RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1201895
BRANCH OF SERVICE:  Army	BOARD DATE:  20130731
SEPARATION DATE:  20020320

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-7 (98C4L/Signals Intelligence Analyst) medically separated for fibromyalgia (FM).  The initial injury occurred in the summer of 1991 when CI pulled a muscle in her neck doing physical therapy (PT).  In 1994 she developed consistent muscle spasms in the paraspinal area and in October 1996 was diagnosed with chronic pain and myofascial pain syndrome (MPS).  She also experienced headaches and gastrointestinal symptoms which began in May of 1999.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent U4 profile and referred for a Medical Evaluation Board (MEB).  The FM condition, “myofascial pain syndrome,” and “chronic cervical strain and spasm” was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  The MEB also identified and forwarded migraine headaches as a medically unacceptable condition.  The PEB adjudicated FM as unfitting rated 20%.  The remaining conditions were determined to be not unfitting and therefore not ratable.  The CI made no appeals, and was medically separated.

CI CONTENTION:  “Rating failed to take into consideration the permanent, debilitating, and degenerative aspects of the medical conditions.”

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 is addressed below.  The Board judged that the migraine headache and mild spondylosis conditions recorded in the MEB were integral, comorbid components of the FM condition and could not be reviewed separately IAW VASRD §4.14. (avoidance of pyramiding).  The Board unanimously agreed the MPS is also known as FM, thus, was not a different and distinct condition.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20020107	VA - (1 Month Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia	5025	20%	20020430	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	10%	20020430	
Mild Spondylosis	Not Unfitting	Cervical Disc Disease, C4-5 w/ Muscle Spasm (claimed as Spondylosis)	5293-5290	10%	20020430	
No Additional MEB/PEB Entries	Other x 7	20020430	
Combined:  20%	Combined:  70%	

ANALYSIS SUMMARY: 

Fibromyalgia Condition.  The CI underwent evaluations with physical medicine/rehab, chiropractor, neurosurgery, pain management, neurology, and rheumatology to rule out specific pathology.  The CI’s symptoms included arthralgia in multiple joints, especially the neck; fatigue and poor sleep.  Some form of each condition was present since 1999; (i.e., neck pain, shoulder pain, hip and arm pain).  Treatment records indicated the CI injured her neck in 1990 and developed neck spasms.  Magnetic resonance imaging (MRI) in October 1999 of the C-spine recorded disk herniation at C4-C5 and C5-C6 with mild right sided neural foraminal narrowing.  Follow up MRI in December 2001 noted mild cervical spondylitic disease, primarily involving the C4-C5 and C5-C6 disk space with mild spinal canal stenosis and “no evidence of obvious disk herniation.”  A nerve conduction study in September 2001 was negative for cervical radiculopathy.  The CI was diagnosed with FM by a rheumatologist in October 2001 after a thorough evaluation for other causes was negative.  On examination the rheumatologist recorded 16 out of 18 tender points meeting the Academy of Rheumatology criteria of 11 out of 18 tender points for the diagnosis.  In the treatment records the CI reported positive response to medication, PT, trigger point injections, acupuncture, and transcutaneous electrical nerve stimulation (TENS) unit for pain relief.  The CI had radiographs of her hips and back with no evidence of inflammatory changes, arthritis, dislocations, fractures, or other abnormalities.  The MEB narrative summary (NARSUM), dictated approximately 8 months prior to separation, noted that the CI had no problems with her neck and shoulder between her initial injury and treatment in 1990, 1991, and 1994 (when her neck problem resurfaced).  On physical examination, there was tenderness to palpation at lower neck and upper trapezius and supraspinatus muscles.  No other findings were noted.  At VA Compensation and Pension (C&P) exam, performed approximately a month after separation, the CI reported neck pain, weakness, fatigue, lack of endurance and stiffness accompanied by occasional numbness and tingling in the left hand.  She had flare ups randomly that lasted 3 to 6 days. However, they were relieved by non-narcotic medication, heat, neck traction, and bilateral shoulder pain that flared up once or twice weekly which were alleviated by TENS.  Additionally, the CI reported upper arm pain, hip, back, and buttock pain.  On physical examination, gait was recorded as normal.  There was some tenderness noted in the right shoulder and range-of-motion (ROM) revealed right shoulder flexion of 175 degrees with pain (180 normal), abduction of 150 degrees with pain (180) and normal external/internal rotation.  Left shoulder ROM measurements were normal.  Cervical ROM measurements were slightly decreased by 5 to 10 degrees in each position with pain at the end of motion.  Hip ROM were all normal range with pain noted at the end.  Muscle spasm and tenderness noted in upper back and there was no evidence of neurological or motor deficits.

The Board directs attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the FM condition at 20% under the code 5025.  A rating of 20% requires widespread pain and tender points with associated symptoms to be episodic and present more than one third of the time.  The Board agreed the NARSUM and the C&P evaluations supported the 20% rating.  The criteria for a higher rating of 40% required evidence that symptoms were constant or nearly constant and were refractory to treatment.  The CI indicated in the C&P examination her symptoms were alleviated by medication, therapy, and rest.  There was no evidence in the record at hand to support the higher rating of 40%.  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.  The Board was unable to ascertain a pathway for higher rating under any applicable VASRD code.

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 PEB adjudication.  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	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20121105, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB),

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130019762 (PD201201895)

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA