Citation Nr: 1304579 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 07-35 730 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for fibromyalgia, including as due to service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for obstructive sleep apnea (OSA), including as due to service-connected PTSD or exposure to herbicides. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from August 1969 to March 1971. This matter initially came to the Board of Veterans' Affairs (Board) on appeal from August and September 2006 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. In August 2010, the Veteran testified during a hearing at the RO before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In December 2010, the Board remanded the Veteran's case to the RO further development. Then, in a February 2012 rating decision, the RO granted service connection for PTSD, Crohn's disease, and an ileostomy. The RO's action represents a full grant of the benefits sought as to these matters. In June 2012, the Board remanded the Veteran's remaining claims on appeal to the RO for further development. FINDINGS OF FACT 1. The evidence of record preponderates against a finding that fibromyalgia had its onset in service, or is otherwise related to the Veteran's military service, including his service-connected PTSD or exposure to herbicides. 2. The evidence of record preponderates against a finding that OSA had its onset in service, or is otherwise related to the Veteran's military service, including exposure to herbicides or his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for fibromyalgia, including as due to PTSD or exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for service connection for OSA, including as due to PTSD or exposure to herbicides, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, this Veterans Law Judge outlined the issues on appeal and suggested that any evidence tending to show that pertinent disability was related to active duty or a service-connected disability would be helpful in establishing the claims. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent letters in September 2005 and January 2012 that provided information as to what evidence was required to substantiate the claims and of the division of responsibilities between VA and a claimant in developing an appeal. A December 2008 letter provided notice as to how VA assigns an appropriate disability rating or effective date. To the extent that Dingess notice did not precede the initial adverse determination, this deficiency has been corrected, as complete notice was later issued, followed by a readjudication of the claims, most recently in December 2012. See Mayfield, 444 F.3d 1328 (Fed. Cir. 2006); Prickett, 20 Vet. App. 370, 376 (2006). Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of his claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file reveals VA treatment records, dated from April to June 2012, that were also considered in the claims on appeal. The Veteran was afforded VA examinations in January 2011 in conjunction with his claims and the examination reports, with the March 2012 Addendum, are of record. As noted above, in June 2012, the Board remanded the Veteran's case to the RO for further development that included scheduling him for a VA examination and obtaining outstanding medical records. There has been substantial compliance with the Board's remand as, in July 2012, the Veteran underwent VA examination and VA medical records dated to June 2012 were obtained. The July 2012 VA examination report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, examined the Veteran, provided clinical findings and diagnoses, and offered an etiological opinion with a rationale from which the Board can reach a fair determination. The July 2012 examination report cures the deficiencies in the January 2011 VA examination reports with the March 2012 addendum. The records satisfy 38 C.F.R. § 3.326 (2012). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. Records obtained from the Social Security Administration (SSA) show that the Veteran was considered totally disabled and unable to work since November 2000, due to osteoarthritis and allied disorders, and to regional enteritis. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Factual Background and Legal Analysis The Board has thoroughly reviewed the record in conjunction with this case that includes VA and non VA medical records, dated from 1973 to 2012, and the Veteran's written statements and oral testimony in support of his claims. Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Under 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). 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 disability was incurred in service. 38 C.F.R. § 3.303(d). Certain specified neurological disorders, if manifest to a degree of 10 percent within one year after separation from active duty, may be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In addition, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). With regard to the matter of establishing service connection for a disability on a secondary basis, the Court has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id.; see also 38 C.F.R. § 3.310(b). With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). This is a direct service connection theory of entitlement. Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible. 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, 1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of respiratory and musculoskeletal/neurologic disease pathology, as is the case here. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board must assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991). While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement. See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). In this case, the Veteran contends, in pertinent part, that he was exposed to Agent Orange in service that caused or contributed to his post service diagnosis of, and treatment for, OSA. He has also variously claimed that his fibromyalgia was also due to exposure to Agent Orange. Veterans who, during active service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. 38 U.S.C.A. §§ 1116; 38 C.F.R. § 3.307. If a veteran was exposed to a herbicide agent (to include Agent Orange) during active military, naval or air service and has contracted an enumerated disease to a degree of 10 percent or more at any time after service (except for chloracne and acute and sub acute peripheral neuropathy which must be manifested within a year of the last exposure to an herbicide agent during service), the veteran is entitled to a presumption of service connection even though there is no record of such disease during service. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.307, 3.309(e). The enumerated diseases do not include fibromyalgia or obstructive sleep apnea. 38 C.F.R. § 3.309(e). Specifically, the Secretary of VA has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for enumerated other disorders, and any other condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See, e.g., Veterans and Agent Orange Update: Update 2010 (Update 2010), 77 Fed. Reg. 47924-8 (Aug. 10, 2012). See also Veterans and Agent Orange Update: Update 2008 (Update 2008), 75 Fed. Reg. 81,332 -335 (Dec. 27, 2010); Veterans and Agent Orange: Update 2006 (2007); Notice, 68 Fed. Reg. 27,630 -41 (May 20, 2003); 72 Fed. Reg. 32,395-407 (June 1, 2007); and Notices at 61 Fed. Reg. 57,586 -589 (1996); 64 Fed. Reg. 59,232 -243 (1999); and 67 Fed. Reg. 42,600 -608 (June 24, 2002). Notwithstanding the foregoing presumption provisions, the United States Court of Appeals for the Federal Circuit has determined that a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Thus, presumption is not the sole method for showing causation. In light of the foregoing, service connection may be presumed for residuals of Agent Orange exposure by showing two elements. First, the Veteran must show that he served in the Republic of Vietnam during the Vietnam era. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must be diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e), or otherwise establish a nexus to service. See Brock v. Brown, 10 Vet. App. 155, 162 (1997). The first determination to be clarified is whether the Veteran was exposed to Agent Orange. The above-described presumptions apply only to Veterans who actually served on the land mass of the Republic of Vietnam. Here, the Veteran's service records show that he served in the Republic of Vietnam from March 1970 to March 1971. Therefore, he is presumed to have been exposed to herbicides during active duty. The next question is whether the Veteran has a disease or disorder that is positively associated with exposure to Agent Orange or is otherwise related thereto. Here, the objective medical evidence fails to demonstrate that he has a disease associated with exposure to Agent Orange or is otherwise related thereto and he has not established a nexus between his claimed fibromyalgia and OSA disorders and military service or to his service-connected PTSD. A. Fibromyalgia The Veteran asserts that he has fibromyalgia due to military service or, alternatively, as a result of his service-connected PTSD. He testified that fibromyalgia was first noted in approximately 2000. See Board hearing transcript at page 38. His wife testified that he had complaints of pain for many years. Id. at 41. Service treatment records do not refer to fibromyalgia. Post service, private medical records from W.M.D., M.D., dated from 2000 to 2009, include complaints of joint pain for which the Veteran was referred to Dr. W.P.M. in September 2000. Medical records from W.P.M., M.D., dated from October 2000 to February 2002, include diagnoses of fibromyalgia. When initially seen by Dr. W.P.M. in October 2000, the Veteran gave a long history of musculoskeletal pain with marked worsening over the last four to five months time. The assessment was that the Veteran's history and physical examination were consistent with fibromyalgia. Dr. W.D.'s records include diagnoses of fibromyalgia, described as severe in September 2003, September 2004, and May 2007. A July 2006 statement from J.R.M., M.D., a private physician and treating pain management specialist, is to the effect that the Veteran suffered from PTSD and associated fibromyalgia and was being treated for his condition as a consequence of his military service. Dr. J.M. did not provide a rationale for his opinion. In January 2011, the Veteran underwent VA examination. According to the examination report, the Veteran had wide spread pain since the late 1980s diagnosed as fibromyalgia approximately ten years earlier. In a March 2012 addendum, the recent VA examiner reviewed a January 2011 VA PTSD examination report (that diagnosed PTSD) and opined that the Veteran's fibromyalgia was less likely than not due to service. The VA examiner said that a new literature search revealed no pathogenesis or cause of fibromyalgia was identified and it would be speculation to attribute the Veteran's fibromyalgia to military service or his service-connected disorders. The VA examiner opined that the Veteran's fibromyalgia was less likely than not due to military service or his current service-connected disorders, using current records and medical scientific literature. The VA examiner noted an Up-To-Date review of medical literature through February 2012 indicating that "[d]espite the numerous abnormalities described in patients with fibromyalgia there is as yet no generally agreed upon explanation for the pathogenesis of the disorder...." The VA examiner said this summary was consistent with his review of medical literature since the January 2011 examination and recent medical society meetings and discussions. In July 2012, the Veteran underwent another VA examination. The VA examiner reviewed the Veteran's medical records and performed a clinical evaluation. The Veteran said he developed increased pain in his low back, hips, and legs in the late 1990s while working as a delivery driver. He was repeatedly seen on an on-going basis by a rheumatology specialist who diagnosed him with a sleep disorder, fibromyalgia, and multiple trigger points. The VA examiner observed that, in the July 11, 2012 edition of Up-To-Date, the online medical reference source, it was noted that [f]ibromyalgia is a chronic pain disorder with unknown etiology and unclear pathophysiology...Alterations in pain and sensory processing in the central nervous system are present in [fibromyalgia]. Patients perceive noxious stimuli, such as heat, electrical current or pressure, as being painful at lower levels of physical stimulation than do healthy controls....However, unlike [fibromyalgia], depression does not seem to affect the level or neuronal activation in sensory pain regions....There is conclusive evidence that alteration in central nervous system pain processing [is] responsible for many of the features of fibromyalgia. Genetic and environmental factors likely interact to promote a state of chronic central and peripheral nervous system hyperirritability. The VA examiner concluded that, given the currently available information, the Veteran's fibromyalgia is "less likely than not caused by his PTSD, because fibromyalgia has no known etiology" and "fibromyalgia is less likely than not aggravated by his PTSD, as the pathophysiology of fibromyalgia is unknown, and no relationship between PTSD and fibromyalgia are identified in the current[ly available] medication literature". The VA examiner stated that PTSD's relationship to fibromyalgia was not documented to his knowledge and current research suggested that different parts of the brain were activated by depression than were activated by fibromyalgia. In the VA examiner's opinion, the Veteran's PTSD was a different category of condition from his fibromyalgia. Here, the Veteran has not asserted, and the records do not show, that he was treated for fibromyalgia in service. Rather, he argues that the disorder developed many years later. The service treatment records do not provide evidence of a fibromyalgia disorder in service. When he was evaluated for discharge in March 1971, no musculoskeletal or neurologic problems were identified. The first documented evidence of any type of fibromyalgia problem after service is from the private records dated in 2000, nearly 30 years after service. Moreover, even the Veteran's own statements tend to place the onset of symptoms later diagnosed as fibromyalgia around the late 1990s, still decades following discharge. In this regard, a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). More significantly, in July 2012, a VA examiner opined that the Veteran's fibromyalgia was less likely than not caused or aggravated by or the result of his service-connected PTSD. The VA examiner provided a clear rationale to support that opinion. The Board acknowledges the July 2006 statement written by Dr. J.M., expressing the opinion that the Veteran's fibromyalgia was associated with his PTSD and that he was being treated for a that disorder as a consequence of his military service. However, where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion. Wray v. Brown, 7 Vet. App. 488, 493 (1995). The Board does, in fact, adopt the July 2012 VA examiner's opinion, on which it bases its determination that service connection for fibromyalgia, including as due to service-connected PTSD, is not warranted. Since the VA examiner's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA examiner provided a valid medical analysis to the significant facts of this case in reaching his conclusion. In other words, the VA examiner did not only provide data and conclusions, but also furnished a clear and reasoned analysis that the Court has held is where most of the probative value of a medical opinion comes is derived. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."); see also Wray v. Brown, 7 Vet. App. at 493. The Court has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999) (a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). The Board therefore places greater weight on the VA examiner's opinion, finding that it was more likely than not that the Veteran's fibromyalgia was not related to military service or to service-connected PTSD, than on Dr. J.M.'s opinion to the effect that the Veteran's fibromyalgia was associated with his PTSD. Dr. J.M. offered no rationale to support his opinion and his opinion is given less probative weight by the Board. See Owens v. Brown, 7 Vet. App. at 433 (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. at 473 ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches"). But a medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. at 304. It is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. at 433. But, we are mindful that we cannot make our own independent medical determinations, and that we must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In evaluating the ultimate merit of this claim, the Board ascribes the greatest probative value to the medical opinion provided by the VA examiner who provided the written opinion in July 2012. This medical specialist had the opportunity to review all the Veteran's medical records regarding the diagnoses of fibromyalgia. The VA examiner opined that the Veteran's fibromyalgia was less likely than not caused by his PTSD, because fibromyalgia had no known etiology. The VA examiner also stated that fibromyalgia was less likely than not aggravated by the Veteran's PTSD, as the pathophysiology of fibromyalgia was unknown, and no relationship between PTSD and fibromyalgia were identified in the current medication literature that the examiner could locate. Additionally, the VA examiner found that PTSD's relationship to fibromyalgia had not been documented to his knowledge and current research suggested that different parts of the brain were activated by depression than were activated by fibromyalgia. In the VA examiner's opinion, the Veteran's PTSD was a different category of condition from his fibromyalgia. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board finds that, given the scope and depth of the VA examiner's rationale, this opinion carries more weight than that of Dr. J.M. See Bloom v. West, Black v. Brown, supra. In sum, the overall evidence demonstrates that the Veteran's fibromyalgia is not related to the Veteran's period of active military service, including his service-connected PTSD. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for fibromyalgia, including as due to service-connected PTSD, must be denied. See Gilbert v. Derwinski, 1 Vet. App at 49. B. Obstructive Sleep Apnea The Veteran also contends that he was exposed to Agent Orange in service that caused or contributed to his post service diagnosis of, and treatment for, OSA. Alternatively, in his October 2006 notice of disagreement, he contended that his sleep apnea was a result of his PTSD and living through combat conditions in service. Service treatment records do not refer to sleep apnea. The private medical records from Dr. W.M.D., dated from 2000 to 2009, show that, in August 2003, the Veteran reported that for a couple of months he felt sleepy during the day and did not sleep well at night. The physician suspected hypersomia and it was noted that the Veteran took many sedating medications. He was advised to cut back on them and see if that affected his symtoms. When seen in March 2004, the Veteran and his wife expressed concern regarding his increased daytime sleepiness for the last year. Daytime hypersomnia was diagnosed and the differential diagnoses included sleep apnea. The Veteran was referred for a sleep consultation. A March 2004 private sleep clinic record from M.A.D., M.D., shows that Veteran's reports appeared compatible with OSA and an overnight polysomnogram was arranged. The pathophysiology of OSA was discussed with the Veteran. Results of a March 2004 private full polysomnogram included moderate OSA. Dr. W.M.D.'s clinical records include a diagnosis of sleep apnea in September 2004 and subsequently. Private records, dated in January 2005, indicate that the Veteran underwent nasal surgery due to hypertrophied inferior turbinates with nasal airway obstruction and OSA. The July 2006 statement from Dr. J.R.M. also associates the Veteran's diagnosis of sleep apnea with PTSD and notes that he was being treated for his condition as a consequence of his military service. Dr. J.M. did not provide a rationale for his opinion. In January 2011, the Veteran underwent a VA examination for sleep apnea. He gave a history of having chronic sleep problems since the 1970s and was diagnosed with sleep apnea seven years earlier after a sleep study. He had a chronic sleep disorder and documented sleep apnea. The VA examiner commented that the Veteran did not currently have psychiatric treatment and he needed more information regarding the Veteran's mental status before offering an opinion on etiology. The VA examiner further stated that it was less likely sleep apnea would be exacerbated by a psychological disorder. However, the VA examiner did not have access to a subsequent VA PTSD examination report and his opinion was not based upon a fully formed review of the record and has limited probative value. See Barr v. Nicholson, 21 Vet. App. 303, 322 (2007). As mentioned above, later in January 2011, the Veteran underwent a VA examination for PTSD. The examiner diagnosed PTSD and considered sleep apnea one of several sleeping disorders secondary to PTSD. However, the examiner did not provide a rationale that specifically addressed the relationship of sleep apnea (as opposed to mere sleep disturbance caused by distressing dreams) to PTSD. The medical bases supporting the VA examiner's positive opinion are unclear. See Nieves-Rodriguez v. Peake, 22 Vet. App. at 304 (to the effect that the probative value of a medical opinion rests in the reasoning that supports the conclusion). According to the July 2012 VA examination report, the Veteran stated that he had chronic sleep problems since the 1970s and was only able to sleep approximately three to five hours. He was diagnosed with OSA in approximately 2004 or 2005 after several sleep studies. The Veteran had surgery for sinus and nasal obstruction to the septum, turbinates and sinuses in 1988, 2004, and 2005. The VA examiner said that review of the Veteran's "very large multi-volume" claims file did not identify any copies of his previous sleep studies. Reference to sleep studies was based on a history provided by the Veteran and his wife (but see the private March 2004 sleep study, discussed supra). The VA examiner noted that, the review of the current Up-To-Date stated that definite risk factors for OSA included obesity, craniofacial abnormalities, and upper airway soft tissue abnormalities. Potential risk factors include heredity, smoking, nasal congestion, and diabetes. According to the VA examiner, with the currently available information, the Veteran's obesity, nasal airway structural problems and chronic rhinitis "are more likely than not" the cause of his OSA. The VA examiner further opined that the Veteran's sleep apnea was "less likely than not" caused by or aggravated by his PTSD, "because PTSD does not cause obstruction of the airways or interfere with flow of breathing during sleep." The Veteran has not asserted, and the records do not show, that he had sleep apnea in service. Rather, he argues that the disorder developed many years later. Here, the service treatment records do not provide evidence of an OSA disorder in service. When he was evaluated for discharge in March 1971, no respiratory or sleep problems were identified. The record unequivocally shows that the first documented evidence of any type of OSA problem after service is from the private records dated in 2004, nearly 33 years after service. In this regard, a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). More importantly, in July 2012, the VA examiner opined that, with the currently available information, the Veteran's obesity, nasal airway structural problems and chronic rhinitis "are more likely than not" the cause of his OSA. The VA examiner further opined that the Veteran's sleep apnea was "less likely than not" caused by or aggravated by his PTSD, "because PTSD does not cause obstruction of the airways or interfere with flow of breathing during sleep." The Board acknowledges the written statement provided by Dr. J.M., who found that the Veteran's sleep apnea was associated with his PTSD and that the Veteran was being treated for his condition as a consequence of his military service. Here, the Board adopts the July 2012 VA examiner's opinion, on which it bases its determination that service connection for OSA, including as due to service-connected PTSD or exposure to herbicides is not warranted. Wray v. Brown, 7 Vet. App. at 493. Since the VA examiner's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim. The Board emphasizes that the VA examiner provided a valid medical analysis to the significant facts of this case in reaching his conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. at 304; see also Wray v. Brown, 7 Vet. App. at 493. The Board therefore places greater weight on the VA examiner's opinion, that finds that it was more likely than not that the Veteran's OSA was not related to military service or to service-connected PTSD, than on Dr. J.M.'s opinion to the effect that the Veteran's OSA was associated with his PTSD. Dr. J.M. offered no rationale to support his opinion and his opinion is given less probative weight by the Board. See Owens v. Brown, 7 Vet. App. at 433; Guerrieri v. Brown, 4 Vet. App. at 473. By contrast, the VA examiner had the opportunity to review all the Veteran's medical records regarding the diagnoses of OSA. The VA examiner stated that the Veteran's obesity, nasal airway structural problems and chronic rhinitis "are more likely than not" the cause of his OSA. The VA examiner further opined that the Veteran's sleep apnea was "less likely than not" caused by or aggravated by his PTSD, "because PTSD does not cause obstruction of the airways or interfere with flow of breathing during sleep". See Prejean v. West, 13 Vet. App. at 448-9. For the above reasons, the July 2012 VA opinion is afforded more probative weight than the July 2006 statement provided by Dr. J.M. See Bloom v. West, Black v. Brown, supra. In sum, the overall evidence demonstrates that the sleep apnea is not related to the Veteran's period of active military service, including his service-connected PTSD. Thus, the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for OSA, including as due to service-connected PTSD or exposure to herbicides, must be denied. See Gilbert v. Derwinski, 1 Vet. App at 49. Both Claimed Disorders Here, the preponderance of the evidence is against a finding that a current fibromyalgia disorder and OSA are related to active service, including the Veteran's service-connected PTSD, or his exposure to herbicides. In so finding, the Board has considered the Veteran's contention that a relationship exists between his current fibromyalgia and OSA disorders and military service. In adjudicating these claims, the Board must assess the Veteran's competence and credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. at 303, the Court, emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). The Veteran is competent to describe his observable symptoms, such as joint pain or sleep difficulty. However, he is not competent to make a statement of causation that is a medical determination (i.e., that can't be based on mere lay observation). Barr v. Nicholson, 21 Vet. App. at 303; Buchanan v. Nicholson, 451 F.3d at 1331. To the extent he is claiming that OSA problems have persisted since service, this is inconsistent with the overall record which reflects fibromyalgia and OSA symptomatology surfaced many years after service. The Board has considered the Veteran's statements as to his incurrence due to service, in light of his service treatment records, post-service medical evidence, and the January 2011 and July 2012 VA medical opinions. Again, the record reflects that the Veteran was not treated for fibromyalgia or OSA during military service, nor does he contend otherwise. The post service records show that fibromyalgia was diagnosed in 2000, nearly 30 years after his discharge from service, and OSA was diagnosed in 2004, nearly 33 after his discharge from active service. The gap of time between in-service and the first post-service medical evidence of fibromyalgia and OSA is, in itself, significant, and weighs against the appellant's claims. See Maxson v. Gober, 230 F.3d at 1333; see also Mense v. Derwinski, 1 Vet. App. at 356. The Board recognizes that the absence of documented post-service treatment cannot, by itself, invalidate the Veteran's claims of continuous symptomatology. However, to the extent that he is claiming continuity of fibromyalgia and OSA symptoms since service, he is not a reliable historian. Indeed, when examined for discharge in 1971, his musculoskeletal and respiratory systems were normal. In February 2000, Dr. W.D. reported the Veteran's long history of pain that worsened in the past few months and, in October 2005, Dr. J.M. noted the Veteran's history of pain for many years, but the Veteran did not report having pain since his discharge from service. In August 2003, Dr. W.D. noted the Veteran's complaints of sleep problems for the past few months but the July 2012 VA examiner reported that the Veteran had sleep problems since the 1970s. Finally, at his Board hearing, he endorsed a history of joint pains only from the late 1990s. Thus, the Board does not find that there is credible evidence of continuity of symptomatology present. Neither the clinical record nor the Veteran's statements support a finding of continuity and, thus, service connection is not warranted on this basis. While the Veteran is competent to state that he experienced sleep difficulty in service or soon after discharge, he is not competent to state that he has fibromyalgia or OSA due to service-connected PTSD, or to exposure to herbicides. These are not conditions that are readily recognizable by a layman, such as varicose veins or acne. See Jandreau v. Nicholson. Even medical professionals rely on sleep studies, laboratory tests, and other diagnostic tools to diagnose fibromyalgia and OSA. Moreover, the July 2012 VA examiner, who was reviewed the Veteran's in-service treatment records and reviewed his post service medical records, concluded that he did not have fibromyalgia or OSA disorder due PTSD. The Veteran's contentions are outweighed by the medical evidence and opinion of the VA examiner that reflects that fibromyalgia and OSA were not incurred during active service and not due to the Veteran's service-connected PTSD. The Veteran has submitted no medical evidence to show that either disorder was caused by exposure to herbicides. In sum, the Board is left with no documented complaints or findings of a diagnosed fibromyalgia disorder or OSA after service until 2000 and 2004, respectively, and a VA medical opinion to the effect that the Veteran's fibromyalgia and OSA were not due military service including his service-connected PTSD, and there is no medical evidence of record that his fibromyalgia or OSA was due to exposure to herbicides. The questions involved regarding causation are medical in nature. As discussed above, the medical opinions of the July 2012 VA examiner (based on a review of the claims file and with knowledge of the Veteran's in-service duties and in-service complaints) were negative. The Board has considered the Veteran's contention that his fibromyalgia and OSA began as a result of his military service, including his service-connected PTSD, or exposure to herbicides, but there is nothing in the record to show that he possesses the requisite medical training or credentials needed to render a competent opinion and it is not contended otherwise. Under these circumstances, the Board is unable to find that there is a state of equipoise of the positive evidence and negative evidence. Again, as detailed, the Board finds such opinion to be of more probative value than the Veteran's contentions. See e.g., King. v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012) (to the effect that the Board need not accept lay statements as determinative and can find medical evidence more probative). In sum, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claim for service connection for fibromyalgia including as due to service-connected PTSD, and OSA, including as due to service-connected PTSD or exposure to herbicides, and his claims must be denied. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). ORDER Service connection for fibromyalgia, including as due to service-connected PTSD, is denied. Service connection for obstructive sleep apnea, including as due to service-connected PTSD or exposure to herbicides, is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs