Citation Nr: 21041411 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 10-08 657 DATE: July 9, 2021 ORDER Entitlement to service connection for bilateral lower extremity neurological disability, including peripheral neuropathy, is denied. Entitlement to service connection for bilateral upper extremity neurological disability, including carpal tunnel syndrome, is denied. Entitlement to service connection for fibromyalgia is denied. REMANDED Entitlement to service connection for psychiatric disability is remanded. Entitlement to service connection for residuals of a shrapnel wound to the back is remanded. FINDINGS OF FACT 1. The Veteran's bilateral lower extremity neurological disability did not have its onset in service, did not manifest to a compensable degree within the first post-service year, and the disability is not otherwise related to an in-service injury or disease. 2. The Veteran's bilateral upper extremity neurological disability did not have its onset in service, did not manifest to a compensable degree within the first post-service year, and the disability is not otherwise related to an in-service injury or disease. 3. The Veteran's fibromyalgia did not have its onset in service and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral lower extremity neurological disability, including peripheral neuropathy, are not met. 38 U.S.C. §§ 101, 1101 (3), 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6(a), 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for bilateral upper extremity neurological disability, including carpal tunnel syndrome, are not met. 38 U.S.C. §§ 101, 1101 (3), 1110, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6(a), 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for fibromyalgia are not met. 38 U.S.C. §§ 101, 1110, 1131, 5107; 38 C.F.R. §§ 3.6(a), 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1977 to October 1977. He had additional service with the Army National Guard, to include a period of active duty for training (ACDUTRA) from March 1975 to July 1975. These matters initially came before the Board of Veterans' Appeals (Board) from August 2008 and March 2012 rating decisions. In April 2015, the Board remanded these matters to schedule the Veteran for a Board hearing. He testified before the undersigned Veterans Law Judge (VLJ) at an August 2015 hearing and a transcript of the hearing is included in the claims file. In February 2016, the Board granted the Veteran's application to reopen the claim of service connection for fibromyalgia and remanded the underlying claim, as well as the other matters on appeal, for further development. In August 2018 and August 2020, the Board again remanded these matters for further development. In the February 2016, August 2018, and August 2020 remands, the Board instructed the agency of original jurisdiction (AOJ) to ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from St. John's Healthcare System, Hillcrest Medical Group, Indian Health Services, Weleetka Emergency Room, Dr. Khuow, Okmulgee Memorial Hospital, Dr. Brookover, Mayo Clinic, Dr. Calvin, Dr. Edwards, and Oklahoma Spine & Brain Institute), obtain the Veteran's outstanding service treatment and personnel records, obtain his outstanding VA treatment records, obtain any outstanding Social Security Administration (SSA) disability records, take appropriate steps to determine whether there was a chemical spill or contamination at Ft. Leonard Wood in 1975 and whether the Veteran was exposed to toxic chemicals (including herbicides), afford the Veteran a VA examination to determine the nature of his claimed upper and lower extremity neurological disabilities, and obtain medical opinions as to whether such disabilities are related to service. Pursuant to the Board's remand, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from St. John's Healthcare System, Hillcrest Medical Group, Indian Health Services, Weleetka Emergency Room, Dr. Khuow, Okmulgee Memorial Hospital, Dr. Brookover, Mayo Clinic, Dr. Calvin, Dr. Edwards, and Oklahoma Spine & Brain Institute) by way of a January 2017 letter. Copies of the authorization forms (VA Forms 21-4142 and 21-4142a) were included with the letter. Also, all outstanding available service treatment and personnel records, SSA disability records, VA treatment records, and private medical records were obtained and associated with the claims file, the Veteran was afforded a VA neurological examination in April 2017, and medical opinions addressing whether his claimed upper and lower extremity neurological disabilities are related to service were most recently obtained in November 2019. As explained below, the Board finds the November 2019 opinions to be adequate and of substantial probative value. Therefore, the AOJ substantially complied with the Board's pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). "Active military, naval, or air service" includes active duty, any period of ACDUTRA during which the individual concerned was disabled from a disease or injury incurred in the line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. 38 U.S.C. § 101 (21), (24); 38 C.F.R. § 3.6 (a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a) (e.g., organic diseases of the nervous system). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). If a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type 2 diabetes; Hodgkin's disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma); parkinsonism; bladder cancer; and hypothyroidism. 38 U.S.C. § 1116 (a)(2); 38 C.F.R. § 3.309 (e). "Early onset" peripheral neuropathy is defined as peripheral neuropathy that becomes manifest to a degree of 10 percent or more within one year after the Veteran's last in-service exposure to herbicide agents. 38 C.F.R. § 3.307 (a)(6)(ii). Although service connection on any of the presumptive bases noted above may not be established, a veteran is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). Entitlement to service connection for bilateral lower extremity neurological disability (including peripheral neuropathy), bilateral upper extremity neurological disability (including carpal tunnel syndrome), and fibromyalgia At the outset, the Board notes that the Veteran has not been afforded a VA examination for his claimed fibromyalgia, and an opinion as to the etiology of this disability has not otherwise been obtained. VA is obliged to provide an examination or obtain a medical opinion in a claim for service connection when the record contains competent evidence that the claimant has current disability or persistent or recurrent symptoms of disability, the record indicates that the disability or symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. A claimant's reports of a continuity of symptomatology can satisfy the requirement for evidence that the claimed disability may be related to service. McLendon, 20 Vet. App. at 83. The types of evidence that "indicate" that current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. There must, however, be sufficient evidence of such a relationship to trigger VA's duty to provide an examination or obtain a medical opinion. Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). A conclusory generalized lay statement suggesting a nexus between current disability and service is not sufficient, as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Id. at 1278-1279. In this case, there is no credible evidence that the Veteran's current fibromyalgia may be associated with service. As explained below, there is no credible evidence of a continuity of symptomatology with respect to this claimed disability and there is no other competent evidence that the current fibromyalgia may be related to service, and neither the Veteran nor his representative has alluded to the existence of any such evidence. Hence, a VA examination or opinion for the claimed fibromyalgia is not necessary. See McLendon, 20 Vet. App. at 83. The Veteran contends that he has current bilateral lower and upper extremity neurological disabilities (including peripheral neuropathy and carpal tunnel syndrome) and fibromyalgia, and that these disabilities are all caused by his exposure to various chemicals in service. The question for the Board is whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board finds, for the following reasons, that, while there is evidence that the Veteran has current bilateral lower and upper extremity neurological disabilities and fibromyalgia and that he was potentially exposed to various toxic chemicals in service, the claimed disabilities are not shown to have had their onset in service or within the first post-service year, or to be otherwise related to a disease or injury in service. Medical records, including an October 2011 VA primary care treatment note, an August 2012 examination report from M.J. Calvin, M.D., and the report of an April 2017 VA neurological examination, reveal that the Veteran experiences bilateral peripheral neuropathy of the upper and lower extremities, bilateral carpal tunnel syndrome, and fibromyalgia. Thus, current bilateral neurological disability of the upper and lower extremities and fibromyalgia have been demonstrated. The Veteran contends that his claimed neurological disabilities and fibromyalgia are related to his exposure to various toxic chemicals in service. In particular, he has reported that he was exposed to various chemicals (including possible herbicide agents, such as Agent Orange) when he was stationed at Fort Leonard Wood during a major flood in 1975. He has also suggested such exposure while performing other general duties during service, including transferring and moving barrels containing toxic waste. Numerous attempts have been made to confirm this flood event and the Veteran's exposure to chemicals during service, but no such confirmation has been obtained. Nevertheless, the Veteran's service personnel records indicate that he was stationed at Fort Leonard Wood during service (to include in 1975), he submitted statements from fellow service members dated in September 2012 who confirm that a significant flood event occurred at Fort Leonard Wood in the Spring of 1975, and his representative has submitted news articles and other evidence documenting a severe weather event in the area of Fort Leonard Wood in 1975. The Veteran is competent to report potential exposure to toxic chemicals during a flood in service. See Jandreau, 492 F.3d 1372; Buchanan, 451 F.3d at 1337. Moreover, there is nothing to explicitly contradict his reports, fellow service members have confirmed a flood at Fort Leonard Wood in 1975, and the Veteran's reports are consistent with the evidence of record and the circumstances of his service. Therefore, the Veteran's reports of potential exposure to various toxic chemicals in service during a flood are credible. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.303 (a). Regardless, even if it assumed that he was exposed to such chemicals in service, his claims must nevertheless be denied, as explained below. With respect to the Veteran's contention that his claimed disabilities are related to chemical exposures from a flood during his period of ACDUTRA from March 1975 to July 1975, the Board points out that a claimant whose claim is based on a period of ACDUTRA or INACDUTRA can never be entitled to a "presumption of service connection" with respect to that period of service. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Such a presumption is not possible in such circumstances because, by definition, the presumption of service connection applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. With regard to a claimant whose claim is based on a period of ACDUTRA or INACDUTRA, however, there must be some evidence that the condition was incurred or aggravated during the relevant period of service. Id. Hence, presumptive service connection for the Veteran's claimed disabilities is not warranted under any circumstance (to include under the provisions pertaining to chronic diseases (such as organic diseases of the nervous system) and herbicide agents (such as Agent Orange)) with respect to his period of ACDUTRA. Id. Rather, in order for service connection to be warranted on the basis of this period of service under the circumstances of this case, there must be direct evidence that the Veteran's disabilities were incurred during this period. The Veteran has suggested on several occasions that he began to experience symptoms associated with his claimed upper and lower extremity neurological disabilities and fibromyalgia immediately following his exposure to chemicals during service in 1975 and that he has continued to experience such symptoms in the years since service. He is competent to report the history of his claimed bilateral upper and lower extremity neurological disabilities and fibromyalgia (including a continuity of symptomatology in the years since service). However, his reports must be weighed against the other evidence of record and their credibility must be assessed. See Jandreau, 492 F.3d at 1377; see also Buchanan, 451 F.3d at 1337. There is no evidence of any complaints of or treatment for neurological or fibromyalgia symptoms in the Veteran's service treatment records and his July 1975 and October 1977 separation examinations were normal other than for scarring. Also, the earliest clinical evidence of possible neurological disability is a January 1989 treatment record from Henryetta Medical Center which reveals that the Veteran was diagnosed as having rule out intracranial lesion and demyelinating disease. The earliest clinical evidence of possible fibromyalgia is a December 2005 VA urgent care note, which reveals that the Veteran reported that he had been experienced generalized pain "all over" for approximately 1 year, and that the pain had worsened during the previous 6 months. He was diagnosed as having arthralgia. The Board acknowledges that there is lay evidence of earlier neurological disability and fibromyalgia symptoms in that the Veteran has alluded to a continuity of symptomatology in the years since service. As explained below, however, the Board finds that the Veteran's reports as to the history of his claimed neurological disabilities and fibromyalgia (to include his reports of a continuity of symptomatology in the years since service) are not credible. The absence of any clinical evidence of neurological disability or fibromyalgia for at least a decade after the Veteran's separation from active service in October 1977, along with the inconsistent statements noted below, is one factor weighing against a finding that his current bilateral neurological disability of the upper and lower extremities and fibromyalgia were present during any period of active service or in the year or years immediately after any period of active service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue)." Moreover, the Veteran has provided information and statements which are inconsistent with his reports of a continuity of neurological disability and fibromyalgia symptomatology in the years since service. As explained above, he has suggested that his bilateral neurological disability of the upper and lower extremities and fibromyalgia had their onset following chemical exposures from a flood during his period of ACDUTRA from March 1975 to July 1975 and that he has experienced continuous neurological and fibromyalgia symptoms in the years since service. However, he reported on report of medical history forms completed for purposes of separation from service dated in July 1975 and October 1977 that he was neither experiencing, nor had he ever experienced, any swollen or painful joints, arthritis/rheumatism/bursitis, neuritis, paralysis, or any other neurological, joint, or muscle problems. He reported during the December 2005 VA urgent care evaluation that he had been experiencing generalized pain "all over" for approximately 1 year. He reported during a February 2006 VA primary care evaluation that he had been experiencing aches in his joints (including hands and elbows) for one year. Also, he reported during an October 2019 VA psychiatric examination that he "started developing neuropathy in 1989. . . ." In light of the fact that there is no evidence of any complaints of or treatment for neurological or fibromyalgia symptoms in the Veteran's service treatment records, the fact that his July 1975 and October 1977 separation examinations were normal other than for scarring, the absence of any clinical evidence of neurological or fibromyalgia problems for at least a decade following his separation from service in October 1977, and the information and statements provided by the Veteran that are inconsistent with his reports of a continuity of neurological and fibromyalgia symptomatology in the years since service, the Board concludes that his reports concerning the history of his claimed bilateral neurological disability of the upper and lower extremities and fibromyalgia (including any reports of a continuity of symptomatology in the years since service) are not credible. In addition, the preponderance of the competent, probative opinions on whether there is a relationship between the Veteran's current bilateral neurological disability of the upper and lower extremities and fibromyalgia and service weigh against the claims. In the August 2012 examination report, Dr. Calvin noted that the Veteran's peripheral neuropathy was related to toxic exposure in service. There was no further explanation or rationale provided for this opinion. The physician who conducted the October 2012 VA neurological examination opined that the Veteran's claimed neurological disability was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. He reasoned that it was not likely ("less likely than not") that the Veteran's symptoms were caused by a peripheral neuropathy associated with exposure to toxic material during a storm cleanup at Fort Leonard Wood in 1975. Rather, it was more likely than not that his symptoms were associated with arthralgias and the aging process, both of which are common occurrences in the general population. He did not seem to have a peripheral neuropathy at the time of the October 2012 examination. He had an entrapment neuropathy (carpal tunnel and ulnar nerve), but that had resolved with surgery (as shown by EMG). There was no evidence that the Veteran was exposed to any type of toxic substance (much less Agent Orange), during the storm cleanup, and he agreed that he could not cite to a single instance of exposure, beyond vague suspicions, that it could have happened. While his constellation of symptoms suggested many diseases (but were indicative of none), he had so many joint symptoms that it was more likely than not arthralgias and the normal aging process. It was telling that the symptoms did not occur until many years later, when these symptoms would be expected in his age group. In May 2017, a VA physician assistant reviewed the Veteran's claims file and opined that his claimed bilateral neurological disability of the upper and lower extremities was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. He reasoned that the Veteran's claim for upper and lower extremity neuropathic conditions was not supported by the evidence of record and that medical literature supports that peripheral neuropathy from neurotoxic exposure will occur acutely and in some cases continue chronically. The evidence of record supports that the symptom constellation reported by the Veteran occurred many years removed from the reported exposure event, and were more likely than not attributable to conditions unrelated to a potential exposure event. There is insufficient evidence for a reasonable and prudent clinician to establish a clinical correlation or causal nexus. Also, the claims file lacked objective medical evidence to confirm diagnosis or treatment for bilateral upper extremity nerve injury/carpal tunnel syndrome during service and there was a 30+ year gap from 1975 to 2006 with no chronicity of care. Overall, a nexus was not established. In October 2017, a VA physician assistant reviewed the Veteran's claims file and opined that his claimed bilateral neurological disability of the upper and lower extremities was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. He reasoned that despite Dr. Calvin's assessment in 2012 that the Veteran's peripheral neuropathy was related to toxic exposure in service, the medical literature supported that peripheral neuropathy from neurotoxic exposure will occur acutely and, in some cases, chronically. The evidence of record supported that the symptom constellation reported by the Veteran occurred many years removed from the reported exposure event and was more likely than not attributable to conditions unrelated to a potential exposure event. There was insufficient evidence for a reasonable and prudent clinician to establish a clinical correlation or causal nexus. In November 2019, a VA nurse practitioner reviewed the Veteran's claims file and opined that his claimed carpal tunnel syndrome was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. She reasoned that there was no objective evidence of a chronic carpal tunnel syndrome condition or complaints during active duty, the Veteran's July 1975 separation examination was silent for complaints, and the entrance and separation examinations for the next period of active service were also silent for carpal tunnel syndrome. Carpal tunnel syndrome was not diagnosed until approximately 2006, which was well after active duty. Also, carpal tunnel syndrome is a repetitive motion injury. Given the Veteran's short time on active duty, it was highly unlikely that carpal tunnel syndrome was able to develop in such a short time. This is true given the evidence of record from his separation examinations, and the fact that the Veteran worked on pipeline construction after active duty. Overall, a nexus was not established to active duty or activities of active duty, and the Veteran's claimed disability was not caused by or related to active duty. The VA nurse practitioner explained in a second November 2019 opinion that the Veteran's claimed bilateral neurological disability of the upper and lower extremities was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. She reasoned that a note from Dr. Edwards referenced neck, mid back, low back, and knee pain. This was most consistent with cervical and lumbar pain and radiculopathy (which is not referenced in notes, but diagnosed as moderate to severe less than 2 years later). There was no evidence of toxic chemical exposure, an EMG showed no evidence of demyelinating disease (i.e., chronic inflammatory demyelinating neuropathy), and EMGs over the years showed carpal tunnel and cubital tunnel syndromes, cervical radiculopathy, and lumbar radiculopathy. These conditions have a clear diagnosis and etiology, and are in no way related to a toxic chemical exposure. Carpal tunnel syndrome is due to repetitive motion to the wrist area, causing compression of the median nerve. Cubital tunnel syndrome occurs as a result of repetitive motion to the elbows (when pulling, reaching, or lifting), leaning on the elbow a lot, or sustaining injury to the area. Cervical/lumbar radiculopathy is due to compression of the nerve root by arthritis in the lumbar or cervical spine, and no nexus to a chemical exposure exists. Also, a July 2007 note indicated multiple car accidents and an assault with an iron poker/head injury 3 to 5 years in the past, all of which complicated peripheral neuropathy complaints. Dr. Calvin's August 2012 opinion is of limited probative value because it is not accompanied by any explanation or rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The October 2012, May 2017, and October 2017 opinions are also of little probative value because they are partially based on an inaccurate finding that the Veteran did not have peripheral neuropathy and that he was not treated for any neurological symptoms until approximately 2006. These opinions did not reflect consideration of Dr. Calvin's August 2012 opinion or the fact that the Veteran was evaluated for demyelinating disease in January 1989. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely"). The November 2019 opinions do not explicitly acknowledge or discuss the Veteran's reports of a continuity of neurological disability symptomatology in the years since service. However, as explained above, any reports of a continuity of symptomatology are not deemed to be credible and an opinion based on such an inaccurate history would be inadequate. Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2006) (it is appropriate for the Board to find a medical opinion inadequate when it relies on lay statements that the Board has found not credible). Moreover, the November 2019 opinions are based upon a review of the Veteran's treatment records and consideration of his reported history, and they are accompanied by specific rationales that are consistent with the evidence of record. Therefore, the November 2019 opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Additionally, lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the dispositive question presented in this case (i.e., whether any relationship exists between the Veteran's bilateral upper and lower extremity neurological disability and fibromyalgia and service, to include chemical exposures) is a question as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). An opinion as to whether there is a link between the Veteran's claimed disabilities and his potential chemical exposures in service (where there is no credible evidence of any neurological disability or fibromyalgia for at least a decade following his separation from service) is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. Moreover, the Board has also considered the medical/scientific literature that has been submitted in this case. Medical article and treatise evidence may suffice to establish nexus in instances where "standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion." Sacks v. West, 11 Vet. App. 314, 317 (1998). However, treatise materials are generally not specific enough to show nexus. Id. Moreover, medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993) (noting that medical opinions directed at specific patients generally are more probative than medical treatises). The medical/scientific literature submitted in this case discusses general information pertaining to chronic inflammatory demyelinating polyneuropathy and the peripheral nervous system and the potential causes of peripheral neuropathy, but the probative weight of this general material is outweighed by the specific, reasoned opinions of the medical professional who provided the November 2019 opinions, which considered all evidence of record along with the specific facts of the Veteran's case. There is no other evidence of a relationship between the Veteran's bilateral neurological disability of the upper and lower extremities and fibromyalgia and service, and neither he nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's claimed disabilities had their onset during any period of active service, had their onset within the first post-service year following his October 1977 separation from service, or that they are otherwise related to service. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt doctrine is not for application, and service connection for bilateral upper and lower extremity neurological disability and fibromyalgia is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for psychiatric disability and residuals of a shrapnel wound to the back are remanded. The Board finds that it is necessary to obtain an adequate medical opinion as to whether the Veteran's claimed psychiatric disability is related to service and to obtain outstanding treatment records. In the August 2020 remand, the Board instructed the AOJ to obtain a medical opinion that addressed whether the Veteran's claimed psychiatric disability began during service or is otherwise related to service. The opinion provider was to acknowledge and discuss the Veteran's service personnel records showing that he was absent without leave (AWOL) on a number of occasions during service, a September 1976 National Guard record showing a referral for a psychiatric evaluation, and a September 2009 VA mental health treatment record showing that the Veteran reported receiving treatment for depression through the Indian Health Service in the 1970s and subsequently taking Valium and an antidepressant for over a year. Pursuant to the Board's remand, a VA psychologist reviewed the Veteran's claims file in October 2020 and opined that his claimed psychiatric disability was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. However, the only rationale provided for this opinion was that the Veteran's depressive symptoms appeared to be secondary to his non service-connected medical conditions, specifically neuropathy. The psychologist did not provide any further explanation or reasoning and did not at all acknowledge or discuss the evidence of potential psychiatric problems experienced by the Veteran around the time of his active service, as noted above. Therefore, another remand of the issue of entitlement to service connection for psychiatric disability is required for compliance with the Board's August 2020 remand instructions. Stegall, 11 Vet. App. at 268. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the Muskogee Vista electronic records system and are dated to August 2020. Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance); see also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. Lastly, as the record currently stands, there is no evidence of any current residual of a shrapnel wound to the back. As additional treatment records are being sought upon remand which may document evidence of such disability, the claim of service connection for residuals of a shrapnel wound to the back is being remanded, as well. The matters are REMANDED for the following action: 1. Obtain all of the VA treatment records for the Veteran dated from August 2020 to the present. 2. Obtain an opinion from an appropriate clinician regarding whether it is at least as likely as not (50 percent probability or more) that any psychiatric disability experienced by the Veteran since approximately January 2008 began in service, was caused by service, or is otherwise related to service, to include his reported chemical exposures during a flood in the Spring of 1975. (Continued on the next page) The clinician must provide reasons for each opinion given. In this regard, the clinician should acknowledge and discuss the potential significance of: (a) service personnel records showing that the Veteran was AWOL on a number of occasions during active service; (b) a September 1976 National Guard record showing a referral for a psychiatric evaluation after the Veteran stated that he "wants out before 'something bad happens'"; and (c) a September 2009 VA mental health treatment record showing that the Veteran reported receiving treatment for depression through the Indian Health Service in the 1970s and subsequently taking Valium and an antidepressant for over a year. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.