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AF | PDBR | CY2012 | PD2012 01578
Original file (PD2012 01578.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXX        BRANCH OF SERVICE: Army
CASE NUMBER: PD1201578   SEPARATION DATE: 20031126
BOARD DATE: 20130227


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (98J10/Non-Communications Interceptor and Analyst), medically separated for fibromyalgia (FM) as diagnosed by a Rheumatologist for which he was intermittently using medications according to the CHCS/Pharmacy data. He also had urinary incontinence and chronic abdominal pain with diarrhea. He had a history of multiple joint arthralgias which began in January 2001. After 2 years of varied joint pain, beginning in his knees and spreading to his hands, arms and shoulders, he saw a Rheumatologist in April 2003 who determined that the CI met the criteria for diagnosis of FM. His abdominal pain began in May 2000 and he was initially treated for gastritis. He had episodes of diarrhea and right lower quadrant pain since and was seen by a Gastroenterologist who diagnosed him with Gilbert’s Syndrome (Irritable Bowel Syndrome). He also had episodes of urinary incontinence of unclear etiology. The CI did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P3/U3/L3 profile and referred for a Medical Evaluation Board (MEB). Adjustment disorder condition, identified in the rating chart below, was also forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the FM, urinary incontinence and chronic abdominal pain conditions as unfitting, bundled into one rating of 10% with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining condition was determined to be not disqualifying. The CI made no appeals, and was medically separated with a 10% disability rating.
CI CONTENTION: “The rating received for IBS of 10% met the criteria for 30%; the VA gave me 10% for COPD and 20% for Detrusor-sphincter dyssnergia with an effective date of November 27, 2003.”


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 ratings for unfitting conditions will be reviewed in all cases. The Irritable Bowel Syndrome (IBS) and Detrusor-Sphincter dyssnergia conditions as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview; and, are addressed below, in addition to a review of the ratings for the unfitting conditions. The other requested chronic obstructive pulmonary disease (COPD) condition is not within the Board’s purview. 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 Army Board of Correction of Military Records.






 RATING COMPARISON :

Service IPEB – Dated 20030902
 VA (2 Mos. Post-Separation) – All Effective Date 20031127
Condition
 Code Rating Condition Code Rating Exam
Fibromyalgia, Urinary Incontinence & Chronic Abdominal Pain 5025 10% Irritable Bowel Syndrome 7319 0% 20040218
Chronic Joint Pain 5099-5002 NSC 20040218
Fibromyalgia 5025 NSC 20040218
Urinary Incontinence* 7599-7512 NSC 20040218
Adjustment Disorder w/ Anxious & Depressed Mood Not Disqualifying Adjustment Disorder w/ Anxiety & Depression 9440 NSC 20040213
↓No Additional MEB/PEB Entries↓
 Chronic Obstructive Pulmonary Disease 6604 10% 20040218
0% X 1 / Not Service-Connected x 11 20040218
Combined: 10%
 Combined: 10%


ANALYSIS SUMMARY:

Fibromyalgia Condition. The CI underwent evaluations with urology and gastroenterology to rule out specific renal/bladder and bowel pathology. The CI’s symptoms included arthralgia in multiple joints, especially the knees; fatigue; poor sleep, abdominal distress, and urinary incontinence. Some form of each condition was present since 2001; (i.e., Knee pain, abdominal pain, and urinary tract symptoms). His gastroenterology symptom onset dated back to May 2000. He was treated for gastritis and improved briefly. CI’s abdominal symptoms returned in 4 months and lasted for about 2 weeks, again resolved. His next episode was in July 2001 where once again he had right lower quad pain and diarrhea. He was sent to gastroenterology to rule out Crohn’s, disease, Gilbert’s syndrome and IBS. The CI had a complete negative gastroenterology workup to include colonoscopy, X-rays and CT scan. He continued to have episodes of right lower quadrant pain with diarrhea. In February 2003, the CI was again evaluated by gastroenterology for “chronic intermittent diarrhea.” Gastroenterology indicated the CI had not returned to the clinic due to his deployment but had continued to have no reduction in symptoms in spite of medical treatment. In February 2003, the CI was referred to urology after a one year report of urine leakage. The CI underwent urodynamic studies to evaluate the integrity of the bladder and kidney; both found to be normal. There were no diagnosable renal/kidney pathology. The CI was diagnosed with FM by a rheumatologist in May 2003 after a thorough evaluation for autoimmune disease was negative. On examination the rheumatologist recorded 18 of 18 tender points, no evidence of synovitis, and noted the CI reported interrupted sleep pattern, fatigue, popping sensation in knees, ankles and feet, low back and hands. The examiner also noted the CI reported partial response to medication for pain relief. The CI had radiographs of his knees, elbows, hands, and shoulder with no evidence of inflammatory changes, arthritis, dislocations, fractures, or other abnormalities. Magnetic resonance imaging (MRI) of thoracic and lumbar spines in search of identifying potential cause of his bowel/bladder conditions was normal.

At the MEB/narrative summary (NARSUM), discated 22 May 2003, approximately 6 months prior to separation, the CI reported a decrease over the past year in gastroenterology episodes of diarrhea of 1-8 times a day with cramping. The stools contain no blood and his weight was stable. His history of multiple joint arthralgias’ since 2001 with evaluation by rheumatology was acknowledged. The CI reported he leaked urine constantly. On physical examination the CI was noted to be cheerful. There was diffuse tenderness to palpation worse in the right lower quadrant, without signs of peritonitis. The exam noted tenderness to palpation in mid thoracic to lumbosacral area. There was no joint swelling or redness in any joint. MEB sought consults from gastroenterology, psychiatry, rheumatology, urology, and physical therapy for formal range-of-motion (ROM), which was normal or near normal in all joints tested. The diagnoses of FM, urinary incontinence and chronic abdominal pain with diarrhea were forwarded to the PEB. At VA Compensation and Pension (C&P) exam, performed 18 February 2004, approximately 3 months after separation, the CI reported a history of joint pain and discomfort primarily in the knees and hands, chronic fatigue, and disturbance of sleep which had not interfered with his ability to perform activities of daily living. He had not missed any time at work since his discharge (working as mortgage broker) due to his symptoms. On physical examination the CI was noted to walk briskly without limping, with a steady, upright gait. His abdomen was flat; there was mild discomfort to deep palpation in the epigastric region without guarding or rebound tenderness. ROM measurements were normal for all joints tested, without additional limitations due to repetition.

The Board noted the PEB to combine the abdominal pain condition and urinary incontinence condition and rated, as a single unfitting condition, FM, 10%, based on the requirement for continuous medication, noting medication records demonstrated intermittent use of medication coded 5025. The VA contended all of the conditions were not service related and therefore did not rate them. Not uncommonly this approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting. The Board undertook to determine if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a. If the Board judges separate ratings are warranted, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. The Board unanimously agreed that the preponderance of evidence in the record supports the FM condition to be unfitting and to warrant a rating of 10% under 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. CI’s “episodes over past year were sporadic”, NARSUM. The service treatment records (STR) do not record frequent visits to PCM for pain and associated symptoms, but CI was deployed for a year, so records are sparse. The commander statement stated the CI initially had a pattern of abdominal pain every 3 or so months but “now he experiences pains sporadically. He experienced knee pain daily, and cramping in his hands frequently at times interfered with work. The command also stated the CI had been a solid performer despite his diminished capabilities. The criteria for a higher rating of 20% were not supported by the evidence at hand. The Board unanimously agreed the abdominal pain and the bladder conditions were integral, comorbid components of the FM condition and could not be rated as single unfitting conditions IAW VASRD §4.14.(avoidance of pyramiding). 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 fibromyalgia 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 fibromyalgia 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, Urinary Incontinence & Chronic Abdominal Pain 5025 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120829, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                 
                  Physical Disability Board of Review


 SFMR-RB                                                                         


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


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130006191 (PD201201578)

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

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