RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02833
BRANCH OF SERVICE:  Army	
DATE OF PLACED ON TDRL:  19991107	DATE OF REMOVAL FROM TDRL:  20030507 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Topographic Analyst, medically separated from the Temporary Disability Retired List (TDRL) for “SLE, manifested by intermittent arthritis, alopecia and fatigue, without documented exacerbations,” rated 10%.  

CI CONTENTION:  “Review all records.”  Her 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 – 19990915/20030424	VARD - 19991223	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
SLE, Manifested by Intermittent Arthritis, Alopecia and Fatigue, without Documented Exacerbations	6350	60%	10%	SLE (Claimed as SLE, Upper Body Muscle Spasms)	6350	60%	60%	
COMBINED RATING:  60% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Systemic Lupus Erythematosus.  The service treatment record (STR) indicated the CI was diagnosed with mild systemic lupus erythematosus (SLE) by a rheumatologist on 13 April 1998 based on a history of 8 years of intermittent alopecia areata (patchy hair loss), 2 years of slight stiffness in the muscles, but not the joints, and abnormal elevated laboratory results including an ANA (antinuclear antibody) and anti-DNA, as well as leukopenia (a low white blood cell count).  No medication was instituted; sun protection was recommended.  At a follow-up rheumatology visit in December 1998 further history revealed that since January 1995 the CI noted the development of arthralgias (joint pain) involving her hands, hips and pelvis.  Treatment consisted of nonsteroidal anti-inflammatory drugs (NSAIDs) with mild improvement in symptoms.  However, physical therapy treatments did not resolve those symptoms.  Examination was unremarkable, but the CI’s condition did not meet the strict criteria for SLE; therefore, additional studies were ordered.  The diagnosis was revised to an undifferentiated connective tissue disease.  An MRI of the brain was in normal with a small angioma in the left frontal lobe in January 1999.  Further laboratory studies for autoimmune diseases like lupus (anti-cardiolipin antibodies and anti-SSA) were positive.  Medications added to the treatment protocol included Relafen (nabumetone, an NSAID), hydroxychloroquine (an anti-inflammatory drug) and Tylenol (acetaminophen, a pain reliever).  A note dated 18 May 1999 indicated that arthralgias and myalgias (muscle pain) interfered with certain activities; actual duty performance was not significantly affected.  The CI noted intermittent paresthesias (abnormal sensations-“pins and needles”) when using the clutch on her vehicle and was diagnosed with mild tarsal tunnel syndrome by a neurologist as well as very, very mild right carpal tunnel syndrome brought on by hand writing and cross stitching.  In June 1999 the CI was diagnosed with SLE, which was clinically stable, and incomplete fibromyalgia syndrome (not in the scope of review) that was tender to palpation about the upper body.  Trazadone (an antidepressant used as a sleep aid) was added to the treatment protocol. 

The commander’s statement dated 22 April 1999 indicated the CI’s performance was marginal at best.  Her medical condition worsened as her stress level increased.  As a result, she spent an enormous amount of time on sick call and appointments.  Her medical condition prevented her from meeting the physical requirements of her occupational specialty and negatively affected her performance The CI reported on a DD Form 2697 dated 5 May 1999, arthritis and more tingling throughout the body, and her shoulder hurt to bend it up.  The MEB narrative summary (NARSUM) dated 12 August 1999 indicated the CI had SLE manifested by polyarthralgias, myalgias, oral ulcers along with alopecia, leukopenia, anticardiolipin antibodies, high titer ANA and anti-double stranded DNA antibodies.  She continued to have problems with fatigue, diffuse myalgias and arthralgias impacting on her ability to remain on active duty.  A P3 profile was issued on 16 August 1999 for systemic lupus erythematosus with limitations of physical training at the CI’s own pace and distance, no physical training test in entirety, no field duty, and no remote assignments.

At the VA Compensation and Pension (C&P) examination dated 13 October 1999, performed 2 months after TDRL placement, the CI reported she was diagnosed with SLE in March 1998, which was confirmed on the basis of abnormal serology and polyarticular (multi-joint) synovitis with alopecia areata.  On examination her posture and gait were normal.  There was evidence of alopecia, but otherwise her skin was unremarkable.  She had trigger point tenderness on the upper back paraspinal area with full range-of-motion (ROM).  Neurologic examination was unremarkable with no joint tenderness and no effusion noted.  

At a rheumatology follow-up visit in November 1999 arthralgias of the proximal interphalangeal joints and both hips along with myalgias were reported.  The pre-TDRL placement medication protocol was continued.  The SLE/FMS (fibromyalgia syndrome) had improved by March 2003 and there was morning stiffness that resolved within minutes, minimal joint pain, and a few questionable oral ulcerations.  There was no swelling, skin rash or other symptoms.  The treatment protocol remained the same.  At a rheumatology examination in August 2000 the CI indication she had increased myalgias and arthralgias after several days of working as a substitute custodian.  However, there was overall improvement with negative anti-DNA antibodies and a positive ANA.  The CI underwent a TDRL removal evaluation for systemic lupus erythematosus on 15 November 2002 at which time she continued to complain of function limiting arthralgias and myalgias with joint pain predominantly in the peripheral joints, especially the small joints of her hands, but also did include the shoulders, hips and knees.  Additionally, she complained of generalized myalgias, fatigue and nonrestorative sleep along with intermittent oral ulcerations involving the gum line.  Morning stiffness was variable and she had intermittent flares of arthralgia and myalgia, which lasted days to several weeks, manifested by a marked increase in her morning stiffness and joint pain. She augmented her medication regimen during those periods with additional NSAIDS and sometimes augmenting her Tylenol regimen as well.  Flares occurred from monthly to quarterly without rhyme or reason.  On a Modified Health Assessment Questionnaire the CI reported she had difficulty with turning regular faucets on and off, tying shoelaces, doing buttons, washing and drying her entire body, getting in and out of a car, walking two miles or participating in sports.  Additionally, she had intermittent function limiting fatigue and sicca syndrome (dry mouth).   On examination she had a normal gait, no rash, no gingival erosions, and no detectable synovitis (joint inflammation) of the upper and lower extremities, but there was generalized tenderness to palpation over the joints and muscles including over both trochanteric areas (hips), right greater than left.  The diagnoses were SLE manifested by intermittent arthritis, alopecia, fatigue, a positive ANA, a positive double stranded DNA, positive anticardiolipin antibodies and leukopenia and fibromyalgia syndrome secondary to SLE.  The CI’s condition was complicated by ongoing diffuse myofascial pain, arthralgias and fatigue.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 60% rating using code 6350 for systemic lupus erythematosus manifested by polyarthralgias, myalgias, oral ulcers, fatigue, alopecia and leukopenia.  The VA assigned a 60% rating using code 6350 for systemic lupus erythematosus.  At TDRL removal the PEB assigned a 10% rating using code 6350 for systemic lupus erythematosus, manifested by intermittent arthritis, alopecia, and fatigue without documented exacerbations.  

The Board sought a route to a higher rating for the TDRL placement, but the CI did not have acute systemic lupus erythematosus with frequent exacerbations producing severe impairment of health.  VASRD §4.1 (Essentials of evaluative rating) indicates “Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability.”  The Board then sought a route for a higher TDRL removal rating.  A 60% rating requires exacerbations lasting a week or more, two or three times per year.  The TDRL NARSUM indicated that the CI intermittently had flares of arthralgia and myalgia, which lasted days to several weeks, albeit she worked temporarily.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change to the disability rating assigned at TDRL placement of the systemic lupus erythematosus condition and a disability rating of 60% upon removal from the TDRL for the systemic lupus erythematosus 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 systemic lupus erythematosus condition, the Board unanimously recommends a disability rating of 60% coded 6350 IAW VASRD §4.88b upon TDRL removal.  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 re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
			PERMANENT	
Systemic Lupus Erythematosus	6350		60%	
COMBINED		60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160007941 (PD201402833)

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 60% 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 60% 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