RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2018-00265
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20061226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Still Photographic Journeyman, medically separated for “fibromyalgia” and “asthma,” rated 10% each, with a combined disability rating of 20%.   

CI CONTENTION:  The CI’s counsel submitted a lengthy Brief in Support of Application in which only fibromyalgia and asthma are contended.  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 PEB - 20061011	VARD - 20080130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	10%	Fibromyalgia	5025	40%	20070726	
Asthma	6602	10%	Asthma	6602	30%	20070726	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Fibromyalgia.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s fibromyalgia condition began in May 2006 with generalized achiness, morning stiffness, and occasional swelling of small joints in the hands and fingers.  She had discomfort over her elbows, back and across her knees.  She reported weakness of the bilateral lower extremities.  At the 15 May 2006 rheumatology visit, she was found to have eight fibromyalgia tender points and was diagnosed with probable fibromyalgia syndrome.

The 12 June 2006 MEB NARSUM examination, 6 months prior to separation, noted complaint of asthma.  An evaluation related to fibromyalgia was not included, likely because a firm diagnosis had not been made at this point.  At the rheumatology clinic visit 4 days later, the examiner noted normal lab findings in relation to autoimmune or infectious processes.  The CI was prescribed medication to address her fibromyalgia symptoms.  During the 18 July 2006 rheumatology clinic visit, the CI requested that she be placed on 6-hour duty shifts “at least until she can sleep well.”  She was prescribed a new medication for sleep as well as a prescription asking for 6-hour work shifts for “the next 3 weeks only until we can get her to sleep well.”  The 15 August 2006 rheumatology clinic follow-up visit, the CI complained of right greater than left knee pain especially when she squats or goes up stairs or run or walks for about 10 minutes.  She complained of slight drowsiness one hour after arising, attributed to the new medication, but was otherwise sleeping well.  The physician assessed her fibromyalgia condition as improved, and wrote, “Return to full duty.” The 23 August 2006 MEB NARSUM addendum examination, 4 months prior to separation, noted complaints of fibromyalgia, osteoarthritis and patellofemoral syndrome.  The CI reportedly noted that she had received a recommended medication regime to control her pain and that it seemed to work well.  According to the addendum, the rheumatology clinic physician had placed her on 6-hour duty days indefinitely, which was in stark contrast to the clinic note above.

During the 19 October 2006 rheumatology visit, 2 months prior to separation, the CI reported improvement in her symptoms.  She stated that she was having a good day, and voiced no complaints.  However, the CI provided a history of gastrointestinal (GI) problems with diarrhea, vomiting, and abdominal pain that required her to seek treatment in the emergency room about four times over a 2-month period.  She reported migraine-type headaches every 2 weeks, and had a past history of migraines.  Physical examination noted areas of tender points over the upper outer quadrants of the buttocks, over the greater trochanters, and over the ribs.  The examination was otherwise unremarkable, and the CI made no specific complaint related to fibromyalgia.  The rheumatologist recommended continuing the medication regimen Cymbalta and Seroquel since the CI noted she had improvement with these medications.  A recommendation for GI referral was also made.  There was no mention of the need to modify duty hours, and no indication that the CI was not working full duty hours.  An STR entry dated 14 November 2006 documented treatment for the diagnosis of gastric ulcer due to H. Pylori bacteria.

At the 26 July 2007 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported pain in her arms, back, hips and neck.  She fatigued easily, had headaches, sleep disturbance, stiffness, anxiety and depression.  Her symptoms reportedly occurred constantly, more than two-thirds of the time per year, and were precipitated by emotional stress but not by environmental stress and overexertion.  The condition had favorable responses to exercise, walking, and medication (Cymbalta and Seroquel).  The examiner noted the CI still required continuous treatment to control the condition and functional impairment was recorded as difficulty walking.  Physical examination showed 18/18 tender points without generalized muscle weakness.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia condition 10%, coded 5025 (fibromyalgia), citing the condition of fibromyalgia “requires continuous medication for control.” Using the same code, the VA rated the fibromyalgia condition that included the conditions of migraine headaches and irritable bowel disease, 40%, based on the C&P examination and citing 40% criteria.

The rating of 20% is met when there is  “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.  The 20 June 2006 commander’s statement (CS), 6 months prior to separation, noted that since early 2006 the CI had missed significant amounts of work “due to numerous medical appointments, quarters, and convalescent leaves which has affected the productivity of her work center.”   A review of the STR demonstrated at least 5 days of quarters had been prescribed prior to the CS.  Two days were prescribed for the right knee pain, in January 2006, and the CI was prescribed 1 day of quarters for asthma in March 2006.  Just a few weeks prior to the CS, 2 days were prescribed for gastroenteritis and dehydration.  The STR also demonstrated the CI was eventually diagnosed with gastric ulcer due to H. Pylori bacteria, and had been granted quarters for an additional 4 days (November 2006), totaling 6 days for that condition.  Panel members agreed, the condition of gastric ulcer was independent of fibromyalgia and therefore, is not considered part of fibromyalgia-impairing symptoms.  The panel noted the 24 hours of quarters was prescribed related to a diagnosis of generalized anxiety disorder for which the CI was being treated for as a separate condition.  However, since there is overlap between anxieties associated with fibromyalgia and generalized anxiety, the panel agreed to include it in the overall consideration of the rating.  However, panel members concluded, the STR did not support the presence of fibromyalgia symptoms with exacerbations present more than one-third of the time.  The panel concluded, there was insufficient evidence to support a rating higher than the 10% adjudicated by the PEB based on the requirement for continuous medication for control of symptoms. 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 fibromyalgia condition.  

Asthma.  According to the STR and MEB NARSUM, the CI’s asthma condition began in April 2006 following a methacholine challenge test.  The CI had reported a history of cough, shortness of breath, and chest tightness with running activity or following exposure to dust or smoke.  Pulmonary function tests on 6 April 2006 showed FEV1 at 79% predicted, and FEV1/FVC at 80%.  At the 12 May 2006 pulmonary office follow-up visit, the CI reported that she had recently been treated in the emergency room for dyspnea, and was prescribed a few days of prednisone. In office spirometry showed FEV1 at 75% and FEV1/FVC was 49%.  Pulmicort was switched for Advair twice a day.  

The 12 June 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of asthma that improve with her current medication regimen of albuterol as needed and pulmcort. Physical examination was unremarkable.  The 23 August 2006 MEB NARSUM addendum examination, 4 months prior to separation, noted the asthma condition was well controlled with Advair twice daily and albuterol as needed.

At the C&P examination the CI reported monthly asthmatic attacks and the need to visit a physician to control the attacks as often as once per month.  She continued with Advair and Albuterol daily.  Physical examination showed normal breath sounds.  Post bronchodilation documented FEV1 as 88% and FEV1/FVC as 81%.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma).  The VA rated the asthma condition 30%, coded 6602, based on the C&P examination, citing the 30% rating criteria for asthma.  A 30% rating stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  Both the NARSUM addendum and C&P examination recorded daily use of Advair.
Advair, in addition to being an inhalational bronchodilator (salmeterol), also contains an inhalational anti-inflammatory medication (fluticasone), and would therefore warrant a 30% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the asthma condition, coded 6602.  

BOARD FINDINGS:  In the matter of the fibromyalgia condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the asthma condition, the panel recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  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	10%	
Asthma	6602	30%	
COMBINED	40%	

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2018-00265.

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 in accordance with 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 the 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  to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 90 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, in such a case, failure to render an election will result in automatic enrollment by law.