BVA9501969 DOCKET NO. 93-03 118 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for a back disorder. 3. Entitlement to service connection for a heart disorder. 4. Entitlement to service connection for a seizure disorder. 5. Entitlement to service connection for organic cause for a tremor. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. G. Mazzucchelli, Associate Counsel INTRODUCTION The veteran served on active duty from September 1982 to February 1990. This appeal arises from an April 1991 rating decision of the Lincoln, Nebraska, regional office. That rating decision denied the veteran's claims for service connection for an acquired psychiatric disorder, a back disorder, a heart disorder, a seizure disorder, and an organic cause for a tremor. After issuance of the statement of the case, the appellant filed a substantive appeal at the Columbia, South Carolinca, regional office (RO). This office certified the appeal to the Board of Veterans' Appeals (Board). CONTENTIONS OF APPELLANT ON APPEAL The veteran contends in part that she has a chronic back disorder which began in service and causes pain and interferes with her ability to sleep. Her representative requests that all reasonable doubt be resolved in the veteran's favor. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports an allowance of service connection for degenerative joint disease of the thoracic spine. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's claim. 2. The veteran had arthritic changes of the thoracic spine with pain within one year of separation from service. CONCLUSION OF LAW Degenerative joint disease of the thoracic spine is presumed to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, she has presented a claim which is plausible. All relevant facts have been properly developed and no further assistance is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The veteran contends that she has a chronic back disorder which was incurred in service. Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131 (West 1991). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1993). Service connection for arthritis may be granted if it is shown to be present in service or manifest to a degree of 10 percent or more within one year from the date of final separation from service. 38 U.S.C.A. §1112 (West 1991); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (1993). The service medical records show that the veteran complained of pain in the thoracic spine region on several occasions during service. Thoracic spine X-rays taken in December 1984 were negative. The veteran's final separation from active service occurred in February 1990. In early November 1990 at AMI St. Joseph Hospital, the veteran was given an infiltration in the most tender area of her thoracic spine. A VA examination was subsequently conducted in November 1990. The veteran complained of upper back distress of eight years duration which kept her awake at night. On examination, there was full range of motion with no tenderness. X-rays showed suggestion of osteophyte at T5-6. The diagnosis was arthritis of the thoracic spine with small osteophyte T5-6. The VA examination demonstrated arthritis by X-rays and a lack of limitation of motion. The schedular criteria for degenerative arthritis contemplates a 10 percent rating if, in the absence of limitation of motion, there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. 38 C.F.R. Part 4, Code 5003. In this case, only one joint group is involved. However, Code 5003 read with 38 C.F.R. § 4.59 states that painful motion of a major joint or groups caused by degenerative arthritis, where the arthritis is established by X- ray, is deemed to be limited motion and entitled to a minimum 10- percent rating even though there is no limitation of motion. Lichtenfels v. Derwinski, 1 Vet.App. 484, 488 (1991). The medical evidence indicates that the veteran had arthritis in the thoracic spine within the first postservice year. This was associated with pain requiring hospital treatment prior to the VA examination. It is understandable that a great deal of pain was not elicited at the time of the VA examination since this was shortly after treatment for back pain. The VA examiner indicated that the veteran reported pain of long duration in the mid-back area. The service medical records and records following service confirm that the veteran had long-standing complaints of mid-back pain. Since the evidence demonstrates that the veteran had arthritis manifest to a degree of at least 10 percent within one year from the date of final separation from service, the Board concludes that she is entitled to service connection for degenerative joint disease of the thoracic spine. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). ORDER Service connection for degenerative joint disease of the thoracic spine is granted. REMAND The veteran also contends in part that she has a chronic acquired psychiatric disorder which began in service. The service medical records show that she complained of anxiety, depression, insomnia, and low self esteem in 1989. The impression was schizotypal personality disorder. A VA examination was conducted in November 1990. The impressions were alcohol abuse, and depressive reaction, moderate, with anxiety features. Psychological testing was accomplished in January 1991. The examiner stated that the results were consistent with the schizotypal personality disorder which was diagnosed and treated in service. Subsequently, the veteran underwent outpatient treatment at Offutt Air Force Base in Nebraska. In April 1991, diagnoses of major depression, recurrent, moderate, psychotic features in remission, dysthymia, and schizotypal personality disorder were made. The Board is of the opinion that the veteran should be scheduled for an examination by a panel of two VA psychiatrists to reconcile the diagnoses, determine whether a chronic acquired psychiatric disorder was manifested in service or within the first postservice year, and to assess the role of any alcohol or substance abuse on any psychiatric disorder. Additionally, any private or VA medical records pertaining to treatments for any of the veteran's claimed conditions which are not in the claims folder should be obtained. VA has a duty to assist the veteran in the development of her claim. 38 U.S.C.A. § 5107(a) (West 1991). In view of the foregoing, the case is REMANDED to the RO for the following: 1. The RO should request from the veteran the names and addresses of all the health care providers who have treated her for any of her claimed disorders since service. She should provide any necessary releases. The RO should then ask the health care providers listed by the veteran to provide complete copies of their notes and records on the veteran which are not in the claims folder. All relevant VA outpatient records should also be obtained. If any records are not available, that fact should be noted in the claims folder. 2. Following the above, the veteran should be examined by a panel of two VA psychiatrists to determine the nature and extent of any current psychiatric disorder. Each psychiatrist should conduct a separate examination. The examination reports should contain detailed accounts of all manifestations of psychiatric pathology found to be present. If there are different psychiatric disorders, the board should reconcile the diagnoses and should specify which symptoms are associated with each disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The entire claims folder and a copy of this REMAND must be made available to and reviewed by the examiners prior to the examinations. All necessary special studies or tests, including psychological testing, should be accomplished. The examiners should express an opinion as to whether the inservice complaints reflected a chronic acquired psychiatric disorder at that time. If a chronic acquired psychiatric disorder was not present in service but is determined to be present at this time, the examiners should express an opinion as to the likely onset of the disorder as well as the relationship between the inservice symptomatology and any current psychiatric pathology. Additionally, the examiners should comment on the presence of any alcohol/substance abuse and whether it is part of or caused by any current psychiatric disorder. If a chronic acquired psychiatric disorder is currently present, the examiners should assign a numerical code under the Global Assessment of Functioning Scale (GAF). It is imperative that the physicians explain what the assigned score represents. The reports of examination should include a complete rationale for the conclusions reached. 3. The RO should review the examination reports and determine if they are adequate for rating purposes and in compliance with this Remand. If not, the report(s) should be returned to the examiner(s) for corrective action. 4. Following completion of these actions, the RO should readjudicate the veteran's claim for service connection for an acquired psychiatric disorder. It should also adjudicate the issue of service connection for alcohol/substance abuse if found on examination. If either claim remains denied, the veteran and her representative should be provided with an appropriate supplemental statement of the case. Thereafter, the case should be returned to the Board for further appellate consideration. No action is required by the veteran until she receives further notice. The issues of service connection for a heart disorder, a seizure disorder, and organic cause for a tremor are hereby deferred. JAN DONSBACH Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).