Citation Nr: 21012275 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 13-07 490 DATE: March 4, 2021 REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to posttraumatic stress disorder (PTSD), gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), sinusitis, and/or asthma, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from May 1986 to May 1992, to include service in the Southwest Asia theater of operations. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this matter for further development in February 2017, December 2017, April 2019, and December 2020. 1. Entitlement to service connection for OSA, to include as secondary to PTSD, GERD, IBS, sinusitis, and/or asthma, is remanded. The Veteran seeks service connection for OSA on a direct basis as well as secondary to service-connected PTSD, GERD, IBS, sinusitis, and/or asthma. See January 2021 Attorney Letter; September 2017 Attorney Letter; July 2014 Attorney Letter; April 2013 Attorney Letter; March 2009 Statement in Support of Claim. In a March 2009 correspondence, the Veteran asserted that his sleep problems began after returning from the Gulf War and have continued to the present. The record contains etiology opinions regarding OSA provided in July 2017, February 2018, November 2019, August 2020, and December 2020. Each of these opinions provided a negative nexus opinion regarding the Veteran’s OSA and his active service and service-connected disabilities. In July 2017, the examiner opined that it was less likely than not that the Veteran’s OSA was proximately due to or aggravated by his GERD, PTSD, and sinusitis. The examiner stated that OSA was caused by an obstructed upper airway and there was no known mechanism by which the Veteran’s service-connected conditions could obstruct the upper airway. The examiner discounted several medical articles provided by the Veteran, noting that they failed to provide a convincing explanation of how the Veteran’s disabilities could obstruct the upper airways. In February 2018, the same examiner opined that it was less likely than not that the Veteran’s OSA was related to GERD, PTSD, asthma, or sinusitis. The examiner also opined that it was less likely than not that the Veteran’s OSA was caused directly by blast waves experienced in combat, which is the only etiology opinion regarding direct service connection in the record. The examiner reasoned that there was no known mechanism by which the Veteran’s various service-connected conditions affected the upper airways. The examiner also opined that there was no evidence demonstrating how blast waves in combat could lead to obstructions in the upper airways. The examiner discounted several medical articles provided by the Veteran, noting that they failed to provide a convincing explanation of how the Veteran’s disabilities could obstruct the upper airways. In November 2019, another examiner opined that it was less likely than not that the Veteran’s OSA was related to GERD, PTSD, asthma, or sinusitis. The examiner provided virtually the same rationale as the prior examiner; that there is no known mechanism by which any of the Veteran’s service-connected conditions could affect the upper airways. The examiner discussed an article submitted by the Veteran from the medical journal Sleep. The examiner noted that although the article’s research indicated an association between psychiatric diagnoses such as PTSD and OSA, association does not equal causation. The examiner instead attributed the Veteran’s sleep apnea to gender and neck size. In August 2020, the same examiner opined that it was less likely than not that the Veteran’s OSA was aggravated by PTSD, GERD, or IBS, because the Veteran’s OSA was stable on treatment. In December 2020, the same examiner opined again that it was less likely than not that the Veteran’s OSA was proximately due to IBS because OSA is caused by upper-airway obstruction and there is no known mechanism by which IBS can affect or obstruct the upper airways. Each medical opinion of record regarding service connection for OSA provides, in essence, the same opinion; that there is no known mechanism by which the Veteran’s service-connected conditions could affect his upper airways. However, the medical articles submitted by the Veteran, some of which were allegedly reviewed by the examiners, provide specific evidence-based explanations for how those conditions could affect the upper airways that were not meaningfully addressed by the examiners. Rather, the examiners simply discounted the articles’ explanations as speculative or deficient in other respects. The Board finds that the medical articles submitted by the Veteran provide detailed and specific explanations of how the various claimed conditions can affect the upper airways and lead to OSA. While the examiners did observe valid deficiencies with some of the articles, the Board is not convinced that the prior examiners adequately reviewed, considered, and discussed the medical articles submitted by the Veteran. In January 2021, the Veteran submitted the 2009 article Obstructive Sleep Apnea Syndrome and Asthma: What Are the Links? published in the Journal of Clinical Sleep Medicine. This article explains that asthma produces an “increased incidence of nasal obstruction” and because the nose is the “preferred breathing route during sleep,” asthma-induced nasal obstruction could result in sleep-disordered breathing conditions such as OSA. See Obstructive Sleep Apnea Syndrome and Asthma: What Are the Links? at 74. The article also explains that “[a]nother cause of the high incidence of [OSA] in asthmatic patients may be the reduction of airway cross-sectional area and upper airway patency.” See id. at 75. In addition, the article notes that “the disruption of sleep architecture following repeated nocturnal asthma attacks might set the scene for [OSA]” by increasing “upper airway collapsibility.” See id. This article and the explanations it proposes regarding asthma and OSA have not been considered and discussed by any examiner. However, the Board notes that it goes against the examiners’ explanations that asthma could not produce OSA because asthma only affects the lungs and OSA only affects the upper airways. In September 2017, the Veteran submitted the 2005 article Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort published in the journal Sleep. The November 2019 examiner noted that this article found a correlation between PTSD and sleep apnea, but not causation, and that the underlying mechanism between the two is not well understood. The examiner also noted that the article indicated that sleep apnea may affect PTSD, rather than the other direction. While the article did not demonstrate proof of a direct correlation between PTSD and OSA, as the examiner noted, the standard to be applied in these proceedings does not require direct proof of causation with complete certainty; rather, the standard is one of equipoise. A medical study indicating that “data strongly support[s] as association between sleep apnea and PTSD” would seem to meet this standard of equipoise. Furthermore, the article cited three other studies conducted by other researchers proposing “an arousal-based mechanism initiated by posttraumatic stress—promoting OSA development in a trauma survivor.” See Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort at 1409 (citing endnotes 28-30). The examiner did not discuss these other studies indicating an arousal-based mechanism by which PTSD could lead to OSA. In September 2017, the Veteran also submitted a website printout about Sleep Apnea and PTSD indicating that PTSD commonly produces risk factors that put “people with PTSD at risk for developing sleep apnea.” In June 2014, the Veteran submitted the 1998 article Posttraumatic Stress Disorder and Obstructive Sleep Apnea Syndrome published in the journal Psychosomatics. This article discusses a case-report of one patient whose PTSD benefitted from OSA treatment. While the article notes that “[i]t is difficult to draw firm conclusions from a single case,” it did advance several theories describing a possible link between PTSD and OSA. Specifically, the article noted effect on sleep architecture and daytime sleepiness; effect on REM sleep; and effect on oxygen saturation. See Posttraumatic Stress Disorder and Obstructive Sleep Apnea Syndrome at 169-71. The July 2017 and February 2018 examiner did not discuss these theories connecting PTSD to OSA; the examiner simply said the article was non-probative because it discussed a single case. The medical theories advanced by the article’s authors, however, could apply to other patients, such as the Veteran, and an examiner should discuss these theories in relation to the Veteran’s claim. In June 2014, the Veteran also submitted a website printout from Northeast Georgia Otolaryngology indicating that “asthma is a legitimate cause of sleep apnea” because asthma produces “frequent inflammation of the airway” and weakens the throat muscles, which in turn increases the tendency of the throat to collapse. The February 2018 examiner, however, stated that there is no link between asthma and OSA because asthma affects the lungs and OSA affects the upper airways and there is “no article that can explain the pathophysiology of how a [restrictive] lung disorder (asthma) can cause [the] Veteran’s upper throat airway to be obstructed.” The November 2019 examiner also noted that asthma affects the lungs and OSA affects the upper airways; thus, there was no connection between the two conditions. The website printout submitted by the Veteran, however, provides a reasonable explanation regarding how asthma could lead to the development of OSA, an explanation which neither examiner discussed. In June 2014, the Veteran also submitted a May 2013 internet article entitled Asthma Tied to Sleep Apnea interviewing researchers whose research demonstrates that patients with asthma were “more likely to develop [OSA]” in a study conducted by the University of Wisconsin. The article does not provide an explanation regarding how asthma could cause OSA, but it does indicate that researchers within the medical community believe there is strong evidence suggesting that asthma could lead to the development of OSA. The July 2017 and February 2018 examiner found this study to be non-probative because it was anecdotal and not published in a peer-reviewed journal. In June 2014, the Veteran also submitted the 2013 article Asthma—A Risk Factor for Sleep Apnea? published on the website of Psychology Today. This article discusses several studies which have demonstrated a link between asthma and OSA, and notes that a new study, the University of Wisconsin study, provides “an important step closer to establishing a causal link between [asthma and OSA]” and that the evidence “suggests that asthma may actually contribute to the onset of [OSA].” The Veteran also submitted a printout from the WebMD website indicating that GERD, allergies, sinus problems, and depression are risk factors for the development of OSA. The Veteran also submitted a New York Times article entitled Sleep Apnea In-Depth Report which offers an explanation regarding how GERD can cause OSA. The article explains that “GERD and sleep apnea often coincide” and that “[r]esearch suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea.” Despite this reasonable explanation, both examiners stated that there is no anatomical manner in which GERD could lead to OSA. The Veteran also submitted an internet article entitled Sleep Problems, PTSD Widespread Following Sept. 11. The article interviews a researcher who explains that prolonged stress caused by PTSD can produce instability of the airway, which in turn could develop into OSA. Neither examiner discussed this theory. In addition, there has not been an adequate opinion regarding direct service connection and the examiners have not considered the Veteran’s statement that he has experienced OSA symptoms since service. Thus, remand is necessary for an addendum opinion to consider the medical articles of record and the Veteran’s statements. Moreover, given the Board’s inability to obtain an adequate opinion, a specialist opinion will be requested under 38 U.S.C. § 5109. Updated VA and private treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. With any necessary assistance from the Veteran, secure any relevant outstanding private treatment records. 3. Then request an independent medical opinion under 38 U.S.C. § 5109/ 38 C.F.R. § 3.328. An updated examination is not required unless indicated by the examiner. After a review of the claims file, the examiner should opine: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s OSA had its onset in or is otherwise related to his active service (50 percent or greater probability), to include as a result of experiencing blast waves in combat. (b.) Whether it is at least as likely as not that the Veteran’s OSA is proximately due to any or all of his service-connected disabilities, to include PTSD, asthma, IBS, GERD, or sinusitis. (c.) Whether it is at least as likely as not that the Veteran’s OSA has been aggravated (worsened) by any or all of his service-connected disabilities, to include PTSD, asthma, IBS, GERD, or sinusitis. In addressing questions (b) and (c) above, please consider each disability individually as well as the cumulative impact of those service-connected disabilities on his OSA. In other words, if you do not believe that any of the disabilities are causing or aggravating his OSA on an individual basis, please consider whether his OSA could be proximately due to or aggravated by the cumulative impact of all those service-connected conditions. Additionally, please note that it is not necessary that the Veteran’s service connected disabilities be service-connected, or even diagnosed, at the time his OSA is incurred, and reliance on this fact in support of a negative opinion will render it inadequate In addressing the above questions, please review, consider, and discuss the following evidence: (1.) The Veteran’s April 8, 2009 Correspondence indicating that he has experienced OSA symptoms since returning from the Gulf War. (2.) The 2009 article Obstructive Sleep Apnea Syndrome and Asthma: What Are the Links? published in the Journal of Clinical Sleep Medicine. Please consider and discuss the entire article as well as the three theories regarding a connection between asthma and OSA; namely, nasal obstruction, reduction of airway cross-sectional area and upper airway patency, and disrupted sleep architecture, on pages 74-75. (3.) The August 2009 article Blast Waves May Cause Human Brain Injury Even Without Direct Head impacts. (4.) The 2005 article Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort published in the journal Sleep. Please consider and discuss the entire article, as well as discussing whether the article’s statement “data strongly support[s] as association between sleep apnea and PTSD” meets the standard of equipoise in these proceedings. Please also discuss the three sources cited by the article which propose an arousal-based mechanism by which PTSD could cause OSA. See p. 1409 (citing endnotes 28-30). (5.) The website printout about Sleep Apnea and PTSD indicating that PTSD commonly produces risk factors that put “people with PTSD at risk for developing sleep apnea.” (6.) The 1998 article Posttraumatic Stress Disorder and Obstructive Sleep Apnea Syndrome published in the journal Psychosomatics. Please consider and discuss the entire article as well as the three theories regarding a connection between PTSD and OSA; namely, effect on sleep architecture, effect on REM sleep, and effect on oxygen saturation. See pp. 169-71. If you find the article non-probative because it only discusses a single case, please explain why the article’s theories cannot be applied to explain a connection between the Veteran’s PTSD and OSA. (7.) The website printout from Northeast Georgia Otolaryngology indicating that “asthma is a legitimate cause of sleep apnea” because asthma produces “frequent inflammation of the airway” and weakens the throat muscles, which in turn increases the tendency of the throat to collapse. (8.) The May 2013 internet article entitled Asthma Tied to Sleep Apnea which interviewed researchers whose research demonstrated that patients with asthma were “more likely to develop [OSA]” in a study conducted by the University of Wisconsin. (9.) The 2013 article Asthma—A Risk Factor for Sleep Apnea? published on the website of Psychology Today. Please consider and discusses the article’s discussion of several studies which have demonstrated a link between asthma and OSA, and a new study, the University of Wisconsin study, that provides “an important step closer to establishing a causal link between [asthma and OSA]” and that the evidence “suggests that asthma may actually contribute to the onset of [OSA].” (10.) The printout from the WebMD website indicating that GERD, allergies, sinus problems, and depression are risk factors for the development of OSA. (11.) The New York Times article entitled Sleep Apnea In-Depth Report which offers an explanation regarding how GERD can cause OSA. Please consider and discuss the article’s explanation that “GERD and sleep apnea often coincide” and that “[r]esearch suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea.” In this regard, please also consider and discuss an August 2000 imaging study of the Veteran indicating chronic nonspecific laryngitis and bilateral arytenoid contact granuloma, and whether these findings have any bearing on the possible link between GERD’s effect on the larynx and OSA development. (12). The internet article entitled Sleep Problems, PTSD Widespread Following Sept. 11. Please consider and discuss the article’s quote of a researcher who explains that prolonged stress caused by PTSD can produce instability of the airway, which in turn could develop into OSA. In addressing the above questions, please note that the correct standard to be applied is equipoise; whether it is at least as likely as not that the Veteran’s OSA had its onset in or is otherwise related to active service, or is proximately due to or aggravated by any of his service-connected conditions. The standard does not require proof demonstrating causation with absolute certainty. Applying a heightened standard of proof will render the opinion inadequate. A complete rationale should be given for all opinions and conclusions expressed. If unable to opine without resorting to speculation, please provide a basis for reaching this conclusion. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. deBruyn, 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.