Citation Nr: 23026331 Decision Date: 05/05/23 Archive Date: 05/05/23 DOCKET NO. 19-14 424 DATE: May 5, 2023 REMANDED Entitlement to service connection for tremors, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1996 to November 2000 and from November 2002 to August 2010. However, in a September 2018 administrative decision, the RO found that his period of service from November 5, 2005, to August 13, 2010, is considered other than honorable for VA purposes and is a bar to VA benefits under the provisions of 38 CFR 3.12(d)(4). The Veteran did not appeal that determination. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2019 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Upon review, the Board finds that additional development is needed prior to adjudication of the issue on appeal. Initially, the Board notes that the Veteran submitted records from the Army Discharge Review Board (ADRB) in November 2019. Specifically, the ADRB denied the request for a change in the character of discharge and/or reason for discharge, but found that block 24 on the DD Form 214 for the character of discharged contained an error and should be administratively corrected to general under honorable conditions. It does not appear that the agency of original jurisdiction (AOJ) has reviewed such evidence or taken any other action. Therefore, the case must be remanded. The Veteran was also afforded VA examinations in October 2018 and January 2019 during which the examiner diagnosed him with myoclonus and essential tremors. After reviewing medical literature, he indicated that the Veteran's myoclonus would appear to be part of the diagnosis of essential tremor. The examiner found that Veteran was noted as having the onset of symptoms during a July 2009 post-deployment examination and that myoclonus would be considered a progression of the condition. He also noted that the medical literature shows that PTSD, anxiety, and depression are the most common psychiatric diagnoses in patients with an essential tremor, but that there is no information indicating that mental health conditions are directly causal of essential tremors. The examiner commented that the mechanism of essential tremors remains unknown according to the medical literature. He also stated that it is clear that the Veteran's essential tremor and myoclonus are not exposure-related conditions due to Gulf War service because they are both diseases with a clear and specific etiology. The examiner stated that it remains possible, but is not at least as likely as not that his essential tremor and myoclonus would be secondary to his service-connected PTSD due to lack of medical evidence. Nevertheless, the Board notes that the VA examiner made inconsistent statements. In particular, he stated that that the mechanism of essential tremors remains unknown, yet then found that the Veteran's essential tremor and myoclonus are not exposure-related conditions due to Gulf War service because they are both diseases with a clear and specific etiology. In addition, the examiner did not address whether the Veteran's service-connected PTSD may have worsened his tremors. Spicer v. McDonough, No. 2022-1239, 2023 U.S. App. LEXIS 5470 (Fed. Cir. Mar. 8, 2023) (holding that, under the causation standard of 38 U.S.C. § 1110, secondary service connection is warranted where a nonservice-connected disability would have been less severe but-for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability). Therefore, the Board finds that an additional medical opinion is needed to determine the etiology of any tremors that may be present. In remanding this matter, the Board notes that the Veteran submitted a June 2019 private medical opinion from Dr. C.M. (initials used to protect privacy) stating that his tremor is worsened by his PTSD. However, Dr. C.M. did not provide a rationale for his opinion. The matters are REMANDED for the following action: 1. The AOJ should review the records submitted by the Veteran in November 2019 regarding a decision made by the Army Discharge Review Board (ADRB) and take any action necessary. It should be noted that the ADRB denied the request for a change in the character of discharge and/or reason for discharge, but found that block 24 on the DD Form 214 for the character of discharge contained an error and should be administratively corrected to general under honorable conditions. 2. After completing the foregoing actions, the AOJ should obtain a VA medical opinion to determine the etiology of the Veteran's tremors. A physical examination is only needed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether the Veteran has tremors that are related to his military service, to include any symptomatology or exposures therein. The examiner should also opine as to whether the Veteran's tremors are caused by or resulted from his service-connected PTSD. He or she should address whether the tremors would have been less severe but-for his service-connected PTSD, to include any worsening of functionality. See June 2019 medical opinion from Dr. C.M. A clear rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should ensure compliance with the prior directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.W. Neiman 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.