Citation Nr: 21073457 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 14-37 984 DATE: December 8, 2021 REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for a respiratory disability, to include bronchitis, is remanded. Entitlement to service connection for tremors, initially claimed as stroke residuals, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from August 1990 to July 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in April 2017. This case was previously before the Board in April 2018 and May 2020, when it was remanded for development. The case has been returned to the Board for further appellate review. 1. Entitlement to service connection for a lumbar spine disability is remanded. 2. Entitlement to service connection for a bilateral knee disability is remanded. 3. Entitlement to service connection for a respiratory disability, to include bronchitis, is remanded. The Veteran was afforded a series of VA examinations in June 2021 in conjunction with these clams. The VA examiner provided one opinion for all of the disabilities still on appeal, concluding that it is less likely than not that these disabilities are related to service because there is no documentation of any trauma, complaints, injuries or conditions during or shortly after military service in any of the medical records. The examiner was prompted to provide an addendum opinion that addressed the Veteran's lay statements regarding each of these claimed disabilities, and again provided the same opinion for all the disabilities still on appeal. The examiner stated that the lay statements did not provide any information to service connect the disabilities, as the lay statements did not specifically say what caused the condition and which year this occurred in. The examiner provided the same conclusion and reasoning for each of the claimed disabilities including lumbar spine disability, respiratory disability, bilateral knee disability, and tremors without discussing the Veteran's particular circumstances or the nature of each disability. The examiner also failed to give a reason why the Veteran's reports of symptoms did not speak to the cause or time of incurrence of any of these disabilities. For these reasons, the June 2021 VA opinions are inadequate, and a remand is necessary to obtain an opinion that adequately addresses all relevant evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). 4. Entitlement to service connection for tremors, initially claimed as stroke residuals, is remanded. In addition to the inadequate direct service connection opinion discussed above, the VA examiner also provided an opinion regarding tremors as secondary to the service-connected migraines. The examiner opined that it is less likely than not the tremors were caused by the Veteran's migraine headaches, because there is no medical literature review that supports headaches causing complications or symptoms such as tremors. The examiner cited "medical literature review," without providing the source of the medical literature quoted in the opinion, as stating that tremors can be caused by a variety of things, including prescription medications, diseases, injuries, caffeine, etc. The examiner did not discuss whether chronic migraines are among the diseases that can cause tremors, or discuss the physiological relationship, if any, between headaches and tremors. Further, the examiner gave the same opinion, verbatim, when asked whether the Veteran's tremors were at least as likely as not aggravated by the service-connected headaches, failing to address the question of aggravation at all. In the addendum opinion, the examiner simply stated that there is no medical literature review that supports that tremors cause or aggravate migraine headaches, and did not expound on whether migraines cause or aggravate tremors. Further, the examiner did not discuss whether the Veteran's lay statements regarding the timing of tremors with headaches indicate any sort of causal or aggravating relationship between the two conditions. The secondary service connection opinion is therefore inadequate, and, on remand, a new opinion should be obtained. See Barr, 21 Vet. App. at 311. The matters are REMANDED for the following action: 1. Forward the claims file to an appropriate clinician to determine whether the current lumbar spine disability is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the lumbar spine disability began in or is otherwise caused by the Veteran's active service. The examiner must specifically address the Veteran's lay statements regarding ongoing back pain and problems since service. The examiner MAY NOT disregard the Veteran's reported history of symptoms solely on the basis that they were not documented in contemporaneous treatment records; if the examiner rejects the Veteran's lay statements, he or she MUST provide a reason for doing so. The examiner should address any other pertinent evidence of record, such as the paralumbar muscle strain treated during service, and complaints of low back pain in September 1996 and April 2000. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 2. Forward the claims file to an appropriate clinician to determine whether the current bilateral knee disability is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the bilateral knee disability began in or is otherwise caused by the Veteran's active service. The examiner should specifically address the Veteran's lay statements regarding ongoing knee pain since service. The examiner MAY NOT disregard the Veteran's reports of symptoms solely on the basis that they were not recorded in contemporaneous treatment records; if the examiner rejects the Veteran's lay statements, he or she MUST provide a reason for doing so. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 3. Forward the claims file to an appropriate clinician to determine whether the current respiratory disability is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the respiratory disability began in or is otherwise caused by the Veteran's active service. The examiner should specifically address the Veteran's lay statements regarding the onset of respiratory symptoms in active duty service, including those made at the April 2017 Board hearing. The examiner MAY NOT disregard the Veteran's statements regarding her history of symptoms solely on the basis they were not documented in contemporaneous treatment records; if the examiner rejects the Veteran's lay statements, he or she MUST provide a reason for doing so. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. Forward the claims file to an appropriate clinician to determine whether the current benign essential tremor is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Please note, if the examiner deems it reasonable, an alternate format such as telehealth interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the tremor began in or is otherwise caused by the Veteran's active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the tremor is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran's migraine headache disability. Please note, causation and aggravation are separate concepts and MUST be addressed independently. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the tremor prior to aggravation by the migraine disability. In providing the requested opinions, the examiner should specifically address the Veteran's lay statements regarding the onset of the tremor and when she typically experiences the tremor. The examiner MAY NOT disregard the Veteran's statements regarding her history of symptoms solely on the basis they were not documented in contemporaneous treatment records; if the examiner rejects the Veteran's lay statements, he or she MUST provide a reason for doing so. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Josey, 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.