Citation Nr: 1326325 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 07-25 824 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for Parkinson's disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from June 1972 to July 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for Parkinson's disease. The Veteran timely appealed that decision. This case was last before the Board in March 2011, when it was remanded for further development. That development having been completed, the case was returned to the Board in May 2013, when the Board sought a Veterans Health Administration (VHA) opinion clarification. Such was obtained in July 2013, and has been associated with the claims file. The case is again before the Board at this time. FINDING OF FACT Resolving all doubt in the Veteran's favor, Parkinson's disease began during the Veteran's period of military service. CONCLUSION OF LAW By resolving doubt in the Veteran's favor, the criteria establishing service connection for Parkinson's disease have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§3.102, 3.303 (2012).l REASONS AND BASES FOR FINDING AND CONCLUSION As provided for by the Veterans Claims Assistance Act of 2000 (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. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In light of the favorable decision, discussed below, as to the issue of service connection for Parkinson's, no further discussion as to VCAA is required at this time. This decision represents a fully favorable grant of benefits sought on appeal. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). The Veteran's service treatment records do not reflect any treatment for or diagnosis of Parkinson's disease. Physical examination at service discharge revealed normal neurologic and psychiatric systems. On his Report of Medical History, the Veteran denied having or having had neuritis, paralysis, epileptic seizures or fits, frequent trouble sleeping and/or nervous trouble of any sort. A February 2001 private medical record shows that the Veteran was found to have idiopathic tremor. A September 2001 private medical record from Dr. T.Z., M.D. shows that the Veteran gave a history of right hand tremor, with action, stiffness and slowness with an onset about a year and a half prior. He was subsequently diagnosed with depression and placed on medication. He was diagnosed with probable Parkinson's disease, although he did not exhibit tremor at the examination. A July 2002 letter from this private provider shows that they had done an extensive work up on the Veteran for idiopathic Parkinsonism, but that he had not responded to medication. She opined that it was possible that he had an atypical Parkinsonism. A December 2002 private medical record from Pearlmutter Health Center shows that the Veteran reported that "some four years ago" he noted some tremulousness in his right hand. It became more obvious two years prior, and he had been diagnosed with Parkinson's 16 months prior. An October 2003 private medical record from Shands Healthcare shows that the Veteran reported that his symptoms of a masked face, decreased arm swing and depression began in 1997 and 1998. A February 2006 private medical record from Pearlmutter Health Center shows that the Veteran reported in December 2002 that he had tremors in his right hand about 4 years prior, which would have been in 1998. The private physician opined that, within a reasonable degree of medical certainty, the Veteran had Parkinson's as of June 1999, since he reported symptoms referable to his Parkinson's disease during the year prior to 1999. A February 2006 letter from a fellow service member shows that he had observed mannerisms of the Veteran, including slow hand motions and routine actions such as getting out of a chair, in 1990 and again in 1993, while serving with the Veteran. A March 2006 statement from the Veteran's wife reflects her observations that in 1990, he began complaining about buttoning his shirts, and that, by the 1997-1998 timeframe, she noticed that he had no facial expressions and that his actions, such as walking, became robotic. A January 2007 private medical records from Dr. G.N., M.D. show that the Veteran was initially diagnosed with Parkinson's in 2001, and that it began with tremors in both hands, which progressively worsened. A June 2011 letter from a private physician, Dr. H.S.P., D.O., F.A.C.N., shows that he had been treating the Veteran since 2005 for idiopathic Parkinson's disease. The Veteran had reported having tremors and weakness for three to five years before Parkinson's was diagnosed. The private physician noted that it was not uncommon for patients with neurological disorders like Parkinson's to have symptoms for a few years before a diagnosis could be made definitively. A July 2011 letter from a private physician, Dr. M.S.O., M.D., shows that he had been following the Veteran in the movement disorders clinic since 2003, and that he had been diagnosed in June 2001. He noted that, typically, patients with Parkinson's could have the disease from months to a few years prior to diagnosis. The Veteran was afforded a VA examination in August 2011. The examiner noted that, while the Veteran reported that he was diagnosed in 2001, he believed the onset of his disease was 1996. The Veteran stated that he manifested some of the symptoms of Parkinson's while in the service, including restless leg syndrome, lack of facial expression, and difficulty with fine motor skills. The examiner concluded that, based on a review of all medical records available, history and examination, she could not resolve the issue without resort to mere speculation. Based on the above evidence, the Board determined that it was necessary to obtain a VHA opinion to clarify the August 2011 VA examiner's opinion. In July 2013, the VHA examiner opined the following: I am a Movement Disorders Neurologist, and I have reviewed the key clinical aspects of this case. After my review, I feel that there is at least a 50 percent probability that the [Veteran]'s Parkinson's disease had its clinical onset within the first post-service year or earlier. This is based primarily on the multiple documents from various physicians of onset of his symptoms that when backdated would put the onset of symptoms in 1998 or 1999. Though the multiple reports are not all totally in agreement on date of onset, and there are no documents from the dates of reported onset documenting his symptoms, this is actually extraordinarily common with Parkinson's disease. The onset is insidious, and symptoms like tremor can be extremely intermittent at first, which makes pinning down an exact date of onset extremely difficult. However given the multiple sources citing an estimated onset in 1998 or 1999, I find the patient's claim reasonable. Additionally, we know now that the brain changes leading to Parkinson's disease actually begin up to 10 years prior to the clinical onset of symptoms, which also supports that there is greater than 50 percent probability that the onset was within the first post-service year or earlier. Resolving all doubt in the Veteran's favor, the Board finds that service connection for Parkinson's disease is warranted in this case. The Board bases this finding on the competent and credible statements of the Veteran, his spouse and his friend, which demonstrate onset of symptomatology during military service. The Board further notes that those competent and credible findings have been found by numerous physicians, including the VHA examiner who was a Movement Disorders Neurologist, as initial manifestations of the Veteran's Parkinson's disease during his period of service. While the Veteran did not report and there is no documentation of symptoms in the service treatment records, the VHA examiner specifically acknowledged that this was indeed exceedingly common in Parkinson's disease cases. He further noted that the initial brain changes associated with Parkinson's disease can occur up to 10 years prior to the manifestations of clinical symptomatology in order to properly diagnose a Parkinson's patient-such a 10-year latency period would clearly place the initial stages of Parkinson's disease in the Veteran as beginning during his period of service. Accordingly, the Board finds that by resolving doubt in the Veteran's favor, a finding that the Veteran's Parkinson's disease began during service is warranted in this case. See 38 C.F.R. §§ 3.102, 3.303. In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for Parkinson's disease is granted. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs