Citation Nr: 18140954 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 14-00 153 DATE: October 9, 2018 ORDER Entitlement to service connection for Parkinson’s disease, previously claimed as body shakes, is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of Parkinson’s disease, and that the Veteran has a disability manifested by body shakes that is related to service or a service-connected disability. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for Parkinson’s disease, previously claimed as body shakes, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Air Force from March 1971 to July 1974 and with the United States Army from January 1980 to May 1983. Review of the record indicates that this matter was remanded on multiple occasions, to include most recently, in October 2017. In October 2017, the Board’s decision remanded this case for additional development to include obtaining VA medical center records from June 2011 forward pertaining to electroencephalogram (EEG) findings and/or tremors/body jerks/shakes and affording the Veteran a new VA examination. A new examination was afforded the Veteran and a missing EEG report was associated with the file. As the requested development has been substantially completed, this matter has been returned to the Board for appellate consideration. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. VA has established certain rules and presumptions for chronic diseases, such as paralysis agitans (Parkinson’s disease). See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Veteran contends that he suffers from tremors or body shakes. He further asserts that he has a current diagnosis of Parkinson’s disease and that the condition was caused by or otherwise related to active service. In evaluating the Veteran’s claim, the threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of Parkinson’s disease and has not had one at any time during the pendency of the claim or recent to the filing of the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). Service treatment records are silent for complaints of tremors or body shakes. Normal physical findings were reported following an enlistment examination in February 1971. The Veteran’s report of medical history noted that he was in excellent health. At separation, no physical findings related to a tremor condition were reported in June 1974. At re-enlistment in February 1978, the Veteran was deemed qualified for active service. No complaints of tremors or body shakes were reported in a report of medical history dated November 1979. A physical examination in April 1981, yielded a substantially normal evaluation. In a corresponding report of medical history, the Veteran reported that he was in good health. No complaints of tremors or body shakes were reported. Post service treatment records show sporadic complaints of tremors and body shakes. A physician’s note, dated January 2007, indicates that the Veteran underwent a physical examination and no evidence of edema or tremors were revealed. In May 2011, a nursing discharge note indicated that the Veteran was admitted for EEG monitoring due to complaints of tremors impacting his whole body. EEG monitoring failed to show any evidence of tremors or seizure activities. A neurology note, also dated May 2011, indicated that the Veteran reported that he was observed having tremors overnight. He had no recollection of them. In June 2011, a neurology note indicated that the Veteran was evaluated for episodes of nocturnal body jerks suggestive of myoclonus (quick, involuntary muscle jerk). Two EEG monitoring studies were performed. The clinical impression afterwards indicated that no epileptiform features were observed. No diagnosis of myoclonus was rendered. While slowing on the left was noted in each study, this was thought to be related to faulty electrode placement and artificial in nature. A neurology note, dated May 2012, described the Veteran’s complaints of all over body tremors. However, magnetic resonance imaging (MRI) of the brain showed non-specific foci of abnormal intensity within the deep white matter tracts bilateral which was deemed most consistent with microvascular disease. No acute intracranial pathology was shown. Review the record shows that the Veteran underwent numerous VA examinations. In February 2011, the examination was conducted by a nurse practitioner. During the clinical evaluation, the Veteran complained of cramps and tremors in his hands, arms, and legs with an onset described as the previous year. The Veteran also reported lack of sense of smell, occasional difficulty swallowing, and diminished short-term memory. Following the clinical evaluation, the examiner noted that the Veteran had not been diagnosed with Parkinson’s disease. There was no evidence that he had stooped posture, balance impairment, bradykinesia or slowed motion, loss of automatic movements, speech changes, tremor, or muscle rigidity and stiffness. The examiner noted moderate depression, mild cognitive impairment, complete loss of smell, moderate sleep disturbance, and mild sexual dysfunction but no difficulty chewing/swallowing, urinary problems, or constipation. The examiner stated that the Veteran could have restless leg syndrome and that any mental manifestations of moderate depression and mild cognitive impairment or dementia may be attributed to diagnoses of depression, dysthymia, and post-traumatic stress disorder (PTSD). In a March 2011 notice of disagreement, the Veteran disputed the VA examiner’s findings. Specifically, he contends that he suffers from at least five of the symptoms described in the criteria for a Parkinson’s diagnosis. Thereafter, subsequent examinations were conducted in October 2015 and April 2016. Similar findings were noted in each evaluation. A VA neurologist examined the Veteran in October 2015 and October 2017, both times finding that a diagnosis of Parkinson’s disease was not appropriate. Following a review of the record, the neurologist offered a series of medical opinions. The neurologist opined that it was less likely than not that the Veteran’s tremor condition was caused by or otherwise related to active service. Complaints of tremors or momentarily body shakes every so often were noted, however, the symptoms were not deemed suggestive of Parkinson’s disease. Although an exact diagnosis or etiology for occasional body jerks was unclear, the neurologist concluded that the symptoms were likely related to a sleep disorder with some nocturnal myoclonus. Other possible sources of the Veteran’s daytime shaking were described as PTSD, restless leg syndrome, or prescription medications. In support of the stated conclusion, the examiner noted that the Veteran first reported tremors or body jerks in 2011, more than two decades after discharge in 1983. In May 2018, the Veteran underwent another VA examination. During the clinical evaluation, he reported nocturnal jerks over a period of years, with worsening symptoms over the prior six-month period. A recent reduction in symptoms was acknowledged. Following the clinical evaluation, the examiner again found no evidence of Parkinson’s disease. Instead, the Veteran’s symptoms were deemed suggestive of myoclonus. Following a review of the record and clinical evaluation, the examiner opined that it is less likely as not that the Veteran’s reported tremors or body movements were caused by or aggravated beyond the natural progression by the Veteran’s service connected disabilities, to include his service-connected PTSD. In support of the stated conclusion, the examiner noted that there is no evidence that physical conditions such the Veteran’s in-service treatment for an arm/shoulder injury or scars, would cause tremors or body movements. Further, review of the record indicates that the Veteran was diagnosed with PTSD in 2006 or 2007. Ongoing treatment to include psychotherapy, was reported thereafter. At no time has the Veteran’s treating physicians suggested a causal linkage between his tremors and PTSD, to include as due to aggravation. Similarly, treatment records show that the Veteran first reported unwitnessed tremors in March 2011. A later report, in May 2011, suggested that the tremors were becoming less frequent. Tremors were not noted on the Veteran’s “problem list” after May 2011. Thus, the examiner concluded that there is no medical evidence that Veteran’s tremors were aggravated by any service-connected disorders, to include PTSD. The examiner also considered the possibility of a causal linkage between myoclonus and active service. The examiner found no basis for a finding of a nexus between the Veteran’s tremors and active service. In support of the stated conclusion, the examiner noted that physiologic myoclonus is a normal phenomenon that occurs in healthy people. There is minimal or no associated disability and any physical examination is typically without abnormality. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of current symptoms, their impact on daily living and employment, and such reporting is deemed credible. However, as to the etiology of a particular claimed disability, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the instant case, there is no evidence that Veteran possesses the required training to diagnose Parkinson’s disease or opine as to the etiology of his tremors. To the extent his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale. Review of the record shows that no complaints of tremors or body movements were reported in service. Post service treatment records reveal only sporadic references to tremors, beginning in 2011. Specifically, in 2011, an EEG monitoring study found no evidence of a seizure disorder or Parkinson’s disease. Physical examination reports dated August 2011, May 2012, and December 2012, made no reference to tremors. In November 2012, the Veteran’s problem list did not include tremors. In multiple VA examinations, no evidence of Parkinson’s disease was shown. Further, no causal linkage was established between the Veteran’s symptoms and his service-connected disabilities, to include PTSD. While the Board is sympathetic to the Veteran’s complaints of symptoms, there is no evidence that his condition is causally related to active service. Further, his contentions are not supported by the competent and credible evidence of record. Taken together with record the Board finds the VA opinions most probative. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for Parkinson’s disease, claimed as body shakes, must be denied. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel