RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01063
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20041010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Master of Arms, medically separated for “stiff man syndrome” with a disability rating of 20%.  

CI CONTENTION:  The Physical Evaluation Board (PEB) and VA discredited her condition.  She feels she was exposed to something while overseas or reacted to vaccines/immunizations and requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and PEB.  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040621	VARD - 20041018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stiff Man Syndrome	5299-5025	20%	Stiff Person Syndrome 	5299-5025	40%	20040903	
Severe Cervical Spine Spasm	Cat II					
Severe Thoracic Spine Spasm	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Stiff Man Syndrome.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s stiff person syndrome condition manifested in approximately October 2002 with an undetermined etiology, although the CI reported chronic low back pain possibly from wearing a belt with heavy weapons.  At a physical therapy evaluation on 31 October 2002 she reported pain from the mid thoracic region to the sacrum with radiation of the pain into both buttocks.  Examination revealed spasm of the paravertebral muscles from T9-L5, the right more than the left.  On 1 December 2002 the CI reported back spasms for 7 years, which worsened in the prior 2 weeks.  The CI had full range of motion (ROM) with pain and tenderness in the back around the spine.  Treatment consisted of intramuscular Toradol (ketorolac, an NSAID).  The CI was also treated with Robaxin (a muscle relaxer) and was felt to have right sacroiliac dysfunction.  After wearing her holster belt she again had a flare of pain.  In January 2003 she reported pain of the hips, sacroiliac joint, right knee, ankles, and the entire spine from the neck to the sacrum.  Treatment consisted of Toradol and Flexeril (cyclobenzaprine, a muscle relaxer).  On 23 January 2003 the CI received a series of Botox (onabotulinumtoxin A, a neurotoxin that paralyzes muscles) injections in the rhomboid muscles to treat the spasms of her neck, which were confirmed by EMG.  Baclofen (a muscle relaxer) was also prescribed.  

The CI underwent chiropractic care on 27 January 2003, which consisted of electrical stimulation, ice applications, and manipulation of the cervical, thoracic, and lumbar spine and the pelvis.  X-rays of the lumbar spine dated 27 January 2003 revealed a small triangular piece of bone lying at the anterior inferior part of L3, called a limbus vertebra or marginal infraction.  Facets of L5-S1 were normal and there was asymmetry in facet positioning of L3-4 and L4-5.  All discs were normal in height and the pars was intact.  The CI underwent chiropractic treatments for several months and was referred to psychology for emotional stress. Her pain waxed and waned depending on whether she worked.  She was subsequently placed on limited duty and was transferred from her duty station.  X-rays of the thoracic spine on 28 May 2003 demonstrated sclerosis over the T4-5 disc space.  Orthopedic evaluation on 29 May 2003 noted positive trigger areas at T7, forward flexion to the toes, extension 15 degrees, sensation and motor functions intact, and no hip pathology.  

In June 2003 the chiropractor noted most of the CI’s discomfort was in the left thoracic paraspinal area with slight soreness in the lower back.  Chiropractic treatments were continued.  At a sick call clinic visit on 17 July 2003 the CI reported doing well with Zoloft (sertraline, an antidepressant) and Ultram (tramadol, an opioid-like medication).  Calcium, vitamin D, and naproxen (an NSAID) were added to the treatment protocol.  The CI reported constant back pain at an orthopedic examination on 10 September 2003.  A trigger point was noted at the left thoracic area.  The examiner raised the possibility of a myofascial pain syndrome and referred the CI to neurology.  At a neurology clinic visit on 9 October 2003 the CI was prescribed a steroid burst and Valium (diazepam, a muscle relaxer).  An MRI of the thoracic and lumbar spine was negative.  Neurologic evaluation on 3 November 2003 revealed paraspinous spasm of the upper thoracic spine with mild tenderness of the lumbar and cervical spine areas with periodic winces of pain from spasm.  The impression of a stiff person syndrome was raised and treatment consisted of baclofen.  The CI was seen in follow-up at the mental health clinic on 18 November 2003.  A mental status examination was unremarkable and her mental status had improved.  The Axis I diagnosis was adjustment disorder with mixed anxiety and depressed mood.  She was found to be fit for full duty from a mental health standpoint. 

The 15 December 2003 MEB NARSUM examination, 10 months prior to separation, noted complaints of back spasms and intermittent severe headaches.  Physical examination showed the CI was alert and oriented times three with normal mood and affect.  Speech was normal.  Cranial nerves II-XII were intact and symmetric.  Motor strength and sensation were normal throughout.  There were bilateral paraspinous muscle spasms throughout the cervical spine, thoracic spine, and lumbar spine.  Her gait was antalgic with a stiff back while walking, but with no evidence of spasticity in the lower extremities.  At a neurology clinic visit on 9 February 2004 it was noted the CI had Botox injections with slight improvement in her pain.  A trial of Keppra (levetiracetam, an anti-epileptic medication) was instituted.  During the 17 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported degenerative disc disease, severe migraine, and depression.  Physical examination revealed muscle spasms of the spine and limited movement.  Additional Botox injections were given on 2 April 2004.  A neurologist’s note dated 13 May 2004 indicated the CI was admitted for a trial of IVIG (intravenous immune globulin) for treatment of the stiff person syndrome, a progressive neurologic disease due to an autoimmune response against the spinal cord and basal ganglia.  The CI reported a 25% improvement in her symptoms after 3 days of IVIG.  A neurology note dated 3 August 2004 indicated the CI had significant improvement for about a 12 week period of time and her symptoms were beginning to recur with back spasms and headaches.  Treatment with IVIG was recommended for a 5-day outpatient course of which the STR had records from 24 August through 27 August 2004.  

At the 3 September 2004 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported chronic back and spinal neuromuscular problems with a diagnosis of stiff man syndrome with severe cervical and thoracic spine spasms, migraines, and depression. Physical examination showed a well-developed, well-nourished female, who was ambulatory, alert, cooperative, and in no apparent distress.  Her neck was supple with a full ROM with slight pain.  The back/spine was straight with no deformity and normal posture.  There was no muscle spasm of the lower back with a full ROM with pain.  Memory and coordination were normal.  Deep tendon reflexes were hyperactive.  Behavior, compression, and social occupational functioning were normal.  

At the 9 September 2004 C&P mental examination the CI reported a history of fatigue, irritability, and depressive symptoms, which stemmed from her limited mobility and difficulty performing her activities.  She was diagnosed with depressive disorder NOS, which was updated to major depressive disorder.  Treatment initially consisted of Zoloft and then Paxil (paroxetine, an antidepressant).  The mental status examination was unremarkable except for her affect that was broad and her mood was slightly depressed.  The Axis I diagnosis was major depressive disorder in partial remission.  Her Global Assessment of Functioning (GAF) score was 70 (some mild symptoms).  The examiner noted the CI’s symptoms were not significantly impairing in terms of their effects on social and occupational functioning.  An undated VA neurology consult (post August 2004) indicated the CI had “ripping, burning, charlie-horse, severe muscle spasms and knots with an extreme amount of back rigidity.  Spasms were widespread.  After the second course of IVIG her symptoms were much better.  Rheumatologic workup was negative and the sedimentation rate was normal.  She remained physically active, but somewhat curtailed.  She was taking Valium, baclofen, and Keppra, which helped her symptoms. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the stiff man syndrome condition 20%, analogously coded 5299-5025 (fibromyalgia).  The Navy PEB listed cervical spine spasm and thoracic spine spasm conditions as related diagnoses (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA rated the stiff man syndrome condition 40%, also coded 5299-5025, based on the C&P examination, citing “whenever there is 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.”  

Panel members noted that, although the diagnoses in the NARSUM were severe cervical spine spasm, severe thoracic spine spasm, and migraine headaches, at the time of separation neurologic evaluation favored the diagnosis of the stiff person syndrome for which treatment other than IVIG failed to resolve the muscle spasms.  IVIG provided initial improvement for at least 12 weeks, and an undated note indicated her symptoms were better; however, she was still taking muscle relaxers and an anti-epileptic drug.  Code 5025 requires symptoms including “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.” The PEB rated 20% where symptoms 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.” However, the CI symptoms were “constant, or nearly so, and refractory to therapy.” Although she did get some relief with the IVIG, the CI’s symptoms and disability are more consistent with a 40% rating rather than a 20% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the stiff man syndrome condition, coded 5099-5025.  

Contended Category III Conditions: Migraine Headaches and Major Depressive Disorder.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither of the conditions were noted on the limited duty form or implicated in her supervisor’s statement.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  However, each of the conditions was related to the Category I stiff man syndrome and could be classified as a Category II conditions.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the stiff man syndrome condition, the panel recommends a disability rating of 40%, coded 5099-5025 IAW VASRD §4.71a.  In the matter of the contended migraine headaches and major depressive disorder conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Stiff Man Syndrome	5099-5025	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 08 May 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.  

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 100 percent rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 40 percent disability rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.
 
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXX
                                  Acting