Citation Nr: 1757723 Decision Date: 12/13/17 Archive Date: 12/28/17 DOCKET NO. 13-25 455 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for Seronegative Polyarthritis (SNPA), also claimed as rheumatoid arthritis, to include as secondary to service-connected posttraumatic stress disorder (PTSD) with major depressive disorder and panic disorder with agoraphobia. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia. 3. Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia. 4. Entitlement to service connection for irritable bowel syndrome (IBS), to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Erin J. Carroll, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1956 to January 1959. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In her September 2013 substantive appeal, the Veteran requested a videoconference hearing. She withdrew this request for a hearing in May 2016. Therefore, the Veteran's request for a Board hearing is considered withdrawn. 38 C.F.R. §§ 20.702 (e); 20.704(e) (2017). In April 2017, the Board remanded the appeal for further development, to include obtaining outstanding treatment records and an addendum medical opinion. Such development has been accomplished. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran's SNPA is not proximately caused or aggravated by her service-connected PTSD nor attributable to the Veteran's active service. 2. The Veteran has hypertension that is proximately caused by her service-connected PTSD. 3. The Veteran's bilateral knee disability is not proximately caused or aggravated by her service-connected PTSD nor attributable to the Veteran's active service. 4. The Veteran has IBS that is proximately caused by her service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for SNPA, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for service connection for hypertension, as secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a bilateral knee disorder, to include as secondary to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for IBS, as secondary to service-connected PTSD, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Overall Due Process Concerns Review of the record reveals that VA has substantially complied with the duties to assist and notify in this appeal. In this regard, the file contains records obtained pursuant to the Board remand, to include SSA records. The record also contains medical evidence, to include medical examination reports with opinions sufficient upon which to address the claims denied in this decision on a secondary service-connection basis. As to direct service connection, the April 2017 opinion is sufficient to address this aspect of the claim under the facts of this appeal. There has also been substantial compliance with the prior Board remand and neither the Veteran nor her representative have raised any additional due process concerns regarding the claims denied in this decision. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Entitlement to Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303(a) (2017). Service connection requires competent evidence showing: (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, 1167 (Fed. Cir. 2004). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Pursuant to 38 C.F.R. § 3.303(b), when a chronic condition (e.g., arthritis) is present, a claimant may establish the second and third elements by demonstrating continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases (e.g., arthritis) may be also presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a). A disability which is proximately due to or the result of a service-connected disease shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability has aggravated a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Effective October 10, 2006, 38 C.F.R. § 3.310 was revised to incorporate the analysis by the Court in Allen. The revised 38 C.F.R. § 3.310 provides, in essence, that in an aggravation secondary service connection scenario, there must be medical evidence establishing a baseline level of severity of disability prior to when aggravation occurred, as well as medical evidence showing the level of increased disability after the aggravation occurred. VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 A. SNPA, also claimed as Rheumatoid Arthritis Service treatment records give no indication of any problems referable to later diagnosed SNPA or rheumatoid arthritis. The Veteran has not specifically asserted direct service connection and the Board cannot find other evidence of direct service connection. In the April 2017 opinion, the examiner noted that these disabilities began years after separation from service, citing the Veteran's own statements. As to this claim, based on the evidence of record, to include the Veteran's lay statements the Board finds that this opinion is sufficient regarding direct service connection. The January 2011 VA examination report documented a diagnosis of SNPA in 1968. In this regard, the requirement for a current disorder is met. In October 2009, a VA clinical social worker submitted an opinion letter in which she stated that the Veteran's significant distress caused by her anxiety symptoms was likely also related to her rheumatoid arthritis. However, she did not provide a rationale in support of her conclusions. Thus, this opinion is afforded no probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In January 2011, the Veteran was afforded a VA examination for SNPA. The examination report noted a history of rheumatoid arthritis that affected multiple joints and required treatment. The examiner opined that the Veteran's SNPA was less likely than not related to her service-connected PTSD based upon other risk factors including gender, age, and her history of smoking. Although the examiner cited a lack of substantial evidence supporting a causal relationship between the two, no further explanation was provided. The examiner did not provide a specific opinion regarding the aggravation prong of secondary service connection. An opinion to the effect that one disability "is not caused by or a result of" another disability does not answer the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Thus, the opinion is of limited probative value. In an April 2017 addendum VA opinion, the examiner opined that the SNPA was less likely than not directly related to the Veteran's active military service, based upon the period of time between separation from service and the diagnosis of rheumatoid arthritis. Additionally, the examiner reasoned that SNPA was not pathologically linked to PTSD, nor was there clear evidence of aggravation. This opinion is afforded some probative weight. See Nieves-Rodriguez, supra; Stefl, supra. Most recently, in a July 2017 addendum VA opinion, the examiner concluded that the Veteran's SNPA was not caused or aggravated by her service-connected PTSD based upon the lack of known causation between the two and the potential influence of other risk factors. Additionally, the examiner further based this opinion on the normal natural progression of the SNPA since its diagnosis. As this opinion had a strong rationale in support of its conclusions, the Board affords it great probative weight. See Nieves-Rodriguez, supra; Stefl, supra. As noted above, the claims file contains treatment records that show a diagnosis of SNPA. However, the VA opinions of record have consistently concluded that the Veteran's SNPA is not linked to her service-connected PTSD. These conclusions have been based upon the normal natural progression of her rheumatoid arthritis, which is not indicative of aggravation beyond the normal baseline, as well as the potential influence of additional risk factors, such as gender and age. The Board notes that a VA clinical social worker has linked the SNPA and the Veteran's service-connected PTSD. However, no supporting rationale was provided to explain this opinion. Therefore, the Board has not found the social worker's opinion to be persuasive and does not find it to outweigh the negative VA medical opinions of record. As the most probative evidence of record is against a finding that the current SNPA is caused or aggravated by the service-connected PTSD; the evidence preponderates against the claim. The preponderance of the evidence is also against direct service connection. Reasonable doubt does not arise, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. B. Hypertension Service treatment records give no indication of any problems referable to later diagnosed hypertension. The January 2011 VA examination report documented a diagnosis of hypertension since 1987. In this regard, the requirement for a current disorder is met. In October 2011, the Veteran was afforded a VA examination for hypertension. The examination report noted the diagnosis of hypertension in 1987, as well as treatment since that time. The examiner opined that the hypertension was less likely than not related to the Veteran's service-connected PTSD based upon the presence of additional risk factors for hypertension, including age, obesity, a history of smoking and alcohol abuse, and diabetes mellitus. However, the examiner did not provide an opinion regarding the aggravation prong of secondary service connection. See El-Amin, supra. Thus, this opinion is of limited probative value. In a December 2011 private medical opinion letter, Dr. S.F. opined that it was possible that the Veteran's PTSD could have contributed to her hypertension diagnosis. In a January 2012 private medical opinion letter, Dr. J. T. opined that it was "quite possible" that the Veteran's PTSD contributed to and/or triggered her hypertension. This opinion was based upon the Veteran's reported psychological history. In a VA medical opinion letter received in April 2012, Dr. D.H. stated that the Veteran suffered from stress-related medical problems, including hypertension. Dr. D. H. noted that medical studies supported an association between PTSD and the medical problems currently experienced by the Veteran. This opinion is afforded probative weight due to its rationale. See Nieves-Rodriguez, supra; Stefl, supra. In an April 2017 addendum VA opinion, the VA examiner opined that hypertension was less likely than not directly related to the Veteran's active military service, again based upon the period of time between separation from service and the diagnosis. Additionally, the examiner concluded that the hypertension was not aggravated by PTSD, based upon the potential influence of other risk factors, including age, obesity, a history of smoking and alcohol abuse, and diabetes mellitus. However, the examiner did not provide an opinion regarding the causation prong of secondary service connection. Thus, the opinion is afforded limited probative weight. Most recently, in July 2017, a VA addendum opinion was obtained in which the examiner opined that the Veteran's hypertension was less likely than not caused or aggravated by her PTSD, based upon the well-controlled status of her hypertension which represented natural progression of the disability. Additionally, the examiner reasoned that there was no irrefutable evidence of direct causation between the two disorders based upon the articles submitted by the Veteran. The Board affords this opinion probative weight. See Nieves-Rodriguez, supra; Stefl, supra. The claims file contains treatment records that show a diagnosis of hypertension, which several treating physicians have linked to the Veteran's service-connected PTSD. The rationale that the hypertension is due to the service-connected PTSD is consistent with the remainder of the clinical record. Additionally, the April 2012 VA medical opinion letter noted that, based upon medical studies, an association was possible between the Veteran's currently diagnosed hypertension and her service-connected PTSD. Although the VA medical opinions have concluded that the Veteran's hypertension has not been caused or aggravated by the service-connected PTSD, the only one of significant probative weight is that of the July 2017 addendum opinion. Further, the Veteran has submitted opinions from three different treatment providers that are consistent with the aggravation of her hypertension by her service-connected PTSD. The Board has not found the negative VA opinions to be persuasive and does not find them to outweigh the positive medical opinions of record. The Board finds that the evidence is at least in equipoise and, therefore, after resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection is warranted for hypertension as caused by a service connected disease. See 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). C. Bilateral Knee Disorder Service treatment records give no indication of any problems referable to a bilateral knee disorder. The Veteran has not specifically asserted direct service connection and the Board cannot find other evidence of direct service connection. In the April 2017 opinion, the examiner noted that these disabilities began years after separation from service, citing the Veteran's own statements. As to this claim, based on the evidence of record, to include the Veteran's lay statements the Board finds that this opinion is sufficient regarding direct service connection. The January 2011 VA examination report documented a diagnosis of bilateral knee osteoarthritis, which the Veteran stated began in 1968. In this regard, the requirement for a current disability is met. In October 2009, a VA clinical social worker submitted an opinion letter in which she stated that the Veteran's significant distress caused by her anxiety symptoms was likely also related to her chronic pain. However, she did not provide a rationale in support of her conclusions, nor did she specify that the chronic pain to which she was referring was that of the bilateral knees. Thus, the opinion is afforded no probative weight. See Nieves-Rodriguez, supra; Stefl, supra. In January 2011, the Veteran was afforded a VA examination for her bilateral knee disorder. The examiner opined that the bilateral knee degenerative joint disease was less likely than not caused by or the result of the service-connected PTSD. This conclusion was based upon the presence of other potential risk factors, including advanced age, obesity, a history of smoking, and SNPA. However, the examiner failed to opine as to the aggravation prong of secondary service connection. See El-Amin, supra. Thus, the opinion is of limited probative weight. In an April 2017 addendum VA opinion, the VA examiner opined that the bilateral knee arthritis was less likely than not directly related to the Veteran's active military service, based upon the period of time between separation from service and the diagnosis. Additionally, the examiner concluded that the bilateral knee arthritis was not pathologically linked to PTSD, nor was there clear evidence of aggravation. However, no further rationale was provided. Thus, this opinion is of limited probative value. See Nieves-Rodriguez, supra; Stefl, supra. Most recently, in a July 2017 VA addendum opinion, the VA examiner opined that the Veteran's bilateral knee disability was less likely than not caused or aggravated by PTSD, based upon imaging studies revealing degenerative changes consistent with rheumatoid arthritis and obesity. Additionally, the examiner reasoned that there was no evidence to suggest direct causation between the two disorders. This opinion is afforded great probative weight. See Nieves-Rodriguez, supra; Stefl, supra. As noted above, the claims file contains treatment records that show a diagnosis of SNPA. However, the VA opinions of record have consistently concluded that the Veteran's bilateral knee disorder is not linked to her service-connected PTSD. These conclusions have been based upon the normal imaging studies revealing degenerative changes that are consistent with rheumatoid arthritis and obesity, as well as the potential influence of additional risk factors, such as gender, SNPA, and age. The Board notes that a VA clinical social worker has linked the chronic pain disorder to the Veteran's service-connected PTSD. However, it is not clear that such pain is the result of the bilateral knee disorder and she did not provide a supporting rationale to explain this opinion. Therefore, the Board has not found the social worker's opinion to be persuasive and does not find it to outweigh the negative VA medical opinions of record. As the most probative evidence of record is against a finding that the current bilateral knee disorder is caused by or aggravated by the service-connected PTSD; the evidence preponderates against the claim. The preponderance of the evidence is also against direct service connection. Reasonable doubt does not arise, and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. D. IBS A November 1957 service treatment record noted the Veteran's complaints of epigastric cramping. A January 2012 private opinion letter, submitted by Dr. J. W., noted a diagnosis of irritable bowel syndrome, for which the Veteran had received treatment since 2007. In this regard, the requirement for a current disorder is met. In January 2011, the Veteran was afforded a VA examination for her gastrointestinal symptoms. The examiner did not provide a nexus opinion related to the claim for service connection for IBS. In a December 2011 private medical opinion letter, Dr. S. F. opined that it was possible that the Veteran's PTSD could have contributed to her IBS diagnosis. In a January 2012 private medical opinion letter, Dr. J. T. opined that it was "quite possible" that the Veteran's PTSD contributed to and/or triggered her IBS. This opinion was based upon the Veteran's reported psychological history. The Board affords this opinion probative weight. See Nieves-Rodriguez, supra; Stefl, supra. Additionally, in the aforementioned January 2012 VA medical opinion letter, Dr. J. W. opined that it was very likely that the Veteran's service-connected PTSD played a role in affecting her IBS, based upon a direct relationship between psychological disorders and bowel dysfunction. Dr. J. W. further based his opinion on the Veteran's gastrointestinal medical history, symptomatology, and related treatment. This opinion is afforded great probative weight. See Nieves-Rodriguez, supra; Stefl, supra. In a VA medical opinion letter received in April 2012, Dr. D. H. stated that the Veteran suffered from stress-related medical problems, including IBS. Dr. D. H. noted that medical studies supported an association between PTSD and the medical problems currently experienced by the Veteran. The Board affords this opinion probative weight. See Nieves-Rodriguez, supra; Stefl, supra. In an April 2017 addendum VA opinion, the VA examiner opined that the IBS was less likely than not directly related to the Veteran's active military service, based upon the period of time between separation from service and the diagnosis. Additionally, the examiner concluded that the IBS was not aggravated by the PTSD based upon the period of time between separation and diagnosis, as well as a lack of a known cause of IBS and a lack of clear evidence connecting the two disabilities. The Board affords this opinion some probative weight. See Nieves-Rodriguez, supra; Stefl, supra. Most recently, a VA addendum opinion was obtained in July 2017, in which the examiner opined that the Veteran's IBS was less likely than not aggravated by her service-connected PTSD. However, the examiner went on to discuss a medical study in which PTSD and IBS were found to be linked, but then concluded that no definitive link had been identified to provide a causal relationship with greater than 50 percent probability. As the examiner's opinion and rationale appear to be inherently contradictory, this opinion is afforded little probative weight. As noted previously, the claims file contains several opinion letters that show a diagnosis of IBS, which several treatment providers have linked to the Veteran's service-connected PTSD. The rationale that the IBS and its associated symptomatology are due to the PTSD is consistent with the remainder of the clinical record. Additionally, Dr. J. W. noted a direct relationship between psychological disorders and bowel dysfunction. Although the VA medical opinions of record have concluded that the Veteran's IBS has not been caused or aggravated by the service-connected PTSD, the Board has not found them to outweigh the positive medical opinions of record. Notably, the July 2017 addendum opinion discussed the findings of a medical study that identified a relationship between IBS and PTSD diagnoses in individuals. Furthermore, the Veteran has submitted several medical opinions that are consistent with the aggravation of her IBS by her service-connected PTSD. The Board finds that the evidence is at least in equipoise and, therefore, after resolving reasonable doubt in favor of the Veteran, the Board finds that entitlement to service connection is warranted for IBS as caused by a service connected disease. See 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). ORDER Entitlement to service connection for SNPA, also claimed as rheumatoid arthritis, to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia, is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia, is granted. Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia, is denied. Entitlement to service connection for IBS, to include as secondary to service-connected PTSD with major depressive disorder and panic disorder with agoraphobia, is granted. ____________________________________________ Nathaniel J. Doan Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs