Author: JOHN J. D'ORAZIO
Last saved by: ADA, ROBERT P CIV USAF SAF/MRBD
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	cASE:  PD-2012-01510
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150305
DATE OF PLACEMENT ONTO TDRL:  20001104
DATE OF REMOVAL FROM TDRL:  20020918

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (2T031/Traffic Management Apprentice) medically separated for fibromyalgia (FM).  This condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty.  He was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “chronic pain syndrome, possible fibromyalgia syndrome” to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “fibromyalgia like syndrome associated with stress related chronic pain syndrome” as unfitting, rated 10%, referencing application of DOD and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The CI appealed to the Formal PEB (FPEB) who found “fibromyalgia currently refractory to medication” unfitting, rated 40% and placed the CI on the Temporary Disability Retired List (TDRL) effective on 4 November 2000.  Approximately 18 months later, the TDRL IPEB determined the FM condition remained unfitting, rated 20%.  The CI appealed to the FPEB and Secretary Air Force Personnel Council (SAFPC), which affirmed the PEB findings and rating and the CI was removed from the TDRL and medically separated.

CI CONTENTION:  “I meet all the criteria for the max rating.  I was denied due to resons [sic] why any condition may or may not be worsened not because I do not meet the standards for the higher rating.  The Air Force’s own doctor stated the severity of my affliction in his statement to the board.  As for my weight causing my simptoms [sic] to be worsened, I have lost over 70 lbs since my appearance before the board and it has done nothing to alleviate my symptoms.  I see this as further proof that my denial was based on guess work rather than the facts at hand.  Although stress does cause an increase in some of my symptoms, I do not suffer from an extreme amount of stress.  This reason was given based on a statement given by my psychotherapist and was taken out of context.  She simply stated that stress increases the pain of fibromyalgia patients.  This is a well known fact and does not mean stress causes these symptoms.  I believe I meet all the standards established for the maximum rating and to second guess doctors and come up with theories as to what would make me better is wrong.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting FM condition is addressed below.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may remain eligible for future consideration by the Board for Correction of Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to the review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.

RATING COMPARISON:

SAF Memo – 20020918 | VA Rating Decision* - 20011001
TDRL Placement – 20001104 | Code | Rating | Condition | Code | Rating Proximate
Condition | | TDRL Placement | TDRL Removal | | | TDRL Placement | TDRL Removal
Fibromyalgia | 5025 | 40% | 20% | Fibromyalgia | 5025 | 40% | 40%
Other x 0 | Other x 0
RATING:  40% → 20% | RATING:  40%
*Derived from VA Rating Decision (VARD) dated 20011001 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Fibromyalgia.  The evidence present for review supports that the CI began complaining of frontal headaches and diffuse joint pains in November 1999.  He was initially evaluated with X-rays of the sinus and lumbar spine, and a head CT scan, which were all normal.  His headaches and joint pains continued and were refractory to medications; and, he was given a tentative diagnosis of Lyme’s disease and treated with antibiotics.  He was evaluated by a neurologist, internist, and a rheumatologist.  Because body bone scan results were normal, the rheumatologist made a tentative diagnosis of FM due to the recent onset of symptoms and the CI was referred to an FM patient education seminar.  A comprehensive rheumatology evaluation in August 2000 contained the following statements:

“He has continued to have severe progressive widespread body pain and aching, worse in his lower back, hips and knees.  It has interfered with his walking and activities.  He had to use a cane for ambulation.  He has been unable to get pain relief nor sleep and he has been quite fatigued.  He has continued to have severe headaches, as well as diffuse irritable symptoms of his body with GI complaints, nausea and trouble concentrating.  His lab test, x-rays, bone scans have been negative. He has been diagnosed with severe fibromyalgia.”

The narrative summary (NARSUM) prepared approximately 2 months prior to TDRL entry contained the following statements:

“Currently, his symptoms have changed little from those on his initial presentation.  He reports severe daily pain in multiple areas, persistent headache and extreme fatigue.  He is virtually unable to exert himself without a notable worsening of his symptoms.  He has not been to work since December, stating that even sitting at a desk and working will significantly exacerbate his symptoms.”

The physical exam revealed a slightly overweight male in moderate distress secondary to pain.  His neck was supple with a full range-of-motion (ROM) and distinct points of tenderness at base of occiput and trapezius, bilaterally.  His abdomen had normal bowel sounds, was soft and non-tender.  The extremity exam revealed subjective tenderness along most joints without warmth, erythema or effusion.  The final diagnosis was chronic pain syndrome, possible FM syndrome.

The Board directed its attention to its TDRL entry rating recommendation based on the above evidence.  In August 2000, the FPEB placed the CI on the TDRL with the diagnosis of “Fibromyalgia, currently refractory to medication” rated at 40%.  The rating criteria are copied below for the reader’s convenience:

5025 Fibromyalgia (fibrositis, primary fibromyalgia syndrome):  With 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 constant, or nearly so, and refractory to therapy ................................................... 40

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 .............................. 20

That require continuous medication for control …................................................................ 10

Upon review of the VASRD criteria, the Board noted that the 40% rating is the highest rating available for FM and was supported by the evidence present for review.  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 FPEB adjudication at TDRL placement for the FM condition.

The Board next considered the following evidence for its rating recommendation at removal from the TDRL.  The CI had a VA Compensation and Pension exam performed 8 months after placement on the TDRL and 16 months prior to TDRL removal.  At that time, “He states it changed who I was.  He stays home most of the time, limits all activities, and cannot work.”  Also noted was the following:

“He has constant headaches.  Increased headaches when he has stress.  He does have a balance problem, he uses a cane.  He is shifting about constantly in his chair because of pain.  He takes his medication which helps somewhat, but not completely.  He has loose stools after eating.  His joints always hurt, 8 on a scale of 0 to 10.”

The physical exam was significant for a well-developed and well-nourished white male in no apparent distress.  His neck was supple.  His abdominal exam was normal.  The musculoskeletal exam revealed normal strength, reflexes and pulses without any other abnormalities noted.  The TDRL NARSUM was accomplished 5 months prior to TDRL removal and was performed by a rheumatologist who included the following statements:

“With his current medications, he still complains of non-restorative sleep, though he does report it is somewhat better than previously.  Despite this, he continues to complain of severe fatigue and has diffuse pain in his muscles and joints that he characterizes as a steady burn.  The pain is variable on the joints and they ache, burn or stab.  He reports morning stiffness of 1 to 2 hours.  He reports much difficulty with walking outdoors on flat ground, bending down to pick up clothing from the floor and getting in and out of a car.  His symptoms have remained stable.  On questions that measure helplessness, he scores quite high.”

The physical exam revealed he dressed and undressed with moderate difficulty, but had more problems bending over to take his socks off and on.  Examination of the abdomen was unremarkable.  The joints had no synovitis and the cervical, thoracic and lumbar spines disclose a full ROM without pain.  His strength was normal in all extremities and deep tendon reflexes were brisk.  He had tender points involving the bilateral occiput, neck, anterior chest, scapula, lumbar regions, greater trochanteric area and medial knees.  The NARSUM also contained the following pertinent entry:

The patient presented also a statement from his psychotherapist, a psychologist, [Dr.’s name] dated February 13, 2002, diagnosing stress related physiologic response affecting fibromyalgia and depression.  No evidence of personality disorder, access through chronic pain syndrome to fibromyalgia and comments that the CI "…responds well to psychotherapeutic modalities which include psychotherapy, progressive muscle relaxation and autogenic training and induction to assist in alleviation of chronic pain.”

The Rheumatologist’s impression was:

“The patient continues to suffer from severe fibromyalgia with all manifestations and associated symptoms.  Specifically, he manifest the widespread pain, neurocognitive deficits, sleep disturbance, profound fatigue, physical examination findings of the characteristic tender points. Further, he has associated irritable bowel syndrome, chronic headaches and has subsequently developed a depression which appeared to be associated with the fibromyalgia.  His prognosis for recovery in the near term few years is poor. His condition has appeared to reach a present level of stability and I do not anticipate that it will change.”

A memo form the CI’s treating rheumatologist to the VA dated 16 July 2002 (3 months prior to TDRL exit) contained the following statements:

“The patient suffers from severe fibromyalgia, knee osteoarthritis and degenerative disc disease of the lumbar spine.  The patient needs an assistive device in which to ambulate.  The patient has secondary depression related to his disease.  The patient’s signs and symptoms increase with stress.”

Additionally noted were the following excerpts from several VA exams completed between 2 and 8 months after TDRL removal:

Two months after TDRL exit:  “Reports benefit from tx and states that he is approx. 75% better.  Also, cold weather increases his fibromyalgia symptoms.  Overall he would say that he is fairly stable and coping ok.”

Four months after TDRL exit:  “Pt also keeps busy taking his 1962 Buick to car shows in the summertime, when he is feeling well enough to do so.”

Six months after TDRL exit:  “His fibromyalgia is still the same with pain off and on.  He is stable since he is on Paxil, Elavil, and wanted to stop his Seroquel and try Ambien instead for sleep.”  

The Board directed its attention to its final rating recommendation at TDRL removal based on the above evidence.  FPEB’s adjudication of the FM condition rated it 20% at TDRL removal and separated the CI with severance pay.  SAFPC reviewed and upheld the FPEB findings.  The Board reviewed the SAFPC memo during its deliberations.  The VA rated the FM condition at 40% approximately 9 months after TDRL placement and 12 months prior to TDRL removal.  The VA continued the 40% rating for the FM condition on subsequent VARDs.  Board deliberations settled on 20% vs 40% rating recommendation.  While the CI did have all manifestations of FM, the majority of the evidence proximate to TDRL removal supports that his symptoms had improved somewhat and where more episodic in nature.  Two months after TDRL removal it was documented that the CI benefited from treatment and he was “approx. 75% better.”  Also noted was that at times he felt well enough to show his classic car at car shows and that “his fibromyalgia is still the same with pain off and on.”  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), Board members agreed that a permanent disability rating of 20% for the FM condition was appropriately adjudicated at TDRL removal.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the FM condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the FPEB adjudication at TDRL placement or removal.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120813, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

			
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB

Dear XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-01510.

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 re-characterization or modification 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 re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD-2012-01510