RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02904
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20060725

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Computer System Operations Craftsman, medically separated for “chronic neck pain, status post C5-6 and C6-7 fusion with normal neuro-diagnostic studies with secondary pain disorder” with a disability rating of 10%.   

CI CONTENTION:  Requested review of major depression and fibromyalgia as well as other conditions rated by the VA.  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 FPEB - 20060607	VARD - 20080201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain, Status Post C5-6 and C6-7 Fusion…with Secondary Pain Disorder	5241-9422	10%	Intervertebral Disc Syndrome, S/P Cervical Fusion, with Cervicalgia	5243	20%	20071115	
			Major Depression Secondary  to Medical Problems, Recurrent	9434	30%	20071119  	
Myofascial Pain Syndrome (Fibromyalgia-like)	5099-5025	Cat II	Fibromyalgia	5025	20%	20071115	
Seasonal Allergic Rhinitis	6522	Cat II	Chronic Maxillary Sinusitis	6513	30%	20071119  	
History of Colon Polyps	7344	Cat II	Colon Polyps	7344-7334	10%	20071115	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Chronic Neck Pain with Secondary Pain Disorder.  The PEB combined a cervical spine condition and secondary pain disorder under a single disability rating employing the hyphenated code 5241-9422 (spinal fusion [rated under the VASRD §4.71a general spine formula] – pain disorder [rated under the VASRD §4.130 general formula for mental disorders]).  The panel’s initial charge in this case was therefore directed at determining if this combining of conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the cervical spine condition and secondary pain disorder are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Neck Pain:  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered from chronic neck pain since 1995.  An MRI in April 2004 demonstrated disc disease at C5/6 and C6/7, with “mild” right C6 neural impingement, and she underwent a C5-C7 fusion a few months later.  The surgery provided interim relief, but symptoms returned.  Repeat imaging demonstrated normal alignment and hardware placement without significant neural impingement.  The pain persisted despite protracted conservative treatment, including multiple epidural steroid injections, and no further surgery was indicated.

Although there was occasional mention of grossly normal range of motion (ROM) in the STR, most clinical entries noted non-specific ROM limitations which were not quantified in degrees, although estimates of “moderate” or “50%” reduction were noted.  There was no documentation of formally measured cervical ROM, and the most probative entry was a neurosurgery note on 9 November 2005 which recorded that “active ROM without inclinometer” of cervical flexion and extension was “moderately limited” by pain.  There was STR documentation of normal spinal contour and no record of incapacitating episodes.

The 31 October 2005 MEB NARSUM examination, 9 months prior to separation, documented non-specific neck pain that limited lifting, load-bearing, and prolonged sitting or standing.  The examiner referred to “neurosurgery notes” for the physical examination (summarized by the evidence above), and correlated all findings to “chronic cervalgia,” with all other conditions solely listed as elements of past medical history.  The U4 profile restrictions were a result of the cervalgia, and the commander’s performance statement, supplemented by five other reviewers, also implicated the neck pain, which was the only condition submitted by the MEB.

The 12 December 2005 initial Informal PEB (IPEB) determined that only the chronic neck pain was unfitting, coded 5241 and rated 10%, and listed allergic rhinitis and colon polyps as Category II (can be unfitting but not compensable or ratable) conditions.  The other pain conditions adjudicated by the Formal PEB (as charted above) were added after appeal and were not addressed in a NARSUM addendum or revised MEB submission that was available in evidence.

At the 15 November 2007 VA Compensation and Pension (C&P) examination, 16 months after separation, the CI reported neck pain that flared “every 3 or 4 months” to a level of 8/10.  She stated “my doctor told me that I am totally incapable of working … because I can’t do any physical activity without more pain.”  The examiner did not elaborate the specific contribution of neck pain, versus other sources of pain, to the CI’s reported limitations.  Physical examination showed a normal spinal contour with tenderness but no mention of spasm; neurological findings were also normal.  Measured ROM was flexion to 20 degrees (normal 45) and a combined ROM of 160 degrees (normal 340), with painful motion but no ROM degradation on repetition.  

The panel first deliberated whether the cervical spine condition could be justified as separately unfitting.  Members considered that it was implicated by the profile and in multiple commanders’ statements; that it was the original basis for MEB referral; and, that it was judged to be separately unfitting by the IPEB with no evidence that it was less severe by the time of the final PEB.  The panel therefore agreed that by a preponderance of the evidence, the cervical spine condition was justified as separately unfitting and thus eligible for separate rating as a single condition.

The panel directed attention to it rating recommendation.  As noted above, the FPEB rated the bundled chronic neck pain and pain disorder 10%, coded 5241-9422.  The VA rated the intervertebral disc syndrome status post cervical fusion 20%, based on the C&P examination, citing flexion greater than 15 degrees but not great than 30 degrees; or combined ROM not greater than 170 degrees.  Members agreed there was satisfactory evidence of painful motion to support a minimum rating of 10% (VASRD §4.59), but no evidence for abnormal spinal contour to support a 20% rating, and no documentation of incapacitating episodes that would provide for a higher rating under that formula.  Members noted the only formally measured ROM found in the C&P examination was fairly temporally remote from separation but met criteria for a 20%.   The panel ultimately agreed that reasonable doubt favored conceding a 20% rating based on these ROM measurements, which were compliant with VASRD §4.46 (accurate measurement), and reasonably corroborated by the service evidence.  A logical extrapolation of the amply documented “moderate” limitation in the STR, was that the ROM fell within 20% parameters, and it was agreed that the CI should not be penalized by the service omission of (or missing evidence for) measured ROM.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a separate disability rating of 20%, for the cervical spine condition, coded 5241.

Secondary Pain Disorder:  The CI was diagnosed with adjustment disorder with symptoms of anxiety and “mild” depression in 2001, and was treated with medication (Wellbutrin).  The diagnosis was changed to “pain disorder due to general medical condition and psychological factors” in 2005 (several months prior to the initial IPEB).  There was no evidence of any significant psychiatric acuity (psychosis, suicidality, etc.) or inpatient treatment, and depression was not a prominent complaint in service mental health notes.  After appealing the initial IPEB adjudication, the CI underwent an additional psychiatric assessment on 10 May 2006.  The diagnosis was unchanged and the DoDI 1332.39 derived assessment of social and industrial impairment was “mild.”  The FPEB decision documented the CI’s testimony that “her only limiting factor regarding activities of daily living and her duty is pain.”  All of the commanders’ performance statements documented good administrative performance, with one explicitly stating that she “has the mental capability to accomplish the work but not the physical.”  The profile remained S1 throughout service.  At the 19 November 2007 C&P mental disorder examination, 16 months after separation, The CI complained of more severe depression, and stated that she had under-reported her symptoms in the military to avoid the “stigma” and “detrimental effects” on her career.

The panel directed attention to its recommendations based on the above evidence.  The PEB’s consolidated rating did not specify any §4.71a criteria; but, cited “mild social and industrial adaptability,” a 10% criterion for psychiatric impairment IAW DoDI 1332.39 (E2.A1.5) that would be applicable only to the pain disorder.  It was noted that the VA diagnosis of major depression was not a service diagnosis, and not within the panel’s scope of review for consideration as a separate and distinct condition.  The panel’s recommendation is based on overall psychiatric impairment independent of a specific diagnosis, and in that regard, members considered whether the pain disorder, when de-coupled from the combined PEB adjudication, could be reasonably justified as separately unfitting.  Members agreed that the psychiatric assessment, profile, and commanders’ statements compellingly indicated that there was no unfitting psychiatric impairment; and, the CI testified as much.  The panel therefore concluded that by a preponderance of the evidence, the secondary pain disorder would not have caused the CI to be referred into the DES or to be found unfit; and, therefore, was not subject to rating.

Contended PEB Condition:  Myofascial Pain Syndrome (Fibromyalgia-like).  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was fairly adjudicated as Category II and not subject to rating.  There were no CI complaints of more generalized pain identified in STR clinical entries before the initial IPEB.  Shortly after the IPEB, a pain specialist documented only cervical associated symptoms.  However, in a follow-up visit 6 weeks later, the examiner noted that the CI “asked about fibromyalgia and has done some research… complains of generalized body soreness consistent with fibromyalgia.”  This appears to be the first STR documentation of symptoms related to a diagnosis of either myofascial pain syndrome or fibromyalgia.  Laboratory testing for lupus and other rheumatologic disorders was negative.  The CI was treated for a working diagnosis of fibromyalgia without apparent improvement, and clinical notes did not provide details or rate the severity of musculoskeletal symptoms.  There was reference to irritable bowel syndrome and fatigue (associated with fibromyalgia), but these were not elaborated.  

A memorandum to the PEB from the CI’s primary care physician of 8 February 2006 (6 months before separation) stated, “Some of her symptoms are similar to pain seen in myofascial pain syndrome and fibromyalgia and may affect her treatment but they are not the source of any physical limitations.”  Although the source examination is not in evidence, the Secretary of the Air Force, Medical Review Board Agency (SAF/MRBA) decision stated that an evaluation by a civilian rheumatologist on 19 May 2006 (2 months before separation) “identified ‘mild tenderness’ along the neck and costochondral junctions, but did not conclude with the diagnosis of fibromyalgia.”

The 15 November 2007 C&P examination stated the CI had been diagnosed with fibromyalgia in January 2006 and also related a diagnosis of lupus (both of these assumptions contrary to the service evidence).  The examiner documented CI complaints of constant pain in multiple bilateral major joints and “stiffness in [her] entire spine,” fatigue, sleep disturbance, and diarrhea alternating with constipation.  The physical examination documented multiple trigger points (10), but not the requisite number (11) to support a diagnosis of fibromyalgia.  

The panel noted that, although the PEB adjudicated the myofascial pain syndrome (fibromyalgia-like) condition as Category II, the SAF/MRBA decision acknowledged the “close interrelationship” of this condition with the neck pain and secondary pain disorder, and concluded that no separate rating could be derived without violation of VASRD §4.14 (avoidance of pyramiding).  The panel agreed with this assessment, with the caveat that the neck pain and psychiatric impairment could be parsed for separate fitness and rating consideration as detailed above.  Members also adjudged that there was insufficient evidence for a diagnosis of fibromyalgia (meeting established criteria and confirmed by a rheumatologist), although analogous rating as fibromyalgia could be justified if indicated. 

Panel members considered that the condition was not profiled (with designations of P1 and L1 encompassing all of the constitutional and non-cervical elements of the condition) and not implicated in multiple commanders’ statements.  The non-cervical pain and somatic complaints were not a cause for MEB referral, and as such, were subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral) that stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  After due deliberation, members agreed that the preponderance of the evidence supported a conclusion that the myofascial pain syndrome was not reasonably justified as separately unfitting; and thus, not subject to rating.

Contended PEB Conditions:  Seasonal Allergic Rhinitis and History of Colon Polyps.  The panel’s main charge is to assess the fairness of the PEB determination that these conditions were fairly adjudicated as Category II and not subject to service rating.  The CI had a chronic history of seasonal rhinitis complicated by occasional sinusitis requiring antibiotics.  Surgery in 2003 resulted in no improvement, but the condition was stable over a 4-year period prior to separation.  The CI also had a history of colon polyps diagnosed in 2000 with no associated excessive bleeding or other complications, and the condition was stable over a 6-year period prior to separation.  There was no STR evidence for any significant clinical acuity of either condition over the period of MEB proceedings.  Neither of the conditions was profiled or implicated in the commanders’ statements, and there was no performance-based evidence from the record that either of them significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB Category II determinations for the seasonal allergic rhinitis or history of colon polyps, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic neck pain with secondary pain disorder, the panel recommends:  an unfitting cervical spine condition rated 20%, coded 5241 IAW with VASRD §4.71a; and a secondary pain disorder that was not justified as separately unfitting and not subject to service disability rating.   In the matter of the contended myofascial pain syndrome, seasonal allergic rhinitis and history of colon polyps, the panel recommends no change from the PEB determinations as Category II and not service ratable.  There are no other conditions within the panel’s scope of review.

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Cervical Disc Disease with Surgical Fusion	5241	20%	
Secondary Pain Disorder 	Not Unfitting	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170403, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2017-02904.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachments:
1.  Directive
2.  Record of Proceedings