Citation Nr: 1337616 Decision Date: 11/18/13 Archive Date: 11/26/13 DOCKET NO. 05-01 792 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to service connection for a thoracic spine disability. 3. Entitlement to service connection for a cervical spine disability. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney at Law ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 1979 to September 1983. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2004 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In May 2007, the Board remanded the case for further development of the evidence. A March 2008 Board decision denied the Veteran service connection for lumbar, thoracic, and cervical spine disabilities. She appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2009 Order, the Court granted a Joint Motion for Remand of the parties (Joint Motion), vacated the Board's March 2008 decision, and remanded the matters on appeal to the Board for action consistent with the terms of the Joint Motion. In August 2009, the Board remanded the case to the RO for further development of the evidence. A December 2012 Board decision again denied the Veteran service connection for lumbar, thoracic, and cervical spine disabilities. He appealed the decision to the Court, and in a July 2013 Order, the Court vacated the Board's decision and remanded the service connection matters to the Board for action consistent with the terms of a July 2013 Joint Motion. Two other issues on appeal (seeking a rating higher than 30 percent for right carpal tunnel syndrome (from a January 2011 rating decision) and a rating higher than 20 percent for left carpal tunnel syndrome (from an August 2007 rating decision), were remanded by the Board in December 2012 for development. The development has not been completed, and the issues have not been recertified to the Board; therefore, they are not addressed herein. FINDINGS OF FACT 1. A chronic lumbar spine disability was not manifested during active duty, arthritis of the lumbar spine was not manifest to a compensable degree within one year following separation from active duty, and the Veteran's current lumbar spine disability including arthritis is unrelated to an injury, disease, or event in service. 2. A chronic thoracic spine disability was not manifested during active duty, arthritis of the thoracic spine was not manifest to a compensable degree within one year following separation from active duty, and the Veteran's current thoracic spine disability including arthritis is unrelated to an injury, disease, or event in service. 3. A chronic cervical spine disability was not manifested during active duty, arthritis of the cervical spine was not manifest to a compensable degree within one year following separation from active duty, and the Veteran's current cervical spine disability including arthritis is unrelated to an injury, disease, or event in service. CONCLUSIONS OF LAW 1. Service connection for a lumbar spine disability is not warranted. 38 U.S.C.A. §§ 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 2. Service connection for a thoracic spine disability is not warranted. 38 U.S.C.A. §§ 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). 3. Service connection for a cervical spine disability is not warranted. 38 U.S.C.A. §§ 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. The VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post-adjudication VCAA notice by letters, dated in June and July 2003 and in June 2007. The Veteran was notified of the evidence needed to substantiate claims of service connection for spinal disabilities; that VA would obtain service records, VA records and records of other Federal agencies; and that she could submit records not in the custody of a Federal agency, such as private medical records or with her authorization VA would obtain any non-Federal records on her behalf. The June 2007 notice included the elements of a service connection claim, including the effective date of an award and the degree of disability. To the extent the June 2007 VCAA notice was provided after the initial adjudication, such timing defect was cured because the claims were readjudicated after the RO provided content-complying VCAA notice. See the supplemental SOCs (SSOCs) dated in August 2007, October 2011, and April 2012. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (A notice timing error is cured by adequate VCAA notice and subsequent readjudication.). In any case, as this decision does not address any effective date or disability rating matters, the Veteran is not prejudiced by any timing defect as to such notice. Under 38 U.S.C.A. § 5103A , VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained the Veteran's service treatment records (STRs) and pertinent post-service treatment records, including those from VA and those identified by the Veteran. To that end and pursuant to the Board's 2009 remand, records were developed from Dr. Cheng of the Colorado School of Traditional Chinese Medicine; Dr. Zinis of Orthopedic Associates, LLC; and Dr. F. Martin of Colorado Rehab & Laser Therapy. In an October 2009 written statement, the Veteran reported that she did not receive back treatment from Denver Physical Therapy or D.C., M.S. As those records are not relevant to the current claims, no further efforts to obtain records from those sources are necessary. The Veteran has not identified any additional pertinent evidence that is available and remains outstanding. The Veteran was afforded VA examinations in July 2003, June 2007 (with a further medical opinion by the June 2007 VA examiner furnished in January 2010 after a review of the claims file), and July 2011. Taken together, the examinations and medical opinion are adequate for rating purposes. In particular, the 2011 examiner considered the entire record, noted the history of the disabilities, and conducted a thorough physical examination of the Veteran, with notation of all clinical findings necessary for a proper determination in this matter. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). In short, VA's duty to assist has been met, and it is not prejudicial for the Board to proceed with appellate review. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Factual Background The Veteran's STRs show a complaint of upper back pain in October 1979; a bed board was recommended. She was seen for neck pain in April 1980. She reported that she had fallen in basic training and injured her back. Examination showed normal range of motion of the neck, with tenderness in the C-7 region. Back range of motion was normal. Deep tendon reflexes and straight leg raising were normal. The impression was chronic neck pain. Subsequent X-rays of the neck and thoracic spine were normal. In December 1981, she complained of low back and chest pain. No history of trauma was noted at that time. Costochondritis and musculoskeletal back pain were noted. A May 1983 physical therapy note indicates she returned for a re-check of mechanical thoracolumbar pain. She had a decrease in upper trapezius tension and was able to perform back extension exercises without difficulty, but her low back pain was persisting. On a National Guard examination in November 1987, the Veteran denied a history of recurrent back pain. She wrote on a report of medical history that she was "in excellent health" and was on no medications. Examination at that time found normal spine and musculoskeletal system. A March 1994 X-ray report noted, in reference to the thoracolumbar spine, anterior spondylitic changes at L3 and L4, with the disc spaces well-preserved. In reference to the cervical spine, the study showed reversal of the physiologic cervical lordosis, which was suspicious for prominent muscle spasm and/or paracervical myositis, without evidence of discogenic disease, spondylolysis, or spondylolisthesis. In August 2001, the veteran reported numbness and paresthesias of both hands, and some well-localized neck pain. Electrophysiologic studies showed carpal tunnel syndrome. (Bilateral carpal tunnel syndrome is service-connected.) A September 2001 VA evaluation did not note any back or neck complaints. In May 2003, the Veteran was seen at the VA for complaints of back tightness which she reported began in service in 1979. The assessment was of "disc injury and lumbar instability arising from initial injury in the military and through repetitive use throughout the years." This record was signed by a physical therapy student and co-signed by a physical therapist. Electromyography (EMG) testing in June 2003 found no evidence of cervical radiculopathy or peripheral neuropathy. VA examination in July 2003 diagnosed strain of the lumbosacral spine, with degenerative disc disease shown by X-ray. The examiner did not offer an opinion as to the etiology of the disability. X-rays in May 2005 showed spondylosis and ventral bridging osteophytes at T9/T10. Magnetic resonance imaging (MRI) of the lumbar spine in October 2005 showed degenerative changes at L5/S1 and mild posterior disc bulge at L4/5. February 2005 to April 2008 records from a Chinese health practitioner note the Veteran had complaints of back pain. On VA examination in June 2007, the examiner, identified as a physician and orthopedic consultant, reviewed the claims folder "in detail" in conjunction with the examination. The diagnoses were lumbosacral spine degenerative disc disease and degenerative joint disease, multilevel, with left radiculitis; thoracic spine degenerative disc disease and degenerative joint disease, multilevel; and chronic cervical strain, with degenerative disc disease and degenerative joint disease. It was the examiner's opinion that "it is less likely as not that the veteran's current lumbosacral spine condition is causally related to service or any incident therein." The examiner noted that the STRs showed complaints of low back pain but "no specific diagnosis of lumbosacral spine pathology, and that the Veteran had no complaint of low back pain on November 1987 reserve examination. A lumbosacral condition (L3-L4 degenerative joint disease) is initially described almost 10 years post-military (March 1994 report.)" The examiner stated that the descriptions of military back injury "appear transient, related to musculoskeletal strain, without evidence of permanent aggravation." He noted that the October 2005 MRI shows multilevel degenerative disc disease and degenerative joint disease, "findings consistent with chronological aging, with no specific evidence of traumatic change." The examiner also opined that it was "less likely as not that the veteran's current thoracic spine condition is causally related to service or any incident therein." He noted that the STRs "do document veteran complained of upper back pain on multiple occasions. However, physical examination found normal range of motion, and thoracic films in 1980 were reported normal. The November 1987 Reserve exam describes no thoracic spine abnormalities." Further, "there is no history of evaluation or treatment for thoracic spine pain post military until 1994, approximately 10 years after military separation, when thoracic X-ray report describes scoliosis, but no degenerative changes." The examiner also stated that it was "less likely as not that the veteran's current cervical spine condition is causally related to service or any incident therein." While the STRs document complaints of neck pain in 1980, "there was no history of neck injury, rather upper back injury described in the previous year on the rifle range. Neck range of motion was normal." There was "C7 tenderness on physical examination noted, and cervical X-rays were normal. No further medical treatment reports pertinent to a neck condition are identified, except 1994 report of normal cervical spine X-rays." The examiner concluded that, for "the cervical, thoracic, and lumbosacral spine, there is insufficient clinical criteria to causally link the veteran's current . . . conditions with remote medical events of military service." Private treatment records from Dr. Martin and Dr. Zinis dated in 2007 reveal that the Veteran slipped and fell in December 2006. Dr. Martin diagnosed lumbar sprain/strain and muscle spasm; and the Veteran had six treatments of cold laser therapy and chiropractic manipulation in March 2007. A June 2007 record of Dr. Zinis notes that a recent MRI found a moderate amount of arthritis in the lumbosacral area. An EMG nerve conduction study was predominantly normal but showed very mild L5 radiculopathy. A February 18, 2008 private medical assessment by Dr. A. K. Agarwal, notes that records were reviewed, including those from Orthopedic Associates, LLC, and Colorado Rehab and Laser Therapy. Dr. Agarwal performed an examination and diagnosed degenerative disc disease of the lumbar, thoracic and cervical spine. Dr. Agarwal concluded that the Veteran "developed some chronic thoracolumbar pain while in the military service which has continued and worsened a bit over the years. Dr. Agarwal also felt that her current spondylosis "develops over years" and noted in a February 14, 2008 medical record that her "spondylosis is an aggravation of injuries sustained with falls at work between 1979-83." He apportioned 3 percent of her impairment to service. In January 2010, the 2007 VA examiner, Dr. Parks, reviewed the file again, and specifically noted that records from Orthopedic Associates, LLC, and Colorado Rehab and Laser Therapy were reviewed as well as Dr. Agarwal's records. Dr. Parks noted Dr. Agarwal's conclusion that the Veteran's back disorder was related to service, but believed that "there appears to be insufficient evidence in the medical records to support this belief." Dr. Parks noted that Dr. Agarwal did not have the benefit of reviewing the Veteran's STRs. Dr. Parks again concluded that it was less likely as not that the Veteran's cervical, thoracic or lumbar spine disability was related to service given the insufficient clinical criteria. A July 2011 VA examiner, Dr. Munger, also reviewed all the evidence of record, including Dr. Agarwal's February 2008 report, and agreed with Dr. Parks' conclusions that it was less likely than not that the Veteran's cervical, thoracic or lumbar spine disability was related to service. Dr. Munger noted that Dr. Agarwal had not provided an opinion as to the etiology of the Veteran's current cervical and thoracic spine disabilities in his February 2008 statement. With respect to the low back, Dr. Munger concluded that "[t]here is no medical evidence that veteran suffered from multiple falls resulting [in] a chronic low back condition while in service. It appears that Dr. Anil [Agarwal] made his conclusion without any medical evidence to support it." Dr. Munger then noted that the Veteran did not complain of back pain on the 1987 reserve examination. Legal Criteria Service connection may be granted for disability resulting from injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Where a veteran served 90 days or more of continuous, active service and a chronic disease, such as arthritis (degenerative joint disease), becomes manifest to a degree of 10 percent within one year from date of separation from service, the disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. 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, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may be granted for a 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). VA must give due consideration to all pertinent medical and lay evidence in a case where a veteran is seeking service connection. 38 U.S.C.A. § 1154(a). The Veteran does not argue and the record does not show that the claimed disabilities were incurred in combat; the provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether medical or lay evidence may be considered, in other words, whether the evidence is admissible as distinguished from weight and credibility, a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The Board, as fact finder, must determine the probative value or weight of the admissible evidence. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005) (citing Elkins v. Gober, 229 F.3d 1369, 1377 (Fed.Cir.2000) ("Fact-finding in veterans cases is to be done by the Board")). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the veteran. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Analysis The Board has reviewed all of the evidence of record (including the Veteran's claims file and Virtual VA), with an emphasis on the evidence relevant to this appeal. The Virtual VA file contains additional VA treatment records which were considered by the RO in the April 2012 SSOC. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. The Veteran contends that she is entitled to service connection for disabilities of the lumbar, thoracic, and cervical spine as they are attributable to back injuries that were incurred during service, beginning in August 1979. She asserts that she has continually sought treatment since service for her disabilities. The Veteran argues that because there is sufficient evidence of record to establish that she suffered in-service injury and experienced continuing symptomatology related to her disabilities ever since then, her claims should be granted. On the basis of the STRs alone, while the Veteran was treated for upper back pain in October 1979, neck pain in April 1980, and low back pain in December 1981 and May 1983, the conditions affecting the lumbar, thoracic, and cervical spine are not shown to have persisted after those occasions. For example, throughout service she was seen for other complaints, but neck or cervical pain was not shown to continue after April 1980, despite an assessment of "chronic" neck pain at that time. Moreover, upper back pain appeared to be an isolated complaint in October 1979, as was the complaint for low back pain in December 1981. A May 1983 note shows that in a re-check for thoracolumbar pain, there were no negative findings in regard to the upper back but that the lower back had some lingering pain. Thereafter, there is no evidence of any further follow up visits, complaints, clinical findings, or diagnosis in reference to a low back disability. The Veteran was discharged from service in September 1983. Many years later, on November 1987 National Guard examination, the Veteran denied any recurrent back pain, and examination showed normal spine and musculoskeletal findings. She in fact declared herself to be in fine health at that time. Given the foregoing findings, a chronic disability of the lumbar, thoracic, and cervical spine was not shown to have had onset during service, and service connection under 38 U.S.C.A. § 1131 and 38 C.F.R. § 3.303(a) (showing inception in service) is not warranted. Alternatively, a showing of continuity of symptomatology after service can also support the claim. 38 C.F.R. § 3.303(b). As described previously, postservice private and VA medical records do not show that a lumbar, thoracic, and/or cervical spine disability was manifest until more than 10 years after the Veteran's discharge from service in September 1983. Objective evidence of chronic lumbar and cervical spine pathology, in particular, was initially demonstrated by X-ray in March 1994. The absence of continuity of symptoms for this prolonged period of time without medical complaint is persuasive evidence against continuity of symptomatology. It is noted that in statements the Veteran has asserted that injury in service has resulted in neck and back problems ever since then. In written statements in May 2003 and June 2003, for example, she reported that she has had constant back discomfort since 1979 and that she has sought out massage therapists and chiropractors to relieve pain "throughout the years." She described falls beginning during basic training where she landed on her back. However, she stated that she "did not keep all that paperwork or all the names of the professionals I sought out." The Board, as fact finder, must determine the probative value or weight of the statements in deciding whether there is continuity of symptomatology. As noted, there is no contemporaneous medical record to show the Veteran had sought postservice treatment for the neck or back before 1994 (more than 10 years following separation from active service), as claimed. Nor are there any medical records showing treatment for other ailments in the period between service and 1994. Given this lack of objective evidence, the 1987 National Guard general physical examination report becomes particularly probative in determining the existence of any spine symptomatology after service (albeit four years after service). The physical examination report does not corroborate the Veteran's allegations of ongoing neck and back symptoms since service. Rather, it stands as significant contemporaneous evidence showing that there were no continuing lumbar, thoracic, or cervical spine symptoms from the time of service. When specifically asked whether she currently had, or had a history of, recurrent back problems, the Veteran in 1987 not only denied any such problems but also pronounced her health to be excellent. The general physical examination at that time likewise showed her spine to be normal. Thus, when presented with the opportunity to mention neck or back complaints at the time, or at least to report a history of recurrent back complaints, the Veteran did not do so and instead affirmed her health status was great. It is also noted that the Veteran claims that she fell on her back (or was thrown a couple of times, hitting her back) on many occasions during service; however, the STRs do not show, other than in one report of history, that she had sustained any trauma to her back. In fact, in December 1981, a history of trauma was negative. In other words, the Veteran's current statements that were made in conjunction with her VA disability claim, originally filed in 2003, are inconsistent with the evidence contemporaneous with service and with the evidence dated in the years between service and 1994 when chronic spine pathology was initially documented postservice. Moreover, the Veteran's statements are self-serving and made for the purpose of obtaining disability compensation, whereas her statements in service and in 1987 (with respect to being in "excellent health" with no mention of neck or back problems) were made for evaluation and treatment purposes and not for any apparent view to receiving compensation based on them. The Veteran has not reconciled her current claims of continuing neck and back problems from injury/trauma in service with the record contemporaneous with service and the years after service, which fails to show multiple falls onto her back during service or continuing back or neck symptomatology on a 1987 physical examination. It is noted that the Veteran is competent to report observable symptoms such as back pain. Layno v. Brown, 6 Vet. App. 465 (1994). Furthermore, lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Nonetheless, to the extent that the Veteran is claiming continuous neck and back symptomatology since injury during active service, the Veteran is not credible. For the reasons just explained, namely, self interest, inconsistent history and complaints, and inconsistency with other evidence submitted, the lay evidence of continuity lacks credibility. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony.); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.). Here, the Board finds that the Veteran's reported history of continued symptomatology since active service, while competent, is nonetheless not credible. The Veteran has also submitted statements of two lay witnesses, dated in August 2005, wherein co-workers indicated that they met the Veteran in 1999 and about 2002 and that the Veteran had told them of having chronic back pain since 1979 due to several injuries and that she had military records showing that she was seen for her condition in service. They observed her experiencing back pain on the job. These statements recount what the Veteran has told them about continuity of symptomatology since service, which are essentially her assertions that have been found to be not credible. Moreover, the lay statements themselves were made in 2005, during the pendency of the Veteran's current claims, and are not contemporaneous to the period just following her discharge from service. Notably, the providers did not meet the Veteran until 1999 and 2002, and did not personally observe neck and/or back symptoms of the Veteran from the time she left service. Thus, the Board finds such lay evidence lacks probative value. For the foregoing reasons, then, continuity of symptomatology has not been established, either by the clinical record or by the statements of the Veteran and lay witnesses. That is, the preponderance of the evidence is against the claims of service connection for disabilities of the lumbar, thoracic, and cervical spine based on continuity of symptomatology under 38 C.F.R. § 3.303(b). The Board next turns to the question of whether service connection for lumbar, thoracic, and cervical spine disability may be granted on the basis that the disability is related to service, even if first diagnosed after service when considering all the evidence, including that pertinent to service under 38 C.F.R. § 3.303(d). There is no question that the Veteran now has cervical, thoracic, and lumbar spine disabilities. Degenerative disc disease and degenerative joint disease (arthritis) at all three levels are shown by diagnostic studies. It is also not in dispute that the Veteran complained of back and neck pain on several occasions in service; the complaints are clearly documented in her STRs. What remains to be shown to establish service connection is that the current disabilities are related to the complaints in service. There is no diagnosis of a chronic disability of the lumbar, thoracic, or cervical spine until more than 10 years after service. Further, the preponderance of the evidence is against there being a link between any current neck or upper or lower back disability and an injury, disease or event in service. In that regard, the record contains evidence both for and against the Veteran's contentions. When evaluating these opinions, the Board must analyze the credibility and probative value of the evidence, account for evidence which it finds to be persuasive or unpersuasive, and provide reasons for rejecting any evidence favorable to the Veteran. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The "positive," or favorable, medical evidence supporting the Veteran's contentions consists of a May 2003 VA treatment record that described "disc injury and lumbar instability arising from initial injury in the military and through repetitive use throughout the years" and the February 2008 conclusions of Dr. Agarwal. As noted by the VA examiner, Dr. Parks, in January 2010, there was no indication that Dr. Agarwal had any opportunity to review the Veteran's STRs (his report actually indicates that he reviewed medical records dated no earlier than 2006). The same can be said of the VA physical therapist who signed the 2003 report. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (finding that a physician's access to the claims file and the thoroughness and detail of the opinion are important factors in assessing the probative value of a medical opinion). Had Dr. Agarwal and the VA physical therapist seen the entire medical record, they would have noted the documented complaints of spine problems during active duty but would also have had to explain their conclusions in light of the National Guard physical examination four years after service, which showed that the Veteran affirmed being in excellent health, without a history of recurrent back pain, and that a spine examination at that time was normal. Clearly, their findings relating a current back disability to injury in service appear to be predicated in no small part on the Veteran's own reported history of complaints of back problems since service, which was disproved by the available medical records as shown by the 1987 National Guard physical examination. Moreover, the Veteran's reported history has been deemed not credible, as previously discussed. It is also noted that the focus of the favorable opinions is the Veteran's low back, or lumbar spine, without any clear assertions with regard to the etiology of the neck and/or upper back conditions. In contrast, the "negative," or unfavorable evidence, provided by VA examiner, Dr. Parks, in June 2007 (with addendum in January 2010 following a review of the record), and the negative opinion of VA Dr. Munger in 2011, is based on a thorough review of the claims folder and detailed description of the Veteran's documented medical history. Dr. Parks specifically indicated that the lay accounts by the Veteran were considered, but that "there is insufficient clinical criteria to causally link the veteran's current cervical, thoracic, and lumbar conditions with remote medical events of military service." He found the STRs showed only transient back problems and that 2005 MRI findings of arthritis in the back and neck were consistent with aging, with no specific evidence of traumatic change. Dr. Munger found no evidence that falls in service resulted in a chronic low back condition. She noted that on the November 1987 reserve examination, conducted more than four years after separation from active service, the Veteran denied any recurrent back pain, and the examination itself found normal spine. Thus, the VA physicians based their opinions in part on the 1987 National Guard physical examination and the Veteran's silence with regard to any spine complaints or history of recurrent back pain at that time, and further remarked that Dr. Agarwal did not render an opinion regarding etiology of the Veteran's thoracic and cervical spine. Greater weight may be placed on one medical opinion over another opinion depending on factors such as reasoning employed by the medical professional, and whether or not, and to what extent, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The Board finds the VA examiners' opinions, taken together, to be entitled to greater probative weight than the opinions of Dr. Agarwal and the VA physical therapist, because the VA examiners took into account a complete review of the Veteran's claims file and medical history, in addition to physical examinations, and they provided a complete rationale as to their conclusions. Moreover, such conclusions were based on consideration of the significant facts of the case, to include the normal physical examination of the spine in 1987 and the Veteran's assertion of being in excellent health then without a history of any recurrent back pain. This cannot be said of the opinions from Dr. Agarwal and the VA physical therapist. In weighing the respective medical opinions, the June 2007, January 2010, and July 2011 VA orthopedists' opinions reflect a full review of all medical evidence of record, including the STRs. They also addressed the findings of Dr. Agarwal and explained why his conclusions were not supported by the evidence of record (because he did not have the benefit of reviewing the STRs, and was not fully aware of what they showed). The VA opinions in 2007, 2010, and 2011 are also buttressed by an explanation of rationale for conclusions, that is, that the clinical evidence did not support a nexus between current disability and service, and are further supported by citation to specific evidence in the record. For example, as earlier noted, the opinions cite to the 1987 National Guard examination that found no ongoing or chronic back pain and noted that the Veteran personally wrote on the report that she was "in excellent health." In addition, they point to a nonservice-related etiology for the disabilities considered more likely, i.e., the aging process. The statement by the VA physical therapist (who is not a physician and clearly based her statement on the Veteran's reported history of ongoing complaints since service), was not accompanied by detailed findings and rationale. Likewise, Dr. Agarwal's report contains only data and conclusions without any supporting analysis. Therefore, it is accorded little probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Notably, Dr. Agarwal's conclusion (labeled "Summary" in his report) was followed by a paragraph-long caveat that began, "[t]he above analysis is based upon the available information at this time, including the history given by the examinee, the medical records and tests provided, and the physical findings." This remark, as mentioned earlier, is significant, because the earliest medical records reviewed by Dr. Agarwal were dated in 2006, which is over 15 years after service. As such, he was not able to account for or reconcile the evidence contained in the STRs including the 1987 National Guard examination report that tends to undermine his own conclusions. The fact that Dr. Agarwal's conclusions are based on an incomplete medical history makes his opinion less probative. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion based upon an inaccurate factual premise has no probative value). As for the Veteran's own statements attributing her current lumbar, thoracic, and cervical spine disabilities to service, although she is competent to describe symptoms, the diagnosed lumbar, thoracic, and cervical spine disabilities are not (under case law) conditions where lay observation has been found to be competent to establish etiology (in the absence of continuity of symptomatology, the Veteran's reports of which the Board has found not credible). Therefore, the determinations as to the diagnoses of the current disabilities and whether they are related to an injury or disease in service are medical in nature and require competent medical evidence. Lumbar, thoracic, and cervical spine degenerative changes are not simple medical conditions because the disabilities are not identifiable by mere personal observation; they cannot be perceived by visual observation or by any other of the senses, but require diagnostic studies and medical expertise. Although the Veteran is competent to relate a contemporaneous medical diagnosis and symptoms that later support a diagnosis by a medical professional, she has not submitted any such evidence that establishes a diagnosis of a chronic back or neck disability before 1994, or probative evidence that a medical professional related her lumbar, thoracic, and cervical spine disabilities to an injury, disease, or event in service. It is not argued or shown that the Veteran is qualified through specialized education, training, or experience to offer a diagnosis of degenerative changes involving the lumbar, thoracic, and cervical spine. Hence, the Board rejects the Veteran's statements as competent evidence to substantiate that the claimed disabilities, first documented many years after service, were present in service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Under certain circumstances, a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). In this case, the cause of the Veteran's back and neck disabilities with degenerative changes cannot be determined by the Veteran's own personal observation without having specialized education, training, or experience. 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (a witness must have personal knowledge in order to be competent to testify to a matter; personal knowledge is that which comes to the witness through the use of the senses.). Is not argued or shown that the Veteran is qualified through specialized, education, training, or experience to offer an opinion on the cause of the current back and neck disabilities. As the Veteran's lay opinion on causation is not competent evidence, her opinion is without probative value. Rather, the competent evidence of record (that is, the diagnoses and opinions of the VA examiners) opposes rather than supports the claims. As the preponderance of the evidence is against the Veteran's claims seeking service connection for lumbar, thoracic, and cervical spine disability based on affirmatively showing inception in service under 38 C.F.R. § 3.303(a), continuity of symptomatology under 38 C.F.R. § 3.303(b), or a disability first diagnosed after service under 38 C.F.R. § 3.303(d), the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). As for presumptive service connection for arthritis as a chronic disease under 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307 and 3.309, degenerative changes in the Veteran's back and neck were first documented no earlier than 1994. This initial finding of degenerative changes is well beyond the one-year presumptive period after discharge from service in 1983 (for presumptive service connection for arthritis of the cervical, thoracic, and/or lumbar spine as a chronic disease). Thus, the preponderance of the evidence is against the claim on this theory of entitlement, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). For the reasons articulated above, service connection for a lumbar spine disability, a thoracic spine disability, and a cervical spine disability is not warranted. ORDER The appeal seeking service connection for a lumbar spine disability is denied. The appeal seeking service connection for a thoracic spine disability is denied. The appeal seeking service connection for a cervical spine disability is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs