Citation Nr: 21070469 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 12-16 260 DATE: November 24, 2021 ORDER Service connection for neurological conditions, to include tremors in hands and restless legs, is denied. FINDING OF FACT 1. It is less likely than not (less than 50 percent probability) that the Veteran has a diagnosis of Parkinsonism or symptoms attributed to Parkinsonism. 2. It is less likely than not (less than 50 percent probability) that the Veteran has had a traumatic brain injury (TBI). 3. It is less likely than not (less than 50 percent probability) that the Veteran's tremors in hands and restless legs occurred during or were otherwise related to his service or his service connected PTSD. CONCLUSION OF LAW The criteria for neurological conditions, to include hand tremors and restless legs have not been met. 38 U.S.C.§§ 1110, 1116, 5107; 38 C.F.R.§§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the U.S. Army from October 1968 to May 1970. He served in Vietnam from April 1969 to May 1970 as an ammunition handler. The Veteran is seeking service connection for neurological conditions in his four extremities, to include tremors in his hands and restless legs, which he believes may have resulted either from injuries during service or as a result of his service connected PTSD. The matter has been before the Board in July 2019, April 2021, and September 2021. In its latest decision in September 2021, the Board remanded the matter for further development to determine whether the Veteran's neurological conditions in his extremities should be classified as Parkinsonism. Such development has been completed. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R.§ 3.303. Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service (nexus). Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to, or aggravated by, a service connected disability. 38 C.F.R.§3.310 (a). In addition, service connection can be established based on herbicide exposure. 38 C.F.R. § 3.307(a)(6). A veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam is presumed to have been exposed to herbicides and the veteran is entitled to a presumption of service connection for certain diseases listed under 38 C.F.R. § 3.309(e). Here, as the Veteran served in Vietnam from April 1969 to May 1970, he is presumed to have been exposed to herbicide agents during service. Parkinson's disease is a disease listed under 38 C.F.R. § 3.309(e) which codifies the diseases that are presumptively considered to have been caused by herbicide exposure. As discussed below, the medical professionals have concluded that Veteran does not have Parkinson's disease and his tremors in hands and restless legs are not symptoms of Parkinson's disease or Parkinsonism. The National Defense Authorization Act for Fiscal Year 2021 added three disorders to the list of presumptively associated diseases with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116 (a)(2) to include Parkinsonism, bladder cancer, and hypothyroidism. The Veteran's representative argued in the written briefs dated July 2021 and November 2021 that the Veteran's tremors in hands and restless legs were symptoms of Parkinsonism. The representative pointed out that per the VA Veteran's Health Library, Parkinsonism is the name for a group of brain conditions that have symptoms similar to Parkinson's disease. Pursuant to the September 2021 Board remand, a VA medical opinion was obtained in September 2021. The VA examiner opined that the Veteran's did not have a diagnosis of Parkinsonism and his tremors in hands and restless legs were not symptoms of Parkinsonism. The examiner provided that following rationale: No symptoms on DBQ Central Nerve System (CNS) are due to Parkinsonism as no diagnosis of Parkinsonism exists. Per 7/18/19 neurology note, gait issues due to low back condition. Per this note, the Veteran has essential tremor in bilateral hands. This is by itself not Parkinsonism. "Parkinsonism comprises a clinical syndrome that presents with a varying degree of rigidity, and a variety of symptoms that include bradykinesia, tremor, and unstable posture, all of which can cause a profound gait impairment." No rigidity or bradykinesia is noted in treatment notes. His condition of sleep issues is entirely unrelated to a CNS condition. His diagnosis of restless leg syndrome is most likely due to lumbar spine condition. Based on literature and treatment notes, no diagnosis of Parkinsonism exists. While the Veteran and his representative believe that the Veteran's tremors in hands and restless legs are symptoms of Parkinsonism, they lack the medical training and expertise to provide such complex medical opinion. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As such, their lay opinions are insufficient establish that the Veteran has Parkinson's disease or Parkinsonism. For that reason, a VA medical opinion was obtained, but the examiner explained why he did not feel that a diagnosis of Parkinsonism was warranted for the Veteran's neurologic complaints. This opinion has not been challenged or contradicted by other medical opinion. Accordingly, service connection for tremors in hands and restless legs cannot be granted based on presumptive service connection for Parkinsonism under 38 U.S.C.§ 1116. Even if service connection is not warranted on a presumptive basis, the Board must consider whether service connection can be granted on a direct or secondary basis. In October 2012, the Veteran underwent a private neuropsychological assessment by Dr. Stern. He reported tremors in his hand, restless legs, along with his psychiatric disorders. Doctor Stern diagnosed him with PTSD, sleep apnea, and traumatic brain injury (TBI) due to explosions he experienced in Vietnam, which rendered him unconscious. At his Board hearing before the undersigned Veterans Law Judge in May 2018, the Veteran testified that he noticed the neurologic problems (hand tremor) after he came back from service, but he did not report any head injuries during service. Service treatment records (STRs) do not show that the Veteran was treated for any brain injuries or tremor or restless legs. His separation physical in May 1970 showed normal head condition and neurological condition. At his report of medical history in conjunction with the separation physical, he denied any head injury, headaches, or periods of loss of consciousness while reporting other health issues, such as eye trouble, a hernia, and mumps. A July 2020 VA examination diagnosed the Veteran with movement disorder, essential tremor, and restless leg syndrome. Based on the Veteran's report and Dr. Stern's assessment in October 2012, the examiner opined that the Veteran's hand tremors and restless leg were at least as likely as not (50 percent or more probability) related to the TBI he sustained during service. However, a November 2020 VA examination conducted by a different examiner found that the Veteran did not have, nor had he ever had, a diagnosis of TBI or residuals of TBI. The examiner explained that, the Veteran did not meet the diagnostic criteria for TBI. He did not have history of any significant injuries to the head that would have resulted in TBI. The Veteran stated that he was near a Howitzer when it fired during service in Vietnam, but he denied experiencing any loss of consciousness, any amnesia of the events, or any confusion. He said that his nose was bleeding due to pressure of the blast, but denied any other injuries. He was not evaluated for this either. He reported returning back to his baseline functioning after the event. It does not appear that he had any lingering symptoms from this incident. In his separation examination dated May 19, 1970, the Veteran did not report any head injuries, or loss of consciousness, or complaints of headaches or concussion symptoms. Furthermore, reviewing his medical records does not reveal any complaints or diagnosis pertaining to traumatic brain injury residual. He had an MRI of his brain (6/5/2019) which showed mild generalized brain volume loss, nonspecific periventricular signals, clinically insignificant and not indicative of TBI. Due to the fact that the Veteran did not report of any TBI events at the time of his separation from the Army, and due to lack of evidence showing continuity of treatment for TBI residuals during or after service, the examiner concluded that the Veteran did not meet the criteria of TBI diagnosis. Additionally, the examiner opined that the Veteran's neurological conditions, to include tremors in hands and restless legs were less likely than not (less than 50 percent probability) incurred in or caused by a TBI during service. In May 2021, a third examiner provided medical opinions that (1) the Veteran does not have a diagnosis of TBI, and that (2) the Veteran's neurological conditions, to include tremors in hands and restless legs are less likely than not (less than 50 percent probability) incurred in or caused by his service. The third examiner concurred with the November 2020 VA examiner that the Veteran did not have a diagnosis of TBI for the same reason articulated by the November 2020 VA examiner. In addition, the third examiner reviewed Dr. Stern's assessment letter dated October 2012, and found that there was no evidence to support episodes of unconsciousness referred in Dr. Stern's letter and there was no evidence to support the fact that Veteran actually sustained a TBI. The third examiner further opined that Veteran's neurological conditions, to include tremors in hands and restless legs were less likely than not (less than 50 percent probability) incurred in or caused by his active service. The third examiner explained that there was no objective finding to suggest that the Veteran suffered any form of TBI in his STRs or documents from the period immediately following separation. None of the Veterans STRs show complaints of either tremors or restless leg syndrome (RLS) in his service. These symptoms were incurred decades after separation. VA treatment records show that the Veteran first sought treatment for tremor in both hands in June 2009. At that time, he reported that the tremor started around 2007 and he had Grave's disease. He was concerned about Parkinson's disease. After examination, the physician assessed that the Veteran did not have Parkinson's disease and his clinical picture is consistent with essential tremor and he was also likely suffering with restless leg syndrome. In July 2019, he was again diagnosed with essential tremor after MRI of brain conducted in June 2019, but the physician indicated no signs and symptoms of Parkinson's disease. The Board finds that the November 2020 and the May 2021 VA medical opinions are based on well-reasoned rationale and supported by ample medical evidence of the record. Conversely, Dr. Stern's diagnosis of TBI in October 2012 and the July 2020 VA opinion on direct nexus are not supported by the evidence of record. The Veteran did not report any brain injury or loss of consciousness occurred during service, and STRs do not show any complains of brain injury or loss of consciousness. VA treatment records show that the Veteran first sought treatment for tremor in both hands in June 2009, approximately 39 years after he separated from service, and reported at that time that the symptoms had onset in the previous few years. As such, the Board gives more probative weight on the November 2020 and the May 2021 VA medical opinions than Dr. Stern's assessment in October 2012 and the July 2020 VA examiner's opinion. With regard to the Veteran's report at his May 2018 Board hearing that he noticed hand tremors after he was discharged from service, this is contradictory to the VA medical records in June 2009 when he reported that the tremor started around 2007, that he had Grave's disease, and that he was concerned about Parkinson's disease at that time. The Board gives more weight on the Veteran's report documented on the contemporaneous treatment records because it is more likely to accurately reflect the Veteran's health information at the time when he sought treatment. Accordingly, service connection for neurological conditions, to include tremors in hands and restless legs cannot be granted on a direct basis. Turning to Veteran's contention that his neurological conditions are secondary to his service connected PTSD. The July 2020 VA examiner opined that the Veteran's neurological conditions were less likely than not (less than 50 percent probability) caused by or aggravated by his PTSD and were more likely attributed to his TBI. The May 2021 VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's neurological conditions, to include symptoms of tremors in hands and restless legs was caused or aggravated by his service connected PTSD, and provided the following rationale: I found no medical evidence in the e-file to suggest a connection [between the claimed condition and PTSD].... I found no medical evidence in the e-file to suggest there has been PTSD-related aggravation. There is no objective evidence in the e-file suggesting the causes of his restless leg and tremors, and correlating the condition or its aggravation to the PTSD would be entirely speculative. The vast majority of cases are idiopathic with completely unexplained causes. RLS [restless leg syndrome] can be either primary or secondary. In most cases, RLS is a primary, idiopathic central nervous system (CNS) disorder. Such idiopathic disease can be familial in 25-75% of cases. In the familial cases, RLS appears to follow a pattern of autosomal dominant or recessive inheritance. Patients with familial RLS tend to have an earlier age of onset (< 45 years) and slower disease progression. In some families, a progressive decrease in age of onset with successive generations (ie, genetic anticipation) has been described. Psychiatric factors, stress, and fatigue can exacerbate symptoms of RLS. Secondary RLS can develop as a result of certain conditions or factors, particularly iron deficiency and peripheral neuropathy. Because of the prevalence of these conditions in the general population, their association with RLS must be interpreted with caution. Other causes of RLS include the following: Folate or magnesium deficiency, Amyloidosis, Diabetes Mellitus, Lumbosacral radiculopathy, Lyme disease, Monoclonal gammopathy of undetermined significance, Rheumatoid arthritis, Sjögren syndrome, Uremia, Vitamin B-12 deficiency, Frequent blood donation. Tremors can be due to multiple possible causes to include Parkinson's Disease, Parkinsonism, essential tremors, cerebral tremors, drug and metabolic tremors, dystonic tremors, psychogenic tremors, etc. The Veteran's VAMC records show he's been diagnosed with essential type tremors. The etiology of essential tremor is not known. No pathologic findings are known to be consistently associated with essential tremor. However, the following has been hypothesized: Essential tremor is the result of an abnormally functioning central oscillator in the brain. The pathophysiology of essential tremor is heterogeneous. Harmane, a heterocyclic amine (HCA), is a potent tremor-producing neurotoxin. It is often found in the human diet. Blood concentrations have been found to be elevated in patients with essential tremor as compared with controls. The most likely etiology appears to be alterations in metabolism rather than increased dietary intake. Fundamental debate exists as to whether essential tremor is a neurodegenerative disease. Data suggesting that it is neurodegenerative includes postmortem findings of pathologic abnormalities in the brainstem and cerebellum, including Lewy bodies and clinical studies demonstrating an association with cognitive and gait changes. Essential tremor probably represents a syndrome, and multiple etiologies will likely be identified. Most or all of these causes are probably genetic. Essential tremor is familial in at least 50-70% of cases. Transmission is autosomal dominant, with incomplete penetrance. Some cases are sporadic with unknown etiology. I found no objective evidence that either condition is caused by or aggravated objectively due to the PTSD. VA opinion in September 2021 suggests that the Veteran's restless leg syndrome is likely due to his lumbar spine condition but did not provide further explanation. The Board finds that the May 2021 VA medical opinion on secondary nexus provided most in-depth discussion of the issue and was based on well-reasoned rationale and supported by medical evidence of the record as well as medical research. This is the best supported opinion, and for that reason it is found to be the most probative and is afforded the greatest weight. Accordingly, service connection for neurological conditions, to include tremors in hands and restless legs cannot be granted on a secondary basis. (Continued on the next page) In sum, service connection for neurological conditions, to include tremors in hands and restless legs is not warranted on a presumptive basis, or a direct basis or a secondary basis. Service connection is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Q. Wang, 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.