RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01332
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060301

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, F16 Avionics System Specialist, medically separated for “pain disorder associated with psychological factors and chronic neck pain associated with fibromyalgia” rated 10%, with a disability rating of 10%.

CI CONTENTION:  The CI contends that his pain is very debilitating at times due to his conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20060203	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Disorder…and Chronic Neck Pain…Fibromyalgia	9422	10%	No VA Examination in Evidence Approximate to Separation	
L4-S1 Spinal Fusion for Congenital Spondylolisthesis	5241	Category II		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Pain Disorder associated with Psychological Factors and Chronic Neck Pain associated with Fibromyalgia.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first seen for neck pain on 12 January 2000.  He was treated with medications and range of motion (ROM) exercises and seen periodically over the next few years.  A CT of the cervical spine on 30 April 2004 was unremarkable.  An MRI on 7 October 2004 was noted by the radiologist to show multilevel disc (degenerative) disease.  He then evaluated by neurosurgery on 17 December 2004.  He was noted to have full ROM and a normal neurological examination other than a very mild right ulnar (peripheral nerve) neuropathy.  Trapezius spasm was present and thought to be the cause of his neck pain.  The MRI was reviewed and the degenerative changes present were thought to be normal for his age.  The neurosurgeon recorded that the CI rejected this opinion.  The CI was then evaluated by a spine surgeon on 20 January 2005.  The CI reported neck pain for over a year.  On examination, the ROM was limited to 75% of normal.  Tenderness of the paraspinal muscles was noted.  The neurological examination was normal.  He was thought to have a facet syndrome (the joints between the vertebrae) and injections recommended.  On 6 April 2005, the CI again reported chronic pain and that the injections had not provided relief.  On examination, the ROM was full and without limitations.  The neurological examination was normal.  Spasm was absent.  Fibromyalgia was discussed as a possible diagnosis.  He was placed on an anti-depressant, but did not tolerate the side effects.  He did report benefit from Ultram (a narcotic).  He noted that the demands at home (his spouse was near delivery) were great when seen on 23 May 2005.  He was also started on a muscle relaxant with benefit.  

The general NARSUM was prepared on 14 September 2005, just less than 6 months prior to separation.  It was noted that the CI had met the criteria for fibromyalgia at an appointment on 25 August 2005.  The CI reported to the NARSUM examiner that he could no longer adequately perform his duties and requested separation from the USAF.  He endorsed pain everywhere as well as periodic numbness of both upper and both lower extremities.  He was tender to palpation globally with 10 trigger points with severe pain.  (The panel noted that the diagnosis of fibromyalgia requires 11/18 trigger points and that global tenderness is atypical).  Weakness of both lower extremities was present at 4/5.  The neurological examination was otherwise normal.  The CI was diagnosed with cervicalgia (neck pain), chronic pain disorder, and fibromyalgia.  The CI was issued a P1U4L1S1 profile that day.  

The commander noted on 9 October 2005 that the CI had missed approximately 12 days of work from quarters and emergency room visits.  It was not noted over what period of time this occurred though.  It was also noted that he missed approximately 3 days a month for medical appointments and treatment.  

On 8 November 2005, the CI had a brain MRI which was normal.  It was recorded that he reported numbness in multiple areas of his body.  The CI was then referred to neurology and seen on 1 December 2005.  He reported back pain, visual spots, fever, chills, and frequent headaches.  The examination was normal.  No diagnosis was made and additional testing recommended.  Electrodiagnostic studies (EDX) of the lower extremities were normal on 21 December 2005.  

The mental health addendum to the NARSUM was dated 30 December 2005, 2 months prior to separation.  The evaluation was conducted for the MEB; the CI had no prior contact with behavioral health.  The CI reported widespread pain in both upper and lower extremities as well as weakness of the upper and lower extremities, left > right.  He reported poor memory and concentration.  Anti-depressants were of no benefit.  He denied depression and reported that he was happy despite his pain.  He stated that he could no longer work in his career field.  On examination, he “walked with a noticeable limp” and “occasionally flinched in his seat as if in severe, shooting pain.”  He was occasionally circumstantial in his medical history and focused on his pain complaints.  The mental status examination was otherwise normal.  On formal neuropsychological testing, it was noted that his “physical symptoms become worse during times of duress and there is clear secondary gain usually associated with them.”  It was noted that his symptoms had a “strong psychological component to them.”  He was diagnosed with a pain disorder with psychological factors and a general medical condition.  His symptoms were more than expected from his known medical problems.  He was not thought to meet retention standards.  

The CI was seen in Rheumatology on 26 January 2006, 1 month prior to separation.  The CI reported the onset of a pain syndrome in July 2004 without a precipitating event.  The pain involved the entire body, but specifically targeted his back, knees, and neck.  He reported poor sleep and chronic fatigue.  He reported that he could not do his duties because of chronic pain.  On examination, he generally appeared to be quite healthy.  No significant inflammation of the joints was present.  Tenderness was present over the paracervical, superior trapezius, rhomboid, perithoracic, and paralumbar muscles.  Trigger points were not recorded.  The neurological examination was normal.  The neck was noted to be supple.  It was noted that he met the criteria of fibromyalgia, but the diagnosis was not actually made.  

The final EPR closed out on 28 February 2006, the day prior to separation, and covered 1 March 2005 through 28 February 2006, the final year of active duty.  Both the rater and additional rater assigned a 5 (out of 5) rating, endorsing immediate promotion.  The additional rater stated “leadership and dedication to duty shows this professional is capable for increased responsibilities- -promote.”  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pain disorder condition 10%, coded 9422 (pain disorder), noting mild social and industrial impairment.  The PEB found the CI to be unfit for a pain disorder with neck pain and associated with fibromyalgia.  The panel first considered if these conditions were separately unfitting.  The CT scan of the neck was normal and the MRI showed normal changes associated with the CI’s age per the examining neurosurgeon.  The ROM and neurological examination were consistently normal other than findings attributed to a peripheral (non-radicular) neuropathy.  Tenderness was present, but tenderness was widespread.  The evidence does not support a finding that a separately unfitting neck condition was present.  The panel then considered the fibromyalgia.  Although the diagnosis was carried on the MEB and PEB, it is not clear from the record on what basis the diagnosis was made.  Regardless, the pain was widespread and the panel did not find that at least 11/18 trigger points were ever present.  The MEB mental health evaluation noted that the CI had a pain disorder which was associated with both psychological factors and a general medical condition.  The PEB concurred that the primary diagnosis was a pain disorder and subsumed the fibromyalgia condition under it.  The panel observed that the symptoms from either diagnosis overlap and were not severable.  The use of these symptoms to support 2 separate diagnoses would violate VASRD §4.14 (avoidance of pyramiding).  Accordingly, the evidence does not support the presence of a separately unfitting fibromyalgia condition at separation for rating purposes.  The panel then considered the rating for the unfitting chronic pain disorder.  A higher 30% rating requires that there be “intermittent periods of inability to perform occupational tasks.”  This was not found in the records; rather, the final rating was 5/5, the highest possible, and recommended immediate promotion.  This level of performance is consistent with the 10% rating adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain disorder condition.  

Contended PEB Condition:   L4-S1 Spinal Fusion for Congenital Spondylolisthesis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended back condition was not profiled at separation or specifically implicated in the commander’s statement.  It was not noted to be an active diagnosis on the MEB NARSUM nor addressed by the MEB. The CI was noted to have weakness on some examinations, but not others.  Electrodiagnostic studies 2 months prior to separation were normal.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  
BOARD FINDINGS:  In the matter of the chronic pain disorder condition and IAW VASRD §4.130, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended L4-S1 spinal fusion condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
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XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01332.

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