RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01374
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Human Resources Specialist, medically separated for “fibromyalgia” and “spells of alteration of consciousness,” rated 20% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends the MEB process was unfair and all her conditions were bundled into one.  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 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 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 determinations 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 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 – 20051122	VARD - 20060501	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia…	5025	20%	Fibromyalgia	5025	40%	20060221	
			Sleep Apnea, Mild, Obstructive	6847	50%	20060227	
Adjustment Disorder with Depressed Mood	Medically Acceptable	Psychosis NoS	9210	70%	20060221	
Panic Disorder Without Agroraphobia	Medically Acceptable					
Spells of Alteration of Consciousness…	8999-8911	0%	No VA Placement	
Abnormal Uterine Bleeding	Medically Acceptable	Uterine Fibroids to Include Hematuria, Ovarian Cyst and
Stress Incontinence	7615-7613	30%	20060221	
Subseptate Uterus and Uterine Fibroid	Medically Acceptable					
Hematuria	Medically Acceptable					
Stress Incontinence	Medically Acceptable					
Right Trochanteric Bursitis	Medically Acceptable	Trochanteric Bursitis, Right Hip	5252-5019	10%	20060221	
Nephrolithiasis	Medically Acceptable	Nephrolithiasis	7508	0%	20060221	
Diabetes Mellitus that Does Require Medication	Not Unfitting	Diabetes Mellitus, Type II	7913	20%	20060221	
Hyperlipidemia	Medically Acceptable	Hyperlipidemia	7199-7114	NSC	20060221	
Stable Liver Cyst	Medically Acceptable	Liver Cyst	7399-7311	0%	20060221	
Non Erosive Esophagitis	Medically Acceptable	No VA Placement	
Mild Persistent Asthma	Medically Acceptable	Mild Persistent Asthma	6602	30%	20060227	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Fibromyalgia Condition.  The VASRD characterizes fibromyalgia (5025) as widespread musculoskeletal pain and tender points (loci in soft tissue area where palpation reveals excessive tenderness), with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms (recurrent finger and toe vasospasm in response to cold or stress).  Per DoDI 1332.39, fibromyalgia must be evaluated by a rheumatologist, and meet the diagnostic criteria put forth by the American College of Rheumatology (history of widespread pain present for at least 3 months; both axial skeletal pain and peripheral pain; pain on digital palpation at 11 of 18 tender point sites; presence of a second clinical disorder does not exclude the diagnosis).  The PEB combined the fibromyalgia, irritable bowel syndrome (IBS), migraine headaches, and hypersomnolence of unclear etiology conditions as a single unfitting condition coded 5025 and rated 20%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the fibromyalgia, IBS, migraine headaches, and hypersomnolence conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to service treatment records (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the constellation of symptoms began approximately 2 years prior to referral for MEB.  The 16 January 2004 bilateral hip diagnostic imaging (MRI) studies were normal.  The 16 January 2004 left knee MRI was unremarkable except for medial meniscus degeneration.  The 15 March 2004 lumbar spine X-rays were normal.  Serial electrodiagnositic (EDx) studies were normal and showed no evidence of a generalized myopathic (skeletal muscle disease) process, neuromuscular transmitter disorder, or right lower extremity radiculopathy (nerve root irritation or injury).  

In the 22 November 2004 MEB addendum by rheumatology, the CI complained of joint pain, lower back pain with radicular (nerve root irritation or injury) symptoms, migraines, rashes, and chronic fatigue.  “Her joint complaints are intermittent and states occasional swelling.”  The CI reported problems with getting started in the morning, sitting or standing for prolonged periods, focusing, shopping, cooking, recreational activities, and activities of daily living.  The review of systems documented “Complains of fevers at night but no temperature, some sweats, weight loss after some gain recently, trouble sleeping, slight thinning hair, complains of rash on hands, face, knees, sensitive to sun (seborrhea per dermatology evaluation by patient report), slight dry eyes with burning, slight shortness of breath but h/o asthma, occasional abdominal pain with GI and OB/GYN evaluation, some nausea, vomiting, diarrhea, constipation, history recurrent urinary tract infection with hematuria (cystoscopy okay by urology per report), states history of frostbite.”  The physical examination revealed mid thoracic and lumbar spine tenderness and 14/18 paired tender points (anterior chest, forearms, trapezius, mid scapular, sacroiliac [SI] joint area, trochanters, knee fat pads).  The joint examination revealed full range of motion (ROM) with no swelling, tenderness, warmth, or edema (excess tissue fluid swelling).  The straight leg raise ([SLR] assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Proximal extremity strength was 4/5.  There was no evidence of inflammatory arthritis by examination or labs.  The diagnosis listed fibromyalgia syndrome (FMS) with arthralgias (joint pains), myalgias (muscle pains), sleep disturbance, headache, IBS, and multiple paired tender points above and below the diaphragm and documented “Treatment involves alterations of sleep hygiene, stretching and exercise with a goal of achieving good aerobic health.  Multidisciplinary approaches may be needed as there is no one medication for treatment.”  The rheumatologist recommended increasing the bedtime tricyclic antidepressant (off-label use for chronic pain; myofascial pain; irritable bowel syndrome) Pamelor from 25 mg to 50 mf to 75 mg and to start stretching exercises with goal of aerobic activity 3 times a week.  

In the review in lieu of (RILO) MEB summary by neurology, the CI complained of headaches (HAs) for 2-3 years.  The 10/10, throbbing right temporal and retro-orbital HAs occurred about once per week and lasted 2-3 days.  These were associated with nausea and light and sound sensitivity.  The interval 4/10, bitemporal (R>L) “regular” HAs lasted 3-4 days.  The HAs were incompletely controlled with prophylactic and abortive medications.  The neurological examination revealed a normal mental status examination, cranial nerves, reflexes, coordination, and gait.  The motor examination revealed normal tone and bulk with “diffuse giveway weakness throughout without lateralization…”  The sensory examination was intact except for subjectively decreased light touch and pin prick sensation in the left lower cheek, leg, and foot.  The Rhomberg (assesses neurological function for balance) test was positive.  The neurologist recounted the findings of the unremarkable brain MRI and normal EEG.  The diagnosis listed chronic migraine headaches.  
The MEB addendum by gastroenterology documented upper endoscopy biopsies revealed chronic active gastritis with Helicobacter Pylori organisms.  The colonoscopy revealed a normal appearing terminal ileum and colon with diverticulosis.  “The pain and upper gastrointestinal symptoms that this soldier describes are suggestive of a functional bowel disorder or irritable bowel syndrome.  No organic disease of the gastrointestinal tract has been found thus far to explain the degree of symptomatology.”  The diagnoses listed chronic functional abdominal pain syndrome and well controlled non-erosive reflux disease.  The MEB addendum by sleep medicine documented “complaints of ‘difficulty sleeping due to pain’, night sweats, excessive daytime sleepiness and loud snoring.”  The 10 January 2005 overnight polysomnogram (sleep study) was completely normal and did not explain her various symptoms.  The 28 March 2005 routine polysomnogram was completely normal with no suggestions that Upper Airways Resistance Syndrome (UARS) was playing a part in her sleep symptoms.  “At this time her sleep diagnoses are not clear.  She does not have sleep apnea.”  The diagnosis listed hypersomnolence of unclear etiology.  

In the 26 April 2005 rheumatology update for the MEB addendum the CI complained of almost constant pain.  The CI reported feeling forgetful, depressed (followed by psychiatry), and feverish and cold at times (did not take temperature).  She complained of little areas of rash on arms and legs with associated increase in pain, occasional chest pain, and slight shortness of breath.  The CI stated that she “does not feel meds have helped a lot” and treated symptoms with pool therapy, stretching (20 minutes), walking, and hot baths.  The physical examination documented a slow gait.  The musculoskeletal examination revealed diffuse back, upper legs, and anterior chest tenderness and multiple paired tender points (anterior chest, arms, posterior neck, scapular, sacral, trochanters, knees).  There was no edema or synovitis (synovial membrane inflammation).  There was a left upper arm faint hyperpigmented area with no erythema (redness).  The assessment listed active fibromyalgia.  The rheumatologist documented “Difficult case due to multiple consultants, complaints, and meds as noted in chart.  Multiple meds now being used that can also be used to treat FMS.  Would ask for consolidation, if possible, of meds thru behavioral health.…I do not have any other therapeutic recs at this time except to try to simplify overall med list as noted above.”  

The 11 May 2005 NARSUM, 8 months before separation, incorporated the addenda from rheumatology, gastroenterology, neurology, and sleep medicine.  The rheumatology addendum diagnosed FMS and noted arthralgias, myalgias, sleep disturbance, headaches, IBS, and multiple paired tender points without evidence for inflammatory arthritis.  Physical medicine and rehabilitation (PM&R) had evaluated the CI for low back pain (LBP) with possible radiculopathy.  “Spine films and EMG have been unremarkable.  The examiner believes that her symptoms are consistent with FMS or possible chronic pain syndrome, deferring to Rheumatology on this, and that he cannot find a separate etiology to explain her LBP.”  The physical examination documented a normal tandem gait.  The musculoskeletal examination revealed diffuse back, anterior chest, and upper leg tenderness and multiple paired tender points (anterior chest, arms, posterior neck, scapular, sacral, trochanters, knees).  There was no swelling, effusion (fluid collection), ligamentous laxity, or rash.  Active ROM was full for all joints and the SLR tests were negative.  Coordination, pulses, strength, and sensation were normal except for decreased sensation to light touch over left lateral foot.  The diagnoses listed FMS, IBS, migraines, and hypersomnolence of unclear etiology.  The 22 December 2005 MEB addendum by sleep medicine documented a polysomnogram revealed mild obstructive sleep apnea (OSA).  A multiple sleep latency test (MSLT) was consistent with narcolepsy (sleep disorder with excessive daytime sleepiness and sudden sleep attacks).  

In the 27 February 2006 VA compensation and pension (C&P) examination the CI complained of right (sometimes left) temple and retro-orbital severe and throbbing HAs.  Symptoms were associated with nausea, photophobia, and phonophobia.  The HAs occurred 3 to 4 times per month and lasted up to 2 to 3 days.  She did not think the prophylactic medication was helping and indicated the abortive medication provided “some benefit.”  The CI reported a history of difficulty falling asleep, staying asleep, and chronic daytime sleepiness.  “She is currently taking Modafinil for narcolepsy, but continues to feel tired in the daytime, also notes sleep paralysis and hypnogogic hallucinations [visual, tactile, auditory, or other sensory events at the transition from wakefulness to sleep].  She also has been given a CPAP mask, which she does not tolerate well.”  The CI complained of daily, episodic, LBP with pain sometimes radiating down both legs to the ankles.  The physical examination documented a slow and painful gait with a normal base.  The back examination revealed lumbar spine, and bilateral lumbar paraspinal muscle, tenderness.  Pain-limited active lumbar spine ROM was flexion of 60 (normal 90), extension of 15 (30), bilateral lateral flexion of 15 degrees (30), and bilateral rotation of 15 degrees (30).  Cranial nerves, coordination, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  “Motor strength is at least 4/5 throughout but difficult to assess accurately due to generalized give-way weakness.”  The diagnoses listed migraine headaches, OSA, narcolepsy, and chronic lumbar strain.

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the fibromyalgia, IBS, migraines, and hypersomnolence conditions remain separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 20% rating (MEB Dx 1-3, 5) under the 5025 code (fibromyalgia) citing fibromyalgia, as diagnosed by a rheumatologist, widespread musculoskeletal pain and tender points, associated fatigue, sleep disturbance, stiffness, severe headaches, significant irritable bowel symptoms, depression, and anxiety, medications, tender points by physical examination without any swelling or synovitis, joint full ROM, and exacerbations of single or multiple complaints.  The VA assigned a 40% rating under the 5025 code (fibromyalgia) based on Service medical records and the VA C&P examinations 1 month after separation, citing fibromyalgia (claimed as low back, right elbow, right knee, and right ankle pain; migraine headaches; narcolepsy; non-epileptic spells with altered unconsciousness; hypersomnolence; gastritis; gastroesophageal reflux disease, irritable bowel syndrome; abdominal pain syndrome, pelvic pain) and rated for widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms that are constant, or nearly so, and refractory to therapy.  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating coded 5025 is a good analogy to both the pathology and disability.  The record does not support that the core symptoms were constant, or nearly so, and refractory to therapy.  The panel agreed the evidence was consistent with the 20% rating.  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 fibromyalgia condition.  

Spells Condition.  According to STRs and the MEB NARSUM, the “spells” (period of bodily or mental distress or disorder) began approximately 2 years prior to referral for MEB.  An 11 August 2004 brain MRI was unremarkable.  An 11 February 2005 neurology evaluation documented “She complains of ‘blackout spells’ which are periods of inability to speak or move, and she usually has no recollection at all about the spell.  She is usually told by nearby people that she, and she recalls people calling her name.  She was told by the EMS that she has a low pulse and BP at that time.  She returns completely to normal when this is over.”  Under assessment, the neurologist documented “Current ‘blackout spells’ sound functional and non-epileptic as well, though will do EEG.  The fact that the motor impairment is bilateral with retained consciousness is suspicious of non-epileptic disorder.”  The electroencephalogram ([EEG] diagnostic test to assess for epilepsy) was normal.  In the RILO MEB summary by neurology, the CI complained of "blackout spells" with approximately 8-10 episodes over past 2 years.  “She has no recollection of these episodes and history is hearsay from witnesses.  She reports no warning or prodromal symptoms.  She has acute onset of LOC during which she is unresponsive for a period of minutes.  She has no bowel or bladder incontinence with these episodes and no tongue biting.  No one has reported to her any abnormal movements during them.  Witnesses have told her that she feels "clammy" during these.  There does not appear to be any post episode confusion.  She denies chest pain, SOB, or palpitations preceding them.  Workup to date from Neurologic standpoint has included a negative EEG and MRI.”  The neurological examination revealed a normal mental status, cranial nerves, reflexes, coordination, and gait.  The motor examination revealed normal tone and bulk with “Diffuse giveway weakness throughout without lateralization…”  The sensory examination was intact except for subjectively decreased light touch and pin prick sensation in the left lower cheek, leg, and foot.  The Rhomberg test was positive.  The neurologist recounted the findings of the unremarkable brain MRI and normal EEG.  “She also remains with episodic periods of Loss of consciousness which remains without a clear etiology.  Neurologic workup has not revealed a likely Neurologic diagnosis.”  The diagnosis listed nonepileptic spells with altered consciousness.  The NARSUM recounted the findings of the RILO MEB summary by neurology regarding spells.  The neurological examination documented a normal gait and strength.  Sensation was reported as decreased to light touch over left lateral foot.  The diagnosis listed nonepileptic spells with altered consciousness.  

The C&P examination documented “She had a normal brain MRI.  She had an episode of loss of consciousness in 2003.  This was witnessed.  She fell to the ground, but no seizure activity was noted.  On awakening she felt somewhat disoriented.  Another similar episode occurred a few months later. She had an outpatient evaluation at Walter Reed Army Hospital, where she had two negative EEG tests.  A diagnosis of non-epileptic spells was made.  She has continued to have these episodes, the most recent in June, 2005, with a 30-minute episode of unconsciousness followed by a period of confusion.  She had 3 or 4 of these episodes in 2005.”  The physical examination documented a slow and painful gait with a normal base.  Cranial nerves, coordination, sensation, and DTRs were normal and pathologic reflexes were absent.  “Motor strength is at least 4/5 throughout but difficult to assess accurately due to generalized give-way weakness.”  The diagnosis listed non-epileptic seizures/pseudoseizures (psychogenic nonepileptic seizures that clinically mimic epileptic seizures).
The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the spells under an analogous 8911 code (epilepsy, petit mal) citing spells of alteration of consciousness, negative EEG, negative MRI, “with soldier reporting 8-10 episodes [lasting 1-2 minutes] in the past year as reported to her by others,” with no reports of  loss of bladder or bowel control, tongue biting, abnormal movements, post episode confusion, injury as a result of episodes, episodes witnessed by medically trained persons,  or first person reports of witnessed episodes in the MEB, and no data to base a higher rating.  The VA did not service connect the spells based on the STR and VA C&P examination.  The panel established there was no confirmed diagnosis of epilepsy with a history of seizures consistent with the 10% rating under 8911.  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 spells condition.  

Contended PEB Conditions:  Adjustment Disorder with Depressed Mood; Panic Disorder Without Agoraphobia; Abnormal Uterine Bleeding; Subseptate Uterus and Uterine Fibroid; Hematuria; Stress Incontinence; Right Trochanteric Bursitis; Nephrolithiasis; Diabetes Mellitus that Does Require Medication; Hyperlipidemia; Stable Liver Cyst; Non Erosive Esophagitis; and Mild Persistent Asthma.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the spells condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with depressed mood; panic disorder without agoraphobia; abnormal uterine bleeding; subseptate uterus and uterine fibroid; hematuria; stress incontinence; right trochanteric bursitis; nephrolithiasis; diabetes mellitus, hyperlipidemia; stable liver cyst; non erosive esophagitis; and mild persistent asthma conditions, the panel unanimously recommends no change from the PEB determinations as medically acceptable.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007565, XXXXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure