Citation Nr: 0003769 Decision Date: 02/14/00 Archive Date: 02/15/00 DOCKET NO. 97-10 359 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for Parkinson's disease. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD L. Cryan, Associate Counsel INTRODUCTION The veteran had active service from March 1942 to June 1970. This case is before the Board of Veterans' Appeals (Board) on appeal from a May 1995 rating decision by the Roanoke, Virginia Regional Office (RO) of the Department of Veterans Affairs (VA) which denied service connection for Parkinson's disease. Pursuant to the veteran's request, a hearing before a Member of the Board in Washington, D.C., was scheduled for June 1999. However, five days prior to the hearing, wife of the veteran, who is now in a nursing home, notified the RO, through her representative, that they would not be attending the hearing. Since that time, no request for rescheduling of the hearing has been received. Under these circumstances, the veteran's request for a hearing is deemed withdrawn. FINDINGS OF FACT The medical evidence is in relative equipoise on the question of whether Parkinson's disease was first manifested during service. CONCLUSION OF LAW With resolution of all reasonable doubt in the veteran's favor, service connection for Parkinson's disease is warranted. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background The veteran served for over 28 years in the Air Force until his discharge in June 1970. His service medical records show that he was often treated for, inter alia, narcolepsy (hypersomnolence, etiology unknown); tendonitis and arthritis of unknown etiology manifested by pain and swelling of the hands, wrists, elbows, knees, and ankles; and was also treated for seborrhea in December 1960 and July 1969. Shortly after service, orthopedic and neurologic examinations conducted in September 1970 in connection with his original claim showed no tremors, a normal gait, and no skin abnormalities. The veteran subsequently was granted service connection for intermittent polyarthritis in multiple joints, currently rated 20 percent disabling; degenerative joint disease, currently rated 40 percent disabling; and simple bone cyst of the greater tuberosity head of the right humerus, left trigger thumb, healed herpes zoster, keratitis of the left eye, post operative residuals of right and left knee meniscectomies, ; and hypersomnolence, of unknown etiology, all rated as noncompensable. The veteran was first diagnosed with Parkinson's disease in late 1972, after noticing difficulty using his left hand and leg. Since the veteran's Parkinson's disease diagnosis, he has received continuous medical treatment for his Parkinson's disease from both private and VA facilities/doctors. His condition continues to deteriorate. The veteran submitted a claim for service connection for Parkinson's disease in April 1993. In support of the veteran's claim, in May 1993, Dr. Ronald E. Pfeiffer, an associate Professor of Neurology and Pharmacology, and the Chief of the Section of Neurology at the University of Nebraska Medical Center, submitted a letter to the RO in response to questions regarding the onset of the veteran's Parkinson's disease. Dr. Pfeiffer indicated that he followed the veteran in the Movement Disorders Clinic at the University of Nebraska Medical Center, and at the Omaha Veteran's Administration Medical Center in the early 1980's. Dr. Pfeiffer stated that the onset of his neurologic symptoms dated to around 1970 although the diagnosis of Parkinson's disease wasn't was not rendered until sometime later. In rating decisions dated January 1995 and May 1995, the RO denied entitlement to service connection for Parkinson's disease based upon a finding that the evidence of record did not show that the disease was incurred during service. Specifically, the RO determined that the evidence of record did not contain a medical opinion stating that the veteran's inservice muscle and joint conditions of unknown etiology were the early stages of Parkinson's disease. The veteran timely appealed the decision. Subsequent to the May 1995 rating decision, Dr. Pfeiffer submitted additional evidence in support of the veteran's claim. In November 1995, Dr. Pfeiffer reviewed the veteran's medical records and provided another opinion as to the onset of the veteran's Parkinson's disease. Dr. Pfeiffer noted that in an April 1973 examination, the veteran had a six-year history of seborrheic dermatitis, and that seborrheic dermatitis is a common feature of Parkinson's disease. As such, Dr. Pfeiffer opined that the veteran's first clinical symptoms of Parkinson's disease quite possibly dated back to 1967. Dr. Pfeiffer also noted that multiple diagnostic studies during 1970 and 1971 uncovered no firm explanation for the symptoms described by the veteran as "the creeping miseries." In retrospect, Dr. Pfeiffer felt that the pain described by the veteran was a result of Parkinson's disease. Dr. Pfeiffer noted that sensory symptoms, particularly poorly defined aches and pains, are actually quite common in Parkinson's disease and may precede the appearance of the more typical motor features. Dr. Pfeiffer also noted that the veteran's symptoms improved significantly when antiparkinson therapy was initiated, further supporting his impression. In sum, Dr. Pfeiffer concluded that "even though the veteran's Parkinson's disease was not actually diagnosed until 1973, it seems quite clear that its symptoms, although unrecognized as such, were present in 1970, and probably as early as 1967." At the veteran's urging, the RO referred the veteran's claims file to the Under Secretary of Health and requested an independent medical opinion to establish whether the veteran's Parkinson's disease had its onset in service as provisioned under 38 C.F.R. § 3.303(d). Such opinion was rendered in December 1996. That physician reviewed the veteran's claims file and opined that the evidence of record did not support the diagnosis of Parkinson's disease during active military service. Specifically, the doctor noted that the veteran's two neurological evaluations performed three months prior to separation from service, were negative for clinical evidence of Parkinson's disease. In addition, the physician pointed out that clinical notes and consultation sheets from May and November 1971 did not indicate the presence of Parkinson's disease, nor did the veteran exhibit tremor, rigidity, bradykinesia, or postural disturbances in the first year following separation from active duty. In response to Dr. Pfeiffer's November 1995 opinion regarding the veteran's seborrheic dermatitis, the physician noted that a January 1981 discharge summary signed by Dr. Pfeiffer indicated that the veteran developed a rash on his abdominal during hospitalization and was seen by dermatology who felt he had xerosis and seborrheic dermatitis, brought on by hospital soap. The doctor concluded, "Thus, seborrheic dermatitis, which is increased in prevalence but is not a primary diagnostic feature of Parkinson's disease, had an alternative explanation." In response to the issue of arthralgias, the physician interpreted the evidence to suggest that the veteran's arthralgias for which he sought medical attention were the manifestation of an inflammatory rheumatologic condition for which the veteran is service connected and which predated the onset of Parkinson's disease by sixteen years. In response to the December 1996 opinion, Dr. Pfeiffer sent correspondence to the veteran in July 1997 and to the RO in September 1997. Dr. Pfeiffer disagreed with the VA physician's interpretation of the record and advised the veteran to request a review by a Parkinson's disease specialist. Dr. Pfeiffer noted that while Dr. Booss is the Chief neurologist for the VA's medical system, he is not a Parkinson's disease specialist. In response to the December 1996 opinion, Dr. Pfeiffer noted that the veteran's seborrheic dermatitis was first noted in the late sixties, and that the dermatologist in 1981 was attributing the abdominal rash to xerosis caused by soap used during hospitalization , not to the seborrheic dermatitis which was diagnosed 8 years previously. In addition, Dr. Pfeiffer reiterated that the veteran's aches and pains improved significantly when anti-Parkinson medication was instituted, pointing toward a cause-effect relationship. As a result of the conflicting medical opinions of record, the RO referred the claims folder to a VA movement disorder specialist for another medical opinion addressing the onset of the veteran's Parkinson's disease. In August 1998, the Chief of Neurology of the San Diego VA Medical Center rendered an opinion regarding the onset of the veteran's Parkinson's disease. That doctor concluded, after a review of the veteran's medical records, that although certain of the veteran's complaints at the time of discharge might have been early manifestations of Parkinson's disease, the records do not indicate that there were unequivocal symptoms and signs of Parkinson's disease until late 1972 and early 1973. Finally, a fourth medical opinion was rendered in July 1999 by Craig Bash, M.D., with respect to the onset of the veteran's Parkinson's disease. Dr. Bash's attached resume indicates that he is currently an Assistant Clinical Professor of Radiology and Nuclear Medicine at the Uniformed Services University of Health Sciences; Deputy Director of Medical Services of the Paralyzed Veteran's of America; and a Guest researcher at the National Institutes of Health, Laboratory of Diagnostic Radiology. Dr. Bash's resume also includes a lengthy background in medicine as well as numerous certifications, awards, and articles regarding movement disorders. Based on a review of the record, as well as a review of the letters from Drs. Booss and Pfeiffer, Dr. Bash opined that the veteran did have early signs of his Parkinson's disease while in service. Specifically, Dr. Bash opined that the veteran's arthritis likely represented the early manifestations of his Parkinson's disease. In addition, Dr. Bash stated that it was likely that the veteran's seborrheic dermatitis was an early manifestation of the veteran's Parkinson's disease. In support of his opinion, Dr. Bash included excerpts from an article by William C. Koller, M.D., Ph.D. entitled, "How Accurately can Parkinson's disease by Diagnosed?" as well as excerpts from an article by Matthew B. Stern entitled, "The Clinical Characteristics of Parkinson's Disease and Parkinsonian Syndromes: Diagnosis and Assessment." Legal Analysis Applicable law provides that entitlement to service connection will be granted if the facts, shown by a preponderance of the evidence, establish that a particular disease or injury resulting in disability was incurred in service. 38 U.S.C.A. § 1110 (West 1991); 38 C.F.R. § 3.303(a) (1999). That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (1999). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Initially, the Board finds that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the Board finds that he has presented a plausible claim. The Board is also satisfied that all relevant facts have been properly developed and that no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(b) (West 1991). This case turns on the issue of the whether the onset of the veteran's Parkinson's disease occurred during service, within the presumptive period following service, or at the time of the diagnosis in 1972. The veteran contends that his Parkinson's disease was first manifested during service even though it was not medically diagnosed until more than two year after his discharge from service. In this regard, the veteran contends that he exhibited symptomatology associated with Parkinson's disease many years prior to the medical diagnosis. Specifically, the veteran stated that he suffered numerous disabling medical problems of unknown etiology, which primarily affected his ability to use his arms and legs. He also contends that his arthritis and dermatitis during service were early manifestations of his Parkinson's disease. However, since the veteran has not been shown to be capable of making medical conclusions, his statements regarding causation are not probative. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). Rather, the medical record must support his statements. As noted above, the record contains four medical opinions that address the issue of the onset of the veteran's Parkinson's disease. Two of those opinions-those by the private physicians-support the veteran's contention that he first experienced symptoms that can be attributable to Parkinson's disease in service. While neither physician is absolutely definitive in his conclusion, they each indicate that it is likely that the veteran's Parkinson's disease was first manifested in service. The remaining two opinions- those by VA physicians-militate against the veteran's claim. While one VA physician concluded that the symptoms experienced in service can be attributed to other disabilities, some of which were ultimately service connected, the fact of prior service connection for other disabilities is not, in and of itself, dispositive of the issue before the Board. After careful consideration of the evidence of record, the Board finds that the opinions by the private doctors are at least as equally persuasive as those by the VA doctors. In this regard, the Board notes that all four opinions were rendered after review of some, if not all of the veteran's medical records. While, clearly, the VA doctors would have access to the veteran's entire claims file whereas the private doctors would not, it is equally as clear that the private doctors had copies of some, if not all of the pertinent medical records. Furthermore, Dr. Bash submitted medical treatise and other evidence to support his conclusions. The Board also notes that specialists in neurology rendered all the opinions. While each of the private doctors also professed a subspecialty in movement disorders, it is unclear whether such expertise is medically necessary to adequately resolve the issue under consideration. Finally, the Board notes that even though the VA physicians reached a contrary conclusion, they did not definitively rule out the possibility that the onset of the veteran's Parkinson's disease was during service, as they did concur with the notion that arthritis and dermatitis often appear as early signs of Parkinson's disease. In sum, then, the Board finds that the evidence is in relative equipoise on the question of whether the veteran's Parkinson's disease was first manifested in service, the pivotal issue in this case. When, as here, after consideration of all evidence and material of record in a case for VA benefits, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (1991). Resolving all reasonable doubt in the veteran's favor, the Board finds that Parkinson's disease is warranted. ORDER Service connection for Parkinson's disease is granted. JACQUELINE E. MONROE Member, Board of Veterans' Appeals