RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01431
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Administrative Specialist-Postal, medically separated for “fibromyalgia with 11/18 tender points,” with a disability rating of 20%.  

CI CONTENTION:  “Review all 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 - 20041221	VARD - 20050712	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia…	5025	20%	Fibromyalgia	5025	40%	20050228	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Fibromyalgia.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s fibromyalgia condition began in June 2002 with severe low back pain and right sided numbness without specific trauma.  Symptoms worsened to include cervical, thoracic, lumbar, and myofascial pain, bilateral upper and right lower extremity numbness, some irritable bowel-type symptoms, and nightly Raynaud’s-like symptoms of the fingers.  The CI was diagnosed as having fibromyalgia by a rheumatologist, and extensive evaluations indicated no secondary cause for the CI’s symptoms.  Pain was to 10/10 and was not relieved by conservative therapy.  The MEB forwarded “fibromyalgia” for PEB adjudication.  

The orthopedic specialty consult for the MEB, dated 17 August 2004 (8 months prior to separation), the CI reported chronic pain in the neck, back, and shoulders with sleep difficulties.  
Physical examination showed tenderness in 11 of 18 fibromyalgia test points with normal control point testing.  Strength, sensation and reflexes were essentially within normal limits.  The physician indicated that the CI had “pain of moderate intensity with constant frequency.  She requires medication intermittently. …She has failed the use of Elavil, other nonsteroidal anti-inflammatories, Topamax and Tramadol, as well as Neurontin.”  

The MEB NARSUM examination on 25 October 2004, 6 months prior to separation, noted complaints of “fibromyalgia with back pain, right side numbness, left arm numbness, and left eye twitching."  Physical examination showed 14 of 18 tender points with control points negative.  There was generalized myofascial tenderness from the neck to the hips over the posterior trunk.  There was moderate sinus tenderness to percussion with the remainder of the exam essentially normal.  The diagnosis was fibromyalgia and the examiner stated, under “present condition,” that the CI reported constant neck and back pain (8/10), “that her current constant pain is worse than when she had natural childbirth in 1999,” and had worsening of her pain to 10/10 without precipitating factors with “no improvement with rest, medical treatment, or multiple physical medicine modalities.  She has had only very temporary relief with chiropractic treatment. Currently, this relief lasts approximately 20 minutes.”  

At the 17 February 2005 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported easy fatigability, headaches, sleep disturbances, stiffness, and paresthesia.  “The symptoms are constant.  The above noted symptoms occur constantly, which means more than 2/3 of the time per year.  The symptoms are not precipitated by environmental stress, emotional stress or overexertion. …She still requires continuous treatment to control this condition because of fibromyalgia.  None, of the treatment methods so far have helped.”  The history sections also broke down symptoms and treatments for unrelieved lower back and neck pain, as well as daily migraine headaches.  Physical examination showed multiple tender points in the lumbar area.  Neurologic examination was normal with normal motor function, reflexes, and sensation.  The physician indicated the diagnosis was fibromyalgia.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia condition 20%, coded 5025 (fibromyalgia), citing “physical is essentially normal.”  The VA rated the fibromyalgia condition 40% coded 5025, based on the C&P examination 2 months before separation, citing symptoms that were constant, or nearly so, and refractory to therapy.  

The panel deliberated on if the CI‘s disability was more nearly approximated by the 40% criteria, as awarded by the VA, or the 20% criteria as awarded by the PEB under code 5025 as excerpted below:  

5025 	Fibromyalgia (fibrositis, primary fibromyalgia syndrome)
	With 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	40
		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	20
		That require continuous medication for control	10

The record documented a rheumatologist-diagnosed condition of fibromyalgia with symptoms that were constant, or nearly so.  Almost every STR note in the year prior to separation indicated starting pain as 10/10, and no notes indicated resolution of symptoms prior to intervention, or sustained periods of symptom relief.  The CI did have “relief following treatment today” following 3 of her 18 chiropractic treatment sessions over the year prior to separation, with the NARSUM indicating temporary relief following chiropractic treatment sessions lasted for approximately 20 minutes.  There were also noted flares of numbness to parts of the body and headaches, although there was no indication that the CI had any significant symptom relief between flares.  The NARSUM indicated there was no improvement with rest, medical treatment, or multiple physical medicine modalities.  The pre-separation VA examination stated the CI’s symptoms were constant and the pain was not relieved by anything.  Panel consensus was that the CI’s symptoms were constant, or nearly so, and refractory to therapy.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 40% for the fibromyalgia condition, coded 5025.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition, the panel majority recommends a disability rating of 40%, coded 5025 IAW VASRD §4.71a.  The single voter for dissent recommended no change and submitted the appended minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Fibromyalgia…	5025	40%	

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

	

Minority Opinion.  A 40% rating under code 5025 requires that the symptoms are constant, or nearly so, and refractory to therapy.  The evidence documented in the CI’s treatment record clearly show that the CI’s symptoms responded to chiropractic manipulative therapy (CMT), and she did have relief following her treatment sessions, even if only temporary.  Other physical medicine treatments were tried, including acupuncture, percutaneous electrical nerve stimulation and trigger point injections but the CI continued her CMT, often several times per month, for over two and a half years up until separation.  In the minority member’s opinion, the frequency and duration of the CMT corroborate the fact that the chiropractic treatment provided some relief, and that the condition was not refractory to therapy.  

Based on the evidence, the minority member concluded that the criteria for a rating of 40% under 5025 were not met in this case, and that there was insufficient cause to recommend a change in the PEB adjudication for the fibromyalgia condition.  The minority member therefore recommends no change in the PEB adjudication.  

AR20170008459 , XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the XXXXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure