Citation Nr: 1315877 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 10-25 326 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for residuals of a head injury, to include concussion, seizures, headaches, syncope, dizziness, memory loss, and mini-strokes. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R.N. Poulson, Counsel INTRODUCTION The Veteran served on active duty from July 1948 to April 1952. He is a Korean veteran who was awarded the Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Currently, the Chicago RO is the agency of original jurisdiction (AOJ). The claim has been recharacterized as noted on the title page to better reflect the Veteran's contentions and the medical evidence of record. In September 2012, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims folder, which shows that the Veteran submitted a waiver of initial RO consideration of the evidence added to the claims file following the hearing. In January 2013, the Board reopened the service connection claim and remanded the underlying claim for additional development. The requested development has been completed, and the appeal has been returned to the Board for further appellate review. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT Residuals of a head injury, to include concussion, seizures, headaches, syncope, dizziness, memory loss, and mini-strokes, were not manifested during service or within one year of separation, and are not otherwise related to the Veteran's active service. CONCLUSION OF LAW Residuals of a head injury, to include concussion, seizures, headaches, syncope, dizziness, memory loss, and mini-strokes, were not incurred or aggravated during active duty service or within one year thereafter. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's 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). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and 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. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, a letter dated in April 2009 complied with VA's duty to notify the Veteran with regards to the service connection issue addressed herein. Specifically, this correspondence apprised the Veteran of what the evidence must show to establish entitlement to the benefit, what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. The letter also notified the Veteran of the criteria for assigning a disability rating and an effective date. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Moreover, the Board finds that VA has complied with its duty to assist the Veteran in the development of his claim. VA has obtained service treatment records (STRs) and VA treatment records. The Veteran has submitted private treatment records. Review of the Virtual VA electronic claims file reveals additional VA outpatient treatment records dated through March 2013. The claims file contains a document printed from Virtual VA summarizing these documents. The Board notes that these records do not contain additional symptomatology not already of record and are therefore essentially cumulative of the evidence already of record. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. See 38 C.F.R. § 3.159 (c)(2). All known and available records relevant to the issue on appeal have been obtained and associated with the Veteran's claim file and he has not contended otherwise. The Veteran underwent a VA examination in March 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the March 2013 opinion is adequate. The examiner considered the pertinent evidence of record, to include the Veteran's statements regarding the in-service head injury, the STRs, VA treatment records, and private treatment records. The examiner did not specifically indicate that she had reviewed the Virtual VA records. However, as discussed above, these records are cumulative of other evidence in the record. The examiner fully examined the Veteran, thoroughly reviewed of the claims file, and answered the questions posed by the AOJ. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claim on appeal has been met. See 38 C.F.R. § 3.159(c)(4). In Bryant v. Shinseki, 23 Vet. App. 488, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ 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. During the hearing, testimony was solicited regarding the service incurrence of the Veteran's head injury, current disability, and a nexus between such disability and service. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. Finally, the Board notes that this appeal was remanded in January 2013. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a Court or Board remand confers upon the appellant the right to compliance with that order). The development requested in that remand, to obtain additional VA treatment records and provide a VA examination, was completed. Accordingly, the Board finds that it may proceed to adjudication of this appeal. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). II. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for any condition listed in 38 C.F.R. § 3.303(b). Any condition not encompassed by Section 3.303 (b) requires a medical nexus. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Certain chronic diseases, such as epilepsy, may be presumed to have been incurred in service if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C.A. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is 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 facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all the evidence is assembled, 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 a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that he has residuals of an in-service head injury. Specifically, he contends symptoms such as concussion, seizures, headaches, syncope, dizziness, memory loss, and mini-strokes are all residuals from the in-service head injury. STRs show that on November 11, 1949, the Veteran was admitted to the hospital after complaining of head pain following a football game. A sudden loss of consciousness was noted. The initial diagnosis was brain concussion. It was noted upon subsequent examination that the Veteran appeared semi-comatose and was flaccid. He responded to commands and made no complaints. There was a small laceration on the left eyelid, but no other evidence of contusion. All tendon reflexes were slightly hyperactive and equal. Babinski reflexes were decreased. Both upper abdominals and right cremasteric reflexes were absent. The admitting diagnoses were "(1) possible cerebral concussion or other CVA (unlikely); (2) hysteria; and (3) drugged." A neurological and fundoscopic examination conducted three days later was normal. The discharge summary, dated November 17, 1949, indicated that a neurological examination was negative. The Veteran was admitted to the hospital in September 1950 because his head was bothering him and had "went black." It was noted that he had previously sustained a concussion. He was admitted to the hospital again in November 1950 for "observation for cerebral concussion." In 1951, the Veteran incurred a gunshot wound during combat in Korea, for which he is service-connected. The Veteran's April 1952 discharge examination contains a normal neurological examination. It was noted that he had been hospitalized for a simple convulsion and had a full recovery. A June 1956 VA examination was conducted with respect to the Veteran's service-connected gunshot wound. Psychological testing resulted in ambiguous results and suggested the possibilities of conversion hysteria and malingering. A March 1989 VA examination shows that the Veteran complained of blackout spells. He related the 1949 football injury and indicated that he had sustained a "severe concussion" that required hospitalization for two weeks. He reportedly had experienced a blackout spell nine months earlier and also in 1984. The spells came without warning and resulted in loss of consciousness for 2-3 minutes. He denied a history of epilepsy. The blackout spells were not accompanied by chest pain, palpitations, headache, blurred vision, or other neurological symptoms. The Veteran also complained of daily headaches for "many years", which he related to his in-service concussion. There were no associated neurological symptoms. Upon examination, fundi showed some arteriolar nicking but no hemorrhages, exudates, or papilledema. A cerebellar exam was intact. The impression included "history of what sounds like syncopal spells." The examiner noted that it was unclear from the Veteran's history whether the spells were secondary to a seizure disorder as opposed to some other etiology. It was noted that cardiac disease should be ruled out. The examiner recommended a CT head scan, given the Veteran's history of head trauma, in order to rule out subdural hematoma or other intracranial mass. He also recommended an EEG to evaluate for seizure disorder. The examiner also diagnosed chronic history of low grade headaches that "may be related to old history of head trauma." It was noted that subdural hematoma and brain tumor should be ruled out. He noted that the Veteran's history was most consistent with tension headaches. It does not appear that the examiner reviewed the claims file. Private treatment records show that, in January 2009, the Veteran complained of intermittent dizziness associated with memory problems and an inability to think clearly. An MRI revealed a small stroke, nonhemorrhagic, in the posteromedial aspect of the right occipital lobe. Echocardiogram and carotid doppler testing were normal. The impression was stroke. The clinician prescribed Aggrenox and Simvastatin. A February 2009 CT head scan showed diffuse white matter change likely related to chronic small vessel ischemia. A February 2009 treatment record contains a diagnosis of small cerebrovascular accident with recurrent transient ischemic attacks that appeared to have stabilized on Aggrenox, and carotid atherosclerosis. In June 2009, the Veteran reported that he had had "two minor spells." The doctor attributed these to noncompliance with medication. The doctor further noted that a complete work up had been completed previously and that he "could not find anything else to explain his problem other than small vessel disease, probably associated with his diabetes." In October 2009, the Veteran reported that he continued to have "little spells" whenever he forgot to take his medication. He also reported having had a "bad day" the week before - he kept forgetting what he was saying and did not feel right - but thought he had taken his medication that day. The diagnoses included history of TIAs with evidence of recurrence. Aspirin was prescribed in addition to the Aggrenox. Private treatment records dated in September 2010 show that the Veteran received emergency treatment while on vacation for what was thought to be a seizure. A CT head scan showed mild to moderate small vessel ischemic change. An MRI revealed chronic microvascular ischemia. An EEG showed focal slowing. The assessment was new onset seizure. The clinician indicated that there may or may not have been a concurrent stroke. It was also noted that the Veteran may or may not have had transient ischemic attacks in the past. The clinician noted that there was a possibility that the Veteran had had some partial seizures "and now secondary generation." The Veteran saw his primary care provider later that month and complained of dizziness and balance problems. The doctor noted that the January 2009 MRI showed occipital lobe CVA and wrote "I anticipate he is having problems with that." In October 2010, the Veteran complained of occasional dizziness. The diagnoses included history of recent CVA with no substantial change and "seizure disorder, possibly related to the above, etiology not totally clear." October 2010 VA treatment records contain a diagnosis of recent onset seizures, etiology unclear. In November 2010, the Veteran indicated that he wanted a second opinion and possible treatment from VA neurology. Treatment records from 2011 indicate that the Veteran's condition was stable with no recurrence of TIA or seizure. An April 2011 private treatment record indicates that the Veteran's condition was stable. The diagnoses included seizure disorder, partial onset with secondary generalization, and dizziness, most likely related to medication. In October 2011, the Veteran reported a five minute episode of transient blindness in the left eye. He was diagnosed with amaurosis fugax. A carotid duplex study was normal. In June 2012, the Veteran complained that he had not had a good sense of smell or taste since his stroke. He also reported balance problems since his stroke. Virtual VA records show that, in July 2012, the Veteran reported a one year history of mild dizziness that he attributed to his antiseizure medication. He also reported the previous episode of transient blindness, which the clinician felt was most likely a TIA. An August 2012 carotid duplex examination suggested mild bilateral carotid disease. An August 2012 EEG was consistent with a focal disturbance of cerebral function in the left temporal area; no seizure tendency was noted. The diagnosis was transient cerebral ischemia. In October 2012, the Veteran reported a history that included an in-service concussion where he was "out" for 2-3 days. He complained of tension-type headaches, dizziness, and blurred vision. It was noted that overall he was doing "about the same" since switching from Aggrenox to aspirin. The clinician noted that "theoretically" the Veteran's seizures could be caused by his in-service head injury, which was a risk factor if the injury was as the Veteran described, although the provider noted that he could not be 100 percent sure. In November 2012, the Veteran reported headaches 2-3 times per week. They occurred in the morning upon wakening and usually lasted 2-3 hours, but occasionally lasted all day. They occurred above the left eye and radiated to the left side of his head. He also reported occasional dizziness and unsteadiness. As instructed by the January 2013 Remand Order, the Veteran submitted to a VA examination in March 2013. He reported that he had sustained an in-service head injury while playing football in Japan. He also reported another problem about a year later while stationed in Korea. The examiner first assessed TBI-related cognitive impairment and conducted neuropsychological testing. The examiner found no subjective symptoms or any mental, physical, or neurological residuals. She noted that the neurological examination was essentially age appropriate, with mild cognitive impairment consistent with microvascular disease. The examiner diagnosed remote traumatic brain injury, mild, without evidence of resultant brain dysfunction structural abnormality or residuals. The date of onset was November 11, 1949. The examiner also diagnosed blast exposure without evidence of brain dysfunction, structural abnormality, or residuals. The date of onset was 1951. The examiner concluded that the 1949 STRs are consistent with "a conversion disorder alone without concurrent minimal to mild brain injury" but gave the Veteran the benefit of the doubt and diagnosed mild traumatic brain injury. She opined, however, that the records "do NOT support a head injury of sufficient magnitude to result in any residual pathology." (Emphasis in original). She explained that "abnormalities on much later (2000) brain imaging are not consistent with the 1949 injury." The examiner next conducted a central nervous system assessment. Speech and strength testing were normal. Gait was slightly wide based due to cerebral vascular disease. She diagnosed cerebral arteriosclerosis and cerebral vascular accident right occipital cortex due to small vessel cerebral atherosclerotic disease. The onset date was 2009. She also diagnosed an alteration in mental status due to a mental health condition. The onset date was September 1950, November 1949, and April 1952. Finally, she diagnosed recurrent alteration in mental status "AKA transient ischemic attack" due to small vessel atherosclerotic disease. The date of onset was February 2009, with numerous recurrences. The examiner opined that "all [neurologic] symptoms noted on this worksheet are attributable to cerebral vascular disease and resultant transient ischemic attacks and prior embolic right occipital stroke." She further opined that "cerebral vascular disease, transient ischemic attacks, and prior stroke all contribute to mild cognitive and functional decline and are as least as likely as not the cause of current seizure and seizure like activity." Next, the examiner evaluated the Veteran's headaches. The Veteran reported constant pain that was localized to the left side of his head. He was unable to remember when the headaches started, just that it had been "years." The examiner diagnosed tension headaches, with no onset date. She also diagnosed "posttraumatic headache RESOLVED without residual," with an onset date of November 1949. The examiner then assessed the Veteran's seizures. The Veteran reported that his seizures had started "over a year ago." The seizures were manifested by convulsions, episodes of unconsciousness, brief interruptions in consciousness or conscious control, episodes of abnormalities of memory, and episodes of impairment of vision. The seizures were controlled with medication. His most recent seizure had occurred in 2011. The examiner diagnosed tonic-clonic seizures or grand mal seizures, with an onset date of October 2010. She also diagnosed alteration of mental status consistent with conversion disorder, with no onset date. She opined that the Veteran had epilepsy associated with a psychotic disorder. She also noted that there were "numerous normal detailed neurological examinations, inpatient observation and psychological evaluations including 6/3/56 [illegible] interview." The examiner concluded that "the psychologically based episodes do not appear to have continued past ~1960s for a period of at least 25 years at which time organic pathology cannot be ruled out and is likely; by the 2009 presentations with altered consciousness/mental status, abnormal imaging supports organic cause." Finally, the examiner conducted a psychiatric evaluation. She diagnosed history of conversion disorder with mixed presentation (resolved). She explained that the STRs note both the presence of past diagnostic criteria and psychiatrist conclusion (6/3/56) of at least one incident of the most likely diagnosis of conversion disorder with sensory, physical symptoms and seizure/fugue like episodes that are not intentionally produced or feigned, are not explained by medical conditions, and that significantly interfere with functioning (i.e., resulted in hospitalization). She noted that this condition was clearly described around the time of the football injury, later related to the lower extremity gunshot wound, and then appears to have resolved. The examiner opined that the more recent seizure like activity/blackouts "are as least as likely as not" a second condition, unrelated to the conversion disorder and due to organic brain pathology. She cited the abnormal central nervous system imaging, objective neurological findings in recent years in the setting of clinical history, and imaging findings that are most consistent with organic pathology and are different and not consistent with prior episodes. There is no evidence that the Veteran's seizures began during or within one year of his active duty military service. Nor is there any evidence of continuity of symptomatology of any seizure disorder. The first evidence of seizures post-service is dated 2010, and the Veteran does not contend otherwise. Thus, the presumptive provisions regarding epilepsy do not apply. See 38 C.F.R. §§ 3.307, 3.309. STRs confirm that the Veteran sustained a head injury in November 1949. Although he was admitted for observation of a possible concussion in September and November 1950, there is no in-service evidence of further symptoms related to the head trauma. In fact, the Veteran went on to serve in combat in Korea, and he received a normal neurological examination upon separation in April 1952. The Board acknowledges that the March 1989 VA examination report indicates a possible nexus between the in-service head injury and the Veteran's headaches, and that the October 2012 VA treatment record indicates a possible nexus between the in-service head injury and the Veteran's seizures. However, the Board affords this evidence less probative value than the March 2013 examination and opinion. When contemplating a medical opinion, the relevant inquiry is whether "the examiner providing the report or opinion is fully cognizant of the claimant's past medical history." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, it is unclear whether the March 1989 VA examiner had access to the claims file. The October 2012 VA physician admittedly based his opinion on the medical history as reported by the Veteran. However, the STRs do not corroborate the Veteran's descriptions of his 1949 in-service injury and treatment thereof. In fact, the March 2013 VA examiner specifically found that the Veteran's reports were inconsistent with his STRs, which clearly document that he was kept in the hospital for six days for observation. The March 2013 VA examiner noted that such observation was "entirely normal." In this respect, the March 2013 opinion that the Veteran's current symptoms are not related to the in-service head injury is highly probative. The physician thoroughly reviewed the pertinent background information and provided a lengthy rationale for her opinion. She concluded that the Veteran's claimed symptoms are not caused by or a result of any event that occurred during his service, to include the identified mild traumatic brain injury and/or the blast exposure. She noted that the 1949 records support a minimal, if any, brain injury. She further noted that afterwards the Veteran was able to fully function in a combat theater and demonstrated no recurrent episodes in controlled settings during treatment for two gunshot wounds. She determined that the 1950 episode "is as least as likely as not" due to a minor physiological disturbance such as dehydration or psychological stress, but is not consistent with seizure activity. The examiner also noted that the Veteran was treated in 1956 for symptoms consistent with conversion disorder that apparently resolved over a relatively short time period. She explained that abnormalities noted on brain imaging in the 2000's are not consistent with the 1949 injury. The examiner diagnosed tension headaches and noted that any posttraumatic headache resolved without residual. She opined that the Veteran's dizziness is likely secondary to vascular disease, diabetes, age, hydration status, and medication. She further opined that his syncope is secondary to cerebral vascular events, and that his memory impairment is at least as likely as not directly due to cerebral vascular disease and its consequences. Finally, she opined that his seizures are "clearly attributable to cerebral vascular disease and its consequences (right occipital stroke and alteration in brain perfusion/blood flow). She acknowledged the October 2012 VA treatment provider's opinion, but stated that the description of the injury given to the provider suggested that the 1949 head injury was severe and that he could not have known that the initial injury was minimal to minor because he did not have access to the STRs. The evidence of record supports the March 2013 opinion. Indeed, the Veteran told the March 1989 VA examiner that he first experienced a blackout spell in 1984 and had experienced headaches "for years." VA treatment records show that he first complained of memory loss in 2009. Further, 2010 private treatment records contain the first mention of dizziness and balance problems. A July 2012 VA treatment record shows that the Veteran reported a one year history of mild dizziness that he attributed to his antiseizure medication. Although it cannot be assumed that the Veteran was not treated for his current symptoms prior to 1989 solely because no records of treatment between 1989 and 2009 are associated with the claims file, the Veteran has not asserted that he received treatment or otherwise had symptoms during that time. See Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005). The Board acknowledges that the Veteran is competent to testify to events that he actually experienced or witnessed, such as incurring a head injury in service. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (holding that a lay witness is competent to testify to that which the witness has actually observed and is within the realm of his personal knowledge). However, while the Veteran's statements have been deemed competent evidence, the Board must also determine whether such evidence is credible. See id. In this respect, as noted by the March 2013 VA examiner, the Veteran's statements regarding the severity of the in-service injury are contradicted by his STRs. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that credibility may be impeached by a showing of inconsistent statements or consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). As a result, the Board finds the Veteran's lay testimony not credible and therefore not competent evidence regarding the incurrence of the head injury during active duty. In certain instances, lay testimony may be competent to establish medical etiology or nexus. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, as residuals of a head injury are not simple questions that can be determined based on mere personal observation by a lay person, the Veteran's lay testimony is not competent to establish medical etiology or nexus. See Jandreau, 492 F.3d at 1376-77; see also Davidson, 581 F.3d at 1316. The question of whether the Veteran currently has residuals of an in-service head injury does not lie within the range of common experience or common knowledge. It is not shown that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical opinion as to residuals of a head injury. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). As the competent and probative evidence of record does not relate any of the Veteran's current symptoms to the in-service head injury, the Board finds that the preponderance of the evidence is against a grant of service connection for residuals of a head injury. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55-56 (1990). ORDER Entitlement to service connection for residuals of a head injury is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs