Office of the Assistant Secretary

DEPARTMENT OF THE AIR FORCE
WASHINGTON DC

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

6 June 2018

DearXXXXXXXXX
Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00091.

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. Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.
I have 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 aforementioned 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 (210) 565-2273 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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-00091
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20080425

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

CI CONTENTION:  “Please 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 - 20080129	VARD – 20081204*	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia	5025	40%	20080814	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	
*Initially rated 10%, determined to be a clear and unmistakable error and corrected to 40% on 20141205.. 

ANALYSIS SUMMARY:

Fibromyalgia.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s fibromyalgia condition began in approximately January 2006 when she noted some discomfort, initially in her hands and later in her back, knees, and ankles, with some swelling in her fingers and some morning stiffness.  She was diagnosed with fibromyalgia in April 2006.  Treatment consisted of sertraline (an antidepressant medication).  Tramadol, an opioid-like medication, was added in January 2007.  At a rheumatology visit that month, the CI had tender points in the left myofascial region of the neck/shoulder.  Physical training was recommended.  In March 2007 the CI reported pain in both knees, not related to injury, but with activity, which was treated with oral steroids.  At a family practice visit on 27 July 2007 the CI complained of a headache and was continued on tramadol, cyclobenzaprine (a muscle relaxer), and sertraline for the fibromyalgia, with the addition of acetaminophen and ibuprofen to the medication protocol.  At a family practice visit on 10 September 2007, her symptoms were manageable with the multiple medications but worse when doing repetitive heavy lifting as part of her duties as an ammunition line delivery troop.  

The 10 September 2007 MEB NARSUM, 8 months prior to separation, noted complaints of progression of the fibromyalgia to increased diffuse joint stiffness, swelling, and pain as well as low back pain.  The examiner noted the CI denied significant difficulty accomplishing daily duties while using her current medication regimen.  However, the use of controlled medication was growing as was the frequency of new pain symptoms.  At the 17 October 2007 rheumatology visit, 6 months prior to separation, the CI related her sleep habits had worsened and she was having more pain, predominantly in her back, hip, neck, and knees, without swelling.  Physical examination revealed tender points of the anterior pectoral, trapezoid, trochanteric, and sacroiliac regions.  Lunesta (eszopiclone) for sleep was added to the medication protocol.  

The 7 November 2007 MEB NARSUM Addendum examination, 6 months prior to separation, noted complaints of continued bilateral shoulder, lower back, hip, and knee pains.  The pain was controlled with tramadol, cyclobenzaprine, eszopiclone for sleep, and acetaminophen.  She could not perform her duties as an armaments technician due to the demands of heavy lifting.  The 17 December 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of fibromyalgia progression with increased diffuse joint stiffness, swelling, and pain as well as low back pain.  

At the 14 August 2008 VA Compensation and Pension (C&P) General evaluation, 4 months after separation, she complained of tenderness of her spine, back, arms, legs, and hips.  All the areas were tight and stiff and she had multiple tender points.  She used tramadol, cyclobenzaprine, and Amitrix (chlordiazepoxide and amitriptyline) for muscle pain.  She had tightness and soreness in all the areas while at work and had problems in the morning when it took 2 hours for her to get ready.  She tired easily, had less strength, and complained of fatigue if she were to walk a half mile.  She also complained of recent memory/cognitive problems.  Activities of daily living were affected only with repetitive activities.  Physical examination showed the right and left knees with no deformity, heat, erythema, or effusion.  There was subpatellar crepitus on the left, but not on the right.  There was no laxity or evidence of a meniscal tear and no antalgic gait.  There were 14/18 tender points in the areas for the diagnosis of fibromyalgia, which needs 11/18 for the diagnosis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia condition 20%, coded 5025 (fibromyalgia).  The VA initially rated the fibromyalgia condition 10%, but revised it to 40% based on a clear and unmistakable error, also coded 5025, based on the C&P evaluation 4 months after separation, citing continuous widespread musculoskeletal pain and tender points. 

Panel members noted the CI had the features of fibromyalgia with multiple tender points necessary for the diagnosis as well as fatigue, sleep disturbance, stiffness, headache, and irritable bowel symptoms.  A 40% rating requires symptoms “that are constant, or nearly so, and refractory to therapy.”  The CI had symptoms from the time of diagnosis through the VA examination, 4 months after separation, even with the myriad of medications she was taking for pain including tramadol.  Members noted that the fibromyalgia was progressive and was constant for some symptoms and nearly constant for other symptoms, while new symptoms developed.  The panel majority felt the CI met the requirement for a 40% rating due to the myriad of constant, or nearly so, symptoms of the fibromyalgia that were not adequately controlled with multiple medications.  The minority member did not agree that the CI’s symptoms were “constant or nearly constant and refractory to treatment” as required by the VASRD criteria for a 40% rating.  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 recommends no re-characterization and elected not to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel majority recommends the CI’s prior determination be modified as follows; and, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective 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 20161221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record