Citation Nr: 22015678 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 18-06 560 DATE: March 18, 2022 ORDER Service connection for left hand tremor (focal dystonia) is granted. FINDING OF FACT 1. The Veteran served on active duty in the Southwest Asia theater of operations. 2. The Veteran's left hand tremor is a medically unexplained chronic multisymptom illness (MUCMI) that manifested after his active duty service. CONCLUSION OF LAW The criteria for service connection for left hand tremor (focal dystonia) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1988 to February 1989, April 1990 to January 1994, January 2002 to February 2002, and from February 2003 to March 2004. This matter comes before the Board of Veterans' Appeals (Board) from a September 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, the Veteran testified before a Decision Review Officer (DRO). In April 2021, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. Transcripts are of record. The Board remanded the issue on appeal in July 2021. Service connection for left hand tremor (focal dystonia) is granted. The Veteran seeks service connection for left hand tremor. The Veteran contends his left hand tremor is related to his active service in the Southwest theater of operations or, alternatively, is secondary to his service-connected PTSD. See July 2017 DRO hearing transcript at 3. Service connection may be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that manifested either during active service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). A qualifying chronic disability is a chronic disability that may result from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). 38 C.F.R. § 3.317(a)(2)(i). The term MUCMI refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). A multisymptom illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Stewart v. Wilkie, 30 Vet. App. 383, 389-90 (2018). A multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. Id. The determination of whether a MUCMI is "medically unexplained," that is, the etiology and pathophysiology of the multisymptom illness, must be particular to the claimant's case. Id. at 291. The Veteran's DD Form 214 reflects service in Southwest Asia from May 2003 to February 2004. Therefore, he is considered a Persian Gulf veteran. 38C.F.R. §3.317(e). The Veteran reports experiencing a left hand tremor since shortly after his service in the Southwest theater of operations. The August 2015 VA examination report shows a diagnosis of 'left hand tremor/focal dystonia.' The opinion and rationale appear to indicate the Veteran's left hand tremor is of unknown etiology and that the tremor condition is diagnosable but partially medically unexplained. The opinion is not clear, however, as to whether the pathophysiology of the claimed left hand condition is known. The Board remanded the appeal in July 2021 for clarifying medical opinion as to whether the etiology and pathophysiology of the claimed left hand condition are known. In compliance with the Board's prior remand directives, an addendum examination and opinion were obtained in November 2021. The November 2021 VA examiner opined that the Veteran's left hand tremor was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the earliest the Veteran can recall having the tremor was approximately 2004, which was the year that he ended active duty. He reported that the tremor was mild at onset, and intermittent. The examiner noted that a May 2015 post-service note indicates the Veteran developed the tremor 3-4 years prior, which would have been approximately 2011 or 2012. The examiner indicated that no records prior to 2013 could be located in which the Veteran reported complaints or symptoms regarding a tremor of the left hand. The examiner further noted a July 2005 examination revealed a normal upper extremity and neurological exam. Based on the medical records, the examiner indicated that it appears that the Veteran did not have the tremor during active duty. Next, the examiner indicated that January 2013 imaging of the Veteran's brain with and without contrast was normal. The examiner noted that the Veteran decided to undergo deep brain stimulation (DBS) in March 2017. The examiner explained that stimulator leads were placed in the right frontal area of the brain in an effort to control the tremors of the left hand, which is performed under the assumption that there is abnormal electrical activity of this area of the brain. However, this did not alleviate the tremor. For these reasons, the examiner found that the Veteran's focal dystonia of the left hand with tremor is a diagnosable chronic multi-symptom illness with an inconclusive etiology and partially explained pathophysiology. The examiner acknowledged that the Veteran did have exposure to environmental hazards during service in the Southwest Asia theater of operations, including but not limited to, high levels of sulfur dioxide in the air from burn pits. The examiner explained that exposure to environmental hazards could possibly cause neurological symptoms; however, in this Veteran's case, it would be mere speculation if this is the etiology of the development of his focal left hand dystonia and tremor eight years later. The examiner reasoned that acquired dystonia can be caused by hereditary diseases, certain infections, exposure to certain medications, aging process, cerebrovascular disease exposure to toxins, and genetic mutations. The Veteran's left hand tremor has existed since at least 2013. Thus, it is considered chronic under the regulatory definition. Under Diagnostic Code 8510 for paralysis of the upper radicular group, a 10 percent rating is warranted for mild incomplete paralysis of the upper radicular group. 38 C.F.R. § 4.124a, Diagnostic Code 8510. The record reflects a tremor of the left hand when it is outstretched or during movements. The tremor 'goes away' if the hand is resting on a surface or is supported. The tremor affects his handwriting, ability to eat and drink, grooming, and fine manipulation. Therefore, resolving reasonable doubt in the Veteran's favor, his left hand tremor appears to have has manifested to a degree of at least 10 percent. While the August 2015 and November 2021 VA examiners provided negative nexus opinions, the August 2015 VA examiner noted that the cause of focal dystonia is unknown. The November 2021 VA examiner also found the Veteran's left hand tremor has an inconclusive etiology. As the November 2021 VA examiner found the Veteran's left hand tremor has an inconclusive etiology, the Board finds the Veteran's left hand tremor is considered a MUCMI. 38 C.F.R. § 3.317(a)(7)(i)-(iii). In conclusion, the Board finds that the Veteran is a Persian Gulf War veteran who has a qualifying disability that manifested to a degree of 10 percent or more following service. Therefore, the Veteran has met the criteria necessary for presumptive service connection under 38 C.F.R. § 3.317. Accordingly, service connection for left hand tremor is granted. See 38 C.F.R. §§ 3.102, 3.317; Gilbert v. Derwinski, 1 Vet. App. 9, 55-57 (1990). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.Aoughsten, 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.