Citation Nr: 1315260 Decision Date: 05/08/13 Archive Date: 05/15/13 DOCKET NO. 07-00 585 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for the residuals of trauma (including head trauma), to include a "bump on the back of the head." REPRESENTATION Appellant represented by: North Carolina Division of Veterans Affairs WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from May 1951 to May 1953. This case originally came before the Board of Veterans Appeals (Board) on appeal of an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In a decision of November 2009, the Board denied entitlement to service connection for the residuals of head trauma (claimed as a bump on the back of the head), as well as for arthritis of the back and neck. In a November 2011 Order, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's November 2009 decision, and, in so doing, remanded the Veteran's case to the Board for action consistent with a March 2011 Joint Motion for Remand. The Veteran's case was subsequently remanded for additional development in November 2011. In a decision of September 2012, the Board denied entitlement to service connection for arthritis of the back and neck. At that same time, the Board remanded for additional development the issue of entitlement to service connection for the residuals of trauma (including head trauma), to include a "bump on the back of the head." The case is now, once more, before the Board for appellate review. Good or sufficient cause having been shown, the Veteran's appeal has been advanced on the Board's docket under the provisions of 38 U.S.C.A. § 7107 (West 2002) and 38 C.F.R. § 20.900(c) (2012). FINDING OF FACT Chronic residuals of trauma (including head trauma), to include a permanent "bump on the back of the head," are not shown to have been present in service, or, to the extent they currently exist, for many years thereafter, nor are they the result of any incident or incidents of the Veteran's period of active military service, including an inservice assault. CONCLUSION OF LAW Chronic residuals of trauma (including head trauma), to include a "bump on the back of the head," were not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, the requirements of 38 U.S.C.A. §§ 5103 and 5103A (West 2002) have been met. There is no issue as to whether the Veteran was provided an appropriate application form, or the completeness of his application. VA notified the Veteran in February and May 2006, as well as in March 2008, November 2011, and October and December 2012, of the information and evidence needed to substantiate and complete his claim, to include notice of what part of that evidence was to be provided by him, and what part VA would attempt to obtain. VA has also fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. During the Board hearing, the undersigned explained the issues then on appeal and asked questions designed to elicit evidence that may have been overlooked with regard to those claims. These actions provided an opportunity for the Veteran and his representative and his representative to introduce material evidence and pertinent arguments. Finally, in reaching this determination, the Board has reviewed all the evidence in the Veteran's claims file, to include testimony presented at a hearing before the undersigned Veterans Law Judge, service treatment records, and both VA (including Virtual VA) and private treatment records and examination reports. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claim, and what the evidence in the claims file shows, or fails to show, with respect to that claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 129-30 (2000). Service Connection The Veteran in this case seeks entitlement to service connection for the residuals of trauma (including head trauma), to include a "bump on the back of the head." In pertinent part, it is contended that the aforementioned disability is the result of an unprovoked attack in service (at which time the Veteran sustained a bump on the back of the head, lacerations of the inside of his lower lip, and severe bruises to his ribs), as well as the explosion of a grenade in close proximity to his location. In that regard, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002). Service connection may also be granted for any disease initially diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (2012). In order to establish service connection for a claimed disability, there must be competent evidence of that disability; medical, or in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and competent evidence of a nexus between the claimed inservice disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); see also Hickson v. West, 12 Vet. App. 247, 253 (1999). In the present case, service treatment records fail to document the presence of chronic residuals of trauma (including head trauma), to include a "bump on the back of the head." In that regard, in December 1951, while in service, the Veteran was struck with an unknown object by an unknown person or persons, sustaining a bump on the back of the head, lacerations of his inside lower lip, and severe bruising of his ribs. There is no indication that, as a result of that assault, he lost consciousness or developed chronic residual disability. In point of fact, as of the time of a service separation examination in May 1953, the Veteran's head, face, and mouth were entirely within normal limits, and no pertinent diagnoses or findings were noted. A VA examination was conducted in 1957. No pertinent complaints or findings were recorded. At the time of a VA general medical examination in March 1978, the Veteran was described as experiencing "some difficulty in...concentration," an examination of his head, face, and neck conducted at that time was entirely within normal limits. He reported that he had suffered a stroke in 1970. Moreover, no pertinent diagnosis or findings were noted. In point of fact, the earliest clear clinical indication of the presence of potential neurological problems is revealed by VA outpatient treatment records dated in 2004, more than 50 years following the Veteran's discharge from service, at which time there were noted complaints of "dizziness" and "confusion," with such confusion suggestive of the presence of small cerebrovascular accidents or other intercranial processes, and not trauma to the head. Significantly, on magnetic resonance imaging of the Veteran's head conducted in January 2005, there was evidence of mild cerebral cortical atrophy and signal abnormalities most compatible with ischemic microvascular white matter disease, and not head trauma. The Board observes that, at a time of a VA neurologic examination in March 2008, which examination involved a full review of the Veteran's claims folder, the Veteran indicated that he had been hospitalized in service for a period of three months because he had been "beaten." However, there currently exists no evidence that, to the extent that the Veteran might have been hospitalized in service, he was, in fact, hospitalized for treatment of injuries sustained in an assault. In like manner, while following the aforementioned examination, the Veteran received a diagnosis of constant diffuse headaches "since 1953 secondary to contusion," with slightly slowed intellectual responses, that diagnosis appears to have been based in large part upon history provided by the Veteran, inasmuch as the first documented complaints of headaches date from a point in time many years following the Veteran's discharge from service. See Leshore v. Brown, 8 Vet. App. 406, 409 (1995); see also Swann v. Brown, 5 Vet. App. 229, 233 (1993). Moreover, that examiner found no evidence of any "lumps on the back of the head." The Board notes that, in an addendum to the aforementioned VA neurologic examination dated in June 2008, a different VA examiner noted that, "by history," the Veteran was assaulted on Christmas Eve of 1951 while in France, at which time he was struck on the back of his head, and reportedly "lost consciousness." However, there was no documentation that the Veteran had, in fact, lost consciousness, only documentation of the assault. While at the time of the assault, the Veteran was noted to have a "lump on the back of the head," there was no further documentation of any lumps on the Veteran's head at any time. Moreover, when examined by another physician in March of 2008, it was clearly indicated that there was no evidence of any lump on the back of the Veteran's head. Physical examination revealed a normal occiput of the head, with no evidence of any lumps or bumps anywhere on the Veteran's head. Moreover, recent magnetic resonance imaging showed only widespread small vessel disease, with no evidence of any lumps or bumps, or anything suggestive of trauma to the back of the head. At a time of a subsequent VA neurologic examination in January 2012, it was noted that the Veteran's claims folder was available, and had been reviewed. According to the examiner, the Veteran was a somewhat poor historian. When questioned, the Veteran indicated that he was injured in 1951, at which time he was assaulted, and suffered a loss of consciousness. While a review of the record showed a note from December 1951 indicating a bump on the back of the Veteran's head, as well as lacerations of the inside of his lower lip, and a severe bruise of the ribs, there were no further records of that particular incident. The severity rating at the time of the injury was described as mild, and the Veteran's condition as "stabilized." On examination, the Veteran's judgment was normal, with social interaction described as "routinely appropriate." The Veteran was well oriented, though visual spatial orientation was mildly impaired, felt possibly to be secondary to his visual problems. An inability to communicate was described as secondary to the Veteran's visual difficulties, which interfered with written communication. However, consciousness was within normal limits. The pertinent diagnoses noted were trauma to the head; headaches of unknown etiology; dizziness and balance difficulties of unknown etiology; visual difficulties noted on last eye examination in January 2012, including a history of right eye branch retinal vein occlusion, dry macular degeneration of both eyes, hypertension with Stage II retinopathy of both eyes, mixed cataracts of both eyes, refractive error with presbyopia of both eyes, and corneal retinal scarring of the right eye, inferior and extending into the macula; and heat intolerance of unknown etiology. According to the examiner, review of the Veteran's claims folder showed a note describing a bump on the back of the head. However, no description was offered of any alterations of consciousness. In the opinion of the examiner, given this singular note, it was less likely than not that the Veteran suffered a traumatic brain injury during his time in the military. Moreover, as far as which emotional behavioral signs and symptoms were part of a comorbid mental disorder representing residuals of traumatic brain injury, it was impossible to make such a determination without resort to speculation. Similarly difficult without resort to speculation was any determination regarding the etiology of the Veteran's other medical problems, given that he was such a poor historian. Finally, given the Veteran's visual and hearing difficulties, phase II testing was unable to be accomplished. Accordingly, insofar as Veteran had complaints regarding memory, attention, concentration, and executive functions, there was no objective evidence of such problems on testing. In an addendum to the aforementioned VA neurologic examination dated in January 2013, the same VA physician who had conducted the January 2012 examination once again noted that the Veteran's claims folder was available, and had been reviewed. As noted on the previous examination, when seen in December 1951, the Veteran had a small bump on the back of the head, as well as lacerations inside his lower lip, and severe bruises of his ribs. Reportedly, the Veteran had been struck by an unknown object by a person or persons unknown. While on previous VA examination, the Veteran had complained of mild memory impairment, as well as difficulties with attention and concentration, Phase II testing was unable to be accomplished secondary to the Veteran's vision and hearing difficulties. Accordingly, the origin of those particular problems was unknown. According to the examiner, while magnetic resonance imaging of the Veteran's head conducted in 2008 showed evidence of chronic microvascular ischemic changes, this finding was more consistent with the Veteran's age than any residual of head injury. Regarding the Veteran's headaches, these headaches reportedly began sometime in the 1960's, and, according to the examiner, would not be secondary to any head trauma in 1951. Regarding complaints of dizziness, it was unknown when this occurred. However, there were no comments in the Veteran's service treatment records regarding dizziness. According to the examiner, the Veteran's dizziness might be secondary to his peripheral neuropathy and/or his poor vision. Regarding the Veteran's insomnia, fatigue, mobility problems, constipation, urinary frequency, and heat intolerance, there were no comments regarding these problems in the Veteran's service treatment records. Moreover, they were likely not secondary to his inservice head trauma. Rather, they were more likely the result of other problems. Regarding the Veteran's vision, he was noted to have age-related macular degeneration, which would not be caused by his head injury. Moreover, the Veteran's cardiovascular status would not be affected by a head injury. According to the examiner, the Veteran had been diagnosed with trauma to the head, and not traumatic brain injury, given that there was no confirmation of any loss or alteration of consciousness. Moreover, current cognitive difficulties were described as possibly secondary to his chronic microvascular ischemic changes. The Board finds the aforementioned VA opinions highly probative, because those opinions were based upon a review of the Veteran's entire claims folder, as well as a full examination of the Veteran, including both history and clinical findings. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion are the physician's access to the claims file, and the thoroughness and detail of the opinion). The VA examiners reviewed the Veteran's claims folder, discussed his medical history, provided well-reasoned medical opinions, and alluded to the evidence which supported those opinions. See Hernandez-Toyens, supra. Those opinions were essentially to the effect that, to the extent that the Veteran suffered from various neurologic problems, including headaches, memory impairment, and cognitive difficulties, those problems were unrelated to his inservice physical assault. In reaching its decision, the Board has a duty to assess the credibility and weight to be given to the evidence of record. See Madden v. Gober, 125 F. 3d 1477 (Fed. Cir. 1997). In that regard, and as noted above, the Veteran has attributed his various difficulties to an inservice assault (at which time he sustained a blow to the head), as well as a grenade explosion. However, not until many years following his discharge from service did the Veteran file a claim for the disabilities at issue. Significantly, the passage of many years between discharge from service and medical documentation of a claimed disability is a factor which tends to weigh against a claim for service connection. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, in the case at hand, the entire weight of the evidence is to the effect that the Veteran's current pathology, to the extent it currently exists, is unrelated to the aforementioned inservice attack and/or grenade explosion. Under the circumstances, the Veteran's claim for service connection must be denied. The Board acknowledges the Veteran's testimony regarding the origin of his current disability. However, the Board rejects those assertions to the extent that the Veteran seeks to etiologically relate his current problems to the aforementioned inservice assault and/or grenade explosion. The Veteran's statements and history, when weighed against the objective evidence of record, are neither credible nor of particular probative value. Moreover, the Veteran, as a lay person, is not competent to create the requisite causal nexus for the disabilities at issue. Rather, evidence which requires medical knowledge must be provided by someone qualified as an expert by knowledge, skill, experience, training, or education, none of which the Veteran possesses. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the aforementioned, the Board is unable to reasonably associate the Veteran's claimed residuals of trauma (including head trauma), to include a "bump on the back of the head," with any incident or incidents of his period of active military service. Accordingly, his claim for service connection must be denied. ORDER Entitlement to service connection for the residuals of trauma (including head trauma), to include a "bump on the back of the head," is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs