RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04516
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060316

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

CI CONTENTION:  No specific contention made.  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 - 20060126	VARD - 20061003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Migraines	8100	30%	20060530	
			Shoulder Strain, Left	5201-5024	10%	20060530	
			Shoulder Strain, Right	5201-5024	10%	20060530	
			Major Depression	9434	10%	20060529	
			Plantar Fasciitis, Bilateral	5299-5275	0%	20060530	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Fibromyalgia (FM).  The MEB forwarded five individual conditions to the PEB.  The FM syndrome and migraine headaches (HAs) were forwarded as not meeting retention standards and bilateral foot pain, bilateral shoulder pain and major depression were forwarded as meeting retention standards.  The PEB adjudicated a single unfitting condition of FM and indicated that migraine headaches were included in the FM  rating under code 5025 (fibromyalgia), citing VASRD §4.14 (avoidance of pyramiding).  In this case the panel disagrees with the PEB’s reasoning for assigning a single rating based on avoidance of pyramiding.  The CI was given a separate diagnosis for her headaches by a neurologist and they were not attributed to the FM diagnosis.  Although headaches may be included in the FM rating, a 5025 rating may be assigned “with or without” headaches and both the FM and migraine conditions were determined to be separately unfitting.  The panel therefore considered ratings for the FM and migraine headaches conditions separately below.  

FM.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered from multiple areas of pain beginning in April 2004 to include the back, neck and shoulders and was diagnosed with FM in June 2005 by a physical medicine specialist.  At that evaluation, the CI reported intermittent back pain for the past 5 years aggravated by activities, including sitting, with a reported pain level of 4/10.  Physical examination showed 18/18 positive FM tender points.  She was treated with antidepressant medication for pain (duloxetine) and pool therapy.  The CI stopped the antidepressant medication due to unwanted side effects but pool therapy “felt good” and was continued.  At physical medicine follow-ups on 11 October 2005 and 1 November 2005, the CI reported pain levels of 3/10 with pain located in the lumbar paraspinal areas and right upper back region.  She also reported a great deal of stress in her life.  The examiner noted the CI did not meet diagnostic criteria for FM at the time of the evaluations.  

At the 11 October 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, physical examination showed bilateral shoulder tenderness anteriorly and posteriorly, with painful ROM and bilateral tenderness of the bottoms of the feet, without swelling.  There was right upper quadrant abdominal tenderness without liver or spleen enlargement, rebound tenderness or guarding.  

At the 24 October 2005 physical therapy range of motion (ROM) evaluation, cervical and thoracolumbar ROMs were noted to be normal except for cervical lateral flexion (after three repetitions) of 25 degrees on the left and 20 degrees on the right (normal 45).  The limitation was due to pain and soft tissue.  

At the 4 November 2005 MEB rheumatology consult, 4 months prior to separation, the CI reported a 7 month history of back pain.  She also reported knee and foot pain, headaches, difficulty sleeping and constipation.  She reported a pain rating of 8/10 refractory to medications, chiropractic treatment or trigger point injections.  She was involved in a weekly exercise regimen including pool therapy and exercise bike.  On examination there was limitation of motion in all planes of the neck due to pain, but no synovitis of any joints.  Bilateral upper and lower extremity ROM was normal, except for limited bilateral shoulder ROM due to pain.  There were 11/18 FM tender points present.  Screening blood work was negative.  Thyroid testing was normal.  Cervical and thoracic spine X-rays were normal and lumbar spine X-rays were normal except for mild narrowing at L5/S1.  Bilateral knee and shoulder X-rays were normal.  Bilateral foot X-rays showed pes planus.  A CT scan of the abdomen was normal.  The rheumatologist confirmed the diagnosis of FM.  He did not recommend any profile limitations “as treatment for FMS includes regular aerobic activity.”  

The 28 November 2005 MEB NARSUM examination noted complaints of “pain.”  The CI reported constant neck and lower back pain aggravated by sitting, standing, walking, bending, twisting and lifting.  Medications were Effexor (antidepressant), Remeron (sedating antidepressant for sleep issues) and Vicodin as needed (narcotic pain medication).  Gait was normal.  Physical examination showed no joint synovitis and there were no enlarged lymph nodes and the skin was normal.  Reflexes and strength were normal throughout.  There were 11/18 positive FM tender points.  

At the 30 May 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported pain of the chest, knees, and back with easy fatigability, sleep disturbance, stiffness, depression and paresthesia.  The VA examiner stated the symptoms occurred “constantly, which means more than 2/3 of the time per year” and were precipitated by overexertion.  The examiner indicated there had been “a favorable response to treatment with pain medication.”  During flare-ups the CI reported she could perform “moderately” with medication.  She reported lost work time of 2 days per month.  Physical examination showed generalized tenderness of the abdomen without masses.  Gait and posture were normal.  Any palpation produced pain to the point of tears.  There were 18/18 positive FM tender points.  Bilateral shoulder ROM was flexion and abduction of 160 degrees (normal 180) with painful motion and there was no additional loss of ROM with repetition.  Bilateral wrist and ankle ROM was normal, without painful motion.  The CI was able to reach the palmar crease with all fingers and the thumbs could oppose all fingers.  Hand strength was normal.  Motion of the right and left finger joints was symmetrical and there was no painful motion.  There was tenderness of both feet with no other abnormality noted.  Radiographs of the bilateral hands, feet, and shoulders were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the FM syndrome 20%, coded 5025, citing FM symptoms present more than one-third of the time.  The VA stated they would not evaluate FM as a separate issue and the CI was granted service connection for five individual conditions.  The VA rated migraine headaches 30%, coded 8100; left and right shoulder strain 10% each, both analogously coded 5201-5024; major depressive disorder 10%, coded 9434; and bilateral plantar fasciitis 0%, analogously coded 5299-5275, based on the C&P examination.  

At visits in the STR, the CI reported improvement with pool therapy and at the C&P examination she reported improvement with rest, heat and narcotic pain medication and the symptoms were precipitated by overexertion.  Fibromyalgia is a chronic condition with exacerbations, however, there was evidence of waxing and waning both in the number of painful locations and severity of symptoms at serial examinations in the STR and at the C&P examination.  Based on the evidence, the panel consensus was that a 20% rating was supported for “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 episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time.”  However, the evidence did not support the next higher rating of 40% for FM symptoms “that are constant, or nearly so, and refractory to therapy” as symptoms were improved by pool therapy, heat, rest, and pain medication.  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 FM syndrome.  

Migraine HAs.  According to the STR and MEB NARSUM and the MEB neurology consult, the CI had a 2-year history of HAs.  At the MEB examination, the CI reported HAs once per month.  Headaches were not documented at physical medicine evaluations from June 2005 to September 2005.  On 17 October 2005, the CI was seen for nausea, vomiting and HAs for 3 days.  The CI was diagnosed with a dehydration HA and was given medication for vomiting and placed on quarters for 24 hours.    

At the 25 October 2005 MEB neurology consult, 5 months prior to separation, the CI reported a 2-year history of HAs occurring every 2 to 3 months lasting 2 or 3 days.  The HAs were throbbing and often associated with photophobia, nausea and vomiting.  There was no premonitory aura.  She did not take any medication, but rested and stayed hydrated until they passed.  She reported she had missed approximately 2 days of duty in the last 6 months due to HAs.  Physical and neurological examinations were normal.  An abortive migraine medication was prescribed (Zomig) for use at the start of a HA.  A brain MRI performed on 31 October 2005 showed no masses, but an incidental cyst was noted.  The commander’s statement dated 25 October 2005 did not mention migraine HAs or any lost time.  

At the C&P examination the CI reported a history of migraine HAs with nausea and vomiting that occurred once per month, lasted 2 days and caused her to stay in bed.  She did not report use of any medications for migraines, but reported missing work six times in the past year due to HAs.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the FM condition 20%, coded 5025, citing FM symptoms present more than one-third of the time and migraine HAs subsumed in the rating.  The VA rated the migraine HAs 30%, coded 8100 based on the C&P examination.  

Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks, however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  There were two encounters for HA care in the year before separation in the record.  Of these, one was for acute HA treatment due to nausea and vomiting and the other was the MEB neurology consult.  

At the MEB examination, the CI reported one HA once per month, but at the MEB neurology consult 2 weeks later she indicated she had a HA once every 2 to 3 months and that she had only missed 2 days of work in the last 6 months due to HAs.  The commander’s statement did not implicate migraine HAs and did not mention frequent loss of work due to any medical condition.  

Other treatment notes in the STR in the year before separation by physical medicine and behavioral health made no mention of HAs.  The evidence provided in the STR and at the MEB neurology consult supports a 0% rating for migraines with less frequent [prostrating] attacks occurring less than once every 2 months.  At the C&P examination the CI reported one HA per month, that required bedrest for the duration of each of them, and she had missed 6 days of work in the last year due to HAs.  However, there was no objective evidence in the record to corroborate the CI’s report of prostrating HAs occurring that frequently.  The panel concluded there was no higher than a 0% rating supported for the migraine HAs.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the migraine HAs, coded 8100.  

BOARD FINDINGS:  In the matter of the fibromyalgia syndrome and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the migraine headaches, the panel recommends a disability rating of 0%, coded 8100 IAW VASRD §4.124a.  There are no other conditions within the panel’s scope of review for consideration.  As the proposed new combined disability ratings result in no change to the combined disability rating previously assigned, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

[AR Number], XXXXXXXXXX

Dear XXXXXXXXXX:

	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.