RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:       BRANCH OF SERVICE:  Army
CASE NUMBER:  PD1001241      SEPARATION DATE:  20030604
BOARD DATE:  20120203


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI) was an active duty SPC/E-4  (92G,
Food  Service  Specialist)  medically  separated  for   fibromyalgia.    Her
symptoms began about 4 months after entering service and  gradually  evolved
into a typical presentation of fibromyalgia.   After  extensive  evaluation,
and despite medication trials and adjunctive therapy, she  did  not  respond
adequately to fully  perform  within  her  Military  Occupational  Specialty
(MOS) or meet physical  fitness  standards.   She  was  issued  a  permanent
P3/U3/L3/S2  profile  and  underwent  a  Medical  Evaluation  Board   (MEB).
Fibromyalgia, mood disorder secondary  to  general  medical  condition,  and
unspecified autoimmune disorder were forwarded to  the  Physical  Evaluation
Board (PEB) as medically unacceptable conditions IAW AR 40-501.  Five  other
conditions, as identified in the rating chart below, were forwarded  by  the
MEB as medically acceptable conditions.   One  other  condition,  borderline
personality disorder, was forwarded as meeting criteria  for  administrative
separation; but, is not a ratable condition  IAW  DoD  and  VA  regulations.
The PEB adjudicated the Fibromyalgia condition as unfitting, rated 20%  with
application of the Veterans Administration Schedule for Rating  Disabilities
(VASRD).  The CI made no appeals, and was medically  separated  with  a  20%
disability rating.


CI CONTENTION:  “Wasn't given a rating for the autoimmune  disorder  related
to military service for which I was service connected.  And  I  believe  the
rating is inaccurate because I had other medical factors that made me  unfit
for military service. The rating should be reviewed  for  the  Fibromyalgia,
Depression and the chronic gastritis and the autoimmune  disorder…   I  only
received a rating of 20% from the military.  And the VA  has  given  me  50%
for  the  Depression,  40%  for  the  Fibromyalgia,  10%  for  the   Chronic
gastritis, and 20% for the Seronegative inflammatory arthritis.”


RATING COMPARISON:

|Service IPEB – Dated 20030130    |VA (3 Mo. Pre Separation) – All       |
|                                 |Effective 20030605                    |
|Condition             |Code      |Rating                                |
|Unspecified Autoimmune|Not       |Not Service Connected*         |2003031|
|Disorder              |Unfitting |                               |9      |
|Borderline Personality|Not       |Not Service Connected          |2003031|
|Disorder              |Unfitting |                               |2      |
|No Additional MEB/PEB Entries    |0% x 3 / Not Service Connected |2003031|
|                                 |x 1                            |9      |
|Combined:  20%                   |Combined:  30%                        |


  *Diagnosis changed to seronegative inflammatory arthritis, 5009-5002 rated
                                                     20% effective 20090512.


ANALYSIS SUMMARY:  The Board acknowledges the sentiment implied in the  CI’s
application regarding the significant impairment  with  which  her  service-
aggravated conditions continue to burden her.  It is a fact,  however,  that
the DES has neither  the  role  nor  the  authority  to  compensate  service
members for  anticipated  future  severity  or  potential  complications  of
conditions resulting in medical separation.   This  role  and  authority  is
granted by Congress to the Department of Veterans’ Affairs (DVA).  The  DVA,
operating under a different set of laws (Title 38, United States  Code),  is
empowered to compensate service connected conditions and to periodically re-
evaluate  said  conditions  for  the  purpose  of  adjusting  the  Veteran’s
disability rating should the degree  of  impairment  vary  over  time.   The
Board notes the current DVA ratings listed by the CI for all of her  service
connected conditions,  but  must  emphasize  that  its  recommendations  are
premised on severity at the time  of  separation.   The  Board  utilizes  VA
evidence proximal to separation in arriving  at  its  recommendations;  and,
DoDI 6040.44 defines a 12-month interval for special consideration to  post-
separation evidence. The Board’s  authority  as  defined  in  DoDI  6044.40,
however, resides in evaluating the fairness of  DES  fitness  determinations
and rating decisions  for  disability  at  the  time  of  separation.  Post-
separation evidence therefore is  probative  only  to  the  extent  that  it
reasonably reflects the disability and fitness implications at the  time  of
separation.

Fibromyalgia Condition.  At the time  of  the  narrative  summary  (NARSUM),
with its rheumatology addendum, the CI’s symptoms had been present for  more
than two years (since basic  training).   These  symptoms  included  feeling
achy all over with generalized myalgias and fatigue, poor  sleep,  decreased
appetite, pain in all joints, and intermittent bi-temporal  headaches.   The
NARSUM documented various  medication  trials  and  physical  therapy  “with
modest  improvement  in  her  symptoms.”   She   also   exhibited   symptoms
consistent with a major depressive disorder,  or  adjustment  disorder  with
depressed mood.  Over the previous six  months  she  had  been  hospitalized
once for a suicide attempt, and again for increased suicidal ideation.   She
was taking a number of psychoactive and  analgesic  medications.   Both  the
MEB examiner and rheumatologist noted essentially normal  examinations  with
the exception of a tender point distribution  diagnostic  for  fibromyalgia;
and, both documented normal joint exams without  evidence  of  synovitis  or
deformity.  Imaging and other ancillary studies were not diagnostic for  any
specific pathology.  The psychiatric consultant made an Axis I diagnosis  of
mood disorder secondary to a general  medical  condition;  and,  recommended
administrative separation under provisions of AR  635-200  for  an  Axis  II
diagnosis of personality disorder.  The treating  physical  therapist  noted
that  the  CI  participated  in  a  variety  of  modalities  with  “moderate
compliance” and “overall mild increase in strength and functional  ability;”
although, by subjective report there was no improvement in  a  multitude  of
somatic symptoms.  Consultants in neurology, orthopedics, neurosurgery,  and
gastroenterology  also  evaluated  and  followed  the  CI’s   symptoms   and
condition.  Some improvement in  the  headache,  orthopedic  complaints  and
sleep disturbance were documented  in  those  entries.   The  rheumatologist
opined that, although he was unable to  confirm  a  specific  diagnosis,  he
suspected an undefined autoimmune disease.  The commander’s statement  noted
that the CI’s condition did not allow her to lift heavy objects  or  perform
strenuous  activities;  but,  noted  that  she  “does  not  appear  to  have
difficulty performing  activities  of  daily  living,  and  basic  tasks  to
include filing, answering telephones, or  customer  service  issues.”    The
CI’s profile restricted her to a four hour duty day.  The pre-separation  VA
Compensation and Pension  (C&P)  evaluation  recorded  similar  symptoms  as
those elaborated above; but, added that whenever “the hands are  exposed  to
cold, the hands will turn blue and painful” (Raynaud's like symptoms).   The
CI reported to the VA examiner that her symptoms occurred  daily;  that  her
hands, face and knees were swollen in the mornings; and, that she  was  able
to drive without  difficulty  or  restriction.   The  VA  examiner  did  not
address  the  “constancy”  of  the  symptoms;  and,  documented  a  detailed
physical exam that was  essentially  normal,  to  include  normal  gait  and
posture, normal motor and sensory functions, normal range of motion with  no
abnormalities in any joints, and no tender spots.  It was noted that the  CI
“has a  depressed  deportment  manifested  in  her  emotional  composure  of
sadness easily induced to weeping.”

The  Board  directed  its  attention  to  its  rating   recommendation   for
fibromyalgia based on evidence presented above.  Fibromyalgia  is  described
in the VASRD as widespread musculoskeletal pain and tender  points  with  or
without  fatigue,  sleep  disturbance,  stiffness,  paresthesias,  headache,
irritable bowel symptoms, depression, anxiety, or Raynaud’s  like  symptoms.
The rating is based  upon  the  frequency  of  symptoms  without  regard  to
severity or impact on function.  A 10% rating applies when the symptoms  are
controlled by medication;  a  20%  rating  applies  when  the  symptoms  are
episodic, with exacerbations present more than one third of the time; a  40%
rating applies when symptoms are constant, or nearly so, and  refractory  to
treatment.  All members agreed that the 10%  rating  criteria  were  clearly
exceeded.  The Board deliberated therefore whether the  CI’s  symptoms  were
best characterized as episodic with frequent exacerbations (20%  rating)  or
constant and refractory to therapy (40% rating).  The Board considered  that
there were no entries in  the  service  treatment  record  (STR)  describing
constant symptoms; that there were several entries  in  the  STR  describing
intermittent or episodic symptoms; that the NARSUM  and  various  consultant
and treatment notes documented improvement  (albeit  modest)  with  therapy;
and that the commander observed  that  the  CI  performed  well  in  a  non-
demanding environment.  The Board also noted that  the  VA  rating  decision
most proximate to separation cited  equivalent  evidence  derived  from  the
concurrent C&P evaluation, and arrived at a  20%  rating  determination  for
the  fibromyalgia  condition.   All  evidence  considered,  there   is   not
reasonable doubt in the CI’s  favor  supporting  a  change  from  the  PEB’s
adjudication of the fibromyalgia condition.

Other PEB Conditions.   The  other  conditions  forwarded  by  the  MEB  and
adjudicated as not unfitting by the PEB  were  mood  disorder  secondary  to
general  medical  condition,  unspecified  autoimmune   disorder,   migraine
headaches, hypertension,  symptomatic  premature  ventricular  contractions,
chronic gastritis and iron deficiency anemia.  The PEB  did  not  judge  the
mood disorder, unspecified autoimmune disorder or migraine conditions to  be
independently unfitting, although these adjudications could  be  challenged.
Even if  any  or  all  of  these  conditions  were  conceded  as  separately
unfitting, however, the distinction would  be  moot  to  disability  rating.
All of these conditions are characteristic elements of the  overarching  and
unfitting fibromyalgia condition.   The  disability  associated  with  these
conditions has therefore been accounted for in the fibromyalgia rating,  and
indeed these conditions serve as a considerable foundation  of  support  for
the 20% rating under the 5025 code.   It  should  be  noted  that  all  were
subsumed in the VA rating approach; and, separate  rating  for  any  one  of
them would both invalidate the 5025 code and violate VASRD §4.14  (avoidance
of pyramiding).

None of the other conditions were profiled, implicated  in  the  commander’s
statement or noted as failing retention standards.   All  were  reviewed  by
the Action Officer and considered by the Board.   There  was  no  indication
from the record that any of these conditions significantly  interfered  with
satisfactory duty  performance.   All  evidence  considered,  there  is  not
reasonable doubt in the CI’s favor supporting recharacterization of the  PEB
fitness adjudication for any of the stated conditions.

Other  Contended  Conditions.   The  CI’s   application   asserts   that   a
compensable  rating  should  be  considered  for  seronegative  inflammatory
arthritis, as per her current VA  rating.   The  Board  notes  that  the  VA
granted  service  connection   for   seronegative   inflammatory   arthritis
(formerly claimed as unspecified autoimmune disorder) with an evaluation  of
20% effective                        May 12, 2009, nearly  six  years  after
the CI’s separation.  The detailed  MEB  and  VA  C&P  exams  provide  ample
evidence that no arthritis, inflammatory  or  otherwise,  existed  prior  to
separation.  As noted above, any disability associated with the  unspecified
autoimmune disorder is fully subsumed  in  the  fibromyalgia  rating.   This
condition was reviewed by the action officer and considered  by  the  Board.
The Board  determined  that  this  condition  was  not  subject  to  service
disability rating.

Remaining Conditions.  A host of additional non-acute conditions or  medical
complaints were identified in the DES file, including memory loss,   trouble
sleeping, change of menstrual  cycle,  light  sensitivity,  joint  pain  and
stiffness,  trouble  with  bending   and   stooping,    occasional   bladder
infections, blurry vision, trouble breathing (when in pain), and  epigastric
burning.  The majority of these complaints overlapped  with  the  conditions
already  addressed.   None  of  them  were   significantly   clinically   or
occupationally  active  during  the  MEB  period;  none   carried   attached
profiles; and, none were implicated in  the  commander’s  statement.   These
conditions  and/or  symptoms  were  reviewed  by  the  action  officer   and
considered by the Board.  It was determined that none  could  be  argued  as
unfitting and subject  to  separation  rating.   No  other  conditions  were
service connected with a compensable rating by the VA within  12  months  of
separation or contended by the CI.  The Board therefore  has  no  reasonable
basis for recommending any additional unfitting  conditions  for  separation
rating.


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  fibromyalgia  condition  and  IAW  VASRD
§4.71a, the Board unanimously recommends no change in the PEB  adjudication.
 In the matter of mood disorder  secondary  to  general  medical  condition,
unspecified   autoimmune   disorder,   migraine   headaches,   hypertension,
symptomatic premature ventricular contractions, chronic gastritis  and  iron
deficiency anemia conditions; the Board  unanimously  recommends  no  change
from the  PEB  adjudications  as  not  unfitting.   In  the  matter  of  the
contended  seronegative  inflammatory   arthritis   condition,   the   Board
unanimously  agrees  that  it  cannot  recommend  a  finding  of  unfit  for
additional rating at separation.  The Board unanimously  agrees  that  there
were no other conditions eligible for Board  consideration  which  could  be
recommended as additionally unfitting for rating at separation.


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 20101026, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record





                 President
                 Physical Disability Board of Review

SFMR-RB


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB /), 2900 Crystal Drive, Suite 300, Arlington, VA  22202

SUBJECT:  Department of Defense Physical Disability Board of Review
Recommendation for


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
                                       Deputy Assistant Secretary
                                           (Army Review Boards)

CF:
(  ) DoD PDBR
(  ) DVA