Citation Nr: 18155332 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 15-14 621A DATE: December 4, 2018 ORDER The 20 percent rating for chronic low back strain is restored from November 5, 2010. Entitlement to service connection for a respiratory disability is denied. Entitlement to service connection for an acquired psychiatric disorder is granted. Entitlement to a compensable rating prior to July 28, 2015 for post-concussive headaches is denied. Entitlement to a 50 percent rating from July 28, 2015 for post concussive headaches is granted. REMANDED Entitlement to service connection for a sleep disorder is remanded. Entitlement to a disability rating in excess of 20 percent for chronic low back strain is remanded. Entitlement to a separate compensable disability rating for residuals of traumatic brain injury (TBI) (other than headaches) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disorders (TDIU) is remanded. REFERRED The Veteran has repeatedly requested that VA replace previously extracted teeth. See, e.g., September 2012 Correspondence. Thus, this issue is referred to the Agency of Original Jurisdiction (AOJ) for appropriate action. See 38 C.F.R. 19.9(b). In October 2010, the RO granted service connection for right ear hearing loss and assigned a noncompensable rating. The Veteran filed a timely Notice of Disagreement (NOD). The RO issued a Statement of the Case (SOC) in July 2012. In a July 8, 2012 VA Form 21-0820, the Veteran indicated that he had not received a copy of the SOC. A handwritten note indicates that another copy was mailed to the Veteran on August 3, 2012. The Veteran filed an untimely VA Form 9 in November 2012. As the Form 9 was not timely, the RO closed the appeal. Therefore, the issue of entitlement to an increased rating for right ear hearing loss is also referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The reduction in the disability rating from 20 percent to 10 percent was not based on improvement in the Veteran’s ability to function under the ordinary conditions of life and work. 2. The preponderance of the evidence is against a finding that the Veteran’s currently diagnosed respiratory disability had its onset in service or is otherwise related to any disease, injury or event service. 3. The Veteran’s currently diagnosed psychiatric disability is secondary to a service-connected disability. 4. Prior to July 28, 2015, the Veteran’s service-connected post-concussive headaches were manifested by less frequent attacks and were not prostrating. 5. Since July 28, 2015, the Veteran’s service-connected post-concussive headaches are manifested by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The reduction in the disability rating for chronic low back strain from 20 percent to 10 percent was not proper. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 3.105(e), 3.344 (2018). 2. The criteria for service connection for a respiratory disability have not been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2018). 3. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107 (2014); 38 C.F.R. §§ 3.102, 3.310 (2018). 4. The criteria for a compensable rating for post-concussive headaches prior to July 28, 2015 have not been met. 38 U.S.C. §§ 1155, 5107(b) (2014); 38 C.F.R. §§ 3.102, 4.1 - 4.6, 4.10, 4.124a, Diagnostic Code (DC) 8100. 5. The criteria for a 50 percent rating for post-concussive headaches since July 28, 2015 have been met. 38 U.S.C. §§ 1155, 5107(b) (2014); 38 C.F.R. §§ 3.102, 4.1 – 4.6, 4.10, 4.124a, Diagnostic Code (DC) 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1977 to November 1987. The RO obtained the Veteran’s vocational rehabilitation folder after the March 2015 SOC was issued and after the case was transferred to the Board. There is no waiver. However, the evidence is not relevant to the claims adjudicated herein. Therefore, remand for adjudication by the AOJ is not warranted. The Board has recharacterized the Veteran’s claims for anxiety and depression as entitlement to service connection for an acquired psychiatric disability to better reflect the medical evidence and the Veteran’s contentions. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009). The Board has recharacterized the claim for a compensable rating for post-concussive headaches with associated dizziness as entitlement to a compensable rating for post-concussive headaches, to include entitlement to a separate rating for residuals of a TBI (other than headaches). The headaches issue has been bifurcated. See Locklear v. Shinseki, 24 Vet. App. 311, 315 (2011) (bifurcation of a claim generally is within VA’s discretion). The Board notes that the January 2013 rating decision that reduced the disability rating for chronic low back strain was in response to a July 2011 claim for an increased rating for chronic low back strain. In his November 2013 NOD, the Veteran indicated that he was appealing the rating reduction and requested an increased rating for the chronic low back strain. In a March 2015 SOC, the RO characterized the issue on appeal in terms of the propriety of the rating reduction, but also addressed the claim for an increased rating for chronic low back strain. Hence, the Board the issue on appeal is entitlement to a rating in excess of 20 percent for chronic low back strain, to include the propriety of the reduction from a 20 percent rating to a 10 percent rating, effective April 1, 2013. As the Board is now restoring the 20 percent rating for chronic low back strain and remanding the issue of entitlement to an increased rating for this disability, the chronic low back issue has been bifurcated. See id. 1. Propriety of the reduction in the disability rating assigned to the Veteran’s service-connected chronic low back strain from 20 percent to 10 percent. Unlike many benefits issues which come to the Board, in the appeal of a rating reduction, the focus is on the actions of the AOJ in effectuating the reduction, both in complying with the special due process requirements applicable to reductions and, substantively, in terms of whether the evidence at the time of the AOJ’s decision supported the reduction. The burden is on VA to justify a reduction in a disability rating. See Brown v. Brown, 5 Vet. App. 413, 421 (1993). If, after considering the evidence, doubt remains as to the propriety of a rating reduction, VA must continue the previously assigned rating. See 38 C.F.R. § 3.344(b). A valid rating reduction must comply with the procedural requirements of 38 C.F.R. § 3.105(e). The AOJ appears to have complied with these procedural requirements by sending the Veteran notice in the form of a July 2012 rating decision, by sending him a letter explaining his right to submit relevant evidence, and by scheduling a pre-reduction hearing for the Veteran, which he later waived. At the time of the January 2013 reduction, the 20 percent rating for the Veteran’s chronic low back strain had been in effect since March 2010. Thus, as the rating had been in effect for less than five years, the provisions of 38 C.F.R. § 3.344 (a), (b), which provide additional regulatory hurdles to rating reductions, do not apply. With respect to ratings that have been in effect for less than 5 years, as in this case, 38 C.F.R. § 3.344 (c) requires improvement before a rating is reduced. Implicit in the regulations is that any improvement must be of such a nature as to warrant a change in the rating. The Board must vacate the January 2013 rating reduction because the evidence fails to satisfy the substantive requirements of 38 C.F.R. § 3.344(c). There are at least two substantive problems with the AOJ’s rating reduction in this case. First, a rating reduction must be based on an adequate examination report. See Tucker v. Derwinski, 2 Vet. App. 201, 203 (1992). 38 C.F.R. § 4.59 requires that adequate range of motion test results include range of motion testing “for pain on both active and passive motion and in weight bearing and nonweight-bearing . . .” Correia v. McDonald, 28 Vet. App. 158, 170 (2016). Because the August 2011 examination findings do not include range of motion test results using each of the testing methods identified in 38 C.F.R. § 4.59, the examination is inadequate for rating purposes and, therefore, also inadequate to support a reduction in the rating previously assigned. Secondly, a rating reduction requires a finding that an improvement in the relevant disability has occurred and that the improvement actually reflects an improvement in the Veteran’s ability to function under the ordinary conditions of life and work. See Brown v. Brown, 5 Vet. App. 413, 420-21 (1993). The January 2013 rating decision which reduced the disability rating demonstrates that the RO appears to have essentially analyzed the issue of reduction of the 20 percent rating in the same manner as it would analyze an increased rating claim. Specifically, the RO did not address whether there was an “actual improvement in the Veteran’s ability to function under the ordinary conditions of life and work.” Id. Overall, the evidence does not reflect that there was any improvement in the Veteran’s ability to function under the ordinary conditions of life and work in light of his chronic low back strain at the time of the September 2011 reduction. Specifically, a January 2013 letter from the Veteran’s treating physician indicated that there was significant degenerative joint disease in the Veteran’s lumbar spine, with “very limited range of motion” which required multiple narcotic pain medications for relief. The physician wrote that he had first treated the Veteran in October 2011 and there had been no subsequent improvement in the lower back condition. Moreover, the physician did not expect the condition of the Veteran’s low back to improve in the future. The competent and credible correspondence from the Veteran’s treating physician indicates that the functional impacts of the Veteran’s chronic low back strain remained the same and potentially worsened. For these reasons, the reduction in the disability rating for the Veteran’s chronic low back strain was not proper. This renders the reduction from 20 percent to 10 percent void ab initio. See Kitchens v. Brown, 7 Vet. App. 320 (1995). Thus, the Board must restore the 20 percent evaluation, effective April 1, 2013. 2. Entitlement to service connection for a respiratory disability The AOJ denied this claim without first arranging a medical examination or obtaining a medical opinion on the issue of whether the claimed disability is related to active duty service. Such an opinion is necessary when the record contains: (1) competent evidence of a current disorder, or persistent or recurrent symptoms of a disorder; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disorder or persistent and recurrent symptoms of a disorder may be associated with the claimant’s active service, but (4) there is insufficient medical evidence for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The evidence in this case satisfies part (1) of the McLendon standard. Although there is not a clear medical diagnosis for of a current respiratory disability, post-service records of VA medical treatment indicate symptoms of respiratory distress. VA treatment records, dated May 2012, indicated “almost constant shortness of breath” apparently associated with coronary artery disease and heart failure. The same group of records refer to decreased breath sounds and a history of smoking. These records satisfy the requirement of persistent or recurrent symptoms of a disability manifested by respiratory distress. Part (2) of the McLendon test is also satisfied. According to his service medical records, the Veteran experienced a mild upper respiratory infection in February 1978. He was diagnosed with strep throat in September 1978 and he had a chest cold in January 1979. He had a cold, with cough and nasal congestion in December 1979. Subsequent records reflect treatment for cold symptoms in February 1982 and for a cough in March 1982. The evidence does not, however, meet part (3) of the test, i.e., the record includes no evidence of any kind suggesting that current symptoms of respiratory distress may be associated with the Veteran’s active duty service. When deciding whether an examination is needed, the requirement that the claimed disability may be associated with an in-service injury or event is a low threshold. Locklear v. Nicholson, 20 Vet. App. 410, 419 (2006) (quoting McClendon, 20 Vet. App. at 83). Nevertheless, there is essentially no evidence of any kind indicating that the respiratory complaints noted in the Veteran’s post-service VA treatment records had their initial onset in service or are otherwise related to any in-service disease, injury, or event. The Veteran’s lungs, chest, mouth, nose, throat, and sinuses were normal at the time of an examination conducted in conjunction with his separation from service in October 1987. Also in October 1987, the Veteran completed a report of medical history form, in which he denied ever having experienced shortness of breath, chronic cough, asthma, sinusitis, or hay fever. The Veteran's initial claim, dated June 2013, requested service connection for “respiratory issues.” Neither his January 2015 notice of disagreement nor his May 2015 substantive appeal (VA Form 9) includes any statements concerning the origins or history of his claimed respiratory disability. No document submitted by the Veteran himself, or submitted on his behalf, attempts to explain why he believes that current respiratory symptoms are related to service. There is likewise no medical evidence in the record suggesting that respiratory infections or cough continued from 1978 until the present day. The report describing normal lungs, chest, mouth, nose and throat at the time of his October 1987 medical examination and the Veteran’s denial of any history of respiratory symptoms in the report of medical history suggest that the Veteran experienced cold-like symptoms early in his active duty services – specifically between February 1978 and March 1982 – but that these symptoms resolved long before his discharge from the Army in October 1987. The Veteran is competent to describe symptoms he has personally experienced. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). And he is competent to provide evidence as to how long those symptoms have persisted. But the Veteran has offered no lay statements, arguments, or even suggestions as to why he believes he is entitled to receive compensation for his current shortness of breath, which treating medical personnel have apparently attributed to coronary artery disease. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, see 38 U.S.C. § 5107(b), and the claim must be denied. 3. Entitlement to service connection for an acquired psychiatric disorder as secondary to a service-connected disability The Veteran claims that he developed his current psychiatric symptoms as a result of his service-connected lower back disability or service-connected headaches. Even if a claimed disability did not begin during active duty service, it is possible that the Veteran may be eligible for compensation on a secondary basis if the claimed disability is proximately due to, the result of, or aggravated by, a disease or injury which is service-connected. See 38 C.F.R. § 3.310. Post-service VA treatment records satisfy the “current disability” requirement of the psychiatric claim. For example, a VA mental health note, dated September 2011, indicates Axis I diagnoses of recurrent major depressive disorder, moderate to severe without psychotic features, and generalized anxiety disorder with panic features. To support his claim, the Veteran has submitted a disability benefits questionnaire, dated March 2016, apparently completed by a psychologist in private practice. The questionnaire identifies the Veteran’s diagnosis as depressive disorder “due to another medical condition . . .” According to the psychologist, the symptoms included depressed mood, anxiety, suspiciousness, sleep impairment, memory loss, impaired judgment, suicidal ideation, impaired impulse control, and persistent delusions or hallucinations. In a separate written report – also dated March 2016 and part of the same electronic document as the questionnaire – the psychologist wrote that the Veteran’s “tinnitus, hemorrhoids, chronic low back strain, right ear hearing loss and post-concussive headaches have caused the depressive disorder.” To support this opinion, the psychologist cited journal articles documenting statistical associations between the Veteran’s service-connected disabilities (particularly tinnitus and headaches) and the prevalence of depression and anxiety. The March 2016 psychologist’s report was based on a review of the relevant documents and a personal examination of the Veteran. Under these circumstances, the psychologist’s opinion is adequate to support a finding that it is at least as likely as not that the Veteran developed his current depressive disorder as a secondary result of the service-connected back disability, headaches, and tinnitus. Consistent with this finding, the Board will grant service connection for an acquired psychiatric disorder as secondary to the Veteran’s service-connected disabilities pursuant to 38 C.F.R. § 3.310. 4. Entitlement to compensable disability rating for post-concussive headaches The Veteran’s headaches are rated as noncompensable under 38 C.F.R. § 4.124a, Diagnostic Code (DC) 8100. Under Diagnostic Code 8100, a non-compensable evaluation is assigned for less frequent attacks. A 10 percent evaluation is assigned for migraines with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent evaluation is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent evaluation, the highest available under Diagnostic Code 8100, is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The term prostrating is not defined by the regulation, nor has the Court defined it. Cf. Fenderson v. West, 12 Vet. App. 119, 127 (1999) (quoting DC 8100 verbatim, but not specifically addressing the matter of what is a prostrating attack). However, “prostration” is defined as extreme exhaustion or powerlessness. See Dorland’s Illustrated Medical Dictionary, 1531 (32nd ed. 2012). It appears that the Veteran contends that the January 2014 VA headaches examination is inadequate. He has criticized the examiner’s report because the examiner indicated “no” next to pre-printed text asking her whether or not she had reviewed the Veteran’s VA claims file. Elsewhere on the examination report form, however, the examiner indicated that she reviewed both the Veteran’s post-service VA medical treatment records and also “VBMS” or the documents available through the Veterans Benefits Management System. This is a system of electronic files which, in this case, includes essentially all the information in the Veteran’s VA claims file. The examiner also personally interviewed the Veteran, described his reported symptomatology, and provided relevant clinical findings necessary to address the applicable rating criteria. Thus, the Board finds that the January 2014 VA examination is adequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The January 2014 examiner diagnosed the Veteran with post-concussive headaches. According to the Veteran, his headaches consisted of sharp pain which he perceived in the front and right sides of his head. He told the examiner that he experienced headaches about three days each week and that each headache lasted about 30 or 40 minutes. The headaches were accompanied by dizziness and blurry vision. According to the examiner’s report, the Veteran did not experience characteristic prostrating attacks of migraine or non-migraine headache pain. The examiner further opined that the Veteran’s headaches did not affect his ability to work. The available post-service VA treatment records say little about the Veteran’s headaches. According to primary care notes, dated October 2011 and March 2012, the Veteran was not experiencing headaches at the time of those appointments. The AOJ also obtained records from the Social Security Administration (SSA). Most of these materials concern the Veteran’s back and mental health disabilities, but a medical examination report conducted for that agency, dated February 2014, describes headaches. To the SSA examiner, the Veteran described headaches as occurring three times each day, with an average duration of 15 minutes. The headaches were accompanied by photophobia, nausea, and blurred vision. The Veteran submitted a July 2015 disability benefits questionnaire, completed by a physician, on the severity of his service-connected headaches. The physician wrote that his answers to the questionnaire were based on his review of the claims file and on an interview with the Veteran. Section II (“Medical History”) of the questionnaire indicates that the Veteran experienced an increase in the severity of his headaches. The physician wrote that the Veteran uses hydrocodone and ibuprofen to control his headaches and that headaches cause constant, pulsating or throbbing pain on both sides of the head, which worsens with physical activity. According to the physician, the Veteran's headaches caused nausea, sensitivity to light, sensitivity to sound, and dizziness. The typical duration of head pain was more than 2 days. According to the physician, the Veteran experienced prostrating attacks of non-migraine headache pain more frequently than once per month. He marked "yes" in response to the question “Does the Veteran have very frequent prostrating and prolonged attacks of non-migraine headache pain?” The physician likewise concluded that the Veteran's headaches affected his ability to work: “He experiences occasional nausea, dizziness, and sensitivity to light and sound. He would miss work several times a month and require frequent unscheduled breaks due to his migraines. He would not be able to maintain gainful employment.” The physician who completed the headaches questionnaire also completed a residual functional capacity evaluation, which is available as part of the same document. According to this evaluation, at their current level of severity, the Veteran’s headaches would likely cause him to miss three or more days of work each month. For more than three days per month, the evaluation continues, the Veteran would be unable to concentrate on work tasks for at least seven hours during an eight-hour work day. Accordingly, the physician concluded that, due to his headaches, the Veteran would not be able to maintain substantially gainful employment. The Veteran also submitted a statement from his wife, dated December 2015, which is consistent with the private headaches questionnaire. She wrote that the Veteran’s headaches “have [been] continually worse over time.” According to his wife, the Veteran has difficulty sleeping due to headaches. She also described what appear to be “prostrating” attacks as described herein: “Whenever he gets these headaches, he has to lie down in a dark room for a while, sometimes a few hours, until he feels better.” The relevant appeal period in this case is June 17, 2013 to the present. Within the appeal period, there is evidence suggesting that the Veteran’s headache symptoms meet the criteria for a higher rating under DC 8100 for only part of that period. For situations like this one, the Board may assign different ratings for separate periods of time. See Fenderson, 12 Vet. App. at 126-27. Before July 28, 2015 – the date of the Veteran’s interview with the physician who completed the most recent headaches questionnaire – there is no evidence that the Veteran’s headaches caused any “prostrating attacks” as the term is defined herein. Prior to this date, the VA treatment records and social security records mentioned headaches, but they did not specifically describe the headaches’ frequency, duration, or severity. The January 2014 headaches examiner reported that the Veteran’s headaches took place approximately three times per week and that each headache lasted 30 or 40 minutes. The report of the SSA examiner, only a few weeks later, indicated more frequent headaches (three times each day), but further indicated that the average duration of these headaches was only fifteen minutes. Because of their relatively brief duration, the Board finds that these attacks were not “prostrating” as that term is defined herein. Since July 28, 2015, the evidence about the Veteran’s headache symptoms comes from the private physician’s questionnaire and the written statement from the Veteran’s wife. Both sources of information report an increase in the severity of the Veteran’s headaches. The July 2015 questionnaire indicates that the Veteran experienced daily headaches which required him to lie down for hours before he could recover. The same physician’s residual capacity evaluation indicates that these headaches would make it impossible for the Veteran to work. This amounts to evidence of severe economic inadaptability for the purpose of DC 8100. Based on this evidence, the Board will assign an increased 50 percent rating, effective July 28, 2015. A compensable rating prior to July 28, 2015 is denied for the reasons discussed above. Regarding extraschedular consideration, the Board finds that it is not warranted in this case. Diagnostic Code 8100 indicates migraines should be rated according to the frequency of prostrating attacks, which incorporates pain, nausea, vomiting, sensitivity to light, sensitivity to sound, and changes in vision. The regular schedular criteria thus contemplate both the symptoms and the level of disability suffered by the Veteran - less than completely prostrating attacks. The effects of the Veteran’s disability have been fully considered and are contemplated in the rating schedule. REASONS FOR REMAND 1. Entitlement to service connection for a sleep disorder is remanded. The Veteran seeks service connection for a sleep disorder. There is conflicting evidence as to whether a separate sleep disorder exists or whether the Veteran’s complaints of sleep-related symptoms are manifestations of other disabilities. According to a medical examination report obtained from the SSA, the examining physician suspected sleep apnea. The December 2015 written statement from the Veteran’s wife attributed sleep difficulties to the Veteran’s headaches. The report of the Veteran’s private psychologist, however, listed chronic sleep impairment as a symptom of depressive disorder. Under these circumstances, the Board will remand the Veteran’s sleep disorder for a VA examination and opinion. 2. Entitlement to a disability rating in excess of 20 percent for the Veteran’s service-connected chronic low back strain is remanded. As discussed above, it appears that the Veteran’s low back disability has worsened. The Veteran’s last VA examination was in August 2011. Since the Veteran is claiming he is experiencing worsening symptoms, and this change in disability would possibly affect his disability rating, the Board finds that a remand is appropriate in order for the Veteran to undergo a new VA examination. 3. Entitlement to a separate compensable disability rating for residuals of TBI, other than headaches, is remanded. The Board finds that a VA TBI examination is warranted. It is unclear whether dizziness or other potential residuals of the Veteran’s in-service head injury are appropriately rated using DC 8045 or some other potentially applicable diagnostic code. Accordingly, remand is required to determine whether a separate rating is warranted for residuals of TBI (other than headaches), to include dizziness. 4. Entitlement to TDIU is remanded. The Veteran's request for a TDIU rating is intertwined with the claims which the Board is remanding. The remanded claims, if they are resolved in the Veteran's favor, could potentially affect whether he is eligible for a TDIU rating. The appropriate remedy when a pending claim is intertwined with an issue on appeal is to defer adjudication of the claim on appeal pending the adjudication of the inextricably intertwined claim. See Smith v. Gober, 236 F.3d 1370, 1372 (Fed. Cir. 2001); Henderson v. West, 12 Vet. App. 11, 20 (1998). The Board will remand the TDIU appeal pending the resolution of the intertwined issues. The matters are REMANDED for the following action: 1. Obtain and associate with the claims folder copies of all records of the Veteran’s VA treatment since January 2015. 2. Schedule the Veteran for a VA examination to evaluate the current severity of the service-connected chronic low back strain. All indicated tests and studies should be performed and findings reported in detail. The claims folder must be made available to the examiner for review prior to examination. The examination should be conducted in accordance with the current disability benefits questionnaire. The examiner should address the impact of the Veteran’s service-connected chronic low back strain on his ability to perform physical and mental tasks in a work-like setting. 3. Schedule the Veteran for a TBI examination to be conducted by a physiatrist, psychiatrist, neurologist, or neurosurgeon. All pertinent symptomatology, findings and clinical manifestations must be reported in detail. All appropriate studies, including additional neuropsychological testing, if indicated, should be performed. The examiner should also review the Veteran’s VA claims file. After the records review and examination are complete, the specialist should complete an examination report describing the current severity of any current residuals of TBI (other than headaches), to include dizziness. 4. Schedule the Veteran for an appropriate examination to determine the nature and etiology of any currently diagnosed sleep disorder. All appropriate studies should be performed. The examiner should also review the Veteran’s complete VA claims file. (a) Please identify any currently diagnosed sleep disorder. (b) For each sleep disorder identified, provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the sleep disorder had its initial onset during active duty service or is otherwise related to any in-service disease, injury or event. (c) For each sleep disorder identified, provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the sleep disorder is caused or aggravated by any of the Veteran’s other service connected disabilities, including post-concussive headaches, psychiatric disability, tinnitus, and/or chronic low back strain. The examiner should provide a full rationale explaining his or her opinions, to include separate rationales for causation and aggravation opinions. REBECCA N. POULSON Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Nye, Associate Counsel