RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01807
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “fibromyalgia,” with a disability rating of 20%.

CI CONTENTION:  The CI states that she was awarded social security disability and an 80% rating from the VA for her health conditions and contends that her conditions “were greatly under evaluated by the Army.”  The 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 - 20030227	VARD - 20030731	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia with Chronic Pain, Headaches, Poor Sleep, Fatigue and Bowel Symptoms	5025	20%	Fibromyalgia	5025	20%	20030626	
			Chronic Mixed Headaches	8199-8100	10%	20030626	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY

Fibromyalgia.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s fibromyalgia symptoms began around January 2001.  She developed body pains, fatigue, sleep disturbance and headaches.  In July 2002 she was evaluated by rheumatology and diagnosed with fibromyalgia.  The CI was also diagnosed with migraine headaches, but that diagnosis was later changed to mixed headaches following a neurology consultation in December 2002.  
The 27 September 2002 MEB NARSUM examination, 7 months prior to separation, noted the CI’s complaint of headaches and body pains.  The examiner recorded that the CI had flares of her fibromyalgia about 3-4 times a month, and in between flares her condition was mild.  The examiner discussed at great length the headaches.  It was noted that she had been in the emergency room (ER) on numerous occasions for headaches.  The CI took narcotic analgesic medications as needed for pain.  Physical examination was unremarkable with the exception of “some tender areas in the upper torso and below.”  The CI had a negative brain MRI, negative x-rays of the spine, and negative laboratory studies for autoimmune diseases.  The electromyogram was negative for the back and upper and lower extremity muscles.  The examiner diagnosed “migraine headaches, prostrating, and fibromyalgia.”  

At the 27 September 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported that her fibromyalgia had limited her to 20 pounds of lifting and that her migraines kept her out of work often.  The physical examination was as noted above.

During the 26 June 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported fibromyalgia and migraine headaches among several other conditions.  The physical exam showed the absence of any signs of pain or tenderness in any of the muscle groups and no muscle weakness in the muscles of the shoulder girdle, elbows, wrists, hands, knees, hips or ankles.  The examiner opined that the CI’s headaches were “more likely related to tension than to migraine, or maybe of a mixed type.”  The examiner noted that evidence of fibromyalgia was absent.  It was noted that the CI “had carried a 25 pound child out, shouldered a heavy appearing backpack on her arms through the straps and walked out with a normal gait and no signs of body pain or distress of any sort.”

Review of the STR revealed 12 encounters of care for headache during the 6 month period before separation.  Of the 12 times in the ER, she presented 10 times without evidence of being in distress and 2 times with noted distress.  There was no evidence of quarters ordered in the 5 months prior to separation, contrary to what was stated in the NARSUM.  On 22 October 2002, 6 months prior to separation, the CI was discharged from the ER with recommended quarters for less than 24 hours.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB included the headache condition in the rating of the fibromyalgia for a 20% rating under 5025 fibromyalgia code.  The VA assigned a 20% rating for the fibromyalgia condition coded 5025, and a 10% rating for the “chronic mixed headaches” condition coded analogously 8199-8100.  

The panel first agreed that the rating of headaches under the fibromyalgia code is an accepted practice since headaches are recognized as a one of the symptoms of fibromyalgia.  However, the panel also agreed it was reasonable to consider a separate rating for the headache condition since it was managed separately and diagnosed as a separate condition.  Therefore, the panel proceeded to determine if the PEB’s approach of combining the fibromyalgia and headache conditions under a single rating was justified in lieu of separate ratings.  The panel agreed that the preponderance of evidence in the record supports the fibromyalgia condition was separately unfitting.  A rating of 40% requires widespread musculoskeletal pain and tender points with or without associated symptoms that are constant or nearly so and refractory to treatment.  The panel considered both NARSUM and C&P examinations, neither of which noted that her condition was refractory to medication.  The CI was only taking a non-steroidal anti-inflammatory medication.  At the time of the C&P examination, there was no evidence of fibromyalgia and pain was not present.  The examiner noted that the CI “had carried a 25 pound child out, shouldered a heavy appearing backpack on her arms through the straps and walked out with a normal gait and no signs of body pain or distress of any sort.”  All panel members agreed, that the evidence of record did not support a rating of 40% for the CI’s condition of fibromyalgia.  

The panel next considered the headache condition.  The STR demonstrated that the CI presented to the emergency room (ER) 12 times in the 6 month period prior to separation.  Of the 12 ER visits, she presented 10 times without evidence of being in acute distress and 2 times with noted distress.  There was no evidence of quarters ordered in the 5 months prior to separation, contrary to what was stated in the NARSUM.  But the panel does note that 6 months prior to separation, the CI was discharged from the ER with recommended quarters for less than 24 hours.  The 30 December 2002 neurology evaluation, 4 months prior to separation, diagnosed mixed headaches with vascular and tension features, and the examiner did not indicate whether the headaches met or failed retention standards.  The panel also noted the absence of performance evaluations.  The commander’s statement acknowledged the headache condition; however, noted that although she was not working in her capacity as Training NCO she was working as an Aid Station NCO responsible for providing healthcare to over 4,000 soldiers.  The commander did not indicate that the CI had difficulty performing her newly assigned duties.  There was no mention of the CI having suffered headaches that required special accommodation, or that she was sent home from duty or sent from work to the ER due to headaches.  Panel members agreed there was not a preponderance of evidence that the headache condition in and of itself cut short the CI’s military career.  Therefore, the panel agreed it was appropriate to include the headache as a component of the fibromyalgia condition.  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.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the Board’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 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009322, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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