Citation Nr: 1319160 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 06-28 155 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a cervical spine disability including as secondary to service-connected nerve root irritation of the thoracic spine. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran had active service from June 1970 to June 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This matter was previously remanded by the Board for further development in August 2010, October 2012, and March 2013. A review of the Virtual VA paperless claims processing system reveals additional VA treatment records that were considered by the RO in a January 2013 supplemental statement of the case (SSOC) and a May 2013 Appellate Brief Presentation by the Veteran's representative. FINDING OF FACT The Veteran's degenerative joint disease of the cervical spine with bone spurs and bulging discs first manifested more than one year after active service and is not caused or aggravated by any aspect of service or by service-connected thoracic spine nerve root irritation. CONCLUSION OF LAW The criteria for service connection for a cervical spine disability including as secondary to service-connected nerve root irritation of the thoracic spine are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION 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); 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 must notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Where complete notice is not timely accomplished, an 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); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In August 2004, the RO provided notice that did not meet all the requirements. The notice informed the Veteran of the criteria for service connection on a secondary basis and explained the Veteran's and VA's respective responsibilities to obtain relevant evidence. The notice did not provide the criteria for service connection on a direct basis or explain the method for assigning a rating and effective date. In May 2006, after the initial decision on the claim, the RO provided an additional notice that explained the process for assignment of a rating and effective date. Although adjudicative documents may not substitute for proper notice, the criteria for service connection on a direct basis were provided to the Veteran in a June 2006 statement of the case. In statements in August 2006, February 2013, and April 2013, the Veteran noted that he had been diagnosed and treated in service for a cervical spine nerve root irritation. He contended that it represented the onset of his cervical spine disability. Therefore, the Board concludes that the timing and notice errors are not prejudicial because the Veteran was informed of the method for assigning a rating and effective date and had actual knowledge of the criteria for direct and secondary service connection. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and relevant VA and indentified private medical records have been associated with the claims file. The duty to assist also includes providing a medical examination or obtaining a medical opinion when it is necessary to make a decision on a claim. The Veteran underwent VA examinations in September 2004 and September 2010 with addenda to the latter in November 2012 and March 2013. The results have been included in the claims file. The examinations involved summary of the history from a review of the record and from reports by the Veteran, a thorough clinical examination in compliance with regulations and protocols, and opinions on the etiology of the disability. In a November 2005 notice of disagreement, the Veteran objected to the September 2004 examiner's manner and attitude. In February and March 2013, the Veteran objected to the examiner's lack of response to his lay statements and to the Board's remand instructions. In all correspondence, the Veteran continued to disagree with the opinions. Nevertheless, the Board concludes that the examinations were performed by a qualified physician with appropriate consideration of the history and clinical observations. The Board will address the facts, rationale for the opinion, and compliance with remand instructions below. Therefore, the Board finds that the examinations are adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). The Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. Additionally, the Board issued successive remands because there had not been substantial compliance with its August 2010 and October 2012 remand directives. However, following a review of all examination report addenda, the Board concludes that there has been substantial compliance. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The RO/AMC requested any additional evidence from the Veteran, obtained VA treatment records, and a VA examination as directed. Following the examinations, the Appeals Management Center (AMC) later issued supplemental statements of the case in January 2012 and January 2013 with an appropriate opportunity to respond. The Board finds that the AMC substantially complied with the mandates of its remand. See Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). Therefore, the Board will proceed to review and decide the claim based on the evidence that is of record. The Veteran served as a U.S. Air Force command pilot and intelligence officer. He retired at the rank of Colonel. He contends that his cervical spine disability first manifested in service, or alternatively, was caused or aggravated by service-connected nerve root irritation of the thoracic spine. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In general, service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Absent a diagnosis of a chronic disease as defined in 38 C.F.R. § 3.309(a), service connection may not be awarded based on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis is among those chronic diseases specified in 38 C.F.R. § 3.309(a). Therefore, the theory of continuity of symptomatology is for consideration. Disorders diagnosed after discharge may still be service-connected if all the evidence, including pertinent service records, establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also 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). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). There was an amendment to the provisions of 38 C.F.R. § 3.310 in 2006. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is rated requiring the establishment of a baseline level of disability prior to aggravation and a showing that the secondary condition was not due to the natural progression of a disease. In a September 2010 VA examination, the Veteran reported that he twisted his neck in a parachute jump and "banged his head" on several occasions while piloting an aircraft in turbulence in 1969 while a cadet at the Air Force Academy. He reported intervals of neck pain since that time. In a September 2004 VA examination, the Veteran reported experiencing mid-thoracic spinal pain since 1978 and a diagnosis of thoracic scoliosis in 1980. In a November 2005 notice of disagreement, the Veteran called attention to treatment for neck pain in late May 1985. Service treatment records treatment during the Veteran's service as an Air Force Academy cadet contain records of an entrance physical examination in 1966 and outpatient treatment for a sports injury to the leg in 1969 but are silent for treatment for any neck or cervical spine symptoms. The Veteran underwent a flight physical examination in August 1970 shorting after graduation. The Veteran denied any history of a head injury, arthritis, or back trouble. The examining physician noted no spinal or head abnormalities. The examiner found the Veteran qualified for flight duty. In March 1980, a physician noted the Veteran's report of mid-back pain for the previous two years. An X-ray showed moderate scoliosis centered over the T-7 region, convex to the left, with no bone or joint abnormalities. There was no mention of any neck or cervical spine symptoms. In late May 1985 while assigned to duty at the Air Force Academy, the Veteran sought treatment for intermittent neck muscle spasms on movement. The Veteran reported no history of trauma. A physician noted a full range of motion and no tenderness. A concurrent X-ray showed no pathology to explain the discomfort. The physician diagnosed muscle spasm of unknown etiology and prescribed medication for pain and a physical therapy evaluation. The same day, a physical therapist noted the Veteran's report of neck pain for the previous six days with no previous history of injury. The therapist noted pain on extreme left rotation and tenderness over the C5-6 areas with some muscle tightness. The therapist diagnosed probable facet involvement at C5-6 with secondary nerve root irritation. The therapist performed mobilization techniques and contrast packs. The Veteran did not appear for any follow up therapy. Four days later, the Veteran was examined by another physician who noted a full range of motion and no tenderness. The physician diagnosed cervical strain that had resolved. The Veteran continued to deny any head injury, arthritis, or back pain on flight physical examinations in February 1987 and February 1988. No neck or spinal abnormalities were noted by examiners on these examinations and on additional periodic flight physical examinations in January 1990 and February 1992. From 1991 through 1993, the Veteran underwent examination and treatment for continued mid-back pain with radiating pain from the T10 distribution. An X-ray in February 1992 showed early degenerative changes of the dorsal spine with mild scoliosis. A magnetic resonance image obtained in February 1993 showed no herniated discs. Throughout the series of examinations and treatment encounters, there was no mention of any neck or cervical spine symptoms or chronic disorders. Except for temporary disqualifications for illnesses such as a common cold, the service treatment records showed that the Veteran remained qualified for flight duty for his entire career. In a May 1994 retirement physical examination medical history questionnaire, the Veteran denied any head injury but reported a history of back pain and arthritis. He noted, "...diagnosis 1985, C5-6 nerve irritation..." presumably made by the physical therapist in 1985, but he did not mention the imaging studies, observations, and conclusions of the physicians in 1985 who diagnosed a resolved cervical strain. On examination, there were no neck or spinal abnormalities. In September 1994, the Veteran underwent VA general medical and spinal examinations. The Veteran reported continued mid to lower thoracic spinal pain but made no reports of neck or cervical spinal symptoms. Examiners noted an adequate range of motion of the cervical spine with no neck abnormalities. In May 1995, the RO granted service connection and a 10 percent rating for chronic back problems, rated as nerve root irritation of the thoracic spine with dextroscoliosis. The claims file contains outpatient treatment records from the Veteran's private primary care physician from August 1997 to October 1999. Although the records are only partially legible, the physician noted references to tenderness in the area of C5-6 starting in October 1998. The physician ordered imaging studies but the results, if recorded, are not legible. However, starting in March 1999, the physician diagnosed the Veteran's cervical spine symptoms as somatic or associated with muscle spasms. Outpatient treatment records from another private primary care physician from April 2002 to March 2003 also show observations of neck and back pain and tightness and one notation of treatment with an injection. From August 2003 to August 2004, the Veteran received mechanical traction, massage, and stretching therapy for the cervical and thoracic spine at a VA clinic. An X-ray of the cervical spine in June 2003 showed minimal degenerative joint disease at C5-6 with narrowing of the interspace and irregularity. The attending physical therapist did not comment on any relationship between the thoracic and cervical spine deficits. In June 2004, the Veteran submitted a claim for service connection for a neck condition secondary to the thoracic spine disability. The Veteran noted that he experienced dull pain, muscle spasms, and restricted range of motion of his neck that interfered with driving an automobile. In September 2004, a VA physician noted the Veteran's reports of the history of thoracic scoliosis and spur formations in service. The Veteran did not report the 1985 episode of cervical pain but rather that he had been experiencing neck pain for the previous three years. The physician referred to the June 2003 X-ray that showed mild degenerative disease at C5-6. On examination, range of motion was less than normal with pain on motion. The physician did not comment on the etiology of the disorder but noted that a relationship between the cervical spine and the thoracic spine disorders was speculative, suggesting that the history and clinical indications were insufficient to form an opinion. In March 2005, the RO denied service connection for cervical pain because the record did not show the onset of a chronic cervical spine disability in service or within one year of service and because there was no medical evidence to support the Veteran's contention that the cervical spine disorder was caused or aggravated by the service-connected thoracic spine disability. In a November 2005 notice of disagreement, the Veteran contended that the June 2003 examiner was indifferent and biased, that the standard requiring proof of a relationship between the two spinal disorders was impossible to meet, and therefore that his claim should not be rejected on the basis that a supportive opinion would be speculative. The Veteran also called attention to the 1985 treatment in service as supportive of his claim. The Veteran requested an additional examination. In an August 2006 substantive appeal, the Veteran noted that the 1985 episode occurred after the onset of his thoracic spine disorder and that it could have been the first manifestation of a cervical spine disorder. The Veteran noted that since a relationship between the disorders could not be proven, the application of the regulations regarding reasonable doubt was warranted in favor of allowance of the claim. In August 2010, the Board remanded the claim for further development to afford the Veteran an additional opportunity to submit private medical evidence, obtain current VA treatment records, and an additional VA examination, finding that an unsupported and speculative opinion was not adequate medical nexus evidence. The Board directed the new examiner to review all the service and post-service records and the Veteran's lay statements, provide a current diagnosis, discuss the Veteran's account of chronicity of symptoms since service, and provide an opinion on the onset of the cervical spine disorder and whether it was caused or aggravated by events in service or by the service-connected thoracic spine disorder. In September 2010, the Veteran submitted a statement from a massage therapist who noted that she provided therapy for the Veteran on a weekly basis for the past eight years. She noted that the treatment for muscle tightening, lack of mobility, and pain in the neck was traction, decompression, and mobilization. The therapist noted that the two areas "seemed to be connected" because the therapy on the back caused neck pain and decompression of the thoracic vertebrae improved neck mobility and decreased neck pain. In September 2010, another VA physician noted a review of the claims file and noted the Veteran's report of neck injuries in 1969 as a cadet when he injured his neck in a parachute jump and in turbulence during flight training with intervals of pain since that time. The physician did not note the May 1985 encounter for treatment for neck pain but noted the date of onset of a cervical spine disorder was in 1997. The Veteran reported constant moderate neck pain and stiffness. On examination, the physician noted tenderness on the left side at C5-6 and a reduced range of motion. There was no loss of sensation or function of the upper extremities. The physician referred to the June 2003 X-ray and diagnosed degenerative joint disease at C5-6 with decreased range of motion. The physician concluded that the cervical spine disease was not likely caused or aggravated by events in military service or caused by the service-connected thoracic spine nerve root irritation. The physician did not discuss the reported injury in 1969 or the May 1985 treatment and did not address the September 2010 therapist statement that suggested aggravation of the cervical spine by the thoracic spinal disorder. In November 2010, the Veteran's primary care physician noted that a recent magnetic resonance image of the cervical spine showed arthritis, bone spurs, and two bulging disks. The physician did not comment on the etiology of the disease. In October 2012, the Board remanded the claim to obtain current VA treatment records and an addendum to the September 2010 examination report, preferably from the same physician. The Board directed the physician to review the recent magnetic resonance image report, record of treatment in service, the September 2010 therapist statement, and the Veteran's lay statements, and provide an opinion whether the cervical spine disease was permanently aggravated beyond the normal progression of the disease by the thoracic spine disability. In November 2012, the same VA physician noted another review of the claims file including the treatment encounter in 1985. The physician attached the entire November 2010 magnetic resonance image report with results as described by the private physician. The physician concluded that the cervical spine disorder did not manifest in service, inaccurately stating that there was no treatment in service. The physician noted that the spine was observed to be normal in the May 1994 retirement physical examination but did not comment on the reference to the 1985 treatment in the history questionnaire. The physician noted that there was no secondary relationship between the two spinal diseases but inconsistently also noted that the cervical spine disorder was caused or aggravated by the thoracic spine disability with no explanation or discussion of the therapist's observations. There was no discussion of the Veteran's lay statements or the observations of the massage therapist. In March 2013, the Board again remanded the claim for another addendum opinion to clarify and explain the conclusions and to address all the relevant evidence. Later in March 2013, the same physician noted another review of the claims file including the lay and therapist statements and provided another addendum. Relevant to the issue of direct service connection, the physician explained the reasons for his conclusions. He noted that the Veteran was treated in May 1985 for neck discomfort and diagnosed with cervical strain that had resolved. Although a physical therapist noted a diagnosis of C5-6 nerve root irritation, it was not confirmed by imaging or by the examining physicians. The Veteran had no further treatment in service. Although the Veteran reported the history of the encounter at the time of his retirement physical examination, the examination physician noted no cervical abnormalities or symptoms. The Veteran was next seen for neck pain four years later and diagnosed with degenerative disease nine years after service. Relevant to secondary service connection, the physician concluded that the Veteran's thoracic spine disease does not aggravate the cervical spine disease. He explained the reasons for his conclusion. He noted that thoracic scoliosis and spondylosis does not aggravate proximal vertebral segments and that cervical spondylosis is typically caused by normal aging. The physician concluded that there was no increase in severity in the cervical disease caused by the thoracic disease. In statements in February and March 2013, the Veteran objected to the lack of detailed explanation provided by the physician and contended that the timing of his treatment in service was not probative because injuries can manifest symptoms later in life. The Veteran also noted that both he and his massage therapist observed that when his thoracic spinal compression is stretched that his neck pain and range of motion improves, thus demonstrating that the two disorders are connected. In a May 2013 written brief, the Veteran's representative contended that the single statement that the physician considered the lay and therapist statements did not address the Veteran's continuity of symptoms and lacked the detail to constitute a "discussion" requested by the Board in its remand. The Board concludes that there has been substantial compliance with the instructions in the Board's three remands. The Board acknowledges that multiple requests for the examiner to acknowledge a review of all evidence and provide explanations for the conclusions were required and that each opinion and addendum could have contained greater detail. However, the Board concludes that when read together, the physician indicated that he had reviewed and considered all the medical and lay evidence. Specifically, he addressed the Veteran's reports of injury in 1969, treatment in 1985, an incomplete citation to that treatment in the retirement examination in 1994, and the onset of symptoms in 1998 as reported by the Veteran him to his primary care physicians. Although he did not comment on a continuity of symptoms, the Veteran reported intermittent pain since 1969 on only one occasion. The credibility of this report is outweighed by other reports of no symptoms and no trauma on many other recorded examinations from 1969 to 1998. After a complete review of the file, it is reasonable that the physician would not comment further on a continuity of symptoms. Regarding the Veteran's report of injury, that report also was outweighed by the record of treatment and examination that was addressed by the physician. Regarding the observations of the effect of thoracic therapy on the cervical spine, the physician acknowledged consideration of those observations but also explained that disease at the thoracic vertebral level does not affect proximal vertebrae, thus assigning less medical probative weight to the Veteran's and therapists theories of connection between the two disease sites. Notably, although offered the opportunity, the Veteran has not sought an opinion from his attending private or outpatient VA physicians. The multiple remand requests are regrettable, but the Board concludes that all the lay and medical evidence and theories have been reviewed and examined and that further development would not be productive. The Board concludes that service connection for a cervical spine disability, best diagnosed as degenerative joint disease with bone spurs and bulging discs is not warranted on a direct or secondary basis. In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). 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); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ('[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence'). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan, supra. The evaluation of evidence generally involves a three step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Then, the Board must determine whether the evidence is credible. The Board must make an express credibility finding regarding lay evidence. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Finally, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. The Veteran is competent to report on his observed symptoms and the twisting of his neck in a parachute jump and flight training in 1969. He is also competent to report on the onset and nature of his neck pain and on the improvements received in physical therapy. The Veteran is not competent to diagnose a chronic spinal disability including as residuals of an injury as this requires clinical training and review of imaging studies. His reports of injuries in 1969 are note credible because they are not supported by any immediate treatment and because he denied any residuals on a 1970 flight physical. Moreover, when treated in 1985 and in VA examinations after service, the Veteran denied any neck trauma. The Veteran was examined and qualified for flight duty many times throughout his career without mention of any neck symptoms. It is reasonable that a senior command pilot would seek medical assessment of a potential chronic cervical spine disorder as it would impair flight safety for him and his crew and degrade mission readiness. A diagnosis of a chronic muscle deficit or spinal disease requires medical expertise and imaging studies. The Veteran noted that he was diagnosed by a therapist with C5-6 nerve root irritation in May 1985. Standing alone, that is a report of a contemporary diagnosis. However, the Board assigns much less probative weight to the statement because it is based on an opinion by a physical therapist that was specifically ruled out by a physician after review of a normal imaging study. The military physician diagnosed cervical strain that had resolved. The Board places much greater probative weight on the physician's final diagnosis because of the level of medical training of the physician and his reference to imaging studies. Moreover, the retirement physical examiner acknowledged the Veteran's report of the therapist's opinion but observed no cervical abnormalities and did not diagnose a residual or chronic disorder. After service, the Veteran acknowledged to his private and VA primary care clinicians that the onset of chronic neck pain was not earlier than 1998. Therefore, the Board concludes that the Veteran's reports of the onset of chronic intermittent neck pain in service and after service prior to 1998 are not credible because they are inconsistent with his other statements to military examiners and his post-service primary care clinicians. The Board concludes that the therapist's diagnosis of C5-6 nerve root irritation warrants much less probative weight than the conclusions of the physicians and that the Veteran's May 1985 episode was found to be a resolved muscle strain. Finally, the Board places substantial probative weight on the VA physician's combined September 2010 report and subsequent addenda in which he reviewed the lay and medical evidence and determined for the reasons noted above that the Veteran's current cervical spine disability was not manifested in service or within one year of service or was caused or aggravated by events in service. Therefore direct service connection is not warranted. Regarding secondary service connection, there is evidence both for and against causation or aggravation of the cervical spine disease by the service-connected thoracic nerve root irritation. The Board notes that the Veteran experienced thoracic spine symptoms since the late 1970s and was extensively examined in service from 1991 to 1993 with no cervical spine symptoms. Starting with the onset of neck symptoms in 1998, none of the Veteran's private or VA primary care physicians made clinical references to a relationship between the thoracic and cervical spine disorders. Evidence in support of a "connection" was provided by the Veteran and a massage therapist. The level of medical qualification of the therapist is not indicated in the statement, but the Board will presume some level of training and licensing in the administration of therapeutic procedures. Although the Board acknowledges the Veteran sincere belief that the two disabilities are somehow related, the Board concludes that neither the Veteran nor the therapist have sufficient training in physiology and clinical diagnoses to determine whether a spinal disease causes or aggravates disease in proximate vertebra. The Veteran and the therapist are competent to observe that an unspecified massage or decompression technique in some way relieves symptoms in both areas of the spine at the same time. Neither provided any explanation to support the hypothesis of a physiological connection. The Board places significantly less probative weight on the derived conclusion that stretching the spine with relief of the symptoms of two proximate disabilities necessarily implies physiological causation or aggravation. It shows only that the therapy, however performed, helps both disabilities. The Board places much greater probative weight on the opinion of the VA physician. Although he did not provide a narrative discussion to reject that hypothesis, he did note that he reviewed it, did not offer comments in support of it, and further explained that spinal disease in one vertebral area does not cause or aggravate proximate vertebra. In this case, the Board concludes that the weight of competent and probative evidence is not in equipoise but rather weighs substantially in favor of the conclusion that the Veteran's degenerative joint disease of the cervical spine, bone spurs, and bulging discs was not caused and is not aggravated by his service-connected thoracic spine nerve root irritation. The weight of the credible evidence demonstrates that the Veteran's current degenerative joint disease of the cervical spine with bone spurs and bulging discs first manifested many years after service and is not related to his active service or secondary to service-connected thoracic spine nerve root irritation. As the preponderance of the evidence is against this claim, the "benefit of the doubt" rule is not for application, and the claim must be denied. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a cervical spine disability including as secondary to service-connected nerve root irritation of the thoracic spine is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs