TREMOR

Summary

The Veteran, a Veteran who served from December 1974 to December 1977, appeals the denial of service connection for essential tremor. The Veteran contends that his essential tremor is due to exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS) during service at Fort Devens. The agency of original jurisdiction conceded toxic exposure risk activity (TERA) based on PFAS exposure. Service treatment records were silent regarding complaints, treatment, or diagnosis of essential tremor. A private medical opinion from April 2024 suggested a link between PFAS exposure and neurological effects impacting motor control, opining it was more likely than not related to service. Conversely, two VA examinations in October 2024 and November 2025 found less likelihood of a service connection, citing a lack of medical literature associating PFAS with essential tremors and noting the condition is largely genetic. The Veteran's spouse provided a statement in November 2025, noting the diagnosis in 2016 and its progression. The Board found the evidence in equipoise due to conflicting medical opinions, with the private opinion citing neurological effects of PFAS and the VA opinions citing a lack of association in medical literature. Applying the benefit of the doubt, service connection for essential tremor was granted.

Rationale

Conflicting medical opinions regarding nexus to service; Private opinion found PFAS exposure more likely than not related to tremor; VA opinions found no known association between PFAS and essential tremor; Service treatment records were silent

Full Decision Text

Citation Nr: A26039939
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 260217-643784
DATE: April 29, 2026

ORDER

Entitlement to service connection for essential tremor is granted.

FINDING OF FACT

Resolving reasonable doubt in favor of the Veteran, his essential tremor is etiologically related to his active service.

CONCLUSION OF LAW

The criteria for service connection for essential tremor have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from December 1974 to December 1977.

In November 2025, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of entitlement to service connection for essential tremor most recently addressed in a November 2024 rating decision. In January 2026, the agency of original jurisdiction (AOJ) issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision. 

In the February 2026 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the January 2026 AOJ decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

Generally, the Board may not decide an appeal before the deadline for requesting an AMA docket switch has elapsed. 38 C.F.R. § 20.202(c)(2) allows appellants to switch AMA dockets by completing and submitting a new VA Form 10182 within 60 days from when the Board receives the original VA Form 10182, or one year from the date the AOJ mails notice of the decision on appeal, whichever is later, unless (1) an appellant has already submitted evidence or testimony as described in 38 C.F.R. §§ 20.302 and 20.303, or (2) the appellant or representative has requested a waiver of the ability to request to switch dockets during this timeframe. Williams v. McDonough, 37 Vet. App. 305. The Veteran, through his attorney representative, submitted a written waiver of the remaining time to change appeal lanes in February 2026. 38 C.F.R. § 20.202(c). As such, the Board finds that the Veteran has explicitly waived his right to change dockets and requested a decision from the Board without delay.

Entitlement to service connection for essential tremor is granted.

The Veteran contends that his essential tremors are due to exposure to toxins during his service at Fort Devens. 

Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

The AOJ found that he Veteran has a diagnosis of essential tremor, and participation in a toxic exposure risk activity (TERA) is conceded based on his exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS) during military service. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). 

Service treatment records (STRs) are silent for any complaints, treatment, or diagnosis for essential tremor, to include his November 1977 separation examination. 

An April 2024 private opinion notes that the Veteran had a diagnosis of essential tremors. The provider indicated that the Veteran did not have any known risk factors for a neurologic disorder. The provider furthered that it
 that he Veteran has a diagnosis of essential tremor, and participation in a toxic exposure risk activity (TERA) is conceded based on his exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS) during military service. The Board is bound by these favorable findings. 38 C.F.R. § 3.104(c). 

Service treatment records (STRs) are silent for any complaints, treatment, or diagnosis for essential tremor, to include his November 1977 separation examination. 

An April 2024 private opinion notes that the Veteran had a diagnosis of essential tremors. The provider indicated that the Veteran did not have any known risk factors for a neurologic disorder. The provider furthered that it is known that exposure to chemical toxins causes diseases that effect the thyroid, nervous system, and kidneys. The provider opined that it is more likely than not that the Veteran's conditions are related to his military service. 

The Veteran was afforded a VA examination in October 2024, which notes a diagnosis of essential tremor. The Veteran reported that the date of onset of his disability was 2015 with intermittent right-hand shaking and right hand weakness that has progressed since onset. The examiner opined that the claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that although the Veteran's healthcare provider stated that the Veteran did not have any known risk factors or family history of essential tremor, medical literature states it is considered to be largely a genetic disorder and additional studies are needed to more definitively establish whether these exposures are associated with essential tremor and if they are of etiological importance. Additionally, citing to medical literature discussing perfluoroalkyl and polyfluoroalkyl substances as well as an article discussing the health effects of exposure, the examiner indicated that none of the articles indicate that PFAS is a known cause of neurologic disorders. A nexus is not established.

In a November 2024 statement, the Veteran's spouse indicated that she had known the Veteran since 1982, after his active service. In pertinent part, the Veteran's spouse indicated that he was diagnosed with essential tremors in his right hand and arm in July 2016. She reported that he was taking medication for this now, but he still had trouble writing and using a laser pointer at work. 

A November 2025 private opinion indicates that, following review of medical records, service records, VA examination, and peer-reviewed literature, establishing a robust causal link to service-connected per- and polyfluoroalkyl substances exposure during his time stationed at Fort Devens, the evidence demonstrates that per- and polyfluoroalkyl substances directly contributed to the onset and progression of these conditions, including essential tremors, through bioaccumulation and long-term toxic effects. The provider, citing medical literature, explained that per- and polyfluoroalkyl substances are highly persistent synthetic chemicals, often termed "forever chemicals," that resist environmental degradation and bioaccumulate in human tissues; once absorbed, they can remain in the body for years allowing them to exert toxic effects long after exposure cease, and there is no safe exposure level.

The provider discussed the Veteran's medical history and indicated that the Veteran was diagnosed with essential tremor in 2016; it has worsened, affecting right-hand fine motor skills. The provider, citing to medical literature, explained that per- and polyfluoroalkyl substances induce neurological effects through inflammation and metabolic disruption, altering pathways that affect motor control. They promote systemic inflammation correlated with biomarkers that can extend to neural tissues, potentially disrupting fine motor regulation. Immune dysfunction from exposure may trigger autoimmune-like responses impacting neural signaling. These chemicals bioaccumulate, leading to long-term disturbances in lipid and protein pathways that influence tremor development. The gap between service and the 2016 diagnosis aligns with persistent effects manifesting decades later. Additionally, the provider noted that there was no family history or other risks. The provider also noted review of the October 2024 VA opinion, noting that the examiner did not consider that altering pathways that affect motor control substances link to immune and neurological dysfunction, emphasizing burn pits over Fort Devens exposure, and neglected persistence for delayed onset. Therefore, the provider opined that it was at least as likely as not that the Veteran's essential tremors were caused by per- and polyfluoroalkyl substances exposure during his military service.

The Veteran was afforded another VA examination in November 2025, which notes a diagnosis of essential tremors. The Veteran reported that the date of onset of his disability was 2015 with essential tremor of bilateral hands, right worse than left. The provider opined that essential tremor was less likely than not caused by the indicated toxic exposure
 VA opinion, noting that the examiner did not consider that altering pathways that affect motor control substances link to immune and neurological dysfunction, emphasizing burn pits over Fort Devens exposure, and neglected persistence for delayed onset. Therefore, the provider opined that it was at least as likely as not that the Veteran's essential tremors were caused by per- and polyfluoroalkyl substances exposure during his military service.

The Veteran was afforded another VA examination in November 2025, which notes a diagnosis of essential tremors. The Veteran reported that the date of onset of his disability was 2015 with essential tremor of bilateral hands, right worse than left. The provider opined that essential tremor was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that essential tremor is most commonly genetic but can also be caused by increased age and caffeine; however, citing to medical literature, the examiner indicated that there is no known association between essential tremors and PFAS exposure.

After a review of the evidence, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran's essential tremor is causally related to his active service. The November 2025 private provider opined that it was at least as likely as not that the Veteran's essential tremors were caused by perfluoroalkyl and polyfluoroalkyl substances exposure during his military service. The provider based this opinion, in part, on a review of medical literature indicating that perfluoroalkyl and polyfluoroalkyl substances induce neurological effects altering pathways that affect motor control. The Board acknowledges the negative nexus opinions provided by the October 2024 and November 2025 VA examiners; however, the Board notes that these opinions are based on examiners' findings that there was a lack of medical literature supporting a connection between exposure to PFAS and essential tremors. Each of the medical opinions appears to be based on a review of the Veteran's medical records and a review of medical literature; however, the clinicians' opinions differed as to whether the Veteran's essential tremors were related to his exposure to PFAS during service. Thus, the Board is unable to afford greater probative value to one opinion over the others.

Given the conflicting medical opinions of record, the Board finds that the evidence is, at minimum, in equipoise as to whether the Veteran's essential tremor is related to his military service. The benefit-of-the-doubt will be conferred in the Veteran's favor and his claim for service connection for essential tremor is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).

 

Thomas H. O'Shay

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	D. Hite, 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.