Citation Nr: 21031446 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-34 746 DATE: May 21, 2021 REMANDED Entitlement to service connection for a disability manifest by hand tremors, to include Parkinson's disease, is remanded. REASONS FOR REMAND The appellant is a Veteran who had active service from April 1980 to October 1980. This matter is before the Board on appeal from a May 2015 rating decision. In March 2020, a hearing in the matter was held before the undersigned; a transcript is in the Veteran's claims file. In December 2020, the case was remanded for further development. The Board regrets the further delay inherent with another remand, but, finds that the December 2020 remand instructions were not adequately fulfilled. See Stegall v. West, 11 Vet. App. 268 (1998). The December 2020 Board remand noted that a June 2016 VA opinion was inadequate for rating purposes because it did not adequately address whether a chronic disability, such as a tremor, became manifest in service. Service treatment records (STRs) note the Veteran's reports of tremors and leg numbness in service; a tremor-manifested disability was not noted on service induction examination, and the Veteran is presumed sound on entry to service. While the examiner mentioned some evidence indicating the condition may have preceded service, such observation is insufficient to rebut the presumption of soundness. In the January 2021 VA opinion received in response to the remand, the provider opined that the Veteran's tremor was less likely than not incurred in or caused by his service. He explained that a review of the pertinent evidence "did not reveal any evidence of in-service injury, event, or illness that could have resulted in the claimed tremor." He also indicated that gas chamber training, with agents such as tear gas or CS gas, has not been shown or linked to tremors or any secondary cause of tremors by any medical literature. The provider noted diagnoses of Parkinson's disease, type 2 diabetes mellitus with neuropathy and tremor and indicated that medical literature has established that nerve damage and neurological disease can cause tremors that can affect the hands and feet. He further opined that the most likely etiology for the tremor was essential tremor and indicated that an article on the Johns Hopkins website entitled Essential Tremor Disorder (2021), notes that essential tremor is the most common trembling disorder and that the cause is unknown, though there is a working theory about the cerebellum not communicating with other parts of the brain. The Board finds that the January 2021 opinion is inadequate because, although the provider explained that gas chamber training has not been shown or linked to tremors or any secondary cause of tremors by any medical literature, he did not consider the Veteran's reports of, and treatment for, tremors in the STRs. Additionally, the rationale regarding the most likely etiology for the tremor (that essential tremor is the most common trembling disorder) is cursory, and the explanation that nerve damage and neurological disease can cause tremors is speculative. Therefore, remand is necessary to obtain an adequate medical advisory opinion regarding the etiology of the Veteran's disability manifested by hand tremors claim. The matter is REMANDED for the following: 1. Arrange for the Veteran's claims file (electronic record) to be forwarded to an appropriate clinician (in neurology if possible) other than the January 2021 provider for review and an addendum medical advisory opinion regarding the nature and likely etiology of the claimed disability. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The consulting provider is asked to respond to: (a) Identify any (and each) chronic disability manifested by tremors shown by the record during the pendency of this claim by diagnosis (to include essential tremor). [If a diagnosis of Parkinson's Disease is noted other than by reported medical history, identify the clinical data in the record to support the diagnosis.] (b) Identify the most likely etiology for each such disability entity diagnosed. Specifically, is it at least as likely as not (a 50 % or greater probability) that the disability was incurred in service. The rationale provided must acknowledge the Veteran's reports of related symptoms noted in his STRs (i.e. July and August 1980 reports of hand tremors), and should also address his contention that such disability resulting from gas chamber training during basic training. Specifically regarding the diagnosis of essential tremor, discuss (noting the presumption of soundness on entry in service with respect to such disability) whether it had its onset in service. (c) If an opinion given is premised on a finding that a tremor disability pre-existed service (as possibly suggested by the June 2016 examiner), indicate whether there is evidence in the record that renders it undebatable from a medical standpoint that the disability pre-existed service, and if so, identify such evidence. (d) If clear and unmistakable evidence of service pre-existence of a diagnosed tremor-manifested disability is identified, opine further whether there is clear and unmistakable evidence that such disability did not increase in severity (beyond natural progression) during service, and if so, identify such evidence. (e) If a currently diagnosed tremor-manifested disability was not manifested in service, opine whether it at least as likely as not is etiologically related to the Veteran's service (to include his noted complaints of tremors and gas chamber training, as alleged, therein). (f) If a currently diagnosed tremor-manifested disability is determined to not etiologically related to service, identify the etiology for the disability that is considered to be more likely, and explain why that is so. All opinions should include complete explanation of rationale, with citation to supporting factual data and medical principles (as deemed appropriate). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bayles, 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.