Citation Nr: 21071691 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 12-15 598 DATE: December 1, 2021 ORDER Entitlement to service connection for a respiratory disorder, to include as secondary to unilateral left diaphragmatic paralysis, is denied. Entitlement to service connection for unilateral left diaphragmatic paralysis, to include as due to exposure to chemicals and/or vaccinations in service, is denied. Entitlement to service connection for a neurological disorder, to include as due to exposure to chemicals and/or vaccinations in service, is denied. REMANDED Entitlement to service connection for a bilateral shoulder disorder is remanded. Entitlement to service connection for a cervical spine disorder (claimed as upper back disorder) is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for migraine headaches, to include as secondary to service-connected hypertension, is remanded. FINDINGS OF FACT 1. A respiratory disorder did not manifest in service and is not related to military service or a service-connected disability. 2. Unilateral left diaphragmatic paralysis did not manifest in service and is not related to military service, including exposure to chemicals and/or vaccinations therein. 3. A neurological disorder did not manifest in service or to a compensable degree within one year thereafter and is not related to military service, including exposure to chemicals and/or vaccinations therein. CONCLUSIONS OF LAW 1. A respiratory disorder, to include asthma, was not incurred in active service and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303; 3.310 2. Unilateral left diaphragmatic paralysis was not incurred in active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. A neurological disorder was not incurred in active service and may be presumed to have been so incurred. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1997 to January 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision. The Veteran testified at a hearing before the undersigned Veterans Law Judge in November 2012. A transcript of that proceeding is associated with the record. The Board remanded the case for further development in January 2015, December 2017, and March 2019. That development has been completed, and the case has since been returned to the Board for appellate review. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As organic diseases of the nervous system are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Respiratory Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for a respiratory disorder, to include asthma. The Veteran was treated in service for acute respiratory conditions, including upper respiratory infections (URI) and influenza. However, an October 2000 separation examination found his lungs and chest to be normal, which is affirmative evidence that he did not have a respiratory disorder at the time of separation from service. In an October 2000 report of medical history, the Veteran also specifically denied any past or present shortness of breath, chronic cough, or pain or pressure in the chest. He did report a history of various other medical problems, including a painful or "trick" shoulder or elbow, foot trouble, and skin diseases. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (citing FED. R. EVID. 803(7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). Thus, the evidence does not show that the Veteran had a respiratory disorder at the time that he separated from service. An April 2015 examiner noted the Veteran's diagnosis of asthma in January 2010 after a bout of pneumonia, but opined that it was less likely than not related to service. The examiner noted that he was not diagnosed with any chronic respiratory condition during service. Although he had been treated for URIs on several occasions in service, his lungs were clear on examination. The examiner also stated that his paralysis of the left hemi-diaphragm could have caused or aggravated his asthma. A March 2018 examiner found that the Veteran did not have a clinical diagnosis of asthma. He opined that the Veteran's symptoms were a result of his left diaphragm paralysis and were incorrectly diagnosed as asthma. In so finding, he stated that the Veteran's pulmonary function tests showed evidence of restrictive lung disease rather than obstructive lung disease. The examiner explained that asthma is an obstructive lung disease that reverses with bronchodilator, whereas the Veteran's pulmonary function tests showed restrictive lung disease that does not reverse. He noted that obstructive defects in people with asthma are usually fully reversible. Therefore, the examiner found that the Veteran did not meet the diagnostic criteria for asthma. A December 2019 examiner later found that the Veteran did have a current diagnosis of asthma with date of onset in October 2019. The examiner explained that the hallmark of asthma is a bronchodilator response on pulmonary functions tests and that, in this case, there was no bronchodilator response until the most recent pulmonary in October 2019. The examiner also noted the diagnosis of restrictive lung disease secondary to unilateral left diaphragmatic paralysis caused by Parsonage Turner Syndrome (PTS) (idiopathic neuralgic amyotrophy). The examiner also clarified that the restrictive defect is directly caused by the left diaphragmatic paralysis and that the Veteran's asthma is separate and distinct from his unilateral left diaphragmatic paralysis. The December 2019 VA examiner opined that the Veteran's asthma is less likely than not related to military service, noting that his pulmonary function testing was not consistent with asthma until 2019, which was many years after military service. He observed that the service treatment records do not indicate an onset of asthma in service, and if the Veteran had developed asthma in service, the bronchodilator response would have been seen in prior pulmonary function tests. Regarding restrictive lung disease, as noted above, the December 2019 VA examiner opined that it is secondary to the Veteran's nonservice-connected left diaphragmatic paralysis. There is no evidence of a restrictive lung defect in service, and the records indicate the Veteran was very active in service and for several years after service. The Board acknowledges the contention of the Veteran's representative that the December 2019 VA examiner impermissibly considered the absence of evidence in the service treatment records and post-service medical records as substantive negative evidence. See September 2021 appellate brief. However, the Board again notes that the October 2000 separation examination found the Veteran's lungs to be normal, which is actually affirmative medical evidence that he did not have a respiratory disorder at that time rather than merely a lack of evidence. In the October 2000 report of medical history, the Veteran also did not report any past or present respiratory symptoms, such as shortness of breath or chest pain/pressure. The medical records do not indicate complaints, diagnosis, or treatment for respiratory problems until 2010, approximately ten years after active service. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). In December 2010, the Veteran himself reported difficulty with shortness of breath dating back to 2005 with a significant worsening of symptoms after a URI in January 2010. See December 2010 private treatment record. Thus, there is affirmative medical and lay evidence showing that the Veteran did not have a respiratory disorder that manifested in service or for years thereafter. Indeed, the December 2019 VA examiner also relied on earlier pulmonary function tests in rendering the opinion rather than a mere absence of evidence in service. Therefore, the Board finds that the opinion is adequate and probative. The Veteran has also claimed that his asthma was caused by his left diaphragmatic paralysis. See November 2012 hearing transcript. However, as discussed below, service connection has not been granted for left diaphragmatic paralysis. Thus, service connection cannot be granted on a secondary basis. Based on the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claim of service connection for a respiratory disorder, to include asthma. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for a respiratory disorder, to include asthma, is not warranted. Unilateral Diaphragmatic Paralysis In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for unilateral left diaphragmatic paralysis. The April 2015 VA examiner opined that his unilateral left diaphragmatic paralysis is less likely than not related to military service, explaining that it was first diagnosed in January 2010 when he had pneumonia, which was many years after service. He noted that there is no indication that the Veteran was diagnosed with a chronic respiratory disorder during service and no history of exposure to chemicals or unusual vaccinations that would cause the disorder nine years after his military service. The examiner also observed noted that he was treated for URIs on several occasions in service, but that his lungs were clear on examination. In the December 2017 remand, the Board noted that, although the April 2015 examiner stated that there was no indication the Veteran was exposed to any unusual vaccinations during service, it is unclear whether the examiner considered any relationship between the Veteran's disorder and the vaccinations he did receive during service. The examiner also stated that the Veteran's left diaphragmatic paralysis did not have its onset until January 2010; however, the examiner did not address the evidence of record indicating the Veteran complained of chronic shortness of breath for years prior to his diagnosis. Moreover, the examiner did not address the Veteran's contention that his left diaphragmatic paralysis is related to a skiing accident during service. See, e.g., May 2010 statement. Therefore, the Board founds that an additional medical opinion was needed. Following the remand, a March 2018 examiner opined that the Veteran's left diaphragmatic paralysis is less likely than not related to service. The examiner explained that, after extensive evaluations at the Pittsburgh VA Medical Center (VAMC) and the Cleveland Clinic, he was diagnosed with left hemidiaphragmatic paralysis secondary to severe phrenic neuropathy. Despite extensive work-up and evaluation by multiple specialists, the disorder has been deemed idiopathic with no specific identifiable cause other than idiopathic myositis with neuralgia. Treatment records note the onset of breathing difficulties in 2005 with a significant worsening in 2010 following a URI. The examiner acknowledged the history of a skiing accident in January 1998, but explained that MRIs of the neck and brachial plexus are not consistent with trauma. He commented that, if the phrenic nerve had been damaged in 1998, the respiratory symptoms would have manifested while the Veteran was still in service, yet he denied any respiratory problems on the separation report of medical history in October 2000. The March 2018 VA examiner also noted that Veteran did not respond to the request to provide evidence of chemical exposure. Moreover, in February 2010, he had denied having a history of smoking or any occupational or environmental exposures. In addition, the examiner indicated that a review of current medical literature for left hemidiaphragmatic paralysis and severe phrenic neuropathy reveals no evidence that vaccines or environmental exposures result in the condition. He also remarked that an in-person VA examination would not reveal the cause of his left hemidiaphragmatic paralysis and severe phrenic neuropathy, which has been determined by multiple specialists after extensive evaluation to be idiopathic, meaning no definite cause can be identified. The December 2019 VA examiner stated that the Veteran's unilateral left diaphragmatic paralysis is caused by his nonservice-connected Parsonage Turner Syndrome (PTS) (idiopathic neuralgic amyotrophy). The examiner discussed the nature of PTS, described as an uncommon neurological disorder characterized by rapid onset of severe pain in the shoulder and arm. He indicated that the exact cause of PTS is unknown, but that it is believed to be caused by an abnormality of the immune system (immune-mediated disorder). In some cases, nerves outside the brachial plexus may be involved, such as the nerves of the lumbosacral plexus, the phrenic nerve, or the recurrent laryngeal nerve. The phrenic nerve sends signals between the brain and the diaphragm, which is the muscle that separates the lungs from the abdomen. Involvement of the phrenic nerve can result in a significant shortness of breath. The Board has considered the Veteran's lay statements that his left diaphragmatic paralysis is related to his military service, including vaccinations and a January 1998 skiing accident. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, the etiology of left diaphragmatic paralysis, falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset of the disorder and the internal processes involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Indeed, even specialists have not been able to determine the etiology after extensive evaluations. Moreover, even assuming that the Veteran is competent to provide such an opinion, the Board finds that the March 2018 and December 2019 VA examiners' opinions are more probative, as they are based on a review of the claims file, including the Veteran's own reported history and lay statements, and are supported by thorough rationale, including a discussion of the relevant medical literature. The VA examiners also relied on their own knowledge, training, and expertise as medical professionals. Furthermore, as the Veteran is not service-connected for PTS or a neurological disorder, secondary service connection for unilateral left diaphragmatic paralysis is not warranted. Based on the foregoing, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for left diaphragmatic paralysis. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for left diaphragmatic paralysis is not warranted. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Neurological Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a neurological disorder. An April 2015 VA examiner stated that there was no clinical indication of any current neurological disorder affecting the upper or lower extremities. However, the examiner did not address the significance of the positive special testing for the median nerve. In addition, during the November 2012 hearing, the Veteran testified that his private physician attributed his neurological symptoms to sarcoidosis. A June 2013 private medical record also noted the Veteran's history of neurological symptoms and indicated that there was weak evidence for a diagnosis of sarcoidosis. The Veteran's VA medical records further note possible diagnoses of sarcoidosis. See, e.g., June 2014 VA neurology record. Therefore, the Board remanded the claim for an additional VA medical opinion in December 2017. In the March 2018 VA medical opinion, the examiner provided a detailed summary of the Veteran's medical history and stated that an in-person examination would not alter his opinion. The examiner diagnosed the Veteran with idiopathic myositis neuralgia and stated that a review of the medical literature for myositis and neuralgia reveals no evidence that it is caused by exposure to chemicals or vaccinations. However, he did not adequately address whether the disorder manifested in service. In particular, he did not discuss the in-service treatment records that documented complaints of numbness and tingling. Therefore, the Board remanded the issue again to obtain an additional VA medical opinion. A December 2019 examiner noted the diagnosis of idiopathic myositis with neuralgia and the more recent diagnosis of PTS, also referred to as idiopathic brachial plexopathy or neuralgic amyotrophy. She stated that the disorder is idiopathic, meaning a disease with an unknown cause or mechanism of apparent spontaneous origin. She indicated that the etiology of the condition is not known in the medical community. Moreover, as documented in 2018, a thorough review of the medical literature reveals no evidence that idiopathic myositis with neuralgia/PTS is caused by exposure to chemicals or vaccinations. Regarding the complaints of numbness and tingling in service and muscle spasm, the examiner explained that this is inconsistent with idiopathic myositis with neuralgia/PTS, which results in muscle atrophy and not hypertrophy or spasm. Based on the foregoing, the competent, credible, and most probative evidence does not show that the Veteran had a neurological disorder that manifested in service or within one year thereafter or that he had continuity of symptomatology. There is no medical opinion otherwise relating the Veteran's idiopathic myositis with neuralgia/PTS to his military service. Therefore, the Board finds that a neurological disorder has not been shown to be causally or etiologically related to an event, disease, or injury in service. The Board finds that, after reviewing the evidence, the VA examiners' opinions are highly probative. The examiners provided medical opinions supported by rationale and a thorough discussion of the facts and medical literature. The Board acknowledges the Veteran's statements that his neurological disorder is the result of his military service, including exposure to chemicals and vaccinations. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the diagnosis and etiology of idiopathic myositis with neuralgia/PTS and whether such a disorder is related to his military service, falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset of the disorder and internal processes involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Indeed, the December 2019 VA examiner indicated that the etiology of the condition is not even known in the medical community. Moreover, even assuming the Veteran's lay assertions regarding the etiology of the disorder are competent, the Board nevertheless finds the December 2019 VA examiner's opinion to be more probative, as it was provided by a medical professional with knowledge, training, and expertise and is supported by a complete rationale based on such knowledge and medical literature. The examiner also reviewed the claims file and considered the Veteran's lay statements. For the reasons outlined above, the Board concludes that the weight of the evidence is against a finding of entitlement to service connection for a neurological disorder. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Bilateral Shoulder Disorder A December 2019 examiner noted diagnoses of bilateral shoulder tendonitis, a bilateral shoulder strain, and right shoulder AC joint degenerative joint disease. She stated that the Veteran's right and left shoulder disorders are separate and distinct from his neurological disorder. The examiner explained that his symptoms of pain, stiffness, and decreased range of motion are attributed to the shoulder pathology and not Parsonage Turner Syndrome (idiopathic neuralgic amyotrophy). She noted the complaints of shoulder pain and muscle spasm in service; however, the examiner stated that she was unable to provide a nexus opinion without resort to mere speculation, noting that she was directed to review the November 2012 hearing transcript, but it was not available. In a March 2021 addendum opinion, the VA examiner opined that the Veteran's bilateral shoulder disorder is less likely than not related to service. She explained that the Veteran claimed that he injured his shoulders when he fell in service, but there is no evidence of an injury in the service treatment records. The examiner stated that the service treatment records only note treatment for mild overuse conditions, but no injuries. She noted the complaints of right shoulder pain in December 1997 and the diagnosis of overuse syndrome. She also noted the June 1998 diagnosis of spasms/strain of the thoracic spine involving the paraspinous and scapular muscles. However, the examiner did not address the complaints of shoulder pain in January 1998. It appears that the examiner's opinion was based on an incomplete or inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an incomplete or inaccurate factual premise has no probative value). During the November 2012 Board hearing, the Veteran testified that he first noticed shoulder problems during pack marches when his shoulders and arms would go numb. He indicated that he then fell while skiing in 1998 or 1999 during cold weather training in full combat gear. He stated that he hurt his arms and shoulders and sought medical treatment. The service treatment records clearly document the January 1998 skiing accident. He reported that he was skiing down a slope and fell feet first with his arms behind his back. Following the accident, the Veteran complained of upper and lower left-sided back pain and left shoulder pain. The diagnoses included a paraspinal muscle strain, musculoskeletal pain of the left scapula and left sacral, and left shoulder musculoskeletal spasm and pain. Therefore, the Board finds that an additional VA medical opinion is needed. Cervical Spine and Lumbar Spine Disorders Similarly, the Veteran testified that he injured his neck and low back during the fall while skiing in service. The December 2019/March 2021 VA examiner noted the current diagnoses of degenerative disc disease of the lumbar spine and thoracic spine and degenerative joint disease of the cervical spine. However, she opined that his current neck and low back disorders are less likely than not related to service, stating that there is no evidence of a falling injury in service. As set forth above, the service treatment records do document the fall while skiing in service, followed by complaints of upper and lower back pain. Therefore, it appears that the examiner's negative nexus opinions were based, in part, on an incomplete or inaccurate factual premise, and an additional VA medical opinion is necessary. Reonal v. Brown, supra. Migraine Headaches The December 2019 VA examiner noted the Veteran's complaints of headaches in service in relation to other conditions, including sinusitis, URIs, the flu, and an injury playing football. She stated that they represent headaches in association with an acute illness or injury and are not indicative of migraine headaches. The examiner also noted that, on the October 2000 report of medical history, the Veteran marked "yes" for sensitivity to chemicals, dust, sunlight, etc., and wrote "headaches." However, she did not specifically discuss the complaints of photophobia in service or the March 2009 private treatment record indicating that the Veteran had a history of migraine headaches with photophobia, as directed on remand. A remand by the Board confers on the claimant, as a matter of law, a right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In addition, the December 2019 VA examiner stated that the Veteran's migraine headaches preexisted service and cited to a February 2011 VA neurology consultation during which the Veteran reported having migraine headaches "since he was a kid." See also May 2010 private treatment record (reporting migraines since approximately 7th grade). Nevertheless, the February 1997 enlistment examination was normal, and the Veteran denied having any history of frequent or severe headaches. As a preexisting disorder was not noted upon entry into active service, the presumption of soundness applies. As such, the burden shifts to VA to rebut the presumption of soundness. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). When a preexisting condition is not noted on a Veteran's entrance examination, the burden is on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. See Wagner, 370 F.3d at 1096. For these reasons, the Board finds that an additional VA medical opinion is needed. The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the disorders remaining on appeal that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of any current migraine headaches. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether the Veteran's migraine headaches clearly and unmistakably preexisted his military service. (The term "clear and unmistakable" means that the evidence is undebatable.) If so, he or she should state whether there was an increase in the severity of the preexisting disorder during service and whether any increase was due to the natural progression of the disorder or whether it represented a chronic worsening of the underlying pathology. If the examiner determines that the disorder did not clearly and unmistakably preexist the Veteran's service, he or she should opine as to whether it is at least as likely as not that the disorder is causally related to his military service, to include any symptomatology therein. The examiner should also provide an opinion as to whether it is at least as likely as not that the Veteran has migraine headaches that are either caused or aggravated by his service-connected hypertension. In rendering his or her opinion, the examiner should consider the following: 1) the Veteran's lay statements regarding the nature and onset of his migraine headaches (see, e.g., May 2010 statement; November 2012 hearing transcript); 2) the service treatment records noting complaints of headaches and photophobia (see, e.g., October 1997, January 1998, August 1998, November 1999, and December 1999 service treatment records); 3) the October 2000 report of medical history that noted headaches; and 4) the VA examination findings and opinions of record. The examiner should address whether the complaints of headaches and photophobia in service were early manifestations of a migraine headache disorder. See March 2009 private treatment record (noting the history of migraine headaches with photophobia/phonophobia). (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of any current lumbar spine disorder. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current lumbar spine disorders. He or she should specifically state whether the Veteran has a lumbar spine disorder that is separate and distinct from any neurological disorder or whether the Veteran's symptoms are attributable to a neurological disorder. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any injury or symptomatology therein. In rendering his or her opinion, the examiner should consider the following: 1) the Veteran's lay statements regarding the nature and onset of his lumbar spine disorder (see, e.g., May 2010 statement; November 2012 hearing transcript); 2) the January 1998 service treatment records that noted assessments of paraspinal muscle strains; 3) the June 1998 service treatment record that noted the Veteran complained of left flank pain moving to the lower right side; 4) the private treatment records that noted the Veteran was found to have elevated CPK insertional activity and occasional fibrillation potentials or positive waves in the right lumbar paraspinal region that were felt to be evidence of process affecting the motor axons (see, e.g., September 2012 private medical record); and 5) the VA examination findings and opinions of record. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a VA examiner for a medical opinion as to the nature and etiology of any current cervical spine disorder (claimed as an upper back disorder). A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current cervical spine and/or upper back disorders. He or she should state whether the Veteran has a cervical spine and/or upper back disorder that is separate and distinct from any neurological disorder or whether the Veteran's symptoms are attributable to a neurological disorder. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any injury or symptomatology therein. In rendering his or her opinion, the examiner should consider the following: 1) the Veteran's lay statements regarding the nature and onset of his cervical spine/upper back pain (see, e.g., May 2010 statement; November 2012 hearing transcript); 2) the January 1998 service treatment records that noted assessments of paraspinal muscle strains; 3) the June 1998 service treatment record that noted an assessment of a left upper paraspinal muscle strain; and 4) the VA examination findings and opinions of record. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a medical opinion as to the nature and etiology of any current bilateral shoulder disorder. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify any current right and left shoulder disorders. He or she should state whether the Veteran has right and left shoulder disorders that are separate and distinct from any neurological disorder or whether the Veteran's symptoms are attributable to a neurological disorder. For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any injury or symptomatology therein. In rendering his or her opinion, the examiner should consider the following: 1) the Veteran's lay statements regarding the nature and onset of his bilateral shoulder symptoms (see, e.g., May 2010 statement; November 2012 hearing transcript); 2) the December 1997 service treatment record that noted an assessment of right shoulder pain and hyper-flexed minor muscle overuse syndrome; 3) the January 1998 service treatment records that noted assessments of left shoulder musculoskeletal spasm and pain; 4) the June 1998 service treatment record that noted assessments of a scapular muscle spasm and shoulder strain; 5) the October 2000 report of medical history in which the Veteran reported having a painful or trick shoulder/elbow; and 6) the VA examination findings and opinions of record. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. The AOJ should review the examination reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. 7. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Chilcote 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.