RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02122
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20031021

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Supply Management Journeyman, medically separated for “pain disorder associated with psychological factors and myofascial pain syndrome” with a disability rating of 10%.

CI CONTENTION:  The CI requests review all conditions.  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 - 20030827	VARD - 20040211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Disorder…	9422	10%	Myofascial Pain Syndrome; Pain Disorder…	9422	30%	STR	
Migraine Headache	Cat II	Migraine Headaches	8100	10%		
History of Tobacco Use	Cat III	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Pain Disorder….  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pain condition began in June 2002 after a motor vehicle accident (MVA).  The Neurology MEB NARSUM examination on 23 April 2003, 6 months prior to separation, noted complaints that back hurt every day, and had constant "painful tingling” type numbness on the right side.  She related 1-2 monthly episodes of total loss of feeling on her entire right side.  The CI also stated: "I generally have a headache every day.”  Physical examination showed a decreased sensation on her right hemi-body to light touch and pinprick.  She had a very slight 4+/5 decreased strength noted in her right shoulder deltoid muscle.  Her gait was not antalgic and she had normal arm swing bilaterally.  The examiner summarized that there was a paucity of findings on examination and imaging to explain the CI's complaints of muscle weakness and hemi-body hypoesthesia.  There did not seem to be an organic cause for the complaints of numbness, and there was no objective evidence of muscle weakness on examination.  

The 25 March 2003 neurology examination, 7 months prior to separation, noted complaints of pain localized primarily to the right thoracic paraspinal region with right shoulder and lower spine pain.  She also complained of several episodes of severe headaches with light sensitivity and numbness followed by right hemi-body numbness and weakness.  She also reported a decrease in sleep, appetite and energy.  Physical examination revealed a mildly antalgic gait with a very mild right motor hemiparesis.  There was a mild loss of fine motor coordination in the right hand.  There was mild loss of pain sensation in the right hemi-body.  There was considerable right paraspinal tenderness in the mid to lower thoracic region.  There was also paraspinal tenderness to a lesser degree in the; cervical, upper thoracic, right lumbosacral, and paraspinal regions as well.  The trapezius muscle was tender.  Muscle tone was normal and muscle strength was 5/5 throughout all major muscle groups.  The examiner concluded that the CI had myofascial pain syndrome and probable complicated migraines.  The Life Skills MEB NARSUM examination on 30 July 2003, 3 months prior to separation, noted complaints of "Right side back pain, headaches, right side numbness, loss of feeling, and decreased strength on right side."  Since the accident, she reported that the pain and her frustration with the military's handling of her medical care had increased her stress level significantly.  She reported being angry "all of the time."  Some of this anger was related to her perception that she received inadequate medical treatment, which contributed to her physical problems.  She was particularly angry that the military medical system had not legitimized her physical pain.  Some anger was also about how the pain and other physical symptoms had impacted her functioning.  The CI also complained that she has no short-term memory, had a reduction in appetite but no significant weight loss.  Further, she reported a loss of sexual desire.  Mental status examination (MSE) was unremarkable.  The diagnoses of “pain disorder associated with both psychological factors and a general medical condition, chronic” was rendered.  Psychiatric examination found the pain caused clinically significant distress or impairment in social and occupational functioning.  The examiner recorded a Global Assessment of Functioning (GAF) score of 60 (moderate), and recommended the treatment of choice for this patient was treatment in a multidisciplinary pain clinic that focused on both medical and behavioral treatment for her pain.  The examiner documented that the CI’s symptoms were not sufficient to fit the criteria for a depressive episode.  The examiner noted that the psychological factors were judged to have an important role in the exacerbation and maintenance of the pain and the symptoms were not intentionally produced or feigned.  The pain was preventing her from completing her duties and engaging in leisure activities.  There was no VA Compensation and Pension (C&P) evaluation performed.  Duty limitations were recommended by Air Force profile dated 16 May 2003, including ½ work days, no regular physical activity, no lifting greater than 15 pounds, nor running or prolonged standing for 6 months due to chronic back pain.  According to the commander’s statement dated 16 June 2003, the CI was non-deployable and was working 4-hour workdays.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pain disorder associated with psychological factors and myofascial pain syndrome condition 10%, coded 9422 (pain disorder), citing mild social and industrial adaptability impairment.  The VA rated the myofascial pain syndrome pain disorder associated with psychological factors and a general medical condition, chronic with depression 30% coded 9422 (pain disorder), based on the STR, citing the use of medication, depression and a GAF score of 60.  All panel members agreed that the provision of §4.129 were not applicable in this case.  The panel considered if there was evidence for a §4.130 rating higher than 10% at time of separation.  The higher 30% rating is for “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  The NARSUM noted that the CI’s pain resulted in her inability to work for a prolonged period; the neurological NARSUM recorded ongoing complaints of severe pain by the CI and she had been on 4 hour work-day schedule (confirmed in the commanders letter) for the previous 6 months that was hard to complete at times, confirming moderate impairment for further military duty due to pain.  The panel considered the reported memory impairment, visit to the emergency room for psychologically related condition (total right sided numbness), and mental health evaluation.  Although the recorded GAF indicated a moderate degree of symptoms or impairment, the MSE was unremarkable.  After deliberation, panel majority agreed that there was evidence to support the higher rating of 30%.  

The panel also considered the included diagnosis of myofascial pain syndrome to see if it could be rated higher than 30% for the benefit of the CI.  The panel noted that the diagnosis was made by the neurologist evaluating and treating the CI with Botox injections that she had gained some mild to moderate improvement.  However, this diagnosis should have been made by or confirmed by a rheumatologist and verified to meet the VASRD diagnostic criteria.  There was no confirmation of the diagnosis and therefore cannot be separately rated using this diagnosis.  There was no limitation of thoracolumbar spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine.  The NARSUM examination did not note the presence of painful motion.  A 10% rating was therefore not warranted.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  There was very slight deltoid muscle weakness (4+) and no atrophy or functional impairment to rate as slight, 0% under Muscle Group III (5303).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 30% for the pain disorder associated with psychological factors and myofascial pain syndrome condition, coded 9422 (Pain Disorder).  

Contended PEB Conditions:  Migraine Headaches. Tobacco Use.  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 pain disorder associated with psychological factors and myofascial pain syndrome condition, the panel majority recommends a disability rating of 30%, coded 9422 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  In the matter of the contended migraine headaches and tobacco use conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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	
Pain Disorder Associated With Psychological Factors And Myofascial Pain Syndrome	9422	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150801, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02122.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  The Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings