RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01730
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Network Switch System Operator/Maintainer, medically separated for “myofascial pain” with a disability rating of 0%.  “Major depressive disorder” and “migraine” conditions were determined to have existed prior to service (EPTS) and were not rated.  

CI CONTENTION:  The CI made a specific contention for myofascial pain condition and EPTS conditions; major depressive disorder and migraine headache 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 Medical Evaluation Board (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 - 20060810	VARD - 20070313	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain	5099-5021	0%	Myofascial Pain Syndrome	5099-5025	10%	20061127	
Major Depressive Disorder	9434	EPTS	Major Depressive Disorder	9434	50%	20061021	
Migraine	8100	EPTS	Migraine Headaches	8100	30%	20061127	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	

ANALYSIS SUMMARY:  

Myofascial Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s myofascial pain syndrome condition began insidiously as neck pain in January 2005 while deployed to Iraq without injury or trauma.  The CI underwent treatment with physical therapy, chiropractic, acupuncture, trigger point injections, and many classes of medications without significant or sustained improvement.  At the conclusion of the 12 April 2006 physical medicine and rehabilitation (PM&R) visit the physician recorded, “Had a long discussion with patient [concerning] the limitations of modern medicine and the fact that nothing we had done to date had achieved improving his quality of life or ability to tolerate the rigors of soldiering and some of what we have done has actually worsened his overall ability to function in society.  I feel that we have attempted all that we have to offer this gentleman.”  At a 2 May 2006 physical therapy (PT) evaluation, 5 months prior to separation, the CI complained of neck pain with movement.  Forward flexion was 40 degrees (normal 45) and combined ROM was 300 degrees (normal 340).  The examiner noted that ROM was limited by pain and cervical dysfunction on the left side of the neck.  

The 1 June 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant neck and back pain that worsened with activity.  The pain interfered with his ability to sleep.  The CI recalled that he had been treated with chiropractic manipulation that provided only temporary relief.  On physical examination his back showed a symmetric, erect, and relaxed posture.  There was bilateral tenderness of the trapezius, levator scapulae, and rhomboid muscles.  Gait was symmetric and non-antalgic.  

At a 17 July 2006 PM&R appointment, 2 months prior to separation, the physician noted that the CI’s symptoms did seem to meet the alternate criteria for the diagnosis of fibromyalgia that included upper and lower body pain on both sides for greater than 6 months and was associated with other syndromes such as migraine, chronic fatigue, depression, and insomnia.  She then opined that since she had already assigned a diagnosis of myofascial pain with palpable trigger points, further assigning a diagnosis of fibromyalgia would be in conflict with the American College of Rheumatology.  The 20 July 2006 PT ROM evaluation, 2 months prior to separation, noted complaints of upper back pain.  Forward flexion was 55 degrees (normal 90) and combined ROM was 175 degrees (normal 240).  The examiner stated that ROM was limited by pain.  At a 2 August 2006 rheumatology consultation, the conclusion of the rheumatologist was that the CI had undergone an extensive evaluation and numerous state of the art interventions with no improvement, and the CI was unlikely to be able to return to full duty.  He added that the CI’s condition did not meet the established criteria for fibromyalgia syndrome.  

At the 27 November 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported chronic daily pain and soreness at the base of the neck and across the upper shoulders which involved the trapezius muscle bilaterally.  He stated that the pain intensified to an extreme level approximately twice each week lasting one or two hours.  The severe episodes were precipitated by incorrect sleeping position, certain neck motions, and prolonged sitting in an upright position.  He also noted mid-thoracic and mid-lumbar discomfort that occurred mostly after walking.  He noted this to be less of a pain and more of a tightness.  He informed the examiner that the neck and back problems caused him to avoid running but otherwise caused no limitations in his daily activities.  Physical examination showed a brisk gait which was non-antalgic.  Cervical spine contour and alignment were normal without muscle spasm.  There was tenderness of bilateral trapezius muscles as well as the rhomboids.  ROM showed forward flexion 30 degrees (normal 45) and combined ROM 250 degrees (normal 340).  Painful motion was noted in most planes.  Thoracolumbar spine contour and alignment were normal with tenderness at the T7-T8 junction.  There was no tenderness or spasm of the paraspinal muscles.  Forward flexion was 90 degrees (normal) and combined ROM was 230 degrees (normal 240).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial pain syndrome condition 0%, coded 5099-5021 (analogous to myositis), citing cervical and thoracolumbar ROM limited by pain and the rheumatology evaluation indicating that the CI did not meet the established criteria for fibromyalgia syndrome.  The VA rated the myofascial pain syndrome condition 10%, coded 5099-5025, (analogous to fibromyalgia), based on the C&P examination, citing he was using over the counter ibuprofen on a daily basis.  

The panel noted that myofascial pain syndrome does not have a disability code listed in the VASRD but that the constellation of symptoms and anatomical regions involved is best represented by fibromyalgia (5025).  In reviewing the available evidence, the panel finds that the CI’s symptoms were treated with daily medications which satisfies the criteria for a 10% rating.  The panel found no evidence of episodic exacerbations precipitated by environmental or emotional stress to justify the next higher 20% 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 10% for the myofascial condition, coded 5099-5025.  

Major Depressive Disorder (MDD).  According to the STR and the MEB NARSUM, the CI’s MDD condition began in childhood with an initial episode at age 12 and a second at age 18, approximately 3 years prior to entering the Army.  He had a trial of multiple antidepressant medications for at least one of these episodes prior to service.  Neither the episodes nor the medications were disclosed on the enlistment physical.  Symptoms returned in early 2005 at the end of, or just after, a deployment to Iraq.  In May 2005 he was referred to mental health due to positive answers on a depression screening questionnaire.  

A 26 April 2006 developmental counseling form (recorded on DA Form 4856), 5 months prior to separation, reported the CI was a hard worker, was eager to take on new tasks and help others.  He was involved in a correspondence course which he independently initiated and his uniform standards were noted to be among the best.  The 2 May 2006 commander’s performance statement focused almost exclusively on the back complaints and noted that the CI “participated in many significant training events that boosted the readiness of [his] unit.”  The statement further notes that the CI “… remain[ed] an asset to this unit despite his condition.”  

The 5 June 2006 psychiatry MEB NARSUM examination, 4 months prior to separation, noted complaints of depressed mood that worsened with increased stress and had a negative impact on his duty performance.  His mood was stable but with continued mild depressive symptoms with constant feelings of worthlessness and hopelessness.  He denied any thoughts of self-harm or harm to others.  Additionally, he noted sporadic complaints of difficulty initiating sleep.  Mental status examination showed he was well groomed and oriented to person, place, time, and situation.  His affect was “strikingly flat.”  He displayed poor eye contact and his posture was head down.  He was noted to be guarded and quiet with low tone speech and flat inflection.  His thoughts were not confused, were linear and goal directed.  At the 11 June 2006 PM&R visit the CI reported that he had been on several antidepressants (Wellbutrin, Paxil, Prozac and Zoloft) as a child.  

At the 21 October 2006 VA C&P evaluation, 1 month after separation, the CI reported he had not been taking any of his medications for the previous 2 weeks because he had run out of them and had not yet established care with a physician.  He complained of depressed mood for the previous two years that he noted was since his return from a deployment to Iraq.  He described symptoms of depressed mood, low energy, low motivation, feelings of worthlessness, increased appetite with a 60 pound weight gain, periods of hypersomnia, anxiety, and worry.  He also complained of irregular sleep and difficulty concentrating.  He denied suicidal or homicidal thoughts.  He stated that he was able to maintain minimal personal hygiene and other basic activities of daily living.  Physical examination showed a severely depressed affect, tearful at times, and very poor eye contact.  The examiner opined that the CI had “some mild thought blocking during the interview” and he had difficulty remembering certain things.  His rate and flow of speech were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the MDD condition, coded 9434 (MDD), citing initial depressive symptoms at ages 12 and 18 and the opinion that the symptoms at the time of separation were consistent with the natural progression of his depressive disorder.  The VA rated the MDD condition 50%, coded 9434 (MDD), based on the C&P examination, citing severe symptoms and the VASRD criteria for a 50% rating.  

The panel first considered the PEB determination that the MDD condition was EPTS and not permanently service-aggravated.  A presumption of service aggravation may only be overcome by competent medical evidence (with such evidence based upon accepted medical principles as opposed to medical opinion) establishing by a preponderance of medical evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service IAW DOD 1338.32 E3.P4.5.2.3.  Panel members noted the CI offered a history of a depressive symptoms as a child and treatment for depression at least once.  The panel also noted that there was no evidence of depression at the time of the CI’s enlistment in 2003 and symptoms did not initiate until after he had returned from a deployment to Iraq.  Considering this data and the fact there was 5 years between the second and third episode, the panel concluded that the CI’s MDD condition was not the natural progression of the disorder.  Therefore, the panel finds it is at least as likely as not the MDD condition was service connected and/or service aggravated and as such recommends an additional disability rating.  

In weighing all of the available evidence, the panel found that although the CI complained of depressed mood, mild memory loss, and occasional difficulty with sleep, the occupational and social impact as characterized in the commander’s impact statement and the developmental counseling form were more representative of mild disorder.  The panel members found more probative value in the official statements of the CI’s commander and immediate supervisor with respect to occupational impairment.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the MDD condition, coded 9434.  

Migraine.  According to the STR and the MEB NARSUM, the CI’s migraine condition began in childhood and was resolved prior to entering the Army but returned with increased frequency and intensity in 2005 after completing a deployment to Iraq.  The 27 March 2006 neurology MEB NARSUM examination addendum, 6 months prior to separation, noted complaints of two separate and distinct type of headaches.  The first type was band-like, involving the temple and occipital region, occurring every other day, and was diagnosed as tension-type headaches.  The second type was more severe and concerning to the CI.  They occurred 1-2 times per week and lasted up to 3 days.  The headaches were described as being behind the right eye and associated with nausea, vomiting, and sensitivity to light, and were improved by sleep in a cold dark room.  He had been tried on a headache prophylactic medication prior to the evaluation which had no effect.  Physical examination showed a normal neurological evaluation.  The examiner referenced a January 2006 non-contrast head CT which was unremarkable.  The 2 May 2006 commander’s impact statement focused exclusively on the back condition and stated that the CI was still an asset to the unit and that he had “…no problem performing basic garrison duties…”  

At the 27 November 2006 C&P evaluation the CI reported he had 2 or 3 severe headaches in childhood beginning at age 6 or 7 years.  The CI reported that he had two types of headaches, the first was a band-like bi-temporal tightness headache which occurred on a daily basis and was not incapacitating.  The second type of headache was more severe and began at the end of his tour in Iraq.  He was having these severe headaches behind one or both eyes, 3 or 4 per week, which were associated with sensitivity to light, nausea, occasional vomiting, and a visual aura which consisted of zigzagging lines.  The headaches lasted from a few hours to all day.  He was not taking any prescription medications at that time but was using over the counter ibuprofen 800mg at the onset of headaches.  He also went to lie in a dark room and used ice packs to treat his headaches.  The examiner reported that the CI was “…completely debilitated to the point he just [got] up to go to the bathroom and stay[ed] in his room…”  Physical examination showed a normal neurological evaluation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the migraine condition, coded 8100 (migraine), citing the neurologist’s memorandum stating that the CI had migraine headaches prior to enlistment and the symptoms proximate to separation were consistent with the natural progression of the disorder.  The VA rated the migraine headaches with aura with tension headaches condition 30%, also coded 8100, based on the C&P examination, citing the CI’s report of headaches that were severe and weekly.  

The panel first considered the PEB determination that the migraine condition was EPTS and not permanently service aggravated.  A presumption of service aggravation may only be overcome by competent medical evidence (with such evidence based upon accepted medical principles as opposed to medical opinion) establishing by a preponderance of medical evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service IAW DOD 1338.32 E3.P4.5.2.3.  The panel noted that while the CI did relate a history of a limited number of similar headaches as a child, there was no evidence of these headaches in the first two years of the CI’s service in the Army.  Additionally, it is well established that neck pain is a potential cause of both tension-type and migraine headache syndromes and panel members noted that the CI’s neck and back pain was initiated close to the time of the commencement of the CI’s headache syndromes.  Therefore, the panel finds it is at least as likely as not that the headache syndromes are service connected and/or service aggravated and as such recommends an additional disability rating.  

Review of the record supported a conclusion that, during the several months prior to separation, the CI experienced prostrating headaches occurring on average once per month.  A rating of 30% was therefore justified.  The highest rating (50%) under 8100 requires that the prostrating attacks are very frequent and prolonged and are productive of severe economic inadaptability.  While the CI may have had frequent and severe headaches, the commander’s statement refutes the 50% rating requirement of being productive of severe economic inability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the migraine condition, coded 8100.  

BOARD FINDINGS:  In the matter of the myofascial pain condition, the panel majority recommends a disability rating of 10%, coded 5099-5025 IAW VASRD §4.71a.  The single voter for dissent recommends modification to 40% and elected not to submit a minority opinion.  In the matter of the MDD condition, the panel recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  In the matter of the migraine condition, the panel recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  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, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Pain	5099-5025	10%	
Migraine	8100	30%	
Major Depressive Disorder	9434	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170401, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005840, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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 U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure