Citation Nr: 21007143 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 18-53 491 DATE: February 8, 2021 REMANDED The service connection claim for essential tremors to the head (essential tremors) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1966 to July 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. In February 2019 the Veteran and her daughter, M.S., testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. In a May 2019 decision, the Board denied the Veteran’s service connection claim for essential tremors. Subsequently, the Veteran appealed the May 2019 Board decision with the United States Court of Appeals for Veterans Claims (CAVC). In a December 2019 Joint Motion for Partial Remand, the parties stipulated that the Board failed to provide an adequate statement of reasons and bases because by dismissing the probative value of the Veteran’s statements, that her essential tremors are attributable to in-service events, including exposure to Agent Orange, the Board determined that VA was under no duty to obtain a medical opinion on service connection, despite her nursing credentials. In a December 2019 Order, CAVC vacated and remanded this issue. In May 2020, the Board remanded the matter for further, additional developments, consistent with the December 2019 CAVC Order. Nonetheless, the Board regrets further delay, as it finds that additional developments are necessary before a decision may be rendered on the issue on appeal. Pursuant to a May 2020 Board remand, the Veteran was afforded a VA examination for her disability, given her assertions that her essential tremors are due her exposure to Agent Orange during active service, in the capacity of her nursing background. However, the Board finds that the corresponding December 2020 VA opinion is inadequate, as it provided an ambiguous, insufficient rationale to support the opinion. In this VA opinion, a VA examiner opined that the Veteran’s essential tremors were less likely than not incurred in, or caused by an in-service injury, event, or illness. As the rationale for this opinion, the VA examiner explained that she was unable to locate any evidence of treatment or complaints of essential tremors during service or within one year of discharge from service. The VA examiner further explained that the exact cause of essential tremors is not understood, but that there is some evidence that this may be an inherited disorder and that sufficient evidence could not be located to support essential tremors due to herbicides exposure. See December 2020 VA Opinion. To support this opinion, the VA examiner ambiguously listed three medical references about essential tremors and Agent Orange, without citing to any specific, particular detail in each source. For example, the VA examiner generally listed an outdated publication, Veterans and Agent Orange: Update 2002, presumably to support her determination that “sufficient evidence could not be located to support essential tremors due to herbicides exposures.” This is an extremely voluminous publication that includes an enumerated list of diseases that have been grouped under one of the following categories: (1) a disease with sufficient evidence of an association with Agent Orange; (2) a disease with limited or suggestive evidence of no association with Agent Orange; or (3) a disease with no evidence of an association with Agent Orange. However, the VA examiner did not identify the pertinent disability and/or disease classification (e.g. a disease that is classified as a “neurobehavioral disorder” or a “neurodegenerative disease”) that is applicable to essential tremors, to support her conclusion that sufficient evidence could not be identified to support a finding that essential tremors is due to exposure to Agent Orange. Pertinently, this publication has been updated five times, since this 2002 publication. As the most recent update, the National Academy of Sciences (NAS) published Veterans and Agent Orange (VAO), Update 2018 (2018), https://www.nap.edu/catalog/25137/veterans-and-agent-orange-update-11-2018#:~:text=Veterans%20and%20Agent%20Orange%3A%20Update%2011%20(2018)%20examines%20peer,2017%2C%20and%20integrates%20this%20information. In the Summary of this report, at Table S-1, on pages 7 – 8, NAS concluded that there is limited or suggestive evidence of an association between Parkinson’s disease, including Parkinsonism and Parkinson-like syndrome; and inadequate or insufficient evidence to determine an association between neurobehavioral disorders (cognitive and neuropsychiatric) and Agent Orange, and neurodegenerative diseases (excluding Parkinson’s Disease) and Agent Orange. At her videoconference hearing, the Veteran explained that she underwent a test, in which it was determined that her condition was not Parkinson’s Disease, but rather, “a different kind of thing.” Nonetheless, 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). Thus, given the suggested similarities between Parkinson’s Disease and essential tremors, it is not clear as to whether the Veteran’s essential tremors may be classified as “Parkinson-like syndrome”, a “neurobehavioral disorder”, or a “neurodegenerative disease”, for purposes of determining the applicable disease classification listed in the 2018 Update of Veterans and Agent Orange. Thus, as the December 2020 VA opinion is not supported by a clear, detailed rationale, and further clarification about the classification of the Veteran disability is needed, a remand is required for a new VA examination and opinion on the etiology of the Veteran’s essential tremors. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new VA examination with a neurologist, or other qualified physician (VA examiner), who has not yet evaluated the Veteran, to determine the nature and etiology of her essential tremors to the head. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: a. Opine whether it is at least as likely as not (50 percent probability or greater) that her essential tremors to the head are the result of an in-service injury, illness, disease, or event. In this respect, the examiner is informed that there is no assertion that her tremors started in service; rather she asserts that they started many years after service discharge. b. Additionally, the VA examiner should specifically opine whether the Veteran’s essential tremors to the head are due to her exposure to Agent Orange, during her active service in the Republic of Vietnam. c. In rendering this opinion, the VA examiner must explain, with a clear rationale, whether the Veteran’s essential tremors to the head is a “Parkinson-like syndrome”, a “neurobehavioral disorder”, or a “neurodegenerative disease”, for purposes of determining the applicable disease classification listed in the most recent update of Veterans and Agent Orange. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board V-N. Pratt 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.