RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-03231
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20061128

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Yeoman, medically separated for “the overall effect of the following diagnoses contribute to the unfit finding: migraine headache, major depressive disorder, fibromyalgia, chronic pelvic pain syndrome, sleep disorder, and endometriosis” with a combined disability rating of 0%.

CI CONTENTION: “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 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 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 - 20070214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	

Overall Effect	

0%	Migraines	8100	50%	20060710	
Major Depressive Disorder			Depressive Disorder	9434	30%	20060710	
Fibromyalgia			Fibromyalgia with…Sleep Disorder	5025	40%	

20060710	
Sleep Disorder							
Pelvic Pain Syndrome			Pelvic Pain Syndrome with Endometriosis and Vestibulitis	
7699-7629	
10%		
Endometriosis							
Vestibulitis	
Category III					
Interstitial Cystitis		Interstitial Cystitis	7512	20%		
Allergic Rhinitis		Allergic Rhinitis	6522	0%		
Reflux Esophagitis		Chronic Heartburn	7399-7346	0%		
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 90%	

ANALYSIS SUMMARY:

Introduction. As detailed in the case summary, the PEB combined multiple conditions under a single service rating. This was based on a PEB determination that these conditions were collectively unfitting due to their overall effect (OE) IAW DoDI 1332.38 (E3.P3.4.4), thus the PEB’s determination for each individual OE condition was that it was not separately unfitting. The panel’s initial charge in this case was therefore directed at determining if combining conditions under OE provisions was justified in lieu of separate ratings. In so doing, the panel had to assess

if there was a preponderance of evidence to establish whether any OE condition in isolation would have caused the CI to be referred into the DES and found unfit. The evidence in this regard is presented separately for each condition. When there is significant clinical and functional overlap of conditions (subject to application of VASRD §4.14, avoidance of pyramiding), they will be subsumed with the most closely associated primary condition. Applicable coding and rating recommendations will be offered for any condition judged to satisfy the preponderance of evidence standard for separate service rating. All conditions not so judged will remain within the PEB’s OE classification, and the panel is not empowered to recommend a change in the OE rating percentage.

Migraine Headaches. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a history of headaches dating to 2002. These were diagnosed as migraines and the clinical features did not appear to change over time.  A neurology note on   19 January 2006 documented a recent escalation of the headaches, corroborated a diagnosis of chronic migraines, and prescribed Elavil (anti-depressant) in addition to maintenance treatment with Topamax already in place. The neurologist recorded a headache frequency of 4-6 times a month, lasting all day, but gave no indication that any were prostrating or interfered with work. A primary care entry, 2 months later, documented treatment of a breakthrough headache (successfully with Zomig) that included a 24-hour quarters assignment. There was no other STR evidence of any emergent treatment, regular specialty management, duty excuses for headaches, or significant clinical acuity.

The 24 April 2006 MEB NARSUM examination, 7 months prior to separation, documented a history of migraines and continued treatment with Topamax. There was no record of symptom acuity, headache frequency, or functional impairment attributed to headaches, and the migraine condition was not listed on any limited duty board (LIMDU) forms. The commander’s non- medical assessment (NMA) did not specify individual conditions or note any functional limitations attributable to headaches. Significant work loss (12 hours per week) was ascribed to all conditions, but there was no indication of work loss specifically due to headaches.

At the 10 July 2006 VA Compensation and Pension (C&P) examination, 5 months before separation, the CI reported one or two prolonged headaches every week that rendered her unable to work. The examiner did not elaborate any history of emergent treatment, physician intervention or authorization, or further details in corroboration of the stated acuity. In contrast with the recorded symptoms, the VA examiner opined that the functional impairment from the migraines was “mild.”

The panel deliberated whether the migraine condition could be justified as separately unfitting, applying the OE preponderance of evidence standard as elaborated above. The significant disparity between the above VA account of headache severity and the overall service evidence was noted, but panel members agreed that the VA evidence was not sufficiently probative as the sole basis for the panel recommendation. There was no STR corroboration of headaches as severe and incapacitating as portrayed in the VA examination. Headaches as the sole basis for the reported work loss would have logically been addressed more aggressively by service providers and warranted specific mention by the commander. Furthermore the migraine condition was not noted on the LIMDU report. Thus, the panel agreed that too much speculation would be required to conclude, based on a preponderance of evidence, that there were migraine- specific performance limitations that would have rendered the CI unfit independently of OE considerations. After due deliberation, the panel determined that there was insufficient cause to recommend a change in the PEB adjudication for the migraine condition.

Major Depressive Disorder (Subsuming Sleep Disorder). The CI reported symptoms of depression shortly before the onset of pelvic pain (addressed below) in late 2004. Intermittent sleep disturbance was variably ascribed to the depression and to pain, and an associated complaint of

fatigue also emerged at that time and was attributed to depression. She was prescribed Lexapro (antidepressant) by primary care, and there was no STR evidence for suicidal ideation or other acute features, and no psychiatric hospitalizations. There was no mental health (MH) diagnosis on the LIMDU form, and the commander’s NMA did not implicate any MH impairment. The MEB psychiatric addendum corroborated the above history and reiterated that the depressive symptoms emerged prior to the pain symptoms. The examiner documented that the CI “states that her depressive symptoms are largely in remission except for sleep problems and fatigue.” The sleep disturbance was cyclical and the fatigue was constant. The mental status examination (MSE) and cognitive functioning were normal. The Axis I diagnosis was “major depressive disorder, moderate, in remission – controlled by Lexapro,” with a Global Assessment of Functioning (GAF) scored (subsuming the Axis IV limitations) of 60 (mild and moderate impairment). The MEB psychiatrist opined that the CI was fit for full duty from a MH standpoint. Probative to the panel’s overall OE assessment, the examiner added, “Due to the constellation of the patient's physical symptoms [emphasis added], she has demonstrated an inability to meet the tasks, rigors and demands of active duty service.”

The 10 July 2006 VA C&P mental disorders examination documented the only active MH symptoms as “feels depressed...tired frequently...poor sleep...[and]...some memory problems [which were attributed to Topamax].” The MSE was normal except for a “slightly dysphoric” mood, and there was no objective memory impairment. The Axis I diagnosis was “depressive disorder, not otherwise specified,” and the GAF score (subsuming Axis III medical problems) was 55 (moderate impairment). The VA psychiatrist stated that the CI had not missed any work due to MH issues.

Of note there were follow-up service MH entries in the STR covering the interval between the VA examination and separation. These portrayed a stable course except for the need for a medication adjustment (Cymbalta substituted for Topamax). The final MH entry on 2 August 2006, documented a favorable response to Cymbalta, a normal MSE, an overall GAF assignment of 60, and continued fit for duty status. The panel deliberated whether the MH condition could be justified as separately unfitting and agreed that there was not a preponderance of evidence for MH-specific performance limitations rendering the CI unfit independently of OE considerations. The MEB psychiatric opinion (unrefuted by the VA psychiatric evidence) would in fact support an argument that there was no unfitting MH impairment. After due deliberation, the panel determined that there was insufficient cause to recommend a change in the PEB adjudication for the depressive disorder.

Fibromyalgia. In mid-2004, well after the diagnosis of migraines, and at least 6 months after the onset of the pelvic pain and depression, the CI developed symptoms that were subsequently diagnosed as fibromyalgia (FMA). There were no routine STR provider entries that appeared to specifically address these complaints, but according to a 15 June 2006 rheumatology addendum to the NARSUM, symptoms included “pain in her back which spread to her neck, knees, wrists and then developed into a total body pain and aching.” The NARSUM documented a history of FMA and “adequate control of her pain” over the preceding months, although it was not specified if this included the FMA complaints or referred just to the pelvic pain. It also noted “frequent flares preventing her from participating in any type of physical training ... [or] ... functioning well while she is at work,” again not specifying whether this referred to all complaints. The LIMDU report listed a diagnosis of FMA with general limitations on physical activities, and the commander’s NMA was nonspecific. The rheumatology addendum confirmed a diagnosis of FMA by trigger points on examination, but ascribed the constellation of musculoskeletal pain, pelvic pain, migraines, depression, insomnia, and fatigue to an overall diagnosis of FMA. In this context, the examiner documented that the symptoms “come and go” but are present “most, if not all, of the time.” The addendum noted exacerbation of the pain with activity and prolonged sitting, and little improvement with the medications already prescribed for chronic pain and depression.

The pre-separation VA C&P examination relied on the service rheumatology diagnosis and stated that the FMA pain was “primarily in the knees, the legs, the back and the neck.” The VA examiner, however, included insomnia, fatigue, and dyspepsia (the Category III reflux esophagitis addressed below) as FMA-related symptoms. The fatigue was characterized as constant, but the frequency and severity of the overall symptoms was not elaborated. The examiner noted a lack of response to water aerobics and acupuncture, but was otherwise silent with regard to the overall response to treatment. The VA examiner stated that the FMA condition (incorporating all of the above symptoms) had resulted in a work loss of approximately 3-4 weeks over the past year, and opined that the functional limitation was “moderate.” Of note, the final MH follow-up entry before separation (referenced above, a month after the C&P examination) stated that the CI was pain- free on that occasion.

Panel members agreed that if the entire constellation of symptoms subsumed with the FMA diagnosis by both the service rheumatologist and the VA examiner were considered together, the combined impairment could be reasonably argued as incompatible with continued service. That premise, however, was not compatible with the clinical evidence (different onsets and pre- existing diagnoses prior to the emergence of FMA symptoms), and the resulting rating would constitute pyramiding. Any attempt to reapportion the conditions under different diagnoses would be fraught with speculation, thus strengthening a conclusion that it was the constellation of conditions that was unfitting (the foundation of an OE determination). If the impairment from the musculoskeletal pain alone was assigned to a diagnosis of FMA, panel members agreed that there was not a preponderance of evidence to establish that it in isolation would have rendered the CI unable to satisfactorily perform her duties. After due deliberation, the panel determined there was insufficient cause to recommend a change in the PEB adjudication for the FMA.

Chronic Pelvic Pain Syndrome (Subsuming Endometriosis and Category III Vestibulitis and Chronic Interstitial Cystitis). The CI suffered an onset of right lower quadrant pelvic pain in November 2004, and an ultrasound revealed ovarian cysts (polycystic ovarian syndrome). A trigger point injection into the involved area resulted in temporary relief, but the pain returned, and she underwent a diagnostic laparoscopy that yielded a diagnosis of endometriosis. The pain responded to hormonal therapy, but was not satisfactorily controlled, and she was additionally diagnosed with interstitial cystitis (chronic inflammation of the bladder wall) contributing to her pelvic pain. The only associated urinary symptom was frequency (no painful urination), and there were no associated infections or other complications. A diagnosis of vestibulitis referred to inflammation of the pelvic floor (vestibule), logically due to the endometriosis (not inner ear disease as commonly connoted by that diagnosis).

The MEB NARSUM noted improvement of the pelvic pain as elaborated above for FMA, albeit with continued impairment of physical activities (not extricable from the FMA pain and other conditions). The NARSUM did not include an abdominal or pelvic examination, and the MEB’s physical examination did not document any positive findings. The LIMDU form listed diagnoses of chronic pelvic pain, endometriosis, and vestibulitis with general limitations as above, and the commander’s NMA was nonspecific.

At the pre-separation VA C&P examination, the examiner documented nonspecific pelvic pain without elaborating specific limitations, but opined that the overall functional impairment was “moderate.” The interstitial nephritis was separately addressed with a history urinary frequency “as often as every hour” and “very rare” incontinence with no associated pain on urination or otherwise. The examiner opined that the overall functional impairment was “minimal.” The abdominal examination was normal without tenderness. The panel noted that the above psychiatric evidence that the CI was pain-free, in the interim both before and after the C&P examination, was applicable to the pelvic pain as well.

The panel deliberated whether the chronic pelvic pain (and subsumed conditions) could be justified as separately unfitting per the OE standard. Panel members agreed that there was not a preponderance of evidence for specific performance limitations attributable to the pelvic pain (and subsumed conditions) that would render the CI unfit independently of OE considerations. The pelvic pain was improving at the time of the NARSUM, and undue speculation would be required to extricate the functional impairment from it alone that would have unacceptably interfered with satisfactory performance of her duties. As with the FMA, there were pyramiding issues, and the urinary symptoms (characterized as mild by the service evidence) would not have significantly impacted fitness. After due deliberation, the panel determined there was insufficient cause to recommend a change in the PEB adjudication for the chronic pelvic pain (and subsumed conditions).

Remaining Category III Conditions: Allergic Rhinitis and Reflux Esophagitis. There was no clinical acuity associated with either of these conditions at the time of separation, and neither was listed on the LIMDU report or implicated in the commander’s NMA. There was no performance-based evidence from the record that either condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the fitness determinations for either of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the migraine headaches, depression (subsuming sleep disorder), fibromyalgia and chronic pelvic pain (subsuming endometriosis, vestibulitis and interstitial cystitis), the panel recommends no change in the PEB’s combined overall effect adjudication. In the matter of the contended allergic rhinitis and reflux esophagitis, the panel recommends no change from the PEB determination as not unfitting. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO :
1850
CORB: 003
10 Sep 20

From: Director, Secretary of the Navy Council of Review Boards To:	

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) Ref:	(a) DoDI 6040.44
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy on 13 Aug 2020 for appropriate action.

2.	On 27 August 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.