Citation Nr: 21073784 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 16-15 856 DATE: December 10, 2021 REMANDED Entitlement to service connection for essential tremors is remanded. REASONS FOR REMAND The Veteran had active service from November 1968 to January 1970. This matter comes before the Board of Veterans Appeals (Board) on appeal from a July 2015 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). The Board previously considered this appeal in June 2019 and April 2021. It remanded for additional development both times. The Veteran contends that he was exposed to an herbicide agent when he served in or near the Korean Demilitarized Zone, and that, in turn, this exposure caused his essential tremors. Establishing service connection on a direct theory of entitlement, as in the Veteran's case, generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). A VA examiner, in March 2020, diagnosed the Veteran with essential tremors. The examiner's diagnosis of essential tremors satisfies the first prong of a direct service connection claim. The Board notes the March 2020 examiner also made clear that the Veteran's essential tremors are not Parkinson's Disease, secondary Parkinsonism, or Parkinson's Plus Syndrome. Parkinson's Plus Syndrome is synonymous with Parkinsonism. In March 2016, the AOJ issued a Statement of the Case (SOC). In the SOC, the AOJ found: Your military personnel records document service in Korea from 4/24/69 to 11/22/69 and that you were part of the 3rd Brigade of the 7th Infantry Division- 2nd Battalion, 17th Infantry, and thus herbicide exposure is conceded as your unit was determined by VA or the Department of Defense (DoD) to have operated in the Korean Demilitarized Zone (DMZ) between April 1, 1968, and August 31, 1971. This finding satisfies the second prong of a direct service connection claim. The Veteran's appeal turns on the third prong of a direct service connection claim medical nexus. That prong requires remand. On January 1, 2021, the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021 (NDAA FY2021) became law. Section 9109 of the NDAA FY2021 amended Section 1116(a)(2) of Title 38 of the U.S. Code by adding bladder cancer, hypothyroidism, and Parkinsonism (a term for neurological disorders that cause movement problems similar to that of Parkinson's disease) to the list of presumptive conditions for Vietnam-era veterans exposed to Agent Orange. The legislation came following two updated reports from the National Academies of Sciences (NAS) studies and scientific literature reviews of health conditions associated with exposure to Agent Orange. In March 2016, the NAS released Veterans and Agent Orange: Update 2014, which changed the classification of certain diseases/conditions among the Categories of Association. The classification of hypothyroidism and bladder cancer changed from "inadequate/insufficient evidence" of association to "limited/suggestive evidence" of association, while Parkinson's disease, including Parkinsonism and Parkinson-like syndrome, remained at a "limited/suggestive evidence" of association. In November 2018, the NAS released Veterans and Agent Orange: Update 11, available at https://www.monmouth.edu/school-of-social-work/documents/2018/11/veterans-and-agent-orange-update-november-2018.pdf/. Update 11 reinforced Update 2014's categorizations on bladder cancer, hypothyroidism, and Parkinson's Disease, including Parkinsonism and Parkinson-like syndromes. It also explained, in Chapter 9, page 16, that: The committee responsible for Update 2014 was charged specifically with determining whether various diagnoses with Parkinsonian symptoms should be included in the presumptive service-related category for PD [i.e., Parkinson's Disease]. Because diagnostic specificity is improbable in both the studies on which the conclusion of limited or suggestive association with exposure to military herbicides was based and in the documentation for the claims submitted to the Department of Veterans Affairs (VA) by Vietnam veterans, the committee clarified that the finding for PD [i.e., Parkinson's Disease] should be interpreted by VA to include all diseases with Parkinson-like symptoms unless those symptoms can be definitively shown to be secondary to an external agent other than the herbicides sprayed in Vietnam. Some medical publications and/or articles suggest that essential tremors may be similar to Parkinson's Disease. See "How Do You Know If Its Parkinson's Disease," in Everyday Health, 16 Apr. 2020, by Krisha McCoy, Medically Reviewed by Lindsey Marcellin, Maryland, MPH, https://www.everydayhealth.com/parkinsons-disease/movement-disorders.aspx (noting that movement disorders that are similar to Parkinson's Disease, include essential tremors); see also "Essential Tremor and Parkinson's Disease: Exploring the Relationship," in Tremor and Other Hyperkinetic Movements, U.S. National Library of Medicine, National Institute of Health, Published online 9 Jan. 2019, by Arjun Tarakad and Joseph Jankovic, Monitoring Editor, Elan D. Louis, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329774/ (stating, among other similarities, that "... the pathology-based definition of [Parkinson's Disease] has been challenged and some have proposed that, similar to [essential tremors, Parkinson's Disease] should also be considered a syndrome as it can present in the setting of different motor and non-motor phenomenologies, heterogenous pathological findings, and with increasingly recognized genetic etiologies"; and that "[mood] disturbances and apathy, similar to those in [Parkinson's Disease], have also been reported at an increased frequency in [essential tremor] patients). Given the suggested similarities between Parkinson's Disease and essential tremors, it is not clear, based on the evidence of record, as to whether the Veteran's essential tremors may be classified as a "Parkinson-like symptom," for purposes of determining the applicable disease classification listed in the 2018 Update of Veterans and Agent Orange. Accordingly, an addendum medical opinion is warranted. The matters are REMANDED for the following action: 1. Return the claims file to the medical professional who examined the Veteran in March 2020 and provided the June 2021 addendum medical opinion. If that medical professional is not available, provide the claims file to a medical professional of approximately similar qualifications. The medical professional who reviews the claims file, to include this Remand, should opine: a) What are "Parkinson-like symptoms," as the National Academy of Sciences used that term in "Veterans and Agent Orange: Update 11"? b) What makes a symptom a "Parkinson-like symptom," as the National Academy of Sciences used that term in "Veterans and Agent Orange: Update 11", as opposed to not? c) Is there a medically accepted list of "Parkinson-like symptoms?" If yes, identify all such symptoms. d) Are any of the symptoms the Veteran experiences with his essential tremors a "Parkinson-like symptom?" Why or why not? Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Sopko, 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.