RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201086 SEPARATION DATE: 20020511 BOARD DATE: 20130416 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Reserve CAPT/0-3 (66H/medical surgical nurse), medically separated for fibromyalgia (FM). FM was diagnosed in 1998. The CI did not improve adequately to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent P2, U3 profile and referred for a Medical Evaluation Board (MEB). FM, degenerative disc disease (DDD) of the neck, hypothyroidism and biliary cirrhosis were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Physical Evaluation Board (PEB) adjudicated the FM as unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI originally requested a Formal PEB (FPEB), but reconsidered, concurred with the IPEB, and was then medically separated with a 10% disability rating. CI CONTENTION: “With no history of colon cancer, a low fat diet, and active life, the primary biliary cirrhosis is believed to be the cause of colon cancer diagnosis in January 2007. These records are at the VA Hospital JP campus Boston MA. The sensitivity to medications as a result of Hypothyroidism, Hashimoto's Disease is another cause for review. The sensitivity to medication has made it difficult to manage the elevated cholesterol along with pain management for the arm and shoulder pain associated with the cervical myalgia. The fatigue with both the primary biliary cirrhosis and the fibromyalgia complicates the ability to sustain the repetitive computer work, causing headaches, jaw and shoulder pain at the end of the day. Currently with the cervical disorder, I am unable to sleep throughout the night, awakening often to reposition my arm which becomes numb during the night. Fatigue, pain and lack of sleep are my most problematic symptoms resulting in the inability to meet the physicality of meeting the demands of production in case reviews, in home care nursing, and inpatient hands- on patient care.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The rating for unfitting FM conditions are within the DoDI 6040.44 defined purview of the Board. The unfitting biliary cirrhosis, DDD of cervical spine and hypothyroidism conditions were contented and, thus are within Board purview and are all addressed below. The Hashimoto's Disease; elevated cholesterol; arm and shoulder pain associated with the cervical myalgia; headaches, jaw and shoulder pain; and sleep disturbance, as per the contention, were not identified by the MEB or PEB; and, thus are not within the Board’s purview. Those and any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected conditions continue to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. RATING COMPARISON: Service IPEB – Dated 20011221 VA (14 Mos. Post-Separation) – All Effective Date 20020512 Condition Code Rating Condition Code Rating Exam Fibromyalgia 5025 10% Fibromyalgia 5025 0% 20030708 DDD Not Unfit DDD C-Spine 5293-5003 10% 20030708 Primary Biliary Cirrhosis Not Unfit Primary Biliary Cirrhosis 7312 10% 20030708 Hypothyroidism, Hashimoto Disease Not Unfit Hypothyroidism, Hashimoto Disease 7903 0% 20030708 No Additional MEB/PEB Entries Other x 1 20030708 Combined: 10% Combined: 20% Derived from VA Rating, dated 20030801 (most proximate to the date of separation) ANALYSIS SUMMARY: Fibromyalgia Condition. The CI’s medical records document evaluations for diffuse myalgias, arthralgias and fatigue as early as 1998. A rheumatology evaluation performed in July 1998 notes improvement in symptoms in response to medication. In October 1998, the CI’s endocrinologist and primary physician noted symptoms of FM. The primary care physician started medication and the CI was referred for rheumatology evaluation. The 25 November 1998 rheumatology evaluation noted improvement with medication and exercise. On examination there were no tender points present. The CI’s endocrinologist, in memorandum dated 27 November 1998, noted significant improvement in symptoms with medication. A medication refill is documented in July 1999 after which primary records no longer show a medication for the condition on medication lists. Due to difficulty performing recruiting duties, an MEB was initiated in January 2001. Rheumatology evaluation on 27 February 2001 recorded active symptoms off of medication including fatigue, headaches, and shooting pains in her extremities. On examination, tender points characteristic of FM were present. The remainder of the examination was normal. There was full range-of-motion (ROM) of extremities without evidence of joint inflammation. Exercise and medication was advised. At the time of a separation examination 10 May 2001, the CI reported her health to be good and experiencing good results from medication treatments. At the time of follow up in the rheumatology clinic 6 August 2001, there was improvement in her symptoms and tender points were no longer present. The commander’s letter 15 November 2001 noted her condition prevented performance of recruiting duties that required extensive travel and had been detailed to the hospital where she served as a nurse. The physical profile dated 28 November 2001 noted that the CI’s “…physical profile does not prevent her from performing nursing duties.” The MEB narrative summary (NARSUM) 4 December 2001, recorded that FM was “currently under control…with regular exercises including yoga” and noted she walked 5 days per week for exercise and passed the alternate physical fitness test (walking). On examination there was some tenderness of the upper trapezius muscles bilaterally, and some left shoulder pain with ROM. The remainder of the examination was normal. The MEB concluded FM was well under control with treatment and concluded that the CI “meets the standards for retention.” The Board directs attention to its rating recommendation based on the above evidence. The Board noted service treatment records indicating the condition responded to medication in 1998 and again in 2001 supporting consideration of the 10% rating. At the time of the MEB NARSUM in December 2001, the condition was controlled with exercise and yoga alone, and the CI was not taking medication for FM, more nearly approximating the 0% rating. Subsequent treatment records after the MEB NARSUM and prior to separation also document no resumption of medication treatment for FM. The Board noted the VA Compensation and Pension examination 14 months after separation reporting recurrent symptoms off of medication. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the FM condition. Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were DDD (cervical spine), hypothyroidism and primary biliary cirrhosis. This Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. Degenerative Disc Disease, Cervical Spine Condition. The CI first noted neck pain and left shoulder pain in 1996 without identified precipitating injury except that the CI noted having fallen onto her left shoulder in 1993. Evaluations noted pain with paresthesias in the left arm and hand. Examination at the time revealed full cervical ROM and tenderness over the left lower trapezius and left infraspinatus muscles. Motor and sensory examination was normal, as was nerve conduction velocity (NCV) and electromyogram (EMG). Neurosurgical evaluation, on 26 February 2001, documented chronic neck pain with radiculopathy that responded to physical therapy. Symptoms were described as “reasonably in abeyance” but exacerbated by physical training or long distance driving. Examination revealed full cervical ROM, with some mid-paraspinal tenderness and pain with extension and left head tilt. Neurological examination was normal. Magnetic resonance imaging (MRI) revealed DDD at C5-6 and C6-7, but without “major disk herniation.” At the MEB NARSUM examination December 2001, there was no cervical pain on flexion or extension, and the ROM was full. There was some left shoulder pain on range of, with tenderness in the upper trapezius bilaterally. The MEB NARSUM noted that her DDD of the cervical spine was “well under control with treatment,” and concluded that the CI met the standard for retention. Hypothyroidism Condition. The thyroid condition was first diagnosed, prior to commissioning, as a goiter in 1989. In July, 1994, prior to her coming onto active duty, she was diagnosed with Hashimoto’s thyroiditis and multi-nodular goiter. In October, 1998, it was noted that the CI had been on thyroid replacement therapy since 1997, and that laboratory parameters showed the condition to be well controlled with Synthroid. An endocrinology consultation in 2001 documented that the CI was “clinically and biochemically euthyroid”; that is, well controlled with medication without side effects. The MEB NARSUM noted a diagnosis of thyroiditis since 1994, and no thyromegaly. Primary Biliary Cirrhosis Condition. The CI was evaluation of abnormal liver blood tests prompted evaluation with a liver biopsy in 1998 that resulted in the diagnosis of primary biliary cirrhosis, for which she was prescribed medication. At the MEB NARSUM examination, the condition was controlled with medication. There were no symptoms or liver function abnormalities. The MEB physical exam noted a normal abdominal examination, mild elevations of liver function tests, and no systemic evidence of liver disease. The MEB concluded that she met the standard for retention for this condition. The Board noted the physical profile report dated 28 November 2001 stating that the CI’s “…physical profile does not prevent her from performing nursing duties.” All conditions were reviewed and considered by the Board. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions; therefore, no additional disability ratings can be recommended. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. In the matter of the FM condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended DDD of the cervical spine, hypothyroidism and primary biliary cirrhosis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Fibromyalgia 5025 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120707, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130009613 (PD201201086) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)