Citation Nr: 21031272 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 15-03 808A DATE: May 21, 2021 REMANDED Entitlement to service connection for bilateral essential tremors is remanded. Entitlement to service connection for a neurological condition of the feet, to include peripheral neuropathy and restless leg syndrome, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1965 to March 1967, including service in the Republic of Vietnam. In March 2018, the Veteran testified under oath before the undersigned Veterans Law Judge at a videoconference hearing. A transcript of the hearing is of record. The Board remanded this claim for additional development in June 2018, April 2020, and January 2021. Although the Board regrets the additional delay, and for the reasons outlined below, another remand is required before this claim can be adjudicated. After reviewing the evidence of record, and in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issue of service connection for peripheral neuropathy of the bilateral feet to encompass any neurological condition of the feet, to include peripheral neuropathy and restless leg syndrome. 1. Entitlement to service connection for bilateral essential tremors is remanded. Based on the Veteran's service in the Republic of Vietnam, exposure to herbicide agents is conceded. The Board notes that an essential tremor is not one of the explicitly listed enumerated conditions found in 38 C.F.R. § 3.309(e) as presumptively caused by exposure to herbicide agents. The Veteran has never been formally diagnosed with Parkinson's disease, which is an explicitly listed enumerated condition found in 38 C.F.R. § 3.309(e). Effective January 1, 2021, however, the National Defense Authorization Act for Fiscal Year 2021 added "Parkinsonism" to 38 U.S.C. § 1116(a)(2) as a condition presumed to be caused by exposure to herbicide agents. The regulations have not been updated yet to reflect this change in the statutory law. Parkinsonism is defined as "a group of neurological disorders characterized by hypokinesia, tremor, and muscular rigidity." Dorland's Illustrated Medical Dictionary, 1383 (32nd ed. 2012). A remand is required for a medical opinion addressing whether the Veteran's bilateral essential tremors constitute "Parkinsonism" for the purposes of applying the presumptive service connection principles under 38 U.S.C. § 1116. If it is determined that the Veteran's disability qualifies as Parkinsonism, then the principals of presumptive service connection apply. The Board also finds that the April 2021 VA medical opinion was based, in part, on an inaccurate factual premise. The April 2021 VA opinion provider stated that a July 2001 Agent Orange registration examination included a diagnosis of tremors with subjective statements of symptoms a few years earlier and that there is "at least a 30[-] year gap between end of service and initial tremor symptoms." During February and May 2013 VA treatment, the Veteran reported tremors for "30+ [years.]" During his April 2019 VA peripheral nerves examination, the Veteran again reported bilateral hand tremor "present since the 1980s (sic)." Accordingly, a new addendum opinion that addresses this earlier onset of bilateral hand tremors must be obtained. 2. Entitlement to service connection for a neurological condition of the feet, to include peripheral neuropathy and restless leg syndrome, is remanded. The January 2021 Board remand requested that an examiner address the Veteran's contention that he noticed symptoms in his feet shortly after returning from his service in Vietnam. The April 2021 VA opinion provider failed to address this contention, necessitating another remand. The Board also notes that the Veteran's VA treatment records appear to include a diagnosis of restless leg syndrome, which has not been addressed thus far. On remand, a VA opinion must be obtained that also addresses the etiology of the Veteran's restless leg syndrome. During the Veteran's March 2018 Board hearing, he testified that he has family members and close friends who could support his statement that the neuropathy or neuropathy-like symptoms started during or shortly after his service in Vietnam. To date, such personal statements have not been submitted. As this claim is being remanded anyway, the Veteran is invited to submit such statements in support of his claim. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. 2. Upon completion of the above, obtain an addendum medical opinion from an appropriate clinician as to the nature and etiology of the Veteran's bilateral essential tremors. Whether an additional physical examination of the Veteran is necessary is left to the examiner's discretion. After a thorough review of the claims file, the examiner should address the following: (a) Does the term "Parkinsonism" include bilateral essential tremors? (b) If "Parkinsonism" does not include bilateral essential tremors, is it at least as likely as not (50 percent probability or greater) that the Veteran's bilateral essential tremors had onset during or were otherwise related to service, to include his conceded exposure to herbicide agents? Although a thorough review of the claim file is required, the examiner's attention is also directed to the Veteran's statements that he had bilateral hand tremors since the 1980s. See February and May 2013 VA treatment records and April 2019 VA peripheral nerves examination. 3. After the development in #1 is complete, obtain an addendum medical opinion from an appropriate clinician as to the nature and etiology of the Veteran's neurological condition of the feet. Whether an additional physical examination of the Veteran is necessary is left to the examiner's discretion. After a thorough review of the claim file, the examiner should address the following: (a) Identify, by diagnosis, all neurological conditions of the feet, to include peripheral neuropathy and restless leg syndrome. (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's bilateral lower extremity peripheral neuropathy had early onset, meaning that symptoms manifested within one year from the last exposure to herbicide agents? In answering this question, the opinion provider is instructed that early-onset peripheral neuropathy refers to signs and symptoms including numbness, tingling, or prickling in the toes or fingers in early stages that may spread to the feet and may cause burning, throbbing, or shooting pain that is worse at night. Other symptoms include pain equally in both feet, muscle weakness, loss of balance or coordination, and extreme sensitivity to touch. Although a thorough review of the claims file is required, the examiner's attention is directed to the following: January 2008 VA treatment record: burning sensation on pads of both feet, first in April 2005; April 2016 VA treatment record: bilateral foot pain and burning for 10 to 15 years; April 2016 VA treatment record: clinical evaluation and Agent Orange history likely point toward sensory neuropathy; March 2018 testimony: Veteran noticed symptoms in his feet shortly after returning from service in the Republic of Vietnam; and April 2018 VA treatment record: neurological symptom of tremor and neuropathy may be caused by Agent Orange exposure. (c) For each disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service, to include conceded exposure to herbicide agents? Although a thorough review of the claims file is required, the examiner's attention is directed to the following: April 2016 VA treatment record: clinical evaluation and Agent Orange history likely point toward sensory neuropathy; April 2018 VA treatment record: neurological symptom of tremor and neuropathy may be caused by Agent Orange exposure; and April 2018 private opinion that neurological symptoms of neuropathy may have been caused by exposure to Agent Orange in the Vietnam War. 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Matta, 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.