Citation Nr: 21012112 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 11-04 144 DATE: March 3, 2021 ORDER Entitlement to an increased rating of 30 percent, but no higher, for intention tremors and drug-induced Parkinson’s like tremors associated with schizophrenia, paranoid type, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 60 percent, but no higher, for chronic fatigue syndrome, heat stroke, also claimed as fatigue, is granted, effective June 16, 2010, subject to the laws and regulations governing they payment of monetary benefits. Entitlement to an increased rating higher than 60 percent for chronic fatigue syndrome, heat stroke, also claimed as fatigue, effective September 8, 2019, is denied. Entitlement to service connection for migraines is granted as a symptom of his chronic fatigue syndrome, heat stroke. Entitlement to service connection for hypothermia associated with schizophrenia, paranoid type is denied. Entitlement to service connection for arthritis and spinal trauma is denied. FINDINGS OF FACT 1. The Veteran has had no more than moderate tremors. 2. For the entire evaluation period, i.e., since June 16, 2010, the Veteran’s symptoms due to the side effects of the medication he has taken for his schizophrenia have included severe tiredness and fatigue that were nearly constant and restricted routine daily activities, which resolving all doubt in the Veteran’s favor, more closely approximates the criteria for debilitating fatigue, which reduced daily activity level to less than 50 percent pre-illness level for six months or longer, with additional cognitive impairment included short-term memory loss. 3. Effective September 8, 2019, the Veteran’s symptoms due to the side effects of the medication he has taken for his schizophrenia do not more nearly approximate symptoms that are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. 4. The Veteran’s migraine headaches are considered a symptom of his chronic fatigue, heat stroke. 5. The Veteran’s cold intolerance/ hypothermia is not secondary to service-connected schizophrenia and is not otherwise related to an in-service injury or disease. 6. The Veteran’s arthritis and spinal trauma was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; current symptomatology is attributable to an intervening 1987 motor vehicle accident; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for an increased rating of 30 percent, but no higher, for intention tremors and drug-induced Parkinson’s like tremors associated with schizophrenia, paranoid type, are met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.124a, Diagnostic Code 8105. 2. The criteria for a rating of 60 percent, but no higher, for chronic fatigue syndrome, heat stroke, also claimed as fatigue, are met, effective June 16, 2010. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.88b, Diagnostic Code 6354 (2018 & 2020). 3. The criteria for an increased rating higher than 60 percent for chronic fatigue syndrome, heat stroke, also claimed as fatigue, effective September 8, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.88b, Diagnostic Code 6354 (2018 & 2020). 4. The criteria for service connection for migraines as a symptom of chronic fatigue syndrome, heat stroke are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for hypothermia due to service-connected schizophrenia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for arthritis and spinal trauma are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to October 1982. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2012 rating decision by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ), which, in pertinent part, denied service connection for arthritis, spinal trauma, hypothermia, and migraines; granted service connection for heat stroke claimed as fatigue with a noncompensable (zero percent) rating effective June 16, 2010; and granted service connection for intention tremors and drug-induced Parkinson’s like tremors as secondary to service-connected psychiatric disability with a 10 percent rating effective June 16, 2010. In a December 2015 substantive appeal (VA Form 9), the Veteran requested a Board hearing. However, the Veteran withdrew his request for such hearing in a written statement received in April 2017. The Board, in pertinent part, most recently remanded the Veteran’s claim in May 2018. The AOJ substantially complied with the Board remand directives, and the case is now returned for appellate review. The issue of service connection for a left shoulder disability was granted in a December 2020 rating decision, with a 20 percent rating, effective March 14, 2007, removing this matter from appellate consideration. Service connection for peripheral neuropathy of the left upper extremity, claimed as loss of use of the left arm, also was granted with a 20 percent rating, effective March 14, 2007. Although the issue had been framed as service connection for a left arm disability in the May 2018 Board remand, the grant for the left shoulder disability and peripheral neuropathy of the left upper extremity encompasses the left arm and satisfies this appeal. The AOJ also granted an increased rating of 60 percent for chronic fatigue syndrome, heat stroke, also claimed as fatigue, effective September 8, 2019, in the December 2020 rating decision. As the Veteran has not indicated that he is satisfied with this rating, this matter is still before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issue of an increased rating for heat stroke claimed as fatigue has been modified as chronic fatigue, heat stroke claimed as fatigue, as noted on the first page of this decision. Increased Rating 1. Entitlement to an increased rating higher than 10 percent for intention tremors The Veteran seeks an increased rating for his intention tremors. The Veteran’s intention tremors are rated under Diagnostic Code 8199-8105. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. The Veteran’s intention tremors have been likened to Sydenham’s chorea (Diagnostic Code 8105), which is a neurological disorder characterized by rapid, jerky, irregular, and involuntary movements. Under Diagnostic Code 8105, a 10 rating is assigned for mild symptoms. A 30 percent rating requires moderate symptoms. A 50 percent rating requires moderately severe symptoms. An 80 percent rating requires severe symptoms. A 100 percent rating requires pronounced symptoms, progressive grave types. Words such as “moderate,” “moderately severe,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Use of terminology such as “severe” by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The question for consideration is whether the intention tremors warrant the assignment of rating greater than 10 percent. The totality of the evidence shows that moderate impairment is demonstrated. Thus, the Veteran is entitled to a rating of 30 percent, but no higher, for intention tremors. A December 2011 VA examination report shows the Veteran was diagnosed with intention tremors and drug-induced Parkinson like tremors of the bilateral upper and lower extremities. He described difficulty using his hands and holding objects for fine motor activity due to the hand tremor. For instance, he would hold a cup of coffee or drink with both hands. On physical examination he had tremor with characteristic hand shaking, “pill-rolling.” The right upper extremity was moderate. The left upper extremity was mild. The right and left lower extremities also were mild. The examiner determined that it was at least as likely as not that the Veteran’s tremors were a side effect from the medications taken to control his paranoid schizophrenia, including Ziprasidone (Geodon), Haloperidol, and Vistaril. A November 8, 2013 VA treatment record notes that the Veteran complained of “bad hand tremors.” A September 2019 VA examination report shows that the Veteran had been diagnosed with intention tremors and drug-induced Parkinson’s like tremors. As for current symptoms the Veteran stated that it was hard for him to try to hold a cup or something and that he would get a little shaky in his right hand. The Veteran had muscle weakness in the upper and/ or lower extremities. His neurologic examination was normal. He walked with a limp but the etiology of this was unknown. He had less than normal strength in the left elbow, wrist, grip, and pinch; but the upper right side was normal. The lower extremities muscle strength testing also was normal. The report later notes, however, that there was moderate right upper extremity muscle weakness and no muscle weakness in the left upper extremity or lower extremities. It was noted that due to the tremors in the right hand that the Veteran’s ability was limited in performing job tasks that required holding objects. In reviewing the evidence of record, the Veteran described difficulty using his hands and holding objects, such as a cup of coffee or other drink. Symptoms in the right upper extremity have been described as moderate as noted on VA examinations in December 2011 and September 2019. The Veteran also had muscle weakness in the upper and/ or lower extremities, including less than normal strength in the left elbow, wrist, grip, and pinch, as noted on examination in September 2019. Resolving all doubt in the Veteran’s favor these symptoms more closely approximate moderate impairment. A rating higher than 30 percent is not warranted, as the medical evidence does not show moderately severe symptoms. Most of the evidence of record is more consistent with mild to moderate symptoms. The Board has considered whether the Veteran’s disability would warrant a higher rating under any other diagnostic code but determined that none are applicable. The Board acknowledges the Veteran’s competent and credible statements describing his tremor symptomology. Overall, the evidence establishes the existence of at most moderate intention tremors warranting entitlement to a 30 percent rating, but no higher. 2. Entitlement to an increased rating for chronic fatigue syndrome, heat stroke, also claimed as fatigue, rated as 0 percent disabling, effective prior to September 8, 2019; and 60 percent, thereafter The Veteran seeks a higher rating for his chronic fatigue syndrome, heat stroke, also claimed as fatigue. The Veteran’s chronic fatigue syndrome, heat stroke is rated under 38 C.F.R. § 4.88b, Diagnostic Code 6354. Effective August 11, 2019, VA revised the criteria for rating infectious diseases, immune disorders, and nutritional deficiencies (including chronic fatigue syndrome). 84 Fed. Reg. 28,227-235 (Jun. 18, 2019). Because the current increased rating claim for chronic fatigue and exhaustion stems from a claim filed in June 2010, the Board is required to consider the claim in light of both the former and revised schedular criteria in order to determine whether a higher rating is warranted for that disability. If application of the revised regulation results in a higher rating, the effective date for the higher disability rating can be no earlier than the effective date of the change in the regulation. 38 U.S.C. § 5110 (g). Prior to the effective date of the change in the regulation, the Board can apply only the original version of the regulation. Under both applicable versions of Diagnostic Code 6354 (i.e., the version in effect prior to August 11, 2019 and the version which became effective on August 11, 2019), the following criteria are provided for rating chronic fatigue syndrome: A 10 percent rating is warrant for symptoms which wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year, or; symptoms controlled by continuous medication. A 20 percent rating is warranted for symptoms which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level; or, for symptoms which wax and wane, resulting in periods of incapacitation of at least two but less than four weeks total duration per year. A 40 percent rating is warranted for symptoms which are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level; or, for symptoms which wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year. A 60 percent rating is warranted for symptoms which are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level; or, for symptoms which wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. A 100 percent rating is warranted for symptoms which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. 38 C.F.R. § 4.88b, Diagnostic Code 6354 (2018 & 2020). Under the version of Diagnostic Code 6354 in effect prior to August 11, 2019, a Note provides that, for the purpose of evaluating chronic fatigue syndrome disability, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. 38 C.F.R. § 4.88b, Diagnostic Code 6354, Note (2018). Under the version of Diagnostic Code 6354 which became effective on August 11, 2019, a Note provides that, for the purpose of evaluating chronic fatigue syndrome disability, incapacitation exists only when a licensed physician prescribes bed rest and treatment. 38 C.F.R. § 4.88b, Diagnostic Code 6354, Note (2020). Under 38 C.F.R. § 4.88a, for VA purposes, the diagnosis of chronic fatigue syndrome requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: (i) acute onset of the condition, (ii) low grade fever, (iii) nonexudative pharyngitis, (iv) palpable or tender cervical or axillary lymph nodes, (v) generalized muscle aches or weakness, (vi) fatigue lasting 24 hours or longer after exercise, (vii) headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), (viii) migratory joint pains, (ix) neuropsychologic symptoms, (x) sleep disturbance. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). As noted above, the Veteran submitted his service connection claim for heat strokes, severe tiredness, and fatigue secondary to the medication he takes for his service-connected schizophrenia on June 16, 2010. In the March 2012 rating decision, the AOJ assigned a zero percent rating for heat strokes claimed as fatigue and severe tiredness and rated the claim as chronic fatigue syndrome, as a diagnosed disability without compensable symptoms. The AOJ noted that in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The AOJ assigned a 60 percent rating for the Veteran’s chronic fatigue, effective September 8, 2019, in a December 2020 rating decision, on the basis of a September 2019 VA examination. The Board finds, however, that for the entire evaluation period, i.e., since June 16, 2010, the Veteran’s symptoms due to the side effects of the medication he has taken for his schizophrenia have included severe tiredness and fatigue that were nearly constant and restricted routine daily activities. Resolving all doubt in the Veteran’s favor, the Board finds that these findings more closely approximate the criteria for debilitating fatigue, which reduced daily activity level to less than 50 percent pre-illness level for six months or longer, with additional cognitive impairment included short-term memory loss. The pertinent evidence of record consists of VA treatment records dated from 2010 to 2018, as well as December 2011 and November 2019 VA examination reports with a December 2020 addendum opinion. A June 2010 VA treatment record shows the Veteran was assessed as having fatigue probably secondary to multiple medications that can cause fatigue. It was noted that he was on two antipsychotics, hydroxyzine and mirtazapine. A December 2011 VA examination report shows the Veteran’s complaints of heat intolerance in the outdoors requiring him to hire others to do his yardwork. He denied any previous medical evaluation or treatment for heat injuries or heat stroke. The examiner noted the Veteran’s subjective complaints of heat intolerance. The examiner determined that the Veteran’s heat stroke was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that clinical evidence, with review of available records and medical literature supported the premise that the Veteran’s heat intolerance was at least as likely as not a side effect from medication taken to control his paranoid schizophrenia, specifically, Haloperidol, Benztropine. The Veteran also was diagnosed with hypersomnolence and fatigue with mild anemia. He described lack of energy for household chores with a moderate effect on daily activities. The Veteran noted that the severe tiredness and fatigue had an onset in 2006-2007. He had a history for sleep disturbance with the schizophrenia and a diagnosis of sleep apnea. Currently, he had daytime hypersomnolence and lack of energy during the day. He slept an average of six hours per night with brief interruptions. Current medications helped to eliminate the voices and decrease the sleep disturbance. It was noted that his sleep apnea was treated with surgery in 2003-2004 and used a continuous positive airway pressure (CPAP) machine. He was taking several medications with sedating side-effects. There was no history of chronic fatigue syndrome. The examiner found that hypersomnolence and fatigue were at least as likely as not side effects from medications taken to control the Veteran’s paranoid schizophrenia, namely Ziprasidone, Haloperidol, Remeron, and Vistaril. The examiner also noted that there was clinical laboratory evidence of mild anemia that could contribute to fatigue. A November 8, 2013 VA treatment record notes that the Veteran was counseled on his psychiatric medication possibly causing heat stroke if exposed to too much sun. In a March 2013 statement, the Veteran complained of heat intolerance. VA treatment records dated from February 2015 to June 2017 show the Veteran consistently complained of feeling tired or having little energy nearly every day. He also complained of having trouble falling or staying asleep or sleeping too much for several days. An August 2018 VA treatment record notes the Veteran’s complaints of short-term memory loss. He was advised to follow up with the mental health clinic if he experienced symptoms such as fatigue, and lightheadedness or sudden dizziness. In September 2018, the Veteran complained of feeling tired or having little energy more than half the days. A November 2019 VA examination report shows the Veteran had been diagnosed with chronic fatigue syndrome in 2017. He also reported onset of heat stroke/ fatigue/ tiredness a few years earlier when he was trimming the hedges and got hot and had to lay down on the floor. He noted that his condition had progressed/ worsened. Continuous medication was not required for control of chronic fatigue syndrome. The Veteran was noted as having an acute onset of chronic fatigue syndrome. He also had debilitating fatigue, which reduced daily activity level to less than 50 percent pre-illness level for six months or longer. Symptoms included debilitating fatigue, low grade fever, and fatigue lasting 24 hours or longer after exercise. He also had generalized muscle aches or weakness, headaches, neuropsychological symptoms, and sleep disturbance. Additional cognitive impairment included short-term memory loss. The symptoms were nearly constant and restricted routine daily activities to less than 50 percent of the pre-illness level. The Veteran’s symptoms of chronic fatigue resulted in periods of incapacitation for at least six weeks per year. Due to fatigue and chronic fatigue, the Veteran was unable to perform his job activities. A December 2020 addendum opinion notes that the Veteran’s chronic fatigue syndrome was a correction to the prior diagnosis of heat stroke. The examiner noted that the records indicated that the Veteran never had a heat stroke but had heat intolerance secondary to psychiatric medications he was taking. At the time of his examination in September 2019 his symptoms were more consistent with chronic fatigue syndrome. As described above, the pertinent evidence during the appeal period shows that the Veteran’s severe tiredness and fatigue that were nearly constant and restricted routine daily activities. He also suffered from sensitivity to heat that required him to lie down after being in the sun too long and restricted his ability to engage in outside activities. While the Veteran’s symptoms were not diagnosed as chronic fatigue syndrome until approximately 2017, he had consistent findings of symptoms that more closely approximated debilitating fatigue, which reduced daily activity level to less than 50 percent pre-illness level for six months or longer for the entire appeal, i.e., since June 16, 2010. It is not clear from the medical evidence effective since June 16, 2010 whether the Veteran had chronic fatigue syndrome for VA purposes under 38 C.F.R. § 4.88a. However, even rating the Veteran’s symptoms by analogy, resolving all doubt in the Veteran’s favor, the Veteran demonstrated onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months. Therefore, his chronic fatigue heat stroke warrants a 60 percent rating under either applicable version of Diagnostic Code 6354. A rating higher than 60 percent is not warranted, as the symptoms reported in the record do not more closely approximate symptoms which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. The examiner in November 2019 specifically left unchecked the box that noted symptoms restrict routine daily activities completely and may occasionally preclude self-care. None of the other medical evidence of record is consistent with the next higher rating under Diagnostic Code 6534. Accordingly, the Board finds that a rating of 60 percent, but no higher, is warranted for the entire appeal for the Veteran’s chronic fatigue heat stroke. See 38 C.F.R. § 4.88b, Diagnostic Code 6354 (2018 & 2020). Service Connection 3. Entitlement to service connection for migraines The Veteran contends that he has migraines as a result of his medication for schizophrenia. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of or was aggravated beyond its natural progress by service-connected disability. The Board concludes that the Veteran’s headaches are a symptom of his service-connected chronic fatigue syndrome; and to that extent are granted on a secondary basis. A September 2019 VA examination report shows that the Veteran complained that his headaches started in 1982. He noted that he was sensitive to light and sounds and had to wear sunglasses. He now had headaches once or twice a week. He took Sumatriptan for his headaches. There was pain on both sides of his head. He had characteristic prostrating attacks of migraine headache pain more frequently than once per month, which were productive of severe economic inadaptability. The examiner found that the Veteran’s migraines were less likely than not related to his service-connected schizophrenia. The rationale was that according to the National Institute of Health, migraine headaches and schizophrenia were highly prevalent and co-occurred but that there was a lack of medical evidence or research to support that schizophrenia caused migraine headaches. The examiner further noted that the Veteran reported onset of headaches in 1982 (during his service) prior to his prescription for schizophrenia. The examiner found that the Veteran’s migraines were not at least as likely as not incurred in or caused by any event during service, as there was a lack of chronicity and continuity of care. The September 2019 VA medical opinion is inadequate because in addressing secondary service connection, the examiner only addressed whether schizophrenia causes migraine headaches, and not whether the Veteran’s medication that he took for schizophrenia had any relationship to his migraine headaches. The examiner also did not address aggravation. As for direct service connection, while the examiner found there was lack of chronicity of care, the Veteran has stated that he first noticed his headaches in 1982, which coincides with the last part of his military service. The examiner noted that the service treatment records dated in August 1982 as part of a medical board evaluation showed that the Veteran complained of migraine headaches, though he checked “no” for frequent or severe headaches on a February 1982 discharge examination. It also is worth noting that service treatment records show complaints of headaches in January 1981 as part of an upper respiratory infection. The September 2019 VA examiner noted that the treatment records for the year after discharge were silent for migraine headaches. The determinative issue for service connection, however, is the chronicity of symptoms, not care. See Savage v. Gober, 10 Vet. App. 488, 496 (1997) (Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology.). Notwithstanding these deficiencies in the examination addressing headaches, the November 2019 VA examination report addressing the Veteran’s chronic fatigue syndrome heat stroke noted that the symptoms associated with his chronic fatigue syndrome included headaches. In addition, the diagnostic criteria for chronic fatigue syndrome contemplates headaches. See 38 C.F.R. § 4.88a. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current headaches are a symptom of his chronic fatigue syndrome heat stroke, and headaches are contemplated in the rating criteria for chronic fatigue syndrome. For compensation purposes, the Veteran is already compensated for headaches under the diagnostic criteria for chronic fatigue syndrome and will not likely receive any additional compensation for his headaches. See 38 C.F.R. § 4.14 (The evaluation of the same disability under various diagnoses is to be avoided.). Nonetheless, after resolving all doubt in favor of the Veteran, the Board finds that service connection for migraine headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for hypothermia associated with schizophrenia, paranoid type The Veteran contends that the medication he takes for schizophrenia causes him to have hypothermia and cold intolerance. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of or was aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has current complaints of cold intolerance that prevent him from spending prolonged periods outside during the winter months, the preponderance of the evidence is against finding that the Veteran’s hypothermia/ cold intolerance is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A December 2011 VA examination report shows that the Veteran had symptoms of cold intolerance in the outdoors during the winter season. He denied any previous medical evaluation or treatment for cold weather injuries or hypothermia. He also did not have a history of immune deficiency disease or Raynaud’s syndrome. The examiner found that the Veteran’s claimed hyperthermia was less likely than not incurred in or caused by the claimed in-service illness. The rationale was that clinical evidence with review of available records and medical literature supported the premise that the Veteran’s cold intolerance was most likely not related to any side effects from medication that he was taking for his schizophrenia. None of the VA treatment records in the file show a diagnosis of cold intolerance or hypothermia. The Veteran believes his symptoms of cold intolerance are proximately due to medication to treat his schizophrenia. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the December 2011 VA examination report. 5. Entitlement to service connection for arthritis and spinal trauma The Veteran contends that he has arthritis and spinal trauma related to his military service. He noted on an October 2020 VA examination report that in 1977 his neck pain started after his head hit the ground while using the “slide for life” (riding a slide head-first). While he has noted arthritis, he has not identified any specific area other than the spine. Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran has a current diagnosis of degenerative arthritis of the spine as evidenced by an October 2020 VA examination report. Arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. The October 2020 VA examination report notes that arthritis of the spine was not diagnosed until November 2005, which is 23 years after his separation from service and 22 years outside of the applicable presumptive period. While the Veteran is competent to report having experienced symptoms of neck pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of arthritis of the spine as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to competent medical evidence, which establishes that these symptoms were instead attributable to a motor vehicle accident after service in 1987. The October 2020 VA examiner noted that an August 2015 treatment record noted that the Veteran had chronic neck pain due to a motor vehicle accident in 1987. Service connection for a cervical spine disability may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s cervical spine disability and an in-service injury, event or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The October 2020 VA examiner opined that the Veteran’s cervical spine disability is not at least as likely as not related to an in-service injury, event, or disease. The rationale was that the medical records did not support that the degenerative pathology of the spine had its genesis during service. The service treatment records were mute for complaints of neck pain. While the Veteran believes that his cervical spine disability is related to an in-service injury, including sliding headfirst in 1977, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah B. Richmond, 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.