Citation Nr: 1219167 Decision Date: 05/31/12 Archive Date: 06/07/12 DOCKET NO. 00-06 999A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for an arthralgia disability manifested by low back pain, pain in the knees, tendonitis of the shoulders, and epicondylitis of the elbows, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 2. Entitlement to service connection for a respiratory disability manifested by a persistent cough and by the build-up of mucus in the nasal passage and throat, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 3. Entitlement to service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. 4. Entitlement to service connection for a disability manifested by insomnia and lack of energy and by memory loss, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran had active service from September 1982 to February 1983 and from November 1990 to May 1991, with service in the Southwest Asia theater of operations during the Persian Gulf War from December 1990 to March 1991. He also had service in the United States Marine Corp Reserve prior to his first period of active service, between his two periods of active service, and subsequent to his second period of active service until his retirement from the Reserve in approximately June 1995. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 1998 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which, in pertinent part, denied claims for bilateral knee pain, claimed as soreness and stiffness in joints, for bilateral shoulder tendinitis, claimed as soreness and stiffness in joints, for epicondylitis of the elbows, claimed as soreness and stiffness in joints, for back pains, for sleep disorder and lack of energy, for constant mucus build up, for headaches, for chronic cough, and for memory loss, claimed as forgetfulness, all claimed as due to an undiagnosed illness. This matter was previously before the Board in July 2001 and April 2004, when it was remanded for additional development. The case was returned to the Board in June 2006 wherein the claims were denied. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2008 Joint Motion For Remand, the parties (Veteran and VA Secretary) asked the Court to vacate the Board decision and remand the case. In a March 2008 Order, the Court granted the motion. In March 2009, the Board then remanded this matter and several VA examinations were conducted as a consequence in June 2009. Unfortunately, the June 2009 VA examiners failed to specifically discuss whether these claimed disorders were related to service or whether any of them, alone or in combination, manifested a qualifying chronic disability under 38 C.F.R. § 3.317. That regulation governs compensation for disability due to an undiagnosed illness or a medically unexplained chronic multi symptom illness for those who served in the Southwest Asia theater of operations. At this point, after unsuccessfully remanding the Veteran's appeal to provide VA examinations and opinions, the Board found that further expert medical review, analysis, and explanation was needed to address whether any of the Veteran's outstanding claims were related to service or manifested, alone or in combination, an undiagnosed or medically unexplained chronic multi symptom illness, such as fibromyalgia. Therefore, based on the medical and lay evidence of record, it recharacterized these issues on appeal as reflected on the title page and, in April 2012, the Board referred this case for an expert medical opinion from a physician with the Veterans Health Administration (VHA). The VHA medical expert's report was received by the Board in May 2012. FINDINGS OF FACT 1. The evidence of record establishes that the Veteran had military service in the Southwest Asia theater of operations during the Persian Gulf War. 2. The evidence of record indicates that the Veteran has chronic pain affecting the low back, knees, shoulders, and elbows that is of unknown etiology, but relates back to service in the Southwest Asia theater of operations during the Persian Gulf War. 3. The evidence of record indicates that the Veteran has a respiratory disability manifested by a persistent cough, and by the build-up of mucus in the nasal passage and throat that is of unknown etiology, but relates back to service in the Southwest Asia theater of operations during the Persian Gulf War. 4. The evidence of record indicates that the Veteran has chronic headaches that are of unknown etiology, but relates back to service in the Southwest Asia theater of operations during the Persian Gulf War. 5. The evidence of record establishes that the Veteran's insomnia, lack of energy, and memory loss are related to a psychiatric disorder; and the Veteran is currently service-connected for PTSD with a 100 percent disability rating; therefore, the evidence of record does not demonstrate any separate and distinct manifestations of these symptoms which have not already been contemplated by the rating in effect for the Veteran's service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for an arthralgia disability manifested by low back pain, pain in the knees, tendonitis of the shoulders, and epicondylitis of the elbows, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, have been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2011). 2. The criteria for service connection for a respiratory disability manifested by a persistent cough and by the build-up of mucus in the nasal passage and throat, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, have been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2011). 3. The criteria for service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, have been met. 38 U.S.C.A. §§ 1110, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.317 (2011). 4. A separate grant of service connection for a disability manifested by insomnia and lack of energy and by memory loss, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is dismissed. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.14 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Given the determinations reached in this decision, the Board is satisfied that adequate development has taken place for the Veteran's service connection claims for an arthralgia disability, a respiratory disability, and for headaches, all as a qualifying chronic disability under 38 C.F.R. § 3.317, and that there is a sound evidentiary basis for granting these claims without detriment to the due process rights of the Veteran. As to the fourth issue, service connection for a disability manifested by insomnia and lack of energy and by memory loss, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, the facts in this appeal are not in dispute and the issue will be decided as a matter of law (see discussion below). The legal outcome is clearly dictated by the existing law regardless of any further notice the Veteran might receive. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (VCAA notice not required where there is no reasonable possibility that additional development will aid the veteran); see also Mason v. Principi, 16 Vet. App. 129, 132 (2002) (VCAA not applicable "because the law as mandated by statute and not the evidence is dispositive of the claim"). Service Connection - Laws and Regulations Service connection may be granted for a disability resulting from an injury sustained or disease incurred in the line of duty or for aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2010); 38 C.F.R. § 3.303 (2011). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21), (24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110. ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserves. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full-time duty performed by a member of the Reserves or the National Guard of any State. 38 C.F.R. § 3.6(d). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Generally, in order to prevail on the issue of service connection on the merits, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. See 38 C.F.R. § 3.303(d) (2011). Because the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may be established under 38 C.F.R. § 3.317. Under this regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016 (see 76 Fed. Reg. 81834 (2011)). 38 C.F.R. § 3.317(a)(1) (2011). In this regard, the Board notes that the Veteran is already service-connected for diarrhea as a qualifying chronic disability. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under the latter provision. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.117, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. A medically unexplained chronic multi symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of the section for a medically unexplained chronic multi symptom illness. A "medically unexplained chronic multi symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs with features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Arthralgia disability The Veteran originally sought service connection for low back pain, for pain in the knees, for tendonitis of the shoulders, and for epicondylitis of the elbows, all claimed as a result of an undiagnosed illness. In April 2012, while preparing to adjudicate these claims and solicit a medical opinion from the VHA, the Board reviewed the medical and lay evidence of record and concluded these issues should be combined into one claim for service connection for an arthralgia disability manifested by low back pain, pain in the knees, tendonitis of the shoulders, and epicondylitis of the elbows, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran essentially claims that he has a chronic disability, to include joint pain associated with the back, knees, shoulders and elbows, which is related to his military service that includes service in the Persian Gulf. The Board need not repeat its review and discussion of the medical evidence previously noted and analyzed in its April 2012 request for a VHA opinion. The Veteran's service treatment records from his two periods of active service and his available service treatment records from his Reserve service are entirely negative for any injury to the low back, knees, shoulders, or elbows during active military service, a period of active duty for training, or a period of inactive duty training. In May 2012, VHA report included a review of the Veteran's claims file and information from VA's website which was attached to the report. The VHA examiner opined that the Veteran's chronic, ongoing pains over the years in the lower back, both knees, both shoulders, and both elbows might be related to a medically unexplained, chronic multi system illness due to the Veteran's Gulf War service. The Report stated that the Veteran could be suffering from chronic fatigue syndrome or fibromyalgia and that he met the criteria for chronic fatigue syndrome (with symptoms such as impaired memory, muscle pains, multiple joint pains, headaches, sleep disturbances, and generalized weakness even after rest lasting for more than six months). As for fibromyalgia, there was no documentation of trigger points although other symptoms were present. The VHA examiner also opined that the Veteran's symptoms of chronic fatigue syndrome and fibromyalgia were at least 10 percent disabling. Therefore, it was concluded that the Veteran's claimed generalized joint and muscle aches were at least as likely as not part of a medically undiagnosed illness or medically unexplained chronic multi system illness, such as chronic fatigue syndrome or fibromyalgia, and related to his service in the Gulf area from 1990 to 1991. The Board notes that the Veteran is service-connected for both PTSD and for diarrhea as due to an undiagnosed illness, which the Board finds lends support and credibility to his complaints of an arthralgia disability manifested by low back pain, pain in the knees, tendonitis of the shoulders, and epicondylitis of the elbows after service in the Southwest Asia theater of operations. Given the competent and credible evidence of an arthralgia disability, the findings and opinion of the May 2012 VHA medical expert that the Veteran met many of the criteria for chronic fatigue syndrome and fibromyalgia, the absence of evidence of an intercurrent cause, and the evidence of service in the Southwest Asia theater of operations during the Persian Gulf War, resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for an arthralgia disability manifested by low back pain, pain in the knees, tendonitis of the shoulders, and epicondylitis of the elbows, to include as a qualifying chronic disability attributable to duty in the Southwest Asia theater of operations, is warranted. 38 U.S.C.A. §§ 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.317. Respiratory disability The Veteran originally sought service connection for a persistent cough and for the build-up of mucus in the nasal passage and throat, all to include as a result of an undiagnosed illness. In April 2012, while preparing to adjudicate these claims and solicit a VHA medical opinion, the Board reviewed the medical and lay evidence of record and concluded these issues should be combined into one claim for service connection for a respiratory disability manifested by a persistent cough and by the build-up of mucus in the nasal passage and throat, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. The Veteran essentially claims that he has a chronic respiratory disability, to include coughing and mucus build-up, which is related to his military service that includes service in the Persian Gulf. The Board need not repeat its review and discussion of the medical evidence previously noted and analyzed in its April 2012 request for a VHA opinion. The Veteran's service treatment records from his two periods of active service and his available service treatment records from his Reserve service fail to show any treatment for a chronic respiratory disorder during active military service, a period of active duty for training, or a period of inactive duty training. In May 2012 VHA report noted a discrepancy in the timing of the start of symptoms of respiratory complaints. Symptoms of intermittent, chronic nasal congestion and stuffiness with mucous drainage, postnasal drip, and dry cough started soon after his discharge from active duty, as the Veteran testified in 1999, although these were not documented at the time. While he denied a chronic cough on his May 1993 Persian Gulf War screening questionnaire, the Veteran complained of a cough with mucus phlegm type production, especially during the humid summer months, during his July 1996 VA examination. There was also a possibility of chronic allergic rhinitis noted in medical records that was unresponsive to anti-allergic medications. Since there was no significant improvement in symptoms with treatment for chronic but intermittent allergies over the years, the VHA examiner opined that it was at least as likely as not to be part of a medically unexplained chronic multi system illness due to the Veteran's service in the Gulf from 1990 to 1991. The VHA examiner believed there was a high probability this was related to burning fires and noted that the Veteran, a helicopter mechanic in Saudi Arabia and Kuwait at the time, was probably in an area with burning oil and other petroleum products. It was also noted that he was part of a reclamation team that salvaged aircraft shot down or crashed and was exposed to burning weapons. The Board notes that the Veteran is service-connected for both PTSD and for diarrhea as due to an undiagnosed illness, which the Board finds lends support and credibility to his complaints of a respiratory disability manifested by a persistent cough and by the build-up of mucus in the nasal passage and throat, to include as a qualifying chronic disability after service in the Southwest Asia theater of operations. Given the competent and credible evidence of a chronic respiratory disability as documented in the claims file, the findings and opinions of the May 2012 VHA medical expert, the absence of evidence of an intercurrent cause, and the evidence of service in the Southwest Asia theater of operations during the Persian Gulf War, resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for a respiratory disability manifested by a persistent cough and by the build-up of mucus in the nasal passage and throat, to include as a qualifying chronic disability attributable to duty in the Southwest Asia theater of operations, is warranted. 38 U.S.C.A. §§ 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.317. Headaches The Veteran seeks service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. He essentially claims that he has a chronic headache disability, which is related to his military service that includes service in the Persian Gulf. The Board need not repeat its review and discussion of the medical evidence previously noted and analyzed in its April 2012 request for a VHA opinion. The Veteran's service treatment records from his two periods of active service and his available service treatment records from his Reserve service fail to show any treatment for chronic headaches during active military service, a period of active duty for training, or a period of inactive duty training. In May 2012 VHA report opined that there was a high possibility that the Veteran's complaints of chronic headaches, associated with and without nausea, tearing, light sensitivity, and various levels of severity, which began in 1991 after discharge from active service, were at least as likely as not part of a medically unexplained, chronic multisystem illness due to his service in the Gulf area in 1990 and 1991. The VHA examiner noted that the chronicity of the headache symptoms over the years, with only partial responsiveness to medications, pointed to some cause like a medically unexplained chronic multi system illness related to the Veteran's last period of active service from November 1990 to May 1991. The Board notes that the Veteran is service-connected for both PTSD and for diarrhea as due to an undiagnosed illness, which the Board finds lends support and credibility to his complaints of headaches, to include as a qualifying chronic disability after service in the Southwest Asia theater of operations. Given the competent and credible evidence of a chronic headache disability, the findings and opinion of the May 2012 VHA medical expert, the absence of evidence of an intercurrent cause, and the evidence of service in the Southwest Asia theater of operations during the Persian Gulf War, resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for a headache disability, to include as a qualifying chronic disability attributable to duty in the Southwest Asia theater of operations, is warranted. 38 U.S.C.A. §§ 1117, 5107(b); 38 C.F.R. §§ 3.102, 3.317. Insomnia, lack of energy and memory loss The Veteran originally sought service connection for a sleep disorder and lack of energy and for memory loss, claimed as forgetfulness, all as due to an undiagnosed illness. As noted in the Introduction, the Board has reviewed the medical and lay evidence of record and concluded these issues should be combined into one claim for service connection for a disability manifested by insomnia and lack of energy and by memory loss, to include as a qualifying chronic disability under 38 C.F.R. § 3.317. As this claim represents symptomatology now incorporated in the Veteran's service-connected PTSD, this claim must be dismissed. The Board notes that in a June 2009 VA examination, the examiner opined that insomnia, lack of energy, and memory problems might be psychiatrically related. In another June 2009 VA examination, the Veteran endorsed a depressed mood and the examiner found that the Veteran's diminished energy and sleep problems were also common symptoms of depression and that the Veteran's memory problems were suggestive of distractability and concentration difficulties commonly associated with major depression. The VA clinical psychologist diagnosed a recurrent severe major depressive disorder with psychotic features and anxiety disorder not otherwise specified. This examiner also found that the Veteran's psychological symptoms were at least as likely as not related to his military service. The March 2011 VA PTSD examiner suggested that symptoms of insomnia and memory loss were associated with a depressive disorder and ascribed the Veteran's difficulty sleeping to PTSD. Diagnosis was PTSD and a recurrent major depressive disorder. This VA examiner also noted that depression and PTSD are known to be comorbid and share similar symptomatology. Subsequently, in a June 2011 rating decision, the Veteran was service-connected for PTSD with a 30 percent disability rating assigned from May 28, 1996 and a 100 percent disability rating assigned from February 10, 2009. The Board concedes that the Veteran does suffer from insomnia, lack of energy, and memory loss, but notes that these symptoms have been ascribed to a psychiatric disorder, either to his PTSD or to a depressive disorder. The Veteran is already service-connected for PTSD with a 100 percent disability rating. Even if he were to be service connected at some future date for depression, the symptoms encompassed in this claim would overlap between the PTSD and the depressive disorder. As there are no separate and distinct manifestations of a disability involving insomnia, lack of energy, and memory loss which have not already been contemplated under the Veteran's current disability rating for his service-connected PTSD, the Board cannot award a separate evaluation for insomnia, lack of energy, and memory loss due to an undiagnosed illness-even if service connection was warranted-as rating such overlapping symptomatology would result in pyramiding. See 38 C.F.R. § 4.14 (2011); see also Estaban v. Brown, 6 Vet. App. 259 (1994) (in cases where separate and distinct manifestations have arisen from the same injury, separate disability ratings may be assigned where none of the symptomatology of the conditions overlaps). Rather, the RO shall take these symptoms into consideration whenever it evaluates the Veteran's disability rating for PTSD. Thus, no issue of law or fact remains to be decided with this claim. Pursuant to 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2011). Therefore, the Veteran's claim of entitlement to service connection for a disability manifested by insomnia and lack of energy and by memory loss, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is dismissed. ORDER Service connection for an arthralgia disability manifested by low back pain, pain in the knees, tendonitis of the shoulders, and epicondylitis of the elbows, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is granted, subject to the laws and regulations governing monetary awards. Service connection for a respiratory disability manifested by a persistent cough and by the build-up of mucus in the nasal passage and throat, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is granted, subject to the laws and regulations governing monetary awards. Service connection for headaches, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is granted, subject to the laws and regulations governing monetary awards. The appeal concerning entitlement to service connection for a disability manifested by insomnia and lack of energy and by memory loss, to include as a qualifying chronic disability under 38 C.F.R. § 3.317, is dismissed. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs