Citation Nr: 1340907 Decision Date: 12/11/13 Archive Date: 12/20/13 DOCKET NO. 08-12 753 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include as secondary to service-connected disabilities of the knees and low back. 2. Entitlement to service connection for a sleep disorder, to include as secondary to residuals of a TBI and/or service-connected disabilities of the knees and low back. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.M. Seay, Counsel INTRODUCTION The Veteran served on active duty from June 1976 to June 1979. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2008 (TBI) and June 2009 (sleep disorder) rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. The issue on appeal has been reframed as entitlement to service connection for residuals of a TBI to allow for consideration of all residuals. In November 2011, the Veteran testified during a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. FINDINGS OF FACT 1. The most probative evidence does not relate residuals of a TBI to active duty or a service-connected disability and the Veteran is not considered credible with respect to his reports of a head injury during active duty. 2. The most probative evidence does not relate a sleep disorder to active duty or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a TBI, to include as secondary to service-connected disabilities of the knees and low back, are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for a sleep disorder, to include as secondary to residuals of a TBI and/or service-connected disabilities of the knees and low back, are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Duty to Notify VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). A March 2008 letter was sent with respect to the claim of entitlement to service connection for residuals of a TBI and satisfied the duty to notify provisions and notified the Veteran of the regulations pertinent to the establishment of an effective date and of a disability rating. An April 2009 letter was sent with respect to the claim of entitlement to service connection for a sleep disorder and included the criteria to substantiate a claim for direct service connection and secondary service connection. The letter also notified the Veteran of the regulations pertinent to the establishment of an effective date and of a disability rating. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In an April 2013 remand, the Board expanded the Veteran's claims for service connection to include as secondary to his service-connected back and knee disabilities. The Veteran was not sent a separate notification letter with respect to secondary service connection for residuals of a TBI. However, the Board finds that the Veteran has not been prejudiced by this notice defect. In this regard, the Board finds that the Veteran had actual knowledge of the information and evidence necessary to substantiate a claim for secondary service connection. Although the April 2009 letter was not specific to the claim for service connection for residuals of a TBI, the letter included the criteria to substantiate a claim for secondary service connection. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant). Duty to assist With regard to the duty to assist, the claims file contains the Veteran's service treatment records (STRs), and private and VA medical treatment records. VA medical treatment records and Social Security Administration (SSA) records were associated with the claims file in compliance with the Board's previous remands. See Stegall v. West, 11 Vet. App. 268 (1998). VA examinations were provided in June 2008, July 2012, and June 2013. An addendum opinion was provided in August 2013. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). First, the Board finds that the June 2008 VA examination is adequate. The examiner reviewed the entire claims file, examined the Veteran, and provided an opinion with supporting rationale. The Veteran was also provided VA examinations in July 2012. In the prior remand, the Board pointed out that the July 2012 examiner did not review the complete record and, therefore, the opinions were not adequate. The claims were remanded for new VA examinations. The Veteran was provided VA examinations in June 2013. The claims file was not available for review. In an August 2013 addendum to the June 2013 examination reports, the examiner provided opinions with respect to the etiology of the residuals of the Veteran's TBI and his sleep disorder. The Board acknowledges that the examiner's opinions are framed as "at least less likely as not." However, the rationale for the opinions shows that the examiner provided negative nexus opinions. In addition, the examiner noted review of all records including electronic records as emphasized by the Board in the prior remand. The Board notes that additional VA treatment records were associated with the record after the August 2013 addendum opinion. However, these records are duplicative and cumulative of the records already reviewed by the examiner. Therefore, the Board finds that the addendum opinion is adequate and substantially complied with the Board's April 2013 remand. See Stegall, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Board recognizes that the April 2013 remand requested that the examiner express an opinion as to whether a sleep disorder was related to active duty. In this respect, the examiner opined that the Veteran did not have a sleep disorder related to a TBI and explained that the Veteran was obese-which was a risk factor for his sleep apnea. An opinion as to direct service connection is not required. The evidence does not reflect complaints or documentation related to a sleep disorder during active duty or for years after separation from active duty. In addition, with respect to contentions of a head injury during active duty, the Board has found the Veteran not to be credible. 38 C.F.R. § 3.159(c)(4) (2013); see McLendon v. Nicholson, 20 Vet. App. 79 (2006). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the Board hearing, the Veteran was assisted at the hearing by an accredited representative from the Wisconsin Department of Veterans Affairs. The issues on appeal was explained by the VLJ. Further, the VLJ asked questions regarding the Veteran's medical treatment. Subsequent to the hearing, the issues on appeal were expanded to include as secondary to his service-connected low back and knee disabilities. As such, the VLJ did not identify the issues on appeal to include as secondary to service-connected low back and knee disabilities. However, as noted above, the Veteran was notified regarding the elements of service connection on a secondary basis and the most recent supplemental statement of the case explained why secondary service connection was not warranted. In addition, neither the representative nor the Veteran has suggested any deficiency in the conduct of the hearing. The Veteran has not been prejudiced and, therefore, any error in notice or assistance by the VLJ constitutes harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist. Legal criteria Service connection Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Analysis The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Service Connection for Residuals of a TBI The Veteran contends that he has residuals from a traumatic brain injury that occurred during his period of active duty service. He states that he experienced such residuals, to include dizziness, blackouts, vertigo, memory loss, cognition difficulties, and headaches since his time in service. The STRs contain complaints related to headaches, dizziness, vertigo, and blackouts. However, there is no indication or suggestion in the STRs that the Veteran experienced any head injury during his period of active duty. A July 1976 record shows that the Veteran complained of stomach cramps, headaches, and dizziness. He had been seen once before for the same complaints. He had pain in the right lower quadrant. He reported headaches and vertigo. The impression was listed as appendicitis. A subsequent July 1976 record from Irwin Army Hospital shows that the Veteran underwent an appendectomy. A July 1976 clinical record indicated that the Veteran was post-op appendicitis. An August 1976 record shows that the Veteran was seen at home for blackouts. Another August 1976 record noted that the Veteran complained of blackouts and stomach cramps and he had been on profile. Objectively, CNII-XII was intact. Romberg's sign was negative. The assessment was listed as: no pathology found, r/o anxiety syndrome. Another record shows that the Veteran stated that he passed out, had blackouts, and felt faint and weak during exercises. The physician noted that he had an appendectomy and was cleared by his surgeon. The impression was listed as no explanation of blackouts and the Veteran may have mild prostatitis. A September 1976 record noted that the Veteran had some vertigo for seven weeks. The Veteran claimed nervousness. The diagnosis was healthy- fit for duty and questionable emotional status. It was noted that the Veteran should return to duty. A February 1978 radiographic report indicated that the Veteran complained of incoordination and fatigue. The report was within normal radiological limits. A June 1977 record noted that the Veteran had fever for one day, anorexia, vertigo, and cold chills. Another record indicated headaches and sinus congestion. The assessment was cold, sinus congestion. A March 1978 record shows that the Veteran still had some fatigue, but there was a negative work-up. He was listed as a normal male. A February 1979 record showed that the Veteran slipped and fell on ice in January and was diagnosed with a fracture of the right ankle. A report of an April 1979 separation medical examination shows that all systems were clinically evaluated as normal except for synovial fistula of the right knee. The report of medical history reveals that the Veteran checked the boxes "no" when asked if he ever had or has now experienced frequent or severe headaches, dizziness or fainting spells, head injury, epilepsy or fits, frequent trouble sleeping, loss of memory or amnesia, or periods of unconsciousness. The report of medical history shows that the Veteran reported undergoing hernia repair, an appendectomy, and that he was going in for surgery in April 1979 for a lateral release of the right patella. He did not mention any head injury or TBI. A June 1979 statement of medical condition shows that the Veteran checked the box to indicate that there has been no change in his medical condition since his last separation examination. Following separation from active service, the Veteran underwent multiple examinations for other claimed disabilities, but did not report experiencing a head injury or residuals of a TBI. See August 1979, September 1985, June 1988, and October 1992 reports of examination. The Board acknowledges a December 1982 record in which the Veteran complained of a chronic headache. However, he believed it was secondary to a long ago discontinued medication. He did not report any head injury. In a September 1991 VA treatment record, the Veteran was asked about his medical history and did not report any head injury or TBI. He denied sleep disturbance, headaches, incoordination, dizziness, recent head trauma, or recent loss of consciousness. He also denied muscle weakness. VA treatment records show assessments of diabetes mellitus with neuropathy. VA treatment records dated in 2007 reveal that the Veteran was seen for a TBI consult and mentioned experiencing several head injuries in service. Specifically, a February 2007 VA note shows that the Veteran reported a syncope episode in 1976 when he hit the back of his head and had amnesia and loss of consciousness. He reported that, in 1977, he fell from the top of a tank and hit his knees and head. He stated he lost consciousness. He stated that, in 1978, he fell on ice and hit his head and broke his leg. He reported that, in 2005, he fell on ice and hit his shoulder and head. The physician noted that the VA treatment records show notations of cognitive problems and disorders secondary to traumatic brain injury. The assessment was listed as male with history of multiple concussions with complaints of cognitive deficits, headache, balance disturbance, mood instability, and sleep disturbance. Other medical conditions including diabetes mellitus with polyneuropathy, obesity, obstructive sleep apnea, chronic pain, and mood disorder with multiple life stressors were likely also contributing to current symptoms and complicate the clinical picture for post-concussive syndrome. A March 2007 VA note included a summary from a detailed neuropsychological report. The results included slowed processing speed with borderline verbal fluency. He had slowed fine motor coordination. The physician stated that the Veteran did not present with a primary memory disorder. The physician stated that the remote history of head injuries were minor and would not expect to result in any worsening of cognitive functions today. In addition, the physician stated that the memory complaints were reported with an onset date of two years ago. It was noted that many of his head injuries occurred during the 1970s, except for one incident in which he fell on his shoulder in 2005, when there was no loss of consciousness. The examining physician was reticent to state that the current cognitive complaints were representative of the remote history of mild closed head injuries. Rather, it was noted there were several etiological considerations including poor sleep hygiene, medication side effects, prominent psychiatric symptoms, and marital strain. It was also noted that the effects of depression and emotional distress on cognition were well known, particularly on attention/concentration, and processing speed. The examiner stated that prominent psychiatric symptoms were likely to account, in part, for the Veteran's perceived cognitive impairments. In addition, common side effects of Gabapentin were noted to include somnolence, dizziness, ataxia, and fatigue. He was currently prescribed 1800 mg BID. The examiner opined that the Veteran's medical history included several risk factors for developing cerebrovascular changes including diabetes, hypercholesterolemia, and chronic obesity. In a May 2007 VA note, the examining physician stated that the Veteran's symptom presentation was multifactorial in nature and likely did not represent isolated postconcussion syndrome (PCS). With respect to TBI, the physician stated that it was unlikely that his current complaints were related to his remote history of mild TBI. Other VA treatment records indicate cognitive impairment and headaches related to TBI. A November 2008 record shows that the Veteran was assessed with organic mental difficulties due to multiple TBIs. A March 2009 VA treatment record noted that the Veteran had cognitive difficulties and headaches secondary to TBI. The Veteran was provided a VA examination in June 2008. The claims file was reviewed. The examiner explained that based on review of the available records, including the results of neuropsychologic testing, she did not think it was likely that the Veteran had evidence of residuals from a TBI due to blackout spells in the service. The examiner observed there was no documentation of head injuries in the Veteran's claims file. It was noted that his medical records did not include any complaints of cognitive problems prior to the TBI evaluation in 2007. The examiner concurred with the neuropsychologic testing impression that "his remote history of head injuries were minor and would not expect to result in any worsening of cognitive functions today." Again, the physician stated that he did not think it was likely that the Veteran had evidence of residuals from a TBI occurring after the service. The Veteran was seen for an injury in 2005 after he slipped on ice and fell. The neuropsychologic testing results were not reported to be consistent with cognitive problems due to a head injury. A private psychological report dated June 2011 shows that the Veteran reported that he suffered a traumatic brain injury in an accident while in the U.S. Army. He said he passed out and fell down and hit his head on a curb. He reported that, since that time, he had short-term memory problems, balance, problems, vertigo, delayed processing, and sleep difficulties. The physician noted that the Veteran reported a history of head injury but according to VA documents, it appeared to have been mild in severity and apparently not a cause of his recently reported difficulties. The physician did not see a formal diagnosis of traumatic brain injury or cognitive disorder in his records as a cause for his problems. Another June 2011 private examination shows that the Veteran reported a history of traumatic brain injury. He indicated that this started when he had a fall four to five years ago, but thought it might be related to earlier injury as well. He stated that, since that time, he had had trouble with balance, memory difficulties, central sleep apnea, vision problems, and headaches. The physician included a conclusion of "traumatic brain injury per patient with residual complaints of balance, memory, vision, and headache problems." The Veteran was provided a VA examination in June 2013. Again, the examiner did not have access to the claims file for review. However, the Board finds the physical findings of the examination are adequate as they provide test results and the Veteran's reported symptoms. In an August 2013 addendum opinion, the examiner reviewed the entire claims file and electronic records. The examiner stated that the Veteran's chronic blackouts, vertigo, dizziness, fatigue, headaches, and weakness, were at least less likely as not caused by or related to the minor injury that was incurred during active duty. The examiner stated that based on medical records, the injury was mild and there was no evidence of post-concussion syndrome. It was also stated that there was no clinical objective evidence of TBI. It was explained that mild traumatic brain injury is defined as a traumatically-induced physiological disruption of brain function manifested by at least one of the following: loss of consciousness less than or equal to 30 minutes; loss of memory for events immediately before or events after the accident less than or equal to 24 hours; any alteration in mental state at the time of the injury, presence of focal neurological deficits, and if given, GCS score greater than or equal to 13. It was also stated that the diagnosis of TBI must be made by a psychiatrist, neurosurgeon or neurologist, and that this has not been the case. It was opined that it was at least less likely than not that the Veteran's claimed blackouts, vertigo, dizziness, fatigue, weakness, sleep apnea, and headaches were caused or aggravated by the service-connected right knee disability, left knee disability, back disability, or residuals of a TBI. The examiner stated that there was no plausible medical rationale for a direct causal relationship between knee pain and back pain and the development of chronic blackouts, vertigo, dizziness, fatigue, weakness, sleep apnea, and headaches and there was no medical documentation to support any causal relationship between knee pain and back pain and the development of chronic blackouts, vertigo, dizziness, fatigue, weakness, and headaches. The Board finds the VA examiner's August 2013 opinion to be probative as the examiner reviewed the entire record, pointed to evidence considered and reviewed, and provided negative opinions with supporting rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (factors for assessing the probative value of a medical opinion include the medical expert's access to the claims file and the thoroughness and detail of the opinion). In review of the entire record, the Board finds that service connection is not warranted for residuals of a TBI on a direct-incurrence basis. Again, the STRs are absent for any indication of a head injury or TBI. The most persuasive medical opinion of record does not relate residuals of a TBI to the Veteran's period of active duty. In addition, the June 2008 examiner stated that the Veteran's current cognition complaints were unlikely related to a TBI. The examiner concurred with the neuropsychologic testing. As noted above, the March 2007 VA note included a detailed neuropsychological report which explained that the Veteran's prominent psychiatric complaints were likely to account in part for his perceived cognitive complaints and that the Veteran had several risk factors for developing cerebrovascular changes including diabetes, hypercholesterolemia, and chronic obesity. The Veteran has stated that he experienced head injuries during active duty; however, the Board finds that the Veteran is not credible. While he is competent to report symptoms and experiences, he is not credible with respect to his assertions regarding his in-service head injuries. For example, the Veteran asserted that he had residuals of a head injury when he was treated for appendicitis. The STRs do not contain any documentation related to a head injury. The Board does not find it reasonable that the Veteran would experience a head injury with loss of consciousness and there would be no documentation in the STRs. See Indiana Metal Prods. v. NLRB, 442 F.2d 46, 51-52 (7th Cir. 1971) (citations omitted) (noting that "definitions of credibility do not necessarily confine that concept to the narrow peg of truthfulness. It has been termed as 'the quality or power of inspiring belief. . . .' Credibility . . . apprehends the over-all evaluation of testimony in the light of its rationality or internal consistency and the manner in which it hangs together with other evidence."). While the STRs reflect symptoms such as fatigue, vertigo, dizziness, and blackouts, these were not identified or related to any head injury. In fact, the Board finds it significant that the Veteran denied experiencing or ever experiencing a head injury prior to separation from active duty. In addition, the Veteran did not report experiencing a TBI or head injury until many years after his separation from active duty. As such, the Board finds that the Veteran is not credible with respect to his reports of a head injury or TBI during his period of active duty. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest . . . [and] inconsistent statements. . . ."); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (Board can consider bias in lay evidence, conflicting statements of the Veteran, and the significant time delay between the affiants' observations and the date on which the statements were written in weighing credibility). Further, the Board recognizes the Veteran's statements relating any current symptoms/residuals to active duty. While there is no bright line exclusionary rule that a lay person cannot provide opinion evidence as to a nexus between an in-service event and a current condition, not all medical questions lend themselves to lay opinion evidence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As to a nexus opinion or diagnosis related to the residuals of a TBI, the Board finds that an opinion regarding the etiology of residuals of a TBI and the diagnosis of a TBI are complex medical questions. The Veteran has not been shown to possess the medical knowledge or expertise to diagnose or provide an opinion as to its etiology and, therefore, is not competent to provide a diagnosis or etiological opinion. See also Kahana v. Shinseki, 24 Vet. App. 428 (2011). With respect to a headache disability, the Board notes that experiencing headaches can be a subjective disorder. However, in terms of a nexus opinion, the Board finds that the Veteran's opinion is of little probative value. He has related his headaches to a head injury during service. The Board has found the Veteran not credible with respect to his reports of an in-service head injury. To the extent that he has stated that they are chronic since active duty, the Board also finds the Veteran not credible with respect to his reports of continuity of symptomatology as the report of separation medical examination and report of medical history did not reflect complaints of headaches and headaches were not noted until several years after service, when the Veteran did not relate them to active duty. Therefore, his opinion relating headaches to active service is afforded little, if any probative value. His opinion is outweighed by that of the persuasive VA examiner's opinion. With respect to the assessments relating residuals to an in-service TBI in the VA treatment records and private examination, the Board finds these assessments and diagnoses to be of little probative value. The physicians did not have access to the entire claims file to include the STRs, which are absent for any documentation of a head injury. Again, the Veteran denied experiencing a head injury in his report of medical history completed prior to separation from active duty. The physicians appeared to provide the assessments based on the Veteran's reported history of in-service head injuries, for which the Board has not found him to be credible. Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider is weighed by such factors as its thoroughness and degree of detail, and whether there was review of the Veteran's claims file. Prejean v. West, 13 Vet. App. 444 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379 (1998). Thus, the Board notes that any assessments in the VA treatment records and private records with respect to residuals of TBI related to active duty are entitled to little probative value. The Board finds that service connection on the basis of continuity of symptomatology is not warranted. The Veteran has asserted that he experienced symptoms of a TBI since active service to include headaches. With respect to his reports of chronic symptoms since service, the Federal Circuit recently held that continuity of symptomatology under 38 C.F.R. § 3.303(b) only applies to those conditions recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system are listed as chronic conditions as well as brain hemorrhage. Even if the Veteran's disability is considered a chronic disease under 38 C.F.R. § 3.309(a), the Board does not find the Veteran to be credible with respect to his reports of continuity of symptomatology. Again, the Board acknowledges the notations of headaches, dizziness, fatigue, blackouts, and vertigo, in the STRs. However, prior to separation from active duty, the Veteran denied experiencing frequent or severe headaches, dizziness or fainting spells, head injury, epilepsy or fits, loss of memory or amnesia, or periods of unconsciousness. In addition, the objective evidence of record does not reflect chronic complaints until years after separation from active duty. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding, in an aggravation context, that the Board may consider a prolonged period without medical complaint when deciding a claim). A 1982 record shows an assessment of chronic headaches; however, the Veteran did not relate them to active duty or a traumatic brain injury and, as noted above, the report of separation medical examination did not reflect any complaints of headaches. The Veteran denied experiencing frequent or severe headaches in his report of medical history. As such, service connection based on continuity of symptomatology is not warranted. 38 C.F.R. § 3.303(b). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply and the claim is denied. 38 U.S.C.A. § 5107(b). In addition, service connection on a secondary basis is not warranted. The August 2013 addendum opinion provided a negative nexus opinion regarding whether the residuals of a TBI were caused or aggravated by the Veteran's service-connected back and knee disabilities. The examiner stated that there was no plausible medical rationale for a direct causal relationship between knee pain and back pain and the development of chronic blackouts, vertigo, dizziness, fatigue, weakness, and headaches and no medical documentation to support any causal relationship between knee pain and back pain and the development of chronic blackouts, vertigo, dizziness, fatigue, weakness, and headaches. The Board finds the examiner's opinion to be probative as the examiner has expertise and reviewed the entire claims file. There is no competent medical evidence to the contrary. The Board acknowledges the Veteran's general assertion that his residuals of a TBI are related to his service-connected disabilities. However, again, the Veteran is not considered competent to provide such an opinion as this is a complex medical question. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Further, even if he were competent to provide such an opinion, he did not provide any reasons or bases for why his service-connected disabilities caused or aggravated his residuals of a TBI and his opinion is outweighed by the probative value of the August 2013 VA opinion. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to secondary service connection. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply and the claim is denied. 38 U.S.C.A. § 5107(b). Sleep Disorder The evidence shows that the Veteran has a current disability. The VA treatment records include diagnoses of sleep apnea. The service treatment records are absent for any documentation or notation regarding a sleep disorder. The separation report of medical history shows that the Veteran denied frequent trouble sleeping. In a September 1991 VA treatment record, the Veteran denied sleep disturbance. An August 2001 VA treatment record shows that the Veteran reported problems with sleeping over the past decade-many years after separation from active duty. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The medical evidence does not relate any current sleep disorder to the Veteran's period of active duty. The Veteran has related his sleep disorder to active duty and stated that he had difficulty sleeping during his period of active duty. As to a nexus opinion or diagnosis related to a sleep disorder, the Board finds that an opinion regarding the etiology of a sleep disorder to be a complex medical question. The Veteran has not been shown to possess the medical knowledge or expertise to diagnose or provide an opinion as to its etiology and, therefore, is not competent to provide a diagnosis or etiological opinion. See also Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran has submitted articles addressing the relationship between sleep apnea and brain damage. However, as discussed previously, the Board finds that the Veteran is not credible with respect to his reports of an in-service head injury or injuries. As a result, the evidence submitted by the Veteran is not probative of a relationship between the Veteran's sleep disorder and any event, injury, or disease incurred in active duty. With respect to continuity of symptomatology, the Veteran is not diagnosed with a chronic condition listed under 38 C.F.R. § 3.309(a). Even so, there is no evidence of a sleep disorder during active duty or for years thereafter. The Veteran stated that he experienced sleep difficulties since service; however, in other statements, he explained that he experienced sleep problems for the past decade (dating years after separation from active duty). Based on the above, service connection based on continuity of symptomatology is not warranted. 38 C.F.R. § 3.303(b). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply and the claim is denied. 38 U.S.C.A. § 5107(b). In addition, secondary service connection is not warranted. The Veteran has claimed that his sleep disorder is secondary to his residuals of a TBI and his service-connected knee disabilities and back disability. First, the Veteran is not service-connected for residuals of a TBI and, therefore, secondary service connection is not warranted. With respect to his back and knee disabilities, a medical opinion was obtained in August 2013. The examiner stated that there was no plausible medical rationale for a direct causal relationship between knee pain and back pain and the development of sleep disorder and no medical documentation to support any causal relationship between knee pain and back pain and the development of a sleep disorder. The Board finds the examiner's opinion to be probative as the examiner has expertise, reviewed the claims file, and provided a well reasoned rationale for the expressed opinion. See Prejean v. West, 13 Vet. App. 444 (2000). The Board acknowledges the Veteran's general assertion that his sleep disorder is related to his service-connected low back and knee disabilities. Again, the Veteran is not considered competent to provide such an opinion as this is a complex medical question. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Further, even if he were competent to provide such an opinion, he did not provide any reasons or bases for why his service-connected disabilities caused or aggravated his sleep disorder and his opinion is outweighed by the probative value of the August 2013 VA addendum opinion. See Schoolman v. West, 12 Vet. App. 307, 310-311 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to secondary service connection. Because the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt provision does not apply and the claim is denied. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for residuals of a TBI, to include as secondary to service-connected disabilities of the knee and low back, is denied. Entitlement to service connection for a sleep disorder, to include as secondary to residuals of a TBI and/or service-connected disabilities of the knees and low back, is denied. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs