RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX						            CASE:  PD-2014-02521
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20031204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Dental Assistant Apprentice) medically separated for fibromyalgia.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a permanent P4 profile and referred for an Medical Evaluation Board (MEB).  Chronic intermittent debilitating right lower quadrant pain of an unknown etiology was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated chronic right lower quadrant pain, etiology unknown as unfitting, rated 10% with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB) which adjudicated “probable fibromyalgia”, rated 20%.  The CI made no further appeal and was medically separated.

CI CONTENTION:  Please consider all conditions.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any condition 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 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 FPEB – Dated 20031031	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Probable Fibromyalgia	5025	20%	Fibromyalgia	5025	20%	20040303	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7	
RATING:  20%	RATING:  60%	
* Derived from VA Rating Decision (VARD) dated 20040419 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Fibromyalgia.  The earliest entry in the service treatment record (STR) which documented a diagnosis of fibromyalgia is a Rheumatology consult on 20 October 2003 (6 weeks pre-separation, after IPEB and before FPEB).  The symptoms at that time were “fatigue and generalized arthralgia and myalgia” which were unchanged from an initial evaluation one month earlier, and neither of these entries specified whether these symptoms were constant or intermittent.  The Rheumatologist diagnosed “probable fibromyalgia;” and, prescribed a single medication, Trazodone®, directed at the associated sleep disturbance.  There is no follow-up clinical entry in evidence which is probative to the clinical course or response to therapy.   There are a host of earlier STR entries in evidence which address diagnoses of pelvic pain and non-specific abdominal pain with associated nausea and alternating diarrhea/constipation.  To the extent that any of these might be considered probative to subsequent rating of fibromyalgia, they portray an intermittent, not constant, course of symptoms.  There are no specific STR entries addressing a complaint of headache, other than the rheumatologist’s initial consult which mentioned “headaches that appear migrainous” (along with “a history of irritable bowel syndrome”).

The MEB narrative summary (NARSUM) was conducted 11 July 2003 (5 months pre-separation) and only addressed the course of the pelvic pain and gastrointestinal complaints (recall that the diagnosis of fibromyalgia was not yet made).  This was characterized as “several recurrent episodes of debilitating pain,” noting that the pelvic pain did not respond to oral contraceptives and that “lying down improves it;” but, did not otherwise address response to treatment.  The documentation yielded the following probative content, “Member is medicated with Trazodone and has a follow up once a month with the Rheumatologist. ... Member testified to performing sedentary work for an 11-hour duty day with only the need to take periodic breaks.  The member is able to do most of the activities of daily living ....”

A VA Compensation and Pension (C&P) examination was conducted 3 March 2003 (2 months post-separation) and documented symptoms of “fatigue, tenderness, and joint aches” attributed to fibromyalgia without elaboration of whether these were constant or intermittent.  The examiner noted that the CI was followed by a rheumatologist and treated with Trazodone, without comment regarding response to that treatment.  Additionally noted (and separately rated by the VA) were “migraine headaches...every other day” and “irritable bowel syndrome,” without elaboration of frequency for the latter or response to treatment for either.  The VA physical examination recorded, “As far as the fibromyalgia, there is no acute joint inflammation or swelling...[but]...discomfort with range of motion [and] repetitive motion ....”  No specific functional or occupational impact was documented.

The Board directed attention to its rating recommendation based on the above evidence.  The VASRD §4.71a description under code 5025 (Fibromyalgia) provides for rating of “widespread musculoskeletal pain” which can subsume “fatigue, sleep disturbance ... headache ... [and] irritable bowel symptoms....”  Members agreed that, especially given the belated diagnosis in Service, the Board’s rating recommendation should fairly subsume the disability attendant to the above specified components in addition to the symptoms specifically attributed to fibromyalgia.  A 20% rating under 5025 is for symptoms “that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time;” and, the only higher rating is 40% for symptoms “that are constant, or nearly so, and [emphasis added] refractory to therapy.”  Members deliberated whether the 40% rating could be fairly recommended in this case.  It was considered that there was no specific documentation in evidence for whether the fibromyalgia symptoms were constant or not and whether they were responsive to treatment or not.  The testimonial evidence from the FPEB’s documentation and the concurrence of the VA rater with the FPEB’s 20% opinion, however, are not reasonably overcome by speculating that symptoms were constant or nearly so and refractory to treatment.  The subsumed symptoms were in fact documented as intermittent.  Members concluded, therefore, that the evidence did not support a 40% recommendation.  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 of the fibromyalgia 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140529, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02521.

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