Citation Nr: 0008001 Decision Date: 03/24/00 Archive Date: 03/28/00 DOCKET NO. 97-30 664 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for multiple sclerosis (MS). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Michelle L. Nelsen, Associate Counsel INTRODUCTION The veteran had active duty from October 1963 to October 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for the equitable disposition of the veteran's appeal. 2. The veteran was diagnosed as having MS in February 1975, more than eight years after her separation from service. 3. The veteran's MS was not manifest in service or to a compensable degree within seven years of her separation from service. CONCLUSION OF LAW MS was not incurred in service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1101(3), 1110, 1112, 1113, 1131, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is well grounded. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.102 (1999). See Murphy v. Derwinski, 1 Vet. App. 78, 91 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented a claim which is not implausible when his contentions and the evidence of record are viewed in the light most favorable to the claim. The Board is also satisfied that all relevant facts have been properly and sufficiently developed to address the issue at hand. Factual Background The veteran's service medical records showed that she incurred a concussion when hit on the head by a patient in March 1964. She was hospitalized with severe headache. Electroencephalography (EEG) revealed minimal paroxysmal breakdown. A repeat EEG in April 1964 revealed some hypopotentia in the posterior areas and an aggravation of the abnormal findings. She was treated with Dilantin. Another EEG performed in June 1964 still showed a paroxysmal tracing. Notes for a July 1964 visit reflected that the veteran stopped taking her medication and that the headaches had recurred. The physician explained that she had an encephalopathy, as demonstrated by EEG. On the report of medical history associated with a September 1964 examination, the veteran reported that, with fatigue or an increase in blood pressure, she underwent a period of tremors, dizziness, nausea, and semi-awareness of her environment, which was followed by a period of weakness. The veteran was afforded a neurology consultation in October 1964. She reported a recurrence of headaches as well as periodic blackout spells. Examination revealed feigned weakness in the left extremities and vague, unanatomic hypesthesia on the left side of the body. Neurological examination was otherwise essentially normal. A new EEG was interpreted as normal. The impression was mild concussion with conversion reaction. The physician did not believe that the veteran had any significant organic disease and that he symptomatology could be explained by conversion reaction. He added that it would not be unusual to see some abnormalities in an EEG after a concussion. In November 1964, the veteran was hospitalized for evaluation. The neurological examination at admission was normal. Another EEG was interpreted as normal. A neurological consultation yielded the opinion that the veteran had suffered a mild concussion in March 1964 with no residual neurological effect. In September 1965, the veteran presented with dizziness and weakness after standing, following by rapid deep breathing and subsequent paresthesias. The examination was entirely normal. The assessment included transient postural hypotension with subsequent hyperventilation syndrome. The veteran returned in December 1965 with similar complaints. The September 1966 separation examination report was negative for abnormal neurological findings or a neurological diagnosis. Records received from Grant Hospital showed that the veteran gave birth in May 1968. The veteran complained of tingling in the left arm and hypesthesias. In a request for a neurological consultation it was explained that she had complained of left arm numbness intermittently throughout the pregnancy. Neurological examination and EEG were negative. The consulting physician reported that there was no change in central nervous system status. The veteran submitted a copy of a medical bill for services rendered in April and May 1969 by R.W. Starkey, M.D., of Central Ohio Medical Clinic. The service code showed charges for a consultation, electromyogram (EMG), nerve conduction velocity studies, and diagnostic X-rays. The records associated with the listed treatment were not available. In a February 1975 letter, Edward F. Steinmetz, M.D., related the veteran's history. In January 1975, following scuba diving, the veteran developed numbness from the waist down and left leg drag. About six years earlier, with her second child, she developed left arm numbness. She saw a neurosurgeon and had an EMG. She was told she might have a pinched nerve. The veteran continued to have intermittent left hand problems. In addition, she had a history of two head injuries, one as a child and one about age 20 in service. Dr. Steinmetz stated that the veteran's subjective complaints were highly consistent with demyelinating process, but the disorder was not documented on examination. He suggested that she be hospitalized for a complete neurological evaluation. Records from Lee Memorial Hospital showed that the veteran was admitted in February 1975. The discharge summary repeated the immediate history beginning in January 1975. The history of left hand numbness with a diagnosis of pinched nerve by EMG was related to six months before. In addition, the veteran described Lhermitte's sign, or shooting sharp sensations up and down the neck, a problem present for many years. After evaluation and laboratory tests, the diagnosis was demyelinating process. In an August 1975 letter, George W. Paulson, M.D., provided a more detailed version of the veteran's medical history. In 1967, while pregnant, the veteran had Leriche's syndrome, with tingling in her left arm at the same time. At that time, a neurosurgeon wondered about brachial plexitis. EMGs and other studies did not reveal anything remarkable. Within one year, the problem had cleared, though she still had some tingling. In addition, since then, she had grinding fatigue, which Dr. Paulson had come to associate with demyelinating disease. With another pregnancy, the veteran again developed Leriche's syndrome. Three weeks after the pregnancy, she felt no more symptoms. She was well until January 1975, when she developed a variety of symptoms. Dr. Paulson stated: "It is clear that these symptoms have come and gone through the years." He added: "I have been struck through the last three years that not only may exacerbations occur, for weeks, but often for a matter of minutes or hours." Additional medical history was provided in a June 1989 letter from Kottil W. Rammohan, M.D., from the Ohio State University Department of Neurology. In 1967, about five months into her first pregnancy, she noticed excessive fatigue. About four months into her second pregnancy, she had numbness and weakness in the left arm, which was diagnosed as a pinched nerve. By the eighth month, she had difficulty walking, which was diagnosed as a separated [blank]. She spent the rest of the pregnancy mostly non-ambulatory. Into about the third month of her third pregnancy, the veteran developed considerable difficulty with walking. In addition, during each of the pregnancies, she described 24 hours of complete blindness that completely and uneventfully resolved. She was back to normal about three weeks after the last pregnancy. Thereafter, she was well until 1975. In a June 1992 letter, Robert J. Thompson, M.D., of Neurological Associates, indicated that the veteran's symptoms dated back to the 1960s. In a February 1999 letter, Dr. Thompson related that he had treated the veteran intermittently since 1982 and that she had been having symptoms of MS since she was 23. Efforts to obtain additional medical records from Wright Patterson Air Force Base, Lockbourne Air Force Base, James W. Webb, M.D., Capital Primary Care, and Central Ohio Medical Group were unsuccessful or received negative replies. In a July 1998 statement, the veteran related that, during service, she spent a week caring for a child who had severe neurological damage from meningitis. She believed that there could be a latent viral-neurological connection. In August 1998, the veteran underwent a VA neurological examination provided by a private neurologist on a fee basis. The examiner stated that he completed a review of the claims folder prior to the examination. Historically, the veteran received a head injury while a student nurse that was diagnosed as a mild concussion with no residual. She did well until her second pregnancy, 1967 to 1968, when she developed weakness and sensory loss in her right arm, which cleared rather quickly after delivery. No specific diagnosis was made at that time, though the question of radial (sic) plexitis was raised. He indicated that there was also mention of an EMG, but the record of the study was not available. After the birth of her third child, the veteran had blindness that lasted only hours. She did well until 1975, when she developed sensory abnormalities and was diagnosed as having MS. The examiner's impression was MS with the first well-defined attack occurring in 1975 when the diagnosis was made. He indicated that the episode that happened in 1967, although certainly characteristic of MS, could not be documented to be an attack, particularly in view of the mention of the record of an abnormal EMG. In an addendum, the examiner stated that the episodes that occurred up to an including December 1965 were not, in his opinion, manifestations of MS. He added that the first episode that could have been a manifestation of MS, which occurred in 1967, was questionable because at that time the question was raised about a nerve compression lesion. Finally, the examiner provided another addendum in November 1998, after reviewing recently submitted medical records from Grant Hospital. He stated that these records tended to reinforce the notion that the numbness reported by the veteran in 1967 was not an attack of MS. Again, it was his opinion that the numbness experienced by the veteran in 1967 was not a manifestation of MS. The veteran testified before a member of the Board in February 2000. She felt that she had symptoms of MS during active duty, 1966 to 1967, with the birth of her first child. The symptoms included she had severe back pain and headaches, nausea, difficulty walking, and blindness. The symptoms stopped immediately after the pregnancy. During her second pregnancy in 1968, the veteran had an EMG for numbness in the right arm, which was diagnosed as a pinched nerve. The symptoms resolved immediately after the pregnancy. During her third pregnancy, 1972 to 1973, she was unable to walk for five months and also had blindness. The symptoms resolved about three weeks after the pregnancy. Her symptoms returned in 1975, when the diagnosis of MS was made. The veteran testified that the independent physician who examined her for VA verbally told her that the EMG did not show a pinched nerve and that he thought it was her first symptom of MS. She sustained a head injury in service that was diagnosed as a concussion. She had headaches thereafter, which lessened in frequency with time. The veteran was a pediatric or newborn nurse, and she had done some work in geriatric home health. She never specialized or worked in neurological disorders. The veteran stated that Dr. Thompson, who she started seeing in 1981, told her that the problems she experienced during pregnancy were the onset of MS, brought on by stress. Analysis Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994) (specifically addressing claims based ionizing radiation exposure). Direct service connection requires a finding that there is a current disability that has a definite relationship with an injury or disease or some other manifestation of the disability during service. Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992). A disorder may be service connected if the evidence of record, regardless of its date, shows that the veteran had a chronic disorder in service or during an applicable presumptive period, and that the veteran still has such a disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488, 494-95 (1997). Such evidence must be medical unless it relates to a disorder that may be competently demonstrated by lay observation. Savage, 10 Vet. App. at 495. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). If the disorder is not chronic, it may still be service connected if the disorder is observed in service or an applicable presumptive period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present disorder to that symptomatology. Id. at 496-97. Again, whether medical evidence or lay evidence is sufficient to relate the current disorder to the in-service symptomatology depends on the nature of the disorder in question. Id. Disorders diagnosed after discharge may still be service connected if all the evidence, including pertinent service records, establish that the disorder was incurred in-service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Some chronic diseases are presumed to have been incurred in service, although not otherwise established as such, if manifested to a degree of ten percent or more within the specified period of time from the date of separation from service. 38 U.S.C.A. § 1112(a)(1); 38 C.F.R. § 3.307(a)(3). Specifically, MS must be manifest to a compensable degree within seven years from separation from service. Id.; see 38 U.S.C.A. § 1101(3) and 38 C.F.R. § 3.309(a) (listing applicable chronic diseases, including MS). In this case, service records show that the veteran had active service from October 1963 to October 1966. MS was diagnosed in February 1975. The veteran asserts entitlement to service connection for MS either as directly incurred in service or under the presumption of in-service incurrence. The Board acknowledges that the statements from Dr. Paulson and Dr. Thompson provide support for her claims, though it is not clear from the statements themselves on what information the doctors based their statements. However, the fee-basis neurologist who examined the veteran for VA opined that the symptoms shown in service and through 1967 were not manifestations of MS. This physician's opinion was based not only on the history as related by the veteran, but also on a complete review of the veteran's claims folder and all associated medical records. Therefore, although Dr. Thompson participated in the veteran's treatment, the Board finds that the VA fee-basis examiner's opinion is more probative on the issue of when MS became manifest. See Guerrieri v. Brown, 4 Vet. App. 467, 472 (1993) (Court declines to adopt rule in which the opinion of a treating physician is accorded more weight in the evaluation of veterans claims). The Board notes that, during her hearing, the veteran testified that both the VA fee-basis examiner and Dr. Thompson had told her that her early symptoms during her pregnancy in 1967 were in fact manifestations of MS. However, the evidence of record does not reflect those opinions. In fact, the written report from the fee-basis examiner specifically states the opinion that symptoms in 1967 did not constitute an MS attack. As discussed above, the statements from Dr. Thompson, though suggestive of such a relationship between the symptoms and MS, are less probative than the opinion of the VA fee-basis examiner. Finally, the veteran has expressed her personal belief that her symptoms of MS began either in service or within the seven-year presumptive period. The Board acknowledges that the veteran is trained as a nurse, though she has been unable to work as a nurse for some time due to MS. However, as conceded during her hearing, she was a pediatric nurse and had no special training or experience in neurology. Therefore, her opinion as to the time her MS was manifest, is not particularly probative. See Black v. Brown, 10 Vet. App. 279 (1997) (opinion of the veteran's wife, a registered nurse, regarding his heart attack was not a competent medical opinion as there was no evidence that she had special knowledge regarding cardiology or that she participated in the veteran's care). In summary, the Board finds that the preponderance of the evidence is against entitlement to service connection for MS. 38 U.S.C.A. §§ 1101(3), 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a)(3), 3.309(a). ORDER Entitlement to service connection for MS is denied. RENÉE M. PELLETIER Member, Board of Veterans' Appeals