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AF | PDBR | CY2012 | PD2012 01383
Original file (PD2012 01383.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1201383
BRANCH OF SERVICE: MARINE CORPS  BOARD DATE: 20130625
SEPARATION DATE: 20011002


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (6531/Aircraft Ordnance Technician) medically separated for fibromyalgia (FM) and major depression. Both conditions were diagnosed in in the 1999 through 2000 timeframe. She did not respond to treatment to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards and was referred for a Medical Evaluation Board (MEB). The FM syndrome and major depressive disorder (MDD) conditions were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The PEB adjudicated FM as Category I rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The other condition was rated as Category II contributing to the unfit. The CI made no appeals, and was medically separated.


CI CONTENTION: “I was only given a rating by the USMC of I0% for fibromyalgia and depression (which is a side-diagnosis of Fibromyalgia). I was given an initial rating of 100% by the department of Veteran's Affairs (50% for fibromyalgia & 40% for depression & 10% times 4 other diagnoses) due to the fact that with those two diagnosis and the others that were given to me at that time, they determined I would not be able to keep employment. (section 12) I have struggled for II years now to try to keep employment because of my illnesses and weaknesses physically. I have been hospitalized several times and am continuously sick with a weakened immune system and weakened physical body structure (my thousands of pages of medical records from the VA Hospitals will attest to). I don't believe at the time of my medical discharge, the severity of how my conditions would affect me for the rest of my life were taken into consideration. Nor were the short term and long term side effects of all of the different medications I have been put on and taken off of, through the years. I will continue to deteriorate health wise until eventually the Department of Veteran's Affairs initial assessment will be correct I will NOT be able to continue with employment. I will be 100% disabled. I struggle every day of my life-on and off hundreds of different medications in the last 13 years-to just make it through the day, physically and mentally. I was perfectly healthy when I joined the United States Marine Corps. Now, I am subject to try to raise my adopted children (due to my unexplainable infertility) and try to maintain full time employment (still working for the US Government) for as long as my body and mind will allow me. Please reconsider my 10% discharge rating.”


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 ratings for the Category I (unfitting FM syndrome) and Category II (unfitting major depression conditions) are addressed below. Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Naval Records.
RATING COMPARISON :

Service IPEB – Dated 20010716
 VA* - (<1 Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Fibromyalgia Syndrome 5025 10% Fibromyalgia 5025 40%** 20010926
Major Depressive Disorder Cat II Depression 9434 50%** 20010926
No Additional MEB/PEB Entries
 Other x 8 20010926
Combined: 10%
 Combined: 80%
* Derived from VA Rating Decision (VA RD ) dated 200 20710 (most proximate to date of separation )
** No change to ratings derived from subsequent C&P exams


ANALYSIS SUMMARY: The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected conditions continue to burden her; 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.

Fibromyalgia Condition. CI presented to rheumatology clinic 15 December 1999 with a 9 month history of poor sleep pattern, fatigue, generalized pain, arthralgias and myalgias. Symptoms of depression were noted to be absent. There was no evidence of underlying inflammatory autoimmune disease and on examination there was soft tissue tender points consistent with the diagnosis was FM. Treatment included physical therapy and medications. The development of depressive symptoms was subsequently noted and treatment with anti-depressant medication was initiated on 23 February 2000. The CI was placed on limited duty on 24 February 2000 for 4 months with restrictions that included no running, forced marching, prolonged walking/standing and no lifting greater than 20 pounds. Following expiration of the period of limited duty, follow up in the rheumatology clinic on 5 July 2000 noted some improvement overall with regular physical training program, with decreased depressive symptoms but persisting pain, sleep disturbance and fatigue. There were no limitations to duty except the Marine Corps Physical Readiness Training. At follow up on 18 October 2000, there was persisting fatigue and diffuse pain that was improved with physical exertion and exercise. The CI noted she enjoyed her work (performing computer network work rather than primary duties in aircraft ordinance). Her symptoms persisted and prevented return to full duty and the CI was referred for MEB. The commander’s non-medical assessment dated 9 April 2001, stated the CI was absent from command duties 8 hours per week and noted she was in constant pain, had noticeable physical tremors and had constant fatigue. Her physical limitations prevented her from performing duties in her primary job in ordinance due to her inability to lift and problems with maintaining total concentration and did not allow her to perform as a Marine (physical fitness test, rifle, swim qualifications, formations, and company physical training). She was currently working as a network administrator and demonstrated outstanding technical capabilities. The rheumatology MEB narrative summary (NARSUM), dictated approximately 5 months prior to separation, stated that the CI reported sleep was better with medication, but there was no improvement of her generalized pain. She was still working, but did not maintain the same active schedule as other Marines. She was unable to run and perform physical fitness training. She complained of decreased cognitive abilities at work and episodes of crying attributed to depressive symptoms. The general physical exam was unremarkable, but the musculoskeletal exam demonstrated more than 11/18 tender points as delineated by the American College of Rheumatology for the diagnosis of FM syndrome. The psychiatry MEB NARSUM performed on 6 April 2001 stated that depressive symptoms developed in the context of difficulty coping with chronic pain due to FM. She enjoyed her work with computers and hoped to work in computers following discharge. She was pending divorce in her second marriage.

At the VA general Compensation and Pension (C&P) medical exam, performed less than a week prior to separation, the CI reported a poor sleep pattern, generalized pain, arthralgias, myalgias and occasional swelling of the fingers. She had fatigue all the time but had good sleep with the Elavil. She stated almost anything precipitated symptoms and she hardly gained relief from anything. She had lost time from work. Exam revealed she had 11 out of 16 trigger points (bilateral) necessary for FM diagnosis. She had decreased muscle strength primarily of the left lower extremity. At the VA joint C&P examination, performed a week prior to separation, the CI reported she has pain all over, all the time, 24 hours a day, 7 days a week and 12 months a year. Medications were reported to be unhelpful. The examiner noted the CI stated that her main problem was that she hated the job she was doing (ordinance), but managed to do her work and physical training. The examiner noted he could not identify any trigger points; pain was not consistent, and not bilateral and symmetrical. He noted the CI walked well, had no postural abnormality, no fixed deformity, could heel and toe walk, could squat, and could slowly do ten toe rising exercises. There was no tenderness over the entire spinous processes from the sacrum up to the cervical spine. There was no paravertebral muscle tenderness. Range-of-motion (ROM) in the lumbar and cervical spine were normal on each side without evidence of pain or tenderness. Neurological exam in the lumbar region was normal. Shoulder, elbow, wrist, knees, hips and ankles joints had normal ROM free of pain. The examiner observed that the CI smiled through the exam, but said she had pain. The VA mental health C&P examination noted depressive symptoms associated with FM which were somewhat better with medication. The examiner recorded that when the CI was not at work she was attending college on line, spending approximately 2 to 3 hours per day studying and had been getting all A’s but had experienced a recent deterioration in grades due to her symptoms. The examiner diagnosed depressive disorder secondary to physical health problems.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the FM syndrome 10% (continuous medication to control symptoms) and coded it 5025. The VA rated the condition 40% (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), also coded 5025. The Board noted the joint C&P examination that reported an absence of tender points to support the diagnosis, but concluded that the numerous rheumatology examinations prior the MEB had established the diagnosis. The Board notes that the VASRD rating guidance under 5025 for FM includes associated symptoms of depression and the Board considered the associated depression symptoms in its rating recommendation. The Board agreed the condition required medication for control supporting the 10% rating adjudicated by the PEB, but noted that there was evidence indicating that the overall disability picture exceeded the 10% rating. Therefore the Board’s discussion centered on the 20% versus 40% rating under VARSD 5025. Medication treatment did not result in improvement to enable return to full duties in aviation ordinance, but treatment records did document partial responses to treatment. The CI was unable to perform her regular military duties in aircraft ordinance due to the strenuous physical demands, but that she continued to work as computer technician which she enjoyed and demonstrated outstanding technical capabilities. The C&P examination also noted she was attending online college courses with good grades when off duty. The Board concluded the preponderance of evidence showed that CI had pain but was functional at work, at home and at school. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the FM condition (5025).

Major Depression Condition. The PEB listed the major depression condition as a Category II condition, a condition that is related to the primary unfitting condition and contributes to the primary unfitting condition but is not separately ratable. At the time of initial diagnosis of the FM condition in December 1999 symptoms of depression were absent, but subsequently depressive symptoms developed related to difficulty coping with the FM prompting treatment with an antidepressant medication beginning in February 2000. The psychiatry MEB NARSUM reported ongoing symptoms of depression that developed in the context of coping with FM. Symptoms included depressed mood, sleep disturbance, fatigue and difficulty concentrating. At the time of evaluation she reported she enjoyed her work with computers and hoped to work in computers following discharge. She was pending divorce in her second marriage. Mental status exam (MSE) showed an alert, fully oriented female who had good eye contact. She had a sad, irritable mood with affect that reflected her mood. Speech was normal. She denied hallucinations, delusions, suicidal or homicidal ideations. She was cognitively intact with intact insight and judgment. MDD was diagnosed and continuance of psychopharmacology medications was recommended. At the general medical C&P examination the CI reported the depression was improving. She cried a bit in the office but was upbeat for the most part. At the VA mental health C&P exam CI reported she still worked in her specialty but did not drill or take tests. She lived with a friend, was undergoing a divorce and was attending college on line. She had been getting all A’s but her grades had recently deteriorated a bit. She could cook, clean and shop, but has difficulty summoning adequate physical and mental energy to do so. She was very fatigued after going out. MSE revealed an intelligent, alert, euthymic (normal mood) person with good cognitive function and intact memory. There was no sign of psychosis and she did not appear anxious. The examiner diagnosed depressive disorder not otherwise specified, secondary to physical health problems. VA rating documents indicate the CI was gainfully employed beginning June 2002. The PEB did not provide a separate rating for the depression condition because it considered it as a related condition that contributed to the primary unfitting diagnosis of FM. The VA granted a separate 50% rating for the depression. There was no evidence that the CI had depression prior to the onset of FM and psychiatric evaluations indicated that the depressive symptoms developed in the context of difficulty coping with chronic pain due to FM. There was also noted to be a transient stressor of ongoing divorce coincident with the MEB process. The VA general and mental health C&P examinations at the time of separation noted improved symptoms and reasonably good sleep. The Board noted that symptoms of FM and depressive symptoms were overlapping and interrelated. Providing two ratings based on the same symptoms is prohibited by VASRD §4.14 (avoidance of pyramiding). The VASRD rating guidance under 5025 for FM includes associated symptoms of depression, anxiety, sleep disturbance and fatigue, and the PEB rating for FM was VASRD compliant in this regard. As noted above, the Board considered the symptoms of depression in its rating recommendation for the unfitting FM. Furthermore, it was the symptoms of musculoskeletal pain with fatigue and sleep disturbance due to FM that prevented the CI from performing the strenuous duties of her military job in aviation ordinance. However, despite symptoms of depression, she enjoyed her alternate duties in computer network at which she excelled and pursued online college courses off duty. The Board concluded that the depression condition alone was not unfitting. 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 major depression as a Category II condition.


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, the Board unanimously recommends a disability rating of 20% coded 5025 IAW VASRD §4.71a. In the matter of the major depression condition, 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Fibromyalgia Syndrome 5025 20%
Major Depression Cat II
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120731, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
 COMMANDER, NAVY PERSONNEL COMMAND
                                          
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) XXXXXXXXXXXXXXXXXX
(c) XXXXXXXXXXXXXXXXXX
(d) PDBR ltr dtd 11 Sep 13 ICO XXXXXXXXXXXXXXXXXX
(e) XXXXXXXXXXXXXXXXXX

1. Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (e).

2. The official records of the following individuals are to be corrected to reflect the stated disposition:

         a . XXXXXXXXXXXXXXXXXX

         b. XXXXXXXXXXXXXXXXXX

         c. XXXXXXXXXXXXXXXXXX , former USMC, XXX XX XXXX : Disability separation with a final disability rating of 20 percent (increased from ten percent) effective 2 October 2001.

 d. XXXXXXXXXXXXXXXXXX
        
3. Please ensure all necessary actions are taken, included the recoupment of disability severance pay if warranted, to implement these decisions and that subject members are notified once those actions are completed.
                                                      XXXXXXXXXXXXXXXXXX
                                                     Assistant General Counsel
                  (Manpower & Reserve Affairs)

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