Citation Nr: 21063140 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 18-03 511 DATE: October 13, 2021 ORDER The claim of entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. The claim of entitlement to service connection for esophagitis is granted. The claim of entitlement to service connection for a hiatal hernia is granted. The claim of entitlement to service connection for a psychiatric disorder is granted. The claim of entitlement to service connection for chronic fatigue is granted. REMANDED The claim of entitlement to service connection for an intestinal disorder, to include abdominal pain is remanded. The claim of entitlement to service connection for migraine headaches, to include as due to a TBI is remanded. The claim of entitlement to service connection for dry eyes is remanded. The claim of entitlement to an initial disability rating in excess of 10 percent for degenerative arthritis of the spine is remanded. FINDINGS OF FACT 1. The probative, competent evidence is at least in relative equipoise as to whether the Veteran's GERD was caused or aggravated by his service-connected low back disorder. 2. The probative, competent evidence is at least in relative equipoise as to whether the Veteran's hiatal hernia was caused or aggravated by his service-connected low back disorder. 3. The probative, competent evidence is at least in relative equipoise as to whether the Veteran's esophagitis was caused or aggravated by his service-connected GERD. 4. The probative, competent evidence is at least in relative equipoise as to whether the Veteran's psychiatric disorder was caused or aggravated by his service-connected low back disorder. 5. The probative, competent evidence is at least in relative equipoise as to whether the Veteran's chronic fatigue was caused or aggravated by his service-connected somatic symptom disorder with depressive/anxious features and insomnia. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for GERD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for establishing entitlement to service connection for a hiatal hernia have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for establishing entitlement to service connection for esophagitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for establishing entitlement to service connection for a psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for establishing entitlement to service connection for chronic fatigue 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 The Veteran had active duty service with the United States Army from January 1989 to February 1992 and from January 1993 to May 1994. In February 2021, the Veteran testified at a virtual teleconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. In Brokowski v. Shinseki, 23 Vet. App. 79 (2009), the Court extended the holding of Clemons to include disabilities outside of psychiatric disorders. In compliance with this case law, the Board expanded the Veteran's claim of entitlement to GERD, and split it into three separate claims to include, a hiatal hernia and esophagitis. With regard to his claim for abdominal pain, the claim has been expanded to include an intestinal disorder. The Veteran's claim for posttraumatic stress disorder (PTSD) is expanded to include any psychiatric disorder. The Veteran's claim for migraine headaches is considered a claim for service connection for migraine headaches, to include as due to a traumatic brain injury (TBI). Finally, the Veteran's claim of entitlement to chronic fatigue syndrome also includes a claim for chronic fatigue. The issues have been recharacterized as stated on the title page. This will provide the most favorable review of the Veteran's claims in keeping with the holding in Clemons. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Although obesity is not a disability for which compensation may be awarded, it can constitute an "intermediate step" in demonstrating service connection on a secondary basis for another condition. Walsh v. Wilkie, 32 Vet. App. 300, 302 (2020). CONTINUED ON NEXT PAGE 1. Entitlement to service connection for GERD. Please see discussion in paragraph 3. 2. Entitlement to service connection for esophagitis. Please see discussion in paragraph 3. 3. Entitlement to service connection for hiatal hernia. The Veteran asserts that his GERD, esophagitis, and hiatal hernia are secondary to his service-connected low back disorder. The Veteran was afforded a VA examination in May 2017. The Veteran reported that his substernal chest pain and vomiting started in the 1990s. His substernal chest pain and vomiting were attributed to GERD. In August 2017 the Veteran underwent another VA examination. The VA examination report included diagnoses of GERD and esophagitis. The Veteran reported that his GERD and esophagitis symptoms started in 2012. A VA medical opinion was provided to determine whether the Veteran's GERD and/or esophagitis were related to exposures in Southwest Asia. The examiner explained that GERD is caused by a frequent acid reflux, back up of stomach acid or bile into the esophagus. The examiner also stated that esophagitis is an inflammation of the esophagus, which can be caused by GERD, eosinophilic esophagitis, or drug inducted esophagitis. The opinion was that it was less likely than not that the Veteran's GERD/esophagitis was caused by a specific exposure event during his service in Southwest Asia. The Veteran submitted a June 2020 private medical opinion completed by T.T., PA-C. Following a review of the record, T.T. opined that the Veteran's GERD and esophagitis were at least as likely as not caused and aggravated by his service-connected low back disorder. The opinion was based on medical literature showing that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are likely to precipitate the development of GERD. T.T., PA-C discussed a November 2008 study that found that NSAID use is a significant risk factor for GERD symptoms. Medical research also indicated that NSAIDs can lower the lower esophageal sphincter function and increase gastric acid production that refluxes into the esophagus leading to the development of GERD. T.T., P.C. noted that this is consistent with the mechanism described by the August 2017 VA examiner as the cause of GERD and the mechanism by which the Veteran developed esophagitis. T.T., PA-C also explained that the Veteran did not experience GERD symptoms until he was prescribed medication for his back pain. The Veteran underwent another VA examination in January 2021. The diagnoses were GERD, hiatal hernia, and esophagitis. The examiner noted a November 2012 endoscopic procedure revealed esophagitis and hiatal hernia. Notes from the medical records showing ongoing use of NSAIDs as treatment for the Veteran's low back disorder were also reviewed. The Veteran reported taking NSAIDs for his back pain for a number of years. He also reported that since the mid-1990s he was unable to exercise as much due to his low back disorder and that his weight slowly increased due to his inability to exercise. The examination report showed that the Veteran's body mass index is 34.1 and in the obese range. The examiner opined that the Veteran's GERD was at least as likely as not proximately due to or the result of the Veteran's service-connected low back disorder. The rationale was that the Veteran had several risk factors for developing GERD, including the use of NSAIDs and his obesity. With regard to his NSAID use, the examiner noted that the Veteran was prescribed NSAIDs to treat his low back disorder. Medical literature indicated that the use of NSAIDs is a risk factor for the development of GERD and for increasing reflux symptoms. With regard to his obesity, increased weight gain, particularly in the obese range, increases an individual's risk of developing GERD. The examiner determined that the Veteran's lack of exercise due to his service-connected low back disorder caused his weight gain. Medical literature also supported an association between increasing body mass index and the development of GERD. Similarly, the examiner opined that the Veteran's obesity led to the development of his hiatal hernia. The examiner provided medical literature to show the association between obesity, hiatal hernias, and esophagitis. The examiner also opined that the Veteran's esophagitis and hiatal hernia were caused by his GERD and weight gain, respectively. Therefore, the examiner concluded that the Veteran's GERD, esophagitis, and hiatal hernia are all secondary to his service-connected low back disorder. Upon review of the record, the Board finds that service-connection is warranted for the Veteran's GERD, hiatal hernia, and esophagitis. In this regard, the June 2020 and January 2021 medical opinions are the only medical opinions of record addressing whether the Veteran's GERD, hiatal hernia, and esophagitis are secondary to his service-connected low back disorder. The Board affords significant probative value to the medical opinions as the examiners take into consideration the Veteran's clinical history, examination findings, and medical literature, as well as included adequate rationale and a thorough review of the evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The June 2020 and January 2021 medical opinions concluded that the Veteran's GERD was due to the Veteran's use of NSAIDs to treat his service-connected low back disorder. Moreover, the January 2021 VA examiner found that the Veteran's obesity is an intermediate step between his GERD and low back disorder, as well as his hiatal hernia and low back disorder. Finally, the Board is granting service-connection for GERD herein, and the medical evidence shows that his esophagitis was caused by his GERD. Accordingly, service connection is warranted for the Veteran's GERD, hiatal hernia, and esophagitis. 4. Entitlement to service connection for a psychiatric disorder. The Veteran seeks service connection for a psychiatric disorder. He contends that his psychiatric disorder is related to his service-connected low back disorder. Alternatively, he asserts that his psychiatric disorder is directly related to service. The claims file contains conflicting medical opinions regarding whether the Veteran's psychiatric disorder is related to his service-connected low back disorder. A May 2020 VA examination report recorded a diagnosis of somatic symptom disorder with depressive/anxious features and insomnia. The examiner noted review of the Veteran's claims file and specifically discussed the Veteran's physical medicine and rehabilitation notes documenting the his complaint of worsening low back pain without relief. The Veteran reported significant chronic pain and reduced mobility for many years. He endorsed secondary mental health symptoms such as, irritability, anger, self-isolation, hopelessness, and passive suicidal ideation. He described anxiety and worry when he is expecting to complete activities that will cause him pain. The examiner opined that the Veteran's somatic symptom disorder was less likely than not proximately due to or the result of the Veteran's service-connected low back disorder. The examiner acknowledged the Veteran's reported significant mental health symptoms and his significantly constricted lifestyle. However, the examiner noted that the Veteran's low back disorder is currently assigned a 10 percent disability rating, which the examiner found indicates that his service-connected low back disorder is a significantly less severe injury. The examiner stated that this "presents the [possibility] that [V]eteran's present symptoms and possible chronic pain are as likely due to his years of working as a truck driver just as much if not more than it is related to his service connected [injury]." In June 2020, S.S., PhD opined that the Veteran's PTSD and somatic symptom disorder are related to his service-connected disorders. The rationale focused on the Veteran's chronic pain in his lower back with radiation to the lower legs, which prevents him from standing or walking longer than 10 minutes. Dr. S. stated that the Veteran's low back symptoms resulted in a reduced quality of life, decreased social dynamics, and overall decrease in health. Dr. S. stated that the Veteran's alteration of gait caused pain and dysfunction in the lower extremities, which could range from the feet to the lower back. Upon review of the record, and resolving doubt in favor of the Veteran, the Board finds that service connection is warranted for the Veteran's psychiatric disorder diagnosed as somatic symptom disorder with depressive/anxious features and insomnia. After reviewing the conflicting medical opinions of record, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's somatic symptom disorder is secondary to the chronic pain caused by his service-connected low back disorder. The May 2020 VA medical opinion was based on the Veteran's assigned rating. However, the examiner did not fully consider the Veteran's lay statements concerning the impairments caused by the low back disorder despite the currently assigned disability rating. The Board also notes tha the low back disorder is currently on appeal for a higher rating. The examiner also appears to suggest that the Veteran's somatic symptom disorder and chronic pain are the result of his service-connected back disorder and his years of working as a truck driver. Therefore, the Board affords less probative value to the May 2020 VA medical opinion. The June 2020 private medical opinion is probative as it was based on a review of the Veteran's medical records and was supported by well-reasoned rationale. Accordingly, resolving the benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's somatic symptom disorder was caused by his service-connected low back disorder. With regard to PTSD, the May 2018 VA examiner found that the Veteran's symptoms did not meet the criteria for PTSD and provided a diagnosis of unspecified anxiety disorder. The Veteran described a stressor related to an ammunition carrier catching fire resulting in no casualties. The VA examiner found that this stressor was not adequate to support a diagnosis of PTSD. The Veteran also did not meet Criterion A through F for a diagnosis of PTSD. The June 2020 private medical opinion provided by Dr. S. indicated that the Veteran developed PTSD as a result of service. However, Dr. S. did not provide medical evidence that the Veteran met the criteria for a diagnosis of PTSD. There was also no discussion of an in-service stressor to support a diagnosis of PTSD. Accordingly, the Board finds that the Veteran does not have a diagnosis of PTSD. With regard to his anxiety disorder, the Board notes that the Veteran has a diagnosis of somatic symptom disorder with depressive/anxious features and insomnia. The May 2018 VA examiner diagnosed unspecified anxiety disorder and found that it was not related to service, to include the stressor of an ammunition truck catching fire. The rationale was that there was no temporal connection between the in-service event and his current symptoms. The examiner noted that the Veteran's anxiety symptoms occurred 27 years after the in-service event. Moreover, his separation examination was absent for any diagnosed psychiatric disorder. There is also no indication that the Veteran's unspecified anxiety disorder is related to his service-connected low back disorder. Therefore, service connection is warranted for a psychiatric disorder, diagnosed as somatic symptom disorder with depressive/anxious features. Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Entitlement to service connection for chronic fatigue. There is a specific standard for "chronic fatigue syndrome" as a diagnosis. Applicable VA regulations specifically define "chronic fatigue syndrome" at 38 C.F.R. § 4.88a in terms of identifying characteristics. A diagnosis of chronic fatigue syndrome requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: (i) acute onset of the condition; (ii) low grade fever; (iii) nonexudative pharyngitis; (iv) palpable or tender cervical or axillary lymph nodes; (v) generalized muscle aches or weakness; (vi) fatigue lasting 24 hours or longer after exercise; (vii) headaches (of a type, severity, or pattern that is different from headaches in a pre-morbid state); (viii) migratory joint pains; (ix) neuropsychologic symptoms; (x) sleep disturbance. 38 C.F.R. § 4.88a. The August 2017 VA examiner found that the Veteran did not have these symptoms and findings, rather, for instance, the examination report indicated no acute onset of chronic fatigue, no reduced daily activity level, no cognitive impairment, no impact on ability to work. The determination was that no objective evidence existed to support a diagnosis of chronic fatigue syndrome. However, the examiner also determined that Veteran met the criteria for a diagnosis of chronic fatigue, not chronic fatigue symptom. The examiner opined that the Veteran's chronic fatigue was likely secondary to his lack of sleep. The examiner acknowledged the Veteran reports of insomnia, four to five hours of sleep per night, and non-refreshing sleep with daytime fatigue and tiredness. The medical opinion was supported by medical literature showing that two-thirds of complaints of chronic fatigue is likely related to medical or a psychiatric diagnosis. Chronic fatigue syndrome with a defined set of criteria is found in less than 10 percent of patients complaining of chronic fatigue. Thus, his chronic fatigue is less likely than not related to a specific exposure event in Southwest Asia. The Veteran submitted a July 2020 private medical report completed by S.V., PA-C. S.V., PA-C provided a diagnosis of chronic fatigue syndrome and found that the Veteran had only some of the symptoms and findings as defined in 38 C.F.R. § 4.88a. Significantly, S.W. noted that the Veteran's fatigue did not have an acute onset, but was instead gradual. Moreover, S.V., PA-C conducted a limited physical examination completed via telemedicine and did not exclude all other clinical conditions that may produce similar symptoms as set forth in 38 C.F.R. § 4.88a. Upon review of the record, and resolving doubt in favor of the Veteran, the Board finds that service connection is warranted for chronic fatigue. The August 2017 examiner stated that the Veteran's diagnosis was chronic fatigue and that the disorder is related to his insomnia. As discussed above, the Veteran is now service connected for somatic symptom disorder with depressive/anxious features and insomnia. The August 2017 private medical opinion is probative as it was based on a review of the Veteran's medical records, included medical literature, and was supported by well-reasoned rationale. There is also no contrary opinion of record addressing whether his chronic fatigue is related to his service-connected psychiatric disorder. Thus, the Board finds that the Veteran has a diagnosis of chronic fatigue related to his service-connected somatic symptom disorder with depressive/anxious features and insomnia. However, the evidence does not support a diagnosis of chronic fatigue syndrome at any point during the period on appeal. As discussed above, in the limited examination conducted by S.V., the report did not include a diagnosis of chronic fatigue syndrome as set forth in 38 C.F.R. § 4.88a. Accordingly, service connection is not warranted for chronic fatigue syndrome. Accordingly, resolving the benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's chronic fatigue was caused by his service-connected somatic symptom disorder with depressive/anxious features and insomnia. REASONS FOR REMAND 1. The claim of entitlement to service connection for an intestinal disorder, to include abdominal pain is remanded. In November 2012, the Veteran underwent an endoscopy for multiple complaints, including abdominal pain. A biopsy was taken to determine whether the Veteran had H. pylori. A rare bacterium was identified, but the biopsy was indeterminate for H. pylori. The Veteran was treated with triple therapy for H. pylori. In July 2013, the Veteran reported that his abdominal pain resolved after treatment with proton pump inhibitors and treatment for H. pylori. The Veteran was afforded a VA examination in May 2017. The Veteran reported diarrhea that occurred from "time to time" and stomach pains that occurred once a month. The examination report noted that his diarrhea occurred every other month and lasted for one to two days, with three to four watery stools per day. The Veteran stated that his diarrhea problems started about four years prior. The examiner determined that his symptoms were mild enough that they could not be related to any physical condition, either diagnosed or undiagnosed. The examiner found that a workup was not warranted due to the mildness of his symptoms. Therefore, the Veteran did not have a chronic gastrointestinal disorder of any etiology. The Board finds that the May 2017 VA medical opinion is inadequate for adjudication purposes. The examiner stated that a workup for the Veteran's abdominal/intestinal symptoms was not warranted due to the mild severity of the symptoms. In light of the Veteran's prior treatment for H. pylori, as well as the symptoms described during the May 2017 VA examination, the Board finds a remand is required to obtain an adequate examination. Although the Veteran's symptoms are described as mild, the Board finds that is an insufficient reason not to conduct a proper workup. Accordingly, a remand is required to obtain another VA examination. 2. The claim of entitlement to service connection for migraine headaches, to include as due to a TBI is remanded. The Veteran asserts that his migraine headaches are related to his service in Southwest Asia. Alternatively, he contends that his headaches are related to an in-service head injury. At the February 2021 Board hearing, the Veteran testified that his migraine headaches started following an in-service head injury that occurred during his first period of service. He stated that he was involved in an accident where a trek vehicle overturned. He testified that he was hospitalized for the injury and wasn't sure if he had sustained a concussion from the accident. Initially, the Board notes that the Veteran's claimed head injury is not documented in the service treatment records of record. However, it appears that the service treatment records are incomplete as they only include records from his second period of active service. The Veteran testified that the head injury occurred during his first period of active duty service. Accordingly, a remand is required to obtain the Veteran's service treatment records from his first period of service. In light of the Veteran's testimony regarding the onset of his migraine headaches, the Board finds that a remand is required to obtain another VA examination and opinion. 3. The claim of entitlement to service connection for dry eyes is remanded. With respect to his claim of entitlement to service connection for dry eyes, the record includes a May 2017 VA medical opinion. The examiner opined that the Veteran's dry eye syndrome was less likely than not related to environmental exposures in Southwest Asia. The rationale was that in order for remote exposures to cause dry eyes, it must have caused a problem creating a tear film deficiency, which was not evidenced on examination. The Board finds that the VA medical opinion is inadequate to the extent that the examiner did not address whether the Veteran's dry eye disorder was otherwise related to service. The record includes an April 1994 service treatment record showing that the Veteran was treated for complaints of a rash around the eyes, itching, and burning. He stated that the symptoms occurred off and on. The diagnosis was allergic blepharitis. At the February 2021 hearing, Veteran testified that his dry eye symptoms continued since service. Accordingly, remand is required to obtain another VA medical opinion. 4. The claim of entitlement to an initial disability rating in excess of 10 percent for degenerative arthritis of the spine is remanded. The evidence indicates that the Veteran's low back disorder worsened since the June 2019 VA examination. At the February 2021 Board hearing, the Veteran reported that his symptoms worsened since the last VA examination. A new VA examination is necessary when there is evidence that a service-connected disability has worsened since the last examination. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); Green v. Derwinski, 1 Vet. App. 121 (1991). Based on the above, a remand is required in order to obtain an orthopedic examination addressing the low back disorder. The matters are REMANDED for the following action: 1. The AOJ should obtain any outstanding service treatment records, to include from the Veteran's first period of active duty service from January 1989 to February 1992. 2. The AOJ should undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claims. If any requested records are not available, the record should be annotated to reflect such, and the Veteran notified in accordance with 38 C.F.R. § § 3.159 (e). 3. Thereafter, the AOJ should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of the Veteran's intestinal disorder, to include abdominal pain. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be accomplished. Following an examination of the Veteran, and a thorough review of the record, the appropriate examiner is requested to: (a) Identify all abdominal/intestinal disorders that have been present during the period of the claim. (b) With respect to each such disorder the examiner should state an opinion as to whether there is a 50 percent probability that the disorder began in or is otherwise related to the Veteran's active duty service, to include as due to environmental hazards in the Persian Gulf. (c) With respect to each such disorder the examiner should state an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder was caused or aggravated by his service-connected GERD, hiatal hernia, or esophagitis. (d) If there are objective manifestations of a disorder manifested by intestinal symptoms or abdominal pain that are not due to a known clinical diagnosis, the examiner should identify those manifestations and state an opinion as to whether there is a 50 percent probability or higher that the manifestations are due to an undiagnosed illness or chronic multisymptom disability of unknown etiology. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 4. Thereafter, the AOJ should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of the Veteran's dry eyes. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be accomplished. Following an examination of the Veteran, and a thorough review of the record, the appropriate examiner is requested to: (a) Identify all eye disorders that have been present during the period of the claim. (b) With respect to each such disorder the examiner should state an opinion as to whether there is a 50 percent probability that the disorder began in or is otherwise related to the Veteran's active duty service, to include as due to environmental hazards in the Persian Gulf. (c) If there are objective manifestations of a disorder manifested by eye symptoms that are not due to a known clinical diagnosis, the examiner should identify those manifestations and state an opinion as to whether there is a 50 percent probability or higher that the manifestations are due to an undiagnosed illness or chronic multisymptom disability of unknown etiology. The examiner must consider and discuss the April 1994 service treatment record showing a diagnosis of allergic blepharitis. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 5. Thereafter, the AOJ should afford the Veteran a VA examination by a physician with sufficient expertise, to determine the nature and etiology of the Veteran's migraine headaches, to include as due to a TBI. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be accomplished. Following an examination of the Veteran, and a thorough review of the record, the appropriate examiner is requested to: (a) The examiner should state an opinion as to whether there is a 50 percent probability that the Veteran's TBI and/or migraine headache disorder began in or is otherwise related to the Veteran's active duty service, to include as due to environmental hazards in the Persian Gulf and/or his reported in-service head injury. (b) If there are objective manifestations of a disorder manifested by headache symptoms that are not due to a known clinical diagnosis, the examiner should identify those manifestations and state an opinion as to whether there is a 50 percent probability or higher that the manifestations are due to an undiagnosed illness or chronic multisymptom disability of unknown etiology. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 6. The AOJ should afford the Veteran a VA examination by an examiner with sufficient expertise to fully assess the severity of his degenerative arthritis of the spine. All pertinent evidence of record should be made available to and reviewed by the examiner. All necessary studies should be performed. The AOJ should ensure that the examiner provides all information required for rating purposes, to specifically include the results of range of motion testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing. In addition, the examiner must determine the extent of any additional limitation of joint motion (in degrees) due to weakened movement, excess fatigability, incoordination, or pain during flare-ups and/or with repeated use. In doing so, the examiner must consider and discuss all procurable and assembled data such as the frequency, duration, characteristics, precipitating and alleviating factors, and the severity of the flare-ups, and then provide an assessment of the functional loss during flares, if possible in degrees of motion lost. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case he or she should clearly explain why that is so. Furthermore, if any opinion cannot be offered without resorting to mere speculation, the examiner should clearly explain why this is the case and identify any additional evidence that may allow for a more definitive opinion. 7. . Then, the AOJ should readjudicate the issues on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. McKinley, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.