Citation Nr: 1334740 Decision Date: 10/30/13 Archive Date: 11/06/13 DOCKET NO. 07-07 977 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include chronic anxiety reaction with psychological gastrointestinal complaints (stomach disability), headaches, and wrist nerve damage. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from July 1962 to July 1966. This matter has come before the Board of Veterans' Appeals (Board) on appeal from a February 2005 letter determination, as well as from rating decisions dated in December 2007 and November 2008 issued by the New Orleans, Louisiana, Department of Veterans Affairs (VA) Regional Office (RO). The matter was remanded in November 2011 and April 2013. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in August 2011. A transcript of the hearing is associated with the claims file. During the hearing, he submitted additional evidence with a waiver of initial RO consideration. See 38 C.F.R. § 20.1304. FINDING OF FACT An alleged traumatic brain injury (TBI), to include chronic anxiety reaction with psychological gastrointestinal complaints (stomach disability), headaches, and wrist nerve damage was not manifested during the Veteran's active duty service, nor is it otherwise related to service. CONCLUSION OF LAW The criteria for an award of service connection for an alleged traumatic brain injury (TBI), to include chronic anxiety reaction with psychological gastrointestinal complaints (stomach disability), headaches, and wrist nerve damage have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such 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); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, the Veteran was sent a letter in October 2012 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. The Board acknowledges that, in the present case, complete notice was not issued prior to the adverse determination on appeal. However, fully compliant notice was issued in an October 2012 communication, and the claim was thereafter readjudicated in supplemental statements of the case dated December 2012 and September 2013. Accordingly, any timing deficiency has here been appropriately cured. Mayfield, 444 F.3d 1328 (Fed. Cir. 2006). Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at an August 2011 before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. Moreover, at the hearing, the undersigned asked questions designed to provide information necessary to substantiate the claim, and to identify any outstanding evidence. Bryant v. Shinseki, 23 Vet. App. 488 (2010). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection The issue before the Board involves a claim of entitlement to service connection. Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also 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). At the August 2011 Board hearing, the Veteran testified that in June 1966 (one month before being discharged from service) he was thrown off his bike and he fell to the ground. He testified that did not completely black out, but he was confused and remained on the ground for a long time. He described it as a "pretty traumatic" accident. He recently learned that stomach problems, headaches, nerve damage, and anxiety can be symptoms of a TBI. He noted that he had filed claims for all these symptoms in the past, but that he did not realize that they were symptoms of a TBI at the time he experienced them. Nor did the VA assist him in filing a claim for service connection for a TBI. The Veteran acknowledged that his separation examination made no mention of his bike accident. He reportedly told the examiner that he had headaches, and that the examiner wrote it on the paper. The Veteran then stated that the examiner explained that such a complaint would delay his discharge, and that he should just go along with it. The Veteran agreed and the examiner scratched out headaches. The Veteran testified that he began experiencing headaches several (4-6) months after service and that they became daily occurrences. He began having stomach problems at approximately the same time. He testified that he began experiencing problems with his wrist in the late 1960s or possibly 1970. The service treatment records reflect that the Veteran was treated for a sore wrist in October 1962, pain in his abdomen (epigastrium region) in April 1964, an irritable colon in August 1964, and an irritated stomach from April 1965 to June 1965. His July 1966 separation examination yielded normal findings. There is no indication that the examiner wrote "headaches" on the separation examination and then crossed it out, as described by the Veteran at his hearing. On his July 1966 Report of Medical History, the Veteran handwrote that he had persisting stomach trouble since April 1964, including chronic pain in his abdomen near epigastrium region. He indicated, by checked box, that he had mumps, chronic or frequent colds, sinusitis, frequent indigestion, stomach, liver, or intestinal trouble, reaction to serum, drug, or medicine, and car, train, sea, or air sickness. He denied, by checked box, that he had frequent or severe headaches, swollen or painful joints, dizziness or fainting spells, arthritis or rheumatism, bone, joint, or other deformity, neuritis, epilepsy or fits, loss of memory or amnesia, and nervous trouble of any sort. In October 1972, the Veteran filed a claim for stomach trouble, nervousness, nausea, and headaches. He underwent a VA examination in October 1972. He complained of recurrent substernal burning pain relieved with antacids. He was diagnosed with epigastritis. He also underwent a VA psychiatric examination. He stated that while he was in service, he experienced nervousness and a stomach ulcer. He reported having inhaled pesticides; and he believed that this may have aggravated his stomach problems. He denied any present nervous trouble; but stated that he still has stomach problems at times. He was diagnosed with chronic anxiety reaction with psychophysiological gastrointestinal complaints. The Veteran underwent another VA examination in December 1972. He complained of a nervous stomach and cramping since 1964 or 1965. He was diagnosed with possible psychophysiological gastrointestinal reaction. The Board notes that the RO denied the claims for a stomach condition and chronic anxiety reaction by way of a December 1972 rating decision. In August 1998, the RO found that no new and material evidence had been received to reopen the service connection claim for a stomach condition. Service connection for headaches was also denied at that time. A November 1999 treatment report from Mid City Health Center reflects that the Veteran complained of sinus headaches and minimal abdominal comfort that he experienced the previous week. He thought that it may have been related to something he ate. In April 2000, the Veteran filed a claim of service connection for right wrist nerve damage. The claim was denied in an August 2000 rating decision. An August 2000 treatment report from Mid City Health Center reflects that the Veteran sought treatment for a tremor in his right hand that began a year earlier. He denied any trauma to his right upper extremity. In October 2002, the Veteran filed an application to reopen his claims of service connection for nerve damage to his right wrist and for headaches. A January 2006 VA treatment report in the Virtual VA (document No. 14, p. 133) reflects that the Veteran's hand tremors were getting worse. He also reported occasional headaches that he felt were related to stress or sinuses. An April 2006 VA treatment report in the Virtual VA (document No. 15, p. 395) reflects that the Veteran sought treatment for headaches. The examiner noted that "they seem to have a large anxiety component." A July 2006 VA treatment report in the Virtual VA (document No. 15, p. 384) reflects complaints of tremors in his right hand since the 1970s, most notably in his right upper extremity. He stated that it became much worse in the 1980s. He also reported chronic headaches of 1 year duration, but he also noted that he has had headaches in the past (including episodes of migraines with severe headaches, photophobia, and phonophobia). The report reflects that in the past year, they have become more frequent, ranging 5-7/10 intensity, bifrontal. The examiner believed them to be related to sinus problems and anxiety. The Veteran reported an increase in anxiety in the past year secondary to recent back to back unexpected deaths of two siblings. Virtual VA (document No. 14, p. 115) reflects that nerve conduction studies conducted in August 2006 showed that motor and sensory distal latencies were prolonged on bilateral median nerves. Compound motor action potential amplitudes were decreased in the right median nerve. Sensory nerve action potential amplitudes were decreased in the right ulnar & sural nerves. Conduction velocities were decreased in the right peroneal & sural nerves. F-waves were prolonged in all tested nerves. The impression was that the Veteran suffered from bilateral carpal tunnel syndrome. There was evidence of mild peripheral neuropathy mainly affecting the lower extremity. The Veteran submitted articles from the internet that state that signs and symptoms of a mild, traumatic brain injury (concussion) include loss of consciousness for a few seconds to a few minutes, no loss of consciousness (but a state of being dazed, confused, or disoriented), memory or concentration problems, headache, dizziness or loss of balance, nausea or vomiting, sensory problems (such as blurred vision , ringing in the ears, or a bad taste in the mouth), sensitivity to light or sound, mood changes or mood swings, feeling depressed or anxious, fatigue or drowsiness, difficulty sleeping, and sleeping more than usual. The articles also noted that some symptoms may appear immediately after the traumatic event, while others may appear days or weeks later. The Veteran underwent a VA examination in December 2011. The examiner stated that the Veteran had a TBI in 1966. It is not clear how the examiner came to that conclusion inasmuch as there is no documentation of such either in 1966 or anywhere in the service treatment records or post service treatment records. Nonetheless, she (Dr. S.K.P.) opined that it was at least as likely as not that the Veteran's TBI and residuals were due to service. Her rationale was that all of the Veteran's memory symptoms, loss of concentration, and headaches began after the injury; and the Veteran still has residuals of memory dysfunction and headaches. The examiner stated that she did not have the claims file available for review. In a September 2012 opinion, Dr. S.K.P. found that the Veteran experiences migraines that are triggered by post-traumatic headaches. However, the Board notes that the medical history contained in the report is not substantiated by the claims file. The medical history contained in the report states that the Veteran fell off his bike during service; that he went to sick bay; that he was given pain pills; and that he has had headaches daily or every other day since then. The Board notes that this in-service history is not documented in the claims file; and the post service history is directly contradicted by some of the post service treatment records (most notably a July 2006 VA outpatient treatment report in the Virtual VA that reflects that the Veteran reported chronic headaches of 1 year duration (as well as in the past)). The examiner submitted a September 2012 addendum in which she stated that she reviewed the claims file and her opinion remained unchanged. Her addendum simply stated that there is sufficient evidence reported in the neurology, sports medicine, and VA practitioner journals about neurological complications of TBI. The Board notes that while it does not dispute that headaches can be a symptom of TBI, the examiner failed to explained how she determined that the Veteran ever sustained a TBI (given that there is no diagnosis of one anywhere in the claims file and the fact that the Veteran's alleged bike injury is not mentioned for more than 40 years after service). The Veteran underwent a November 2012 psychiatric examination, and the examiner found that anxiety and stomach problems were less likely than not related to service. The Veteran also underwent a November 2012 VA neurologic examination, and the examiner (Dr. D.L.B.) found that seizures were less likely than not related to service. However, this examiner provided no rationale for the opinion. Finally, the Veteran underwent another VA examination in May 2013. The examiner (Dr. D.L.B.) reviewed the claims file in conjunction with the examination. She initially checked the box for a TBI diagnosis. However, it appears that the initial diagnosis was made based on the history provided by the Veteran. (She would later state that she could not determine whether the Veteran sustained a head injury of any kind in service). Under "Medical History" the examiner noted that the Veteran fell off a bicycle and struck his head on the sidewalk. He reported that he was semiconscious and that he lay on the ground for about 10 minutes. He reported that he was drowsy and went to sick bay, where he was given pain medication and the rest of the day off. He reported that he got better, but that he has had headaches and dizziness for years. Upon examination, the Veteran had no complaints of memory, attention concentration, or executive functioning. His judgment was normal. Social interaction was routinely appropriate. He was always oriented to person, place, time, and situation. He had normal motor activity and visual spatial orientation. The examiner noted that the Veteran had subjective symptoms of anxiety and headaches with dizziness. There were no neurobehavioral effects. The Veteran was able to communicate, and consciousness was normal. Subjective symptoms attributable to a TBI included headaches, a mental disorder (to include emotional, behavioral, or cognitive), and dizziness that may occur with headaches. The examiner noted that neuropsychological testing had been performed in December 2012 and that it showed anxiety (not PTSD). It was felt that the anxiety predated the alleged head injury. The examiner noted that the Veteran worked at a hardware store, and when he has a bad headache (once or twice per week), it will affect his concentration. The examiner opined that the Veteran sustained a TBI during service and that his residuals were at least as likely as not incurred in or caused by the claimed in-serivce injury. Her rationale was that headaches and decreased concentration began after the head injury with TBI, and that he had no difficulty with these symptoms prior to the TBI. The case was returned to the VA examiner because she failed to provide an adequate rationale for her opinions. Upon reviewing the evidence for a second time, she noted that the Veteran sought treatment for headaches once during service (March 1966) and that at separation from service in July 1966, he denied experiencing frequent headaches. She also noted that the service treatment records do not substantiate a TBI due to a bicycle accident. She stated that in the past 13 years, he has treated with by neurology, but not for headaches. Although she noted that he was diagnosed with migraines. Based on a second review of the evidence, the examiner opined that it was less likely than not that the Veteran's current headaches were incurred in or caused by his in-service headaches or TBI. As to whether the Veteran even sustained a TBI in service, she stated that his history of a fall from a bicycle with subsequent symptoms consistent with a mild TBI is a believable story. However, she could not say whether or not the head injury actually occurred without resorting to speculation or guessing, since there is no record of it in the service treatment records. The Veteran underwent a CT scan in August 2013. The scan revealed mild, age-related changes of the brain. Otherwise, it was negative. The May 2013 VA examiner noted that the CT brain scan neither substantiated a TBI in service, nor did it negate the possibility that a TBI occurred during service. Therefore, even with the benefit of diagnostic testing, she could not say whether the Veteran sustained a TBI in service without resorting to speculation. Analysis In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). With regard to the first element, the Board recognizes that the Veteran suffers from headaches, dizziness, wrist problems, stomach problems, and other symptoms that he attributes to a TBI. However, service connection for the alleged residuals was denied in previous rating decisions. Medical evidence of a current TBI disability is in dispute. There is also considerable doubt as to the second element. Though the Veteran's service treatment records reflect a single complaint of headaches, they fail to contain any finding attributed to a TBI. Moreover, they fail to reflect any bicycle accident or injury to the Veteran's head. The only evidence in support of the Veteran having sustained a head injury due to an in-service bicycle accident is his own testimony. The Board finds this testimony to be somewhat dubious, for reasons discussed below. Finally, the Veteran's claim also falls short with respect to the third element of service connection. The Board acknowledges that the Veteran's 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). Moreover, the Board is mindful that competent medical evidence is not necessarily required where the determinative issue in a case involves medical causation or a medical diagnosis. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. Sept. 14, 2009), citing Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). In this case, although the Veteran is competent to describe symptoms of headaches, stomach problems, and wrist problems, he is not competent to comment on the etiology of such a disorder or to diagnose a TBI. In so finding, the Board acknowledges the Court's holding that a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through observation, such as a fall leading to a broken leg. Jandreau, 492 F.3d 1372, 1376-77. The instant case, however, involves a higher level of medical complexity, with numerous symptoms potentially attributable to different causes, and thus extends beyond a simple, lay-observable, cause and effect relationship. Thus, in this case the Veteran is not competent to opine on the question of etiology and, therefore, a statement from him asserting a relationship between residuals of a TBI with headaches, dizziness, etc. and service do not constitute competent medical evidence on which the Board can make a service connection determination. Moreover, the Board has serious doubts as to whether the Veteran sustained a head injury at all. He testified that the fall off of his bicycle was "pretty traumatic" and that while he did not completely black out, he was confused and lay there for a long time. However, the service treatment records fail to mention the accident at all. He was seen on one occasion for headaches, but again, there is no mention of these being related to a head injury or a bicycle accident. In fact, the complaint of headaches occurred in March 1966 (three months before the alleged June 1966 bicycle accident). If the head injury were "pretty traumatic," causing cognitive difficulties in the form of confusion, then it would be reasonably expected that there would be some, if not numerous, treatment reports and follow-up visits. However, there are none of record. Additionally, the Veteran's separation examination reflects normal findings. Perhaps more importantly, in the Veteran's Report of Medical History, he denied, by checked box, that he had frequent or severe headaches, swollen or painful joints, dizziness or fainting spells, arthritis or rheumatism, bone, joint, or other deformity, neuritis, epilepsy or fits, loss of memory or amnesia, and nervous trouble of any sort. He testified that he was told in an exit interview that a mention of the injury could delay his discharge. However, that did not stop him from, on the same form, handwriting that he had persisting stomach trouble since April 1964, including chronic pain in his abdomen near epigastrium region. He also indicated, by checked box, that he had mumps, chronic or frequent colds, sinusitis, frequent indigestion, stomach, liver, or intestinal trouble, any reaction to serum, drug, or medicine, and car, train, sea, or air sickness. Thus, the statements from the Veteran to the effect that he failed to report headaches because he was truly concerned that voicing complaints would delay his discharge are not persuasive as they are inconsistent with his other actions at that time. Furthermore, the Veteran failed to mention this "pretty traumatic" bicycle accident and head injury for another 40 years after service. Indeed, he filed his original service connection claim for headaches in February 1998. At that time, he failed to mention a head injury in service or a bicycle accident. He sought to reopen the claim in October 2002. Once again, there was no mention of a head injury or bicycle accident. He sought treatment for sinus headaches in November 1999, sought treatment for tremors in his right hand in August 2000, and sought treatment for worsening hand tremors and headaches in January 2006. There was no mention of an in-service head injury or any bicycle accident on any of these occasions. To the contrary, the January 2006 treatment report states that the Veteran felt that his headaches were related to either a sinus problem or stress. An April 2006 examiner stated that the headaches "seem to have a large anxiety component." The Veteran continued to seek treatment in July 2006, and underwent nerve conduction studies in August 2006. Throughout all of this treatment, he somehow never thought to mention the "pretty traumatic" injury that he suffered in service. Instead, the first mention of the alleged injury occurs in his February 2007 substantive appeal (VA Form 9), which is more than 40 years after the alleged accident and head injury. For the forgoing reasons, the Board finds that the Veteran's statements as to the incurrence of a head injury, and as to continuous symptomatology to be not credible here. The Board notes that even if the Veteran did sustain a head injury during service, whether he sustained a TBI is also in question. There are two medical opinions which address whether the Veteran sustained a TBI and whether his current symptoms are residuals of the TBI. Dr. S.K.P. rendered an opinion weighing in the Veteran's favor, while Dr. D.L.B. rendered an opinion that weighs against the Veteran's claim. The Court has held that the Board must determine how much weight is to be attached to each medical opinion of record. See Guerrieri v. Brown, 4 Vet. App. 467 (1993). Greater weight may be placed on one medical professional's opinion over another, depending on factors such as reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). Adequate reasons and bases, in short, must be presented if the Board adopts one medical opinion over another. In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. 444, 448-9 (2000). In some cases, the physician's special qualifications or expertise in the relevant medical specialty or lack thereof may be a factor. In every case, the Board must support its conclusion with an adequate statement of its reasoning of why it found one medical opinion more persuasive than the other. There are substantial and significant factors which favor the valuation of Dr. D.L.B. over the opinion of Dr. S.K.P. in this case. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. In this case, Dr. S.K.P. did not have access to the claims file when she conducted her December 2011 VA examination. With regard to the relevant medical history, the only history noted in her examination report was that provided to her by the Veteran. She diagnosed a TBI based solely on the history reported by the Veteran, and her examination report failed to include any diagnostic testing. There was no neuropsychological testing, diagnostic imaging studies, or laboratory testing. The claims file was made available to her in January 2012, and she indicated that her final diagnosis remained the same. However, she failed to discuss the evidence in the service treatment records (or lack thereof). She examined the Veteran again in September 2012, and although she described the nature of his headaches (as reported to her by the Veteran), there was no diagnostic testing performed, nor was there any discussion of the service treatment records or post service treatment. In her addendum, she simply stated that "There is sufficient evidence reported in the neurology, sports medicine and VA practitioner journals about the neurological complications of TBI." The Board once again notes that there is no dispute that a TBI can result in neurological complications. However, Dr. S.K.P. has never indicated what medical evidence was used in her determination that the Veteran sustained a TBI, or any head injury, in service. The May 2013 VA examiner (Dr. D.L.B.) had also examined the Veteran in November 2012. At that time, she reviewed the claims file and noted that the Veteran had a mild, fine, tremor of both upper extremities with posturing and on intention, right more pronounced than left. She opined that the Veteran had a benign essential tumor which was unrelated to any head injury received in service. When she examined the Veteran again in May 2013, she noted that neuropsychological was performed in December 2012 and that it revealed anxiety that was felt to have predated any head injury. She initially stated that the Veteran's TBI was at least as likely as not incurred in or caused by service. Her rationale was that headaches and decreased concentration began after the head injury, and that he had no such symptoms before the TBI. However, in her addendum, she acknowledged that the Veteran was treated for headaches once during service and then denied headaches upon separation from service. She also noted that no service treatment records substantiated a TBI or a fall off of a bicycle. These were facts that Dr. S.K.P. never acknowledged, discussed, or apparently even considered. They were the basis for Dr. D.L.B.'s revised opinion that the Veteran's headaches were less likely than not incurred in or caused by service. Consequently, the Board finds that Dr. D.L.B. was more acutely aware of the relevant history. Unlike Dr. S.K.P., who only noted the history as reported by the Veteran, Dr. D.L.B. considered both the history as reported by the Veteran, and the findings of the service treatment records. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that both Dr. S.K.P. and Dr. D.L.B. provided a fully articulated opinion as to whether the Veteran's symptoms are due to service. Dr. S.K.P. found that they are as likely as not related to service, and Dr. D.L.B. found that they are less likely than not related to service. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). As already noted, Dr. S.K.P. failed provide any rationale to support her diagnosis that the Veteran sustained a TBI. She did not discuss the service treatment records and she did not reference any diagnostic testing. Dr. D.L.B., on the other hand, acknowledged the service treatment records, she had previously examined the Veteran in November 2011, and she noted that neuropsychologic diagnostic testing had revealed anxiety that appeared to predate any alleged head injury. Moreover, Dr. D.L.B. (unlike Dr. S.K.P.) saw fit to schedule the Veteran for a CT scan of the brain. The CT scan showed only mild age-related changes of the brain, which Dr. D.L.B. noted neither substantiates or negates the possibility of a TBI. Her rationale was that the Veteran only sought treatment for headaches in service on one occasion and that he denied having headaches at separation. Inasmuch as Dr. S.K.P. provided no rationale for her opinions, the Board finds that Dr. D.L.B.'s rationale is more probative. Consequently, the Board finds Dr. D.L.B.'s medical opinion to be more probative than that of Dr. S.K.P. Additionally, the Board notes that even the internet articles that the Veteran submitted do not necessarily support his claim. While the Veteran does suffer from some of the signs and symptoms associated with a TBI, the articles state that some symptoms may appear immediately after the traumatic event, while others may appear days or weeks later. In this case, the Veteran has admitted that headaches and stomach problems began several months after service and that his wrist condition did not begin until years later. Moreover, the service treatment records reflect that most of the Veteran's symptoms pre-date the alleged June 1966 bicycle accident. Once again, he was treated for a sore wrist in October 1962, pain in his abdomen (epigastrium region) in April 1964, an irritable colon in August 1964, and an irritated stomach from April 1965 to June 1965, and headaches in March 1966. The Board notes that service connection can potentially be granted on the basis of continuity of symptomatology. However, this only applies for disabilities termed as chronic diseases under 38 C.F.R. § 3.309(a). As TBI is not among such diseases, service connection based solely on continuity of symptomatology is not for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In any event, the Veteran's lay statements are not deemed credible here, as explained above, and thus the lay evidence does not support a finding of actual continuity. In conclusion, the Board finds that the preponderance of the evidence is against the claim for service connection for residuals of a TBI with chronic anxiety reaction with psychological gastrointestinal complaints (stomach disability), headaches, and wrist nerve damage. Because the preponderance of the evidence is against the claim, the benefit of the doubt provision does not apply. Therefore, the Board concludes that service connection for residuals of a TBI with chronic anxiety reaction with psychological gastrointestinal complaints (stomach disability), headaches, and wrist nerve damage is not warranted. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). ORDER Entitlement to service connection for an alleged TBI with chronic anxiety reaction with psychological gastrointestinal complaints (stomach disability), headaches, and wrist nerve damage is denied. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs