Citation Nr: 1340447 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 10-25 864 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to service connection for a cervical spine disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1975 to July 1977 and from October 2006 to November 2006. She had additional service in the United States Navy Reserve. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Veteran testified at a hearing before the undersigned Veterans Law Judge in May 2012. A transcript of the hearing is associated with the claims file. In February 2013, the Board remanded the case for further development. After completing the requested development, the Appeals Management Center (AMC) denied the claim (as reflected in a June 2013 supplemental statement of the case (SSOC)) and returned the case to the Board for appellate review. In addition to the paper claims file, there are Virtual VA and Veterans Benefits Management System (VBMS) paperless files associated with the Veteran's claim. A review of the documents in the paperless claims files reveals documents that are either duplicative of the evidence in the paper claims file or irrelevant to the issues on appeal. FINDINGS OF FACT 1. There is clear and unmistakable evidence the Veteran's cervical spine disorder preexisted her military service. 2. The Veteran has not been shown by competent medical evidence to currently have a cervical spine disorder that is related to any aggravation during service of her preexisting disorder or otherwise etiologically related to her military service. CONCLUSION OF LAW A cervical spine disorder was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1111, 1153, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The RO provided the Veteran with a notification letter in May 2008, prior to the initial decision on the claim in July 2008. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met and to decide the appeal would not be prejudicial to the claimant. Moreover, the requirements with respect to the content of the notice were met in this case. The letter informed the Veteran of the information and evidence needed to substantiate her claims for service connection and notified her of the division of responsibilities in obtaining such evidence. The letter also explained how a disability rating is determined for a service-connected disorder and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess, 19 Vet. App. at 490-491. In addition, the duty to assist the appellant has also been satisfied in this case. The Veteran's service treatment records from her Reserve service, including her October 2006 to November 2006 mobilization, as well as all identified and available post-service private treatment records, are in the claims file and were reviewed by both the RO and the Board in connection with the claim. The record reflects that the Veteran's service treatment records for her initial period of active duty service from August 1975 to July 1977 have not been obtained. The Board is aware that in such cases, VA has a heightened duty to explain its findings and conclusions and to consider carefully the benefit-of-the doubt rule. See Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of the Veteran's claim for service connection has been undertaken with these heightened duties in mind. In the February 2013 remand, the Board directed the RO to contact the National Personnel Records Center (NPRC) and any other appropriate location to request all service personnel records and service treatment records, to specifically include the service treatment records pertaining to the Veteran's first period of active duty service from August 1975 to July 1977. The RO was directed to continue efforts to locate such records until it was reasonably certain that such records did not exist or that further efforts to obtain those records would be futile, and to notify the Veteran of any actions taken, pursuant to 38 U.S.C.A. § 5103A(b)(3) and 38 C.F.R. § 3.159(c)(2). In March 2013, the AMC emailed a request for the service treatment records to the Records Management Center (RMC). In April 2013, a negative response was received from the RMC. In May 2013, a Personnel Information Exchange System (PIES) request was submitted and rejected. In May 2013, the AMC sent a letter to the Veteran that notified her that the AMC had been unable to obtain her service treatment records and requested that she submit any records in her possession or information related to the location of the records. In addition, she was provided with examples of documents that could substantiate her claim for service connection and related to her claimed disability during service. No response was received from the Veteran. Thereafter, in May 2013, the AMC issued a formal finding on the unavailability of the service treatment records from the Veteran's first period of active duty service and associated the memorandum with the claims file. The Board notes that the RO also made several unsuccessful attempts to obtain private neurology treatment notes. In January 2010, the Veteran was informed of the failed requests. In March 2010, the RO was informed that the physician had moved his practice to Prescott, Arizona. In the February 2013 remand, the Board directed the RO to ascertain if the Veteran received any VA, non-VA, or other medical treatment that was not evidenced by the record, to include private treatment records from a private neurologist located in Prescott, Arizona. In March 2013, the AMC sent the Veteran a letter with an authorization form for non-VA providers. The Veteran was specifically asked to provide an authorization form with the complete address and dates of treatment from a private neurologist in Prescott, Arizona. The Veteran did not respond. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA is only obligated to obtain records that are adequately identified and for which necessary releases have been submitted. See 38 C.F.R. § 3.159(c)(1). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran was afforded a VA neck conditions examination in April 2013, pursuant to the February 2013 remand. Additionally, a VA addendum opinion was provided in June 2013. Specifically, in the February 2013 remand, the Board directed the examiner to provide opinions as to the nature and etiology of any cervical spine disorder that may be present. The examiner was requested to state whether it was at least as likely as not that the disorder manifested in service or was otherwise causally or etiologically related to the Veteran's military service. In addition, the examiner was requested to opine as to the likelihood that any preexisting cervical spine disorder underwent an increase in severity during any period of active duty service, active duty for training, or inactive duty for training. The Board finds that the medical opinions obtained in this case are adequate, as they are predicated on a full reading of the available service treatment records and post-service treatment records contained in the Veteran's claims file. They consider all of the pertinent evidence of record and provide a complete rationale for the opinions stated. Additionally, the VA examiners were fully responsive to the February 2013 remand directives and provided the requested opinions in their opinions. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Additionally, as previously noted, the Veteran was provided the opportunity to testify at a hearing before the undersigned Veterans Law Judge in May 2012. The undersigned Veterans Law Judge clearly set forth the issue to be discussed, and the hearing focused on the elements necessary to substantiate the claim. Questions were asked regarding the Veteran's symptoms before service, during service, and the progression of the disorder since service. The undersigned Veterans Law Judge also inquired as to whether the Veteran was receiving any current treatment in order to determine whether there was any outstanding evidence and asked whether the Veteran had spoken to any doctors about the cause of her current disorder in order to determine whether there may be a medical opinion that could be obtained from a treatment provider. The Veteran indicated that she was treated by private physicians and not by VA providers, which is part of the reason the case was remanded to obtain a VA medical opinion. For these reasons, the Board finds that VA fully complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). VA has further assisted the appellant and her representative throughout the course of this appeal by providing them with a statement of the case (SOC) and SSOCs which informed them of the laws and regulations relevant to the Veteran's claim. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide the particular claim on appeal. She has been given ample opportunity to present evidence and argument in support of her claim. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. Laws and Regulations Following her first period of active duty service from August 1975 to July 1977, the Veteran was commissioned as a Supply Officer in the Navy Reserve. She was mobilized to active duty in October 2006. She contends that she injured her neck while training in preparation for deployment during her mobilization. Specifically, she asserts that wearing body armor and carrying loaded packs and weapons aggravated a preexisting cervical spine disorder. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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). The term "chronic disease," whether as manifest during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 U.S.C.A. § 1101 and 38 C.F.R. § 3.309(a). Walker v. Shinseki, No. 2011-7184, slip op. at 13 (U.S. Fed. Cir. Feb. 21, 2013). The Board notes that 38 C.F.R. § 3.303(b) applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With respect to the current appeal, this list includes arthritis. See 38 C.F.R. § 3.309(a). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). However, in order for the presumption to apply, the evidence must indicate that the disability became manifest to a compensable degree within one year of separation from service. See 38 C.F.R. § 3.307. The term "active military, naval, or air service" includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a), (d). The advantage of certain evidentiary presumptions, provided by law, that assist veterans in establishing service connection for a disability do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to Veteran's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway, 13 Vet. App. at 67 (citing Paulson, 7 Vet. App. at 469-70, for the proposition that, "if a claim relates to period of [ACDUTRA], a disability must have manifested itself during that period; otherwise, the period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim" (emphasis in McManaway)); see also Biggins v. Derwinski, 1 Vet. App. 474, 479 (1991) (Steinberg, J., concurring). Thus, the evidentiary burden is on the claimant to show that he or she became disabled from an injury or disease incurred in line of duty during ACDUTRA or from an injury incurred in line of duty during INACDUTRA. As noted above, while arthritis may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service, this presumption does not apply to periods of ACDUTRA and INACDUTRA. See 38 U.S.C.A. § 1112. Therefore, with respect to whether this chronic disability manifested within one year of separation, this presumption does not apply to the Veteran's periods of ACDUTRA or INACDUTRA. In order to establish entitlement to service connection for a disability, the 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by the veteran of the preservice existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003) (citing Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)) and Vanerson, 12 Vet. App. at 258, 261; id. at 263 (Nebeker, C.J., concurring in part and dissenting in part). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the preexisting condition. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); 38 U.S.C.A. § 1153. A presumption is an assumption of fact resulting from a rule of law which requires such fact to be assumed from another fact or group of facts found or otherwise established in the action. Black's Law Dictionary 1067 (5th ed. 1979). Therefore, where the presumption of sound condition at entrance to service cannot be rebutted, the fact for which the presumption stands--that is, that the veteran was in sound condition at entry to service as to the disability for which he seeks service connection--must be assumed as a matter of law. Accordingly, where the government fails to rebut the presumption of soundness under section 1111, the veteran's claim must be considered one for service incurrence or direct service connection. See Wagner, 370 F.3d at 1094, 1096 (indicating that, in cases where the presumption of soundness cannot be rebutted, the effect is that claims for service connection based on aggravation are converted into claims for service connection based on service incurrence). Where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). For veterans who served during a period of war or after December 31, 1946, clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service, and clear and unmistakable evidence includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). The usual effects of medical and surgical treatment in service, having the effect of ameliorating disease or other conditions incurred before enlistment, will not be considered service connected unless the disease or injury is otherwise aggravated by service. 38 C.F.R. § 3.306(b)(1). Factual Background Service personnel records show the Veteran served on active duty from August 1975 to July 1977 as a corpsman in the Navy. Following her first period of active duty service, she was commissioned as a Supply Officer in the Navy Reserve. Service personnel records show the Veteran had several periods of ACDUTRA from June 1985 to September 2000. Specifically, she had ACDUTRA service, including annual training, from June 17, 1985, to June 28, 1985; from June 16, 1986, to June 27, 2986; from January 22, 1989, to February 3, 1989; from January 21, 1990, to February 2, 1990; from October 16, 1990, to October 28, 1990; from October 19, 1992, to October 30, 1992; on February 5, 1996; from June 1, 1997, to June 15, 1997; from February 15, 1998, to February 27, 1998; on June 8, 2000; and from September 12, 2000, to September 24, 2000. Service personnel records also show the Veteran was mobilized to active duty in October 2006. She participated in Army training at Camp Shelby in preparation for deployment to Afghanistan during her mobilization. In a December 1984 enlistment examination, the examining medical officer noted a normal examination of the neck and spine. He determined that the Veteran was qualified for all duties on land and at sea. In an associated report of medical history, the Veteran reported that she was in "good health." She denied a history of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and recurrent back pain. In a May 1986 annual examination, the examining medical officer noted a normal examination of the neck and spine. He determined that the Veteran was qualified for all duties of her rank or rate at sea and in the field. In an associated report of medical history, the Veteran reported that she was in "good health." She again denied a history of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and recurrent back pain. During a period of ACDUTRA from June 16, 1986, to June 27, 1986, the Veteran complained of a stiff neck. Specifically, in a service treatment note dated on June 16, 1986, the Veteran complained of a stiff neck with some difficulty swallowing. She indicated that her neck pain started after she drove from Youngstown, Ohio, to Norfolk, Virginia, for training. She demonstrated 50 percent of forward flexion, 75 percent of extension, 60 percent rotation to the left, and 50 percent rotation to the right. The examiner noted a moderated lower cervical paravertebral muscle spasm. The diagnosis was an acute cervical strain. In a June 16, 1986 physical therapy consultation report, the Veteran complained of right side cervical pain. She indicated that the pain had a gradual onset since the night before after she drove ten hours. An examination showed that range of motion of the cervical spine was within normal limits. The Veteran described some tingling on the right side of her neck and radiating pain from the right ear down to her right shoulder. The diagnosis was a cervical strain. In a June 18, 1986, physical therapy follow-up evaluation, the Veteran stated that she was doing better and had some improvement of range of motion in her cervical spine. She denied any radicular symptoms. There were no acute muscle spasms on examination. There was a mild decrease in range of motion, specifically in rotation and bending bilaterally, but flexion and extension were within normal limits. The diagnosis was a cervical strain. In a statement dated on June 27, 1986, the Veteran reported that there had been "no adverse change in [her] health while on [ACDUTRA]." In an October 1987 re-enlistment examination, the examining medical officer noted a normal examination of the neck and spine. He determined that the Veteran was qualified for retention or all duties of her rank or rate worldwide. In associated reports of medical history, the Veteran reported that she was in "good health." She denied a history of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and recurrent back pain. In April 1988 and June 1991 periodic examinations, the examining medical officers noted normal examinations of the neck and spine. They determined that the Veteran was qualified for retention or all duties of her rank or rate worldwide. In associated reports of medical history, the Veteran reported that she was in "good health." She denied a history of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and recurrent back pain in each report. In a December 1994 private treatment note, the Veteran complained of chronic neck pain and a deteriorating disc status-post epidural injections. She reported that the first injection provided relief for one year and the second injection provided relief for less than one year. She reported numbness in the right side of her face secondary to her neck problem and pain with lateral movement. The diagnosis was chronic neck pain. In a June 1995 annual certificate of physical condition, the Veteran reported that, within the past 12 months, a cervical strain with muscle spasms that caused her to be absent from school, duty, or her civilian occupation for more than three consecutive days. She indicated that she treated her symptoms with Tylenol, anti-inflammatory medications, and muscle relaxers. She reported that she was not treated by a physician in the past 12 months and she was not currently taking any medications. She reported that she did not have any physical defects that might restrict her performance on active duty or prevent her mobilization. In a June 1996 periodic examination, the examining medical officer noted a normal examination of the neck and spine. He determined that the Veteran was qualified for retention or all duties of her rank or rate worldwide. In an associated report of medical history, the Veteran reported that she was in "good health." She denied a history of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and recurrent back pain. August 2000 private x-rays of the cervical spine showed a normal examination with the exception of a slight narrowing of the disc space at the C5-C6 level. A September 2000 private magnetic resonance imaging (MRI) study of the cervical spine showed disc degeneration changes at C5-C6 with osteophyte complex narrowing of the ventral subarachnoid space. There was no cord deformity or signal abnormality at that level, and there was no apparent foraminal stenosis. The interpreting physician noted that, otherwise, it was an unremarkable MRI of the cervical spine. In a June 2001 periodic examination, the examining medical officer noted a normal examination of the neck and spine. She determined that the Veteran was qualified for retention or all duties of her rank or rate worldwide. In an associated report of medical history, the Veteran reported that she was in "good health." She denied a history of bone, joint, or other deformity; and recurrent back pain. She reported that she had a history of arthritis, and the examining medical officer noted that the Veteran had arthritis in her neck that flared up approximately two times per year. In a January 2004 private MRI study report, the interpreting physician noted that the Veteran complained of neck pain with right arm numbness and associated tingling over the past two years. The MRI of the cervical spine showed moderate hypertrophic disc desiccation at the C5-C6 level with associated posterior disc bulging and minimal posterior osteophyte formation causing moderate flattening of the anterior thecal sac without central spinal stenosis or significant neural foraminal impingement at that level. The MRI also showed straightening of the normal lordotic curvature and subtle levoscoliosis, suspected for mild spasm; no central spinal stenosis, disc herniation, or other level of neural foraminal narrowing; and no focal area of abnormal enhancement or demyelination. In a July 2004 annual certificate of physical condition, the Veteran reported that she was treated by a physician for a bulging disc at C5-C6 in the past year. She related that she had a MRI in December 2003, was subsequently diagnosed with a bulging disc, and prescribed medications for a short time. She indicated that she took Neurotin and Skelaxin for one month and Vicodin for two weeks in May 2004, but she stated that she was not currently taking any medications. In a March 2005 statement, the Veteran's treating private chiropractor reported that the Veteran could drill without restrictions and her cervical spine and back conditions should not restrict her Naval Reserve duty status. In a May 2005 Navy Reserve periodic health assessment, the Veteran was found fit for duty and worldwide assignments. In a June 2005 report of medical examination, the examining medical officer noted normal examinations of the neck and spine. In an associated report of medical history, the Veteran indicated that she had a history of numbness or tingling in the face secondary to disc herniation in her neck for two and a half years. She also noted that chiropractic treatments helped relieve her symptoms. The Veteran denied recurrent back pain or any back problems; swollen or painful joints; and bone, joint, or other deformity. She indicated that she was treated in the past for neck pain, spasms, and suspected meningitis in 1997. The examining medical officer noted that the Veteran's neck discomfort was relieved with decreased stress and chiropractic treatment. In a May 2006 private treatment note, the Veteran reported that she had chronic neck pain. She indicated that she had been treated by multiple physicians and had x-rays that showed degenerative joint disease. She related that chiropractic treatment provided good effect, but she occasionally had flare ups of neck pain, usually following motorcycle rides or physical exertion like staking ten holes for trees. She indicated that her flares of pain resolved well with Naproxen. The diagnosis was neck pain likely related to osteoarthritis or degenerative joint disease. In a September 2006 report of medical history for a pre-deployment health assessment, the Veteran indicated that she had a history of arthritis, rheumatism, or bursitis; and minor numbness or tingling. She denied recurrent back pain or any back problems; swollen or painful joints; and bone, joint, or other deformity. She reported that she was treated in an emergency room in the past for severe neck pain and to rule out meningitis. The examining medical officer noted that there was no change in the Veteran's medical history and determined that she was fit for full duty. In a September 2006 pre-deployment health assessment, the Veteran stated that her general health was "excellent," and she denied any medical problems. The examining medical officer determined that the Veteran was deployable. In a November 2006 private physical medicine and rehabilitation consultation report, the examining physician noted that the Veteran was referred by a nurse at Camp Shelby. The Veteran complained of neck pain, and she indicated that she had a history of chronic neck problems. She reported that a past MRI showed degenerative changes in her neck two years ago. She related that, since she wore body armor during a recent training drill, she had developed increasing neck and parascapular soreness. On examination, she had general tenderness to palpation in the neck. She had forward flexion from her chin to her chest, and she had extension to 10 degrees. She was able to side bend left and right 20 degrees, and she could rotate left and right 80 degrees. The diagnoses were suspected degenerative disc disease of the cervical spine and increased neck pain. A November 2006 private MRI of the cervical spine showed C5-C6 mild cervical spondylitic changes with loss of disc height and broad-based osteophytic lipping and a very minor disc bulge in the right paracentral area at C6-C7. The interpreting physician noted an otherwise unremarkable cervical spine MRI scan. In a November 2006 service treatment note, a list of active medications included Naproxen, Tramadol, Carbamide Peroxide, Metaxalone, and Doxycycline Hyclate for neck pain and spasms. The medications were last filled approximately one week ago, and the Veteran was instructed to begin taking the Doxycycline Hyclate two days prior to deployment daily throughout deployment. The examining physician noted that the Veteran was recently evaluated by physical medicine. She indicated that she reviewed the private treatment notes and MRI. The Veteran reported that her cervical spine pain was unimproved with medication and that she was unable to wear individual body armor (IBA) for longer than ten minutes. The diagnosis was a bulging disc at C5-C6. In November 2006, the Veteran's treating medical officer addressed a memorandum to the Commander at Camp Shelby that stated that the Veteran was not deployable due to unresolved medical issues. In a November 2006 report of medical assessment, the Veteran indicated that she began the current period of active duty in October 2006. She indicated that her overall health was worse since her last medical assessment because she injured her neck as a result of wearing body armor. She reported that she received treatment at Camp Shelby and that she felt that she could not be assigned to duty that required her to wear body armor. In a March 2007 report of medical history, the Veteran reported that she had a history of arthritis, rheumatism, or bursitis; recurrent back pain or any back problem; numbness or tingling; swollen or painful joints; and bone, joint, or other deformity. Specifically, she noted that her neck was painful, she had degenerative disc disease at C5-C6-C7, and the right side of her face was numb or tingling. She reported that she was treated in an emergency room for her neck to rule out meningitis in approximately 1996. She also reported that she was discharged in November 2006 due to a line of duty injury during mobilization and she was "immediate[ly] reaffiliate[d]" in the Reserves. The examining physician noted that the Veteran had a past medical history that was significant for cervical herniated discs at C5-C6 and C6-C7. In a March 2007 report of medical examination, the examining medical officer noted normal examinations of the neck and spine. She noted that the Veteran had full range of motion of the head with normal strength. She also noted that a cervical MRI showed herniated discs at C5-C6 and C6-C7 and that the Veteran had intermittent neck pain treated with intermittent use of nonsteroidal anti inflammatory drugs and muscle relaxants. In April 2007, the Navy Chief of the Bureau of Medicine and Surgery determined that the Veteran was not physically qualified for active service, promotion, transfer to, or retention in the Ready Reserve or ACDUTRA at that time due to cervical disc degeneration. In May 2007, the Commander at Navy Personnel Command assigned the Veteran a Physical Risk Classification of "4" and notified her that she was not authorized to perform annual ACDUTRA or INACDUTRA after April 2007 until the medical review process was finalized. In a May 2007 statement, a private physician indicated that the Veteran had surgery in May 2007 and that she would be able to return to work in June 2007 without restrictions. In a June 2007 private treatment note, the Veteran reported that she needed a note to resume Reserve duty. She indicated that she was placed on restrictive duty because of her neck pain after training with full body armor. The physician noted that the Veteran had been symptom-free for the past six months, and she had no current neck pain. The physician reported that the Veteran had good range of motion in her neck and she had no numbness in her arms. The Veteran related that she had been able to perform heavy duties at home without difficulty, she exercised on a regular basis, and she felt that she would have no problem resuming her Reserve duties. The physician reported that the Veteran's cervicalgia had resolved, and she was cleared to participate in her Reserve duties. In a June 2007 statement, the private physician reported that the Veteran was cleared to return to her reserve duty and that there were currently no residual effects from her medical condition. The physician stated that the Veteran had no physical restrictions, and she was able to participate in the physical fitness test. In a June 2007 statement addressed to the medical department at Navy Operational Support Center in San Diego, California, a private chiropractor reported that the Veteran presented for treatment complaining of pain in the right side of the cervical spine that radiated to her right arm in March 2005. She related that the pain began after a motor vehicle accident in November 2003. She indicated that she ran into the car ahead of her at a speed of five miles per hour. She reported that a past MRI showed degenerative joint disease in her cervical spine at the C5-C6 cervical joint with no herniated discs. Her initial examination showed a 30 percent reduction in cervical flexion, extension, and bilateral lateral flexion motions. There was a bilateral 25 percent limitation in the cervical rotation motions and muscle tension was palpated bilaterally at the fifth cervical joint. The chiropractor noted that he treated the Veteran conservatively with specific spinal adjustments without twisting motions. He noted that, in June 2007, the Veteran complained of"tightness in her neck that just ache[d]." Her cervical flexion and extension motions were both limited by 20 percent, cervical rotation was limited by 10 percent bilaterally, and cervical lateral flexion was limited by 40 percent bilaterally. The chiropractor diagnosed the Veteran with torticollis, thoracic neuritis, and intercostals neuritis. In the June 2007 correspondence, the chiropractor reported: I feel that the low cervical condition is a chronic condition. [The Veteran] came to this office November 8, 2006 after returning from training that was to prepare her for deployment to Afghanistan. She had been sent home from training because of pain across her low cervical spine and upper thoracic spine from not being able to hold up under the weight of full body armor and full combat gear. The chiropractor also opined that "a resumption of training wearing body armor along with full combat gear will result in the same problems as the training in the autumn of 2006" because of the chronic degenerative joint disease between the C5-C6 cervical vertebrae. He also indicated that he expected that training at the firing range in the prone position while looking up to fire at targets would cause a flare up of neck pain. He reported that the Veteran would not be able to "look up for any appreciable periods of time due to pain and stiffness" at the C5-C6 joint, and cervical extension for periods of more than one minute "would be expected to take a heavy physical toll on her, likely causing an acute flare up of low neck pain." In a July 2007 internal medicine service treatment note, the examining medical officer reported that the Veteran was currently a Physical Risk Classification 4 following demobilization during training for neck pain aggravated by wearing body armor. He noted that she had a history of cervical disc problems and neck pain "since at least the mid 1980s." He noted that the first entry for neck pain in the Veteran's service treatment notes was dated on June 16, 1986, when she was treated for neck pain related to driving for ten hours. He indicated that the only entry pertaining to complaints while on ACDUTRA was in November 2006, when the Veteran had difficulty with training at Camp Shelby. He noted that the history of the medical problems during training "apparently revolve around the inability to wear body armor without neck pain" which was "attributed to the presence of bulging discs identified on MRI." In the July 2007 service treatment note, the examining medical officer noted that the Veteran denied any current pain. She reported that she had long periods of neck pain or stiffness with periods of discomfort. On examination, she demonstrated active and passive range of motion that was "nearly normal with mild limitation in side bending to approximately 45 degrees bilaterally. There was no evidence of pain at the extremes of her range of motion. The physician noted that there was no evidence of arthrosis. He diagnosed the Veteran with an intermittent history of neck pain not associated with a hard neurologic deficit, and radiographic evidence of mild spondylosis with disc height loss and some osteophyte changes at C5-C6 without a neurologic element of impingement. In the July 2007 service treatment note, the physician stated, "The occasional or episodic events date back far enough to suggest muscle tension or mild sprain as etiologic at least in the past." He stated that there was some current radiographic evidence to support findings of mild to moderate degenerative changes which did not identify any impingemental neurologic structures. He opined that the degenerative changes could account for some episodes of neck pain, but, he noted that the Veteran did not report any consistent, regular, or daily pain. He also noted that the Veteran had been cleared for unrestricted activity by her primary care provider and her treating chiropractor. His assessment was that the Veteran's episodic neck pain was musculotendonous and related to isolated sprains or activity. He reported that the Veteran's neck was "possibly aggravated by minor degenerative changes in the [cervical] spine which are probably age normal or at least common to age." He also opined that the November 2006 episode of neck pain might have represented an acute sprain process and he did not predict regular recurrence. In an August 2007 private treatment note, the Veteran reported that her chronic neck pain from disc degeneration had increased in severity after she was involved in a motorcycle accident in which she was struck by a truck one week earlier. She indicated that she was wearing a helmet and she denied any loss of consciousness. The physician diagnosed the Veteran with acute cervicalgia. In a May 2008 private treatment note, the Veteran complained of two weeks of neck pain following a 12 mile bike ride. The physician noted a two year history of bulging discs in the area of C5-C6. The Veteran reported that she felt some radiation or tingling in the right side of her face and in her right upper arm with jolts of pain in her neck and throbbing occipital headaches. The physician noted that range of motion was "pretty good." An examination showed mild lower cervical midline tenderness and right paravertebral tenderness. No spasms were noted. The diagnosis was acute cervicalgia, and the physician noted that it was "likely cervical disc disease." A May 2008 private MRI of the cervical spine showed mild multilevel spondylosis, most prominent at C5-C6. There was a circumferential disc or osteophyte complex present resulting in the effacement of the ventral subarachnoid space at C5-C6 with mild contact of the ventral cord. There was no evidence of significant compression at C5-C6. There was a right central disc protrusion at C6-C7 that resulted in mild effacement of the ventral subarachnoid space. There was no evidence of cord contact or cord compression at C6-C7. In a May 2008 private treatment note, the Veteran complained of progressive pain in the posterior cervical area for approximately two months. There was tightness and tenderness on motion and pain on palpation of the lateral masses of the neck. The anterior neck structures were normal, and muscle strength was within normal limits. The physician's impression was cervical facet joint syndrome. In May 2008 and June 2008, the Veteran had C6-C7 cervical zygapophyseal joint injections. In a June 2008 private procedure note, the Veteran reported that she experienced 30 to 40 percent pain relief which lasted approximately 48 hours after her first injection in May 2008. She was provided a second injection in June 2008. In a May 2009 statement, the Veteran reported that her November 2003 motor vehicle accident was a "minor fender-bender at a stop light" and that there were no injuries resulting from the accident. In a June 2009 private treatment note, the Veteran reported that she had at least 10 months of complete pain relief following the May 2008 and June 2008 injections. She indicated that her symptoms had since returned gradually. The diagnosis was cervical facet joint syndrome. During a July 2009 hearing before the Decision Review Officer (DRO) at the RO, the Veteran reported that she had a chronic cervical spine disorder that preexisted her active duty service in October 2006. The Veteran's representative indicated that the Veteran was recalled to active duty and that her unit was mobilized to the Middle East. In support of the mobilization, the Veteran related that she had to undergo training and was required to wear body armor and full field gear that weighed approximately 80 pounds for at least 12 hours per day. He noted that the Veteran weighed approximately 125 to 135 pounds at that time, and the body armor caused her discomfort and pain and aggravated her preexisting neck condition. He noted that private medical records, dated in November 2006 showed a disc bulge at C5-C6 that was not as severe prior to her October 2006 training. The Veteran reported that she had degenerative disc disease in C5-C6 that was aggravated during training, and she currently had additional problems with C6-C7. Prior to beginning training at Camp Shelby, she indicated that she occasionally had stress-induced tension and stiffness in her neck with arthritis in the C5-C6 region. She stated that the pain became constant and more severe with stiffness and tingling in her face. She indicated that chiropractic care provided some relief for her acute episodes prior to October 2006, but it no longer helped. With respect to the November 2003 motor vehicle accident reported in the record, during the July 2009 hearing, the Veteran's representative indicated that the accident had "nothing to do with the pain and discomfort" that the Veteran experienced during training for deployment. In a June 2010 statement, the Veteran reported that she injured her neck while training with the Army prior to deployment in October 2006 after she was mobilized. She stated that her neck injury "resulted in [two] compromised disk spaces with some bulging." She indicated that, prior to the October 2006 injury, she "only had disk degeneration in [one] disk space [at] C5-C6." She reported that she currently had limitations in her activity level and knew that certain activities aggravated her neck. She also indicated that she woke up every morning with neck pain that she had never had before. During a May 2012 travel board hearing, the Veteran's representative reported that the Veteran was treated for discomfort in her neck at sick call on several occasions during her initial period of active service from August 1975 to July 1977. See transcript, p. 1. He indicated that she was activated in October 2006 and reinjured or aggravated her preexisting neck condition during training in preparation for deployment during her mobilization. During the May 2012 hearing, the Veteran reported that her neck pain began when she was participating in two weeks of ACDUTRA during her Reserve service and was treated for neck strain. See transcript, pp. 4-5. She indicated that the neck strain resolved, and her current problem was a disc problem in her cervical spine that began when she was in her late forties in approximately June 2005. Id. at 6-8. She also related that a private physician told her that most people had disc problems at that age and that it was nothing unusual. See transcript, p. 9. She contended that her neck condition was aggravated when she wore body armor at training after she was activated in October 2006. She stated that she noticed an increased worsening of her neck condition "probably about the two and half, three week mark, into the training." Id. at 10. She related that her pain increased to the point where she was unable to wear the body armor for five minutes before she buckled over and tried to get the weight off of her neck. Id. at 11. She indicated that she went to sick call and had an MRI that showed a bulging disc in her cervical spine. Id. She reported that she had some relief of her symptoms after she stopped wearing the body armor, but it "took probably several months of follow-up... treatment, and... a few injections in [her] neck... to alleviate [the pain]." Id. at 12. She reported that her problems continued to the present day and limited her activities due to the disc bulge. Id. at 13. During an April 2013 VA neck conditions examination, the Veteran reported that her neck began hurting to the point that she was unable to tolerate any weight after she participated in training in preparation for deployment in October 2006. She indicated that she was performing physical training in full body armor with the Army. She stated that she was found unfit for deployment and was discharged from the Reserves due to her neck condition. She indicated that she had flare-ups of pain with hyperextension or looking up for a sustained amount of time, and she was unable to tolerate any weight on her neck. She reported that her neck became stiff and hurt when she was holding her grandchildren. She indicated that she took nonsteroidal anti-inflammatory drugs with good relief. Range of motion testing of the neck was normal, and an x-ray of the cervical spine showed no evidence of degenerative joint disease or vertebral fracture. The examiner noted that October 2006 x-rays showed C5-C6 and C7-T1 degenerative disc disease. The examiner diagnosed the Veteran with degenerative disc disease. In the April 2013 VA examination report, the examiner opined that the Veteran's claimed cervical spine disorder clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. She noted that a review of the claims file showed service treatment notes and private treatment records for cervical pain with a bulging disc prior to 2006. She noted that further review of the private treatment notes showed a history of pain "coming on in approximately 2008, with no mention of any of [the Veteran's] prior history." She also indicated that there was a conflicting report as to whether the Veteran had neck pain after the 2003 motor vehicle accident. She specifically referenced a 2007 statement by a physician that stated that the Veteran had neck pain following the accident and a 2009 statement in which the Veteran denied any neck pain following the accident. The examiner also noted that there was a lack of documentation as to the continuity of the Veteran's neck pain. She noted that the Veteran's denial of any problems in 2009 led her to the conclusion that the Veteran's neck condition was not aggravated by active duty in 2006. In a June 2013 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's claimed neck condition was caused by or aggravated beyond its natural and normal aging process by her month of active service in 2006. She referenced a March 2005 private treatment note in which the examining physician documented the Veteran's complaints of right-sided cervical spine pain radiating down her right arm. A March 2005 physical examination showed the Veteran had a 30 percent reduction in cervical flexion, extension, and lateral movement, bilaterally, and the physician opined that the presumed etiology was a 2003 automobile accident. The VA examiner also noted that private treatment notes, dated just prior to the Veteran's 2006 period of active duty, in January 2006 and May 2006, confirmed the existence of chronic neck pain and x-rays showed degenerative joint disease. Following the November 2006 determination that the Veteran was nondeployable due to unresolved medical issues, the VA examiner indicated that a May 2008 private MRI showed mild multilevel spondylosis, most prominent at C5-C6. Additionally, a May 2008 private treatment note showed the chronic pain did not respond to conservative therapy and interventional pain control. The VA examiner stated, "I am in total agreement with the [April 2013 VA examiner]. The examiner stated[,] 'The claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness.' Furthermore, in my opinion, the one month [period of active duty] was LESS LIKELY THAN NOT an aggravator or aggravated the condition beyond its normal progress but was an immediate signal of the Veteran's 'unfit' condition[,] thus[,] not the cause of or aggravator of her neck condition due to military service." Analysis In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a cervical spine disorder. As noted above, the Veteran contends that she injured her neck while training in preparation for deployment during her mobilization in October 2006. Specifically, she asserts that wearing body armor and carrying loaded packs and weapons aggravated a preexisting cervical spine disorder. She has not alleged that it is related to an earlier period of service. In fact, she has stated that her earlier neck strain during a period of ACDUTRA had resolved. See e.g. transcript, pp.4-8. In this case, the presumption of soundness applies because, during a September 2006 pre-deployment health assessment conducted before her October 2006 mobilization, the Veteran reported that her general health was "excellent" and she denied any medical problems. The examining medical officer determined that the Veteran was deployable. The medical officer did not refer the Veteran to any specialists for further evaluation, and she did not provide any comments with her determination. There was no notation of a cervical spine disorder. Nevertheless, as an initial matter, the Board finds that the Veteran had a preexisting cervical spine disorder prior to her October 2006 mobilization. In cases where disorders are not noted on the entrance or enlistment examination, as in this case, VA's General Counsel has clarified that VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). With respect to the first prong of the rebuttal standard, the Board finds there is clear and unmistakable evidence that the Veteran's cervical spine disorder preexisted her October 2006 mobilization. In fact, in a September 2006 report of medical history for the pre-deployment health assessment, the Veteran indicated that she had a history of arthritis, rheumatism, or bursitis; and minor numbing or tingling. She also reported that she was treated in an emergency room in the past for severe neck pain and to rule out meningitis. In previous service treatment notes, she indicated that she was treated for suspected meningitis in approximately 1996 or 1997. See June 2005 report of medical examination and March 2007 report of medical history. The Board notes that a history provided by the Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson, 7 Vet. App. at 470; Crowe, 7 Vet. App. at 246. However, the record contains numerous service treatment notes and private treatment notes that document complaints of, treatment for, and diagnoses pertaining to the Veteran's neck. Therefore, the Board finds that the record shows, by clear and unmistakable evidence, that the Veteran's cervical spine disorder preexisted service. With respect to the second prong of the rebuttal standard, the Board finds that the preexisting cervical spine disorder was not aggravated by service. The Veteran clearly sought treatment for neck pain during her October 2006 period of active duty. As noted above, in a November 2006 private physical medicine and rehabilitation consultation report, the examining physician noted that the Veteran was referred by a nurse at Camp Shelby. The Veteran complained of neck pain and indicated that she had a history of chronic neck problems. In a November 2006 service treatment note, a medication list showed that the Veteran was prescribed medications for neck pain and spasms. During the November 2006 treatment, the Veteran reported that her cervical spine pain was not improving with medication and that she was unable to wear individual body armor for longer than ten minutes. In addition, in a November 2006 report of medical assessment, the Veteran indicated that her overall health had worsened during her mobilization because she injured her neck as a result of wearing body armor. Based on the foregoing, it is clear that the Veteran did have some complaints and treatment during her mobilization. However, such symptomatology alone is not enough. Instead, the evidence must show that there was an increase in her preexisting cervical spine disorder during service that was beyond the natural progress of the disorder. The April 2013 VA examiner opined that the Veteran's preexisting cervical spine disorder was not aggravated beyond its natural progression by her October 2006 mobilization. She noted that her review of the claims file showed service treatment notes and private treatment notes that documented the Veteran had cervical pain with a bulging disc prior to 2006. However, her review of the private treatment notes following the Veteran's period of active duty from October 2006 to November 2006 showed a history of pain "coming on in approximately 2008, with no mention of any of [the Veteran's] prior history." She also referenced a 2009 private treatment note in which the Veteran denied any problems pertaining to her neck. In addition, the June 2013 VA examiner indicated that she was in "total agreement" with the April 2013 VA examiner's opinion. The Board also notes that, prior to the Veteran's mobilization in October 2006, there were several complaints of chronic neck pain in her service treatment notes and private treatment notes. Specifically, the Veteran complained of neck pain, stiffness, muscle spasms, numbness in the right side of her face, and pain radiating to her right shoulder before her mobilization. See December 1994 private treatment note, June 1995 annual certificate of physical condition, June 2005 report of medical history, May 2006 private treatment note, and September 2006 report of medical history. After her mobilization, she complained of the same symptoms. See March 2007 report of medical history, August 2007 private treatment note, May 2008 private treatment note, May 2008 private treatment note, July 2009 DRO hearing, and April 2013 VA neck conditions examination. Additionally, in a July 2007 service treatment note, the examining medical officer had "occasional or episodic events" of neck pain. He also reported that the Veteran did not complain of any consistent, regular, or daily pain. Rather, his assessment was that the Veteran's episodic neck pain was musculotendonous and related to isolated sprains or activity. As previously noted, temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Based on this evidence, it appears that the Veteran's episodic complaints appeared to resolve and that she had only temporary or intermittent flare-ups of symptoms. Indeed, in a June 2001 periodic examination report, the examining medical officer noted that the Veteran had arthritis in her neck that flared up approximately two times per year. Specific events of episodic neck pain that resolved included complaints of a stiff neck in June 1986 during a period of ACDUTRA. She reported that her neck pain began after she drove ten hours from Youngstown, Ohio, to Norfolk, Virginia, for training. The examiner noted some limitation in range of motion of the cervical spine and a moderate lower cervical paravertebral muscle spasm. A physical therapy consultation report dated on the same day indicated that range of motion of the cervical spine was within normal limits and included the Veteran's complaints of some tingling on the right side of her neck and pain that radiated from her right ear down to her right shoulder. The diagnosis was acute cervical strain. In a follow-up physical therapy evaluation dated two days later, the Veteran stated that she was "doing better" and had some improvement in the range of motion of her cervical spine. She also denied any radicular symptoms and there were no acute muscle spasms on examination. In a statement, dated seven days after her initial complaints of neck pain, the Veteran reported that there had been "no adverse change in [her] health while on [ACDUTRA]." In addition, during the May 2012 hearing, the Veteran reported that her neck pain began when she was participating in two weeks of ACDUTRA and she was treated for neck strain; however, she also stated that her neck strain from that period of ACDUTRA had resolved. See transcript, pp. 4-6. In a June 1995 annual certificate of physical condition, the Veteran reported that a cervical strain with muscle spasms caused her to be absent from school, duty, or her civilian occupation for more than three consecutive days in the past twelve months; however, she reported that she did not have any physical defects that might restrict her performance on active duty or prevent her mobilization. In addition, in a June 1996 periodic health examination, the examining medical officer noted a normal examination of the neck and spine. In addition, there is some disparity in the record concerning a November 2003 motor vehicle accident prior to her mobilization. In a June 2007 statement, the Veteran's treating chiropractor indicated that the Veteran's neck pain began following the November 2003 motor vehicle accident. However, in a May 2009 statement, the Veteran reported that the November 2003 motor vehicle accident was a "minor fender-bender at a stop light" and that there were no injuries resulting from the accident. In addition, during the July 2009 DRO hearing, the Veteran's representative indicated that the accident had "nothing to do with the pain and discomfort" that the Veteran experienced during training for deployment. The Board agrees with the representative to the extent that whether the Veteran injured her neck during the November 2003 accident has little bearing on whether her preexisting cervical spine condition was aggravated beyond its natural progression by her October 2006 mobilization. There is evidence that the Veteran's episodic flare-ups of symptoms related to her cervical spine disorder resolved with medication, chiropractic treatment, cortisone injections, and/or a reduction in stress before and after her mobilization. For example, in a December 1994 private treatment note, the Veteran complained of chronic neck pain and a deteriorating disc status-post epidural injections. She indicated that a cortisone injection provided relief for one year and a second injection provided relief for less than one year. In a June 1995 annual certificate of physical condition, she reported that she treated her symptoms with Tylenol, anti-inflammatory medications, and muscle relaxers. In a July 2004 annual certificate of physical condition, the Veteran reported that she was prescribed medications for a "short time," including Neurotin and Skelaxin for a period of one month and Vicodin for a period of two weeks. She indicated that she was not taking any medication at that time. In a June 2005 report of medical examination, the medical officer noted that the Veteran's neck discomfort was relieved with decreased stress and chiropractic treatment. In a May 2006 private treatment note, the Veteran reported that she occasionally had flare-ups of neck pain, usually following motorcycle rides or heavy physical exertion, but her flare-ups of pain resolved well with Naproxen. Following her mobilization, in a March 2007 report of medical examination, the examining medical officer noted that the Veteran had intermittent neck pain treated with intermittent use of nonsteroidal anti-inflammatory drugs and muscle relaxants. During the July 2009 DRO hearing, the Veteran reported that, before she began training at Camp Shelby in October 2006, she occasionally had stress-induced tension and stiffness in her neck with arthritis in the C5-C6 region. She stated that, after mobilization, the pain became constant and more severe with stiffness and tingling in her face and she indicated that chiropractic care no longer helped relieve her symptoms. However, she subsequently stated that her symptoms had resolved. During the May 2012 travel board hearing, she indicated that she had some immediate relief of her symptoms after she stopped training and wearing body armor, but it "took probably several months of follow-up... treatment, and... a few injections in [her] neck... to alleviate [the pain]." See hearing transcript, p. 12. In June 2007 correspondence, the Veteran's treating chiropractor noted that the Veteran had "acute flare[-]up[s] of low neck pain" and a resumption of training, including wearing body armor and full combat gear, would likely result in the same problems as she had in October 2006. This evidence suggests that the Veteran's neck symptoms had resolved by June 2007. Further, in a June 2007 private treatment note, the Veteran's private treating physician reported that the Veteran had been "symptom free" for the past six months and that she had no current neck pain. She had good range of motion in her neck and she had no numbness in her arms. She had been able to perform heavy duties at home without difficulty, exercised on a regular basis, and felt that she would have no problem resuming her Reserve duties. The physician reported that the Veteran's cervicalgia had resolved and that she was cleared to participate in her Reserve duties. In a subsequent June 2007 statement, the physician reported that the Veteran was cleared to return to her Reserve duty and that there were "currently no residual effects from her medical condition." Moreover, in a July 2007 service treatment note, the examining medical officer opined that the episode of neck pain might have represented an acute sprain process, and he did not predict regular recurrence. Additionally, the Board notes that, during the July 2009 DRO hearing, the Veteran's representative asserted that the Veteran's disc bulge at C5-C6 was not as severe prior to her October 2006 mobilization. The Veteran also reported that, before her mobilization, she had degenerative disc disease in C5-C6 that was aggravated during training and resulted in additional problems with C6-C7. The Board notes that a January 2004 private MRI study showed moderate hypertrophic disc dessication at the C5-C6 level with associated posterior disc bulging and minimal posterior osteophyte formation, whereas a November 2006 private MRI of the cervical spine showed mild cervical spondylitic changes at C5-C6 and a "very minor disc bulge" in the right paracentral area at C6-C7. However, in a July 2007 service treatment note, the examining medical officer suggested that the Veteran's neck was "possibly aggravated by minor degenerative changes in the [cervical] spine which are probably age normal or at least common to age." Indeed, the Veteran also reported that her current neck problem was related to a disc problem in her cervical spine that began when she was in her late forties, in approximately 2005, and a private physician had told her that "most people had disc problems at that age and that it was nothing unusual." See transcript, pp. 6-9. The Veteran has not submitted any other medical evidence addressing whether her preexisting cervical spine disorder permanently increased in severity beyond the natural progression of the disorder. The Board does acknowledge the Veteran's contentions that her cervical spine disorder was aggravated during her mobilization and that she had increased cervical spine pain since October 2006. Lay persons may provide competent testimony as to visible symptoms and manifestations of a disorder, they are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006). In this case, the Veteran is competent to attest to her experiences and symptoms in service and thereafter. The Board also acknowledges that she did have symptomatology in service. However, her statements are outweighed by the medical opinions of the April 2013 and June 2013 VA examiners in this case who determined that her cervical spine disorder was not aggravated by her military service beyond the natural progression of the disorder. The examiners considered the claims file and the reported medical history, including the statements and contentions of the Veteran. Moreover, they are medical professionals with training, expertise, and experience that the Veteran does not have and provided clear rationales for their conclusions that are supported by the evidence of record. Thus, the Board finds that the medical opinions are entitled to greater probative value than the Veteran's lay assertions. Based on the foregoing, the Board concludes that the Veteran's preexisting cervical spine disorder was not aggravated by her mobilization in October 2006. Although there is evidence showing treatment during that period of active duty service, the probative evidence does not indicate that such symptomatology represented a permanent worsening beyond the natural progression of the disorder. The Board has also considered the Veteran's claim of service connection for a cervical spine disorder on a direct basis. As previously noted, the Veteran has not specifically contended that her current cervical spine disorder was caused or aggravated by active service or during a period of ACDUTRA. However, during the May 2012 hearing, the Veteran's representative reported that the Veteran was treated for neck discomfort at sick call "on several occasions during her initial period of active service from August 1975 to July 1977." See transcript, p. 1. In addition, during the hearing, the Veteran reported that her neck pain began when she was participating in two weeks of ACDUTRA during her Reserve service and she was treated for neck strain. Id. at 4-5. The Board notes that the Veteran's service treatment notes from her initial period of active duty service from August 1975 to July 1977 are not associated with the record. However, in December 1984 and May 1986 Reserve examinations, the examining medical officers noted normal examinations of the Veteran's neck and spine. In associated medical histories, the Veteran reported that she was in "good health," and she denied a history of arthritis, rheumatism, or bursitis; bone, joint, or other deformity; and recurrent back pain. In addition, the Veteran's own testimony at the May 2012 hearing contradicts the representative's report that she was treated for neck discomfort on several occasions at sick call during her initial period of active duty service. Specifically, during the hearing, she stated that her neck pain began when she was participating in two weeks of ACDUTRA during her Reserve service, following her initial period of active duty service. See hearing transcript, pp. 4-5. With respect to the Veteran's report that her neck pain first manifested during a period of ACDUTRA, as discussed above, the Board notes that she was treated for an acute episode of neck strain in October 1986. However, the Veteran reported that her neck strain had resolved and that her current problems were related to disc problems. See hearing transcript, pp. 6-8. Additionally, in the June 2013 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's claimed neck condition was caused by her month of active service from October 2006 to November 2006. Likewise, in a July 2007 service treatment note, the examining medical officer opined that the Veteran's episodic neck pain was musculotendonous and related to isolated sprains or activity. He noted that the Veteran did not report any consistent, regular, or daily pain. Moreover, in a June 2007 private treatment note, the examining physician noted that the Veteran had been symptom-free for six months with no current neck pain, and on examination in July 2007, the Veteran denied any current pain. In fact, the June 2007 private physician noted that the cervicalgia had resolved. She subsequently complained of increased neck pain following a motorcycle accident in August 2007 and a 12 mile bike ride in May 2008. See August 2007 and May 2008 private treatment notes. The Board finds that the VA examiner's opinion pertaining to the Veteran's etiology of the cervical spine disorder is entitled to great probative weight. Indeed, as previously noted, the June 2013 VA examiner specifically considered the claims file and the reported medical history, including the statements and contentions of the Veteran. Nevertheless, the examiner, who is a medical professional, found that the current cervical spine disorder was not caused by or aggravated beyond its natural and normal aging process by her October 2006 mobilization. The Board finds that such an opinion has greater probative value than the lay statements of record. Therefore, the preponderance of the evidence is against the claim for entitlement to service connection for a cervical spine disorder. Accordingly, the benefit-of-the-doubt doctrine is not for application, and the claim must be denied. ORDER Service connection for a cervical spine disorder is denied. ____________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs