RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04237
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20091128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, Materiel Management Craftsman, medically separated for “fibromyalgia” and “low back pain (LBP) due to degenerative disc disease (DDD),” rated 20% and 0% respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Request the PDBR 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’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 - 20090616	VARD - 20100123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia also claimed as Chronic Pain Syndrome	5025	10%	20091118	
LBP due to DDD	5242	0%	Mechanical Back Pain	5237	10%	20091118	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Fibromyalgia and LBP due to DDD.  The panel notes that fibromyalgia and LBP have many overlapping symptoms and treatments; therefore, both conditions are addressed together, but will be adjudicated and rated separately.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s fibromyalgia condition began sometime in 2007 following a cholecystectomy in January 2007. The CI reported LBP at a family practice clinic visit on 20 February 2007.  Treatment consisted of a nonsteroidal anti-inflammatory drug (NSAID) and Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  On 26 March 2007, the CI had a flare of back pain all weekend, which was dull with a constant ache, and worse with prolonged sitting.  There was no radicular pain or bowel and bladder dysfunction.  Gabapentin (for nerve pain) was added to the treatment protocol in March 2007.  X-rays of the lumbar spine on 25 April 2007 showed no abnormality.  An MRI of the lumbar spine on 21 July 2007 demonstrated only the most minor early degenerative changes affecting the lumbar apophyseal joints without evidence of neural compromise at the lower three lumbar disc levels.  No focal disc herniation or localized radicular impingement was evident.  

The CI underwent physiotherapy including acupuncture, which eased her pain symptoms a little, but the pain flared up constantly with minimal exercise.  X-rays of the lumbar spine on 25 July 2008 were normal.  On 8 September 2008, the CI was referred to rheumatology for fibromyalgia evaluation and treatment.  Two days later the CI underwent thoracic and lumbar dorsal root ganglion injections on the right and a caudal epidural injection.  Improvement in her back pain was reported on 19 September 2008; however, she still continued to have arthralgias and soft tissue problems affecting predominantly the hands, knees, and back.  Her sleeping was better and her symptoms of anxiety and depression had improved with treatment including analgesics and a combination of antidepressants.  

On 29 September 2008, the CI reported a history of depression and anxiety.  Medications including Percocet, Effexor (venlafaxine, antidepressant), Elavil (amitriptyline, an antidepressant and also used for nerve pain) and Ultram (an opioid-like medication) were refilled for the fibromyalgia.  A family practice note on 7 October 2008 indicated the CI saw a rheumatologist who agreed with the use of tramadol and amitriptyline.  On 15 October 2008, the CI underwent thoracic and lumbar dorsal root ganglion injections and on 12 November 2008 she received facet joint injections which gave her a period of initial pain relief indicating the facet joints were a significant source of her pain.  However, she still had pain sites at the back of the right shoulder and in the low back that radiated into the hip and buttock along with some pulling and cramping sensations in the backs of the legs.  Range of motion (ROM) measurements performed by a physical therapist on 26 November 2008 revealed 90 degrees of flexion (normal) and a combined ROM of 240 degrees (normal) with painful motion only on extension.  On 6 January 2009 the CI was seen in the family practice clinic for follow-up of fibromyalgia and anxiety. Tramadol and venlafaxine were refilled.  

The 9 January 2009 MEB NARSUM examination, 11 months prior to separation, noted complaints of chronic low back and muscle pain.  The CI’s chronic medical conditions included generalized anxiety disorder, irritable bowel syndrome, DDD and fibromyalgia.  Physical examination showed a normal ROM of the lumbar spine with no deformity and no muscle spasm.  The CI had a normal stance and gait.  Motor strength was preserved throughout her lower extremities. Neurologic evaluation was unremarkable.  Plane films of the lumbar spine and sacroiliac joints were normal. 

At a pain medicine visit on 17 February 2009 the examiner noted the CI was better for a month and then the pain recurred.  She continued to require the use of tramadol, ibuprofen, Effexor, and amitriptyline.  She described some general neck pain as well as LBP that radiated into the upper buttock and towards the back of the knee.   On examination the CI had dysesthesia and hyperalgesia across both buttocks and backs of both thighs below the L5/S1 level with tenderness at L5/S1 and S1/2 on the right.  The thoracic region was without tenderness or sensory abnormality. There was some cervical paravertebral tenderness between C3 and C7 on the right with some dysesthesia and hyperalgesia.  A trial of pregabalin (for nerve pain) was started.  An MRI of the cervical and thoracic spine on 21 February 2009 was normal with no significant localized neural compromise at the cervical level and no paraspinal soft tissue abnormality was evident.  

At a pain clinic visit on 19 May 2009 the CI complained of problems in the thoracic region again even though it was denervated at the beginning of December 2008.  The examiner expected a thoracic facet joint denervation to last for 12-24 months rather than 6 months.  The CI reported using codeine (a narcotic), venlafaxine, pregabalin, and diazepam, had chiropractic treatments, used a TENS (transcutaneous electrical nerve stimulation) device, and did yoga or Pilates exercises.  The examiner recommended escitalopram (an antidepressant) to help her cope with adverse life events and to minimize her use of narcotics.  On 28 May 2009, the CI underwent thoracic facet joint denervations. The next day, the pain management consultant wrote her assessment of the CI’s condition, which was thought to be fibromyalgia, but the consultant felt was not the case and that instead the CI suffered from abnormal levels of nerve irritability in the painful regions, but the cause could not be identified.  Further injections or denervations with the use of strong analgesics were felt to be needed since the CI’s condition was considered unstable.  

On 9 June 2009 the CI was seen in the emergency department for neck, shoulder, and LBP with radiation down both arms; she was treated with Percocet.  A consultant rheumatologist noted on 6 July 2009 that the CI had widespread arthralgia and soft tissue pains in addition to lower back problems related to chronic LBP and fibromyalgia.  Despite multiple pain medications, combinations of anti-depressants, and pregabalin as well as physical therapies including chiropractic, physiotherapy, dorsal root injections, and relaxation techniques, her symptoms continued to progress.  The rheumatologist noted the symptoms “unfortunately remain refractory to therapies both physical and pharmaceutical.”  On 16 September 2009, the CI underwent thoracic and lumbar facet joint injections.  A note dated 9 October 2009 by a physiotherapist indicated the CI received 10 sessions of acupuncture to the lumbar and cervical spine as well as to her shoulders to effectively treat a fibromyalgia flare-up.  On 16 October 2009 Lortab (hydrocodone, a narcotic, and acetaminophen, a pain reliever) and lorazepam (for anxiety) were refilled.  

At the 18 November 2009 VA Compensation and Pension (C&P) examination, 9 days before separation, the CI reported fibromyalgia and back pain and was taking morphine (a narcotic), oxycodone (a narcotic), diclofenac (an NSAID), and Effexor for anxiety.  Her pain was constant or nearly constant and was often precipitated by environmental or emotional stress or overexertion.  Physical examination showed a normal gait and tenderness in the cervical and lumbar regions of the spine.  There were tender points of the low cervical regions, second ribs, suboccipital, trapezius, gluteal, and supraspinatus muscles, lateral epicondyles, greater trochanters, and the medial joint lines of the knees.  ROM measurements of the thoracolumbar spine showed a flexion of 80 degrees with painful motion initially and 90 degrees with repetition, and a combined ROM of 195 degrees (normal 240) initially and pain on motion with repetition. 

The panel directed attention to its rating recommendation for the fibromyalgia condition based on the above evidence.  The PEB and the VA rated the fibromyalgia condition 10% and 20%, respectively, using code 5025.  The PEB cited that the condition met the VASRD criteria for a 20% rating.  The VA based the 10% rating on the C&P examination, citing continuous medication required to control the CI’s symptoms.

Panel members noted the CI had symptoms of fibromyalgia “with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, and anxiety,” and the symptoms “were constant, or nearly so.” However, the panel majority did not feel the CI’s fibromyalgia condition was “refractory to therapy.”  A potpourri of pharmacologic interventions including narcotics, NSAIDs, anti-anxiety medication, and medication for nerve pain, and treatments ranging from physiotherapy and chiropractic as well as injections and ablations, which were directed predominantly, but not exclusively, toward facet and back pain, did not afford long-term symptom relief.  A vigorous discussion ensued and the panel majority noted the PEB’s indication that the CI was able to perform assigned duties, although she could not perform the required lifting or moving of heavy equipment or objects of her primary military specialty nor was she able to perform the full spectrum of physical training.  Despite awareness of the aforementioned, the panel majority felt the rating of 20% afforded by the PEB was reasonable.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the fibromyalgia condition.  

The panel next directed attention to its rating recommendation for the LBP with DDD based on the above evidence.  The PEB rated the LBP 0%, coded 5242 (degenerative arthritis of the spine), citing the CI’s active flexion was 90 degrees and acknowledged the CI moved slowly through the full ROM due to symptoms of pain.  The VA rated the LBP (mechanical, but not degenerative) 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing limitation of motion since X-rays were negative for any degenerative changes. 

There was no limitation of thoracolumbar spine motion with repetition to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine; however, the physical therapy and VA examinations noted the presence of painful motion.  A 10% rating is therefore warranted. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the low back condition, coded 5242.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the low back pain, the panel recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  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, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Fibromyalgia	5025	20%	
Low Back Pain due to Degenerative Disc Disease	5242	10%	
COMBINED	30%	

The following documentary evidence was considered:

Minority Opinion.  The minority voter recommends a rating of 40% for the fibromyalgia.  The requirements for a 40% rating are crystal clear according to the VASRD, which states “with 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.”  Both the STR and at the VA examination recorded that the CI’s symptoms were noted to be constant.  Even with several prescribed narcotics including Percocet, codeine, Lortab, oxycodone, and morphine as well as gabapentin and pregabalin, and injections along with antidepressant and anti-anxiety medications, one of which is also indicated for nerve pain, the CI remained replete with symptoms including pain, which limited her carrying and lifting capability that diminished her job performance.  Moreover, the consultant rheumatologist, an expert in diagnosing and treating fibromyalgia wrote unequivocally and to the point about the CI’s symptoms that they “unfortunately remain refractory to therapies both physical and pharmaceutical.”  

Neither the PEB, VA, nor the panel majority gave sufficient weight to the rheumatologist’s words, which were based on the CI’s reports, physical findings, and his deep understanding and insight into fibromyalgia, a condition in which the exact etiology and pathophysiology was unknown at the time of separation and are still not fully known even today.  Therefore, based on the totality of the incontrovertible evidence including the fact that at the VA examination, 9 days prior to separation, the CI continued to report constant pain, took narcotics, an NSAID, and antidepressant and anti-anxiety medications, the minority voter recommends a 40% rating for the fibromyalgia versus a 20% rating that requires the symptoms to be “episodic.”

Therefore, the minority voter recommends the ROP be modified to read:  

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the fibromyalgia condition, coded 5025.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition, the panel recommends a disability rating of 40%, coded 5025 IAW VASRD §4.71a.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Fibromyalgia	5025	40%	
Low Back Pain due to Degenerative Disc Disease	5242	10%	
COMBINED	50%	

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

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04237.

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.