Citation Nr: 21069716 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 18-47 632 DATE: November 19, 2021 REMANDED Entitlement to service connection for a lower back disability is remanded. Entitlement to service connection for gastritis, to include as due to Gulf War service and exposures therein, is remanded. Entitlement to service connection for irritable bowel syndrome (IBS), to include as due to Gulf War service and exposures therein, is remanded. Entitlement to service connection for migraines is remanded. REASONS FOR REMAND The Veteran had active military service from April 2009 to March 2012. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 2016 and October 2018 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge during a December 2020 virtual Board hearing. A copy of the transcript has been associated with the file. 1. Entitlement to service connection for a lower back disability is remanded. The Veteran seeks service connection for a lower back disability. The Veteran was provided a VA Back examination in August 2015. A 2011 diagnosis of lumbago was documented, after an in-service report of lower back pain and the Veteran was put on a profile. During examination, no flare-ups of the lower back were reported, and initial range of motion testing was normal. The examiner opined that the Veteran's lower back condition was less likely than not related to service. For rationale, the examiner noted there was no diagnosed disability. Years later, during the December 2020 virtual Board hearing, the Veteran testified that her back has gotten worse since her Iraq deployment and she can't stand or sit for long periods of time. See Hearing Transcript, Page 4. She testified she will even have to "lay down because the pain is so bad, but then there's piercing pain all the way up my back." See Hearing Transcript, Page 4. She reported her back problems began in Iraq after getting "tossed around in the turret" and her lower back would "slam into it," with problems continuing to present. See Hearing Transcript, Page 4. The August 2015 examiner failed to consider whether the Veteran's lower back condition could be considered a disability pursuant to Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Under Saunders, pain alone resulting in functional impairment of earning capacity, even if there is no identified underlying diagnosis, can constitute a disability. During the August 2015 VA examination and the December 2020 Board hearing, the Veteran explained that she has lower back pain when sitting or standing for long periods of time. Therefore, to fully address the Veteran's contentions, and to assist in developing the Veteran's claim, a supplemental VA examination with medical opinion is warranted. The examiner should address the foregoing when providing an opinion as to whether the Veteran's lower back disability is related to service, to include any symptoms resulting in functional impairment of earning capacity. The Board also notes that the absence of evidence, such as a diagnosis of a claimed disability in service treatment records, does not automatically constitute substantive negative evidence. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). On remand, the examiner should refrain from basing any etiologic opinion on the lack of diagnosis of any claimed disability in the Veteran's service treatment records. 2. Entitlement to service connection for gastritis, to include as due to Gulf War service and exposures therein, is remanded. 3. Entitlement to service connection for irritable bowel syndrome (IBS), to include as due to Gulf War service and exposures therein, is remanded. The Veteran contends entitlement to service connection for gastrointestinal conditions, to include gastritis and IBS. The Veteran contends that her IBS began during service in Iraq and has chronically continued following service. During her December 2020 virtual Board hearing, she testified to experiencing stomach pain, diarrhea, gassiness, and bloating. See Hearing Transcript, Page 9. The Veteran was provided a VA Stomach Conditions examination in October 2018. The examiner opined that there was insufficient clinical evidence to support a diagnosis associated with gastritis, as there were no symptoms of dyspepsia or upper gastrointestinal (GI) upset. Reports have indicated increased symptoms associated with milk intake, therefore, it is at least as likely as not that the Veteran's GI symptoms are causally related to food allergies/intolerance. The Veteran was provided an Intestinal Conditions VA examination in October 2018. The Veteran reported in approximately 2010-2011 she began experiencing abdominal cramping that occurred 2-3 times a week, with feeling gassy and passing copious gas daily. The Veteran noted increased gassiness with milk consumption. Diarrhea was noted once a month. The examiner noted there was insufficient clinical evidence to support a diagnosis associated with IBS because the symptoms did not meet the criteria for a diagnosis with a single episode of diarrhea per month. Reports noted increased symptoms associated with milk intake, therefore, it is at least as likely as not that her gastrointestinal symptoms are causally related to food allergies/intolerance. During her December 2020 Board hearing, the Veteran testified to first experiencing issues with her stomach in Iraq. She testified she currently experiences gastrointestinal symptoms "pretty much every day." See Hearing Transcript, Page 10. She reported the gastrointestinal symptoms affect her employment, in that she has to make "at least four to five trips to the bathroom" during a work day. Her representative also argued that her gastrointestinal conditions could be the result of her service in the Gulf War. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A VA examination is warranted to consider the Veteran's lay testimony of her symptoms, including both those in service and since service. In addition, remand is warranted to obtain an opinion as to whether her gastrointestinal condition(s) could be related to exposure events during service in Southwest Asia during the Gulf War. Consequently, on remand, a VA opinion should be obtained to determine whether the Veteran has a diagnosis of any gastrointestinal conditions, and if so, the etiology, including whether her symptoms are related to service in the Gulf War. 4. Entitlement to service connection for migraines is remanded. The Veteran seeks entitlement to service connection for migraines. In June 2018, the Veteran's employer provided written correspondence detailing the Veteran's accommodations needed with arrival time and absences as a result of her migraines. Her employer noted that her migraines occur approximately once a month and affect her for several days. The Veteran was provided a VA Headaches examination in September 2018. A September 2018 diagnosis of tension headaches was noted. The Veteran reported onset of her headaches in late 2010 and that she was initially evaluated for headaches in July 2018. The Veteran indicated she has missed between 25-30 days of work in the past 12 months due to this condition. Prostrating attacks of migraine/non-migraine headaches were noted, on average, once every month. The examiner noted that tension type migraine headaches are a disease with a clear and specific etiology and diagnosis, that being musculoskeletal in origin, which are not known to be causally related to environmental exposures incurred during service in Southwest Asia. Most recently, the Veteran was provided a VA Headaches examination in May 2020. A diagnosis of acute/intermittent tension headaches were noted. The Veteran reported onset in late 2010 and her headaches occur about once a month and last 3-5 days with intensity of 7/8 out of 10. The examiner opined that the Veteran's condition was less likely than not proximately due to or the result of a service-connected condition. For rationale, the examiner noted there is no medical literature stating PTSD causes tension headaches. Tension headaches are a separate entity entirely from PTSD and unrelated to it. Additionally, the Veteran was diagnosed with tension headaches, not migraine headaches. Tension-type headaches involve both a central mechanism and a peripheral mechanism. The central mechanism likely involves hypersensitivity of pain fibers from the trigeminal nerve. The peripheral mechanism is probably related to the contraction of the jaw and neck muscles (McCance & Huether, 2010). During the December 2020 virtual Board hearing, the Veteran testified to experiencing migraines right after returning from Iraq and testified she experiences migraines numerous times a month. See Hearing Transcript, Page 5-6. She testified they can last anywhere from three to seven days, with some migraines lasting up to 10 days. She also noted that high stress levels and lack of sleep can also trigger the onset of her migraines. See Hearing Transcript, Page 7. The Board finds the May 2020 VA medical opinion as to secondary service connection to be inadequate, as the VA examiner failed to address whether the Veteran's headaches were aggravated by her service-connected PTSD. A medical opinion as to secondary service connection should address both causation and aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Thus, remand is required to obtain an opinion that addresses both secondary causation and aggravation. As the record does not contain an opinion on direct service connection, both a direct and secondary opinion is needed upon remand. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's lower back disability. Following a review of the claims file, the examiner is asked to opine: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's lower back disability had onset in, or is otherwise related to, active military service. The examiner is directed to report the Veteran's current symptomatology and to address whether the Veteran's lower back pain results in any functional impairment, to include pain on her ability to stand, walk, run, and maintain balance. The examiner should address the Veteran's contentions during the December 2020 Board hearing, to include that she has difficulty sitting and standing for prolonged periods of time. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's GI condition(s), including her contended gastritis and IBS. Following a review of the claims file, the examiner is asked to opine: (a.) Whether the Veteran has a diagnosis of any GI condition, including gastritis and/or IBS. Specifically note all reported GI symptoms, and state whether any of the Veteran's complaints are attributable to known diagnoses. (b.) Whether it is at least as likely as not (50 percent or greater probability) that any diagnosed GI condition had onset in, or is otherwise related to, active military service. (c.) If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, indicative of an undiagnosed illness attributable to her service in Southwest Asia or a medically unexplained chronic multi-symptom illness, the examiner should identify such symptomatology. The examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. A medically unexplained chronic multi-symptom illness is a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Signs or symptoms which may be manifestations of medically unexplained chronic multi-symptom illness include, but are not limited to fatigue, skin signs or symptoms, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, upper or lower respiratory systems signs or symptoms, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's headaches. Following a review of the claims file, the examiner is asked to opine: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's headaches had onset in, or is otherwise related to, active military service. (b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's headaches were caused by her service-connected PTSD. (c.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's headaches were aggravated beyond its natural progression by her service-connected PTSD. The examiner should identify the nature, frequency, duration, and severity of the Veteran's headaches. Specifically, address whether the Veteran has migraines and, if so, the frequency and duration of any prostrating attacks, to include whether such result in severe economic inadaptability. (Continued on the next page) The examiner should also describe the functional impairment associated with the Veteran's headaches. A complete rationale for all opinions reached should be provided. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Krista Johnson, Associate 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.