Citation Nr: 1647102 Decision Date: 12/16/16 Archive Date: 12/30/16 DOCKET NO. 16-16 527 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for eye disorder. 3. Entitlement to service connection for a right knee disorder. 4. Entitlement to service connection for a left knee disorder. 5. Entitlement to service connection for any acquired mental health disorder to include posttraumatic stress disorder, anxiety, depression, night terrors, and gender dysphoria. 6. Entitlement to service connection for migraine headaches. 7. Entitlement to service connection for traumatic brain injury (TBI) with memory problems. 8. Entitlement to service connection for left foot disorder. 9. Entitlement to special monthly compensation based on aid and attendance/housebound. 10. Entitlement to specially adapted housing. 11. Entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only. REPRESENTATION Appellant represented by: William R. Fisher, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The Veteran served on active duty from June 1991 to October 1991 and from July 2002 to October 2002. This matter comes before the Board of Veterans' Appeals (Board) on an appeal from rating decisions issued by the RO in October 2014 and March 2016. The Veteran testified before the undersigned Veterans Law Judge at videoconference hearings held in June 2016 and October 2016. At the October 2016 hearing, the undersigned granted an advancement of this appeal on the docket due to financial hardship pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for migraines, entitlement to special monthly compensation based on aid and attendance/housebound, entitlement to specially adapted housing and entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The evidence is approximately evenly balanced as to whether the Veteran's PTSD is related to an in-service assault. 2. The evidence is in equipoise as to whether the Veteran's current diagnosis of TBI is a result of an in-service assault. 3. Prior to the promulgation of a decision by the Board, the Veteran at her June 2016 hearing, of her intent to withdraw her appeal of the issues of entitlement to service connection for disabilities of the right knee, left knee, left foot, eyes and bilateral hearing loss. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102 , 3.303, 3.304 (2015). 2. The criteria for service connection for TBI are met. 38 U.S.C.A. §§ 1110, 1131, 1154(b) (West 2014); 38 C.F.R. §§ 3.303, 3.304(d) (2015). 3. The criteria for withdrawal of an appeal by the Veteran regarding the issues of entitlement to service connection for disabilities of the right knee, left knee, left foot, eyes and bilateral hearing loss are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Claims The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.156(a), 3.159, 3.326(a) (2015). As will be discussed in further detail in the following decision, the Board finds that the competent and probative evidence of record supports the grant of service connection for PTSD and TBI. This award represents a full grant of these issues on appeal. Accordingly, assuming without deciding that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. Service connection may be granted for a disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2015). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Service connection may also be granted for chronic disabilities, to include psychoses, if such are shown to have been manifested to a compensable degree within one year after the veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b) (2015). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a), such as psychoses. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background for Traumatic Brain Injury and Psychiatric Disorder The Veteran alleges that service connection is warranted for both a psychiatric disorder claimed alternatively as PTSD, depression, night terrors, and gender dysphoria, and for TBI as the result of the same inservice incident, which includes assault and military sexual trauma (MST). She alleges both in written statements and hearing testimony that she was assaulted in service based on her issues at the time with gender identity. In a statement received in VBMS on January 12, 2016 she indicated that in August 2002 she confided in a fellow soldier of being homosexual and was subsequently mocked and made to feel threatened, culminating in an incident where she was reportedly beaten, stabbed, shot at and raped. She indicated that she was advised by an officer that it was unsafe for her to remain in the service and she was discharged for being homosexual. She indicated that since then she suffered from symptoms from TBI and psychiatric symptoms including those of PTSD and major depression. She described receiving ongoing treatments for these symptoms. In her June 2016 hearing she provided further insight into the inservice traumas. In her hearing she described herself as a transgender who had to act male in the service, but around the end of August 2002 her true nature was discovered by another service member. This individual told others and she was subsequently threatened and harassed. This culminated in the assault incident. She described herself as transgender but had to act male in the service. She indicated that around the end of August 2002 this secret was discovered by another service member who told other service members about this. The Veteran indicated that after this was discovered she was subjected to threats and harassment. This culminated in an incident around September 2002 where she was attacked by multiple service members who beat her severely, including around her head, cut her with a knife and sexually assaulted her. She described being left unconscious. She was afraid to report the attack and was subsequently discharged with the reason given in the discharge paperwork was for homosexual behavior, though she was actually transgender. See 6/15/16 Hearing Transcript pgs 3-6. She described symptoms since this happened as including migraine headaches 22 to 24 times a month, memory loss, being fearful of going anywhere and requiring constant therapy. Id. at 7-10. Because the Veteran's TBI and psychiatric disorders are alleged to have been caused by the same incident in service, the Board shall discuss the factual background for both issues together. Service treatment records revealed that her examination was normal psychiatrically and for head inspection on her National Guard entrance examination in December 1990 with the accompanying report of medical history negative for any issues either for head injury, or for any psychiatric complaints. There were no records from her 1991 period of active service showing any issues with head injury or psychiatric issues. See 35 pg STRS entered into VBMS 11/12/09 at pgs 6, 13. Likewise she was psychiatrically and physically normal with no history of psychiatric issues, head injury or complaints of the same on entrance examination and report of medical history for this second period of service in July 2002. See 48 pg STRS entered into VBMS 10/24/02 at pgs 26, 30, 36. Although these records from 2002 do not document any sort of assault, they are noted to contain records referencing complaints of headaches beginning in July 2002, and noted also in August 2002. Id. at 18-19, 24. No cause for the headaches was given and they were described as migraines, with some records suggesting they pre-existed service, having been present for 2 years. The service treatment records also contain a record dated August 29, 2002 where the Veteran was noted to be in some form of psychological distress as difficulty with supervisors was reported and she was noted to have issues with her spouse at the time planning to go to college and apparently not staying with her. She was referred to mental health for psychiatric complaints. Id. at pg 8. Her separation examination from September 2002 was normal psychiatrically and for inspection of her head, with the accompanying report of medical history negative for any issues either for head injury, or for any psychiatric complaints. See 132 pg SPRS (Marked DPRIS Response) at pgs 112-117. Service personnel records confirm that in September 2002 the Veteran was subjected to administrative proceedings for homosexual behavior with the evidence including sworn statements of other individuals who indicated they were aware of such behavior. The records included a sworn statement from the Veteran admitting such behavior expressing a fear of physical harm particularly from specific individuals. She was administratively discharged from the service under honorable conditions for admitting committing homosexual acts. See 132 pg SPRS (Marked DPRIS Response) at 89-108 (see 108 for Veteran's statement). Post service records reveal a lengthy history of treatment for psychiatric complaints and cognitive issues including memory problems. The records also address issues concerning her gender transitioning process including psychiatric difficulties. The records also include a history of other head injuries besides the claimed assault. A September 2010 neuropsychiatric evaluation gave a history of head injuries from a motor vehicle accident in 1992 or 1993 and a 1995 incident where a piece of shelving fell on her head. This history would be repeated in later records. The neuropsychiatric evaluation also gave a history of an assault described as being assaulted and choked by someone on the streets with no timeframe given. Behavioral observations included tangential and disorganized thought, anxious mood and euthymic affect. The impressions from this evaluation included language based learning disorder, cognitive disorder NOS, dysthymia and anxiety disorder NOS. See 142 pg SSA record at pg 92. Similar findings are shown in subsequent records. In April 2011 she underwent an occupational evaluation which included review of comprehensive testing done in February 2011 and a review and evaluation of her cognitive skills and executive function with an observation that she displayed symptoms often seen following subtle brain injury, which included headaches, and slowed cognitive functioning among others. Her history of multiple traumas to the head included the nonservice related accidents in the 1990's and a history of beatings and assaults from what was described as hate crimes. She was noted to have issues processing sensory information; panic and anxiety attacks; isolation from others and cognitive issues that included problems with attention, concentration, and memory. Id. at pg 18-24. Other records related to such occupational evaluation and testing done in February and March 2011 described similar symptoms with sensory processing, emotional processing and cognition and she was said to have suffered many head injuries, (including from hate crime attacks) with probable resultant subtle brain injury. See 110 pg SSA recs at pg 31-32. In May 2011 she was treated by a private neurological clinician until July 2011 with a discharge report giving essentially the same head injury history of the 2 injuries in the 1990's as given in the September 2010 neurological evaluation, but also suggested a possibly more recent injury in 2009 when hit by a car. The testing was noted to show weaknesses in memory, problem solving and conceptional reasoning and psychiatric testing showed high levels of depression and anxiety. Language difficulties were also noted and thought to be probably from a language based learning disorder. The conclusion was again drawn that the effect of at least 2 head injuries were contributing to inattention, distractibility and difficulty with thought organization. Anxiety was also thought to contribute to such problems. The Veteran was noted to be quite anxious during the interview and thought processes were quite tangential and disorganized. The examiner noted the prior medical opinions suggesting evidence of subtle head trauma symptoms, with the multiple symptoms noted to include physical symptoms such as migraines as well as mental, cognitive and sensory impairments detailed at length. The impression was of a transgendered individual with a complex developmental history marked by considerable trauma. The cognitive impairments were consistent with a history of emotional and physical abuse, anxiety, depression and concussion. See 102 pg SSA recs at pgs 79-81. Problems with headaches and syncope were noted in June 2011, August 2011 and October 2011 although no cause was given and there were indications of headaches along with issues with depression and anxiety since teenage years. See 142 pg SSA record at pg 27, 35, 66. In addition to the treatment for TBI symptoms she continued treatment for psychiatric symptoms with an October 2011 record noting a history of referral to mental health clinic a year and a half ago for symptoms of depression and anxiety. Id at pg 30. As for psychiatric symptoms, the treatment records are noted to provide multiple diagnoses with a June 2011 psychiatry record assessing gender identity disorder, dysthymia, anxiety disorder NOS, language based learning disorder, expression disorder and cognitive disorder. Id. at 5. Records documenting continued treatment for psychiatric and cognitive symptoms include records from 2014 and 2015 that now include a diagnosis of PTSD. In June 2014 she was seen for a Social Security disability evaluation where she was noted to be difficult to evaluate with a history that was very scattered due to her not being a good informant. She did related a history of abuse by family members in childhood and of an in-service assault that she described as being shot and stabbed, but also gave a story of being exposed to an IED device in service, although it was not clear where the IED incident took place. She was noted to have severe anxiety and panic attacks which caused her to drop to the ground in a fetal position. She was also noted to have attention problems and was very hard to direct conversationally. She was noted to have hallucinations described as flashbacks of sorts if she saw garbage in the road and was very upset throughout the entire interview. She was diagnosed with dysthymia, anxiety, PTSD, learning disorder NOD and cognitive disorder NOS. In January 2015 she was seen to establish primary care at the VA and gave a history of MST. She also reported service in Iraq and Afghanistan which is not supported by the service department records. She was diagnosed with a complicated mental health history and was referred for further mental health treatment. The Veteran continued with treatment throughout 2015 for ongoing symptoms associated with diagnosed psychiatric disorders of anxiety, depression, PTSD (chronic). An October 2015 MHC clinic note included details given by the Veteran of her in-service assault where she described being beaten and stabbed and indicated that a police officer who came to assist was told not to take her to the hospital and so there was no documentation of the incident. See 92 pg CAPRI in Virtual VA 1/25/16 at 31-32, 82. In January 2016 the Veteran underwent a neuropsychology evaluation. She gave a history of the in-service assault where she described sustaining a TBI. She reported that her mental health difficulties began with this assault. She was also noted to have begun mental health treatment while in the military. Mental status examination was noteworthy for her being quite anxious and tearful and she generally appeared to be a decent historian but struggled with specific details on recall. Testing disclosed significant impairments with attention and memory as well as a generally slowed processing speed. The PTSD screening test was also noted to be positive. Following testing and interview, the evaluator concluded that she was disabled secondary to an assault in service. She was noted to have been referred for this evaluation by her psychiatrist due to inattention and ongoing headaches in the context of TBI. Because of her difficulties with adequate test engagement no clear conclusions were deemed possible regarding any prior TBI, but given her report of the presumed period of unconsciousness ranging from "minutes to hours" in the in-service assault, the examiner concluded that she most likely suffered a mild TBI from which she would be expected to have recovered fully from a cognitive standpoint. She also indicated that she had some worsening of motor and cognitive functions over time which would not be an expected outcome of TBI. Given the overall presentation and history this examiner opined it appears more likely than not that her ongoing difficulties are related more to psychological trauma than head/brain injury. In September 2016 the Veteran underwent a private psychiatric evaluation. She was noted to have a past medical history that included TBI, memory loss and migraines. Her history of being beaten and assaulted in service was noted. Review of systems noted her treating extensively with psychotherapy and with medications as well as hormone therapy for gender transitioning. She gave a history that was unremarkable prior to service, but detailed being attacked and struck in the head as well as stabbed and subjected to MST because she was wearing female clothing. Mental status examination was noted to be significant for her being almost incoherent at times, and it was difficult to understand what she was saying at times. She had an apparent disjointedness between thought and affect. She seemed hypervigilant and her hands shook and sweated. She had significantly impaired concentration, attention span and marked memory disturbance. She had impaired judgment and difficulty interpreting proverbs. She seemed preoccupied with the beating in service. This examiner diagnosed PTSD and Major Neurocognitive Disorder due to TBI. The September 2016 private examiner gave a discussion that the Veteran's history of inservice attack meets criterion A for a diagnosis of PTSD and it is at least as likely that her PTSD arises from this attack and therefore is due to service. This attack included significant head injuries with loss of consciousness and hemorrhaged from her head and chest. The examiner noted that the records included head injuries in the 1990's from a motor vehicle accident and from a shelf falling on her. This examiner opined that these did not appear to be contributing significantly to her current problems in that her MEPs report indicated she was clinically normal. The examiner concluded that it was at least as likely as not that the inservice assault is at least as likely as not the result of her current major neurocognitive disorder due to TBI. In providing this opinion, this examiner confirmed review of records including STRS, MEPS, and private medical records. Psychiatric Disorder to Include PTSD Service connection for PTSD requires medical evidence diagnosing the disorder in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). As previously noted, the Veteran claims that her diagnosed PTSD is related to an assault that included a physical beating and MST that occurred during her brief period of service in 2002. VA regulations provide that in the case of a claimed in-service stressor based on personal assault, evidence other than the Veteran's service records can corroborate the occurrence such stressor. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include evidence of behavior changes following the claimed assault. This section (38 C.F.R. § 3.304 (f)(5)) also provides that VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. In Menegassi v. Shinseki, 638 F.3d 1379 (Fed. Cir. 2011), the Federal Circuit held that under 38 C.F.R. § 3.304(f)(5), medical opinion evidence may be submitted for use in determining whether the occurrence of a claimed stressor, and such opinion evidence should be weighed along with the other evidence of record in making this determination. Id. at 1382 & n. 1. In this case, the Veteran's service records do not contain evidence of a sexual assault. However, in cases involving an allegation that PTSD is connected to military sexual assault, the Federal Circuit has held that "the absence of a service record documenting an unreported sexual assault is not pertinent evidence that the sexual assault did not occur." AZ v. Shinseki, 731 F.3d 1303, 1306 (Fed. Cir. 2013). The service records tend to support the Veteran's contentions of having been threatened and assaulted due to her gender identity issues, which she indicated resulted in her being discharged for committing homosexual acts. The service department records confirm that she was investigated and subsequently discharged from the service for such behavior in September 2002 around the time she indicated the assault took place. Her statements at the time indicated she greatly feared physical harm from other individuals in service. The Board acknowledges that there are some credibility problems in the record with some records describing the Veteran as having a very scattered and confused thought process and some records suggesting she served in areas such as Iraq or Afghanistan are wholly unsupported by the service department records. However her contentions of being assaulted for her gender identity issues are supported by the evidence including the supporting paperwork for her General Discharge. The contentions are further supported by her current status as a transitioning female and the ongoing difficulties she experiences in this situation. Additionally the Board notes that she did seek counseling in August 2002 for possible mental health issues, although no mention was made of sexual identity problems at the time. Thus the Board finds that there is credible evidence to support a finding that an assault took place in service, and it is in equipoise as to whether this assault took place. The September 2016 private examiner found that the Veteran had PTSD based on the described in-service physical and sexual assault. This opinion was accompanied by a rationale that confirmed review of pertinent records as well as based on examination of the Veteran. It is further supported by the opinion from the January 2016 neuropsychiatric examination which determined the Veteran has a psychiatric disorder related to her inservice assault and also noted a positive PTSD, as well as the other medical evidence showing a diagnosis of PTSD, with a history of assault noted. The above regulations and cases provide that such medical opinion evidence may be weighed along with the other evidence of record in determining whether a claimed in-service sexual assault occurred. As such, the evidence of record including the medical opinions is at least evenly balanced on this question, as well as the question of whether this diagnosed PTSD is due to the in-service assault as described. Because the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, the Board finds that entitlement to service connection for PTSD is warranted. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Traumatic Brain Injury--Analysis Based on a review of the foregoing the Board finds that it is likely as not that the Veteran has residuals of a TBI incurred as the result of the reported inservice assault. As noted in the above discussion about PTSD, it has been found as likely as not that she was assaulted in service and the assault as likely as not included injury to her head from beatings. Although the Veteran's medical history also includes a history of other head injuries from a motor vehicle accident and a shelf falling on her head both in the 1990's prior to her second period of service, there is no clear and unmistakable evidence showing a pre-existing head injury/disorder affecting her head or brain before she entered service in February 2002 thus the Board need not address the presumption of soundness. The September 2016 private examiner clarified further that these prior incidents were noted but the examiner concluded that they did not appear to result in any lasting injury with rationale provided for this explanation. The September 2016 examiner has provided a favorable opinion as to the nature and etiology of the Veteran's TBI, finding it as likely as not is the result of the inservice assault. This favorable opinion is further supported by the medical evidence suggesting the presence of a subtle brain injury as noted in records and testing from February March and April 2011 and the July 2011 discharge report from the neurological services provider which also suggested her cognitive impairments were consistent with a history that included concussion. Although there is unfavorable evidence suggesting that the Veteran's cognitive impairments are the result of the Veteran's psychiatric disorder rather than to head trauma as contained in the opinion from the January 2016 neuropsychology evaluation, the Board finds that this unfavorable evidence is in equipoise with the aforementioned favorable evidence in this matter. As the evidence supporting this claim for service connection for TBI is in equipoise, service connection is warranted. 38 U.S.C.A. § 5107(b) (West 2014); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Dismissal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. Withdrawal may be made by the appellant or by his or her authorized representative and must be in writing, except for appeals withdrawn on the record at a hearing. 38 C.F.R. § 20.204. In this case, the Veteran at her June 2016 videoconference hearing confirmed that she wished to withdraw the claims for entitlement to service connection for disabilities of the following: right knee, left knee, left foot, eyes and bilateral hearing loss. (See June 2016 Transcript at pg 2). Thus, the Veteran has withdrawn the appeal concerning entitlement to service connection for disabilities of the right knee, left knee, left foot, eyes and bilateral hearing loss, and there remain no allegations of errors of fact or law for appellate consideration on these issues. Withdrawal of the appeal included withdrawal of both the notice of disagreement and the substantive appeal in this case. See 38 C.F.R. § 20.204(c). Accordingly, the Board does not have jurisdiction to review the appeal, and it is dismissed. ORDER Entitlement to service connection for residuals of a TBI is granted. Entitlement to service connection for PTSD is granted. The appeal concerning the issues of entitlement to service connection for disabilities of the right knee, left knee, left foot, eyes and bilateral hearing loss is dismissed. REMAND The Veteran is seeking entitlement to service connection for a migraine headache disorder. Given that service connection is now in effect for residuals of a TBI, further development is warranted to properly address this issue. Specifically it is unclear whether the Veteran's claimed headaches are symptoms of the TBI to be addressed under the criteria for TBI or whether a separate migraine headache disorder exists. The service treatment records are noted to include some episodes of treatment for headaches as early as July 2002 which is prior to the alleged assault, with an August 2002 record suggesting migraines for 2 years which would pre-exist the 2002 period of service. Accordingly VA examination is warranted to determine whether the Veteran has a separate migraine headache disorder that was caused by or aggravated by service to include the established inservice assault. Also the Board finds that it is necessary to defer the issues of entitlement to, entitlement to special monthly compensation based on aid and attendance/housebound, entitlement to specially adapted housing and entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only. These issues are found to be inextricably intertwined with the issue of entitlement to service connection for a migraine headache disorder which is being remanded for further development. Additionally as entitlement to these benefits may be contingent upon the disability ratings to be assigned for the newly service connected grants for PTSD and TBI, they are likewise intertwined with these grants. Therefore consideration of these issues should be deferred pending the RO's implementation of these service connection grants for TBI and PTSD. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain and associate with the claims file any additional treatment records pertinent to these issues identified by the Veteran should be. 2. After completing the development above, schedule the Veteran for a VA examination with the appropriate specialist to determine the etiology of her claimed migraine headache disability(ies). The claims folder, including this remand, is to be reviewed by the examiner and such review should be noted in the examination report. The examiner is to identify all headache disabilities found on examination and identified during the pendency of the claim (since July 2014). For any diagnosed headache disability, the examiner should provide an opinion to the following: a. Did any diagnosed headache disability and unmistakably pre-exist any period of active military service? b. If so, has any pre-existing headache disability clearly and unmistakably NOT been aggravated (permanently worsened beyond its natural progression) by any period of active military service? c. If either or both (a) and (b) above are answered in the negative, the examiner must determine whether it is at least as likely as not (a 50 percent or greater probability) that any diagnosed headache disability had its onset during military service. d. If (c) is answered in the negative, is the current headache disorder (1) caused or (2) aggravated by her service-connected TBI and/or PTSD. In answering these questions, the examiner is asked to discuss the evidence which includes the service treatment records from July 2002 and August 2002 which suggest a headache disorder pre-existed her 2002 period of active service by 2 years. The examiner should also address the TBI which has been diagnosed and for which service connection has been granted by the Board and discuss whether any headache disorder noted may be symptoms of the TBI as opposed to a separate and distinct migraine headache disability. All opinions must be accompanied by a comprehensive rationale. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Finally, readjudicate the remaining appealed issues based on the entire, relevant evidence of record. Regarding the issues of the issues of entitlement to special monthly compensation based on aid and attendance/housebound; entitlement to specially adapted housing; and entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only, readjudicate after the intertwined issues have been properly addressed. If any benefits sought on appeal remains denied, issue an supplemental statement of the case and provide the Veteran and her attorney an opportunity to respond before returning to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs