Citation Nr: 21076767 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-33 869 DATE: December 27, 2021 REMANDED Service connection for a lower back condition is remanded. Service connection for neurological problems is remanded. Service connection for foreign accent syndrome is remanded. Service connection for an eye condition (blindness) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1990 to March 1992, October 2008 to December 2008 and June 2009 to June 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2014 and February 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran and her son testified at a Board hearing before the undersigned Veterans Law Judge in January 2020. A transcript of the hearing is of record. Service connection for a lower back condition is remanded. The Veteran testified at the January 2020 Board hearing that her back condition is related to her duties in service and her service-connected knee and ankle disabilities. Specifically, the Veteran testified that she suffered muscle strains and sprains in service carrying heavy packs and lifting and toting equipment while deployed. The Veteran also testified that her bilateral knee and left ankle conditions caused her legs to bruise and swell, which caused her to limp. According to the Veteran, doctors have told her that the imbalance in her gait caused her back to shift and compress in different areas, causing her back pain. VA treatment records confirm the Veteran's complaints of chronic back pain. To date, the Veteran has not been afforded a VA examination for her claimed lower back condition. VA must provide an examination when there is competent evidence of a disability (or persistent or recurrent symptoms of a disability) that may be associated with an in-service event, injury, or disease, but there is insufficient information to decide the claim. See 38 U.S.C. § 5103A(d); McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Lay testimony as to continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service, and the threshold for finding that the disability (or symptoms of a disability) may be associated with service is low. See McClendon, 20 Vet. App. at 83. Furthermore, the Veteran is competent to testify to in-service injuries, symptoms and events. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the Board finds the Veteran's testimony is sufficient to warrant a VA examination to determine the nature and etiology of her lower back pain, including whether it is secondarily related to her service-connected knee and ankle disabilities. Accordingly, the matter is remanded. Service connection for neurological problems, foreign accent syndrome and an eye condition (blindness) is remanded. Although the Veteran has been afforded VA examinations for her claims for service connection for neurological problems, foreign accent syndrome and an eye condition, the Board finds the examinations inadequate, thus warranting remand. Barr v. Nicholson, 21 Vet. App. 303 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion it must ensure that the examination or opinion is adequate.) Specifically, the Veteran was afforded VA examinations for eye conditions in June 2014, February 2015 and March 2017. The June 2014 VA examiner diagnosed the Veteran as legally blind, but did not provide a nexus opinion. The February 2015 VA examiner noted that the Veteran's eye exam was normal, she did not have a definitive diagnosis and her subjective complaints of visual disturbances would likely need to be examined by a neurologist. The March 2017 VA examiner noted that the Veteran had complaints of visual disturbances, but also concluded that there was no pathology to render a diagnosis. The Veteran testified at the January 2020 Board hearing that she is very light sensitive and is unable to see white or black or dark or light, and only sees in a "flood of rainbows." The Veteran also testified at the Board hearing that her foreign accent started in January 2013 and that, after being tested for a stroke or seizure, her physicians could not determine the cause of her speech and visual symptoms. A March 2017 VA examination for PTSD noted the Veteran's symptoms included the onset of speech difficulties evolving into speaking with a foreign accent. A March 2017 VA medical opinion for the foreign accent syndrome claim concluded that there was no accepted diagnosis for such a condition and deferred any further comment on the Veteran's symptoms to a neurologist. The Veteran was also afforded a March 2017 Gulf War medical examination, The examiner noted that a February 2017 neurology consultation determined that the Veteran had conversion disorder, a mental condition in which a person's blindness, paralysis or other nervous system symptoms cannot be explained by medical evaluation. Again, however, no nexus opinion was provided in the March 2017 VA examination. VA treatment records confirm an inability to determine the etiology of the Veteran's neurologic problems, visual disturbances and foreign accent syndrome. Specifically, an August 2017 psychiatric assessment noted the Veteran's symptoms and suggested that while they may be indicative of a conversion disorder, they could also likely have neurological components. The assessor emphatically opined that the Veteran needed an objective neurological evaluation. A November 2017 psychiatric assessment diagnosed the Veteran as having foreign accent syndrome pursuant to the DSM-5 but could not rule out an organic etiology as opposed to a conversion disorder. A November 2018 pain rehabilitation assessment noted that the veteran had a central nervous system issue with vision and speech issues that were not clearly diagnosed. The Veteran contends that the examinations for her eye condition, foreign accent syndrome and neurological complaints are inadequate and that she should be examined by a neurologist. The Board agrees that an addendum medical opinion is warranted. To the extent the examiners determined that the Veteran did not have an eye condition or foreign accent syndrome because of the lack of a formal diagnosis, they failed to consider whether the Veteran's subjective complaints established the existence of a disability or whether those symptoms were caused by the Veteran's service, including her exposure to burn pits while deployed. Moreover, although the VA examiners and treatment providers recognized the need for an examination by a neurologist to determine the nature and etiology of the Veteran's neurological problems, foreign accent syndrome and visual disturbances, no opinion from a neurologist has been provided. Accordingly, the Board concludes that further remand is warranted to provide the Veteran with an adequate VA examination, by a neurologist, to determine the nature and etiology of her neurological problems, foreign accent syndrome and eye condition. Accordingly, the matters are remanded. The matters are REMANDED for the following action: 1. Obtain updated VA and private treatment records and associate them with the claims file. 2. After completing the development in item 1, schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and etiology of the Veteran's lower back condition. A copy of the claims file, (including this remand) should be made available to and be reviewed by the examiner. All necessary tests should be conducted. The examiner is asked to opine: (a.) Whether it is at least as likely as not that any currently diagnosed lower back condition was incurred in or is otherwise related to service. (b.) If not related to service, whether is it at least as likely as not that any currently diagnosed lower back condition is causally related to her service-connected bilateral knee or left ankle disabilities. (c.) If not caused by the service-connected bilateral knee or left ankle disabilities, is it at least as likely as not that the Veteran's low back condition has been aggravated by these service-connected conditions? Please explain why or why not. In proffering this opinion, the examiner must determine whether the Veteran's service-connected bilateral knee and left ankle conditions caused any increase, even transient, in the Veteran's low back condition, regardless of permanence. (d.) If the examiner finds that the Veteran's low back condition has been aggravated by her bilateral knees or left ankle conditions, please describe the baseline of the Veteran's low back condition without the service-connected conditions and the degree in aggravation beyond that baseline that is attributable to the Veteran's service-connected bilateral knee or left ankle conditions. 3. After completing the development in item 1, schedule the Veteran for a VA examination to be conducted by a neurologist to determine the nature and etiology of the Veteran's neurological problems, foreign accent syndrome and eye conditions. If formal conditions cannot be diagnosed, but the Veteran manifests signs or symptoms that cause functional impairment, the examiner should consider them disabilities for the purpose of providing the requested opinions. The neurologist is asked to opine: (a.) Whether it is at least as likely as not that any currently diagnosed neurological problems were incurred in or are otherwise related to service, including the Veteran's exposure to burn pits in service. (b.) Whether it is at least as likely as not that any currently diagnosed foreign accent syndrome disability was incurred in or is otherwise related to service, including the Veteran's exposure to burn pits in service. (c.) Whether it is at least as likely as not that any currently diagnosed eye condition disability was incurred in or is otherwise related to service, including the Veteran's exposure to burn pits in service. (d.) If none of the above (neurological problems, foreign accent syndrome, or diagnosed eye condition) are determined to be unrelated to the Veteran's active service, including exposure to burn pits, please provide an opinion as the most likely etiology of each. The examiners should specifically consider and comment on the Veteran's lay statements regarding her conditions and duties in active service in formulating the requested opinions. A complete rationale for the examiner's opinions should be provided, citing to specific evidence of record, as necessary. If the examiner cannot provide opinions without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). If the inability to provide an opinion without resorting to speculation is due to a deficiency in the record (additional facts are required), the AOJ should develop the claim to the extent it is necessary to cure any such deficiency. If the inability to provide an opinion is due to the examiner's lack of requisite knowledge or training, then the AOJ should obtain an opinion from a medical professional who has the knowledge and training needed to render such an opinion. S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Snyder, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.