Citation Nr: 21075967 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 14-35 208A DATE: December 22, 2021 ORDER Entitlement to service connection for low back pain with arthritis is granted. Entitlement to service connection for right knee disability is denied. Entitlement to service connection for left knee disability is denied. Entitlement to service connection for pitting edema of the right lower extremity (RLE) is denied. Entitlement to service connection for pitting edema of the left lower extremity (LLE) is denied. Entitlement to service connection for esophagitis and hiatal hernia with varices, gastroesophageal reflux disease (GERD), and aspiration pneumonia is denied. Entitlement to service connection for traumatic brain injury (TBI) is granted. FINDINGS OF FACT 1. The Veteran's chronic low back pain, with evidence of lumbar spine arthritis, is at least as likely as not related to events in service including carrying heavy equipment and exposure to explosions of improvised explosive devices (IEDs) and other weapons in combat in 2007. 2. Chondromalacia in the Veteran's right knee diagnosed a few years after his last period of active service is less likely than not related to any in-service injury, disease, or events, including physically demanding activities and any episodes of knee pain. 3. Chondromalacia in the Veteran's left knee diagnosed a few years after his last period of active service is less likely than not related to any in-service injury, disease, or events, including physically demanding activities and any episodes of knee pain. 4. Pitting edema of the Veteran's RLE that arose several years after service was not caused or aggravated by disease, injury, or events in service or caused or aggravated by any service-connected disorder. 5. Pitting edema of the Veteran's LLE that arose several years after service was not caused or aggravated by disease, injury, or events in service or caused or aggravated by any service-connected disorder. 6. The Veteran's esophagitis, hiatal hernia, esophageal varices, GERD, and any aspiration pneumonia, had onset more than a year after his last active service period, and were less likely than not proximately caused or aggravated by his PTSD, his alcohol dependence, or a self-extubation in 2010. 7. The Veteran's exposure to nearby explosions in combat conditions in Iraq at least as likely caused TBI. CONCLUSIONS OF LAW 1. The criteria for service connection for low back pain with arthritis have been met. 38 U.S.C. §§ 1110, 1131, 1154(b), 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 3. The criteria for service connection for left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for pitting edema of the RLE have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 5. The criteria for service connection for pitting edema of the LLE have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 6. The criteria for service connection for esophagitis and hiatal hernia with varices, GERD, and aspiration pneumonia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 7. The criteria for service connection for TBI have been met. 38 U.S.C. §§ 1110, 1131, 1154(b), 5107; 38 C.F.R. § 3.303. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for visual disorientation, also claimed as photophobia, is remanded. Entitlement to service connection for OSA is remanded. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 2002 to February 2003, and from May 2006 to September 2007 with a period of active duty for training from August 1997 to December 1997. The 2002 to 2003 period included service in Afghanistan. The 2006 to 2007 period included service in Iraq. In April 2007 the Veteran was awarded the Combat Action Badge for events in February 2007, when he was actively engaging or being engaged by the enemy. The Veteran also had Reserve service. In a July 2013 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for low back pain with arthritis, disabilities of the right and left knees, pitting edema of the RLE and LLE, esophagitis and hiatal hernia with varices, GERD and aspiration pneumonia, TBI, headaches, visual disorientation, and OSA. The Veteran appealed those denials to the Board of Veterans' Appeals (Board). In December 2020 the Board remanded those matters to the RO for additional action. In the December 2020 Board remand, the Board instructed the RO to schedule the Veteran for new VA examinations with file review and opinion as to the likely etiology of the Veteran's low back disorder and knee disorders, his esophagitis, hiatal hernia with varices, GERD, and aspiration pneumonia, his claimed TBI, and his OSA. The RO scheduled examinations of the Veteran based on the remand instructions. The Veteran cancelled the examinations. He indicated that, as he already had a 100 percent disability rating for another service-connected disability, he did not need to have examinations. The RO later left messages for the Veteran regarding the cancellation about his examinations. The Veteran has not related willingness to attend examinations. The Board will address the remanded claims based on the evidence of record, except where a current grant of an intertwined claim warrants additional remand. Service Connection Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including arthritis, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. 38 C.F.R. § 3.310(b). When a veteran engaged in combat during active service, lay or other evidence of service incurrence of combat related disease or injury will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence during service, and, to that end, VA shall resolve every reasonable doubt in favor of the veteran. 38 U.S.C. § 1154(b). The United States Court of Appeals for Veterans Claims (Court) has indicated that the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Low back pain with arthritis The Veteran reports that during his service in Iraq he began to experience low back pain. He contends that current chronic low back pain is attributable to carrying heavy equipment during that service. He contends that his low back problems may also be related to exposure in service to IED blasts. Some medical records from the Veteran's active service periods and reserve service were added to the Veteran's claims file in 2013. In May 2021 the RO sought any additional service treatment records (STR) for the Veteran. The VA Records Management Center responded that all available STR were previously mailed and associated with the claims file. The Veteran's assembled STR do not reflect any complaints or treatment involving his low back. His STR and his service personnel records (SPR) are silent as to any exposure to IED explosions. As noted above, in April 2007 he was awarded the Combat Action Badge for events in February 2007, when he was actively engaging or being engaged by the enemy. The Veteran's claims file does not contain any post-service medical records from 2007 or 2008 that address the condition of his low back. In VA treatment in August 2010, the Veteran reported chronic low back pain. In November 2010 the Veteran had private emergency department treatment for worsening chronic back pain. He stated that he had back problems from military service. In private treatment in December 2010 and June 2011 the Veteran reported chronic back pain. Subsequent VA and private treatment records contain reports of back pain. On VA examination in December 2012, the Veteran reported onset of back problems during service in Iraq in 2007. He related that he regularly carried gear that weighed about 100 pounds, and that low back pain gradually developed. He stated that presently he had mild low back pain constantly and moderate pain intermittently. Examination revealed pain on motion of the thoracolumbar spine. The examiner noted that February 2011 lumbar spine x-rays showed minimal spurring of lumbar vertebrae. In an October 2014 substantive appeal, the Veteran wrote that he did not experience low back problems before his service in Iraq. He stated that in Iraq he frequently carried excessively heavy equipment. He expressed that his low back problems also could be related to his exposure to IED blasts. The Veteran has current low back disability. From 2010 forward he has reported current low back pain. Lumbar spine x rays have shown arthritis in the form of minimal spurring. The assembled evidence does not show that arthritis in the Veteran's lumbar spine became manifest to a degree of 10 percent disabling or more within one year from his 2007 discharge from his last period of active service. The evidence does not provide a basis to presume service connection for his lumbar spine arthritis. The Veteran reports that in 2007, during his service in Iraq, he experienced gradual onset of low back pain. He attributes the pain and eventual arthritis to repeated carrying of very heavy equipment and possibly to IED explosions. The Veteran's SPR reflect that in Iraq he had duties as a vehicle mechanic and vehicle driver. His account of carrying heavy equipment is reasonably consistent with those duties. While his service records do not mention exposure to IED explosions, his exposure to combat and his duties driving vehicles in Iraq in 2007 are reasonably consistent with exposure to IED explosions. The Board concludes that he at least as likely as not carried heavy equipment and was exposed to IED explosions. While the Veteran's STR do not reflect complaints of back pain, as early as 2010 he reported that he began to experience low back pain during service. It is quite plausible that he could accurately recall the onset of symptoms three years earlier. His accounts support continuity of symptoms after his 2006 to 2007 service period. Resolving reasonable doubt in the Veteran's favor, the Board accepts that chronic low back pain had onset in service and continued after service, and that arthritic changes found on x-rays are related to the chronic pain. The Board therefore grants service connection for lumbar spine arthritis manifested by chronic low back pain. 2. Right knee disability 3. Left knee disability The Veteran contends that bilateral knee problems, eventually diagnosed as chondromalacia patella, had onset during active service. He indicates that he experienced onset of bilateral knee pain during his 2006 to 2007 active service period but did not seek treatment. He states that the pain later worsened and that he had treatment after service. The Veteran's assembled STR do not contain any complaints of knee problems. In private treatment in November 2010, the Veteran reported having had bilateral knee pain for a while. He denied any recent traumas or falls. A clinician found that both knees had full ranges of motion and had some patellar tenderness to palpation. The clinician's impression was probable musculoskeletal strains versus arthritis. In December 2010 the Veteran had private treatment after he slipped and fell and landed on his left knee. In August 2011 he had private and VA treatment after he slipped and fell and landed with his right knee flexed. On VA examination in December 2012, the Veteran reported that pain in both knees started during his service in Iraq. He noted that he did a lot of running with heavy gear. The examiner diagnosed chondromalacia in the patellofemoral joints of both knees. The examination report did not address the etiology of the current disorder. In the October 2014 substantive appeal, the Veteran wrote that he did not experience knee pain until he returned from Iraq. He stated that during service he experienced pain in both of his knees but did not seek treatment. He related that the pain later worsened. He contended that his current knee problems, diagnosed as chondromalacia or arthritis, could have been caused by carrying heavy equipment in service or excessive running in service. In the December 2020 Board remand, the Board instructed the RO to schedule the Veteran for a new VA examination ,with file review and opinion as to the likely etiology of the Veteran's knee disorders. The Veteran has current bilateral knee disorders diagnosed as chondromalacia. During his active service periods he did not report knee pain or problems. In November 2010, about three years after his last active service period, he reported having had bilateral knee pain for some time. He did not specify that his knee pain began during service, as he did regarding his back pain. It was not until December 2012, about five years after the last active service period, that he indicated that his bilateral knee pain began during that service period. In 2014 he repeated that history. Taken together, his accounts provide somewhat weak support for the existence of knee symptoms during service. The Veteran is in a position to relate bilateral knee pain during and after his last active service period. No healthcare professional has addressed whether reported pain in service was a manifestation of chondromalacia diagnosed a few years after service. There is no medical finding or opinion that the Veteran's symptoms in service were signs of a chronic knee disorder, or that his activities in service caused the chondromalacia found later. The assembled evidence does not show that the current bilateral chondromalacia is at least as likely as not related to his activities and symptoms in service. The Board denies service connection for his right and left knee disabilities. 4. Pitting edema of the RLE 5. Pitting edema of the LLE The Veteran contends that pitting edema in his bilateral lower extremities is secondary to bilateral knee disabilities for which he has sought service connection. The Veteran's assembled STR do not contain any reports of lower extremity edema. In April 2011 the Veteran had private emergency department treatment for bilateral lower extremity edema. He stated that two days earlier he began to experience swelling in both ankles, both feet, and a little bit in both lower legs about to the knees. He reported that he had not experienced such edema before. A clinician observed swelling in the legs from the knees down, greatest in the feet, with 1-2+ pitting edema in the feet and ankles and 1+ pitting edema in the mid lower legs. The edema was treated with a diuretic. In June 2011, a clinician noted that the edema treated in April 2011 was diagnosed as dependent edema. In the October 2014 substantive appeal, the Veteran contended that his lower extremity pitting edema was partly due to braces he wore due to pain in his knees. He asserted that other contributing causes were some medications that he took and fatty liver that was recently diagnosed. In December 2020, the Board found that the edema service connection claims were intertwined with the knee disability service-connection claims. The Board therefore remanded the edema claims along with the knee disability claims. In the present decision, above, the Board has denied service connection for the Veteran's right and left knee disabilities. His knee disabilities therefore cannot form a basis for secondary service connection for pitting edema in his lower extremities. As the Veteran does not report, and records do not suggest, lower extremity edema during any service period, the evidence does not provide any basis for direct service connection for his lower extremity edema. The Board denies service connection for pitting edema of the RLE and LLE. 6. Esophagitis and hiatal hernia with varices, GERD, and aspiration pneumonia The Veteran contends that heavy lifting during active service caused his hiatal hernia. He contends that he has esophagitis, hiatal hernia, esophageal varices, GERD, and aspiration pneumonia secondary to his service-connected post-traumatic stress disorder (PTSD) and alcohol dependence. VA established service connection for his PTSD and alcohol dependence and evaluates them as a combined mental disorder. The Veteran's assembled STR do not contain any reports of symptoms involving his stomach, esophagus, or lungs. In a private psychiatric evaluation in May 2009, the Veteran reported a history of nursing school and work in nursing. In VA treatment in October 2009, the Veteran reported that he had GERD sometimes. In December 2010 the Veteran had private inpatient treatment following a suicide attempt. During treatment he was intubated and had vomiting following intubation. A clinician found no signs of aspiration before or after the vomiting episode. Later in the day of admission the Veteran extubated himself. The Veteran had private treatment in January 2011 for fever, cough, vomiting, and difficulty breathing. Chest x-rays showed interstitial infiltrate. He was started on antibiotics for pneumonia. In private psychiatric treatment later in January 2011, it was noted that the Veteran had GERD. From March 30 to April 1, 2011, the Veteran had private emergency and inpatient treatment. He presented with dyspnea and coughing. He was noted to have a history of PTSD and depression. He stated that, after his intubation and self-extubation in December 2010, he developed aspiration pneumonia. He stated that since then he experienced recurrent aspiration and difficulty swallowing. He reported that his present symptoms felt like those of aspiration pneumonia. Chest x rays showed pulmonary infiltrate. He was treated with medications for presumed aspiration pneumonia. In private treatment later in April 2011, it was noted that the Veteran had a history of aspiration pneumonia. On examination his lungs were clear. A clinician prescribed medication to treat GERD. In private treatment in June 2011, the Veteran was seen for fever and a productive cough. He reported that he awoke with vomitus in his mouth and had shortness of breath that felt the same as his symptoms when he had aspiration pneumonia. Chest x-rays had normal results. In private treatment later in June 2011, a clinician noted that the Veteran had epigastric abdominal pain, established esophageal reflux, suspected reflux esophagitis, suspected esophageal varices, and possible silent aspiration. Upper gastrointestinal (GI) endoscopy showed a medium-sized hiatal hernia, esophagitis, varices in the esophagus, and erythema of gastric mucosa. In May 2012 the Veteran's wife informed a VA medical facility that the Veteran shot himself in the chest in a suicide attempt. In VA treatment in June 2012 it was noted that the Veteran had GERD. On VA examination in December 2012, the Veteran reported that he did not remember having heartburn symptoms before his service in Iraq and he did not remember when he started to have heartburn. He stated that presently he had daily burning in his esophagus. The examiner found that the Veteran had GERD and hiatal hernia, each diagnosed in June 2011. In the October 2014 substantive appeal, the Veteran reported that he did not have GERD or aspiration pneumonia before his service in Iraq. He contended that his GERD and aspiration pneumonia are partly due to his alcoholism and partly due to his extubating himself after a suicide attempt related to his PTSD. He asserted that his esophageal varices were also related to those factors. He contended that his hiatal hernia is partly due to extensive heavy lifting during his service. In VA treatment in November 2016, a clinician noted that the Veteran had GERD and documented esophageal varices. In December 2020 the Board noted that the December 2012 examination did not address the etiology of the Veteran's esophagitis, hiatal hernia with varices, GERD, and aspiration pneumonia. The Board remanded the service connection claim for a new VAX with opinions regarding etiology of those disorders, including the Veteran's theories regarding the etiology. Findings on the endoscopy in 2011 are sufficient to show that the Veteran has current esophagitis, hiatal hernia, and esophageal varices. Treatment records from 2009 forward establish that he has GERD. The Veteran has been treated for pneumonia, but the medical records are less clear as to whether his pneumonia and subsequent episodes of respiratory symptoms have constituted aspiration pneumonia. The Veteran has not contended that his esophagitis, esophageal varices, GERD, or claimed aspiration pneumonia were symptomatic or manifest during any of his active service periods. His assembled STR do not reflect symptoms of any of those disorders. In the absence of evidence of in-service incurrence or aggravation of any of those disorders, direct service connection is not warranted. The Veteran contends that his hiatal hernia is partly due to extensive heavy lifting during active service. However, his assembled STR do not reflect symptoms or findings of hiatal hernia. His GERD, possibly a symptom of hiatal hernia, was not reported until about two years after his last active service period. A diagnosis of hiatal hernia was not confirmed until 2011. No clinician has found or opined that the Veteran's hiatal hernia was incurred or aggravated during any of his active service periods. The preponderance of the evidence is against direct service connection for his hiatal hernia. The Veteran contends that his PTSD and alcohol dependence partly caused or aggravated his esophagitis, hiatal hernia, esophageal varices, GERD, and claimed aspiration pneumonia. He contends that the self-extubation after the December 2010 suicide attempt partly caused or aggravated his esophageal varices, GERD, and claimed aspiration pneumonia. Those contentions are matters of medical etiology or etiology. No healthcare professional has addressed the likelihood of any of those causation or aggravation relationships. The Veteran has reported that he attended nursing school and has worked as a nurse. However, competent opinions on the questions of causation and aggravation associated with this matter require a level of medical expertise beyond his training and experience. His opinions alone are insufficient to indicate that his PTSD, alcohol dependence, or self-extubation at least as likely as not proximately caused or aggravated his esophagitis, hiatal hernia, esophageal varices, GERD, or claimed aspiration pneumonia. In summary, as the preponderance of the evidence is against direct or secondary service connection for the Veteran's esophagitis, hiatal hernia, esophageal varices, GERD, or claimed aspiration pneumonia, the Board denies service connection for each of those disorders. 7. TBI The Veteran reports that during service in Iraq he was exposed to explosions from weapons. He contends that he sustained TBI. He asserts that physicians have found that he sustained TBI and has residuals of that injury. The Veteran's assembled STR do not contain any reports of head injury. After his last active service period, he had a VA TBI screening in December 2008. He reported that during deployment in Operation Iraqi Freedom (OIF) and/or Operation Enduring Freedom (OEF) he was exposed to blasts from weapons such as IEDs, rocket propelled grenades (RPGs), land mines, and grenades. He indicated that immediately after one or more explosions he felt dazed or confused. He denied that any problems or symptoms continued after or worsened after the initial reaction to an explosion. A clinician indicated that the Veteran's responses constituted a negative screening for TBI. In a private psychiatric evaluation in May 2009, the Veteran reported that during service in Iraq he ran convoys and often experienced hostile fire, including from IEDs, RPGs, mortars. He stated that he did not suffer any wounds but that he lost some of his hearing. The Board notes that the Veteran sought and VA established service connection for hearing loss and tinnitus. On a VA TBI screening in October 2009, the Veteran responded that during a deployment he experienced blasts or explosions from IED and other weapons. He denied having any symptoms immediately afterward. A clinician found that the screening was negative for TBI. On VA mental disorders examination in January 2010, the Veteran reported that in service in Iraq he accompanied many convoys. He stated that while on convoys he ran into IEDs and came under mortar attack. He related that on one occasion a mortar exploded very near him and he barely missed being injured by shrapnel. He stated that he also witnessed others being wounded, injured, and killed. In a VA TBI screening in August 2010, the Veteran reported exposure to explosions during service. He related being dazed or confused afterward. He stated that memory problems, irritability, headaches, and sleep problems started or worsened afterward. He reported that presently he had memory problems, irritability, headaches, and sleep problems. The clinician indicated that the screening was positive for TBI. In VA mental health treatment in September 2010, a clinician noted that the Veteran had no history of concussion. In December 2010 the Veteran had private emergency department after he fought with police while intoxicated and banged his head against a car window. In VA treatment in February 2011, the Veteran reported a history of combat and of TBI. The Veteran had a VA TBI history evaluation in April 2011. He reported three incidents of exposure to explosions in Iraq, from a mortar explosion 25 feet away, from his truck being hit by an IED explosion, and from an IED exploding near his vehicle. He related symptoms following each explosion and cognitive difficulties since his Iraq service. In VA mental health treatment of the Veteran in July 2011, a clinician listed diagnoses of PTSD and TBI. In February 2012 the Veteran reported TBI in Iraq due to IED explosion. In May 2012 he related history of TBI and ongoing memory and speech impairment. In June 2012 he stated that in Iraq he was near several IED blasts and sustained a TBI. In July 2012, a clinician listing the Veteran's medical history included TBI. VA TBI examination in October 2012 included psychological testing. J. B. P., Ph.D., the psychologist who administered the testing, found that the Veteran's cognition was grossly intact, with no discernible cognitive problems except inattention. On cognitive testing the Veteran's score was in the range of mild cognitive impairment, or cognitive disorder. The Veteran had problems in the areas of focus, attention, and concentration. The examiner found that it could not be determined whether the Veteran's cognitive difficulties indicated cerebral dysfunction or impairment. The examiner stated that the impairment could stem from his PTSD, from prescribed medications, or from past alcohol abuse. The examiner wrote that he could not ascribe the test results to closed head injury or as sequelae to TBI. The examiner reported that he did not see conclusive evidence of TBI residuals or evidence to support TBI. The examiner stated that other factors more likely contributed to the results. On psychiatric examination in October 2012, the Veteran reported that during active service he experienced several roadside IED blasts. He stated that he had a TBI with an IED explosion in 2007. He reported that he did not remember the incident, that he did not know how long he was unconscious, and that he was disoriented and confused for approximately one hour. He stated that from then he had headaches, impairment of memory and attention, and angry outbursts. VA psychiatrist D.G., M.D., noted that the Veteran had been diagnosed with TBI in 2010. Dr. G. found that there was objective evidence that the Veteran had moderate impairment of memory, attention, concentration, or executive functions. Dr. G. found mild impairment of judgment. Orientation and motor activity were normal. In a July 2013 addendum, examiner D. G., M.D., wrote that, because the Veteran provided different history at different times, his reliability was questionable. Dr. G. stated that there was no record of exposure to IED explosions except for the Veteran's statements. Dr. G. stated that there was no cognitive function impairment of psychological testing. Dr. G. expressed the opinion that there was insufficient clinical evidence to diagnose TBI. In the October 2014 substantive appeal, the Veteran wrote that during service he did not know that one can sustain a TBI just from the percussion of a blast. He indicated that he believed that he had a TBI in service because after service he had an abnormal EEG, he was told that he had partial complex seizures, he had impaired short term memory, and he had impulsivity issues. He stated that physicians had found that he had TBI residuals. While the assembled service records do not document head injury, the Veteran's combat participation as indicated by his Combat Action Badge warrants consideration under 38 U.S.C. § 1154(b). His reports of exposure to explosions while in vehicles in convoys are consistent with the circumstances of his combat exposure in Iraq. From as early as 2008, fairly soon after his 2006 to 2007 Iraq service, he reported nearby explosion followed by confusion and altered consciousness. Resolving every reasonable doubt in his favor, the Board accepts that his accounts of exposure to explosions and grants service connection for TBI. REASONS FOR REMAND 1. Headaches 2. Visual disorientation 3. OSA The Board is remanding these service connection claims for VA medical opinion. The Veteran contends that his headaches, his visual disorientation, and his OSA each are secondary to his TBI. In the present decision, above, the Board has granted service connection for his TBI. The Board is remanding the above matters for appropriate clinicians to review the claims file and provide opinion as to the etiology of each of the claimed disorders. The matters are REMANDED for the following action: 1. Provide the Veteran's claims file to an appropriate clinician or clinicians for file review and opinions as to the likely etiologies of his headaches, his visual disorientation (also described as photophobia), and his obstructive sleep apnea (OSA). Ask the reviewer(s) to provide opinions, with clear explanations of the reasons and bases, addressing the following questions: A. Are the Veteran's headaches at least as likely as not proximately due to or the result of his traumatic brain injury (TBI)? B. Are the Veteran's headaches at least as likely as not aggravated by his TBI? C. Is the Veteran's visual disorientation or photophobia at least as likely as not proximately due to or the result of his TBI? D. Is the Veteran's visual disorientation or photophobia at least as likely as not aggravated by his TBI? E. Is the Veteran's obstructive sleep apnea (OSA) at least as likely as proximately due to or the result of his TBI, his psychiatric medications, his alcohol dependence and use, or his self-extubation during treatment in December 2010? F. Is the Veteran's obstructive sleep apnea (OSA) at least as likely aggravated by his TBI, his psychiatric medications, his alcohol dependence and use, or his self-extubation during treatment in December 2010? 2. Then readjudicate the remanded claims. Journet Shaw Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. J. Kunz, 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.