Citation Nr: 1330277 Decision Date: 09/20/13 Archive Date: 09/25/13 DOCKET NO. 10-18 842 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea due to autoimmune disorder associated with Gulf War environmental exposure. 2. Entitlement to service connection for headaches due to autoimmune disorder associated with Gulf War environmental exposure. 3. Entitlement to service connection for shortness of breath due to autoimmune disorder associated with Gulf War environmental exposure. REPRESENTATION Appellant represented by: AMVETS WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from June 1989 to July 1995 and from March 2003 to February 2005. The Veteran's service included service in Southwest Asia. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the VA Regional Office (RO) in Reno, Nevada. In March 2011, the Veteran testified at a hearing conducted before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. The case was remanded in February 2012 to obtain additional treatment records, Social Security Administration (SSA) records and afford him VA examinations. Although the Veteran did not report for scheduled examinations, VA medical opinions were obtained. Therefore, review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. Obstructive sleep apnea was not present during service and the currently diagnosed obstructive sleep apnea did not develop as a result of any incident during service, including the service-connected autoimmune disorder associated with Gulf War environmental exposure. 2. The Veteran has headaches that are as likely as not caused by his service-connected herniated disc C6-C7. 3. Shortness of breath was not present during service and a currently diagnosed respiratory disorder did not develop as a result of any incident during service, including the service-connected autoimmune disorder associated with Gulf War environmental exposure. CONCLUSIONS OF LAW 1. Obstructive sleep apnea was not incurred or aggravated in service and is not proximately due to or the result of the service-connected autoimmune disorder associated with Gulf War environmental exposure. 38 U.S.C.A. §§ 1101, 1101, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317 (2013). 2. The criteria for service connection for headaches have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2013). 3. Shortness of breath was not incurred or aggravated in service and is not proximately due to or the result of the service-connected autoimmune disorder associated with Gulf War environmental exposure. 38 U.S.C.A. §§ 1101, 1101, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310, 3.317 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a) (2013). 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 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. Such 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). In light of the fully favorable determination as to the issue of service connection for headaches, no discussion of compliance with VA's duty to notify and assist is necessary. As for the other issues, the Veteran was notified in letters dated in April 2009 and January 2011 regarding the type of evidence necessary to establish his claims. He was instructed how to establish service connection. The Veteran was notified of 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 letters notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs), post-service medical records, SSA records and also secured examinations and opinions in furtherance of his claims. A pertinent VA examination was obtained in March 2010; a VA opinion was obtained in April 2013. 38 C.F.R. § 3.159(c)(4). The VA examination and opinion obtained in this case are sufficient, as the March 2010 examiner conducted a complete examination and recorded all findings considered relevant under the applicable law and regulations; both examiners reviewed the evidence and offered well supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. II. Analysis 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. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, 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 (Fed. Cir. 2004). Service connection may also be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more. 38 U.S.C.A. § 1117 (West 2002 & Supp. 2012); 38 C.F.R. § 3.317 (2013). For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Further, lay persons are competent to report objective signs of illness. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2). There are currently no diagnosed illnesses that have been determined by the Secretary to warrant a presumption of service connection under 38 C.F.R. § 3.317(a)(2)(C). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). Additionally, presumptive service connection is warranted with the manifestation of the following infectious diseases: (i) brucellosis, (ii) campylobacter jejuni, (iii) Coxiella burnetii (Q fever), (iv) malaria, (v) mycobacterium tuberculosis, (vi) nontyphoid salmonella, (vii) shigella, (viii) visceral leishmaniasis, and (ix) West Nile virus. 38 C.F.R. § 3.317(c). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Lastly, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(c). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Furthermore, any disability that is proximately due to or the result of a service-connected disease or injury is considered service connected, and when thus established, this secondary condition is considered a part of the original condition. 38 C.F.R. § 3.310(a). Additionally, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). 1. Obstructive Sleep Apnea A review of the Veteran's STRs shows no treatment for, or diagnosis of, obstructive sleep apnea or any other sleep disorder. Examinations in January 1985, September 1988 and December 1991 all revealed clinically normal lungs and chest. Reports of medical histories for those examinations all show that the Veteran denied symptoms such as frequent trouble sleeping. Chest X-rays in January 1985 were within normal limits while X-rays in January 1992 were normal. A January 1992 treatment record for allergic rhinitis shows that the Veteran had some obstructive symptoms. The Veteran denied pulmonary symptoms in January 1994. An examination in January 1995 revealed clinically normal lungs and chest. Chest X-rays in February 1995 following a complaint of increased shortness were read to say "may represent pneumonia." Examinations in May 1997 and May 1998 again revealed clinically normal lungs and chest. Reports of medical histories in May 1996, May 1997, May 1998, May 1999 and June 2000 all show that the Veteran denied symptoms such as frequent trouble sleeping. Post-deployment health assessments dated in November 2003 and February 2004 both show that the Veteran denied still feeling tired after sleeping. There is no indication in his STRs that he snored in service or that he sought treatment for any symptoms associated with obstructive sleep apnea. According to post-service treatment records, the first indication of obstructive sleep apnea was in October 2008 when the Veteran requested a sleep study consultation after his roommate stated that he was having periods of apnea. A record dated in December 2008 shows that the Veteran was found to have obstructive sleep apnea symptoms. A sleep study in March 2009 confirmed a diagnosis of obstructive sleep apnea; no opinion regarding the etiology was provided. The Veteran was afforded a VA examination in March 2010. He reported that although the March 2009 sleep study diagnosed obstructive sleep apnea, he believed that it was actually central sleep apnea and that since the service-connected autoimmune labyrinthitis was a central condition, the sleep apnea was all part of that. The Veteran stated that although some records state he complained of snoring, he did not really have a snoring problem although his partner told him that he "gurgles sometimes." The Veteran stated that he had multiple ENT evaluations and that no one ever said he had any evidence of obstruction and his body habitus was thin, he did not have a short neck or any of the other usual findings in someone with obstructive sleep apnea. He reported that his fatigue began at the end of 2004. The Veteran reported that he now knew he had undiagnosed sleep apnea in 2005 and that in early 2005, he was gurgling and waking up at night short of breath. Following examination, he was diagnosed with obstructive sleep apnea. The examiner opined that the Veteran's sleep apnea was not caused by or a result of an autoimmune disease caused by environmental Gulf War exposure. The rationale was that the Veteran's sleep study did not show evidence of central sleep apnea. Obstructive sleep apnea that was successfully treated by CPAP was a problem with superfluous tissues in the back of the throat that caused obstruction when a patient was supine and was not related to any type of autoimmune disorder. The examiner's opinion cited a medical treatise related to central sleep apnea. According to that treatise, recurrent central sleep apnea was most commonly found in the presence of cardiac failure or neurologic disease, especially stroke. Spontaneous central sleep apnea was rare and could be classified on the basis of the arterial PCO2. Hypercapnic central sleep apnea occurred in conjunction with diminished ventilatory drive in Ondine's curse. Patients with normocapnic spontaneous central sleep apnea have a normal or low arterial PCO2 when awake, with brisk ventilator responses to hypercapnia. Patients may present with sleep maintenance insomnia, which was relatively unusual in obstructive sleep apnea. Daytime sleepiness may occur. Many apneas previously labeled central because of absent thoracoabdominal movement were actually obstructive. Central sleep apnea can only be identified with certainty if either esophageal pressure or respiratory muscle electromyography is recorded and shown to be absent during the events. At his March 2011 hearing, the Veteran testified that his sleep apnea was due to his service-connected chronic fatigue syndrome. March 2011 Hearing Transcript (T.) at 5. He testified that sleep apnea was a combination of anatomy and physiology in that it was dependent on how deeply you sleep. Id. at 8. The Veteran testified that due to his chronic fatigue syndrome, he deeply slept, which in turn caused the sleep apnea. Id. at 9. The Veteran testified that he "definitely" had obstructive sleep apnea. Id. The Veteran also testified that he was a medical doctor who did a residency in family practice. Id. at 6, 13. A VA medical opinion from a pulmonologist was obtained in April 2013. After reviewing all of the Veteran's records, in response to whether the Veteran's obstructive sleep apnea was related to or had its onset in service, the examiner opined that the Veteran's obstructive sleep apnea appeared to have started at a later date and they did not see any connection to service at that time. Sleep apnea syndrome was an obstructive type and not central, as reported in the sleep study. Obstructive sleep apnea syndrome was most likely caused by the noted large tongue and elongated uvula, as well as the weakening of the upper airway muscles, which often occurred, leading to that syndrome. The examiner also opined that there was no supportive literature that obstructive sleep apnea was commonly caused by autoimmune disease or chronic fatigue syndrome. Based on a review of the evidence, the Board concludes that service connection for obstructive sleep apnea is not warranted on both direct and secondary bases. Although the Veteran is currently diagnosed with obstructive sleep apnea, the pertinent evidence of record fails to show that it is related to his military service. Initially, the evidence does not support a finding that it is directly related to service. As the Veteran had service in Southwest Asia during the Persian Gulf War, the Board concedes environmental exposures as an in-service injury to his pulmonary system in service. However, even with such injury, the evidence fails to show that the Veteran's obstructive sleep apnea is directly related to such exposures or had its onset in service. As noted above, the March 2010 VA examiner opined that obstructive sleep apnea successfully treated by CPAP was a problem with superfluous tissues in the back of the throat that caused obstruction. Additionally, the April 2013 pulmonologist opined that obstructive sleep apnea syndrome was most likely caused by the noted large tongue and elongated uvula, as well as the weakening of the upper airway muscles. These opinions weigh against a finding that any in-service environmental exposures caused the Veteran's currently diagnosed obstructive sleep apnea. In this case, the evidence of record does not show that the Veteran's obstructive sleep apnea is due to a specific injury to his pulmonary system such as in-service environmental exposures. The Veteran's contentions during this appeal indicate that he believes that his obstructive sleep apnea is due to service-connected disabilities resulting from such exposures, as opposed to the obstructive sleep apnea itself being directly caused by those exposures. Furthermore, the evidence does not show that the obstructive sleep apnea had its onset during the Veteran's military service. Although the Veteran reported having undiagnosed sleep apnea in 2005 at the March 2010 VA examination, the first indication of obstructive sleep apnea was in October 2008, over three years after the Veteran was discharged from his second period of active duty in February 2005. At his March 2011 hearing, the Veteran specifically contended that his obstructive sleep apnea was due to his service-connected chronic fatigue syndrome as opposed to being directly related to his service. T. at 5. In this case, the April 2013 pulmonologist opined that the Veteran's obstructive sleep apnea was not directly related to his service. That opinion is premised upon a full review of the Veteran's records. None of the Veteran's STRs shows any complaints of symptoms that have been found to be associated with obstructive sleep apnea, weighing against a finding that the Veteran's obstructive sleep apnea had its onset in service. Moreover, his post-service treatment records do not contain opinions relating such disorder to the Veteran's military service. The Veteran's pertinent records for his obstructive sleep apnea do not show that he reported that its onset was in service. As noted above, the Veteran did not report symptoms associated with sleep apnea until 2008; at that time, he did not report having symptoms during his military service. Absent evidence supporting a finding that the Veteran's obstructive sleep apnea is due to in-service environment exposures or that it had its onset during his military service, the Board concludes that service connection on a direct basis is not warranted. The evidence also fails to support a finding that service connection on a secondary basis is warranted. The Veteran has both contended that it is due to an autoimmune disability as well as being due to chronic fatigue syndrome. Regarding being secondary to an autoimmune disability, the Veteran is currently service connected for an undiagnosed illness manifested by disequilibrium, which the March 2010 examiner characterized as autoimmune labyrinthitis. It was the examiner's opinion that obstructive sleep apnea was not caused by or a result of autoimmune disease. This opinion was premised upon an interview with, and examination of, the Veteran, as well as a review of the Veteran's records and medical literature. None of the Veteran's treatment records contain any opinion relating the Veteran's obstructive sleep apnea to a service-connected autoimmune disease. The pertinent medical evidence of record fails to support such conclusion. In finding that the medical evidence of record does not support a nexus between the Veteran's obstructive sleep apnea and a service-connected autoimmune disease, the Board acknowledges that the Veteran is a physician with experience in family practice. As such, the Veteran is competent to provide medical opinions. However, the Board finds that the Veteran's assertions are not as probative as that of the March 2010 VA examiner. In this case, the VA examiner provided information regarding the causation of obstructive sleep apnea. As already noted above, the examiner opined that obstructive sleep apnea successfully treated by CPAP was a problem with superfluous tissues in the back of the throat that caused obstruction, weighing against a finding that it is caused by autoimmune disease. The Veteran himself has not addressed the medical literature regarding the causation of obstructive sleep apnea. Furthermore, the Veteran's contentions at the March 2010 examination indicate that he believed there was a secondary relationship due to him having what he believed to be central sleep apnea. At that examination, the Veteran contended that since the service-connected autoimmune labyrinthitis was a central condition, the sleep apnea was all part of that. However, the March 2010 VA examiner indicated that the Veteran had obstructive sleep apnea, which is supported by the March 2009 sleep study. Furthermore, at his hearing, the Veteran affirmatively testified that he had obstructive sleep apnea. As such, the Board concludes that the evidence does not support a finding that the Veteran's obstructive sleep apnea is related to the autoimmune labyrinthitis. The evidence also fails to show that the obstructive sleep apnea is secondary to the service-connected chronic fatigue syndrome. The April 2013 pulmonologist, after reviewing the evidence, opined that there was no supportive literature that obstructive sleep apnea was commonly caused by autoimmune disease or chronic fatigue syndrome. The examiner's opinion that obstructive sleep apnea syndrome was most likely caused by the noted large tongue and elongated uvula, as well as the weakening of the upper airway muscles also weighs against a finding that it is due to chronic fatigue syndrome. None of the Veteran's treatment records indicate a causal relationship between the service-connected chronic fatigue syndrome and the obstructive sleep apnea. The Board acknowledges the Veteran's competent opinion that his obstructive sleep apnea is due to chronic fatigue syndrome as he slept deeply due to his chronic fatigue syndrome and that obstructive sleep apnea was related to how deeply one sleeps. However, the Board finds this opinion less probative than that of the April 2013 pulmonologist. The Veteran did not provide any support for this assertion. While he does have clinical experience as a physician, he is not a pulmonologist like the provider of the April 2013 opinion. Whereas the April 2013 pulmonologist indicated reviewing medical literature, the Veteran did not provide such support for his opinion. As such, the Board finds that the April 2013 opinion has greater probative value. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Therefore, the Board concludes that the evidence does not support a finding that the Veteran's obstructive sleep apnea is caused by his service-connected chronic fatigue syndrome. The evidence also fails to show that the Veteran's service-connected autoimmune disability and chronic fatigue syndrome aggravate his obstructive sleep apnea. The Veteran has not provided any statements indicating how a service-connected disability has permanently worsened the obstructive sleep apnea. As a physician, the fact that the Veteran has not made such contentions weighs against a finding of aggravation. Furthermore, no other medical professional has provided any such opinion. There is no indication in the Veteran's pertinent treatment records and examinations that a service-connected disability aggravates the obstructive sleep apnea. As such, the Board finds that secondary service connection due to aggravation is not warranted. Without evidence of the onset of obstructive sleep apnea in service, or competent evidence of an association between obstructive sleep apnea and the Veteran's active duty, to include a service-connected disability, service connection for obstructive sleep apnea is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for obstructive sleep apnea due to autoimmune disorder associated with Gulf War environmental exposure. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for obstructive sleep apnea due to autoimmune disorder associated with Gulf War environmental exposure on both direct and secondary bases is denied. See 38 U.S.C.A §5107 (West 2002 & Supp. 2012). 2. Headaches The Veteran's STRs show that he complained of increased frontal headaches in December 1990; he was diagnosed with sinusitis. There is no indication that he had treatment for, or diagnosis of, a chronic headache disorder. Examinations throughout his service revealed a clinically normal neurologic system. Post-service treatment records also do not show treatment for, or diagnosis of, a chronic headache disorder. However, at his hearing, the Veteran testified having problems with headaches that began after his service. T. at 7. The Veteran is both competent and credible to report having headaches, especially as he is a physician. A VA medical opinion was obtained from a neurologist in May 2013. After reviewing the claims file, the examiner opined the Veteran's headaches were as likely as not related to service-connected cervical spine disease or sleep apnea. Based on a review of the evidence, the Board concludes that service connection for headaches is warranted. The evidence shows that the Veteran currently experiences headaches. The evidence also supports a finding that the Veteran's headaches are due to a service-connected disability. After reviewing the evidence, the May 2013 neurologist opined that the Veteran's headaches are due to his service-connected cervical spine disability. As this opinion was premised upon a review of the pertinent evidence, the Board accords it great probative value. As such, the evidence supports a finding that the Veteran's headaches are secondary to his service-connected cervical spine disability of a herniated disc at C6-C7. Thus, after considering all of the evidence of record, the Board concludes that a finding of service connection is warranted. Service connection for headaches as secondary to the service-connected herniated disc at C6-C7 is, therefore, granted. See 38 U.S.C.A §5107. 3. Shortness of Breath The Veteran contends that he has shortness of breath that is due to autoimmune disorder associated with Gulf War environmental exposure. Specifically, he contends that his shortness of breath is associated with his obstructive sleep apnea. T. at 12. For the reasons set forth above, the Board concludes that obstructive sleep apnea is not related to the Veteran's military service. Therefore, the Board will focus on whether the Veteran has a separate disorder manifested by shortness of breath for which service connection can be granted. A review of the Veteran's STRs shows that examinations in January 1985, September 1988 and December 1991 all revealed clinically normal lungs and chest. Chest X-rays in January 1992 were normal and a spirometry test was also normal. Reports of medical histories for those examinations all show that the Veteran denied symptoms such as shortness of breath. The Veteran denied pulmonary symptoms in January 1994. An examination in January 1995 revealed clinically normal lungs and chest. Chest X-rays in February 1995 following a complaint of increased shortness were opined to read "may represent pneumonia." Examinations in May 1997 and May 1998 again revealed clinically normal lungs and chest. Reports of medical histories in May 1996, May 1997, May 1998, May 1999 and June 2000 all show that the Veteran denied symptoms such as shortness of breath. Post-deployment health assessments dated in November 2003 and February 2004 both show that the Veteran denied difficulty breathing. There is no indication in his STRs that he experienced chronic shortness of breath in service or that he sought treatment for any respiratory disorder in service. According to post-service medical records, the Veteran has not been treated for shortness of breath or any respiratory disorders. His lungs were shown to be clear in early August 2007. Chest X-rays in later August 2007 revealed left lung pneumonia; subsequent X-rays the next day showed probable pulmonary edema had improved. Chest X-rays in May 2008 showed no evidence of acute cardiopulmonary disease. A June 2008 VA examination report specifically showed that there was no pulmonary disease. His lungs were clear to auscultation and there were no rales or rhonchi and no wheezing in September 2008. Chest X-rays in July 2009 showed that the Veteran's lungs remained clear. He reported having no breathing difficulties in September 2009. Chest X-rays in March 2010 revealed early chronic obstructive pulmonary disease (COPD). At the March 2010 VA examination, the examiner noted that the Veteran was a smoker and had some evidence of emphysema on chest X-rays, but denied symptoms related to that. He reported that his claim of shortness of breath was secondary to the sleep apnea. Following examination, the Veteran was diagnosed with sleep apnea with occasional awakening with feeling of shortness of breath. The examiner opined that the Veteran's shortness of breath was not caused by or a result of an autoimmune disease caused by environmental Gulf War exposure. The examiner noted that the Veteran's claim was secondary to sleep apnea; since sleep apnea was not caused by Gulf War exposures, neither was the shortness of breath. The April 2013 pulmonologist opined that they did not have any supportive literature that shortness of breath was commonly caused by autoimmune disease or chronic fatigue syndrome. They also opined that there was no evidence of emphysema through a chest X-ray, although there has been a reported history of tobacco use. They could not find any CT scan of the chest or pulmonary function testing in the medical records to ascertain for a separate disability. It was their opinion that the Veteran had shortness of breath, which could be due to clinical emphysema or COPD, but was not due to treated obstructive sleep apnea syndrome at that time. Based on a review of the evidence, the Board concludes that service connection for shortness of breath is not warranted. To the extent that the Veteran contends that his shortness of breath is a symptom of his obstructive sleep apnea, as service connection for that disorder has been denied, the Board will not address those contentions any further. In this case, the evidence suggests that the Veteran may have shortness of breath associated with emphysema and/or COPD. The evidence does not show, nor does the Veteran contend, that emphysema and/or COPD are due to his military service on any basis. The Veteran's STRs show one instance of a complaint of shortness of breath in 1992; it was thought to represent pneumonia. Despite that, the Veteran's examinations throughout service showed clinically normal lungs and chest. The Veteran also repeatedly denied shortness of breath in service. The Veteran's STRs fail to show that the onset of emphysema, COPD or any other respiratory disorder occurred during service. No medical professional has provided such opinion. Furthermore, post-service records, with the exception of left lung pneumonia in 2007, repeatedly show that chest X-rays were normal until March 2010. The first indication of emphysema was at the March 2010 VA examination, while chest X-rays also in March 2010 reveal the first indication of COPD. The fact that diagnostic tests prior to March 2010 fail to show either emphysema or COPD supports the Board's conclusion that those disorders did not have their onset in service. The evidence also fails to show that they are directly related to an in-service event, injury or disease. While the Veteran's environmental exposures in service have been conceded, no medical professional has opined, nor has the Veteran contended, that emphysema and/or COPD are due to such exposures. As such, the evidence fails to support a finding that emphysema and/or COPD are due to the Veteran's military service. In this case, the competent evidence fails to show that the Veteran has emphysema and/or COPD that are related to his military service. No medical professional, to include the Veteran, has provided any opinion indicating that those disorders are directly related to his military service. There are also no opinions, to include those from the Veteran, that such disorders are secondary to any service-connected disability. Therefore, based on a review of the evidence, the Board concludes that service connection for shortness of breath is not warranted. Without evidence of the onset of a disability other than obstructive sleep apnea manifested by shortness of breath in service, or competent evidence of an association between a disability other than obstructive sleep apnea manifested by shortness of breath and the Veteran's active duty, to include a service-connected disability, service connection for shortness of breath is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for shortness of breath due to autoimmune disorder associated with Gulf War environmental exposure. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for shortness of breath due to autoimmune disorder associated with Gulf War environmental exposure is denied. See 38 U.S.C.A §5107. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for obstructive sleep apnea due to autoimmune disorder associated with Gulf War environmental exposure is denied. Entitlement to service connection for headaches as secondary to the service-connected herniated disc C6-C7 is granted. Entitlement to service connection for shortness of breath due to autoimmune disorder associated with Gulf War environmental exposure is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs