RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX  	CASE:  PD-2017-05400
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050408

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Communication Cable Systems Journeyman, medically separated for “narcolepsy associated with anxiety disorder” with a disability rating of 10%.  

CI CONTENTION:  She was discharged due to narcolepsy but contends there were other disorders resulting from military service.  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 FPEB – 20050217	VARD - 20060208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Narcolepsy Associated with Anxiety Disorder	8108-8910	10%	Narcolepsy	8108	10%	20050811	
Fibromyalgia	Cat II	Fibromyalgia with Associated Muscular Neck Pain, Midback Pain, Anxiety Symptoms, …	5025	40%		
Adjustment Disorder	Cat III	Personality Disorder with Some Mood Instability and Somatic Focus (Claimed as Adjustment Disorder,…)	9499-9410	NSC	20050801	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Narcolepsy Associated with Anxiety Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI complained of daytime sleepiness in 2004 with a history of fibromyalgia and anxiety.  At a neurology clinic consultation dated 30 July 2004, the CI indicated she had a 1-year history of a gradual onset with staying awake with a form of excessive daytime somnolence.  She reported hypnagogic and hypnopompic hallucinations, denied any sleep paralysis, but had sleep attacks during the day.  She had to take naps up to 2 hours and was not refreshed.  She reported cataplexy with emotion and with emotional states.  The fibromyalgia was treated with amitriptyline, which caused a paradoxical effect and she could not fall asleep.  The neurologist noted the CI had a sleep study performed on 24 June 2004 which was normal, but a multiple sleep latency test (MSLT) showed REMs (rapid eye movements) with quick onset in two of four naps taken.  The sleep specialist noted that finding supported the clinical diagnosis of narcolepsy.  Neurologic examination was within normal limits.  Provigil was recommended and a narcolepsy-associated antigen level (HLADQB1 0602) was to be obtained.  At a follow-up neurology clinic visit on 31 August 2004, she noted decreased muscle tone with emotions, but had not yet started on the Provigil and still had excessive daytime somnolence, but denied sleep attacks.

The 5 August 2004 and 10 November 2004 MEB NARSUM psychiatry addendum examinations, 8 months and 5 months prior to separation, noted a history of stress and somatic complaints in March 2002.  In February 2003 she was treated for anger and anxiety issues and was diagnosed with an adjustment disorder (see below) with mixed disturbances of conduct and emotion.  She improved and treatment was terminated in May 2003.  In April 2004 she reported sleep problems, numerous areas of bodily pain, mood lability, and anger; she was diagnosed with anxiety disorder not otherwise specified (NOS) and dyssomnia NOS (a sleep disorder marked by excessive sleepiness during the day due to the reduced quantity, quality or timing of sleep).  While on medication, she had sleep studies with the finding of narcolepsy and the anxiety was a secondary disorder.  Ambien was prescribed for sleep.  Mental status examination revealed the CI was alert and oriented to person, place, and time.  She appeared fatigued, but was pleasant, cooperative, and neatly dressed.  She displayed good eye contact and her speech was of normal volume and fluent with normal rhythm.  Her mood was described as “overwhelmed” and she displayed an anxious affect without lability.  Thought processes were linear, logical, and goal directed.  She denied hallucinations, delusions, and suicidal or homicidal ideation.  Insight and judgment were good, and intellect appeared to be average.  The examiner noted the CI’s “narcolepsy and fibromyalgia are without doubt the primary causes for her anxiety as supported by the lack of efficiency of psychotropic medications.”  The examiner opined that should her narcolepsy and fibromyalgia be appropriately treated, she should have significant improvement of her anxiety.”  The social/industrial impairment was mild.  

At the 11 August 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported daily decreased concentration and daytime sleepiness, which was worse in the afternoon.  Provigil worked “amazingly well.”  Her concentration and focus improved and her daytime sleepiness resolved.  She was in process of trying Ritalin (a central nervous system stimulant), which kept her awake, but did not help with her focus, and it caused headaches and some agitation.  Physical examination showed the CI appeared healthy without any problems with concentration or sleepiness during the interview.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the narcolepsy condition 10%.  The PEB analogously coded 8108-8910 (narcolepsy-grand mal epilepsy).  The VA coded 8108, based on the C&P examination, citing a need for continuous medication to help control the narcolepsy condition.  

The panel noted that code 8108 is rated IAW code 8911 (epilepsy, petit mal) rather than code 8910, which the PEB used.  Code 8911 Note (2) indicates “A minor seizure consists of a brief interruption in consciousness or conscious control associated with staring or rhythmic blinking of the eyes or nodding of the head (“pure” petit mal), or sudden jerking movements of the arms, trunk, or head (myoclonic type) or sudden loss of postural control (akinetic type).”  The CI had no documented objective cataplexy, although she reported “cataplexy with emotion and with emotional states” at one visit and “decreased muscle tone with emotions” at a follow-up visit.  For a 20% rating the General Rating Formula for Major and Minor Epileptic Seizures requires “at least one major seizure in the last 2 years; or at least two minor seizures in the last 6 months.”  Neither the STR nor the VA C&P examination reported episodes of narcolepsy or cataplexy proximate to separation, and at the VA examination, the CI reported the prescribed medication, Provigil, worked “amazingly well.”  Therefore, there was insufficient evidence to support a rating higher than 10% assigned by the PEB and the VA.  As noted above, the anxiety was secondary to the narcolepsy and fibromyalgia and does not warrant a separate rating since by itself, it would not be construed as separately unfitting or being referred into the disability evaluation system.  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 narcolepsy associated with anxiety disorder.  

Contended PEB Condition:  Fibromyalgia.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was profiled and implicated in the commander’s statement, which indicated the CI had been on profile to prevent lifting and over-exertion.  However, the CI did not request the formal PEB find the fibromyalgia unfitting.  She had a history of difficulty sleeping with generalized aches, pains and anxiety attacks in 2001.  With time the symptoms progressed.  At a rheumatology clinic visit on 2 June 2004, examination revealed all her joints in the axial skeleton and peripheral extremities had a full ranges of motion without signs of active synovitis.  Muscle strength was normal.  All fibromyalgia points were diffusely tender with negative control points.  The examiner’s impression based on the CI’s chronic aches pains, anxiety attacks, difficulty sleeping, and waking up feeling unrefreshed and tired, and the physical findings were suggestive of fibromyalgia.  

The 29 June 2004 MEB NARSUM examination, 9 months prior to separation, noted issues with multiple musculoskeletal trigger points, back pain, and chest pain.  Physical examination showed pain at the wrists, elbows, shoulders, hips, knees, and back.  The examiner noted the fibromyalgia
“suspected outcome is good considering the member is being followed by specialists and treatment is pending” and the “prognosis is good with ongoing treatment.”  On 15 July 2004 she was treated with Ambien for insomnia.  When the prescription for Ambien ran out, the fibromyalgia was worse.  On 2 September 2004 she was treated with cyclobenzaprine, a muscle relaxer.  A flare of fibromyalgia in 9 December 2004 was treated with tramadol (a narcotic-like medication) and Tylenol (a pain reliever).  At the 11 August 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported pain in, back, chest, and elbows.  Physical examination showed she had greater than 11 positive trigger points with negative controls.  There was no redness in any of her joints.

The panel majority determined there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel majority concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

Adjustment disorder .  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended adjustment disorder is not a condition that constitutes a physical disability IAW DoDI 1332.38.  Therefore, the panel has no basis for recommending it as unfitting.   

BOARD FINDINGS:  In the matter of the narcolepsy condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended adjustment disorder, 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.  

SAF/MRB

Dear XXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05400.

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 appropriate.  Accordingly, the Board recommended no rating modification or re-characterization of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that modification of your disability rating or characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.

						

Minority Opinion.  The minority voter determined the fibromyalgia was separately unfitting and warrants a 10% rating.  The fibromyalgia was clearly profiled with a P4 as was the narcolepsy with restrictions specifically related to the fibromyalgia including “no lifting greater than 15 lbs.” as well as no sit-ups, no pushups, no 1.5 mile run, no cycle ergometry, and no squadron PT.”  The commander’s statement indicated the CI had been on profile to prevent lifting and over-exertion.  The majority noted, “As the representative for the Service Secretary, the PEB has the authority to essentially waive fitness criteria & change mission requirements . . .”   However, DoDI 6044.44 Enclosure 3 (1) states:  As part of its review, the PDBR may, at the request of an eligible member as provided for in Reference (b), review conditions identified but not determined to be unfitting by the PEB of the Military Department concerned.”  Furthermore, Enclosure 3 Organization and Responsibilities (5) notes:  “If upon review of the PDBR, the PDBR determines that a previous “fit” determination by the PEB of the Military Department concerned should be changed to “unfit,” the PDBR shall make the recommendation and assign a rating to that condition which will be combined with the other disability rating(s).”  Therefore, the PDBR has the authority to determine fitness.  

The CI had a P4 profile for the fibromyalgia with restrictions that would clearly and unequivocally affect her capability of performing the duties related to her AFSC as a Communication Cable Systems Journeyman.  Furthermore, the commander’s statement noted the CI was not working in her primary AFSC and added additional support by referring to her profile for the fibromyalgia that prevented lifting and overexertion, while the phrase “allowing late arrival for work in the morning” was clearly related to the narcolepsy.  The commander’s statement further indicates the CI’s condition “does affect her ability to satisfy duty requirements due to lifting restrictions and medications,” although the medications referred to were possibly for the narcolepsy (Provigil and Effexor XR), but could also be have been the medications (Ambien or tramadol, but likely not the Tylenol) for the fibromyalgia.  The commander’s statement then reiterated she “does have duty restrictions on lifting.”

Because the profile and the commander’s statement obviously addressed fitness, it is unquestionably and eminently apparent that the CI was unfit for the fibromyalgia and therefore warrants a rating of at least 10%, which requires continuous medication for control.  A higher rating is not warranted since there was insufficient evidence to confirm “exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time.”  Therefore, the minority voter recommends the ROP be modified as follows:  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of fibromyalgia favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5025 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the narcolepsy condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended fibromyalgia condition, the panel agrees it was unfitting and recommends a disability rating of 10%, coded 5025 IAW VASRD §4.71a.  In the matter of the contended adjustment disorder, 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.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Narcolepsy	8108-8911	10%	
Fibromyalgia	5025	10%	
COMBINED	20%