TIC DOULOUREUX OR TRIGEMINAL NEURALGIA

Summary

The Veteran, a Veteran who served from May 1966 to May 1970, including service in Vietnam, appeals the denial of service connection for essential tremors, claimed as Parkinson's-like symptoms. The Veteran contends his tremors are related to his service, particularly his Vietnam service and conceded exposure to herbicide agents. To establish service connection, a claimant generally needs evidence of a current disability, an in-service event or injury, and a nexus linking the two. The Board found that while the Veteran has essential tremors and was exposed to herbicides, the evidence did not support a link to service. The Veteran's service treatment records were silent regarding tremors. A July 2018 neurology consult noted essential tremors were not associated with Agent Orange exposure. A subsequent October 2021 VA examination diagnosed essential tremors, dating back to 2016, and found no Parkinson's disease. The examiner opined that the Veteran's insomnia was likely due to hip surgery pain, and his urinary incontinence and sexual dysfunction were due to prostate cancer. The Board found the VA examiner's opinion probative, noting the diagnosis of essential tremors and the lack of association with Agent Orange exposure. While Parkinson's disease is a presumptive condition for herbicide exposure, essential tremors are not. The Board concluded that the evidence weighed against a direct or presumptive service connection, and VA's duty to obtain a medical opinion was not triggered as no competent evidence suggested a link between the Veteran's herbicide exposure and his tremors. Service connection for essential tremors was denied.

Rationale

Service treatment records silent for tremors.; Neurologist opined essential tremors not associated with Agent Orange.; VA examiner diagnosed essential tremors, not Parkinson's disease.; Evidence weighs against direct or presumptive service connection.

Full Decision Text

Citation Nr: A22017545
Decision Date: 08/31/22	Archive Date: 08/31/22

DOCKET NO. 220810-266577
DATE: August 31, 2022

ORDER

Entitlement to service connection for essential tremor (claimed as Parkinson's like symptoms) is denied.

FINDING OF FACT

The competent and persuasive evidence does not support the Veteran's essential tremors are causally related to his service.

CONCLUSION OF LAW

The criteria for entitlement to service connection for essential tremor (claimed as Parkinson's like symptoms) have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.309.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from May 1966 to May 1970, to include service in the Republic of Vietnam.

The Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA) was signed into law on August 23, 2017. The AMA creates a new framework for Veterans dissatisfied with VA's decision on their claim to seek review. This decision has been written consistent with the AMA framework.

The Veteran's claim was denied in an August 2022 rating decision. The Veteran appealed that decision directly to the Board and chose the Direct docket. See August 2022 VA Form 10182. Therefore, the Board can only review evidence that was part of the record as of the August 2022 rating decision.

Entitlement to service connection for essential tremor, claimed as Parkinson's like symptoms

The Veteran contends that his essential tremors are related to his service, to include during his service in Vietnam.

Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999).

The Board concludes that, while the Veteran was diagnosed with essential tremors, the persuasive evidence of record is against finding that the disabilities began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, is presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307 (a)(6)(iii).

Certain diseases associated with exposure to certain herbicide agents used in support of military operations in Vietnam during the Vietnam era will be considered to have been incurred in service. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.307(a)(6). The presumption of service connection requires exposure to an herbicidal agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii).

The evidence confirms that the Veteran served in Vietnam and is presumed to have been exposed to herbicide agents. 

In the August 2022 rating decision, the AOJ made the following favorable findings: that the Veteran had been exposed to Agent Orange during service, he had a confirmed diagnosis of essential tremors and he had sufficient service the meet the minimum requirements for presumptive service connection. The AOJ further found that the Veteran's claimed condition meets the requirement for presumptive service connection. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). However, the Board also notes that a "claimed condition" is different than a medically "diagnosed condition."

The Veteran's service treatment records (STRs), to include entrance and separation examinations are silent
 is presumed to have been exposed to herbicide agents. 

In the August 2022 rating decision, the AOJ made the following favorable findings: that the Veteran had been exposed to Agent Orange during service, he had a confirmed diagnosis of essential tremors and he had sufficient service the meet the minimum requirements for presumptive service connection. The AOJ further found that the Veteran's claimed condition meets the requirement for presumptive service connection. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). However, the Board also notes that a "claimed condition" is different than a medically "diagnosed condition."

The Veteran's service treatment records (STRs), to include entrance and separation examinations are silent for any complaints, diagnoses or treatment for tremors or any other neurological manifestations.

In July 2018, VA treatment records document a neurology consult regarding the Veteran's tremors. The neurologist stated that an essential tremors diagnosis had not been associated with Agent Orange exposure. The neurology consult documented the Veteran's diagnosis as intention tremors as of November 2016. The Veteran had a neurology consult in May 2021, where he was again diagnosed with essential tremors. 

The Veteran was given a VA examination in October 2021. The examiner reported that the Veteran was not diagnosed with Parkinson's disease. The examiner further stated that the Veteran has a diagnosis of essential tremors which date back to 2016. Although, the Veteran reported an increase in tremors this year, his 2021 neurology consult endorsed essential tremors, for which he could increase propranolol if desired, and start using hand weights. The examiner also opined that the Veteran's reports of insomnia could be due to surgical pain from his hip; his urinary incontinence and sexual dysfunction are due to his prostate cancer and prostatectomy. The Veteran reported to the October 2021 VA examiner that he has occasional difficulty swallowing large pills, but no difficulty with chewing or swallowing on a regular basis. The Veteran also reported having difficulty writing and carrying dishes and glasses due to his essential tremors. The Veteran did endorse any mental manifestations associated with Parkinson's disease. The Veteran had a steady gait with use of a walker that is associated with soreness to his right hip after recent hip surgery. 

After review of the evidence of record, the Board finds that the evidence weighs persuasively against a finding that the Veteran's tremors are due to his period of service on a direct or presumptive basis. The Board finds probative the findings of the October 2021 examiner that the Veteran did not diagnosis the Veteran with Parkinson's disease or Parkinsonism. Rather, the examiner provided a diagnosis of essential tremors. These findings are probative as they are based upon a through examination of the Veteran, interview of the Veteran regarding his symptoms and a review of his medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). 

While Parkinson's disease is listed a disease that warrants presumptive service connection, essential tremors are not among the diseases for which presumptive service connection is warranted based on that exposure. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). As such, service connection is not warranted for the Veteran's tremors on a presumptive basis. However, the Veteran is not precluded from establishing service connection with proof of direct causation between the Veteran's herbicide exposure and his essential tremors. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994).

Unfortunately, none of the competent evidence of record supports a relationship between the Veteran's in-service exposure to herbicide agents and his current disability. The Board notes that the medical records associated with the claims file do not report such a link. Rather, the 2018 neurologist informed the Veteran that essential tremors had not been associated with exposure to Agent Orange. 

The Board considered the Veteran's statements that his tremors are Parkinson like. Although lay persons are competent to provide opinions on some medical issues, the diagnosis and etiology of tremors is outside the realm of common knowledge of a lay person because it involves complex medical issues that go beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

The Board acknowledges that a medical opinion regarding whether the Veteran's essential tremors were directly related to his conceded exposure to herbicide agents was not obtained; however, the Board finds that the evidence of record did not trigger VA's duty to obtain such an opinion. VA must provide a medical
 competent to provide opinions on some medical issues, the diagnosis and etiology of tremors is outside the realm of common knowledge of a lay person because it involves complex medical issues that go beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

The Board acknowledges that a medical opinion regarding whether the Veteran's essential tremors were directly related to his conceded exposure to herbicide agents was not obtained; however, the Board finds that the evidence of record did not trigger VA's duty to obtain such an opinion. VA must provide a medical examination or opinion when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with a veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA Secretary to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 5103A (d). While the Veteran has a current diagnosis of essential tremors and conceded exposure to herbicide agents during active service, none of the competent evidence of record, even potentially, supports an etiological relationship between the Veteran's in-service exposure and his current disability. Specifically, the Board notes that the July 2018 neurologist did not indicate any relationship between the Veteran's essential tremors and his Agent Orange exposure. Further, the Veteran has not provided any other evidence of such a relationship beyond his own lay statements. The Veteran's conclusory lay statements that the Veteran's essential tremors are due to his exposure to herbicide agents is insufficient to require an examination. The Board finds that the low threshold set forth in McLendon was not satisfied and VA was not required to obtain a medical opinion regarding whether the Veteran's condition was due to his exposure to herbicides on a direct basis. 

Accordingly, as the persuasive evidence of record is against the claim, service connection for essential tremors, on a direct or presumptive basis, is denied. Thus, the benefit of the doubt doctrine is not for application. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

 

 

Patrick M. Johnson

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. G. Perkins, 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.