shoulders, ankles, neck and left foot with flare ups daily of moderate severity that lasted many hours.  She had not been employed since separation from the service.  She reported fibromyalgia severely affected chores, shopping, exercise, sports, recreation, traveling, grooming, and driving.  

The Board directed its attention to its rating recommendation based on the above evidence.  Both the PEB and the VA coded the condition 5025 (Fibromyalgia).  The PEB assigned a 20% disability rating noting the illness was responding to medical management while the VA assigned a 40% disability rating citing the presence of significant symptoms impacting daily activities.  The Board deliberated therefore whether the CI’s symptoms were best characterized as episodic with frequent exacerbations (20% rating) or constant and refractory to therapy (40% rating).  Both the NARSUM and the rheumatology NARSUM exams documented the presence of the requisite trigger points, essential criteria for a diagnosis of fibromyalgia.  

The Board noted that while the CI reported improvement with five pain medications that included narcotic medication (about four pills daily) in addition to monthly IV lidocaine therapy, she still reported daily pain that limited her activities.  Members agreed that pain appeared constant even with broad pain treatment.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the fibromyalgia condition.  

Contended Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that depression NOS, irritable bowel syndrome (IBS), gastroesophageal reflux (GERD), attention deficit hyperactivity disorder (ADHD), and tobacco habituation conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The rheumatology NARSUM examination noted the diagnosis of fibromyalgia is associated with multiple comorbidities which included the CI’s past diagnoses of ADHD, depression, IBS and GERD.  Tobacco habituation cannot be found unfitting and is not compensable, or ratable.  The Board agreed that assigning multiple ratings for separate fibromyalgia symptoms (including mental symptoms) runs the considerable risk of pyramiding, and is to be avoided IAW VASRD §4.14.  

The ADHD, depression, IBS and GERD and tobacco habituation 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 these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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 ADHD, depression, IBS and GERD and tobacco habituation contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the fibromyalgia condition, the Board recommends a disability rating of 40%, coded 5025 IAW VASRD §4.71a.  In the matter of the ADHD, depression, IBS and GERD and tobacco habituation contended conditions; the Board 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 recommends that 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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Fibromyalgia	5025	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140318, with attachments
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-2014-01356.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 
cc:
SAF/MRBR
DFAS-IN