Before I NOD, seeking input on SC sleep apnea

[Marine1342]

Hello HadIt Community,

TL:DR
Skip down to bold section “So that brings us to today….”

I've been a bit of lurker on the forums, searching and researching information already presented, hence the lack of postings.
I was not quite sure where to post this, in the “Appeals” section or the “Disability and Claims” section.”  I decided on the “Appeals” section due to the fact that the claim was already submitted and decided on, and so the next step logically would be an appeal.  Moderators, if it needs to be moved, please move it to the correct section.

I know that there is a lot of postings, questions, and information in regards to sleep apnea and trying to get it service connected, namely to PTSD and/or TBI.  I hope that by sharing my path/progress it will help others who are in a similar situation.

I am SC for TBI (70%), PTSD (50%), Mechanical neck pain syndrome (10%), tinnitus (10%).  Total combined rating with fuzzy math puts me at 90%.

This path of medical issues and nuances began in 2007 when I was in the Marine Corps, and it has taken my up until this year to really get most of my issues addressed and sorted.  What delayed the entire process would be attributed to not knowing the secondary effects to injuries.  Certain things were obvious (a head injury has secondary consequences like memory issues), but other things (namely the PTSD) were not.  The VA, for me, has done an excellent job in diagnosing things, as well as the therapy afterwards.  I know that this is not the case for everyone, but I was persistent and proactive towards trying to learn about myself and the changes I was going through and had been through.  Not having considered PTSD as a problem for me (denial maybe?), I had attributed everything (headaches, poor sleep, attention problems, behavioral changes) to the head injury.  Turns out that a lot of the symptoms of TBI are shared with PTSD, making treatment harder.  Is the poor sleep because of the head injury or the PTSD? If the memory and lack of focus because of the head injury or the PTSD, etc.

It took me a year and a half, after 6 months of initial therapy, to go through the medicine trial run.  Try different medications, see if I feel any different.  If I do, do I feel better?  Once the right medicine is found, then it’s about finding the best dosage for me.  Because everyone is different, and we are all wired differently, no 1 chemical will react the same way for everyone.  At times, it felt that nothing was really working, and it didn’t help that the trial period takes time for your body to adjust to the new drugs.  But with an open line of communication with my psychiatrist made it easier to track changes and make the changes so that I felt better.  For me, it’s been a night and day difference.  Looking back and remembering how I felt, it was almost as if my brain was in a constant fog.  I was awake and aware of things, but almost as if things were in a dream-like state.  I don’t know how else to describe it, but it felt like the drag I had on my mind and shoulders was eased.  There are still bad spells and moments, but that is where the discipline and focus really comes into play.  It hasn’t been easy, and I can’t even begin to imagine how it is for those who have a bigger challenge than I.  But what I do know, is that you need to be wanting to make things better for yourself.  It’s a bit of a process.  Therapy isn’t the easiest, as you need to revisit certain areas in your life that you don’t want to.  It takes time, and you feel quite low during certain times.  In some ways, it allowed me to learn more about myself, and what I needed to do and go through to make myself better (know yourself and seek self-improvement…).  But it gets better, I promise.

Biggest takeaway from disability claims with the VA, is to make sure you have your paperwork in order BEFORE you submit things.  At the beginning I did not know what I had, how the VA system worked, or anything at all.  So my first claim consisted of:  neck pain, lower back pain, headaches, memory problems.  Very broad and generic symptoms.  They were denied, but through the intake process, I did learn that I should talk to the VA clinic, namely the poly-trauma area to have my TBI assessed.  From there, it was evaluation after evaluation to try and get an answer as to why I was having problems.  TBI led to tinnitus and neck problems.  TBI therapy then lead to depression screening which led to PTSD screening.  PTSD screening then led to therapy.  Once those two main areas (TBI and PTSD) were stable enough for me, I started to address other issues, namely sleeping problems.  Headaches every day when I wake up, cold sweats every other night (changing sheets couple time a week….), nightmares.  I had attributed all those symptoms to the head injury, but that was when I had learned that it could be partially the head injury, and partially the PTSD.  More research lead to asking for a sleep study done.  I figured that if there is something going on while I sleep, maybe it’ll show up on the results and give me a better idea to what’s going on.  Having a better idea, it would allow me to attack the problem from a different angle.

I found that throughout the entire VA process (starting in 2007), the best way to tackle things is to focus on it like a puzzle.  Define the problem, get a better idea of what it is, and this then leads to knowing how you can attack it head on. 

I don’t know what exactly I was expecting out of the sleep study, but I certainly did not think that I would have an issue with breathing while I sleep.  I had assumed that my combination of injuries was manifesting itself while I was sleeping (my most relaxed state).  Long story short with my sleeping habits from the past, the sleep study showed that I had mild sleep apnea, namely obstructive sleep apnea.  CPAP machine was then issued.
Now to me, that didn’t make any sense at all.  I don’t fit the OSA poster-boy, at all.  Overweight?  Thick neck? Older? I’m 28, 6’, 165 lbs.  But I had some answers.  My shallow breathing would cause decreased oxygen intake which causes an increase in CO₂ in my blood.  Heart pumps faster, fight/flight response starts, body is working harder to supply blood to muscles, cold sweats start to try and dump CO₂.  Then I wake up and I have to go use the bathroom, 1-2 times per night.  I just figured I was well hydrated…haha…

With the answer of sleep apnea of the obstructive kind, I started to research causes for it, and correlations to different injuries.  One thing leads to another and there are correlations between head injuries and PTSD.  So at that point (more answers…yay), I go back to VA research and learn that there can be claims filed for OSA.  Since I was diagnosed with OSA outside of service, then I would need to either prove it happened while I was in (no evidence, so scratch that), or have a secondary connection to a service connected disability.
Seeing that I was SC for TBI and PTSD, that would be the route I would take.  What this meant was that I would need to present information to the VA showing a correlation between the injuries, and have the weight of a doctor behind it.
I made sure to file an Intent to File notice so that my date was locked in for retroactive pay.
With this date locked in, I needed to go about finding information on IMOs.  Researching and learning, I decided to go with Dr. Anaise and get an Independent Medical Expert Opinion.  $1500 later I had a nice sizeable book with him stating (and with evidence too) that he opined that it is more likely than not that my sleep apnea is secondary to my service-connected PTSD, TBI and tinnitus. 
With my new information and medical opinion in hand, I submitted a Fully Developed Claim, since I had no more information to submit (IMO from private doctor, and the VA had all my medical records including the sleep study).  6 months of waiting and checking eBennies (torture….) and it finally finished and showed that a decision had been made.  Paperwork comes in the mail and the claim is denied…

Frustrated? Not really, since I had expected that it would be denied.  Most claims, unfortunately seem to be denied the first time around.  Bit let down sure.  But it is what it is, I can’t change that, so now time to look at how to keep pushing forward.

 

 

So that brings us to today….
I do plan to submit a Notice of Disagreement to have it reviewed again.  I have been told that the reviewal process is in the time length of 2-5 years (frustrating but backpay will be nice…).
 

My posting on HadIt is based on wanting to get other people’s input and a fresh set of eyes on the information I have and what the next steps are, different viewpoints, and maybe anything I missed/am missing, as well as posting my information and path on here for others to read and learn from.

Medication:
Venlafaxine 300mg for PTSD
Zolpidem Tartrate 5mg for sleep (Ambien)

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VA Decision letter verbatim:

Issue/Contention

• sleep apnea

Explanation

• The evidence does not show that sleep apnea is related to the service-connected condition of traumatic brain injury, nor is there any evidence of this disability during military service.

• Service connection for sleep apnea is denied since this condition neither occurred in nor was caused by your service.

• Your service treatment records do not contain complaints, treatment, or diagnosis for this condition.  The evidence does not show an event, disease or injury in service.  The evidence does not show that your condition resulted from, or was aggravated by, a service-connected disability.  The VA examiner stated that your current sleep apnea is due to the airways in your throat relaxing too much to allow normal breathing and closure of your muscles than your service connected TBI, tinnitus, and/or PTSD.

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VA Examination
I was not there for the exam because verbatim:
[X] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence.

 

Verbatim:

MEDICAL OPINION SUMMARY

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opinion ---OSA 2/2 to PTSD

LESS LIKLEY THEN NOT THE OSA IS 2/2 TO PTSD --

RATIONALE --OSA IS A OBSTRUCTIVE DEFECT Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula ? a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood and cause a buildup of carbon dioxide. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it. You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths. You may make a snorting, choking or gasping sound. This pattern can repeat itself five to 30 times or more each hour, all night long.

These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours. People with obstructive sleep apnea may not be aware that their sleep was interrupted.

In fact, many people with this type of sleep apnea think they slept well all night

 

/es/ *Name removed* FNPC

PRIMARY CARE PROVIDER

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IMO excerpts verbatim

“After reviewing the veteran’s c-file and the pertinent recent medical literature, I opine that is more likely than not that the veteran’s sleep apnea is secondary to his service connected PTSD, TBI and tinnitus”

“After reviewing all of the veteran’s medical and military records, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran’s sleep apnea is secondary to his service-connected PTSD and TBI.  The scientific observation that the derangement of REM sleep prominent in the PTSD patient is the cause for sleep apnea is of particular importance in this case.  It is more likely than not that the veteran’s sleep apnea is secondary to his service-connected tinnitus.”

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The report is 7 pages long with 5 5 exhibits of evidence (scientific journal reports).  If needed for better clarity, I can scan the 7 pages in (edited for privacy).
I can also post the findings from the sleep study if needed as well.

 

I don’t want to provide my thoughts and input on this just yet, as I would like to see what the community’s thoughts are on where things are so far, based on what there is.

What I ultimately am looking for, besides getting my claim granted, is to gain a better idea of what route I should take based on what I have.  The VSO who I was working with suggested a simple medical statement that says my medication for PTSD affects my OSA (throat muscles relaxing), was also recommended to have a DRO review the case (instead of a RO?) since it might speed up the process because it was more ‘in-house’. De Novo review? CUE?

Thank you in advance for your thoughts, view points, and suggestions

 

 

The CPAP machine, took a bit of time getting used to, but it is a night and day different (no pun intended ha).  The nightmares are less, the cold sweats are essentially gone, morning headaches aren’t there, and I feel rested now when I wake up and throughout the day.  Getting sleepy while driving isn’t there anymore.  I wanted to see its effectiveness, so I decided to try sleeping 2 nights without the mask, and the first night, instantly the prior symptoms came back.  Headaches, cold sweats, over tired all day.

 

My conclusion, from my personal experience, is that if you have PTSD, TBI or both, get a sleep study done.  There is strong enough correlation between the three to have symptoms overlap and exacerbate one another.  I may not know the exact scientific workings behind it, but logically it makes sense.  PTSD or TBI, get testing and therapy done to better understand the challenge that YOU have, and how to better work through/around/over it.  If they recommend medication, ask why.  Not to push back against it, but so that you understand what the purpose of it will be, how it will help you.  Self-knowledge and self-learning are very important in order to have a better grasp of things pertaining to you.
Be patient with medication, and be honest with your prescribing doc.  Everyone reacts differently to medication, and only YOU can determine how you feel.  I might even recommend keeping a small journal of how you FEEL throughout either therapy or medication trials.
Be patient with your meds.  Medicine doesn’t work overnight, especially finding the right one and dosage.
Be patient with therapy.  Not during therapy necessarily, but in the length of things.  It takes time depending on severity.  You will feel worse some days more than others.  Therapy, like medicine, is unique to YOU.  What worked for me, may not work exactly (or at all) for you.  But you need to be honest with yourself and with your guides (therapists and docs).

I had a small ‘good luck charm’, a grounding tool, that I would touch and hold when my mind would start to wander.  Helped to keep/bring me back to reality.  Grounding techniques worked wonders, but you need to be disciplined about it.  My good luck charm was a 550 cord bracelet I made when I was in.  Feeling the knots and mentally talking to myself kept me ‘here’.  Doesn’t have to be something big.  Just a small item that has meaning and significance to YOU.  You don’t even have to tell people what it is or does or anything.
But it gets better, I promise.

[Berta]

One question -with the 90% now are you still employed?

If not did your rep advise you to file for TDIU? If you did that and/or the VA knew that you were unemployed when they rendered this decision, how did they consider you for TDIU in this decision?

There has been much discussion here on this same situation..re: the PTSD and OSA link...

"The VSO who I was working with suggested a simple medical statement that says my medication for PTSD affects my OSA (throat muscles relaxing)",  and that is a good point to consider...have you searched for all side affects of the PTSD  meds you take?As well as any other meds you take that could cause or excerbate OSA?

Others will sure chime in. 

[Marine1342]

The 90% disability rating was recent (as in this year).  I was re-evaluated this year for my PTSD and TBI, and while the PTSD rating stated the same from the last review, the TBI was rated higher.  This made it go from 70% to 90%.
When I submitted the claim for the sleep apnea, I was working and going to school, but trying to juggle the two was too much (among other things) so I decided to focus just on schooling for now.
So to answer your questions "with the 90% now are you still employed?", no I am not.  Just focusing on school right now.

The rep did not advise I apply for TDIU, in fact it was never mentioned or discussed, as far as I can recall.  This is probably because of the fact that I was working when I started working on the VA claim.

I need to look into the medications I take, to see if a connection with side effects can be made between the two.

[Buck52]

Be careful when you list the medication side effect's  that needs to come from a Specialist Dr of Internal Medicine.

My PCP is an Internal Medicine Dr..and I ask her about the medications I take for PTSD and she said no they could not cause OSA problems other than my pain meds( Hydrocodone is an opiate)

Although I check the side effects on three of my different PTSD Meds and they do mention OSA, drowsiness /dizzy/headaches ect,,ect,,\

Generally speaking, Benzodiazepines, Opiates, and Barbiturates have the potential to cause respiratory depression (difficulty breathing), which can worsen sleep apnea.

...if I was you I would stick with the PTSD that could be aggravated your OSA as a secondary claim for S.A. but you need a Specialist Dr to link the two together'' as likey as not''

 MEDICAL Study's have shown it (PTSD) could be a relationship  with S.A./OSA

If you don't have medical Records of OSA/or any type sleep disturbance  while on A.D.  it is very hard to connect S.A. to PTSD Medications...But some veterans on here has done it...with a good veteran friendly Dr Opine 

Other wise its pure speculation and on that & it probably will be denied.

...................Buck

Edited October 19, 2016 by Buck52

[jamescripps2]

In your situation I would get one more medical opinion concurring with the one that you already have. You don't need to sell the farm to get another opinion either. Just make an appointment with an outside doctor. Be up front, tell the doctor that you are a disabled veteran and what the purpose for the visit is. Show the doctor the first opinion and ask if he/she concurs with that opinion and if so, ask if you can obtain a concurring properly written letter. Expect to pay in the neighborhood of $100.00 for the visit and opinion, or use outside insurance if you have it.. You can ask for the price of the visit before you make an appointment. Try the local Vet center. Ask those guys for an opinion and treatment. They understand your problems and will be sympathetic in your cause and your claim as they deal with the VA and claims all of the time.

When you get that other opinion dispute your C&P exam as an inadequate exam and ask for new / proper exam and a reconsideration at the RO level. That will beat an appeal and waiting for years while trying to rebuild your claim. With new and material evidence a reconsideration is a viable request at the RO level if the one year time limit since the date of the decision has not been exceeded.

Consider saying this on a 21-4138 and turn it in to the RO at the same time as the request for a reconsideration.

"Actually, I did not have a adequate C&P exam because the only thing the examiner did was to restate and summarize my VA medical records which were already available to the rater. I was not afforded the opportunity to attend the C&P exam and therefore my claim was denied without me being afforded a proper C&P". 

For the proper format of a nexus letter( see USVA 101.org ) then click on nexus letter  at the top right and copy it, take it to the doctor and ask for a conforming letter. 

[jamescripps2]

By the way marine 1342, Thanks for your service and when you ask for that reconsideration give them an ultimatum, Tell them that you are asking for a 100% award based upon the new evidence submitted, to include a new C&P exam, or re adjudicate the claim and award TDIU. Sometimes it works just to instruct them as to what you want done in your claim. If they happen to award the TDIU, then bag it and press on with the other issues and go for the plus 60% ("S" award)

 

[Marine1342]

To Buck:

Thank you for your insight and information.
I figured that going down the route of medication and its relation to PTSD and SA/OSA would require a validated statement (i.e. Dr. letter). 

18 hours ago, Buck52 said:

...if I was you I would stick with the PTSD that could be aggravated your OSA as a secondary claim for S.A. but you need a Specialist Dr to link the two together'' as likey as not''

The IMO I had done, stated something similar to this.  Here is where my knowledge and experience is lacking.  I do know/have read that wording is key as well as document/factual support. 

On ‎10‎/‎18‎/‎2016 at 1:05 PM, Marine1342 said:

IMO excerpts verbatim

“After reviewing the veteran’s c-file and the pertinent recent medical literature, I opine that is more likely than not that the veteran’s sleep apnea is secondary to his service connected PTSD, TBI and tinnitus”

“After reviewing all of the veteran’s medical and military records, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran’s sleep apnea is secondary to his service-connected PTSD and TBI.  The scientific observation that the derangement of REM sleep prominent in the PTSD patient is the cause for sleep apnea is of particular importance in this case.  It is more likely than not that the veteran’s sleep apnea is secondary to his service-connected tinnitus.”

Unfortunately, I never bothered with going to get medically looked at for sleeping issues.  I did complain about sleeping issues after my head injury, since that was the only physical injury I had.  Never considered PTSD until I was going through therapy as a possible cause of issues.  So having sleep apnea diagnosed/documented on AD medical documents is a no-go.
Hence, why I am trying to go the route of the Dr. Opine IMO letter, which (per quote above) I thought that would be it.