RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXX	CASE: PD-2017-04313
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20050622

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Communication Information System Specialist, medically separated for “fibromyalgia” and “migraine headaches,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: Fibromyalgia has had a significant impact on the CI’s life. 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 - 20050321	VARD - 20060818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	10%	Fibromyalgia	5025	40%	20060515	
Migraine Headache	8100	10%	Migraine Headaches with Vertigo	8100	10%	20060515	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Fibromyalgia. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s fibromyalgia condition began with a history of chronic low back pain following a motor vehicle accident in 1996, was then exacerbated by a fall in 1998, and increased with each of her four pregnancies. An MRI of the back revealed mild disc bulge at T12-L1, L1-2, and L2-3 without nerve root compromise. Around 2003, the CI noticed increased pain in multiple joints unrelieved by nonsteroidal anti-inflammatory drugs. She also reported sleep disturbances,

fatigue, chronic headaches, paresthesias, irritable bowel symptoms, frequent urination, and irritation without known causes. She subsequently was diagnosed with fibromyalgia symptoms in April 2004 by a primary care provider who noted 16/18 tender points. The pain was unresponsive to a trial of medications and the CI was referred to rheumatology for evaluation and treatment. At the rheumatology clinic on 3 June 2004, the examiner concurred with the diagnosis of fibromyalgia syndrome manifested by diffuse tender points, sleep disturbance, chronic fatigue, widespread chronic musculoskeletal pain, frequent headaches, paresthesias, and an irritable bladder; the CI’s condition was noted as likely exacerbated by irregular work schedules (working two daytime 12-hour shifts and two nighttime 12-hour shifts per week). He suspected the chronic low back pain was a fibromyalgia symptom since the MRI was fairly unremarkable with very minimal upper lumbar disk bulges without stenosis or nerve root impingement.

Physical examination revealed a well-developed, well-nourished woman in no acute distress. There was no skin rash, joint synovitis, cervical adenopathy, or edema, but 18/18 points were tender with 4 kg of pressure. Recommendations included consideration of tramadol (Ultram, an opioid-like medication) and increasing the dose of Elavil (for nerve pain). There was no response to Elavil and she tried trazadone for sleep instead. The tramadol was not working at all for the pain and she was referred to the pain clinic. The trazadone was stopped and Pamelor (for nerve pain) was prescribed. At the pain clinic visit on 9 August 2004, she reported her body pains were worse with lack of physical movement or strenuous physical activity and the migraine headaches (see below) were made worse with work. She coped with her condition fairly well until the exacerbation of post-pregnancy pain. She was referred to a pain management group and biofeedback-assisted relaxation treatment was discussed.

The 23 September 2004 MEB NARSUM examination, 9 months prior to separation, noted complaints of chronic pain and migraine headaches (see below). Physical examination showed a well-nourished, well developed female, alert and oriented times three. She walked slowly into the clinic and carefully mounted the examination table. There was no antalgic gait. Vital signs were within normal limits. There was no enlargement or tenderness of the nodes of the neck ad her neck was supple. The lungs were clear to auscultation bilaterally and the heart had a regular rate and rhythm without any murmurs. Neurological findings were unremarkable. She had 4/5 strength in all muscles of the arms and legs and no edema or effusions. She had 18/18 tender points. The examiner noted the CI continued to experience daily pain, unrelieved by several pain management regimens including medications and other modalities. She was unable to work a full day and missed several days per week due to pain or headaches.

At a clinic visit on 30 November 2004, the CI complained of colon spasm from irritable bowel syndrome (IBS). A prescription was given for Bentyl (an antispasmodic medication) and increased fiber intake was discussed. At a clinic visit on 18 January 2005, the CI reported chronic muscle pain for 3 years that increased during her last pregnancy. Pain was 8-10/10 in the calves and much less in the thighs, hips, and back with most of the back pain in the right sacroiliac area. Examination revealed tenderness of the right sacroiliac joint, the rhomboid and supraspinatus muscles, and the iliotibial band of the thighs. There was a full range of motion (ROM) of the back without pain. Treatment consisted of gabapentin for nerve pain. The CI subsequently reported no relief with the gabapentin and Roxicet (a narcotic/pain reliever combination medication). At a 30 March 2005 clinic visit she was prescribed Prozac (an antidepressant) for the fibromyalgia, and the examiner had a long discussion with the CI about experimental and alternative therapies. At the 10 May 2005 clinic visit, Roxicet was refilled.

At the 15 May 2006 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported fibromyalgia. Physical examination showed multiple trigger points of the neck, trapezius, deltoid, and gluteal muscles, at the soft tissues over the greater tuberosity, at the medial knee and at the pectoral region. She also had some point tenderness in the feet

and the ankles. The back tenderness was in the sacroiliac joint superiorly. Flexion was to 105 degrees (normal 90) and the combined ROM was 215 degrees (normal 240). Strength was normal and reflexes were within normal limits. Posture and gait were normal. There was no incapacitation in the prior 12 months.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the fibromyalgia condition 10%, coded 5025 (fibromyalgia). The VA used the same coding and rated the fibromyalgia (also claimed as IBS, urinary frequency) 40%, coded 5025, based on the C&P examination, citing multiple trigger points.

The panel noted the disparity between the PEB rating of 10% that requires continuous medication for control and the VA rating of 40% that requires symptoms that are constant, or nearly so, and refractory to therapy. However, the VA rating was based on all the positive trigger points, IBS symptoms, and symptoms related to urinary frequency, which are not components of fibromyalgia. The NARSUM examiner noted the CI continued to experience daily pain, unrelieved by several pain management regimens including medications and other modalities, and she missed several days of work. Furthermore, the commander’s statement noted that since being diagnosed, the CI spent little time at work, and when she was at work, she was not productive. Panel members discussed a 20% rating versus a 40% rating and noted that after her most recent pregnancy her pain increased and required use of a narcotic/pain reliever medication. Therefore, the panel favored a 40% rating for symptoms that were constant, or nearly so, and were refractory to therapy. 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.

Migraine Headache. According to the STR and MEB NARSUM, the CI was seen on 1 March 2004 with the complaint of a headache that was present for about a week, which went away a day earlier, but came back. She noted light sensitivity, felt tired, and did not sleep well because of back pain. On examination she did not have maxillary or frontal sinus tenderness. The examiner’s assessment was a migraine headache without an aura. Treatment consisted of Zomig (for migraine relief) and avoidance of certain foods. On 26 April 2004 she reported the migraines were somewhat relieved by the Zomig. On 7 June 2004 she reported having a headache and was not aware she could take the Zomig with Elavil (for nerve pain). She was unable to perform Smart Clinic therapies secondary to the headaches.

A CT scan of the head without contrast dated 9 June 2004 was normal. Tylenol) as needed was recommended for the headaches on 27 July 2004. At a pain management clinic visit dated 9 August 2004 the examiner recommended biofeedback-assisted relaxation for the migraine headaches. At a neurology clinic visit 3 days later, the examiner noted the CI’s headaches became unresponsive to Zomig after she started using Ultram for her body muscle pain in combination with Pamelor. The examiner believed the chronic daily headaches were a result of the use of daily pain medication. The dose of Pamelor was recommended to be increased and the Ultram use was minimized to prevent a rebound headache effect. Maxalt was prescribed for an acute headache. On 17 August 2004 the CI was treated for a migraine headache with intravenous fluids, Reglan (for heartburn or reflux), and Zomig. In September 2004, the CI reported she stopped the Pamelor due to vivid dreams and edginess.

The 23 September 2004 MEB NARSUM examination noted the complaint of migraine headaches. Physical examination showed the CI to be alert and oriented. The cranial nerves appeared intact and reflexes were within normal limits. On 6 January 2005 the CI reported one headache a week and she had some relief with the Maxalt and biofeedback. At a clinic visit on 14 March 2005, the examiner noted the migraines had decreased in frequency and were controlled with Maxalt.

At the VA C&P examination the CI reported headaches three times a week, which eased up after service separation, but recurred after she relocated. The headaches lasted for a few hours. She discontinued the Maxalt, which she felt did not work. Physical examination showed an unremarkable neurologic evaluation.

The panel directed attention to its rating recommendation based on the above evidence. The PEB and the VA both rated the migraine headache condition 10%, coded 8100 (migraine). The VA based the rating on the C&P examination, citing headaches about three times a week that lasted for a few hours.

The panel noted the CI had fibromyalgia, which can have headaches as a component of the condition. However, the CI had migraine headaches that were independent of the fibromyalgia and were treated with medications normally used for migraine headaches. Therefore, the panel determined the migraine headaches represented a separately unfitting condition. Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.” The panel considered the results of the PEB and VA examinations along with the evidence of the treatment records to accurately assess the overall disability picture (§4.2) at the time of separation. Review of the record did not show prostrating headaches occurring on average once every 2 months, or more frequently, over the last several months prior to separation to support a rating higher than the 10% adjudicated by the PEB. 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 adjudication for the migraine headache condition.

BOARD FINDINGS: In the matter of the fibromyalgia condition, the panel recommends a disability rating of 40%, coded 5025 IAW VASRD §4.71a. In the matter of the migraine headache condition and IAW VASRD §4.124a, 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 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%	
Migraine Headache	8100	10%	
	COMBINED	50%	

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 12 Oct 20

From: To:
Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 
PHYSICAL DISABILITY BOARD OF REVIEW {PDBR)
(a) DoDI 6040.44
(b)	PDBR ltr of 13 Aug 19
(b)	

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate action.

2.	On 5 October 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 20 to SO percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the Navy Personnel Command, for correction of your records as stated above.	You will be notified once those changes are complete.