Citation Nr: 1330872 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 08-00 130 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for dizziness, to include as due to an undiagnosed illness. 2. Entitlement to service connection for right hand tremors, to include as due to an undiagnosed illness. 3. Entitlement to service connection for a cervical spine disability, to include as due to an undiagnosed illness. 4. Entitlement to service connection for a bilateral knee disability, to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD M. Riley, Counsel INTRODUCTION The Veteran served on active duty from August 1984 to April 1987 and from November 1990 to June 1991; she served in Saudi Arabia during the Persian Gulf War. This case comes before the Board of Veterans' Appeals (Board) on appeal from October 2006 and July 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In May 2011 and January 2013 the Board remanded the case for further action by the originating agency. The case has now returned to the Board for further appellate action. FINDINGS OF FACT 1. The Veteran's nonspecific episodes of dizziness are associated with service-connected fibromyalgia. 2. The Veteran served in the Southwest Asia theatre of operations and has a current neurological disability manifested by right hand tremors that has not been attributed to a known clinical diagnosis. 3. A cervical spine disability, diagnosed as cervicalgia and levoscoliosis, was first manifested years after active duty service, is not etiologically related to a disease or injury during active duty service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. 4. A bilateral knee disability, diagnosed as degenerative arthritis of the left knee and chondromalacia patella of the right knee, was first manifested years after active duty service, is not etiologically related to a disease or injury during active duty service, and is not a manifestation of an undiagnosed illness or medically unexplained chronic multisymptom illness. CONCLUSIONS OF LAW 1. Service connection for dizziness as a manifestation of fibromyalgia is warranted. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). 2. Service connection for a neurological disability manifested by right hand tremors as a qualifying chronic disability is warranted. 38 U.S.C.A. §§ 1110, 1117, 1131; 38 C.F.R. §§ 3.303, 3.317. 3. A cervical spine disability, diagnosed as cervicalgia and levoscoliosis, was not incurred or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.317. 4. A bilateral knee disability, diagnosed as degenerative arthritis of the left knee and chondromalacia patella of the right knee, was not incurred or aggravated by active duty service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Claims Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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"-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). See also Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007). When a chronic disease is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Id. When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Id. For this purpose, a chronic disease is one listed at 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)(holding that the term "chronic disease in 38 C.F.R. § 3.309(b) is limited to a chronic disease listed at 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, for veteran's who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, such as arthritis, are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). VA is authorized to pay compensation to any Persian Gulf veteran suffering from a "qualifying chronic disability." A "qualifying chronic disability," includes (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B) (West 2002). To obtain service connection for an undiagnosed illness or combination of undiagnosed illnesses, a veteran needs to show (1) that he or she is a Persian Gulf veteran; (2) who exhibits objective indications of chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as those listed in paragraph (b) of 38 C.F.R. § 3.317; (3) that have become manifest either 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 not later than December 31, 2016 and (4) that such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C.A. § 1117 (West 2002); 38 C.F.R. § 3.317(a) (2012). Manifestations of an undiagnosed illness or multisymptom illness include, but are not limited to, fatigue, headache, muscle pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, or abnormal weight loss. 38 C.F.R. § 3.317(b). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period are considered chronic. 38 C.F.R. § 3.317(a)(ii)(4). Dizziness The Veteran contends that service connection is warranted for dizziness as an undiagnosed illness related to her active duty service in the Persian Gulf. After review of the evidence, the Board finds that service connection is warranted for this condition as a manifestation of service-connected fibromyalgia. The Veteran first complained of dizziness in the February 2006 claim for service connection. Upon VA examination in September 2009, she reported experiencing occasional episodes of dizziness several times a year. The ears, nose, and throat (ENT) examiner diagnosed mild nonspecific dizziness that was not described as vertigo. A similar conclusion was reached by the April 2013 VA ENT examiner, who also found that the Veteran's dizziness was not vertigo. The April 2013 examiner concluded that the Veteran's dizziness was most likely associated with her service-connected fibromyalgia and Gulf War exposure. The record therefore contains competent medical evidence of an association between the claimed dizziness and service-connected fibromyalgia. Service connection is warranted for the disability as a manifestation of fibromyalgia. Right Hand Tremors The Board finds that service connection is warranted for the Veteran's claimed right hand tremors as an undiagnosed illness in accordance with 38 C.F.R. § 3.317. Initially, the record establishes the Veteran's active service in the Southwest Asia theater of operations during the Persian Gulf War. Her DD-214 indicates that her Army reserve unit was activated in support of Operation Desert Shield/Desert Storm and she served in Southwest Asia from January 1991 to May 1991. The Veteran also exhibits objective indications of a chronic neurological disability. In June 2006, during a physical examination at the St. James Community Based Outpatient Clinic (CBOC), a mild right hand tremor was noted by the examiner and the Veteran was diagnosed with an essential tremor. Although a MRI of the Veteran's head was normal in February 2006 and the right hand tremor was not observed by any other medical professionals during the claims period, 38 C.F.R. § 3.317 only requires that the record establish objective indications of a chronic disability. Objective indications of a 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)(2)(ii)(3). The Veteran has consistently reported the occurrence of a right hand tremor and neurological signs or symptoms are specifically listed as a manifestation of an undiagnosed illness capable of service connection. 38 C.F.R. § 3.317(b). Thus, the competent lay reports of a right hand tremor and the findings of the Veteran's physician in June 2006 constitute objective indications of a chronic neurological disability. The Board must now determine whether the objective indications became manifest during active military service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. Review of the Veteran's service records shows that her right hand tremor was clearly not manifest during her service in Southwest Asia. Service records are negative for complaints or treatment related to a hand tremor and the Veteran has reported the onset of the condition in 1998 or 1999, several years after her discharge from active duty service. Therefore, the Veteran's claimed undiagnosed illness did not manifest during active military service in the Southwest Asia theater of operations during the Persian Gulf War. Service connection is only possible for the claimed undiagnosed illness if the evidence establishes that it manifested to a degree of 10 percent or more not later than December 31, 2016. The Veteran's complaints of a hand tremor are not specifically listed in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4 (2012). However, for the purposes of determining the appropriate rating for the claimed disability, the Board will use Diagnostic Code 8515, pertaining to paralysis of the median nerve. Under this diagnostic code, a 10 percent evaluation is assigned for mild incomplete paralysis of the median nerve. 38 C.F.R. § 4.114, Diagnostic Code 8515 (2013). The Veteran has consistently complained of an occasional right hand tremor since June 2006. While objective testing, such as a February 2006 brain MRI and 2009 nerve conduction study, did not establish a neurological condition to account for the tremor, a right hand tremor was observed during a physical examination at the VAMC in June 2006. At that time, the examining nurse practitioner specifically characterized the tremor as mild. The Board therefore finds that the Veteran's consistent complaints of an occasional right hand tremor with intentional movement are contemplated by mild incomplete paralysis of the median nerve and a 10 percent evaluation under Diagnostic Code 8515. As the competent medical and lay evidence establishes that the Veteran's claimed disability most nearly approximates the criteria associated with a 10 percent rating under Diagnostic Code 8515, it has manifested to a degree of 10 percent or more not later than December 31, 2016. Finally, the evidence establishes that the symptomatology identified by the Veteran cannot be attributed to any known clinical diagnosis. Her VA Medical Center (VAMC) problem list has only identified the condition as an "essential and other specified forms of tremor." In addition, an April 2013 VA examiner specifically found that the Veteran's essential tremor was not associated with any known clinical diagnosis and was not a manifestation of carpal tunnel syndrome or service-connected fibromyalgia. The competent medical evidence therefore establishes that the Veteran's symptomatology cannot be attributed to any known clinical diagnosis. The criteria for an award of service connection under 38 C.F.R. § 3.317 are all present, and service connection is warranted for the claimed right hand tremor as a neurological disability due to an undiagnosed illness. Cervical Spine The Veteran contends that service connection is warranted for a cervical spine disability as a manifestation of an undiagnosed illness due to her service in Southwest Asia. As a preliminary matter, the Board finds that the record establishes the presence of a current disability. Upon VA examination in October 2009, she was diagnosed with cervicalgia and muscle spasms of the neck. X-rays performed in connection with VA examinations in October 2009 and April 2013 also demonstrated a levoscoliosis curvature of the cervical spine. Therefore, to the extent the Veteran contends that service connection is warranted for a cervical spine disability under 38 C.F.R. § 3.317 for certain disabilities due to an undiagnosed illnesses, the record clearly shows that the Veteran has been diagnosed with cervicalgia and levoscoliosis of the cervical spine. The April 2013 VA examiner specifically found that the Veteran's complaints were due to a known clinical diagnosis, and service connection is not warranted for the claimed disability as due to an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). Although a current disability is demonstrated, the record does not contain competent evidence of an in-service injury. Service treatment records are entirely negative for any complaints or treatment pertaining to the Veteran's neck and her neck was normal upon physical examination in October 1986 and April 1991. She also denied experiencing any painful joints on an April 1991 report of medical history accompanying the separation examination for her second period of active service. The Veteran has also not reported any injuries of the neck that occurred during active service. She has consistently contended that her neck pain is a manifestation of an undiagnosed illness and has never reported the incurrence of a neck injury or trauma during service. In fact, she specifically denied experiencing any such injuries during the April 2013 VA examination. As there is no competent lay or medical evidence of an injury during active service, the second element of service connection is not established. There is also no competent evidence of a nexus between the Veteran's current cervical spine disability and any incident of active duty service. As noted above, service treatment records are negative for any chronic cervical conditions and the Veteran has not reported any neck injuries during service. There is also no evidence of a cervical spine disability until September 2003, more than 10 years after the Veteran's separation from active duty service, when she complained of neck pain and stiffness to a private physician following involvement in a motor vehicle accident. A chronic condition was not diagnosed until several years later, when the July 2006 VA examiner diagnosed cervicalgia. The absence of any clinical evidence for years after service weighs the evidence against a finding that the Veteran's cervical spine disability was present in service or in the years immediately after service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Furthermore, none of the Veteran's treating physicians have linked her neck pain to any incident of active duty service. The only medical opinion of record, that of the April 2013 VA examiner, weighs against the claim. After physically examining the Veteran and reviewing the complete claims file, the April 2013 VA examiner found that the Veteran's disability was not causally related to active duty service and was not a manifestation of service-connected fibromyalgia. The Board has considered the contentions of the Veteran connecting her cervical spine disability to service in Southwest Asia, but as a lay person, she is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent report observable symptoms, but finds that her opinion as to the cause of the symptoms simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). Furthermore, the Veteran has not reported a history of continuing symptoms since service. As noted above, treatment records do not document any complaints of neck pain until September 2003, and the Veteran has consistently reported the onset of cervical spine symptoms several years after her discharge from service. The Board discusses the Veteran's reported symptoms in the context of using lay evidence to prove the nexus element of a service connection claim under 38 C.F.R. § 3.303(a) and (d), but not 38 C.F.R. § 3.303(b). See Davidson, 581 F.3d 1313; Walker, 708 F.3d at 1331. In sum, the competent post-service medical and lay evidence of record shows that the first evidence of the Veteran's claimed disability was many years after her separation from service. In addition, there is no evidence of an in-service injury or competent evidence linking the current cervical spine condition to active duty or an undiagnosed illness. The Board therefore concludes that the evidence is against a nexus between the Veteran's cervical spine disability and any incident of active duty service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107(b) (West 2002). Bilateral Knees The Veteran contends that service connection is warranted for a bilateral knee disability as it was incurred due to active duty service, or in the alternative, developed as an undiagnosed illness due to her service in the Southwest theater of operations during the Persian Gulf War. In an August 2010 notice of disagreement (NOD), the Veteran stated that during her first period of active duty service with the Army she participated in long runs, marches, and hikes. She also reported jumping off the back of many vehicles while serving on active duty service in Saudi Arabia with the Army reserves. The record clearly establishes the presence of a current bilateral knee disability. The Veteran was diagnosed with bilateral chondromalacia patella by a private physician in February 2007. X-rays of the knees were normal except for abnormal positioning of the patellae aligned to the outside. More recently, she was diagnosed with left knee moderate degenerative arthritis and right knee chondromalacia patella by a VA examiner in April 2013. The Board also finds that an in-service injury is demonstrated. Service treatment records are negative for findings of complaints related to the knees and the Veteran's lower extremities were normal during examinations conducted in October 1986 and April 1991. Despite the lack of any medical evidence of chronic knee problems during service, the Veteran has reported physical activity during active duty that could result in injury to the knees. The Veteran is competent to report injuries that occurred during service, and the Board will resolve any doubt in her favor. The Board therefore finds that an in-service injury is established. Regarding the third element of service connection, a nexus between the Veteran's current knee disabilities and the in-service injury, the Board notes that service records do not indicate such a link. As noted above, no chronic knee conditions were identified on physical examinations conducted during the Veteran's two periods of active duty service. The Veteran also specifically denied experiencing a "trick" or locked knee, painful joints, and arthritis on reports of medical history completed in October 1986 and April 1991. There are also no complaints or treatment for knee pain at anytime during the two periods of active service. Service connection is also possible on a presumptive basis for arthritis as a chronic disease under 38 C.F.R. §§ 3.307 and 3.309. However, there is no medical evidence of knee complaints within a year from the Veteran's discharge from service. In fact, the earliest objective evidence of knee pain dates from June 2006, 15 years after the Veteran's separation from active duty, when she complained of bilateral knee pain at the St. James CBOC. A chronic disability was not diagnosed until February 2007, when a private doctor diagnosed bilateral chondromalacia patellae. The absence of any clinical evidence for years after service weighs the evidence against a finding that the Veteran's knee disability was present in service or in the years immediately after service. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Thus, service connection on a presumptive basis as a chronic disease is not warranted. Service connection is also possible for certain chronic disabilities, such as arthritis, under 38 C.F.R. § 3.309(b) based on a continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). While the Veteran has not reported a clear continuity of symptoms, her August 2010 NOD indicates that symptoms may have been present since service and continued to the present day. She specifically reported that her knee condition was not severe at the time of the separation examination in April 1991, but has progressively worsened. The Board interprets this statement as reporting a continuity of symptoms since active duty. Lay statements, such as those made by the Veteran, are considered to be competent evidence when describing the features or symptoms of an injury or illness. Falzone v. Brown, Vet. App. 398 (1995). However, 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")). In this case, the Board finds that the Veteran's reports of continuous knee symptoms since service are not credible. As noted above, service treatment records are entirely negative for findings of a chronic knee disability and the physician that performed the April 1991 separation examination found that the Veteran's lower extremities were normal. This finding from a medical professional is at odds with the Veteran's recent statements. Furthermore, the Veteran's August 2010 report of knee pain during and since service is at odds with the history of the disability she previously presented. During a June 2006 VA examination, the Veteran stated that her knee pain began in 2004, almost 15 years after her discharge from service. Similarly, in a January 2008 statement, the Veteran reported the onset of knee pain only 4-5 years earlier. The Veteran also specifically denied having any joint pain or knee abnormalities on the April 1991 report of medical history that accompanied her military separation examination. Most recently, during the April 2013 VA examination she stated that she could not recall any specifics regarding the onset of her knee symptoms. The objective medical evidence of record is also devoid of any complaints related to the Veteran's knees until 15 years after her discharge from service. The Board finds that the Veteran's history reported in August 2010 for compensation purposes many years after service is not credible in light of the conflicting statements regarding the onset of her knee pain and the complete absence of complaints or treatment for years after service. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (holding that lay statements were not rendered insufficient by the absence of confirming medical evidence, but that the evidence could serve to support a finding that lay statements were not credible). There is also no competent medical evidence in support of the claim. None of the Veteran's treating physicians have linked her current knee conditions to service, and the only medical opinion of record, that of the April 2013 VA examiner, weighs against the claim. After examining the Veteran and reviewing the complete claims file, the April 2013 VA examiner concluded that the Veteran's knee disabilities were less likely as not incurred or caused by active duty service. The examiner observed that service treatment records did not contain evidence that suggested a chronic condition was present during service. Additionally, the Veteran's private physician had attributed her knee problems to an abnormal stance and gait. The Veteran was also unable to clarify the timing and onset of her knee symptoms when asked by the examiner. The Board finds that the April 2013 VA medical opinion was rendered following an accurate review of the facts of the case and was well-supported by a fully reasoned rationale that made specific reference to evidence in the claims file. It is therefore afforded significant probative weight. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board has considered the contentions of the Veteran connecting her knee problems to service, but as a lay person, she is not competent to opine as to medical etiology or render medical opinions. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Grover v. West, 12 Vet. App. 109, 112 (1999). The Board acknowledges that the Veteran is competent report observable symptoms, but finds that her opinion as to the cause of the symptoms simply cannot be accepted as competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1131, 1336 (Fed. Cir. 2006). Finally, to the extent the Veteran contends that service connection is warranted for a bilateral knee disability under 38 C.F.R. § 3.317 for certain disabilities due to undiagnosed illnesses for veterans who served in the Persian Gulf, the record clearly shows that the Veteran has been diagnosed with arthritis and chondromalacia patella. As the Veteran's knee symptoms have been attributed to known clinical diagnoses, service connection is not warranted for the claimed disability as due to an undiagnosed illness. 38 C.F.R. § 3.317(a)(1)(ii). In sum, the post-service medical evidence of record shows that the first evidence of the Veteran's claimed disability was 15 years after her separation from service. In addition, there is no medical evidence that the Veteran's knee conditions are related to active duty or an undiagnosed illness. The Board therefore concludes that the evidence is against a nexus between the Veteran's claimed disability and her active duty service. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107(b) (West 2002). Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)) defined VA's duties to notify and assist a veteran in the substantiation of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA 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; (3) and that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini II), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). With respect to the claims for service connection for dizziness and a right hand tremor, VA has substantially satisfied the duties to notify and assist. To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this appeal given the favorable nature of the Board's decision to grant the claims. Regarding the other claims on appeal, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in March 2006 and April 2010 letters. The Veteran also received notice regarding the disability-rating and effective-date elements of the claims in the April 2010 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice should be given before an initial AOJ decision is issued on a claim. Pelegrini II, 18 Vet. App. at 119-120. While complete VCAA notice, specifically notice of the Dingess elements, was provided after the initial adjudication of some of the claims, this timing deficiency was remedied by the issuance of VCAA notice followed by readjudication of the claims. Mayfield v. Nicholson, 444 F. 3d 1328 (Fed. Cir. 2006). The claims were readjudicated in the May 2013 SSOC. Therefore, any timing deficiency has been remedied. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, records of VA treatment, and private medical records. Additionally, the Veteran was provided proper VA examinations and medical opinions in April 2013. The Board also finds that VA has complied with the May 2011 and January 2013 remand orders of the Board. In response to the Board's remands, the Veteran's complete treatment records from the Columbia VAMC were obtained and associated with the virtual claims file. The Veteran was also mailed a letter in July 2011 asking that she identify all physicians who had treated the disabilities on appeal. She was also notified that she may submit lay statements in support of her claims. Additional VA examinations and medical opinions addressing the nature and etiology of the claimed disabilities were also conducted in April 2013. The case was then readjudicated in a May 2013 supplemental statement of the case (SSOC). Therefore, VA has complied with the remand orders of the Board. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. ORDER Entitlement to service connection for dizziness as a manifestation of service-connected fibromyalgia is granted. Entitlement to service connection for right hand tremors as due to an undiagnosed illness is granted. Entitlement to service connection for a cervical spine disability, to include cervicalgia and levoscoliosis and as due to an undiagnosed illness, is denied. Entitlement to service connection for a bilateral knee disability, to include as due to an undiagnosed illness, is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs