RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03263
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061014

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling member of the National Guard E-5 (Wheel Vehicle Mechanic) medically separated for fibromyalgia (FM), rated 0%.

CI CONTENTION:  “Please consider all conditions.” 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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 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:  

IPEB – Dated 20060627	VA* – ~32 Mos. Post-Separation  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia…	5025	0%	Fibromyalgia	5025	40%	20090516	
Other x 0 (Not In Scope)	Other x 4 	
RATING:  0%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20090624 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The MEB forwarded four conditions to the PEB as noted above in the summary of case section.  The PEB combined the “persistent LBP,” “persistent left shoulder pain” and “persistent neck pain” conditions and adjudicated a single unfitting condition of FM.  The Board noted its agreement with the adjudication of FM, which was the diagnosis which resulted from the evaluations of the CI’s reported persistent muscle and joint pains.  As noted by the PEB, there was no evidence in the record of specific pathology causing the persistent neck, back or shoulder pain and the FM diagnosis was reconfirmed by a second Rheumatologist in the MEB Rheumatology addendum requested by the PEB.  Therefore, the Board deliberated a rating recommendation for the unfitting FM condition below.

FM Condition.  The narrative summary (NARSUM) noted that the CI was injured during annual training in July 2005 when he was riding in the back of a truck.  The truck hit a bump and the CI was thrown off his seat and impacted his back and left shoulder.  Magnetic resonance imaging (MRI) of the shoulder 31 August 2005 did not show any rotator cuff injury or cartilage damage.  A lumbar spine magnetic resonance imaging (MRI) the same day noted mild degenerative disc and joint disease of the spine.  According to the NARSUM, an electro-myelogram (EMG) of the left upper extremity (UE) was also performed.  The CI was treated conservatively without improvement.  An Orthopedic evaluation on 30 November 2005 noted decreased neck and low back range-of-motion (ROM), without radiating pain, with normal UE and lower extremity (LE) strength, sensation, reflexes, and negative straight leg raise testing.  There was tenderness to palpation (TTP) of the lower back and the bilateral sacroiliac joints.  Cervical spine X-rays noted mild degenerative changes.  Physical therapy (PT) was recommended.  At a primary care (PC) visit on 7 December 2005 a diagnosis of FM was considered and the CI was treated with a muscle relaxant and pain medication.  At a follow-up PC visit on 22 December 2005, the CI reported benefit from medications, with “more good days than bad days now.”  A rheumatology evaluation on 9 January 2006 noted a history of headaches (HA) and limited gastrointestinal (GI) symptoms.  The exam noted neck tenderness with full painful ROM of all joints but without swelling or warmth.  There were positive FM tender points (TPs).  Bilateral exam of the extremities was normal.  The Rheumatologist noted that the CI was having mostly muscle pain and the exam and testing did not show any evidence of an inflammatory arthritis, and was consistent with FM syndrome.  The examiner noted the CI could not tolerate the initial non-steroidal anti-inflammatory (NSAID) medications he was prescribed due to GI side effects, and prescribed a third NSAID, and a different muscle relaxant was recommended at bedtime to help with sleep.  A second orthopedic opinion was obtained on 17 January 2006 and noted no surgical indications for either the left shoulder or the lumbar spine on the MRIs or X-rays.  The left shoulder was injected and PT was recommended.  The NARSUM notes that the CI reported benefit from the steroid injection.  An initial PT evaluation on 10 February 2006 noted the CI was on “zero” medications and had reduced cervical and lumbar ROM with multiple TPs.  A follow-up PT evaluation on 3 March 2006 noted that the CI was responding to therapy with increased neck and shoulder ROM and one evaluation on 15 March 2006 indicated that cervical and lumbar ROM was “within normal limits of motions.”  At the PT MEB ROM evaluation 5 days later cervical and lumbar spine ROM was again reduced, as well as ROM of the left shoulder.  The CI reported daily, constant pain of the entire spine and the left scapular area greater than the right.  

At the MEB exam performed 22 March 2006, 7 months before separation, the CI reported neck, low back, left shoulder pain, and symptoms of irritable bowel syndrome (IBS).  The MEB physical exam noted a normal gait, with normal exam of the extremities. There was no muscle spasm or atrophy.  The CI had good muscle strength and was able to heel and toe walk.  The PT MEB ROM evaluation was cited, which noted moderately decreased ROM of the lumbar spine and left shoulder.  

The PEB was discontinued on 2 May 2006 and a second Rheumatology opinion was requested.  The MEB Rheumatology addendum dated 29 May 2006 noted the CI did not tolerate the third anti-inflammatory medication he was prescribed and was using only over-the-counter medication, without significant benefit.  The examiner indicated that the review of systems noted intermittent HAs, sleep difficulties, IBS symptoms, neck stiffness, joint pain without any swelling, left shoulder pain with movement, but no right shoulder pain, pain of the entire spine, and no specific pain of the elbows, wrists, hands fingers, hips, knees, or ankles.  On exam there was muscle spasm of the entire spine noted, with painful, limited cervical ROM.  There was TTP of the wrists, finger joints, and left shoulder.  There was no swelling of any joint noted.  There were 18/18 bilateral positive FM TPs.  Neurological exam was normal and no limping was observed.  The rheumatologist diagnosed chronic pain syndrome and FM.  A comprehensive pain management program was recommended, including regular medications, counseling, PT, and aerobic activities.  

At the initial VA Compensation and Pension (C&P) Rheumatology exam performed 5 March 2009, 29 months after separation, the CI reported daily constant pain of all joints and muscles which was worse with weather but improved by hot showers.  He reported constant fatigue, sleep difficulties, HAs, and IBS, but denied depression or anxiety.  He reported he was not being treated by a rheumatologist and was using narcotic pain medication as needed for pain.  The CI was looking for a job. He had just graduated with a Master’s degree and had been working as a graduate assistant while in school.  The exam noted tenderness of the bilateral shoulders, elbows, wrists, fingers, and knees.  The examiner commented that the CI was tender all over the body but “the fibromyalgia tender points from 18 out of 18 are more tender than the other areas.”  The VA Rheumatologist agreed with the diagnosis of FM.  

At the VA C&P joints exam on16 May 2009, 31 months after separation, the CI reported neck and LBP, left shoulder pain, and bilateral hand pain.  He denied flare-ups or any periods of incapacitation, and indicated that he was able to perform routine daily activities, with occasional assistance.  He reported pain medication provided relief and he was not using a muscle relaxant because it caused too much drowsiness.  He denied use of a cane or crutch for ambulation.  The exam noted TTP of the spinal muscles and the shoulder blades that reproduced “a lot of his symptoms.”  There was full ROM of the cervical spine, left shoulder and bilateral finger joints with no pain, with mildly reduced painful ROM of the thoracolumbar spine.  There was no additional loss of ROM with repetition for any joint ROM.  A full neurological exam was normal.  A lumbar spine MRI in February 2009 was unchanged from the previous MRI and X-rays of the bilateral hands, left shoulder, and lumbar and cervical spines were normal.  The VA orthopedic examiner indicated that the exam of the CI’s neck, back, shoulder, and hands was essentially normal; there was no evidence of joint pathology of the left shoulder; and, the CI’s symptoms were related to his FM diagnosis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the FM condition 0%, coded 5025.  The PEB DD Form 199 noted “Fibromyalgia…, not requiring continuous medication for control.”  The remote VA rating decision 32 months after separation rated the FM condition 40%, coded 5025.  The Board noted that the VA C&P evidence was outside the 12-month period for special consideration of post-separation VA evidence IAW DoDI 6040.44, and the C&P exams are considered only to the degree that they provide information that reflects the CI’s condition proximate to the date of separation.  The Board noted that the VA Rheumatology C&P provided support for a 0% rating, despite the VA rating of 40%, as the CI was not on continuous medication for control of his FM.  However, as noted the CI’s condition at the exam nearly 3 years after separation cannot be relied on solely for the Board’s rating recommendation.  The Board turned its attention to the CI’s condition at the time of separation as evidenced by the MEB exam, the MEB rheumatology addendum, notes in the STR, and any evidence at the C&P exams which reflected the CI’s condition in the 12 months after separation.  The PEB indicated the CI’s FM condition did not require continuous medication in determining a 0% rating, however, the evidence in record supports that proximate to separation the condition did require treatment to include medications, as indicated by the MEB Rheumatology addendum.  Thus, the Board agreed that the disability due to the FM condition at separation met the 5025-coded 10% rating criteria specified as FM symptoms “that require continuous medication for control” and the Board reviewed to see if a higher evaluation was supported by the evidence.  The Board considered the two higher 5025 ratings of 20% and 40% and noted that they are differentiated based upon the frequency of FM symptoms and response to treatment.  The 20% rating criteria specifies FM symptoms (including TPs, fatigue, sleep problems, HA, Raynaud’s type symptoms, and depression or anxiety) “that are episodic, with exacerbations…precipitated by environmental or emotional stress, or by overexertion, but that are present more than one-third of the time.”  The 40% rating specifies FM symptoms “that are constant, or nearly so, and refractory to therapy.”  

Members agreed that the evidence provided support for the 20% rating as noted above, and that the CI’s FM symptoms could be characterized as “nearly constant”, in addition to “present more than one third of the time.”  The Board therefore next considered if the evidence supported that the FM condition was “refractory to treatment”, required to meet the 40% rating criteria.  Therapeutic benefit was documented from treatment with medications, PT and shoulder injection before separation, and relief with pain medications used as needed, was documented after separation.  He reported no periods of incapacitation due to his FM symptoms.  He had been in school, working, had just recently graduated, and was looking for a job.  Members therefore agreed that proximate to separation, the evidence did not support characterizing the FM condition as “refractory to treatment” and that the disability due to the FM condition was best rated 20% and not 40%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the FM condition.  

BOARD FINDINGS:  In the matter of the FM condition, the Board unanimously recommends a disability rating of 20%, coded 5025 IAW VASRD §4.71a.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Fibromyalgia Condition	5025	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140601, 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

JUL 13 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160004505 (PD201403263)

1. I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (DoD PDBR) recommendation and record of proceedings pertaining to the
subject individual. Under the authority of Title 10, United States Code, section 1554a,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

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.

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