RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-04221
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090331

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Paralegal Specialist, medically separated for “fibromyalgia” with a disability rating of 20%.

CI CONTENTION: She was given a higher rating by the VA for the fibromyalgia condition. The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (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 - 20090224	VARD - 20090915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia	5025	40%	20090630	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 80%	
	
ANALYSIS SUMMARY:

Fibromyalgia. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI initially developed back and bilateral hip pain in 2005 that progressively worsened and spread to both hands and other joints. Despite conservative treatment, her body pain continued. A rheumatology consultation rendered a fibromyalgia diagnosis after noting fatigue, myalgias, non-restorative and interrupted sleep symptoms; and also multiple musculoskeletal  trigger  points.     To  help  control  fibromyalgia  pain,  the  CI  was  placed    on

medications which were discontinued in early 2008 after she became pregnant. The rheumatologist referred further medical management to the CI’s obstetrician and psychiatrist.

At the 18 November 2008 narrative summary (NARSUM) examination, 4 months prior to separation, the CI’s chief complaint was “fibromyalgia.” The CI endorsed the ability to perform basic activities of daily living, but she was unable to march, run, jump, stoop, crawl, or perform push-ups or sit-ups. The physical examination (PE) was normal except for the presence of trigger points of pain. Joint and spine range of motion (ROM) were not documented. The provider documented that “Positive trigger points were noted in the occipital (back of the head) muscles bilaterally, anterior lower cervical area bilaterally, second costochondral (upper rib cage) junction bilaterally, trapezius muscles bilaterally, supraspinatus muscles bilaterally, greater trochanteric area of the hips bilaterally, the lateral epicondyles (elbows) bilaterally, and the medial aspect of the knees bilaterally.”  The fibromyalgia diagnosis was continued.

At the 30 June 2009 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported that her fibromyalgia condition was located in her “entire body.” The examiner documented that “the [CI] has easy fatigability, headaches, sleep disturbance and depression,” and also noted were that her symptoms occur constantly, “which means more than 2/3 of the time per year.” She was reported to have no stiffness, anxiety, Raynaud's-like symptoms, paresthesia, musculoskeletal pain or weakness and no gastrointestinal disturbances.

The summary also stated that the symptoms were precipitated by emotional stress and environmental stress of extreme cold. Symptoms were alleviated by rest. Her ability to perform daily functions during flare-ups was sometimes at a bare minimum. She reported no prior hospitalizations or surgery and functional impairment was described as “…some days difficult to get out of bed.” She did not miss any time from work due to the fibromyalgia. Current medications included Lyrica and morphine sulfate which both were reported as having a favorable response to her condition. The VA PE was detailed and noted the presence of 12 tender points over areas from the CI’s head to her knees which included her spine, shoulders, chest, and arms. The condition was considered not to cause generalized muscle weakness or wasting. Various X-rays to include the sinuses, knees and feet were normal. Lumbar spine X-rays revealed minimal and diffuse degenerative arthritis with mild multilevel degenerative disc space narrowing.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the fibromyalgia condition 20%, coded 5025 (fibromyalgia), citing episodic flares with symptoms present more than one-third of the time with exacerbations precipitated by environmental stress. The VA used the same code and rated the fibromyalgia condition 40%, based on the C&P examination, citing 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 first agreed the pre-separation NARSUM and post-separation VA examination held equivalent probative value based upon the description of physical findings as well as the detailed clinical examination. The minimum compensatory VASRD criterion for fibromyalgia is based upon the continuous use of medication for the control of symptoms. In this case, panel members acknowledged that the CI’s pregnancy significantly interfered with her ability to take certain medications, but the evidence of her being placed back on pain medication shortly after separation (and post-delivery) supported that such medication was required near the time of separation and thus supported a 10% rating for requiring continued medication for control.

A 20% rating includes “episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time,” while

a 40% rating requires having “constant or nearly so [symptomatology], and [being] refractory to therapy.” Panel members agreed a 20% impairment was supported based on the CI’s symptoms that were episodic with exacerbations often precipitated by environmental or emotional stress and according to the VA provider, present more than two-thirds of the time per year.

The panel deliberated and considered the CI’s condition episodic and not refractory to therapy which does not support a 40% rating. The VA evidence, which was more proximate to separation, showed the CI had a “favorable response” to fibromyalgia medication, was able to perform daily activities except during “flare-ups,” and had “some days” when it was difficult to get out of bed. Therefore, after due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB’s 20% adjudication for the fibromyalgia condition.

BOARD FINDINGS: In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. The panel recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

	PD-2017-04221

AR20190012193, XXXXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

	PD-2017-04221