New Study: Gulf War Presumptive Pain Condition Overlaps with Restless Legs Syndrome

Many People With Fibromyalgia May Also Have Restless Legs Syndrome and Poor Sleep Quality, New Study Finds

By Bill Hendrick, WebMD Health News; Reviewed by Laura J. Martin, MD

Oct. 15, 2010 -- People who have fibromyalgia are much more likely to also have restless legs syndrome, according to a new study. Restless legs syndrome is a baffling disorder that causes uncomfortable sensations in the legs and/or the urge to move the legs.

The study, published in the Oct. 15 issue of the Journal of Clinical Sleep Medicine, found that 33% of people with fibromyalgia also had restless legs syndrome, compared to 3.1% who did not have fibromyalgia.

The findings are important because sleep disruption caused by restless legs syndrome may exacerbate the symptoms of fibromyalgia, researchers say.

But the good news, they say, is that restless legs syndrome can be treated and may improve the quality of life of people who have fibromyalgia.

Fibromyalgia affects 2%-4% of the U.S. population and is more common in women, according to the American College of Rheumatology.

A Visual Guide to Fibromyalgia

Sleep Disturbances Are Common in Fibromyalgia Patients

“Sleep disruption is common in fibromyalgia and often difficult to treat,” Nathaniel F. Watson, MD, one of the authors and an associate professor of neurology at the University of Washington in Seattle, says in a news release. “It is apparent from our study that a substantial portion of sleep disruption in fibromyalgia is due to restless legs syndrome.”

The study involved 172 people with fibromyalgia, 93% of whom were women. They were compared with 63 people who were free of pain and fatigue. Those in the control group were younger, with a mean age of 41, compared to 50 for those with fibromyalgia.

A measure of sleep quality showed that problems with sleeping were more severe among people with fibromyalgia and restless legs syndrome.

The researchers conclude that a substantial portion of sleep disturbance found in patients with fibromyalgia may be related to restless legs syndrome.

They suggest that doctors routinely ask fibromyalgia patients about the symptoms of restless legs syndrome, because treatment may improve their sleep and quality of life.

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Fibromyalgia, Irritable Bowel Syndrome, and Chronic Fatigue Syndrome are all presumptive conditions for Gulf War veterans, meaning disability claims are, in theory, nearly “automatic”

 

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Restless Leg Syndrome (RLS) Overview

Restless leg syndrome is a disorder in which there is an urge or need to move the legs to stop unpleasant sensations.

Symptoms

RLS leads to sensations in the lower legs that make you uncomfortable unless you move your legs. These sensations:

• Usually occur at night when you lie down, or sometimes during the day when you sit for long periods of time
• May be described as creeping, crawling, aching, pulling, searing, tingling, bubbling, or crawling
• May last for 1 hour or longer
• Sometimes also occur in the upper leg, feet, or arms

You will feel an irresistible urge to walk or move your legs, which almost always relieves the discomfort.

Most patients have rhythmic leg movements during sleep hours, called periodic limb movement disorder (PLMD).

All of these symptoms often disturb sleep. Symptoms can make it difficult to sit during air or car travel, or through classes or meetings.

Note: Symptoms may be worse during stress or emotional upset.

Treatment

There is no known cure for restless leg syndrome, but there are treatments that can help improve symptoms.

Treatment is aimed at reducing stress and helping the muscles relax. The following techniques may help:

• Warm baths
• Gentle stretching exercises
• Massage

Low doses of pramipexole or ropinirole (Requip) can be very effective at controlling symptoms in some people.

If your sleep is severely disrupted, your health care provider may prescribe medications such as Sinemet (an anti-Parkinson's medication), gabapentin and pregabalin, or tranquilizers such as clonazepam. However, these medications may cause daytime sleepiness.

Patients with iron deficiency will receive iron supplements.

Low doses of narcotics may sometimes relieve symptoms of restless leg syndrome.

Causes

Restless leg syndrome (RLS) occurs most often in middle-aged and older adults. Stress makes it worse. The cause is not known in most patients.

RLS may occur more often in patients with:

• Peripheral neuropathy
• Chronic kidney disease
• Parkinson's disease
• Pregnancy
• Iron deficiency
• Use of certain medications

A form of RLS may be passed down in families. This may be a factor when symptoms start at a younger age. The abnormal gene has not yet been identified.

Restless leg syndrome can result in a decreased quality of sleep (insomnia). This lack of sleep can lead to daytime sleepiness, anxiety or depression, and confusion or slowed thought processes.

Tests & diagnosis

There is no specific examination for restless leg syndrome. The health care provider will not usually find any abnormalities, unless you also have peripheral nerve disease. Blood tests (CBC and serum ferritin) may be done to rule out iron deficiency anemia, which in rare cases can occur with restless leg syndrome.

Examination and testing may be used to rule out other disorders with similar symptoms.

Prognosis

Restless leg syndrome is not dangerous or life-threatening, and it is not a sign of a serious disorder. However, it can be uncomfortable and disrupt your sleep.

Prevention of Symptoms

Techniques to promote muscle relaxation and stress reduction may reduce the incidence of restless leg syndrome in people prone to the condition.

Complications

Insomnia may occur.

When to contact a doctor

Call for an appointment with your health care provider if:

• You have symptoms of restless leg syndrome
• Your sleep is disrupted

VA Q&A: Presumptive Service-Connection for Nine Rare Disease Endemic to Southwest Asia and Afghanistan Service

 

QUESTIONS AND ANSWERS

“Presumptions of Service Connection for Southwest Asia and Afghanistan Service”

September 28, 2010

1. What does this final rulemaking do?

This final regulation implements a decision by the Secretary of Veterans Affairs that there is a positive association between service in Southwest Asia beginning on August 2, 1990(including Iraq), or in Afghanistan on or after September 19, 2001, and the subsequent development of certain infectious diseases. The effect of this final regulation is to establish a presumption of service connection for these diseases for qualifying service during those periods.

Under VA regulations, the Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations.

2. What types of claims for VA benefits does the final rulemaking affect?

The final rule affects compensation claims filed by Veterans with service during certain time periods in Southwest Asia or in Afghanistan, for Brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis, and West Nile virus, that are pending before VA or received on or after the rule change takes effect. Pending claims include claims on appeal or that have not yet been finally decided.

3. Why is this final rulemaking necessary?

The Secretary, in accordance with The Persian Gulf War Veterans Act of 1998, has determined that there is a basis to establish a presumption of service connection at this time, based on service during certain time periods in Southwest Asia or in Afghanistan for certain time periods, for Brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis, and West Nile virus as identified in the National Academy of Sciences (NAS) October 16, 2006 report, titled “Gulf War and Health Volume 5: Infectious Diseases.” In this regard, the Secretary of Veterans Affairs determined, based upon the NAS report, that there is a positive association between service in Southwest Asia or in Afghanistan, and the subsequent development of the listed infectious diseases.

4. How does this final rulemaking help veterans?

The final rule will expedite the processing of claims for service connection. A claimant will not be required to establish, with medical evidence, an actual connection between military service in Southwest Asia or Afghanistan and diagnosed Brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis, and West Nile virus. Instead, a claimant who served during certain time periods in Southwest Asia or Afghanistan, will only have to show that he or she had one of the nine diseases within a certain time after service and has a current disability as a result of that disease.

5. What are the nine new presumptive diseases?

• Brucellosis A bacterial disease with symptoms such as profuse sweating and joint and muscle pain. The illness may be chronic and persist for years. It must be at least 10% disabling within 1 year from the date of military separation.

• Campylobacter Jejuni A disease with symptoms such as abdominal pain, diarrhea, and fever. It must be at least 10% disabling within 1 year from the date of military separation.

• Coxiella Burnetii (Q Fever) A bacterial disease with symptoms such as fever, severe headache, and gastrointestinal problems such as nausea and diarrhea. In chronic cases, the illness may cause inflammation of the heart. It must be at least 10% disabling within 1 year from the date of military separation.

• Malaria An infectious disease caused by a parasite. Symptoms include chills, fever, and sweats. It must be at least 10% disabling within 1 year from the date of military separation or at a time when standard or accepted treatises indicate that the incubation period began during a qualifying period of military service.

• Mycobacterium Tuberculosis An illness that primarily affects the lungs and causes symptoms such as chest pain, persistent cough (sometimes bloody), weight loss and fever.

• Nontyphoid Salmonella A condition characterized by symptoms such as nausea, vomiting, and diarrhea. It must be at least 10% disabling within 1 year from the date of military separation.

• Shigella A condition characterized by symptoms such as fever, nausea, vomiting, and diarrhea. It must be at least 10% disabling within 1 year from the date of military separation.

• Visceral Leishmaniasis A parasitic disease characterized by symptoms such as fever, weight loss, enlargement of the spleen and liver, and anemia. The condition may be fatal if left untreated.

• West Nile Virus A disease spread by mosquitoes characterized by symptoms such as fever, headache, muscle pain or weakness, nausea, and vomiting. Symptoms may range from mild to severe. It must be at least 10% disabling within 1 year from the date of military separation.

The presumptive periods for each of the nine diseases have been determined on the basis of the NAS report and reflect the observation that six of the nine diseases ordinarily manifest within a short period of time following infection. The one-year period is also consistent with the existing presumption of service connection for tropical diseases found at 38 U.S.C. § 1112(a). The presumptive periods for the other three diseases are based on existing statutes and medical treatises.

6. What are the cost estimates for the nine new presumptives?

Benefit payments are estimated to be $1.5 million during the first year, $11.5 million for five years, and $36.4 million to approximately 600 Veterans and survivors over ten years.

7. What caused VA to include these presumptions now and why did it take VA nearly 4 years from publication of the IOM report to create presumptions of service connection?

The nine illnesses covered by the new presumptions are all infectious diseases and are noted in the 2006 Institute of Medicine (IOM) report, Gulf War and Health Volume 5: Infectious Diseases, as endemic to the Middle East/Southwest Asia area. In some cases, infection with one of these agents may lead to some of the chronic multi-symptom illnesses suffered by some troops of the Gulf Wars. At this time, VA does not believe there is a single Gulf War Illness or Syndrome. The issue is far more complex and varies with each individual service member’s environmental exposures during service in the early and ongoing Gulf Wars. However, VA has been treating and compensating Veterans for undiagnosed or chronic unexplained multi-symptom illnesses related to service in Southwest Asia and the Middle East for nearly two decades. The illnesses and diseases included under this umbrella are compiled by VA funded Gulf War research and verified by the Institutes of Medicine (IOM).

After the IOM published their report on October 16, 2006, then Secretary of Veterans R. James Nicholson appointed a task force that included Under Secretaries for Health and Benefits, Assistant Secretary for Policy and Planning, and the General Counsel to study the report and recommend what action he should take regarding the establishment of new presumptions. He was succeeded by Secretary James B. Peake in December 2007. The task force presented its report to Secretary Peake on January 10, 2008. After reviewing the task force report, he sent letters to Congressional leaders on January 14, 2008, informing them that he had determined that 9 infectious diseases were associated with Gulf War service and therefore presumptions of service connection were warranted. On April 2, 2009, VA published a notice in the Federal Register stating that VA was drafting regulations creating those presumptions, and that no other presumptions were warranted. On March 18, 2010, VA published a proposed rule (AN24) proposing to create those presumptions. We received 18 public comments which we responded to in the Final Rule published September 29, 2010.

8. How do Veterans know if they have any of these presumptive diseases?

The key to the new presumptions is the development of symptoms during or very shortly after service in the Middle East/Southwest Asia, usually within the same year of exposure. However, visceral leishmaniasis and Mycobacterium Tuberculosis have been granted unlimited presumption since they can develop much later.  Many of the diseases share symptoms with the flu or common illnesses such as frequent fevers or skin rashes. Veterans who served in Southwest Asia or Afghanistan who suffer chronic illness since their service in the Gulf should seek treatment at a VA medical facility for diagnoses.  Veterans can find their nearest medical facility at www.va.gov.

9. When will VA start processing claims for this new regulation?

VA will begin processing claims when the final rule is published on September 29, 2010.

10. Will these claims be processed under the planned automated system intended to be used for the Agent Orange presumptives?

No, because of the small number of anticipated claims, this change does not lend itself well to the special processes being explored for the potentially very large number of Agent Orange claims we anticipate.

11. If a veteran has multiple issues (such as heart issue, knee problem, back issue) does he/she submit all three at one time or submit for the presumption first and then submit the other issues?

Veterans should file claims for all issues they believe to have been incurred in or aggravated by service at one time. If evidence supporting the presumptive disease is sufficient, it may be processed before other issues.

12. If a veteran has been denied for an issue that is now a presumption does he/she have to resubmit a claim in order to be reconsidered?  And if so, from what date would compensation be paid?

Yes, the veteran should resubmit his or her claim. If entitlement is established, service connection will be granted from the date of the publication of the final rule. For claims submitted more than one year after the publication of the final rule, VA may pay up to one year of retroactive benefits. Compensation, or additional compensation payable if the Veteran is already service connected for another disability, resulting from this rule will be payable from the first of the month following publication.

13. Does VA plan to do any special outreach to Southwest Asia and Afghanistan veterans, who either have or had a compensation claim related to the nine presumptives or are still on active duty?

VA will work closely with Veterans Service Organizations, the Department of Defense and stakeholders to ensure that potentially affected Veterans are made aware of the rule and the benefits and services available to them and their dependents.

Through the work of the GWVI-TF, VA developed a unique process to directly engage Gulf War Veterans for their ideas, questions, and concerns regarding the services and benefits they receive at the VA. The report recommends greater outreach to Veterans, and moves the outreach model from “pushing” information to Veterans towards a “pulling” model where VA “pulls” or reaches out to welcome them into the VA for health care, benefits and other services. VA will continue to strengthen its critical partnerships with Veterans Service Organizations, Non Governmental Organizations, and other Veteran advocates to help spread the word about health care and benefits for Gulf War Veterans.

14. What training did VA employees receive?

On February 4, 2010, VA issued a Training Letter to its benefits employees that provided guidance on the new process for developing and adjudicating disability claims of Gulf War Veterans based on their service. Additional information on broader environmental hazard exposure was included in a second Training Letter, issued April 26, 2010. VA also initiated new clinician training for treating Gulf War Veterans that was developed collaboratively by front-line providers, Compensation & Pension examiners, social workers, and policy experts. This training will improve the care provided to Gulf War Veterans to be more patient-centered and focused on their unique health concerns. VA has held well-attended environmental exposures seminars in Portland, Oregon, and Indianapolis, Indiana, and is scheduled to expand to other locations next year. VA’s War Related Illness and Injury Study Center program is fully operational with facilities operating in three locations: Washington, DC, East Orange, NJ, and Palo Alto, CA.

15. What is the Gulf War Task Force and what is its relationship to the nine new presumptives?

The decision to add the nine new presumptives predated the Gulf War Veteran Illness Task Force. The overarching responsibility of the Gulf War Veteran Illness Task Force (GWI-TF) is to regain Gulf War Veterans’ confidence in VA’s health care, benefits, and services and reconfirm VA is 100% committed to Veterans of all eras. The GWI-TF is not a static, one-time initiative but will continue to build on its work with annual reports issued every August. The focus centers on unanswered Gulf War Veterans’ health issues, improving access to benefits, ensuring cutting edge research into treatments, and to make sure Veterans’ concerns are heard and addressed. This includes continuing to solicit Veterans, experts, advocates and stakeholders to share their views to better inform the important work of the GWI-TF.

16. What organizations does VA partner with related to Gulf War issues?

VA has a long history of working with the Veteran Service Organizations and the Department of Defense (DoD). This is evidenced in many ways, including the the development of the Disability Evaluation Pilot Programs, the MyHealtheVet and eBenefits portals, and the Qarmat Ali medical surveillance program. DoD input for the GWVI-TF was solicited from working groups within its Health Executive Council, Office of the Surgeons General, and Office of the Assistant Secretary of Defense for Health Affairs. VA-funded research projects often involve collaborators who are located at affiliated universities, allowing VA researchers to utilize expertise that may not be available at VA. VA researchers also participate as researchers in DoD’s Gulf War Illness Research Program administered by the Congressional Directed Medical Research Programs. These programs fund innovative research to identify effective treatments, improve definition and diagnosis, and better understand pathobiology and symptoms. The Center for Disease Control (CDC) has also been very receptive to working with VA and has agreed to increase VA participation in the development of future medical surveys.

17. What is Disability Compensation

Disability compensation is a non-taxable monetary benefit paid to Veterans who are disabled as a result of an injury or illness that was incurred or aggravated during active military service. Presently, the basic monthly rate of compensation ranges from $123 to $2,673 for Veterans without any dependents.

Last year, VA received more than one million claims for disability compensation and pension. VA provides compensation and pension benefits to over 3.8 million Veterans and beneficiaries.

18. Where can I go to get more information about health care and benefits related to these new presumptives?

For information about health problems associated with military service during operations Desert Shield, Desert Storm, Iraqi Freedom, and Enduring Freedom, go to www.publichealth.va.gov/exposures/gulfwar/.

For information about how to apply for disability compensation, go to www.va.gov or http://www.publichealth.va.gov/exposures/gulfwar/compensation_benefits.asp.

VA Q&A: Presumptive Service-Connection for Nine Rare Disease Endemic to Southwest Asia and Afghanistan Service

 

QUESTIONS AND ANSWERS

“Presumptions of Service Connection for Southwest Asia and Afghanistan Service”

September 28, 2010

1. What does this final rulemaking do?

This final regulation implements a decision by the Secretary of Veterans Affairs that there is a positive association between service in Southwest Asia beginning on August 2, 1990(including Iraq), or in Afghanistan on or after September 19, 2001, and the subsequent development of certain infectious diseases. The effect of this final regulation is to establish a presumption of service connection for these diseases for qualifying service during those periods.

Under VA regulations, the Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations.

2. What types of claims for VA benefits does the final rulemaking affect?

The final rule affects compensation claims filed by Veterans with service during certain time periods in Southwest Asia or in Afghanistan, for Brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis, and West Nile virus, that are pending before VA or received on or after the rule change takes effect. Pending claims include claims on appeal or that have not yet been finally decided.

3. Why is this final rulemaking necessary?

The Secretary, in accordance with The Persian Gulf War Veterans Act of 1998, has determined that there is a basis to establish a presumption of service connection at this time, based on service during certain time periods in Southwest Asia or in Afghanistan for certain time periods, for Brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis, and West Nile virus as identified in the National Academy of Sciences (NAS) October 16, 2006 report, titled “Gulf War and Health Volume 5: Infectious Diseases.” In this regard, the Secretary of Veterans Affairs determined, based upon the NAS report, that there is a positive association between service in Southwest Asia or in Afghanistan, and the subsequent development of the listed infectious diseases.

4. How does this final rulemaking help veterans?

The final rule will expedite the processing of claims for service connection. A claimant will not be required to establish, with medical evidence, an actual connection between military service in Southwest Asia or Afghanistan and diagnosed Brucellosis, Campylobacter jejuni, Coxiella burnetii (Q fever), Malaria, Mycobacterium tuberculosis, Nontyphoid Salmonella, Shigella, Visceral leishmaniasis, and West Nile virus. Instead, a claimant who served during certain time periods in Southwest Asia or Afghanistan, will only have to show that he or she had one of the nine diseases within a certain time after service and has a current disability as a result of that disease.

5. What are the nine new presumptive diseases?

• Brucellosis A bacterial disease with symptoms such as profuse sweating and joint and muscle pain. The illness may be chronic and persist for years. It must be at least 10% disabling within 1 year from the date of military separation.

• Campylobacter Jejuni A disease with symptoms such as abdominal pain, diarrhea, and fever. It must be at least 10% disabling within 1 year from the date of military separation.

• Coxiella Burnetii (Q Fever) A bacterial disease with symptoms such as fever, severe headache, and gastrointestinal problems such as nausea and diarrhea. In chronic cases, the illness may cause inflammation of the heart. It must be at least 10% disabling within 1 year from the date of military separation.

• Malaria An infectious disease caused by a parasite. Symptoms include chills, fever, and sweats. It must be at least 10% disabling within 1 year from the date of military separation or at a time when standard or accepted treatises indicate that the incubation period began during a qualifying period of military service.

• Mycobacterium Tuberculosis An illness that primarily affects the lungs and causes symptoms such as chest pain, persistent cough (sometimes bloody), weight loss and fever.

• Nontyphoid Salmonella A condition characterized by symptoms such as nausea, vomiting, and diarrhea. It must be at least 10% disabling within 1 year from the date of military separation.

• Shigella A condition characterized by symptoms such as fever, nausea, vomiting, and diarrhea. It must be at least 10% disabling within 1 year from the date of military separation.

• Visceral Leishmaniasis A parasitic disease characterized by symptoms such as fever, weight loss, enlargement of the spleen and liver, and anemia. The condition may be fatal if left untreated.

• West Nile Virus A disease spread by mosquitoes characterized by symptoms such as fever, headache, muscle pain or weakness, nausea, and vomiting. Symptoms may range from mild to severe. It must be at least 10% disabling within 1 year from the date of military separation.

The presumptive periods for each of the nine diseases have been determined on the basis of the NAS report and reflect the observation that six of the nine diseases ordinarily manifest within a short period of time following infection. The one-year period is also consistent with the existing presumption of service connection for tropical diseases found at 38 U.S.C. § 1112(a). The presumptive periods for the other three diseases are based on existing statutes and medical treatises.

6. What are the cost estimates for the nine new presumptives?

Benefit payments are estimated to be $1.5 million during the first year, $11.5 million for five years, and $36.4 million to approximately 600 Veterans and survivors over ten years.

7. What caused VA to include these presumptions now and why did it take VA nearly 4 years from publication of the IOM report to create presumptions of service connection?

The nine illnesses covered by the new presumptions are all infectious diseases and are noted in the 2006 Institute of Medicine (IOM) report, Gulf War and Health Volume 5: Infectious Diseases, as endemic to the Middle East/Southwest Asia area. In some cases, infection with one of these agents may lead to some of the chronic multi-symptom illnesses suffered by some troops of the Gulf Wars. At this time, VA does not believe there is a single Gulf War Illness or Syndrome. The issue is far more complex and varies with each individual service member’s environmental exposures during service in the early and ongoing Gulf Wars. However, VA has been treating and compensating Veterans for undiagnosed or chronic unexplained multi-symptom illnesses related to service in Southwest Asia and the Middle East for nearly two decades. The illnesses and diseases included under this umbrella are compiled by VA funded Gulf War research and verified by the Institutes of Medicine (IOM).

After the IOM published their report on October 16, 2006, then Secretary of Veterans R. James Nicholson appointed a task force that included Under Secretaries for Health and Benefits, Assistant Secretary for Policy and Planning, and the General Counsel to study the report and recommend what action he should take regarding the establishment of new presumptions. He was succeeded by Secretary James B. Peake in December 2007. The task force presented its report to Secretary Peake on January 10, 2008. After reviewing the task force report, he sent letters to Congressional leaders on January 14, 2008, informing them that he had determined that 9 infectious diseases were associated with Gulf War service and therefore presumptions of service connection were warranted. On April 2, 2009, VA published a notice in the Federal Register stating that VA was drafting regulations creating those presumptions, and that no other presumptions were warranted. On March 18, 2010, VA published a proposed rule (AN24) proposing to create those presumptions. We received 18 public comments which we responded to in the Final Rule published September 29, 2010.

8. How do Veterans know if they have any of these presumptive diseases?

The key to the new presumptions is the development of symptoms during or very shortly after service in the Middle East/Southwest Asia, usually within the same year of exposure. However, visceral leishmaniasis and Mycobacterium Tuberculosis have been granted unlimited presumption since they can develop much later.  Many of the diseases share symptoms with the flu or common illnesses such as frequent fevers or skin rashes. Veterans who served in Southwest Asia or Afghanistan who suffer chronic illness since their service in the Gulf should seek treatment at a VA medical facility for diagnoses.  Veterans can find their nearest medical facility at www.va.gov.

9. When will VA start processing claims for this new regulation?

VA will begin processing claims when the final rule is published on September 29, 2010.

10. Will these claims be processed under the planned automated system intended to be used for the Agent Orange presumptives?

No, because of the small number of anticipated claims, this change does not lend itself well to the special processes being explored for the potentially very large number of Agent Orange claims we anticipate.

11. If a veteran has multiple issues (such as heart issue, knee problem, back issue) does he/she submit all three at one time or submit for the presumption first and then submit the other issues?

Veterans should file claims for all issues they believe to have been incurred in or aggravated by service at one time. If evidence supporting the presumptive disease is sufficient, it may be processed before other issues.

12. If a veteran has been denied for an issue that is now a presumption does he/she have to resubmit a claim in order to be reconsidered?  And if so, from what date would compensation be paid?

Yes, the veteran should resubmit his or her claim. If entitlement is established, service connection will be granted from the date of the publication of the final rule. For claims submitted more than one year after the publication of the final rule, VA may pay up to one year of retroactive benefits. Compensation, or additional compensation payable if the Veteran is already service connected for another disability, resulting from this rule will be payable from the first of the month following publication.

13. Does VA plan to do any special outreach to Southwest Asia and Afghanistan veterans, who either have or had a compensation claim related to the nine presumptives or are still on active duty?

VA will work closely with Veterans Service Organizations, the Department of Defense and stakeholders to ensure that potentially affected Veterans are made aware of the rule and the benefits and services available to them and their dependents.

Through the work of the GWVI-TF, VA developed a unique process to directly engage Gulf War Veterans for their ideas, questions, and concerns regarding the services and benefits they receive at the VA. The report recommends greater outreach to Veterans, and moves the outreach model from “pushing” information to Veterans towards a “pulling” model where VA “pulls” or reaches out to welcome them into the VA for health care, benefits and other services. VA will continue to strengthen its critical partnerships with Veterans Service Organizations, Non Governmental Organizations, and other Veteran advocates to help spread the word about health care and benefits for Gulf War Veterans.

14. What training did VA employees receive?

On February 4, 2010, VA issued a Training Letter to its benefits employees that provided guidance on the new process for developing and adjudicating disability claims of Gulf War Veterans based on their service. Additional information on broader environmental hazard exposure was included in a second Training Letter, issued April 26, 2010. VA also initiated new clinician training for treating Gulf War Veterans that was developed collaboratively by front-line providers, Compensation & Pension examiners, social workers, and policy experts. This training will improve the care provided to Gulf War Veterans to be more patient-centered and focused on their unique health concerns. VA has held well-attended environmental exposures seminars in Portland, Oregon, and Indianapolis, Indiana, and is scheduled to expand to other locations next year. VA’s War Related Illness and Injury Study Center program is fully operational with facilities operating in three locations: Washington, DC, East Orange, NJ, and Palo Alto, CA.

15. What is the Gulf War Task Force and what is its relationship to the nine new presumptives?

The decision to add the nine new presumptives predated the Gulf War Veteran Illness Task Force. The overarching responsibility of the Gulf War Veteran Illness Task Force (GWI-TF) is to regain Gulf War Veterans’ confidence in VA’s health care, benefits, and services and reconfirm VA is 100% committed to Veterans of all eras. The GWI-TF is not a static, one-time initiative but will continue to build on its work with annual reports issued every August. The focus centers on unanswered Gulf War Veterans’ health issues, improving access to benefits, ensuring cutting edge research into treatments, and to make sure Veterans’ concerns are heard and addressed. This includes continuing to solicit Veterans, experts, advocates and stakeholders to share their views to better inform the important work of the GWI-TF.

16. What organizations does VA partner with related to Gulf War issues?

VA has a long history of working with the Veteran Service Organizations and the Department of Defense (DoD). This is evidenced in many ways, including the the development of the Disability Evaluation Pilot Programs, the MyHealtheVet and eBenefits portals, and the Qarmat Ali medical surveillance program. DoD input for the GWVI-TF was solicited from working groups within its Health Executive Council, Office of the Surgeons General, and Office of the Assistant Secretary of Defense for Health Affairs. VA-funded research projects often involve collaborators who are located at affiliated universities, allowing VA researchers to utilize expertise that may not be available at VA. VA researchers also participate as researchers in DoD’s Gulf War Illness Research Program administered by the Congressional Directed Medical Research Programs. These programs fund innovative research to identify effective treatments, improve definition and diagnosis, and better understand pathobiology and symptoms. The Center for Disease Control (CDC) has also been very receptive to working with VA and has agreed to increase VA participation in the development of future medical surveys.

17. What is Disability Compensation

Disability compensation is a non-taxable monetary benefit paid to Veterans who are disabled as a result of an injury or illness that was incurred or aggravated during active military service. Presently, the basic monthly rate of compensation ranges from $123 to $2,673 for Veterans without any dependents.

Last year, VA received more than one million claims for disability compensation and pension. VA provides compensation and pension benefits to over 3.8 million Veterans and beneficiaries.

18. Where can I go to get more information about health care and benefits related to these new presumptives?

For information about health problems associated with military service during operations Desert Shield, Desert Storm, Iraqi Freedom, and Enduring Freedom, go to www.publichealth.va.gov/exposures/gulfwar/.

For information about how to apply for disability compensation, go to www.va.gov or http://www.publichealth.va.gov/exposures/gulfwar/compensation_benefits.asp.

VA Fast Letter to Claims Staff To Clarify “Medically Unexplained Chronic Multisystem Illness” for Gulf War Claims

Comp & Pen Director calls IBS, FM, CFS “examples” of medically unexplained chronic multisymptom illnesses, not “exclusive list”

U.S. Department of Veterans Affairs

July 21, 2010                                                                  

Director (00/21)                                                             

In Reply Refer To:  211AAll   

Regional Offices and Centers                                Fast Letter 10-26VA

SUBJ:  Revisions to 38 C.F.R. § 3.317 to clarify the Meaning of “Medically Unexplained Chronic Multisystem Illness” Related to Gulf War and Southwest Asia Service

Purpose

This letter provides information on a regulatory change being developed by VA to clarify the  meaning of a diagnosed “medically unexplained chronic multisymptom illness” for disability claims based on Gulf War and Southwest Asia service.   

Background

VA has statutory authority under 38 U.S.C. § 1117 to compensate Veterans for qualifying chronic disabilities resulting from Gulf War and Southwest Asia service when the disability is an “undiagnosed illness” or a diagnosed “medically unexplained chronic multisymptom illness.”  Section 1117 provides the following as examples of qualifying diagnosed multisymptom illnesses:  chronic fatigue syndrome, irritable bowel syndrome, and fibromyalgia.  However, the regulatory language of section 3.317 implementing the statute suggests that these three diagnosed illnesses are an exclusive listing, rather than just examples. 

Regulatory Change

VA is revising § 3.317 to clarify that the three listed diagnosed multisymptom illnesses are not exclusive, but rather are examples that can serve to inform VA medical examiners and adjudicators of the general types of medically unexplained chronic multisymptom illnesses that may qualify for service connection under the § 1117 authority.  

Questions

Submit questions concerning this fast letter to your Veterans Service Officer (VSO).

Bradley G. Mayes 

Director

Compensation and Pension Service

Letter to VA Disability Compensation Advisory Committee Calls for Changes on Fibromyalgia, IBS Compensation

 

DATE:  June 22, 2010

TO:  VA Advisory Committee on Disability Compensation, ATTN: Ms. Ersie Farber, Designated Federal Officer, U.S. Department of Veterans Affairs, Veterans Benefits Administration (211A), 810 Vermont Avenue, N.W, Washington, DC 20420

SUBJECT: Gulf War Related Compensation – Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome

Dear Committee Members:

While searching the Public Record on another issue, I came across the notice for your public meetings, which concluded today. While my written submission obviously won’t make it to you in time for consideration at the current meeting, I hope that you will take it under consideration for your next meeting, or in the interim.

By way of introduction, I’m a service-disabled veteran, and I’ve been active on policy issues related to deployment, deployment health, and Gulf War veterans’ illnesses for about 15 years. As such, I’m an appointed member of the VA’s Research Advisory Committee on Gulf War Veterans’ Illnesses (RACGWVI), DoD’s Congressionally Directed Medical Research Program (CDMRP) Gulf War Illness Research Program (GWIRP) integration panel, and the newly created VA Gulf War Steering Committee (GWSC), which had its first meeting today.

I’m informed by my more than seven years active duty military service as a member of the U.S. Army special operations community, including service in Somalia and the 1991 Gulf War. my service as a former senior public official with the State of Wisconsin Department of Veterans Affairs, an ex-Congressional aide, active involvement with the Disabled American Veterans (DAV), the State of Wisconsin Council on Veterans Programs, 91outcomes.com (a health/news website I publish for my fellow Gulf War veterans), Veterans of Modern Warfare (VMW), and regular communications with the National Gulf War Resource Center (NGWRC).

Presumptive Claims for Gulf War Veterans. Currently, there are three “ill-defined” illnesses that are presumptive for Gulf War veterans. They are: Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome.

I believe that these presumptions are appropriate, and are consistent with countless peer-reviewed scientific studies that have concluded that these conditions and/or their symptom sets have high, unusual prevalence among veterans of the 1991 Gulf War.

The first of three presumptive conditions for Gulf War veterans, Chronic Fatigue Syndrome (CFS), can currently be rated as high as 100% depending upon the level of debilitation. I believe this is appropriate and should remain as it is.

However, the second of the three conditions, Fibromyalgia (FM), can only be rated at a maximum of 40% under the current rating schedule, even though chronic fatigue and other debilitating symptoms can be totally and permanently disabling. And, because CFS is a diagnosis of last resort, a diagnosis of FM excludes a diagnosis of CFS, even if the veteran is clearly suffering from both debilitating chronic widespread pain and debilitating chronic fatigue. In other words, veterans who may be the worst off can only receive a maximum 40% rating if they have the diagnosis of FM, even with all the symptoms of CFS. VA should review these contorted rules so that veterans with FM can be rated as high as 100%, depending upon the level of debilitation.

For the third of the three current presumptive conditions, Irritable Bowel Syndrome (IBS) can be rated to a maximum rating of 30%. This rating can be made in conjunction with a rating for CFS or FM (but not both, as previously stated). VA should also review the rules governing the maximum rating for this condition to allow for higher ratings relative to the actual level of debilitation.

Given the predominance in epidemiological studies of Gulf War veterans complaining of upper and lower respiratory, digestive, and neurological symptoms, and conditions, VA should review the rules to grant presumptive service-connection for upper and lower respiratory, digestive, and neurological conditions to grant presumptive service-connection for these conditions, including but not limited to Gastro-Esophageal Reflux Disease (GERD), diagnosed respiratory disorders including but not limited to asthma, bronchitis, bronchiolitis, and chronic obstructive pulmonary disease (COPD), and diagnosed neurological disorders involving pain, cognition, and other symptoms widely reported symptoms among Gulf War veterans.

Finally, VA should work hard to establish an appropriate listing of presumptive illnesses for Gulf War veterans disability claims – the gateway to their VA health care.

Thank you for your service on behalf of all veterans.

Sincerely,

Anthony D. Hardie

VA Proposes Rule Change to Ensure Total Disability Benefits for All Veterans with ALS

Public Comments must be received by July 23

Graphic:  What is ALS?  Courtesy Huntsville Times

(91outcomes.com) - The U.S. Department of Veterans Affairs (VA) has announced that it proposes to amend its Schedule for Rating Disabilities by revising the evaluation criterion for amyotrophic lateral sclerosis (ALS) to provide a 100-percent evaluation for any veteran with service-connected ALS. 

According to VA, this change is necessary to adequately compensate veterans who suffer from this progressive, untreatable, and fatal disease. VA says this change is intended to provide a total disability rating for any veteran with service-connected ALS.

Comments must be received on or before July 23, 2010.

Written comments can be submitted:

• ONLINE
• FAX:  (202) 273-9026
• MAIL/HAND-DELIVERY – Deliver to:  Director, Regulations Management (02REG), Department of Veterans Affairs, 810 Vermont Ave., NW., Room 1068, Washington, DC 20420

Comments should indicate that they are submitted in response
to ``RIN 2900-AN60-Schedule for Rating Disabilities; Evaluation of Amyotrophic Lateral Sclerosis.''

VA proposes to amend its Schedule for Rating Disabilities (38 CFR part 4) by revising the evaluation criterion for ALS under diagnostic code 8017 in Sec.  4.124a, the schedule of ratings for neurological conditions and convulsive disorders. Currently, the schedule provides only a single criterion for ALS, a minimum disability evaluation of 30 percent. VA proposes to remove this criterion and replace it with a minimum disability evaluation of 100 percent. The Secretary has authority to make this amendment pursuant to 38 U.S.C.
1155.

ALS, also known as Lou Gehrig's disease, is a motor neuron disease that results in muscle weakness leading to a wide range of serious disabilities, including problems with mobility. It often affects the muscles that control swallowing, leading to the possibility of aspiration (the inspiratory sucking of fluid into the airways) and pneumonia. It eventually paralyzes the respiratory muscles, and the most common cause of death in ALS is respiratory failure. ALS is a terminal illness; the life expectancy of a person with ALS ordinarily ranges from about 3 to 5 years after diagnosis. Fifty percent of patients die within 3 years of diagnosis, about 20 percent live 5 years, and 10 percent survive for 10 or more years.

ALS is rated under 38 CFR 4.124a, diagnostic code 8017, which currently provides a minimum disability evaluation of 30 percent. However, the guidelines in 38 CFR 4.120 (Evaluations by comparison) direct that disability from neurologic conditions be rated in proportion to the impairment of motor, sensory, or mental function.

Therefore, any level of evaluation, including 100 percent, can currently be assigned for ALS under diagnostic code 8017. However, individuals with ALS have a rapidly deteriorating course of illness and quickly reach a level of total disability. Providing a 100-percent evaluation in all cases would obviate the need to reassess and reevaluate veterans with ALS repeatedly over a short period of time, as the condition worsens and inevitably and relentlessly progresses to total disability. Therefore, VA proposes to change the minimum
evaluation for ALS from 30 to 100 percent. Although ALS may not be totally disabling at the time of diagnosis or when VA compensation is claimed for the condition, ALS is a seriously disabling, rapidly progressive, untreatable, and fatal condition.

VA's schedule of ratings for neurological conditions and convulsive disorders provides a 100-percent disability evaluation for certain other motor neuron diseases that progressively lead to disability or death. See 38 CFR 4.124a, Diagnostic Codes 8005 (Bulbar palsy), 8105 (Sydenham's chorea of the ``progressive grave type''), and 8106 (Huntington's chorea). Given that ALS is a rapidly progressing neurodegenerative disease and that many of its disabling effects are similar to other neurological disorders that VA rates at 100 percent, VA proposes to compensate veterans with ALS similarly. The 100-percent rating would ensure that veterans with ALS are evaluated adequately and would eliminate any delay in reaching an appropriate level of compensation as their disease rapidly progresses.

In addition, VA proposes to add a note to consider the need for special monthly compensation (SMC), which VA says will be quite a common need in these veterans.

Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1063B, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call (202) 461-4902 (this is not a toll-free number) for an appointment.

In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at http://www.regulations.gov/search/Regs/home.html#docketDetail?R=VA-2010-VBA-0021, and on the page, select “Public Submissions” as the only selection.

FOR FURTHER INFORMATION CONTACT: Thomas J. Kniffen, Chief, Regulations Staff (211D), Compensation and Pension Service, Veterans Benefits Administration, U.S. Department of Veterans Affairs, 810 Vermont Ave., NW., Washington, DC 20420, phone: (202) 461-9725. (This is not a toll-free number.)

-----------------------

For more information on ALS:

• Treatment for Amyotrophic Lateral Sclerosis (ALS) / Lou Gehrig's Disease
• Mayo Clinic:  ALS Complications
• NINDS Fact Sheet on ALS 

APNewsBreak: VA to reopen Gulf War vets' files

By KIMBERLY HEFLING, The Associated Press

(WASHINGTON – AP) - The Veterans Affairs Department will re-examine the disability claims of what could be thousands of Gulf War veterans suffering from ailments they blame on their war service, the first step toward potentially compensating them nearly two decades after the war ended.

VA Secretary Eric Shinseki said the decision is part of a "fresh, bold look" his department is taking to help veterans who have what's commonly called "Gulf War illness" and have long felt the government did little to help them. The VA says it also plans to improve training for medical staff who work with Gulf War vets, to make sure they do not simply tell vets that their symptoms are imaginary - as has happened to many over the years.

"I'm hoping they'll be enthused by the fact that this ... challenges all the assumptions that have been there for 20 years," Shinseki told The Associated Press in an exclusive interview.

The changes reflect a significant shift in how the VA may ultimately care for some 700,000 veterans who served in the Gulf War. It also could change how the department handles war-related illness suffered by future veterans, as Shinseki said he wants standards put in place that don't leave veterans waiting decades for answers to what ails them.

The decision comes four months after Shinseki opened the door for as many as 200,000 Vietnam veterans to receive service-related compensation for three illnesses stemming from exposure to the Agent Orange herbicide.

About 175,000 to 210,000 Gulf War veterans have come down with a pattern of symptoms that include rashes, joint and muscle pain, sleep issues and gastrointestinal problems, according to a 2008 congressionally mandated committee that based the estimate on earlier studies.

But what exactly caused the symptoms has long been unanswered. Independent scientists have pointed to pesticide and pyridostigmine bromide pills, given to protect troops from nerve agents, as probable culprits. The 2008 report noted that since 1994, $340 million has been spent on government research into the illness, but little has focused on treatments.

Last week, Shinseki and Sen. Jay Rockefeller, D-W.Va., a member of the Senate Veterans' Affairs committee, met privately in Charleston, W.Va., with several Gulf War veterans. In an interview after the meeting, Rockefeller told the AP that Shinseki's background as a former Army chief of staff made the changes possible. He said either the military has been reluctant over the years to release paperwork related to the war or kept poor records about exposures in the war zone, which made it harder for the veterans to prove they needed help.

"The paperwork isn't very accurate, but the pain is very real," Rockefeller said.

Shinseki has publicly wondered why today there are still so many unanswered questions about Gulf War illness, as stricken veterans' conditions have only worsened with age.

Last fall, he appointed a task force led by his chief of staff, John Gingrich, a retired Army colonel who commanded a field artillery battalion in the 1991 war, to review benefits and care for Gulf War veterans. The changes stem from the task force's work.

Gingrich said in an interview that he feels a personal stake because some of his own men who were healthy during the war are dealing with these health problems. Gingrich said the VA isn't giving a new benefit to Gulf War veterans, just making sure the claims they submitted were done correctly.

"We're talking about a culture change, that we don't have a single clinician or benefits person saying 'you really don't have Gulf War illness, this is only imaginary' or 'you're really not sick,'" Gingrich said.

A law enacted in 1994 allows the VA to pay compensation to Gulf War veterans with certain chronic disabilities from illnesses the VA could not diagnosis. More than 3,400 Gulf War have qualified for benefits under this category, according to the VA.

The VA says it plans to review how regulations were written to ensure the veterans received the compensation they were entitled to under the law. The VA would then give veterans the opportunity to have a rejected claim reconsidered.

The VA doesn't have an estimate of the number of veterans who may be affected, but it could be in the thousands.

Of those who deployed in the Gulf War, 300,000 submitted claims, according to the VA. About 14 percent were rejected, while the rest received compensation for at least one condition.

Mich. Gulf War Veteran Wins VA Claim After 15 Years

Written by Anthony Hardie, 91outcomes

(91outcomes.blogspot.com) -- Journalist Ted Roelofs had an excellent article in today's Grand Rapids Press about Michigan's state budget cuts to funding for claims service officers. Tucked down at the bottom was a reference to western Michigan Gulf War veteran Don Harp, for whom it took 15 years to "win" his disability claim from the VA.

According to the article, the Army veteran's claim was for "combat injuries, a closed-head injury, and Gulf War Syndrome."

For countless Gulf War veterans of the 1991 Gulf War and the service officers who have sought to assist them, VA's repeated denials of Gulf War veterans' claims has all too often been the norm rather than an exception.

The most current VA report on Gulf War veterans (Aug. 2007, pp. 7-8) shows that out of 696,842 veterans of the 1991 Gulf War, an astronomical 40 percent (278,149) filed claims for VA service-connected disability -- highlighting just how many Gulf War veterans have been significantly affected by their military service.

Veterans claims service officers have long known that filing for undiagnosed illnesses for Gulf War veterans is next to impossible to have approved. Even still, VA shows 12,788 claims filed by 1991 Gulf War veterans for undiagnosed illnesses, with only 26 percent (3,280) of those approved -- meaning 74 percent were denied!

The Grand Rapids article noted that Harp was among the veterans planning to protest the State's budget cuts that included a $1 million cut to funding for the state's 11 veterans service organizations that provide assistance to Michigan's veterans filing disability claims with the VA.

While Michigan's cuts are deeply disappointing and politically questionable, some underlying questions remain for the federal government, including Congress and the new Obama Administration.

First, for veterans like Harp, where is the outreach been that VA repeatedly told Congress it has been conducting?

The U.S. Senate perenially introduces legislation (S. 315 in the current Congress) that would define outreach for the VA and require VA to fiscally account for what it spends on outreach as a line item -- only to have VA officials protest that such legislation is unneccesary, and that VA is already conducting it. Certainly that's not true for Mr. Harp and the other 74 percent of Gulf War veterans claiming undiagnosed illnesses following their Gulf War service.

Second, where is the claims assistance that VA supposedly provides, as required by law under the Veterans Claims Assistance Act of 2000? Why did it take 15 years for this veteran to get his claim approved?

Third, what is VA doing to alleviate the fiscal burden on States and Counties that cause nearly every State and the Counties in about half the states to have to provide service officers to assist their veterans? Most veterans likely have no idea that with the exception of State Veterans Homes and Cemeteries, the benefits, programs, and services provided to them by their States, Counties, and veterans service organizations -- including assistance with VA claims -- is done without a dime of federal support.

Only the federal government creates veterans. So, why is it then left to the States, Counties, and innumerable Veterans Service Organizations to help veterans fight VA to get their claims approved (like the unnamed Catholic War Veterans service officer hometown hero who helped Harp)?

This valiant Vietnam and Gulf War veteran was given the final word in the Grand Rapids article: "Without these people, guys like me would have been shafted. If we have to hire attorneys, we are going to get shafted big time," Harp said.

Finally, the real story is that Gulf War veterans like Harp are still unable to receive effective treatments for Gulf War Syndrome. A November 2008 federal government report finally recognized that, "Gulf War illness is real, that it is the result of neurotoxic exposures during Gulf War deployment, and that few veterans have recovered or substantially improved with time." (p.17) Yet, despite years of effort by the Gulf War veteran community seeking effective treatment from VA, the report also noted:
who, the article noted, had to wait

"Substantial federal Gulf War research funding has been used for studies that have little or no relevance to the health of Gulf War veterans, and for research on stress and psychiatric illness....[and] overall federal funding for Gulf War research has declined dramatically since 2001....

"A renewed federal research commitment is needed to identify effective treatments for Gulf War illness and address other priority Gulf War health issues. Adequate funding is required to achieve the critical objectives of improving the health of Gulf War veterans and preventing similar problems in future deployments. This is a national obligation, made especially urgent by the many years that Gulf War veterans have waited for answers and assistance." (p.2)

Change is needed for our nation's Gulf War veterans -- desperately.